Journal of Liver Cancer

Volume 10(1); June 2010

Review Articles

Diagnosis of Hepatocellular Carcinoma: Jin-Wook Kim; Journal of the Korean Liver Cancer Study Group. 2010;10(1):1-5. Published online June 30, 2010

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Abstract PDF: The Korean Liver Cancer Study Group (KLCSG) and the Center for Liver Cancer at the National Cancer Center (NCC) in Korea compiled a clinical practice guideline for the management of hepatocellular carcinoma (HCC) in 2003, and the guideline has been revised in 2009 to incorporate newly published scientific evidence in the diagnosis and treatment of HCC. The surveillance and diagnostic criteria of HCC of the 2009 guideline is reviewed with respect to practical application. Several unresolved issues were also discussed.

2009 Treatment Guideline for Hepatocellular Carcinoma: Surgical Resection and Liver Transplantation: Sung Hoon Kim, Kyung Sik Kim; Journal of the Korean Liver Cancer Study Group. 2010;10(1):6-10. Published online June 30, 2010

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Abstract PDF: The effort we are trying to set up the treatment guideline for hepatocellular carcinoma has produced various guidelines after drawing a conclusion from Barcelona EASL meeting in 2000. Especially in Korea, the Korean Liver Cancer Study Group and the National Cancer Center have collaborated on making treatment guideline for hepatocellular carcinoma in the early stage of setting up the guideline, 2003, and it was a great help to treatment, study and education. However, a need of revision had been raised due to many changes in the latest treatments and an accumulation of international and domestic experience. After the proposal of amending the treatment guideline for Hepatocellular carcinoma in the Cancer Control Forum of the National Cancer Control Planning Board on October 17th, 2008, “2009 Guideline” has been reported in the Conference of the Korean Liver Cancer Study Group held on June 27th, 2009. When revising the guideline, there are some suggestions of continuous modification to reflect evidence based medical knowledge, and recently there are some debates about the drawback of the surgical field which was not handled in EASL and AASLD Guidelines. Therefore, it will broaden your understanding of liver surgical resection and liver transplantation and it will also be a place for the discussion of disputable issues.

Debate and Explanation of the “Practice Guidelines for Management of Hepatocellular Carcinoma 2009”: Radiation Therapy: Hee Chul Park; Journal of the Korean Liver Cancer Study Group. 2010;10(1):11-16. Published online June 30, 2010

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Abstract PDF: According to the 2003 clinical practice guideline reported by Korean Liver Cancer Study Group (KLCSG) and National Cancer Center (NCC), Radiation therapy (RT) has been considered as alternative or complementary modality in cases where surgical resection is not possible, local treatment or trans-hepatic arterial chemo-embolization (TACE) does not provide a cure. At that time, the guideline suggested that further studies are needed to confirm the beneficial role of RT in the management of HCC because RT lacked the high quality scientific evidences at that time. However, the 2003 guideline did the pivotal role in accentuating research efforts to enlighten the role of RT in HCC management. Recently, many scientific evidences are piled up strengthening the level of evidence. Also there was the quantitative expansion of reported studies dealing with RT role in HCC management. In the 2009 Practice guidelines for the management of HCC, radiation oncologists participated as member of revision committee put every efforts to make good of RT related guideline. And to place RT related guidelines as a special feature of Korean version of HCC management guidelines. Discussions were made among radiation oncologists in the revision committee. The participating radiation oncologists realized that still there are no randomized controlled trials exploring the role of RT in HCC management. The role of RT in the management of HCC is underestimated still. To prepare the next version of practice guideline, the every effort must go on to invigorate the role of RT in the management of HCC.

Partial Hepatectomy vs. Radiofrequency Ablation for Treatment of Hepatocellular Carcinoma: Moon Seok Choi; Journal of the Korean Liver Cancer Study Group. 2010;10(1):17-21. Published online June 30, 2010

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Abstract PDF: Hepatocellular carcinoma (HCC) is the third most common cause of death from cancer in men and the sixth most common cause in women worldwide. Fortunately, significant improvement in prognosis of HCC has been noted from increasing early diagnosis of HCC since the introduction of surveillance and from outstanding progress in various treatment modalities. Radiofrequency ablation (RFA) effectively controls by temperature changes from high-frequency alternating current via electrodes placed within the tissue to achieve coagulation necrosis and tissue desiccation. RFA has been commonly applied as an alternative curative therapy to surgical resection for small HCC due to effective local tumor control. Several previous studies comparing the outcomes of surgery and RFA for HCC have reported variable results probably caused by differences in the study protocol. We compared indication, limitation, therapeutic results of partial hepatectomy and percutaneous RFA to provide better understanding of current status of the two treatment modality and hopefully to give some useful advices for setting up treatment strategy.

Clonorchis sinensis and Biliary Stones as Etiological Factors of Cholangiocarcinoma: Dongil Choi, Jae Hoon Lim; Journal of the Korean Liver Cancer Study Group. 2010;10(1):22-28. Published online June 30, 2010

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Abstract PDF: C. sinensis induces adenomatous hyperplasia of the epithelium of the bile ducts, and the epithelium of the bile duct persistently exposed to biochemically altered bile may undergo the sequence, hyperplasia-metaplaisa-dysplasia-carcinoma. Cholangiocarcinomas were developed in most hamsters treated with an N-nitroso compound and then infected with C. sinensis. In the patients with intrahepatic duct stones, bile usually infected with bacteria. Mechanical stimuli due to stones, long-lasting bile stasis, and bacterial infection are considered to be the other significant causative factors in cholangiocarcinogenesis. Radiological examinations are essential in the diagnosis and treatment of biliary tree diseases including clonorchiasis, biliary stone disease, and cholangiocarcinoma. As both C. sinensis and intrahepatic duct stones are common, radiological and clinical findings should be attentively investigated for the possible presence of cholangiocarcinoma in patients with clonorchiasis or intrahepatic duct stones.

Radioembolization of Unresectable Hepatocellular Carcinoma: Yun Hwan Joseph Kim, Sung Bum Cho, Hwan Hoon Chung; Journal of the Korean Liver Cancer Study Group. 2010;10(1):29-34. Published online June 30, 2010

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Abstract PDF: Transarterial radioembolization (TARE) using Yttrium-90 (Y-90) microspheres is emerging as a mainstream treatment modality in the management of patients with primary and metastatic liver cancer. Yttrium-90 is a high energy beta particle emitting radioisotope. The intellectual basis of Y-90 microsphere treatment is the preferential distribution of microspheres, when injected in the hepatic artery, yielding much higher concentrations in the tumor compartment than the normal liver parenchyma. The technique involves the administration of Y-90 microspheres into the hepatic artery accessed via transfemoral route, showing almost similar procedure with transarterial chemoembolization (TACE). The Y-90 microspheres are entrapped within the microvasculature, and release beta radiation. The high tumor to liver concentration ratio results in an effective tumoricidal radiation absorbed dose whilst limiting the radiation injury to the normal liver. With such a therapeutic mechanism of this method, Y-90 microspheres have been used as a treatment modality both for primary HCC and for pre-transplant management of HCC with promising results. But preliminary evidence also suggests that the TACE and TARE provided similar effectiveness and toxicity in patients with unresectable HCC. In conclusion, we think that prospective, randomized controlled trials using current therapies are needed to better define optimal management of unresectable HCC.

Case Reports

A Case of Complete Remission in Hepatocellular Carcinoma by Metronomic Hepatic Artery Infusion Chemotherapy: Myeong Jon Song, CHung-Hwa Park, Si Hyun Bae, Jong Young Choi, Seung Kew Yoon, Ho Jong Chun; Journal of the Korean Liver Cancer Study Group. 2010;10(1):35-39. Published online June 30, 2010

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Abstract PDF: A 53-year-old man patient was admitted for evaluation of abdominal pain. Liver dynamic CT showed infiltrative type mass in right hepatic angle with arterial enhancement and rapid washout. Also low density tumor thrombus is filled with in right portal vein. He was diagnosed HCC (UICC stage IVa) with liver cirrhosis (Child-Pugh class B). With the sixth cycle of metronomic hepatic artery infusion chemotherapy for infiltrative mass, HCC showed no stain in hepatic angiography and tumor marker are normalized at seven month from initial diagnosis.

A Case of Hepatocellular Carcinoma Exhibited over Partial Response after Hepatic Arterial Infusion Chemotherapy: Chang Wook Park, Young Lan Kown, Yong Jin Kim, Yoon Jung Kim, Hye Jin Seo, Kyung In Lee, Eun Soo Kim, Byung Kook Jang, Woo Jin Jeong, Kyung Sik Park, Kwang Bum Jo, Jae Seok Hwang, Young Hwan Kim, Jung Hyuk Kwon; Journal of the Korean Liver Cancer Study Group. 2010;10(1):40-43. Published online June 30, 2010

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Abstract PDF: Hepatocellular carcinoma (HCC) is one of the cancers with poor prognosis. Especially potal vein invasion is a grave prognostic indicator in the setting of HCC. There is currently no effective method for treatment of HCC with portal vein invasion. A 61-year-old female patient was diagnosed a massive HCCs in both hepatic lobe with portal vein thrombosis, based on computed tomography (CT) and increased tumor marker, α-fetoprotein. She was treated with intrahepatic arterial CDDP (10 mg on 1~5 day), 5-FU (250mg on 1~5 day) and leukovorin (12mg on 1~5 day) infusion via percutaneously implantable port system (PIPS) every 3 weeks, totally seven times. The patient was still living 6 months after first hepatic arterial infusion chemotherapy (HAIC) and follow-up CT showed partial response with necrosis of HCCs. We report here a case of advanced HCC with portal vein thrombosis that was effectively treated with HAIC via PIPS.

A Case of Hepatocellular Carcinoma showing Progressive Disease in Systemic Chemotherapy, but Partial Response in Hepatic Arterial Infusion Chemotherapy with the Same Regimen: Soung Min Jeon, Do Young Kim, Sang Hoon Ahn, Kwang Hyub Han, Chae Yoon Chon, Jun Yong Park; Journal of the Korean Liver Cancer Study Group. 2010;10(1):44-48. Published online June 30, 2010

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Abstract PDF: Hepatocellular carcinoma (HCC) is the third most common malignancy in Korea. Despite recent advances in the area of HCC, a considerable number of HCC patients require non-surgical treatments and systemic therapies because of poor liver function or intermediate to advanced cancer stages at the time of diagnosis. Unfortunately, chemotherapy for advanced HCC has limited response rates and provides a marginal survival benefit. Several studies have supported potential advantages of hepatic arterial infusion chemotherapy (HAIC), designed to improve chemotherapy benefits by increasing the amount of chemotherapy delivered to the site of the tumor and to minimizes the side-effects of the chemotherapy. However, there hasn’t been any report showing different responses between systemic chemotherapy and HAIC for the same patient. Herein, we report a case of HCC showing progressive disease in systemic chemotherapy, but partial response in HAIC with the same regimen for the same patient with portal vein thrombosis. This case implies HAIC might be alternative option for HCC patient showing ineffective response to systemic chemotherapy, even with the same regimen.

A Case of Multiple HCC with Decompensated Liver Cirrhosis Treated by Intra-arterial Chemotherapy: Yun Suk Shim, Sae Hwan Lee, Hong Soo Kim; Journal of the Korean Liver Cancer Study Group. 2010;10(1):49-51. Published online June 30, 2010

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Abstract PDF: Hepatocelluar carcinoma (HCC) is one of the cancers with poor prognosis as HCC develops on base of cirrhosis in majority cases, which requires multidisciplinary approach. Hepatic arterial infusion chemotherapy (HAIC) allows for relatively easy replenishment of administering agents into the hepatic artery and achieves higher intrahepatic concentrations. We report a case of multiple HCC with decompensated liver cirrhosis treated by HAIC.

A Case of Pulmonary Metastasis from Hepatocellular Carcinoma Partially Responsive to Sorafenib: Nae-Yun Heo, Han Chu Lee, Ju Hyun Shim, Young-Suk Lim, Young-Hwa Chung, Yung Sang Lee, Dong Jin Suh; Journal of the Korean Liver Cancer Study Group. 2010;10(1):52-54. Published online June 30, 2010

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Abstract PDF: Hepatocellular carcinoma (HCC) is one of the most important causes of cancer death in South Korea. Unfortunately, more than half of the patients are diagnosed in the advanced stage with multiple intra- or extrahepatic metastasis, so no more than 30% of patients are suitable to undergo curative resection. Lung is the most common organ of extrahepatic metastasis of HCC, and the pulmonary metastasis is known as poor prognosis factor, but no standard systemic therapy is established yet. Sorafenib is the only molecularly targeted agent which has been proven clinical benefit in the randomized clinical trials, but pulmonary metastasis is known as predictive factor of poor response. However, we experience a case of pulmonary metastasis from hepatocellular carcinoma partially responsive to sorafenib, and report it.

Two Cases of Hepatocellular Carcinoma with Extrahepatic Metastasis Who Showed Complete Remission Following Doxorubicin and Cisplatin (AP) Combination Chemotherapy in Reduced Dosage: Seung Bum Nam, Chul Ju Han, Ho Jin Lee, Youn Joo Kim, Ki Young Yang, Su Cheol Park, Jin Kim, Yu Cheol Kim; Journal of the Korean Liver Cancer Study Group. 2010;10(1):55-60. Published online June 30, 2010

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Abstract PDF: The effect of systemic chemotherapy in patients with advanced HCC is very limited, not only in regard to poor response to cytotoxic chemotherapeutic agents but also poor tolerance to therapy and related adverse effects. Herein, we report two
case
s of hepatocellular carcinoma (HCC) with extrahepatic metastasis who achieved complete remission following administration of doxorubicin and cisplatin in reduced dosage. The first case was a 41-year-old male who had HCC with multiple lung and intraabdominal lymph nodes metastasis. After 9 cycles of chemotherapy with 50% reduced dosage, he achieved a complete remission of both primary and metastatic lesions. He showed no evidence of disease for 11 more months during follow-up and still lives without recurrence. The second case was a 61-year-old female who had HCC with inferior vena cava thrombosis and multiple lung metastasis. After one cycle of treatment with 25% reduced dosage, she underwent life-threatening toxicities and poor tolerance to chemotherapy and further treatment was discontinued. However, she achieved a complete remission of both primary and metastatic lesions. Following 26 months of recurrence free period, she suffered from a recurrent tumor near previously treated lesion, which was successfully treated by TACE and radiation therapy. This modified doxorubicin and cisplatin regimen in reduced dosage could be used as means of evading life threatening toxicity and selecting out responders to systemic chemotherapy with reduced risk.

Hepatocellular Carcinoma Diagnosed with Metastatic Lesion of the Cervical Spine: Chung-Hwa Park, Myeong Jun Song, Hee Yeon Kim, Si Hyun Bae, Seung Kew Yoon, Jong Young Choi; Journal of the Korean Liver Cancer Study Group. 2010;10(1):61-63. Published online June 30, 2010

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Abstract PDF: Bone metastases in hepatocellular carcinoma (HCC) are usually treated with non-operative procedures such as radiotherapy, hormonal therapy, bisphosphonates, or sometimes with surgical procedures. Here we describe a case with 3rd cervical spine metastasis of HCC. A 62-year-old female with liver cirrhosis presented with neck pain. After evaluation, the patient was diagnosed of hepatocellular carcinoma with cervical spine metastasis. The metastatic lesion was treated with tomotherapy while the primary lesion in the liver was treated with transarterial chemoembolization using drug-eluting beads, and the patient is tolerable waiting for the next treatment.

A Case of Hepatocellular Carcinoma Presenting with Rib Metastasis: Kyung In Lee, Young Lan Kwon, Yoon Jung Kim, Hye Jin Seo, Yong Jin Kim, Chang Wook Park, Eun Soo Kim, Byoung Kuk Jang, Woo Jin Chung, Kyung Sik Park, Kwang Bum Cho, Jae Seok Hwang, Jung Hyeok Kwon; Journal of the Korean Liver Cancer Study Group. 2010;10(1):64-68. Published online June 30, 2010

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Abstract PDF: Bone metastasis is not uncommon and shows poor survival in patients with hepatocellular carcinoma (HCC). We describe a case of HCC presenting with rib metastasis in a 54-year-old man. In spite of radiotherapy for rib metastasis, pain was sustained and size of lesions were increased. So we performd CT-guided percutaneous ethanol injection therapy (PEIT). Whenever new metastatic bone lesions were detected, we have done PEIT. However, abdominal CT scan at 25th month after diagnosis shows residual viable tumors in pelvic bone and multiple metastatic nodules in both lung. He is alive by taking conservative management for 27 months after diagnosis.

A case of hepatocellular carcinoma presented with bone metastasis: EJ Kang, SW Jeong, JY Jang, SH Lee, SG Kim, YK Chun, YS Kim, YD Cho, HS Kim, BS Kim; Journal of the Korean Liver Cancer Study Group. 2010;10(1):69-72. Published online June 30, 2010

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Abstract PDF: Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide in terms of incidence. The majority of tumors are diagnosed when advanced. The long-term prognosis of HCC remains poor, with a 5-year survival rate of <5%. However, recent progress in the treatment of HCC has made it possible for the patient to survive longer, and as a result, distant metastasis from HCC, including bone metastasis has increased and attracted more attention than before. Of the various metastatic sites, the most common site is the lungs, followed by the lymph nodes and bone. The most frequent sites of bone metastasis are the spine, pelvis and rib in that order. Single bone lesion was associated with a favorable outcome, while multiple bone lesions may be associated with severe pain and increasing rate of leucopenia, anemia, and thrombocytopenia, sometimes making radiotherapy administration difficult. The incidence of bone metastasis in HCC is low. Moreover HCC diagnosed with bone metastasis is very rare. We report a patient who present with bone metastasis before the diagnosis of a primary cancer.

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