Comparing Hepatic Resection and Transarterial Chemoembolization for Barcelona Clinic Liver Cancer (BCLC) Stage B Hepatocellular Carcinoma: Change for Treatment of Choice?

Background

Compared to transarterial chemoembolization (TACE) for patients with hepatocellular carcinoma (HCC), stage B in the Barcelona Clinic Liver Cancer (BCLC) classification, the role of hepatic resection remains unclear. The present study compared the long-term outcome of hepatic resection with TACE in the treatment of BCLC stage B HCC.

Methods

A total of 171 patients with BCLC stage B, Child’s classification A (Child A), HCC were included in this retrospective study. Of these, 93 patients underwent hepatic resection (group I) and 73 patients received TACE (group II). We evaluated the long-term outcome and therapy-related mortality in both groups. The risk factors of mortality were assessed. The survival curve was analyzed by the Kaplan–Meier method.

Results

The 1-, 2-, and 3-year overall survival rates for the two groups after hepatic resection and TACE were 83%, 62%, 49% and 39%, 5%, 2%, respectively (P < 0.0001). We did not observe significant differences in the therapy-related mortality between the two groups (P = 0.78). Treatment modality and serum albumin level were independent risk factors for survival by Cox regression analysis.

Conclusions

Our study demonstrated that hepatic resection for BCLC stage B, Child A HCC patients had better survival rates than TACE group. Thus, hepatic resection is indicated in selected patients with BCLC stage B.     

Surgery Versus Transarterial Chemoembolization for Solitary Large Hepatocellular Carcinoma of BCLC Stage A

Background/Aims

The aim of this study was to compare the outcomes of surgery and transarterial chemoembolization (TACE) for a solitary huge hepatocellular carcinoma (HCC) of Barcelona Clinic Liver Cancer (BCLC) stage A.

Methods

One hundred twenty-three consecutive patients with a solitary large (>5 cm) HCC classified at the BCLC stage A were analyzed. The posttreatment survival outcomes of patients that underwent surgery or TACE were compared.

Results

The median age was 58 years (range, 29–90 years). The most common cause of HCC is hepatitis B virus infection (61.8 %). Median tumor size was 8.0 cm (range, 5.1–25 cm), and 97 patients (78.9 %) were of Child–Turcotte–Pugh class A. Median posttreatment follow-up duration was 18 months (range, 0.1–136 months). Of the 123 patients, 62 (50.4 %) underwent surgery and 61 (49.6 %) underwent TACE. Cumulative overall survival rates in the surgical group at 1, 3, and 5 years were significantly higher than those in the TACE group (83.2, 75.7, and 65.0 % vs 68.5, 45.0, and 17.5 %, respectively, P?<?0.01). In subgroup analysis, the cumulative overall survival in both surgical groups was significantly greater than in corresponding TACE subgroups (P?=?0.04 for ≥8-cm subgroup and P?<?0.01 for 5- to 8-cm-sized subgroups). Multivariate analysis showed that a larger tumor size (≥8 cm) (hazard ratio [HR] 2.14, P?=?0.02) was significantly associated with posttreatment mortality, whereas surgery (HR 0.37, P?<?0.01) compared with TACE was inversely associated with posttreatment mortality.

Conclusions

Surgery may be the more effective treatment modality than TACE for a solitary large HCC of the BCLC stage A, regardless of tumor size.     

Surgical Resection Versus Transarterial Chemoembolization for Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis: A Propensity Score Analysis

Background

The long-term survival in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) who received surgical resection (SR) or transarterial chemoembolization (TACE) remains unclear. We compared the efficacy of SR and TACE by using a propensity score analysis.

Methods

A total of 247 and 181 HCC patients with PVTT undergoing SR and TACE, respectively, were evaluated. One hundred eight pairs of matched patients were selected from each treatment arm by using a propensity score analysis.

Results

Of all patients, the estimated 1-, 3-, and 5-year survival rates of patients receiving SR and TACE were 85 versus 60 %, 68 versus 42 %, and 61 versus 33 %, respectively (p < 0.001). Patients selected for SR were significantly younger and had better liver functional reserve, performance status, and smaller tumor burden. In the propensity model, the survival benefit of SR remained significant. The estimated 1-, 3-, and 5-year survival rates of patients receiving SR and TACE were 84 versus 71 %, 69 versus 50 %, and 59 versus 35 %, respectively (p = 0.004). The two groups of patients in the propensity score analysis were similar in baseline characteristics. In the Cox proportional hazards model, patients receiving TACE had a 2.044-fold increased risk of mortality compared with patients receiving SR (95 % confidence interval: 1.284–3.252, p = 0.003).

Conclusions

For either unselected patients or patients in the propensity model, SR provides significantly better long-term survival than TACE. SR should be considered as a priority treatment in this subgroup of HCC patients.     

Complete Necrosis After Transarterial Chemoembolization Could Predict Prolonged Survival in Patients with Recurrent Intrahepatic Hepatocellular Carcinoma After Curative Resection

Background

We explored the predictors of response to transarterial chemoembolization (TACE) in patients with recurrent intrahepatic hepatocellular carcinoma (HCC) after hepatectomy and investigated the survival of these patients according to the response to TACE.

Methods

We analyzed data from 199 consecutive HCC patients who underwent curative liver resection and who later received repeat TACE for intrahepatic HCC recurrence.

Results

Of 199 patients, 139 (69.8%) achieved complete necrosis (CN) of HCC after repeated TACE (mean TACE session number, 1.3) and the other 60 (30.2%) (non-CN group) did not achieve CN. At hepatectomy, the CN group showed significantly smaller proportions of tumor capsular invasion, microvascular invasion, and pathologic tumor–node–metastasis stage III or IV HCCs. At first TACE, the CN group showed a significantly greater proportion of patients with time to recurrence ≥ 1 year, Child–Pugh class A, serum alpha-fetoprotein (AFP) levels < 200 ng/mL, tumor size < 3 cm, solitary tumors, and nodular tumor types; portal vein invasion were less common than seen in the non-CN group. After multivariate analysis, tumor size < 3 cm and a single tumor at first TACE were independently related to attainment of CN after TACE. Median survival after first TACE was significantly longer in the CN group (48.9 versus 17.0 months). In a Cox regression model, CN after TACE was an independent predictor of favorable survival outcome after first TACE.

Conclusions

CN after repeat TACE for postresection intrahepatic recurrence was attained more commonly in patients with smaller tumor size and lower tumor number at first TACE and favored longer survival in recurrent patients.     

Establishment of a Multidisciplinary Hepatocellular Carcinoma Clinic is Associated with Improved Clinical Outcome

Purpose

To evaluate differences in overall survival in patients with hepatocellular carcinoma (HCC) after the establishment of a multidisciplinary clinic (MDC) for HCC.

Methods

Patient demographic and tumor characteristics of 355 patients diagnosed with HCC were collected between October 2006 and September 2011. Patients diagnosed after the initiation of the HCC MDC on October 1, 2010, were compared to patients diagnosed in the 4 years before. Patient demographics, tumor characteristics, treatment regimens, and overall survival were analyzed between the groups.

Results

A total of 105 patients were diagnosed in the time period after HCC MDC initiation compared to 250 patients in the previous 4 years. Patients diagnosed with HCC after the HCC MDC had fewer symptoms at presentation (64 vs. 78 %, p = 0.01) and earlier stage of tumor presentation [Barcelona Clinic for Liver Cancer (BCLC) A stage, 44 vs. 26 %, p = 0.0003; tumor, node, metastasis classification system stage 1, 44 vs. 30 %, p = 0.003) compared with patients diagnosed before MDC formation. The median time to treatment after diagnosis in the later period was significantly shorter than in the earlier time period (2.3 vs. 5.3 months, p = 0.002). On multivariate analysis, being seen in the HCC MDC remained independently associated with better overall survival (hazard ratio 2.5, 95 % confidence interval 2–3), after adjusting for BCLC stage and recipient of curative treatment. Patients diagnosed after HCC MDC initiation had a median survival of 13.2 months compared to the 4.8 months observed in patients diagnosed before MDC formation (p = 0.005).

Conclusions

The implementation of a MDC for the evaluation and treatment of patients with HCC is associated with improved overall survival.     

Impact of Spontaneous Hepatocellular Carcinoma Rupture on Recurrence Pattern and Long-term Surgical Outcomes after Partial Hepatectomy

Background

The clinical significance of spontaneous hepatocellular carcinoma (HCC) rupture association with recurrence pattern and long-term surgical outcomes remains under debate. We investigated the impact of spontaneous HCC rupture on recurrence pattern and long-term surgical outcomes after partial hepatectomy.

Methods

From 2000 to 2012, 119 patients with diagnosed ruptured HCC were reviewed. To compare outcomes between staged hepatectomy in spontaneously ruptured HCC and hepatectomy in non-ruptured HCC, we performed propensity score-matching to adjust for significant differences in patient characteristics. Overall survival, disease-free survival, and recurrence pattern were compared between the matched groups.

Results

Forty-four patients with newly diagnosed ruptured HCC and Child A class were initially treated with transcatheter arterial embolization for hemostasis. Three patients underwent emergency laparotomy, 18 underwent staged hepatectomy, and 23 received transarterial chemoembolization (TACE) alone after transcatheter arterial embolization. Among the 23 patients treated with TACE alone, 10 had resectable tumors. The staged hepatectomy group shows significantly higher overall survival with TACE alone than the resectable tumor group (P < 0.001). After propensity score-matching, overall survival, disease-free survival, and recurrence pattern were not significantly different between the ruptured HCC with staged hepatectomy group and the non-ruptured HCC with hepatectomy group. Peritoneal recurrence rates were similar at 14.3 % versus 10.0 %, respectively (P = 0.632).

Conclusions

Patients with spontaneously ruptured HCC with staged hepatectomy show comparable long-term survival and recurrence pattern as patients with non-ruptured HCC having similar tumor characteristics and liver functional status. Thus, spontaneous HCC rupture may not increase peritoneal recurrence and decrease long-term survival after partial hepatectomy.     

Albumin-bilirubin grade predicts the outcomes of liver resection versus radiofrequency ablation for very early/early stage of hepatocellular carcinoma

Background and purpose

Whether liver resection or ablation should be the first-line treatment for very early/early hepatocellular carcinoma (HCC) in patients who are candidates for both remains controversial. The aim of this study was to determine if the newly-developed Albumin-Bilirubin (ALBI) grade might help in treatment selections and to evaluate the survival of patients treated with liver resection and radiofrequency ablation (RFA).

Transarterial Chemoembolization for Unresectable Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis: A Prospective Comparative Study

Background

For patients with hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT), the survival benefit of transarterial chemoembolization (TACE) compared with conservative treatment largely remains controversial. The objective of this study was to determine whether TACE confers a survival benefit to patients with HCC and PVTT, and to uncover prognostic factors.

Methods

Between July 2007 and July 2009, a prospective two-arm nonrandomized study was performed on consecutive patients with unresectable HCC with PVTT. In one arm, patients were treated by TACE using an emulsion of lipiodol and anticancer agents ± gelatin sponge embolization. In another arm, patients received conservative treatment.

Results

A total of 164 patients were recruited for the study (TACE group, n = 84; conservative treatment group, n = 80). Patients in the TACE group received a mean of 1.9 (range, 1–5) TACE sessions. The overall median survival for all patients was 5.2 months, and the 12- and 24-month overall survival rates were 18.3% and 5.6%, respectively. The 12- and 24-month overall survival rates for the TACE and conservative groups were 30.9%, 9.2%, and 3.8%, 0%, respectively. The TACE group had significantly better survivals than the conservative group (P < 0.001). On subgroup analysis of segmental and major PVTT, the TACE group also had significantly better survivals (P = 0.002, P = 0.002). The treatment type, PVTT extent, tumor size, and serum bilirubin were independent prognostic factors of survival on multivariate analysis.

Conclusions

TACE was safe and feasible in selected HCC patients with PVTT and it had survival benefit over conservative treatment.     

Transarterial Chemoembolization for the Treatment of Advanced-Stage Hepatocellular Carcinoma

It remains controversial whether transarterial chemoembolization (TACE) should be performed in patients with advanced-stage hepatocellular carcinoma (HCC). The present large retrospective cohort study aimed to define the survival outcome following TACE of advanced HCC and to identify the prognostic factors. Five hundred eight patients with Barcelona Clinic Liver Cancer (BCLC) C-stage HCC, Child-Pugh A/B who were treated with TACE between November 1998 and December 2013 were identified. There was no significant difference in overall survival (OS) between patients with Eastern Cooperative Oncology Group (ECOG) 0 and those with ECOG ≥1 (10.5 months vs. 11.9 months, P?=?0.87). The median OS of patients without portal vein tumor thrombosis (PVTT) was longer than that of patients with PVTT (16.9 vs. 6.1 months, P?<?0.001). Child-Pugh B class, PVTT, extrahepatic metastasis, tumor size ≥5 cm, number of tumors ≥3, and alpha-fetoprotein ≥400 ng/dL were significantly associated with decreased survival and were used for determining the risk scores. All patients were divided into two groups (low-risk and high-risk groups) according to the cutoff value of 6.5 for risk scores. The patients with a value <6.5 (low-risk group) had significantly longer survival than those with >6.5 (high-risk group) (24.1 vs. 7.5 months, respectively; P?<?0.001). TACE is an effective therapy for select patients with advanced stage HCC and may provide equal or improved survival as compared with reported outcomes with sorafenib. The results highlight the need for a differentiated approach to therapeutic recommendations for patients with BCLC C.     

Medium-Sized (3.1–5.0 cm) Hepatocellular Carcinoma: Transarterial Chemoembolization Plus Radiofrequency Ablation Versus Radiofrequency Ablation Alone

Purpose

This study was designed to retrospectively compare the effectiveness of combined transarterial chemoembolization (TACE) plus radiofrequency ablation (RFA) with that of RFA alone in patients with medium-sized (3.1–5.0 cm) hepatocellular carcinoma (HCC).

Methods

From March 2000 to April 2010, 57 patients, each with a single medium-sized HCC, were treated with combined TACE and RFA, and 66 were treated with RFA alone.

Results

During follow-up (mean, 42.5 ± 33.2 months; range, 2.6–126.2 months), local tumor progression was observed in 40% of treated lesions in the combined treatment group and in 70% in the RFA-alone group. The 1-, 3-, 5-, and 7-year local tumor progression rates were significantly lower in the TACE + RFA group (9%, 40%, 55%, and 66%, respectively) than in the RFA-alone group (45%, 76%, 86%, and 89%, respectively; P < 0.001). Multivariate analysis showed that treatment allocation (odds ratio [OR], 1.78; P = 0.016) and Child-Pugh class (OR, 1.96; P = 0.008) were significant independent factors associated with patient survival. The rates of major complications were 0% for the combined treatment group and 3% for the RFA-alone group.

Conclusions

The combination of TACE and RFA is safe and provides better local tumor control than RFA alone for the treatment of patients with medium-sized HCC. Our multivariate analysis showed that RFA-alone treatment and Child-Pugh class B were poor independent factors for determining the patient survival period.     

Comparison of Surgical Resection and Transarterial Chemoembolization for Hepatocellular Carcinoma beyond the Milan Criteria: A Propensity Score Analysis

Background

Treatment for patients with intermediate-stage hepatocellular carcinoma (HCC) is controversial. This study compared the long-term survival of patients beyond the Milan criteria who received surgical resection (SR) or transarterial chemoembolization (TACE).

Methods

A total of 268 and 455 HCC patients beyond the Milan criteria undergoing SR and TACE, respectively, were retrospectively evaluated. After propensity score analysis to adjust for baseline differences, 146 pairs of matched patients were selected from each treatment arm. Long-term survival was compared by the Kaplan?CMeier method. Independent prognostic predictors were determined by the Cox proportional hazards model.

Results

Long-term survival was significantly better for the SR group by univariate survival analysis (P?P?P?P?Conclusions For HCC patients beyond the Milan criteria, SR is considered equally safe as TACE and provides better long-term survival. SR may be regarded as the priority treatment for these patients.     

Inflammatory Markers are Associated with Outcome in Patients with Unresectable Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization

Background

The serum neutrophil–lymphocyte ratio (NLR) is associated with outcomes in several solid organ cancers, including hepatocellular carcinoma (HCC).

Methods

We reviewed our experience in patients with HCC who underwent transarterial chemoembolization (TACE) as the initial treatment. Serum complete blood counts were used to calculate the NLR before and after TACE. The Kaplan–Meier method was used to determine survival and significant differences between groups by the log-rank test.

Results

There were 103 patients identified who underwent TACE for HCC. The median age was 60.5 years. Median overall survival was 12.6 (95 % confidence interval 8.3–17) months. Median survival in patients with a high preprocedural NLR was 4.2 months compared to 15 months in those with a normal NLR (p = 0.021). In those whose NLR either rose 1 month after treatment or remained elevated, survival was worse compared to those who normalized or remained normal (18.6 vs. 10.6 months, p = 0.026). The same was true at 6 months (21.3 vs. 9.5 months, p = 0.002). An unresponsive NLR was associated with very poor outcome (median survival 3.7 months). Multivariate analysis of clinicopathologic factors showed that presence of extrahepatic disease and high NLR were independent factors associated with worse survival.

Conclusions

Our study demonstrates that periprocedural trends of serum NLR are associated with outcome in unresectable HCC undergoing TACE. Serum NLR is easy to calculate from a routine complete blood count with differential. Along with liver function, serum NLR may be helpful to clinicians in providing prognostic information and monitoring response to therapy.     

DNA Methylation Profiling Identifies EYA4 Gene as a Prognostic Molecular Marker in Hepatocellular Carcinoma

Background

DNA hypermethylation plays important roles in carcinogenesis by silencing key genes. This study aims to identify pivotal genes in hepatocellular carcinoma (HCC) by DNA methylation microarray and to assess their prognostic values.

Materials and Methods

DNA methylation microarray was performed in 45 pairs of HCC and adjacent nontumorous tissues and six normal liver tissues to identify hypermethylated genes in HCC. Potential prognosis-related genes were selected among hypermethylated genes by analyzing influences of methylation levels on disease-free survival (DFS) and overall survival (OS) in 45 patients. Their prognostic values were validated in 154 patients with HCC (including the initial 45 patients) to determine the independent prognostic gene.

Results

Altogether, 54 CpG islands in 44 genes were hypermethylated in HCC compared with liver tissues. Among them, methylation levels of ERG and HOXA11 were inversely associated with DFS (both P < 0.050), and methylation levels of EYA4 were inversely related to DFS and OS (both P < 0.050). EYA4 expression was inversely related to tumor size (P < 0.050). Lower EYA4 expression and larger tumor size were independent predictors of both shorter DFS and OS, and higher Barcelona Clinic Liver Cancer (BCLC) staging was an independent predictor of shorter OS (all P < 0.050).

Conclusions

EYA4 functions as a prognostic molecular marker in HCC. Its aberrant hypermethylation and subsequent down-regulation may promote tumor progression.     

Surgical Resection Versus Conformal Radiotherapy Combined With TACE for Resectable Hepatocellular Carcinoma With Portal Vein Tumor Thrombus: A Comparative Study

Background

The aim of this study was to compare the results of surgical resection with three-dimensional conformal radiotherapy (3D-CRT) in the treatment of resectable hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). Transarterial chemoembolization (TACE) was given to both groups of patients when possible.

Methods

A retrospective study of 371 patients with resectable HCC with PVTT was conducted in two tertiary referral centers. The treatment of choice for these patients in one center was surgical resection. In the other center it was 3D-CRT. In the radiotherapy group (RG, n = 185), patients received 3D-CRT to the tumor and PVTT for a total radiation dose of 30–52 Gy (median 40 Gy). In the surgical group (SG, n = 186), patients underwent surgical resection. TACE was applied after surgery or 3D-CRT and then was repeated every 4–6 weeks if the patient tolerated the treatment.

Results

The median survival was 12.3 months for RG and 10.0 months for SG. The 1-, 2-, and 3-year overall survivals were 51.6, 28.4, and 19.9 %, respectively, for RG and 40.1, 17.0, and 13.6 %, respectively, for SG (p = 0.029). Stepwise multivariate analysis showed that the extent of PVTT and mode of treatment were independent risk factors of overall survival. The most common cause of death after treatment was liver failure as a consequence of progressive intrahepatic disease.

Conclusions

3D-CRT gave better survival than surgical resection for HCC with PVTT.     

Survival Advantage of Radiofrequency Ablation Over Transarterial Chemoembolization for Patients with Hepatocellular Carcinoma and Good Performance Status Within the Milan Criteria

Background

Performance status is closely linked with survival in patients with hepatocellular carcinoma (HCC). We evaluated the impact of performance status on patients with small HCC receiving radiofrequency ablation (RFA) versus transarterial chemoembolization (TACE).

Methods

A total of 424 and 282 patients within the Milan criteria undergoing RFA and TACE, respectively, were analyzed. Patients were classified as performance status 0 (n = 516) and performance status ≥1 (n = 190) groups. A propensity-score matching analysis with preset caliper width was used. A total of 167 and 68 matched pairs were selected from patients with a performance status of 0 and ≥1, respectively.

Results

Radiofrequency ablation provided significantly better long-term survival than TACE for patients within the Milan criteria (p < 0.01). After being stratified by performance status and matched in the propensity model, the baseline characteristics were similar between the RFA and TACE groups for patients with a performance status of 0 or ≥1. RFA provided significantly better long-term survival than TACE in patients with a performance status of 0 in the propensity model (p < 0.05); TACE was significantly associated with 1.784-fold increased risk of mortality (95 % confidence interval 1.075–2.506) by using the Cox proportional hazards model. TACE was not a significant prognostic predictor in patients with a performance status ≥1 in the propensity model.

Conclusions

For HCC patients within the Milan criteria with a performance status of 0, RFA provides better long-term survival than TACE. RFA should be considered a priority treatment in inoperable HCC patients within the Milan criteria. Performance status is a feasible surrogate marker to enhance treatment allocation.     

Surgical Resection Is Better than Transarterial Chemoembolization for Hepatocellular Carcinoma Beyond Milan Criteria Independent of Performance Status

Background and Aims

Performance status is tightly linked with survival in patients with hepatocellular carcinoma (HCC). We investigated the impact of performance status on HCC patients beyond the Milan criteria receiving surgical resection (SR) or transarterial chemoembolization (TACE).

Methods

A total of 909 patients with HCC beyond the Milan criteria were retrospectively analyzed by using propensity score analysis.

Results

The baseline characteristics were similar between the SR and TACE group for patients with performance status 0 in the propensity model. More patients in the TACE group with performance status ≥1 had Child-Turcotte-Pugh class A compared to the SR group (p?=?0.044) in the propensity model. SR provided significantly better long-term overall survival than TACE in patients selected in the propensity model regardless of performance status (both p?TACE was associated with 2.279-fold and 3.066-fold increased risk of mortality in performance status 0 and performance status ≥1 in the propensity model (95 % confidence interval, 1.476–3.591 and 1.570–5.989), respectively.

Conclusions

For either performance status 0 or ≥1 HCC patients beyond the Milan criteria, SR provides significantly better long-term survival than TACE. SR should be considered a priority treatment in these patients independent of performance status.     

Assessing Prognostic Significance of Preoperative Alpha-Fetoprotein in Hepatitis B-Associated Hepatocellular Carcinoma: Normal is not the New Normal

Background

Hepatitis B (HBV)-associated hepatocellular carcinoma (HCC) is often associated with alpha-fetoprotein (AFP) production. Although serum AFP has been demonstrated to be a prognostic factor for patient survival, optimal cutoff levels remain unclear.

Methods

Patients with HBV-associated HCC treated by primary liver resection were prospectively followed at a single institution between 1995 and 2008. AFP level was categorized into quintiles for Kaplan–Meier analysis and multivariable Cox proportional hazards regression models.

Results

Best 5-year survival after surgery was observed for patients with AFP in the first quintile (1.4–4.1 ng/mL), with progressively worse outcomes for patients in each increasing quintile. AFP was associated with overall survival (HR = 1.61; 95 % CI 1.30–1.98), disease-free survival (HR = 1.26; 95 % CI 1.10–1.44), and 2-year recurrence (HR = 1.30; 95 % CI 1.07–1.57) in multivariate analysis. Noncirrhotic patients (Ishak 1–5) with AFP in quintile 1 had 94 % 5-year survival, compared with 0 % survival for patients with AFP in quintile 5 (2,332.7–327,560.0 ng/mL) and Ishak stage 6 cirrhosis.

Conclusions

Preoperative serum AFP is an independent predictor of prognosis among HBV-HCC patients following surgical resection. Categorizing AFP into quintiles creates the opportunity to observe differences in outcomes even at low serum levels within the normal range. Additionally, combining AFP quintiles and fibrosis staging provides a predictive model of prognosis for HCC. Thus, even small differences in AFP within the normal range may impact prognosis and disease progression for HBV-HCC.     

Predictors of Futile Liver Resection for Patients with Barcelona Clinic Liver Cancer Stage B/C Hepatocellular Carcinoma

Background

There is little information concerning futile liver resection for patients with Barcelona Clinic Liver Cancer (BCLC) stage B/C hepatocellular carcinoma (HCC). This study aimed to establish a predictive model of futile liver resection for patients with BCLC stage B/C HCC.

Methods

The outcomes of 484 patients with BCLC stage B/C HCC who underwent liver resection at our centre between 2010 and 2016 were reviewed. Patients were randomised and divided 2:1 into training and validation sets. A novel risk-scoring model and prognostic nomogram were developed based on the results of multivariate analysis.

Results

Fifty-seven futile operations were observed. Multivariate analyses revealed tumour numbers > 3, Vp4 portal vein tumour thrombosis (PVTT) and alpha-fetoprotein (AFP) > 400 ng/ml independently associated with futile liver resection. A risk-scoring model based on the above-mentioned factors was developed (predictive risk score = 1 × (if AFP > 400 ng/ml) + 2 × (if tumour number > 3) + 3 × (if with Vp4 PVTT)). The area under the receiver-operating characteristic curve of this model was 0.845, with a sensitivity of 60.0% and a specificity of 94.8%. A prognostic nomogram was also developed and achieved a C-index of 0.831. The validation studies optically supported these results.

Conclusion

A risk-scoring model and predictive nomogram for futile liver resection were developed in the present study. T`he BCLC stage B/C HCC patients with a high risk obtained no benefit from liver resection.

     

Recurrence Patterns and Prognostic Factors in Patients with Hepatocellular Carcinoma in Noncirrhotic Liver: A Multi-Institutional Analysis

Background

Hepatocellular carcinoma (HCC) primarily affects patients with a cirrhotic liver. Reports on the characteristics of patients with HCC in noncirrhotic liver, as well as predictors of recurrence and survival, are scarce.

Methods

Between 1992 and 2011, 334 patients treated for HCC in noncirrhotic liver were identified from three major hepatobiliary centers. Clinicopathological characteristics were analyzed and independent predictors of recurrence and overall survival were identified using Cox proportional hazards models.

Results

Median patient age was 58 years and 77 % were male. Most patients had a solitary (81 %) and poorly or undifferentiated tumor (56 %); median size was 6.5 cm. The majority of patients (96 %) underwent liver resection (microscopically negative margins in 94 %), whereas a few had transarterial chemoembolization or transplantation (4 %). Median recurrence-free survival (RFS) was 2.5 years, and 1- and 5-year RFS was 71.1, and 35 %, respectively. Elevated alkaline phosphatase levels [hazards ratio (HR) = 1.82], poor tumor differentiation (HR = 1.4), macrovascular invasion (HR = 2.18), and the presence of satellite lesions (HR = 1.9), or intrahepatic metastases (HR = 2.59) were independently associated with shorter RFS; in contrast, an intact tumor capsule independently prolonged RFS (HR = 0.46). Median overall survival was 5.9 years, and 1- and 5-year overall survival was 86.9, and 54.5 %, respectively. Tumor size ≥5 cm (HR = 2.27), macrovascular (HR = 2.72) or adjacent organ invasion (HR = 3.34), and satellite lesions (HR = 2.18) were independently associated with shorter overall survival, whereas an intact tumor capsule showed a protective effect (HR = 0.51).

Conclusions

Following resection of HCC in the setting of no cirrhosis, more than one-half of patients were alive after 5 years. However, even among patients with no cirrhosis, recurrence was common. Factors associated with RFS and overall survival included tumor characteristics, such as tumor capsule, satellite lesions, and vascular invasion.     

Mortality Risk After Preoperative Versus Postoperative Chemotherapy and Radiotherapy in Lymph Node-Positive Rectal Cancer

Introduction

Persistent lymph node-positive disease after preoperative radiotherapy for rectal cancer is associated with adverse outcomes. We quantified mortality risks of persistent pathologic lymph nodes in lymph node-positive rectal cancer patients treated with preoperative versus postoperative chemoradiation.

Methods

This was a retrospective population-based analysis of 2,038 patients with stage III rectal cancer diagnosed 1994–2005 with follow-up through 2007 using data from the California Cancer Registry. Survival estimates were generated using the Kaplan–Meier method. Multivariate cancer-specific and overall mortality analyses were performed using Cox proportional hazard ratios with adjustment for age, gender, race/ethnicity, tumor grade, T stage, N stage, socioeconomic status, and time period (1994–1997, 1998–2001, and 2002–2005).

Results

Overall survival was higher among lymph node-positive patients receiving postoperative chemoradiation compared to lymph node-positive patients receiving preoperative chemoradiation (median overall survival?=?87 versus 62 months, P?=?0.0002). In adjusted analyses, patients with persistent lymph node-positive disease after preoperative chemoradiation treatment had increased overall (HR?=?1.69; 95 % CI, 1.42–2.01) and CRC-specific (HR?=?1.78; 95 % CI, 1.44–2.19) mortality risk compared to lymph node-positive disease after postoperative chemoradiation treatment.

Conclusions

Stage III rectal cancer patients with persistent pathologic lymph nodes after preoperative chemoradiation represent a high-risk group, with higher mortality than those treated with postoperative chemoradiation.