Hepatocellular Carcinoma In Non-cirrhotic Liver Research Articles

An Uncommon Presentation of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the most frequent type of primary liver cancer, with an important characteristic being the development on a background of cirrhosis. HCC in non-cirrhotic liver is rare. We report a case of an HCC on a non-cirrhotic liver in a 66-year-old patient who was admitted with a 3 months history of right hypochondriac pain and weight loss. He had a medical history of hypertension, type 2 diabetes, obesity, and no alcohol abuse. Abdominal computed tomography (CT) and hepatic magnetic resonance imaging (MRI) showed a 115x100x110mm mass in the segment V and VIII, hypodense with heterogeneous and early arterial enhancement, and clearing in portal and late phase. He underwent a liver biopsy that confirmed an HCC without underlying cirrhosis. Surgical treatment was not an option since our patient presented multiple risk factors of recurrence. The patient underwent two sessions of transarterial chemoembolization (TACE) but the follow-up showed signs of progression.

The expression of VEGF and cyclin D1/EGFR in common primary liver carcinomas in Egypt: an immunohistochemical study.

The most common types of primary malignant liver tumours are hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA). Treatment options for patients who are inoperable/advanced, or recurring are challenging. Cyclin D1, epidermal growth factor (EGFR) and vascular endothelial growth factor (VEGR) are common carcinogenic proteins that have potential therapeutic targets in various cancers. They have been implicated in the development of HCC and CCA. In this study, we aimed to evaluate the oncogenic function expression of cyclin D1, EGFR and VEGF in HCC and CCA of Egyptian patients. This could help to validate their therapeutic potential. Tumour cases were selected from 82 cases of primary liver carcinomas, with 58 cases being from HCC and 24 cases from CCA compared to 51 non-tumour adjacent liver cases and 18 from normal liver tissue. The immunohistochemical study of cyclin D1, EGFR and VEGR was conducted. Cyclin D1, EGFR and VEGF are overexpressed in HCC and CCA as compared to the control group (p < 0.001). Cyclin D1 was related to well-differentiated grade and early pathologic stage in HCC (p = 0.016 and p = 0.042, respectively). The well-differentiated grade showed significantly higher VEGF levels (p = 0.04). In the CCA group, however, EGFR was strongly related to high tumour size (p = 0.047). EGFR and VEGF were overexpressed in HCC raised in the non-cirrhotic liver compared to those developed in post-hepatitic liver cirrhosis (p = 0.003 and p = 0.014). Cyclin D1, EGFR and VEGF shared significant overexpression in HCC and CCA. EGFR and VEGF may play an oncogenic function in the development of HCC in non-cirrhotic liver. Furthermore, cyclin D1 and VEGF may play a good prognostic function in HCC, but EGFR may play a bad prognostic role in CCA.

Prognostic biomarkers in and selection of surgical patients with hepatocellular carcinoma.

The Faculty of Health and Medical Sciences at the University of Copenhagen has accepted this dissertation for public defence for the doctoral degree in medicine, Copenhagen, January 10, 2023 Bente Merete Stallknecht, Head of Faculty Assessment committee Chair Professor Susanne Dam Poulsen, University of Copenhagen Opponents Professor Pål-Dag Line, University of Oslo Professor Christian Toso, University of Geneva Chair of the defence ceremony Professor Kirsten Grønbæk, University of Copenhagen The defense took place on February 14, 2023 at 14:00 CET at Rigshospitalet, Auditorium 2, Blegdamsvej 9, 2100 Copenhagen Ø This thesis summarizes a significant part of the research that I carried out from 2015 to 2020 alongside my surgical specialization. Since defending my PhD in 2013, my research area of interest has shifted towards liver surgery and transplantation, in particular prognostic aspects related to malignancy. The complexity of liver surgery, including anatomy, technique and medical aspects has always sparked my interest. The work in this thesis has paved the way for the current and future area of interest of my research group at Department of Surgery and Transplantation, Rigshospitalet. I would like to express my deepest appreciation to Allan Rasmussen for inspiration and guidance. Allan introduced me to this specific field of research and to many important research partners in Rigshospitalet, Denmark and Scandinavia. I would like to thank Jens Hillingsø and all of my wonderful colleagues at Department of Surgery and Transplantation, Rigshospitalet for their support and for offering me the opportunity to carry out my research. I would also like to thank the collaborators on the studies for their excellent work and important scientific inputs. These include: Andreas Rostved, Carina Lund Sørensen, Peter Nørgaard Larsen and Nicolai Schultz, Department of Surgery and Transplantation, Rigshospitalet; Jakob Burcharth and Jacob Rosenberg, Department of Surgery, Herlev Hospital; Jane Preuss Hasselby and Gro Linno Willemoe, Department of Pathology, Rigshospitalet; Jan-Michael Kugler, Institute for Molecular and Cellular Medicine, Panum Institute; Christina Westmose Yde, Lise Ahlborn and Finn Cillius Nielsen, Center for Genomic Medicine, Rigshospitalet; Claus Lindbjerg Andersen and Tenna Henriksen, Department for Molecular Medicine (MOMA), Aarhus University Hospital/Skejby; Kristoffer Rohrberg, Phase 1 Unit, Department of Oncology, Rigshospitalet; Lau Caspar Thygesen, National Institute of Public Health, University of Southern Denmark; and the European Liver and Intestine Transplant Association (ELITA) study group. Thanks to my research group for daily inspiration, good discussions and laughs (Delal Akdag, Jeanett Klubien, Lucas Knøfler og Sophie Nordkild). This work was financially supported by the Harboe foundation, the Risom foundation and the Dagmar Marchall foundation, for which I am grateful. Finally, I would like to thank my wife Line for her tremendous support over the many years where my research mostly has been conducted in my spare time. Thanks to my three children for filling me with love each day and thanks to my mother and my brother for continuous support. A special thanks to my father who passed away in the fall. He was always proud, supportive and encouraging. Hans-Christian PommergaardMD, DMSc, PhDDepartment of Surgery and TransplantationRigshospitalet, University of Copenhagen Charlottenlund, January 2023 Pommergaard HC, Burcharth J, Rosenberg J, Rasmussen A. Serologic and molecular biomarkers for recurrence of hepatocellular carcinoma after liver transplantation: a systematic review and meta-analysis. Transplant Rev (Orlando). 2016 Jul;30(3):171–7. Pommergaard HC, Hasselby JP, Willemoe GL, Ralbovska A, Rostved AA, Rasmussen A, Schultz NA, Hillingsø J, Larsen PN, Kugler JM. Peroxisome proliferator-activated receptor activity correlates with poor survival in patients resected for hepatocellular carcinoma. J Hepatobiliary Pancreat Sci. 2021 Apr;28(4):327–35. Pommergaard HC, Rasmussen A, Hillingsø J, Kugler JM. Aldehyde dehydrogenase expression may be a prognostic biomarker and associated with liver cirrhosis in patients resected for hepatocellular carcinoma. Surg Oncol. 2021 Nov 23;40:101677. Pommergaard HC, Yde CW, Ahlborn LB, Andersen CL, Henriksen TV, Hasselby JP, Rostved AA, Sørensen CL, Rohrberg KS, Nielsen FC, Rasmussen A. Personalized circulating tumour DNA in patients with hepatocellular carcinoma: a pilot study. Mol Biol Rep. 2021 Nov 22. Pommergaard HC, Rostved AA, Adam R, Thygesen LC, Salizzoni M, Gómez Bravo MA, Cherqui D, Filipponi F, Boudjema K, Mazzaferro V, Soubrane O, García-Valdecasas JC, Prous JF, Pinna AD, O'Grady J, Karam V, Duvoux C, Rasmussen A. Vascular invasion and survival after liver transplantation for hepatocellular carcinoma: a study from the European Liver Transplant Registry. HPB (Oxford). 2018 Aug;20(8):768–75. Pommergaard HC, Rostved AA, Adam R, Thygesen LC, Salizzoni M, Gómez Bravo MA, Cherqui D, De Simone P, Boudjema K, Mazzaferro V, Soubrane O, García-Valdecasas JC, Fabregat Prous J, Pinna AD, O'Grady J, Karam V, Duvoux C, Rasmussen A. Locoregional treatments before liver transplantation for hepatocellular carcinoma: a study from the European Liver Transplant Registry. Transpl Int. 2018 May;31(5):531–9. Pommergaard HC, Rostved AA, Adam R, Rasmussen A, Salizzoni M, Gómez Bravo MA, Cherqui D, De Simone P, Houssel-Debry P, Mazzaferro V, Soubrane O, García-Valdecasas JC, Prous JF, Pinna AD, O'Grady J, Karam V, Duvoux C, Thygesen LC. Mortality after transplantation for hepatocellular carcinoma: a study from the European Liver Transplant Registry. Liver Cancer. 2020 Aug;9(4):455–67. Hepatocellular carcinoma (HCC) is the sixth most common cancer and the fourth leading cause of cancer deaths globally with increasing incidence. In most cases, HCC develops as a result of an underlying chronic liver disease. The stage at the time of diagnosis is closely correlated with prognosis with a 5-year survival of more than 70% for patients with early-stage HCC. These patients are generally suitable for curative treatment, such as resection, ablation or liver transplantation. In contrast, 5-year survival may be as low as 5% for patients in advanced stages of the disease. Due to organ shortage and the risk of mortality for patients on the waiting list for liver transplantation, survival in patients undergoing transplantation due to HCC should be comparable to those with benign indications. However, there is an ongoing debate concerning the best criteria for the selection of patients with HCC for transplantation, as the current criteria may rule out patients with a good prognosis. Liver resection may be performed in patients with HCC in non-cirrhotic livers and cirrhotic livers with preserved liver function. However, careful selection of patients is crucial due to high recurrence risk (>50%) and severe complications in >10% of liver resections for HCC. The aims of this thesis were to identify prognostic biomarkers in and improve the selection of patients undergoing transplantation and resection for HCC, respectively. Yet another aim was to improve upon the existing early detection of recurrence. The seven studies included in this thesis provided novel insights into prognostic biomarkers and selection of surgical patients with HCC. Firstly, the literature was reviewed regarding biomarkers to detect recurrence after transplantation for HCC. Next, two novel tumour-related prognostic biomarkers were identified and the applicability of circulating tumour DNA (ctDNA) was evaluated. Moreover, using data from the European Liver Transplant Registry (ELTR), vascular invasion and locoregional treatment were identified as important prognostic markers. Lastly, using propensity score calibration, prognostic differences between HCC in cirrhotic and non-cirrhotic livers were clarified. The studies included in this thesis add important knowledge towards better selection of patients for transplantation and resection of HCC, respectively. In future guidelines, alpha-fetoprotein, radiological markers of vascular invasion and response to locoregional treatment may be included in selection criteria for transplantation of patients with HCC. In addition, the novel biomarkers identified may add important prognostic information and improve the selection of patients. For resected patients, a proper balance between survival benefit and risk of recurrence and complications may be ensured. For transplanted patients, optimized selection means that the utility of donor organs is maximized by more accurately selecting patients with favourable tumour biologies. Hepatocellulært karcinom (HCC) er den sjette mest almindelige kræftsygdom og den fjerde hyppigste årsag til kræftdødsfald globalt med stigende forekomst. I de fleste tilfælde udvikler HCC sig som følge af en underliggende kronisk leversygdom. Stadie på diagnosetidspunktet er tæt korreleret med prognose med femårs overlevelse på mere end 70% hos patienter med HCC i tidligt stadium. Disse patienter kan generelt modtage kurativt intenderet behandling, såsom resektion, ablation eller levertransplantation. I modsætning hertil kan femårs overlevelse være helt ned til 5% hos patienter med fremskredne stadier. På grund af organmangel og død på venteliste til levertransplantation bør overlevelse hos patienter der transplanteres for HCC være sammenlignelig med overlevelse for benigne indikationer. Der er aktuelt debat om de bedste kriterier til at selektere patienter med HCC til transplantation, da nuværende kriterier udelukker visse patienter med en god prognose. Leverresektion kan udføres hos patienter med HCC i en ikke-cirrotisk lever eller i en cirrotisk lever med bevaret leverfunktion. Imidlertid er omhyggelig udvælgelse af patienter afgørende på grund af en høj risiko for recidiv (>50%) og alvorlige komplikationer i >10% af leverresektioner for HCC. Formålet med denne disputats var at identificere prognostiske biomarkører og forbedre selektion af patienter til henholdsvis transplantation og resektion for HCC. Desuden var målet at forbedre tidlig identifikation af recidiv. De syv studier inkluderet i denne disputats giver ny indsigt i prognostiske biomarkører og selektion af kirurgiske patienter med HCC. Eksisterende biomarkører for recidiv efter transplantation for HCC blev systematisk undersøgt. Dernæst blev to nye tumorrelaterede prognostiske biomarkører identificeret, og anvendeligheden af cirkulerende tumor-DNA (ctDNA) blev evalueret. Ved hjælp af data fra European Liver Transplant Registry (ELTR) blev mikrovaskulær invasion og lokalbehandling af HCC identificeret som vigtige prognostiske markører. Endelig blev prognostiske forskelle mellem HCC i cirrotisk og ikke-cirrotisk lever afklaret ved hjælp af propensity score kalibrering. Studierne inkluderet i denne disputats tilfører vigtig viden til bedre selektion af patienter til henholdsvis transplantation og resektion af HCC. I fremtidige retningslinjer kan alfa-føto protein, radiologiske markører for microvaskulær invasion og respons på lokalbehandling muligvis inkluderes i selektionskriterier for transplantation af HCC. Derudover kan de nye identificerede biomarkører tilføje vigtig prognostisk information og forbedre udvælgelsen af patienter. For resecerede patienter kan der skabes en balance mellem overlevelsesgevinst og risiko for recidiv og komplikationer. For transplanterede patienter betyder optimeret selektion, at udnyttelse af donororganer maksimeres ved mere præcis udvælgelse patienter med en gunstig tumorbiologi. Hepatocellular carcinoma (HCC) is the sixth most common cancer and the fourth leading cause of cancer deaths globally with increasing incidence. HCC represents 75–85% of primary liver cancers and has a strong male predominance, both regarding incidence and mortality [1, 2]. In 70–90% of cases, HCC arises in patients with cirrhotic livers [3, 4]. Approximately one-third of patients with cirrhosis will develop HCC in their lifetime (1–8% annual incidence) [5, 6]. On a global level, hepatitis B virus (HBV) is the primary cause of HCC (33%), followed by alcohol (30%), hepatitis C virus (HCV) (21%) and other aetiologies (16%) [2]. Most deaths due to HCC occur in Asia, and the primary cause is endemic HBV infections. However, the incidence of HCC is rising in Western countries as a result of the increasing prevalence of non-alcoholic fatty liver disease (NAFLD), non-alcoholic steatohepatitis (NASH) and alcohol-related liver disease [7]. HCC seems to be less frequent in patients with alcoholic and NASH cirrhosis than in patients with viral hepatitis [6, 8]. However, the annual incidence of HCC in patients with NASH is 1–2%, and it is estimated that 6 million people in the United States alone have NASH [9] and that obesity and/or diabetes accounts for approximately 37% of the HCC cases [10]. Current guidelines suggest that patients with cirrhosis (Child-Pugh A/B and Child-Pugh C (awaiting transplantation)) and non-cirrhotic HBV patients with intermediate or high risk of HCC should undergo surveillance for HCC with abdominal ultrasound every 6 months [11]. This modality has a limited sensitivity (45%) for the detection of HCC [12], which may be reduced further by obesity and cirrhosis [13]. However, evidence suggests that surveillance improves the identification of HCC at an early stage and hence the chances of curative treatment and survival [14]. Patients with early-stage HCC are generally suitable for curative treatments, such as resection, ablation or liver transplantation. In contrast, patients with advanced-stage disease are typically only offered palliative oncologic treatment or the best supportive care. Patients with intermediate-stage disease may be offered chemo-embolization [15]. Consequently, the stage at the time of diagnosis is closely correlated with the prognosis with a 5-year survival of more than 70% for patients with early-stage HCC compared with only 5% for patients in advanced stages of the disease [11, 16]. In most centres, a multidisciplinary approach is adopted with treatment allocation based on the stage of the disease, using, for example, the Barcelona Clinic Liver Cancer (BCLC) classification [17]. A contemporary approach includes treatment stage migration, wherein a patient with a specific disease stage not suited for the first-line treatment may be allocated a treatment recommended for a different disease stage [18-20]. The concepts are integrated with the 2022 BCLC guideline update [15] (Fig. 1). With evidence suggesting that prognosis is related to first-line treatment irrespective of tumour stage, an alternative approach has been suggested [21]. In the concept of therapeutic hierarchy (Fig. 2), treatments are decided independent of stage and hierarchical use of available therapies according to their specific survival benefit [22]. Previously, sorafenib was the only available systemic treatment. It is associated with significant adverse events and only minor survival benefits [23]. Based on the evidence from phase III trials, several additional systemic therapies have been approved including atezolizumab plus bevacizumab, lenvatinib, regorafenib, cabozantinib and ramucirumab [24]. Moreover, trials are now evaluating combination therapies. According to the 2022 guideline update from BCLC, Atezolizumab-Bevacizumab/Durvalumab-Tremelimumab is now recommended as first-line systemic treatment [15] (Fig. 1). Hepatocellular carcinoma may be diagnosed solely based on imaging using the Liver Imaging Reporting and Data System (LI-RADS) [25], thereby eliminating the need for preoperative histological diagnosis by tumour biopsy. LI-RADS is valid in patients with high-risk of developing HCC, namely patients with cirrhosis, chronic HBV and current or prior HCC. However, LI-RADS may not be applied in patients without these risk factors, in patients under 18 years of age and in those with cirrhosis due to a vascular disorder or congenital hepatic fibrosis [25]. Moreover, a recent study showed that LI-RADS may be valid in a larger proportion of patients with an increased risk of HCC than previously considered [26]. However, biopsy in patients without increased risk, including patients with non-cirrhotic livers, is still needed to confirm diagnosis. Due to organ shortage and the risk of mortality for patients on waiting list for liver transplantation, survival in patients undergoing transplantation due to HCC should be comparable to those with benign indications [27]. However, there is an ongoing debate concerning the best criteria for selection of patients with HCC for transplantation. Some argue that the current criteria may rule out patients with a good prognosis [28]. Thus, better selection criteria are needed. Patients with HCC in a non-cirrhotic liver without macrovascular invasion or extra-hepatic spread may undergo curative liver resection. Liver resection may also be performed in patients with HCC in a cirrhotic liver with preserved liver function, no portal hypertension and sufficient volume of the future liver remnant (FLR) [11]. Careful selection of patients is essential due to a high recurrence risk (>50%) [29] and severe complications in >10% of liver resections for HCC. Age, model for end-stage liver disease (MELD) score, liver stiffness and serum albumin were independent predictors of complications [30], while portal hypertension, extend of resection, MELD score, bilirubin and indocyanine green (ICG) clearance were associated with the risk of postoperative liver failure [31-33]. However, knowledge of cancer-related prognostic biomarkers is lacking. To optimize the selection of patients who will benefit from a high-risk surgical procedure, prognostic biomarkers are needed. Furthermore, as liver disease may not be easily diagnosed in some patients, additional biomarkers to identify high-risk patients, for example, with fibrosis/cirrhosis may be useful [34]. However, so far, no prognostic biomarkers have been widely accepted in clinical practice. Early identification of recurrence after surgical treatment may be associated with better prognosis [29]. Imaging studies currently used for follow-up may be insufficient for smaller lesions (<2 cm) [35, 36]. Thus, tools for early detection of recurrence are needed. Hypothesis 1 was investigated by conducting a systematic review and a meta-analysis using the PubMed and Scopus databases on studies investigating biomarkers for recurrence of HCC after liver transplantation. Hypotheses 2 and 3 were investigated using tissue stored in the Danish Cancer Biobank from patients undergoing liver resection for HCC at Rigshospitalet, Denmark between 2014 and 2018. Hypothesis 4 was investigated by evaluating the detection of ctDNA in blood preoperatively in a prospective pilot study in patients undergoing liver resection for HCC at Rigshospitalet, Denmark in 2018 and 2019. Hypotheses 5, 6 and 7 were investigated using data from the European Liver Transplant Registry (ELTR) for the period from 1990 to 2016, where pre-, peri- and postoperative data from 174 liver transplantation centres in 28 European countries have been collected, including data on tumour characteristics and locoregional treatment in patients with HCC. Regarding liver transplantation, donor livers are scarce with substantial mortality of patients in waiting lists [37]. Thus, the prognosis for recipients transplanted for HCC should be comparable to that of benign indications to justify transplantation [27]. Current selection criteria, based on the size and number of HCC, are insufficient, as they may rule out patients with good prognosis despite being outside the established criteria [28]. Inclusion of biomarkers in the selection criteria may improve the selection of patients for liver transplantation for HCC. However, except for alpha-fetoprotein (AFP), no biomarkers are included in the existing selection criteria for transplantation due to HCC. Surgical resection for HCC may be a high-risk procedure, especially in patients with cirrhosis, with a substantial risk of recurrence [11] and complications, including liver failure [30]. Prognostic biomarkers may improve the selection of patients who will benefit from a surgery and also provide more precise preoperative information to them. Currently, tumour burden, liver function and performance score are used to select patients for surgical resection [15]. Thus, biomarkers may be used in conjunction with these criteria to determine the optimal treatment strategy. Currently, no biomarkers have been widely incorporated into clinical practice. A prognostic biomarker may be defined as a factor indicating the likelihood of a future recurrence, progression or death in a population [38]. For the purpose of this thesis, a prognostic biomarker was defined as a blood or tumour marker associated with prognosis not currently included in standard diagnostic workups. A vast amount of research has been conducted in an effort to identify clinically useful biomarkers in patients with HCC. However, relatively less effort has gone into the validation of positive results. In an attempt to gain an overview of the level of evidence, directions for the design of studies and the possibilities for clinical implementation, a systematic review and a meta-analysis were conducted in Study I. PubMed and Scopus databases were searched up to the year 2016 to identify observational studies investigating blood-borne or tumour markers for recurrence of HCC after liver transplantation. Meta-analyses were performed in biomarkers investigated in multiple studies with sufficient homogeneity. Meta-analysis was omitted when heterogeneity was above 75% as assessed by the I2 test. The generic inverse variance method was utilized to incorporate adjusted hazard ratio (HR) estimates from individual studies. This was applied to adjust for confounding in individual studies. Alpha-fetoprotein was investigated in 49 studies of which 17 studies were included in the meta-analysis. These studies were defined by using a pre-transplant AFP >400 NT/mL as cut-off [39-55]. The pooled estimate (HR) regarding risk of recurrence was 2.69 [2.08–3.47], with an acceptable heterogeneity of 46% (Fig. 3). However, the funnel plot indicated a risk of publication bias with a lack of smaller negative studies. Des-gamma-carboxy prothrombin (DCP/PIVKA) was investigated in seven studies. Four studies [45, 48, 57, 58] with comparable outcome definition and cut-off levels (PIVKA level >100–400 mAU/mL) were included in a meta-analysis with an HR of 5.99 [3.27–10.98] regarding the risk of recurrence. Heterogeneity of the four studies was 0% (Fig. 4). Neutrophil to lymphocyte ratio (NLR) was found to be associated with recurrence in four studies [59-62]. However, a meta-analysis was not conducted due to the high heterogeneity (>75%) between the studies. Moreover, circulating DNA – particularly single nucleotide polymorphisms rs894151 and rs12438080 – was found to be associated with recurrence in one of the studies [63]. Following protein markers in HCC tumours has been shown to be associated with recurrence: anti-Ki67 [64], calpain small subunit 1 (Capn4) [65], CD34 antigen [66], CD147 [67], NDRG1 [68], cadherins [64], x-linked inhibitor of apoptosis protein-associated factor 1 (XAF1) [69], hepatocyte nuclear factor 1 (HNF1) [70] and hippo cell signal pathway [71]. Enzymes were investigated in four studies. Two of them investigated matrix metalloproteinases (MMPs) measured in tumour [67, 72]. In a meta-analysis, there was no association with recurrence with an HR of 2.12 [0.21–21.43], with a high heterogeneity of 74% (Fig. 5). However, MMP measured in adjacent stromal tissue may be associated with recurrence [67]. In two additional studies, histone deacetylases (HDACs) [73] and O-GlcNAcylation [52] were associated with recurrence. Micro-RNA in tumour was associated with recurrence in four studies [41, 44, 54, 74]. Moreover, long noncoding RNAs, in particular, HOTAIR in tumour [50] and MALAT-1 [75], were associated with recurrence. DNA/genes associated with recurrence included CIMP [76], MACC1 [42, 51], and cell-cycle genes pRb and p16 [77]. Lastly, allelic imbalance in microsatellites was associated with recurrence in a meta-analysis with two studies and an HR of 13.49 [3.17–57.30] and 0% heterogeneity [78, 79] (Fig. 6). The majority of biomarkers were only investigated in a single study, and results have not been validated. The included studies considered different types of aetiology for HCC, and patients may therefore not be comparable. Moreover, outcome definition differed between the studies. For meta-analyses, there was an insufficient number of studies for meaningful evaluation of publication bias by means of funnel plots, except for AFP where a lack of smaller negative studies suggested a risk of publication bias. Since the publication of Study I in 2016, additional studies have been published on biomarkers for recurrence after liver transplantation for HCC. Thus, an updated literature search was performed. Regarding blood-borne biomarkers, platelet-to-lymphocyte ratio (PLR), controlling nutritional status (CONUT) and the prognostic nutritional index (PNI) were associated with recurrence [80]. Serum homocysteine was associated with recurrence in recipients with AFP-negative disease [81]. Moreover, markers of angiogenesis and inflammation (plasma VEGFR1, VEGF and VEGF-C) and circulating exosomal miR-92b were associated with recurrence [82, 83]. Regarding tumour tissue biomarkers, increased LGALS3 and LGALS3BP gene and protein expression were associated with recurrence [84]. In addition, TP53 mutations, high fractional allelic loss, hypomethylation of 8 tumour suppressors and absence of CTNNB1 mutations were of prognostic significance [85]. Lastly, tumour evolutionary distance by genome-wide single-nucleotide polymorphism genotyping was associated with recurrence and validated in a replication cohort [86]. As in liver transplant recipients, AFP is the most commonly evaluated biomarker after liver resection for HCC. However, only 10–20% of early-stage HCC patients present with abnormal AFP, which may be correlated with an aggressive HCC type (e.g., S2 class, epithelial cell adhesion molecule (EpCAM) positive) [87-89]. Moreover, AFP has low accuracy, as elevated AFP in patients with cirrhosis may reflect viral hepatitis and background liver disease in addition to HCC development [90]. Despite these limitations, AFP level was associated with recurrence with results externally validated in international cohorts [91, 92]. Furthermore, AFP level at recurrence predicted survival [93]. The following additional blood-borne biomarkers were associated with recurrence after resection for HCC: DCP [94], albumin-bilirubin score [91], circulating EpCAM positive tumour cells [95], preoperative CRP [96], preoperative neutrophil-to-lymphocyte ratio [97] and ratio of postoperative to preoperative circulating levels of cancer stem cell (CSC) markers K19 and CD44 [98]. Peroxisome proliferator-activated receptors (PPARs) are ligand-dependent nuclear receptors that regulate lipid metabolism and transduce metabolic and nutritional signals into transcriptional responses [99-101]. The association between PPAR and the development of HCC is not fully understood, and studies are somewhat conflicting. Moreover, the relationship may depend on context and species [102]. In some studies, high PPAR activity seems beneficial. Thus, it may reduce tumour growth via anti-inflammatory mechanisms [103], improve liver function [104] and resolve NASH [105]. As opposed to this, studies suggested unwanted consequences of PPAR activation, such as the induction of HCC due to regulation of the cell cycle [106] or formation of steatosis [107]. However, the prognostic importance in patients with HCC has not been investigated in a clinical setting. In Study II, we presented the results of RNA sequencing of HCC and non-tumour liver tissue in 52 patients undergoing liver resection. Based on the expression of PPAR target genes in heat maps (Fig. 7), we identified a group of patients (cancer cluster 3) with decreased overall survival (3-year overall survival of 48.6% vs 81.7% amongst controls, Fig. 8). The correlation remained significant in multivariate analysis adjusted for age, cirrhosis, microvascular invasion, number of tumours and resection margins (Table 1). Furthermore, we found that PPAR expression in non-tumour liver tissue was correlated with cirrhosis. In an earlier study using publicly available data from The Cancer Genome Atlas (TCGA), it was found that patients with HCC and low PPAR activity in tumour had significantly reduced overall survival [109]. However, in that study, PPAR activity from tumour tissue in patients with HCC was compared with liver tissue from healthy patients. Moreover, in a large study, PPAR expression evaluated with immunohistochemistry was correlated with shorter survival [110]. While immunohistochemistry may be a good surrogate for PPAR activity, transcriptome analysis allows a more direct evaluation of activity, as PPAR requires ligands and co-receptors to regulate gene expression [111]. In a phase 2 trial, patients with NASH were randomized to receive Lanifibranor, a PPAR agonist or a placebo [112]. Patients in the treatment arm receiving 1200 mg daily had reduced disease activity measured by the steatosis, activity and fibrosis [SAF] scoring system without the worsening of fibrosis. This suggested a possible clinical implication of PPAR not confined to HCC. Together with the correlation between PPAR and cirrhosis found in Study II, these findings may reflect that PPAR activity is important for liver cell homoeostasis. To our knowledge, Study II was the first clinical study to establish the prognostic value of PPAR gene activit

Case Report: Non-Cirrhotic Hepatoma BCLC-C With Vertebrae Metastasis

  Background: Hepatocellular carcinoma (HCC) can arise from either cirrhosis or non-cirrhosis of the liver. HCC in non-cirrhotic livers is still uncommon and can present insidiously in patients. HCC may develop in people with non-cirrhotic chronic liver illness, such as chronic hepatitis B virus infection and chronic HCV infection. More than half of non-cirrhotic individuals with HCC may not exhibit any symptoms, and the disease is frequently detected when it is advanced and incurable. Case Report: Here we presented a 47-year-old man went to the emergency room complaining of upper right side abdominal discomfort that suddenly arose and spread to the back and right shoulder. He also experiencing upper right abdominal fullness for the past two months, along with a sense of a lump growing larger and harder. Hepatic stigmata were not discovered, whole blood revealed a thrombocytosis and significant rising AFP from the expected result of 71,000 ng/dL, with hepatitis B testing was positive. Abdominal ultrasound revealed hepatomegaly and several hypo-hyperechoic nodules. CT scan revealed multiple solid lesions and lytic lesions of the vertebrae bodies. The patient recieved palliative treatment.. Conclusion: This case study demonstrates a non-cirrhotic hepatoma that came at an80 tan advanced stage and was more likely to be asymptomatic than a cirrhotic hepatoma that showed signs of liver failure, such as hepatic stigmata and other physiologic abnormalities. This case report demonstrates the This case study demonstrates the importance of strengthening general HHC preventative measures in order to lower non-cirrhotic HHC's incidence and fatality rate.

Giant hepatocellular carcinoma in non-cirrhotic liver: Treatment with ALPPS and MINIALPPS

Background: Oncological resection of liver tumors continues to be the best alternative to increase survival and the disease-free period of patients. Thanks to liver regeneration, liver hypertrophy techniques are a great alternative in the surgical management of patients with high tumor burden. A few years ago, a surgical technique for liver hypertrophy called ALPPS (Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy) was described. In recent years, groups in Chile and Argentina have developed a variant of this which they have called MINIALPPS.

Outcome after Resection for Hepatocellular Carcinoma in Noncirrhotic Liver-A Single Centre Study.

Liver cirrhosis is the most common risk factor for the development of hepatocellular carcinoma (HCC). However, 10 to 15% of all HCC arise in a non-cirrhotic liver. Few reliable data exist on outcome after liver resection in a non-cirrhotic liver. The aim of this single-centre study was to evaluate the outcome of resection for HCC in non-cirrhotic liver (NC-HCC) and to determine prognostic factors for overall (OS) and intrahepatic recurrence-free (RFS) survival. From 2008 to 2020, a total of 249 patients were enrolled in this retrospective study. Primary outcome was OS and RFS. Radiological and pathological findings, such as tumour size, number of nodules, Tumour-, Nodes-, Metastases- (TNM) classification and vascular invasion as well as extent of surgical resection and laboratory liver function were collected. Here, 249 patients underwent liver resection for NC-HCC. In this case, 50% of patients underwent major liver resection, perioperative mortality was 6.4%. Median OS was 35.4 months (range 1–151 months), median RFS was 10.5 months (range 1–128 moths). Tumour diameter greater than three centimetres, multifocal tumour disease, vascular invasion, preoperative low albumin and increased alpha-fetoprotein (AFP) values were associated with significantly worse OS. Our study shows that resection for NC-HCC is an acceptable treatment approach with comparatively good outcome even in extensive tumours.

Imaging Features of Hepatocellular Carcinoma in the Non-Cirrhotic Liver with Sonazoid-Enhanced Contrast-Enhanced Ultrasound.

Purpose: To investigate the Sonazoid-enhanced contrast-enhanced ultrasound (CEUS) features of hepatocellular carcinoma (HCC) in a non-cirrhosis liver background, in comparison to those in liver cirrhosis. Methods: In this retrospective study, 19 patients with surgery and histopathologically proven HCC lesions in non-cirrhosis liver background were included regarding Sonazoid-enhanced CEUS characteristics. Two radiologists evaluated the CEUS features of HCC lesions according to the WFUMB (World Federation of Societies for Ultrasound in Medicine and Biology) guidelines criteria. Thirty-six patients with HCC lesions in liver cirrhosis were included as a control group. Final diagnoses were confirmed by surgery and histopathological results. Results: Liver background of the non-cirrhosis group including normal liver (n = 7), liver fibrosis (n = 11), and alcoholic liver disease (n = 1). The mean size of non-cirrhosis HCC lesions was 60.8 ± 46.8 mm (ranging from 25 to 219 mm). During the arterial phase of Sonazoid-enhanced CEUS, most HCCs in non-cirrhotic liver (94.7%, 18/19) and in cirrhotic liver (83.3%, 30/36) presented non-rim hyperenhancement. During the portal venous phase, HCC lesions in the non-cirrhosis liver group showed relatively early washout (68.4%, 13/19) (p = 0.090). Meanwhile, HCC lesions in liver cirrhosis background showed isoenhancement (55.6%, 20/36). All lesions in the non-cirrhotic liver group showed hypoenhancement in the late phase and the Kupffer phase (100%, 19/19). Five cases of HCC lesions in liver cirrhosis showed isoenhancement during the late phase and hypoenhancement during the Kupffer phase (13.9%, 5/36). The rest of the cirrhotic HCC lesions showed hypoenhancement during the late phase and the Kupffer phase (86.1%, 31/36). Additional hypoenhanced lesions were detected in three patients in the non-cirrhosis liver group and eight patients in the liver cirrhosis group (mean size: 13.0 ± 5.6 mm), which were also suspected to be HCC lesions. Conclusions: Heterogeneous hyperenhancement during the arterial phase as well as relatively early washout are characteristic features of HCC in the non-cirrhotic liver on Sonazoid-enhanced CEUS.

Genomic and transcriptomic somatic alterations of hepatocellular carcinoma in non-cirrhotic livers

•Non-cirrhotic HCC genomically resembles cirrhotic HCC•Comprehensive genome- and transcriptome-wide profiling allows detection of novel structural variants, fusions, and undiagnosed viral infections•NR1H4 fusions may represent a novel mechanism for tumorigenesis in HCC•Non-cirrhotic HCC is characterized by genotoxic mutational signatures and dysregulated liver metabolism•Clinical history and comprehensive omic profiling incompletely explain underlying etiologies for non-cirrhotic HCC highlighting the need for further research Worldwide, there are approximately 750,000 new cases of hepatocellular carcinoma (HCC) each year [[1]Ferlay J. Soerjomataram I. Dikshit R. Eser S. Mathers C. Rebelo M. et al.Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012.Int J Cancer. 2015; 136: E359-E386Crossref PubMed Scopus (19883) Google Scholar]. Although HCC has the 5th highest incidence rate in men and 9th highest incidence rate in women, it has the second highest mortality rate of all cancer types [[1]Ferlay J. Soerjomataram I. Dikshit R. Eser S. Mathers C. Rebelo M. et al.Cancer incidence and mortality worldwide: sources, methods and major patterns in GLOBOCAN 2012.Int J Cancer. 2015; 136: E359-E386Crossref PubMed Scopus (19883) Google Scholar]. HCC is traditionally associated with inflammation-inducing risk factors, which promote liver cirrhosis including: chronic hepatitis infections, such as hepatitis b virus (HBV) and hepatitis c virus (HCV), alcohol abuse, and non-alcoholic fatty liver disease [[2]Fattovich G. Stroffolini T. Zagni I. Donato F. Hepatocellular carcinoma in cirrhosis: incidence and risk factors.Gastroenterology. 2004; 127: S35-S50Abstract Full Text Full Text PDF PubMed Scopus (1835) Google Scholar]. However, approximately 20% of patients present with non-cirrhotic HCC in the absence of these risk factors [[3]Alkofer B. Lepennec V Chiche L. Hepatocellular cancer in the non-cirrhotic liver.J Visc Surg. 2011; 148: 3-11Crossref PubMed Google Scholar]. If diagnosed early, patients with non-cirrhotic HCC maintain adequate liver function, allowing for effective tumor resection with exceptional prognosis when compared to patients with cirrhotic HCC [[4]Maeda T. Shimada M. Harimoto N. Tsujita E. Aishima S.-I. Tanaka S. et al.Prognosis of early hepatocellular carcinoma after hepatic resection.Hepatogastroenterology. 2008; 55: 1428-1432PubMed Google Scholar]. However, late-stage diagnosis of non-cirrhotic HCC typically presents with larger and more aggressive tumors that are prone to metastasis [[5]Llovet J.M. Brú C. Bruix J. Prognosis of hepatocellular carcinoma: the BCLC staging classification.Semin Liver Dis. 1999; 19: 329-338Crossref PubMed Google Scholar]. Even with extensive tumor resection, approximately 50% of patients relapse within three years post-treatment [[6]Shah S.A. Cleary S.P. Wei A.C. Yang I. Taylor B.R. Hemming A.W. et al.Recurrence after liver resection for hepatocellular carcinoma: risk factors, treatment, and outcomes.Surgery. 2007; 141: 330-339Abstract Full Text Full Text PDF PubMed Scopus (307) Google Scholar]. Using high-throughput sequencing, researchers have previously characterized the genomic landscape of cirrhotic HCC [7Schulze K. Imbeaud S. Letouzé E. Alexandrov L.B. Calderaro J. Rebouissou S. et al.Exome sequencing of hepatocellular carcinomas identifies new mutational signatures and potential therapeutic targets.Nat Genet. 2015; 47: 505-511Crossref PubMed Scopus (872) Google Scholar, 8Fujimoto A. Furuta M. Totoki Y. Tsunoda T. Kato M. Shiraishi Y. et al.Whole-genome mutational landscape and characterization of noncoding and structural mutations in liver cancer.Nat Genet. 2016; 48: 500-509Crossref PubMed Scopus (412) Google Scholar, 9Cancer Genome Atlas Research Network. Electronic address: [email protected], Cancer Genome Atlas Research Network. Comprehensive and Integrative Genomic Characterization of Hepatocellular Carcinoma.Cell. 2017; 169 (e23): 1327-1341Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar, 10Laurent-Puig P. Zucman-Rossi J. Genetics of hepatocellular tumors.Oncogene. 2006; 25: 3778-3786Crossref PubMed Scopus (298) Google Scholar, 11Guichard C. Amaddeo G. Imbeaud S. Ladeiro Y. Pelletier L. Maad I.B. et al.Integrated analysis of somatic mutations and focal copy-number changes identifies key genes and pathways in hepatocellular carcinoma.Nat Genet. 2012; 44: 694-698Crossref PubMed Scopus (961) Google Scholar, 12Kan Z. Zheng H. Liu X. Li S. Barber T.D. Gong Z. et al.Whole-genome sequencing identifies recurrent mutations in hepatocellular carcinoma.Genome Res. 2013; 23: 1422-1433Crossref PubMed Scopus (349) Google Scholar, 13Fujimoto A. Totoki Y. Abe T. Boroevich K.A. Hosoda F. Nguyen H.H. et al.Whole-genome sequencing of liver cancers identifies etiological influences on mutation patterns and recurrent mutations in chromatin regulators.Nat Genet. 2012; 44: 760-764Crossref PubMed Scopus (638) Google Scholar]. These studies included whole genome, whole exome, and/or transcriptome sequencing with a focus on analyzing HCC induced by HBV, HCV, and/or cirrhosis. Prior studies, which have evaluated the genomics of cirrhotic and non-cirrhotic HCC, report that among the most significant and recurrent alterations are TERT mutations which typically occur at the promoter region [[8]Fujimoto A. Furuta M. Totoki Y. Tsunoda T. Kato M. Shiraishi Y. et al.Whole-genome mutational landscape and characterization of noncoding and structural mutations in liver cancer.Nat Genet. 2016; 48: 500-509Crossref PubMed Scopus (412) Google Scholar,[9]Cancer Genome Atlas Research Network. Electronic address: [email protected], Cancer Genome Atlas Research Network. Comprehensive and Integrative Genomic Characterization of Hepatocellular Carcinoma.Cell. 2017; 169 (e23): 1327-1341Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,[14]Jhunjhunwala S. Jiang Z. Stawiski E.W. Gnad F. Liu J. Mayba O. et al.Diverse modes of genomic alteration in hepatocellular carcinoma.Genome Biol. 2014; 15: 436PubMed Google Scholar]. Mutations within this region have been observed in a variety of cancer types beyond cirrhotic HCC, suggesting a common role of activating TERT promoter variants in oncogenesis and metastasis [15Mosrati M.A. Malmström A. Lysiak M. Krysztofiak A. Hallbeck M. Milos P. et al.TERT promoter mutations and polymorphisms as prognostic factors in primary glioblastoma.Oncotarget. 2015; 6: 16663-16673Crossref PubMed Google Scholar, 16Huang F.W. Hodis E. Xu M.J. Kryukov G.V. Chin L. Garraway L.A. Highly recurrent TERT promoter mutations in human melanoma.Science. 2013; 339: 957-959Crossref PubMed Scopus (1225) Google Scholar, 17Hosen I. Rachakonda P.S. Heidenreich B. de Verdier P.J. Ryk C. Steineck G. et al.Mutations in TERT promoter and FGFR3 and telomere length in bladder cancer.Int J Cancer. 2015; 137: 1621-1629Crossref PubMed Google Scholar]. TERT expression in terminally differentiated cells promotes telomere maintenance and elongation [[18]Jafri M.A. Ansari S.A. Alqahtani M.H. Shay J.W. Roles of telomeres and telomerase in cancer, and advances in telomerase-targeted therapies.Genome Med. 2016; 8: 69Crossref PubMed Scopus (295) Google Scholar]. Telomere maintenance is required for late stage cancer propagation with TERT misregulation being harnessed by human cancers to evade mitotic catastrophe and apoptosis [[19]Blasco M.A. Telomeres and human disease: ageing, cancer and beyond.Nat Rev Genet. 2005; 6: 611-622Crossref PubMed Scopus (1166) Google Scholar]. Previous studies have recognized that increases in TERT expression could serve as a proxy for telomere maintenance; however, late-stage tumors exhibit shortened telomeres in comparison to their normal counterparts, due to high turnover rates [[20]Saini N. Srinivasan R. Chawla Y. Sharma S. Chakraborti A. Rajwanshi A. Telomerase activity, telomere length and human telomerase reverse transcriptase expression in hepatocellular carcinoma is independent of hepatitis virus status.Liver Int. 2009; 29: 1162-1170Crossref PubMed Google Scholar,[21]Fredriksson N.J. Ny L. Nilsson J.A. Larsson E. Systematic analysis of noncoding somatic mutations and gene expression alterations across 14 tumor types.Nat Genet. 2014; 46: 1258-1263Crossref PubMed Scopus (188) Google Scholar]. While counterintuitive, the presence of shortened telomeres in tumors with TERT overexpression is thought to arise in one of two ways. One manner is when somatic cells with critically short telomeres undergo senescence and selective pressure leading to the acquisition of the TERT promoter mutations and regeneration of telomerase to overcome telomeric crisis [[22]Heidenreich B. Kumar R. TERT promoter mutations in telomere biology.Mutat Res - Rev Mut Res. 2017; 771: 15-31Crossref PubMed Scopus (0) Google Scholar]. Another pathway to shortened telomeres is that a TERT promoter mutation is acquired by the pre-cancerous cell. At first, TERT and telomerase levels are marginal and do not prohibit telomere shortening. Critically short telomeres start accumulating and cells with TERT promoter mutations can then gradually upregulate TERT to stabilize critically short telomeres [[23]Lorbeer F.K. Hockemeyer D. TERT promoter mutations and telomeres during tumorigenesis.Curr Opin Genet Dev. 2020; 60: 56-62Crossref PubMed Scopus (19) Google Scholar]. Among studies specific to cirrhotic HCC, the putative mechanisms of TERT activation can be divided into three categories: 1) HBV integration events in the TERT promoter [[8]Fujimoto A. Furuta M. Totoki Y. Tsunoda T. Kato M. Shiraishi Y. et al.Whole-genome mutational landscape and characterization of noncoding and structural mutations in liver cancer.Nat Genet. 2016; 48: 500-509Crossref PubMed Scopus (412) Google Scholar,[24]Jiang Z. Jhunjhunwala S. Liu J. Haverty P.M. Kennemer M.I. Guan Y. et al.The effects of hepatitis B virus integration into the genomes of hepatocellular carcinoma patients.Genome Res. 2012; 22: 593-601Crossref PubMed Scopus (199) Google Scholar], 2) point mutations (C228T and C250T) in the promoter region mutually exclusive of HBV integration [[9]Cancer Genome Atlas Research Network. Electronic address: [email protected], Cancer Genome Atlas Research Network. Comprehensive and Integrative Genomic Characterization of Hepatocellular Carcinoma.Cell. 2017; 169 (e23): 1327-1341Abstract Full Text Full Text PDF PubMed Scopus (0) Google Scholar,[25]Kawai-Kitahata F. Asahina Y. Tanaka S. Kakinuma S. Murakawa M. Nitta S. et al.Comprehensive analyses of mutations and hepatitis B virus integration in hepatocellular carcinoma with clinicopathological features.J Gastroenterol. 2016; 51: 473-486Crossref PubMed Google Scholar], and 3) structural variations of the TERT promoter region [[8]Fujimoto A. Furuta M. Totoki Y. Tsunoda T. Kato M. Shiraishi Y. et al.Whole-genome mutational landscape and characterization of noncoding and structural mutations in liver cancer.Nat Genet. 2016; 48: 500-509Crossref PubMed Scopus (412) Google Scholar,[14]Jhunjhunwala S. Jiang Z. Stawiski E.W. Gnad F. Liu J. Mayba O. et al.Diverse modes of genomic alteration in hepatocellular carcinoma.Genome Biol. 2014; 15: 436PubMed Google Scholar]. This study characterizes biomarkers and elucidates recurrent anomalies in non-cirrhotic HCC. We identified somatic variants in 117 tumor samples whereby 52 samples were cirrhotic, 63 samples were non-cirrhotic, and 2 samples had an unspecified cirrhotic status. Using this cohort, we analyzed single nucleotide variants (SNVs), insertions and deletions (INDELs), structural variation (SV), copy number variation (CNV), loss of heterozygosity (LOH), differential expression, and viral integration events. This comprehensive approach uncovered the genomic features implicated in non-cirrhotic HCC to improve its diagnosis, prognosis, and treatment. The discovery cohort consisted of 30 primary tumor and adjacent matched non-tumor liver samples obtained through surgical resection from adult patients diagnosed with HCC between 2000 to 2011 at the Washington University School of Medicine. Within this cohort, 13 were male and 17 were female. Additionally, 2 were African American and 28 were Caucasian. None of these samples exhibited evidence of hepatocellular adenoma (HCA) and the non-cirrhotic samples did not show signs of advanced fibrosis. 1 sample was HBV positive and 4 samples were HCV positive according to clinical data. All other samples within the discovery cohort had an unknown clinical etiology. The extension-alpha and extension-beta cohorts had 16 HCC tumors with matched non-tumor liver and 71 tumor-only HCC samples, respectively. Discovery and extension-alpha cohort samples were flash-frozen prior to banking and extension-beta samples were derived from formalin fixed paraffin embedded (FFPE) blocks. Across both extension cohorts, 27 were female and 58 were male. Furthermore, 2 were Asian, 13 were African American, and 70 were Caucasian. Within the extension-alpha cohort, two samples were HCV positive, one had chronic cholestasis, and the others had no known clinical etiology. Clinical data for the extension-beta cohort was as follows: 5 had known alcohol use, 8 were HBV positive, 29 were HCV positive, 2 were diagnosed with primary sclerosing cholangitis (PSC), and 6 samples were diagnosed with non-alcoholic steatohepatitis (NASH). From the extension-alpha cohort, 2 patients did not provide information on race and gender (Table S1). All patient samples were acquired after informed consent to an approved study by the Washington University School of Medicine Institutional Review Board (IRB 201106388). DNA and RNA from samples in the discovery cohort were extracted using the QIAamp DNA Mini kit and Qiagen RNeasy Mini kit, respectively. Whole genome sequencing libraries were constructed using Kapa HYPER kits for use on the Illumina HiSeq 2000 platform. The Ovation RNA-seq System V2 (NuGen Inc) kit was used to generate RNAseq libraries. Resulting barcoded libraries were pooled prior to Illumina sequencing. To validate variants identified from WGS, a hybrid capture panel (CAP1) was designed and executed on the Illumina platform to capture fragments from the WGS libraries. The QIAamp DNA Mini kit was used to extract DNA from extension-alpha samples, which was subsequently sequenced using the CAP1 strategy. Finally, CAP1 sequencing was used to identify variants from the DNA extracted from extension-beta samples with the QIAamp DNA FFPE Tissue kit. A second hybrid capture panel (CAP2) utilized Nimblegen and spiked-in IDT probes that hybridized to the TERT promoter locus and HBV genome (designed against a consensus sequence for 10 common HBV strains, see supplementary methods). CAP2 sequencing was employed on all 117 samples. TERT promoter variants were also detected in the discovery and extension-alpha cohorts with Sanger sequencing. cDNA capture was performed on pooled samples from the extension cohorts. WGS and CAP1 data were aligned to GRCh37 via the Genome Modeling System (GMS) using BWA [[26]Griffith M. Griffith O.L. Smith S.M. Ramu A. Callaway M.B. Brummett A.M. et al.Genome Modeling System: A Knowledge Management Platform for Genomics.PLoS Comput Biol. 2015; 11e1004274Crossref Scopus (53) Google Scholar,[27]Li H. Durbin R. Fast and accurate short read alignment with Burrows-Wheeler transform.Bioinformatics. 2009; 25: 1754-1760Crossref PubMed Scopus (23536) Google Scholar]. Reads from the CAP2 data were competitively aligned using BWA [[27]Li H. Durbin R. Fast and accurate short read alignment with Burrows-Wheeler transform.Bioinformatics. 2009; 25: 1754-1760Crossref PubMed Scopus (23536) Google Scholar] against the human reference genome (GRCh37) along with ten HBV genotypes for which complete genomes were available. RNAseq data were aligned with bowtie/tophat and expression was evaluated with cufflinks [[28]Trapnell C. Williams B.A. Pertea G. Mortazavi A. Kwan G. van Baren M.J. et al.Transcript assembly and quantification by RNA-Seq reveals unannotated transcripts and isoform switching during cell differentiation.Nat Biotechnol. 2010; 28: 511-515Crossref PubMed Scopus (9695) Google Scholar,[29]Trapnell C. Pachter L. Salzberg S.L. TopHat: discovering splice junctions with RNA-Seq.Bioinformatics. 2009; 25: 1105-1111Crossref PubMed Scopus (8604) Google Scholar]. All raw RNAseq reads from the discovery cohort were also aligned against the HBV genomes for evidence of HBV expression at the RNA level. The predominant HBV strain was determined using relative coverage for competitive alignments. The precise location of the HBV integration site was identified from discordant read pairs from realigning HBV CAP2 reads to GRCh37 and the predominant HBV strain's genome. A similar procedure was performed for HCV whereby both WGS and RNAseq reads were aligned against six HCV genotypes. The predominant HCV strain was determined using the total read support. To detect AAV1 and AAV2 integration, RNAseq reads were competitively aligned using kallisto [[30]Bray N.L. Pimentel H. Melsted P. Pachter L. Near-optimal probabilistic RNA-seq quantification.Nat Biotechnol. 2016; 34: 525-527Crossref PubMed Scopus (3035) Google Scholar] against AAV1 and AAV2 sequences. Telomeric tumor:normal read ratios were determined from WGS data using the GMS and visualized in R. A Wilcoxon-Mann-Whitney test measured the significance of differences between telomere length in tumor and normal samples. Somatic variant analysis for single nucleotide variants (SNV) and insertions/deletions (INDEL) were performed on all three cohorts while germline variant analysis for these variants was performed on the discovery and extension-alpha cohort. Several computational tools within and outside of the GMS [[31]Griffith M. Griffith O.L. Smith S.M. Ramu A. Callaway M.B. Brummett A.M. et al.Genome Modeling System: A Knowledge Management Platform for Genomics.PLoS Comput Biol. 2015; 11e1004274Crossref Scopus (53) Google Scholar] were employed to facilitate variant calling and subsequent filtering based on variables including variant allele frequency, read count, and predicted pathogenicity. WGS data from samples within the discovery cohort were analyzed for structural variants (SV), copy number variation (CNV), and loss of heterozygosity (LOH). Manta [[32]Chen X. Schulz-Trieglaff O. Shaw R. Barnes B. Schlesinger F. Källberg M. et al.Manta: rapid detection of structural variants and indels for germline and cancer sequencing applications.Bioinformatics. 2016; 32: 1220-1222Crossref PubMed Scopus (589) Google Scholar] was used to identify SV events. Manta-reported breakpoints, along with a 10kb flank were annotated with biomaRt and ensembl (GRCh37.p13). Regions of CNV were identified with the GMS and LOH were identified using VarScan2 [[31]Griffith M. Griffith O.L. Smith S.M. Ramu A. Callaway M.B. Brummett A.M. et al.Genome Modeling System: A Knowledge Management Platform for Genomics.PLoS Comput Biol. 2015; 11e1004274Crossref Scopus (53) Google Scholar,[33]Koboldt D.C. Zhang Q. Larson D.E. Shen D. McLellan M.D. Lin L. et al.VarScan 2: somatic mutation and copy number alteration discovery in cancer by exome sequencing.Genome Res. 2012; 22: 568-576Crossref PubMed Scopus (2656) Google Scholar]. The DNAcopy circular binary segmentation algorithm generated segments of LOH and CNV, which served as input for GISTIC [[34]Mermel C.H. Schumacher S.E. Hill B. Meyerson M.L. Beroukhim R. Getz G. GISTIC2.0 facilitates sensitive and confident localization of the targets of focal somatic copy-number alteration in human cancers.Genome Biol. 2011; 12: R41Crossref PubMed Scopus (1487) Google Scholar] to conduct a recurrence analysis. Fusion detection algorithms identified samples in the discovery cohort harboring gene fusions from RNAseq data. Fusion predictions involving NR1H4 were validated across all 117 samples using a NanoString nCounter® Elements™ TagSets assay. Sequences for predicted transcripts of the fusion calls that met certain read support criteria (≥10 spanning + encompassing reads and ≥1 spanning read) were sent to NanoString for probe design. The R “survival” package [[35]Therneau T.M. Grambsch P.M. Modeling Survival Data: Extending the Cox Model. Springer Science & Business Media, 2013Google Scholar] was used to associate SV-affected genes and CNV/LOH-affected genomic regions with overall survival and recurrence free survival. Only mutated genes and genomic regions occuring in ≥ 4 discovery cohort samples were included in this analysis. A survival analysis was also applied to SNV/INDELs observed in all non-cirrhotic samples from the three cohorts. All Kaplan-Meier survival plots were created in R. Fisher's exact test was used to test for clinical associations with variables: lymphovascular space invasion (LVSI), tumor differentiation status, cirrhosis, and liver disease. Samples without relevant clinical data were excluded. Significance was measured with a multiple test correction using the FDR methodology (q-value < 0.05). Read counts for genes mutated in non-cirrhotic tumors and matched normal samples of the discovery cohort were used by the DEseq2 Bioconductor package [[36]Love M.I. Huber W. Anders S. Moderated estimation of fold change and dispersion for RNA-seq data with DESeq2.Genome Biol. 2014; 15https://doi.org/10.1186/s13059-014-0550-8Crossref Scopus (24864) Google Scholar] to perform differential gene expression analysis using a negative binomial distribution with samples as a blocking factor. Significance was measured with a Wald test and Benjamini & Hochberg multiple test correction (q-value < 0.5). Pathway analysis was performed using log2 differential expression data. There were 30 patients included in the discovery cohort with tumors which were surgically resectable. These surgically resectable tumors were untreated, providing the opportunity to study HCC in the absence of chemotherapeutic intervention, which is normally incorporated in the treatment of cirrhotic HCC. Three of the patients within this cohort developed HCC in the setting of cirrhosis, all of which had been previously diagnosed with HCV. The remaining 27 individuals developed non-cirrhotic HCC, two of these individuals were diagnosed with HBV and another two individuals were diagnosed with HCV. To elucidate the genomic landscape of resected, primarily non-cirrhotic HCC, we performed whole genome sequencing (WGS), hybrid capture sequencing (CAP1), and transcriptome sequencing (RNAseq) on these 30 samples (Table 1). WGS failed for one tumor sample in the discovery cohort, therefore the final data for this cohort included WGS and CAP1 data for 29 samples (26 non-cirrhotic, 3 cirrhotic), and RNAseq data for 30 samples (27 non-cirrhotic, 3 cirrhotic). The sequencing analysis revealed a single previously unknown and undiagnosed HBV case with viral integration occurring at the TERT promoter (Figure S1, Table S1). Median haploid coverage for WGS data was 35.6x (range: 28.5-39.3) and 58.4x (range: 46.8-94.4) for normal and tumor samples, respectively.Table 1Discovery (N=29)Extension-alpha (N=16)Extension-beta (N=71)Sample TypeTumor/Non-tumorTumor/Non-tumorTumorWGSYesNoNoCAP1YesYesYesCAP2YesYesYesRNAseqYesNoNo Open table in a new tab After filtering, we observed a median mutation burden of 1.31 mutations/Mb (range: 0.033-3.28), comprised of 2,633 SNVs and INDELs across all samples (range: 2-200, median: 77.5, mean=87.8) (Figure 1, Table S1). These variants were discovered across 2,245 genes with 258 of these genes mutated in more than one sample. Using WGS data from the 26 non-cirrhotic samples, we identified 6 genes that were significantly mutated above background mutation rates according to MuSiC: ALB, APOB, CTNNB1, TP53, RB1, and RPS6KA3 (Figure 1, Table S1). With regards to all methods of sequencing (WGS, RNAseq, CAP1, and CAP2), the most frequently encountered variant was a SNV in the telomerase reverse transcriptase (TERT) promoter (C228T; G1295228A), which was identified in 17/30 samples and resulted in overexpression of TERT (Figure S2, Table S2). Within the exome, TP53 was the most recurrently mutated gene and was observed in 8/29 of samples (Table S1). Beta catenin 1 (CTNNB1) was also significantly mutated within this cohort (6/29), whereby the majority of variants occurred at amino acids S37 and S45, both of which reside in a putative GSK3B phosphorylation site in exon 3 (ENST00000349496) (Figure S3) [[37]Miyoshi Y. Iwao K. Nagasawa Y. Aihara T. Sasaki Y. Imaoka S. et al.Activation of the beta-catenin gene in primary hepatocellular carcinomas by somatic alterations involving exon 3.Cancer Res. 1998; 58: 2524-2527PubMed Google Scholar]. Frameshift mutations in APOB were observed in 4/29 of samples (Table S1). Mutation signatures using the COSMIC database for the discovery cohort were investigated. Signatures 5 (unknown etiology), 4 (smoking damage association), 16 (unknown etiology), and 12 (liver damage association) were most prevalent and contributed to the overall cohort signature at 23%, 14%, 8%, and 7%, respectively (Figure S4). Differential gene expression analysis performed on the non-cirrhotic samples revealed that 11% of genes, including TERT, were upregulated (4,468/39,392) and 10% of genes, including CTNNB1 and WISP2, were downregulated (4,114/39,392) compared to adjacent non-tumor liver tissue (q-value < 0.1) (Table S1). Comparison of gene log2 fold changes derived from the differential expression analysis revealed the cell cycle pathway as upregulated in the KEGG signaling and metabolism database (q-value ≤ 0.05). Similarly, we observed 16 pathways as down-regulated (q-value ≤ 0.05), most of which are related to metabolic liver processes. Genes such as ADH5 and EHHADH were observed with reduced expression levels and participate in 38% (6/16) of these pathways. Using the Gene Ontology biological process database, we observed 107 pathways as significantly upregulated (q-value ≤ 0.05). The majority of the upregulated pathways were related to cellular division and DNA repair. In addition, 28 pathways were identified as significantly downregulated (q-value ≤ 0.05), many of which were related to liver metabolism (Table S2). When evaluating the samples within the discovery cohort for telomere length at the DNA level, we observed that the majority of tumor samples exhibited shortened telomeres compared to their paired normal sample (p-value = 0.00011) (Figure S2). One exception was seen in sample HCC16_D, which was distinguished by abnormally high expression of TERT (FPKM=36) (Figure S5). We observed recurrent large scale amplification of the q-arm of chromosome 1 in ≥ 50% of the discovery cohort. Similarly, large scale deletions of the p-arms of chromosomes 8 and 17 were found in ≥ 40% of the cohort (Figure 2). In total, analysis with GISTIC and subsequent manual review revealed 75 unique regions across 17 chromosomes as recurrently amplified and 45 unique regions across 17 chromosomes as significantly deleted (q < 0.05) (Table S1). No significant associations with tumor differentiation status were made (α=0.05). Each CNV and LOH event was tested for their association with overall survival and recurrence free survival but no significant association could be made following multiple test correction. A total of 33 genes identified as recurrently deleted by GISTIC showed concordant decreased expression in tumor samples (Table S1). These include genes previously characterized as relevant to HCC development and progression: HEYL [[38]Kuo K.-K. Jian S.-F. Li Y.-J. Wan S.-W. Weng C.-C. Fang K. et al.Epigenetic inactivation of transforming growth factor-β1 target gene HEYL, a novel tumor suppressor, is involved in the P53-induced apoptotic pathway in hepatocellular carcinoma.Hepatol Res. 2014; 45: 782-793Crossref PubMed Scopus (11) Google Scholar] (q-value = 0.032), UQCRH [[39]Park E.-R. Kim S.-B. Lee J.-S. Kim Y.-H. Lee D.-H. Cho E.-H. et al.The mitochondrial hinge protein, UQCRH, is a novel prognostic factor for hepatocellular carcinoma.Cancer Med. 2017; 6: 749-760Crossref PubMed Scopus (19) Google Scholar] (q-value = 0.032), and MUTYH [[40]Krupa R. Czarny P. Wigner P. Wozny J. Jablkowski M. Kordek R. et al.The Relationship Between Single-Nucleotide Polymorphisms, the Expression of DNA Damage Response Genes, and Hepatocellular Carcinoma in a Polish Population.DNA Cell Biol. 2017; https://doi.org/10.1089/dna.2017.3664Crossref PubMed Scopus (13) Google Scholar] (q-value = 0.048). A subset of these genes have also been implicated in tumorigenesis, metastasis, and progression of other cancer types and may prove to be relevant for HCC development and progression: RPL11 [[41]Takafuji T. Kayama K. Sugimoto N. Fujita M. GRWD1, a new player among oncogenesis-related ribosomal/nucleolar proteins.Cell Cycle. 2017; : 1-7Google Scholar] (q-value = 0.048), UBE2D3 [[42]Guan G.G. Wang W.B. Lei B.X. Wang Q.L. Wu L. Fu Z.M. et al.UBE2D3 is a positive prognostic factor and is negatively correlated with hTERT expression in esophageal cancer.Oncol Lett. 2015; 9: 1567-1574Crossref PubMed Scopus (17) Google Scholar] (q-value = 0.032), ARRB1 [[43]Miele E. Po A. Begalli F. Antonucci L. Mastronuzzi A. Marras C.E. et al.β-arrestin1-mediated acetylation of Gli1 regulates Hedgehog/Gli signaling and modulates self-renewal of SHH medulloblastoma cancer stem cells.BMC Cancer. 2017; 17: 488Crossref PubMed Scopus (0) Google Scholar] (q-value = 0.032), ENG [[44]Kokaji E. Shimomura A. Minamisaka T. Nakajima T. Miwa S. Hatta H. et al.Endoglin (CD105) and SMAD4 regulate spheroid formation and the suppression of the invasive ability of human pancreatic cancer cells.Int J Oncol. 2018; 52: 892-900PubMed Google Scholar] (q-value = 0.049), and ABLIM2 [[45]Hwang S.J. Lee H.W. Kim H.R. Song H.J. Lee D.H. Lee H. et al.Overexpression of microRNA-95-3p suppresses

Differentiation of hepatocellular adenoma by subtype and hepatocellular carcinoma in non-cirrhotic liver by fractal analysis of perfusion MRI

BackgroundTo investigate whether fractal analysis of perfusion differentiates hepatocellular adenoma (HCA) subtypes and hepatocellular carcinoma (HCC) in non-cirrhotic liver by quantifying perfusion chaos using four-dimensional dynamic contrast-enhanced magnetic resonance imaging (4D-DCE-MRI).ResultsA retrospective population of 63 patients (47 female) with histopathologically characterized HCA and HCC in non-cirrhotic livers was investigated. Our population consisted of 13 hepatocyte nuclear factor (HNF)-1α-inactivated (H-HCAs), 7 β-catenin-exon-3-mutated (bex3-HCAs), 27 inflammatory HCAs (I-HCAs), and 16 HCCs. Four-dimensional fractal analysis was applied to arterial, portal venous, and delayed phases of 4D-DCE-MRI and was performed in lesions as well as remote liver tissue. Diagnostic accuracy of fractal analysis was compared to qualitative MRI features alone and their combination using multi-class diagnostic accuracy testing including kappa-statistics and area under the receiver operating characteristic curve (AUC). Fractal analysis allowed quantification of perfusion chaos, which was significantly different between lesion subtypes (multi-class AUC = 0.90, p < 0.001), except between I-HCA and HCC. Qualitative MRI features alone did not allow reliable differentiation between HCA subtypes and HCC (κ = 0.35). However, combining qualitative MRI features and fractal analysis reliably predicted the histopathological diagnosis (κ = 0.89) and improved differentiation of high-risk lesions (i.e., HCCs, bex3-HCAs) and low-risk lesions (H-HCAs, I-HCAs) from sensitivity and specificity of 43% (95% confidence interval [CI] 23–66%) and 47% (CI 32–64%) for qualitative MRI features to 96% (CI 78–100%) and 68% (CI 51–81%), respectively, when adding fractal analysis.ConclusionsCombining qualitative MRI features with fractal analysis allows identification of HCA subtypes and HCCs in patients with non-cirrhotic livers and improves differentiation of lesions with high and low risk for malignant transformation.

Is there a role for liver transplantation in the treatment of hepatocellular carcinoma in non-cirrhotic liver?

Is there a role for liver transplantation in the treatment of hepatocellular carcinoma in non-cirrhotic liver?

Histopathological growth patterns modify the prognostic impact of microvascular invasion in non-cirrhotic hepatocellular carcinoma.

Microvascular invasion (MVI) is an established prognosticator in hepatocellular carcinoma (HCC). Histopathological growth patterns (HGPs) classify the invasive margin of hepatic tumors, with superior survival observed for the desmoplastic HGP. Our aim was to investigate non-cirrhotic HCC in light of MVI and the HGP. A retrospective cohort study was performed in resected non-cirrhotic HCC. MVI was assessed prospectively. The HGP was determined retrospectively, blinded, and according to guidelines. Overall and disease-free survival (OS, DFS) were evaluated by Kaplan-Meier and multivariable Cox regression. The HGP was determined in 155 eligible patients, 55 (35%) featured a desmoplastic HGP. MVI was observed in 92 (59%) and was uncorrelated with HGP (64% vs 57%, p=0.42). On multivariable analysis, non-desmoplastic and MVI-positive were associated with an adjusted HR [95%CI] of 1.61 [0.98-2.65] and 3.22 [1.89-5.51] for OS, and 1.59 [1.05-2.41] and 2.30 [1.52-3.50] for DFS. Effect modification for OS existed between HGP and MVI (p<0.01). Non-desmoplastic MVI-positive patients had a 5-year OS of 36% (HR: 5.21 [2.68-10.12]), compared to 60% for desmoplastic regardless of MVI (HR: 2.12 [1.08-4.18]), and 86% in non-desmoplastic MVI-negative. HCCs in non-cirrhotic livers display HGPs which may be of prognostic importance, especially when combined with MVI.

Higher Accumulation of Visceral Adipose Tissue Is an Independent Risk Factor for Hepatocellular Carcinoma among Viral Hepatitis Patients with Non-Cirrhotic Livers.

Simple SummaryHepatocellular carcinoma (HCC) occurring in non-cirrhotic livers is often overlooked in clinical practice because the present HCC surveillance strategies usually focus only on patients with cirrhotic livers. This study aimed to determine the risk factors for HCC among viral hepatitis patients with non-cirrhotic livers. The findings of this study could be very useful in detecting HCC at an early stage, especially in patients with viral hepatitis who may not have developed extensive cirrhosis.This study aimed to determine the risk factors for hepatocellular carcinoma in non-cirrhotic livers among viral hepatitis patients. A total of 333 HCC cases, including 69 hepatitis B virus (HBV)-related and 264 hepatitis C virus (HCV)-related, were divided into cirrhotic (Fibrosis-4 [FIB-4] index > 3.25) and non-cirrhotic groups (FIB-4 index ≤ 3.25). The clinical characteristics of the two groups were compared. The independent risk factors for the development of HCC were analyzed using logistic regression analysis. The patients with HBV-related HCC were significantly younger, had better Child-Pugh scores, lower FIB-4 index and Mac-2 binding protein glycosylated isomers (M2BPGi) levels, more progressive cancer stage, and higher alpha-fetoprotein (AFP) levels than those with HCV-related HCC. Diabetes mellitus and hypertension were less common in patients with HBV-related HCC. The non-cirrhotic group with HBV-related HCC had a higher visceral adipose tissue index (VATI), better Child-Pugh score, and higher hemoglobin A1c (HbA1c), whereas the one with HCV-related HCC had a higher proportion of men, higher VATI, better Child-Pugh score, higher HbA1c, and a higher prevalence of hypertension, than the corresponding cirrhotic groups. Logistic regression analyses demonstrated that age, male sex, VATI, HbA1c, the presence of hypertension, and HBV etiology were independent risk factors for HCC in a non-cirrhotic liver. A high accumulation of VAT is a risk factor for HCC in patients with non-cirrhotic livers.

Hepatocellular Carcinoma: Does the Background Liver With or Without Cirrhosis Matter?

The pathologic differences between hepatocellular carcinoma (HCC) arising in noncirrhotic and cirrhotic livers have not been well studied. We performed a retrospective analysis of 378 HCC cases (95 in noncirrhotic, 283 in cirrhotic livers) from pathology archives (2010-2017). Patients without cirrhosis were more likely to have hepatitis B (13.68% vs 2.83%, P < .001) or no known liver disease (30.53% vs 4.24%, P < .001), while hepatitis C was more common in patients with cirrhosis (65.72% vs 30.53%, P < .001). HCCs in noncirrhotic livers were larger in size (P < .001); were more likely to have a macrotrabecular histologic pattern (13.68% vs 4.95%, P < .01); were more likely to have fibrolamellar (3.16% vs 0%, P = .02), macrotrabecular-massive (13.68% vs 6.01%, P = .03), and clear cell (16.84% vs 6.71%, P < .01) subtypes; have a higher histologic grade (P < .01); be anaplastic tumor cells (P < .001); have a higher rate of vascular invasion (P < .01); and have a higher tumor stage (P = .04). The findings indicate that HCCs in noncirrhotic livers demonstrate a larger tumor size; have a more macrotrabecular histologic pattern; have fibrolamellar, macrotrabecular-massive, and clear cell subtypes; have a higher tumor grade and stage; have a higher rate of vascular invasion; and have more anaplastic tumor cells compared with cirrhotic livers. Further studies to explore different pathways that promote oncogenesis in noncirrhotic livers are needed to better understand the pathogenesis of HCC.

Hepatocellular Carcinoma in Non-cirrhotic Liver Arises with a More Advanced Tumoral Appearance: A Single-Center Cohort Study.

A small proportion of all hepatocellular carcinomas (HCCs) arise in a non-cirrhotic liver (NCL). However, our knowledge about the HCCs developing in a NCL is scarce. This study was undertaken to investigate the characteristics and survival course of this patient group. We retrospectively analyzed the database of patients with HCC at a tertiary center during a 10-year period (2009-2019). All demographic, clinical, laboratory, and tumoral features with survival outcomes were compared between the HCC-CL and HCC-NCL groups. Out of 384 HCC cases, 11.2% (n = 43) had no cirrhosis. The dominant etiology in the HCC-NCL group was hepatitis B virus (n = 26, 60.5%), followed by non-alcoholic fatty liver disease (n = 10, 23.2%), and hepatitis C virus (n = 7, 16.3%). The maximum tumor diameter was approximately 2 times larger in the HCC-NCL group (HCC-NCL: 90 mm vs. HCC-CL: 46.5 mm, P < .001). The proportion of patients with vascular (HCC-NCL: 27.9% vs. HCC-CL: 8.6%, P < .001) and extrahepatic invasion (HCC-NCL: 14% vs. HCC-CL: 3%, P = .001) were prominently higher in the HCC-NCL group. Patients with HCC-NCL were less often detected in early-curable stages (BCLC 0-A) than those in the HCC-CL group (HCC-NCL: 16.3% vs. HCC-CL: 34.9%, P = .004). The overall survival was not different between the 2 groups (HCC-NCL: 19.4 ± 9.8 months vs. HCC-CL: 17.5 ± 2.3 months, P = .581). HCC in NCL is diagnosed at more advanced tumoral stages with larger tumor size and more often with vascular and extrahepatic spread. Despite the preserved liver functions, the overall survival is not prolonged in HCCs without cirrhosis, due to the late recognition.

[Liver Resections Can Be Safely Performed in Cirrhotic Patients after Careful Patient Selection].

Hepatocellular Carcinoma (HCC) is the most frequent malignant primary liver tumour in a cirrhotic liver. Liver transplantation and resection are the only curative treatment options in compensated liver cirrhosis, but liver resections are associated with increased perioperative morbidity and mortality. We identified 108 cirrhotic patients, who underwent liver resections at the University Hospital of Mainz between January 2008 and December 2019. During the same period, 185 liver resections were performed for HCC in non-cirrhotic livers. Furthermore, 167 liver resections served as control group, which were performed for colorectal liver metastases (CRLM) with comparable extent of resection to HCC in cirrhotic livers. Preoperatively, we assessed the Charlson Comorbidity Index (CCI), MELD and Child scores in addition to the general patient characteristics. Perioperative morbidity was graded according to the Clavien-Dindo classification. Resections of HCC in cirrhosis and liver metastases were additionally compared by a matched-pair analysis. The three groups were comparable in age. Preoperative liver function was best in patients with CRLM (p < 0.001). Resections for HCC in non-cirrhotic livers were more extended than in cirrhotic livers (p < 0.001). The overall morbidity (Clavien/Dindo stage III - IV) was higher after resections in cirrhotic livers than in CRLM resections (p = 0.026). Postoperative mortality was comparably low in all three groups (2.2%). Neither MELD nor Child score was predictive for postoperative morbidity or mortality (area under the curve: AUC < 0.6, each). Preoperative CCI was predictive for postoperative mortality (AUC = 0.78). Liver resections in cirrhotic livers are feasible after adequate patient selection and limitation of the extent of surgery. Comorbidities additionally increase the postoperative mortality in addition to impaired liver function and should therefore always be included into the preoperative assessment of patients undergoing liver surgery.

Hemoperitoneum caused by spontaneous rupture of hepatocellular carcinoma in noncirrhotic liver. A case report and systematic review.

IntroductionHepatocellular carcinoma (HCC) is the sixth most common cancer. Spontaneous rupture of HCC is an acute complication with a high mortality rate. The HCC principally arises in the background of chronic liver disease and cirrhosis of the liver. In the last few years, the rising incidence of HCC in noncirrhotic liver suggests the presence of other factors that may play a role in liver carcinogenesis.MethodsWe reviewed all cases treated at the University Surgical Department of Ospedali Riuniti of Foggia from 2009 to 2018. Only a single case of hemoperitoneum caused by spontaneous rupture of HCC in noncirrhotic liver was found. An extensive search of the relevant literature was carried out using MEDLINE, and a total of 58 published studies were screened from the sources listed.ConclusionsThe management of this devastating emergency should be carefully analyzed, with stabilization of vital signs as soon as possible. Patient with ruptured HCC and hemoperitoneum without a prior history of cirrhosis and viral infections benefited from the role of transcatheter arterial embolization (TAE) as the preliminary treatment in order to have a more precise diagnosis and an optimal stabilization of the patient. Delayed or staged hepatectomy after TAE represents the definitive treatment.

New frontiers in liver resection for hepatocellular carcinoma.

SummaryLiver resection is one of the main curative options for early hepatocellular carcinoma (HCC) in patients with cirrhosis and is the treatment of choice in non-cirrhotic patients. However, careful patient selection is required to balance the risk of postoperative liver failure and the potential benefit on long-term outcomes. In the last decades, improved surgical techniques and perioperative management, as well as better patient selection, have enabled the indications for liver resection to be expanded. In this review, we aim to describe the main indications for liver resection in the management of HCC, its role compared to percutaneous ablation and liver transplantation in the therapeutic algorithm, as well as the recent advances in liver surgery that could be used to improve the prognosis of patients with HCC.

[Surgical treatment of hepatic tumors-liver resection and transplantation].

The most frequent primary hepatic malignancies are hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (intrahepatic cholangiocellular adenocarcinoma [iCCA]). For HCC in cirrhosis, liver transplantation offers the advantage of acomplete hepatectomy radically removing all tumorous tissue along with the surrounding cirrhotic parenchyma, which is otherwise associated with a very high risk of recurrence. For HCC in non-cirrhotic livers and iCCA, liver resection is the treatment of choice. Nowadays, even extended resections can be performed with low mortality in experienced centers. Surgical therapy is more and more embedded into multimodal treatment concepts and decision making should be interdisciplinary as for other gastrointestinal tumors.

Mortality after Transplantation for Hepatocellular Carcinoma: A Study from the European Liver Transplant Registry

Background and Aims: Prognosis after liver transplantation differs between hepatocellular carcinoma (HCC) arising in cirrhotic and non-cirrhotic livers and aetiology is poorly understood. The aim was to investigate differences in mortality after liver transplantation between these patients. Methods: We included patients from the European Liver Transplant Registry transplanted due to HCC from 1990 to November 2016 and compared cirrhotic and non-cirrhotic patients using propensity score (PS) calibration of Cox regression estimates to adjust for unmeasured confounding. Results: We included 22,787 patients, of whom 96.5% had cirrhosis. In the unadjusted analysis, non-cirrhotic patients had an increased risk of overall mortality with a hazard ratio (HR) of 1.37 (95% confidence interval [CI] 1.23–1.52). However, the HR approached unity with increasing adjustment and was 1.11 (95% CI 0.99–1.25) when adjusted for unmeasured confounding. Unadjusted, non-cirrhotic patients had an increased risk of HCC-specific mortality (HR 2.62, 95% CI 2.21–3.12). After adjustment for unmeasured confounding, the risk remained significantly increased (HR 1.62, 95% CI 1.31–2.00). Conclusions: Using PS calibration, we showed that HCC in non-cirrhotic liver has similar overall mortality, but higher HCC-specific mortality. This may be a result of a more aggressive cancer form in the non-cirrhotic liver as higher mortality could not be explained by tumour characteristics or other prognostic variables.

Hepatocellular carcinoma in the non-cirrhotic liver: a two-center experience with 19 cases

Background: Hepatocellular carcinoma is the most common type of primary liver cancer and is the third cause of cancer related deaths; 80% of the HCC are associated with cirrhotic livers or chronic liver diseases, which constitute the main risk factor. Chronic inflammation, necrosis and regeneration due to these conditions produce genetic mutation and development of tumor cells. Yet, 10% develop in non-cirrhotic healthy livers without precipitating factors. Material and methods: We conducted a retrospective analysis of the characteristics and survival of patients with diagnosis of hepatocellular carcinoma in non-cirrhotic liver and absence of a history of liver cirrhosis or chronic liver disease undergoing surgery in two hepato-pancreato-biliary units between January 2007 and January 2016. Results: Mean age was 65 years and 13 patients were men. Abdominal pain was the most common clinical presentation. Liver panel was normal in 60% of the cases and alpha-fetoprotein was elevated in only 16%. The diagnosis was made by imaging tests in 61% of the cases. Mean tumor size was 110.6 cm. All the patients underwent surgery. Complications were observed in 36.8% of the patients and survival at 5 years was 62.3%. Conclusion: hepatocellular carcinoma is usually diagnosed as a large lesion in imaging tests ordered due to abdominal pain. Surgery provides curative treatment, and large resections can be safely performed, with low perioperative morbidity and mortality and low incidence of postoperative liver failure,since the liver remnant is healthy and liver function is maintained.