- Email: [email protected]
mitomycin-C and ethiodol or adriamycin drug eluting beads
JVIR 䡲 Scientific Sessions
Sunday 䡲 S17
8:56 AM
Abstract No. 33
Dynamic first-pass area-detector perfusion CT for the evaluation of perfusion changes following intra-arterial therapy in the liver VX2 model S. Mirpour, A. Gholamrezanezhad, P. Rao, O. Pellerin, J.F. Geschwind, E. Liapi; Interventional Radiology, Johns Hopkins Hospital, Baltimore, MD Purpose: To prospectively evaluate whether dynamic first-pass area-detector CT imaging can depict perfusion changes following intra-arterial therapy in the liver VX2 model. Materials and Methods: 17 liver VX2 bearing rabbits were scanned in a 320-detector row CT scanner (Acquilion One, Toshiba, Japan) before and at 7 days following intra-arterial therapy (DEB-embolization or bland embolization). The volumetric scanning parameters were: FOV⫽22 cm, kV⫽120, mA⫽80, slice thickness⫽0.5 mm, scan delay⫽6 sec, intermittent scanning for 67 sec (arterial phase q 2 sec, portal venous phase q 3 sec). Rabbits were injected with 1.5 ml/kg of isoosmolar CM at 1 ml/sec, followed by a saline flush. CT data were analyzed using the Toshiba CT body perfusion software and calculated tumor, ipsilateral and contralateral to tumor hepatic perfusion using the maximum slope model. Blood samples for liver function tests (LFTs) were obtained at baseline and before euthanasia. All rabbits were euthanized after the final CT scan and tumor and liver samples were evaluated for percentage of tumor necrosis, presence of peritumoral fibrous capsule and microsphere count per tumor slide. Results: Following treatment, arterial flow (AF) of the tumor was significantly reduced (AF pre⫽130.03, AF post⫽78.15, p⫽0.0009), while tumor portal flow (PF) and perfusion index (PI) remained unchanged (p⫽0.49 and 0.31, respectively). AF to the ipsilateral liver lobe was significantly reduced after treatment (AF pre⫽132.412, AF post⫽74.09, p⫽0.04). PF of the ipsilateral liver lobe was also slightly reduced after treatment (p⫽0.07). AF, PF and PI to the contralateral liver lobe remained unchanged after treatment (p⫽0.87, 0.41 and 0.41, respectively). No statistically significant difference was observed between baseline and final
LFTs. On pathology, all tumors were successfully embolized, with an average of 7 beads/tumor slide. Tumors had a fibrous capsule with a mean tumor necrosis of 67.7%. No correlation was found between the percentage of tumor necrosis and changes in the tumor AF. Conclusion: Dynamic first-pass area-detector CT imaging can successfully depict changes in liver and tumor perfusion at 7 days following intra-arterial therapy in the liver VX2 model.
9:04 AM
Abstract No. 34
䡲 FEATURED ABSTRACT Comparison of three chemoembolization regimens for hepatocellular carcinoma: adriamycin and ethiodol has shorter time to progression than cisplatin/adriamycin/ mitomycin-C and ethiodol or adriamycin drug eluting beads N.J. Petruzzi, A. Gupta, A. Frangos, V.J. Navarro, H. Hann, S.K. Herrine, J.M. Fenkel, S. Rossi, E.L. Rosato, J.W. McCann, D.J. Eschelman, C.F. Gonsalves, D.B. Brown; Thomas Jefferson University, Philadelphia, PA Purpose: Transarterial chemoembolization (TACE) regimens for hepatocellular carcinoma (HCC) vary greatly without a defined gold standard. There is minimal data regarding comparative efficacy. We evaluated differences in tumor response on follow-up imaging in HCC patients treated with adriamycin/ethiodol (AE), cisplatin/adriamycin/mitomycinc/ethiodol (CAM) or adriamycin drug-eluting beads (DEB). Materials and Methods: We reviewed HCC patients at our institution that received a single TACE regimen for all visits without crossover to a different TACE regimen/Yttrium-90. All patients had imaging follow-up. Patients received AE, CAM or DEB based on operator preference. Child Pugh class (A vs B/C) and TNM stage (1 and 2 vs 3 and 4) at baseline was compared between groups. Tumor response was tracked with RECIST to calculate partial response rate, time to progression (TTP), and risk of progression. Results: 215 infusions were performed in 123 patients: 59 AE, 31 CAM, and 33 DEB. Of the 123 patients, 85 (69.1%) were Childs-Pugh A and 103 patients had T1 or T2 disease (83.8%). The subgroups were similar in regards to Child Pugh status (p⫽0.45) and TNM 1-2 (p⫽0.5). The mean number of treatments was: AE 2.25 ⫹/⫺ 1.35, CAM 1.61 ⫹/⫺ 0.72, and DEB 1.36 ⫹/⫺ 0.55. AE patients underwent significantly more procedures than CAM (p⫽0.0043) or DEB (p⬍0.0001). Mean total follow-up was 288 ⫹/⫺ 222, 336 ⫹/⫺ 257, and 247 ⫹/⫺ 125 days for AE, CAM and DEB respectively (p⫽0.24). 10/59 AE patients, 14/31 CAM patients, and 11/33 DEB patients had a partial response (p⫽0.23). 23/59 AE patients, 7/31 CAM patients, and 6/33 DEB progressed at a mean of 168.5 ⫹/⫺ 123, 172 ⫹/⫺ 83, and 227 ⫹/⫺ 120 days respectively. While TTP was similar between groups (0.60), patients treated with AE were much more likely to develop progressive disease than those treated with either CAM (p⫽0.02) or LC Beads (p⫽0.02). Conclusion: In a single center evaluation of comparable patient groups, patients undergoing AE TACE required sig-
SUNDAY: Scientific Sessions
significantly different expression (p-value⬍0.05, ⫾2-fold change) between 2 groups were selected. Results: At D7, bland SAP did not cause necrosis and only 68 genes were deregulated. Among them, 10 genes related to angiogenesis. VEGF was not different vs control. Dox-SAP caused parenchyma necrosis at D7 (presence on 92% of the tissue sections), which was progressively resorbed between M1 (31%) and M3 (0%) and replaced by an inflammatory reaction and a fibrotic remodeling tissue after the microspheres emptied, finally resulting in regenerated liver. In parallel, the overall number of modulated genes and the number of angiogenesis-related genes decreased from D7 to M1 and M3 (resp. 770, 257 and 46 modulated genes by Dox-SAP; and among them 71, 34 and 6 modulated related to angiogenesis). VEGF decreased at D7 and M1. The angiogenesis related-genes did not included VEGF and HIF1A but were interleukins and chemokines which mark an inflammatory reaction, and collagen molecules, metallopeptidases, growth factors, and adhesion molecules which orchestrate the tissue remodeling. Conclusion: Angiogenesis following chemoembolization in normal liver, associated to the inflammatory response and tissue remodeling, participates to the healing phase replacing the necrosis induced by Dox. This repair angiogenesis must be distinguished from tumoral angiogenesis.
S18 䡲 Sunday
Scientific Sessions 䡲 JVIR
cirrhosis nificantly more treatment sessions and had a significantly greater risk of tumor progression than patients treated with CAM or DEB with a similar amount of follow-up.
SUNDAY: Scientific Sessions
9:12 AM
Abstract No. 35
Comparative study of short-term therapeutic effects of miriplatin-lipiodol suspension and cisplatin-lipiodol suspension in transcatheter arterial chemo-embolization for hepatocellular carcinoma S. Oguro1, S. Hashimoto1, T. Tanaka1, M. Inoue1, S. Nakatsuka1, K. Asakura2, S. Kuribayashi1; 1 Department of Diagnostic Radiology, Keio University Hospital, Tokyo, Japan; 2Department of Preventive Medicine and Public Health, Keio University Hospital, Tokyo, Japan Purpose: Miriplatin hydrate (Miripla; Dainippon Sumitomo Pharma Co. Ltd. Osaka, Japan) was released in 2010 and has been developed in Japan. Miriplatin contains a lipophilic platinum complex with a higher affinity for iodized oil than the cisplatin powder. The purpose of this study was to investigate the short-term therapeutic effects and adverse effects associated with the use of Miriplatin-lipiodol suspension in TACE for HCC as a single-institution retrospective study, using a cisplatinlipiodol suspension as a control. Materials and Methods: The study included consecutive 48 patients with HCC who underwent TACE with Miriplatin-lipiodol suspension between January 2010 and February 2011, as well as 50 patients who underwent TACE with cisplatin-lipiodol suspension between January 2008 and July 2010. The miriplatin group included 36 men and 12 women patients with a mean age of 70.9 ⫾ 10.1 years, and the cisplatin group included 39 men and 11 women patients with a mean age of 70.2 ⫾ 9.8 years. Therapeutic effect was evaluated based on mRECIST at the first follow up imaging. Adverse effects related to TACE were graded according to the Common Terminology Criteria for Adverse Events version 4.0. Therapeutic effect and adverse effects were compared between the miriplatin group and the cisplatin group using Fisher’s exact test and multivariate logistic regression. Results: Complete remission, partial response, stable disease and progress disease were 37.5%, 18.8%, 33.3%, 10.4% for the miriplatin group, and 54.0%, 32.0%, 14.0%, 0.0% for the cisplatin group respectively. The miriplatin group showed statistically significantly worse short-term therapeutic effects than the cisplatin group even after adjusting for tumor size and Child-pugh classification (p⬍0.05). The rates of vomiting, creatinine elevation and ALP elevation in the miriplatin group were statistically significantly lesser than those in the cisplatin group (p⬍0.05). Conclusion: TACE using miriplatin-Lipiodol suspension showed worse short-term response than TACE using cisplatin-lipiodol suspension in patients with HCC, and the rate of adverse events were significantly lesser in the miriplatin group than the cisplatin group.
9:20 AM
Abstract No. 36
Chemoembolization (TACE) of hepatocellular carcinoma (HCC): comparison of disease outcomes between alcohol and viral induced
E. Liapi, S. Mirpour, A. Gholamrezanezhad, K. Hong, T. Wahlin, C. Georgiades, J. Hebert, J.F. Geschwind; Interventional Radiology, Johns Hopkins Hospital, Baltimore, MD Purpose: To report the outcome patients with HCC and history of either hepatitis B (Hep B) or C (Hep C) infection or alcoholinduced cirrhosis (AIC) treated with TACE with a focus on disease outcomes [tumor size change according to RECIST, Child-Pugh (CP) score and survival]. Materials and Methods: 178 patients with history of either Hep B or C or AIC were selected from a comprehensive database of 347 patients with unresectable HCC that were treated in our institution between 1996 and 2007. Patients with combined history of alcohol abuse and viral hepatitis infection or combined coinfection were excluded from this study. Tumor response was assessed according to the RECIST criteria. T-tests, chi-square and Wilcoxon signed rank tests were used to assess differences in disease characteristics. Overall survival (OS) rates were calculated with the Kaplan-Meyer test and comparison of survival differences with the Log rank test. Results: 51 patients were diagnosed with hep B, 91 with hepatitis C and 36 patients with AIC. There was no significant difference in the baseline distribution of CP scores among the 3 groups. Mean baseline tumor size was 8.3 cm for hep B, 5.9 cm for hep C and 5.7 cm for AIC patients (p⬎0.05).There was no significant difference in tumor response among the 3 groups. AIC patients had a slightly higher percentage of partial response and a slightly higher OS rate compared to hep C patients (p⫽0.07 and 0.06, respectively). All other survival time comparisons were not statistically significant different. Mean OS for hep B patients was 38.57 months (median 18.9, SE: 12.745). Mean OS for hep C patients was 25.36 months (median 19.5, SE: 2.57). Mean OS for AIC patients was 34.67 months (median 26.3, SE: 4.33). Conclusion: In this selected cohort of patients with unresectable HCC treated with TACE, no statistically significant differences were noted between OS and tumor response rates between patients with alcohol-induced cirrhosis and history of hepatitis B or C infection. Patients with alcohol-related cirrhosis showed slightly better survival and a marginally higher percentage of partial response than patients with hepatitis C infection following treatment with conventional chemoembolization.
9:28 AM
Abstract No. 37
䡲 FEATURED ABSTRACT Does response to transarterial chemoembolization of hepatocellular carcinoma improve survival in patients undergoing liver transplantation? A. Shuster, J.D. Jaskolka, T.J. Huynh, D.C. Huynh; Radiology, UHN/Mount Sinai Hospital, Toronto, ON, Canada Purpose: Transarterial chemoembolization (TACE) is often performed as a “bridge” to orthotopic liver transplantation (OLT) in patients with hepatocellular carcinoma (HCC). The purpose of this study was to determine
Sunday 䡲 S17
8:56 AM
Abstract No. 33
Dynamic first-pass area-detector perfusion CT for the evaluation of perfusion changes following intra-arterial therapy in the liver VX2 model S. Mirpour, A. Gholamrezanezhad, P. Rao, O. Pellerin, J.F. Geschwind, E. Liapi; Interventional Radiology, Johns Hopkins Hospital, Baltimore, MD Purpose: To prospectively evaluate whether dynamic first-pass area-detector CT imaging can depict perfusion changes following intra-arterial therapy in the liver VX2 model. Materials and Methods: 17 liver VX2 bearing rabbits were scanned in a 320-detector row CT scanner (Acquilion One, Toshiba, Japan) before and at 7 days following intra-arterial therapy (DEB-embolization or bland embolization). The volumetric scanning parameters were: FOV⫽22 cm, kV⫽120, mA⫽80, slice thickness⫽0.5 mm, scan delay⫽6 sec, intermittent scanning for 67 sec (arterial phase q 2 sec, portal venous phase q 3 sec). Rabbits were injected with 1.5 ml/kg of isoosmolar CM at 1 ml/sec, followed by a saline flush. CT data were analyzed using the Toshiba CT body perfusion software and calculated tumor, ipsilateral and contralateral to tumor hepatic perfusion using the maximum slope model. Blood samples for liver function tests (LFTs) were obtained at baseline and before euthanasia. All rabbits were euthanized after the final CT scan and tumor and liver samples were evaluated for percentage of tumor necrosis, presence of peritumoral fibrous capsule and microsphere count per tumor slide. Results: Following treatment, arterial flow (AF) of the tumor was significantly reduced (AF pre⫽130.03, AF post⫽78.15, p⫽0.0009), while tumor portal flow (PF) and perfusion index (PI) remained unchanged (p⫽0.49 and 0.31, respectively). AF to the ipsilateral liver lobe was significantly reduced after treatment (AF pre⫽132.412, AF post⫽74.09, p⫽0.04). PF of the ipsilateral liver lobe was also slightly reduced after treatment (p⫽0.07). AF, PF and PI to the contralateral liver lobe remained unchanged after treatment (p⫽0.87, 0.41 and 0.41, respectively). No statistically significant difference was observed between baseline and final
LFTs. On pathology, all tumors were successfully embolized, with an average of 7 beads/tumor slide. Tumors had a fibrous capsule with a mean tumor necrosis of 67.7%. No correlation was found between the percentage of tumor necrosis and changes in the tumor AF. Conclusion: Dynamic first-pass area-detector CT imaging can successfully depict changes in liver and tumor perfusion at 7 days following intra-arterial therapy in the liver VX2 model.
9:04 AM
Abstract No. 34
䡲 FEATURED ABSTRACT Comparison of three chemoembolization regimens for hepatocellular carcinoma: adriamycin and ethiodol has shorter time to progression than cisplatin/adriamycin/ mitomycin-C and ethiodol or adriamycin drug eluting beads N.J. Petruzzi, A. Gupta, A. Frangos, V.J. Navarro, H. Hann, S.K. Herrine, J.M. Fenkel, S. Rossi, E.L. Rosato, J.W. McCann, D.J. Eschelman, C.F. Gonsalves, D.B. Brown; Thomas Jefferson University, Philadelphia, PA Purpose: Transarterial chemoembolization (TACE) regimens for hepatocellular carcinoma (HCC) vary greatly without a defined gold standard. There is minimal data regarding comparative efficacy. We evaluated differences in tumor response on follow-up imaging in HCC patients treated with adriamycin/ethiodol (AE), cisplatin/adriamycin/mitomycinc/ethiodol (CAM) or adriamycin drug-eluting beads (DEB). Materials and Methods: We reviewed HCC patients at our institution that received a single TACE regimen for all visits without crossover to a different TACE regimen/Yttrium-90. All patients had imaging follow-up. Patients received AE, CAM or DEB based on operator preference. Child Pugh class (A vs B/C) and TNM stage (1 and 2 vs 3 and 4) at baseline was compared between groups. Tumor response was tracked with RECIST to calculate partial response rate, time to progression (TTP), and risk of progression. Results: 215 infusions were performed in 123 patients: 59 AE, 31 CAM, and 33 DEB. Of the 123 patients, 85 (69.1%) were Childs-Pugh A and 103 patients had T1 or T2 disease (83.8%). The subgroups were similar in regards to Child Pugh status (p⫽0.45) and TNM 1-2 (p⫽0.5). The mean number of treatments was: AE 2.25 ⫹/⫺ 1.35, CAM 1.61 ⫹/⫺ 0.72, and DEB 1.36 ⫹/⫺ 0.55. AE patients underwent significantly more procedures than CAM (p⫽0.0043) or DEB (p⬍0.0001). Mean total follow-up was 288 ⫹/⫺ 222, 336 ⫹/⫺ 257, and 247 ⫹/⫺ 125 days for AE, CAM and DEB respectively (p⫽0.24). 10/59 AE patients, 14/31 CAM patients, and 11/33 DEB patients had a partial response (p⫽0.23). 23/59 AE patients, 7/31 CAM patients, and 6/33 DEB progressed at a mean of 168.5 ⫹/⫺ 123, 172 ⫹/⫺ 83, and 227 ⫹/⫺ 120 days respectively. While TTP was similar between groups (0.60), patients treated with AE were much more likely to develop progressive disease than those treated with either CAM (p⫽0.02) or LC Beads (p⫽0.02). Conclusion: In a single center evaluation of comparable patient groups, patients undergoing AE TACE required sig-
SUNDAY: Scientific Sessions
significantly different expression (p-value⬍0.05, ⫾2-fold change) between 2 groups were selected. Results: At D7, bland SAP did not cause necrosis and only 68 genes were deregulated. Among them, 10 genes related to angiogenesis. VEGF was not different vs control. Dox-SAP caused parenchyma necrosis at D7 (presence on 92% of the tissue sections), which was progressively resorbed between M1 (31%) and M3 (0%) and replaced by an inflammatory reaction and a fibrotic remodeling tissue after the microspheres emptied, finally resulting in regenerated liver. In parallel, the overall number of modulated genes and the number of angiogenesis-related genes decreased from D7 to M1 and M3 (resp. 770, 257 and 46 modulated genes by Dox-SAP; and among them 71, 34 and 6 modulated related to angiogenesis). VEGF decreased at D7 and M1. The angiogenesis related-genes did not included VEGF and HIF1A but were interleukins and chemokines which mark an inflammatory reaction, and collagen molecules, metallopeptidases, growth factors, and adhesion molecules which orchestrate the tissue remodeling. Conclusion: Angiogenesis following chemoembolization in normal liver, associated to the inflammatory response and tissue remodeling, participates to the healing phase replacing the necrosis induced by Dox. This repair angiogenesis must be distinguished from tumoral angiogenesis.
S18 䡲 Sunday
Scientific Sessions 䡲 JVIR
cirrhosis nificantly more treatment sessions and had a significantly greater risk of tumor progression than patients treated with CAM or DEB with a similar amount of follow-up.
SUNDAY: Scientific Sessions
9:12 AM
Abstract No. 35
Comparative study of short-term therapeutic effects of miriplatin-lipiodol suspension and cisplatin-lipiodol suspension in transcatheter arterial chemo-embolization for hepatocellular carcinoma S. Oguro1, S. Hashimoto1, T. Tanaka1, M. Inoue1, S. Nakatsuka1, K. Asakura2, S. Kuribayashi1; 1 Department of Diagnostic Radiology, Keio University Hospital, Tokyo, Japan; 2Department of Preventive Medicine and Public Health, Keio University Hospital, Tokyo, Japan Purpose: Miriplatin hydrate (Miripla; Dainippon Sumitomo Pharma Co. Ltd. Osaka, Japan) was released in 2010 and has been developed in Japan. Miriplatin contains a lipophilic platinum complex with a higher affinity for iodized oil than the cisplatin powder. The purpose of this study was to investigate the short-term therapeutic effects and adverse effects associated with the use of Miriplatin-lipiodol suspension in TACE for HCC as a single-institution retrospective study, using a cisplatinlipiodol suspension as a control. Materials and Methods: The study included consecutive 48 patients with HCC who underwent TACE with Miriplatin-lipiodol suspension between January 2010 and February 2011, as well as 50 patients who underwent TACE with cisplatin-lipiodol suspension between January 2008 and July 2010. The miriplatin group included 36 men and 12 women patients with a mean age of 70.9 ⫾ 10.1 years, and the cisplatin group included 39 men and 11 women patients with a mean age of 70.2 ⫾ 9.8 years. Therapeutic effect was evaluated based on mRECIST at the first follow up imaging. Adverse effects related to TACE were graded according to the Common Terminology Criteria for Adverse Events version 4.0. Therapeutic effect and adverse effects were compared between the miriplatin group and the cisplatin group using Fisher’s exact test and multivariate logistic regression. Results: Complete remission, partial response, stable disease and progress disease were 37.5%, 18.8%, 33.3%, 10.4% for the miriplatin group, and 54.0%, 32.0%, 14.0%, 0.0% for the cisplatin group respectively. The miriplatin group showed statistically significantly worse short-term therapeutic effects than the cisplatin group even after adjusting for tumor size and Child-pugh classification (p⬍0.05). The rates of vomiting, creatinine elevation and ALP elevation in the miriplatin group were statistically significantly lesser than those in the cisplatin group (p⬍0.05). Conclusion: TACE using miriplatin-Lipiodol suspension showed worse short-term response than TACE using cisplatin-lipiodol suspension in patients with HCC, and the rate of adverse events were significantly lesser in the miriplatin group than the cisplatin group.
9:20 AM
Abstract No. 36
Chemoembolization (TACE) of hepatocellular carcinoma (HCC): comparison of disease outcomes between alcohol and viral induced
E. Liapi, S. Mirpour, A. Gholamrezanezhad, K. Hong, T. Wahlin, C. Georgiades, J. Hebert, J.F. Geschwind; Interventional Radiology, Johns Hopkins Hospital, Baltimore, MD Purpose: To report the outcome patients with HCC and history of either hepatitis B (Hep B) or C (Hep C) infection or alcoholinduced cirrhosis (AIC) treated with TACE with a focus on disease outcomes [tumor size change according to RECIST, Child-Pugh (CP) score and survival]. Materials and Methods: 178 patients with history of either Hep B or C or AIC were selected from a comprehensive database of 347 patients with unresectable HCC that were treated in our institution between 1996 and 2007. Patients with combined history of alcohol abuse and viral hepatitis infection or combined coinfection were excluded from this study. Tumor response was assessed according to the RECIST criteria. T-tests, chi-square and Wilcoxon signed rank tests were used to assess differences in disease characteristics. Overall survival (OS) rates were calculated with the Kaplan-Meyer test and comparison of survival differences with the Log rank test. Results: 51 patients were diagnosed with hep B, 91 with hepatitis C and 36 patients with AIC. There was no significant difference in the baseline distribution of CP scores among the 3 groups. Mean baseline tumor size was 8.3 cm for hep B, 5.9 cm for hep C and 5.7 cm for AIC patients (p⬎0.05).There was no significant difference in tumor response among the 3 groups. AIC patients had a slightly higher percentage of partial response and a slightly higher OS rate compared to hep C patients (p⫽0.07 and 0.06, respectively). All other survival time comparisons were not statistically significant different. Mean OS for hep B patients was 38.57 months (median 18.9, SE: 12.745). Mean OS for hep C patients was 25.36 months (median 19.5, SE: 2.57). Mean OS for AIC patients was 34.67 months (median 26.3, SE: 4.33). Conclusion: In this selected cohort of patients with unresectable HCC treated with TACE, no statistically significant differences were noted between OS and tumor response rates between patients with alcohol-induced cirrhosis and history of hepatitis B or C infection. Patients with alcohol-related cirrhosis showed slightly better survival and a marginally higher percentage of partial response than patients with hepatitis C infection following treatment with conventional chemoembolization.
9:28 AM
Abstract No. 37
䡲 FEATURED ABSTRACT Does response to transarterial chemoembolization of hepatocellular carcinoma improve survival in patients undergoing liver transplantation? A. Shuster, J.D. Jaskolka, T.J. Huynh, D.C. Huynh; Radiology, UHN/Mount Sinai Hospital, Toronto, ON, Canada Purpose: Transarterial chemoembolization (TACE) is often performed as a “bridge” to orthotopic liver transplantation (OLT) in patients with hepatocellular carcinoma (HCC). The purpose of this study was to determine