Yukio Osaki

Prognostic staging system for hepatocellular carcinoma (CLIP score): its value and limitations, and a proposal for a new staging system, the Japan Integrated Staging Score (JIS score)

A clinical staging system for cancer patients provides guidance for patient assessment and making therapeutic decisions. It is useful in deciding whether to treat a patient aggressively, and in avoiding the overtreatment of patients who would not tolerate the treatment or patients whose life expectancy rules out any chance of treatment. Clinical staging is also an essential tool for comparison between groups in therapeutic trials and for comparison between different studies. The current classifications most commonly used for hepatocellular carcinoma (HCC) are the Okuda stages, the Child-Pugh staging system, tumor node metastasis (TNM) staging, and the Cancer of the Liver Italian Program (CLIP) score. Among these, the CLIP score is currently the most commonly used integrated staging score, including both tumor stage and liver disease stage. Although the CLIP score has been well validated by many authors in terms of its prognostic value in HCC patients, this score has some problems and limitations when applied to currently diagnosed HCC patients, who are diagnosed in the early stage of disease. First, the CLIP score can discriminate score 0- to 3-patient populations, but it is not able to discriminate score 4- to 6-patient groups. Second, the definition of tumor morphology in the best prognostic group is too advanced, i.e., uninodular and a tumor extent of less than 50% of the liver. As a result, the prognosis of the CLIP system best prognostic group is not so good. In other words, this system cannot identify the best prognostic group who would benefit from curative and aggressive treatment. Third, nearly 80% of the patient population is classified as having a CLIP score of 0–2, as confirmed by many studies, which shows poor stratification ability. In contrast, a new staging system based on the Liver Cancer Study Group of Japan (LCSGJ), the Japan Integrated Staging (JIS) score is currently proposed in Japan. This staging system combines Child-Pugh grade (grade A, score 0; grade B, score 1; grade C, score 2) and TNM staging by the LCSGJ criteria (stage I, score 0; stage II, score 1; stage III, score 2; stage IV, score 3). The stratification ability of the JIS scoring system is much better than that of the CLIP scoring system. The JIS scoring system also performed better than the CLIP scoring system in selecting the best prognostic patient group. The cumulative 10-year survival rates of the best prognostic groups in the CLIP staging system (CLIP score 0) and JIS staging system (JIS score 0) were 23% and 65%, respectively (P < 0.01). All scoring systems arise as a compromise between simplicity and discriminatory ability. We confirmed that the JIS score increases predictive efficacy, while remaining simple compared with the CLIP score. Because the JIS score is quite easily obtained and is objective, we strongly propose it for widespread use as a prognostic staging system for HCC in clinical practice.

Validation of a New Prognostic Staging System for Hepatocellular Carcinoma: the JIS Score Compared With the CLIP Score

The Japan Integrated Staging score (JIS score), which combines the Child‐Turcotte‐Pugh classification and tumor‐node‐metastasis staging, has been proposed as a better prognostic staging system for hepatocellular carcinoma (HCC) than the Cancer of the Liver Italian Program (CLIP) scoring system. In this study, validation was performed among a larger patient population. A total of 4,525 consecutive patients with HCC who had been diagnosed at five institutions were included. Stratification ability, prognostic predictive power, and reproducibility were analyzed and compared with results from the CLIP scoring system. Only 45% (1,951 of 4,525) of all patients were categorized as early stage HCC according to JIS score (0 or 1), whereas 63% (2,878 of 4,525) of the patients were categorized as having a CLIP score of 0 or 1. Significant differences in survival curves were not observed among CLIP scores 3 to 6. In contrast, survival curves showed significant differences among all the JIS scores. The same JIS scoring subgroups showed a similar prognosis, and good internal reproducibility was observed in each of the institutions. Multivariate analysis of the prognosis in all 4,525 patients proved the JIS score to be the best prognostic factor. Furthermore, the Akaike information criteria proved that the JIS scoring system was statistically a better model for predicting outcome than the CLIP scoring system. In conclusion, the stratification ability and prognostic predictive power of the JIS score were much better than that of the CLIP score and were simple to obtain and remember. (HEPATOLOGY 2004; 40:1396–1405.)

Multicenter prospective analysis of newly diagnosed hepatocellular carcinoma with respect to the percentage of Lens culinaris agglutinin-reactive α-fetoprotein1

Background and Aim: The Lens culinaris agglutinin‐reactive fraction of α‐fetoprotein (AFP‐L3) has been reported to be a highly useful marker for hepatocellular carcinoma (HCC) compared with a conventional serum AFP concentration, which allows earlier detection of HCC compared with using other imaging modalities and predicting prognosis after therapy. A collaborative prospective study involving nine Japanese hospitals was conducted to analyze the relationships between the tumor characteristics of a HCC patient and the percentage of AFP‐L3/AFP total at the initial detection.

Antibody to hepatitis B core antigen and risk for hepatitis C-related hepatocellular carcinoma : A prospective study

Context Retrospective studies suggest that exposure to hepatitis B virus (HBV) may contribute to the development of hepatocellular carcinoma (HCC) in hepatitis C virus (HCV)positive patients with cirrhosis. Contribution These investigators prospectively studied patients with chronic HCV infection and evidence of occult HBV infection (negative results for hepatitis B surface antigen and HBV DNA but positive results for antibody to hepatitis B core antigen [anti-HBc] on serologic testing). Patients with HCV-related cirrhosis and positive results for anti-HBc on serologic testing were at high risk for HCC. Anti-HBc positivity was associated with increased risk for HCC, even in patients with a virologic response to interferon therapy. Caution The effect of alcohol cannot be fully assessed because of the small number of study patients who drank moderately. Implication Anti-HBc serologic testing may be a valuable indicator of special risk for HCC in patients with HCV-related cirrhosis. The Editors Hepatocellular carcinoma (HCC) is one of the most common types of cancer worldwide, and its incidence has been increasing (1, 2). In Japan, an endemic area for hepatitis B virus (HBV) and hepatitis C virus (HCV), it is well known that more than 75% of cases of HCC are attributable to HCV-related chronic liver disease, and nearly 15% are attributable to HBV-related liver disease (3). Several reports have focused on the clinical role of HBV as a unique infection, in which HBV DNA is detectable in the liver despite the absence of serum hepatitis B surface antigen (HBsAg) (46). It is increasingly recognized that after a person is exposed to HBV, infection persists in the liver for a prolonged period (710). This unique persistent infection, known as occult (or latent) HBV infection, is characterized by HBV DNA in the liver but no HBsAg in the serum (1113). In most cases, antibody to hepatitis B core antigen (anti-HBc) is detectable, and thus anti-HBc is believed to be a surrogate marker for latent carriers (14). In fact, we recently showed that HBV infection invariably occurred through grafts from anti-HBcpositive donors in HBV-naive recipients through living-donor liver transplantation (15). In addition to our data, other reports showing frequent HBV transmission from anti-HBcpositive cadaveric donors to recipients indicate that most healthy persons who are positive for anti-HBc, even at low titers, have latent HBV infection in liver tissue (11, 1618). Indeed, we have shown that most anti-HBcpositive healthy persons have a latent episomal form of HBV infection accompanied by ongoing viral replication (19, 20). In contrast, the prevalence of latent HBV infection in anti-HBcpositive patients with HCV-related chronic liver disease, including chronic hepatitis, cirrhosis, and HCC, remains controversial (21). However, several reports have revealed that the HBV genome is frequently detectable in liver tumors in anti-HBcpositive, HBsAg-negative patients with HCV-related liver disease, which suggests that occult HBV infection may contribute to the progression of liver damage and the development of HCC in HCV-positive patients (14, 2227). In a large-scale retrospective study of the prevalence of anti-HBc among 2014 patients with chronic HCV infection, we found that nearly 50% of patients with HCV-related liver disease had anti-HBc (28). Moreover, we found a strong correlation between the prevalence of anti-HBc and the clinical progression of liver disease. The prevalence of anti-HBc was approximately 60% in patients with HCV-related HCC (28). This high prevalence of anti-HBc in HCV-positive patients, particularly those with HCC, strongly suggests that previous exposure to HBV plays an important role in the development of HCC in patients with HCV-related chronic liver disease. Therefore, we performed a prospective study to determine whether previous exposure to HBV affects the clinical course, especially in development of HCC, in patients with chronic HCV infection. Methods Patients Patients with chronic HCV infection who presented to Kyoto University, Kyoto, Japan, and 14 affiliated core hospitals from May 1995 to June 1995 were enrolled. To be eligible, patients had to have serologically confirmed HCV infection without HBsAg and HBV DNA in sera. All patients had been followed with biochemical tests, including -fetoprotein, and ultrasonography or computed tomography (CT) every 3 to 6 months before and after enrollment. We excluded patients who had elevated -fetoprotein levels or those in whom HCC had been diagnosed before enrollment. As a result, 872 patients with chronic HCV infection were enrolled. We discontinued follow-up in patients who moved from the study districts but included their clinical data until they moved. The end of follow-up was defined as the date of diagnosis of HCC, date of death, date of move from the study district, or the closing date of the study (15 May 2005). A total of 384 patients were classified into the hepatitis group or cirrhosis group on the basis of histologic findings on liver biopsy. The differential diagnosis of cirrhosis or hepatitis was made in the remaining 488 patients by using the cirrhosis discriminant score (29, 30). This score is based on 3 laboratory variables: platelet count, alanine aminotransferaseaspartate aminotransferase ratio, and prothrombin time. It has been shown to be highly sensitive in identifying cirrhosis in patients with HCV infection. In accordance with the original definition, patients with a high score (8) were classified into the cirrhosis group. Patients with ascites confirmed by ultrasonography or CT or previous variceal bleeding were given a diagnosis of cirrhosis, regardless of their score, because these findings are strong indicators of portal hypertension and most likely cirrhosis. As a result, 597 (68.5%) patients had a diagnosis of chronic hepatitis and 275 (31.5%) patients had a diagnosis of cirrhosis at the time of enrollment. The patients had regular clinical assessments, biochemical tests, and ultrasonography or CT of the liver every 3 to 6 months during the follow-up period. Patients were stratified into 3 categories according to their smoking habits: nonsmokers, light smokers who smoked fewer than 20 pack-years, and heavy smokers who smoked 20 pack-years or more. Similarly, we stratified patients into 3 categories according to their drinking habits: nondrinkers, moderate drinkers with an average ethanol intake less than 30 g/d, and heavy drinkers with an average ethanol intake greater than 30 g/d. Information on average alcohol intake was based on the patients drinking habits during the 15 years before study entry. All patients provided informed consent to participate in the study, and the study was designed in accordance with the Declaration of Helsinki (31). Serologic Studies At study entry, serum samples from each patient were tested for serologic markers of HCV. Detection of HBsAg, anti-HBc, and antibody to hepatitis B surface antigen (anti-HBs) was performed by using commercial enzyme immunoassay kits (Dainabot, Tokyo, Japan) (28). Results of the anti-HBc assays were expressed as the percentage of inhibition, and the specimen was considered to be anti-HBc positive when the percentage of inhibition was greater than 50% (19). Detection of HBV DNA was done by using DNA probe assay (32). Anti-HCV was assessed by using second-generation assays (Dainabot) (28). Serum HCV RNA levels were determined in 254 patients by using a competitive reverse transcriptionpolymerase chain reaction assay, and positivity of HCV RNA was confirmed in all patients who were examined at study entry (33). History of Interferon Therapy Of the 576 patients with chronic hepatitis, 224 had a history of interferon therapy. One hundred ninety-two patients received 5 to 10 million U of interferon- intramuscularly every day for the first 2 weeks and then 3 times weekly for the following 22 weeks. The remaining 32 patients were treated with 3 to 6 million U of interferon- intravenously every day for 8 weeks. No patient received pegylated interferon or combination therapy with ribavirin. Patients who received interferon were divided into 3 groups based on their virologic response to therapy. Patients with a sustained virologic response were defined as those with no detectable HCV RNA by qualitative assay at least 24 weeks after cessation of therapy. Patients with relapse were defined as those with disappearance of viremia at the end of treatment followed by reappearance of viremia with 24 weeks. Nonresponders included patients whose serum HCV RNA remained positive during therapy. Statistical Analysis The incidence rates for HCC are expressed as the number of HCC cases per 1000 person-years. Incidence rate ratios were calculated by dividing rates, and the exact 95% CIs for the rate ratios were calculated on the basis of a binomial distribution, which is a conditional distribution for 2 independent Poisson distributions. The Cox proportional hazards model was used to calculate the incidence rate ratios for the association between HBc seropositivity and HCC incidence. The multivariate model, with adjustment for potential risk factors, included male sex, age, alcohol intake (none, 0 to 30 g/d, and 30 g/d), smoking (none, 0 to 20 pack-years, and 20 pack-years), and history of interferon therapy (yes or no). The associated 95% Wald CIs were calculated. Analyses were done by using PC-SAS, version 8.2 (SAS Institute, Inc., Cary, North Carolina) and JMP, version 4.0 (SAS Institute, Inc.). Role of the Funding Source The Japan Society for the Promotion of Science provided funding for the study. The funding source had no role in the collection, analysis, or interpretation of the data or in the decision to submit the paper for publication. Results Characteristics of Patients at Enrollment We followed 846 of the 872 enrolled patients. The remaining 26 patients were excluded from the analysis. Twenty-on

Genetic heterogeneity of hepatitis C virus in association with antiviral therapy determined by ultra-deep sequencing.

Background and Aims The hepatitis C virus (HCV) invariably shows wide heterogeneity in infected patients, referred to as a quasispecies population. Massive amounts of genetic information due to the abundance of HCV variants could be an obstacle to evaluate the viral genetic heterogeneity in detail. Methods Using a newly developed massive-parallel ultra-deep sequencing technique, we investigated the viral genetic heterogeneity in 27 chronic hepatitis C patients receiving peg-interferon (IFN) α2b plus ribavirin therapy. Results Ultra-deep sequencing determined a total of more than 10 million nucleotides of the HCV genome, corresponding to a mean of more than 1000 clones in each specimen, and unveiled extremely high genetic heterogeneity in the genotype 1b HCV population. There was no significant difference in the level of viral complexity between immediate virologic responders and non-responders at baseline (p = 0.39). Immediate virologic responders (n = 8) showed a significant reduction in the genetic complexity spanning all the viral genetic regions at the early phase of IFN administration (p = 0.037). In contrast, non-virologic responders (n = 8) showed no significant changes in the level of viral quasispecies (p = 0.12), indicating that very few viral clones are sensitive to IFN treatment. We also demonstrated that clones resistant to direct-acting antivirals for HCV, such as viral protease and polymerase inhibitors, preexist with various abundances in all 27 treatment-naïve patients, suggesting the risk of the development of drug resistance against these agents. Conclusion Use of the ultra-deep sequencing technology revealed massive genetic heterogeneity of HCV, which has important implications regarding the treatment response and outcome of antiviral therapy.

Diagnostic Accuracy of Imaging for Liver Cirrhosis Compared to Histologically Proven Liver Cirrhosis

Objective: To evaluate the diagnostic accuracy of liver cirrhosis by imaging modalities, including CT, MRI and US, compared to results obtained from histopathological diagnoses of resected specimens. Materials and Methods: CT, MRI and US examinations of 142 patients with chronic liver disease who underwent surgery for complicated hepatocellular carcinoma (<3 cm in diameter) in 10 institutions were blindly reviewed in a multicenter study by three radiologists experienced in CT, MRI and US. The images were evaluated for five imaging parameters (irregular or nodular liver surface, blunt liver edge, liver parenchymal abnormalities, liver morphological changes and manifestations of portal hypertension) using a severity scale. The diagnostic imaging impression score was also calculated. Patients were histologically classified into chronic hepatitis (CH; n = 54), liver cirrhosis (LC; n = 71) and pre-cirrhosis (P-LC; n = 17) by three pathologists, independently, who reviewed the resected liver specimens. The results of the three imaging methods were compared to those from histological diagnoses, and a multivariate analysis (stepwise forward logistic regression analysis) was performed to identify independent predictive signs of cirrhosis. The diagnostic efficacies for LC and early cirrhosis were also compared among CT, MRI and US using a receiver-operating characteristic (ROC) curve analysis. Results: The differences in the five imaging parameters evaluated by CT, MRI and US between LC and CH were statistically significant (p < 0.001) except for the manifestations of portal hypertension on US. Irregular or nodular surface, blunt edge or morphological changes in the liver were selected as the best predictive signs for cirrhosis on US whereas liver parenchymal abnormalities, manifestations of portal hypertension and morphological changes in the liver were the best predictive signs on MRI and CT by multivariate analysis. The predictive diagnostic accuracy, sensitivity and specificity in discriminating LC from CH based on the best predictive signs were 71.9, 77.1 and 67.6% by CT; 67.9, 67.5 and 68.3% by MRI, and 66.0, 38.4 (lower than CT and MRI, p =0.001) and 88.8% (higher than CT and MRI, p =0.001)by US. According to the imaging impression scoring system, diagnostic accuracy, sensitivity and specificity were 67.0, 84.3 and 52.9% by CT; 70.3, 86.7 and 53.9% by MRI, and 64.0, 52.4 (lower than CT and MRI, p =0.0001) and 73.5% (higher than CT and MRI, p < 0.003) by US. ROC analysis showed that MRI and CT were slightly superior to US in the diagnosis of LC but no statistically significant difference was found between them. For the pathological diagnosis of P-LC, cirrhosis was diagnosed in 59.5, 46.7 and 41.7% of the P-LC cases by US, CT and MRI, respectively, with no significant difference among these methods. Conclusion: US, CT and MRI had different independent predictive signs for the diagnosis of LC. MRI and CT were slightly superior to US in predicting cirrhosis, especially regarding sensitivity. Noninvasive imaging techniques play an important role in the diagnosis of cirrhosis, especially in the evaluation of P-LC.

High prevalence of anti-hepatitis B virus serological markers in patients with hepatitis C virus related chronic liver disease in Japan

BACKGROUND/AIMS Evidence is accumulating that hepatitis B virus (HBV) is present in patients who are hepatitis B surface antigen negative but have antibody to hepatitis B core antigen (anti-HBc). Furthermore, recent studies have shown that patients with hepatocellular carcinoma who have antibody to hepatitis C virus (HCV) often possess HBV related serological markers. Data on the seroprevalence of HBV infection in patients with HCV related chronic liver disease were collected to evaluate the significance of the presence of antibodies to HBV. METHODS The prevalence of HBV related serological markers was analysed in a total of 2014 Japanese patients with HCV infection. The control group comprised 352 subjects without liver disorder. RESULTS A large number of patients (49.9%) with HCV related chronic liver disease including hepatocellular carcinoma were positive for anti-HBc. In addition, the prevalence of anti-HBc closely correlated with the clinical stage of the liver disease. There was no relation between a past history of blood transfusion and the prevalence of anti-HBc. Notably, anti-HBc was the only serological marker for HBV infection in a significant number of patients with HCV related chronic liver disease (24.1%). CONCLUSIONS Our data provide further evidence for the high prevalence of anti-HBc in patients with HCV related chronic liver disease, particularly those with hepatocellular carcinoma, suggesting that HBV infection, probably including latent infection, may play an important role in carcinogenesis in these patients.

Prognostic value of pretreatment levels of tumor markers for hepatocellular carcinoma on survival after curative treatment of patients with HCC

BACKGROUND/AIMS We evaluated the prognostic value of the pretreatment elevation of tumor markers for hepatocellular carcinoma (HCC) in patients who underwent curative treatment. METHODS We studied 801 patients who had been diagnosed as initial HCC and fulfilled the following criteria: maximum tumor size, < or = 3 cm; number of tumors, < or = 3; remnant liver function, Child-Pugh class A or B; treated by hepatectomy or locoregional thermal ablation (LTA); and alpha-fetoprotein (AFP), Lens culinaris agglutinin A-reactive fraction of AFP (AFP-L3), and des-gamma carboxy prothrombin (DCP) were measured at diagnosis. We analyzed the effects of elevated tumor markers on patient survival in these 2 distinct groups with different types of treatment, i.e. hepatectomy and LTA. RESULTS By multivariate analysis in 345 patients who underwent hepatectomy, no tumor marker significantly affected decreased survival rate. In the 456 patients who underwent LTA, the elevation of AFP-L3 (p=0.0171) and DCP (p=0.0004) significantly affected decreased survival rate; DCP elevation had the strongest effect on patient survival. CONCLUSIONS The prognostic value of pretreatment tumor marker elevation was different in patients who underwent the curative treatment according to the type of treatment. Pretreatment elevation of AFP-L3 and DCP had prognostic values only in patients treated with LTA.

Severe Complications of Radiofrequency Ablation Therapy for Hepatocellular Carcinoma: An Analysis of 3,891 Ablations in 2,614 Patients

Objective: To clarify information on and frequency of complications as well as mortality rate after radiofrequency ablation (RFA) for hepatocellular carcinoma.Methods: The results of a questionnaire obtained mainly from members of the Osaka Liver Cancer Study Group at 43 departments of 38 facilities were analyzed in order to clarify the current status of RFA, and information on and frequency of complications and death occurring after RFA. Results: Between January 1999 and May 2002, a total of 3,891 RFA therapies were performed percutaneously in 2,542 patients, laparoscopically in 23, and operatively in 49 (2,614 patients in total). Complications were observed in 207 of 2,614 patients (7.9%), and 9 (0.3%) died within 3 months after RFA. Among these 9 nonsurvivors, 3 had liver failure, 3 rapid progression and sarcomatous changes, 1 biliary injury, 1 gastrointestinal bleeding, and 1 acute myocardial infarction. The departments that treated larger numbers of patients per month had a smaller number of complications and deaths. Conclusion: It is possible that complications of RFA can be reduced by gathering experience.

Effect of vitamin K2 on the recurrence of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is characterized by frequent recurrence, even after curative treatment. Vitamin K2, which has been reported to reduce HCC development, may be effective in preventing HCC recurrence. Patients who underwent curative ablation or resection of HCC were randomly assigned to receive placebo, 45 mg/day, or 90 mg/day vitamin K2 in double‐blind fashion. HCC recurrence was surveyed every 12 weeks with dynamic computed tomography/magnetic resonance imaging, with HCC‐specific tumor markers monitored every 4 weeks. The primary aim was to confirm the superiority of active drug to placebo concerning disease‐free survival (DFS), and the secondary aim was to evaluate dose‐response relationship. Disease occurrence and death from any cause were treated as events. Hazard ratios (HRs) for disease occurrence and death were calculated using a Cox proportional hazards model. Enrollment was commenced in March 2004. DFS was assessed in 548 patients, including 181 in the placebo group, 182 in the 45‐mg/day group, and 185 in the 90‐mg/day group. Disease occurrence or death was diagnosed in 58, 52, and 76 patients in the respective groups. The second interim analysis indicated that vitamin K2 did not prevent disease occurrence or death, with an HR of 1.150 (95% confidence interval: 0.843‐1.570, one‐sided; P = 0.811) between the placebo and combined active‐drug groups, and the study was discontinued in March 2007.