Journal of Liver Cancer

Volume 14(1); March 2014

Review Articles

Radioembolization in Hepatocellular Carcinoma: Ho Jong Chun; Journal of the Korean Liver Cancer Study Group. 2014;14(1):1-6. Published online March 31, 2014; DOI: https://doi.org/10.17998/jlc.14.1.1

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Abstract PDF: Radioembolization is an emerging treatment modality in patients with hepatocellular carcinoma (HCC) and is a form of brachytherapy in which intra-arterially injected Ytrrium-90 microspheres are used for internal radiation purpose. Ytrrium-90 is a high energy beta particle-emitting radioisotope. Ytrrium-90 microspheres administered via arterial route direct the highly concentrated radiation to the tumor while normal liver parenchyma is relatively spared due to its preferential blood supply from portal venous blood. Main complications do not result from the microembolic effect, even in patients with portal vein thrombosis, but rather from an excessive irradiation to the non-target tissues including the liver. All the evidence that support the use of radioembolization in HCC is based on retrospective series or non-controlled prospective studies. However, reliable data can be obtained from the literature, particularly since the recent publication of large series. When compared to the standard of treatment for the intermediate and advanced stages (TACE and sorafenib), radioembolization consistently provides similar survival rates. Many randomized controlled trials using radioembolization are underway and will provide optimal evidences as standard treatment for unresectable HCC.

The Usefulness of Contrast-Enhanced Ultrasonography in the Diagnosis of Hepatocellular Carcinoma: Moon Young Kim; Journal of the Korean Liver Cancer Study Group. 2014;14(1):7-13. Published online March 31, 2014; DOI: https://doi.org/10.17998/jlc.14.1.7

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Abstract PDF: Contrast enhanced ultrasonography (CEUS) using microbubble ultrasonography agent is able to show the vascular structure and enhancement patterns of lesions, so it has an worth in the diagnosis of hepatocellular carcinoma (HCC) which is a typical cancer that has a characteristic neovascularization. CEUS shows 3 phase vascular pattern like computer tomography (CT) typical arterial enhancement and portal or late wash out in HCC. CEUS can show a enhancement pattern of HCC in a real time and it has no nephrotoxicity or radiation hazard. Beyond the diagnosis, CEUS has also shown usefulness in the guidance of locoregional treatment and estimation of treatment response of HCC. In addition, recently, a few data which show a usefulness of CEUS in the early estimation of response after target therapy in the advanced HCC, also have been reported. However, CEUS has limitations in clinical practice yet and more wide investigation is needed for the validation of usefulness and wide application in clinical practice. However, CEUS also has many advantages in the field of the diagnosis and management of HCC, so in in this review, we are going to introduce CEUS and overview its clinical usefulness briefly.

Original Articles

Clinical Significance of the Up-To-Seven Score for the Assessment of the Tumor Stage in Patients with Hepatocellular Carcinoma: Chang Ho Jung, Yeon Seok Seo, Jae Min Lee, Seok Bae Yoon, Tae Jung Yun, Sun Young Yim, Hyong gin An, Soon Ho Um, Chang Duck Kim, Ho Sang Ryu; Journal of the Korean Liver Cancer Study Group. 2014;14(1):14-22. Published online March 31, 2014; DOI: https://doi.org/10.17998/jlc.14.1.14

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Abstract PDF: Background/Aim
s: Up-to-seven criteria was proven to be useful for predicting prognosis after liver transplantation in patients with hepatocellular carcinoma (HCC). The aim of this study was to evaluate that up-to-seven score could be useful method for prediction of prognosis in patients with HCC who did not undergo liver transplantation.
Methods
Between January 2006 and December 2008, 216 HCC patients without vascular invasion, lymph node and distant metastasis were analyzed retrospectively. We investigated the prognostic impact of laboratory findings, clinical characteristics, modified UICC T stage, and up-to-seven score in HCC. The survival analyses were performed using Kaplan-Meier method and Cox-regression analysis.
Results
Two-hundred sixteen patients with HCC were included. Age was 60.1±11.3 years and 74.5% were male. Chronic hepatitis B was the most common cause of liver disease (60.6%). T stage was T1, T2, and T3 in 36 (16.7%), 118 (54.6%), and 62 (28.7%) patients, respectively. Up-to-even score was 5.5±4.0 and it was <3 (UTS 1), ≥3 and ≤7 (UTS 2), and >7 (UTS 3) in 36 (16.7%), 133 (61.6%), and 47 (21.8%) patients, respectively. The 10 (8.5%) patients of T2 stage were classified into UTS 3 and 25 (40.3%) patients of T3 stage were classified into UTS 2. The prognosis was significantly different in patients with T2 or T3 according to their UTS. Multivariate analysis showed that Child-Pugh score and UTS were significantly associated factors with survival.
Conclusions
Up-to-seven score was useful to predict prognosis and to evaluate tumor stage in patients without vascular invasion, lymph node and distant metastasis.

Hepatic Venous Pressure Gradient and Associated Factors in Survival Prediction in Patients with Liver Cirrhosis and Early and Very Early Hepatocellular Carcinoma: Tae Yeob Kim, Moon Young Kim, Jae Young Jang, Ki Tae Suk, Soung Won Jeong, Dong Joon Kim, Joo Hyun Sohn, Soon Koo Baik; Journal of the Korean Liver Cancer Study Group. 2014;14(1):23-30. Published online March 31, 2014; DOI: https://doi.org/10.17998/jlc.14.1.23

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Abstract PDF: Background/Aim
s: To analyze the usefulness of hepatic venous pressure gradient (HVPG) in survival prediction in cirrhotic patients with early and very early hepatocellular carcinoma (HCC).
Methods
We consecutively collected data of 45 stable cirrhotic patients (male 41, median age 57.2 years, BCLC A 29) with early-stage HCC undergoing HVPG measurement. Prognostic accuracy of HVPG was analyzed by the area under curve (AUC). Survival curves and the associated factors of HVPG status were obtained using Kaplan-Meier method and logistic regression analysis, respectively.
Results
The AUC value for prediction of survival by HVPG were 0.754 (95% CI, 0.603-0.870, P=0.006). The cut-off value of HVPG to predict death was 12 mmHg. Among the 45 patients, 11 patients (24.4%) died: 11 of 28 patients in the high HVPG group and none of 17 patients in the low HVPG group during followup period (P=0.003). The survival rate with high HVPG group was higher than those of low HVPG group (log rank P=0.008). In Child-Turcott-Pugh (CTP) class, the survival rate with CTP A class was higher than that with CTP B class (log rank P<0.001). The only associated factor with HVPG ≥12 mmHg in CTP A class and early-stage HCC was the presence of medium or large sized esophageal varices (odds ratio 66.8, 95% CI, 1.3-3530.4, P=0.038).
Conclusions
HVPG ≥12 mmHg may be suggested a predictor of survival in cirrhotic patients with early-stage HCC. In CTP A class, the presence of medium or large sized esophageal varices were associated with high HVPG.

Sorafenib Combined with Transarterial-Chemoembolization in Child-Pugh Class B Patients with Hepatocellular Carcinoma: Jong Sik Lee, Sun Young Moon, Kyung Ann Lee, Jae Ki Min, Sung Jin Jeon, In Ae Kim, Kang Hoon Lee, Won Hyeok Choe, Jeong Han Kim, So Young Kwon; Journal of the Korean Liver Cancer Study Group. 2014;14(1):31-36. Published online March 31, 2014; DOI: https://doi.org/10.17998/jlc.14.1.31

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Abstract PDF: Background/Aim
s: The aim of the study is to investigate efficacy and safety of sorafenib combined with transarterial chemoembolization (TACE) in Child-Pugh (CP) class-B patients with hepatocellular carcinoma (HCC).
Methods
A total of 12 CP class-B patients who were initially treated with sorafenib combined with TACE were retrospectively reviewed. At 14 days after the first TACE, patients were continuously treated with sorafenib until unacceptable adverse events (AEs) or diseaseprogression. Consecutive TACEs were also performed, if patients were tolerable.
Results
Of 12 patients, 8, 3 and 1 patients had CP-score 7, 8, and 9, respectively. The median overall survival was 85 days. Patients underwent median 2 sessions of TACE (range 1-4) and the median duration of sorafenib was 48days (range, 12-92 days). Three patients refused repeated TACEs and 4 patients required delay of the consecutive TACE due to AEs of sorafenib. Six patients required transient or permanent discontinuation of sorafenib, due to its AEs (grade 1/2 AEs, 2 patients; grade 3/4 AEs, 4 patients). High CP score (score 8/9 vs. 7) was tended to be association with interruption of sorafenib (P=0.061) and requirement of refusal/ delay of consecutive TACE (P=0.081).
Conclusions
Sorafenib combined with TACE were frequently interrupted or delayed in CP class-B patients, mostly because of its side effects, even though there were not serious. Our experiences suggest that combination with sorafenib and TACE might interface with each other due to its side effects in CP class-B patients, especially patients with CP score 8/9 liver cirrhosis.

Case Reports

A Case of Hepatoid Adenocarcinoma with High Serum Alpha-Fetoprotein Mimicking Hepatocellular Carcinoma: Yuri Cho, Yoon Jun Kim; Journal of the Korean Liver Cancer Study Group. 2014;14(1):37-40. Published online March 31, 2014; DOI: https://doi.org/10.17998/jlc.14.1.37

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Abstract PDF: Hepatoid adenocarcinoma is a type of cancer with both adenocarcinomatous and hepatocellular differentiation. Hepatoid adenocarcinoma has a typical character of high serum alpha-fetoprotein (AFP) level. A 61-year-old female patient was admitted to the hospital with abdominal pain and hepatic mass. Abdominal ultrasonography revealed a 20 cm sized mass in liver. A huge hepatic mass looked like primary hepatocellular carcinoma (HCC) on liver CT and MRI. Also, serum AFP was elevated to 24215.7 ng/mL. Right trisectionectomy was done under the impression of HCC. However, the result of pathological findings including immunohistochemical staining revealed that it was a hepatoid adenocarcinoma which was originated from gallbladder

Metastatic Liver Cancer Mimicking Hepatocellular Carcinoma in Alcoholic Cirrhosis: Hee Yeon Kim, Chang Wook Kim, Chang Don Lee, Su Lim Lee, Yoo Dong Won, Ye Il Kim; Journal of the Korean Liver Cancer Study Group. 2014;14(1):41-45. Published online March 31, 2014; DOI: https://doi.org/10.17998/jlc.14.1.41

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Abstract PDF: A 50-year-old male patient visited for further evaluation of arterial enhancing nodules in cirrhotic liver. Computed tomography (CT) scan revealed vaguely nodular, arterial phaseenhancing nodules at segment 8 of the liver with cirrhotic background. Magnetic resonance imaging (MRI) showed four small nodules with early work-up enhancement in arterial phase and rapid washout. Angiography showed hypervascular nodular stains. Hepatocellular carcinoma (HCC) was diagnosed according to the noninvasive diagnostic criteria for HCC. A positron emission tomography (PET) scan was done for staging work-up, and increased uptake was noted in rectum. Subsequently, sigmoidoscopy revealed an ulceroinfiltrative lesion encircling the lumen of the rectosigmoid junction. Laparoscopic low anterior resection with wedge resection of liver was done, suspecting concurrent primary tumors of the rectum and liver. Pathologic examination demonstrated moderately differentiated adenocarcinoma in both rectum and liver, suggesting metastatic rectal carcinoma. The present case indicates that metastatic carcinoma as well as HCC should be considered in the differential diagnosis of irregularly enhancing small nodules even in high-risk patient group for HCC.

A Case of Perforation of Gastric Ulcer after Complete Remission of Huge Hepatocellular Carcinoma Invading Main Portal Vein with Combination Therapy of Stereotactic Body Radiation Therapy and Sorafenib: Sang Youn Hwang, Seon-Mi Lee, Jung Woo Im, Joon Suk Kim, Sang Bu Ahn, Eun Kyeong Ji, Chul Won Choi, Gwang-Mo Yang; Journal of the Korean Liver Cancer Study Group. 2014;14(1):46-52. Published online March 31, 2014; DOI: https://doi.org/10.17998/jlc.14.1.46

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Abstract PDF

Hepatocellular carcinoma (HCC) patients with main portal vein invasion have a poor prognosis associated with a median survival time of 2.7 months. Though many guidelines recommended sorafenib in HCC patients with macrovascular invasion (MVI), many clinicians or centers still select locoregional therapy (LRT) such as transarterial chemoembolization (TACE), radiation therapy (RT), or combination with LRT and sorafenib because the survival improvement by sorafenib only is expected to be shorter than that without MVI. However this multidisciplinary approach may increase treatment related toxicity such as liver failure etc. Stereotactic body radiation therapy (SBRT) is new technology providing very highly conformal ablative radiation dose for a small numbers (3-5 fractions) of large fraction size and is expected to new effective modality for HCC with MVI. Based on above suggestions, we herein offer our experience of a patient with perforation of radiation induced gastric ulcer after complete remission of tumor and main portal vein thrombosis by combination therapy of SBRT and sorafenib. Further study, maybe regarding a combination of locoregional and systemic therapy, is necessary on how to manage HCC patients with main portal vein invasion.

Citations

Citations to this article as recorded by

Novel management of expected post-radiotherapy complications in hepatocellular carcinoma patients: a case report
Sung Hoon Chang, Tae Suk Kim, Yong Hwan Jeon, Nuri Hyun Jung, Dae Hee Choi
Journal of Liver Cancer.2022; 22(2): 183. CrossRef

A Case of Hepatocelluar Carcinoma Mimicking Focal Nodular Hyperplasia: Eui Ju Park, Jae Young Jang, Soung Won Jeong, Sae Hwan Lee, Sang Gyune Kim, Young Seok Kim, Hong Soo Kim, Boo Sung Kim, So Young Jin, Ji Young Hwang; Journal of the Korean Liver Cancer Study Group. 2014;14(1):53-59. Published online March 31, 2014; DOI: https://doi.org/10.17998/jlc.14.1.53

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Abstract PDF: Recently, detection of an incidental hepatic tumor has rapidly increased with the introduction of multi-modality imaging techniques. And then, it is very important to determine whether these tumors are malignant or benign lesions. In some cases, differentiation from other hepatic tumors such as focal nodular hyperplasia or hepatic adenoma and hepatocellular carcinoma can be extremely difficult, both clinical and radiologic finding. Therefore, it is suggested that combination of multi-modality imaging study than using only a single imaging test. Despite advanced imaging studies such as computed tomography (CT), magnetic resonance imaging (MRI), contrast enhanced ultrasonography, and positron emission tomography (PET) showed a high sensitivity and specificity, role of liver biopsy is still remained to confirm the diagnosis. The use of liver biopsy in the diagnosis of hypervascular hepatic tumors is controversial. However if the tumors was shown rapid growth tendency and heterogeneous radiological appearance, liver biopsy or surgical resection should be considered to provide final diagnosis and prompt curative treatment. We report a case of a hepatocelluar carcinoma showing similar radiologic characteristics to focal nodular hyperplasia in patients without high risk factors of hepatocelluar carcinoma.

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