Author Affiliations: Department of Hepatobiliary Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China (Liu Y, Wang ZX, Cao Y, Zhang G, Chen WB and Jiang CP)

Corresponding Author: Chun-Ping Jiang, MD, Department of Hepatobiliary Surgery, the Affiliated Drum Tower Hospital of Nanjing University Medical School, 321 Zhongshan Road, Nanjing 210008, China (Tel: +86-25-83304616 ext60926; Fax: +86-25-83307115; Email: chunpingjiang@163.com)

 

© 2016, Hepatobiliary Pancreat Dis Int. All rights reserved.

doi: 10.1016/S1499-3872(16)60094-2

Published online May 9, 2016.

 

 

Contributors: WZX and JCP conceived this study. LY and CY collected and analyzed the data. ZG and CWB assisted in data analysis. LY, WZX and CY wrote the manuscript and contributed equally to this article. JCP revised the manuscript and gave final approval for publication. All authors contributed to the design and interpretation of the study and to further drafts. JCP is the guarantor.

Funding: This research was supported by grants from the National Natural Science Foundation of China (81572393), Key Project of Medical Science and Technology Development Foundation, Nanjing Department of Health (ZKX15020), Jiangsu Province Innovation for Ph.D. Candidate (KYLX_0058), and Scientific Research Foundation of Graduate School of Nanjing University (2013CL14).

Ethical approval: This study was approved by Institutional Ethics Committee of the Affiliated Drum Tower Hospital of Nanjing University Medical School.

Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

 

 

BACKGROUND: Recurrence of hepatocellular carcinoma (HCC) after curative resection remains a major cause of treatment failure and tumor-related death. Patterns of HCC recurrence can be categorized into early recurrence and late recurrence which have different underlying mechanisms. In this study, we investigated if simple inflammation-based clinical markers can distinguish patterns of recurrence after curative resection of HCC.

 

METHODS: A retrospective analysis of 223 patients who underwent curative hepatectomy for HCC was performed. Preoperative inflammation-based factors including neutrophil/lymphocyte ratio (NLR), platelet/lymphocyte ratio, γ-glutamyl transferase/alanine aminotransferase ratio, aspartate aminotransferase/platelet ratio index (APRI) and prognostic nutritional index together with other clinicopathologic parameters were evaluated by univariate analysis and multivariate analysis to identify independent prognostic factors. By combining risk factors, predictive models were established to distinguish populations at high risk of early or late recurrence.

 

RESULTS: Age ≤50 years, resection margin ≤1 cm, TNM stage III-IV, NLR>2.75, APRI>0.23 and positive alpha-fetoprotein were independent adverse prognostic factors for early recurrence. Patients with three or more risk factors were at significant higher risk of early recurrence. APRI>0.23 and positive hepatitis B e antigen (HBeAg) were independent risk factors of late recurrence, the coexistence of high APRI and positive HBeAg increased the risk of late recurrence.

 

CONCLUSIONS: Preoperative inflammation-based prognostic factors predict early and late recurrence of HCC after curative resection. Different prognostic factor combinations distinguish high-risk populations of early or late HCC recurrence.

 

(Hepatobiliary Pancreat Dis Int 2016;15:266-274)

 

KEY WORDS: hepatocellular carcinoma; inflammation; prognosis; recurrence; hepatectomy

Despite recent improvement in the treatment of hepatocellular carcinoma (HCC), the prognosis of this deadly disease remains poor.^{[1, 2]} To date, surgical resection of HCC has become a safe procedure with a low mortality rate.^[3] However, high incidence of recurrence remains a major cause of death after curative resection.^{[4, 5]} The recurrence of HCC could originate from either intrahepatic metastasis of primary tumor or de novo tumor arising from the remnant liver.^[5] This notion is supported by different patterns of recurrence observed: early recurrence (<1 year after surgery) and late recurrence (>1 year).^[6] Identified risk factors also indicate that early recurrence is mainly associated with invasive tumor characteristics whereas late recurrence is largely contributed by continuous liver disease.^{[5, 7]} Understanding and predicting recurrence pattern may help improve the outcome of HCC.

 

Recent research reveals that inflammation facilitates HCC malignant behavior and is correlated with poor prognosis.^[8] Inflammation participates in the process of liver carcinogenesis, tumor growth and metastasis through various molecular pathways.^[8] However, these molecular markers are not readily observable in daily medical practice. Several inflammation-based scores or indices derived from simple clinical tests are proposed to serve as prognostic predictors of cancer patients. Neutrophil/lymphocyte ratio (NLR), as a systemic inflammation index, is associated with the prognosis of many cancers including HCC.^{[9, 10]} Another inflammation-based marker platelet/lymphocyte ratio (PLR) also has prognostic value in HCC patients receiving transplantation.^[11] Moreover, prognostic nutritional index (PNI) and aspartate aminotransferase (AST)/platelet ratio index (APRI) incorporate inflammation markers and variables indicating nutrition status or liver function. They also have significant prognostic value in HCC patients.^{[12, 13]} Based on common liver enzymes, elevated γ-glutamyl transferase/alanine aminotransferase ratio (GGT/ALT) reflects liver inflammatory microenvironment and correlates with poor prognosis of HCC.^{[14, 15]} However, potential relationship between these inflammation-based prognostic markers and HCC recurrence patterns has not yet been elucidated.

 

Therefore, the present study investigated whether preoperative inflammation-based markers predict early and late recurrence patterns in patients undergoing curative resection of HCC.

 

 

The data of patients who had undergone hepatectomy for HCC at the Department of Hepatobiliary Surgery, the Affiliated Drum Tower Hospital of Nanjing University between July 2004 and April 2011 were retrieved from a prospectively maintained database and were analyzed retrospectively. Only patients with complete follow-up information and required clinicopathologic data were included. Patients with evidence of infection or systemic inflammatory diseases were excluded. Curative hepatectomy was defined as complete removal of HCC without grossly and microscopically identifiable tumor residue on resection margin. Among the 223 patients analyzed, 77 underwent left hemihepatectomy, right hemihepatectomy or central bisectionectomy, and 87 underwent segmentectomy, bisegmentectomy or trisegmentectomy. The other 59 patients underwent local tumor resection. Anatomical liver resection was performed in 177 patients. Tumor enucleation or atypical liver resection was conducted in 46 patients. Among these patients, three underwent radiofrequency ablation (RFA) before surgery. Twenty received transarterial chemoembolization (TACE) prior to resection. Diagnosis of HCC was based on imaging, serum alpha-fetoprotein (AFP) test and was finally confirmed by at least two experienced pathologists. Systemic chemotherapy or sorafenib was not used after surgery. Thirty-five patients underwent TACE after liver resection as adjuvant therapy. All procedures performed in this study were in accordance with the ethical standards of the institutional and national research committees and with the Declaration of Helsinki 1964 and its later amendments or comparable ethical standards.

 

Follow-up was conducted regularly in outpatient clinic of our hospital. Monthly serum AFP test was performed during the first three months after surgery. Chest X-ray, abdominal ultrasonography (US) or contrast-enhanced computed tomography (CT) was regularly performed at least every three months in the first two years. After that, patients were followed up and received serum and imaging examination every six months during the third to fifth years. Five years afterwards, the follow-up was carried out annually. Tumor recurrence was diagnosed by imaging and laboratory tests. The median follow-up period was 26.1 months (range 1.9-72.6). Recurrence within one year after surgery was defined as early recurrence.^{[5, 16]} For the treatment of HCC recurrence, TACE was the most frequently used treatment of recurrent HCC. Forty-nine patients with early recurrence and 21 with late recurrence underwent TACE treatment. RFA was performed in 18 early recurrence and 18 late recurrence patients. Eight patients with early recurrence underwent recurrent tumor resection and one patient received liver transplantation. For late recurrence, 11 patients underwent surgical resection. Patients who were unsuitable for invasive treatment received best supportive care.

 

Inflammation-based scores were calculated using preoperative data from whole blood cell count and liver function test. TNM staging was performed according to the American Joint Committee on Cancer staging manual (7th edition). Barcelona Clinic Liver Cancer (BCLC) staging was determined as previously described.^[17] The status of tumor was also assessed by the Milan criteria (single lesion ≤5 cm in diameter or up to 3 nodules ≤3 cm in each diameter, no extrahepatic metastasis, no vascular invasion).^[18] Liver function was evaluated by Child-Turcotte-Pugh (CTP) classification and Model for End-stage Liver Disease (MELD) score.

 

Continuous variables were dichotomized by normal limits of laboratory tests or cut-off values determined by receiver-operating characteristics (ROC) analysis. The cut-off values were determined by seeking the maximal sum of sensitivity and specificity. Recurrence-free survival (RFS) rates were evaluated by the Kaplan-Meier method. RFS between groups was compared by the log-rank test. Univariate and multivariate analysis were performed by the Cox proportional hazard model. Parameters with statistical significance in univariate analysis (P<0.05) were put into a forward stepwise regression model. Step selections were determined by maximal likelihood ratio test and only significant variables were kept in the model. Statistical tests were performed by MedCalc 13 software (Ostend, Belgium) and PASW statistics 18 (Chicago, IL, USA).

 

 

The baseline characteristics of patients are shown in Table 1. The median age of patients was 54 years (range 21-82). 189 (84.8%) patients were male and 34 (15.2%) were female. Most of the patients (78.0%) were infected with hepatitis B virus (HBV). Only a small portion of the patients had hepatitis C (0.9%). No hepatitis B and hepatitis C coinfection was observed. 211 (94.6%) patients had CTP grade A liver function while 12 (5.4%) were CTP grade B. The median MELD score of the included patients was 7 (range 6-17). Sixty-eight (30.5%) patients were classified in advanced TNM stage (III-IV) and 97 (43.5%) patients in BCLC stage B-C. 151 (67.7%) patients had tumors beyond the Milan criteria. The distributions of inflammation-based scores are listed in Table 1.

 

Cumulative RFS was estimated by the Kaplan-Meier method (Fig. 1A). The median RFS was 22.2 months. Among the 223 patients, 143 (64.1%) developed recurrent tumor, 96 (43.0%) had early recurrence, and 47 (21.1%) had late recurrence. The 1-, 3- and 5-year cumulative RFS rates were 56.5%, 36.5% and 26.0% after surgery. As shown in Fig. 1B, survival after recurrence differed between early recurrence and late recurrence groups. Patients with early recurrence had even worse prognosis than those with late recurrence (median survival: 13.2 vs 28.0 months; log-rank test, P=0.006).

 

For inflammation-based scores, optimal cut-off values with best predictive value were determined by ROC analysis. When setting cut-off value as 2.75, the sensitivity of NLR for recurrence prediction was 30.1% with a specificity of 88.7% [area under curve (AUC)=0.606, P=0.006]. To our surprise, PLR did not show any discriminative value for recurrence (AUC=0.502, P=0.954). This marker was therefore excluded from further analysis. For GGT/ALT, the best cut-off value was 1.33 with a specificity and sensitivity equal to 65.0% and 53.7% respectively (AUC=0.591, P=0.023). Similarly, optimal cut-off values were set as 46 for PNI (sensitivity=32.9%, specificity=85.0%, AUC=0.601, P=0.009) and 0.23 for APRI (sensitivity=74.1%, specificity=51.2%, AUC=0.637, P<0.001), respectively.

 

Patients were divided into the no recurrence, early recurrence and late recurrence groups. Inflammation-based scores and indices, together with important clinicopathologic factors were compared in the early recurrence and late recurrence groups with the no recurrence group by univariate analysis to identify potential risk factors associated with early recurrence and/or late recurrence. A total of 30 variables including demographic characteristics, etiology, liver function status, surgical parameters, tumor characteristics, and inflammation-based markers were analyzed (Tables 2-4). Age ≤50 years (P=0.023), resection margin close to tumor (≤1 cm, P=0.005), positive AFP (P=0.001), multiple tumors (P=0.021), microvascular invasion (P=0.011), macrovascular invasion (P=0.001), TNM stage III-IV (P<0.001) BCLC stage B-C (P<0.001) and tumors beyond the Milan criteria (P=0.007) were risk factors for early recurrence. Of note, all tested inflammation-based scores including NLR (P=0.001), GGT/ALT (P=0.003), APRI (P=0.002) and PNI (P=0.011) were associated with early recurrence.

 

For late recurrence, only positive hepatitis B e antigen (HBeAg, P<0.001), APRI>0.23 (P=0.024) and PNI≤46 (P=0.009) were significant risk factors.

 

Variables with statistical significance in univariate analysis were entered into Cox proportional hazard model for multivariate analysis to determine independent risk factors for early and late recurrence. As shown in Table 5, only age ≤50 years (P=0.013), resection margin ≤1 cm (P=0.006), TNM stage III-IV (P<0.001), positive AFP (P=0.017), NLR>2.75 (P=0.005) and APRI>0.23 (P=0.016) remained independent risk factors for early recurrence. For late recurrence, APRI>0.23 (P=0.030) and positive HBeAg (P<0.001) were independent risk factors.

 

We next sought to explore if combination of independent adverse prognostic factors provides better discriminative value for early and late recurrence. ROC analysis indicated that for predicting early recurrence, when the number of combined risk factors was set to >2, the model had best predictive value with an AUC=0.753 (P<0.001, Fig. 2A). The sensitivity and specificity were 72.9% and 66.9%, respectively. Kaplan-Meier curve showed that patients with at least three risk factors had significant lower 1-year RFS rate compared with those with two or less risk factors (log-rank test, P<0.001, Fig. 2B).

 

For late recurrence, the optimal cut-off value for the number of combined risk factors was >1. The sensitivity and specificity of this model were 27.7% and 96.2%, respectively (AUC=0.681, P<0.001, Fig. 2C). Patients with two risk factors were at higher risk of developing late recurrence (log-rank, P<0.001, Fig. 2D).

 

 

Surgical resection represents a potentially curative treatment to HCC. However, recurrence of HCC is a major cause of treatment failure and death.^[19] Accumulating evidence suggests that recurrence of HCC after curative resection may arise from either intrahepatic metastasis or de novo tumor in remnant liver.^[5] Indeed, the pattern of HCC recurrence could be categorized into early recurrence and late recurrence which are supported by observed two-peak recurrence curve after surgery.^{[7, 20]} This phenomenon indicates that early and late recurrent HCC may actually develop through different mechanism.

 

Current research revealed that host inflammation response plays an important role in cancer development, progression, invasion and metastasis.^{[21, 22]} For HCC, inflammation is critical since it underlies the pathogenesis of background liver disease and tumor microenvironment, thus may contribute to both liver specific and tumor-related prognosis. Multiple signaling pathways have been identified to be associated with inflammation in HCC, including NF-κB,^[23] JAK-STAT^[24] and MAPK^[25] pathways, etc. Importantly, inflammation is also linked to cancer-related malnutrition.^[26] However, in clinical situation, these molecular pathways are not readily accessible and clinical significance of the molecular markers is ambiguous for clinicians.

 

The importance of inflammation in cancer led to the proposal of inflammation-based prognostic scores and indices which serves as good tools for clinicians to predict prognosis. One of the most well-known inflammation-based indices is NLR. Numerous studies have demonstrated that elevated NLR is associated with poor prognosis in patients receiving surgical resection,^[10] liver transplantation,^[27] TACE^[28] and RFA.^[29] However, the role of NLR in early- and late-phase recurrence of HCC remains elusive. In our study, we found that elevated NLR is an independent adverse prognostic factor for HCC early recurrence. Interestingly, however, NLR did not significantly alter the risk of late recurrence in our series. As an indicator of systemic inflammation status, NLR also suggests inflammatory liver microenvironment. The study from Motomura et al^[27] showed that high NLR is associated with shorter RFS after liver transplantation and higher expression of VEGF, IL-8 and IL-17, which plays an important role in HCC angiogenesis and inflammation. IL-17 producing cells and tumor associated macrophages were also more prevalent in HCC with higher NLR. These inflammatory cells and cytokines are known to promote tumor invasion and metastasis. This finding supports our result since early recurrence is originated from intrahepatic metastasis of invasive tumor. Systemic inflammation, as indicated by high NLR, may facilitate the metastasis of primary HCC and lead to early recurrence.

 

Another inflammation-based index is PLR. Although PLR is reported to correlate with prognosis of several cancers,^{[30, 31]} its role in HCC is still debatable.^{[11, 32]} Our result did not support PLR as a predictor of HCC recurrence. APRI incorporates both liver enzyme AST and platelet count. This index has been widely used in cases of inflammatory liver disease and showed good predictive value of liver injury.^{[33, 34]} APRI also demonstrated prognostic value in HCC as an adverse factor.^{[35, 36]} In this analysis, we showed that APRI serves as independent risk factor for both early and late recurrence. Of note, the dataset of this present study was derived from a population mainly consisting of cirrhotic patients. In this setting, APRI serves as a strong indicator of liver inflammation and necrosis on the background of fibrotic/cirrhotic liver.^[37] High APRI may reflect both inflammatory liver environment that promotes tumor invasion and continuous liver damage that predisposes patients to de novo tumors, which leads to early recurrence and late recurrence, respectively.

 

Elevated GGT/ALT ratio reflects inflammation disturbance in liver microenvironment.^[15] This inflammatory marker is suggested as an important prognostic factor for HCC.^[14] In univariate analysis, GGT/ALT ratio showed significant association with early recurrence but not late recurrence. However, multivariate analysis demonstrated that GGT/ALT ratio is not an independent factor for early recurrence. Similarly, PNI, which incorporates lymphocyte and serum albumin to reflect nutritional status,^[13] also showed significant correlation with early recurrence and was removed from independent factors in multivariate analysis. A previous study also suggested that PNI is not an independent prognostic indicator for HCC.^[12] Our results confirmed the previous study and ruled out this index from the model for prediction of HCC recurrence.

 

This study also demonstrated that early and late recurrence have remarkably different risk factors. As for early recurrence, age less than 50 years is a significant risk factor. Interestingly, the incidence of HCC indeed drops significantly in elder population with attenuated inflammation response to stimulation.^[38] Younger age as a risk factor indicates inflammation plays an important role in HCC early recurrence with other inflammation-based prognostic indicators. Other factors contributing to early recurrence include TNM stage III-IV, resection margin ≤1 cm and positive serum AFP, which are all well-established risk factors for HCC recurrence. Our study elucidated that only APRI>0.23 and positive HBeAg predict late recurrence. Considering the notion that late recurrence of HCC is actually newly formed tumor in diseased liver, the authors further emphasized the importance of antiviral therapy and control of liver injury in postoperative treatment of HCC to prevent disease recurrence.^[39]

 

Since the predictive value of single inflammation-based marker is not satisfactory (with small AUC), we investigated if combination of risk factors better predicts early and late recurrence. By incorporating identified independent risk factors in our study, we found that patients with at least three risk factors have a significantly higher rate of recurrent disease within one year after hepatectomy. This six-parameter model provides good sensitivity (72.9%) and specificity (66.9%) with simple variables readily obtained in clinical practice. To predict late recurrence, we found that patients with both risk factors for late recurrence have significantly shorter RFS in long-term observation. These two predictive models may help surgeons predict the possibility of early and late recurrence in patients after surgical resection of HCC and to apply proper observation plan or active prevention against recurrence. For patients who are at high risk of early recurrence, postoperative follow-up should be applied more intensive to diagnose possible early-phase relapse. Postoperative adjuvant therapy such as TACE might also be used to prevent recurrence in this group of patients.^[40] For patients with high risk of late recurrence, postoperative antiviral therapy and liver protection therapy may be more important since late recurrence may arise from continuously injured liver. As indicated in this study, HBeAg status is an independent risk factor for late recurrence. Patients should be actively treated and followed up to ensure the activity of liver injury is under control.

 

In conclusion, our results suggest that preoperative inflammation-based prognostic factors predict early and late recurrence. Combination of proper inflammation-based factors with selected conventional clinicopathologic characteristics provides good predictive ability for early and late recurrence. Further prospective studies are warranted to confirm the role of inflammation-based markers in the prediction of recurrence patterns of HCC.

 

 

1 Yang JD, Roberts LR. Hepatocellular carcinoma: A global view. Nat Rev Gastroenterol Hepatol 2010;7:448-458. PMID: 20628345

2 Maluccio M, Covey A. Recent progress in understanding, diagnosing, and treating hepatocellular carcinoma. CA Cancer J Clin 2012;62:394-399. PMID: 23070690

3 Fan ST, Lo CM, Liu CL, Lam CM, Yuen WK, Yeung C, et al. Hepatectomy for hepatocellular carcinoma: toward zero hospital deaths. Ann Surg 1999;229:322-330. PMID: 10077043

4 Poon RT, Fan ST, Lo CM, Liu CL, Wong J. Long-term survival and pattern of recurrence after resection of small hepatocellular carcinoma in patients with preserved liver function: implications for a strategy of salvage transplantation. Ann Surg 2002;235:373-382. PMID: 11882759

5 Poon RT, Fan ST, Ng IO, Lo CM, Liu CL, Wong J. Different risk factors and prognosis for early and late intrahepatic recurrence after resection of hepatocellular carcinoma. Cancer 2000;89:500-507. PMID: 10931448

6 Portolani N, Coniglio A, Ghidoni S, Giovanelli M, Benetti A, Tiberio GA, et al. Early and late recurrence after liver resection for hepatocellular carcinoma: prognostic and therapeutic implications. Ann Surg 2006;243:229-235. PMID: 16432356

7 Imamura H, Matsuyama Y, Tanaka E, Ohkubo T, Hasegawa K, Miyagawa S, et al. Risk factors contributing to early and late phase intrahepatic recurrence of hepatocellular carcinoma after hepatectomy. J Hepatol 2003;38:200-207. PMID: 12547409

8 Sun B, Karin M. Obesity, inflammation, and liver cancer. J Hepatol 2012;56:704-713. PMID: 22120206

9 Xiao WK, Chen D, Li SQ, Fu SJ, Peng BG, Liang LJ. Prognostic significance of neutrophil-lymphocyte ratio in hepatocellular carcinoma: a meta-analysis. BMC Cancer 2014;14:117. PMID: 24559042

10 Mano Y, Shirabe K, Yamashita Y, Harimoto N, Tsujita E, Takeishi K, et al. Preoperative neutrophil-to-lymphocyte ratio is a predictor of survival after hepatectomy for hepatocellular carcinoma: a retrospective analysis. Ann Surg 2013;258:301-305. PMID: 23774313

11 Lai Q, Castro Santa E, Rico Juri JM, Pinheiro RS, Lerut J. Neutrophil and platelet-to-lymphocyte ratio as new predictors of dropout and recurrence after liver transplantation for hepatocellular cancer. Transpl Int 2014;27:32-41. PMID: 24118272

12 Kinoshita A, Onoda H, Imai N, Iwaku A, Oishi M, Fushiya N, et al. Comparison of the prognostic value of inflammation-based prognostic scores in patients with hepatocellular carcinoma. Br J Cancer 2012;107:988-993. PMID: 22878374

13 Pinato DJ, North BV, Sharma R. A novel, externally validated inflammation-based prognostic algorithm in hepatocellular carcinoma: the prognostic nutritional index (PNI). Br J Cancer 2012;106:1439-1445. PMID: 22433965

14 Ju MJ, Qiu SJ, Fan J, Zhou J, Gao Q, Cai MY, et al. Preoperative serum gamma-glutamyl transferase to alanine aminotransferase ratio is a convenient prognostic marker for Child-Pugh A hepatocellular carcinoma after operation. J Gastroenterol 2009;44:635-642. PMID: 19387533

15 Tang ZY. Liver transplantation: a simple inflammation marker predicts liver cancer prognosis. Nat Rev Gastroenterol Hepatol 2011;8:367-368. PMID: 21725351

16 Li T, Qin LX, Gong X, Zhou J, Sun HC, Wang L, et al. Clinical characteristics, outcome, and risk factors for early and late intrahepatic recurrence of female patients after curative resection of hepatocellular carcinoma. Surgery 2014;156:651-660. PMID: 24998159

17 Forner A, Reig ME, de Lope CR, Bruix J. Current strategy for staging and treatment: the BCLC update and future prospects. Semin Liver Dis 2010;30:61-74. PMID: 20175034

18 Mazzaferro V, Regalia E, Doci R, Andreola S, Pulvirenti A, Bozzetti F, et al. Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis. N Engl J Med 1996;334:693-699. PMID: 8594428

19 Belghiti J, Fuks D. Liver resection and transplantation in hepatocellular carcinoma. Liver Cancer 2012;1:71-82. PMID: 24159575

20 Du ZG, Wei YG, Chen KF, Li B. Risk factors associated with early and late recurrence after curative resection of hepatocellular carcinoma: a single institution’s experience with 398 consecutive patients. Hepatobiliary Pancreat Dis Int 2014;13:153-161. PMID: 24686542

21 Ramakrishna G, Rastogi A, Trehanpati N, Sen B, Khosla R, Sarin SK. From cirrhosis to hepatocellular carcinoma: new molecular insights on inflammation and cellular senescence. Liver Cancer 2013;2:367-383. PMID: 24400224

22 Subramaniam A, Shanmugam MK, Perumal E, Li F, Nachiyappan A, Dai X, et al. Potential role of signal transducer and activator of transcription (STAT)3 signaling pathway in inflammation, survival, proliferation and invasion of hepatocellular carcinoma. Biochim Biophys Acta 2013;1835:46-60. PMID: 23103770

23 Luedde T, Schwabe RF. NF-κB in the liver--linking injury, fibrosis and hepatocellular carcinoma. Nat Rev Gastroenterol Hepatol 2011;8:108-118. PMID: 21293511

24 He G, Karin M. NF-κB and STAT3 - key players in liver inflammation and cancer. Cell Res 2011;21:159-168. PMID: 21187858

25 Neuzillet C, Tijeras-Raballand A, de Mestier L, Cros J, Faivre S, Raymond E. MEK in cancer and cancer therapy. Pharmacol Ther 2014;141:160-171. PMID: 24121058

26 Laine A, Iyengar P, Pandita TK. The role of inflammatory pathways in cancer-associated cachexia and radiation resistance. Mol Cancer Res 2013;11:967-972. PMID: 23788634

27 Motomura T, Shirabe K, Mano Y, Muto J, Toshima T, Umemoto Y, et al. Neutrophil-lymphocyte ratio reflects hepatocellular carcinoma recurrence after liver transplantation via inflammatory microenvironment. J Hepatol 2013;58:58-64. PMID: 22925812

28 McNally ME, Martinez A, Khabiri H, Guy G, Michaels AJ, Hanje J, et al. Inflammatory markers are associated with outcome in patients with unresectable hepatocellular carcinoma undergoing transarterial chemoembolization. Ann Surg Oncol 2013;20:923-928. PMID: 22965570

29 Chen TM, Lin CC, Huang PT, Wen CF. Neutrophil-to-lymphocyte ratio associated with mortality in early hepatocellular carcinoma patients after radiofrequency ablation. J Gastroenterol Hepatol 2012;27:553-561. PMID: 21913982

30 Neofytou K, Smyth EC, Giakoustidis A, Khan AZ, Cunningham D, Mudan S. Elevated platelet to lymphocyte ratio predicts poor prognosis after hepatectomy for liver-only colorectal metastases, and it is superior to neutrophil to lymphocyte ratio as an adverse prognostic factor. Med Oncol 2014;31:239. PMID: 25218270

31 Ishizuka M, Oyama Y, Abe A, Kubota K. Combination of platelet count and neutrophil to lymphocyte ratio is a useful predictor of postoperative survival in patients undergoing surgery for gastric cancer. J Surg Oncol 2014;110:935-941. PMID: 25146385

32 Parisi I, Tsochatzis E, Wijewantha H, Rodríguez-Perálvarez M, De Luca L, Manousou P, et al. Inflammation-based scores do not predict post-transplant recurrence of hepatocellular carcinoma in patients within Milan criteria. Liver Transpl 2014;20:1327-1335. PMID: 25088400

33 Lin CS, Chang CS, Yang SS, Yeh HZ, Lin CW. Retrospective evaluation of serum markers APRI and AST/ALT for assessing liver fibrosis and cirrhosis in chronic hepatitis B and C patients with hepatocellular carcinoma. Intern Med 2008;47:569-575. PMID: 18379139

34 Sène D, Limal N, Messous D, Ghillani-Dalbin P, Charlotte F, Thiollière JM, et al. Biological markers of liver fibrosis and activity as non-invasive alternatives to liver biopsy in patients with chronic hepatitis C and associated mixed cryoglobulinemia vasculitis. Clin Biochem 2006;39:715-721. PMID: 16765932

35 Guo P, Shen SL, Zhang Q, Zeng FF, Zhang WJ, Hu XM, et al. Prognostic evaluation of categorical platelet-based indices using clustering methods based on the Monte Carlo comparison for hepatocellular carcinoma. Asian Pac J Cancer Prev 2014;15:5721-5727. PMID: 25081692

36 Shen SL, Fu SJ, Chen B, Kuang M, Li SQ, Hua YP, et al. Preoperative aspartate aminotransferase to platelet ratio is an independent prognostic factor for hepatitis B-induced hepatocellular carcinoma after hepatic resection. Ann Surg Oncol 2014;21:3802-3809. PMID: 24849520

37 Shoaei SD, Sali S, Karamipour M, Riahi E. Non-invasive histologic markers of liver disease in patients with chronic hepatitis B. Hepat Mon 2014;14:e14228. PMID: 24693307

38 Sheedfar F, Di Biase S, Koonen D, Vinciguerra M. Liver diseases and aging: friends or foes? Aging Cell 2013;12:950-954. PMID: 23815295

39 Huang G, Lau WY, Wang ZG, Pan ZY, Yuan SX, Shen F, et al. Antiviral therapy improves postoperative survival in patients with hepatocellular carcinoma: a randomized controlled trial. Ann Surg 2015;261:56-66. PMID: 25072444

40 Sun JJ, Wang K, Zhang CZ, Guo WX, Shi J, Cong WM, et al. Postoperative adjuvant transcatheter arterial chemoembolization after R0 hepatectomy improves outcomes of patients who have hepatocellular carcinoma with microvascular invasion. Ann Surg Oncol 2016;23:1344-1351. PMID: 26714945