European Radiology: How to predict preoperative recurrence in hepatocellular carcinoma? The perfect combination of imaging and clinical

Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related death and is increasing worldwide
.
At this stage, hepatectomy is a potential curative treatment for patients with resectable HCC and intact liver function.

Consistent with the Barcelona Clinical Liver Cancer (BCLC) staging system, Western guidelines recommend that hepatectomy is reserved for patients with very early and early HCC (BCLC stage 0 and A
).
However, multiple studies suggest that surgical resection may provide survival benefits
for HCC patients with intermediate and advanced disease.
As a result, guidelines in the Asian region have expanded the criteria for surgical resection to allow liver resection
in selected patients with intermediate to advanced HCC (BCLC stage B and C).
Unfortunately, about 50-70% of patients will have tumor recurrence
within 5 years.

Therefore, accurate recurrence risk assessment is essential
for individualized treatment, management, and monitoring strategies.
Patients at high risk of recurrence after resection may benefit
from adjuvant therapy.
To date, several clinical staging systems, such as the BCLC system, the Joint Committee on Cancer (AJCC) tumor-node-metastasis (TNM) system, the Hong Kong Liver Cancer (HKLC) system, and the Japanese Comprehensive Staging (JIS) score, together constitute HCC prognosis stratification and treatment options cornerstones
.
However, predicting HCC recurrence based solely on the above systems can be challenging
.

Gadolinium acid enhanced magnetic resonance imaging (EOB-MRI) has become the first-line option
for diagnosis, staging, and monitoring of HCC.
Recently, many encouraging signs and evidence have been presented clinically regarding the potential value of EOB-MRI in predicting the prognosis of HCC patients.

EOB-MRI features such as perianeurysm enhancement, tumor margin irregularity, low peritumor signal in the hepatobiliary phase (HBP), satellite nodules, and tumor size predict postoperative HCC recurrence
.
Despite the predictive potential of these imaging markers, few studies have conducted a comprehensive assessment
of tumor-related features on EOB-MRI.
In addition, it is unclear
whether prognostic tools incorporating novel imaging markers can compete with traditional clinical staging systems for HCC recurrence prediction.
To our knowledge, no studies have compared the prognostic value
of preoperative EOB-MRI-based models with existing clinical staging systems.

A study published today in the journal European Radiology established a recurrence risk score based on clinical parameters of HCC patients after preoperative EOB-MRI and liver resection, and compared
it with postoperative scores and performance of four clinical staging systems.

This review retrospectively included successive patients with surgically confirmed HCC who underwent preoperative EOB-MRI between July 2015 and November 2020
。 Two recurrence risk scores were constructed by the Cox regression model, one containing only the preoperative variables and the other containing all preoperative and postoperative variables
.

A total of 214 patients (derivation set, n = 150; test set, n = 64)
were included.
Six preoperative variables, namely tumor number, appearance of infiltration, enhancement, alpha-fetoprotein (AFP) levels, aspartate aminotransferase (AST) levels, and sex, were independently associated with
recurrence.
After adding postoperative features, microvascular invasion and tumor differentiation are additional important variables
for replacement enhancement and AFP levels.
Using the above variables, the preoperative score had a C-index of 0.
741 on the test set, which was comparable to the postoperative score (0.
729; p = 0.
235).

The preoperative score at 1 year (0.
844) produced a larger time dependent region under the ROC curve (0.
734-0.
742; all p < 0.
05)
compared to the existing three systems.
In addition, the preoperative score divided patients into two risk strata with different prognosis, with low and high risk of recurrence (p < 0.
001).

Plot the recurrence-free survival curves for the two risk layers defined by the preoperative score

This study shows that preoperative scores combining EOB-MRI characteristics, serum AFP and AST levels, and sex can accurately predict HCC recurrence with similar performance to postoperative evaluation
.
In addition, preoperative scores are advantageous
over existing HCC recurrence prediction staging systems.

Original source:

Hong Wei,Hanyu Jiang,Yun Qin,et al.
Comparison of a preoperative MR-based recurrence risk score versus the postoperative score and four clinical staging systems in hepatocellular carcinoma: a retrospective cohort study.
DOI:10.
1007/s00330-022-08811-6