R. Tateishi

Proposal of a new prognostic model for hepatocellular carcinoma: an analysis of 403 patients

Background: The prognosis of hepatocellular carcinoma (HCC) is highly dependent on tumour extension and liver function. Recently, two new prognostic scoring systems—the CLIP score, developed by Italian investigators and the BCLC score, developed in Barcelona—have been widely used to assess prognosis in patients presenting with hepatocellular carcinoma. Each system has its own relative limitations. Aims: To create a new prognostic scoring system which is simple, easy to calculate, and suitable for estimating prognosis during radical treatment of early HCC. Methods: A total of 403 consecutive patients with HCC treated by percutaneous ablation at the Department of Gastroenterology, University of Tokyo Hospital, between 1990 and 1997 were used as the training sample to identify prognostic factors for our patients and used to develop the Tokyo score. As a testing sample, 203 independent patients who underwent hepatectomy at the Department of Hepato-Biliary-Pancreatic Surgery were studied. Prognostic factors were analysed by univariate and multivariate Cox proportional hazard regression. Results: The Tokyo score consists of four factors: serum albumin, bilirubin, and size and number of tumours. Five year survival was 78.7%, 62.1%, 40.0%, 27.7%, and 14.3% for Tokyo scores 0, 1, 2, 3, and 4–6, respectively. The discriminatory ability of the Tokyo score was internally validated by bootstrap methods. The Tokyo score, CLIP score, and BCLC staging were compared by Akaike information criterion and Harrell’s c index among training and testing samples. In the testing sample, the predictive ability of the Tokyo score was equal to CLIP and better than BCLC staging. Conclusions: The Tokyo score is a simple system which provides good prediction of prognosis for Japanese patients with HCC requiring radical therapy.

Artificial ascites technique for percutaneous radiofrequency ablation of liver cancer adjacent to the gastrointestinal tract

Percutaneous radiofrequency ablation (RFA) of liver tumours adjacent to the gastrointestinal tract is controversial. This study assessed the value of an intraperitoneal water infusion (artificial ascites) technique for percutaneous RFA of such tumours.

Percutaneous radiofrequency ablation of liver cancer in the hepatic dome using the intrapleural fluid infusion technique

Intrapleural fluid infusion improves ultrasonographic visualization of tumours in the hepatic dome. The aim of this study was to assess the safety and long‐term efficacy of ultrasonographically guided percutaneous radiofrequency ablation for tumours in the hepatic dome with intrapleural infusion.

Sustained viral response prolonged survival of patients with C-viral hepatocellular carcinoma

Abstract: Background: We conducted this retrospective study to evaluate the position of interferon therapy in the curative treatment of hepatitis C virus‐associated hepatocellular carcinoma (HCC).

Extrahepatic biliary obstruction after percutaneous tumour ablation for hepatocellular carcinoma: aetiology and successful treatment with endoscopic papillary balloon dilatation.

Background and aims: Percutaneous tumour ablation (PTA), such as ethanol injection and radiofrequency ablation, is now recognised as a primary treatment for hepatocellular carcinoma (HCC). Although PTA is a relatively safe procedure, it can cause biliary obstruction as a rare complication. As patients with cirrhosis undergoing surgery or endoscopic retrograde cholangiopancreatography/sphincterotomy have a high mortality rate from bleeding, we adopted the use of endoscopic papillary balloon dilatation (EPBD) in these patients and now report the results. We retrospectively analysed the incidence of biliary obstruction after PTA and the efficacy of treatment with EPBD. Patients and methods: A total of 1043 patients with HCC were treated by PTA, of whom 538 were treated with transarterial embolisation with up to eight years of follow up. Results: There were 17 (1.6%) cases of hilar obstruction due to tumour progression and 35 (3.4%) cases of extrahepatic obstruction. Apart from the expected causes of biliary obstruction (haemobilia n = 11, gallstones n = 11, and three miscellaneous causes), we found that 10 patients had obstruction due to biliary casts. This is the first description of biliary casts after percutaneous tumour ablation therapy. Extrahepatic biliary obstruction by procedure related haemobilia occurred within three days of PTA while other causes occurred between 0 and 17 (average 4.9) months. Biliary casts occurred more frequently after ethanol injection than after radiofrequency ablation. EPBD successfully dissipated biliary obstruction in 33 of 35 cases, while two died due to hepatic failure despite successful drainage. Conclusions: Extrahepatic biliary obstruction is an uncommon complication after PTA for HCC, and can be safely and effectively treated with EPBD, despite impaired liver function.

Influence of anti‐HBc seropositivity on the risk of hepatocellular carcinoma in HCV‐infected patients after adjusting for confounding factors

Summary.  It is controversial whether past hepatitis B virus infection constitutes an additional risk of hepatocellular carcinoma (HCC) among patients with hepatitis C virus (HCV). The incidence of HCC between 1994 and 2004 was analysed among 1262 patients who were only positive for HCV. The cumulative incidence of HCC was assessed by Kaplan–Meier analysis and the difference between two groups was assessed by the log‐rank test. The effect of anti‐HBc positivity on the risk of HCC was assessed with multivariate Cox proportional analysis. Anti‐HBc was positive in 522 (41.4%) patients. The proportion of male patients (56.7 vs 46.8%, P < 0.001) and mean age (60.8 vs 56.9 years, P < 0.001) were significantly higher in the anti‐HBc positive group. HCC developed in 339 patients (mean follow‐up 7.0 years), with cumulative incidence rates at 3, 5 and 10 years of 12.7, 24.5 and 41.9% in the anti‐HBc positive group and 10.6, 17.7 and 33.4% in the negative group, respectively (P = 0.005). However, anti‐HBc seropositivity did not reach statistical significance in multivariate analysis including age and gender (hazard ratio, 1.06; 95% CI, 0.85–1.31; P = 0.63). Anti‐HBc positivity and HCC incidence were confounded by male gender and older age.

703 MITOCHONDRIAL ISOENZYME OF CREATINE KINASE IS A NOVEL SERUM PREDICTIVE MARKER FOR HEPATOCARCINOGENESIS IN CHRONIC VIRAL HEPATITIS

VEGF −634 GG and GC genotypes as well as +936 CT and TT genotypes are significantly associated with higher levels of VEGF (p =0.01 and 0.000, respectively). A significant positive correlation was observed between serum VEGF and tumor size (r = 0.573, p =0.000), multiple tumor masses (r = 0.564, p =0.004), and AFP (r = 0.623, p =0.000). Conclusion: Serum VEGF and both +936 and −634 gene polymorphisms have the potential to be useful biomarkers for prognosis of HCC Egyptian patients.

651 THE MORTALITY AND COMPLICATION RATES OF HEPATECTOMY, RADIOFREQUENCY ABLATION, AND TRANS-CATHETER ARTERIAL EMBOLIZATION FOR LIVER TUMORS: ANALYSIS OF JAPANESE NATIONWIDE DATABASE

months [5.5–20.8]) and extra-hepatic spread (no EHD vs. EHD: 10.2 [8.2–11.7] vs. 7.4 months [4.3–13.1]) but these differences were not statistically significant (p = 0.926 and p=0.137, respectively). Survival was similar by Child–Pugh class (‘A’ vs. ‘B’: 9.7 [8.2– 13.1] vs. 10.0 months [6.1–14.5]; p = 0.668); but differed by number of nodules 1.5mg/dL (8.3 [5.5–10.3] vs. 10.4 months [7.6–13.1]; p = 0.009). Fatigue was common postradioembolisation (112 patients; 61.2%), mostly as grade 1 (84.9% of cases), and affected a significantly higher proportion with ECOG ‘1’–‘2’ than ECOG ‘0’ (69.9% vs. 27.0%; p < 0.001). Other AEs included: nausea and/or vomiting (31.0%); abdominal pain (28.4%), fever (12.0%) and gastrointestinal ulcer (4.4%). Grade 3/4 changes in bilirubin were observed in 6.0% of patients (p = 0.002). No other significant changes were observed in LFTs including: albumin, prothrombin, ALT and platelet counts. Conclusions: Radioembolisation was well-tolerated in patients with BCLC ‘C’ disease with no significant differences for the defining characteristics (PVO, PS, and EHD).

1013 IMPACT OF NEWLY DEVELOPED HIGH-SENSITIVE (I-FETOPROTEIN-L3 FRACTION ASSAY ON THE DIAGNOSIS AND TREATMENT EVALUATION OF HEPATOCELLULAR CARCINOMA

1012 HEPATOCELLULAR CARCINOMA IN JAPANESE PATIENTS WITH NONALCOHOLIC FATTY LIVER DISEASE, ALCOHOLIC LIVER DISEASE AND CHRONIC LIVER DISEASE OF UNKNOWN ETIOLOGY: REPORT OF THE NATIONWIDE SURVEY M. Taniai, E. Hashimoto, K. Tokushige, K. Kodama, T. Kogiso, N. Torii, K. Shiratori. Internal Medicine, Institute of Gastroenterology, Tokyo Women’s Medical University, Tokyo, Japan E-mail: taniai@ige.twmu.ac.jp

601 CLINICAL FEATURES OF ADVANCED HEPATOCELLULAR CARCINOMA WITH EXTRAHEPATIC METASTASIS

Background and Aims: Despite great advances in treatment for intrahepatic lesions, prognosis of hepatocellular carcinoma (HCC) with extrahepatic metastasis is still poor. The aim of this study is to elucidate exact clinical courses of such patients, especially on prognosis determinants. Methods: We enrolled a total of 342 patients with extrahepatic metastasis of HCC diagnosed at the authors’ department between 1990 and 2006. Extrahepatic metastasis was diagnosed at the time of initial diagnosis of HCC in 28 patients and during the follow-up in the remaining 314. We analyzed their clinical features, prognosis, and treatments. Results: The sites of extrahepatic metastasis were as follows: lung in 135 (35.9%), lymph node in 117 (31.1%), bone in 87 (23.1%), adrenal gland in 30 (8.0%), brain in 4 (1.1%), spleen in 2 (0.5%), and mamma in 1 (0.3%). 228 (66.7%) patients received treatments for extrahepatic metastasis including surgical resection, chemotherapy, irradiation, transcatheter arterial chemoembolization, and percutaneous ablation. During the observation period 301 patients (88.0%) died. The cause of death was related to tumor progression in 273 (90.7%), liver dysfunction in 15 (5.0%), and liver-unrelated in 13 (4.3%). Extrahepatic metastasis was directly related to death in 23 cases (7.6%): 17 cases died of respiratory failure due to lung metastasis, 5 cases died of cerebral hemorrhage from brain metastasis, and 1 case of bone metastasis died of liver failure caused by hemorrhage from bone fracture due to bone metastasis. The median survival time after diagnosis of metastasis was 8.1 (range 0.03–108.7) months. Among the sites of metastasis, adrenal gland (P = 0.032) and lung (P = 0.035) were related to better and poor prognosis, respectively. Univariate analysis with Cox proportional hazard model revealed that number of intrahepatic lesions, presence of vascular invasion, Child–Pugh classification, AFP, AFP-L3 and DCP were significantly associated with poor prognosis. In multivariate analysis, number of intrahepatic lesions, presence of vascular invasion, Child– Pugh classification, AFP and adrenal metastasis retained statistical significance. Conclusions: The prognosis of advanced HCC patients with extrahepatic metastasis depends on the extent of intrahepatic lesion rather than extrahepatic lesion itself. Treatment to intrahepatic lesions may not be discouraged.