Recommended 10-Year Follow-Up Strategy for Small Hepatocellular Carcinoma After Radiofrequency Ablation: A Cost-Effectiveness Evaluation

INTRODUCTION

An optimal follow-up schedule for small (≤3-cm) hepatocellular carcinoma (HCC) after radiofrequency ablation (RFA) remains unclear in clinical guidelines. We aimed to assess the cost-effectiveness of follow-up strategies in patients with small HCC after RFA.

METHODS

In total, 11,243 patients were collected from global institutions to calculate recurrence rates. Subsequently, a Markov model covering a 10-year period was developed to compare 25 surveillance strategies involving different surveillance techniques (computed tomography [CT], magnetic resonance imaging or ultrasonography [US], and α-fetoprotein [AFP]) and intervals (3 or 6 months). The study endpoint was incremental cost-effectiveness ratio (ICER), which represented additional cost per incremental quality-adjusted life year. Sensitivity analysis was conducted by varying the values of input parameters to observe the ICER.

RESULTS

In a base case analysis, the dominant strategy was CT every 3 months during an initial 2 years, followed by semiannual CT, and then switch to biannual the combination of US screening and AFP testing after 5 years (m3_CT-m6_CT-m6_USAFP), with an ICER of $68,570.92 compared with the "not followed" strategy. One-way sensitivity analysis showed the ICER consistently remained below the willingness-to-pay threshold of $100,000.00. In a probabilistic sensitivity analysis, m3_CT-m6_CT-m6_USAFP was the most cost-effective approach in 95.6% of simulated scenarios at a willingness-to-pay threshold.

DISCUSSION

For small HCC after RFA, the recommended follow-up strategy is CT, with scans scheduled every 3 months for the first 2 years, every 6 months thereafter, and transition to biannual the combination of US screening and AFP testing after 5 years.

Hepatic arterial infusion therapy for advanced hepatocellular carcinoma after systemic treatment failure: A multi-center, real-world study

AIM

The study was conducted to evaluate the feasibility and safety profile of hepatic arterial infusion chemotherapy with oxaliplatin, 5-fluorouracil, and leucovorin (HAIC-FOLFOX) as an alternative therapeutic choice for patients with advanced hepatocellular carcinoma (HCC) that is refractory to systemic treatment including immune checkpoint blockades or molecular targeting agents.

METHODS

245 consecutive patients with advanced HCC who received HAIC-FOLFOX treatment after systemic treatment failure were retrospectively reviewed in six institutions and their survival, tumor response, and tolerance were assessed.

RESULTS

The median OS and PFS of the 209 included participants were 10.5 months (95%CI 8.1-12.9) and 6.0 months (95%CI 5.1-6.9), respectively. According to RECIST 1.1 criteria, the objective response rate was 21.1%, and the disease control rate was 64.6%. Multivariate analysis of risk factors of OS were ALBI grade (2 and 3 vs 1, HR = 1.57; 95%CI, 1.05-2.34; P = 0.028), tumor number (> 3 vs 1-3, HR = 2.18; 95% CI, 1.10-4.34; P = 0.026), extrahepatic spread (present vs absent, HR = 1.61, 95%CI, 1.06-2.45; P = 0.027), synchronous systemic treatment (present vs absent, HR = 0.55, 95%CI, 0.37-0.83; P = 0.004) and treatment response (responder vs nonresponder, HR = 0.30, 95%CI, 0.17-0.53; P < 0.001). Grade 3-4 AEs occurred in 59 (28.2%) HCC patients. All AEs were manageable, and deaths related to HAIC treatment were not observed.

CONCLUSIONS

Our findings support the effectiveness and safety of HAIC-FOLFOX treatment for patients with advanced HCC who have failed systemic treatment. This article is protected by copyright. All rights reserved.

Cost-effectiveness and prognostic model of hepatic arterial infusion chemotherapy for hepatocellular carcinoma with high tumor burden and/or Vp4 tumor thrombus compared with sorafenib: a post-hoc analysis of the FOHAIC-1 trial

OBJECTIVES

The phase III FOHAIC-1 trial revealed that hepatic arterial infusion of chemotherapy (HAIC) improved overall survival compared to sorafenib in the high-risk hepatocellular carcinoma (HCC). This study therefore set out to evaluate the cost-effectiveness and establish a prognostic clinico-radiological score of HAIC.

MATERIALS AND METHODS

A total of 409 patients with high-risk HCC who received HAIC between 2014 and 2020 were included. A Markov model was applied in the cost-effectiveness analysis using data from the FOHAIC-1 trial. In prognosis analysis, a clinico-radiological score was developed using a Cox-regression model and subsequently confirmed in the internal validation and test cohorts. The area under the curve from receiver operator characteristic analysis was used to assess the performance of the clinico-radiological score.

RESULTS

HAIC resulted in an incremental cost-effectiveness ratio of $10190.41/quality-adjusted life years compared to sorafenib, which was lower than the willingness-to-pay threshold. Probabilistic sensitivity analysis predicted a ≥99.9% probability that the incremental cost-effectiveness ratio was below the willingness-to-pay. The Cox analysis identified five factors, namely extrahepatic metastasis (m), arterial enhancing type (a), tumor number (nu), albumin-bilirubin index (a), and involved lobe (l), which together comprise the clinico-radiological score (HAIC-manual). Patients were classified into three groups based on the number of factors present, with cutoffs at 2 and 4 factors. The stratified median overall survival for these groups were 21.6, 10.0, and 5.9 months, respectively ( P <0.001). These findings were verified through internal validation and test cohorts with a significance level of P ≤0.01. The time-dependent area under the curve from receiver operator characteristic for the ability of the HAIC-manual to predict survival in 1, 2, and 3 years were 0.71, 0.76, and 0.78, which significantly outperformed existing staging systems.

CONCLUSION

HAIC is a promising and cost-effective strategy for patients with high-risk HCC. The clinico-radiological score may be a simple prognostic tool for predicting HAIC treatment.

[Construction and analysis of gene co-expression networks in intracranial aneurysm]

Objective: To analyze the expression microarray data in the public databases of intracranial aneurysms (IA) using bioinformatics, and to provide important information for the study of disease mechanisms. Methods: Gene co-expression network was constructed by weighted gene co-expression network analysis (WGCNA) based on the dataset (GSE75436) and pivot genes were identified. Using the online tool DAVID (Database for Annotation, Visualization, and Integrated Discovery) to perform GO function enrichment and KEGG path analysis on modules highly related to IA. Results: Three IA-related modules were screened out, and 14 pivot genes (COL3A1, SPARC, CDH11, COL5A1, HOPX, CLEC11A, GALNT10, ADAMTS2, CEMIP, KIAA1755, COL11A1, ZIC2, CDKN2A, and LINC00460) in the brown module were identified; the analysis of GO showed that the brown module was mainly enriched in extracellular matrix organization, extracellular matrix organization, cell adhesion and other biological processes; the analysis of KEGG indicated that the brown module involved in ECM-receptor interaction, Focal adhesion, protein digestion and absorption, PI3K-Akt signaling pathway. Conclusion: Based on WGCNA, we identified modular and pivotal genes that are critical to the development of IA, and they may become potential biomarkers and/or therapeutic targets.

[Analysis of the relevant factors for recurrent sudden sensorineural hearing loss]

Objective: To investigate the possible factors related to recurrence and prognosis of sudden sensorineural hearing loss(SSNHL). Methods: Four hundred and ninety-five patients with unilateral sudden sensorineural hearing loss between January 2013 to April 2014 were analyzed retrospectively(34 patients lost to follow-up with a dropout rate of 6.87%). Twenty of the 495 patients were diagnosed as recurrent SSNHL and treated again in the same hospital. The data of the patients were summarized to analyze the related factors which might influence the recurrence and prognosis of SSNHL. Results: In the 20 patients with recurrent SSNHL, 19 had the second attack in same ear as the first attack, and the other one had in both ears. There were seven male patients, and thirteen female patients. Patients ranged in age from 24 to 77years, with a median age of 39.5 years. Types of hearing loss: low frequency in eight patients, high frequency in two patients, flat frequency in eight patients, total deafness in two patients, the types of the second attack in 17 patients were same as the first attack, only one patient was changed from total deafness to flat frequency, one case was changed from flat frequency to high frequency, one case changed from flat frequency to total deafness. The intervals between of the first attack time and the second attack time were 1-36 months with the median time of 3.5 months. After systemic oral and (or) transtympanic steroid treatment, recovered in three cases, effective in three cases and 14 cases invalid, the cure rate was 15%, and the total effective rate was 30%. There were statistically significant differences in the recovery rate(χ²=8.640, P<0.05) and the overall response rate(χ²=12.379, P<0.01)between the first and the second treatments. For the patients with vertigo and/or dizziness, with a history more than seven days, with hypertension or diabetes mellitus, and with a type of hearing loss except low frequency type, the treatment effect was invalid. The patients with hearing loss at low frequency had the best outcomes. The total effective rates were significant different between patients younger and old than 34 years old(P<0.05). There was no difference in the total effective rate between genders, and patients with or without tinnitus and/or aural fullness in the recurrent SSNHL(P>0.05). The recurrence rates of patients with various types of hearing loss were different(F=7.744, P<0.05), with a highest recurrence rate in patients with hearing loss at low frequency. Other factors such as gender, age, accompanied diseases (hypertension or diabetes mellitus), associated symptoms, interval from onset to treatment had no effects on the recurrence rate. Conclusions: Recurrence of SSNHL is more likely to be found in patients with hearing loss of low frequency and flat type. The prognosis of recurrent SSNHL is poorer than that of the first episode, and may be related to the age and type of hearing loss.

Nonfunctioning pancreatic endocrine tumors. An immunohistochemical and electron microscopic analysis of 26 cases

Twenty-six patients with non-functioning pancreatic endocrine tumor (NFPET) were operated on during a 22-year period (1968-1990) at PUMC Hospital, Beijing. Of these, 19 were female and 7 were male with a mean age of 33 years. All these tumors, including 12 malignant and 14 benign, were solitary, and most of them were well-encapsulated. Immunohistochemical staining showed 23 (88.5%) containing 1-4 kinds of peptide hormone and 18 (69.2%) being multihormonal. In 7 of the 9 tumors subjected to electron microscopic study, various amounts of neurosecretory granules were found. Tumors of this series were clinically silent, but they contained some immunoreactive peptides, although the amount of the peptides varied from tumor to tumor.

Gastric gastrinoma

Two patients with Zollinger-Ellison Syndrome were diagnosed and treated in PUMC Hospital, the primary tumors were found in the stomach. On sectioning of the gastrectomized specimens, 85 tumors ranging from 0.1 to 1.0 cm in diameter were disclosed in Case 1, and a large ulcero-infiltrative carcinoma-like tumor in Case 2. Both tumors had already metastasized to regional lymph nodes and/or liver. Tumor cells in both cases exhibited gastrin, NSE, GH and hCG alpha immunoreactivity immunocytochemically, and abundant neurosecretory granules of 100-250 nm in diameter under electron microscope. The clinicopathological, immunocytochemical and ultrastructural findings of tumors from these two cases met the criteria of primary malignant gastrinoma of the stomach.

Insulinoma: 31 years of tumor localization and excision

This report is based on 31 years of experience with 116 cases of hyperinsulinism. Six cases had hypertrophy of the islets of Langerhans, 3 had widespead metastasis from malignant insulinomas, and 107 were benign adenoma cases. An immunoreactive insulin to glucose ratio of 0.3 of the peripheral venous blood before operation is of great value in diagnosing hyperinsulinism. Intraoperatively, immunoreactive insulin assay of the portal blood (IRI) is very valuable in determining if an insulinoma remains. The dividing line is 100 microU.ml-1. In localizing the tumor, "differential" PTPC is important before operation. During the operation, fine needle aspiration cytology may assist in ascertaining if the palpable tumor is an insulinoma. Multiple fine needle aspiration cytology examinations can sometimes reveal an insulinoma in an indurated pancreas. Portal vein blood IRI and blood sugar assays may serve to confirm if removal of the insulinoma is complete. Removal of the insulinoma controls hypoglycemia satisfactorily, but the brain damage incurred by prolonged hypoglycemia cannot be significantly altered. Removal of the tumor should be by enucleation, and the raw surface of the pancreas should be drained not sutured.

Watery diarrhea syndrome caused by multihormonal malignant pancreatic islet cell tumor secreting somatostatin, vasoactive intestinal peptide, serotonin, and prostaglandin E--a clinicopathological, biochemical, immunohistochemical, and ultrastructural study

The pathophysiological, biochemical, histological, ultrastructural, and immunohistochemical characters of a case of malignant pancreatic islet cell tumor with watery diarrhea syndrome were carefully investigated. Four hormones or mediators--somatostatin (SST), vasoactive intestinal peptide (VIP), serotonin, and prostaglandin E--were markedly elevated in the circulation. The diagnosis was further confirmed by exploratory laparotomy and autopsy. The contents of SST and VIP in tumor tissues were very high. Gel chromatography of tumor extract revealed single peaks for both SST and VIP. Immunohistochemical studies of tumor tissues showed numerous immunoreactive cells to anti-SST, moderate amount of VIP-positive cells, and a few hCG-, insulin-, and glucagon-positive cells. In conclusion, this is an unusual case of Verner-Morrison syndrome in which three kinds of bioactive hormones or mediators were simultaneously secreted; peptides, amine, and prostaglandin.

Insulinoma. An immunocytochemical and morphologic analysis of 95 cases

One hundred twenty-seven insulinomas from 95 cases (1 malignant and 94 benign) were studied pathologically. Thirty-six tumors (35 cases) were examined by electron microscopy. Typical beta-cell secretory granules of crystalloid-form cores and/or atypical secretory granules were discerned in all tumors examined. A new type of secretory granule, with high electron-dense crystalloid-form cores and moderate electron-dense granular substance filling the space between the core and the limiting membrane, were observed in two cases. Among 68 insulinomas (67 cases) subjected to immunocytochemical investigations with ten peptide hormones (insulin, glucagon, somatostatin, pancreatic polypeptide (PP), gastrin, motilin, secretin, vasoactive intestinal polypeptide (VIP), gastric inhibitory polypeptide (GIP), and neurotensin), 42 were found to be multihormonal, varying from two to four peptides secreted. The hormones contained were insulin, glucagon, PP, somatostatin, and gastrin in different combinations. One patient had hyperinsulinemia and hypergastrinemia concurrently, and two islet tumors were excised at an interval of 10 months. Both electron microscopy and immunocytochemistry confirmed the presence of beta- and alpha-cells in the first tumor, whereas the second tumor revealed only G-cells by electron microscopy, and G- and beta-cells on immunocytochemical staining. The morphologic and immunocytochemical characteristics of the insulinomas in this series are discussed.