Circulating Tumor Cells in Hepatocellular Carcinoma (HCC) and their Association with Early Recurrence after Surgery: A Preliminary Study

Introduction: HCC recurrence is observed in up to 60% of patients after curative resection. Circulating tumor cells (CTCs) have been recently advocated as a source of recurrence. The aim of this study is to determine the correlation between CTCs from peripheral blood samples and the risk of recurrence after resection. Methods: From 2019, 24 patients with HCC at first diagnosis, no other oncological history and BCLC stage 0-A-B were prospectively enrolled.They underwent liquid biopsies at day 0-30-90-180-365. Median follow-up was 365 days. EpCAM, N-cadherin and CD90 were selected as biomarkers to isolate CTCs. Epithelial-mesenchymal transition (EMT) was analyzed by an index estimated as ratio between the number of EpCAM+/N-cad- and EpCAM+/N-cad+ cells (EMT Index). Relapse occurred in 5 patients, then they were divided in 2 groups according to recurrence. Results: Expression of EpCAM+/Ncad+ (double+) and EpCAM+/Ncad+/CD90+ (triple+) cells was higher in the no-relapse group. EMT index was lower in the no-relapse group before surgery. Cut-offs were established by ROC for triple+ cells and for EMT Index. Higher number of triple+ cells cases did not reach the median recurrence free survival (RFS), while lower expression cases had median RFS of 185 days (p<0.0001). Patients with higher EMT Index before surgery had 1-year RFS of 50.8% vs 100% for lower index (p=0.0038). Conclusion: EMT transition of CTCs appears to be correlated with recurrence and our preliminary data showed that a lower expression of triple positive cells or an increased EMT index before surgery are associated with a higher rate of recurrence.