Development of a prognostic scoring system for resectable hepatocellular carcinoma

AIM To develop a prognostic scoring system for overall survival(OS) of patients undergoing liver resection(LR) for hepatocellular carcinoma(HCC).METHODS Consecutive patients who underwent curative LR for HCC between 2000 and 2013 were identified. The series was randomly divided into a training and a validation set. A multivariable Cox model for OS was fitted to the training set. The beta coefficients derived from the Cox model were used to define a prognostic scoring system for OS. The survival stratification was then tested, and the prognostic scoring system was compared with the European Association for the Study of the Liver(EASL)/American Association for the Study of Liver Diseases(AASLD) surgical criteria by means of Harrell's C statistics.RESULTS A total of 917 patients were considered. Five variables independently correlated with post-LR survival: Model for End-stage Liver Disease score, hepatitis C virus infection, number of nodules, largest diameter and vascular invasion. Three risk classes were identified, and OS for the three risk classes was significantly different both in the training(P < 0.0001) and the validation set(P = 0.0002). Overall, 69.4% of patients were in the low-risk class, whereas only 37.8% were eligible to surgery according to EASL/AASLD. Survival of patients in the low-risk class was not significantly different compared with surgical indication for EASL/AASLD guidelines(77.2 mo vs 82.5 mo respectively, P = 0.22). Comparison of Harrell's C statistics revealed no significant difference in predictive power between the two systems(-0.00999, P = 0.667).CONCLUSION This study established a new prognostic scoring system that may stratify HCC patients suitable for surgery, expanding surgical eligibility with respect to EASL/AASLD criteria with no harm on survival.

Therapeutic strategies for post-transplant recurrence of hepatocellular carcinoma

Despite stringent selection criteria,hepatocellular carcinoma recurrence after liver transplantation(LT)still occurs in up to 20%of cases,mostly within the first 2–3 years.No adjuvant treatments to prevent such an occurrence have been developed so far.However,a balanced use of immunosuppression with minimal dose of calcineurin inhibitors and possible addition of mammalian target of rapamycin inhibitors is strongly advisable.Moreover,several pre-and posttransplant predictors of recurrence have been identified and may help determine the frequency and duration of post-transplant follow-up.When recurrence occurs,the outcomes are poor with a median survival of 12 mo according to most retrospective studies.The factor that most impacts survival after recurrence is timing(within 1–2 years from LT according to different authors).Several therapeutic options may be chosen in case of recurrence,according to timing and disease presentation.Surgical treatment seems to provide a survival benefit,especially in case of late recurrence,while the benefit of locoregional treatments has been suggested only in small retrospective studies.When systemic treatment is indicated,sorafenib has been proved safe and effective,while only few data are available for lenvatinib and regorafenib in second line.The use of immune checkpoint inhibitors is controversial in this setting,given the safety warnings for the risk of acute rejection.