Postoperative peak serum C-reactive protein is a predictor of outcome following liver transplantation for hepatocellular carcinoma

Current status and prospect of treatments for recurrent hepatocellular carcinoma

Owing to its heterogeneous and highly aggressive nature, hepatocellular carcinoma (HCC) has a high recurrence rate, which is a non-negligible problem despite the increasing number of available treatment options. Recent clinical trials have attempted to reduce the recurrence and develop innovative treatment options for patients with recurrent HCC. In the event of liver remnant recurrence, the currently available treatment options include repeat hepatectomy, salvage liver transplantation, tumor ablation, transcatheter arterial chemoembolization, stereotactic body radiotherapy, systemic therapies, and combination therapy. In this review, we summarize the strategies to reduce the recurrence of high-risk tumors and aggressive therapies for recurrent HCC. Additionally, we discuss methods to prevent HCC recurrence and prognostic models constructed based on predictors of recurrence to develop an appropriate surveillance program.

Role of inflammatory markers in predicting hepatocellular carcinoma recurrence after liver transplantation

Background

Liver transplantation (LT) is the best treatment for selected patients with cirrhosis and small hepatocellular carcinoma (HCC) who are not candidates for resection. The proinflammatory effects of systemic inflammatory response have been linked with HCC. Therefore, the measurement of inflammatory markers represents a significant tool to limit recurrence after LT.

Results

There are eleven patients with HCC recurrence post-transplantation. Pre-transplantation AFP can predict HCC recurrence with the best cutoff value of > 17.8 ng/ml with a sensitivity of 82% and specificity of 70%. Post-transplantation CRP can predict HCC recurrence with the best cutoff value of > 0.85 (mg/dl) with a sensitivity of 73% and specificity of 71%. Other inflammatory markers NLR and PLR were not significant in predicting HCC recurrence. Moreover, HCC recurrence significantly affects the outcome of patients undergoing LT (p value < 0.001) with a worse prognosis.

Conclusion

Our results showed additional benefits of inflammatory markers as CRP to standard parameters in predicting HCC recurrence to refine recipient selection and achieve better survival outcomes post-LT.

New Insights in Mechanisms and Therapeutics for Short- and Long-Term Impacts of Hepatic Ischemia Reperfusion Injury Post Liver Transplantation

Liver transplantation has been identified as the most effective treatment for patients with end-stage liver diseases. However, hepatic ischemia reperfusion injury (IRI) is associated with poor graft function and poses a risk of adverse clinical outcomes post transplantation. Cell death, including apoptosis, necrosis, ferroptosis and pyroptosis, is induced during the acute phase of liver IRI. The release of danger-associated molecular patterns (DAPMs) and mitochondrial dysfunction resulting from the disturbance of metabolic homeostasis initiates graft inflammation. The inflammation in the short term exacerbates hepatic damage, leading to graft dysfunction and a higher incidence of acute rejection. The subsequent changes in the graft immune environment due to hepatic IRI may result in chronic rejection, cancer recurrence and fibrogenesis in the long term. In this review, we mainly focus on new mechanisms of inflammation initiated by immune activation related to metabolic alteration in the short term during liver IRI. The latest mechanisms of cancer recurrence and fibrogenesis due to the long-term impact of inflammation in hepatic IRI is also discussed. Furthermore, the development of therapeutic strategies, including ischemia preconditioning, pharmacological inhibitors and machine perfusion, for both attenuating acute inflammatory injury and preventing late-phase disease recurrence, will be summarized in the context of clinical, translational and basic research.

Lower mean platelet volume is a risk indicator of hepatocellular carcinoma recurrence following liver transplantation

BACKGROUND

Lower mean platelet volume (MPV) is an indicator of platelet activity in the setting of tumor development. This study was to assess the relationship between preoperative MPV and survival outcomes of patients with hepatocellular carcinoma (HCC) following liver transplantation (LT).

METHODS

The demographic and clinical characteristics of 304 HCC patients following LT were retrieved from an LT database. All the patients were divided into the normal and lower MPV groups according to the median MPV. The factors were first analyzed using a Kaplan-Meier survival analysis, then the factors with P < 0.10 were selected for multivariate Cox regression analysis and were used to define the independent risk factors for poor prognosis.

RESULTS

The 1-, 3-, and 5-year tumor free survival was 95.34%, 74.67% and 69.29% in the normal MPV group, respectively, and 95.40%, 59.97% and 42.94% in the lower MPV group, respectively (P < 0.01). No significant difference was observed in post-LT complications between the normal and lower MPV groups. Portal vein tumor thrombosis (PVTT) [hazard ratio (HR = 2.24; 95% confidence interval: 1.46-3.43; P < 0.01) and lower MPV (HR = 1.58; 95% confidence interval: 1.05-2.36; P = 0.03) were identified as independent prognostic risk factors for recipient survival.

CONCLUSION

Preoperative lower MPV is a risk indicator of HCC patients survival outcomes after LT.

Serological Risk Index Based on Alpha-Fetoprotein and C-Reactive Protein to Indicate Futile Liver Transplantation Among Patients with Advanced Hepatocellular Carcinoma

BACKGROUND

The aim of this study was to establish a preoperatively available serological risk index using alpha-fetoprotein (AFP) and C-reactive protein (CRP) for predicting oncologically futile liver transplantation (LT) in hepatocellular carcinoma (HCC) patients.

METHODS

A total of 119 liver transplant patients with HCC were retrospectively analyzed. The prognostic impact of clinical and histopathologic factors including pre-LT serum AFP and CRP values was determined.

RESULTS

Apart from microvascular tumor invasion (MVI; odds ratio [OR] 15.77), pretransplant serum levels of AFP > 100 ng/ml (OR 13.31) and CRP > 0.8 mg/dl (OR 13.97) were identified as independent predictors of HCC recurrence. The cumulative risk of HCC relapse at 5 years post-LT was 2.3% in low serological tumor activity (STA) index (AFP ≤ 100 ng/ml + CRP ≤ 0.8 mg/dl), 17.1% in intermediate STA (AFP ≤ 100 ng/ml or CRP ≤ 0.8 mg/dl), and 91.6% in high STA index (AFP > 100 ng/ml + CRP > 0.8 mg/dl; p < 0.001), respectively. High STA index was identified as most powerful pre-LT available predictor of MVI (OR 15.31) and posttransplant HCC recurrence (OR 54.44). Five-year recurrence-free survival rate in Milan Out patients with high STA was 0%, compared to 91.7% and 83.6% in those with low or intermediate STA index (p < 0.001), respectively.

CONCLUSION

Our proposed serological risk index based on pretransplant serum AFP and CRP values is able to predict oncologically futile LT among advanced HCC patients.

Proteasome Activity and C-Reactive Protein Concentration in the Course of Inflammatory Reaction in Relation to the Type of Abdominal Operation and the Surgical Technique Used

Surgical tissue damage and the accompanying inflammatory response lead to proteasome activation, initiation of damaged protein degradation, and induction of acute-phase inflammatory response. The aim of this study was to investigate the rate of change in proteasome chymotrypsin-like (ChT-L) activity and C-reactive protein concentration depending on the degree of tissue damage and their correlation with prealbumin concentrations in children before and after abdominal surgery. This experimental study included children who underwent abdominal surgery between 2015 and 2017. Plasma prealbumin concentrations and C-reactive protein levels (CRP) were determined by standard biochemical laboratory procedures. Proteasome activity was assessed using a Suc-Leu-Leu-Val-Tyr-AMC peptide substrate. Elevation of plasma proteasome activity was noted in children after laparoscopic and open abdominal surgeries. However, 20S proteasome activity in children undergoing conventional open surgery was significantly higher (P < 0.05) than in patients subjected to laparoscopy. At the same time, an increase in the CRP level was observed. However, there was no correlation between C-reactive protein concentrations and the type of abdominal surgery while there was a correlation observed in the case of proteasomes. Proteasome activity correlates with the degree of surgical tissue damage and prealbumin concentrations. More invasive surgery leads to a stronger activation of the proteasome involved in removing proteins that were damaged due to the surgical procedure. Proteasomes are more specific markers because there is a correlation between proteasome activity and the type of abdominal surgery in contrast to C-reactive protein concentrations which are not different in response to surgery performed in regard to ovarian cysts or cholelithiasis.

Role of inflammatory markers as hepatocellular cancer selection tool in the setting of liver transplantation

Since the advent of the Milan criteria in 1996 and its widespread adoption for selection of patients with hepatocellular carcinoma (HCC) who would benefit from transplant, there has been an extensive hunt for the ideal clinical biomarker to predict HCC recurrence. This is because Milan lack does not include tumor biology indices and recurrence rates remain in the 15-20% range worldwide. While a 'silver-bullet' biomarker has not been found, several useful inflammatory markers have been identified and used in scoring systems that supersede Milan in their ability to predict HCC recurrence post liver transplantation (LT). In this review, we aim to summarize the role of inflammatory markers paly in the selection of HCC patients awaiting LT.

Prognostic value of red blood cell distribution width in hepatocellular carcinoma

Red blood cell distribution width (RDW) is a simple, inexpensive, routinely measured and automatically reported blood test parameter, which reflects the degree of anisocytosis of red blood cells in peripheral blood. RDW was found to be associated with and retain clinical significance for assessing disease severity and outcomes in a number of hematological and solid malignancies. Motley of interacting clinical and biochemical factors have an impact on the red cell population biology. Malignancies per se can act as a causative factor, or anisocytosis may develop as a result of chronic inflammation. RDW has also been shown to be affected by nutritional status, which is typically deranged in malignancies. RDW is shown to be a clinically useful marker of disease severity and level of fibrosis in liver cirrhosis of various causes such as hepatitis B, hepatitis C and non-alcoholic fatty liver disease. Whether liver cirrhosis patients with higher RDW are at increased risk of hepatocellular cancer is yet to be determined, but several lines of evidence confirm that RDW has clinical significance in hepatocellular carcinoma (HCC). In this review, we specifically discuss the current literature about the association between RDW and HCC. The available evidences were summarized and the potential underlying mechanisms were analyzed.

Incidence and risk factors of hepatocellular carcinoma after orthotopic liver transplantation

BACKGROUND

The incidence of hepatocellular carcinoma has doubled over the past 2 decades, becoming the fifth most common cancer worldwide. Orthotopic liver transplant is the gold standard treatment for those with hepatocellular carcinoma meeting eligibility criteria, although recurrence rates of hepatocellular carcinoma after orthotopic liver transplant still remain an understudied obstacle.

METHODS

We performed a single-center, retrospective, longitudinal study with the aim of determining the predominant baseline and follow-up variables associated with hepatocellular carcinoma recurrence. We gathered pre- and post-transplant data and conducted univariate and multivariate analysis to assess variables predicting hepatocellular carcinoma recurrence after orthotopic liver transplant.

RESULTS

Between 2003 and 2015, 141 patients underwent orthotopic liver transplant for hepatocellular carcinoma. We identified 9 (6.4%) cases of documented hepatocellular carcinoma recurrence. Univariate analysis indicated that the difference in serum alpha-fetoprotein levels (most recent prior to transplant subtracted from maximum level) was lower in the hepatocellular carcinoma recurrence group (median 3 ng/mL vs 0 ng/mL, P = .052) as well as the pretransplant serum cholesterol level (median 158 mg/dL vs 113 mg/dL, P = .019) and days between hepatocellular carcinoma neoadjuvant treatment initiation and transplantation (median 122 vs 0, P = .045). Multivariate analysis revealed that a low pretransplant serum cholesterol level (<100 mg/dL) was independently associated with hepatocellular carcinoma recurrence (hazard ratio 11.0, P = .004).

CONCLUSION

The risk of hepatocellular carcinoma recurrence after orthotopic liver transplant was low, at 6.4%, in this cohort. Low pretransplant serum cholesterol was the strongest predictor of recurrence and may help clinicians risk stratify patients for appropriate post-transplant monitoring and follow-up.