Journal of Liver Cancer

Case Reports

A Case of Hepatocellular Carcinoma with Bile Duct Invasion Treated with Transarterial Chemoembolization: Hee Yeon Kim, Chang Wook Kim, Chang Don Lee, Soo Lim Lee, Yoo Dong Won, Ye Il Kim; Journal of the Korean Liver Cancer Study Group. 2013;13(2):158-163. Published online September 30, 2013; DOI: https://doi.org/10.17998/jlc.13.2.158

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Abstract PDF: A 53-year-old female patient visited our hospital complaining of intermittent right upper quadrant pain for 6 months. Computed tomography (CT) scan revealed an irregular shaped tumor at segment 4 of the liver with biliary tumor thrombi extending into the common bile duct. Percutaneous transhepatic biliary drainage was done for decompression of bile duct dilatation. The patient underwent 6 sessions of transarterial chemoembolization (TACE). Partial response was obtained shortly after TACE. However, regrowth of intraductal tumor resulted in an obstructive jaundice. After a slight decompression of the obstructive jaundice, the patient underwent TACE. Jaundice temporarily worsened following the TACE, but improved, and follow-up CT demonstrated some shrinkage of the intraductal mass. This case indicates that obstructive-type jaundice may not be a contraindication for TACE, and aggressive TACE may improve prognoses of patients with hepatocellular carcinoma and biliary tumor thrombi.

A Case of Partial Response of Hepatocellular Carcinoma Induced by Concurrent Chemoradiation and Hepatic Arterial Infusion Chemotherapy after Trans-Arterial Chemoembolization: Myung Eun Song, Sangheun Lee, Mi Na Kim, Dong-Jun Lee, Beom Kyung Kim, Seung Up Kim, Jun Yong Park, Sang Hoon Ahn, Chae Yoon Chon, Kwang-Hyub Han, Jinsil Seong, Do Young Kim; Journal of the Korean Liver Cancer Study Group. 2013;13(2):152-157. Published online September 30, 2013; DOI: https://doi.org/10.17998/jlc.13.2.152

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Abstract PDF: A 63-year-old man patient was referred for treatment of infiltrative hepatocellular carcinoma with hilar invasion after transarterial chemoembolization. Serum alkaline phosphatase and bilirubin were elevated, liver dynamic CT showed infiltrative type mass in left hepatic lobe and right hepatic dome with hilar invasion and left intrahepatic duct dilatation. Also CT showed obliteration of left portal vein and metastasis of lymph node around common bile duct. He was diagnosed as hepatocellular carcinoma (UICC stage IV-A, BCLC stage C). With the percutaneous transhepatic biliary drainage and the concurrent chemoradiation therapy and the 4th cycle of hepatic arterial infusion chemotherapy for infiltrative mass, viable tumor was decreased in resectable size at eight months from initial diagnosis.

Two Cases of Spontaneous Bacterial Peritonitis Developed Right after Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma: Jung Hoon Lee, Joo Hyun Sohn, Tae Yeob Kim, Ji Young Lee, Ki Sul Chang, Dong Hoon Lee, Eun Sik Park; Journal of the Korean Liver Cancer Study Group. 2013;13(2):145-151. Published online September 30, 2013; DOI: https://doi.org/10.17998/jlc.13.2.145

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Abstract PDF: Although acute hepatic failure (AHF) after transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) is not a rare complication, the development of spontaneous bacterial peritonitis (SBP) is uncommon. We describe two cases who suffered SBP and AHF right after TACE for HCCs. In the first case, 5 days after TACE ascites and jaundice newly developed and SBP was diagnosed at 9 days after TACE. After use of secondary antibiotics (imipenam) due to failure of primary therapy with 3rd cephalosporin, he discharged with resolution of SBP. In the second case, jaundice, abdominal pain and fever developed with increased ascites 3 days after TACE. After 8 days, SBP was diagnosed and treated with imipenam due to primary treatment failure, but clinical course was deteriorated. Eighteen days after discharge, she died of AHF. In patients with increased ascites and fever after TACE, clinician should be considered SBP with AHF among post-TACE complications, and prompt management is needed.

Original Articles

The Comparison of Overall Survival between Child C with Early Stage HCC and Child A with Advanced Stage HCC: Eui Ju Park, Jae Young Jang, Soung Won Jeong, Jin Woo Choo, Jin Nyoung Kim, Soon Ha Kwon, Byoung Moo Lee, Sae Hwan Lee, Sang Gyune Kim, Sang-Woo Cha, Young Seok Kim, Young Deok Cho, Hong Soo Kim, Boo Sung Kim; Journal of the Korean Liver Cancer Study Group. 2013;13(2):136-144. Published online September 30, 2013; DOI: https://doi.org/10.17998/jlc.13.2.136

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Abstract PDF: Background/Aim
s: The prognosis of hepatocellular carcinoma (HCC) is affected by stage as well as liver function. We analyzed the survival outcome of early stage HCC in Child class C patients and advanced HCC in Child class A patients.
Methods
Among 453 HCC patients with good performance status, Group A included 33 consecutive Child class C patients with early stage (I, II) HCC, and Group B included 45 consecutive Child class A patients with advanced stage (III, IV) HCC. We investigated the clinical characteristics, cirrhotic complications, and prognostic factors related with survival in each group, and compared overall survival between two groups.
Results
Age, prothrombin time, total bilirubin and Model for End-Stage Liver Disease (MELD) scores were significantly higher in Group A. Male sex, platelet count, albumin, sodium (Na), hepatitis B virus, alpha fetoprotein (AFP) and portal vein thrombosis were significantly higher in Group B. Complications of cirrhosis such as variceal bleeding, ascites, and hepatic encephalopathy were increased in Group A (P<0.05). Patients with an elevated AFP (>400 ng/mL) tended to exhibit poor survival as it increased in Group A (P=0.084). MELD scores>15 (Hazard ratio[HR] 17.84, 95% confidence interval [CI] 3.70-85.93, P<0.001), stage IV (HR:3.27, 95% CI 1.10-9.75, P=0.033), and absence of HCC treatment (HR: 3.70, 95% CI 1.06-12.50, P=0.040) were independent poor prognostic factors in Group B. Median overall survival was 24.6 months (95% CI 10.6-38.4) for Group A and 13.5 months (95% CI 4.6-22.3) for Group B (P=0.278). In the HCC treatment group, there were no significant differences of median overall survival between Group A and Group B, respectively (27.1 vs. 15.7 months, P=0.338). In patients with conservative treatment, Group A and Group B had a significantly different median overall survival of 13.6 and 2.5 months, respectively (P=0.012). In patients of Group B, median overall survival was significantly higher in patients who received treatment of HCC compared to those who did not, respectively (15.7 vs. 2.5 months, P<0.001).
Conclusions
Overall median survival was not different between both groups. However, in Child class A patients with advanced stage HCCs, the cumulative median survival was higher in patients who received treatment of HCC compared to those who did not. Therefore, advanced stage HCC patients with good liver function should be considered for HCC treatments.

Occurrence Rates of Hepatocellular Carcinoma in Patients with Adefovir-rescue Therapy for Lamivudine-Resistant Chronic Hepatitis B: Jihyun Kim, Sae Hwan Lee, Kanghyug Choi, Yun Nah Lee, Soung won Jeong, Sang Gyune Kim, Jae Young Jang, Young Seok Kim, Hong Soo Kim, Boo Sung Kim; Journal of the Korean Liver Cancer Study Group. 2013;13(2):130-135. Published online September 30, 2013; DOI: https://doi.org/10.17998/jlc.13.2.130

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Abstract PDF: Background/Aim
s: Suboptimal virological response to adefovir (ADV) rescue therapy was commonly experienced in patient with lamivudine-resistant chronic hepatitis B. The aim of this study is to compare occurrence of hepatocellular carcinoma (HCC) of patients with adefovir rescue therapy to naïve patients with entecavir.
Methods
Electronic medical records of 156 patients with lamivudine-resistant chronic hepatitis B who treated with ADV and of 186 naïve-patients who received entecavir 0.5 mg, as control group, were reviewed retrospectively. Study subjects were matched using estimated propensity score and 107 matched subjects in each group were analyzed. Cumulative occurrence of HCC was evaluated during antiviral therapy and the association between clinical variables and development of HCC were analyzed using Kaplan-Meyer curve and risk factor for HCC was evaluated with Cox-proportional hazard model.
Results
Age, gender, Child-Pugh score, underlying cirrhosis, HBeAg, and HBV DNA level were not different in both groups, except treatment duration with ADV or entecavir (mean 52.6±17.5 vs 46.7±11.4 months, P=0.004). Cumulative virological response rates were 16% and 42% in patient with ADV rescue therapy and 68% and 85% in naïve-patients received entecavir at 1 and 3 years (P<0.001), respectively. HCC were diagnosed in 6 of 107 patients with lamivudine-resistance and 9 of 107 naïve-patients during follow-period and cumulative occurrence rates of HCC was not different between both group (P=0.308). Cumulative occurrence rates of HCC in total 214 subjects were 2.3%, 4.8%, and 9.6% at 1, 3, and 5 years, respectively. Age, underlying cirrhosis, and baseline HBV DNA level were associated with the occurrence of HCC, however gender, HBeAg status, ADV rescue therapy, and cumulative virological response were not correlated in univariate analysis. In multivariate analysis, age (P=0.008) and underlying cirrhosis (P=0.002) were independent risk factors for occurrence of HCC.
Conclusions
Long-term ADV rescue therapy in patients with lamivudine-resistant chronic hepatitis B did not increase the occurrence rates of HCC.

Epidemiologic Changes in Hepatocellular Carcinoma: A 10-year Single Center Experience in Gangneung, Korea: Young Don Kim, Woo Sung Jang, Jang Hoon Kwon, Jong Sam Hong, Gab Jin Cheon; Journal of the Korean Liver Cancer Study Group. 2013;13(2):123-129. Published online September 30, 2013; DOI: https://doi.org/10.17998/jlc.13.2.123

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Abstract PDF: Background/Aim
s: Hepatocellular carcinoma (HCC) is common cause of liver related death in Korea, and the importance of alcohol as an etiology of chronic liver disease including cirrhosis is emphasized recently. We investigated the epidemiologic changes of HCC during last 10 years in single tertiary center in Gangneung, Korea.
Methods
We retrospectively reviewed the medical records of admitted patients diagnosed as HCC in year 2002 and 2012 respectively, and their clinical characteristics were compared.
Results
A total of 214 patients were enrolled. Mean age was 60.1 years and 179 (83.6%) was male. Number of patient with cirrhosis was 160 (74.8%) and with viral hepatitis was 164 (74.8%). Chronic hepatitis B (CHB) was the most common cause of HCC patients with liver cirrhosis (61.9%), and alcohol was 14.4%. The possible curative group (by BCLC stage 0 or A) was only 36.4% (n=78), and had not decreased during the study periods (36.3 % vs. 36.6%, P=0.144), and other clinical variables also had no statistical differences.
Conclusions
The clinical characteristics of HCC including clinical stage at the time of diagnosis were not changed over the last 10 year period, and CHB was still the most common etiology of HCC in Gangneung, Korea.

Review Articles

Role of Radiation Therapy as an Ablative Modality for Hepatocellular Carcinoma: Hee Chul Park; Journal of the Korean Liver Cancer Study Group. 2013;13(2):114-122. Published online September 30, 2013; DOI: https://doi.org/10.17998/jlc.13.2.114

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Abstract PDF: Before the introduction of radiation therapy (RT) in the clinical management guidelines for hepatocellular carcinoma (HCC), radiation was used not very frequently in the course of HCC management. According to the “Practice guidelines for management of HCC 2009” published by the Korean Liver Cancer Study Group and the National Cancer Center, Korea, RT can be used for HCC with portal vein tumor thrombosis and can be effective to relieve the symptoms caused by HCC and its metastases once the RT is believed safe in terms of radiobiological considerations. The introduction of RT in the Korean HCC management guideline did the pivotal role in accentuating research efforts to enlighten the role of RT in HCC management. Recently, the application of stereotactic ablative body radiotherapy (SABR), an extra-cranial version of radiosurgery such as Gamma-knife, is tested as an ablative modality for HCC. There are already some published prospective series to test SABR for HCC. In Korea, there is a prospective trial published by Korea Cancer Center Hospital. A multicenter prospective trial (KROG 12-02) is on-going as a Korean Radiation Oncology Group (KROG) study and already 26 patients were accrued to the target number of 54 patients. In this review, the background, rationale and the discussion points in the application of SABR as an ablative modality for HCC will be covered. And the experience of hypofractionated ablative RT for small size HCC less than 3 cm by the author will be introduced.

Diagnostic Performance of CT and MRI for Small HCC Less Than 1 cm: Jung Hoon Kim; Journal of the Korean Liver Cancer Study Group. 2013;13(2):105-113. Published online September 30, 2013; DOI: https://doi.org/10.17998/jlc.13.2.105

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Abstract PDF: Hepatocellular carcinoma (HCC) is the most common primary liver cancer. Worldwide, the surveillance program of HCC is well-established for the patients with high risk. The early stage of HCC has the highest likelihood for cure. It is therefore important to make the early diagnosis of HCC. The imaging criteria for the diagnosis of HCC have established detailing the characteristic enhancement pattern of HCC including hypervascularity in the arterial phase and washout in the portal or delayed phase of dynamic imaging. However, in the current practical guidelines, there are controversies for HCC smaller than 1 cm in size because of the low sensitivity of CT and MR for HCC smaller than 1 cm in size. Recent advances in CT and MR hardware and software allow for rapid acquisition times that can reduce many of motion artifacts. Furthermore, recently introduced hepatocyte-specific MR contrast agents have showed its superior efficacy in both detection and characterization of small focal liver lesion by providing both dynamic imaging and hepatobiliary phase imaging. So, we reviewed the diagnostic performance of CT and MRI for HCC smaller than 1 cm in size. In addition, we introduced our experience for HCC smaller than 1 cm in size.

Case Report

A Case of Stereotactic Body Radiation Therapy (SBRT) for HCC: Jang Won Park, Gang Mo Kim; Journal of the Korean Liver Cancer Study Group. 2013;13(1):80-84. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.80

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Abstract PDF: RT is an effective local therapy that has the potential to benefit patients unsuitable for and/or at high risk of complication following standard local-regional therapies. All of the following have facilitated the safe delivery of tumorcidal doses to focal HCCs using conformal RT: advances in imaging, RT planning techniques, image-guided radiotherapy, tumor immobilization, and improved knowledge of what volume of liver is required to be spared from radiation to preserve function. SBRT has more recently been used to treat focal HCC. SBRT is widely available and more convenient for patients than conventionally fractionated RT, as it is delivered in far fewer fractions than standard fractionated RT. We report our experience for a patient treated successfully with SBRT.

Review Article

Directions for Future Hepatocellular Carcinoma Treatment Guidelines; Hepatologist’s Perspective: Systemic Approach to Multidisciplinary Treatment: Soo Young Park, Won Young Tak; Journal of the Korean Liver Cancer Study Group. 2013;13(1):8-13. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.8

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Abstract PDF: Hepatocellular carcinoma is one of the most important malignancies in Korea with high mortality rates. Although current guidelines define treatment algorithm by performance status, underlying liver function, size and number of hepatocellular carcinoma, those are not fully reflect the complexities of patients’ characteristics and recently advanced available therapeutic options. Treatment can be optimized by available therapeutic options based on the patients’ characteristics. Because of the heterogeneity in presentation among patients, it is now widely accepted that management of hepatocellular carcinoma requires multimodality and multidisciplinary treatment approaches involving hepatologists, surgeons, interventional radiologists, and radiation oncologists. These approaches are important in improving the survival of patients with hepatocellular carcinoma.

Case Reports

A Case of Recurred Hepatocellular Carcinoma after Treated by Trans-Arterial Chemoembolization: Sangheun Lee, Mi Na Kim, Young Eun Chon, Beom Kyung Kim, Seung Up Kim, Jun Yong Park, Do Young Kim, Sang Hoon Ahn, Chae Yoon Chon, Kwang-Hyub Han; Journal of the Korean Liver Cancer Study Group. 2013;13(1):74-79. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.74

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Abstract PDF: Hepatocelluar carcinoma (HCC) is the most common primary liver cancer in the world and the most prevalent cancer among patients liver cirrhosis. The management of HCC depends on tumor stage and the degree of liver dysfunction. Patients with intermediate-stage HCC are ineligible for surgical or local ablative treatments. Current treatment guidelines recommend trans-arterial chemoembolization (TACE) for intermediate stage of HCC. However, tumor recurrence after TACE is universal and the survival benefit is relatively small. Hence, new strategies are needed to improve the outcome of HCC patients undergoing TACE. Recently, the combination of target agents with TACE has shown promising overall survival in advanced HCC. It is necessary to investigate new treat strategy how to increase treatment outcome of advanced HCC by new treat strategy.

A Case of Good Responsed Bile Duct Invasion of Hepatocellular Carcinoma on Cyberknife Therapy: Dae Han Choi, Jae Young Jang, Soung Won Jeong, Sae Hwan Lee, Sang Gyune Kim, Young Seok Kim, Hong Soo Kim, Boo Sung Kim, A ram Jang; Journal of the Korean Liver Cancer Study Group. 2013;13(1):70-73. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.70

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Abstract PDF: Hepatocellular carcinoma (HCC) is one of the common tumor worldwide and recorded as third most common cause of cancer-related deaths. Invasion of the portal and hepatic veins by HCC is common. But intrabiliary invasion is rare. Radiotherapy (RT) is considered appropriate for unresectable, locally advanced HCC without extrahepatic metastasis. With the conventional RT, it is not possible to deliver a high radiation dose to a treatment volume in a short time and narrow lesion. Recent technological developments in radiation therapy, such as stereotactic body radiation therapy (SBRT), make it possible to deliver a substantial dose of radiation to the tumor and avoid radiosensitive normal liver in the vincinity. We report a patient who were treated by cyberknife therapy for bile duct invasion of progressing HCC despite of treatment.

A Case of Unresectable Hepatocellular Carcinoma Treated by Repeated Transcatheter Arterial Chemoembolization Using DC beads® Followed with Resection: Jeong-Yeop Song, Young Seok Kim, Jae Myeong Lee, Soo Ji Jin, Kyu Sung Choi, Yun Nah Lee, Sang Hyune Kim, Sung Won Jeong, Jae Young Jang, Sae Hwan Lee, Hong Soo Kim, Boo Sung Kim; Journal of the Korean Liver Cancer Study Group. 2013;13(1):65-69. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.65

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Abstract PDF: In patients with unresectable hepatocellular carcinoma (HCC) and no anti-cancer treatment, the prognosis is quite poor. But in some cases, repeated sessions of transcatheter arterial chemoembolization (TACE) reduce the tumor size even to resectable, and post-TACE resection may prolong the survival time. We present a case of 50-year-old HBV carrier woman with abdominal distension. The diagnosis was huge HCC with intrahepatic metastasis. Repeated intra-arterial injections of adriamycin mixed lipiodol or DC beads® (100-300/300-500/500-700 μm, ©BIOCOMPATIBLES UK LTD) were instituted through ten sessions for 13 months. The tumor size became reduced with a partial response after 10th TACE and post-TACE resection was performed. No visible HCCs and decreased tumor markers were noted on the examinations 3 months after the resection.

Living Donor Liver Transplantation for Hepatocellular Carcinoma with Portal Vein Tumor Thrombus: YoungRok Choi, Kwang-Woong Lee, Hae Won Lee, Nam-Joon Yi, Kyung-Suk Suh; Journal of the Korean Liver Cancer Study Group. 2013;13(1):62-64. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.62

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Abstract PDF: Malignant portal vein thrombosis is a contraindication to liver transplantation for hepatocellular carcinoma because of the high risk of its recurrence and the poor patient survival. With a newly developed immunosuppressant and a chemotherapeutic agent, however, living donor liver transplantation can be considered for a patient of hepatocellular carcinoma, showing a slow growth rate and good response for transarterial chemoembolization. We report a HBV related liver cirrhosis patient with HCC and portal vein tumor thrombus who underwent living donor liver transplantation and survived without recurrence of hepatocellular carcinoma for 18 months in our center.

A Case of Huge Hepatocellular Carcinoma with Complete Remission of Intrahepatic Tumor and Adrenal Gland Metastasis Treated with Combination Therapy of Transarterial Chemoembolization and 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. 2013;13(1):57-61. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.57

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Abstract PDF: Extrahepatic metastasis (EHM) associated with hepatocellular carcinoma (HCC) has been increasing due to prolonged survival with recent advances in therapeutic approaches including locoregional therapy such as transarterial chemoemoblization (TACE), radiofrequency ablation and radiation therapy (RT). Though many guidelines recommended systemic therapy such as sorafenib in this situation, some clinicians or centers still select locoregional therapy because the survival improvement of 2 or 3 months by sorafenib is far from optimal. Moreover, some studies showed that complete and partial response of intrahepatic tumors can result in significant improvement of patient survival even in situation of EHM. Based on above suggestions, we herein offer our experience of a patient with complete remission of intrahepatic tumor and adrenal gland metastasis treated with combination therapy of TACE and RT and sorafenib. Further study, maybe regarding a combination of locoregional and systemic therapy (so called multidisciplinary approach), is necessary on how to manage HCC patients with EHM.

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