Advances and challenges in laparoscopic surgery in the management of hepatocellular carcinoma

Resection Versus Transplant for Hepatocellular Carcinoma: How to Offer the Best Modality

Liver resection and liver transplantation are the mainstay of treatment for patients with hepatocellular carcinoma. Patient comorbidities, tumor resectability, and perioperative morbidity and mortality risk, specifically of post-hepatectomy liver failure, are determining factors when deciding between liver resection and liver transplantation in patients who do not have an obvious contraindication to either treatment. Liver resection is preferred in patients without cirrhosis, and it may be a reasonable choice in patient with cirrhosis but preserved liver function and no portal hypertension if the size and function of the future liver remnant are appropriate, especially if organ availability is scarce.

Cytomorphology of paediatric hepatocellular carcinoma: A useful diagnostic adjunct

INTRODUCTION

Hepatocellular carcinoma (HCC) is a common primary malignancy of the liver but is rare in the paediatric age group; thus, it may be misdiagnosed as the more common tumour, hepatoblastoma. Management varies in both these tumours, and pathological diagnosis thus plays an important role for definitive therapy. Only a few case reports available in the literature have described the cytological characteristics of paediatric HCC. The present study was thus planned to evaluate the cytomorphological features of paediatric HCC.

METHODS

Cases diagnosed with HCC on ultrasound-guided fine needle aspiration cytology over a period of 14 years were retrieved. The cases were evaluated for detailed cytological features including cellularity, architecture, sinusoidal wrapping, trabecular thickness, necrosis, anisonucleosis, chromatin, nucleoli, nuclear contours, bi- or multinucleation, intranuclear and intracytoplasmic inclusions, naked nuclei, extra-medullary haematopoiesis, monomorphism, and nuclear overlapping.

RESULTS

Twelve cases of HCC were included in the study. The median age at diagnosis was 10 years. Serum alpha-fetoprotein level was raised in most of them. Five of the 12 cases were characterised as moderately differentiated, three as poorly differentiated, two as well differentiated, and two as the fibrolamellar type of HCC. Cytohistological correlation was performed in seven cases.

CONCLUSIONS

Ultrasound-guided fine needle aspiration serves as a useful tool to diagnose paediatric HCC and differentiate it from other primary hepatic malignancies, especially hepatoblastoma which closely mimics HCC in this age group, as serum alpha protein levels and imaging findings are unable to distinguish these two tumours.

Early experiences with developing techniques for pure laparoscopic explant hepatectomy in living donor liver transplantation

In recent years, laparoscopic techniques for liver resection or living donor hepatectomy have become common surgical methods. However, reports on laparoscopic surgeries for recipients are lacking. Our center has launched the minimally invasive living donor liver transplantation (LDLT) program in March 2020, which is led by two surgeons who are experienced in laparoscopic surgeries. Recently, we reported our first successful pure laparoscopic recipient explant hepatectomy and the first laparoscopic explant hepatectomy and robotic-assisted graft implantation. In this article, we introduce a series of minimally invasive surgical cases that were conducted by a single experienced surgeon to share our early experiences leading to our recent successes. We included 10 cases performed from June 2020 to May 2021 in our initial attempt at laparoscopic explant hepatectomy, graft implantation using midline incision, and robotic-assisted graft implantation surgery. The first four cases required open conversion during the liver mobilization process because of bleeding. The next two cases required open conversion to facilitate portal vein and hepatic artery division. We successfully performed pure laparoscopic explant hepatectomy in the last four cases. For the last case, we attempted to perform graft implantation using a robotic system, but bleeding required open conversion. All patients recovered without any significant acute postoperative problems and were discharged within 2 weeks. All 10 patients were followed up at outpatient clinics, and only one of the 10 patients had a late complication of LDLT. This study has shown that the minimally invasive approach in LDLT may be conducted safely without significant complications if it is performed by highly experienced surgeons working in high-volume centers.

A novel predictive model of microvascular invasion in hepatocellular carcinoma based on differential protein expression

BACKGROUND

This study aims to construct and verify a nomogram model for microvascular invasion (MVI) based on hepatocellular carcinoma (HCC) tumor characteristics and differential protein expressions, and explore the clinical application value of the prediction model.

METHODS

The clinicopathological data of 200 HCC patients were collected and randomly divided into training set and validation set according to the ratio of 7:3. The correlation between MVI occurrence and primary disease, age, gender, tumor size, tumor stage, and immunohistochemical characteristics of 13 proteins, including GPC3, CK19 and vimentin, were statistically analyzed. Univariate and multivariate analyzes identified risk factors and independent risk factors, respectively. A nomogram model that can be used to predict the presence of MVI was subsequently constructed. Then, receiver operating characteristic (ROC) curve, calibration curve, and decision curve analysis (DCA) were conducted to assess the performance of the model.

RESULTS

Multivariate logistic regression analysis indicated that tumor size, GPC3, P53, RRM1, BRCA1, and ARG were independent risk factors for MVI. A nomogram was constructed based on the above six predictors. ROC curve, calibration, and DCA analysis demonstrated the good performance and the clinical application potential of the nomogram model.

CONCLUSIONS

The predictive model constructed based on the clinical characteristics of HCC tumors and differential protein expression patterns could be helpful to improve the accuracy of MVI diagnosis in HCC patients.

Prognostic Value and Immunological Role of KIFC1 in Hepatocellular Carcinoma

As one of the members of the kinesin family, the role and potential mechanism of kinesin family member C1 (KIFC1) in the development of liver hepatocellular carcinoma (LIHC), especially in the immune infiltration, have not been fully elucidated. In this study, multiple databases and immunohistochemistry were employed to analyze the role and molecular mechanism including the immune infiltration of KIFC1 in LIHC. Generally, KIFC1 mRNA expression was overexpressed in LIHC tissues than normal tissues, and its protein was also highly expressed in the LIHC. KIFC1 mRNA expression was correlated with tumor grade and TNM staging, which was negatively correlated with overall survival and disease-free survival. Moreover, univariable and multivariate Cox analysis revealed that upregulated KIFC1 mRNA is an independent prognostic factor for LIHC. The KIFC1 promoter methylation level was negatively associated with KIFC1 mRNA expression and advanced stages and grade in LIHC. The different methylation sites of KIFC1 had a different effect on the prognosis of LIHC. Specifically, the KIFC1 mRNA expression level showed intense correlation with tumor immunity, such as tumor-infiltrating immune cells and immune scores as well as multiple immune-related genes. Moreover, KIFC1 co-expressed with some immune checkpoints and related to the responses to immune checkpoint blockade (ICB) and chemotherapies. Significant GO analysis showed that genes correlated with KIFC1 served as catalytic activity, acting on DNA, tubulin binding, histone binding, ATPase activity, and protein serine/threonine kinase activity. KEGG pathway analysis showed that these genes related to KIFC1 are mainly enriched in signal pathways such as cell cycle, spliceosome, pyrimidine metabolism, and RNA transport. Conclusively, KIFC1 was upregulated and displayed a prognostic value in LIHC. Moreover, KIFC1 may be involved in the LIHC progression partially through immune evasion and serve as a predictor of ICB therapies and chemotherapies.

circRNA hsa_circ_104566 Sponged miR-338-3p to Promote Hepatocellular Carcinoma Progression

Circular RNAs (circRNAs) could sponge micro-RNAs (miRNAs) to regulate tumor progression of hepatocellular carcinoma (HCC). Hsa_circ_104566 contributes to papillary thyroid carcinoma progression. However, the tumorigenic mechanism of hsa_circ_104566 on HCC remains enigmatic. The role of hsa_circ_104566 on HCC was therefore evaluated in this study. First, the high expression of hsa_circ_104566 was found in HCC tissues, which was significantly associated with poor prognosis in HCC patients. Second, Hsa_circ_104566 promoted HCC progression by decreasing apoptosis and E-cadherin, while increasing cell viability, proliferation, migration, invasion, and N-cadherin. On the other hand, HCC progression was suppressed by knockdown of hsa_circ_104566. Hsa_circ_104566 could target miR-338-3p, and its expression was negatively correlated with miR-338-3p in HCC patients. Moreover, miR-338-3p suppressed protein expression of Forkhead box protein 1 (FOXP1) and had a negative correlation with FOXP1 in HCC patients. Functional assay further indicated that the promotion of HCC progression by hsa_circ_104566 was reversed by miR-338-3p, and miR-338-3p inhibitor could counteract the effect of hsa_circ_104566 knockdown on the suppression of HCC progression. In vivo assay indicated that hsa_circ_104566 knockdown suppressed HCC tumor growth and metastasis. In conclusion, hsa_circ_104566 sponged miR-338-3p to promote HCC progression, providing a potential therapeutic target for cancer intervention.

Circular RNA hsa_Circ_101141 as a Competing Endogenous RNA Facilitates Tumorigenesis of Hepatocellular Carcinoma by Regulating miR-1297/ROCK1 Pathway

As a novel class of noncoding RNAs, circular RNAs (circRNAs) have been recently reported to be involved in cell development and function. However, the functional role of circRNAs in hepatocellular carcinoma (HCC) remains unclear. In the present study, we found that the expression of human circ_101141 was upregulated in HCC tissues and cells. In addition, downregulation of circ_101141 dramatically inhibited cell proliferation, migration, and invasion in HCC cells. In addition, by using the bioinformatics tools, the potential target of circ_101141 was predicted. Mechanistic investigations indicated that circ_101141 acted as a miR-1297 “sponge”; meanwhile, Rho-associated, coiled-coil-containing protein kinase 1 (ROCK1) was a direct target of miR-1297. Further experiments demonstrated that circ_101141 contributed to the progression of HCC by acting as competing endogenous RNA (ceRNA) of miR-1297 to regulate ROCK1 expression. Furthermore, knockdown of circ_101141 attenuated HCC tumorigenesis in vivo. Taken together, these findings indicated that circRNA circ_101141 acted as a ceRNA to facilitate tumorigenesis of HCC by regulating miR-1297/ROCK1 pathway.

hsa_circ_102559 Acts as the Sponge of miR-130a-5p to Promote Hepatocellular Carcinoma Progression Through Regulation of ANXA2

Circular RNAs (circRNAs) are critical regulators in tumor initiation and development and participate in the pathological process of hepatocellular carcinoma (HCC). However, the specific role and mechanism of circRNA, hsa_circ_102559, in HCC remains elusive. First, analysis of HCC-related circRNA expression profile GSE97332 and HCC patients showed a significant upregulation of hsa_circ_102559 in HCC tissues. Upregulation of hsa_circ_102559 in HCC cells was associated with the metastatic properties. Second, hsa_circ_102559 significantly promoted HCC metastasis, while knockdown of hsa_circ_102559 reversed the promotive effects on HCC progression. Functionally, hsa_circ_102559 could target and colocalize with miR-130a-5p in the cytoplasm of HCC cells. Annexin A2 (ANXA2) was identified as a target gene of miR-130a-5p, and overexpression of ANXA2 counteracted with the suppressive effects of hsa_circ_102559 silence on HCC metastasis. Lastly, xenograft experiment was established and results indicated that knockdown of hsa_circ_102559 inhibited HCC growth and metastasis through the downregulation of ANXA2. In conclusion, hsa_circ_102559 inhibited HCC progression via sponging miR-130a-5p to reduce ANXA2 expression, suggesting that hsa_circ_102559 might be a potential biomarker or therapeutic target for HCC.

Phenformin synergistically sensitizes liver cancer cells to sorafenib by downregulating CRAF/ERK and PI3K/AKT/mTOR pathways

Sorafenib is a first-line drug to treat advanced hepatocellular carcinoma (HCC), which can prolong the median overall survival of patients by approximately 3 months. Phenformin is a biguanide derivative that has been shown to exhibit antitumor activity superior to that of metformin. We herein explored the ability of phenformin to enhance the anti-cancer activity of sorafenib against HCC and the mechanisms underlying such synergy. The Hep-G2 and SMMC-7721 HCC cell lines were treated with sorafenib and/or phenformin, after which the proliferation of these cells was evaluated via MTT and colony formation assays, while invasion and apoptotic cell death were evaluated via Transwell and flow cytometry assays, respectively. In addition, protein levels were assessed by Western blotting, drug synergy was assessed with the CompuSyn software, and xenograft models were established by implanting Hep-G2 cells into nude mice and then assessing drug antitumor efficacy. Sorafenib and phenformin exhibited a synergistic ability to suppress HCC cell proliferation, migration, and survival. Phenformin further bolstered the ability of sorafenib to inhibit the CRAF/ERK and PI3K/AKT/mTOR pathways. Strikingly, the combination of these two drugs achieved better in vivo efficacy in a murine model system, without causing significant weight loss or hepatorenal toxicity. Sorafenib and phenformin can synergistically suppress CRAF/ERK and PI3K/AKT/mTOR pathway activation in HCC cells, and may thus represent a promising approach to treating this deadly cancer.

The Epidemiology, Staging and Outcomes of Sarcomatoid Hepatocellular Carcinoma: A SEER Population Analysis

BACKGROUND

Hepatocellular carcinoma (HCC) subtypes differ in terms of histopathology and prognosis. Sarcomatoid HCC is rare and literature concerning the survival of patients with sarcomatoid HCC is scarce.

MATERIALS AND METHODS

Data of patients with sarcomatoid HCC, diagnosed from 1989 to 2016, were extracted from the Surveillance, Epidemiology and End Results (SEER) database. We evaluated the baseline and tumor related data, overall survival (OS), disease-specific survival and the performance (Harrell's concordance index - OS c-index) of the eighth edition of the American Joint Committee on Cancer TNM staging system (AJCC8). In addition, univariate and multivariate forward stepwise cox regression analyses were performed to identify factors associated with increased risk of death.

RESULTS

The SEER cohort consisted of 71 patients, mostly males (n=49, 69.0%), of White race (n=51, 71.8%) and the most common stage at presentation was stage IVB (n=30, 42.3%). The overall predictive ability of AJCC8 was mediocre, with an OS c-index=0.577 (SE=0.048). Surgery (hazard ratio=0.25, p<0.001) was significantly associated with reduced risk of death. Advanced TNM stage was not associated with increased risk of death.

CONCLUSION

Sarcomatoid HCC, a rare subtype of HCC, is associated with poor outcomes in terms of overall and disease-specific survival across all disease stages. Surgery seems to be of utmost importance. The eighth edition of the AJCC8 for HCC underperforms in predicting the survival of patients with sarcomatoid subtype.

Usefulness and safety of midline incision for right-sided hepatectomy: Cohort study

Background

While the adoption rates of laparoscopic hepatectomy are increasing, most patients still undergo open hepatectomy. Open hepatectomies use inverted L-shaped or Mercedes incisions for right-sided liver tumor. To decrease procedural invasiveness, we performed midline incisions in such cases, excluding those of laparoscopic hepatectomy. This retrospective study examined the effects of this change in treatment policy on overall patient surgical outcomes.

Materials and methods

From 2012 to 2018, 374 patients who underwent hepatectomy for right-sided hepatocellular carcinoma were enrolled, and short-term patient outcomes were compared following stratification into the 1st (n = 157) or 2nd (n = 217) Era group based on whether procedures occurred before or after the policy change, respectively.

Results

Short-term outcomes were mostly comparable between the two groups, with significantly increased postoperative aspartate aminotransferase maximum values found in the 2nd Era group relative to the 1st Era group (median: 393 vs. 331, p < 0.05). Pain scores at rest during postoperative day 1 and while moving on postoperative days 1, 2, and 3 were significantly lower in the 2nd Era group than in the 1st Era group (p < 0.05, <0.01, <0.05, <0.01, respectively).

Conclusions

Utilization of midline incisions may provide some benefits in postoperative outcomes for right-sided open hepatectomy cases.

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Utilization of midline incisions may provide better postoperative outcomes in cases of right-sided open hepatectomy.

Surgical management of pediatric hepatocellular carcinoma: An analysis of the National Cancer Database

PURPOSE

This study evaluates overall survival (OS) between liver transplantation (LT) and liver resection (LR), while assessing the effect of margin status, in children with hepatocellular carcinoma (HCC).

METHODS

The National Cancer Database was queried (2004-2015) for children (<18 years) with non-metastatic HCC undergoing surgery.

RESULTS

One hundred six children with HCC treated surgically (LT 34, LR 72) were identified. For T1 stage, no difference in OS was observed for LT vs. margin-negative liver resection [LR(-)] (log-rank, p = 0.47). For T2/T3/T4 stage, no difference in OS was observed for LT vs. LR(-) (log-rank, p = 0.08); both subgroups exhibited superior OS vs. margin-positive liver resection [LR(+)] (log-rank, LT vs. LR(+): p = 0.001 and LR(-) vs. LR(+): p = 0.04). On multivariable Cox regression: (i) histology (fibrolamellar vs. not) and T stage (T1 vs. T2/T3/T4) were not associated with OS (both p = 0.06), (ii) chemotherapy and size >5 cm were not associated with OS (both p ≥ 0.42), (iii) when compared to LT, both LR(-) (p = 0.03) and LR(+) (p = 0.001) were associated with increased likelihood of mortality.

CONCLUSION

Although margin-negative resection may be obtained with LT or LR, early LT consultation is warranted for children at high risk of LR(+) regardless of Milan criteria due to the negative impact of LR(+) on OS.

TYPE OF STUDY

Retrospective cohort study.

LEVEL OF EVIDENCE

III.

Is Single-Incision Laparoscopic Liver Surgery Safe and Efficient for the Treatment of Malignant Hepatic Tumors? A Systematic Review

PURPOSE

The objective of this review was to evaluate the safety and efficiency of single-incision laparoscopic liver surgery (SILLS) for malignant liver lesions.

METHODS

A retrospective review of the Medline database was performed, including studies published up to February 2019.

RESULTS

Overall, 69 patients (50 males) with a median age of 61 years (range, 31-90) from 16 studies underwent SILLS for malignant liver disease and were included in this review. The majority of patients underwent resection for hepatocellular carcinoma (n = 52, 75 %), followed by metastatic disease (n = 15, 22 %). The hepatic lesions were located in anterolateral liver segments in 62 patients (90 %) and in posterosuperior liver segments in 7 patients (10 %). Sixty-five patients (94 %) underwent minor liver resection. The median blood loss was 200 mL (range 0-2500), while 4 patients that underwent single-port resection were converted to either conventional laparoscopy or open resections. Two cases were reported to be associated with postoperative complications in the single-port group (1 [1.7 %] grade Dindo-Clavien I-II, 1 [1.7 %] grade Dindo-Clavien III-IV), while no complications were noted in the multiport group. All patients successfully underwent R0 resection.

CONCLUSIONS

SILLS seems to be a safe and efficient treatment modality for malignant liver disease when performed by experienced surgeons in carefully selected patients. More studies are needed to better identify which patients may benefit from such an operative approach.

The Role of Immunotherapy in Hepatocellular Carcinoma: A Systematic Review and Pooled Analysis of 2,402 Patients

BACKGROUND

Immune checkpoints inhibitors (ICIs) have emerged as a treatment option for several malignancies. Nivolumab, pembrolizumab, nivolumab plus ipilimumab, and atezolizumab plus bevacizumab have been approved for the management of advanced-stage hepatocellular carcinoma (HCC). We aimed to systematically review the literature and summarize the characteristics and outcomes of patients with HCC treated with ICIs.

METHODS

A systematic literature search of PubMed, the Cochrane Library, and ClinicalTrials.gov was performed according to the PRISMA statement (end of search date: November 7, 2020). Quality of evidence assessment was also performed.

RESULTS

Sixty-three articles including 2,402 patients were analyzed, 2,376 of whom received ICIs for unresectable HCC. Response to ICIs could be evaluated in 2,116 patients; the overall objective response rate (ORR) and disease control rate (DCR) were 22.7% and 60.7%, respectively, and the mean overall survival (OS) was 15.8 months. The ORR, DCR, and OS for nivolumab (n = 846) were 19.7%, 51.1%, and 18.7 months, respectively; for pembrolizumab (n = 435) they were 20.7%, 64.6% and 13.3 months, respectively. The combination of atezolizumab/bevacizumab (n = 460) demonstrated an ORR and DCR of 30% and 77%, respectively. The overall rate of treatment discontinuation because of adverse events was 14.9%. Fifteen patients received ICIs in the liver transplant (LT) setting (one pre-LT for bridging, 14 for post-LT recurrence); fatal graft rejection was reported in 40.0% (n = 6/15) and mortality in 80.0% (n = 12/15).

CONCLUSION

ICIs are safe and effective against unresectable HCC, but caution is warranted regarding their use in the LT setting because of the high graft rejection rate.

IMPLICATIONS FOR PRACTICE

This systematic review pooled the outcomes from studies reporting on the use of immune checkpoint inhibitors (ICIs) for the management of 2,402 patients with advanced-stage hepatocellular carcinoma (HCC), 2,376 of whom had unresectable HCC. The objective response rate and disease control rate were 22.7% and 60.7%, respectively, and the mean overall survival was 15.8 months. The overall rate of treatment discontinuation because of adverse events was 14.9%. Fifteen patients received ICIs in the liver transplant (LT) setting (one pre-LT for bridging, 14 for post-LT recurrence). Six of these patients experienced graft rejection (40.0%).

Retroperitoneal laparoscopic hepatectomy of recurrent hepatocellular carcinoma: case report and literature review

BACKGROUND

Almost all liver tumours can be removed laparoscopically, but some difficult tumour locations complicate laparoscopic surgery. Recurrent liver tumours often pose great difficulties to laparoscopic surgery due to adhesions caused by previous operations. Referring to laparoscopic adrenalectomy, a retroperitoneal approach is proposed to remove liver tumours near the adrenal gland, which will provide a new method for liver surgery.

CASE PRESENTATION

Our case involves a patient with recurrent hepatocellular carcinoma (HCC) whose last operation was laparoscopic hepatectomy in our department, with a recurrence of HCC 2 years after the first surgery. In this case, based on preoperative CT and MRI, through a retroperitoneal approach, combined with intraoperative ultrasound (IOUS) localization and indocyanine green (ICG) fluorescence navigation, laparoscopic hepatectomy was successfully performed to precisely resect recurrent hepatocellular carcinoma in segment VII. The patient was discharged on the third day after the operation. The AFP decreased to normal levels on the 28th postoperative day.

CONCLUSIONS

Retroperitoneal hepatectomy has the advantages of less trauma, shorter operation times, fewer complications and faster recovery for hepatic tumours near the adrenal gland. Accurate localization of tumours is needed to ensure accurate resection; therefore, IOUS and ICG fluorescence are very important. Liver parenchyma was severed strictly according to fluorescent labelling during hepatectomy, which prevented the deviation of liver parenchyma from the plane and ensured that the margin of hepatectomy was tumour-free. In order to ensure a radical resection of the tumour, it may be necessary to enter the abdominal cavity.

Is 3D faster and safer than 4K laparoscopic cholecystectomy? A randomised-controlled trial

BACKGROUND

Laparoscopic surgery has well-established benefits for patients; however, laparoscopic procedures have a long and difficult learning curve, in large part due to the lack of stereoscopic depth perception. Developments in high-definition and stereoscopic imaging have attempted to overcome this. Three-dimensional high-definition (3D HD) systems are thought to improve operating times compared to two-dimensional high-definition systems. However their performance against new, ultra-high-definition ('4K') systems is not known.

METHODS

Patients undergoing laparoscopic cholecystectomy were randomised to 3D HD or 4K laparoscopy. Operative videos were recorded, and the time from gallbladder exposure to separation from the liver (minus on table cholangiogram) was calculated. Blinded video assessment was performed to calculate intraoperative error scores.

RESULTS

One hundred and twenty patients were randomised, of which 109 were analysed (3D HD n = 54; 4K n = 55). No reduction in operative time was detected with 3D HD compared to 4K laparoscopy (median [IQR]; 23.41 min [17.00-37.98] vs 20.90 min [17.67-33.03]; p = 0.91); nor was there any decrease observed in error scores (60 [56-62] vs 58 [56-60]; p = 0.27), complications or reattendance. Stone spillage occurred more frequently with 3D HD, but there were no other differences in individual error rates. Gallbladder grade and operating surgeon had significant effects on time to complete the operation. Gallbladder grade also had a significant effect on the error score.

CONCLUSIONS

A 3D HD laparoscopic system did not reduce operative time or error scores during laparoscopic cholecystectomy compared with a new 4K imaging system.

KIFC1 promotes the proliferation of hepatocellular carcinoma in vitro and in vivo

Hepatocellular carcinoma (HCC) is a common type of malignant tumor worldwide with a high mortality rate. In the past 20 years, the morbidity rate of HCC has increased. Progress has been made in the clinical diagnosis and therapy for HCC. However, due to the high heterogeneity and metastasis targeted therapy for HCC exhibits great promise, and novel therapeutic targets for HCC are urgently required. Kinesin family member C1 (KIFC1) is a member of the kinesin superfamily of proteins. Previous studies have indicated a potential association between KIFC1 and cancer progression. However, the potential role of KIFC1 in the development of HCC remains unclear. The present study aimed to explore the function of KIFC1 in HCC. Immunohistochemical (IHC) assays were performed to explore the KIF15 expression levels in 74 samples of HCC and corresponding non-tumor tissues. The potential association between KIF15 expression levels and clinical features was analyzed, and the effects of KIF15 on cell proliferation of HCC were detected by colony formation and MTT assays. In addition, the proliferation-related proteins Ki67 and PCNA were detected by western blotting. The possible effects of KIF15 on tumor growth were measured in mice. The results demonstrated that a high expression level of KIFC1 was associated with poor prognosis of HCC. Further results indicated that KIFC1 promoted cell proliferation of HCC in vitro. In addition, knockdown of KIFC1 suppressed tumor formation and growth in mice. Therefore, these results provide a potential therapeutic target for the treatment of HCC.

Safety and efficacy of hepatic arterial infusion chemotherapy with raltitrexed and oxaliplatin post-transarterial chemoembolization for unresectable hepatocellular carcinoma

Objective

To investigate the safety, efficacy, and prognostic factors of hepatic arterial infusion chemotherapy (HAIC) with raltitrexed and oxaliplatin post-transarterial chemoembolization (TACE) for unresectable hepatocellular carcinoma (uHCC).

Methods

Thirty-seven patients with uHCC who received HAIC with raltitrexed and oxaliplatin post-TACE between June 2014 and December 2016 at our hospital were recruited. The primary endpoint was overall survival (OS), and secondary endpoint was progression-free survival (PFS). The overall response rate (ORR) was evaluated using the modified Response Evaluation Criteria in Solid Tumors. Toxicity was assessed according to the Common Terminology Criteria for Adverse Events (v4.0). The OS and prognostic factors were analyzed using the Kaplan–Meier method, log-rank test, and Cox regression models.

Results

Three (8.1%) patients achieved complete response, 17 (46.0%) patients achieved partial response, and the ORR was54.0%.The median OS and median PFS were 19.0 months and 12.0 months, respectively. The common toxicities included grade 3–4 increased aspartate aminotransferase levels (8/37,21.6%), grade 1–2 hyperbilirubinemia (75.7%, 28/37), nonspecific abdominal pain and fever, and grade 2–3 thrombocytopenia (18.9%, 7/37); no patients developed grade 3–4 neutropenia. Univariate analysis showed that the tumor diameter (≤50 mm, p = 0.028), Barcelona Clinic Liver Cancer (BCLC) stage (p = 0.012), hepatitis B virus DNA level (p = 0.033), and derived neutrophil-to-lymphocyte ratio (dNLR; derived neutrophils/leukocytes minus neutrophils) (p = 0.003) were predictive factors for prognosis. Multivariate analysis showed that patients with BCLC stage B disease (p = 0.029) and dNLR≤2 before therapy (p = 0.004) had better prognosis.

Conclusions

HAIC with raltitrexed and oxaliplatin post-TACE is a safe and efficacious therapy for patients with uHCC; in particular, those with BCLC stage B and dNLR≤2 have better prognosis.

Early recurrence detected in hepatocellular carcinoma patients after transcatheter arterial chemoembolization treatment with plasma cell-free DNA

OBJECTIVE

Hepatocellular carcinoma (HCC) is one of the most lethal malignancies worldwide with poor prognosis due to the high incidence of recurrence. For patients with advanced HCC, transcatheter arterial chemoembolization (TACE) is the preferred treatment option owing to the minimal invasive clinical treatment with optimum therapeutic outcomes. But, there is a paucity of studies on early detection of residual cancer and relapse that result in the bottleneck of long-term effects after TACE therapy.

PATIENTS AND METHODS

Using next-generation sequencing platform targeting a panel of 622 cancer-associated genes, we prospectively evaluated the predictive significance of plasma cell-free DNA (cfDNA) to detect minimal residual disease in plasma cfDNA in comparison with DNA obtained from tumor tissue and blood cells of three eligible cases with HCC following TACE therapy.

RESULTS

The results indicated that the mutational spectrum from plasma cfDNA was consistent with tumor-derived DNA and potentially suggested disease progression. Next, we determined if the dynamic variation of plasma cfDNA could indicate treatment response, the findings suggested that the mutation burden of plasma cfDNA could reveal relapse before alterations in conventional computed tomography imaging and serum α-fetoprotein values.

CONCLUSION

The mutation burden in plasma cfDNA may serve as a novel prognostic biomarker by providing early evidence of residual disease and identifying high risk of recurrence in patients with HCC following TACE therapy.

Long noncoding RNA HAGLROS promotes cell proliferation, inhibits apoptosis and enhances autophagy via regulating miR-5095/ATG12 axis in hepatocellular carcinoma cells

In this research, we planned to dig the possible influences and mechanism of long noncoding (lnc) RNA HAGLROS in the development and progression of hepatocellular carcinoma (HCC). The levels of lncRNA HAGLROS in HCC tumor samples and their relationship with clinicopathological characteristics and prognosis of patients with HCC were studied. Subsequently, overexpression and silenced approaches were used in HCC cells for detecting the effects of lncRNA HAGLROS on cell viability, apoptosis, and autophagy. Furthermore, we investigated whether HAGLROS could function as a competing endogenous RNA (ceRNA) to regulate miR-5095 expression in HCC cells, and explored the correlation between miR-5095 and ATG12. Besides, the correlation of HAGLROS, the consequent PI3K/AKT/mTOR signaling pathway was further explored. The level of HAGLROS was higher in HCC tissues and correlated with clinical performances including tumor stages or tumor differentiation. In contrast to the lower level, a higher level of HAGLROS correlated with a shorter survival time of patients with HCC. The suppression of HAGLROS decreased cell viability, promoted apoptosis, and inhibited autophagy. Moreover, HAGLROS negatively regulated miR-5095 expression, which further regulated HCC cell viability, apoptosis, and autophagy. In addition, ATG12 was targeted by miR-5095 and was then involved in miR-5095-regulated HCC cell biological processes including viability, apoptosis, and autophagy. Furthermore, overexpression of HAGLROS activated PI3K/AKT/mTOR signals. Our results revealed that HAGLROS is highly expressed in HCC, and its high level may correlate with the progression and development of HCC involving the processes of cell viability, apoptosis, and autophagy through the miR-5095/ATG12 axis and PI3K/AKT/mTOR signals.

Exosome circRNA secreted from adipocytes promotes the growth of hepatocellular carcinoma by targeting deubiquitination-related USP7

Hepatocellular carcinoma (HCC), the major form of liver cancer, has shown increasing incidence and poor prognosis. Adipose tissue is known to function in energy storage and metabolism regulation by the secretion of adipokines. Circular RNAs (circRNAs), a novel type of noncoding RNA, have recently been recognized as key factors in tumor development, but the role of exosome circRNAs derived from adipose tissues has not been defined yet. Here, adipose-secreted circRNAs were found to regulate deubiquitination in HCC, thus facilitating cell growth. It was observed that exosome circ-deubiquitination (circ-DB) is upregulated in HCC patients with higher body fat ratios. Moreover, in vitro and in vivo studies showed that exo-circ-DB promotes HCC growth and reduces DNA damage via the suppression of miR-34a and the activation of deubiquitination-related USP7. Finally, the results showed that the effects of adipose exosomes on HCC cells can be reversed by knockdown of circ-DB. These results indicate that exosome circRNAs secreted from adipocytes promote tumor growth and reduce DNA damage by suppressing miR-34a and activating the USP7/Cyclin A2 signaling pathway.

Annual hospital volume of surgery for gastrointestinal cancer in relation to prognosis

BACKGROUND

Studies examining hospital volume for surgery for various gastrointestinal (GI) cancer types have shown conflicting results regarding the influence on long-term prognosis. The aim of this study was to examine annual hospital volume in relation to long-term survival after elective surgery for all GI cancers (esophagus, stomach, liver, pancreas, bile ducts, small bowel, colon, and rectum).

METHODS

Population-based cohort study including all 45,908 patients who underwent elective surgery for GI cancers in Sweden in 2005-2013. Follow-up was until 2016 for disease-specific 5-year mortality (main outcome) and 2018 for all-cause 5-year mortality (secondary outcome). Hospitals were divided into quartiles for each GI cancer according to a 4-year average annual volume of the year of surgery and three years earlier. Multivariable Cox regression provided hazard ratios (HRs) with 95% confidence intervals (CIs), adjusted for relevant confounders.

RESULTS

Higher hospital volume was associated with a survival benefit in the large group of patients (n = 26,688) who underwent colon cancer resection, with HR 0.89 (95% CI 0.84-0.96) for disease-specific 5-year mortality comparing the highest with the lowest quartile. Higher hospital volume improved 5-year mortality in sub-groups of patients who underwent surgery for cancer of the esophagus, pancreas, and rectum. No such improvements were found for cancer of the stomach, liver, bile ducts, or small bowel.

CONCLUSION

Long-term survival was improved at higher volume hospitals for some GI cancers (colon, esophagus, pancreas, rectum), but not for others (stomach, liver, bile ducts, small bowel).

Prospects of Noncoding RNAs in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a global health problem and one of the most common malignant tumors. Recent studies have shown that noncoding RNAs (ncRNAs) contribute to the pathogenesis of hepatocellular carcinoma (HCC). These RNAs may be involved in a variety of pathological processes such as cell proliferation, apoptosis, angiogenesis, invasion, and metastasis. In addition, abnormal expression of ncRNAs in HCC may provide potential prognostic or diagnostic biomarkers. This review provides an overview of the role and potential applications of ncRNAs, miRNAs, lncRNAs, circRNAs, and snoRNAs in liver cancer.