Combination of structural and vascular optical coherence tomography for differentiating oral lesions of mice in different carcinogenesis stages

Differentiating between early malignancy and benign lesions in oral cavities is difficult using current optical tools. As has been shown in previous studies, microvascular changes in squamous epithelium can be regarded as a key marker for diagnosis. We propose the combination of structural and vascular optical coherence tomography (OCT) imaging for the investigation of disease related changes. Progressive thickness changes of epithelium and the destruction of underlying lamina propria was observed during cancer development in a 4- nitroquinoline-1-oxide (4NQO) mouse model. At the same time, microvascular changes in hyperplasia, dysplasia, carcinoma in situ and advanced cancer were observed. Findings from OCT imaging were compared with histology.

Validation of the albumin-bilirubin grade-based integrated model as a predictor for sorafenib-failed hepatocellular carcinoma

BACKGROUND & AIMS

Sorafenib is the standard treatment for advanced hepatocellular carcinoma (HCC) but is challenging after treatment failure. Appropriate criteria for enrolling patients into second-line trials are still limited. In this study, we aimed to establish more objective criteria based on Albumin-Bilirubin (ALBI) grade to select patients with better post-progression survival (PPS) for second-line treatment.

METHODS

Consecutive 404 advanced HCC patients receiving sorafenib were retrospectively enrolled. All patients were in Child-Pugh class A and BCLC stage C with either portal vein invasion or extrahepatic metastasis at the beginning of sorafenib treatment. Radiological evaluation based on mRECIST criteria and clinical assessments with compliance were performed on schedule.

RESULTS

During the median follow-up period of 5.8 months, 310 patients developed progressive disease (PD) and 350 deaths occurred. The PD patients were randomized into derivation and validation cohorts by a 1:1 ratio. The independent predictors of poor PPS in derivation cohort were ALBI grade 3 at PD (hazard ratio [HR]=3.24, P = .002), new extrahepatic lesions (NEH) (HR=1.75, P = .011), and early PD within 4 months (HR=1.88, P = .037). ALBI-PD criteria were proposed by incorporating these three risk factors. In the validation cohort, PPS could be independently predicted by presence of early PD, NEH as well as ALBI grade 3 at PD. Patients within ALBI-PD criteria had significant longer median PPS than those beyond it even in Child-Pugh A (9.7 vs 4.9 months, P = .005) subpopulations.

CONCLUSIONS

The ALBI-PD criteria can differentiate PPS and stratify the patients with advanced HCC for the second-line trials or salvage therapy.

The susceptibility of anti-tuberculosis drug-induced liver injury and chronic hepatitis C infection: A systematic review and meta-analysis

BACKGROUND

Anti-tuberculosis drug-induced liver injury (ATDILI) is a major safety concern in the treatment of tuberculosis (TB). The impact of chronic hepatitis C (CHC) infection on the risk of ATDILI is still controversial. We aimed to assess the influence of CHC infection on ATDILI through a systematic review and meta-analysis.

METHODS

We systemically reviewed all English-language literature in the major medical databases with the subject search terms "anti-tuberculosis drug-induced liver injury" and "anti-tuberculosis drug-induced hepatotoxicity". We then performed a systematic review and meta-analysis of the papers relevant to hepatitis C in qualified publications.

RESULTS

A total of 14 studies were eligible for analysis, which included 516 cases with ATDILI and 4301 controls without ATDILI. The pooled odds ratio (OR) of all studies for CHC infection to ATDILI was 3.21 (95% confidence interval (CI): 2.30-4.49). Subgroup analysis revealed that the CHC carriers had a higher risk of ATDILI than those without CHC both in Asians (OR = 2.96, 95% CI: 1.79-4.90) and Caucasians (OR = 4.07, 95% CI: 2.70-6.14), in those receiving standard four combination anti-TB therapy (OR = 2.94, 95% CI: 1.95-4.41) and isoniazid monotherapy (OR = 4.18, 95% CI: 2.36-7.40), in those with a strict definition of DILI (serum alanine aminotransferase [ALT] > 5 upper limit of normal value [ULN], OR = 2.59, 95% CI: 1.58-4.25) and a loose definition of DILI (ALT > 2 or 3 ULN, OR = 4.34, 95% CI: 2.96-6.37), and in prospective studies (OR = 4.16, 95% CI: 2.93-5.90) and case-control studies (OR = 2.43, 95% CI: 1.29-4.58).

CONCLUSION

This meta-analysis suggests that CHC infection may increase the risk of ATDILI. Regular liver tests are mandatory for CHC carriers under anti-TB therapy.

Serum adrenomedullin and urinary thromboxane B2 help early categorizing of acute kidney injury in decompensated cirrhotic patients: A prospective cohort study

AIMS

Increases in the systemic vasodilator adrenomedullin and the renal vasoconstrictors thromboxane A₂ in cirrhotic patients are pathogenic factors for the development of functional acute kidney injury (AKI), including pre-renal azotemia (PRA) and hepatorenal syndrome (HRS), which is associated with high mortality. This study aims to find biomarkers that can diagnose HRS at an early stage, to enable treatment as soon as possible.

METHODS

Acute decompensated cirrhotic patients who had been admitted to hospital were enrolled in this prospective cohort study. Blood and urinary samples were collected immediately after admission. In addition to initially categorizing AKI cases into PRA, acute tubular necrosis (ATN), and HRS groups, their final diagnosis was adjudicated by a nephrologist and a hepatologist who checked the corrected and misclassification rates for significant biomarkers.

RESULTS

The cut-off values for serum adrenomedullin and urinary thromboxane B₂ (TXB₂ ), when used as predictors for functional AKI (adrenomedullin >283 pg/mL, urinary TXB₂ >978 [pg/mg urinary creatinine]), for HRS (adrenomedullin >428, urinary TXB₂  >1604), and for good terlipressin plus albumin treatment responders (adrenomedullin >490, urinary TXB₂  >1863), were observed. Patients with HRS who could be treated, due to high mortality, had significantly higher serum adrenomedullin and urinary TXB₂ levels compared to HRS patients receiving standard treatment. In addition to predicting 60-day mortality, a combination of these two markers further increased diagnostic accuracy for HRS among functional AKI.

CONCLUSIONS

Prompt diagnosis of HRS by differentiating it from PRA and ATN can be achieved by using serum adrenomedullin and urinary TXB₂ in acute decompensated cirrhotic patients. In combination with severe clinical courses, these two markers are useful to select HRS patients who cannot be treated.

Risk of recurrence in chronic hepatitis B patients developing hepatocellular carcinoma with antiviral secondary prevention failure

Background

Nucleos(t)ide analogues (NUCs) treatment can reduce the risk of hepatocellular carcinoma (HCC) development and recurrence in chronic hepatitis B (CHB) patients. However, the risk of recurrence in CHB patients who develop HCC despite NUC treatment remains unclear.

Methods

167 consecutive CHB patients receiving curative resection for HCC with NUC therapy after surgery were retrospectively enrolled. Thirty-eight patients who developed HCC despite NUC therapy for more than 1 year were defined as secondary prevention failure. The other 129 patients started NUC therapy after surgery. Factors associated with recurrence-free survival (RFS) and overall survival (OS) were evaluated.

Results

The 5-year RFS and OS rates were 44.7% and 77.3%, respectively. Sex, BMI, BCLC stage, AFP levels and cirrhosis status were the independent predictors of RFS, while microvascular invasion was the independent predictor of OS. The RFS was comparable between patients with and without NUC secondary prevention. In the subgroup analysis, the RFS was significantly worse in cirrhotic patients with secondary prevention failure (hazard ratio = 2.373, p = 0.009). Secondary prevention failure did not have adverse impact on OS. Among 84 patients with recurrence, 58.3% of the cases remained in BCLC stage A, and 53.6% received a second curative treatment. Long-term NUC therapy may lead to a decline of non-invasive indices of hepatic fibrosis in HCC patients.

Conclusions

In general, the risk of recurrence and survival are comparable between patients with and without secondary prevention failure. However, a higher risk of recurrence was observed in cirrhotic patients with secondary prevention failure.

Impact of tumor burden on prognostic prediction for patients with terminal stage hepatocellular carcinoma: A nomogram study

BACKGROUND

The recently proposed nomogram of Barcelona Clinic Liver Cancer (BCLC) lacks predictive accuracy for patients with stage D hepatocellular carcinoma (HCC). Tumor burden is crucial in prognostic prediction but is not included in the criteria of stage D HCC. This study aims to develop a nomogram with tumor burden as the core element for BCLC stage D patients.

METHODS

A total of 386 patients were randomly grouped into derivation and validation sets (1:1 ratio). The multivariate Cox proportional hazards model was used to select factors with significant prognostic effect and generate the nomogram. Concordance indices and calibration plots were used to evaluate the performance of nomogram.

RESULTS

Overall survival of study patients was significantly associated with tumor burden as well as hepatitis B, serum α-fetoprotein level, cirrhosis and performance status in multivariate Cox regression (all p<0.05). Beta-coefficients of these variables in derivation set were used to generate the nomogram. Each patient was assigned with a total nomogram point that predicted individualized 6-month and 1-year survival. The derivation and validation sets had a c-index of 0.759 (95% confidence interval [CI]: 0.552-0.923) and 0.741 (95% CI: 0.529-0.913), respectively. The calibration plots were close to the 45-degree line for 6-month and 1-year survival prediction for all quarters of patients in both derivation and validation sets.

CONCLUSION

Tumor burden is significantly associated with the outcome for patients with stage D HCC. The tumor burden-incorporated nomogram may serve as a feasible and easy-to-use tool in predicting survival on an individual level.

Mechanisms of the prevention and inhibition of the progression and development of non-alcoholic steatohepatitis by genetic and pharmacological decoy receptor 3 supplementation

AIMS

Treatment of non-alcoholic steatohepatitis (NASH) is difficult due to the absence of a proven treatment and its comprehensive mechanisms. In the NASH animal model, upregulated hepatic inflammation and oxidative stress, with the resultant M1 polarization of macrophages as well as imbalanced adipocytokines, all accelerate NASH progression. As a member of the tumor necrosis factor receptor superfamily, decoy receptor 3 (DcR3) not only neutralizes the death ligands, but also performs immune modulations. In this study, we aimed to investigate the possible non-decoy effects of DcR3 on diet-induced NASH mice.

METHODS

Methionine- and choline-deficient (MCD) diet feeding for 9 weeks was applied to induce NASH in BALB/c mice. Decoy receptor 3 heterozygous transgenesis or pharmacological pretreatment with DcR3a for 1 month were designed as interventions. Intrahepatic inflammatory status as well as macrophage polarization, oxidative stress, and steatosis as well as lipogenic gene expression and fibrotic status were analyzed. Additionally, acute effects of DcR3a on HepG2 cells, Hep3B cells, and primary mouse hepatocytes in various MCD medium-stimulated changes were also evaluated.

RESULTS

Both DcR3 genetic and pharmacologic supplement significantly reduced MCD diet-induced hepatic M1 polarization. In addition, DcR3 supplement attenuated MCD diet-increased hepatic inflammation, oxidative stress, adipocytokine imbalance, steatosis, and fibrogenesis. Moreover, acute DcR3a incubation in HepG2 cells, Hep3B cells, and mouse hepatocytes could normalize the expression of genes related to lipid oxidation along with inflammation and oxidative stress.

CONCLUSION

The ability of DcR3 to attenuate hepatic steatosis and inflammation through its non-decoy effects of immune modulation and oxidative stress attenuation makes it a potential treatment for NASH.

Acute kidney injury predicts mortality in cirrhotic patients with gastric variceal bleeding

BACKGROUND AND AIM

The International Club of Ascites (ICA) recently proposed a new definition of acute kidney injury (AKI) in cirrhotic patients. The study evaluated the ICA-AKI criteria and their association with the prognosis of cirrhotic patients with gastric variceal bleeding (GVB).

METHODS

A retrospective cohort study using prospective database of cirrhotic patients hospitalized with the first presentation of acute GVB at Taipei Veterans General Hospital from April 2007 to December 2010 was performed to evaluate the development of AKI. The study used Cox proportional hazards model to examine the association of ICA-AKI criteria and mortality.

RESULTS

Of 113 patients, 46 (41%) fulfilled the ICA-AKI criteria and most (70%) initially had stage 1 AKI. Child-Pugh score, systemic blood pressure at admission, and number of blood units transfused before endoscopy were independent predictors of AKI. Among patients with AKI, 30% progressed to higher stages with more advanced liver disease, lower serum sodium, more units of blood transfusion, higher frequency of infection, and higher serum creatinine levels at diagnosis of AKI. The 6-week mortality rate was significantly higher in patients with AKI than in patients without AKI (37% vs 3%, P < 0.001), and AKI stages were independent predictors of 3-month survival (93% in patients without AKI, 73% in stage 1, and 30% in stages 2 and 3, P = 0.005).

CONCLUSIONS

The occurrence of AKI as defined by the ICA criteria is common in cirrhotic patients with acute GVB. The presence of AKI was associated with much higher 6-week mortality, and the stages of AKI further predicted 3-month survival.

Cholecystectomy decreased the recurrent cholangitis after clearance of bile duct stones by ERCP in patients with gallstone-related cholangitis

BACKGROUND

This study assessed whether cholecystectomy can decrease recurrent cholangitis and all-cause mortality in patients who received endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy and successful clearance of bile duct (BD) stones after gallstone-related cholangitis.

METHODS

We analyzed data from the National Health Insurance research database of Taiwan. Patients who had gallstone-related cholangitis and underwent successful endoscopic clearance of BD stones were eligible for enrollment. This population-based, propensity score (PS)-matched cohort study involved 2 cohorts; (1) patients who underwent cholecystectomy after ERCP with BD stone clearance as the study group; and (2) those who had no cholecystectomy after ERCP with BD stone clearance as the control group. The primary endpoint was recurrent cholangitis, and the secondary endpoint was all-cause mortality.

RESULTS

During a mean 5.7-year follow-up, the incidence rates of recurrent cholangitis were 20.47 per 1000 person-years in the cholecystectomy cohort, and 34.60 per 1000 person-years in the PS-matched control cohort. The risk of recurrent cholangitis was significantly lower in the cholecystectomy cohort than in the control cohort (HR, 0.62; 95% confidence interval [CI], 0.45-0.87; P = 0.006). The HR for all cause mortality among the cholecystectomy cohort was 0.70 (95% CI, 0.54-0.90; P = 0.006) compared with the control cohort.

CONCLUSION

Cholecystectomy decreased the recurrent cholangitis and all-cause mortality in patients with endoscopic sphincterotomy and successful clearance of BD stones after gallstone-related cholangitis.

Ascorbate lacks significant influence in rats with bile duct ligation-induced liver injury

BACKGROUND

Liver inflammation may induce fibrogenesis, cirrhosis and portal hypertension. Liver cirrhosis is characterized by increased intrahepatic resistance and enhanced vasoconstrictive response. The splanchnic vasodilatation, angiogenesis and portosystemic collaterals formation further bring about lethal complications. Ascorbate is a potent antioxidant with anti-inflammation, anti-fibrosis, and anti-angiogenesis effects. However, the relevant influences in chronic liver injury have not been sufficiently explored.

METHODS

Chronic liver injury was induced in Spraque-Dawley rats with common bile duct ligation (BDL). Ascorbate (250 mg/kg/day, oral gavage) or vehicle was administered starting on the 1st day after operation. On the 8th (hepatitis) and 29th (cirrhosis) day, serum biochemistry parameters, hepatic concentrations of lipid peroxidation-related substances, protein expressions of α-SMA, TGF-β, iNOS, eNOS, p-eNOS-Ser1177, p-eNOS-Thr496, VEGF, VEGFR2, p-VEGFR2, and liver histology were evaluated. In three series of paralleled groups, rats treated with 28-day ascorbate or vehicle received hemodynamic measurements, hepatic and collateral vasoresponsiveness perfusion experiments, mesenteric CD31 immunofluorescence staining, and Western blot analyses of mesenteric VEGF, VEGFR2, pVEGFR2, PDGF, PDGFβ, COX1, COX2, eNOS, p-eNOS-Thr495, p-eNOS-Ser1177 protein expressions. In another series, the severity of portosystemic shunting was evaluated.

RESULTS

Ascorbate did not influence hepatitis, oxidative stress, fibrosis, and hemodynamic parameters in BDL rats. The intrahepatic and collateral vasoresponsiveness were not affected, either from direct incubation or acute treatment with ascorbate. Furthermore, the mesenteric angiogenesis and severity of shunting were not influenced.

CONCLUSION

The oxidative stress, fibrosis, hemodynamic derangements, angiogenesis and vascular functional changes in BDL-induced chronic liver injury may be too overwhelming to be modulated by ascorbate.

Statins decrease the risk of decompensation in hepatitis B virus- and hepatitis C virus-related cirrhosis: A population-based study

Statin use decreases the risk of decompensation and mortality in patients with cirrhosis due to hepatitis C virus (HCV). Whether this beneficial effect can be extended to cirrhosis in the general population or cirrhosis due to other causes, such as hepatitis B virus (HBV) infection or alcohol, remains unknown. Statin use also decreases the risk of hepatocellular carcinoma (HCC) in patients with chronic HBV and HCV infection. It is unclear whether the effect can be observed in patients with pre-existing cirrhosis. The goal of this study was to determine the effect of statin use on rates of decompensation, mortality, and HCC in HBV-, HCV-, and alcohol-related cirrhosis. Patients with cirrhosis were identified from a representative cohort of Taiwan National Health Insurance beneficiaries from 2000 to 2013. Statin users, defined as having a cumulative defined daily dose (cDDD) ≥28, were selected and served as the case cohort. Statin nonusers (<28 cDDD) were matched through propensity scores. The association between statin use and risk of decompensation, mortality, and HCC were estimated. A total of 1350 patients with cirrhosis were enrolled. Among patients with cirrhosis, statin use decreased the risk of decompensation, mortality, and HCC in a dose-dependent manner (P for trend <0.0001, <0.0001, and 0.009, respectively). Regression analysis revealed a lower risk of decompensation among statin users with cirrhosis due to chronic HBV (adjusted hazard ratio [HR], 0.39; 95% confidence interval [CI], 0.25-0.62) or HCV infection (HR, 0.51; 95% CI, 0.29-0.93). The lowered risk of decompensation was of borderline significance among statin users with alcohol-related cirrhosis (HR, 0.69; 95% CI, 0.45-1.07).

CONCLUSION

Statin use decreases the decompensation rate in both HBV- and HCV-related cirrhosis. Of borderline significance is a decreased decompensation rate in alcohol-related cirrhosis. (Hepatology 2017;66:896-907).

A New Treatment-integrated Prognostic Nomogram of the Barcelona Clinic Liver Cancer System for Hepatocellular Carcinoma

The nomogram of the Barcelona Clinic Liver Cancer (BCLC) has accurate outcome prediction. This study aims to propose a treatment-integrated nomogram derived from BCLC for patients with hepatocellular carcinoma (HCC). A total of 3,371 patients were randomly grouped into derivation (n = 2,247) and validation (n = 1,124) sets. Multivariate Cox proportional hazards model was used to generate the nomogram from tumor burden, cirrhosis, performance status (PS) and primary anti-cancer treatments. Concordance indices and calibration plots were used to evaluate the performance of nomogram. The derivation and validation sets had the same concordance index of 0.774 (95% confidence intervals: 0.717-0.826 and 0.656-0.874, respectively). In calibration plots, survival distributions predicted by the nomogram and observed by the Kaplan-Meier method were similar at 3- and 5-year for patients from derivation and validation sets. Validation group patients divided into 10 subgroups by the original and new treatment-integrated BCLC nomogram were used to evaluate the prognostic performance of integrating primary anti-cancer treatments. Compared to the nomogram of original BCLC system, the treatment-integrated nomogram of BCLC system had larger linear trend and likelihood ratio X². In conclusion, based on the results of concordance index tests, integrating primary anti-cancer treatments into the BCLC system provides similar discriminatory ability.

Prognostic role of noninvasive liver reserve markers in patients with hepatocellular carcinoma undergoing transarterial chemoembolization

Background

Various noninvasive liver reserve markers were proposed to indicate the severity of liver damage. However, the role and feasibility of these markers to predict the prognosis of patients with hepatocellular carcinoma (HCC) are unknown. We aimed to identify the prognostic role of the 8 currently used hepatic reserve markers in patients with HCC undergoing transarterial chemoembolization (TACE).

Methods

Between 2002 and 2013, a total of 881 patients with HCC undergoing TACE were prospectively identified and retrospectively analyzed. The baseline characteristics, tumor status and noninvasive markers were collected. Homogeneity and corrected Akaike information criteria (AICc) were compared between these markers. The Cox proportional hazards model was used to identify independent predictors of survival.

Results

Significant differences in survival distribution were found for albumin-bilirubin (ALBI) grade, Child-Turcotte-Pugh (CTP) class, Lok index, fibrosis index based on 4 factors (FIB-4), Göteborg University cirrhosis index (GUCI), cirrhosis discriminant index (CDI) and model for end-stage liver disease (MELD) score (all p values <0.05). Among these markers, the ALBI grade showed the highest homogeneity and lowest AICc value, indicating a better prognostic performance. Cox multivariate analysis confirmed that ALBI grade 2, ascites, serum alkaline phosphatase and α-fetoprotein level, tumor diameter, vascular invasion and performance status were significant independent prognostic predictors. The distribution of the ALBI score well correlated with baseline CTP and MLED scores.

Conclusions

Our data suggest that among the currently used liver reserve markers, ALBI grade may serve as an objective and feasible surrogate to predict the prognosis of HCC patients undergoing TACE.

Hepatocellular Carcinoma: Nomograms Based on the Albumin-Bilirubin Grade to Assess the Outcomes of Radiofrequency Ablation

Purpose To construct a nomogram with the albumin-bilirubin (ALBI) grade to assess the long-term outcomes of patients with early-stage hepatocellular carcinoma (HCC) after radiofrequency ablation (RFA). Materials and Methods This retrospective study was approved by the institutional review board, and informed consent was waived. We studied 622 treatment-naïve patients with HCC according to the Milan criteria who subsequently underwent RFA from 2002 to 2013. Baseline characteristics were collected to identify the risk factors for determination of poor overall survival after RFA. The multivariate Cox proportional hazards model based on significant prognostic factors of overall survival was used to construct the nomogram. Results After a median follow-up time of 35.7 months, 190 patients had died. The cumulative 5- and 10-year overall survival rates were 63.1% and 48.7%, respectively. Stratified according to ALBI grade, the cumulative 5- and 10-year survival rates were 80.0% and 67.9% for patients with grade 1, respectively, and 48.6% and 35.1% for those with grades 2-3, respectively (P < .001). Multivariate analysis results showed that patient age older than 65 years, a prothrombin time international normalized ratio greater than 1.1, α-fetoprotein level greater than 20 ng/mL, multiple tumors, and ALBI grade 2 or 3 were associated with overall mortality. A nomogram was developed on the basis of these five variables. Internal validation with 200 bootstrapped sample sets had a good concordance index of 0.770 (95% confidence interval: 0.633, 0.876). Conclusion This simple nomogram based on the ALBI grade offers personalized long-term survival data for patients with early-stage HCC who undergo RFA. ^© RSNA, 2017 Online supplemental material is available for this article.

Metallic Stent Expansion Rate at Day One Predicts Stent Patency in Patients with Gastric Outlet Obstruction

BACKGROUND AND AIMS

Self-expandable metallic stent insertion has been a mainstream treatment for relieving the obstructive symptoms of malignant gastric outlet obstruction (MGOO), a late-stage complication of gastrointestinal malignancies. This study aims to investigate the predictive value of stent expansion rates in clinical outcomes in patients with MGOO.

METHODS

Eighty-seven patients with inoperable MGOO receiving metallic stents were reviewed retrospectively from April 2010 to December 2014. Clinical outcomes, predictors of stent patency, and survival were analyzed.

RESULTS

The technical and clinical success rates were 100 and 94.3%, respectively. The median stent patency time was 114 days (range 13-570 days). The median survival time was 133 days (range 13-1145 days). Stent dysfunctions occurred in 28 patients (32.2%), with restenosis accounting for the majority (82%). The stent expansion rate ≥75% at Day 1 predicted the stent patency [hazard ratio (HR) 0.12, P = 0.04]. However, it did not correlate with survival. Non-gastric cancer origins (HR 2.41, P = 0.002) and peritoneal carcinomatosis (HR 2.54, P = 0.001) correlated with poor survival. However, post-stent chemotherapy (HR 0.55, P = 0.03) was related to better outcome. The comparison of clinical outcomes of first and second stent insertions showed no significant difference in the stent expansion rate either at Day 0 and Day 1 (P = 0.97 and P = 0.57).

CONCLUSIONS

Self-expandable metallic stent insertion is a safe and effective treatment for relieving the obstructive symptoms. The stent expansion rate ≥75% at Day 1 is a novel stent-related predictor of stent patency.

ALBI and PALBI grade predict survival for HCC across treatment modalities and BCLC stages in the MELD Era

BACKGROUND AND AIM

The severity of liver dysfunction in hepatocellular carcinoma (HCC) is often estimated with Child-Turcotte-Pugh (CTP) classification or model for end-stage liver disease (MELD) score. We aim to investigate the performance of albumin-bilirubin (ALBI) and platelet-albumin-bilirubin (PALBI) grade, which are recently reported to be simple and objective measurements for liver reserve in HCC.

METHODS

Between 2002 and 2014, consecutive 3182 HCC patients were enrolled to follow up their survival. The area under receiver-operator-characteristic curve (AUC) was calculated to test the discriminatory powers over 1-year, 3-year, and 5-year survival.

RESULTS

Significant survival differences were found across all ALBI and PALBI grades (both P < 0.001). The majority (73%) of patients were CTP class A. Within CTP class A, ALBI revealed two prognostic groups while PALBI segregated three prognostic groups. The PABLI grade also identified three different survival groups for patients undergoing resection, ablation, and chemoembolization. Both ALBI and PALBI grade were capable of discerning survival among different HCC stages. The PALBI grade had significantly higher AUC compared with CTP classification and ALBI grade at 1, 3, and 5 years. For CTP class A patients, the PALBI grade was also associated with significantly higher AUC compared with ALBI grade at 1-year and 3-year intervals. The MELD score has the lowest AUC compared with other systems.

CONCLUSIONS

Both ALBI and PALBI grade are adequate models to assess liver dysfunction in HCC. The PALBI grade is consistently better in all patients, in patients with minimally decreased liver function, and in patients receiving different aggressive therapies.

Prognostic impact of diabetes mellitus on hepatocellular carcinoma: Special emphasis from the BCLC perspective

BACKGROUND

Diabetes mellitus (DM) is associated with higher incidence and poorer prognosis of hepatocellular carcinoma (HCC). The influence of DM on patient survival in different HCC stages is not known.

METHODS

A prospective dataset of 3,182 HCC patients was collected between 2002 and 2014. Patients were divided into three groups according to BCLC stages (BCLC stage 0 and stage A, BCLC stage B, BCLC stage C and stage D). We compared the cumulative survival rate of diabetic and non-diabetic patients in different BCLC groups. The correlation between DM and overall survival was also analyzed by multivariate Cox regression model within each group.

RESULTS

DM is present in 25.2% of all patients. Diabetic patients had lower cumulative survival in BCLC stage 0 plus BCLC stage A group (log rank p<0.001), and BCLC stage B group (log rank p = 0.012), but not in BCLC stage C plus BCLC stage D group (log rank p = 0.132). Statistically significant differences in overall survival are found between diabetic and non-diabetic patients in BCLC stage 0 plus stage A group (adjusted hazard ratio [HR] = 1.45, 95% confidence interval [CI] 1.08-1.93, p = 0.013), and BCLC stage B (adjusted HR = 1.77, 95% CI 1.24-2.51, p = 0.002). In contrast, the survival difference is not seen in BCLC stage C plus stage D group (adjusted HR = 1.09, 95% CI 0.90-1.30, p = 0.387).

CONCLUSIONS

DM is prevalent in HCC, and is associated with lower survival rate in HCC patients with BCLC stage 0 plus stage A and B, but not in those with BCLC stage C plus stage D.

Higher platelet counts are associated with metabolic syndrome independent of fatty liver diagnosis

BACKGROUND

Platelet count (PC) and fatty liver are both associated with metabolic syndrome (MS), obesity, and type 2 diabetes. While PC increases in obesity and type 2 diabetes, the severity of hepatic fibrosis caused by fatty liver reduces PC. We aimed to investigate the correlation of PC and MS in patients with and without fatty liver.

METHODS

We enrolled consecutive patients who received health check-ups at Taipei Veterans General Hospital from 2002 to 2009. Ultrasonography was used to diagnose fatty liver, and MS was diagnosed according to the criteria defined by the International Diabetes Federation Task Force on Epidemiology and Prevention.

RESULTS

Among the 29,797 patients, MS was present in 28.74%. Higher PC was correlated with MS using multivariate analysis, while fatty liver had the strongest association with MS. After dividing the patients by the presence or absence of fatty liver, higher PC was still associated with MS in both groups. The patients were further stratified by age and gender, and MS was correlated with PC among all age groups in women and in men under 60 years of age; however, the association between PC and MS did not reach statistical difference in men older than 60 years.

CONCLUSION

There is a significant correlation between PC and MS, and the correlation exists independent of gender, age, and fatty liver. PC may act as a surrogate marker for MS, and physicians should be concerned with the presence of MS among patients with high PC.

The impact of esophagogastric varices on the prognosis of patients with hepatocellular carcinoma

Whether or not esophagogastric varices (EGV) could determine the outcomes of patients with hepatocellular carcinoma (HCC) is still unclear. A total of 990 treatment-naive HCC patients who received an esophagogastroduodenoscopy at the time of HCC diagnosis were retrospectively enrolled. The factors in terms of prognosis were analyzed by Cox proportional hazards model and propensity score matching analysis. Among the enrolled patients, 480 (48.5%) patients had EGV. Patients with EGV had a significantly lower cumulative 5-year survival rate than those without EGV (24.9% versus 46.4%, p < 0.001). It was confirmed by a multivariate analysis and propensity score matching analysis. Stratified by tumor stage, the patients with EGV had lower survival rates than the patients without EGVs in all Barcelona Clinic Liver Cancer stages except stage D. Moreover, the patients with EGV had lower survival rates than those without EGV, both by curative or non-curative treatment modalities. In conclusion, EGV was an independent risk factor predicting poor prognosis for the patients with HCC by multivariate analysis, propensity score matching analysis, and subgroup analysis.

Scientific publications in gastroenterology and hepatology in Taiwan: An analysis of Web of Science from 1993 to 2013

BACKGROUND

Scientific publications are important for evaluating the achievements of a medical specialty or discipline. Gastroenterology and Hepatology is a medical specialty in great demand in Taiwan, therefore, this study aimed to analyze the Gastroenterology and Hepatology publications from 1993 to 2013 in Taiwan, using the Web of Science (WoS) database.

METHODS

Scientific publications from departments/institutes of gastroenterology and hepatology were retrieved and analyzed from the WoS database, which included articles published in the Science Citation Index Expanded and Social Science Citation Index journals from 1993 to 2013.

RESULTS

Among 229,030 articles published from departments/institutes of gastroenterology and hepatology worldwide during 1993-2013, 5061 (2.21%) were published in Taiwan, ranking the country 13^th in the world. In total, 4759 articles from Taiwan were selected for further analysis, excluding meeting abstracts and corrections. During these two decades, the number of gastroenterology and hepatology publications increased rapidly. There were 440 articles published during 1993-1997, 646 articles during 1998-2002, 1211 articles during 2003-2007, and up to 2462 articles during 2008-2013. However, the mean number of articles cited decreased from 25.35 to 27.25 to 20.64 to 7.28, and the mean impact factor of publishing journals decreased from 5.0 to 4.20 to 4.13 to 4.03 during 1993-1997, 1998-2002, 2003-2007, and 2008-2013, respectively. Most of those publications belong to the subject category gastroenterology and hepatology (2346 articles, 49.30%), followed by surgery (677 articles, 14.23%), medicine, general and internal (358 articles, 7.52%), oncology (316 articles, 6.64%), and pharmacology pharmacy (286 articles, 6.01%). The Journal of Gastroenterology and Hepatology published the most papers (326 articles, 6.9%), followed by World Journal of Gastroenterology (201 articles, 4.2%), Hepato-Gastroenterology (165 articles, 3.5%), Gastrointestinal Endoscopy (159 articles, 3.3%), and Hepatology (146 articles, 3.1%).

CONCLUSION

Scientific publications from departments/institutes of gastroenterology and hepatology in Taiwan increased rapidly from 1993 to 2013. However, there were decreasing trends in the number of articles cited and journal impact factors.

Cholecystectomy Reduces Recurrent Pancreatitis and Improves Survival After Endoscopic Sphincterotomy

BACKGROUND

The aim of this study was to assess whether cholecystectomy can decrease the recurrent pancreatitis in the elderly patients who received endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (EST) and successful clearance of bile duct (BD) stones after gallstone-related acute pancreatitis.

METHODS

We analyzed data from National Health Insurance Research Database of Taiwan. Elderly patients (age ≧70 years old) who had gallstone-related acute pancreatitis and underwent successful EST with BD stones clearance were eligible for enrollment. This nationwide, population-based, propensity score (PS)-matched cohort study involved two cohorts: (1) patients who underwent cholecystectomy after ERCP with BD stone clearance as study group and (2) those who adopted wait-and-see strategy (without cholecystectomy) after ERCP with BD stone clearance as control group. The primary and secondary endpoints were recurrent acute pancreatitis and all-cause mortality, respectively.

RESULTS

During the study period, a total of 670 elderly patients (male 291, female 379) with a mean age of 79.1 was enrolled for analysis after PS matching. The incidence rate of recurrent acute pancreatitis was 12.39 per 1000 person-years in the cholecystectomy cohort and 23.94 per 1000 person-years in the PS-matched control cohort. The risk of recurrent acute pancreatitis was significantly lower in the cholecystectomy cohort (HR, 0.56; 95 % confidence interval [CI], 0.34-0.91; P = 0.021). The HR for all-cause mortality among the cholecystectomy cohort was 0.75 (95 % CI, 0.59-0.95; P = 0.016) compared with the control cohort.

CONCLUSIONS

Cholecystectomy decreased the subsequent recurrent acute pancreatitis and the all-cause mortality in elderly patients with EST and clearance of BD stones after gallstone-related acute pancreatitis.

The telomere-binding protein TRF2 is required for metronomic therapeutic effects of gemcitabine and capecitabine

Gemcitabine and capecitabine are two effective anticancer agents against solid tumors. The pharmacological mechanisms have been known as incorporation into DNA and thereby inhibition of DNA synthesis. When used as metronomic chemotherapy, they may inhibit angiogenesis and induce immunity. In our previous study, we showed that low-dose gemcitabine caused telomere shortening by stabilizing TRF2 that was required for XPF-dependent telomere loss. In this report, we established a SKOV3.ip1 ascites cell model. Tumor-bearing mice were treated with low-dose gemcitabine (GEM) or capecitabine (CAP). Both GEM and CAP caused telomere shortening and increased expression of TRF2 with improved ascites in nude mice and decreased in vitro clonogenic activity. TRF2 knockdown altered telomeres to a shortened but new status that may evade XPF-dependent telomere loss and conferred resistance of SKOV3.ip1 ascites cells to low-dose GEM and CAP. Our study provides a new mechanism of metronomic chemotherapy i.e. TRF2 is required for metronomic therapeutic effects of gemcitabine and capecitabine.