Early Detection and prediction of survival of patients with Hepatocellular Carcinoma Using Transient Elastography

Background: Detection of early cases of HCC allows for offering curative interventions that may positively impact the survival of patients. Screening depends on the use of ultrasound with or without alpha-fetoprotein. However, some cases might need to be noticed, so alternatives are needed. Transient elastography can be studied as an effective alternative. Methods: Patients were divided into groups with liver cirrhosis and HCC and another group without HCC. Demographic criteria and laboratory profiles were compared. Transient elastography was then performed, and values of Controlled Attenuation Parameters (CAP) and liver stiffness were compared between both groups. Results: One


Introduction
Hepatocellular carcinoma (HCC) is a leading cause of mortality and morbidity globally, specifically in Egypt, where Hepatitis C Virus infection was endemic for decades.This remained a global threat even after the successful introduction of the direct-acting antiviral agent for HCV, and the incidence of HCC was still shown to be there after achieving sustained virological response (SVR) to HCV treatment (1).
Surveillance programs are applied to patients with liver cirrhosis to diagnose the occurrence of HCC in early stages, which enables the possibility of providing a curative treatment.
Currently, the screening modalities for screening for HCC include ultrasound (US) with or without alpha-fetoprotein (AFP) every six months.However, limitations exist, and false negative results Original research may be obtained, allowing for missing some cases with HCC, especially those with small lesions.Therefore, other screening modalities are required to aid in catching those with early HCC.
Multiple risk factors exist that can affect the development of HCC.However, the presence of advanced liver fibrosis is the most important and common risk factor in chronic liver disease patients (2).
Thus, assessing liver fibrosis can help detect those with a high risk of developing HCC.The most accurate assessment for liver fibrosis can be obtained using a liver biopsy.However, owing to its drawbacks, such as being an invasive technique with potential complications such as bleeding and infection, other non-invasive methods were established, the most accurate to date being transient elastography.
Transient elastography (TE) is a non-invasive diagnostic tool used for evaluating liver fibrosis by measuring the elasticity of the liver parenchyma using ultrasonography (US) (3).
Transient elastography helps diagnose early compensated liver cirrhosis.Accordingly, several liver stiffness-based HCC prediction models using TE have been adopted (4).
In addition, the quantification of liver stiffness was also shown in multiple studies to correlate with the prediction of treatment outcomes and survival in patients with HCC (5).
This study aimed to evaluate the role of Transient Elastography (Fibroscan) in triaging high-risk patients for close follow-up for early prediction of HCC and prediction of their survival.

Type of the study:
This is an observational study with a time frame from January 2020 to December 2022, where patients with HCC were recruited from the multidisciplinary HCC clinic at Kasr-Alainy Hospital, Cairo University, Egypt.In addition, we recruited patients with liver cirrhosis without HCC as a control group from the endemic medicine department at Cairo University.
Afterward, patients with HCC were treated according to international guidelines and followed up to detect survival.
HCC was diagnosed according to the criteria in the guidelines of the American Association for the Study of Liver Diseases (AASLD), using computerized tomography (CT) or magnetic resonance imaging (MRI) techniques and alpha-fetoprotein (AFP).

❖ Inclusion Criteria:
1-Chronic hepatitis C virus-related liver cirrhosis patients with or without HCC.
2-Recently diagnosed HCC patients did not receive any previous treatment for HCC.

❖ Exclusion Criteria:
Original research 1-Patients with other chronic liver diseases than HCV, e.g., HBV, alcohol-related, autoimmune liver disease, and patients co-infected with HIV.
2-HCC patients who received any previous treatment to HCC.

Methods:
All studied patients were subjected to the following: Entire history taking and clinical assessment.Baseline laboratory tests were collected in the form of complete blood count, liver function tests, renal functions, Alpha-fetoprotein (AFP) measurement in addition to tumor characteristics according to the dynamic imaging, whether CT or MRI (focal lesion site, size and number, portal vein, and abdominal lymph node assessment).

Transient Elastography (Fibroscan):
The probe was applied on the right hepatic lobe through intercostal spaces on patients lying in the dorsal decubitus position with the right arm in maximal abduction.The tip of the transducer of the probe was placed between the rib bones.The operator, assisted by an ultrasonic time-motion image, located a liver portion away from HCC and free of large vascular structures.
An established diagnosis of cirrhosis was obtained by the following criteria: radiological or transient elastography >12.5 kPa.
Original research HCC patients were assessed by Eastern Cooperative Oncology Group performance status (PS) (6) and managed according to the Barcelona Clinic Liver Cancer (BCLC) guideline (7).

Statistical analysis
All statistical analyses were performed using the SPSS program for Windows (version 20 statistical software; Texas Instruments, IL, USA).Categorical variables are given as numbers and percentages.Continuous data are expressed as the mean and standard deviation or as the Median with the Interquartile range (25% -75%).Comparison between distributions of categorical variables will be performed using the Chi-square (X 2 ) test.Besides, variables are described as odds ratio (OR) with a 95% confidence interval (95% CI) where appropriate.The data are considered significant t if p values were < 0.05 and highly effective if p < 0.01.The associations between the gene polymorphisms and HCC stages will be tested using the crosstabs test.The Kaplan-Meier method will be used to calculate the survival rates, and the log-rank test will be used to test the significance of the difference in the patient's survival.

Results
Patients with HCC were significantly older and with male predominance (p-value < 0.001).There was no difference between the studied groups regarding their BMI.Cigarette smoking was significantly more common in patients with HCC (p-value 0.003).We found no significant difference among the studied groups regarding the presence of diabetes mellitus (p-value > 0.05) There was a significant difference between both groups as regards the complete blood count, where hemoglobin level and platelet count were significantly lower in patients with HCC.In contrast, the white cell count was considerably higher.In addition, liver function tests in the form of albumin, bilirubin, and INR were significantly different among both groups, where lower albumin and higher INR levels, as well as more elevated bilirubin and aminotransferase levels, were encountered in patients with HCC.The alpha-fetoprotein level was also significantly higher in HCC patients (p-value <0.001) (Tab 2).The overall survival for patients with HCC was measured from the day of HCC diagnosis till the death of the patient or till the end of the study.The mean overall survival was 29.81 months.Univariate analysis revealed that smoking was a significant predictor of mortality of patients with HCC.In contrast, the multivariate analysis showed that the independent factor affecting mortality was the gender of the patients with HCC (Tab 4).

Original research
Several observational case-control and cohort studies have reported an increased incidence of HCC in smoker populations, stratified by the severity of smoking (13).In our study, it was shown that there was a statistically significant difference between patients with HCC and patients without HCC as regards tobacco smoking, where those with HCC were more frequent users of Tobacco.
The risk of HCC increases with the advancement in the degree of liver decompensation, and patients with Child scores B and C are shown to have a higher incidence of developing HCC.That was clear in the current study, where synthetic functions of patients with HCC in the form of albumin, bilirubin, and coagulation profile were worse than those without HCC.Also, alphafetoprotein level, a recognized glycoprotein marker for HCC, was higher in patients with HCC, with a median value of 62.5 ng/ml.This agrees with several studies that support the utility of AFP as a diagnostic modality for HCC (14)(15).However, other studies raised the debate about the value of AFP in diagnosing HCC.For example, El Serag et al. mentioned that AFP is not always elevated in HCC and showed that its sensitivity and specificity are 79% and 89%, respectively . Moreover, in small HCC lesions, AFP may show average values (17).
Non-alcoholic fatty liver disease (NAFLD) is one of the main etiologies of chronic liver disease and HCC (18).Substantial evidence is present that steatosis is one of multiple risk factors for HCC in patients with chronic HCV infection, even after viral cure by the novel direct-acting antiviral drugs which is also related to the increased prevalence of hepatic steatosis, is also shown to be an independent risk factor for HCC development in patients with chronic HCV (19).
On the contrary, a study by Mak et al. in 2021 showed that reduced liver steatosis in patients with chronic hepatitis B infection was inversely proportional to the incidence of HCC.A suggested explanation was that in the terminal stage of steatohepatitis, i.e., the burnt-out phase, no more excess fat is deposited in the liver, which may reflect the lower values of CAP in this population In the current study, the overall survival for patients with HCC was measured from the day of the first visit to our multidisciplinary clinic till the death of the patient or till the end of the study.The mean overall survival was 29.81 months.By using univariate analysis, smoking was a Original research significant predictor for mortality of HCC patients.In contrast, the multivariate analysis showed that gender was an independent predictor for mortality in patients with HCC.
Liver stiffness measurement by transient elastography failed to be a good predictor for mortality in our study.This contradicted other studies, which showed that higher LSM can be associated with poor overall survival in patients with HCC with different cut-off values.For example, Rekik and his colleagues showed a TE value ≥ 40 kPa was associated with shorter median overall survival (34 months) compared to a TE value < 40 kPa (59 months, P = 0.0008 for the logrank test) (33).
In conclusion, detecting early HCC is essential to benefit from the available therapeutic options.Liver fibrosis estimation through transient elastography may provide an adequate tool for diagnosing patients in the early stages of the tumor.This might be reflected significantly in the survival and treatment response rates in patients with HCC.Patients with higher LSM are not at an increased risk for HCC-related deaths.

Fig 1 .
Fig 1. ROC curve of liver stiffness in discrimination of liver cirrhosis and HCC.

(
19).There is ongoing debate about the pathogenic relationship between steatosis and HCC and the potential carcinogenic mechanisms related explicitly to steatosis and steatohepatitis (20).In Original research a study done in 2003, the degree of hepatic steatosis and HCC development were directly proportional (21).In addition, it was shown that patients with steatosis had an increased risk of developing HCC by 2.81 times compared to patients who did not have steatosis (22).Obesity,

features of the studied groups.
Tab 2. Laboratory p≤0.05 is considered statistically significant, and p≤0.01 is considered highly statistically substantial.Steatosis levels were lower in patients with HCC as measured by CAP using transient elastography (p-value < 0.001).Most patients with HCC (85.7%) had no or mild steatosis (S0 and S1).On the other hand, liver stiffness measurement was significantly different between both groups, showing a higher level in those with HCC (p-value < 0.001) (Tab 3).Tab3.Comparisons

Tab 4 . Univariate and multivariate regression analysis of the risk factors for mortality in patients with HCC Univariate analysis Multivariate analysis
In addition, a study done by Yi et al. showed that, with advancing age, the effects of alcohol use and HCV on the development of HCC become stronger (12).
B: Regression coefficient; S.E.: Standard error, CI: Confidence interval.Original researchIn addition, Multi-detector CT or dynamic MR imaging is not cost-effective for surveillance in general because of the considerable rate of false-positive findings and the need to use contrast agents to achieve adequate sensitivity (9).Liver fibrosis is a well-established risk factor for developing HCC, and The HCC incidence rate of cirrhosis is 2-4% per year (10).Thus, liver fibrosis quantification might be a valuable tool for predicting HCC in cirrhotic patients.The gold standard diagnostic method for liver fibrosis is liver biopsy.However, other non-invasive modalities exist due to the invasive nature of liver biopsy.Transient elastography is an approved imaging technique for liver fibrosis assessment, so this study aimed to evaluate the role of transient elastography in predicting the risk of HCC in patients with liver cirrhosis.This study included 133 patients with liver cirrhosis compared to 133 patients with HCC on top of liver cirrhosis.Most patients with HCC were males, and they were older, which suggests that aging may be related to a higher risk of HCC development.This was stated by Asahina et al., who confirmed that aging and male gender were independent risk factors associated with HCC (11).

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Our study agreed with this, as 87.7% of patients with HCC had no or mild steatosis (S0 and S1) compared to 66.1% of patients without HCC.A possible explanation might be that fat deposition might be evaded with advanced fibrosis, tumor infiltration, and lower CAP values.

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Salem Youssef Mohamed, Osama Ahmed Khalil.This open-access article is distributed under the Creative Commons Attribution License (CC BY).The use, distribution, or reproduction in other forums is permitted, provided the original author(s) and the copyright owner(s) are credited.The original publication in this journal is cited by accepted academic practice.No use, distribution, or reproduction is permitted, complying with these terms.research the Barcelona Clinic Liver Cancer system.Hepatology.Issue 1. January 2013, Pages 112- 8-Singal A., Volk M.L., Waljee A., et al.Meta-analysis: surveillance with ultrasound for early-stage hepatocellular carcinoma in patients with cirrhosis.Aliment Pharmacol Ther.2009; 30: 37-47.9-Pocha C., Dieperink E., McMaken K.A., Knott A., Thuras P., Ho S.B. Surveillance for hepatocellular cancer with ultrasonography vs. computed tomographya randomized study.Aliment Pharmacol Ther.2013; 38: 303-312.