Clinical Value Of Tace For Postoperative Treatment Of Hepatocellular Carcinoma And The Relationship With The Clinicopathologic Characteristics

Part I The Protein Expression of P53, P21, nm23and VEGF and theVariations of the MtDNA D-Loop Region in Hepatocellular CarcinomaObjective To study the expression of P53, P21, nm23and vascularendothelial growth factor (VEGF) and analyze the sequences of themitochondrial DNA (mtDNA) D-Loop region in hepatocellular carcinoma(HCC). And the relationship between the protein expression or the sequencesvariations and the clinicopathologic characteristics were also explored.Methods140cases with HCCs were employed, of them123cases weremale and17were female, and the median age was47.0years (ranged from25to79years). These cases should meet the criteria as follows:(1) Including criteria:first, the case diagnosed liver tumor should receive the radical resection in thedepartment of hepatobiliary surgery of the first affiliated hospital to Guangximedical university from January2003to August2012; second, the case wasdiagnosed as hepatocellular carcinoma in pathology; third, the records of theinpatient department and the outpatient department for the case should be integrated.(2) Excluding criteria: first, the case who didn’t receive radicalresection; second, the case who died during the perioperative period; third, thecase who recurred in two months after the operation; forth, the case whoserecords of the inpatient department and the outpatient department wereunintegrated; fifth, the case with other serious medical diseases.(3) Radicalresection criteria for HCC: first, the whole tumor was removed completely andthere was no residual tumor along the radical margins; second, tumor numberwas no more than2; third, without tumor embolus in trunk or branch portal vein,nor in common hepatic duct or the primary branches, nor in hepatic vein trunkor in postcava; forth, without porta hepatis lymph node metastases; fifth, withoutextrahepatic metastases; sixth, the serum AFP dropped to normal if preoperativeserum AFP was high and there was no residual tumor screened by images in twomonths after resection. The expression of P53, P21, nm23and VEGF weredetected by immunohistochemical method and the mtDNA D-Loop sequenceswere analyzed by polymerase chain reaction (PCR) and direct sequencing. Andthen the data were analyzed by medical statistics.Results (1) Of the140cases, the positive expression for P53protein was58.6%(82/140), and it was significantly related with the infection of liver fluke,tumor size, HBV DNA, tumor necrosis and microscope embolus (P<0.05). Theexpression rates for P53protein in cases with liver fluke infected, tumor sizelarger than3cm (or8cm), HBV DNA positive, tumor necrosis and microscopeembolus were remarkably higher, and they were75.0%,62.8%(or73.0%),72.2%,74.2%and80.0%, respectively.(2) Of the140cases, the positiveexpression for P21protein was44.3%(62/140), and it was significantly relatedwith differentiation degrees (Edmondson grades) and cirrhosis (P<0.05). Theexpression rates for P21protein in cases with well, moderate or poor differentiation were25.9%,44.9%and62.5%; and48.6%for cases withcirrhosis.(3) Of the140cases, the positive expression for nm23protein was77.9%(109/140), and it was significantly related with HBeAg, tumor necrosisand microscope embolus (P<0.05). The expression rates for nm23protein incases with positive HBeAg, and without tumor necrosis nor microscope emboluswere remarkably higher, and they were84.6%,81.9%and83.8%, respectively.(4) Of the140cases, the positive expression for VEGF protein was75.7%(106/140), and it was significantly related with age, infection of liver fluke andHBeAb (P<0.05). The expression rates for VEGF protein in cases with youngerthan47years old, liver fluke infected and positive HBeAb were remarkablyhigher, and they were82.9%,93.8%and82.5%.(5) Of the140cases, there were150points variations (13.4%,150/1122) for the mtDNA D-Loop sequences,and of them13were point mutations,8were insertions and20were deletions.There were116polymorphisms altogether. Most of the variations were locatedin hypervariable segments I (NT57-372) and II (NT16024-16383), and theywere46points (30.7%,46/150) and63(42.0%,63/150), respectively. The typesof the bases variations were T>A (18), A>T (29), C>G (21), G>C (34) anddeletions (16). The types of the bases mutations were G>A (5), T>A (3), A>T (3),A>C (1), C>G (1), C>A (1), and the mutation rate was10.0%(14/140). Therewas a special region named D310with poly C, and the types for it were C5TC63(2.1%), C8TC664(45.7%), C8TC764(45.7%), C9TC63(2.1%), C8CC6(C15)3(2.1%), and the rest3cases were standard type C8TC6(2.1%).Conclusion (1) There is a high rate for P53protein expression in HCCs,and it maybe related with the infection of liver fluke, especially coinfected withHBV. For the advanced HCCs, the expression of P53protein is remarkablyhigher.(2) The rates for P21protein expression in HCCs are variable. And there maybe a negative correlation with the differentiation degrees (Edmondsongrades) and a positive correlation with cirrhosis.(3) The expression rates fornm23protein in cases with positive HBeAg, and without tumor necrosis normicroscope embolus are remarkably higher. And it seems that the protein ofnm23could suppress tumor metastasis.(4) There is a high rate for VEGFprotein expression in HCCs, and it maybe related with the infection of liverfluke.(5) The sequences of the mtDNA D-Loop region are variable, and most ofthem are located in hypervariable segments I and II. The D310region is alsovariable. Part II The Prognoses for Hepatocellular Carcinoma after RadicalResection and the Clinical Value of Postoperative Adjuvant TACEObjective To explore the prognoses for hepatocellular carcinoma afterradical resection and analyze the clinical value of postoperative adjuvant TACE.Methods The clinicopathologic characteristics and the postoperativetreatments were collected for140cases with hepatocellular carcinomas (HCCs).And the recurrent time as well as the dead time were recorded carefully.Univariate analysis and multivariate analysis were performed according to theclinicopathologic characteristics and the postoperative treatments. The survivalanalysis was also performed for the tumor free survival and the overall survival.TACE was performed by the Seldinger technique, and the chemotherapeutic agents included pirarubicin, cisplatin and fluorouracil (5-FU), and the embolicagent was lipiodol.Results (1) The median follow-up was40.9months (ranged from8to126months), and there were100cases with HCCs received postoperative adjuvantTACE before recurrence and the rest40without, but just received follow-upvisits through outpatient department. Until31December,2013, there were129cases with recurrences (median time was12.0months, ranged from3to77) and107cases dead (median time was37.0months, ranged from8to126). For129cases with recurrences, operations were performed again for42cases (49timesaltogether, twice for7cases); the treatments of TACE were354times,radiofrequency ablation (RFA) were31, and percutaneous ethanol injection (PEI)were152.(2) If the recurrent time was no longer than1year after the radicalresection, it was characterized as early recurrence; if not, it was late recurrence.In the univariate analysis, the clinicopathologic characteristics including age,tumor size, tumor capsule, surgical margin, blood transfusion during operation,HBeAg, HBV DNA, gamma-glutamyl transpeptidase (GGT), alanineaminotransferase (ALT), aspartate amino transferase (AST), differentiationdegree (Edmondson grade), cirrhosis, microscope embolus, TNM stage,adjuvant TACE, the locus16129(G/A) of mtDNA, the locus16192(C/T) ofmtDNA, the locus16297(T/C) of mtDNA, the locus150(C/T) of mtDNA, thelocus199(T/C) of mtDNA, and the locus204(T/C) of mtDNA weresignificantly different between the early recurrent group and the late (P<0.05).But only age, HBV DNA, TNM stage, adjuvant TACE (≤2or>2) and the locus150(C/T) of mtDNA were independent factors in the logistic regression. And ofthem, adjuvant TACE (≤2or>2) and the locus150(C/T) of mtDNA were protective factors, while the rest were risk. It seemed that there was norelationship between the protein expression of P53, P21, nm23, VEGF and theearly recurrences. Stratification analysis was also performed, and the cases withTNM stage Ⅱ, moderate differentiation, cirrhosis, positive HBsAg, positiveHBeAg, the locus16162of mtDNA with A, the locus16172of mtDNA with T,the locus16304of mtDNA with T, or the locus150of mtDNA with T whoreceived adjuvant TACE might decrease the recurrent rate. And the best benefittimes for them were more than2.(3) For140cases, the median tumor freesurvival was12.0months, and the recurrent rate for1,2,3,4,5years were50%,70%,79%,89%and92%, respectively. The clinicopathologic characteristicsincluding infection of liver fluke, HBV DNA, Child pugh class, TNM stage,adjuvant TACE (≤2or>2) and the locus310of mtDNA were independentfactors for tumor free survival according to the Cox proportional hazardregression model. And of them, Child pugh class and adjuvant TACE (≤2or>2)were protective factors, while the rest were risk. The cases with Child pugh classA or received more than2times adjuvant TACE might decrease the recurrentrate and prolong the tumor free survival. It seemed that there was no relationshipbetween the protein expression of P53, P21, nm23, VEGF and the tumor freesurvival. Surprisingly, the cases with tumor size no larger than3cm whoreceived more than2times adjuvant TACE had a shorter median tumor freesurvival (38.0vs19.0months, P=0.024) according to the stratification analysis.(4) For140cases, the median overall survival was37.0months, and the survivalrate for1,2,3,4,5years were94%,72%,56%,40%and27%, respectively. Theclinicopathologic characteristics including recurrent types (early/late), GGT(≥100U/L/<100U/L), Child pugh class (A/B) and the adjuvant treatment aftertumor recurrence (none or one/more than one treatment) were independent factors for overall survival according to the Cox proportional hazard regressionmodel. And of them, Child pugh class (A/B) and the adjuvant treatment aftertumor recurrence (none or one/more than one treatment) were protective factors,while the rest were risk. The cases with Child pugh class A or received morethan one adjuvant treatment after tumor recurrence might decrease the mortalityrate and prolong the overall survival. It seemed that there was no relationshipbetween the protein expression of P53, P21, nm23, VEGF and the overallsurvival.Conclusions To analyze the clinicopathologic characteristics might have aprediction for early recurrence after HCCs resection. The cases with age≤47years, larger tumor size, without tumor capsule, surgical margin <2.0cm,consisted of blood transfusion during operation, positive HBeAg, positive HBVDNA, GGT≥50U/L, ALT≥90U/L, AST≥80U/L, moderate or poor differentiationdegree (Edmondson grade), cirrhosis, microscope embolus, TNM stage Ⅲ,adjuvant TACE≤2times, the locus16129of mtDNA with G, the locus16192ofmtDNA with C, the locus16297of mtDNA with T, the locus150of mtDNAwith C, the locus199of mtDNA with T, or the locus204of mtDNA with Tmight have a high rate of early recurrence. And of them, age, HBV DNA, TNMstage, adjuvant TACE (≤2or>2) and the locus150of mtDNA were independentfactors.(2) The cases with TNM stage Ⅱ, moderate differentiation, cirrhosis,positive HBsAg, positive HBeAg, the locus16162of mtDNA with A, the locus16172of mtDNA with T, the locus16304of mtDNA with T, or the locus150ofmtDNA with T who received adjuvant TACE might decrease the recurrent rate.And the best benefit times for them were more than2.(3) The recurrent rate ishigh after radical resection for HCC. And the infection of liver fluke, HBV DNA, Child pugh class, TNM stage, adjuvant TACE (≤2or>2) and the locus310ofmtDNA are independent factors for tumor free survival. To treat hepatitis B, toimprove liver function, and to receive more than2times adjuvant TACE mightdecrease the recurrent rate, and prolong the tumor free survival.(4) Thepostoperative adjuvant TACE might postpone the tumor recurrence but notavoid.The postoperative adjuvant TACE doesn’t benefit every case; in fact,some of them might have a shorter tumor free survival.(5) To prevent the tumorrecurrence after operation, to improve the liver function, and to treat withdifferent treatments after tumor recurrence might have a favorable benefit foroverall survival.(6) There are less utilities for the expression of P53, P21, nm23and VEGF protein to predict the prognoses of HCC.(7) To analyze thesequences variations of the mtDNA D-Loop region might have a favorablebenefit to predict the prognoses of HCC. Part Ⅲ The Cost Effectiveness Analysis of the Postoperative AdjuvantTACE for the Prevention for Hepatocellular Carcinoma RecurrenceObjective To establish the health economics evaluation model forpreventative treatment of TACE after the radical resection for hepatocellularcarcinoma (HCC).Methods140cases were divided into TACE group and non-TACE group according to the treatment after the radical resection for HCCs. For the TACEgroup, TACEs were performed; and for the non-TACE group, without TACE butjust received follow-up visits through outpatient department. The direct medicalcosts of the two groups were collected and the recurrent rate and the tumor freesurvival were picked up as effectiveness. Then the cost effectiveness and theincremental cost effectiveness were analyzed. At last the sensitivity analysis wasalso conducted.Results (1) For40cases in the non-TACE group, the average fee for theoutpatient care was7121.44yuan per patient. Meanwhile, for100cases in theTACE group, the average fees were5234.81yuan per patient for the outpatientcare and23015.64yuan per patient for the hospitalization treated with TACE.And the total fee for the TACE group was28250.45yuan per patient beforetumor recurrences.(2) The tumor free survival rate for1,2,3,4,5years were60.0%,76.0%,81.3%,89.3%and100.0%, respectively for the non-TACE groupwhile46.0%,67.1%,78.6%,88.2%and92.9%, respectively for the TACEgroup, and there was no significant difference between the two groups (P＞0.05).And the tumor free survivals were similarly between the two groups (18.3±3.0months vs22.1±2.0months or10.0months vs15.0months in median, P=0.322).(3) The cost effectiveness ratio was389.15yuan/month for non-TACE groupwhile1278.30yuan/month for TACE group. Based on the non-TACE group, theincremental cost effectiveness ratio was5560.27yuan/month.(4) For thesensitivity analysis, the cost rose up or declined with10%. And then the costeffectiveness ratio was350.84yuan/month for non-TACE group while1215.81yuan/month for TACE group. Based on the non-TACE group, the incrementalcost effectiveness ratio was5381.35yuan/month. Conclusions For the health economics aspect, the preventative treatment ofTACE after the radical resection for hepatocellular carcinoma (HCC) is not thebest choice, at least is not suitable for every case to receive. It seems that theoutpatient care is more economic under the similar effectiveness (recurrent rateand tumor free survival).