Relationship between Serum Hyaluronic Acid Level and Patient Prognosis in Hepatocellular Carcinoma Patients Who Underwent Hepatectomy.doc

Journal of Cancer Therapy, 2021, 4, 359-366359 :/dx.doi.org/10.4236/jct.2021.42A043 Published Online February 2021 ( :/ scirp.org/journal/jct)Relationship between Serum Hyaluronic Acid Level andPatient Prognosis in Hepatocellular Carcinoma PatientsWho Underwent HepatectomyAtsushi Nanashima , Takafumi Abo, Goushi Murakami, Masaki Kunizaki, *Hiroaki Takeshita, Shigekazu Hidaka, Kazuo To, Tomoshi Tsuchiya, Takeshi Nagayasu Division of Surgical Oncology, Department of Surgery, Nagasaki University Graduate School of Biomedical Sciences, Nagasaki, Japan.a-nanasmnagasaki-u.ac.jp, tac-apop11.odn.ne.jp, mkgsmkgsyahoo.co.jp, masaki2002yahoo.co.jp,Email:*takehironagasaki-u.ac.jp, hidaka-snagasaki-u.ac.jp, tokazunagasaki-u.ac.jp, tomoshinagasaki-u.ac.jp,nagayasunagasaki-u.ac.jpReceived November 23 , 2021; revised December 21 , 2021; accepted December 30 , 2021rd st thABSTRACTWe examined the relationship between hyaluronic acid (HA) and tumor-related factors after hepatectomy in 158 pa-tients with hepatocellular carcinoma (HCC) who underwent hepatectomy. We examined serum HA levels beforehepatectomy by evaluating data for clinicopathological parameters, surgical records, postoperative complications andsurvival. The mean HA level was 190 ± 202 ng/ml. Patients were divided into 3 groups: group A had serum HA levelsless than 50 ng/ml (normal range), group B had levels between 50 and 190 ng/ml, and group C had levels over 190ng/ml. Group C had a higher rate of poor liver function compared to others. Multiple tumors were significantly morefrequent in groups B and C compared to A. The grade of fibrosis and the inflammatory responses were positively corre-lated with the serum HA level. Postoperative long-term ascites was significantly more frequent in group C compared toothers. Although the recurrence rate and the relapse-free period were not significantly related to the serum HA level, theserum HA level was significantly associated with overall survival after hepatectomy (p < 0.05). Coxs multivariateanalysis did not show a significant relationship between HA level and survival. Serum HA reflects progression and sur-vival in HCC patients.Keywords: Hepatocellular Carcinoma; Hepatectomy; Serum Hyaluronic Acid Level; Prognosis1. Introductionerative survival in HCC patients.The serum hyaluronic acid (HA) level is a well-knownmarker of hepatic fibrosis and hepatic sinusoidal endo-thelial function 12,13. Our previous study also showedthat HA was significantly associated with poor hepaticfunction and postoperative complications such as long-term ascites and hepatic fibrosis 14,15. HA might bethe most important factor related to poor hepatic func-tional reserve 16. Therefore, we hypothesized that theserum HA level, which is a marker of reliable hepaticfunction, could be applied to predict patient survival inHCC patients. To our knowledge, the relationship be-tween the serum HA level and postoperative prognosis inHCC patients has not been examined. Identification ofthe relationship between non-tumor related factors andsurvival is useful to predict patient prognosis. We retro-spectively examined the relationship between the serumHA level and clinicopathological factors, postoperativecourse, tumor recurrence and patient survival in 156 pa-tients with HCC who underwent hepatectomy.Hepatic resection is still the most curative treatment forhepatocellular carcinoma (HCC) 1. However, tumorrecurrence is frequent, and some patients have a poorprognosis 2. Some factors associated with patient sur-vival have been identified 3-5. Markers of poor hepaticfunction and tumor-related factors are significantly asso-ciated with tumor recurrence and lower survival 6-8.Our previous study showed that an advanced grade ofhepatic fibrosis, hepatitis, postoperative long-term ascitesor postoperative levels of alpha-feto protein (a marker ofchronic hepatitis) were significantly associated withshorter survival due to carcinoma after hepatectomy 9-11. Deteriorated liver function and co-existing hepatitiswould influence tumor progression and subsequent car-cinogenesis. Therefore, reliable functional parametersidentifying deteriorated liver function or postoperativehepatic complications would be useful to predict postop-*Corresponding author.Copyright © 2021 SciRes.JCT 360Relationship between Serum Hyaluronic Acid Level and Patient Prognosis in HepatocellularCarcinoma Patients Who Underwent Hepatectomy2. Methods2.1. Patients resected specimen. For assessment, we used the rules laidout by the Liver Cancer Study Group of Japan for theclassification of primary liver cancer 17.This study examined 156 patients with HCC who werescheduled for surgery and admitted to the Division ofSurgical Oncology at Nagasaki University GraduateSchool of Biomedical Sciences (NUGSBS) between1996 and 2021. Patients with distant metastasis wereexcluded from the present study. The patients included121 males and 35 females with a mean age at the time ofsurgery of 66.6 ± 10.0 years (±SD, range 28 - 84 years).Twenty-three patients had normal livers, and several pa-tients had background liver disease, including alcoholicliver dysfunction in 9 patients, non-alcoholic liver dys-function in 4 patients, and chronic viral hepatitis in 120patients (including hepatitis B in 47 patients, hepatitis Cin 55 patients and co-existing hepatitis B and C in 18patients). Liver cirrhosis was observed in 56 patients(37%). The operative procedures included hemihepatec-tomy or more extensive hepatectomy in 49 patients,segmentectomy or sectionectomy in 55 patients and par-tial resection in 52 patients. Radical hepatectomy wasperformed, and hepatic tumors were completely resectedwithout macroscopic exposure of the amputated sectionto the remaining liver.After primary treatment, serum levels of AFP andPIVKA-II were measured every 3 months, and enhancedcomputed tomography of the liver was obtained every 6months for at least the first 5 years after hepatectomy inorder to monitor the tumor recurrence. The minimumfollow-up period after the hepatic resection of HCC was12 months (range 12 - 78 months). Fifty-two of the 156(33%) patients who survived were lost to follow-up, 99patients died of cancer, and 5 patients died of unrelateddiseases. Because these deaths were not cancer-related,data from these 5 patients were excluded.2.3. Measurement of Serum HA Peripheral blood samples were collected from each pa-tient in the early morning before surgery, when the pa-tient was in stable condition. The blood sample was cen-trifuged at 3000 rpm for 15 minutes, and serum wasstored at 80C. HA was assayed using the sandwichbinding protein assay by SRL, Inc. (Tokyo, Japan). Thenormal value for the serum HA level reported by SRL,Inc. is less than 50 ng/ml. The staging of the tumor, thegrading score for hepatic fibrosis and the histologic ac-tivity index (HAI) score as defined by Knodell et al. 18were used for the histopathological evaluation.2.4. Statistical Analysis Differences in categorical data between groups and dif-ferences in prevalence were assessed by the chi-squaretest, Fischers exact test or Dunnetts multiple compari-son test. Differences in continuous data between groupswere evaluated by Students t-test or the Mann-Whitneytest. The disease-free interval and overall survival werecalculated using the Kaplan-Meier method, and differ-ences between groups were tested for significance usingthe log-rank test. Multivariate analysis was performedusing Coxs proportional hazards regression modeling. Atwo-tailed P value of <0.05 was considered significant.Statistical analyses were performed using the SAS soft-ware (Statistical Analysis System Inc., Cary, NC).3. Results3.1. Perioperative Parameters All study protocols were approved by the Human Eth-ics Review Board of our institution. Informed consent fordata collection was obtained from each patient duringthis period. Anesthesia data and patient data were re-trieved from the NUGSBS database.According to the Child-Pugh classification, 143 (92%)patients were classified as A, and 13 patients were classi-fied as B. The mean alpha-feto protein (AFP) level was7411 ± 48,724 µg/ml (median 67), and the mean pro-tein-induced vitamin K antagonist and agonist (PIVKA)-II level was 7593 ± 24,764 µg/ml (median 346). Thepathological tumor node metastasis (TNM) stage of HCCaccording to the Liver Cancer Study Group of Japan wasstage I in 10 patients (6%), stage II in 60 patients (39%),stage III in 50 patients (32%) and stage IVA in 38 pa-tients (23%). A solitary tumor was found in 110 patients(65%), and 46 patients had multiple tumors. The size ofthe tumor was less than 2 cm in 24 patients (15%), 2 - 5cm in 72 patients (46%), and greater than 5 cm in 60 pa-tients (39%). Vascular tumor thrombus was observed in58 patients (37%). Transarterial chemoembolization orthermal ablation pretreatment was performed in 40 pa-tients (26%). The mean hyaluronic acid (HA) level was2.2. Measurement of Tumor Markers and Histological Findings Clinicopathological patient data was retrieved from thearchives at our institute. The PIVKA-II level was exam-ined by an enzyme-linked immunoassay using Eitest®PIVKA-II (Sanko Junyaku Co., Tokyo, Japan). In ourhospital, the normal value of AFP in patients with HCCis less than 20 ng/mL. The reported normal value ofPIVKA-II is <40 mAU/ml. Elevated levels of AFP andPIVKA-II were defined as those exceeding the normallevels. The tumor-related factors were compared to thefindings from the histopathological examination of theCopyright © 2021 SciRes.JCT Relationship between Serum Hyaluronic Acid Level and Patient Prognosis in HepatocellularCarcinoma Patients Who Underwent Hepatectomy361190 ± 202 ng/ml (range 9 - 1356 ng/ml, median 128ng/ml). The patients were divided into 3 groups: group Ahad serum HA levels less than 50 ng/ml (normal), groupB had levels between 50 and 190 ng/ml, and group C hadlevels over 190 ng/ml.The stage of histological fibrosis was 0 in 5 patients(4%), 1 in 28 patients (21%), 2 in 19 patients (14%), 3 in40 patients (30%) and 4 (cirrhosis) in 43 patients (32%).The mean blood loss was 1160 ± 678 ml, and blood lossover 1500 ml was observed in 28 patients (18%). Ablood transfusion was performed in 58 patients (37%).After hepatectomy, hepatic failure occurred in 8 patients(5%), and long-term ascites was observed in 45 patients(29%).macroscopic finding or TNM stage among the groups.Concerning the non-tumor liver parenchyma, the scoresfor staging, which reflect the grade of fibrosis, and grad-ing, which reflects the grade of inflammatory response,were positively correlated with the serum HA level, andthese results were significant. More extensive hepatec-tomy was significantly more frequent in group A com-pared to groups B or C. Intraoperative blood loss was notsignificantly different between the groups. Postoperativelong-term ascites, even with the use of diuretics, wassignificantly more frequent in group C than in groups Aor B. Hepatic failure tended to be more frequent in groupC than in groups A or B, but this trend was not signifi-cant.3.2. Relationship between Clinicopathological Parameters and Serum HA Level 3.3. Relationship between Preoperative Hyaluronic Acid Levels and Incidence of Tumor Recurrence/Post-Treatment Survival In the 158 patients, age and the serum HA level were notsignificantly correlated with gender or the conventionaltumor markers for HCC (Table 1). Group C showed asignificantly higher rate of poorer liver function (Childclassification B or Liver Damage grade B) compared togroups A or B. Groups B and C had significantly higherrates of viral chronic hepatitis compared to group A.Multiple tumors were significantly more frequent ingroups B and C than in group A, but there were no sig-nificant differences in tumor size, vascular involvement,The 1- and 3-year survival rates were 59% and 36%, re-spectively, and the median survival period was 40.2months. The 3-, 5- and 8-year survival rates were 55%,40% and 26%, respectively, and the median survival pe-riod was 62.7 months. The tumor recurrence rate was notsignificantly related to the level of serum HA, and theserum HA level was not significantly associated withtumor-free survival after hepatectomy (Table 2 and Fig-ure 1(a). However, the serum HA level was signifi-Table 1. Relationship between hyaluronic acid levels and patient demographics, clinicopathological parameters and post-treatment tumor recurrence.Group A1) (n = 25)Group B2) (n = 81)Group C3) (n = 50) P value 0.31 Gender (male/female) Age 21/4 62 ± 10 1048 ± 3207 550 ± 1259 24/1 63/18 66 ± 9 37/13 69 ± 10 n.s AFP (ug/mL) 1797 ± 4626 747 ± 2852 81/0 1478 ± 8232 882 ± 2371 38/12 n.s PIVKA-II (mAU/ml) Child-Pugh (A/B) Liver Damage Grade (A/B) n.s <0.001 <0.001 22/3 72/9 27/23 Viral status (None/B/C/B&C) Pre-treatment (No/Yes) 8/8/7/2 21/4 21/29/24/7 57/24 5/11/25/9 38/12 0.016 0.32 Number of tumors (solitary/multiple) Tumor size (<2/2 - 5/5 cm) Vascular involvement (No/Yes) Macroscopic finding (S/SC/C) TNM classification (1/2/3/4a) Staging (0/1/2/3) 23/2 53/28 26/24 0.009 0.61 2/11/12 18/7 13/35/33 48/33 9/25/16 30/18 0.53 12/8/5 1/17/4/3 2/13/3/6/0 5/15/5 26/23/32 5/27/33/17 3/12/14/20/21 9/35/37 14/17/19 4/17/14/15 0/3/3/15/22 2/7/41 0.35 0.12 <0.001 <0.001 Grading (0/1/2 or more) Operative procedure Partial/segmentectomy or sectionectomy/ hemihepatec tomy or more 3/16/6 22/27/32 27/12/11