Does surgical resection of hepatocellular carcinoma accelerate cancer dissemination

Two elder cases of hepatocellular carcinoma adjacent to intrahepatic vessels successfully treated by carbon ion radiotherapy

The treatment for hepatocellular carcinoma (HCC) adjacent to the portal vein and/or bile duct requires considerable caution to avoid the complications, such as hepatic infarction and obstructive jaundice. Carbon ion radiotherapy (CIRT) has been attempted for HCC and has become accepted as a promising modality for minimizing hepatic damage with good local tumor control. We experienced two elder cases of HCC adjacent to intrahepatic vessels successfully treated by CIRT. Case 1, a 75-year-old man, was treated by CIRT for a 2-cm HCC near the porta hepatis adjacent to the right first portal branch. The treatment was sufficiently effective, and no vascular damage was demonstrated after CIRT. The liver function transiently deteriorated after CIRT, but recovered quickly. Alpha-fetoprotein transiently increased after the treatment and decreased thereafter. Tumor stain persisted for 3 months after CIRT, so a liver tumor biopsy was performed. However, no viable carcinoma cells were detected. There was no local recurrence or complications for 17 months. Case 2, 76-year-old male HCC patient, showed dilation of the peripheral bile duct in the left lobe, suggesting tumor invasion to the duct. The tumor was hypovascular and was found to be well-differentiated HCC by a tumor biopsy. He was treated with CIRT, because he had a history of cerebral infarction and was being administered an antiplatelet agent daily. He achieved complete remission, and no adverse events were observed after the treatment for 3 years.

Clinical indications for, and the future of, circulating tumor cells

Circulating tumor cells (CTCs) are cells that have detached from the primary tumor and entered circulation with potential to initiate a site of metastasis. Currently, CTC detection using CellSearch is cleared by the Food and Drug Administration for monitoring metastatic breast, prostate, and colorectal cancers as a prognostic biomarker for progression-free and overall survival. Accumulating evidence suggests CTCs have similar prognostic value in other metastatic and non-metastatic settings. Current research efforts are focused on extending the utility of CTCs beyond a prognostic biomarker to help guide clinical decision-making. These include using CTCs as a screening tool for diagnosis, liquid biopsy for molecular profiling, predictive biomarker to specific therapies, and monitoring tool to assess response and guide changes to treatment. CTCs have unique advantages vs circulating tumor DNA in this endeavor. Indications for CTCs in daily practice will expand as isolation techniques improve and clinical studies validating their utility continue to grow.

Significance of liver hanging maneuver for anatomical hepatectomy in patients with a large hepatocellular carcinoma compressing intrahepatic vasculatures

Backgrounds/Aims

To achieve complete anatomic hepatectomy in a large hepatocellular carcinoma (HCC), hepatic transection through an anterior approach is required. Liver hanging maneuver (LHM) is a useful procedure for transection of an adequately cut plane in anatomical liver resection. It may reduce intraoperative bleeding and transection time.

Methods

We examined records of 27 patients with large HCC (over 10 cm in size) who underwent anatomic hepatic resection with LHM (n=11, between 2001 and 2007) or without LHM (n=16, between 2000 and 2003). The two groups were retrospectively compared in terms of patient demographics, preoperative hepatic function, surgical records, and post-hepatectomy outcome.

Results

Although transection time was not significantly different between the two groups, the amount of intraoperative blood loss was significantly lower in the LHM group than that in the non-LHM group (1,269±1,407 ml vs. 2,197±1,281 ml, p=0.039). Related blood transfusion or total operation time in the LHM group tended to be lower than those in the non-LHM group, although differences between the two groups were not statistically significant (p<1.0). Prevalence of total complications in the LHM group tended to be lower than that in the LHM group (36% vs. 88%, p=0.011). However, prevalence of hepatectomy-related complications or length of hospital stay was not significantly different between the two groups.

Conclusions

LHM can reduce intraoperative blood loss. It is useful for transecting adequately cut plane in a hepatectomy for a large HCC. However, postoperative outcomes are not improved by LHM compared to those by non-LHM.

Circulating Tumour Cell Release after Cement Augmentation of Vertebral Metastases

Cement augmentation via percutaneous vertebroplasty or kyphoplasty for treatment of spinal metastasis is a well-established treatment option. We assessed whether elevated intrametastatic pressure during cement augmentation results in an increased dissemination of tumour cells into the vascular circulation. We prospectively collected blood from patients with osteolytic spinal column metastases and analysed the prevalence of circulating tumour cells (CTCs) at three time-points: preoperatively, 20 minutes after cement augmentation, and 3–5 days postoperatively. Enrolling 21 patients, including 13 breast- (61.9%), 5 lung- (23.8%), and one (4.8%) colorectal-, renal-, and prostate-carcinoma patient each, we demonstrate a significant 1.8-fold increase of EpCAM+/K+ CTCs in samples taken 20 minutes post-cement augmentation (P < 0.0001). Despite increased mechanical CTC dissemination due to cement augmentation, follow-up blood draws demonstrated that no long-term increase of CTCs was present. Array-CGH analysis revealed a specific profile of the CTC collected 20 minutes after cement augmentation. This is the first study to report that peripheral CTCs are temporarily increased due to vertebral cement augmentation procedures. Our findings provide a rationale for the development of new prophylactic strategies to reduce the increased release of CTC after cement augmentation of osteolytic spinal metastases.

Diffuse intrahepatic recurrence after percutaneous radiofrequency ablation for solitary and small hepatocellular carcinoma

Two patients developed segmental, diffuse intrahepatic recurrence after percutaneous radiofrequency ablation (RFA) to treat a primary, solitary, and small (2.5 cm) hepatocellular carcinoma (HCC). Despite the size of the HCC, levels of the tumor markers (α-fetoprotein, α-fetoprotein-L3%, and des-γ-carboxyprothrombin) were all elevated before RFA, and tumors in both patients were contiguous with a major branch of the portal vein. Tumor biopsies of both patients revealed moderately differentiated HCC but diagnostic imaging showed an area of reduced tumor blood flow, suggesting a poorly differentiated component. Since early detection of post-RFA malignancies by standard ultrasonography and contrast-enhanced computed tomography was difficult, the most sensitive indicator of recurrence in these two patients was the elevated tumor markers. The diffuse intrahepatic recurrence was thought to be caused by increased intratumoral pressure during RFA, resulting in the dissemination of cancer cells through the contiguous portal vein. The clinical course of these tumors indicate that the choice of RFA should be carefully considered when treating specific subtype of HCC that is adjacent to main portal vein branch and involves a possible poorly differentiated component and that surgical resection or combinations of RFA with other treatment modalities such as transcatheter arterial chemoembolization should be considered as alternative treatment strategies.

Extrahepatic metastasis of hepatocellular carcinoma: incidence and risk factors

BACKGROUND

Extrahepatic metastasis of hepatocellular carcinoma (HCC) is of growing importance as the survival of patients has been improved owing to advances in treatments to intrahepatic lesions.

METHODS

To elucidate the incidence and risk factors of extrahepatic metastasis of HCC, we enrolled 1573 (1131 treatment-naïve and 442 previously treated on referral) patients with HCC without extrahepatic tumour spread treated at the authors' department between 1990 and 2003. Patients received medical treatment including percutaneous ablation and transcatheter arterial chemoembolization, and followed by dynamic computed tomography (CT) or magnetic resonance imaging (MRI) and tumour markers every 3-4 months. Extrahepatic metastasis was diagnosed by plain X-ray, CT, MRI and scintigraphy. Clinical parameters at the time of treatment to intrahepatic lesions were evaluated as a predictor of subsequent extrahepatic metastasis among the 1131 treatment-naïve patients by Cox's proportional hazard model.

RESULTS

During the average observation period of 3.9 years, extrahepatic metastasis was diagnosed in 123 in the treatment-naïve and 53 in the patients treated previously. The incidence rate of extrahepatic metastasis, as detected during the lifetime after medical treatment of HCC, was approximately 13% at 5 years. Multivariate analysis with Cox proportional hazard model revealed that positivity for viral markers, lager tumour diameter, multiple tumour nodules, presence of vascular tumour invasion and elevated tumour markers were associated with the development of extrahepatic metastasis.

CONCLUSION

The incidence of extrahepatic metastasis of HCC diagnosed during clinical course was not frequent. Advanced intrahepatic lesions, presence of vascular tumour invasion, elevated tumour markers and presence of viral hepatitis were risk factors for extrahepatic metastasis.

Detecting carcinoma cells in peripheral blood of patients with hepatocellular carcinoma by immunomagnetic beads and rt-PCR

BACKGROUND

Increasing the sensitivity and specificity of detecting circulating carcinoma cells of patients with hepatocellular carcinoma (HCC) is very important for monitoring recurrence.

GOAL

To establish a novel method of detecting circulating carcinoma cells.

STUDY

For method development, 3 sets of controls using HCC cell line HepG2 cells were used. (A): Serial dilutions of HepG2 cells were directly used to extract total RNA for nested reverse transcription-polymerase chain reaction (RT-PCR). (B): Five milliliter of healthy blood was spiked with a serial dilution of HepG2 cells and was used for Ficoll density gradient centrifugation to recover cells. The cells were used to extract total RNA for RT-PCR. (C): After cell recovery with the same procedure as B, the cells were sorted sequentially by CD45 and Ber-EP4 immunomagnetic beads and used for RNA extraction and RT-PCR. For clinical samples, 44 patients with HCC and 7 healthy subjects were included. The alpha-fetoprotein mRNA was amplified using nested RT-PCR technique.

RESULTS

The spiking experiments using HepG2 cells showed that 10 cells in 5 mL blood could be detected by method C and an excellent dose-response to the number of spiked cells. Whereas, method B lacked any dose-response and would yield high false-positive rates. In clinical samples, the improved method led to a positive detection rate of 52.9%, 76.9%, and 92.9% in Child-Plug class A, B, and C, respectively. There was significant difference between class A and class C (P<0.05). The total positive detection rate was 72.7%.

CONCLUSIONS

Combining negative and positive immunomagnetic beads with RT-PCR technique may improve the sensitivity and specificity of detecting circulating HCC cells.

Declining Plasma Fibrinogen Alpha Fragment Identifies HER2-Positive Breast Cancer Patients and Reverts to Normal Levels after Surgery

Breast cancer is the most common nonskin malignancy affecting women. Currently, no simple, blood-based diagnostic test exists to complement radiological screening and increase sensitivity of detection. To screen plasma specimens and identify biomarkers that detect HER2-positive breast cancer, automated robotic sample processing followed by surface-enhanced laser desorption ionization time-of-flight (SELDI-TOF) mass spectroscopy was used. Multiple statistical algorithms were used to select biomarkers that segregate cancer patients versus controls and produced average CV rates ranging from 20% to 29%. A set of seven biomarkers were validated on an independent test data set and achieved the best error rate of 19.1%. A permutation test indicated a p-value for CV error less than 0.002. Moreover, a ROC curve using these biomarkers achieved an area-under-the-curve value of 0.95 on an independent test data set. The marker responsible for most of the resolving power was identified as a fragment of Fibrinogen Alpha (FGA) encompassing residues 605-629. This marker was present at lower levels in cancer patients as compared to controls. The importance of this biomarker was validated in a longitudinal study comparing pre- and post-operative levels and was shown to revert to normal levels after surgery. This fragment may serve as a useful diagnostic and treatment-monitoring marker.

Role of blood AFP mRNA and tumor grade in the preoperative prognostic evaluation of patients with hepatocellular carcinoma

AIM

To explore the potential prognostic role of preoperative tumor grade and blood AFP mRNA in a cohort of patients with hepatocellular carcinoma (HCC) eligible for radical therapies according to a well-defined treatment algorithm not including nodule size and number as absolute selection criteria.

METHODS

Fifty patients with a diagnosis of HCC were prospectively enrolled in the study. Inclusion criteria were: (1) histological assessment of tumor grade by means of percutaneous biopsies; (2) determination of AFP mRNA status in the blood; (3) patient's eligibility for radical therapies.

RESULTS

At preoperative evaluation, 54% of the study group had a well-differentiated HCC, 42% had AFP mRNA in the blood, 40% had a tumor larger than 5 cm and 56% had more than one nodule. Surgery (resection or liver transplantation) was performed in 29 patients, while 21 had percutaneous ablation procedures. After a median follow-up of 28 mo, 12-, 24-, and 36-mo survival rates were 78%, 58%, and 51%, respectively. Surgical therapy, performance status and three tumor-related variables (AFP mRNA, HCC grade and gross vascular invasion) resulted as significant survival predictors at univariate analysis. Nodule size and number did not perform as significant prognosticators. Multivariate study selected only surgical therapy and a biologically early HCC profile (AFP mRNA negative and well-differentiated tumor without gross vascular invasion) as independent survival variables.

CONCLUSION

The preoperative determination of tumor grade and blood AFP mRNA status may potentially refine the prognostic evaluation of HCC patients and improve the selection process for radical therapies.

Contrast-enhanced dynamic magnetic resonance imaging findings of hepatocellular carcinoma and their correlation with histopathologic findings

PURPOSE

To investigate the correlations of contrast-enhanced magnetic resonance (MR) imaging findings of large (> 5 cm) hepatocellular carcinomas with tumor size and histopathologic findings.

MATERIALS AND METHODS

MR imaging was performed in 30 patients with a histopathologic diagnosis of hepatocellular carcinoma. The imaging protocol included non-contrast, hepatic arterial, portal venous and late phases. The signal intensities relative to the liver, enhancement patterns and the morphologic features of the lesions were evaluated in relation to size and degree of differentiation.

RESULTS

On histopathologic examination, 12 of 30 (40%) tumors were well-differentiated (grade 1), 6 of 30 (20%) were moderately differentiated (grades 2 and 3) and 12 of 30 (40%) were poorly differentiated (grade 4). Tumor size, tumor boundry, serum alpha-fetoprotein level and portal vein invasion were found to have statistically significant correlations with the degree of differentiation (p < 0.05). Portal vein invasion, capsule formation and tumor surface characteristics showed statistically significant correlations with tumor size (p < 0.05).

CONCLUSION

MR imaging findings of hepatocellular carcinomas larger than 5 cm are partially dependent on tumor size and degree of differentiation.

Detecting AFP mRNA in peripheral blood of the patients with hepatocellular carcinoma, liver cirrhosis and hepatitis

BACKGROUND

The low frequency of disseminated carcinoma cells in the blood now makes immunomagnetic bead sorting and reverse transcriptase-polymerase chain reaction (RT-PCR) technique more popular.

METHODS

Three milliliters of peripheral blood were collected from 91 patients and 18 normal donors. The circulating carcinoma cells were enriched with CD45 and Ber-EP4 immunomagnetic beads. The alpha-fetoprotein (AFP) mRNA was amplified with nested RT-PCR.

RESULTS

The total positive detection rate was 72.1%, 43.8%, 25.0%, 100%, and 66.7% in patients with hepatocellular carcinoma (HCC) untreated, liver cirrhosis (LC), hepatitis, metastasis liver cancer, and postsurgery of hepatocellular carcinoma, respectively. There was a significant difference among the patients with HCC, LC and hepatitis (HCC vs. LC, P<0.05; HCC vs. hepatitis, P<0.01) and between Class A and B of the HCC patients (P<0.05). Meanwhile, AFP mRNA was markedly expressed in HCC patients compared to the patients with no HCC (LC and hepatitis). The levels of aspartate transaminase (AST) and gamma-glutamyltranspeptidase (GGT) were significantly different in AFP mRNA-positive patients with autoimmune chronic active hepatitis B (CAHB) or LC in contrast to the corresponding negative patients.

CONCLUSION

Combining negative and positive immunomagnetic bead sorting and RT-PCR technique can effectively detect circulating tumor cells. AFP mRNA is a more reliable marker of metastasis compared to serum AFP.

Identification of HCC-22-5 tumor-associated antigen and antibody response in patients

BACKGROUND

Serological identification of antigens by recombinant expression cloning (SEREX) is a promising method used to analyze tumor-associated antigen (TAA). Nineteen primary HCC-associated antigens have been found from a HCC cDNA library using autogenous serum by the SEREX approach. We searched for HCC-associated antigens and applied them to HCC diagnosis.

METHODS

Nine of 19 primaries HCC-associated antigens identified by SEREX method were tested their immune response again with distinct allogeneic sera. One of the screened HCC-associated antigens, HCC-22-5 was recombined and expressed and made the frequency analysis of its seropositivity in various patients using the methods of Western-blot and ELISA.

RESULTS

SEREX analysis showed that 9 primary HCC-associated antigens had high-titered IgG antibody in the majority of HCC patients. Western-Blot method confirmed that 3/7 HCC patients had antibodies against HCC-22-5, which demonstrated that expressed HCC-22-5 antigen had the character of antigen. Sera samples from 341 patients and 80 normal individuals have been tested for autoantibodies against HCC-22-5 by ELISA method. The results found that 51/128 of HCC, 11/76 of chronic hepatitis, 11/22 of liver cirrhosis and 8/54 of nasopharynx cancer patients had antibodies against HCC-22-5. No antibody response to HCC-22-5 had been found in the sera of 7 lung cancers, 54 gastric-intestine patients and 80 normal individuals. The groups of HCC and liver cirrhosis had higher antibody positive rate than that of other groups (p<0.05). In the HCC sera with alpha-fetoprotein (AFP) negative, the positive rate of HCC-22-5 was as high as 78.9%.

CONCLUSIONS

HCC-22-5 can be used for HCC serologic screening, especially for the patients with AFP negative.

Liver resection for hepatocellular carcinoma in non-cirrhotic liver without underlying viral hepatitis

BACKGROUND

Hepatocellular carcinoma (HCC) arising in normal liver parenchyma is rare and the outcome after hepatectomy is not well documented.

METHODS

Between June 1998 and September 2003, 33 patients without viral hepatitis underwent resection for HCC in a non-cirrhotic, non-fibrotic liver. Data were analysed with regard to operative details, pathological findings including completeness of resection, and outcome as measured by tumour recurrence and survival.

RESULTS

Twenty-three major hepatectomies and ten segmentectomies or bisegmentectomies were performed. After potentially curative resection, 19 of 29 patients were alive at a median follow-up of 25 months, with calculated 1- and 3-year survival rates of 87 and 50 per cent respectively. Survival was significantly better after resection of tumours without vascular invasion (3-year survival rate 89 versus 18 per cent; P = 0.024). Disseminated recurrence developed in nine of 29 patients, leading to death within 28 months of operation in all but one of the nine.

CONCLUSION

These data justify hepatic resection for HCC arising in non-cirrhotic, non-fibrotic liver without underlying viral hepatitis. Liver transplantation is rarely indicated because the outcome is good after resection of tumours without vascular infiltration, whereas vascular invasion is invariably associated with diffuse extrahepatic recurrence.