Growth rate of early-stage hepatocellular carcinoma in patients with chronic liver disease

Tumor Growth in Overdrive: Detailing an Aggressive Course of Hepatocellular Carcinoma

Hepatocellular carcinoma ranks as the third leading cause of cancer-related mortality globally. We present a case of a rapidly progressive hepatocellular carcinoma in an 81-year-old female with metabolic abnormalities. The patient initially presented with non-specific signs and symptoms and was managed for sepsis of suspected urinary source. Unresolving laboratory markers led to repeat abdominal imaging demonstrating new hepatic lesions within six days. Biopsy confirmed moderately differentiated hepatocellular carcinoma. The patient received conservative inpatient treatment with recommendation for nutritional and performance status optimization prior to oncologic therapies, however continued to decline and passed away three months later.

Quantifying the natural growth rate of hepatocellular carcinoma: A real-world retrospective study in southwestern China

BACKGROUND

In recent years, approximately half of the newly diagnosed cases and mortalities attributed to hepatocellular carcinoma (HCC) have been reported in China. Despite the high incidence of HCC, there remains a paucity of data regarding the natural growth pattern and the determination of optimal surveillance intervals specific to the Chinese population.

AIM

To quantify the natural tumor growth pattern of HCC in regional China.

METHODS

A retrospective analysis was performed on patients from a single institution in Southwest China who had undergone two or more serial dynamic computed tomography or magnetic resonance imaging scans between 2014 and 2020, without having received any anti-cancer therapy. Tumor growth was assessed using tumor volume doubling time (TVDT) and tumor growth rate (TGR), with volumes measured manually by experienced radiologists. Simple univariate linear regression and descriptive analysis were applied to explore associations between growth rates and clinical factors.

RESULTS

This study identifies the median TVDT for HCC as 163.4 d, interquartile range (IQR) 72.1 to 302.3 d, with a daily TGR of 0.42% (IQR 0.206%-0.97%). HCC growth patterns reveal that about one-third of tumors grow indolently with TVDT exceeding 270 d, another one-third of tumors exhibit rapid growth with TVDT under 90 d, and the remaining tumors show intermediate growth rates, with TVDT ranging between 3 to 9 months.

CONCLUSION

The identified TGRs support biannual surveillance and follow-up for HCC patients in certain regions of China. Given the observed heterogeneity in HCC growth, further investigation is warranted.

Radiographic and serologic response in patients with unresectable hepatocellular carcinoma receiving systemic antineoplastic treatments: A trial-level analysis

BACKGROUND

In a disease like unresectable hepatocellular carcinoma, overall survival is an inadequate outcome measure for evaluating the effectiveness of treatments given the high risk of death from liver failure. There is an unmet need for reliable alternative end points for clinical trials and daily clinical practice. To evaluate treatment response in patients with unresectable or metastatic hepatocellular carcinoma (mHCC), imaging-related end points are often used, whereas serologic end points have been developed for patients with serum alpha-fetoprotein levels >20 ng/mL. The objective of this study was to evaluate clinical trials that report concomitant assessment of radiographic and serologic response in patients with mHCC.

METHODS

After a systematic review, studies that evaluated response according to radiographic and serologic criteria were selected. A correlation between progression-free survival (PFS) and overall survival (OS) was performed, and a linear regression of each response-related outcome measure with OS was reported. Finally, the effect of eight baseline variables on OS and response-related measures was evaluated.

RESULTS

Twenty-six studies were included, including 16 first-line studies and 10 second-line studies. PFS and response rates demonstrated a significant relationship with OS, whereas disease control rates did not. The responses were correlated with OS, particularly in the first-line setting, after targeted therapy, and whenever assessment was early. Among the baseline variables, only performance status had a prognostic role, whereas hepatitis B virus-related liver disease was associated with higher radiographic response rates.

CONCLUSIONS

PFS and radiographic and serologic response rates appear to be reliable intermediate end points in patients with mHCC who are undergoing systemic antineoplastic therapy. However, the serologic response is available earlier.

The impact of waiting time and delayed treatment on the outcomes of patients with hepatocellular carcinoma: A systematic review and meta-analysis

Hepatocellular carcinoma (HCC) is the sixth most diagnosed cancer worldwide. Healthcare resource constraints may predispose treatment delays. We aim to review existing literature on whether delayed treatment results in worse outcomes in HCC. PubMed, Embase, The Cochrane Library, and Scopus were systematically searched from inception till December 2022. Primary outcomes were overall survival (OS) and disease-free survival (DFS). Secondary outcomes included post-treatment mortality, readmission rates, and complications. Fourteen studies with a total of 135,389 patients (delayed n = 25,516, no delay n = 109,873) were included. Age, incidence of male patients, Child-Pugh B cirrhosis, and Barcelona Clinic Liver Cancer Stage 0/A HCC were comparable between delayed and no delay groups. Tumor size was significantly smaller in delayed versus no delay group (mean difference, -0.70 cm; 95% confidence interval [CI]: -1.14, 0.26; p = 0.002). More patients received radiofrequency ablation in delayed versus no delay group (OR, 1.22; 95% CI: 1.16, 1.27; p < 0.0001). OS was comparable between delayed and no delay in HCC treatment (hazard ratio [HR], 1.13; 95% CI: 0.99, 1.29; p = 0.07). Comparable DFS between delayed and no delay groups (HR, 0.99; 95% CI: 0.75, 1.30; p = 0.95) was observed. Subgroup analysis of studies that defined treatment delay as > 90 days showed comparable OS in the delayed group (HR, 1.04; 95% CI: 0.93, 1.16; p = 0.51). OS and DFS for delayed treatment were non-inferior compared to no delay, but might be due to better tumor biology/smaller tumor size in the delayed group.

Hepatocellular Carcinoma Incidence Threshold for Surveillance in Virologically Cured Hepatitis C Individuals

BACKGROUND & AIMS

Guidelines recommend biannual surveillance for hepatocellular carcinoma (HCC) in hepatitis C individuals with cirrhosis if the HCC incidence rate is above 1.5 per 100 person-years (PY). However, the incidence threshold for surveillance in individuals who achieve a virologic cure is unknown. We estimated the HCC incidence rate above which routine HCC surveillance is cost-effective in this growing population of virologically cured hepatitis C individuals with cirrhosis or advanced fibrosis.

METHODS

We developed a Markov-based microsimulation model of the natural history of HCC in individuals with hepatitis C who achieved virologic cure with oral direct-acting antivirals. We used published data on the natural history of hepatitis C, competing risk post virologic cure, HCC tumor progression, real-world HCC surveillance adherence, contemporary HCC treatment options and associated costs, and utilities of different health states. We estimated the HCC incidence above which biannual HCC surveillance using ultrasound and alpha-fetoprotein would be cost-effective.

RESULTS

In virologically cured hepatitis C individuals with cirrhosis or advanced fibrosis, HCC surveillance is cost-effective if HCC incidence exceeds 0.7 per 100 PY using $100,000 per quality-adjusted life year willingness-to-pay. At this HCC incidence, routine HCC surveillance would result in 2650 and 5700 additional life years per 100,000 cirrhosis and advanced fibrosis persons, respectively, compared with no surveillance. At $150,000 willingness-to-pay, surveillance is cost-effective if HCC incidence exceeds 0.4 per 100 PY. Sensitivity analysis showed that the threshold mostly remained below 1.5 per 100 PY.

CONCLUSIONS

The contemporary HCC incidence threshold is much lower than the previous 1.5% incidence value used to guide HCC surveillance decisions. Updating clinical guidelines could improve the early diagnosis of HCC.

Based on Gadolinium Ethoxybenzyl DTPA-Enhanced MRI: Diagnostic Performance of the Category-Modified LR-5 Criteria in Patients At Risk for Hepatocellular Carcinoma

Introduction: We aimed to modify the LR-5 strategy to improve the diagnostic sensitivity for hepatocellular carcinoma (HCC) in high-risk patients while maintaining specificity. Methods: This study retrospectively analyzed 412 patients with 445 liver observations who underwent preoperative gadolinium ethoxybenzyl DTPA (GD-EOB-DTPA)-enhanced MRI followed by surgical procedures or biopsies. All observations were classified according to LI-RADS v2018, and the classifications were adjusted by modifying major features (MF)(substituting threshold growth with a more HCC-specific ancillary features (AF): presence of blood products within the mass, arterial phase hyperenhancement (APHE) was interpreted with hypointensity on precontrast imaging- isointensity in arterial phase (AP) and extending washout to transitional phase (TP)(2 min)). The specificity, sensitivity, and positive predictive value (PPV) were assessed to compare LR-5 (definitely HCC) diagnostic efficacy between LI-RADS version 2018 and modified LI-RADS. Results: Apart from nonenhancing "capsule", the interreader agreement of MFs and HCC-specific AFs between the two readers reached substantial or excellent ranges (κ values ranging from 0.631 to 0.911). According to LI-5 v2018, the specificity, sensitivity and PPV of HCC were 90.74%, 82.35%, and 98.17%, respectively. Based on a more HCC-specific AF, signal intensity in AP and TP (2 min), the sensitivity of the three modified strategies were 86.19%, 93.09%, 96.67% (P < .05)), while maintaining high specificity and PPV rates at 88.89% and 98.25% (P > .05) Conclusion: Further investigation into the efficacy of threshold growth as a MF is warranted. By utilizing GD-EOB-DTPA-enhanced MRI, enhancing the sensitivity of the modified LR-5 category may be achieved without compromising specificity and PPV in diagnosing HCC among high-risk patients.

Threshold growth has a limited role in differentiating hepatocellular carcinoma from other focal hepatic lesions

BACKGROUND AND OBJECTIVE: The role of threshold growth, as one of the major features (MFs) of hepatocellular carcinoma (HCC) in the Liver Imaging Reporting and Data System (LI-RADS) is inconsistent. This study evaluated the LI-RADS diagnostic performance for HCC when threshold growth was removed or replaced by independently significant ancillary features (AFs). MATERIALS AND METHODS: This retrospective institutional review board-approved study included patients with a high HCC risk who underwent gadoxetic acid-enhanced MRIs. The MRI findings were consistent with pathologically proven focal hepatic observations. The pathological results were used as the gold standard reference. The sizes of the lesions with and without threshold growth were compared. Univariate and multivariate logistic regression analyses were used to confirm the independently significant AFs of HCC. In addition to the classification criteria of LI-RADS version 2018 (LI-RADS v2018), the lesions were also reclassified according to the following two schemes: scheme A, using all MFs except threshold growth, with threshold growth feature treated as an AF favouring malignancy; and scheme B, replacing the threshold growth feature with independently significant AFs and treated them as new MFs. The diagnostic performance of the above two LI-RADS schemes for HCC was calculated and compared with that of LI-RADS v2018. RESULTS: A total of 379 patients and 426 observations were included. Threshold growth was not an independent significant MF for HCC diagnosis [odds ratio (OR), 1.0; 95% confidence interval (CI), 0.6-1.8; p = 0.927]. For all three groups of observations (HCCs, non-HCC malignancies, and benign lesions), the mean size with threshold growth was smaller than that without threshold growth (all p < 0.05). The nodule-in-nodule feature was an independent significant AF (OR, 9.8; 95% CI, 1.2-79.3; p = 0.032) and was used to replace threshold growth as a new MF in scheme B. The sensitivities of schemes A and B were 74.0% and 75.6%, respectively. The specificities of schemes A and B were the same (88.6%). None of the diagnostic performance metrics for HCC (sensitivity, specificity, accuracy) of either scheme A or B was significantly different from those of LI-RADS v2018 (all p > 0.05). CONCLUSION: Threshold growth is not an independently significant MF for HCC diagnosis. The diagnostic performance of LI-RADS for HCC is not affected regardless of whether threshold growth is removed from the list of MFs or replaced with an independently significant and more HCC-specific AF, which is the nodule-in-nodule feature.

Performance and effectiveness of hepatocellular carcinoma screening in individuals with HBsAg seropositivity in China: a multicenter prospective study

Current guidelines recommend hepatocellular carcinoma (HCC) surveillance for at-risk individuals, including individuals with hepatitis B virus infection. However, the performance and survival benefits of annual screening have not been evaluated through multicenter prospective studies in a Chinese population. Between 2017 and 2021, we included 14,426 participants with hepatitis B surface antigen seropositivity in an annual HCC screening study in China using a multicenter prospective design with ultrasonography and serum alpha-fetoprotein. After four rounds of screening and follow-up, the adjusted hazard ratios of death after correction for lead-time and length-time biases for screen-detected cancers at the prevalent and incident rounds were 0.74 (95% confidence interval = 0.60-0.91) and 0.52 (95% confidence interval = 0.40-0.68), respectively. A meta-analysis demonstrated that HCC screening was associated with improved survival after adjusting for lead-time bias. Our findings highlight the 'real-world' feasibility and effectiveness of annual HCC screening in community settings for the early detection of HCC and to improve survival.

Physics-based tissue simulator to model multicellular systems: A study of liver regeneration and hepatocellular carcinoma recurrence

We present a multiagent-based model that captures the interactions between different types of cells with their microenvironment, and enables the analysis of the emergent global behavior during tissue regeneration and tumor development. Using this model, we are able to reproduce the temporal dynamics of regular healthy cells and cancer cells, as well as the evolution of their three-dimensional spatial distributions. By tuning the system with the characteristics of the individual patients, our model reproduces a variety of spatial patterns of tissue regeneration and tumor growth, resembling those found in clinical imaging or biopsies. In order to calibrate and validate our model we study the process of liver regeneration after surgical hepatectomy in different degrees. In the clinical context, our model is able to predict the recurrence of a hepatocellular carcinoma after a 70% partial hepatectomy. The outcomes of our simulations are in agreement with experimental and clinical observations. By fitting the model parameters to specific patient factors, it might well become a useful platform for hypotheses testing in treatments protocols.

Current status of ultrasonography in national cancer surveillance program for hepatocellular carcinoma in South Korea: a large-scale multicenter study

Background/Aim

Abdominal ultrasonography (USG) is recommended as a surveillance test for high-risk groups for hepatocellular carcinoma (HCC). This study aimed to analyze the current status of the national cancer surveillance program for HCC in South Korea and investigate the effects of patient-, physician-, and machine-related factors on HCC detection sensitivity.

Methods

This multicenter retrospective cohort study collected surveillance USG data from the high-risk group for HCC (liver cirrhosis or chronic hepatitis B or C >40 years of age) at eight South Korean tertiary hospitals in 2017.

Results

In 2017, 45 experienced hepatologists or radiologists performed 8,512 USG examinations. The physicians had a mean 15.0±8.3 years of experience; more hepatologists (61.4%) than radiologists (38.6%) participated. Each USG scan took a mean 12.2±3.4 minutes. The HCC detection rate by surveillance USG was 0.3% (n=23). Over 27 months of follow-up, an additional 135 patients (0.7%) developed new HCC. The patients were classified into three groups based on timing of HCC diagnosis since the 1st surveillance USG, and no significant intergroup difference in HCC characteristics was noted. HCC detection was significantly associated with patient-related factors, such as old age and advanced fibrosis, but not with physician- or machine-related factors.

Conclusions

This is the first study of the current status of USG as a surveillance method for HCC at tertiary hospitals in South Korea. It is necessary to develop quality indicators and quality assessment procedures for USG to improve the detection rate of HCC.

Impact of SARS-CoV-2 Pandemic on the Management of Patients with Hepatocellular Carcinoma

Worldwide, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) significantly increases mortality and morbidity. The Coronavirus Disease 2019 (COVID-19) outbreak has had a considerable impact on healthcare systems all around the world, having a significant effect on planned patient activity and established care pathways, in order to meet the difficult task of the global pandemic. Patients with hepatocellular carcinoma (HCC) are considered a particularly susceptible population and conceivably at increased risk for severe COVID-19 because of two combined risk factors: chronic advanced liver disease and HCC itself. In these challenging times, it is mandatory to reshape clinical practice in a prompt way to preserve the highest standards of patient care and safety. However, due to the stay-at-home measures instituted to stop the spread of COVID-19, HCC surveillance has incurred a dramatic drop, and care for HCC patients has been rearranged by refining the algorithm for HCC treatment to the COVID-19 pandemic, permitting these patients to be safely managed by identifying those most at risk of neoplastic disease progression.

The impact of the COVID-19 pandemic on patients with chronic liver disease: Results from the Global Liver Registry

Patients with preexisting chronic liver disease (CLD) may experience a substantial burden from both coronavirus 2019 (COVID-19) infection and pandemic-related life disruption. We assessed the impact of the COVID-19 pandemic on patients with CLD. Patients enrolled in our Global Liver Registry were invited to complete a COVID-19 survey. As of June 2021, 2500 patients (mean age ± SD, 49 ± 13 years; 53% men) from seven countries completed the survey. Of all survey completers, 9.3% had COVID-19. Of these patients, 19% were hospitalized, 13% needed oxygen support, but none required mechanical ventilation. Of all patients including those not infected with COVID-19, 11.3% reported that the pandemic had an impact on their liver disease, with 73% of those reporting delays in follow-up care. The Life Disruption Event Perception questionnaire confirmed worsening in at least one area (food/nutrition, exercise, social life, vocation/education, financial situation, housing, or health care) in 81% and 69% of patients with and without a history of COVID-19, respectively (p = 0.0001). On a self-assessed Likert health score scale (range, 1-10; 10 indicates perfect health), patients with a COVID-19 history scored lower (mean ± SD, 6.7 ± 2.2 vs. 7.4 ± 2.2, respectively; p < 0.0001) despite reporting similar health scores if there was no pandemic (mean ± SD, 8.5 ± 1.4 vs. 8.4 ± 1.6, respectively; p = 0.59). After adjustment for country of enrollment, liver disease etiology and severity, age, sex, body mass index, diabetes, and history of psychiatric comorbidities, COVID-19 was found to be independently associated with lower self-assessed health scores (beta = -0.71 ± 0.14; p < 0.0001). The COVID-19 pandemic resulted in a substantial burden on the daily life of patients with CLD.

Focal liver lesions in cirrhosis: Role of contrast-enhanced ultrasonography

Contrast-enhanced ultrasound (CEUS) represents a great innovation for the evaluation of focal liver lesions (FLLs). The main advantage of CEUS is the real-time imaging examination and the very low toxicity in patients with renal failure. Liver cirrhosis has been recognized as a major risk factor for the onset of hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). HCC in liver cirrhosis develops as the last step of a complex that leads to the gradual transformation from regenerative nodule through dysplastic nodule to HCC. In patients with liver cirrhosis, a surveillance program is recommended consisting of ultrasound (US) for detecting small focal lesions. A wide spectrum of benign and malignant lesions other than HCC may be found in the cirrhotic liver and their differentiation is important to avoid errors in staging diseases that may preclude potentially curative therapies. Several published studies have explored the value of CEUS in liver cirrhosis and they have been shown to have excellent diagnostic and prognostic performances for the evaluation of non-invasive and efficient diagnosis of FLLs in patients at high risk for liver malignancies. The purpose of this article is to describe and discuss CEUS imaging findings of FLLs including HCC and ICC, all of which occur in cirrhotic livers with varying prevalence.

Distinguishing excess mutations and increased cell death based on variant allele frequencies

Tumors often harbor orders of magnitude more mutations than healthy tissues. The increased number of mutations may be due to an elevated mutation rate or frequent cell death and correspondingly rapid cell turnover, or a combination of the two. It is difficult to disentangle these two mechanisms based on widely available bulk sequencing data, where sequences from individual cells are intermixed and, thus, the cell lineage tree of the tumor cannot be resolved. Here we present a method that can simultaneously estimate the cell turnover rate and the rate of mutations from bulk sequencing data. Our method works by simulating tumor growth and finding the parameters with which the observed data can be reproduced with maximum likelihood. Applying this method to a real tumor sample, we find that both the mutation rate and the frequency of death may be high.

Tumors frequently harbor an elevated number of mutations, compared to healthy tissue. These extra mutations may be generated either by an increased mutation rate or the presence of cell death resulting in increased cellular turnover and additional cell divisions for tumor growth. Separating the effects of these two factors is a nontrivial problem. Here we present a method which can simultaneously estimate cell turnover rate and genomic mutation rate from bulk sequencing data. Our method is based on the estimation of the parameters of a generative model of tumor growth and mutations. Applying our method to a human hepatocellular carcinoma sample reveals an elevated per cell division mutation rate and high cell turnover.

Chinese expert recommendations on management of hepatocellular carcinoma during COVID-19 pandemic: a nationwide multicenter survey

BACKGROUND

This study aimed to investigate the work status of clinicians in China and their management strategy alteration for patients with hepatocellular carcinoma (HCC) during the COVID-19 pandemic.

METHODS

A nationwide online questionnaire survey was conducted in 42 class-A tertiary hospitals across China. Experienced clinicians of HCC-related specialties responded with their work status and management suggestions for HCC patients during the pandemic.

RESULTS

716 doctors responded effectively with a response rate of 60.1%, and 664 were included in the final analysis. Overall, 51.4% (341/664) of clinicians reported more than a 60% reduction of the regular workload and surgeons declared the highest proportion of workload reduction. 92.5% (614/664) of the respondents have been using online medical consultation to substitute for the "face-to-face" visits. Adaptive adjustment for the treatment strategy for HCC was made, including the recommendations of noninvasive and minimally invasive treatments such as transcatheter arterial chemoembolization for early and intermediate stage. Targeted therapy has been the mainstay for advanced stage and also as a bridge therapy for resectable HCC.

DISCUSSION

During the COVID-19 pandemic, online medical consultation is recommended to avoid social contact. Targeted therapy as a bridge therapy is recommended for resectable HCC considering the possibility of delayed surgery.

Nonalcoholic fatty liver disease-related hepatocellular carcinoma growth rates and their clinical outcomes

Aim:

Nonalcoholic fatty liver disease (NAFLD)-associated hepatocellular carcinoma (HCC) is projected to become the leading indication for liver transplantation. Previous studies indicate that tumor growth rates (TGR) may predict survival and were helpful in determining HCC surveillance intervals. Therefore, we aimed to determine its usefulness in predicting clinical outcomes and treatments.

Methods:

We conducted a retrospective study of hepatitis B, C and NAFLD-HCC cases. TGR was measured using 2-consecutive pre-treatment contrast-enhanced imaging studies ≥ 25 days apart. A multivariate regression model was used to determine predictors of TGR. In addition, the Cox regression model was used to evaluate the relationship between TGR and overall survival.

Results:

From 2000–2019, the study cohort comprised 38, 60, and 47 HBV, HCV, and NAFLD patients, respectively, with TGRs. NAFLD-HCC tumor size was inversely correlated to the extent of liver disease as measured by Child-Pugh score (7.2 cm in non-cirrhosis; 3.7 cm, 2.6 cm, and 2.1 cm in Child A, B, and C, respectively; P < 0.001). After adjusting for baseline characteristics, the TGR per month was fastest in HBV (9.4%, 95%CI: 6.3%-12.5%) compared to HCV (4.9%, 95%CI: 2.8%-7%) and NAFLD patients (3.6%, 95%CI: 1.6%-6.7%). Predictors of TGR included elevated AFP, low albumin, and smaller tumor size. Fast TGR in viral etiologies had higher mortality [adj. hazard ratio (HR) = 2.6, 95%CI: 1.2–5.7, P = 0.02] than slow TGRs, independent of treatments. Fast TGR in NAFLD had a trend towards higher mortality (HR = 3.6, 95%CI: 0.95–13.3, P = 0.059).

Conclusion:

NAFLD-HCC patients have more indolent growths than viral-related HCC TGRs. The addition of TGR as a biomarker may assist in stratifying treatment options.

Tumor Lysis Syndrome in Patients With Hepatocellular Carcinoma: A Systematic Review of Published Case Reports

Tumor lysis syndrome (TLS) is a life-threatening oncologic emergency. It is characterized by massive tumor cell death leading to metabolic derangements and multiple organ failure. It is a rare complication of hepatocellular carcinoma (HCC) with only a few cases have been reported in the literature to date.

We collected and summarized published case reports of tumor lysis syndrome in patients with HCC. We also reported one additional case who developed TLS after sorafenib therapy and wrote a clinical vignette. A comprehensive and current search for relevant articles was conducted in Medline and EMbase through May 2018. A systematic review was performed following the guideline of Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). 

A total of 28 cases of TLS associated with HCC were enrolled in our review. The median age of included cases was 55.5 years with a male to female ratio of 25:3. The two most common attributed factors of TLS were transcatheter arterial chemoembolization (TACE) (12 cases, 42.9 %) and sorafenib (nine cases, 32.1%). Among enrolled cases, the diameter of the largest tumor was 12 cm. Regarding Barcelona Clinic Liver Cancer (BCLC) staging, seven cases were at least stage A (22.6%), 11 cases were at least stage B (35.5%), and 10 cases were at least stage C (32.3%). The median time of onset of TLS was three days. As for uric acid-lowering agents, nine cases (32.1%) used allopurinol and four cases (14.3%) used rasburicase. Ten cases (35.7%) did not specify the medication prescribed. The overall mortality rate of this cohort was 67.9%.

Compared with patients developing TLS following TACE, patients who had TLS following sorafenib therapy had a later onset of TLS (two days versus seven days, p < 0.001) and a more advanced stage of HCC (p = 0.002). There was a trend toward increased mortality of patients in the sorafenib group in comparison with those in the TACE group (77.8% versus 41.7%, p = 0.18).

The results of this current review suggest that TLS rarely occurs in HCC but carries significantly higher mortality compared to TLS occurring in hematologic malignancies. It may occur shortly after TACE or with a delayed onset following sorafenib therapy. Considering the kaleidoscope of novel therapies and diverse pathogenesis of HCC, it is crucial for clinicians to recognize the clinicolaboratory derangements suggestive of TLS and initiate appropriate management. The present review highlights the need for clinicians to consider TLS within differentials when caring for patients with HCC.

Progression Rates of LR-2 and LR-3 Observations on MRI to Higher LI-RADS Categories in Patients at High Risk for Hepatocellular Carcinoma: A Retrospective Study

Background: Reported rates of hepatocellular carcinoma (HCC) for LR-2 and LR-3 observations are generally greater than what may be expected based on clinical experience, possibly reflecting some studies' requirement for pathologic reference. Objective: To determine progression rates to higher LI-RADS categories of LR-2 and LR-3 observations in patients at high risk for HCC. Methods: This retrospective study included 91 patients (mean age 62 years; 64 men, 27 women) at high risk for HCC with clinically reported LR-2 (n=55) or LR-3 (n=36) observations on MRI and who also underwent follow-up CT or MRI after at least 12 months. A study coordinator annotated the location of a single LR-2 or LR-3 observation per patient, based on the clinical reports. Using LI-RADS v2018 criteria, two radiologists independently assigned LI-RADS categories on the follow-up examinations. Progression rates from LR-2 or LR-3 to higher categories were determined. A post hoc consensus review was performed of observations that progressed to LR-4 or LR-5. Subgroup analyses were performed with respect to presence or prior HCC (n=34) or a separate baseline LR-5 observation (n=12). Results: For LR-2 observations, progression to LR-4 was 0.0% (95% CI 0.0%-6.7%) and LR-5 was 3.6% (95% CI 0.4%-13.1%) for both readers. For LR-3 observations, progression to LR-4 was 22.2% (95% CI 9.6%-43.8%) and LR-5 was 11.1% (95% CI 3.0%-28.4%) for both readers. Fourteen observations progressed to LR-4 or LR-5 for both readers (post hoc analysis: no LR-2 to LR-4; two LR-2 to LR-5; eight LR-3 to LR-4; four LR-3 to LR-5). Progression rate from LR-3 to LR-5 was higher (p<.001) among patients with versus without a separate baseline LR-5 observation (100.0% vs 3.0%, respectively) for both readers; progression rate from LR-2 to LR-5 was not associated with a separate baseline LR-5 observation for either reader (p=.30). Progression rates were not different (p>.99) between patients with versus without prior HCC. Conclusion: Based on progression to LR-4 or LR-5, LR-2 and LR-3 observations showed lower progression rates than reported in studies incorporating pathology in determining progression. Clinical Impact: The findings refine understanding of the clinical significance of LR-2 and LR-3 observations.

SBRT for HCC: Overview of technique and treatment response assessment

Stereotactic body radiation therapy (SBRT) is an emerging locoregional treatment (LRT) modality used in the management of patients with hepatocellular carcinoma (HCC). The decision to treat HCC with LRT is evaluated in a multidisciplinary setting, and the specific LRT chosen depends on the treatment intent, such as bridge-to-transplant, down-staging to transplant, definitive/curative treatment, and/or palliation, as well as underlying patient clinical factors. Accurate assessment of treatment response is necessary in order to guide clinical management in these patients. Patients who undergo LRT need continuous imaging evaluation to assess treatment response and to evaluate for recurrence. Thus, an accurate understanding of expected post-SBRT imaging findings is critical to avoid misinterpreting normal post-treatment changes as local progression or viable tumor. SBRT-treated HCC demonstrates unique imaging findings that differ from HCC treated with other forms of LRT. In particular, SBRT-treated HCC can demonstrate persistent APHE and washout on short-term follow-up imaging. This brief review summarizes current evidence for the use of SBRT for HCC, including patient population, SBRT technique and procedure, tumor response assessment on contrast-enhanced cross-sectional imaging with expected findings, and pitfalls in treatment response evaluation.

Should Threshold Growth Be Considered a Major Feature in the Diagnosis of Hepatocellular Carcinoma Using LI-RADS?

OBJECTIVE

Based on the Liver Imaging Reporting and Data System version 2018 (LI-RADS, v2018), this study aimed to analyze LR-5 diagnostic performance for hepatocellular carcinoma (HCC) when threshold growth as a major feature is replaced by a more HCC-specific ancillary feature, as well as the frequency of threshold growth in HCC and non-HCC malignancies and its association with tumor size.

MATERIALS AND METHODS

This retrospective study included treatment-naive patients who underwent gadoxetate disodium-enhanced MRIs for focal hepatic lesions and surgery between January 2009 and December 2016. The frequency of major and ancillary features was evaluated for HCC and non-HCC malignancies, and the LR-category was assessed. Ancillary features that were significantly more prevalent in HCC were then used to either replace threshold growth or were added as additional major features, and the diagnostic performance of the readjusted LR category was compared to the LI-RADS v2018.

RESULTS

A total of 1013 observations were analyzed. Unlike arterial phase hyperenhancement, washout, or enhancing capsule which were more prevalent in HCCs than in non-HCC malignancies (521/616 vs. 18/58, 489/616 vs. 19/58, and 181/616 vs. 5/58, respectively; p < 0.001), threshold growth was more prevalent in non-HCC malignancies than in HCCs (11/23 vs. 17/119; p < 0.001). The mean size of non-HCC malignancies showing threshold growth was significantly smaller than that of non-HCC malignancies without threshold growth (22.2 mm vs. 42.9 mm, p = 0.040). Similar results were found for HCCs; however, the difference was not significant (26.8 mm vs. 33.1 mm, p = 0.184). Additionally, Fat-in-nodule was more frequent in HCCs than in non-HCC malignancies (99/616 vs. 2/58, p = 0.010). When threshold growth and fat-in-nodule were considered as ancillary and major features, respectively, LR-5 sensitivity (73.2% vs. 73.9%, p = 0.289) and specificity (98.2% vs. 98.5%, p > 0.999) were comparable to the LI-RADS v2018.

CONCLUSION

Threshold growth is not a significant diagnostic indicator of HCC and is more common in non-HCC malignancies. The diagnostic performance of LR-5 was comparable when threshold growth was recategorized as an ancillary feature and replaced by a more HCC-specific ancillary feature.

Exploration and time-serial validation of logistic regression models composed of multiple laboratory tests for early detection of HCV-associated hepatocellular carcinoma

BACKGROUND

We developed a laboratory test-based regression model for early detection of hepatocellular carcinoma (HCC) associated with HCV in its surveillance.

METHODS

This matched case-control study was conducted by enrolling 452 patients with chronic hepatitis and/or cirrhosis, including 129 patients complicated with HCC. One-to-one propensity score matching was performed by referring to sex, age, and fibrosis-4 index, which resulted in 102 patients each in HCC and non-HCC groups. Logistic regression models (LRM) for distinguishing the two groups were explored from variable combinations of laboratory tests. The model was validated by our new scheme of applying it retroactively to trimonthly previous datasets.

RESULTS

Models with a practical level of diagnostic accuracy (C-statistic) were α-fetoprotein (AFP) alone (0.810), LRM3 comprising AFP, AST, and ALT (0.850), and LRM4 comprising AFP, AFP/(AST × ALT), and AST (0.862). After retroactive application of each model, LRM4 showed the highest distinction of the two groups at -12M, -6M, -3M with C-statistics of 0.654, 0.786, 0.834, respectively. LRM4 was accurate even after limiting cases to early-stage HCC.

CONCLUSIONS

LRM4 was proved useful in prompting clinicians to perform timely image study in the surveillance. The retroactive validation scheme is applicable to assess diagnostic models of other neoplastic diseases.

Effect of cell microenvironment on the drug sensitivity of hepatocellular cancer cells

The native hepatocellular cancer (HCC) microenvironment is characterized by more hypoxic, hypoglycemic, and acidic conditions than those used in standard cell culture. This study aimed to investigate whether HCC cells cultured in more native conditions have an altered phenotype and drug sensitivity compared to those cultured in standard conditions. Six HCC cell lines were cultured in “standard” (21% O₂, 25 mM glucose) or more “native” (1% O₂, 5 mM glucose, 10 mM lactate) conditions. Cells were assessed for growth rates, cell cycle distribution, relevant metabolite and protein levels, genome-wide gene expression, mitochondrial DNA sequence and sensitivity to relevant drugs. Many differences in cellular and molecular phenotypes and drug sensitivity were observed between the cells. HCC cells cultured in native conditions had slower doubling times, increased HK2 and GLUT, lower PHDA and ATP levels, and mutations in mitochondrial DNA. Thirty-one genes, including the hypoxia-associated NDRG1, were differentially expressed between the cells. HCC patients in The Cancer Genome Atlas (TCGA) with tumors with a high score based on these 31 genes had a poorer prognosis than those with a low score (p = 0.002). From 90 comparisons of drug sensitivity, increased resistance and sensitivity for cells cultured in native conditions was observed in 14 (16%) and 8 (9%) comparisons respectively. In conclusion, cells cultured in more native conditions can have a more glycolytic and aggressive phenotype and varied drug sensitivity to those cultured in standard conditions, and may provide new insights to understanding tumor biology and drug development.

How frequently does hepatocellular carcinoma develop in at-risk patients with a negative liver MRI examination with intravenous Gadobenate dimeglumine?

OBJECTIVE

To determine the rate of development of clinically significant liver nodules (LR-4, LR-5, LR-M) after a negative MRI in an HCC screening population.

METHODS

This retrospective study included patients at risk of developing HCC requiring imaging surveillance who had undergone multiphase Gadobenate dimeglumine-enhanced MRI that was negative and had follow up LI-RADS compliant multiphase CTs or MRIs for at least 12 months or positive follow-up within 12 months. Follow-up examinations were classified as negative (no nodules or only LR-1 nodules) or positive (nodule other than LR-1). Time-to-first positive examination, types of nodules, and cumulative incidence of nodule development were recorded.

RESULTS

204 patients (mean age 58.9 ± 10.2 years, 128 women), including 172 with cirrhosis, were included. Based CT/MRI follow-up (median 35 months, range 12-80 months), the overall cumulative incidence of developing a nodule was 10.5%. Cumulative incidence of nodule development was: 0.5% at 6-9 months and 2.1% at 12 ± 3 months, including one LR-4 nodule, one LR-M nodule, and two LR-3 nodules. The cumulative incidence of clinically significant nodule development was 1.1% at 9-15 months. 70% (143/204) of patients also underwent at least one US follow-up, and no patient developed a positive US examination following index negative MRI.

CONCLUSION

Clinically significant liver nodules develop in 1.1% of at-risk patients in the first year following negative MRI. While ongoing surveillance is necessary for at-risk patients, our study suggests than longer surveillance intervals after a negative MRI may be reasonable and that further research is needed to explore this possibility.

Surveillance for HCC After Liver Transplantation: Increased Monitoring May Yield Aggressive Treatment Options and Improved Postrecurrence Survival

BACKGROUND

Currently, no surveillance guidelines for hepatocellular carcinoma (HCC) recurrence after liver transplantation (LT) exist. In this retrospective, multicenter study, we have investigated the role of surveillance imaging on postrecurrence outcomes.

METHODS

Patients with recurrent HCC after LT from 2002 to 2016 were reviewed from 3 transplant centers (University of California San Francisco, Mayo Clinic Florida, and University of Toronto). For this study, we proposed the term cumulative exposure to surveillance (CETS) as a way to define the cumulative sum of all the protected intervals that each surveillance test provides. In our analysis, CETS has been treated as a continuous variable in months.

RESULTS

Two hundred twenty-three patients from 3 centers had recurrent HCC post-LT. The median follow-up was 31.3 months, and median time to recurrence was 13.3 months. Increasing CETS was associated with improved postrecurrence survival (hazard ratio, 0.94; P < 0.01) as was treatment of recurrence with resection or ablation (hazard ratio, 0.31; P < 0.001). An receiver operating characteristic curve (area under the curve, 0.64) for CETS covariate showed that 252 days of coverage (or 3 surveillance scans) within the first 24 months provided the highest probability for aggressive postrecurrence treatment.

CONCLUSIONS

In this review of 223 patients with post-LT HCC recurrence, we found that increasing CETS does lead to improved postrecurrence survival as well as a higher probability for aggressive recurrence treatment. We found that 252 days of monitoring (ie, 3 surveillance scans) in the first 24 months was associated with the ability to offer potentially curative treatment.

Hepatocellular carcinoma tumour volume doubling time: a systematic review and meta-analysis

BACKGROUND

Tumour growth patterns have important implications for surveillance intervals, prognostication and treatment decisions but have not been well described for hepatocellular carcinoma (HCC). The aim of our study was to characterise HCC doubling time and identify correlates for indolent and rapid growth patterns.

METHODS

We performed a systematic literature review of Medline and EMBASE databases from inception to December 2019 and national meeting abstracts from 2010 to 2018. We identified studies reporting HCC tumour growth or tumour volume doubling time (TVDT), without intervening treatment, and abstracted data to calculate TVDT and correlates of growth patterns (rapid defined as TVDT <3 months and indolent as TVDT >9 months). Pooled TVDT was calculated using a random-effects model.

RESULTS

We identified 20 studies, including 1374 HCC lesions in 1334 patients. The pooled TVDT was 4.6 months (95% CI 3.9 to 5.3 months I²=94%), with 35% classified as rapid, 27.4% intermediate and 37.6% indolent growth. In subgroup analysis, studies from Asia reported shorter TVDT than studies elsewhere (4.1 vs 5.8 months). The most consistent correlates of rapid tumour growth included hepatitis B aetiology, smaller tumour size (continuous), alpha fetoprotein doubling time and poor tumour differentiation. Studies were limited by small sample sizes, measurement bias and selection bias.

CONCLUSION

TVDT of HCC is approximately 4-5 months; however, there is heterogeneity in tumour growth patterns, including more aggressive patterns in Asian hepatitis B-predominant populations. Identifying correlates of tumour growth patterns is important to better individualise HCC prognostication and treatment decisions.

Can Immediately Treating Subcentimeter Hepatocellular Carcinoma Improve the Survival of Patients?

Background

With the development of imaging technology, an increasing number of subcentimeter hepatocellular carcinoma (HCC) has been detected. How to manage these lesions remains controversial and lacks evidence. We aimed to explore whether timely treating subcentimeter HCC is necessary considering the risks of false-positives and treatment failure.

Methods

In this retrospective study, we reviewed HCC patients treated with hepatectomy or ablation in our institution. Then, we enrolled 439 HCC patients with solitary lesion measuring up to 2 cm from November 1, 2009 to June 30, 2019. The baseline and clinical characteristics of these patients were collected. The patients were classified into primary and recurrent groups. The Kaplan–Meier method with Log-rank test was performed to compare the overall survival (OS) and recurrence-free survival (RFS) between patients with subcentimeter HCC and those with HCC measuring 1–2 cm. Univariate and multivariate analyses were adopted to identify prognostic factors for survival.

Results

The OS and RFS did not differ significantly between patients with subcentimeter HCC and those with HCC measuring 1–2 cm in the primary group (p = 0.12 and 0.75). Similar results were found in the recurrent group. In multivariate analysis, the albumin-bilirubin (ALBI) grade and serum alpha fetoprotein (AFP) level were significantly associated with OS and RFS in the primary group. The serum AFP level was the only factor that correlated with OS and RFS in the recurrent group.

Conclusion

Routine screening for subcentimeter HCC is feasible. Considering uncertain diagnosis and treatment difficulties, it is more considerable to follow patients until lesions are larger than 1 cm and then provide curative treatments.

Hepatocellular Carcinoma Demonstrates Heterogeneous Growth Patterns in a Multicenter Cohort of Patients With Cirrhosis

BACKGROUND AND AIMS

There are limited data on hepatocellular carcinoma (HCC) growth patterns, particularly in Western cohorts, despite implications for surveillance, prognosis, and treatment. Our study's aim was to quantify tumor doubling time (TDT) and identify correlates associated with indolent and rapid growth.

APPROACH AND RESULTS

We performed a retrospective multicenter cohort study of patients with cirrhosis diagnosed with HCC from 2008 to 2017 at six US and European health systems with two or more contrast-enhanced imaging studies performed ≥ 30 days apart prior to HCC treatment. Radiologists independently measured tumors in three dimensions to calculate TDT and specific growth rate (SGR). We used multivariable ordinal logistic regression to identify factors associated with indolent (TDT > 365 days) and rapid (TDT < 90 days) tumor growth. In the primary cohort (n = 242 patients from four centers), median TDT was 229 days (interquartile range [IQR], 89-627) and median SGR was 0.3% per day (IQR, 0.1%-0.8%). Over one-third (38%) of HCCs had indolent growth, 36.8% intermediate growth, and 25.2% rapid growth. In multivariable analysis, indolent growth was associated with larger tumor diameter (odds ratio [OR], 1.15, 95% confidence interval [CI], 1.03-1.30) and alpha-fetoprotein < 20 ng/mL (OR, 1.90; 95% CI, 1.12-3.21). Indolent growth was more common in nonviral than viral cirrhosis (50.9% versus 32.1%), particularly in patients with T1 HCC (OR, 3.41; 95% CI, 1.08-10.80). Median TDT (169 days; IQR 74-408 days) and SGR (0.4% per day) were similar in an independent cohort (n = 176 patients from two centers).

CONCLUSIONS

In a large Western cohort of patients with HCC, we found heterogeneous tumor growth patterns, with one-fourth exhibiting rapid growth and over one-third having indolent growth. Better understanding different tumor growth patterns may facilitate a precision approach to prognostication and treatment.

Natural history of hepatocellular carcinoma after stereotactic body radiation therapy

PURPOSE

To determine the long-term natural history of size change in SBRT-treated HCC to identify an imaging biomarker to help assess treatment response.

METHODS

This was a retrospective cohort study of consecutive HCCs treated with SBRT from January 2008 to December 2016 with either 2 years post-treatment MRI follow-up or post-treatment resection histology. Size, major features for HCC, and mRECIST and LI-RADS v.2018 treatment response criteria were assessed at each post-treatment MRI. Local progression, distant progression, and survival were modeled with Kaplan Meier analyses.

RESULTS

56 HCCs met inclusion criteria. Mean baseline HCC diameter was 30 mm (range: 9-105 mm). At 3 months, 76% (N = 43) of treated HCCs decreased in size (mean reduction: 8 mm, range: 5-99 mm) and 0% (N = 0) increased in size. By 24 months, 11% (N = 5) had increased in size and were considered local progression. APHE remained in 77% (43/56) at 3 months, 38% (19/50) at 12 months, and 23% (11/47) at 24 months. mRECIST-defined viable disease was observed in 77% (43/56) at 3 months and 20% (9/47) at 24 months. LI-RADS v.2018 criteria identified viable or equivocal disease in 0% at 3 months and 10% (5/47) at 24 months.

CONCLUSION

Gradual loss of APHE and slow decrease in size are normal findings in HCCs treated with SBRT, and persistent APHE does not indicate viable disease. mRECIST is not accurate in the assessment of HCC after SBRT due to an overreliance on APHE to define viable disease. Increasing mass size or new nodular APHE at the treatment site may indicate local progression.

Diagnostic performance of Liver Imaging Reporting and Data System in patients at risk of both hepatocellular carcinoma and metastasis

OBJECTIVE

The purpose of this study was to evaluate the diagnostic performance of the Liver Imaging Reporting and Data System (LI-RADS) in patients with both chronic liver disease and a history of extrahepatic malignancy.

MATERIALS AND METHODS

This retrospective study included 59 hepatocellular carcinomas (HCCs) and 45 metastases pathologically confirmed between 2008 and 2017 in 104 patients with chronic liver disease (cirrhosis or chronic hepatitis B) and a history of extrahepatic malignancy. Two radiologists blinded to the final diagnosis independently reviewed MRI (95 patients) or CT (9 patients) images, and their consensus data were used to calculate the diagnostic performance of LI-RADS categories. Serum tumor markers, tumor multiplicity, and suspected metastatic lymph nodes were also evaluated.

RESULTS

The sensitivity, specificity, and accuracy of LR-5 for diagnosing HCC were 69% (95% confidence intervals [CI] 56-81), 98% (95% CI 88-99), and 82% (95% CI 73-89), respectively, and those of LR-M for diagnosing metastasis were 89% (95% CI 76-96), 88% (95% CI 77-95), and 88% (95% CI 81-94), respectively. Elevation of serum carcinoembryonic antigen (P = 0.01) or carbohydrate antigen 19-9 levels (P = 0.02) and tumor multiplicity (P = 0.004) were more frequently observed in metastasis than in HCC. Three of four metastases categorized as LR-4 or LR-5 were smaller than 2 cm.

CONCLUSIONS

The LI-RADS provides high specificity (98%) for differentiating HCC from metastases in patients with both chronic liver disease and a history of extrahepatic malignancy.

Hepatocellular carcinoma Liver Imaging Reporting and Data Systems treatment response assessment: Lessons learned and future directions

Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality worldwide, with rising clinical and economic burden as incidence increases. There are a multitude of evolving treatment options, including locoregional therapies which can be used alone, in combination with each other, or in combination with systemic therapy. These treatment options have shown to be effective in achieving remission, controlling tumor progression, improving disease free and overall survival in patients who cannot undergo resection and providing a bridge to transplant by debulking tumor burden to downstage patients. Following locoregional therapy (LRT), it is crucial to provide treatment response assessment to guide management and liver transplant candidacy. Therefore, Liver Imaging Reporting and Data Systems (LI-RADS) Treatment Response Algorithm (TRA) was created to provide a standardized assessment of HCC following LRT. LI-RADS TRA provides a step by step approach to evaluate each lesion independently for accurate tumor assessment. In this review, we provide an overview of different locoregional therapies for HCC, describe the expected post treatment imaging appearance following treatment, and review the LI-RADS TRA with guidance for its application in clinical practice. Unique to other publications, we will also review emerging literature supporting the use of LI-RADS for assessment of HCC treatment response after LRT.

Retrospective CT/MRI Texture Analysis of Rapidly Progressive Hepatocellular Carcinoma

Rapidly progressive hepatocellular carcinoma (RPHCC) is a subset of hepatocellular carcinoma that demonstrates accelerated growth, and the radiographic features of RPHCC versus non-RPHCC have not been determined. The purpose of this retrospective study was to use baseline radiologic features and texture analysis for the accurate detection of RPHCC and subsequent improvement of clinical outcomes. We conducted a qualitative visual analysis and texture analysis, which selectively extracted and enhanced imaging features of different sizes and intensity variation including mean gray-level intensity (mean), standard deviation (SD), entropy, mean of the positive pixels (MPP), skewness, and kurtosis at each spatial scaling factor (SSF) value of RPHCC and non-RPHCC tumors in a computed tomography (CT) cohort of n = 11 RPHCC and n = 11 non-RPHCC and a magnetic resonance imaging (MRI) cohort of n = 13 RPHCC and n = 10 non-RPHCC. There was a statistically significant difference across visual CT irregular margins p = 0.030 and CT texture features in SSF between RPHCC and non-RPHCC for SSF-6, coarse-texture scale, mean p = 0.023, SD p = 0.053, MPP p = 0.023. A composite score of mean SSF-6 binarized + SD SSF-6 binarized + MPP SSF-6 binarized + irregular margins was significantly different between RPHCC and non-RPHCC (p = 0.001). A composite score ≥3 identified RPHCC with a sensitivity of 81.8% and specificity of 81.8% (AUC = 0.884, p = 0.002). CT coarse-texture-scale features in combination with visually detected irregular margins were able to statistically differentiate between RPHCC and non-RPHCC. By developing an image-based, non-invasive diagnostic criterion, we created a composite score that can identify RPHCC patients at their early stages when they are still eligible for transplantation, improving the clinical course of patient care.

Uncovering Biological Factors That Regulate Hepatocellular Carcinoma Growth Using Patient-Derived Xenograft Assays

BACKGROUND AND AIMS

Several major factors limit our understanding of hepatocellular carcinoma (HCC). First, human HCCs are infrequently biopsied for diagnosis and thus are not often biologically interrogated. Second, HCC initiation and progression are strongly influenced by the cirrhotic microenvironment, and the exact contributions of intrinsic and extrinsic tumor factors are unclear. A powerful approach to examine the personalized biology of liver cancers and the influence of host tissues is with patient-derived xenograft (PDX) models. In Asia, HCCs from patients with hepatitis B virus have been efficiently converted into PDXs, but few parallel efforts from the west have been reported.

APPROACH AND RESULTS

In a large-scale analysis, we implanted 93 HCCs and 8 cholangiocarcinomas (CCAs) to systematically analyze host factors and to define an optimized platform for PDX development from both surgical and biopsy samples. NOD Scid IL-2Rγ^-/- (NSG) mice that had undergone partial hepatectomy (PHx) represented the best combination of engraftability, growth, and passageability, but overall rates were low and indicative of a unique intrinsic biology for HCCs in the United States. PDX models preserved the histology and genetic features of parental tumors, and ultimately, eight models were usable for preclinical studies. Intriguingly, HCC PDXs were differentially sensitive to regorafenib and sorafenib, and CCA PDXs were also highly sensitive to regorafenib.

CONCLUSIONS

PDX models functionalize early and advanced stage HCCs and revealed unique biological features of liver cancers from the United States.

Gadoxetic acid-enhanced MRI for diagnosis of hepatocellular carcinoma in patients with chronic liver disease: can hypointensity on the late portal venous phase be used as an alternative to washout?

PURPOSE

To investigate the added value of considering hypointensity on late portal venous phase (LPVP) images as washout for diagnosis of hepatocellular carcinoma (HCC) using gadoxetic acid-enhanced MRI (Gd-EOB-MRI) in patients with chronic liver disease (CLD).

METHODS

This retrospective study comprised 97 patients at high risk for HCC who underwent Gd-EOB-MRI including unenhanced, multi-arterial phase, conventional portal venous phase (CPVP, 60 s), and LPVP (mean, 99.9 ± 9.1 s; range, 90-119 s) images. A total of 115 hepatic lesions were identified by histopathological or clinical diagnosis. Three independent radiologists assessed the MRI images by consensus. Diagnosis of HCC was made using criteria of arterial hyperenhancement and hypointensity relative to the surrounding liver parenchyma (1) on CPVP or (2) on CPVP and/or LPVP images. The generalized estimating equation was used to compare diagnostic performance for HCC between Criterion 1 and 2.

RESULTS

In 82 HCCs, the frequency of hypointensity differed significantly between the CPVP and LPVP images (64.6% [53/82] vs. 84.1% [69/82], P < 0.001). Among 33 non-HCCs, two cHCC-CCs showed additional hypointensity on LPVP than CPVP images (33.3% [11/33] vs. 39.4% [13/33], P = 0.500). Criterion 2 provided significantly greater sensitivity for diagnosing HCC than Criterion 1 (54.9% [45/82] vs. 74.4% [61/82], P < 0.001), with relatively little reduction in specificity (90.9% [30/33] vs. 84.8% [28/33], P = 0.145).

CONCLUSION

Additional use of LPVP hypointensity as washout could significantly improve sensitivity for HCC diagnosis when utilizing Gd-EOB-MRI in patients with CLD, without a significant decrease in specificity.

Liver Care and Surveillance: The Global Impact of the COVID-19 Pandemic

As social distancing and strict stay‐at‐home orders have been instituted to slow the spread of coronavirus disease 2019 (COVID‐19), unintentional outcomes among those with chronic diseases including screening for the lethal hepatocellular carcinoma (HCC) may be occurring. We aimed to describe the changes in liver care before and after COVID‐19 restricted access to health care. We obtained data on the number of liver clinic visits, abdominal ultrasound, computed tomography, and magnetic resonance imaging using electronic query or clinic registry at three medical centers in the United States, Japan, and Singapore for the following periods: February 1 to March 14, 2018, 2019, and 2020; and March 15 to May 1, 2018, 2019, and 2020. We performed trend analysis using logistic regression. In total, 14,403 visits were made to the liver clinics at the three centers: 5,900 in 2018, 5,270 in 2019, and 3,233 in 2020. Overall, there were no significant changes in the distribution of males and females between February 1 and May 1 from 2018 to 2020, but there was a lower proportion of seniors ages 65 years and older (P < 0.001). There were significant decreasing trends in the total number of liver clinic visits overall (p‐trend = 0.038) and in the subanalysis for chronic hepatitis B, C, and other liver diseases. HCC/cirrhosis visits also dropped from 883 to 538 (39.07% decrease) overall and 665 to 355 (46.62% decrease) for the US site. In addition, there was a significant decreasing trend in the number of abdominal ultrasounds (P‐trend = 0.004) and computed tomography/magnetic resonance imaging (P‐trend = 0.007) performed overall. Conclusion: Liver clinic visits, hepatoma surveillance, and diagnostic abdominal imaging fell dramatically as social distancing measures were instituted. Care providers must find ways to recall patients for important care monitoring, including HCC surveillance.

Follow-up schedule for initial recurrent hepatocellular carcinoma after ablation based on risk classification

Background

To date, no standard follow-up guidelines exist regarding patients receiving ablation for initial recurrent hepatocellular carcinoma (HCC). We aimed to explore whether intensive follow-up could benefit these patients.

Methods

We reviewed the clinical data of patients who received complete ablation for initial HCC recurrence after curative treatments in our institution from January 2005 to June 2017. Risk factors for second recurrence of HCC were identified by univariate and multivariate analyses. Patients were classified into low- and high-risk groups according to the outcome of the classification and regression model. The patients were further categorized into short- (< 3 months) and long-interval (3–6 months) follow-up subgroups based on their surveillance in the first 2 years after complete ablation for initial recurrence. The Kaplan-Meier method with log-rank test was performed to compare the overall survival (OS) based on follow-up intervals in each risk group. We also validated our results by stratifying patients into subgroups with different numbers of risk factors and comparing the OS between patients with different follow-up intervals.

Results

A total of 361 patients were enrolled. The risk factors for secondary recurrence included the Barcelona Clinic Liver Cancer (BCLC) stage at initial recurrence and first recurrence-free survival after curative treatments for primary HCC (p < 0.001 and p = 0.002). Two risk groups (low and high) were identified. In both the low- and high-risk groups, the OS of patients was not associated with intervals of follow-up (p = 0.29 and 0.49). No significant difference was found in the rates of BCLC 0/A stage, tumor location or curative treatments for the second recurrence by different follow-up intervals in each risk group (p = 0.34 and 0.87; p = 0.69 and 0.97). The same tendency was found in subgroups with 0/1/2 risk factors for secondary recurrence during validation.

Conclusion

The long-interval follow-up did not compromise the survival of patients with complete ablation for initial recurrent HCC.

Strategy for the practice of digestive and oncological surgery during the Covid-19 epidemic

The Covid-19 pandemic is changing the organization of healthcare and has a direct impact on digestive surgery. Healthcare priorities and circuits are being modified. Emergency surgery is still a priority. Functional surgery is to be deferred. Laparoscopic surgery must follow strict rules so as not to expose healthcare professionals (HCPs) to added risk. The question looms large in cancer surgery-go ahead or defer? There is probably an added risk due to the pandemic that must be balanced against the risk incurred by deferring surgery. For each type of cancer-colon, pancreas, oesogastric, hepatocellular carcinoma-morbidity and mortality rates are stated and compared with the oncological risk incurred by deferring surgery and/or the tumour doubling time. Strategies can be proposed based on this comparison. For colonic cancers T1-2, N0, it is advisable to defer surgery. For advanced colonic lesions, it seems judicious to undertake neoadjuvant chemotherapy and then wait. For rectal cancers T3-4 and/or N+, chemoradiotherapy is indicated, short radiotherapy must be discussed (followed by a waiting period) to reduce time of exposure in the hospital and to prevent infections. Most complex surgery with high morbidity and mortality-oesogastric, hepatic or pancreatic-is most often best deferred.

Prevention and control strategies of general surgeons under COVID-19 pandemic

The novel coronavirus SARS-CoV-2 and the disease caused by it, COVID-19, have spread to virtually all countries worldwide within just a few months. The economic and sanitary impact has been enormous. In March 2020, the World Health Organization declared COVID-19 a pandemic. How to effectively prevent and control SARS-CoV-2 transmission while providing care to surgical patients during the pandemic is a crucial topic. In order to minimize the risk of cross-infection between patients and physicians, many hospitals have taken measures to limit outpatient services, elective hospitalizations, and the number of operations. Based on the prevention and control measures stipulated by major medical institutions in China, this overview provides recommendations for surgeons from three aspects: outpatient treatment, ward management and perioperative protection. Telemedicine should be encouraged as a means of social distancing. Outpatient examination should be selected. Reasonable spatial arrangement and effective environmental disinfection are important for ward management. Patient selection for surgery and timing of operations should be carefully discussed within multi-disciplinary teams. Appropriate personal protective equipment should be worn adapted to the situational risk. On December 31, 2019, China reported to the WHO Country Office a pneumonia of unknown cause detected in Wuhan [1], [3]. Subsequently, the disease later named COVID-19 affected a substantial proportion of the population in Wuhan and spread to other areas of China. Relying on a nationwide shutdown and mandatory quarantine, China has effectively curtailed the domestic outbreak. However, due to the high transmissibility of SARS-Cov-2 and the mobility of people, COVID-19 spread to the rest of the world. Many hospitals worldwide were faced with confirmed and suspected SARS-Cov-2 infections, putting a huge strain on the safety of patients and employees. Consequently, surgical patients who seek medical care during the COVID-19 pandemic present significant challenges. This paper summarizes medical care and infection prevention and control in general surgery patients during the COVID-19, pandemic in the light of the current situation in China. It provides reference for surgeons and decision makers in health care in other countries suffering from the COVID-19 pandemic.

Non-invasive liver fibrosis scores are strongly associated with liver cancer mortality in general population without liver disease

BACKGROUND & AIMS

In a general population without known liver disease, we tested whether: (a) increased liver fibrosis scores (FIB-4 and APRI) are associated with liver cancer mortality and (b) the probability that a person with a higher score died of liver cancer.

METHODS

In a retrospective occupational cohort who underwent annual/biennial health examinations (between 2002 and 2015), subjects were excluded with known chronic liver disease. Based on their baseline FIB-4 and APRI scores, subjects were categorised in low-/intermediate-/high-risk groups for advanced liver fibrosis. Using Cox proportional hazards regression analyses adjusted hazard ratios (aHR) were estimated for liver cancer mortality, with the low-risk FIB-4/APRI group as the reference. Harrell's C statistics were also calculated.

RESULTS

In 200 479 participants, mean (SD) age was 36.4 (7.7) years. Median follow-up was 4.1 years (IQR 2.10-8.03) with 80 liver cancer deaths. High baseline FIB-4 or APRI scores occurred in 0.25% and 0.09% of subjects respectively. A high FIB-4 or APRI score was associated with a markedly increased risk of liver cancer mortality (aHRs 629.10 [95% CI 228.74-1730.20] and 80.42 [95% CI 34.37-188.18]) respectively. C statistics were FIB-4 = 0.841 (95% CI 0.735-0.946) and APRI = 0.933 (95% CI 0.864-0.999).

CONCLUSIONS

In a general population without known liver disease, high FIB-4 or high APRI (in keeping with a high probability of advanced fibrosis) occurred in 0.25% (FIB-4) and 0.09% (APRI) of subjects. Both scores were associated with a markedly increased risk of liver cancer mortality and FIB-4 and APRI models both strongly predicted liver cancer mortality.

[Strategy for the practice of digestive and oncologic surgery in COVID-19 epidemic situation]

La pandémie due au COVID-19 modifie l’organisation des soins et change la réalisation de la chirurgie digestive. Les priorités sanitaires et les circuits de soins sont modifiés. La chirurgie d’urgence reste prioritaire. Les interventions pour chirurgie fonctionnelles sont à reporter. La chirurgie par laparoscopie doit suivre des règles strictes pour ne pas exposer les professionnels à un surrisque. Le questionnement principal concerne la chirurgie oncologique, opérer ou reporter ? Il existe probablement un sur risque opératoire induit par la pandémie qui doit être mis en balance avec le retard de prise en charge chirurgical. Pour chaque type de cancer, colon, pancréas, œsogastrique, hépatocarcinome, la morbi-mortalité est rappelée et mise en parallèle avec le risque oncologique lié au retard à la chirurgie et/ou au temps de doublement de la tumeur. Cette comparaison permet de proposer des stratégies, ainsi pour les cancers coliques (T1-2, N0), il est souhaitable de retarder la chirurgie. Pour les lésions coliques avancées, il semble prudent de recommander une chimiothérapie néo adjuvante et d’attendre. Pour les cancers du rectum T3-4 et/ou N+, une radio-chimiothérapie est indiquée, une radiothérapie courte devra être discutée (suivie d’une période d’attente) afin de réduire le temps d’exposition à l’hôpital et d’éviter les infections. La majorité des chirurgies complexes à forte morbi-mortalité, œsogastrique, hépatique ou pancréatique doivent sans doute le plus souvent être reportée.

Influence of pretreatment tumor growth rate on objective response of hepatocellular carcinoma treated with transarterial chemoembolization

BACKGROUND AND AIM

The study aims to assess the influence of pretreatment tumor growth rate (TGR) on modified response evaluation criteria in solid tumors (mRECIST) objective response (OR) after a first session of selective transarterial chemoembolization (TACE) for the treatment of hepatocellular carcinoma (HCC).

METHODS

One hundred fifteen patients (101 men [88%], mean 65.1 ± 10.5 years [range 26-87]) with 169 tumors (mean 34.2 ± 29.3 mm [10-160]), undergoing a first session of selective TACE for the treatment of HCC between 2011 and 2016, were included. TGR was calculated as the percentage change in tumor volume per month (%/month) on imaging before treatment. TGR cut-off for prediction of OR was identified by receiver operating characteristic curve analysis.

RESULTS

Overall 88/189 (52%) and 46/189 (27%) tumors showed complete response (CR) and partial response (PR) (OR rate 79%), while 32/189 (19%) showed stable disease (SD), and 3/189 (2%) were progressive disease (PD) on computed tomography at 1-month post-TACE. The mean pretreatment TGR was 12.0 ± 15.4 (-3.2-90.4) %/month. TGR of tumors showing CR, PR, SD, and PD was a mean 13.2 ± 16.4%, 12.1 ± 15.1%, 5.3 ± 4.5%, and 44.8 ± 20.4%, respectively (P < 0.001). The three tumors showing PD had TGR values > 20%/month. TGR was significantly higher in tumors with OR (12.8 ± 15.9% vs 5.3 ± 4.5% in SD, P = 0.009). A cut-off value of 6.5%/month had the highest predictive value of OR (AUROC 0.65 ± 0.05, P = 0.009).

CONCLUSION

Pretreatment TGR is highly variable in HCC before TACE with a U-shaped distribution for the prediction of tumor response. It provides insight into tumor biology that may be used during pretreatment workup to help stratify patients.

Intra-procedural dual phase cone beam computed tomography has a better diagnostic accuracy over pre-procedural MRI and MDCT in detection and characterization of HCC in cirrhotic patients undergoing TACE procedure

PURPOSE

This study was directed to compare diagnostic accuracy of dual-phase cone beam computed tomography (DP-CBCT) vs pre-procedural second line imaging modality (SLIM [multidetector computed tomography and magnetic resonance imaging]) to detect and characterize hepatocellular carcinoma (HCC) in cirrhotic patients with indication for trans-arterial chemoembolization (TACE).

METHODS

This is a single centre, retrospective, and observational study. Exclusion criteria were not-assisted DP-CBCT TACE, and unavailable follow-up SLIM. We evaluated 280 consecutive patients (January/2015-Febraury/2019). Seventy-two patients were eligible. Three radiologists in consensus reviewed: pre-procedural SLIM, DP-CBCT, and SLIM at follow-up, with 4 months of interval between each reading. Hyper-vascular foci (HVF) were detected and characterized. Diameter was recorded. Radiological behaviour, according to LI-RADS criteria, of HFV throughout follow-up time was the reference standard. Diagnostic accuracy was calculated for pre-procedural SLIM and DP-CBCT and evaluated through receiver operating characteristic curve. HVF only visible on DP-CBCT (defined as occult) were analysed. Tumour diameters were compared.

RESULTS

Median time between pre-procedural SLIM and DP-CBCT and between DP-CBCT and definitive radiological diagnosis of HVF were 46.0 days (95%CI 36.5-55.0) and 30.5 days (95%CI 29.0-33.0), respectively. DP-CBCT had a better diagnostic performance than pre-examination SLIM (sensitivity 99%vs78%; specificity 89%vs85%; PPV 99%vs99%; NPV 92%vs30%; and accuracy 94%vs79%). DP-CBCT diagnosed 63 occult HVF. Occult HCC were 54/243 (22.2%). Six were occult angiomas. Three were false positive. Mean diameter was significantly higher in DP-CBCT vs pre-procedural SLIM (+7.5% [95%CI 3.7-11.3], p < 0.05).

CONCLUSIONS

DP-CBCT has a better diagnostic accuracy and NPV than pre-procedural SLIM in cirrhotic patients with indication for TACE.

Pathologic complete response to chemoembolization improves survival outcomes after curative surgery for hepatocellular carcinoma: predictive factors of response

BACKGROUND

We identified the predictive factors and prognostic significance of transarterial chemoembolization (TACE) for achieving pathologic complete response (pCR) before curative surgery for hepatocellular carcinoma (HCC) in hepatitis B-endemic areas.

METHODS

Among 753 HCC patients treated with surgery, 124 patients underwent preoperative TACE before liver resection (LR), and 166 before liver transplantation (LT) between 2005 and 2016. Overall survival (OS) and recurrence-free survival (RFS) were analyzed. Pathologic response (PR) was defined as the mean percentage of necrotic area, and pCR was defined as the absence of viable tumor.

RESULTS

A total of 34 (27%) and 38 (23%) patients had pCR before LR and LT, respectively. Alpha-fetoprotein (AFP) < 100 ng/mL and single tumor were significant preoperative predictors of pCR. OS and RFS were significantly improved in patients with pCR or a PR ≥ 90%, but not in patients with PR ≥ 50% after LR and LT. On multivariate analyses, PR ≥ 90% remained an independent predictor of better OS and RFS in LR and LT groups.

CONCLUSION

Overall, our data clearly demonstrate that pCR predicts favorable prognosis after curative surgery for HCC, and predictors of pCR are AFP <100 ng/mL and single tumor.

Optimal lexicon of gadoxetic acid-enhanced magnetic resonance imaging for the diagnosis of hepatocellular carcinoma modified from LI-RADS

PURPOSE

To define the optimal lexicon of major imaging findings on gadoxetic acid-enhanced MRIs to diagnose HCC to improve diagnostic performance of the LI-RADS.

METHODS

Two hundred forty-one hepatic lesions (149 HCC, six other malignancies, 86 benign lesions) in 177 treatment-naïve patients at risk of HCC who underwent gadoxetic acid-MRIs from January 2013 to December 2015 were retrospectively reviewed using either histopathological or follow-up imaging findings as a standard reference. Two board-certified radiologists independently evaluated the imaging features and categorized the nodules based on the original and the following modified definitions in LI-RADS: (1) washout appearance in the portal venous phase (PVP) only versus that in the PVP or transitional phase, and (2) enhancing capsule only versus enhancing or non-enhancing capsule. Diagnostic performance and inter-observer agreement of LR-5 were assessed and compared between the algorithms using generalized estimation equation.

RESULTS

The sensitivity [79.2% (95% confidence interval 71.9, 85.0)] and accuracy [84.6% (79.5, 88.7)] of LR-5 were significantly higher for modified lexicon compared with original LI-RADS [60.4% (52.3, 67.9) and 73.9% (67.9, 79.0); P < 0.001 in all cases]. There was no significant difference in specificity [93.5% (86.2, 97.0) and 95.7% (89.0, 98.4); P = 0.153]. Subgroups of lesions < or ≥ 2 cm showed similar tendencies. Inter-observer agreement for capsule appearance was fair to moderate, whereas that for other imaging findings was good to excellent.

CONCLUSIONS

Compared to original LI-RADS, LI-RADS with modified lexicon showed higher sensitivity for the diagnosis of HCC using gadoxetic acid-MRI, with similar specificity.

Status of, and strategies for improving, adherence to HCC screening and surveillance

Hepatocellular carcinoma (HCC) represents the second leading cause of cancer deaths worldwide and the main cause of death in patients with cirrhosis. Secondary prevention of HCC can be accomplished through the serial application of screening tests (ultrasound with or without alpha-fetoprotein) to detect the presence of subclinical lesions amenable to potentially curative treatment, such as surgery and ablation. The efficacy of HCC screening is accepted by hepatologists in terms of decline in cancer-specific mortality, but its translation into clinical practice is less than ideal. The effectiveness of HCC screening is hampered by several factors: failure to identify at-risk patients, failure to access care and failure to detect HCC. For each of these steps, possible improvements are discussed in order to face the changing etiology of cirrhosis and expand the screening of at-risk populations by including selected nonalcoholic fatty liver disease patients.

The Optimal Management for Sub-Centimeter Hepatocellular Carcinoma: Curative Treatments or Follow-Up?

Background

The optimal strategy for dealing with sub-centimeter hepatic nodules has not yet been established. This study aimed to assess whether there was a need to provide curative treatments for sub-centimeter hepatocellular carcinomas (HCCs) to patients at risk for high false positives.

Material/Methods

We identified patients with primary pathologically diagnosed HCC ≤2 cm from 2004 to 2015 in the Surveillance, Epidemiology and End Results (SEER) database. They were divided according to the interventions they received: local ablation, surgical resection, or liver transplantation. In each group, overall survival and cancer-specific survival were used as endpoints to compare the prognoses between patients with sub-centimeter HCC and patients with HCC measuring 1 to 2 cm by Kaplan-Meier. Propensity score matching was performed to reduce bias. We also compared the survival of patients with a primary solitary HCC based on interventions, in the different tumor size groups. Bootstrapping was performed to validate the findings.

Results

Overall, 10.4% of patients (197 out of 1894) had HCCs <1 cm, and 89.6% of patients (1697 out of 1894) had HCCs in the 1 to 2 cm range. There was no significant difference in overall and cancer-specific survival between patients with HCCs <1 cm and those with HCCs in the 1 to 2 cm range, in all treatment groups. After adjusting confounding factors, no significant correlation was found between tumor size and survival time. In patients with HCCs measuring ≤2 cm, overall survival and cancer-specific survival were superior in liver transplantation compared with surgical resection and local ablation. Surgical resection provided better survival than local ablation.

Conclusions

Compared to patients with HCCs measuring 1 to 2 cm, the survival rates of patients with sub-centimeter HCCs was not improved through curative treatments, risking high false positives.

Combination Suicide Gene Delivery with an Adeno-Associated Virus Vector Encoding Inducible Caspase-9 and a Chemical Inducer of Dimerization Is Effective in a Xenotransplantation Model of Hepatocellular Carcinoma

Current treatment approaches for hepatocellular carcinoma (HCC) have a narrow therapeutic index and alternate modes of treatment are thus required. We have utilized a gene delivery vector containing inducible caspase 9 (iCasp9) gene, which is a synthetic analogue based on the mammalian caspase 9 and fused to a human FK506 binding protein that allows its conditional dimerization to a synthetic, small molecule [chemical inducer of dimerization, AP20187] and results in target cell apoptosis. In our studies, we have tested these synthetic vectors based on an adeno-associated virus platform for their potential anti-tumorigenic effect in human HCC cells in vitro and in a HCC tumor model developed in nude mice. Our data demonstrates that the iCasp9-AP20187 bioconjugate is able to trigger terminal effectors of cellular apoptosis and presents a viable approach for the potential treatment of HCC.

A continuous-time hidden Markov model for cancer surveillance using serum biomarkers with application to hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fourth most common cause of cancer deaths worldwide, and its early detection is a critical determinant of whether curative treatment is achievable. Early stage HCC is typically asymptomatic. Thus, screening programmes are used for cancer detection in patients at risk of tumour development. Radiological screening methods are limited by imperfect data, cost and associated risks, and additionally are unable to detect lesions until they have grown to a certain size. Therefore, some screening programmes use additional blood/serum biomarkers to help identify individuals in whom to target diagnostic cancer investigations. The GALAD score, combining the levels of several blood biomarkers, age and sex, has been developed to identify patients with early HCC. Here we propose a Bayesian hierarchical model for an individual's longitudinal GALAD scores whilst in HCC surveillance to identify potentially significant changes in the trend of the GALAD score, indicating the development of HCC, aiming to improve early detection compared to standard methods. An absorbent two-state continuous-time hidden Markov model is developed for the individual level longitudinal data where the states correspond to the presence/absence of HCC. The model is additionally informed by the information on the diagnosis by standard clinical practice, taking into account that HCC can be present before the actual diagnosis so that there may be false negatives within the diagnosis data. We fit the model to a Japanese cohort of patients undergoing HCC surveillance and show that the detection capability of this proposal is greater than using a fixed cut-point.