Determinants of survival following hepatocellular carcinoma in Egyptian patients with untreated chronic HCV infection in the pre-DAA era

Background and Study Aims

In this study we assessed rates and determinants of survival in people with untreated chronic HCV infection and hepatocellular carcinoma (HCC) in an Egyptian liver clinic setting.

Hepatocellular carcinoma in a large Canadian urban centre: Stage at treatment and its potential determinants

OBJECTIVE:

To determine whether there is a significant difference in tumour stage between patients initially found with hepatocellular carcinoma (HCC) at a tertiary hepatobiliary centre and patients referred with tumours detected elsewhere; and to determine variables associated with referral in a palliative stage.

METHODS:

A retrospective review of 12,199 patients seen at a liver clinic over a 10.5-year period revealed 236 patients with HCC first detected internally (internal) and 163 who were referred with a known mass (referred). All patients were staged at the time of treatment using the Milan criteria for transplantation and Barcelona Clinic Liver Cancer (BCLC) staging system. Curative disease was defined as BCLC stages 0 and A. In the referred group, univariate and multivariate analyses were used to determine which of the following factors were significantly associated with presentation in a palliative stage: age, sex, ethnicity, cause of liver disease, presence of cirrhosis, location of residence and quintile of neighbourhood income.

RESULTS:

In comparing the internal versus referred patients, significant differences were found in the proportion of patients fulfilling Milan criteria (72% versus 36%), those with curative disease (75% versus 49%) and those with very early stage tumour (BCLC stage 0, 23% versus 7%); all differences were statistically significant (P<0.001). In patients referred for treatment of HCC from an outside institution, none of the variables tested were associated with presentation in a palliative stage.

CONCLUSION:

Patients with HCC referred to a liver treatment centre were more likely to be in palliative stages than those whose tumour was detected internally.     

Ultrasound Elastography for Fibrosis Surveillance Is Cost Effective in Patients with Chronic Hepatitis C Virus in the UK

Background

Chronic hepatitis C (HCV) is a significant risk factor for cirrhosis and subsequently hepatocellular carcinoma (HCC). HCV patients with cirrhosis are screened for HCC every 6 months. Surveillance for progression to cirrhosis and consequently access to HCC screening is not standardized. Liver biopsy, the usual test to determine cirrhosis, carries a significant risk of morbidity and associated mortality. Transient ultrasound elastography (fibroscan) is a non-invasive test for cirrhosis.

Purpose

This study assesses the cost effectiveness of annual surveillance for cirrhosis in patients with chronic HCV and the effect of replacing biopsy with fibroscan to diagnose cirrhosis.

Method

A Markov decision analytic model simulated a hypothetical cohort of 10,000 patients with chronic HCV initially without fibrosis over their lifetime. The cirrhosis surveillance strategies assessed were: no surveillance; current practice; fibroscan in current practice with biopsy to confirm cirrhosis; fibroscan completely replacing biopsy in current practice (definitive); annual biopsy; annual fibroscan with biopsy to confirm cirrhosis; annual definitive fibroscan.

Results

Our results demonstrate that annual definitive fibroscan is the optimal strategy to diagnose cirrhosis. In our study, it diagnosed 20 % more cirrhosis cases than the current strategy, with 549 extra patients per 10,000 accessing screening over a lifetime and, consequently, 76 additional HCC cases diagnosed. The lifetime cost is £98.78 extra per patient compared to the current strategy for 1.72 additional unadjusted life years. Annual fibroscan surveillance of 132 patients results in the diagnosis one additional HCC case over a lifetime. The incremental cost-effectiveness ratio for an annual definitive fibroscan is £6,557.06/quality-adjusted life years gained.

Conclusion

Annual definitive fibroscan may be a cost-effective surveillance strategy to identify cirrhosis in patients with chronic HCV, thereby allowing access of these patients to HCC screening.     

Strategy for improving survival and reducing recurrence of HCV-related hepatocellular carcinoma

Hepatocellular carcinoma(HCC)is the sixth most common cancer and the third leading cause of cancerrelated death in the world.With advances in imaging diagnostics,accompanied by better understanding of high-risk patients,HCC is now frequently detected at an early stage;however,the prognosis remains poor.The recurrence rate after treatment of HCC is higher than that associated with cancers of other organs.This may be because of the high incidence of intrahepatic distant recurrence and multicentric recurrence,especially with hepatitis C virus(HCV)-related hepatocellular carcinoma.The Barcelona Clinic Liver Cancer(BCLC)classification has recently emerged as the standard classification system for the clinical management of patients with HCC.According to the BCLC staging system,curative therapies(resection,transplantation,transcatheter arterial chemoembolization,percutaneous ethanol injection therapy,percutaneous microwave coagulation therapy and percutaneous radiofrequency ablation)can improve survival in HCC patients diagnosed at an early stage and offer a potential long-term cure.However,treatment strategies for recurrent disease are not mentioned in the BCLC classsification.The strategy for recurrence may differ according to the recurrence pattern,i.e.,intrahepatic distant recurrence vs multicentricrecurrence.In this article,we review recurrent HCC and the therapeutic strategies for reducing recurrent HCC,especially HCV-related HCC.     

Profile of hepatocellular carcinoma in a tertiary care hospital in Punjab in northern India

Purpose/Aim

Hepatocellular carcinoma (HCC) is a major cause of morbidity and mortality in all parts of the world. We analyzed the clinical presentation, etiology, and tumor characteristics of HCC presenting to our hospital.

Methods

All patients diagnosed to have HCC from September 2007 to August 2010 were prospectively enrolled. HCC was diagnosed according to EASL criteria—USG/CT/MRI of the abdomen and/or serum alpha-fetoprotein and/or histology (where indicated). Detailed clinical and laboratory parameters were noted. Barcelona Clinic Liver Cancer (BCLC) staging was done.

Results

One hundred and twenty-eight patients (22 females, mean±SD; age, 49.8?±?10.2 years) were diagnosed to have HCC. Underlying cirrhosis was present in 99.2 %. Hepatitis C virus infection, alone (21.9 %) or with alcohol (22.9 %) was the most common etiological factor, followed by alcohol alone; 33.6 % of the patients had more than one etiological factor. Most patients (83.5 %) presented with features of decompensated cirrhosis. HCC leading to decompensation of cirrhosis was the first presentation of the liver disease in nearly one third of the cases. Serum alpha-fetoprotein was >200 ng/mL in 67.2 % of the patients, while it was normal in 18.7 % of the patients. The mean±SD size of HCC was 5.3?±?2.9 cm. HCC was multicentric in 57 %, and portal vein thrombosis was present in 34.4 %. About 66 % of the patients belonged to BCLC stage C or D.

Conclusions

Hepatitis C virus infection was the most common cause of HCC in Punjab. One-third of the patients had multiple etiological factors and almost all had underlying cirrhosis and presented at advanced stage.     

Short-term outcomes after major hepatic resection in patients with cirrhosis: a 75-case unicentric western experience

Background

The benefit of performing major hepatic resection (MHR) for hepatocellular carcinoma (HCC) in patients with cirrhosis remains controversial because of its high risk of posthepatectomy liver failure (PHLF). This study was conducted to assess the risk of MHR for HCC in patients with cirrhosis.

Quality Improvement Measures Lead to Higher Surveillance Rates for Hepatocellular Carcinoma in Patients with Cirrhosis

Background

Cirrhosis is a major risk factor associated with the development of hepatocellular carcinoma (HCC). The American Association for the Study of Liver Diseases recommends surveillance for HCC in cirrhosis patients with ultrasound every six months. However, various studies suggest that surveillance rates in actual practice are quite low.

Aim

The aims of this study were to evaluate the effectiveness of implementing quality improvement (QI) measures in increasing the rate of HCC surveillance among patients in a tertiary care facility.

Methods

Patients with cirrhosis were prospectively enrolled into a chronic disease management program, which integrates nursing-based protocols with automatic reminders when patients are due for surveillance. Patients enrolled in this program between March 2010 and April 2011 were compared to a prior cohort in 2008–2009. The primary endpoint was the receipt of at least one abdominal imaging study performed for the purposes of surveillance during the study period.

Results

Of the 355 patients enrolled, 331 (93 %) had imaging performed for HCC surveillance, compared to 119/160 (74 %) patients in the previous cohort (p < 0.001). Chart review revealed the most common reasons for failure to undergo surveillance were patients’ lack of insurance and lack of follow-up on studies ordered at outside institutions. Six patients were diagnosed with HCC during the study period, of which three were at early stage.

Conclusions

Implementation of QI measures incorporating automatic reminders of surveillance status for providers can significantly increase the rate of HCC surveillance among cirrhosis patients.     

Current systemic treatment of hepatocellular carcinoma: A review of the literature

Hepatocellular carcinoma (HCC) is the fifth most common form of human cancer worldwide and the third most common cause of cancer-related deaths. The strategies of various treatments for HCC depend on the stage of tumor, the status of patient’s performance and the reserved hepatic function. The Barcelona Clinic Liver Cancer (BCLC) staging system is currently used most for patients with HCC. For example, for patients with BCLC stage 0 (very early stage) and stage A (early stage) HCC, the curable treatment modalities, including resection, transplantation and radiofrequency ablation, are taken into consideration. If the patients are in BCLC stage B (intermediate stage) and stage C (advanced stage) HCC, they may need the palliative transarterial chemoembolization and even the target medication of sorafenib. In addition, symptomatic treatment is always recommended for patients with BCLC stage D (end stage) HCC. In this review, we will attempt to summarize the historical perspective and the current developments of systemic therapies in BCLC stage B and C in HCC.     

Clinical features of hepatocellular carcinoma in patients with autoimmune hepatitis in Japan

Background

The occurrence of hepatocellular carcinoma (HCC) in patients with autoimmune hepatitis (AIH) is rare compared to that in patients with viral hepatitis. To clarify the status of HCC in patients with AIH in Japan, the clinical features of HCC in patients with AIH were analyzed.

Methods

A primary survey gathered data from 496 member institutions of the Liver Cancer Study Group of Japan, and a secondary survey collected additional information from 250 HCC patients out of a total 4869 AIH patients who were identified in the primary survey.

Results

Of the 250 patients identified through the secondary survey, 127 patients (50.8 %) from throughout Japan were found to have HCC. The mean age at diagnosis of HCC was 69 years, and the male-to-female ratio was 1:5.7. The mean period from diagnosis of AIH to detection of HCC was 8 years, and Child–Pugh status at the time of HCC diagnosis was class A in 61.8 %; of the patients analyzed, 77.9 % also had cirrhosis of the liver. The mean value of maximum tumor diameter was 4.3 cm, and clinical stages were I in 20.1 % of patients, II in 47.6 %, III in 23.4 %, and IV in 8.9 %. The therapeutic modality used was surgery in 30.2 %, percutaneous therapy in 29.5 %, transcatheter arterial chemoembolization in 36.4 %. Cumulative survival rate was 85.4 % at one year.

Conclusion

The survey results showed that HCC developed in 5.1 % of patients with AIH in Japan, with cirrhosis of the liver commonly found in elderly individuals; when HCC was diagnosed at an early clinical stage, in many cases, the liver function was relatively preserved. After diagnosis of AIH, observation of its progression with close attention to potential HCC complications is necessary.     

Surveillance factors change outcomes in patients with hepatocellular carcinoma due to chronic hepatitis C virus infection in New Zealand

Although surveillance for Hepatocellular Carcinoma (HCC) with 6 monthly imaging is recommended for patients with cirrhosis secondary to chronic hepatitis C virus (HCV) infection, international studies report poor adherence and there is paucity of data on its effect on patient outcomes. The primary aim of this study was to review cases of HCC secondary to HCV to determine the impact of adherence with HCC surveillance on survival. A total of 520 patients with confirmed HCC secondary to chronic HCV from 31 January 2001 to 31 May 2018 were identified from a prospective national HCC database. Computerized clinical records, general practitioner referral letters and secondary care clinic letters were subsequently retrospectively analysed for methods of HCC detection. HCC was detected through routine surveillance in only 224 patients (44%). HCC was detected either incidentally or following the onset of symptoms in nonadherent (12%), suboptimal surveyed (3%), undiagnosed cirrhotic (12%) or recently diagnosed HCV patients (21%) or were never offered surveillance (2%). Routine surveillance improved overall survival, OR 0.41 (95% CI [0.32, 0.53], P < .0001), with an overall mean survival of 91.5 months (95% CI 76.4, 106.6) compared to 43.0 (95% CI 34.2, 51.9) for those patients not receiving regular surveillance Outcome following diagnosis of HCC secondary to chronic HCV is determined by early detection when curative intervention is possible. Lack of diagnosis of HCV and nonadherence to HCC surveillance results in late diagnosis and poor outcomes. Under‐diagnosis of HCV infection and lack of diagnosis of cirrhosis in patients known to have HCV infection reduce the benefit of current HCC surveillance strategies.     

A comparison of factors associated with the temporal improvement in the overall survival of BCLC stage 0 hepatocellular carcinoma patients

BackgroundIt is uncertain whether the prognosis of Barcelona Clinical Liver Cancer (BCLC) stage 0 hepatocellular carcinoma (HCC) has improved.AimsTo evaluate whether the outcomes of BCLC stage 0 patients has improved, and if so, what are the reasons behind the noted improved outcome.MethodsA total of 591 patients with BCLC stage 0 HCC diagnosed at Samsung Medical Center, Seoul, Korea were grouped based on year of diagnosis (earlier cohort; 2007–2009 and later cohort; 2013–2015) and compared.ResultsThe overall survival (OS) was improved for BCLC stage 0 patients at later cohort (5-year survival rate: 82.1% vs. 92.0% for earlier cohort and later cohort, p = 0.015). However, after adjustment, the treatment period was not an independent factor for OS, especially when the albumin-bilirubin (ALBI) grade was adjusted. The incidence of liver cirrhosis (LC)-related death was increased from 10.4% to 33.3%, while the incidence of HCC-related death decreased from 57.5% to 28.6% in the latter cohort.ConclusionsThe survival improvement of BCLC stage 0 patients was largely explained by better liver function at diagnosis. Mortality from LC-related death was increasing, which calls for careful attention for finding strategies for preserving the liver function for BCLC stage 0 patients.     

Factors affecting prognosis of small hepatocellular carcinoma in Taiwanese patients following hepatic resection

BACKGROUND:

Small hepatocellular carcinoma (HCC) affects millions of individuals worldwide. Surveillance of high-risk patients increases the early detection of small HCC.

OBJECTIVE:

To identify prognostic factors affecting the overall survival (OS) and recurrence-free survival (RFS) of patients with small HCC.

METHODS:

The present prospective study enrolled 140 Taiwanese patients with stage I or stage II small HCC. Clinical parameters of interest included operation type, tumour size, tumour histology, Child-Pugh class, presence of hepatitis B surface antigen and liver cirrhosis, hepatitis C status, alpha-fetoprotein, total bilirubin and serum albumin levels, and administration of antiviral and salvage therapies.

RESULTS:

Tumour size correlated significantly with poorer OS in patients with stage I small HCC (P=0.014); however, patients with stage II small HCC experienced a significantly poorer RFS (P=0.033). OS rates did not differ significantly between patients with stage I and stage II small HCC. Tumour margins, tumour histology and cirrhosis did not significantly affect OS or RFS (P>0.05).

DISCUSSION:

Increasing tumour size has generally been associated with poorer prognoses in cases of HCC. The present study verified the relationship between small HCC tumour size and OS; however, a reduction in OS with increasing tumour size was demonstrated for patients with stage I – but not for stage II – small HCC.

CONCLUSION:

Patients with stage II small HCC may benefit from aggressive surveillance for tumour recurrence and appropriate salvage treatment. Further studies are needed for additional stratification of stage I patients to identify those at increased risk of death.     

Hepatitis C Virus-Associated Primary Hepatocellular Carcinoma in Non-cirrhotic Patients

Background

There is limited literature on hepatocellular carcinoma (HCC) in patients with chronic hepatitis C virus (HCV) infection in the absence of cirrhosis.

Aims

To investigate the relationship between HCV and HCC in the absence of cirrhosis and to characterize patients with HCV infection presenting with HCC in the absence of cirrhosis.

Methods

We identified all adult patients with histological confirmation of HCC between 1994 and 2007 (404 patients). A case?Ccontrol design (four controls for each case with non-cirrhotic HCC) was chosen to compare characteristics and survival of HCV in HCC patients without (cases) and with (controls) cirrhosis. Conditional logistic regression analysis was used to identify factors independently associated with HCV in non-cirrhotic HCC.

Results

Eighty-seven patients with non-cirrhotic HCC were identified, six (7?%) had HCV infection in comparison with 107 of 317 (55.7?%) with cirrhotic HCC (P?<?0.001). Compared with the HCV-associated HCC cirrhotic group, patients with HCV-associated HCC in the absence of cirrhosis were more likely to present with a single nodule (100 vs. 66.7?%), larger nodule size (>5?cm) (100 vs. 16.7?%), and macrovascular invasion (66.7 vs. 17.4?%) at time of diagnosis. Four of six patients with HCV-associated HCC in the absence of cirrhosis where alive at three years (all had resection), which was better survival than for HCC arising in cirrhotic livers of HCV-infected individuals (66.7 vs. 39.1?%).

Conclusion

We found that HCV is responsible for a small minority of non-cirrhotic HCC cases representing an uncommon and poorly defined subgroup of HCC.     

Characterization of hepatocellular carcinoma (HCC) in non-alcoholic fatty liver disease (NAFLD) patients without cirrhosis

Background

The incidence of hepatocellular carcinoma (HCC) has increased significantly in United States over the last few decades in parallel with the epidemic of nonalcoholic fatty liver disease (NAFLD). Limited data suggests that HCC could arise in steatotic liver without the presence of cirrhosis. The present study was conducted to characterize patients with NAFLD presenting with HCC in non-cirrhotic liver (NCL) compared to the NAFLD- HCC patients in association with cirrhotic liver (CL).

Methods

A retrospective analysis of all patients diagnosed with HCC and NAFLD diagnosis seen at our institution between 2003 and 2012 was done. The patients were characterized based on demographic and clinical variables as well as histological and tumor features. Comparisons between the NCL and CL groups were done using analysis of variance (ANOVA) or the non-parametric Kruskal–Wallis tests and Pearson's chi-square tests or Fisher's Exact tests as appropriate. P value of <0.05 was considered statistically significant.

Results

Thirty-six patients with NAFLD and HCC in NCL (HCC-NCL group) were identified and compared to 47 patients with NAFLD-HCC and Liver Cirrhosis (HCC-LC group). Liver fibrosis was not present in 55.9 % of patients in the HCC-NCL group (F0), stage 1 was present in 17.6 %, stage 2 in 8.8 % and stage 3 in 17.6 %. Lobular inflammation was present in 63.6 % of non-cirrhotic patients. Patients in the HCC-NCL were older (67.5 ± 12.3 vs. 62.7 ± 8.1 years), and less likely to be obese (52 % vs. 83 %) or have type 2 diabetes (38 % vs. 83 %), with p value <0.05 for all. More importantly, compared with the HCC-CL group, those in the HCC-NCL group were more likely to present with a single nodule (80.6 % vs. 52.2 %), larger nodule size (>5 cm) (77.8 % vs. 10.6 %), and receive hepatic resection as the modality of HCC treatment (66.7 % vs. 17 %); and were less likely to receive loco-regional therapy (22.3 % vs. 61.7 %) or orthotopic liver transplantation (OLT) (0 % vs. 72.3 %), with p value <0.001 for all. Furthermore, 86 % of patients without cirrhosis had HCC recurrence compared to only 14 % in patients with cirrhosis (p < 0.001). Unadjusted analysis indicates that non-cirrhotics had worse survival with mortality rate of 47 % vs. 28 % in CL group (p = 0.03); however this difference in survival between two groups was not significant after adjusting for age or OLT (p > 0.05).

Conclusion

Patients with HCC in the absence of liver cirrhosis are more likely to present at an older age with larger tumor and have higher rates of tumor recurrence. Studies to assess the cost-effectiveness of HCC surveillance in this group should be conducted.

     

Risk factors for hepatocellular carcinoma in Japanese patients with autoimmune hepatitis type 1

Background

Hepatocellular carcinoma (HCC) is occasionally seen even in patients with autoimmune hepatitis (AIH) without prior infection either with hepatitis C virus (HCV) or hepatitis B virus. The aim of this study was to identify the incidence of and risk factors for HCC with AIH in a large-scale population with a long-term follow-up in Japan.

Methods

One hundred and eighty patients diagnosed with AIH were enrolled (F/M?=?159/21; mean age, 59.9?years; mean observation period, 80.2?months). Patients with positive HCV antibody/serum HCV RNA and/or positive HBs Ag were excluded. Initial treatment included immunosuppressant therapy (n?=?147), other drugs (n?=?28), and no drug (n?=?5). Patients underwent abdominal ultrasonography at intervals of 3–6?months during observation. Patients’ demographic factors, biochemical data, liver histology, medications, response to treatment, and complications were evaluated in relation to HCC.

Results

During the observation period, six patients (3.3%) developed HCC. Univariate analysis showed that risk factors for HCC were cirrhosis at diagnosis with AIH (p?=?0.0002), absence of a treatment response (p?=?0.033), abnormal alanine aminotransferase (ALT) at the final observation (p?=?0.0002), and diabetes (p?=?0.0015). Multivariate analysis showed that risk factors for HCC were cirrhosis at diagnosis of AIH (odds ratio 4.08) and abnormal ALT at final observation (odds ratio 3.66).

Conclusion

This retrospective study showed that cirrhosis at diagnosis of AIH and abnormal ALT at final observation were independently associated with HCC development. It is important to pay attention to the presence of cirrhosis at diagnosis of AIH and to normalize ALT.     

Hepatocellular carcinoma risk in patients with porphyria cutanea tarda

AIM: It has been suggested that patients with porphyria cutanea tarda (PCT) are at high risk of developing hepatocellular carcinoma (HCC); however, this has not been confirmed by other workers. The aim of our study was to evaluate the incidence of HCC in patients with PCT, and to assess the possible co-factors associated with cancer development. METHODS: Thirty-nine consecutive patients with a diagnosis of PCT were included. Hepatitis B virus and hepatitis C virus (HCV) infection was investigated, and a percutaneous liver biopsy was performed. Patients were treated with phlebotomies, which resulted in a clinical remission in all. These patients were included in a surveillance programme for the detection of HCC, with ultrasonography and serum alpha-fetoprotein every 6 months. RESULTS: Thirty-nine patients (92% male; mean age, 55 +/- 16 years) with PCT were included. Alcohol abuse was reported in 87% of the cases. The mean follow-up time since the initial diagnosis of PCT was 9.7 years (378 patient-years of follow-up). Serological markers of past infection with hepatitis B virus were found in 20% of the patients, while HCV infection was diagnosed in 56%. The stage of fibrosis in patients having liver biopsy was: 0 (32%), 1 (32%), 2 (9%), 3 (18%), and 4 (9%). HCC was diagnosed in 1/39 patients with PCT (cumulative incidence, 2.6%), giving a yearly incidence of 0.26% per patient-year. This patient was a 69-year-old male, alcohol abuser, with HCV infection, with a 12-year period between diagnosis of PCT and HCC, and with liver biopsy (3 years before) showing fibrosis stage 3. CONCLUSION: The risk of developing HCC in patients with PCT in our area is relatively low (a yearly incidence of less than 1% per patient-year of follow-up), and perhaps attributable, at least in part, to concomitant HCV infection. Patients presenting with PCT should undergo both HCV infection determination and liver biopsy, and those with concomitant HCV infection or advanced fibrosis/cirrhosis should probably be included in a standard surveillance programme in order to achieve early diagnosis of HCC.     

Treatment allocation in hepatocellular carcinoma: Assessment of the BCLC algorithm

Background and aims. The Barcelona Clinic Liver Cancer (BCLC) staging system is the algorithm most widely used to manage patients with hepatocellular carcinoma (HCC). We aimed to investigate the extent to which the BCLC recommendations effectively guide clinical practice and assess the reasons for any deviation from the recommendations.Material and methods. The first-line treatments assigned to patients included in the prospective Bern HCC cohort were analyzed.Results. Among 223 patients included in the cohort, 116 were not treated according to the BCLC algorithm. Eighty percent of the patients in BCLC stage 0 (very early HCC) and 60% of the patients in BCLC stage A (early HCC) received recommended curative treatment. Only 29% of the BCLC stage B patients (intermediate HCC) and 33% of the BCLC stage C patients (advanced HCC) were treated according to the algorithm. Eighty-nine percent of the BCLC stage D patients (terminal HCC) were treated with best supportive care, as recommended. In 98 patients (44%) the performance status was disregarded in the stage assignment.Conclusion. The management of HCC in clinical practice frequently deviates from the BCLC recommendations. Most of the curative therapy options, which have well-defined selection criteria, were allocated according to the recommendations, while the majority of the palliative therapy options were assigned to patients with tumor stages not aligned with the recommendations. The only parameter which is subjective in the algorithm, the performance status, is also the least respected.     

Expanded use of aggressive therapies improves survival in early and intermediate hepatocellular carcinoma

Background

Despite the increasing annual incidence of hepatocellular carcinoma (HCC) in the USA, now estimated at 2.7 cases per 100 000 population, only a small proportion of patients receive treatment and 5-year survival rates range from 9% to 17%.

Objectives

The present study examines the effects of multimodal treatment on survival in a mixed-stage HCC cohort, focusing on the impact of radical therapy in patients with Barcelona Clinic Liver Cancer (BCLC) stage B disease.

Methods

A retrospective review of the medical records of 254 patients considered for HCC treatment between 2003 and 2011 at a large tertiary referral centre was conducted.

Results

A total of 195 (76.8%) patients were treated with a median of two liver-directed interventions. Median survival time was 16 months. In proportional hazards analysis, radiofrequency ablation (RFA) and resection were associated with significantly improved 1- and 5-year survival among patients with BCLC stage 0–A disease. In patients with BCLC stage B disease, RFA conferred a survival benefit at 1 year and resection was associated with significantly improved survival at 5 years.

Conclusions

As one of few studies to track the complete course of sequential HCC therapies, the findings of the present study suggest that HCC patients with intermediate-stage (BCLC stage B) disease may benefit from aggressive interventions not currently included in societal guidelines.     

Hepatocellular carcinoma: Epidemiological profile from a cohort of federal employees in Mexico

Introduction. Hepatocellular carcinoma (HCC) has become a frequent type of cancer in Mexico. At the present time it represents the 19th cause of death in the population.Objective. To recognize the epidemiological profile and the treatment results in a cohort of federal employees with HCC.Material and methods. We analyzed 47 consecutive cases with HCC diagnosis from January 2004 till December 2007. Twenty four demographic data, tumor staging, clinical, and biochemical variables were analyzed to identify parameters predicting survival by computing Kaplan-Mier and Mantel-Cox survival curves.Results. Patient reference increased 5% each year. The mean age was 60.4 years, 63.8% female sex, and 72.3% had cirrhosis, 44.7% had Hepatitis C infection. Most patients presented with advanced disease: 55.3% were AJCC stage 3 and 21.3% stage 4, 51.1% were BCLC class D. Mean tumor size was 8.09 cm. Median survival time from diagnosis was 122 days. Patients that did not receive treatment had a median survival of 70 days; the longest survival of patients was of those that received transarterial chemoembolization with a median of 707 days, followed by surgery with 683 days. Univariate analysis showed survival was associated to MELD score, AJCC and BCLC staging, creatinine level and ascites. Multivariate analysis showed tumor differentiation, AJCC staging and the choice of treatment to be related to the risk of death.Conclusion. An increase in the referral of HCC was demonstrated. Most patients had cirrhosis and HCV infection. Due to advance disease staging, TACE was the treatment that offered longest survival.     

Multimodal treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) represents the most common liver cancer with an increasing incidence and it accounts for the third most common cause of cancer-related death worldwide. Even though the clinical diagnosis and management of HCC improved significantly in the last decades, this malignant disease is still associated with a poor prognosis. It has to be distinguished between patients with HCCs, which developed from liver cirrhosis, and patients without underlying liver cirrhosis as classification systems, prognosis estimation and therapy recommendations differ in-between. In case of HCC in patients with liver cirrhosis in Europe, treatment allocation and prognosis estimation are mainly based on the Barcelona-Clinic Liver Cancer (BCLC) staging system. Based on this staging system different surgical, interventional radiological/sonographical and non-interventional procedures have been established for the multimodal treatment of HCC. The BCLC classification system represents a decision guidance; however because of its limitations in selected patients treatment allocation should be determined on an individualized rather than a guideline-based medicine by a multidisciplinary board in order to offer the best treatment option for each patient. This review summarizes the current management of HCC and illustrates controversial areas of therapeutic strategies.