Hepatocellular carcinoma: From diagnosis to treatment

Hepatocellular carcinoma(HCC) is the sixth most prevalent malignancy worldwide and is a rising cause of cancer related mortality. Risk factors for HCC are well documented and effective surveillance and early diagnosis allow for curative therapies. The majority of HCC appears to be caused by cirrhosis from chronic hepatitis B and hepatitis C virus. Preventive strategies include vaccination programs and anti-viral treatments.Surveillance with ultrasonography detects early stage disease and improves survival rates. Many treatment options exist for individuals with HCC and are determined by stage of presentation. Liver transplantation is offered to patients who are within the Milan criteria and are not candidates for hepatic resection. In patients with advanced stage disease, sorafenib shows some survival benefit.

Hepatocellular carcinoma beyond Milan criteria: Management and transplant selection criteria

Liver transplantation(LT) for hepatocellular carcinoma(HCC) has been established as a standard treatment in selected patients for the last two and a half decades. After initially dismal outcomes, the Milan criteria(MC)(single HCC ≤ 5 cm or up to 3 HCCs ≤ 3 cm) have been adopted worldwide to select HCC patients for LT, however cumulative experience has shown that MC can be too strict. This has led to the development of numerous expanded criteria worldwide. Morphometric expansions on MC as well as various criteria which incorporate biomarkers as surrogates of tumor biology have been described. HCC that presents beyond MC initially can be downstaged with locoregional therapy(LRT). Post-LRT monitoring aims to identify candidates with favorable tumor behavior. Similarly, tumor marker levels as response to LRT has been utilized as surrogate of tumor biology. Molecular signatures of HCC have also been correlated to outcomes; these have yet to be incorporated into HCC-LT selection criteria formally. The ongoing discrepancy between organ demand and supply makes patient selection the most challenging element of organ allocation. Further validation of extended HCCLT criteria models and pre-LT treatment strategies are required.

Radiologic-histological correlation of hepatocellular carcinoma treated via pre-liver transplant locoregional therapies

BACKGROUND:Locoregional therapies(LRTs) are treatments to achieve local control of hepatocellular carcinoma(HCC).Correlation between radiologic response to LRT and degree of induced tumor necrosis is not well understood.The aim of this study was to evaluate different levels of radiologic response after pre-liver transplant(LT) LRT and its correlation with percentage of tumor necrosis on explanted histopathology.METHODS:Institutional Review Board approved LT database was queried for treated HCC in patients undergoing LT.Radiologic response was evaluated to predict tumor necrosis in the explanted liver.Tumor response was evaluated 1 to 3 months after LRT with computed tomography or MRI via Response Evaluation Criteria in Solid Tumors(RECIST),and European Association for the Study of the Liver(EASL) guidelines.LRT was repeated as needed until time of LT.Histological tumor necrosis was graded as complete(100%),partial(50%-99%),or poor(【50%).RESULTS:Between 2002 and 2011,128 patients(97 men and 31 women) received pre-LT LRT including transarterial therapy(93),radiofrequency ablation(20),or combination of both(15).The mean age of the patients was 58±9 years.Their mean follow-up was 35±27 months.The median waitlist time was 55 days.One hundred(78%) patients had HCC within the Milan criteria at the initial radiologic diagnosis.Nineteen(15%) of the patients had complete tumor necrosis on histopathology analysis.Fifty(39%) of the patients exhibited partial necrosis,52(41%) showed poor or no necrosis and 7(5%) showed progressive disease.The overall pre-LT radiologic staging was correlated with explant pathology in 73(57%) of the patients.Underestimated tumor stage was noted in 49(38%) patients,and overestimated tumor stage in 6(5%) patients.The post-LT 3-year overall survival and disease free survival were 82% and 80%,and the rates for complete and partial tumor necrosis were 100% vs 78%(P=0.02) and 100% vs 75%(P=0.03),respectively.CONCLUSIONS:In the current era,interpretation of radiologic response after LRT for HCC does not correlate accurately with histologic tumor necrosis.Total tumor necrosis is the goal of LRT;therefore,evolution in its performance is needed.Similarly,ways to predict therapy induced tumor necrosis via radiological investigation need to be improved.

血清白蛋白水平预测肝门部胆管癌患者的生存

背景与目的:肝门部胆管癌是一种极具威胁的恶性肿瘤,其发生率随地域及其他危险因素的不同而有所差异,其快速进展的疾病特点及难以早期诊断的现状使相当数量的患者无法得到根治性治疗。本研究的目的是明确影响肝门部胆管癌患者总体生存的预后因素。方法:收集2003-2013年间经组织学证实的成人肝门部胆管癌患者,评估其预后影响因素,评估变量包括入院时人口学资料、实验室指标、症状及影像学特征。结果:116例经病理诊断的肝门部胆管癌患者纳入研究。血清白蛋白>3.0 g/dL(P<0.01)、CA19-9200 U/mL(P=0.03)、癌胚抗原10μg/L(P<0.01)、有肝硬化病史(P<0.01)或有糖尿病病史(P=0.02)者,其总体生存时间延长。其中血清白蛋白>3.0 g/dL是一项独立的预后保护因素(HR=0.31,95%CI:0.14~0.70),可以得到44周的生存获益。结论:本研究是目前对于肝门部胆管癌预后因素的最大宗病例分析。血清白蛋白>3.0 g/dL是一项独立的预后指标,可以显著延长生存期。