Liver transplantation for hepatocellular carcinoma: Where do we stand?

The use of machine learning in transarterial chemoembolisation/transarterial embolisation for patients with intermediate-stage hepatocellular carcinoma: a systematic review

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related deaths worldwide. Intermediate-stage HCC is often treated with either transcatheter arterial chemoembolisation (TACE) or transcatheter arterial embolisation (TAE). Integrating machine learning (ML) offers the possibility of improving treatment outcomes through enhanced patient selection. This systematic review evaluates the effectiveness of ML models in improving the precision and efficacy of both TACE and TAE for intermediate-stage HCC. A comprehensive search of PubMed, EMBASE, Web of Science, and Cochrane Library databases was conducted for studies applying ML models to TACE and TAE in patients with intermediate-stage HCC. Seven studies involving 4,017 patients were included. All included studies were from China. Various ML models, including deep learning and radiomics, were used to predict treatment response, yielding a high predictive accuracy (AUC 0.90). However, study heterogeneity limited comparisons. While ML shows potential in predicting treatment outcomes, further research with standardised protocols and larger, multi-centre trials is needed for clinical integration.

Transplantation of Patients with Hepatocellular Carcinoma Through Increased Utilization of Machine Perfusion Technology

Background

With the intent to mitigate waitlist disparities, the median model for end-stage liver disease (MELD) at transplant minus 3 policy nevertheless decreased access to liver transplant for patients with hepatocellular carcinoma (HCC). However, the adoption of machine perfusion (MP) technologies has shown promise in improving deceased donor graft yield and utilization. To understand current use for patients with HCC, we examined liver transplant patterns with MP and the characteristics of patients with HCC receiving an MP liver.

Methods

Adult patients with HCC undergoing deceased donor liver transplant from September 29, 2021, to March 30, 2024, were identified using the United Network for Organ Sharing Standard Transplant Analysis and Research files. Patients were excluded if listed as status 1A or they underwent multiorgan or split liver transplant. Multivariate analysis compared patients with HCC receiving an MP liver with those receiving a static cold storage liver.

Results

Of 3774 liver recipients with HCC, 593 (15.7%) underwent transplant with an MP graft. Compared with patients donation after circulatory death graft receiving a graft with static cold storage preservation, those with MP had less advanced disease (ie, Child-Pugh class C cirrhosis 22.9% versus 29.9%, P < 0.01) and lower median match MELD (13 versus 17, P < 0.001). Tumor characteristics were similar between groups, including alpha-fetoprotein level, maximum tumor size, and locoregional treatments. Donor factors, and not tumor burden, were most predictive of receipt of an MP liver (donation after circulatory death graft: odds ratio [OR], 14.81; macrosteatosis >30%; OR, 3.85; donor age older than 60 y; OR, 2.34). A shorter waitlist time (6.5 versus 7.2 mo, P < 0.01), with similar 1-y patient survival (93.6% versus 93.2%, P = 0.82) and graft survival (92.0% versus 91.6%, P = 0.84), was also noted in patients undergoing MP transplant.

Conclusions

The strategic use of MP livers may improve graft utilization and access to liver transplants, helping offset the disadvantages of the MELD at transplant minus 3 policy for patients with HCC.

Investigation of the Effectiveness of Oleuropein in a Three-Dimensional In Vitro Hepatocellular Tumor Sphere Model

OBJECTIVES

This study was conducted to examine the dose-related effects over time of oleuropein on the proliferation and area of tumor spheroids in hepatocellular carcinoma cells.

MATERIALS AND METHODS

We examined the possible effects of 100 to 500 μM dose concentrations of oleuropein on HepG2 cell proliferation using a real-time cell analyzer. A 3-dimensional hepatocellular carcinoma tumor spheroid model was established by seeding HepG2 cells at a density of 160 cells/well in custom 96-well microplates with low attachment surfaces and culturing for 3 days. Tumor spheres were treated with increasing oleuropein doses for 72 hours, and images were captured every 24 hours. The dose-dependent effects of oleuropein on tumor sphere size were analyzed by measuring the area of tumor spheres with ImageJ software. We conducted oleuropein viability and cytotoxicity analyses using calcein acetoxymethyl ester-based and propidium iodide-based staining in the tumor model.

RESULTS

Oleuropein inhibited cell proliferation; as the dose concentration of oleuropein increased, so did its capacity to inhibit cell proliferation (P < .001). The size of untreated tumor spheres increased at 72 hours (P < .001). However, treatment with 100 to 500 μM oleuropein reduced tumor size by 63.56% to 88.06% compared with untreated cells at the end of 72 hours (P < .001). With increasing concentrations, oleuropein inhibited the viability of tumor spheres, eliminating necrotic death caused by tumor hypoxia.

CONCLUSIONS

Overall, oleuropein reduced the size of tumors by inhibiting tumor proliferation and viability. In this context, oleuropein could be a candidate molecule for further extensive studies to reduce hepatocellular carcinoma tumors to meet Milan criteria for liver transplant.

Evolving Indications for Liver Transplantation for Hepatocellular Carcinoma Following the Milan Criteria

Background/Objectives: Since their introduction in the 1990s, the Milan criteria have been the gold standard of indication for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC). Nevertheless, several institutions have reported wider indication criteria for LT with comparable survival outcomes. Methods: This paper summarizes the recent indications for LT for HCC through a literature review. Results: There are several criteria expanding the Milan criteria, which can be subdivided into the "based on tumor number and size only", "based on tumor number and size plus tumor markers", and "based on tumor differentiation" groups, with the outcomes being comparable to those of patients included within the Milan criteria. Besides the tumor size and number, which are included in the Milan criteria, recent criteria included biomarkers and tumor differentiation. Several retrospective studies have reported microvascular invasion (MVI) as a significant risk factor for postoperative recurrence, highlighting the importance of preoperatively predicting MVI. Several studies attempted to identify preoperative predictive factors for MVI using tumor markers or preoperative imaging findings. Patients with HCC who are LT candidates are often treated while on the waiting list to prevent the progression of HCC or to reduce the measurable disease burden of HCC. The expanding repertoire of chemotherapeutic regiments suitable for patients with HCC should be further investigated. Conclusions: There are several criteria expanding Milan criteria, with the outcomes being comparable to those of patients included within the Milan criteria.

HepatoPredict Accurately Selects Hepatocellular Carcinoma Patients for Liver Transplantation Regardless of Tumor Heterogeneity

BACKGROUND/OBJECTIVES

Hepatocellular carcinoma (HCC) is a major cause of cancer-related deaths rising worldwide. This is leading to an increased demand for liver transplantation (LT), the most effective treatment for HCC in its initial stages. However, current patient selection criteria are limited in predicting recurrence and raise ethical concerns about equitable access to care. This study aims to enhance patient selection by refining the HepatoPredict (HP) tool, a machine learning-based model that combines molecular and clinical data to forecast LT outcomes.

METHODS

The updated HP algorithm was trained on a two-center dataset and assessed against standard clinical criteria. Its prognostic performance was evaluated through accuracy metrics, with additional analyses considering tumor heterogeneity and potential sampling bias.

RESULTS

HP outperformed all clinical criteria, particularly regarding negative predictive value, addressing critical limitations in existing selection strategies. It also demonstrated improved differentiation of recurrence-free and overall survival outcomes. Importantly, the prognostic accuracy of HP remained largely unaffected by intra-nodule and intra-patient heterogeneity, indicating its robustness even when biopsies were taken from smaller or non-dominant nodules.

CONCLUSIONS

These findings support the usage of HP as a valuable tool for optimizing LT candidate selection, promoting fair organ allocation and enhancing patient outcomes through integrated analysis of molecular and clinical data.

Acute postoperative pain management after living donor hepatectomy during the transition from an open to minimally invasive surgical approach

Background

Acute post-surgical pain is a common concern for patients undergoing living donor hepatectomy (LDH), potentially leading to unfavorable outcomes if not treated adequately. This study aimed to evaluate the impact of the transition of surgical techniques from open and laparoscopic to robot-assisted minimally invasive surgical (MIS) approach, and the different types of graft resection, including right, left, and left lateral partial lobectomy (LL), on analgesia requirements during the first two postoperative days.

Methods

A single-center retrospective electronic chart review of all patients who underwent LDH procedures between 2018 and 2020 was performed.

Results

Patients underwent LDH procedure (n = 414) through open (n = 93, 22%), laparoscopic (n = 68, 16%), or robot-assisted MIS (n = 253, 61%) approaches; and had right lobectomy (n = 215, 52%), left lobectomy (n = 121, 29%), or LL (n = 78, 19%). Postoperatively within the first 48 h, the pain reported on a 3-point Visual Analogue Scale (VAS), was mild 77%, moderate 21%, or severe only 2%. The laparoscopic approach and LL resection were associated with higher pain scores, whereas the robotic approach was the least painful overall.

Conclusions

Robot-assisted MIS approach for LDH procedure resulted in lower acute pain scores when compared with other surgical approaches, obviating the need for intravenous (IV) patient-controlled analgesia (PCA).

Comparative analysis of patients transplanted due to hepatocellular carcinoma. Are there survival differences between those who meet the Milan criteria and those who exceed them?

INTRODUCTION AND AIM

The Milan criteria have been the subject of discussion in recent years due to their restrictive nature. Expansion of the criteria and the use of locoregional therapies to downstage patients and increase the number of transplant candidates have been proposed. Our study analyzed the results of patients that underwent transplant due to hepatocellular carcinoma, comparing those that met the Milan criteria and those that exceeded them.

MATERIALS AND METHODS

A retrospective, observational, single-center study was conducted on liver transplantations due to hepatocellular carcinoma, within the time frame of 2010-2021. Demographic and clinical variables, overall survival, and disease-free survival were analyzed. The Student's t test or Mann-Whitney U test were applied for the quantitative variables and the Fisher's exact test for the categorical variables. The survival function was estimated through the Kaplan-Meier method and the log-rank test was applied for comparing the groups.

RESULTS

Of the 96 transplanted patients, 78 met the Milan criteria and 18 exceeded them. Patients that did not meet the Milan criteria had a higher number of nodules (1.6 vs. 3.5 nodules; p = 0.000), larger main lesions (24.38 vs. 38.55 mm; p = 0.000), a higher bilobar hepatocellular carcinoma rate (21.79% vs. 72.22%, p = 0.000), and higher tumor burden. There were no significant differences regarding overall survival, but there was a lower rate of disease-free survival in the group exceeding the criteria.

CONCLUSION

Downstaged patients that received locoregional therapies had lower disease-free survival rates than patients that met the Milan criteria, but there were no significant differences regarding overall survival.

Long-term outcomes of more than a decade treating patients with stereotactic body radiation therapy for hepatocellular carcinoma

Purpose/Objectives

To evaluate if stereotactic body radiotherapy (SBRT) for hepatocellular carcinoma (HCC) has a durable effect on tumor control and can be delivered safely.

Materials/Methods

Patients included in this retrospective study have been treated at our institution from January 2008 to December 2022. Eligibility criteria were diagnosis of HCC, BCLC stage 0-A-B, non-cirrhotic liver or liver with cirrhosis Child-Pugh class A, and a maximum of three lesions with a cumulative diameter of ≤ 6 cm. Patients with relapses after surgery, thermal ablation or TACE or patients awaiting transplant were also candidates for SBRT. SBRT was delivered in 6 fractions of 8 or 9 Gy. The primary endpoint was local (target) control (LC). Secondary endpoints were time to progression (TTP), overall survival (OS), response rate (RR) and toxicity.

Results

A total of 52 patients received SBRT at our institution and 51 were included in this study. One patient objected and was excluded. Median follow-up was 2.1 years for LC and 2.3 years for OS. Median tumor size was 26 mm. LC rates at 1, 2, and 5 years were 100 %, 95 % and 95 % respectively. Median TTP was 45.6 months. Median OS was 7.1 years. RR was 96 %. No patients in this study have experienced SBRT related CTC AE grade ≥ 3 toxicity.

Conclusion

SBRT resulted in excellent long-term local control rates and absence of severe toxicity in a group of HCC patients. The reported outcomes compare favorably with other local therapies. SBRT should be considered as one of the available local treatment options for HCC.

Artificial intelligence-based model for the recurrence of hepatocellular carcinoma after liver transplantation

BACKGROUND

Artificial intelligence-based models might improve patient selection for liver transplantation in hepatocellular carcinoma. The objective of the current study was to develop artificial intelligence-based deep learning models and determine the risk of recurrence after living donor liver transplantation for hepatocellular carcinoma.

METHODS

The study was a single-center retrospective cohort study. Patients who underwent living donor liver transplantation for hepatocellular carcinoma were divided into training and validation cohorts (n = 192). The deep learning models were used to stratify patients in the training cohort into low- and high-risk groups, and 5-year recurrence-free survival was assessed in the validation cohort.

RESULTS

The median follow-up period was 59.1 (33.9-72.4) months. The artificial intelligence model (pretransplant factors) had an area under the curve of 0.86 in the training cohort and 0.71 in the validation cohort. The largest tumor diameter and alpha-fetoprotein level had the greatest Shapley Additive exPlanations values for recurrence (>0.4). The 5-year recurrence-free survival rates in the low- and high-risk groups were 92.6% and 45% (P < .001). In the second artificial intelligence model (pretransplant factors + grade), the area under the curve for the validation cohort was 0.77, with 5-year recurrence-free survival rates of 96% and 30% in the low- and high-risk groups (P < .001). None of the low-risk patients outside the Milan and University of California San Francisco Criteria had recurrence during follow-up.

CONCLUSIONS

The artificial intelligence-based hepatocellular carcinoma transplant recurrence models might improve patient selection for liver transplantation.

Is DEB-TACE as locoregional therapy before liver transplantation for hepatocellular carcinoma effective?

BACKGROUND

The objectives were to assess the safety and efficacy of drug-eluting bead transarterial chemoembolization (DEB-TACE) as locoregional therapy (LRT) in hepatocellular carcinoma (HCC) before liver transplantation (LT) beyond Hangzhou criteria (HC) and to analyze the prognostic factors.

METHODS

Forty patients with HCC beyond HC who received DEB-TACE only before LT were retrospectively analyzed between January 2017 and December 2022. Data on patient demographics, disease characteristics, treatment response, and adverse events (AE) were collected. Overall survival (OS) and recurrence-free survival (RFS) were evaluated with Kaplan-Meier curves. Univariate and multivariate Cox regression analyses were performed to identify factors independently associated with RFS and OS.

RESULTS

All patients successfully underwent LT following DEB-TACE with a mean interval of 2.3 months. The objective response rates (ORRs) for these patients following DEB-TACE was 82.5%. The primary AE was post-embolization syndrome (PES), with affected patients experiencing grades I and II. The median RFS and OS were 12.0 months (95%CI: 0.0-30.1) and 52.0 months (95%CI: 11.8-92.2) over the follow-up period until December 2022. The 2-year RFS and OS rates were 42.5%, and 67.5%. Multivariate analyses revealed Child-Pugh classification (HR = 6.24; 95%CI,1.83-21.24; P = 0.01) and macrovascular invasion (MAV) (HR = 3.89; 95%CI,1.07-14.15; P = 0.04) were both significant independent predictors of OS.

CONCLUSIONS

DEB-TACE can serve as a safe and effective LRT in HCC patients beyond HC before LT, and can improve the prognosis of patients, especially without MAV. The higher Child-Pugh classification and MAV are independent prognostic factors after LT.

Hepatocellular carcinoma: An analysis of the expression status of stress granules and their prognostic value

BACKGROUND

Hepatocellular carcinoma (HCC) is a global popular malignant tumor, which is difficult to cure, and the current treatment is limited.

AIM

To analyze the impacts of stress granule (SG) genes on overall survival (OS), survival time, and prognosis in HCC.

METHODS

The combined The Cancer Genome Atlas-Liver Hepatocellular Carcinoma (TCGA-LIHC), GSE25097, and GSE36376 datasets were utilized to obtain genetic and clinical information. Optimal hub gene numbers and corresponding coefficients were determined using the Least absolute shrinkage and selection operator model approach, and genes for constructing risk scores and corresponding correlation coefficients were calculated according to multivariate Cox regression, respectively. The prognostic model’s receiver operating characteristic (ROC) curve was produced and plotted utilizing the time ROC software package. Nomogram models were constructed to predict the outcomes at 1, 3, and 5-year OS prognostications with good prediction accuracy.

RESULTS

We identified seven SG genes (DDX1, DKC1, BICC1, HNRNPUL1, CNOT6, DYRK3, CCDC124) having a prognostic significance and developed a risk score model. The findings of Kaplan-Meier analysis indicated that the group with a high risk exhibited significantly reduced OS in comparison with those of the low-risk group (P < 0.001). The nomogram model’s findings indicate a significant enhancement in the accuracy of OS prediction for individuals with HCC in the TCGA-HCC cohort. Gene Ontology and Gene Set Enrichment Analysis suggested that these SGs might be involved in the cell cycle, RNA editing, and other biological processes.

CONCLUSION

Based on the impact of SG genes on HCC prognosis, in the future, it will be used as a biomarker as well as a unique therapeutic target for the identification and treatment of HCC.

Hepatocellular carcinoma: An analysis of the expression status of stress granules and their prognostic value

BACKGROUND

Hepatocellular carcinoma (HCC) is a global popular malignant tumor, which is difficult to cure, and the current treatment is limited.

AIM

To analyze the impacts of stress granule (SG) genes on overall survival (OS), survival time, and prognosis in HCC.

METHODS

The combined The Cancer Genome Atlas-Liver Hepatocellular Carcinoma (TCGA-LIHC), GSE25097, and GSE36376 datasets were utilized to obtain genetic and clinical information. Optimal hub gene numbers and corresponding coefficients were determined using the Least absolute shrinkage and selection operator model approach, and genes for constructing risk scores and corresponding correlation coefficients were calculated according to multivariate Cox regression, respectively. The prognostic model's receiver operating characteristic (ROC) curve was produced and plotted utilizing the time ROC software package. Nomogram models were constructed to predict the outcomes at 1, 3, and 5-year OS prognostications with good prediction accuracy.

RESULTS

We identified seven SG genes (DDX1, DKC1, BICC1, HNRNPUL1, CNOT6, DYRK3, CCDC124) having a prognostic significance and developed a risk score model. The findings of Kaplan-Meier analysis indicated that the group with a high risk exhibited significantly reduced OS in comparison with those of the low-risk group (P < 0.001). The nomogram model's findings indicate a significant enhancement in the accuracy of OS prediction for individuals with HCC in the TCGA-HCC cohort. Gene Ontology and Gene Set Enrichment Analysis suggested that these SGs might be involved in the cell cycle, RNA editing, and other biological processes.

CONCLUSION

Based on the impact of SG genes on HCC prognosis, in the future, it will be used as a biomarker as well as a unique therapeutic target for the identification and treatment of HCC.

MASLD-Related HCC: A Comprehensive Review of the Trends, Pathophysiology, Tumor Microenvironment, Surveillance, and Treatment Options

Hepatocellular carcinoma (HCC) represents a significant burden on global healthcare systems due to its considerable incidence and mortality rates. Recent trends indicate an increase in the worldwide incidence of metabolic dysfunction-associated steatotic liver disease (MASLD) and a shift in the etiology of HCC, with MASLD replacing the hepatitis B virus as the primary contributor to new cases of HCC. MASLD-related HCC exhibits distinct characteristics compared to viral HCC, including unique immune cell profiles resulting in an overall more immunosuppressive or exhausted tumor microenvironment. Furthermore, MASLD-related HCC is frequently identified in older age groups and among individuals with cardiometabolic comorbidities. Additionally, a greater percentage of MASLD-related HCC cases occur in noncirrhotic patients compared to those with viral etiologies, hindering early detection. However, the current clinical practice guidelines lack specific recommendations for the screening of HCC in MASLD patients. The evolving landscape of HCC management offers a spectrum of therapeutic options, ranging from surgical interventions and locoregional therapies to systemic treatments, for patients across various stages of the disease. Despite ongoing debates, the current evidence does not support differences in optimal treatment modalities based on etiology. In this study, we aimed to provide a comprehensive overview of the current literature on the trends, characteristics, clinical implications, and treatment modalities for MASLD-related HCC.

The roles of cancer stem cell-derived secretory factors in shaping the immunosuppressive tumor microenvironment in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most prevalent malignancies worldwide and has a poor prognosis. Although immune checkpoint inhibitors have entered a new era of HCC treatment, their response rates are modest, which can be attributed to the immunosuppressive tumor microenvironment within HCC tumors. Accumulating evidence has shown that tumor growth is fueled by cancer stem cells (CSCs), which contribute to therapeutic resistance to the above treatments. Given that CSCs can regulate cellular and physical factors within the tumor niche by secreting various soluble factors in a paracrine manner, there have been increasing efforts toward understanding the roles of CSC-derived secretory factors in creating an immunosuppressive tumor microenvironment. In this review, we provide an update on how these secretory factors, including growth factors, cytokines, chemokines, and exosomes, contribute to the immunosuppressive TME, which leads to immune resistance. In addition, we present current therapeutic strategies targeting CSC-derived secretory factors and describe future perspectives. In summary, a better understanding of CSC biology in the TME provides a rational therapeutic basis for combination therapy with ICIs for effective HCC treatment.

Design, Synthesis, and Mechanistic Studies of (R)-3-Amino-5,5-difluorocyclohex-1-ene-1-carboxylic Acid as an Inactivator of Human Ornithine Aminotransferase

Human ornithine aminotransferase (hOAT), a pyridoxal 5'-phosphate (PLP)-dependent enzyme, has been shown to play an essential role in the metabolic reprogramming and progression of hepatocellular carcinoma (HCC). HCC accounts for approximately 75% of primary liver cancers and is within the top three causes of cancer death worldwide. As a result of treatment limitations, the overall 5-year survival rate for all patients with HCC is under 20%. The prevalence of HCC necessitates continued development of novel and effective treatment methods. In recent years, the therapeutic potential of selective inactivation of hOAT has been demonstrated for the treatment of HCC. Inspired by previous increased selectivity for hOAT by the expansion of the cyclopentene ring scaffold to a cyclohexene, we designed, synthesized, and evaluated a series of novel fluorinated cyclohexene analogues and identified (R)-3-amino-5,5-difluorocyclohex-1-ene-1-carboxylic acid as a time-dependent inhibitor of hOAT. Structural and mechanistic studies have elucidated the mechanism of inactivation of hOAT by 5, resulting in a PLP-inactivator adduct tightly bound to the active site of the enzyme. Intact protein mass spectrometry, 19F NMR spectroscopy, transient state kinetic studies, and X-ray crystallography were used to determine the structure of the final adduct and elucidate the mechanisms of inactivation. Interestingly, despite the highly electrophilic intermediate species conferred by fluorine and structural evidence of solvent accessibility in the hOAT active site, Lys292 and water did not participate in nucleophilic addition during the inactivation mechanism of hOAT by 5. Instead, rapid aromatization to yield the final adduct was favored.

Integrated transcriptomics and histopathology approach identifies a subset of rejected donor livers with potential suitability for transplantation

BACKGROUND

Liver transplantation is an effective treatment for liver failure. There is a large unmet demand, even as not all donated livers are transplanted. The clinical selection criteria for donor livers based on histopathological evaluation and liver function tests are variable. We integrated transcriptomics and histopathology to characterize donor liver biopsies obtained at the time of organ recovery. We performed RNA sequencing as well as manual and artificial intelligence-based histopathology (10 accepted and 21 rejected for transplantation).

RESULTS

We identified two transcriptomically distinct rejected subsets (termed rejected-1 and rejected-2), where rejected-2 exhibited a near-complete transcriptomic overlap with the accepted livers, suggesting acceptability from a molecular standpoint. Liver metabolic functional genes were similarly upregulated, and extracellular matrix genes were similarly downregulated in the accepted and rejected-2 groups compared to rejected-1. The transcriptomic pattern of the rejected-2 subset was enriched for a gene expression signature of graft success post-transplantation. Serum AST, ALT, and total bilirubin levels showed similar overlapping patterns. Additional histopathological filtering identified cases with borderline scores and extensive molecular overlap with accepted donor livers.

CONCLUSIONS

Our integrated approach identified a subset of rejected donor livers that are likely suitable for transplantation, demonstrating the potential to expand the pool of transplantable livers.

Analytical validation and algorithm improvement of HepatoPredict kit to assess hepatocellular carcinoma prognosis before a liver transplantation

Objectives

To verify the analytical performance of the HepatoPredict kit, a novel tool developed to stratify Hepatocellular Carcinoma (HCC) patients according to their risk of relapse after a Liver Transplantation (LT).

Methods

The HepatoPredict tool combines clinical variables and a gene expression signature in an ensemble of machine-learning algorithms to forecast the benefit of a LT in HCC patients. To ensure the accuracy and reliability of this method, extensive analytical validation was conducted to verify its specificity and robustness. The experiments were designed following the guidelines for multi-target genomic assays such as ISO201395-2019, MIQE, CLSI-MM16, CLSI-MM17, and CLSI-EP17-A. The validation process included reproducibility between operators and between RNA extractions and RT-qPCR runs, and interference of input RNA levels or varying reagent levels. A recently retrained version of the HepatoPredict algorithms was also tested.

Results

The validation process demonstrated that the HepatoPredict kit met the required standards for robustness (p > 0.05), analytical specificity (inclusivity of 95 %), and sensitivity (LoB, LoD, linear range, and amplification efficiency between 90 and 110 %). The operator, equipment, input RNA, and reagents used had no significant effect on the HepatoPredict results. Additionally, the testing of a recently retrained version of the HepatoPredict algorithm, showed that this new version further improved the accuracy of the kit and performed better than existing clinical criteria in accurately identifying HCC patients who are more likely to benefit LT.

Conclusions

Even with the introduced variations in molecular and clinical variables, the HepatoPredict kit's prognostic information remains consistent. It can accurately identify HCC patients who are more likely to benefit from a LT. Its robust performance also confirms that it can be easily integrated into standard diagnostic laboratories.

Navigating nonalcoholic fatty liver disease (NAFLD): Exploring the roles of estrogens, pharmacological and medical interventions, and life style

The pursuit of studying this subject is driven by the urgency to address the increasing global prevalence of Non-Alcoholic Fatty Liver Disease (NAFLD) and its profound health implications. NAFLD represents a significant public health concern due to its association with metabolic disorders, cardiovascular complications, and the potential progression to more severe conditions like non-alcoholic steatohepatitis (NASH), fibrosis, and cirrhosis. Liver estrogen signaling is important for maintaining liver function, and loss of estrogens increases the likelihood of NAFLD in postmenopausal women. Understanding the multifaceted mechanisms underlying NAFLD pathogenesis, its varied treatment strategies, and their effectiveness is crucial for devising comprehensive and targeted interventions. By unraveling the intricate interplay between genetics, lifestyle, hormonal regulation, and gut microbiota, we can unlock insights into risk stratification, early detection, and personalized therapeutic approaches. Furthermore, investigating the emerging pharmaceutical interventions and dietary modifications offers the potential to revolutionize disease management. This review reinforces the role of collaboration in refining NAFLD comprehension, unveiling novel therapeutic pathways, and ultimately improving patient outcomes for this intricate hepatic condition.

Prognostic Factors for Mortality in Hepatocellular Carcinoma at Diagnosis: Development of a Predictive Model Using Artificial Intelligence

BACKGROUND

Hepatocellular carcinoma (HCC) accounts for 75% of primary liver tumors. Controlling risk factors associated with its development and implementing screenings in risk populations does not seem sufficient to improve the prognosis of these patients at diagnosis. The development of a predictive prognostic model for mortality at the diagnosis of HCC is proposed.

METHODS

In this retrospective multicenter study, the analysis of data from 191 HCC patients was conducted using machine learning (ML) techniques to analyze the prognostic factors of mortality that are significant at the time of diagnosis. Clinical and analytical data of interest in patients with HCC were gathered.

RESULTS

Meeting Milan criteria, Barcelona Clinic Liver Cancer (BCLC) classification and albumin levels were the variables with the greatest impact on the prognosis of HCC patients. The ML algorithm that achieved the best results was random forest (RF).

CONCLUSIONS

The development of a predictive prognostic model at the diagnosis is a valuable tool for patients with HCC and for application in clinical practice. RF is useful and reliable in the analysis of prognostic factors in the diagnosis of HCC. The search for new prognostic factors is still necessary in patients with HCC.

Management of hepatocellular carcinoma recurrence after liver surgery and thermal ablations: state of the art and future perspectives

Despite the improvements in surgical and medical therapy for hepatocellular carcinoma (HCC), recurrence still represents a major issue. Up to 70% of patients can experience HCC recurrence after liver resection (LR), as well as 20% of them even after liver transplantation (LT). The patterns of recurrence are different according to both the time and the location. Similarly, the risk factors and the management can change not only according to these patterns, but also according to the underlying liver condition and to the first treatment performed. Deep knowledge of such correlation is fundamental, since prevention and effective management of recurrence are undoubtedly the most important strategies to improve the outcomes of HCC treatment. Without adjuvant therapy, maintaining very close monitoring during the first 2 years in order to diagnose curable recurrence and continue this monitoring beyond 5 years because late recurrences exist, remains our only possibility today. Surgery represents the cornerstone treatment for HCC, including both LT and LR. However, new interesting therapeutic opportunities are coming from immunotherapy that has shown encouraging results also in the adjuvant setting. In such a complex and evolutionary scenario, the aim of this review is to summarize current strategies for the management of HCC recurrence, focusing on the different possible scenarios, as well as on future perspectives.

Stereotactic Body Radiation Therapy With or Without Transarterial Chemoembolization Versus Transarterial Chemoembolization Alone in Early-Stage Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

PURPOSE

This study aims to review the current evidence on the utility of stereotactic body radiation therapy (SBRT), with or without transarterial chemoembolization (TACE), for early-stage hepatocellular carcinoma (ESHCC) patients not amenable to standard curative treatment options.

METHODS

Literature search was conducted using PubMed, ScienceDirect, and Google Scholar. Comparative studies reporting oncologic outcomes were included in the review.

RESULTS

Five studies (one phase II randomized controlled trial, one prospective cohort, three retrospective studies) compared SBRT versus TACE. Pooled analysis showed an overall survival (OS) benefit after 3 years (OR 1.65, 95% CI 1.17-2.34, p = 0.005) which persisted in the 5-year data (OR 1.53, 95% CI 1.06-2.22, p = 0.02) in favor of SBRT. RFS benefit with SBRT was also seen at 3 years (OR 2.06, 95% CI 1.03-4.11, p = 0.04) which continued after 5 years (OR 2.35, 95% CI 1.47-3.75, p = 0.0004). Pooled 2-year local control (LC) favored SBRT over TACE (OR 2.96, 95% CI 1.89-4.63, p < 0.00001). Two retrospective studies compared TACE + SBRT versus TACE alone. Pooled analysis showed significantly improved 3-year OS (OR 5.47; 95% CI 2.47-12.11, p < 0.0001) and LC (OR: 21.05; 95% CI 5.01-88.39, p ≤ 0.0001) in favor of the TACE + SBRT group. A phase III study showed significantly improved LC and PFS with SBRT after failed TACE/TAE versus further TACE/TAE.

CONCLUSIONS

Taking into account the limitations of the included studies, our review suggests significantly improved clinical outcomes in all groups having SBRT as a component of treatment versus TACE alone or further TACE. Larger prospective studies are warranted to further define the role of SBRT and TACE for ESHCC.

Liver Transplantation for Hepatocellular Carcinoma in Patients with Inherited Metabolic Liver Diseases: A Single-Center Analysis

BACKGROUND/AIMS

Liver transplantation is an acceptable treatment for some selected hepatocellular carcinoma. We report our experience of 6 patients with liver transplantation for hepatocellular carcinoma with background inherited metabolic disease.

MATERIALS AND METHODS

This is a single-center retrospective, descriptive study. Consecutive patients who underwent liver transplantation for hepatocellular carcinoma with background inherited metabolic disease were included in the study. The record of the patients was accessed, and the following data were extracted: sociodemographic variables, type of metabolic disease, date of liver transplantation, tumor characteristics, laboratory parameters, Model for End-Stage Liver Disease score, immediate- and long-term outcome after transplantation, disease-free survival, and overall survival. Data were analyzed using Statistical Package for the Social Sciences version 25.0.

RESULTS

Six patients received liver transplantation for hepatocellular carcinoma with background inherited metabolic liver disease. The median age was 4.5 years. The median Model for End-Stage Liver Disease score was 29.30. The median maximum tumor diameter was 2.15 cm. Three patients had multiple tumor nodules. Half of the patients had microvascular invasion. Four of the patients had a moderately differentiated tumor. Progressive familial intrahepatic cholestasis type II is the commonest inherited metabolic disease seen in 3 patients. Median follow-up is 46.1 months. Half of the patients are currently more than 5 years post liver transplantation with no features of recurrence. The estimated survival rates at 1, 3, and 5 years are 100%, 83.3%, and 83.3%, respectively.

CONCLUSION

Liver transplant for these categories of patients is associated with good disease-free and overall survival, even in the presence of some seemingly poor prognostic features.

Quantitative dual-energy computed tomography with cesium as a novel contrast agent for localization of thermochemical ablation in phantoms and ex vivo models

BACKGROUND

Thermochemical ablation (TCA) is a minimally invasive therapy under development for hepatocellular carcinoma. TCA simultaneously delivers an acid (acetic acid, AcOH) and base (sodium hydroxide, NaOH) directly into the tumor, where the acid/base chemical reaction produces an exotherm that induces local ablation. However, AcOH and NaOH are not radiopaque, making monitoring TCA delivery difficult.

PURPOSE

We address the issue of image guidance for TCA by utilizing cesium hydroxide (CsOH) as a novel theranostic component of TCA that is detectable and quantifiable with dual-energy CT (DECT).

MATERIALS AND METHODS

To quantify the minimum concentration of CsOH that can be positively identified by DECT, the limit of detection (LOD) was established in an elliptical phantom (Multi-Energy CT Quality Assurance Phantom, Kyoto Kagaku, Kyoto, Japan) with two DECT technologies: a dual-source system (SOMATOM Force, Siemens Healthineers, Forchheim, Germany) and a split-filter, single-source system (SOMATOM Edge, Siemens Healthineers). The dual-energy ratio (DER) and LOD of CsOH were determined for each system. Cesium concentration quantification accuracy was evaluated in a gelatin phantom before quantitative mapping was performed in ex vivo models.

RESULTS

On the dual-source system, the DER and LOD were 2.94 and 1.36-mM CsOH, respectively. For the split-filter system, the DER and LOD were 1.41- and 6.11-mM CsOH, respectively. The signal on cesium maps in phantoms tracked linearly with concentration (R2  = 0.99) on both systems with an RMSE of 2.56 and 6.72 on the dual-source and split-filter system, respectively. In ex vivo models, CsOH was detected following delivery of TCA at all concentrations.

CONCLUSIONS

DECT can be used to detect and quantify the concentration of cesium in phantom and ex vivo tissue models. When incorporated in TCA, CsOH performs as a theranostic agent for quantitative DECT image-guidance.

Immunomodulatory role of mitochondrial DAMPs: a missing link in pathology?

In accordance with the endosymbiotic theory, mitochondrial components bear characteristic prokaryotic signatures, which act as immunomodulatory molecules when released into the extramitochondrial compartment. These endogenous immune triggers, called mitochondrial damage-associated molecular patterns (mtDAMPs), have been implicated in the pathogenesis of various diseases, yet their role remains largely unexplored. In this review, we summarise the available literature on mtDAMPs in diseases, with a special focus on respiratory diseases. We highlight the need to bolster mtDAMP research using a multipronged approach, to study their effect on specific cell types, receptors and machinery in pathologies. We emphasise the lacunae in the current understanding of mtDAMPs, particularly in their cellular release and the chemical modifications they undergo. Finally, we conclude by proposing additional effects of mtDAMPs in diseases, specifically their role in modulating the immune system.

Racial, ethnic, and socioeconomic disparities impact post-liver transplant survival in patients with hepatocellular carcinoma

INTRODUCTION AND OBJECTIVES

Liver transplantation can be a curative treatment for patients with hepatocellular carcinoma (HCC); however, the morbidity and mortality associated with HCC varies by socioeconomic status and race and ethnicity. Policies like Share 35 were implemented to ensure equitable access to organ transplants; however, their impacts are unclear. We aimed to characterize differences in post-liver transplant (LT) survival among patients with HCC, when considering race and ethnicity, income, and insurance type, and understand if these associations were impacted by Share 35.

MATERIALS AND METHODS

We conducted a retrospective cohort study of 30,610 adult LT recipients with HCC. Data were obtained from the UNOS database. Survival analysis was carried out using Kaplan-Meier curves, and multivariate Cox regression analysis was used to calculate hazard ratios.

RESULTS

Men (HR: 0.90 (95% CI: 0.85-0.95)), private insurance (HR: 0.91 (95% CI: 0.87-0.92)), and income (HR: 0.87 (95% CI: 0.83-0.92)) corresponded with higher post-LT survival, when adjusted for over 20 demographic and clinical characteristics (Table 2). African American or Black individuals were associated with lower post-LT survival (HR: 1.20 (95% CI: 1.12-1.28)), whereas. Asian (HR: 0.79 (95% CI: 0.71-0.88)) or Hispanic (HR: 0.86 (95% CI: 0.81-0.92)) individuals were associated with higher survival as compared with White individuals (Table 2). Many of these patterns held in the pre-Share 35 and Share 35 periods.

CONCLUSIONS

Racial, ethnic, and socioeconomic disparities at time of transplant, such as private insurance and income, influence post-LT survival in patients with HCC. These patterns persist despite the passage of equitable access policies, such as Share 35.

An Atypical Presentation of Hepatocellular Carcinoma with Multisite Metastasis following a Curative Liver Transplant

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy, and liver transplantation is usually curative. HCC recurrences are rare after curative treatment options, although they are prevalent depending on various risk factors. We present a 71-year-old female patient with an unusual pattern of disease progression following a curative liver transplant with a metastatic presentation in the absence of alpha-fetoprotein elevation after 3 years of disease-free clinical presentation. We present this case to emphasize the importance of intermittent cross-sectional imaging in addition to ultrasound screening in HCC surveillance.

Cell-Free DNA as a Surveillance Tool for Hepatocellular Carcinoma Patients after Liver Transplant

The liver is the world's sixth most common primary tumor site, responsible for approximately 5% of all cancers and over 8% of cancer-related deaths. Hepatocellular carcinoma (HCC) is the predominant type of liver cancer, accounting for approximately 75% of all primary liver tumors. A major therapeutic tool for this disease is liver transplantation. Two of the most significant issues in treating HCC are tumor recurrence and graft rejection. Currently, the detection and monitoring of HCC recurrence and graft rejection mainly consist of imaging methods, tissue biopsies, and alpha-fetoprotein (AFP) follow-up. However, they have limited accuracy and precision. One of the many possible components of cfDNA is circulating tumor DNA (ctDNA), which is cfDNA derived from tumor cells. Another important component in transplantation is donor-derived cfDNA (dd-cfDNA), derived from donor tissue. All the components of cfDNA can be analyzed in blood samples as liquid biopsies. These can play a role in determining prognosis, tumor recurrence, and graft rejection, assisting in an overall manner in clinical decision-making in the treatment of HCC.

The Role of mTOR Inhibitors after Liver Transplantation for Hepatocellular Carcinoma

Liver transplantation is a treatment option for nonresectable patients with early-stage HCC, with more significant advantages when Milan criteria are fulfilled. An immunosuppressive regimen is required to reduce the risk of graft rejection after transplantation, and CNIs represent the drugs of choice in this setting. However, their inhibitory effect on T-cell activity accounts for a higher risk of tumour regrowth. mTOR inhibitors (mTORi) have been introduced as an alternative immunosuppressive approach to conventional CNI-based regimens to address both immunosuppression and cancer control. The PI3K-AKT-mTOR signalling pathway regulates protein translation, cell growth, and metabolism, and the pathway is frequently deregulated in human tumours. Several studies have suggested the role of mTORi in reducing HCC progression after LT, accounting for a lower recurrence rate. Furthermore, mTOR immunosuppression controls the renal damage associated with CNI exposure. Conversion to mTOR inhibitors is associated with stabilizing and recovering renal dysfunction, suggesting an essential renoprotective effect. Limitations in this therapeutic approach are related to their negative impact on lipid and glucose metabolism as well as on proteinuria development and wound healing. This review aims to summarize the roles of mTORi in managing patients with HCC undergoing LT. Strategies to overcome common adverse effects are also proposed.

Artificial intelligence, machine learning, and deep learning in liver transplantation

Liver transplantation (LT) is a life-saving treatment for individuals with end-stage liver disease. The management of LT recipients is complex, predominantly because of the need to consider demographic, clinical, laboratory, pathology, imaging, and omics data in the development of an appropriate treatment plan. Current methods to collate clinical information are susceptible to some degree of subjectivity; thus, clinical decision-making in LT could benefit from the data-driven approach offered by artificial intelligence (AI). Machine learning and deep learning could be applied in both the pre- and post-LT settings. Some examples of AI applications pre-transplant include optimising transplant candidacy decision-making and donor-recipient matching to reduce waitlist mortality and improve post-transplant outcomes. In the post-LT setting, AI could help guide the management of LT recipients, particularly by predicting patient and graft survival, along with identifying risk factors for disease recurrence and other associated complications. Although AI shows promise in medicine, there are limitations to its clinical deployment which include dataset imbalances for model training, data privacy issues, and a lack of available research practices to benchmark model performance in the real world. Overall, AI tools have the potential to enhance personalised clinical decision-making, especially in the context of liver transplant medicine.

Hepatic Resection vs Particle Therapy as an Initial Treatment for Single Hepatocellular Carcinoma: Bi-institutional Propensity Score-Matched Analysis

BACKGROUND

Curative treatment for hepatocellular carcinoma (HCC) is limited to hepatic resection (HR), radiofrequency ablation, and liver transplantation, but the value of particle therapy (PT) as an initial treatment remains unclear. This study aimed to compare the outcomes of HR and PT for single HCC.

STUDY DESIGN

A total of 554 patients with single HCC without vascular invasion were enrolled from January 2000 to December 2015. Patients underwent either HR (n = 279) or PT (n = 275) as initial treatments. A one-to-one propensity score-matching analysis was performed to evaluate the overall survival (OS) and progression-free survival after dividing patients according to liver function as assessed by the modified albumin-bilirubin grade.

RESULTS

The median OS (130 vs 85 months, p = 0.001) and progression-free survival (47 vs 30 months HR, p = 0.004) of HR were also significantly better than that of PT in the propensity score-matching cohort with modified albumin-bilirubin grade 1/2a (n = 145 per group). Meanwhile, in a propensity score-matching cohort with modified albumin-bilirubin grade 2b/3 (n = 53 per group), there were no significant differences in median OS and progression-free survival between HR and PT.

CONCLUSIONS

HR may be preferable as an initial treatment for patients with single HCC without vascular invasion, especially those with preserved liver function. PT can be an acceptable alternative to HR for patients without surgical indication and/or impaired liver function.

Liver transplantation for alcohol-associated hepatitis

PURPOSE OF REVIEW

Early liver transplantation is emerging as a treatment option for severe alcohol-associated hepatitis refractory to pharmacotherapies. This review outlines the current status of transplantation for alcohol-associated hepatitis and the treatment of alcohol use disorder after liver transplantation.

RECENT FINDINGS

Rates of early liver transplantation for alcohol-associated hepatitis are increasing with significant heterogeneity in practices across the Unites States. Recent studies have demonstrated a substantial survival benefit in patients transplanted for alcohol-associated hepatitis with improved outcomes in early vs. late transplantation, first vs. prior hepatic decompensation, and posttransplant abstinence/delayed relapse vs. early return to alcohol use. Several prediction algorithms have been developed to ascertain patients' risk of alcohol relapse and aid in candidate selection, though data on treatment of alcohol use disorders in transplant recipients remains limited.

SUMMARY

Although controversial, early liver transplantation for severe alcohol-associated hepatitis has shown to be a lifesaving intervention. Additional research is needed to evaluate its long-term outcomes, optimize candidate selection, and understand treatment of alcohol use disorder posttransplant.

Microwave Ablation of Recurrent Hepatocellular Carcinoma after Curative Surgical Resection

PURPOSE

To evaluate the efficacy and safety of microwave ablation (MWA) as a treatment for recurrent hepatocellular carcinoma (HCC) after initial successful surgical resection.

METHODS

This retrospective study included 40 patients (11 women and 29 men; mean age: 62.3 ± 11.7 years) with 48 recurrent lesions of HCC after initial surgical resection that were treated by percutaneous MWA. Several parameters including complications, technical success, local tumor progression (LTP), intrahepatic distant recurrence (IDR), overall survival (OS), and progression-free survival (PFS) were evaluated in order to investigate the safety and efficacy of MWA for these recurrent HCC lesions after surgical treatment.

RESULTS

All MWA treatments were performed without complications or procedure-related deaths. Technical success was achieved in all cases. Two cases developed LTP at a rate of 5%, and IDR occurred in 23 cases at a rate of 57.5% (23/40). The 1-, 2-, 3-, 4-, and 6-year OS rates were 97%, 89.2%, 80.3%, 70.2%, and 60.2%, respectively. The 1- and 3-year PFS rates were 50.2% and 34.6%, respectively.

CONCLUSION

MWA is effective and safe as a local treatment for recurrent HCC after initial surgical resection.

Predictors of early and late hepatocellular carcinoma recurrence

Hepatocellular carcinoma (HCC) is the most frequent liver neoplasm, and its incidence rates are constantly increasing. Despite the availability of potentially curative treatments (liver transplantation, surgical resection, thermal ablation), long-term outcomes are affected by a high recurrence rate (up to 70% of cases 5 years after treatment). HCC recurrence within 2 years of treatment is defined as "early" and is generally caused by the occult intrahepatic spread of the primary neoplasm and related to the tumor burden. A recurrence that occurs after 2 years of treatment is defined as "late" and is related to de novo HCC, independent of the primary neoplasm. Early HCC recurrence has a significantly poorer prognosis and outcome than late recurrence. Different pathogenesis corresponds to different predictors of the risk of early or late recurrence. An adequate knowledge of predictive factors and recurrence risk stratification guides the therapeutic strategy and post-treatment surveillance. Patients at high risk of HCC recurrence should be referred to treatments with the lowest recurrence rate and when standardized to combined or adjuvant therapy regimens. This review aimed to expose the recurrence predictors and examine the differences between predictors of early and late recurrence.

Management of Hepatocellular Carcinoma in Decompensated Cirrhotic Patients: A Comprehensive Overview

Primary liver cancer is the sixth most common cancer and the fourth leading cause of cancer-related death. Hepatocellular carcinoma (HCC) accounts for 75% of primary liver cancer cases, mostly on the basis of cirrhosis. However, the data and therapeutic options for the treatment of HCC in patients with decompensated cirrhosis are rather limited. This patient category is often considered to be in a terminal stage without the possibility of a specific treatment except liver transplantation, which is restricted by several criteria and liver donor shortages. Systemic treatments may provide a solution for patients with Child Pugh class B or C since they are less invasive. Although most of the existing trials have excluded patients with decompensated cirrhosis, there are increasing data from real-life settings that show acceptable tolerability and satisfying efficacy in terms of response. The data on the administration of locoregional treatments in such patients are also limited, but the overall survival seems to be potentially prolonged when patients are carefully selected, and close adverse event monitoring is applied. The aim of this review is to analyze the existing data regarding the administration of treatments in decompensated patients with HCC, evaluate the effect of therapy on overall survival and highlight the potential risks in terms of tolerability.

Cost-Effectiveness Analysis of Interventional Liver-Directed Therapies for a Single, Small Hepatocellular Carcinoma in Liver Transplant Candidates

PURPOSE

To assess the cost effectiveness of 3 main locoregional therapies (LRTs) (transarterial chemoembolization [TACE], transarterial radioembolization [TARE], and percutaneous ablation) as bridging therapy.

MATERIALS AND METHODS

A cost-effectiveness analysis was performed comparing the 3 LRTs for patients with a single hepatocellular carcinoma (HCC) with a diameter of 3 cm or less over a 5-year time horizon from a payer's perspective. The clinical courses, including transplantation, decompensation resulting in delisting, and the need for a second LRT, were based on data from the United Network for Organ Sharing (2016-2019). Costs and effectiveness were measured in U.S. dollars and quality-adjusted life-years, respectively. Probabilistic and deterministic sensitivity analyses were performed.

RESULTS

A total of 2,594, 1,576, and 903 patients underwent TACE, ablation, and TARE, respectively. Ablation was the dominant strategy, with the lowest expected cost and highest effectiveness. The probabilistic sensitivity analysis demonstrated that ablation was the most cost-effective strategy in 93.9% of simulations. A subgroup analysis was performed for different wait times, with ablation remaining the most cost-effective strategy. The sensitivity analysis showed that ablation was most effective if the risk of waitlist dropout was less than 2.00% and the rate of transplantation was more than 15.1% quarterly. TARE was most effective if the risk of dropout was less than 1.19% and the rate of transplantation was more than 24.0%. TACE was most effective if the risk of dropout was less than 1.01% and the rate of transplantation was more than 45.7%. Ablation remained the most cost-effective modality until its procedural cost was more than $34,843.

CONCLUSIONS

Ablation is the most cost-effective bridging strategy for patients with a single, small (≤3 cm) HCC prior to liver transplantation. The conclusion remained robust in multiple sensitivity analyses.

Current therapeutic modalities and chemopreventive role of natural products in liver cancer: Progress and promise

Liver cancer is a severe concern for public health officials since the clinical cases are increasing each year, with an estimated 5-year survival rate of 30%-35% after diagnosis. Hepatocellular carcinoma (HCC) constitutes a significant subtype of liver cancer (approximate75%) and is considered primary liver cancer. Treatment for liver cancer mainly depends on the stage of its progression, where surgery including, hepatectomy and liver transplantation, and ablation and radiotherapy are the prime choice. For advanced liver cancer, various drugs and immunotherapy are used as first-line treatment, whereas second-line treatment includes chemotherapeutic drugs from natural and synthetic origins. Sorafenib and lenvatinib are first-line therapies, while regorafenib and ramucirumab are second-line therapy. Various metabolic and signaling pathways such as Notch, JAK/ STAT, Hippo, TGF-β, and Wnt have played a critical role during HCC progression. Dysbiosis has also been implicated in liver cancer. Drug-induced toxicity is a key obstacle in the treatment of liver cancer, necessitating the development of effective and safe medications, with natural compounds such as resveratrol, curcumin, diallyl sulfide, and others emerging as promising anticancer agents. This review highlights the current status of liver cancer research, signaling pathways, therapeutic targets, current treatment strategies and the chemopreventive role of various natural products in managing liver cancer.

Salvage locoregional therapies for recurrent hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the second most common cause of cancer-related death worldwide. Despite the advent of screening efforts and algorithms to stratify patients into appropriate treatment strategies, recurrence rates remain high. In contrast to first-line treatment for HCC, which relies on several factors, including clinical staging, tumor burden, and liver function, there is no consensus or general treatment recommendations for recurrent HCC (R-HCC). Locoregional therapies include a spectrum of minimally invasive liver-directed treatments which can be used as either curative or neoadjuvant therapy for HCC. Herein, we provide a comprehensive review of recent evidence using salvage loco-regional therapies for R-HCC after failed curative-intent.

INDICATION FOR LIVER TRANSPLANTATION DUE TO HEPATOCELLULAR CARCINOMA: ANALYSIS OF 1,706 PROCEDURES OVER THE PAST DECADE IN THE STATE OF PARANÁ

BACKGROUND

Patients listed for liver transplantation and hepatocellular carcinoma are considered priority on the waiting list, and this could overly favor them.

AIM

This study aimed to evaluate the impact of this prioritization.

METHODS

We analyzed the liver transplants performed in adults from 2011 to 2020 and divided into three groups: adjusted Model of End-Stage Liver Disease (MELD) score for hepatocellular carcinoma, other adjusted Model of End-Stage Liver Disease situations, and no adjusted Model of End-Stage Liver Disease.

RESULTS

A total of 1,706 patients were included in the study, of which 70.2% were male. Alcoholism was the main etiology of cirrhosis (29.6%). Of the total, 305 patients were with hepatocellular carcinoma, 86 with other adjusted Model of End-Stage Liver Disease situations, and 1,315 with no adjusted Model of End-Stage Liver Disease. Patients with hepatocellular carcinoma were older (58.9 vs. 53.5 years). The predominant etiology of cirrhosis was viral hepatitis (60%). The findings showed that group with adjusted Model of End-Stage Liver Disease had lower physiological Model of End-Stage Liver Disease (10.9), higher adjusted Model of End-Stage Liver Disease (22.6), and longer waiting list time (131 vs. 110 days), as compared to the group with no adjusted Model of End-Stage Liver Disease. The total number of transplants and the proportion of patients transplanted for hepatocellular carcinoma increased from 2011 to 2020. There was a reduction in the proportion of patients with hepatocellular carcinoma and adjusted Model of End-Stage Liver Disease of 20 and there was an increase on waiting list time in this group. There was an increase in the proportion of those with adjusted Model of End-Stage Liver Disease of 24 and 29, but the waiting list time remained stable.

CONCLUSION

Over the past decade, prioritization of hepatocellular carcinoma resulted in an increased proportion of transplanted patients in relation to those with no priority. It also increased waiting list time, requiring higher adjusted Model of End-Stage Liver Disease to transplant an organ.

Novel Benchmark Values for Redo Liver Transplantation: Does the Outcome Justify the Effort?

OBJECTIVE

To define benchmark cutoffs for redo liver transplantation (redo-LT).

BACKGROUND

In the era of organ shortage, redo-LT is frequently discussed in terms of expected poor outcome and wasteful resources. However, there is a lack of benchmark data to reliably evaluate outcomes after redo-LT.

METHODS

We collected data on redo-LT between January 2010 and December 2018 from 22 high-volume transplant centers. Benchmark cases were defined as recipients with model of end stage liver disease (MELD) score ≤25, absence of portal vein thrombosis, no mechanical ventilation at the time of surgery, receiving a graft from a donor after brain death. Also, high-urgent priority and early redo-LT including those for primary nonfunction (PNF) or hepatic artery thrombosis were excluded. Benchmark cutoffs were derived from the 75th percentile of the medians of all benchmark centers.

RESULTS

Of 1110 redo-LT, 373 (34%) cases qualified as benchmark cases. Among these cases, the rate of postoperative complications until discharge was 76%, and increased up to 87% at 1-year, respectively. One-year overall survival rate was excellent with 90%. Benchmark cutoffs included Comprehensive Complication Index CCI ® at 1-year of ≤72, and in-hospital and 1-year mortality rates of ≤13% and ≤15%, respectively. In contrast, patients who received a redo-LT for PNF showed worse outcomes with some values dramatically outside the redo-LT benchmarks.

CONCLUSION

This study shows that redo-LT achieves good outcome when looking at benchmark scenarios. However, this figure changes in high-risk redo-LT, as for example in PNF. This analysis objectifies for the first-time results and efforts for redo-LT and can serve as a basis for discussion about the use of scarce resources.

What Is the Role of Body Composition Assessment in HCC Management?

In the last decade, body composition (BC) assessment has emerged as an innovative tool that can offer valuable data concerning nutritional status in addition to the information provided by the classical parameters (i.e., body mass index, albumin). Furthermore, published data have revealed that different types of body composition are associated with different outcomes. For example, abnormalities of skeletal muscle, a common finding in cirrhotic and oncologic patients, are associated with poor outcome (i.e., high morbidity and high mortality). The disposition (visceral/subcutaneous adipose tissue) and radiodensity of adipose tissue proved to also be determinant factors for HCC outcome. Despite all the advantages, BC assessment is not part of the standard pre-therapeutic workup. The main reasons are the high heterogeneity of data, the paucity of prospective studies, the lack of a standard assessment method, and the interpopulation variation of BC. This paper aims to review the available evidence regarding the role of BC as a prognostic tool in the HCC population undergoing various therapies.

Hepatocellular Carcinoma Recurrence and Mortality Rate Post Liver Transplantation: Meta-Analysis and Systematic Review of Real-World Evidence

BACKGROUND

liver transplantation (LT) is the best curative option for eligible patients with hepatocellular carcinoma (HCC), however recurrence remains a major concern. This meta-analysis aimed to investigate the prevalence and risk factors of HCC recurrence.

METHODS

studies were selected using PubMed, Epistemonikas, and Google Scholar databases published from inception to 15 May 2022 and a meta-analysis of the proportions was conducted. Observational studies reporting the prevalence of recurrent HCC after an LT were included, with the analysis being stratified by an adherence to the Milan criteria (MC), geographical region, AFP levels, and donor type.

RESULTS

out of 4081 articles, 125 were included in the study. The prevalence of recurrent HCC was 17% (CI: 15-19). Patients beyond the MC were more likely to recur than patients within the MC. Asian populations had the greatest prevalence of HCC recurrence (21%; CI: 18-24), whereas North American populations had the lowest recurrence (10%; CI: 7-12). The mortality rate after HCC recurrence was 9%; CI: 8-11. North American populations had the greatest prevalence of mortality with 11% (CI: 5-17).

CONCLUSIONS

the recurrence, overall survival, and mortality rates among patients with HCC post-LT remains high, with substantial differences between regions.

The reasonable therapeutic modality for biliary duct-to-duct anastomotic stricture after liver transplantation: ERCP or PTC?

Objective

To compare the initial success rate, feasibility, and effectiveness of endoscopic retrograde cholangiopancreatography (ERCP) versus percutaneous transhepatic cholangiography (PTC) for anastomotic biliary stricture after liver transplantation (LT).

Methods

We retrospectively analyzed the data collected during January 2015 to December 2021 from liver transplantation recipients who developed anastomotic biliary stricture after liver transplantation and treated by ERCP and/or PTC. The success rate, complications and patients’ survival rate of ERCP and PTC procedures was evaluated.

Results

Forty-eight patients who underwent LT and were confirmed to have the anastomotic biliary stricture were enrolled. Overall, 48/48 patients underwent single or multiple ERCP procedures as the first line therapy; 121 therapeutic ERCPs (3.36 ± 2.53 ERCPs per patient) were performed in 36/48 patients successfully. All the 12 patients who failed ERCP tend to have special bile duct conditions such as overlong, angle shaped, and/or extremely narrowed bile duct and underwent PTC as an alternative treatment. The initial success rate of ERCP was 75% (36/48) while the success rate of ERCP for the 12 patients with special bile duct was 0% (0/12). PTC was an effective second-line treatment for those 12 patients who failed ERCP, and 58.33% (7 of 12 cases) were treated successfully. The average procedure time in PTC group was significantly lower than ERCP group (t=2.292, P=0.027). The feasibility of ERCP was associated with the anatomical shape of bile duct and the severity of the stricture site. Finally, the cumulative survival rate was 100% (12/12) in PTC group compared to 86.11% (31/36) in ERCP group (χ^{2 =}0.670, P=0.413).

Conclusion

ERCP is the gold standard method for the diagnosis and effective intervention for the management of biliary complications after LT. However, its use in certain types of biliary complications (e.g., patients with severe anastomotic biliary stricture and those with overlong and angle shaped bile ducts) is not promising and associated with significant risk of complications. PTC and other interventions should be studied along with ERCP for patients for whom ERCP may not work. The feasibility and efficacy of primary management can be predicted by the noninvasive imaging examinations like Magnetic Resonance Cholangiopancreatography (MRCP) before the procedure, which may help with the choice of the most reasonable therapeutic modality and avoiding unnecessary financial burden and complications.

Variation of Hepatocellular Carcinoma Treatment Patterns and Survival Across Geographic Regions in a Veteran Population

BACKGROUND

Veteran populations have five times the incidence of hepatocellular carcinoma (HCC) compared with the general population. The incidence of HCC has increased in the Veteran's Affairs Health System (VAHS), primarily due to the increased prevalence of cirrhosis. This study aimed to characterize differences in treatment patterns and overall survival rates across the five VAHS geographic regions.

METHODS

Using the VA Corporate Data Warehouse, the authors built a comprehensive national dataset of Veteran patients with HCC diagnosed between 2001 and 2015 to compare patients across VAHS regions. A multivariable Cox proportional hazards model was used to identify factors associated with 5-year all-cause mortality. Kaplan-Meier curves were used to visualize the patient survival function, and the log-rank test was applied to test statistical significance.

RESULTS

This retrospective study analyzed 13,434 patients. The West region had the highest rate of overall treatment receipt (63.6%), and the Southwest had the lowest rate (52.9%). After adjustment for demographic, clinicopathologic, treatment, and hospital factors, treatment in a non-West region continued to be significantly associated with a 10% to 13% increased risk of 5-year mortality (Midwest: hazard ratio [HR], 1.11; 95% confidence interval [CI], 1.03-1.17; Northeast: HR, 1.10; 95% CI, 1.03-1.17; Southeast: HR, 1.13; 95% CI, 1.06-1.21; Southwest: HR, 1.11; 95% CI, 1.03-1.19) (p < 0.01).

CONCLUSIONS

Treatment patterns and overall survival rates of HCC patients differ significantly across VAHS geographic regions. Targeted interventions to increase the rate of treatment in the non-West regions are needed to improve survival of HCC Veterans and provide uniformly high-quality care across VAHS facilities.

Modelling kidney outcomes based on MELD eras - impact of MELD score in renal endpoints after liver transplantation

Background

Acute kidney injury is a common complication in solid organ transplants, notably liver transplantation. The MELD is a score validated to predict mortality of cirrhotic patients, which is also used for organ allocation, however the influence of this allocation criteria on AKI incidence and mortality after liver transplantation is still uncertain.

Methods

This is a retrospective single center study of a cohort of patients submitted to liver transplant in a tertiary Brazilian hospital: Jan/2002 to Dec/2013, divided in two groups, before and after MELD implementation (pre-MELD and post MELD). We evaluate the differences in AKI based on KDIGO stages and mortality rates between the two groups.

Results

Eight hundred seventy-four patients were included, 408 in pre-MELD and 466 in the post MELD era. The proportion of patients that developed AKI was lower in the post MELD era (p 0.04), although renal replacement therapy requirement was more frequent in this group (p < 0.01). Overall mortality rate at 28, 90 and 365 days was respectively 7%, 11% and 15%. The 1-year mortality rate was lower in the post MELD era (20% vs. 11%, p < 0.01). AKI incidence was 50% lower in the post MELD era even when adjusted for clinically relevant covariates (p < 0.01).

Conclusion

Liver transplants performed in the post MELD era had a lower incidence of AKI, although there were more cases requiring dialysis. 1-year mortality was lower in the post MELD era, suggesting that patient care was improved during this period.

Peroxisome proliferator-activated receptor gamma as a therapeutic target for hepatocellular carcinoma: Experimental and clinical scenarios

Hepatocellular carcinoma (HCC) is the most common type of liver cancer worldwide. Viral hepatitis is a significant risk factor for HCC, although metabolic syndrome and diabetes are more frequently associated with the HCC. With increasing prevalence, there is expected to be > 1 million cases annually by 2025. Therefore, there is an urgent need to establish potential therapeutic targets to cure this disease. Peroxisome-proliferator-activated receptor gamma (PPARγ) is a ligand-activated transcription factor that plays a crucial role in the patho-physiology of HCC. Many synthetic agonists of PPARγ suppress HCC in experimental studies and clinical trials. These synthetic agonists have shown promising results by inducing cell cycle arrest and apoptosis in HCC cells and preventing the invasion and metastasis of HCC. However, some synthetic agonists also pose severe side effects in addition to their therapeutic efficacy. Thus natural PPARγ agonists can be an alternative to exploit this potential target for HCC treatment. In this review, the regulatory role of PPARγ in the pathogenesis of HCC is elucidated. Furthermore, the experimental and clinical scenario of both synthetic and natural PPARγ agonists against HCC is discussed. Most of the available literature advocates PPARγ as a potential therapeutic target for the treatment of HCC.

Proton Beam Therapy for Multifocal Hepatocellular Carcinoma (HCC) Showing Complete Response in Pathological Anatomy After Liver Transplantation

We describe a patient with multifocal recurrent hepatocellular carcinoma (HCC) who received proton beam therapy (PBT) and then underwent donation after brain dead (DBD) liver transplantation. The anatomy of the explanted diseased liver was examined pathologically post-transplantation. The patient was a 52-year-old male with hepatitis B virus infection and liver cirrhosis of Child-Pugh class B. Right lobe and caudate lobectomy were performed for primary HCC. However, three recurrent tumors appeared in the remnant liver in segments S2 (two sites) and S4, of sizes 23 mm, 10 mm, and 32 mm, respectively. Liver transplantation was required due to these multiple HCCs and liver cirrhosis, but the patient was ineligible for living donor liver transplantation (LDLT) based on Milan criteria. He was registered as a candidate on the waiting list for DBD transplantation. In consideration of the long waiting time for a deceased donor transplant for more than one year, the progression of multiple recurrent HCCs, and the risk of death, the patient had limited treatment options other than PBT for poor liver function and multifocal HCC and eventually received 65 GyE/18 fractions of PBT. Eleven months after the start of PBT, the tumors remained progression-free and liver function did not deteriorate, allowing the patient to wait for liver transplantation. After transplantation, the histopathology of the explanted liver showed that the left lobe of the liver treated by PBT showed no evidence of solid tumors and tumor cells in visual and microscopic examinations. There was also no significant damage to normal liver tissue. This case demonstrates that PBT is a prospective option for patients with HCC with poor liver function, multiple tumors, and no other treatment options. PBT can achieve control or even complete response of HCC while maintaining liver function and may be an effective pre-transplant method for tumor downstaging and prolonging survival. PBT may enable more people to wait for a donor liver or to become eligible for liver transplantation.

Phase II clinical trial of cabozantinib for the treatment of recurrent hepatocellular carcinoma after liver transplantation

Recurrent hepatocellular carcinoma (HCC) develops in 15-20% of liver transplant recipients, and it tends to be more aggressive due to underlying immunosuppression. The multikinase inhibitor cabozantinib has been shown to be effective for the treatment of advanced HCC. However, there is no study evaluating this medication in patients with recurrent HCC. Adult patients with measurable biopsy-proven recurrent HCC are eligible for enrollment provided they are not amenable to curative treatments and no prior treatment with cabozantinib. In this study, 60 mg once daily cabozantinib will be administered orally. Participants will receive study treatment as long as they continue to experience clinical benefit or until there is unacceptable toxicity. Tumor measurements will be repeated every 8 weeks to evaluate response. The primary end point of this study will be the disease control rate at 4 months after treatment. The secondary end points will be overall survival, progression-free survival and safety profile of cabozantinib. Furthermore, potential biomarkers will be evaluated to identify their role in tumor progression. The total duration of this trial is expected to be 3 years. We anticipate that this trial will show the effectiveness and safety of cabozantinib in the treatment of post-liver transplant recurrent HCC. Cabozantinib is expected to be an effective treatment due to its activity against many protein kinases, including MET and AXL which are not inhibited by sorafenib.

Identification and Validation of a Prognostic Model Based on Three MVI-Related Genes in Hepatocellular Carcinoma

MVI has significant clinical value for treatment selection and prognosis evaluation in hepatocellular carcinoma (HCC). We aimed to construct a model based on MVI-Related Genes (MVIRGs) for risk assessment and prognosis prediction in patients with HCC. This study utilized various statistical analysis methods for prognostic model construction and validation in the Cancer Genome Atlas (TCGA) and International Cancer Genome Consortium (ICGC) cohorts, respectively. In addition, immunohistochemistry and qRT-PCR were used to analyze and identify the value of the model in our cohort. After the analyses, 153 differentially expressed MVIRGs were identified, and three key genes were selected to construct a prognostic model. The high-risk group showed significantly lower overall survival (OS), and this trend was observed in all subgroups: different age groups, genders, stages, and grades. Risk score was a risk factor independent of age, gender, stage, and grade. Moreover, the ICGC cohort validated the prognostic value of the model corresponding to the TCGA. In our cohort, qRT-PCR and immunohistochemistry showed that all three genes had higher expression levels in HCC samples than in normal controls. High expression levels of genes and high-risk scores showed significantly lower recurrence-free survival (RFS) and OS, especially in MVI-positive HCC samples. Therefore, the prognostic model constructed by three MVIRGs can reliably predict the RFS and OS of patients with HCC and is valuable for guiding clinical treatment selection and prognostic assessment of HCC.

External Validation of the RETREAT Score for Prediction of Hepatocellular Carcinoma Recurrence after Liver Transplantation

Simple Summary

Liver transplantation (LT) is a potentially curative treatment option for hepatocellular carcinoma (HCC), but is frequently complicated by HCC recurrence. In order to estimate the recurrence risk a novel risk score was developed in the United States: the Risk Estimation of Tumor Recurrence After Transplant (RETREAT). External validation of this novel risk score, in a different patient population with other LT selection criteria, is needed. In this study we demonstrate that the RETREAT score is able to predict the risk of HCC recurrence after liver transplantation in a European population. These findings may be used to inform patients of recurrence risk and as a basis for studies on surveillance strategies.

Abstract

Background. We aimed to externally validate the performance of the RETREAT score in a European population. Methods. This single center retrospective cohort study enrolled all consecutive patients with HCC who underwent LT between 1989 and 2019. The performance of RETREAT was assessed in the overall population and after stratification between being within or beyond the Milan criteria based on the explant pathology report. Recurrence probabilities were estimated by using the Kaplan–Meier method and compared by log-rank test. Results. We studied 203 patients; 42 patients were beyond the Milan criteria based on explant pathology. The median follow-up was 26.8 months (IQR 7.2–60.7). Overall cumulative HCC recurrence rates were 10.6%, 21.3%, and 23.0% at 2, 5, and 10 years, with the majority of recurrences extrahepatic and at multiple sites. Higher RETREAT scores were associated with higher recurrence rates, with a 10-year recurrence rate of 60.5% in patients with RETREAT ≥ 3 (n = 65), compared to 6.2% in those with RETREAT ≤2 (n = 138; p < 0.001). HCC recurrence rates were even lower in patients within the Milan criteria who also had a low RETREAT score (n = 122; 2.7% at 10 years). Conclusion. Low RETREAT scores identify patients at low risk of HCC recurrence after LT in patients within the Milan criteria based on explant pathology.