Ann Surg Oncol (2015) 22:2253–2261 DOI 10.1245/s10434-014-4221-5
ORIGINAL ARTICLE – HEPATOBILIARY TUMORS
Impact of Steatosis on Prognosis of Patients with Early-Stage Hepatocellular Carcinoma After Hepatic Resection Chien-Wei Su, MD, PhD1,2, Gar-Yang Chau, MD, MPH2,3, Hung-Hsu Hung, MD2,4,5, Yi-Chen Yeh, MD2,4,6, HaoJan Lei, MD2,3, Cheng-Yuan Hsia, MD2,3, Chiung-Ru Lai, MD2,6, Han-Chieh Lin, MD1,2, and Jaw-Ching Wu, MD, PhD4,7 Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; 2Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; 3Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; 4Institute of Clinical Medicine, School of Medicine and Cancer Research Center, National Yang-Ming University, Taipei, Taiwan; 5Division of Gastroenterology, Department of Medicine, Cheng Hsin General Hospital, Taipei, Taiwan; 6Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; 7Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
1
ABSTRACT Background. It is still unclear whether steatosis determines the prognosis of patients with hepatocellular carcinoma (HCC). This study aimed to compare the clinical manifestations and outcomes between early-stage HCC patients with and without steatosis after hepatic resection. Methods. We enrolled 188 patients who underwent hepatic resection for HCC within the Milan criteria. After surgery, fibrosis, steatosis, lobular inflammation, portal inflammation, and ballooning in the background liver were assessed. Factors related to prognosis after surgery were analyzed by multivariate analysis. Results. Seventy-four patients (39.4 %) had steatosis. Patients with steatosis had larger body mass index, higher fasting glucose levels, and higher rates of ballooning than
those without steatosis. After a median follow-up period of 69.8 months, 73 patients died. The cumulative survival rates at 5 years were 57.8 and 75.6 % for patients with and without steatosis, respectively (p = 0.008). Multivariate analysis disclosed that an age of [ 65 years [hazard ratio (HR) 1.996, p = 0.009], platelet count of \105/mm3 (HR 2.198, p = 0.005), indocyanine green retention rate at 15 min of [10 % (HR 2.037, p = 0.022), multinodularity (HR 2.389, p = 0.004), and steatosis (HR 1.773, p = 0.023) were independent risk factors associated with poor overall survival after resection. The impact of steatosis on postsurgical prognosis was more apparent in patients without cirrhosis. Conclusions. The presence of steatosis in the background liver was associated with a poor prognosis in early-stage HCC patients after hepatic resection, especially for noncirrhotic patients.
Presented as an oral presentation at the annual meeting of the American Association for the Study of the Liver, Washington, DC, USA, November 1–5, 2013.
Electronic supplementary material The online version of this article (doi:10.1245/s10434-014-4221-5) contains supplementary material, which is available to authorized users. Ó Society of Surgical Oncology 2014 First Received: 26 June 2014; Published Online: 10 December 2014 G.-Y. Chau, MD, MPH e-mail: [email protected] J.-C. Wu, MD, PhD e-mail: [email protected]
Hepatocellular carcinoma (HCC) is the third most common cause of cancer death in the world.1,2 Recently, the impact of metabolic disorders and steatosis on hepatic carcinogenesis has become an important issue because of the increasing incidences of obesity and diabetes globally.3–7 One prospective cohort study involving U.S. adults found that the relative risk of mortality from liver cancers were 4.52 and 1.68 for men and women, respectively, with a body mass index (BMI) of C35 kg/m2 compared to those with a normal BMI.8 This indicates that metabolic disorder and steatosis may play increasingly important roles in HCC development.
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Hepatic resection is recommended as the first-line treatment modality in patients with early-stage HCC.1 Although the long-term outcomes of HCC patients after resection are improving, they are still not ideal. The 5-year survival rate is only around 50–70 %.9–12 To improve the prognosis of these patients, it is crucial to identify correctable factors that affect their outcomes. Although steatosis and metabolic syndrome have been proven to be associated with hepatocarcinogenesis, whether they determine the prognosis of HCC patients after resection has not been fully elucidated.13–15 We hypothesized that metabolic disorder and steatosis, like antiviral therapy, might be modifiable prognostic factors in HCC patients undergoing resection.2,16,17 To test this hypothesis, we comprehensively compared clinical manifestations and prognoses between early-stage HCC patients with and without steatosis after hepatic resection.
C.-W. Su et al.
HCC patients underwent surgical resection (n=1073)
Exclusion criteria: 1. Beyond Milan criteria (n=541) 2. Non-tumor part pathology is not available (n=271) 3. With antiviral treatment(n=34) or unknown antiviral treatment (n=39)
Fulfilled the exclusion criteria: 1. Within Milan criteria 2. Non-tumor part pathology available 3. No antiviral treatment (n=188)
Is non-tumor part cirrhosis?
MATERIALS AND METHODS Patients and Follow-up We retrospectively reviewed 1,073 consecutive treatment-naı¨ve HCC patients who underwent hepatic resection at the Taipei Veterans General Hospital (TVGH) from 1991 to 2006 (Fig. 1). The criteria for resectable HCC were as follows: (1) Child’s grade of liver function of A or B, with indocyanine green 15-min retention rate (ICG-15R) of B30 %; (2) tumor involving no more than two Healey segments and without main portal vein trunk involvement; and (3) absence of extrahepatic tumor dissemination.9 The exclusion criteria for the current study were as follows: (1) failure to meet Milan criteria (a single tumor B5 cm or up to 3 nodules, each B3 cm in size, and without major vascular invasion); (2) unavailable nontumor part pathology; and (3) antiviral treatment after surgery or unknown antiviral treatment history.18 A total of 188 patients who fulfilled the criteria were included in the final analysis. After surgery, patients were assessed every 3 months for serum liver biochemistry and for a-fetoprotein (AFP) levels; they also underwent ultrasound. Tumor recurrence was suspected if serum AFP levels were progressively elevated or new lesions were detected by surveillance ultrasound. The suspected tumor recurrences were further diagnosed by dynamic computed tomography or magnetic resonance imaging. The study complied with the standards of the Declaration of Helsinki and was approved by the institutional review board of TVGH. Biochemical and Serologic Markers Serum levels of hepatitis B surface antigen (HBsAg) were measured using a radioimmunoassay kit (Abbott
No; ISHAK fibrosis score 0-4 (n=77)
Yes; ISHAK fibrosis score 5-6 (n=111)
FIG. 1 Study flow chart
Laboratories, North Chicago, IL), while antibodies against hepatitis C virus (HCV) were tested using a second-generation enzyme immunoassay kit (Abbott Laboratories, North Chicago, IL). Serum biochemistries were measured using the Roche/Hitachi Modular Analytics System (Roche Diagnostics GmbH, Mannheim, Germany), and serum AFP levels were measured using a radioimmunoassay kit (Serono Diagnostic SA, Coinsin/VD, Switzerland). Pathology Grading Two experienced pathologists performed pathology grading (Y.C.Y. and C.R.L.) after reaching consensus. The degree of inflammation and the stage of fibrosis in the background liver were scored on an Ishak grading scale.19 Tissues given an Ishak fibrosis score of 5 or 6 were diagnosed as cirrhotic. The stigmata of steatohepatitis, including steatosis, lobular inflammation, portal inflammation, and ballooning, were assessed by the criteria proposed by Brunt and colleagues.20,21 Statistical Analysis Baseline characteristics were selected to be evaluated according to the European Association for the Study of the Liver guidelines published in 2001.22 Pearson’s Chi square analysis or Fisher’s exact test was performed to compare
23.70; 21.70–26.30
Body mass index (kg/m2)
Anti-HCV positive/negative (%)
84.5; 66.0–107.25
Alk-P (U/L)
1.00; 1.00–1.05 140000; 104500–177000
ICG-15R (%)
PT/INR
Platelet (/mm3)
Microscopic vascular invasion (yes/no) (%)
143/45 (76.1 %/23.9 %) 70/118 (37.2 %/62.8 %) 92/96 (48.9 %/51.1 %)
Ishak fibrosis (0–2/3–4/5–6) (%)
Lobular inflammation (0–1/2–3) (%)
Portal inflammation (0–1/2–4) (%)
Ballooning (yes/no) (%)
36/78 (31.6 %/68.4 %)
37/77 (32.5 %/67.5 %)
90/24 (78.9 %/20.9 %)
19/27/68 (16.7 %/23.7 %/59.6 %)
21/54/39 (18.4 %/47.4 %/34.2 %)
58/56 (50.4 %/49.6 %)
4/110 (3.5 %/96.5 %)
6/75/29/2 (5.4 %/67.0 %/25.9 %/1.7 %)
56/18 (75.7 %/24.3 %)
33/41 (44.6 %/55.4 %)
53/21 (71.6 %/28.4 %)
14/17/43 (18.9 %/23.0 %/58.1 %)
12/34/28 (16.2 %/45.9 %/37.8 %)
40/34 (54.1 %/45.9 %)
3/71 (4.1 %/95.9 %)
2/48/21/1 (2.8 %/66.7 %/29.2 %/1.3 %)
53/21 (71.6 %/28.4 %)
38.4; 8.0–190.0
63/11 (85.1 %/14.9 %)
2.50; 2.00–3.43
139000; 107500–177500
1.00; 1.00–1.07
12; 7–16
97; 87–119
1.0; 0.9–1.13
173.5; 144.0–195.8
87.0; 65.5–108.5
45.0; 30.5–65.5
53.0; 38.5–83.5
0.8; 0.59–1.0
4.0; 3.8–4.3
12/58 (17.1 %/82.9 %)
55/17 (76.4 %/23.6 %)
25.10; 23.10–26.80
64/10 (86.5 %/13.5 %)
60.5; 51.8–70.3
Steatosis (n = 74)
PT/INR prothrombin time/international normalized ratio
Alk-P alkaline phosphatase
HBsAg hepatitis B surface antigen, HCV hepatitis C virus, ALT alanine aminotransferase, AST aspartate aminotransferase, ICG-15R indocyanine green 15-min retention rate, AFP a-fetoprotein
Continuous variables are expressed as median (25th and 75th percentiles); other variables are expressed as n/N (%)
33/88/67 (17.6 %/46.8 %/35.6 %) 33/44/111 (17.6 %/23.4 %/59.0 %)
Ishak activity (0–3/4–6/7–13) (%)
Pathological factors in background liver
7/181 (3.7 %/96.3 %) 98/90 (52.1 %/47.9 %)
Macroscopic vascular invasion (yes/no) (%)
73/40 (64.6 %/35.4 %)
126/61 (67.4 %/32.6 %) 8/123/50/3 (4.3 %/66.8 %/27.2 %/1.6 %)
Cut margin B 1/[ 1 cm (%)
Edmondson grading (I/II/III/IV) (%)
15.98; 6.62–220.00
19.70; 7.03–212.50
AFP (ng/mL)
98/16 (86.0 %/14.0 %)
2.50; 1.93–3.20 161/27 (85.6 %/14.4 %)
Single tumor/multinodularity (%)
2.50; 1.90–3.20
140500; 102250–176750
1.00; 1.00–1.04
13; 8–17
91; 84–101
1.0; 0.9–1.2
169; 147–188
84; 66–106
45; 31–63
50.0; 29.0–83.0
0.7; 0.6–1.1
4.1; 3.8–4.3
28/78 (26.4 %/73.6 %)
82/29 (73.9 %/26.1 %)
23.03; 21.05–25.88
88/26 (77.2 %/22.8 %)
62.5; 52.0–71.0
No steatosis (n = 114)
Tumor size (cm)
Tumor factors
93; 85–104.75 13; 7–17
Glucose (mg/dL)
171; 145.5–192.5
45; 31–65
AST (U/L)
1.0; 0.9–1.2
50; 32–83
ALT (U/L)
Creatinine (mg/dL)
0.8; 0.6–1.0
Total bilirubin (mg/dL)
Cholesterol (U/L)
4.1; 3.8–4.3
Albumin (g/dL)
Serum biochemistry tests and liver functional tests
137/46 (74.9 %/25.1 %) 40/136 (22.7 %/77.3 %)
HBsAg positive/negative (%)
Virus factors
61.5; 52.0–70.75 152/36 (80.9 %/19.1 %)
Sex (male/female) (%)
All (n = 188)
Age (year)
Patient demographics
Parameter
TABLE 1 Demographic data of hepatocellular carcinoma patients who underwent hepatic resection
0.627
0.098
0.263
0.743
0.583
0.672
0.848
0.552
0.314
0.925
0.875
0.562
0.756
0.720
0.703
0.028
0.235
0.365
0.355
0.435
0.609
0.655
0.588
0.914
0.924
0.001
0.100
\0.001
p
Steatosis and HCC Prognosis 2255
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categorical variables, while continuous variables were compared by the Mann–Whitney U test. Cumulative recurrence rates or overall survival rates were estimated by the Kaplan–Meier method and compared by the log-rank test. Moreover, the assumption of proportional hazards was confirmed by the log minus log plot of survival in the Cox regression analysis. Variables for which statistically significant (p \ 0.05) or close to statistically significant (p \ 0.1) differences were observed by univariate analysis were included in multivariate analysis by a backward stepwise Cox regression model. A two-tailed p value of \0.05 was considered statistically significant. All statistical analyses were performed by SPSS 17.0 for Windows software (IBM, Armonk, NY).
C.-W. Su et al.
Subgroup analysis of the prognostic implications of steatosis in determining overall survival after resection As shown in Supplementary Table 2, steatosis was correlated with poor overall survival after resection in the following subgroups: age B65 years, male patients, presence of HBsAg in sera, negativity for anti-HCV, serum albumin [ 4 g/dL, alanine aminotransferase (ALT) B 40 U/L, AST B 45 U/L, ICG-15R B 10 %, single tumor, tumor size B 3 cm, no macroscopic vascular invasion, no cirrhosis, lobular inflammation score B 1, portal inflammation score B 1, and no ballooning in background liver. Factors Associated with Overall Survival in Noncirrhotic Patients
RESULTS Baseline Clinical Characteristics Of the 188 patients, 74 (39.4 %) had steatosis and the remaining 114 patients did not have steatosis in the background liver. As summarized in Table 1 and Supplementary Table 1, patients with steatosis had a larger BMI, higher fasting glucose levels, and higher rates of ballooning compared to those without steatosis. Other factors, including demographic, tumor, and pathological factors as well as type of resection, were comparable between the two groups.
Factors Associated with Prognosis after Resection in All Patients After a median follow-up period of 69.8 months (25th– 75th percentile 34.1–98.6 months), 73 patients died and 115 were still alive on their last visit. Stratified by the status of steatosis, the cumulative overall survival rates at 1, 3, and 5 years were 97.3, 86.5, and 75.6 %, respectively, for patients without steatosis and 94.6, 79.3, and 57.8 %, respectively, for those with steatosis (Fig. 2a; p = 0.008). According to a multivariate analysis, an age of [65 years, a platelet count of B105/mm3, an ICG-15R of [10 %, multinodularity, and steatosis were independent risk factors associated with poor overall survival after resection (Table 2). Furthermore, 123 patients developed tumor recurrence after surgery. The cumulative recurrence rates at 1, 3, and 5 years were 23.6, 55.8, and 73.8 %, respectively. According to a multivariate analysis, serum aspartate aminotransferase (AST) levels of [45 U/L, macroscopic vascular invasion, presence of cirrhosis, and presence of ballooning were independent risk factors correlated with recurrence (Table 3).
There were 77 patients who were noncirrhotic in the background liver. The distribution of the scores of Ishak fibrosis was as follows: 0, 6 patients; 1, 11 patients; 2, 16 patients; 3, 23 patients; and 4, 21 patients. Patients with steatosis had a larger BMI, lower rate of HCV seropositivity, and higher rate of ballooning compared to those without steatosis (Supplementary Table 3). As shown in Fig. 2b, the cumulative overall survival rate was significantly higher in patients without steatosis than in those with steatosis (p = 0.047). A multivariate analysis showed that presence of steatosis remained an independent factor that predicts a higher mortality rate after resection, together with age [65 years and serum albumin levels B 4 g/dL (Supplementary Table 4). Factors Associated with Overall Survival in Cirrhotic Patients Of the 111 cirrhotic patients, 46 patients died during the follow-up period. As shown in Supplementary Table 5, a multivariate analysis revealed that ICG-15R [ 10 %, multinodularity, more severe portal inflammation, and presence of ballooning were correlated with poor survival after resection. In addition, cirrhotic patients with steatosis showed a trend of lower overall survival rates than those without steatosis in the nontumor part of their liver specimens (Fig. 2c; p = 0.079). DISCUSSION According to numerous epidemiological surveys, fatty liver disease is the most common factor for chronic liver disease in both high and low endemic countries for viral hepatitis.4,23 In a population-based study in the United States, Welzel et al. found that while chronic hepatitis B
Steatosis and HCC Prognosis
Overall survival rate (%)
A
2257 b FIG. 2 Cumulative curves of overall survival rates stratified by
100
status of steatosis. Patients with steatosis in nontumor part of liver specimens had significantly lower rate of overall survival than those without steatosis (a, p = 0.008), especially in noncirrhotic patients (b, p = 0.047). For cirrhotic patients, those with steatosis showed a trend of a lower rate of overall survival after resection as compared with their counterparts (c, p = 0.079)
80
60
No steatosis 40
With steatosis
20
0 0
2
4
6
8
10
12
14
16
18
6 2
2
2
20
Follow-up (years) Patients at risk No steatosis 114 101 With steatosis 74 62
Overall survival rate (%)
B
74 37
59 23
37 16
18 6
7 3
100
80
No steatosis
60
40
With steatosis 20
0 0
2
4
6
8
10
12
14
16
18
3
2
2
20
Follow-up (years)
C
100
Overall survival rate (%)
Patients at risk No steatosis 46 With steatosis 31
80
43 27
37 18
32 13
21 10
10 3
4 1
60
No steatosis 40
20
With steatosis
0 0
2
4
6
8
10
12
14
3 2
3 2
16
Follow-up (years) Patients at risk No steatosis 68 With steatosis 43
58 35
37 19
27 10
16 6
8 3
virus (HBV) or HCV infection had a higher odds ratio as a risk factor for HCC, diabetes and/or obesity had the largest population-attributable fraction (36.6 %) for HCC,
suggesting a dominant role for diabetes and obesity in hepatic carcinogenesis.4 Adipose tissue expansion in patients with fatty liver promoted the release of proinflammatory cytokines, including tumor necrosis factor and interleukin-6; the reduction of anti-inflammatory adipokines such as adiponectin; and the induction of lipotoxicity accompanied by increased blood levels of insulin.3,24 All of these factors might contribute to hepatic carcinogenesis in patients with fatty liver. Moreover, in patients with chronic viral hepatitis, Chen et al. found a more than 100-fold increased risk of developing HCC among HBV carriers with both obesity and diabetes compared to those without these factors.25 These results imply that steatosis may act synergistically with viral infection in HCC development. Our current study further suggests that steatosis might play an important role in determining the prognosis of virusinduced HCC after resection. Surgical resection is recommended as the first-line treatment for Barcelona Clinic for Liver Cancer stage A HCC or for tumors that meet the Milan criteria.1 Previous studies demonstrated that both tumor factors (e.g., tumor size, number, vascular invasion, and gene signature) and field factors (including grade of hepatic inflammation, stage of fibrosis, portal hypertension, liver functional reserve, and virus replications) influence the prognoses of HCC patients after hepatic resection.10,26,27 For patients with early-stage HCC, tumor factors are less relevant than field factors in determining prognosis.28–31 Among the field factors, antiviral therapies and metabolic syndrome seem to be modifiable factors. Recent studies revealed that prescriptions of antiviral therapies after hepatic resection could improve overall survival and decrease recurrence, especially in early-stage HCC.2,16,17 In our present study, we excluded patients who received antiviral therapies after resection to minimize these confounding effects and to focus on the impact of steatosis on postoperative prognosis. Our results showed that the presence of steatosis in the background liver was associated with a poor prognosis after resection. Of note, the effects were more apparent in noncirrhotic patients and in patients with better liver functional reserve, less hepatic necroinflammation, and early-stage HCC. This finding indicates that steatosis, an important field factor, is crucial in determining the prognosis of patients with early-stage HCC and well-preserved liver function.
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C.-W. Su et al.
TABLE 2 Factors associated with poor overall survival after resection for hepatocellular carcinoma Characteristic
n/N
Univariate analysis
Multivariate analysis
Hazard ratio (95 % confidence interval)
p
Hazard ratio (95 % confidence interval)
p
1.996 (1.189–3.344)
0.009
1.550 (0.915–2.626)
0.103
Age [ 65/B65 year
72/116
2.093 (1.136–3.329)
0.002
Sex female/male
36/152
0.594 (0.295–1.195)
0.144
Body mass index [24/B24 kg/m2 HBsAg positive/negative
84/99 137/46
1.174 (0.734–1.878) 1.080 (0.931–1.245)
0.504 0.308
Anti-HCV positive/negative
40/136
0.983 (0.861–1.124)
0.806
Albumin B4/[4 g/dL
90/93
1.866 (1.153–3.021)
0.011
Bilirubin [1.6/B1.6 mg/dL
7/181
0.986 (0.355–2.735)
0.978
ALT [40/B40 U/L
118/69
1.041 (0.645–1.679)
0.870
AST [45/B45 U/L
89/98
1.423 (0.893–2.265)
0.138
Platelet B105/[105/mm3
38/135
2.232 (1.344–3.704)
0.002
2.198 (1.274–3.793)
0.005
ICG-15R [10 %/B10 %
112/73
2.271 (1.327–3.889)
0.003
2.037 (1.107–3.745)
0.022
PT/INR [1.1/B1.1
28/158
2.145 (1.262–3.647)
0.005
1.637 (0.887–3.012)
0.115
90/94
0.989 (0.617–1.587)
0.964 2.389 (1.319–4.367)
0.004
1.152 (0.613–2.163)
0.660
AFP [20/B20 ng/mL Multiple tumor (yes/no)
27/161
1.657 (0.949–2.893)
0.075
Tumor size [3/B3 cm
53/135
0.860 (0.504–1.465)
0.579
Cut margin B1/[1 cm
126/61
1.894 (1.100–3.268)
0.021
Edmondson grading (III ? IV/I ? II)
53/131
1.048 (0.634–1.733)
0.854
7/181 98/90
1.021 (0.250–4.184) 1.406 (0.882–2.247)
0.977 0.152
Macroscopic vascular invasion (yes/no) Microscopic vascular invasion (yes/no) Ishak fibrosis (5–6/0–4)
77/111
1.581 (0.980–2.548)
0.060
1.260 (0.684–2.319)
0.458
Steatosis (yes/no)
114/74
1.863 (1.173–2.957)
0.008
1.773 (1.081–2.915)
0.023
Lobular inflammation (2–3/0–1)
45/143
1.101 (0.624–1.946)
0.740
Portal inflammation (2–4/0–1)
118/70
1.821 (1.136–2.915)
0.013
1.815 (0.970–3.397)
0.062
92/96
1.630 (1.017–2.615)
0.043
1.603 (0.923–2.786)
0.094
Ballooning (yes/no)
HBsAg hepatitis B surface antigen, HCV hepatitis C virus, ALT alanine aminotransferase, AST aspartate aminotransferase, ICG-15R indocyanine green 15-min retention rate, AFP a-fetoprotein PT/INR prothrombin time/international normalized ratio
Recently, several studies compared the clinical manifestations and prognoses between HCC originating from HCV infection and from steatohepatitis.14,32,33 Yet, the impact of steatosis on the long-term outcomes of virusinduced HCC after curative resection had been little studied.13 Wu et al. compared the clinicopathological characteristics and postoperative prognoses of HCC patients with and without steatosis in the background liver.13 They observed that patients with steatosis had smaller tumor size, lower serum AFP levels, lower rates of vascular invasion, and advanced tumor grade compared to those without steatosis. Moreover, patients with steatosis who had a tumor larger than 5 cm had better overall survival after resection. Nevertheless, the postoperative outcomes were not significantly different between these two groups for patients with tumors smaller than 5 cm. In our current study, patients with steatosis were associated with higher BMI, fasting glucose levels, and hepatic cell ballooning. Therefore, steatosis could be considered the
hepatic manifestation of obesity and related metabolic disorders such as diabetes. Moreover, our study showed that for patients with HCC who satisfied the Milan criteria, those with steatohepatitis had significantly lower overall survival rates. Interestingly, steatosis in the background liver had a more profound effect in determining postoperative prognosis in noncirrhotic patients, but it was less apparent in the cirrhotic group. In its place, other important stigmata of steatohepatitis, such as portal inflammation and ballooning, were independent risk factors of poor overall survival in cirrhotic patients. Law and Brunt observed that lobular inflammation in fatty liver was usually mild, and it was more common in alcoholic steatohepatitis than in nonalcoholic steatohepatitis.21 In contrast, portal inflammation is more common in patients with fatty liver disease.21 Ballooning, one of the characteristic markers of liver cell injury in fatty liver disease, was found to be closely linked to insulin resistance and disease progression.34,35 When steatohepatitis patients progress to the end stage of liver disease, the
Steatosis and HCC Prognosis
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TABLE 3 Factors associated with tumor recurrence after resection for hepatocellular carcinoma Characteristic
n/N
Univariate analysis
Multivariate analysis
Hazard ratio (95 % confidence interval)
p
Age [65/B65 year
72/116
1.320 (0.911–1.911)
0.142
Sex female/male
36/152
0.872 (0.548–1.385)
0.561
Body mass index [24/B24 kg/m2 HBsAg positive/negative
84/99 137/46
1.272 (0.882–1.834) 1.074 (0.966–1.195)
0.197 0.187
Anti-HCV positive/negative
40/136
1.112 (1.014–1.219)
0.025
90/93
1.212 (0.844–1.742)
0.298 0.828
Albumin B4/[4 g/dL Bilirubin [1.6/B1.6 mg/dL
7/181
1.089 (0.503–2.358)
ALT [40/B40 U/L
118/69
1.260 (0.859–1.850)
0.238
AST [45/B45 U/L
89/98
1.646 (1.144–2.367)
0.007
3
38/135
1.208 (0.783–1.866)
0.393
ICG-15R [10 %/B10 %
112/73
1.146 (0.787–1.666)
0.478
PT/INR [1.1/B1.1
28/158
1.155 (0.717–1.859)
0.553
90/94
1.094 (0.761–1.572)
0.629
27/161
1.554 (0.993–2.433)
0.054
5
5
Platelet B10 /[10 /mm
AFP [20/B20 ng/mL Multiple tumor (yes/no)
Hazard ratio (95 % confidence interval)
p
1.072 (0.975–1.178)
0.149
1.647 (1.136–2.390)
0.009
1.565 (0.995–2.461)
0.053
Tumor size [3/B3 cm
53/135
0.944 (0.623–1.431)
0.787
Cut margin B1/[1 cm
126/61
0.748 (0.505–1.110)
0.149
Edmondson grading (III ? IV/I ? II)
53/131
1.113 (0.751–1.650)
0.593
7/181 98/90
4.386 (1.751–10.989) 1.008 (0.706–1.439)
0.002 0.965
5.556 (1.953–15.872)
0.001
111/77
1.874 (1.285–2.732)
0.001
1.790 (1.221–2.624)
0.003
Macroscopic vascular invasion (yes/no) Microscopic vascular invasion (yes/no) Ishak fibrosis (5–6/0–4) Steatosis (yes/no)
114/74
1.270 (0.885–1.821)
0.194
Lobular inflammation (2–3/0–1)
45/143
1.404 (0.922–2.137)
0.114
Portal inflammation (2–4/0–1)
118/70
1.631 (1.101–2.414)
0.015
1.367 (0.900–2.075)
0.143
92/96
1.732 (1.189–2.525)
0.004
1.694 (1.158–2.476)
0.007
Ballooning (yes/no)
HBsAg hepatitis B surface antigen, HCV hepatitis C virus, ALT alanine aminotransferase, AST aspartate aminotransferase, ICG-15R indocyanine green 15-min retention rate, AFP a-fetoprotein PT/INR prothrombin time/international normalized ratio
histological features of steatohepatitis, including steatosis, necroinflammation, and ballooning, might disappear in socalled burnout steatohepatitis.36 This disappearance could lead to underestimation of steatosis in cirrhotic patients with steatohepatitis. This phenomenon may explain why other main determinants of steatohepatitis, including portal inflammation and ballooning, were still independent risk factors of poor overall survival and recurrence in such patients, while steatosis could not predict postsurgical prognosis in the cirrhotic group. Furthermore, steatosis, older age, lower platelet counts, higher ICG-15R, and multinodularity were also associated with poorer overall survival after resection in our cohort, consistent with results from prior studies.37 There are several potential limitations of this study. First, as a result of its retrospective study design, it lacks detailed information on diabetes history, smoking, alcohol consumption, and HBV and HCV virus genotypes. We therefore could not completely exclude the impact of
alcohol on steatosis and on prognoses after resection in our cohort. However, one community study conducted in Taiwan showed that elevated serum ALT levels were attributable to alcohol consumption in only 0.8 % of subjects.38 Previous studies also demonstrate that more than 90 % of HCC cases in Taiwan are attributable to HBV or HCV infections. In our cohort, only 7 patients were both negative for serum HBsAg and anti-HCV. These results suggest that alcohol consumption may play only a minor role in steatosis and hepatic carcinogenesis in Taiwan. Second, because most of our patients had chronic viral liver disease, we could not evaluate the impact of pure metabolic steatosis on postoperative prognoses in the absence of viral hepatitis in our cohort. However, our study demonstrated that steatosis negatively affected the prognoses of HCC patients after resection, especially for those with chronic HBV infection (Supplementary Table 1). Because HBV infection is the most common cause of HCC worldwide, our data highlighted the importance of steatosis
2260
C.-W. Su et al.
in the background liver in determining the outcomes of patients with HBV-related HCC after hepatic resection. Third, steatosis is the hepatic manifestation of metabolic syndrome. Cauchy et al. reported that HCC patients with metabolic syndrome had a high rate of postoperative complications, especially for those without severe fibrosis in the background liver.15 However, because our current study is a retrospective one, we could not assess the impact of metabolic syndrome score on postsurgical prognoses as a result of lack of data on waist circumference and levels of triglyceride and high-density lipoprotein cholesterol.39 Prospective studies are needed to elucidate whether the lower overall survival rates of patients with steatosis was due to steatosis per se or due to poor general health associated with metabolic syndrome. In conclusion, the presence of steatosis in the background liver was associated with a poor prognosis after hepatic resection in patients with HCC satisfying the Milan criteria, especially those without cirrhosis and with earlystage tumors. ACKNOWLEDGMENT This work was supported by grants from the National Science Council of Taiwan (NSC 101-2314-B-075-013MY2), Taipei Veterans General Hospital (V102C-117, C103C-055, VGHUST100-G7-2-1), Yang-Ming University (101AC-T501, Ministry of Education, Aim for the Top University Plan), and the Center of Excellence for Cancer Research at TVGH (DOH102-TD-C-111007), Taipei, Taiwan. DISCLOSURE
The authors declare no conflict of interest.
REFERENCES 1. de Lope CR, Tremosini S, Forner A, Reig M, Bruix J. Management of HCC. J Hepatol. 2012;56(Suppl 1):S75–87. 2. Su CW, Chiou YW, Tsai YH, et al. The influence of hepatitis B viral load and pre-S deletion mutations on post-operative recurrence of hepatocellular carcinoma and the tertiary preventive effects by anti-viral therapy. PLoS One. 2013;8:e66457. 3. Baffy G, Brunt EM, Caldwell SH. Hepatocellular carcinoma in non-alcoholic fatty liver disease: an emerging menace. J Hepatol. 2012;56:1384–91. 4. Welzel TM, Graubard BI, Quraishi S, et al. Population-attributable fractions of risk factors for hepatocellular carcinoma in the United States. Am J Gastroenterol. 2013;108:1314–21. 5. Wong VW, Wong GL, Choi PC, et al. Disease progression of non-alcoholic fatty liver disease: a prospective study with paired liver biopsies at 3 years. Gut. 2010;59:969–74. 6. Armstrong MJ, Houlihan DD, Bentham L, et al. Presence and severity of non-alcoholic fatty liver disease in a large prospective primary care cohort. J Hepatol. 2012;56:234–40. 7. Vernon G, Baranova A, Younossi ZM. Systematic review: the epidemiology and natural history of non-alcoholic fatty liver disease and non-alcoholic steatohepatitis in adults. Aliment Pharmacol Ther. 2011;34:274–85. 8. Calle EE, Rodriguez C, Walker-Thurmond K, Thun MJ. Overweight, obesity, and mortality from cancer in a prospectively studied cohort of US adults. N Engl J Med. 2003;348:1625–38.
9. Su CW, Lei HJ, Chau GY, et al. The effect of age on the longterm prognosis of patients with hepatocellular carcinoma after resection surgery: a propensity score matching analysis. Arch Surg. 2012;147:137–44. 10. Fan ST, Mau Lo C, Poon RT, et al. Continuous improvement of survival outcomes of resection of hepatocellular carcinoma: a 20year experience. Ann Surg. 2011;253:745–58. 11. Kim SH, Choi SB, Lee JG, et al. Prognostic factors and 10-year survival in patients with hepatocellular carcinoma after curative hepatectomy. J Gastrointest Surg. 2011;15:598–607. 12. Santi V, Buccione D, Di Micoli A, et al. The changing scenario of hepatocellular carcinoma over the last two decades in Italy. J Hepatol. 2012;56:397–405. 13. Wu TH, Yu MC, Chan KM, et al. Prognostic effect of steatosis on hepatocellular carcinoma patients after liver resection. Eur J Surg Oncol. 2011;37:618–22. 14. Reddy SK, Steel JL, Chen HW, et al. Outcomes of curative treatment for hepatocellular cancer in nonalcoholic steatohepatitis versus hepatitis C and alcoholic liver disease. Hepatology. 2012;55:1809–19. 15. Cauchy F, Zalinski S, Dokmak S, et al. Surgical treatment of hepatocellular carcinoma associated with the metabolic syndrome. Br J Surg. 2013;100:113–21. 16. Wu CY, Chen YJ, Ho HJ, et al. Association between nucleoside analogues and risk of hepatitis B virus-related hepatocellular carcinoma recurrence following liver resection. JAMA. 2012;308: 1906–14. 17. Chan AC, Chok KS, Yuen WK, et al. Impact of antiviral therapy on the survival of patients after major hepatectomy for hepatitis B virus– related hepatocellular carcinoma. Arch Surg. 2011;146:675–81. 18. Mazzaferro V, Regalia E, Doci R, et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med. 1996;334:693–9. 19. Ishak K, Baptista A, Bianchi L, et al. Histological grading and staging of chronic hepatitis. J Hepatol. 1995;22:696–9. 20. Brunt EM, Janney CG, Di Bisceglie AM, Neuschwander-Tetri BA, Bacon BR. Nonalcoholic steatohepatitis: a proposal for grading and staging the histological lesions. Am J Gastroenterol. 1999;94:2467–74. 21. Law K, Brunt EM. Nonalcoholic fatty liver disease. Clin Liver Dis. 2010;14:591–604. 22. Bruix J, Sherman M, Llovet JM, et al. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver. J Hepatol. 2001;35:421–30. 23. Wu WC, Wu CY, Wang YJ, et al. Updated thresholds for serum alanine aminotransferase level in a large-scale population study composed of 34346 subjects. Aliment Pharmacol Ther. 2012; 36:560–8. 24. Stickel F, Hellerbrand C. Non-alcoholic fatty liver disease as a risk factor for hepatocellular carcinoma: mechanisms and implications. Gut. 2010;59:1303–7. 25. Chen CL, Yang HI, Yang WS, et al. Metabolic factors and risk of hepatocellular carcinoma by chronic hepatitis B/C infection: a follow-up study in Taiwan. Gastroenterology. 2008;135:111–21. 26. Wu JC, Huang YH, Chau GY, et al. Risk factors for early and late recurrence in hepatitis B–related hepatocellular carcinoma. J Hepatol. 2009;51:890–7. 27. Nault JC, De Reynies A, Villanueva A, et al. A hepatocellular carcinoma 5-gene score associated with survival of patients after liver resection. Gastroenterology. 2013;145:176–87. 28. Hung HH, Chiou YY, Hsia CY, et al. Survival rates are comparable after radiofrequency ablation or surgery in patients with small hepatocellular carcinomas. Clin Gastroenterol Hepatol. 2011;9:79–86.
Steatosis and HCC Prognosis 29. Roayaie S, Obeidat K, Sposito C, et al. Resection of hepatocellular cancer B2 cm: results from two Western centers. Hepatology. 2013;57:1426–35. 30. Hung HH, Su CW, Lai CR, et al. Fibrosis and AST to platelet ratio index predict post-operative prognosis for solitary small hepatitis B–related hepatocellular carcinoma. Hepatol Int. 2010;4:691–9. 31. Wu WC, Chiou YY, Hung HH, et al. Prognostic significance of computed tomography scan–derived splenic volume in hepatocellular carcinoma treated with radiofrequency ablation. J Clin Gastroenterol. 2012;46:789–95. 32. Sanyal AJ, Banas C, Sargeant C, et al. Similarities and differences in outcomes of cirrhosis due to nonalcoholic steatohepatitis and hepatitis C. Hepatology. 2006;43:682–9. 33. Ascha MS, Hanouneh IA, Lopez R, Tamimi TA, Feldstein AF, Zein NN. The incidence and risk factors of hepatocellular carcinoma in patients with nonalcoholic steatohepatitis. Hepatology. 2010;51:1972–8. 34. Brunt EM, Kleiner DE, Wilson LA, Belt P, Neuschwander-Tetri BA. Nonalcoholic fatty liver disease (NAFLD) activity score and the histopathologic diagnosis in NAFLD: distinct clinicopathologic meanings. Hepatology. 2011;53:810–20.
2261 35. Pais R, Charlotte F, Fedchuk L, et al. A systematic review of follow-up biopsies reveals disease progression in patients with non-alcoholic fatty liver. J Hepatol. 2013;59:550–6. 36. Hashimoto E, Yatsuji S, Tobari M, et al. Hepatocellular carcinoma in patients with nonalcoholic steatohepatitis. J Gastroenterol. 2009;44(Suppl 19):89–95. 37. Tandon P, Garcia-Tsao G. Prognostic indicators in hepatocellular carcinoma: a systematic review of 72 studies. Liver Int. 2009;29: 502–10. 38. Chen CH, Huang MH, Yang JC, et al. Prevalence and etiology of elevated serum alanine aminotransferase level in an adult population in Taiwan. J Gastroenterol Hepatol. 2007;22:1482–9. 39. Alberti KG, Eckel RH, Grundy SM, et al. Harmonizing the metabolic syndrome: a joint interim statement of the International Diabetes Federation Task Force on Epidemiology and Prevention; National Heart, Lung, and Blood Institute; American Heart Association; World Heart Federation; International Atherosclerosis Society; and International Association for the Study of Obesity. Circulation. 2009;120:1640–5.
ORIGINAL ARTICLE – HEPATOBILIARY TUMORS
Impact of Steatosis on Prognosis of Patients with Early-Stage Hepatocellular Carcinoma After Hepatic Resection Chien-Wei Su, MD, PhD1,2, Gar-Yang Chau, MD, MPH2,3, Hung-Hsu Hung, MD2,4,5, Yi-Chen Yeh, MD2,4,6, HaoJan Lei, MD2,3, Cheng-Yuan Hsia, MD2,3, Chiung-Ru Lai, MD2,6, Han-Chieh Lin, MD1,2, and Jaw-Ching Wu, MD, PhD4,7 Division of Gastroenterology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; 2Faculty of Medicine, School of Medicine, National Yang-Ming University, Taipei, Taiwan; 3Division of General Surgery, Department of Surgery, Taipei Veterans General Hospital, Taipei, Taiwan; 4Institute of Clinical Medicine, School of Medicine and Cancer Research Center, National Yang-Ming University, Taipei, Taiwan; 5Division of Gastroenterology, Department of Medicine, Cheng Hsin General Hospital, Taipei, Taiwan; 6Department of Pathology and Laboratory Medicine, Taipei Veterans General Hospital, Taipei, Taiwan; 7Division of Translational Research, Department of Medical Research, Taipei Veterans General Hospital, Taipei, Taiwan
1
ABSTRACT Background. It is still unclear whether steatosis determines the prognosis of patients with hepatocellular carcinoma (HCC). This study aimed to compare the clinical manifestations and outcomes between early-stage HCC patients with and without steatosis after hepatic resection. Methods. We enrolled 188 patients who underwent hepatic resection for HCC within the Milan criteria. After surgery, fibrosis, steatosis, lobular inflammation, portal inflammation, and ballooning in the background liver were assessed. Factors related to prognosis after surgery were analyzed by multivariate analysis. Results. Seventy-four patients (39.4 %) had steatosis. Patients with steatosis had larger body mass index, higher fasting glucose levels, and higher rates of ballooning than
those without steatosis. After a median follow-up period of 69.8 months, 73 patients died. The cumulative survival rates at 5 years were 57.8 and 75.6 % for patients with and without steatosis, respectively (p = 0.008). Multivariate analysis disclosed that an age of [ 65 years [hazard ratio (HR) 1.996, p = 0.009], platelet count of \105/mm3 (HR 2.198, p = 0.005), indocyanine green retention rate at 15 min of [10 % (HR 2.037, p = 0.022), multinodularity (HR 2.389, p = 0.004), and steatosis (HR 1.773, p = 0.023) were independent risk factors associated with poor overall survival after resection. The impact of steatosis on postsurgical prognosis was more apparent in patients without cirrhosis. Conclusions. The presence of steatosis in the background liver was associated with a poor prognosis in early-stage HCC patients after hepatic resection, especially for noncirrhotic patients.
Presented as an oral presentation at the annual meeting of the American Association for the Study of the Liver, Washington, DC, USA, November 1–5, 2013.
Electronic supplementary material The online version of this article (doi:10.1245/s10434-014-4221-5) contains supplementary material, which is available to authorized users. Ó Society of Surgical Oncology 2014 First Received: 26 June 2014; Published Online: 10 December 2014 G.-Y. Chau, MD, MPH e-mail: [email protected] J.-C. Wu, MD, PhD e-mail: [email protected]
Hepatocellular carcinoma (HCC) is the third most common cause of cancer death in the world.1,2 Recently, the impact of metabolic disorders and steatosis on hepatic carcinogenesis has become an important issue because of the increasing incidences of obesity and diabetes globally.3–7 One prospective cohort study involving U.S. adults found that the relative risk of mortality from liver cancers were 4.52 and 1.68 for men and women, respectively, with a body mass index (BMI) of C35 kg/m2 compared to those with a normal BMI.8 This indicates that metabolic disorder and steatosis may play increasingly important roles in HCC development.
2254
Hepatic resection is recommended as the first-line treatment modality in patients with early-stage HCC.1 Although the long-term outcomes of HCC patients after resection are improving, they are still not ideal. The 5-year survival rate is only around 50–70 %.9–12 To improve the prognosis of these patients, it is crucial to identify correctable factors that affect their outcomes. Although steatosis and metabolic syndrome have been proven to be associated with hepatocarcinogenesis, whether they determine the prognosis of HCC patients after resection has not been fully elucidated.13–15 We hypothesized that metabolic disorder and steatosis, like antiviral therapy, might be modifiable prognostic factors in HCC patients undergoing resection.2,16,17 To test this hypothesis, we comprehensively compared clinical manifestations and prognoses between early-stage HCC patients with and without steatosis after hepatic resection.
C.-W. Su et al.
HCC patients underwent surgical resection (n=1073)
Exclusion criteria: 1. Beyond Milan criteria (n=541) 2. Non-tumor part pathology is not available (n=271) 3. With antiviral treatment(n=34) or unknown antiviral treatment (n=39)
Fulfilled the exclusion criteria: 1. Within Milan criteria 2. Non-tumor part pathology available 3. No antiviral treatment (n=188)
Is non-tumor part cirrhosis?
MATERIALS AND METHODS Patients and Follow-up We retrospectively reviewed 1,073 consecutive treatment-naı¨ve HCC patients who underwent hepatic resection at the Taipei Veterans General Hospital (TVGH) from 1991 to 2006 (Fig. 1). The criteria for resectable HCC were as follows: (1) Child’s grade of liver function of A or B, with indocyanine green 15-min retention rate (ICG-15R) of B30 %; (2) tumor involving no more than two Healey segments and without main portal vein trunk involvement; and (3) absence of extrahepatic tumor dissemination.9 The exclusion criteria for the current study were as follows: (1) failure to meet Milan criteria (a single tumor B5 cm or up to 3 nodules, each B3 cm in size, and without major vascular invasion); (2) unavailable nontumor part pathology; and (3) antiviral treatment after surgery or unknown antiviral treatment history.18 A total of 188 patients who fulfilled the criteria were included in the final analysis. After surgery, patients were assessed every 3 months for serum liver biochemistry and for a-fetoprotein (AFP) levels; they also underwent ultrasound. Tumor recurrence was suspected if serum AFP levels were progressively elevated or new lesions were detected by surveillance ultrasound. The suspected tumor recurrences were further diagnosed by dynamic computed tomography or magnetic resonance imaging. The study complied with the standards of the Declaration of Helsinki and was approved by the institutional review board of TVGH. Biochemical and Serologic Markers Serum levels of hepatitis B surface antigen (HBsAg) were measured using a radioimmunoassay kit (Abbott
No; ISHAK fibrosis score 0-4 (n=77)
Yes; ISHAK fibrosis score 5-6 (n=111)
FIG. 1 Study flow chart
Laboratories, North Chicago, IL), while antibodies against hepatitis C virus (HCV) were tested using a second-generation enzyme immunoassay kit (Abbott Laboratories, North Chicago, IL). Serum biochemistries were measured using the Roche/Hitachi Modular Analytics System (Roche Diagnostics GmbH, Mannheim, Germany), and serum AFP levels were measured using a radioimmunoassay kit (Serono Diagnostic SA, Coinsin/VD, Switzerland). Pathology Grading Two experienced pathologists performed pathology grading (Y.C.Y. and C.R.L.) after reaching consensus. The degree of inflammation and the stage of fibrosis in the background liver were scored on an Ishak grading scale.19 Tissues given an Ishak fibrosis score of 5 or 6 were diagnosed as cirrhotic. The stigmata of steatohepatitis, including steatosis, lobular inflammation, portal inflammation, and ballooning, were assessed by the criteria proposed by Brunt and colleagues.20,21 Statistical Analysis Baseline characteristics were selected to be evaluated according to the European Association for the Study of the Liver guidelines published in 2001.22 Pearson’s Chi square analysis or Fisher’s exact test was performed to compare
23.70; 21.70–26.30
Body mass index (kg/m2)
Anti-HCV positive/negative (%)
84.5; 66.0–107.25
Alk-P (U/L)
1.00; 1.00–1.05 140000; 104500–177000
ICG-15R (%)
PT/INR
Platelet (/mm3)
Microscopic vascular invasion (yes/no) (%)
143/45 (76.1 %/23.9 %) 70/118 (37.2 %/62.8 %) 92/96 (48.9 %/51.1 %)
Ishak fibrosis (0–2/3–4/5–6) (%)
Lobular inflammation (0–1/2–3) (%)
Portal inflammation (0–1/2–4) (%)
Ballooning (yes/no) (%)
36/78 (31.6 %/68.4 %)
37/77 (32.5 %/67.5 %)
90/24 (78.9 %/20.9 %)
19/27/68 (16.7 %/23.7 %/59.6 %)
21/54/39 (18.4 %/47.4 %/34.2 %)
58/56 (50.4 %/49.6 %)
4/110 (3.5 %/96.5 %)
6/75/29/2 (5.4 %/67.0 %/25.9 %/1.7 %)
56/18 (75.7 %/24.3 %)
33/41 (44.6 %/55.4 %)
53/21 (71.6 %/28.4 %)
14/17/43 (18.9 %/23.0 %/58.1 %)
12/34/28 (16.2 %/45.9 %/37.8 %)
40/34 (54.1 %/45.9 %)
3/71 (4.1 %/95.9 %)
2/48/21/1 (2.8 %/66.7 %/29.2 %/1.3 %)
53/21 (71.6 %/28.4 %)
38.4; 8.0–190.0
63/11 (85.1 %/14.9 %)
2.50; 2.00–3.43
139000; 107500–177500
1.00; 1.00–1.07
12; 7–16
97; 87–119
1.0; 0.9–1.13
173.5; 144.0–195.8
87.0; 65.5–108.5
45.0; 30.5–65.5
53.0; 38.5–83.5
0.8; 0.59–1.0
4.0; 3.8–4.3
12/58 (17.1 %/82.9 %)
55/17 (76.4 %/23.6 %)
25.10; 23.10–26.80
64/10 (86.5 %/13.5 %)
60.5; 51.8–70.3
Steatosis (n = 74)
PT/INR prothrombin time/international normalized ratio
Alk-P alkaline phosphatase
HBsAg hepatitis B surface antigen, HCV hepatitis C virus, ALT alanine aminotransferase, AST aspartate aminotransferase, ICG-15R indocyanine green 15-min retention rate, AFP a-fetoprotein
Continuous variables are expressed as median (25th and 75th percentiles); other variables are expressed as n/N (%)
33/88/67 (17.6 %/46.8 %/35.6 %) 33/44/111 (17.6 %/23.4 %/59.0 %)
Ishak activity (0–3/4–6/7–13) (%)
Pathological factors in background liver
7/181 (3.7 %/96.3 %) 98/90 (52.1 %/47.9 %)
Macroscopic vascular invasion (yes/no) (%)
73/40 (64.6 %/35.4 %)
126/61 (67.4 %/32.6 %) 8/123/50/3 (4.3 %/66.8 %/27.2 %/1.6 %)
Cut margin B 1/[ 1 cm (%)
Edmondson grading (I/II/III/IV) (%)
15.98; 6.62–220.00
19.70; 7.03–212.50
AFP (ng/mL)
98/16 (86.0 %/14.0 %)
2.50; 1.93–3.20 161/27 (85.6 %/14.4 %)
Single tumor/multinodularity (%)
2.50; 1.90–3.20
140500; 102250–176750
1.00; 1.00–1.04
13; 8–17
91; 84–101
1.0; 0.9–1.2
169; 147–188
84; 66–106
45; 31–63
50.0; 29.0–83.0
0.7; 0.6–1.1
4.1; 3.8–4.3
28/78 (26.4 %/73.6 %)
82/29 (73.9 %/26.1 %)
23.03; 21.05–25.88
88/26 (77.2 %/22.8 %)
62.5; 52.0–71.0
No steatosis (n = 114)
Tumor size (cm)
Tumor factors
93; 85–104.75 13; 7–17
Glucose (mg/dL)
171; 145.5–192.5
45; 31–65
AST (U/L)
1.0; 0.9–1.2
50; 32–83
ALT (U/L)
Creatinine (mg/dL)
0.8; 0.6–1.0
Total bilirubin (mg/dL)
Cholesterol (U/L)
4.1; 3.8–4.3
Albumin (g/dL)
Serum biochemistry tests and liver functional tests
137/46 (74.9 %/25.1 %) 40/136 (22.7 %/77.3 %)
HBsAg positive/negative (%)
Virus factors
61.5; 52.0–70.75 152/36 (80.9 %/19.1 %)
Sex (male/female) (%)
All (n = 188)
Age (year)
Patient demographics
Parameter
TABLE 1 Demographic data of hepatocellular carcinoma patients who underwent hepatic resection
0.627
0.098
0.263
0.743
0.583
0.672
0.848
0.552
0.314
0.925
0.875
0.562
0.756
0.720
0.703
0.028
0.235
0.365
0.355
0.435
0.609
0.655
0.588
0.914
0.924
0.001
0.100
\0.001
p
Steatosis and HCC Prognosis 2255
2256
categorical variables, while continuous variables were compared by the Mann–Whitney U test. Cumulative recurrence rates or overall survival rates were estimated by the Kaplan–Meier method and compared by the log-rank test. Moreover, the assumption of proportional hazards was confirmed by the log minus log plot of survival in the Cox regression analysis. Variables for which statistically significant (p \ 0.05) or close to statistically significant (p \ 0.1) differences were observed by univariate analysis were included in multivariate analysis by a backward stepwise Cox regression model. A two-tailed p value of \0.05 was considered statistically significant. All statistical analyses were performed by SPSS 17.0 for Windows software (IBM, Armonk, NY).
C.-W. Su et al.
Subgroup analysis of the prognostic implications of steatosis in determining overall survival after resection As shown in Supplementary Table 2, steatosis was correlated with poor overall survival after resection in the following subgroups: age B65 years, male patients, presence of HBsAg in sera, negativity for anti-HCV, serum albumin [ 4 g/dL, alanine aminotransferase (ALT) B 40 U/L, AST B 45 U/L, ICG-15R B 10 %, single tumor, tumor size B 3 cm, no macroscopic vascular invasion, no cirrhosis, lobular inflammation score B 1, portal inflammation score B 1, and no ballooning in background liver. Factors Associated with Overall Survival in Noncirrhotic Patients
RESULTS Baseline Clinical Characteristics Of the 188 patients, 74 (39.4 %) had steatosis and the remaining 114 patients did not have steatosis in the background liver. As summarized in Table 1 and Supplementary Table 1, patients with steatosis had a larger BMI, higher fasting glucose levels, and higher rates of ballooning compared to those without steatosis. Other factors, including demographic, tumor, and pathological factors as well as type of resection, were comparable between the two groups.
Factors Associated with Prognosis after Resection in All Patients After a median follow-up period of 69.8 months (25th– 75th percentile 34.1–98.6 months), 73 patients died and 115 were still alive on their last visit. Stratified by the status of steatosis, the cumulative overall survival rates at 1, 3, and 5 years were 97.3, 86.5, and 75.6 %, respectively, for patients without steatosis and 94.6, 79.3, and 57.8 %, respectively, for those with steatosis (Fig. 2a; p = 0.008). According to a multivariate analysis, an age of [65 years, a platelet count of B105/mm3, an ICG-15R of [10 %, multinodularity, and steatosis were independent risk factors associated with poor overall survival after resection (Table 2). Furthermore, 123 patients developed tumor recurrence after surgery. The cumulative recurrence rates at 1, 3, and 5 years were 23.6, 55.8, and 73.8 %, respectively. According to a multivariate analysis, serum aspartate aminotransferase (AST) levels of [45 U/L, macroscopic vascular invasion, presence of cirrhosis, and presence of ballooning were independent risk factors correlated with recurrence (Table 3).
There were 77 patients who were noncirrhotic in the background liver. The distribution of the scores of Ishak fibrosis was as follows: 0, 6 patients; 1, 11 patients; 2, 16 patients; 3, 23 patients; and 4, 21 patients. Patients with steatosis had a larger BMI, lower rate of HCV seropositivity, and higher rate of ballooning compared to those without steatosis (Supplementary Table 3). As shown in Fig. 2b, the cumulative overall survival rate was significantly higher in patients without steatosis than in those with steatosis (p = 0.047). A multivariate analysis showed that presence of steatosis remained an independent factor that predicts a higher mortality rate after resection, together with age [65 years and serum albumin levels B 4 g/dL (Supplementary Table 4). Factors Associated with Overall Survival in Cirrhotic Patients Of the 111 cirrhotic patients, 46 patients died during the follow-up period. As shown in Supplementary Table 5, a multivariate analysis revealed that ICG-15R [ 10 %, multinodularity, more severe portal inflammation, and presence of ballooning were correlated with poor survival after resection. In addition, cirrhotic patients with steatosis showed a trend of lower overall survival rates than those without steatosis in the nontumor part of their liver specimens (Fig. 2c; p = 0.079). DISCUSSION According to numerous epidemiological surveys, fatty liver disease is the most common factor for chronic liver disease in both high and low endemic countries for viral hepatitis.4,23 In a population-based study in the United States, Welzel et al. found that while chronic hepatitis B
Steatosis and HCC Prognosis
Overall survival rate (%)
A
2257 b FIG. 2 Cumulative curves of overall survival rates stratified by
100
status of steatosis. Patients with steatosis in nontumor part of liver specimens had significantly lower rate of overall survival than those without steatosis (a, p = 0.008), especially in noncirrhotic patients (b, p = 0.047). For cirrhotic patients, those with steatosis showed a trend of a lower rate of overall survival after resection as compared with their counterparts (c, p = 0.079)
80
60
No steatosis 40
With steatosis
20
0 0
2
4
6
8
10
12
14
16
18
6 2
2
2
20
Follow-up (years) Patients at risk No steatosis 114 101 With steatosis 74 62
Overall survival rate (%)
B
74 37
59 23
37 16
18 6
7 3
100
80
No steatosis
60
40
With steatosis 20
0 0
2
4
6
8
10
12
14
16
18
3
2
2
20
Follow-up (years)
C
100
Overall survival rate (%)
Patients at risk No steatosis 46 With steatosis 31
80
43 27
37 18
32 13
21 10
10 3
4 1
60
No steatosis 40
20
With steatosis
0 0
2
4
6
8
10
12
14
3 2
3 2
16
Follow-up (years) Patients at risk No steatosis 68 With steatosis 43
58 35
37 19
27 10
16 6
8 3
virus (HBV) or HCV infection had a higher odds ratio as a risk factor for HCC, diabetes and/or obesity had the largest population-attributable fraction (36.6 %) for HCC,
suggesting a dominant role for diabetes and obesity in hepatic carcinogenesis.4 Adipose tissue expansion in patients with fatty liver promoted the release of proinflammatory cytokines, including tumor necrosis factor and interleukin-6; the reduction of anti-inflammatory adipokines such as adiponectin; and the induction of lipotoxicity accompanied by increased blood levels of insulin.3,24 All of these factors might contribute to hepatic carcinogenesis in patients with fatty liver. Moreover, in patients with chronic viral hepatitis, Chen et al. found a more than 100-fold increased risk of developing HCC among HBV carriers with both obesity and diabetes compared to those without these factors.25 These results imply that steatosis may act synergistically with viral infection in HCC development. Our current study further suggests that steatosis might play an important role in determining the prognosis of virusinduced HCC after resection. Surgical resection is recommended as the first-line treatment for Barcelona Clinic for Liver Cancer stage A HCC or for tumors that meet the Milan criteria.1 Previous studies demonstrated that both tumor factors (e.g., tumor size, number, vascular invasion, and gene signature) and field factors (including grade of hepatic inflammation, stage of fibrosis, portal hypertension, liver functional reserve, and virus replications) influence the prognoses of HCC patients after hepatic resection.10,26,27 For patients with early-stage HCC, tumor factors are less relevant than field factors in determining prognosis.28–31 Among the field factors, antiviral therapies and metabolic syndrome seem to be modifiable factors. Recent studies revealed that prescriptions of antiviral therapies after hepatic resection could improve overall survival and decrease recurrence, especially in early-stage HCC.2,16,17 In our present study, we excluded patients who received antiviral therapies after resection to minimize these confounding effects and to focus on the impact of steatosis on postoperative prognosis. Our results showed that the presence of steatosis in the background liver was associated with a poor prognosis after resection. Of note, the effects were more apparent in noncirrhotic patients and in patients with better liver functional reserve, less hepatic necroinflammation, and early-stage HCC. This finding indicates that steatosis, an important field factor, is crucial in determining the prognosis of patients with early-stage HCC and well-preserved liver function.
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TABLE 2 Factors associated with poor overall survival after resection for hepatocellular carcinoma Characteristic
n/N
Univariate analysis
Multivariate analysis
Hazard ratio (95 % confidence interval)
p
Hazard ratio (95 % confidence interval)
p
1.996 (1.189–3.344)
0.009
1.550 (0.915–2.626)
0.103
Age [ 65/B65 year
72/116
2.093 (1.136–3.329)
0.002
Sex female/male
36/152
0.594 (0.295–1.195)
0.144
Body mass index [24/B24 kg/m2 HBsAg positive/negative
84/99 137/46
1.174 (0.734–1.878) 1.080 (0.931–1.245)
0.504 0.308
Anti-HCV positive/negative
40/136
0.983 (0.861–1.124)
0.806
Albumin B4/[4 g/dL
90/93
1.866 (1.153–3.021)
0.011
Bilirubin [1.6/B1.6 mg/dL
7/181
0.986 (0.355–2.735)
0.978
ALT [40/B40 U/L
118/69
1.041 (0.645–1.679)
0.870
AST [45/B45 U/L
89/98
1.423 (0.893–2.265)
0.138
Platelet B105/[105/mm3
38/135
2.232 (1.344–3.704)
0.002
2.198 (1.274–3.793)
0.005
ICG-15R [10 %/B10 %
112/73
2.271 (1.327–3.889)
0.003
2.037 (1.107–3.745)
0.022
PT/INR [1.1/B1.1
28/158
2.145 (1.262–3.647)
0.005
1.637 (0.887–3.012)
0.115
90/94
0.989 (0.617–1.587)
0.964 2.389 (1.319–4.367)
0.004
1.152 (0.613–2.163)
0.660
AFP [20/B20 ng/mL Multiple tumor (yes/no)
27/161
1.657 (0.949–2.893)
0.075
Tumor size [3/B3 cm
53/135
0.860 (0.504–1.465)
0.579
Cut margin B1/[1 cm
126/61
1.894 (1.100–3.268)
0.021
Edmondson grading (III ? IV/I ? II)
53/131
1.048 (0.634–1.733)
0.854
7/181 98/90
1.021 (0.250–4.184) 1.406 (0.882–2.247)
0.977 0.152
Macroscopic vascular invasion (yes/no) Microscopic vascular invasion (yes/no) Ishak fibrosis (5–6/0–4)
77/111
1.581 (0.980–2.548)
0.060
1.260 (0.684–2.319)
0.458
Steatosis (yes/no)
114/74
1.863 (1.173–2.957)
0.008
1.773 (1.081–2.915)
0.023
Lobular inflammation (2–3/0–1)
45/143
1.101 (0.624–1.946)
0.740
Portal inflammation (2–4/0–1)
118/70
1.821 (1.136–2.915)
0.013
1.815 (0.970–3.397)
0.062
92/96
1.630 (1.017–2.615)
0.043
1.603 (0.923–2.786)
0.094
Ballooning (yes/no)
HBsAg hepatitis B surface antigen, HCV hepatitis C virus, ALT alanine aminotransferase, AST aspartate aminotransferase, ICG-15R indocyanine green 15-min retention rate, AFP a-fetoprotein PT/INR prothrombin time/international normalized ratio
Recently, several studies compared the clinical manifestations and prognoses between HCC originating from HCV infection and from steatohepatitis.14,32,33 Yet, the impact of steatosis on the long-term outcomes of virusinduced HCC after curative resection had been little studied.13 Wu et al. compared the clinicopathological characteristics and postoperative prognoses of HCC patients with and without steatosis in the background liver.13 They observed that patients with steatosis had smaller tumor size, lower serum AFP levels, lower rates of vascular invasion, and advanced tumor grade compared to those without steatosis. Moreover, patients with steatosis who had a tumor larger than 5 cm had better overall survival after resection. Nevertheless, the postoperative outcomes were not significantly different between these two groups for patients with tumors smaller than 5 cm. In our current study, patients with steatosis were associated with higher BMI, fasting glucose levels, and hepatic cell ballooning. Therefore, steatosis could be considered the
hepatic manifestation of obesity and related metabolic disorders such as diabetes. Moreover, our study showed that for patients with HCC who satisfied the Milan criteria, those with steatohepatitis had significantly lower overall survival rates. Interestingly, steatosis in the background liver had a more profound effect in determining postoperative prognosis in noncirrhotic patients, but it was less apparent in the cirrhotic group. In its place, other important stigmata of steatohepatitis, such as portal inflammation and ballooning, were independent risk factors of poor overall survival in cirrhotic patients. Law and Brunt observed that lobular inflammation in fatty liver was usually mild, and it was more common in alcoholic steatohepatitis than in nonalcoholic steatohepatitis.21 In contrast, portal inflammation is more common in patients with fatty liver disease.21 Ballooning, one of the characteristic markers of liver cell injury in fatty liver disease, was found to be closely linked to insulin resistance and disease progression.34,35 When steatohepatitis patients progress to the end stage of liver disease, the
Steatosis and HCC Prognosis
2259
TABLE 3 Factors associated with tumor recurrence after resection for hepatocellular carcinoma Characteristic
n/N
Univariate analysis
Multivariate analysis
Hazard ratio (95 % confidence interval)
p
Age [65/B65 year
72/116
1.320 (0.911–1.911)
0.142
Sex female/male
36/152
0.872 (0.548–1.385)
0.561
Body mass index [24/B24 kg/m2 HBsAg positive/negative
84/99 137/46
1.272 (0.882–1.834) 1.074 (0.966–1.195)
0.197 0.187
Anti-HCV positive/negative
40/136
1.112 (1.014–1.219)
0.025
90/93
1.212 (0.844–1.742)
0.298 0.828
Albumin B4/[4 g/dL Bilirubin [1.6/B1.6 mg/dL
7/181
1.089 (0.503–2.358)
ALT [40/B40 U/L
118/69
1.260 (0.859–1.850)
0.238
AST [45/B45 U/L
89/98
1.646 (1.144–2.367)
0.007
3
38/135
1.208 (0.783–1.866)
0.393
ICG-15R [10 %/B10 %
112/73
1.146 (0.787–1.666)
0.478
PT/INR [1.1/B1.1
28/158
1.155 (0.717–1.859)
0.553
90/94
1.094 (0.761–1.572)
0.629
27/161
1.554 (0.993–2.433)
0.054
5
5
Platelet B10 /[10 /mm
AFP [20/B20 ng/mL Multiple tumor (yes/no)
Hazard ratio (95 % confidence interval)
p
1.072 (0.975–1.178)
0.149
1.647 (1.136–2.390)
0.009
1.565 (0.995–2.461)
0.053
Tumor size [3/B3 cm
53/135
0.944 (0.623–1.431)
0.787
Cut margin B1/[1 cm
126/61
0.748 (0.505–1.110)
0.149
Edmondson grading (III ? IV/I ? II)
53/131
1.113 (0.751–1.650)
0.593
7/181 98/90
4.386 (1.751–10.989) 1.008 (0.706–1.439)
0.002 0.965
5.556 (1.953–15.872)
0.001
111/77
1.874 (1.285–2.732)
0.001
1.790 (1.221–2.624)
0.003
Macroscopic vascular invasion (yes/no) Microscopic vascular invasion (yes/no) Ishak fibrosis (5–6/0–4) Steatosis (yes/no)
114/74
1.270 (0.885–1.821)
0.194
Lobular inflammation (2–3/0–1)
45/143
1.404 (0.922–2.137)
0.114
Portal inflammation (2–4/0–1)
118/70
1.631 (1.101–2.414)
0.015
1.367 (0.900–2.075)
0.143
92/96
1.732 (1.189–2.525)
0.004
1.694 (1.158–2.476)
0.007
Ballooning (yes/no)
HBsAg hepatitis B surface antigen, HCV hepatitis C virus, ALT alanine aminotransferase, AST aspartate aminotransferase, ICG-15R indocyanine green 15-min retention rate, AFP a-fetoprotein PT/INR prothrombin time/international normalized ratio
histological features of steatohepatitis, including steatosis, necroinflammation, and ballooning, might disappear in socalled burnout steatohepatitis.36 This disappearance could lead to underestimation of steatosis in cirrhotic patients with steatohepatitis. This phenomenon may explain why other main determinants of steatohepatitis, including portal inflammation and ballooning, were still independent risk factors of poor overall survival and recurrence in such patients, while steatosis could not predict postsurgical prognosis in the cirrhotic group. Furthermore, steatosis, older age, lower platelet counts, higher ICG-15R, and multinodularity were also associated with poorer overall survival after resection in our cohort, consistent with results from prior studies.37 There are several potential limitations of this study. First, as a result of its retrospective study design, it lacks detailed information on diabetes history, smoking, alcohol consumption, and HBV and HCV virus genotypes. We therefore could not completely exclude the impact of
alcohol on steatosis and on prognoses after resection in our cohort. However, one community study conducted in Taiwan showed that elevated serum ALT levels were attributable to alcohol consumption in only 0.8 % of subjects.38 Previous studies also demonstrate that more than 90 % of HCC cases in Taiwan are attributable to HBV or HCV infections. In our cohort, only 7 patients were both negative for serum HBsAg and anti-HCV. These results suggest that alcohol consumption may play only a minor role in steatosis and hepatic carcinogenesis in Taiwan. Second, because most of our patients had chronic viral liver disease, we could not evaluate the impact of pure metabolic steatosis on postoperative prognoses in the absence of viral hepatitis in our cohort. However, our study demonstrated that steatosis negatively affected the prognoses of HCC patients after resection, especially for those with chronic HBV infection (Supplementary Table 1). Because HBV infection is the most common cause of HCC worldwide, our data highlighted the importance of steatosis
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in the background liver in determining the outcomes of patients with HBV-related HCC after hepatic resection. Third, steatosis is the hepatic manifestation of metabolic syndrome. Cauchy et al. reported that HCC patients with metabolic syndrome had a high rate of postoperative complications, especially for those without severe fibrosis in the background liver.15 However, because our current study is a retrospective one, we could not assess the impact of metabolic syndrome score on postsurgical prognoses as a result of lack of data on waist circumference and levels of triglyceride and high-density lipoprotein cholesterol.39 Prospective studies are needed to elucidate whether the lower overall survival rates of patients with steatosis was due to steatosis per se or due to poor general health associated with metabolic syndrome. In conclusion, the presence of steatosis in the background liver was associated with a poor prognosis after hepatic resection in patients with HCC satisfying the Milan criteria, especially those without cirrhosis and with earlystage tumors. ACKNOWLEDGMENT This work was supported by grants from the National Science Council of Taiwan (NSC 101-2314-B-075-013MY2), Taipei Veterans General Hospital (V102C-117, C103C-055, VGHUST100-G7-2-1), Yang-Ming University (101AC-T501, Ministry of Education, Aim for the Top University Plan), and the Center of Excellence for Cancer Research at TVGH (DOH102-TD-C-111007), Taipei, Taiwan. DISCLOSURE
The authors declare no conflict of interest.
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