Recent advances in diagnosis, treatment and

prevention of Hepatocellular Carcinoma (HCC)

K. Tanikawa, M.D., Ph.D.
Professor Emeritus, Kurume University
President, Int. Institute for Liver Research, Kurume

Causes of death in liver diseases in Japan (1999)

Annual death 51,000
HCC
34,000 (3rd among malignancies)
LC and others 17,000

HCC death in Japan

1995
1994
1992
1990
1988
1986
1984
1982
1980
1978
1976
1974
1972
1970
1968
1966
1964
1962
1960
1958

0-39
40-49
50-59
60-69
70-79
80-

(yr)

5000

10000

15000

20000

25000

30000

35000

Number of death from HCC

30,000

HCV-associated

HBV-associated
1945

1975
25 yrs
Blood transfusion
IV injection
Drug abuse

2000

Baseline diseases of HCC

1996/1~2000/12; 498 patients with HCC
12.5% HBcAb(-)

HCVAb(+)
79.8%

HBsAg(+)
11.0%

HCVAb(-)
HBsAg (-)
8.4%

87.5% HBcAb(+)

HCVAb(+)
HBsAg (+)
0.8%

Associated chronic liver diseases in HCC (1986-1987)

Fibrosis (4.5 )
Chronic hepatitis (4.5 )
Fibrosis (4.5 )
Chronic hepatitis (4.5 )
Cirrhosis (85.4 )

Cirrhosis (85.4 )
Autopsy (n=1021)

(Liver Cancer Study Group of Japan)

Carcinogenesis of HCC due to HBV or HCV

1. Direct effect of virus
X gene of HBV
Core gene of HCV
2. Associated inflammation (oxidative stress
in HCV) and fibrosis
3. Others
Iron deposit
Retinoid depletion

HCC occurrence rate

%
100

HCV +

50
HBV +

10

15 (y)

Cumulative occurrence rates of HBV-and HCV-associated HCC in cirrhosis

(Torano-mon Hosp)

HCC develops almost exclusively in

patients with chronic liver diseases
(mostly cirrhosis) due to persistent
Infection of HBV or HCV

Early detection of small HCC

by periodic examinations (every
3 to 6 months) in the risky group
with ultrasonography
and
tumor markers
AFP
PIVKA-II
(des- -carboxy prothrombin
-abnormal prothrombin)

Incidence of HCC increases with progress of C type chronic hepatitis

normal

CH

LC

HCC

Annual incidence of HCC

0
normal

0.5

1.5

3.0

F1

F2

F3

CH

7.0

20-30%

LC

HCC

Principle of Eitest PIVKA-II

Enzyme - Labeled Anti-F1 2 Antibody
S
T
V

CHO

R
80

G
R
Y

MU-3
P
20 L
C

C
I

W
Q L

90
T

T
S 130
P
T
L
R
R
E

Y C W P

120

T
I
S
G
D
P
N

E
R
C
G
C
70
F
140
S

G
V
E
G
L
E
P
A
R
D
A
V
C
110
C

G
G
Q
D
E
S L S A T A F W A K Y T
150
R
L
A
V T V E V I P
40
C
C 60
E
50
E
S
L F G K N A
N
NH2
A
L
R

N
E
P R

K
P
E
100 I

S
T
T

CHO

Hinge domain

C S R

A F

A L
30

L N G K R V
10

R S

160
G G S T T

thrombin

Gla domain

Kringle domain

F1

Thrombin

S
S
230
E
V
A
Q

G
200
Y C W
A
A
A
E
D
K
A
L
Q
E
L
R
P
D
S
G
G
G
274
180
K
D 240
R
D
R
F
D
P
Y
G
E
E
N
Q
Y
E
R
R
D
C
C 220
I

G R
F
N
270 A
210
N
D
L
E
A
N
P
A
P
D

Y
V
P V
P
C
C
L
D
E 250
170 T
P
E
E
D
L
L
E
P
260
G
P
V
S
L
S Q
R
D G
D L G D
T

C
G 190
L A
S

Kringle domain

F2

Positive rates in various diseases

10

100

1,000

10,000

75,000 mAU/mL

HCC

196 407
48.2

LC

14 265
5.3

Chr. Hep

2 54
3.7

Acute Hep

13
33.3

Cut off value 40mAU/mL

50
30

Cases
Cases

10
1

Cases
Cases

(Takatsu)

Tumor size and positivity rates with PIVKA-II

Tumor size (mm)

Number of patients

Positive

<20

59

12 (20.3 %)

21-30

34

13 (38.2 %)

31-50

10

8 (80.0 %)

51<

26

25 (96.2 %)

Sensitivity, specificity, and accuracy of PIVKA-II and AFP

AFP

PIVKA-II
>20 ng/ml

>200 ng/ml

Sensitivity

45.0 %

66.7 %

26.4 %

Specificity

92.8 %

80.7 %

94.0 %

Accuracy

63.7 %

72.5 %

53.1 %

Des-gamma carboxy prothrombin is a more sensitive

and reliable marker for hepatocellular carcinoma
than alpha-fetoprotein in American patients
PIVKA-II

>20

AFP
>100

>500

Sensitivity

86

73

60

32

Specificity

98

86

98

99

AFP units are ng/ml; PIVKA-II units are mAU/ml

(ASLD 52ND Annual Meeting, 2001 University of Michigan, Ann Arbor, MI)

Correlation between serum AFP and PIVKA-ll levels

PIVKA-ll (mAU/m )

1000

100

10

10

100

1000

AFP (ng/ml)
P=0.229 (not significant)

PIVKA-ll and AFP combined assay

single tumor,less than 20 mm in diameter

multiple tumors or over 21 mm in diameter

n =79

n
=132
70

45
40
35
30
25
20
15
10
5
0

60
50
40
30
20
10
0

PIVKA-ll

AFP

combined

PIVKA-ll

AFP

combined
(Saito)

Serial changes in blood PIVKA-II level

HCC group:21

1000

LC group:57

1000

Detection of HCC

8/21
6/21

100
40

100
40

10

10
-24

PIVKA- (mAU/mL)

PIVKA- (mAU/mL)

9/21

-18

-12
Months

-6

-24

-18

-12
-6
Months

M. Tanaka et al.:PIVKA-II Symposium, 1996

Change in blood DCP levels before and two weeks

after operation
-fetoprotein
ng/mL

mAU/mL

PIVKA-
104

103

103

102

102

10

before

after

before

after

M. Sakon et al. : J Jpn Surg Socity, 91, 558, 1990

PIVKA-II
Clinical Utility in Japan
-Diagnosis of HCC
Screening of high-risk group
Liver cirrhosis, Chronic hepatitis
-As a marker in the evaluation of therapeutic effects on HCC
-As a detector of recurrence of HCC
Clinical Comparison to Alpha-fetoprotein(AFP)
AFP:Most common marker of HCC

-PIVKA-II is often produced in patients with HCC who are

negative for AFP
-PIVKA-II is not correlation with AFP

Gross Features of Small Hepatocellular Carcinoma

Treatment of small HCC

- Completely curative 1. Surgical resection
2. Percutaneous ethanol injection (PEIT)
3. Radiofrequency ablation (RF)
4. Microwave coagulation (MC)

Cumulative Survival of Patients with

Well-differentiated HCC in Clinical Stage I & II after
PEIT
100

5-year survival: 69
80
7-year survival: 49
60
40
20

PEIT (n=147)

0
1

9 year

Radiofrequency ablation
Hooked arrays electrode
Conventional
monopolar electrode

1.6 cm
(ablation area)

Cooled-tip electrode

Ion agitation is produced within the tissues surrounding the electrode.

This agitation is converted by friction into heat, inducing cellular death
via coagulative necrosis.

Changes of US image of tumor during RFA

1

gas gas

Randomized control trial (PEIT vs RFA)

PEIT (55)

RFA(56)

Number of session

6.7

Days in hospital

27.1 10.3

Complications

2.6

Fever over 3 days

20

Local recurrence

1.9 0.6

p<0.0001

10.3

3.3

p<0.0001

(38%)

p=0.901

0
(36%)

21
0

p=0.027

(H. Shiina, 2001)

Chemotherapy for advanced HCC

Association with LC
Arterial Supply
No single effective anticancer agents

Low dose, frequent administration

Transcatheter arterial infusion
Implantable injection port
Biochemical modulation using two or three agents
(not indicated for cases with highly advanced LC)

Drug Delivery System of Totally Implanted Reservoir

Case S.N. 66y.o. male

Regimen
Before treatment, Mar. 1992

After treatment,
Apr. 1992

After treatment,
Mar. 1993

day 1x4 weeks

MIT 4mgx4
day 1-5 x 4 weeks
CDDP 10mg x 20
5FU 250mg x 20

Cumulative survival rate in relation to clinical stage

cumulative survival

100

80

p<0.0001

60

CS1(n=41)

40

CS2(n=61)

20

CS3(n=12)

years

Classification of clinical stage (CS) of HCC

clinical stage
1
2
3

Ascites
abscent
present, controlable
present, uncontrolable

total bilirubin
(mg/dl)
<=2.0
2.0< <=3.0
3.0<

Albumin
(g/dl)

ICG R15(%)

prothrombin
time(%)

3.5<=
3.0<= <3.5
<3.0

<=15
15< <=40
40<

80<=
50<= <80
<50

Combined Intraarterial 5-Fluorouracil and

Subcutaneous Interferon- therapy for Advanced
Hepatocellular Carcinoma with Tumor Thrombi in the
Major Portal Branches
M Sakon, et al

(Cancer 2002; 94: 435-42)

Indication of IFN combined 5FU chemotherapy

HCC

Portal tumor thrombus

Extrahepatic metastasis

Vp3 or more advanced

none
<70

age
Liver function

GOT
GPT
T.bil

<100
<100
Normal

Blood

platellet

>80,000

Renal function

Serum Cr

<1.5

PS

0, 1

Protocol of IFN combined 5FU chemotherapy (one cycle)

5FU 450-500 mg/body

14 days

IFN 5x106 U (im)/ days, 4ws

Liver function of patients with tumor thrombi in major branches of the portal vein,treated with
a combination of 5-FU arterial chemotherapy and subcutaneous administration of IFN-

Age
(yrs)

42

HCV

2.0

9780

3.0

80

46

HBV

1.5

5450

4.0

88

74

HCV

1.2

4420

3.0

63

70

HCV

1.8

4100

3.5

79

70

HCV

1.8

5640

3.4

78

67

HCV

1.3

4590

3.7

76

64

HCV

1.0

4730

3.7

100

60

HBV

2.3

4690

3.0

89

70

HBV

1.9

8990

3.2

80

10

63

HCV

0.9

3710

3.0

60

11

31

HBV

1.2

7460

2.6

69

Gender

Hepatitis

Platelet
(x105/L)

Leukocyte/L

Albumin
(g/dL)

Hepaplastin Child-Pugh
classification
Test (%)

Case

Clinical outcome of patients with tumor thrombi in major branches of the portal vein, treated with
a combination of 5-FU arterial chemotherapy and subcutaneous administration of IFN-

Case

1
2
3
4
5
6
7
8
9
10
11

Tumor
pathology

Tumor
Diameter
(cm)

Treatment
cycles

AFP (ng / mL)

(pre / post)

PIVKA-II
(mAU / mL)
(pre / post)

Response

Side effects

Outcome (mos)

4.5

9900 / <5

7140 / < 40

CR

Thrombocytopenia 21, alive

4.0

448 / <5

8988 / < 65

PR

Leukopenia

17, alive, brain

Vp3, multiple

5.5

32 / 9

7056 / 630

PR

Depression,

metastases

Vp3, Vv3

3.5

5/5

<65 / < 65

PR

5.0

12 / 5

3750 / 14,637

SD

15, alive

6.0

191 / 5

448 / < 40

CR

13, alive

5.0

4400 / <5

4430 / <40

CR

8, alive

Vp3, multiple

Right lobe

10 / 12

40,110 / 195,300

PD

6, alive

Vp3

6.0

336 / 364

ND

PR

Vp3, multiple

Right lobe

28,700 / 28,100

5635 / 11,739

PD

Vp3, B2

5.0

Vp3, multiple
Vp3, multiple

Vp3, multiple
Vp3/Vv2
Vp3, multiple

thrombocytopenia15, dead, recurrence

Leukopenia

Diffuse type

5, alive
Depression
-

Diffuse type

5, alive
5, dead

70,000 / 41,200

790 / <40

PR

3, alive

Potential mechanisms of IFN+5FU

1. Direct but separate anti-proliferative
effects
2. Increased active metabolite of 5FU by IFN
3. Cell cycle effects
4. Combined cytotoxic action (5FU) and
activated host defense mechanisms (IFN)
5. Others

Studies of immunochemotherapy with interferon- for hepatocellular carcinoma

Author

Drugs

One term

2 mos

Nair, et al

IFN- 3 MU, I.m. (daily)

Sachs, et al

IFN- 12 and 50 MU / m , I.m. (3 times / week)

Creagan, et al

IFN- 12 MU, I.m. (daily, 5 days) doxorubicin 25 mg / m 2, I.v. (day 1)

GTSG

IFN- 5-15 MU / m2, I.m. (3 times / week)

Kardinal ,et al

IFN- 12 MU, I.m. (daily, Day 1-5 / week) doxorubicin 25-40 mg / m , I.v. (Day 1)

Feun, et al

IFN- 20 MU, I.m. (weekly, 1st 3 weeks) doxorubicin 20 mg / m 2, I.v. (weekly, 1st 3 weeks)

Patt, et al

IFN- 5 MU, I.m. (3 time / week) 5-FU 750 mg / m 2, continous I.v. (5 days, 1st week)

Lai, et al

IFN- 5 MU / m , I.m. (3 times / week)

Leung, et al

CDDP (20 mg / m2, I.v. Days 1-4, every week) doxorubicin (40 mg / m 2, I.v., Day 1),

12 wks

5-fluorouracil (400 mg / m2 I.v., Days 1-4) IFN- (5 MU / m2 s.c., Days 1-4) I.m.
Urabe, et al

IFN- 3 MU, I.m. (3 times / week), 5-FU 750 mg / m 2, I.a. (weekly), CDDP 75 mg / m2 , I.a. (every
2 weeks), MTX 30 mg / m2 , I.a. (every 4 weeks) leucovorin 30 mg / m 2 , I.v. (every 4 weeks)

Llovet, et al

IFN- 3 MU, I.m. (3 times / week)

Chung, et al

5 MU / m , I.m. (3 time / week), CDDP 2 mg / kg, continuous I.a. (ever 8 weeks)IFN- 3 MU, I.m.
2

4 wks
1-3 wks
4 wks
5 wks
2 wks
1 wk
3 wks

Response CR
+ PR / total
(%)
0 / 2 (0)
0 / 30 (0)
1 / 7 (17)
2 / 30 (7)
1 / 30 (3)
2 / 21 (10)
6 / 28 (21)
11 / 35 (31)
13 / 50 (26)

4 wks

7 / 15 (47)

1 yr

2 / 30 (7)

8 wks

6 / 18 (33)

Treatment of advanced HCC

1. Transcatheter arterial infusion chemotherapy
using an implantable injection port
1) CDDP + 5 FU
2) CDDP + 5 FU + IFN
2. Oral administration of Tegafur / uracil

Four points for prevention of HCC

1. Prevention of HBV or HCV infection
2. Eradication of HCV or suppressed proliferation of HBV
in chronic disease (mostly chronic hepatitis)
3. Prevention of HCC development in chronic liver
diseases (mostly cirrhosis)
4. Prevention of recurrence after HCC treatments

Prevention of persistent HBV or HCV

Infection
At present in Japan
* Few mother to infant infection of HBV
* No transfusion hepatitis (HCV)
* Few iatrogenic infection
* Only drug abuser (not many)

Prevention of HCC development in chronic viral

liver diseases is the most important
1. Eradication of infected virus or
Reduction of viral load (inhibition of viral replication)
2. Reduction of associated inflammation
3. Suppression of cell growth and induction of apotosis
by retinoid, vit. K et al
4. Removal of overloaded iron
5. etc

IFN treatment in C type chronic hepatitis

HCC incidence
30

20
NR N=585

10

IR N=145
0

10

CR N=461
15

(y)

HCC incidence in C type chronic hepatitis in regard to response to IFN

Overall results of IFN therapy

In chronic hepatitis type C and HCC occurrence
HCC occurrence
30%

Complete responder
(HCV RNA (-))
(ALT normalized)

10%

Biochemical responder
(HCV RNA (+))
(ALT normalized)

30%

ALT level lowered

significantly lower

1/2 in occurrence

Peg IFN + Ribavirin for one year

Responder rate
10 20 % increase

Adverse reactions of interferon therapy for chronic

hepatitis C (6412 cases)
(%)
1. Mental disorders (depression, etc) 81 (1.26)
2. Neurological disorders
18 (0.28)
3. Interstitial pneumonia
14 (0.20)
4. Abnormal thyroid functions
67 (1.06)
5. Autoimmune diseases
15 (0.22)
6. Diabetes
23 (0.36)
7. Renal, circulatory diseases
15 (0.23)
8. Eye disorders
26 (0.42)
9. Infectious diseases
10 (0.16)
10. Skin Iesions
-------------

KL-6

21,000

(Y Otsuki)

Serum KL-6 Levels in Lung Diseases

Serum KL-6 UmL

Antibiotic
Syou-saiko-tou

1,600
1,400
1,200
1,000
800
600
400
200

IFN

Cut-Off Value
500U/mL
Healthy
N=44

IIP*

Radiation
pneumonia

Drug induced
pneumonia

*IIP : Idiopatic Interstitial Pneunonia

Nakajima M, et al. : Am J Respir Crit Care Med, 151(4), A541(1995)

HCC development and serum ALT

in liver cirrhosis type C (5 years)
100

HCC detection (%)

80
60

44.0 %

40
20
0

8.0 %
ALT< 80u

(n=25)

ALT> 80u
(n=27)

(Tarao)

Anti-inflammatory agents
1. Glycyrrhizin prevalation (IV)
2. Sho-Saiko-to (herbal medicine)
3. Ursodeoxycholic acid
4. etc.

HCC development in SNMC (minophagen C)

and non treatment groups
(%)
100

50

SNMC(-)

SNMC(+)
0
0

10

15

(year)

Prevention of recurrence (including the

second primary) after the initial treatment
IFN
Retinoid
Adoptive immunotherapy
Vitamin K

Cumulative recurr ence rate(%)

Cumulative Recurrenece Rate of Patients

with Small HCC after PEIT
100

5-year recurrence rate:

80

3-year recurrence rate:

60

67%

40

27%
(n=281)

1-year recurrence rate:

20
0

9 years

88%

cumulative
incidence100
of distant
recurrence
80
(%)

Non-IFN group
(n=22)
p<0.01

60
40
20

IFN group
(n=18)

0
0

10

years after initial treatment

Cumulative incidence of distant recurrence according to interferon therapy

(Suou, et al. 2001)

cumulative
survival 1.0
rate

IFN group
(n=18)

0.5
Non-IFN group
(n=22)
p<0.01

0
0

10

years after initial treatment

Cumulative survival rate according to interferon therapy

(Suou, et al. 2001)

Vitamin K on HCC cell lines

Growth inhibitory effects
Potent inducer of apotosis
J Biochem
Hepatology
JBC
J Cell Physiol

1995
1995
1995
1995

Inhibitory effects of Vitamin K against the portal venous

invasion (PVI) after treatment of DCP positive HCC

Development of PVI

1yr

2yr

Vit K (+) (45mg/day)

2%

13%

21%

55%

Vit K(-)

(Koike 2002)

Inhibitory effects of Vitamin K against the recurrence

of HCC after curative treatment

recurrence

1yr

2yr

Vit K (+)

9%

37%

Vit K(-)

37%

84%
(Mizuta 2002)

IFN + Vitamin K2

seems to be a choice of prevention after

the initial treatment for prevention of
recurrence

Conclusion
*Prevention of HCC in chronic liver diseases by IFN
*Early detection and treatment
*Prevention of the second primary HCC by IFN, Vit K
*Treatment of advanced HCC by chemotherapy with IFN