Jorge A. Marrero

Diagnosis and treatment of hepatocellular carcinoma

The diagnosis and treatment of hepatocellular carcinoma (HCC) have witnessed major changes over the past decade. Until the early 1990s, HCC was a relatively rare malignancy, typically diagnosed at an advanced stage in a symptomatic patient, and there were no known effective palliative or therapeutic options. However, the rising incidence of HCC in several regions around the world coupled with emerging evidence for efficacy of screening in high-risk patients, liver transplantation as a curative option in select patients, ability to make definitive diagnosis using high-resolution imaging of the liver, less dependency on obtaining tissue diagnosis, and proven efficacy of transarterial chemoembolization and sorafenib as palliative therapy have improved the outlook for HCC patients. In this article, we present a summary of the most recent information on screening, diagnosis, staging, and different treatment modalities of HCC, as well as our recommended management approach.

Prognosis of hepatocellular carcinoma: Comparison of 7 staging systems in an American cohort

Currently there is no consensus as to which staging system is best in predicting the survival of patients with hepatocellular carcinoma (HCC). The aims of this study were to identify independent predictors of survival and to compare 7 available prognostic staging systems in patients with HCC. A total of 239 consecutive patients with cirrhosis and HCC seen between January 1, 2000, and December 31, 2003, were included. Demographic, laboratory, and tumor characteristics and performance status were determined at diagnosis and before therapy. Predictors of survival were identified using the Kaplan–Meir test and the Cox model. Sixty‐two percent of patients had hepatitis C, 56% had more than 1 tumor nodule, 24% had portal vein thrombosis, and 29% did not receive any cancer treatment. At the time of censorship, 153 (63%) patients had died. The 1‐ and 3‐year survival of the entire cohort was 58% and 29%, respectively. The independent predictors of survival were performance status (P < .0001), MELD score greater than 10 (P = .001), portal vein thrombosis (P = .0001), and tumor diameter greater than 4 cm (P = .001). Treatment of HCC was related to overall survival. The Barcelona Clinic Liver Cancer (BCLC) staging system had the best independent predictive power for survival when compared with the other 6 prognostic systems. In conclusion, performance status, tumor extent, liver function, and treatment were independent predictors of survival mostly in patients with cirrhosis and HCC. The BCLC staging system includes aspects of all of these elements and provided the best prognostic stratification for our cohort of patients with HCC. (HEPATOLOGY 2005.)

α-Fetoprotein, Des-γ Carboxyprothrombin, and Lectin-Bound α-Fetoprotein in Early Hepatocellular Carcinoma

BACKGROUND & AIMS Alpha-fetoprotein (AFP) is widely used as a surveillance test for hepatocellular carcinoma (HCC) among patients with cirrhosis. Des-gamma carboxy-prothrombin (DCP) and lectin-bound AFP (AFP-L3%) are potential surveillance tests for HCC. The aims of this study were to determine performance of DCP and AFP-L3% for the diagnosis of early HCC; whether they complement AFP; and what factors affect DCP, AFP-L3%, or AFP levels. METHODS We conducted a large phase 2 biomarker case-control study in 7 academic medical centers in the United States. Controls were patients with compensated cirrhosis and cases were patients with HCC. AFP, DCP, and AFP-L3% levels were measured blinded to clinical data in a central reference laboratory. RESULTS A total of 836 patients were enrolled: 417 (50%) were cirrhosis controls and 419 (50%) were HCC cases, of which 208 (49.6%) had early stage HCC (n = 77 very early, n = 131 early). AFP had the best area under the receiver operating characteristic curve (0.80, 95% confidence interval [CI]: 0.77-0.84), followed by DCP (0.72, 95% CI: 0.68-0.77) and AFP-L3% (0.66, 95% CI: 0.62-0.70) for early stage HCC. The optimal AFP cutoff value was 10.9 ng/mL leading to a sensitivity of 66%. When only those with very early HCC were evaluated, the area under the receiver operating characteristic curve for AFP was 0.78 (95% CI: 0.72-0.85) leading to a sensitivity of 65% at the same cutoff. CONCLUSIONS AFP was more sensitive than DCP and AFP-L3% for the diagnosis of early and very early stage HCC at a new cutoff of 10.9 ng/mL.

MR Imaging of Hepatocellular Carcinoma in the Cirrhotic Liver: Challenges and Controversies

The incidence of hepatocellular carcinoma (HCC) is expected to increase in the next 2 decades, largely due to hepatitis C infection and secondary cirrhosis. HCC is being detected at an earlier stage owing to the implementation of screening programs. Biopsy is no longer required prior to treatment, and diagnosis of HCC is heavily dependent on imaging characteristics. The most recent recommendations by the American Association for the Study of Liver Diseases (AASLD) state that a diagnosis of HCC can be made if a mass larger than 2 cm shows typical features of HCC (hypervascularity in the arterial phase and washout in the venous phase) at contrast material-enhanced computed tomography or magnetic resonance (MR) imaging or if a mass measuring 1-2 cm shows these features at both modalities. There is an ever-increasing demand on radiologists to detect smaller tumors, when curative therapies are most effective. However, the major difficulty in imaging cirrhosis is the characterization of hypervascular nodules smaller than 2 cm, which often have nonspecific imaging characteristics. The authors present a review of the MR imaging and pathologic features of regenerative nodules and dysplastic nodules and focus on HCC in the cirrhotic liver, with particular reference to small tumors and lesions that may mimic HCC. The authors also review the sensitivity of MR imaging for the detection of these tumors and discuss the staging of HCC and the treatment options in the context of the guidelines of the AASLD and the imaging criteria required by the United Network for Organ Sharing for transplantation. MR findings following ablation and chemoembolization are also reviewed.

Improving the prediction of hepatocellular carcinoma in cirrhotic patients with an arterially-enhancing liver mass

In the United States, cirrhotic patients with known or suspected hepatocellular carcinoma (HCC) are prioritized for liver transplantation. Noninvasive criteria for the diagnosis of HCC rely on arterial enhancement of a mass. The aim of this study was to determine whether clinical, laboratory, and / or radiologic data can improve the prediction of HCC in cirrhotic patients with an arterially‐enhancing mass. Between May 2002 and June 2003, dynamic gadolinium‐enhanced magnetic resonance imaging (MRI) of consecutive patients with liver cirrhosis and a solid mass were reviewed by 2 radiologists blinded to the clinical diagnosis. Clinical, laboratory, and radiologic data were recorded for all patients. A total of 94 patients with cirrhosis and an arterially‐enhancing liver mass were studied, 66 (70%) of whom had HCC. Alpha‐fetoprotein (AFP) >20 ng/mL (P = .029), tumor size >2 cm (P = .0018), and delayed hypointensity (P = .0001) were independent predictors of HCC. Delayed hypointensity of an arterially‐enhancing mass had a sensitivity of 89% and a specificity of 96% for HCC. The presence of delayed hypointensity was the only independent predictor of HCC among patients with arterially‐enhancing lesions <2 cm (odds ratio, 6.3; 95% confidence interval [CI], 1.8‐13), with a sensitivity of 80% and a specificity of 95%. In conclusion, delayed hypointensity of an arterially‐enhancing mass was the strongest independent predictor of HCC, regardless of the size of the lesion. If additional studies confirm our results, the noninvasive criteria utilized to make a diagnosis of HCC should be revised. (Liver Transpl 2005;11:281–289.)

Antibody Microarray Profiling Reveals Individual and Combined Serum Proteins Associated with Pancreatic Cancer

We used antibody microarrays to probe the associations of multiple serum proteins with pancreatic cancer and to explore the use of combined measurements for sample classification. Serum samples from pancreatic cancer patients (n = 61), patients with benign pancreatic disease (n = 31), and healthy control subjects (n = 50) were probed in replicate experiment sets by two-color, rolling circle amplification on microarrays containing 92 antibodies and control proteins. The antibodies that had reproducibly different binding levels between the patient classes revealed different types of alterations, reflecting inflammation (high C-reactive protein, alpha-1-antitrypsin, and serum amyloid A), immune response (high IgA), leakage of cell breakdown products (low plasma gelsolin), and possibly altered vitamin K usage or glucose regulation (high protein-induced vitamin K antagonist-II). The accuracy of the most significant antibody microarray measurements was confirmed through immunoblot and antigen dilution experiments. A logistic-regression algorithm distinguished the cancer samples from the healthy control samples with a 90% and 93% sensitivity and a 90% and 94% specificity in duplicate experiment sets. The cancer samples were distinguished from the benign disease samples with a 95% and 92% sensitivity and an 88% and 74% specificity in duplicate experiment sets. The classification accuracies were significantly improved over those achieved using individual antibodies. This study furthered the development of antibody microarrays for molecular profiling, provided insights into the nature of serum-protein alterations in pancreatic cancer patients, and showed the potential of combined measurements to improve sample classification accuracy.

A Novel Model Measuring the Harm of Transplanting Hepatocellular Carcinoma Exceeding Milan Criteria

No empirical studies have defined the posttransplant survival that would justify expansion of the Milan criteria for liver transplantation of hepatocellular carcinoma. We created a Markov model comparing the survival benefit of transplantation for a patient with >Milan HCC, versus the harm caused to other patients on the waiting list.

SELDI-TOF MS profiling of serum for detection of the progression of chronic hepatitis C to hepatocellular carcinoma†

Proteomic profiling of serum is an emerging technique to identify new biomarkers indicative of disease severity and progression. The objective of our study was to assess the use of surface‐enhanced laser desorption/ionization time‐of‐flight mass spectrometry (SELDI‐TOF MS) to identify multiple serum protein biomarkers for detection of liver disease progression to hepatocellular carcinoma (HCC). A cohort of 170 serum samples obtained from subjects in the United States with no liver disease (n = 39), liver diseases not associated with cirrhosis (n = 36), cirrhosis (n = 38), or HCC (n = 57) were applied to metal affinity protein chips for protein profiling by SELDI‐TOF MS. Across the four test groups, 38 differentially expressed proteins were used to generate multiple decision classification trees to distinguish the known disease states. Analysis of a subset of samples with only hepatitis C virus (HCV)‐related disease was emphasized. The serum protein profiles of control patients were readily distinguished from each HCV‐associated disease state. Two‐way comparisons of chronic hepatitis C, HCV cirrhosis, or HCV‐HCC versus healthy had a sensitivity/specificity range of 74% to 95%. For distinguishing chronic HCV from HCV‐HCC, a sensitivity of 61% and a specificity of 76% were obtained. However, when the values of known serum markers α fetoprotein, des‐gamma carboxyprothrombin, and GP73 were combined with the SELDI peak values, the sensitivity and specifity improved to 75% and 92%, respectively. In conclusion, SELDI‐TOF MS serum profiling is able to distinguish HCC from liver disease before cirrhosis as well as cirrhosis, especially in patients with HCV infection compared with other etiologies. (HEPATOLOGY 2005;41:634–642.)

Two-color, rolling-circle amplification on antibody microarrays for sensitive, multiplexed serum-protein measurements

The ability to conveniently and rapidly profile a diverse set of proteins has valuable applications. In a step toward further enabling such a capability, we developed the use of rolling-circle amplification (RCA) to measure the relative levels of proteins from two serum samples, labeled with biotin and digoxigenin, respectively, that have been captured on antibody microarrays. Two-color RCA produced fluorescence up to 30-fold higher than direct-labeling and indirect-detection methods using antibody microarrays prepared on both polyacrylamide-based hydrogels and nitrocellulose. Replicate RCA measurements of multiple proteins from sets of 24 serum samples were highly reproducible and accurate. In addition, RCA enabled reproducible measurements of distinct expression profiles from lower-abundance proteins that were not measurable using the other detection methods. Two-color RCA on antibody microarrays should allow the convenient acquisition of expression profiles from a great diversity of proteins for a variety of applications.

Lack of Tumor Seeding of Hepatocellular Carcinoma After Percutaneous Needle Biopsy Using Coaxial Cutting Needle Technique

OBJECTIVE The objective of our study was to determine the incidence of tumor seeding after biopsy of hepatocellular carcinoma (HCC) using a coaxial cutting needle technique. Seeding along the needle track is a dreaded complication of percutaneous biopsy in patients with HCC, particularly in potential liver transplant recipients. Reported seeding rates range from 0.6% to 5.1% using various biopsy techniques. To our knowledge, the rate of seeding using a coaxial cutting needle technique has not been reported. MATERIALS AND METHODS Retrospective review identified 128 patients with imaging-guided percutaneous liver biopsies positive for HCC. A coaxial cutting needle technique was uniformly used with a 17-gauge introducer and 18-gauge biopsy needle. Radiology and clinical reports were reviewed, and findings at clinical and imaging follow-up were assessed. RESULTS During the 6-year study period, 1,012 liver mass biopsies were performed, with 128 positive for HCC (100 men and 28 women; average age, 58.4 years). One hundred one patients had more than 30 days of clinical or imaging follow-up (or both) after biopsy (mean, 410 days; range, 33-1,989 days) and constituted the study population. The remaining 27 were excluded because of inadequate follow-up. No suspected or confirmed tumor seeding on imaging, physical examination, or laparotomy was identified. CONCLUSION We found no tumor seeding after percutaneous biopsy of HCC using a coaxial cutting needle technique. This rate, 0%, is lower than those reported with other techniques. The use of a needle introducer that remains in position during multiple cutting needle passes protects normal tissue along the track and may reduce seeding. This has particular importance for patients with stage I-II HCC, for whom liver transplantation may be curative.