Nevena Damjanov, MD

Patients with hepatocellular carcinoma (HCC) that has not spread outside the liver have several treatment options available. This month we will review articles that analyze outcomes after liver transplantation, liver resection, as well as radiofrequency ablation.

In HCC patients within the Milan criteria, the 5-year overall survival rate after transplant is about 70%, and the 5-year HCC recurrence rate is about 10%. Patients with tumors beyond the Milan criteria are frequently down staged with locoregional therapies to fall within the Milan criteria. The incidence of HCC recurrence in these patients is around 15.5% at 5 years. In this study, Lee et al demonstrated that statin use substantially reduced the risk of HCC recurrence. In this retrospective analysis of a longitudinal cohort of 430 patients transplanted between September 1995 and December 2019, 323 patients (75.1%) were statin non-users and 107 (24.9%) were statin  users. Statin use was defined as at least 90 days of statin therapy, prescribed according to the treatment guidelines for dyslipidemia for primary or secondary prevention of CVD.   At a median follow-up of 64.9 months, HCC recurred in 79 patients (18.4%), including 72 (22.3%) in the statin non-user group and 7 (6.5%) in the statin user group. Of those, 61 (77.2%) patients had HCC recurrence that initially presented at extrahepatic site regardless of the presence of intrahepatic tumors.  Sixty-three patients (79.7%) had recurrence within 2 years of liver transplantation. The cumulative incidence of HCC recurrence at 2 and 5 years was 18.9% and 22.3% in the statin non-user group, and 3.8% and 5.7% in the statin user group, respectively (P < 0.001).

Liang et al evaluated the importance of tumor size in predicting the likelihood of HCC recurrence following surgical resection. In this retrospective study, a total of 813 cirrhotic patients who underwent curative-intent hepatectomy for solitary HCC without macrovascular invasion between 2001 and 2014 were evaluated. Overall, 464 patients had tumor size ≤ 5 cm, and 349 had tumor size > 5 cm. The 5-year RFS and OS rates were 38.3% and 61.5% in the ≤ 5 cm group, compared with 25.1% and 59.9% in the > 5 cm group. Long-term survival outcomes were significantly worse as tumor size increased. Multivariate analysis indicated that tumor size > 5 cm was an independent risk factor for tumor recurrence and long-term survival.

Finally, Sulaiman et al reported the survival rate of the early and intermediate stage HCC patients who underwent radiofrequency ablation (RFA). In this retrospective analysis, patients with BCLC A and B HCC who underwent RFA treatments between January 2015 to December 2017 were evaluated. Out of 62 patients 46 (74.2%) were reported to have RFA as their only first line of treatment, while 12 (25.8%) were reported to have a combination of RFA and other therapeutic modalities. At a mean follow up of 27 months, the survival rate at 12 and 36 months in patients who received RFA was 82.3% and 57.8%, respectively. A relatively high 36-month survival rate was seen in patients who had a response to RFA compared to the non-response group (100% vs 44.8%, P = 0.021). In terms of prognosis, BCLC staging of liver cancer and response after RFA were significantly associated with survival.

Patients with hepatocellular carcinoma (HCC) that has not spread outside the liver have several treatment options available. This month we will review articles that analyze outcomes after liver transplantation, liver resection, as well as radiofrequency ablation.

In HCC patients within the Milan criteria, the 5-year overall survival rate after transplant is about 70%, and the 5-year HCC recurrence rate is about 10%. Patients with tumors beyond the Milan criteria are frequently down staged with locoregional therapies to fall within the Milan criteria. The incidence of HCC recurrence in these patients is around 15.5% at 5 years. In this study, Lee et al demonstrated that statin use substantially reduced the risk of HCC recurrence. In this retrospective analysis of a longitudinal cohort of 430 patients transplanted between September 1995 and December 2019, 323 patients (75.1%) were statin non-users and 107 (24.9%) were statin  users. Statin use was defined as at least 90 days of statin therapy, prescribed according to the treatment guidelines for dyslipidemia for primary or secondary prevention of CVD.   At a median follow-up of 64.9 months, HCC recurred in 79 patients (18.4%), including 72 (22.3%) in the statin non-user group and 7 (6.5%) in the statin user group. Of those, 61 (77.2%) patients had HCC recurrence that initially presented at extrahepatic site regardless of the presence of intrahepatic tumors.  Sixty-three patients (79.7%) had recurrence within 2 years of liver transplantation. The cumulative incidence of HCC recurrence at 2 and 5 years was 18.9% and 22.3% in the statin non-user group, and 3.8% and 5.7% in the statin user group, respectively (P < 0.001).

Liang et al evaluated the importance of tumor size in predicting the likelihood of HCC recurrence following surgical resection. In this retrospective study, a total of 813 cirrhotic patients who underwent curative-intent hepatectomy for solitary HCC without macrovascular invasion between 2001 and 2014 were evaluated. Overall, 464 patients had tumor size ≤ 5 cm, and 349 had tumor size > 5 cm. The 5-year RFS and OS rates were 38.3% and 61.5% in the ≤ 5 cm group, compared with 25.1% and 59.9% in the > 5 cm group. Long-term survival outcomes were significantly worse as tumor size increased. Multivariate analysis indicated that tumor size > 5 cm was an independent risk factor for tumor recurrence and long-term survival.

Finally, Sulaiman et al reported the survival rate of the early and intermediate stage HCC patients who underwent radiofrequency ablation (RFA). In this retrospective analysis, patients with BCLC A and B HCC who underwent RFA treatments between January 2015 to December 2017 were evaluated. Out of 62 patients 46 (74.2%) were reported to have RFA as their only first line of treatment, while 12 (25.8%) were reported to have a combination of RFA and other therapeutic modalities. At a mean follow up of 27 months, the survival rate at 12 and 36 months in patients who received RFA was 82.3% and 57.8%, respectively. A relatively high 36-month survival rate was seen in patients who had a response to RFA compared to the non-response group (100% vs 44.8%, P = 0.021). In terms of prognosis, BCLC staging of liver cancer and response after RFA were significantly associated with survival.

Patients with hepatocellular carcinoma (HCC) that has not spread outside the liver have several treatment options available. This month we will review articles that analyze outcomes after liver transplantation, liver resection, as well as radiofrequency ablation.

In HCC patients within the Milan criteria, the 5-year overall survival rate after transplant is about 70%, and the 5-year HCC recurrence rate is about 10%. Patients with tumors beyond the Milan criteria are frequently down staged with locoregional therapies to fall within the Milan criteria. The incidence of HCC recurrence in these patients is around 15.5% at 5 years. In this study, Lee et al demonstrated that statin use substantially reduced the risk of HCC recurrence. In this retrospective analysis of a longitudinal cohort of 430 patients transplanted between September 1995 and December 2019, 323 patients (75.1%) were statin non-users and 107 (24.9%) were statin  users. Statin use was defined as at least 90 days of statin therapy, prescribed according to the treatment guidelines for dyslipidemia for primary or secondary prevention of CVD.   At a median follow-up of 64.9 months, HCC recurred in 79 patients (18.4%), including 72 (22.3%) in the statin non-user group and 7 (6.5%) in the statin user group. Of those, 61 (77.2%) patients had HCC recurrence that initially presented at extrahepatic site regardless of the presence of intrahepatic tumors.  Sixty-three patients (79.7%) had recurrence within 2 years of liver transplantation. The cumulative incidence of HCC recurrence at 2 and 5 years was 18.9% and 22.3% in the statin non-user group, and 3.8% and 5.7% in the statin user group, respectively (P < 0.001).

Liang et al evaluated the importance of tumor size in predicting the likelihood of HCC recurrence following surgical resection. In this retrospective study, a total of 813 cirrhotic patients who underwent curative-intent hepatectomy for solitary HCC without macrovascular invasion between 2001 and 2014 were evaluated. Overall, 464 patients had tumor size ≤ 5 cm, and 349 had tumor size > 5 cm. The 5-year RFS and OS rates were 38.3% and 61.5% in the ≤ 5 cm group, compared with 25.1% and 59.9% in the > 5 cm group. Long-term survival outcomes were significantly worse as tumor size increased. Multivariate analysis indicated that tumor size > 5 cm was an independent risk factor for tumor recurrence and long-term survival.

Finally, Sulaiman et al reported the survival rate of the early and intermediate stage HCC patients who underwent radiofrequency ablation (RFA). In this retrospective analysis, patients with BCLC A and B HCC who underwent RFA treatments between January 2015 to December 2017 were evaluated. Out of 62 patients 46 (74.2%) were reported to have RFA as their only first line of treatment, while 12 (25.8%) were reported to have a combination of RFA and other therapeutic modalities. At a mean follow up of 27 months, the survival rate at 12 and 36 months in patients who received RFA was 82.3% and 57.8%, respectively. A relatively high 36-month survival rate was seen in patients who had a response to RFA compared to the non-response group (100% vs 44.8%, P = 0.021). In terms of prognosis, BCLC staging of liver cancer and response after RFA were significantly associated with survival.

For patients with hepatocellular carcinoma (HCC) and liver-dominant disease, liver-directed therapy is frequently used as the initial attempt to control this malignancy. This month we will review several journal articles that address different forms of localized HCC management.

Ding W et al. analyzed 401 patients with early HCC who were treated in one center, either with microwave ablation (MWA, n=240) or robotic-assisted hepatectomy (RH, n=161). Following propensity-score matching (PSM) and inverse probability of treatment weight analysis, the authors found that both treatments can achieve safe, comparable therapeutic effects. The 3-year recurrence-free survival (RFS), overall survival (OS) and cancer-specific survival (CSS) of MWA group and RH group were 52.2% vs 65.8%, 91.5% vs 91.3% and 91.5% vs 91.3%, respectively. OS and CSS were comparable (P = 0.44 and 0.96), while RFS of patients treated with MWA was slightly lower but not significantly so (P = 0.097). The authors concluded that both minimally-invasive approaches are effective in the treatment of early HCC. MWA was less invasive, while RH had better accuracy and caused less damage to the liver parenchyma.

Transarterial therapies are frequently withheld in patients who have major vascular invasion (HCC-MVI), and patients usually receive palliative systemic therapy instead. Kwee et al. examined the National Cancer Database (NCDB) data to comparatively evaluate overall survival (OS) between transarterial radioembolization (TARE) and systemic therapy in hepatocellular carcinoma (HCC) with major vascular invasion (HCC-MVI). OS was compared by propensity-score matched Cox regression and landmark analysis in 1514 patients with HCC-MVI who were treated between 2010 and 2015. Propensity-score matched and landmark-time adjusted analysis associated TARE with a median OS 7.1 months (95% CI 5.0 to 10.5) vs 4.9 months (95% CI 3.9 to 6.5) for patients treated with systemic therapy only, HR 0.74 (95% CI 0.60 to 0.91, P = 0.005). The authors were encouraged by these results, and suggested that additional prospective studies using TARE as treatment of HCC-MVI should be undertaken.

The SARAH trial (Vilgrain et al., Lancet Oncology 2017) compared the efficacy and safety of sorafenib to that of selective internal radiotherapy (SIRT) with yttrium-90 (90Y) resin microspheres (also termed TARE, transarterial radioembolization) in patients with hepatocellular carcinoma. The final conclusion was that overall survival did not significantly differ between the two groups. Pereira et al. published this ancillary study of the SARAH trial that compares health-related quality of life (HRQoL) between the two groups. HRQoL was preserved longer with TARE than with sorafenib in locally advanced HCC. The median time to deterioration for the global health status was 3.9 months (95% confidence interval [CI] 3.7–4.3) in the TARE group, vs 2.6 months (95% CI 2.0–3.0) in the sorafenib group. The authors concluded that the differences in HRQoL should inform decisions when recommending initial treatment of patients with HCC, though it does not take into account recently developed advancements in systemic therapy including immunotherapy.

For patients with hepatocellular carcinoma (HCC) and liver-dominant disease, liver-directed therapy is frequently used as the initial attempt to control this malignancy. This month we will review several journal articles that address different forms of localized HCC management.

Ding W et al. analyzed 401 patients with early HCC who were treated in one center, either with microwave ablation (MWA, n=240) or robotic-assisted hepatectomy (RH, n=161). Following propensity-score matching (PSM) and inverse probability of treatment weight analysis, the authors found that both treatments can achieve safe, comparable therapeutic effects. The 3-year recurrence-free survival (RFS), overall survival (OS) and cancer-specific survival (CSS) of MWA group and RH group were 52.2% vs 65.8%, 91.5% vs 91.3% and 91.5% vs 91.3%, respectively. OS and CSS were comparable (P = 0.44 and 0.96), while RFS of patients treated with MWA was slightly lower but not significantly so (P = 0.097). The authors concluded that both minimally-invasive approaches are effective in the treatment of early HCC. MWA was less invasive, while RH had better accuracy and caused less damage to the liver parenchyma.

Transarterial therapies are frequently withheld in patients who have major vascular invasion (HCC-MVI), and patients usually receive palliative systemic therapy instead. Kwee et al. examined the National Cancer Database (NCDB) data to comparatively evaluate overall survival (OS) between transarterial radioembolization (TARE) and systemic therapy in hepatocellular carcinoma (HCC) with major vascular invasion (HCC-MVI). OS was compared by propensity-score matched Cox regression and landmark analysis in 1514 patients with HCC-MVI who were treated between 2010 and 2015. Propensity-score matched and landmark-time adjusted analysis associated TARE with a median OS 7.1 months (95% CI 5.0 to 10.5) vs 4.9 months (95% CI 3.9 to 6.5) for patients treated with systemic therapy only, HR 0.74 (95% CI 0.60 to 0.91, P = 0.005). The authors were encouraged by these results, and suggested that additional prospective studies using TARE as treatment of HCC-MVI should be undertaken.

The SARAH trial (Vilgrain et al., Lancet Oncology 2017) compared the efficacy and safety of sorafenib to that of selective internal radiotherapy (SIRT) with yttrium-90 (90Y) resin microspheres (also termed TARE, transarterial radioembolization) in patients with hepatocellular carcinoma. The final conclusion was that overall survival did not significantly differ between the two groups. Pereira et al. published this ancillary study of the SARAH trial that compares health-related quality of life (HRQoL) between the two groups. HRQoL was preserved longer with TARE than with sorafenib in locally advanced HCC. The median time to deterioration for the global health status was 3.9 months (95% confidence interval [CI] 3.7–4.3) in the TARE group, vs 2.6 months (95% CI 2.0–3.0) in the sorafenib group. The authors concluded that the differences in HRQoL should inform decisions when recommending initial treatment of patients with HCC, though it does not take into account recently developed advancements in systemic therapy including immunotherapy.

For patients with hepatocellular carcinoma (HCC) and liver-dominant disease, liver-directed therapy is frequently used as the initial attempt to control this malignancy. This month we will review several journal articles that address different forms of localized HCC management.

Ding W et al. analyzed 401 patients with early HCC who were treated in one center, either with microwave ablation (MWA, n=240) or robotic-assisted hepatectomy (RH, n=161). Following propensity-score matching (PSM) and inverse probability of treatment weight analysis, the authors found that both treatments can achieve safe, comparable therapeutic effects. The 3-year recurrence-free survival (RFS), overall survival (OS) and cancer-specific survival (CSS) of MWA group and RH group were 52.2% vs 65.8%, 91.5% vs 91.3% and 91.5% vs 91.3%, respectively. OS and CSS were comparable (P = 0.44 and 0.96), while RFS of patients treated with MWA was slightly lower but not significantly so (P = 0.097). The authors concluded that both minimally-invasive approaches are effective in the treatment of early HCC. MWA was less invasive, while RH had better accuracy and caused less damage to the liver parenchyma.

Transarterial therapies are frequently withheld in patients who have major vascular invasion (HCC-MVI), and patients usually receive palliative systemic therapy instead. Kwee et al. examined the National Cancer Database (NCDB) data to comparatively evaluate overall survival (OS) between transarterial radioembolization (TARE) and systemic therapy in hepatocellular carcinoma (HCC) with major vascular invasion (HCC-MVI). OS was compared by propensity-score matched Cox regression and landmark analysis in 1514 patients with HCC-MVI who were treated between 2010 and 2015. Propensity-score matched and landmark-time adjusted analysis associated TARE with a median OS 7.1 months (95% CI 5.0 to 10.5) vs 4.9 months (95% CI 3.9 to 6.5) for patients treated with systemic therapy only, HR 0.74 (95% CI 0.60 to 0.91, P = 0.005). The authors were encouraged by these results, and suggested that additional prospective studies using TARE as treatment of HCC-MVI should be undertaken.

The SARAH trial (Vilgrain et al., Lancet Oncology 2017) compared the efficacy and safety of sorafenib to that of selective internal radiotherapy (SIRT) with yttrium-90 (90Y) resin microspheres (also termed TARE, transarterial radioembolization) in patients with hepatocellular carcinoma. The final conclusion was that overall survival did not significantly differ between the two groups. Pereira et al. published this ancillary study of the SARAH trial that compares health-related quality of life (HRQoL) between the two groups. HRQoL was preserved longer with TARE than with sorafenib in locally advanced HCC. The median time to deterioration for the global health status was 3.9 months (95% confidence interval [CI] 3.7–4.3) in the TARE group, vs 2.6 months (95% CI 2.0–3.0) in the sorafenib group. The authors concluded that the differences in HRQoL should inform decisions when recommending initial treatment of patients with HCC, though it does not take into account recently developed advancements in systemic therapy including immunotherapy.

Treatment of hepatocellular carcinoma (HCC) benefits from a multidisciplinary approach. This month we will review some articles that address both localized and systemic therapies.

The first paper is a retrospective review of patients who underwent living donor liver transplantation (LDLT). Bhatti et al reviewed the outcomes of 244 patients with HCC who underwent LDLT at one center. All patients had AFP <1000 at time of LDLT. Out of those, 159 had tumors within UCSF criteria (single tumor ≤ 6.5 cm, up to 3 tumors ≤ 4.5 cm, total tumor diameter ≤ 8 cm), while 58 patients had tumors that were outside UCSF but <10cm, and 27 patients who were outside UCSF with macrovascular invasion (UCSF+). All patients within UCSF criteria were offered upfront LDLT. Patients outside UCSF criteria (UCSF+) were also considered for upfront LDLT, however patients with AFP >1000 ng/ml and UCSF + tumors were considered for downstaging. The authors reported that survival at 5 years was similar in the UCSF and UCSF+ groups (72% vs 69%, P = 0.7), while the rate of HCC recurrence was 13% vs 36% (P = 0.1). They concluded that carefully selected patients with HCC outside UCSF may benefit from LDLT.

Chemoembolization is a common treatment used for patients with localized HCC. Postembolization syndrome (abdominal pain, nausea, vomiting, fever and/or infection) is a frequent complication that adversely affects the patient’s quality of life. Lu et al report the results of a retrospective study of the use of dexamethasone in patients undergoing transarterial chemoembolization (TACE). The course of 255 HCC patients who underwent TACE were reviewed. The patients were divided into 2 nonrandomized groups to receive TACE using lipiodol + chemotherapeutic emulsion group (133 patients) or TACE using lipiodol + dexamethasone 10 mg + chemotherapeutic emulsion group (122 patients). Incidence of postembolization syndrome was reduced in the dexamethasone group: abdominal pain, 55.6% vs 36.1% (P = .002); fever, 37.6% vs 13.1% (P < .05); nausea, 60.9% vs 41.0% (P = .001); vomiting, 48.1% vs 21.3% (P < .05). Incidence of infection was 1.5% vs 2.5% (P = .583). The authors concluded that the incidence of postembolization syndrome could be reduced by adding dexamethasone to TACE.

Hepatic arterial infusion (HAI) chemotherapy has been used in the treatment of several types of liver-dominant tumors. Abdelmaksoud et al report on their experience using HAI to treat HCC with portal vein thrombosis and compensated cirrhosis. In this case-controlled study, 20 patients were treated with HAIC (50 mg doxorubicin and 50 mg cisplatin infused into the hepatic artery), 42 patients received best supportive care, and 29 patients were treated with sorafenib. The authors report that patients who received HAI had the longest survival compared with the best supportive care and sorafenib groups (29.2 ± 21.8, 4.55 ± 11.41, and 11.52 ± 8.72 months respectively, P = 0.007), concluding that HAI is an effective option for selected patients with HCC and portal vein thrombosis.

Finally, Hiraoka et al reported a retrospective study of 171 adults with unresectable HCC who received systemic therapy with atezolizumab with bevacizumab. In this report, only 75 patients received this as their first-line systemic therapy. After 6 weeks of treatment, the overall response rate was 10.6% (9.7% for previously treated and 12.2% for previously untreated), and the disease control rate was 79.6%.  In 111 patients, the albumin-bilirubin score that assesses liver function was significantly worse at 3 weeks after starting treatment (−2.525 ± 0.419 vs −2.323 ± 0.445, P < .001), but then recovered at 6-weeks, confirming the efficacy and safety of this treatment regimen.

Treatment of hepatocellular carcinoma (HCC) benefits from a multidisciplinary approach. This month we will review some articles that address both localized and systemic therapies.

The first paper is a retrospective review of patients who underwent living donor liver transplantation (LDLT). Bhatti et al reviewed the outcomes of 244 patients with HCC who underwent LDLT at one center. All patients had AFP <1000 at time of LDLT. Out of those, 159 had tumors within UCSF criteria (single tumor ≤ 6.5 cm, up to 3 tumors ≤ 4.5 cm, total tumor diameter ≤ 8 cm), while 58 patients had tumors that were outside UCSF but <10cm, and 27 patients who were outside UCSF with macrovascular invasion (UCSF+). All patients within UCSF criteria were offered upfront LDLT. Patients outside UCSF criteria (UCSF+) were also considered for upfront LDLT, however patients with AFP >1000 ng/ml and UCSF + tumors were considered for downstaging. The authors reported that survival at 5 years was similar in the UCSF and UCSF+ groups (72% vs 69%, P = 0.7), while the rate of HCC recurrence was 13% vs 36% (P = 0.1). They concluded that carefully selected patients with HCC outside UCSF may benefit from LDLT.

Chemoembolization is a common treatment used for patients with localized HCC. Postembolization syndrome (abdominal pain, nausea, vomiting, fever and/or infection) is a frequent complication that adversely affects the patient’s quality of life. Lu et al report the results of a retrospective study of the use of dexamethasone in patients undergoing transarterial chemoembolization (TACE). The course of 255 HCC patients who underwent TACE were reviewed. The patients were divided into 2 nonrandomized groups to receive TACE using lipiodol + chemotherapeutic emulsion group (133 patients) or TACE using lipiodol + dexamethasone 10 mg + chemotherapeutic emulsion group (122 patients). Incidence of postembolization syndrome was reduced in the dexamethasone group: abdominal pain, 55.6% vs 36.1% (P = .002); fever, 37.6% vs 13.1% (P < .05); nausea, 60.9% vs 41.0% (P = .001); vomiting, 48.1% vs 21.3% (P < .05). Incidence of infection was 1.5% vs 2.5% (P = .583). The authors concluded that the incidence of postembolization syndrome could be reduced by adding dexamethasone to TACE.

Hepatic arterial infusion (HAI) chemotherapy has been used in the treatment of several types of liver-dominant tumors. Abdelmaksoud et al report on their experience using HAI to treat HCC with portal vein thrombosis and compensated cirrhosis. In this case-controlled study, 20 patients were treated with HAIC (50 mg doxorubicin and 50 mg cisplatin infused into the hepatic artery), 42 patients received best supportive care, and 29 patients were treated with sorafenib. The authors report that patients who received HAI had the longest survival compared with the best supportive care and sorafenib groups (29.2 ± 21.8, 4.55 ± 11.41, and 11.52 ± 8.72 months respectively, P = 0.007), concluding that HAI is an effective option for selected patients with HCC and portal vein thrombosis.

Finally, Hiraoka et al reported a retrospective study of 171 adults with unresectable HCC who received systemic therapy with atezolizumab with bevacizumab. In this report, only 75 patients received this as their first-line systemic therapy. After 6 weeks of treatment, the overall response rate was 10.6% (9.7% for previously treated and 12.2% for previously untreated), and the disease control rate was 79.6%.  In 111 patients, the albumin-bilirubin score that assesses liver function was significantly worse at 3 weeks after starting treatment (−2.525 ± 0.419 vs −2.323 ± 0.445, P < .001), but then recovered at 6-weeks, confirming the efficacy and safety of this treatment regimen.

Treatment of hepatocellular carcinoma (HCC) benefits from a multidisciplinary approach. This month we will review some articles that address both localized and systemic therapies.

The first paper is a retrospective review of patients who underwent living donor liver transplantation (LDLT). Bhatti et al reviewed the outcomes of 244 patients with HCC who underwent LDLT at one center. All patients had AFP <1000 at time of LDLT. Out of those, 159 had tumors within UCSF criteria (single tumor ≤ 6.5 cm, up to 3 tumors ≤ 4.5 cm, total tumor diameter ≤ 8 cm), while 58 patients had tumors that were outside UCSF but <10cm, and 27 patients who were outside UCSF with macrovascular invasion (UCSF+). All patients within UCSF criteria were offered upfront LDLT. Patients outside UCSF criteria (UCSF+) were also considered for upfront LDLT, however patients with AFP >1000 ng/ml and UCSF + tumors were considered for downstaging. The authors reported that survival at 5 years was similar in the UCSF and UCSF+ groups (72% vs 69%, P = 0.7), while the rate of HCC recurrence was 13% vs 36% (P = 0.1). They concluded that carefully selected patients with HCC outside UCSF may benefit from LDLT.

Chemoembolization is a common treatment used for patients with localized HCC. Postembolization syndrome (abdominal pain, nausea, vomiting, fever and/or infection) is a frequent complication that adversely affects the patient’s quality of life. Lu et al report the results of a retrospective study of the use of dexamethasone in patients undergoing transarterial chemoembolization (TACE). The course of 255 HCC patients who underwent TACE were reviewed. The patients were divided into 2 nonrandomized groups to receive TACE using lipiodol + chemotherapeutic emulsion group (133 patients) or TACE using lipiodol + dexamethasone 10 mg + chemotherapeutic emulsion group (122 patients). Incidence of postembolization syndrome was reduced in the dexamethasone group: abdominal pain, 55.6% vs 36.1% (P = .002); fever, 37.6% vs 13.1% (P < .05); nausea, 60.9% vs 41.0% (P = .001); vomiting, 48.1% vs 21.3% (P < .05). Incidence of infection was 1.5% vs 2.5% (P = .583). The authors concluded that the incidence of postembolization syndrome could be reduced by adding dexamethasone to TACE.

Hepatic arterial infusion (HAI) chemotherapy has been used in the treatment of several types of liver-dominant tumors. Abdelmaksoud et al report on their experience using HAI to treat HCC with portal vein thrombosis and compensated cirrhosis. In this case-controlled study, 20 patients were treated with HAIC (50 mg doxorubicin and 50 mg cisplatin infused into the hepatic artery), 42 patients received best supportive care, and 29 patients were treated with sorafenib. The authors report that patients who received HAI had the longest survival compared with the best supportive care and sorafenib groups (29.2 ± 21.8, 4.55 ± 11.41, and 11.52 ± 8.72 months respectively, P = 0.007), concluding that HAI is an effective option for selected patients with HCC and portal vein thrombosis.

Finally, Hiraoka et al reported a retrospective study of 171 adults with unresectable HCC who received systemic therapy with atezolizumab with bevacizumab. In this report, only 75 patients received this as their first-line systemic therapy. After 6 weeks of treatment, the overall response rate was 10.6% (9.7% for previously treated and 12.2% for previously untreated), and the disease control rate was 79.6%.  In 111 patients, the albumin-bilirubin score that assesses liver function was significantly worse at 3 weeks after starting treatment (−2.525 ± 0.419 vs −2.323 ± 0.445, P < .001), but then recovered at 6-weeks, confirming the efficacy and safety of this treatment regimen.

First is an article from Elshaarawy O et al. who looked at preoperative and postoperative models to evaluate postresection survival. Between December 2010 and January 2017, 120 patients who underwent resection with curative intent, were analyzed for survival, liver decompensation, and posthepatectomy liver failure (PHLF). It will come as no surprise that HCC recurrence following resection adversely affected survival (hazard ratio (HR) = 11.67, 95%CI: 4.19-32.52, P < 0.001). Also affecting survival were the preoperative MELD score [HR = 1.37, 95%CI: 1.16-1.62, P < 0.001] and grades A through C of the PHLF score. Significant independent predictors of postoperative liver decompensation were the preoperative MELD score >10 [odds ratio (OR) = 2.7, 95%CI: 1.2-5.7, P = 0.013], tumor diameter >5 cm (OR = 5.4, 95%CI: 2-14.8, P = 0.001) and duration of hospital stay (6. 8 days vs 11.26 days; OR = 2.5, 95%CI: 1.5-4.2, P = 0.001).

Next, Lei GY et al. undertook a retrospective study of 244 patients with HCC who underwent hepatic resection with curative intent between January 200 and December 2017. They found that the overall postoperative 90-day mortality rate for HCC patients after hepatic resection was 5.3%. Significant predictors of mortality Child-Pugh score (p < 0.001), intraoperative blood loss (P = 0.013), the 50-50 criteria for PHLF (P < 0.001) on postoperative day 5, and peak serum bilirubin >119 µmol/L (P = 0.007) on postoperative day 3. In these patients, the overall postoperative 90-day mortality rate for HCC patients after hepatic resection was 5.3%.

Taken together, these studies confirm that underlying liver function both before and after surgery is a key predictor of how well a patient is likely to do after curative-intent surgery. Excellent multidisciplinary care remains important for patient well-being.

Finally, for patients who are not candidates for liver resection, Han X et al. evaluated the efficacy of radiofrequency ablation (RFA) and microwave ablation (MWA) in a retrospective study of 201 consecutive patients whose tumors were within Milan criteria, but were in challenging locations for resection. RFA was performed in 150 patients, while 51 patients underwent MWA between January 2012 and December 2016.  Median follow-up was 36.7 months. Cumulative overall survival rates at 1, 3, and 5 years were 97.9%, 92.3%, and 80.6%, respectively, for MWA patients and 96.4%, 87.4%, and 78.2%, respectively, for RFA patients (P = 0.450).  Major complication rates also were similar between the two groups (3.3% vs. 3.9%). The authors concluded that both procedures are equally safe and effective in patients with HCC.

First is an article from Elshaarawy O et al. who looked at preoperative and postoperative models to evaluate postresection survival. Between December 2010 and January 2017, 120 patients who underwent resection with curative intent, were analyzed for survival, liver decompensation, and posthepatectomy liver failure (PHLF). It will come as no surprise that HCC recurrence following resection adversely affected survival (hazard ratio (HR) = 11.67, 95%CI: 4.19-32.52, P < 0.001). Also affecting survival were the preoperative MELD score [HR = 1.37, 95%CI: 1.16-1.62, P < 0.001] and grades A through C of the PHLF score. Significant independent predictors of postoperative liver decompensation were the preoperative MELD score >10 [odds ratio (OR) = 2.7, 95%CI: 1.2-5.7, P = 0.013], tumor diameter >5 cm (OR = 5.4, 95%CI: 2-14.8, P = 0.001) and duration of hospital stay (6. 8 days vs 11.26 days; OR = 2.5, 95%CI: 1.5-4.2, P = 0.001).

Next, Lei GY et al. undertook a retrospective study of 244 patients with HCC who underwent hepatic resection with curative intent between January 200 and December 2017. They found that the overall postoperative 90-day mortality rate for HCC patients after hepatic resection was 5.3%. Significant predictors of mortality Child-Pugh score (p < 0.001), intraoperative blood loss (P = 0.013), the 50-50 criteria for PHLF (P < 0.001) on postoperative day 5, and peak serum bilirubin >119 µmol/L (P = 0.007) on postoperative day 3. In these patients, the overall postoperative 90-day mortality rate for HCC patients after hepatic resection was 5.3%.

Taken together, these studies confirm that underlying liver function both before and after surgery is a key predictor of how well a patient is likely to do after curative-intent surgery. Excellent multidisciplinary care remains important for patient well-being.

Finally, for patients who are not candidates for liver resection, Han X et al. evaluated the efficacy of radiofrequency ablation (RFA) and microwave ablation (MWA) in a retrospective study of 201 consecutive patients whose tumors were within Milan criteria, but were in challenging locations for resection. RFA was performed in 150 patients, while 51 patients underwent MWA between January 2012 and December 2016.  Median follow-up was 36.7 months. Cumulative overall survival rates at 1, 3, and 5 years were 97.9%, 92.3%, and 80.6%, respectively, for MWA patients and 96.4%, 87.4%, and 78.2%, respectively, for RFA patients (P = 0.450).  Major complication rates also were similar between the two groups (3.3% vs. 3.9%). The authors concluded that both procedures are equally safe and effective in patients with HCC.

First is an article from Elshaarawy O et al. who looked at preoperative and postoperative models to evaluate postresection survival. Between December 2010 and January 2017, 120 patients who underwent resection with curative intent, were analyzed for survival, liver decompensation, and posthepatectomy liver failure (PHLF). It will come as no surprise that HCC recurrence following resection adversely affected survival (hazard ratio (HR) = 11.67, 95%CI: 4.19-32.52, P < 0.001). Also affecting survival were the preoperative MELD score [HR = 1.37, 95%CI: 1.16-1.62, P < 0.001] and grades A through C of the PHLF score. Significant independent predictors of postoperative liver decompensation were the preoperative MELD score >10 [odds ratio (OR) = 2.7, 95%CI: 1.2-5.7, P = 0.013], tumor diameter >5 cm (OR = 5.4, 95%CI: 2-14.8, P = 0.001) and duration of hospital stay (6. 8 days vs 11.26 days; OR = 2.5, 95%CI: 1.5-4.2, P = 0.001).

Next, Lei GY et al. undertook a retrospective study of 244 patients with HCC who underwent hepatic resection with curative intent between January 200 and December 2017. They found that the overall postoperative 90-day mortality rate for HCC patients after hepatic resection was 5.3%. Significant predictors of mortality Child-Pugh score (p < 0.001), intraoperative blood loss (P = 0.013), the 50-50 criteria for PHLF (P < 0.001) on postoperative day 5, and peak serum bilirubin >119 µmol/L (P = 0.007) on postoperative day 3. In these patients, the overall postoperative 90-day mortality rate for HCC patients after hepatic resection was 5.3%.

Taken together, these studies confirm that underlying liver function both before and after surgery is a key predictor of how well a patient is likely to do after curative-intent surgery. Excellent multidisciplinary care remains important for patient well-being.

Finally, for patients who are not candidates for liver resection, Han X et al. evaluated the efficacy of radiofrequency ablation (RFA) and microwave ablation (MWA) in a retrospective study of 201 consecutive patients whose tumors were within Milan criteria, but were in challenging locations for resection. RFA was performed in 150 patients, while 51 patients underwent MWA between January 2012 and December 2016.  Median follow-up was 36.7 months. Cumulative overall survival rates at 1, 3, and 5 years were 97.9%, 92.3%, and 80.6%, respectively, for MWA patients and 96.4%, 87.4%, and 78.2%, respectively, for RFA patients (P = 0.450).  Major complication rates also were similar between the two groups (3.3% vs. 3.9%). The authors concluded that both procedures are equally safe and effective in patients with HCC.

The next study explored ways to identify patients who have HCC using PIVKA-II (prothrombin induced by vitamin K deficiency/antagonist – II), a promising marker that may be more sensitive/specific than AFP in identifying patients with liver cancer. Feng et al. used enzyme-linked immunosorbent assay (ELISA) to measure serum PIVKA-II levels in 168 patients with HCC, 150 patients with benign liver disease, and 153 healthy controls. Patients with HCC had significantly higher median PIVKA-II levels (181.50 mAu/mL), compared with atients with noncancerous liver disease (28.6 mAU/mL) or healthy controls 21.82 mAU/mL), with p<0.0001. In addition, PIVKA-II was more sensitive (83.9% vs 64.3%) and more specific (91.5% vs 84.7%) than AFP in identifying patients with HCC. When PIVKA-II and AFP were combined, sensitivity (81.95%) and specificity (89.3%) were increased more, suggesting that this combination of markers may be most useful in clinical practice to identify patients who have HCC.

Finally, in patients whose HCC was treated with orthotopic liver transplantation, acute organ rejection was found to be linked to HCC recurrence. Gul-Klein et al. identified 252 patients who underwent liver transplantation for HCC between 2001 and 2015, 91 of whom had confirmed acute rejection, and 47 of whom had recurrent HCC (the median time to HCC recurrence was 20 months). HCC recurrence was identified in 28.6% of patients with acute rejection, and in 13% of patients without acute rejection (p=0.002). Acute rejection within 20 months of liver transplantation was identified as a significant risk factor for HCC recurrence in multivariate analysis (hazard ratio of 2.91). The authors suggested that more intensive monitoring for HCC recurrence may be appropriate for patients who have evidence of acute rejection.

The next study explored ways to identify patients who have HCC using PIVKA-II (prothrombin induced by vitamin K deficiency/antagonist – II), a promising marker that may be more sensitive/specific than AFP in identifying patients with liver cancer. Feng et al. used enzyme-linked immunosorbent assay (ELISA) to measure serum PIVKA-II levels in 168 patients with HCC, 150 patients with benign liver disease, and 153 healthy controls. Patients with HCC had significantly higher median PIVKA-II levels (181.50 mAu/mL), compared with atients with noncancerous liver disease (28.6 mAU/mL) or healthy controls 21.82 mAU/mL), with p<0.0001. In addition, PIVKA-II was more sensitive (83.9% vs 64.3%) and more specific (91.5% vs 84.7%) than AFP in identifying patients with HCC. When PIVKA-II and AFP were combined, sensitivity (81.95%) and specificity (89.3%) were increased more, suggesting that this combination of markers may be most useful in clinical practice to identify patients who have HCC.

Finally, in patients whose HCC was treated with orthotopic liver transplantation, acute organ rejection was found to be linked to HCC recurrence. Gul-Klein et al. identified 252 patients who underwent liver transplantation for HCC between 2001 and 2015, 91 of whom had confirmed acute rejection, and 47 of whom had recurrent HCC (the median time to HCC recurrence was 20 months). HCC recurrence was identified in 28.6% of patients with acute rejection, and in 13% of patients without acute rejection (p=0.002). Acute rejection within 20 months of liver transplantation was identified as a significant risk factor for HCC recurrence in multivariate analysis (hazard ratio of 2.91). The authors suggested that more intensive monitoring for HCC recurrence may be appropriate for patients who have evidence of acute rejection.

The next study explored ways to identify patients who have HCC using PIVKA-II (prothrombin induced by vitamin K deficiency/antagonist – II), a promising marker that may be more sensitive/specific than AFP in identifying patients with liver cancer. Feng et al. used enzyme-linked immunosorbent assay (ELISA) to measure serum PIVKA-II levels in 168 patients with HCC, 150 patients with benign liver disease, and 153 healthy controls. Patients with HCC had significantly higher median PIVKA-II levels (181.50 mAu/mL), compared with atients with noncancerous liver disease (28.6 mAU/mL) or healthy controls 21.82 mAU/mL), with p<0.0001. In addition, PIVKA-II was more sensitive (83.9% vs 64.3%) and more specific (91.5% vs 84.7%) than AFP in identifying patients with HCC. When PIVKA-II and AFP were combined, sensitivity (81.95%) and specificity (89.3%) were increased more, suggesting that this combination of markers may be most useful in clinical practice to identify patients who have HCC.

Finally, in patients whose HCC was treated with orthotopic liver transplantation, acute organ rejection was found to be linked to HCC recurrence. Gul-Klein et al. identified 252 patients who underwent liver transplantation for HCC between 2001 and 2015, 91 of whom had confirmed acute rejection, and 47 of whom had recurrent HCC (the median time to HCC recurrence was 20 months). HCC recurrence was identified in 28.6% of patients with acute rejection, and in 13% of patients without acute rejection (p=0.002). Acute rejection within 20 months of liver transplantation was identified as a significant risk factor for HCC recurrence in multivariate analysis (hazard ratio of 2.91). The authors suggested that more intensive monitoring for HCC recurrence may be appropriate for patients who have evidence of acute rejection.