Journal of Liver Cancer

Volume 13(1); February 2013

Review Articles

Emergencies in Patients with Hepatocellular Carcinoma: Chang Wook Kim, Chang Don Lee; Journal of the Korean Liver Cancer Study Group. 2013;13(1):1-7. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.1

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Abstract PDF: Patients with hepatocellular carcinoma (HCC) may be suffered by various emergency conditions such as spontaneous rupture of HCC with intraperitoneal hemorrhage, variceal bleeding with portal vein tumor thrombus, hemobilia, obstructive jaundice, distant metastasis of HCC in central nervous system, spinal bone metastasis of HCC with cord compression and so on. These emergencies can be categorized into 4 types, conditions with spontaneous rupture of HCC, distant metastasis of HCC, direct invasion of HCC and paraneoplastic syndrome. According to HCC status and liver function, some these patients showed more beneficial effects with active palliative treatments than with best supportive cares. Various palliative treatments can be used such as surgical resection, transarterial chemoembolization, radiotherapy, systemic chemotherapy and combination of above therapies. We reviewed the emergencies in patients with HCC for improving survival and quality of life.

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.

Directions for Future Hepatocellular Carcinoma Treatment Guidelines; Surgeon’s Perspective: Extension of Surgical Indication: Dong-Sik Kim; Journal of the Korean Liver Cancer Study Group. 2013;13(1):14-17. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.14

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Abstract PDF: Since the second edition of practice guidelines for management of hepatocellular carcinoma in 2009, several other organizations have added newer versions of guidelines. It must be a good opportunity to review trends in changes of recent guidelines focusing on surgical filed. At the same time, issues that have been suggested or discussed so far regarding Korean guidelines will be discussed.

Systemic Cytotoxic Therapy in Advanced HCC: Seung Tae Kim, Yeul Hong Kim; Journal of the Korean Liver Cancer Study Group. 2013;13(1):18-21. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.18

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Abstract PDF: Hepatocellular carcinoma (HCC) is an aggressive tumor that occurs in chronic liver disease and cirrhosis. Surgical therapy including transplantation or local ablation may offer the prospect of cure. However, most patients were diagnosed with unresectable, advanced disease. For these patients, providing liver function and performance status permit, systemic therapies are often used with palliative intent. Although recently molecular targeted therapies have been employed with some success, cytotoxic chemotherapy had been used in general. Efficacy with conventional cytotoxic chemotherapy is modest at best, and the duration of benefit is limited. Although few randomized trials have been conducted, no single regimen has emerged as superior to any other, and no drug or regimen has been unequivovally shown to improve survival.

Staging Systems of HCC: SoonHo Um; Journal of the Korean Liver Cancer Study Group. 2013;13(1):22-43. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.22

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Abstract PDF: A well-designed staging system of cancer is an essential tool for assessing the prognosis of patients and establishing therapeutic plan, and for comparing the effect of various anti-cancer therapeutic modalities. To date, many (at least 15) staging schemes have been developed for hepatocellular carcinoma (HCC). It remains, however, which system fits best to stratify the patients with HCC according to the survival and therapeutic plan. In this review article, the staging systems for HCC were explained in detail and the results of many studies that had compared the predictive powers of staging systems of HCC were described, including the studies performed in our institution. In summary, TNM staging systems remains to be a mainstay of tumor staging for classifying the tumor extent and anatomic progression of HCC, although they are inferior to clinical staging systems in terms of predictive power. In the current clinical situations, in which TNM staging of HCC is generally determined by imaging studies because a majority of HCC patients are treated by nonsurgical treatment, the modified 5th UICC TNM system for HCC devised by liver cancer study group of Japan appears to be more competent than the AJCC TNM systems for HCC. Child-Pugh classification is still useful for evaluating the severity of liver dysfunction of patients with HCC. BCLC staging have the highest prognostic power among various clinical staging systems for HCC, especially in patients with early and intermediate stage of HCC that can be subject to curative or palliative treatment. In addition, BCLC staging can offer the general guideline for therapeutic plan. However, a more sophisticated staging system will be required for accurate prediction of survival and for proper planning of treatment.

Assessment of Tumor Characteristic with Imaging: Young Kon Kim; Journal of the Korean Liver Cancer Study Group. 2013;13(1):44-47. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.44

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Abstract PDF: Magnetic resonance imaging (MRI) has a strongpoint in the detection and characterization of hepatic tumor as it provides multiparametric information. With active implementation of a surveillance program for high-risk hepatocellular carcinoma patients, early hepatocellular carcinoma or cholangiocarcinoma with atypical vascular pattern is being detected with increasing frequency. Therefore, in daily practice, it is challenging to differentiate atypical HCC from dysplastic nodule, hypervascular cholangiocarcinoma and focal nodular hyperplasia-like nodules. Gadoxetic acid and diffusion-weighted imaging has opened new horizons for liver MRI with promising results for liver lesion detection and characterization. Combined both has the potential to be robust liver MR protocol in that it is targeting three processes of hepatic carcinogenesis-hemodynamic changes, hepatocyte function, and tissue diffusivity. In that sense, liver MRI has the potency to fulfill the above two-fold requirement in a more satisfactorily than other liver imaging modalities.

Genomic Heterogeneity of Hepatocellular Carcinomas: Hyun Goo Woo; Journal of the Korean Liver Cancer Study Group. 2013;13(1):48-50. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.48

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Abstract PDF: Hepatocellular carcinoma (HCC) and cholangiocarcinoma (CC) are major primary liver cancers in adults, comprising liver cancer spectrum. The existence of combined hepatocellular-cholangiocarcinoma (CHC), a histopathologic intermediate form between HCC and CC, suggests phenotypic overlap between these tumors. By applying an integrative oncogenomic approach, we identified a novel HCC subtype, i.e., cholangiocarcinoma-like HCC (CLHCC), which expressed cholangiocarcinoma-like traits (CC signature). In addition, we found that CLHCC coexpressed embryonic stem cell–like expression traits (ES signature) suggesting its derivation from bipotent hepatic progenitor cells. Further histopathological evaluation revealed a variant HCC with fibrous stromal component, i.e. scirrhous HCC, has CC-like genomic features, suggesting that the fibrous stromal component in HCC may contribute to the acquisition of CC-like gene expression trait in HCC. Our integrative analysis combining histopathological and genomic data would be a powerful approach to delineate the tumor heterogeneity.

Case Reports

A Case of Successful Treatment by Radiofrequency Ablation for Pulmonary Metastasis of Hepatocellular Carcinoma: Jae Chan Park, Yun Soo Kim, Young Kul Jung, Myung Hee Kang, Oh Sang Kwon, Duck Joo Choi, Yang Suh Ku, Ju Hyun Kim; Journal of the Korean Liver Cancer Study Group. 2013;13(1):51-56. Published online February 28, 2013; DOI: https://doi.org/10.17998/jlc.13.1.51

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Abstract PDF: Surgical resection or liver transplantation is a main curative modality for hepatocellular carcinoma (HCC). But nowadays local ablation therapy is being accepted as a useful option for local control therapy for HCC. Here we present a case of 59 years old male with hepatitis B virus related liver cirrhosis, who underwent surgery for HCC at S6 two years ago. He had received percutaneous ethanol injection (PEI), radiofrequency ablation (RFA) and multiple sessions of transarterial chemoembolization (TACE) for intrahepatic recurrences of HCC after surgery. A small radio-opaque lesion occurred at the left upper lobe of lung. Metastatic HCC was confirmed by CT-guided percutaneous needle core biopsy. CT-guided RFA for pulmonary metastasis was performed. Now it is been 11 months after the treatment without any recurrence.

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.

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 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.

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 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 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.

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