Portal hypertension and the outcome of surgery for hepatocellular carcinoma in compensated cirrhosis: a systematic review and meta-analysis

Combination Of ALBI And APRI To Predict Post-Hepatectomy Liver Failure After Liver Resection For HBV-Related HCC Patients

Purpose

Post-hepatectomy liver failure (PHLF) is a severe complication in hepatocellular carcinoma (HCC) patients who have undergone hepatectomy. This research aimed to investigate the combination of albumin–bilirubin (ALBI) score and aspartate aminotransferase-platelet ratio index (APRI) as a novel approach in predicting PHLF risk in hepatitis B virus (HBV)-related HCC patients.

Patients and methods

HBV-related HCC patients who underwent hepatectomy from January 2006 to October 2013 were enrolled in this study. A novel model was constructed using a combination of ALBI and APRI scores to predict PHLF risk, and the prognostic value of the model was evaluated and compared with Child-Pugh (C-P) grade, ALBI score and APRI score.

Results

A total of 1,055 HCC patients were retrospectively studied, which included 151 experienced PHLF. Univariable and multivariate analyses showed that the ALBI and APRI scores were independent predictors of PHLF. The area under the ROC curve (AUC) of the ALBI score, APRI score, and C-P grade was 0.717, 0.720, and 0.602, respectively, with AUC (ALBI) > AUC (C-P) (P <0.001) and AUC (APRI) > AUC (C-P) (P <0.001). After ALBI was associated with APRI, the AUC (ALBI-APRI) was 0.766, and AUC (ALBI-APRI) > AUC (ALBI) (P <0.001), AUC (ALBI-APRI) > AUC (APRI) (P =0.047). Our results indicated that ALBI and APRI scores had higher discriminatory abilities than C-P grade in predicting the risk of PHLF, and the ALBI-APRI model could enhance the capability of predicting PHLF compared to ALBI or APRI alone.

Conclusion

ALBI-APRI score is a novel and effective predictive model of PHLF for HBV-related HCC patients, and its accuracy in predicting the risk of PHLF is better than that of C-P, ALBI and APRI scores.

Portal pressure monitoring-state-of-the-art and future perspective

Portal hypertension is a serious symptom of chronic liver diseases, which can lead to many critical complications, such as the formation of varices related to upper digestive bleeding, ascites, infection, hepatic encephalopathy, renal failure, and even death. As a result, portal pressure monitoring has important prognostic and clinical implications. The hepatic venous pressure gradient measurement, a gold-standard method applied to monitor portal pressure, is invasive and only available in experienced centers. Over the past decade, noninvasive methods aimed at monitoring the portal pressure have been increasingly investigated, including serum markers, radiological features, ultrasound elastography, doppler and contrast-enhanced ultrasonography. In this study, we focused on both invasive and noninvasive methods for portal pressure monitoring and explored their roles in clinical setting. The advantages and limitations of various techniques for future research are also discussed.

A global view of hepatocellular carcinoma: trends, risk, prevention and management

Hepatocellular carcinoma (HCC) is the fourth most common cause of cancer-related death worldwide. Risk factors for HCC include chronic hepatitis B and hepatitis C, alcohol addiction, metabolic liver disease (particularly nonalcoholic fatty liver disease) and exposure to dietary toxins such as aflatoxins and aristolochic acid. All these risk factors are potentially preventable, highlighting the considerable potential of risk prevention for decreasing the global burden of HCC. HCC surveillance and early detection increase the chance of potentially curative treatment; however, HCC surveillance is substantially underutilized, even in countries with sufficient medical resources. Early-stage HCC can be treated curatively by local ablation, surgical resection or liver transplantation. Treatment selection depends on tumour characteristics, the severity of underlying liver dysfunction, age, other medical comorbidities, and available medical resources and local expertise. Catheter-based locoregional treatment is used in patients with intermediate-stage cancer. Kinase and immune checkpoint inhibitors have been shown to be effective treatment options in patients with advanced-stage HCC. Together, rational deployment of prevention, attainment of global goals for viral hepatitis eradication, and improvements in HCC surveillance and therapy hold promise for achieving a substantial reduction in the worldwide HCC burden within the next few decades.

Comparison of new prognostic systems for patients with resectable hepatocellular carcinoma: Albumin-Bilirubin grade and Albumin-Indocyanine Green Evaluation grade

AIM

We aimed to compare the prognostic abilities of two novel liver function-estimating models, Albumin-Bilirubin (ALBI) and Albumin-Indocyanine Green Evaluation (ALICE) grades, in patients with hepatocellular carcinoma.

METHODS

Data of 1270 patients who underwent initial hepatectomy for hepatocellular carcinoma between 1986 and 2016 were retrospectively collected from a multi-institutional database. The prognostic impact of each system was analyzed according to the results of the area under the receiver operating characteristic curve, the Cox regression model and the linear trend χ² -test.

RESULTS

The ALBI and ALICE scores, which were obtained before grading status, were significantly correlated (correlation coefficient 0.930; P < 0.001). Both ALBI and ALICE grades stratified well in terms of overall survival, and were found to be independent prognostic factors on multivariate analysis (P < 0.05). The area under the receiver operating characteristic curves for 5-year survival in both groups were equivalent (0.602 vs. 0.614, P = 0.402); however, homogeneity, discriminatory ability, and the Akaike information criterion were superior for the ALICE grade than for the ALBI grade (73.8 vs. 65.7, 43.4 vs. 34.9, and 7204.1 vs. 7212.2, respectively).

CONCLUSIONS

Both grading systems could estimate the liver function of patients with hepatocellular carcinoma. Regarding hepatectomy patients, the ALICE grade was a more suitable model than the ALBI grade.

Expanding the Surgical Pool for Hepatic Resection to Treat Biliary and Primary Liver Tumors

Surgical management of primary liver and biliary tract tumors has evolved over the past several decades, resulting in improved outcomes in these malignancies with historically poor prognoses. Expansion of patient selection criteria, progress in neoadjuvant and adjuvant therapies, development of techniques to increase future liver remnant, and the select utilization of liver transplantation have all contributed to increasing the patient pool for surgical intervention. Ongoing and future studies need to focus on improving multimodality treatment regimens and further refining the selection criteria for transplantation in order to optimize utilization of limited organ resources.

Albumin-Indocyanine Green Evaluation (ALICE) grade combined with portal hypertension to predict post-hepatectomy liver failure

AIM

The aim of this study was to evaluate the role of liver function factors in predicting a postoperative large-volume ascites (LA) and post-hepatectomy liver failure (PHLF).

METHODS

We included 1025 consecutive patients undergoing hepatectomy for hepatocellular carcinoma between 2002 and 2014. Univariate and multivariate analyses were carried out to evaluate the role of each factor of liver function in predicting LA and PHLF. Factors included the presence of portal hypertension (PH), extent of resection, Model for End-stage Liver Disease (MELD) score, and Albumin-Indocyanine Green Evaluation (ALICE) grade.

RESULTS

The ALICE score was the strongest predictor for LA (odds ratio [OR], 5.02) and PHLF (OR, 10.94). Conversely, MELD score was not a significant predictive factor for LA or PHLF based on the multivariate analysis. In the ALICE grade 2 group, patients with PH showed a significantly high incidence of developing LA and experiencing PHLF compared with those without PH (LA, 22.4% vs. 10.3%, P < 0.001; PHLF, 8.6% vs. 1.3%, P < 0.001, respectively). Of patients in the ALICE 2 group, those undergoing sectoriectomy or more extensive resection were associated with extremely poor outcomes (LA, 54.2%; PHLF, 29.2%).

CONCLUSIONS

A combination of ALICE grade and presence of PH is a useful predictor of LA and PHLF.

Demographic and facility volume related outcomes in radiofrequency ablation for early-stage hepatocellular carcinoma

BACKGROUND

To evaluate outcomes related to disparities in facility volume and patient demographics in patients with early-stage hepatocellular carcinoma (HCC) treated with radiofrequency ablation (RFA).

METHODS

This is a retrospective study of patients with stage I/II HCC treated with RFA in the National Cancer Database. Independent contributors to overall survival were determined with Cox regression analysis. The Kaplan-Meier method and log-rank analyses were used to estimate overall survival and compare survival curves. A propensity score matched cohort analysis was performed. P-values < 0.05 were considered statistically significant.

RESULTS

In total, 2911 patients were included. Stage II disease (p-value = 0.006), increasing alpha fetoprotein (p-value = 0.007), and increasing bilirubin (p-value < 0.001) were associated with worse survival. Improved survival was seen in patients treated at high-volume centers (p-value = 0.004), which persisted following propensity score adjustment (p-value = 0.003). Asian race was associated with significantly improved survival (p-value < 0.001), while governmental insurance was associated with a significant decrease in survival (p-value < 0.001).

CONCLUSION

Treatment at a high-volume center and Asian race were significantly associated with improved survival following RFA for early-stage HCC. Governmental insurance, increasing alpha fetoprotein, increasing bilirubin, and higher disease stage were significantly associated with worse survival.

Bone Mineral Density as a Risk Factor for Patients Undergoing Surgery for Hepatocellular Carcinoma

BACKGROUND

We have reported the impact of sarcopenia and body composition on patients undergoing hepatectomy for hepatocellular carcinoma (HCC). However, the impact of bone mineral density (BMD) on outcomes after hepatectomy for HCC and correlation with other parameters including sarcopenia are unclear.

METHODS

We retrospectively analyzed 465 patients who underwent primary hepatectomy for HCC between April 2005 and March 2015. We analyzed the plain CT images at the level of the eleventh thoracic vertebra with the region of interest and defined as preoperative BMD.

RESULTS

In this cohort, male (n = 367) and female (n = 98) patients showed significant heterogeneity in age, body composition markers, tumor factors, peri-operative parameters and so on. The median preoperative BMD in male and female patients was 155 and 139 HU, respectively (P = 0.005). BMD was negatively correlated with age in female (r = -0.590, P < 0.001) and intramuscular adipose tissue content in both male and female (r = -0.332 and -0.359, respectively, P < 0.001). For males, BMD < 160 HU was associated with worse cancer-specific survival post-hepatectomy (P = 0.015). In contrast, females were not (P = 0.135). For male patients, multivariate analysis identified low BMD as an independent risk factor for death (hazard ratio 1.720, 95% confidence interval 1.038-2.922, P = 0.035) after hepatectomy for HCC.

CONCLUSION

Preoperative low BMD was an independent risk factor for cancer-specific mortality after hepatectomy for HCC.

Prophylactic Endoscopic Therapy for Variceal Bleeding in Patients with Hepatocellular Carcinoma

Background & Aims: To evaluate the efficacy and timing of secondary prophylactic endoscopic therapy for variceal bleeding. To determine the long-term survival and identify the prognostic factors in patients with hepatocellular carcinoma.

Methods: A Retrospective study was conducted. We included patients with concurrent hepatic carcinoma who received endoscopic therapy for variceal bleeding. A Kaplan-Meier survival analysis was performed. Potential factors for prediction were compared with Cox's proportional hazard model analysis.

Results: 192 patients were included between January 2008 and December 2014. During follow-up (median 17 months), 102 patients presented with an episode of rebleeding. The cumulative 6-month, 1- and 5-year rebleeding rates were 40.9%, 49.3% and 71.2%. A total of 98 patients died during follow-up. The overall 6-month, 1-and 5-year cumulative mortality rates were 33.5%, 45.8% and 65.7%. BCLC C/D stage (P=0.035, HR=1.53, 95% CI 1.003-2.327) was an independent predictor of bleeding relapse, while BCLC C/D staging (P=0.035, HR=1.59, 95% CI 1.033-2.454) and male gender (P=0.007, HR=1.58, 95% CI 1.135-2.198) predicted shorter survival times. Combination ligation and cyanoacrylate was associated with a decreased rebleeding and mortality rate in patients with both esophageal and gastric varices (P=0.003). The start time of the initial endoscopic procedure did not affect treatment efficacy.

Conclusions: Ligation combined with cyanoacrylate could be preferred for HCC patients presented with both esophageal and gastric varices. BCLC C/D stage predicted shorter survival times and bleeding relapse, while male gender was an independent predictor of poor survival.

Is anatomical resection necessary for early hepatocellular carcinoma? A single institution retrospective experience

Aim: The present study aimed to determine whether anatomical resection was necessary for early hepatocellular carcinoma. Methods: A log-rank test or two-stage test was used for univariate analysis. A Cox proportional hazards model was used for multivariable analysis. Results: For patients without microvascular invasion, a resection margin ≥1 cm provided the longest recurrence-free survival time regardless of whether they underwent anatomical resection (p = 0.005) or nonanatomical resection (p = 0.006). For patients with microvascular invasion, anatomical resection combined with a resection margin ≥1 cm provided the longest recurrence-free survival time compared with other treatments (p = 0.001). Conclusion: Anatomical resection was not necessary for patients without microvascular invasion. However, for patients with microvascular invasion, both anatomical resection and a resection margin ≥1 cm were necessary.

Simultaneous radiofrequency ablation combined with laparoscopic splenectomy: a safe and effective way for patients with hepatocellular carcinoma complicated with cirrhosis and hypersplenism

Purpose: This study aimed to evaluate the safety and effectiveness of simultaneous radiofrequency ablation (RFA) combined with laparoscopic splenectomy (Lap-Sp) for patients with hepatocellular carcinoma (HCC) complicated with cirrhosis and hypersplenism.Material and methods: Between January 2013 and June 2014, 42 patients with primary HCC complicated with cirrhosis and hypersplenism who underwent simultaneous RFA combined with Lap-Sp were enrolled at the Department of General Surgery, Beijing Di Tan Hospital. The median number of tumors ablated using RFA was one (range 1-3), and the median sum of the maximum diameter of tumors was 2.5 cm (range 1.2-5.4 cm). The related indicators before and after surgery, complications, and long-term effects were retrospectively analyzed.Results: The median operative time for 42 patients undergoing simultaneous RFA combined with Lap-Sp was 4.5 h (range 2.5-8.5 h), and the median blood loss was 120 mL (range 5-2200 mL). The incidence of moderate-to-severe postoperative complications and the perioperative mortality after surgery were 31.0 and 0%, respectively. The disease-free survival rate for one, three, and five years was 73.8, 19.7, and 16.4%, respectively. The overall survival rate was 90.5, 73.3, and 60.4%, respectively.Conclusion: Simultaneous RFA combined with Lap-Sp was safe and effective for patients with HCC complicated with cirrhosis and hypersplenism.

Controversies in the management of hepatocellular carcinoma

The management of hepatocellular carcinoma (HCC) has evolved considerably over the last decade. Surveillance of cirrhotic patients and refinements to imaging techniques have enabled a relevant proportion of patients to be diagnosed at an early stage, when effective therapies are feasible. Resection, transplantation and ablation are all options in patients with early stage HCC. Thus, there is some controversy regarding which is the best treatment approach in challenging scenarios. There have also been major developments in locoregional therapies, particularly in intra-arterial approaches. Finally, the systemic treatment for HCC has changed dramatically following the demonstration of a survival benefit with sorafenib; there are currently several first-line (sorafenib and lenvatinib) and second-line (regorafenib, cabozantinib and ramucirumab) treatments that have shown a survival benefit. Expectations for immune checkpoint inhibitors are high, with the results of the ongoing phase III trials eagerly awaited. In this review we discuss some of the controversies in the management of HCC, focussing in particular on systemic therapy.

Whole-course management of interventional treatment in liver cancer patients with portal hypertension

Primary liver cancer often occurs in patients with hepatitis and cirrhosis. Some patients have portal hypertension due to cirrhosis, and present with varying degrees of collateral circulation, splenomegaly and hypersplenism, ascites, and liver dysfunction. It often interferes with the treatment of tumors and affects the disease prognosis. There are internationally recognized guidelines for interventional treatment of liver cancer and portal hypertension which will not be repeated in this paper. This paper focuses on how to treat portal hypertension and intervene with tumors in the treatment of liver cancer to optimize the management of patients with liver cancer and portal hypertension. We propose that the Interventional Management Mode of Liver Cancer with Portal Hypertension can improve the treatment of liver cancer patients with portal hypertension.

Hepatectomy for hepatocellular carcinoma after perioperative management of portal hypertension

Background

Indications for hepatectomy in patients with hepatocellular carcinoma (HCC) who have portal hypertension (PH) have been controversial. Some studies have concluded that PH is a contraindication to hepatectomy, whereas others have suggested that perioperative prophylactic management (PPM) can help overcome complications after hepatectomy associated with PH. The objective of this retrospective study was to assess the short- and long-term outcomes after hepatectomy for HCC in patients with PH, with or without PPM.

Methods

Records were reviewed of consecutive patients who underwent hepatectomy for HCC, with or without PPM of PH, in a single institution from 1994 to 2015. Patients were divided into three groups: those who received PPM for PH (PPM group), patients who had PH but did not receive PPM (no-PPM group) and those without PH (no-PH group).

Results

A total of 1259 patients were enrolled, including 123 in the PPM group, 181 in the no-PPM group and 955 in the no-PH group. Three- and 5-year overall survival rates were 74·3 and 53·1 per cent respectively in the PPM group, 69·2 and 54·9 per cent in the no-PPM group, and 78·1 and 64·2 per cent in the no-PH group (P = 0·520 for PPM versus no PPM, P = 0·027 for PPM versus no PH, and P &lt; 0·001 for no PPM versus no PH). Postoperative morbidity and mortality rates were 26·0 and 0·8 per cent respectively in the PPM group, 29·8 and 1·1 per cent in the no-PPM group, and 20·3 and 0 per cent in the no-PH group.

Conclusion

The present study has demonstrated acceptable outcomes among patients with HCC who received appropriate management for PH in an Asian population. Enhancement of the safety of hepatic resection through use of PPM may provide a rationale for expansion of indications for hepatectomy in patients with PH.

Short-term and long-term outcomes of liver resection for HCC patients with portal vein tumor thrombus

BACKGROUND

Portal vein tumor thrombosis (PVTT) in hepatocellular carcinoma (HCC) is a sign of advanced stage disease, which is associated with poor prognosis. Liver resection (LR) may provide better prognosis in selected patients. In the present study, we aimed to assess information from HCC patients with PVTT who died within 3 months or 2 years after LR in order to identify preoperative factors correlated to short-term or long-term survival, by which inappropriate selection of patients for LR might be avoided in the future.

METHODS

A retrospective cohort study consisting of 487 consecutive cases of HCC patients with PVTT was performed from 2008 to 2010 at Eastern Hepatobiliary Surgery Hospital. Medical records, including laboratory values, imaging results and treatment information, were obtained from participants. Study endpoints were survival at 3 months and 2 years post-hepatectomy. Logistic regression analysis was utilized to determine the significant pre-operative factors influencing short-term or long-term survival.

RESULTS

In multivariable analysis, α-fetoprotein, total bilirubin and radiologic ascites were significantly associated with short-term survival, while α-fetoprotein level, clinical significant portal hypertension, extent of PVTT and tumor differentiation were factors significantly associated with long-term survival.

CONCLUSIONS

The independent risk factors of poor short-term survival were the liver function-associated, such as factors radiologic ascites and total bilirubin, while tumor differentiation indicating the tumor biology was associated with longer-term survival. In addition, α-fetoprotein was a risk factor associated with both short-term and longer-term survivals.

Synchronous hepatectomy and splenectomy vs hepatectomy for selected patients with hepatocellular carcinoma and clinically significant portal hypertension: A systematic review and meta-analysis

 This review aimed to evaluate the safety, feasibility, and effectiveness of synchronous hepatectomy and splenectomy for selected patients with hepatocellular carcinoma and clinically significant portal hypertension compared to hepatectomy alone. A systematic search in electronic databases was conducted. A total of 8 studies including 1445 patients were reviewed. While perioperative safety was satisfactory, synchronous hepatectomy and splenectomy were associated with a significant improvement of 5-year overall survival (odds ratio = 1.81; 95% confidence interval: 1.35, 2.42; P < 0.0001).

Preoperative aspartate aminotransferase-to-platelet-ratio index as a predictor of posthepatectomy liver failure for resectable hepatocellular carcinoma

Purpose

This study aimed to investigate the efficacy of preoperative aspartate aminotransferase-to-platelet-ratio index (APRI) score to predict the risk of posthepatectomy liver failure (PHLF) in patients with hepatocellular carcinoma (HCC) after liver resection, and to compare the discriminatory performance of the APRI with the Child–Pugh score, model for end-stage liver disease (MELD) score, and albumin–bilirubin (ALBI) score.

Patients and methods

A total of 1,044 consecutive patients with HCC who underwent liver resection were enrolled and studied. Univariate and multivariate analyses were performed to investigate risk factors associated with PHLF. Predictive discrimination of Child–Pugh, MELD, ALBI, and APRI scores for predicting PHLF were assessed according to area under the ROC curve. The cutoff value of the APRI score for predicting PHLF was determined by ROC analysis. APRI scores were stratified by dichotomy to analyze correlations with incidence and grade of PHLF.

Results

PHLF occurred in 213 (20.4%) patients. Univariate and multivariate analyses revealed that Child–Pugh, MELD, ALBI, and APRI scores were significantly associated with PHLF. Area under the ROC analysis revealed that the APRI score for predicting PHLF was significantly more accurate than Child–Pugh, MELD, or ALBI scores. With an optimal cutoff value of 0.55, the sensitivity and specificity of the APRI score for predicting PHLF were 72.2% and 68.0%, respectively, and the incidence and grade of PHLF in patients with high risk (APRI score >0.55) was significantly higher than in the low-risk cohort (APRI score <0.55).

Conclusion

The APRI score predicted PHLF in patients with HCC undergoing liver resection more accurately than Child–Pugh, MELD, or ALBI scores.

Varices on computed tomography are surrogate of clinically significant portal hypertension and can predict survival in compensated cirrhosis patients

BACKGROUND AND AIM

To investigate prognostic value of varices on computed tomography (CT) and redefine surrogate criteria for clinically significant portal hypertension (CSPH).

METHODS

We retrospectively enrolled 241 patients with compensated cirrhosis who underwent hepatic venous pressure gradient (HVPG) measurement from 2008 to 2013. Using CT and upper endoscopy findings obtained within 3 months from HVPG measurement, patients were classified into three groups: presence of standard surrogate for CSPH, defined as presence of varices on upper endoscopy and/or splenomegaly associated with thrombocytopenia (Group 1, n = 139); varices on CT without standard surrogate for CSPH (Group 2, n = 41); and free from both (Group 3, n = 61). HVPG value and overall survival (OS) rates were compared among three patient groups. Revised surrogate for CSPH was defined as presence of standard surrogate and/or presence of varices on CT (i.e. both Group 1 and Group 2).

RESULTS

Mean HVPG value in Group 2 was significantly higher than that in Group 3 (10.3 mmHg vs 6.5 mmHg, P < 0.001), but significantly lower than that in Group 1 (10.3 mmHg vs 13.1 mmHg, P < 0.001). Seven-year OS rates in Group 2 was similar to those in Group 1 (57.0% vs 62.7%, P = 0.591), but significantly poorer than those in Group 3 (57.0% vs 84.0%, P = 0.015). The presence of revised surrogate for CSPH was a significant predictive factor for OS (P = 0.025, Hazard ratio = 2.71 [1.14-6.45]) on multivariate analysis whereas standard surrogate for CSPH was not (P = 0.849).

CONCLUSION

The presence of varices on CT was a significant sign for CSPH, predicting poor OS outcome in patients with compensated cirrhosis.

VI consensus document by the Spanish Liver Transplantation Society

The goal of the Spanish Liver Transplantation Society (La Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, on October 20, 2016, the 6th Consensus Document Meeting was held, with the participation of experts from the 24 authorized Spanish liver transplantation programs. This Edition discusses the following subjects, whose summary is offered below: 1) limits of simultaneous liver-kidney transplantation; 2) limits of elective liver re-transplantation; and 3) liver transplantation after resection and hepatocellular carcinoma with factors for a poor prognosis. The consensus conclusions for each of these topics is provided below.

Impact of clinically significant portal hypertension on outcomes after partial hepatectomy for hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

Whether clinically significant portal hypertension (CSPH) is a contraindication of partial hepatectomy for patients with hepatocellular carcinoma (HCC) remains controversial. The aim was to assess the impact of CSPH on surgical morbidity, mortality and long-term survival of HCC patients who underwent partial hepatectomy.

METHODS

A systematic review and meta-analysis was conducted through analyzing the data published before October 2016 on outcomes following partial hepatectomy for HCC patients with CSPH from the Medline, Embase and CENTRAL databases and related literature.

RESULTS

A total of 16 studies involving 4029 patients met the inclusion criteria. HCC patients with CSPH had increased incidences of severe postoperative complications (pooled odds ratio [OR]: 1.66; 95% CI: 1.31-2.10), surgical mortality (2.56, 1.77-3.70) and 5-year mortality (1.29, 1.11-1.50) compared with patients without CSPH. Subgroup analysis suggested that CSPH had no impact on peri-operative mortality and long-term survival for European HCC patients whose CSPH was diagnosed by the standard surrogate criteria (1.95, 0.96-3.96; 1.24, 0.98-1.55).

CONCLUSIONS

CSPH had a negative impact on short- and long-term prognoses for HCC patients undergoing partial hepatectomy. However, CSPH did not affect the prognoses in a subgroup of European HCC patients whose CSPH was diagnosed by the standard surrogate criteria.

Lowering hepatic venous pressure agent carvedilol versus variceal banding ligation for clinical outcomes of cirrhotic portal hypertension

OBJECTIVE

Carvedilol is nonselective beta-blocker with a mild anti-alpha-1-adrenergic effect. Several studies proposed improved hemodynamic effects of carvedilol compared with propanolol. Our study was to perform a systematic review and meta-analysis of randomized control trials comparing carvedilol with variceal banding ligation (VBL).

METHODS

Studies were searched on online databases MEDLINE, EMBASE(Ovid), the Cochrane Library, Chinese Wanfang Database, and China National Knowledge Infrastructure between January 2000 and May 2018. Incidence of bleeding and mortality were main outcome measures. Subgroup analysis and sensitivity analysis were conducted to ensure the robustness of pooled estimates.

RESULTS

Ten randomized control trials including 1,269 cirrhotic patients were chosen. Compared with VBL, carvedilol showed similar preventive efficacy of risk ratios (RRs) in variceal bleeding, and bleeding-related mortality over different follow-up periods from 6 months to 24 months. Also, significant differences between carvedilol and VBL in overall mortality and other causes of mortality were failed to be found. Carvedilol achieved a lower incidence of portal hypertension gastropathy in both 6 months (RR=0.49, 95% CI: 0.38-0.64, P<0.00001) and 12 months (RR=0.35, 95% CI: 0.26-0.47, P<0.00001). Two trials compared combination of carvedilol and VBL with VBL alone; however, the results failed to find an improved preventive efficacy of bleeding (RR=0.71, 95% CI: 0.15-3.30, P=0.67).

CONCLUSION

Carvedilol is equivalent to invasive VBL for variceal bleeding prevention. It can be well tolerated and may be of benefit to portal hypertension gastropathy. However, available data during 24 months follow-up did not support a potential advantage of carvedilol for prognosis as a lowering hepatic venous pressure agent.

Outcomes in patients with portal hypertension undergoing gastrointestinal surgery: A propensity score matched analysis from the NSQIP dataset

BACKGROUND/AIM

We aim to study the impact of PH in patients undergoing gastrointestinal surgery (GI).

METHODS

We queried the ACS-NSQIP database from 2005 through 2010 for patients undergoing GI surgery with PH. Esophageal varices (EV) diagnosis was used as a surrogate of PH.

RESULTS

A total of 192,296 patients underwent GI surgery, of which 379 had PH. Regression analyses revealed that patients with PH had a 6-fold (95% CI 4.6-7.9) increase in 30-day mortality, a 3-fold (95% CI 2.5-3.7) increase in morbidity, a 3.2-fold (95% CI 2.6-3.9) increase in critical care complications (CCC), and a 6.5-day (95% CI 5.1-7.8) increase in hospital LOS. After PSM, the impact of PH on the outcomes remained. These differences were significant regardless of the emergent or elective status of the procedure. AUC analysis demonstrated that MELD and MELDNa + score greater than 10.5 was the most predictive of peri-operative mortality in elective PH cases.

CONCLUSIONS

PH is associated with an increased risk of poor surgical outcomes in patients undergoing elective and emergent gastrointestinal surgery.

Portal hypertension predicts short-term and long-term outcomes after hepatectomy in hepatocellular carcinoma patients

BACKGROUND AND AIMS

The impact of portal hypertension (PH) on postoperative short-term outcomes and long-term survival in hepatocellular carcinoma (HCC) patients has lately been discussed controversially. This study aimed to explore the influence of PH on postoperative outcomes in HCC patients undergoing surgical resection.

METHODS

Patients undergoing hepatectomy for HCC from 2010 to 2014 were enrolled. The impact of PH on postoperative complications, posthepatectomy liver failure (PHLF) and overall survival (OS) was evaluated.

RESULTS

A total of 355 HCC patients were enrolled; 129 (36.3%) experienced postoperative complications and 21 (5.9%) developed PHLF. PH was identified as an independent predictor of PHLF. Patients with PH experienced a higher incidence of complications and PHLF than patients without PH. On the Cox proportional hazards regression model, PH was verified as a risk factor of OS for BCLC stage 0/A and B patients. Patients without PH had significantly better long-term survival compared to patients with PH both in the total cohort and in cirrhosis subgroup.

CONCLUSION

Liver resection in HCC patients with PH showed a significantly increased postoperative complications and PHLF, and revealed a decreasing long-term survival than non-PH patients. Besides, tumor burden also played an important role in determining the OS. However, due to the improvement in surgical technique and perioperative management, surgery was feasible in carefully selected HCC patients with PH.

The power of tumor sizes in predicting the survival of solitary hepatocellular carcinoma patients

Background

Vascular invasion, rather than tumor size, was applied into the 7th edition of the AJCC TNM staging system to predict survival of solitary hepatocellular carcinoma (HCC) patients. However, does this mean tumor size is of little value in prognostic prediction? The current study was designed to explore the prognostic ability of tumor sizes in solitary HCC.

Methods

A total of 18 591 patients with solitary HCC categorized as T1 and T2 were retrieved from the Surveillance Epidemiology and End Results (SEER) database. The Cox proportional hazards regression model was adopted to evaluate the impact of tumor sizes on overall survival (OS) and disease‐specific survival (DSS) in general and in subgroups stratified by vascular invasion and surgery type.

Results

Large tumor sizes (>39 mm) were associated with unfavorable clinicopathologic characteristics. Compared with tumors ≤30 mm, tumors between 31‐50 mm and tumors >50 mm showed significantly worse OS and DSS in general using multivariate analysis (all P < 0.001). In subgroup analyses, for patients without vascular invasion, tumor size was a notable prognostic indicator for OS in the radiofrequency ablation group (P < 0.001), rather than in the liver resection or transplantation group. Nevertheless, for patients with vascular invasion, tumor sizes exhibited a notable impact on OS in the liver resection and transplantation group.

Conclusions

The AJCC TNM staging system for solitary HCC would be more comprehensive if tumor sizes were integrated into the T2 classification. Additionally, for T1 patients, tumor sizes play no role in the choice between resection and transplantation.

Esophageal varices are not predictive of patient prognosis after surgical resection of hepatocellular carcinoma

OBJECTIVE

The predictive value of esophageal varices (EV) in determining the patient outcome in hepatocellular carcinoma (HCC) remains unresolved. We aimed to assess the impact of EV on the prognosis of HCC patients after surgical resection.

MATERIALS AND METHODS

We consecutively enrolled 446 treatment-naive HCC patients who underwent surgical resection and esophagogastroduodenoscopy from 2003 to 2015. Prognostic factors were analyzed using the Cox proportional hazards model and a propensity score matching analysis.

RESULTS

A total of 89 (20.0%) HCC patients presented with EV. Compared with those without EV, patients with EV had poorer preservation of liver function and higher rates of cirrhosis in the nontumor part of liver specimens. After a median follow-up period of 34.6 months (25-75 percentiles; 12.8-59.3 months), 130 patients had died. The cumulative 5-year overall survival (OS) rates were 62.3 and 70.6% in patients with and without EV, respectively (P=0.102). A multivariate analysis showed that serum albumin level less than or equal to 4 g/dl (P=0.020), α-fetoprotein level greater than 20 ng/ml (P<0.001), as well as the presence of vascular invasion (P<0.001), but not the presence of EV, were independent risk factors associated with poor OS. Moreover, 67 patients were matched in each group using the one-to-one nearest-neighbor matching method. After matching, the OS rates were comparable between HCC patients with and without EV.

CONCLUSION

EV is not an independent risk factor predictive of poor prognosis for HCC patients after resection surgery if they have well-preserved liver function.

Comparison of the ability of Child-Pugh score, MELD score, and ICG-R15 to assess preoperative hepatic functional reserve in patients with hepatocellular carcinoma

BACKGROUND

Assessing hepatic functional reserve before hepatectomy is beneficial to reduce the incidence of posthepatectomy liver failure (PHLF). This study aimed to compare the ability of the Child-Pugh score, model for end-stage liver disease (MELD) score, and retention test at 15 minutes (indocyanine green [ICG]-R15) to assess hepatic functional reserve.

METHODS

A total of 185 patients with hepatocellular carcinoma (HCC) undergoing hepatectomy were enrolled in this study. The ability of Child-Pugh score, MELD score, and ICG-R15 predicting severe PHLF were compared.

RESULTS

A total of 23 patients (12.4%) developed severe PHLF. Multivariate analyses identified that platelet count, ICG-R15, clinically significant portal hypertension, and major resection were independent factors for predicting severe PHLF. The area under the receiver operating characteristic curve of ICG-R15 for predicting severe PHLF was higher than that of both Child-Pugh score and MELD score. With an optimal cutoff value of 7.1%, the sensitivity and specificity of ICG-R15 for predicting severe PHLF were 52.2% and 89.5%, respectively. Both the incidence of severe PHLF and mortality in patients with ICG-R15 >7.1% were significantly higher than the figures for patients with ICG-R15 ≤7.1%.

CONCLUSION

ICG-R15 is more accurate than the Child-Pugh score and MELD score in predicting hepatic functional reserve before hepatectomy.

The Prognosis of Single Large Hepatocellular Carcinoma Was Distinct from Barcelona Clinic Liver Cancer Stage A or B: The Role of Albumin-Bilirubin Grade

BACKGROUND/AIMS

Whether single large hepatocellular carcinoma (SLHCC) is classified as Barcelona Clinic Liver Cancer (BCLC) stage A or B is still controversial. We aimed to compare the clinical manifestations, treatment modalities, and prognoses among patients with SLHCC and those in BCLC stage A and B.

METHODS

We enrolled 2,285 treatment-naive hepatocellular carcinoma (HCC) patients with BCLC stage A or B from October 2007 to December 2015. Factors in terms of prognoses were analyzed by multivariate analysis.

RESULTS

We enrolled 1,210, 466, and 609 patients in a BCLC-A, SLHCC, and BCLC-B group, respectively. After a median follow-up duration of 21.2 months, 898 patients had died. The cumulative 5-year survival rates were 57.0, 42.6, and 27.3% for patients in the BCLC-A, SLHCC, and BCLC-B groups, respectively, which were significantly different (p < 0.001). Multivariate analysis indicated that the following independent risk factors were associated with poor prognosis: age > 65 years, alkaline phosphatase > 100 U/L, creatinine > 1.0 mg/dL, alpha-fetoprotein > 20 mg/mL, noncurative treatment, albumin-bilirubin (ALBI) grade, and HCC staging. Subgroup analysis also confirmed that patients in the SLHCC group had a survival rate intermediate to those in the BCLC-A and BCLC-B groups. However, for patients in the SLHCC group and with ALBI grade 1, outcomes were close to those in the BCLC-A group, especially in the setting of curative treatment. For those with ALBI grades 2 or 3, the prognoses were similar to those of the SLHCC and BCLC-B groups.

CONCLUSION

Patients in the SLHCC group had an overall survival rate intermediate to those of the BCLC-A and BCLC-B groups. It is suggested that the SLHCC group could be classified as occupying a different stage from the BCLC stages A and B. The ALBI grade could help to stratify SLHCC into a different prognostic group. However, the results need to be validated externally in other regions of the world.

Resection for hepatocellular cancer: overpassing old barriers

Several recent studies have shown that the selection limits commonly used for patients with hepatocellular cancer (HCC) potentially requiring a liver resection (LR) are too restrictive. The present review aims at investigating the studies showing that LR is no longer a treatment suitable only for highly selected patients, but also for patients selectively presenting one-to-more negative factors. Several specific variables have been investigated, none of them showing to be an absolute contraindication for LR: age; single vs. multiple diseases; the dimension of the nodule; hyperbilirubinemia; clinically relevant portal hypertension; Child-Pugh status; macrovascular invasion. As a consequence, LR for the treatment of HCC-on-cirrhosis is a safe and effective procedure not only in "ideal cases", but also for selected patients presenting risk factors. The presence of only one of these factors does not represent an absolute contraindication for LR. On the opposite, the contemporaneous presence of risk factors should contraindicate the procedure. Further studies investigating the "borderline" cases are required, mainly looking at the possible decisive role of laparoscopy in this setting.

Clinical application of magnetic resonance elastography in chronic liver disease

Recent evidence highlighted that the accurate assessment of liver fibrosis is important for evaluating the progression of chronic liver disease. During the past decade, many non-invasive methods have been developed to reduce the need for core-needle biopsy in fibrosis staging and to overcome its limitations, such as invasiveness, high cost, low reproducibility, and poor patient consent. The diagnostic performance of magnetic resonance elastography (MRE) is promising for use in clinical practice to evaluate not only liver fibrosis, but also survival and major clinical end-points such as liver decompensation, portal hypertension, development of hepatocellular carcinoma, and surgical outcomes. Together with other clinical markers, MRE can be used to better categorize patients with advanced fibrosis and cirrhosis, and assign them to different classes of risk for significant clinical outcomes. This review discusses clinical applications of MRE in the management strategy of patients with chronic liver disease.

Influence of liver fibrosis on prognosis after surgical resection for resectable single hepatocellular carcinoma

BACKGROUND

Surgical resection (SR) is recommended for single hepatocellular carcinoma (HCC) in patients with well-preserved liver function. However, unexpected liver fibrosis sometimes found at the SR which leads to a poor outcome. This study investigated the influence of liver fibrosis on prognosis after SR for HCC.

METHODS

A total of 189 patients with Child-Turcotte-Pugh grade A who underwent curative SR for a single HCC <5 cm were evaluated. Patients were assigned to two groups based on the degree of fibrosis (mild or severe), as determined by histological evaluation.

RESULTS

Severe fibrosis was present in 49 patients (25.9%); these patients had greater posthepatectomy liver failure (P = 0.000) and HCC recurrence (P = 0.016). Severe liver fibrosis (hazard ratio (HR) = 1.849, 95% confidence interval (CI) 1.191-2.869; P = 0.006), microvascular invasion (HR = 1.854, 95% CI 1.183-2.906; P = 0.007), and poor histologic grade (HR = 2.097, 95% CI 1.230-3.574; P = 0.007) were related to HCC recurrence.

CONCLUSION

Severe fibrosis can be found even in patients with well-preserved liver function and it leads to poorer early post-operative and late oncologic outcomes, therefore it should be considered before therapeutic decision making of HCC.

Clinical Assessment and Management of Portal Hypertension

The development of portal hypertension in a patient with cirrhosis portends a poor prognosis. Untreated or progressive portal hypertension has serious clinical outcomes, which are often fatal. It is important to recognize portal hypertension early to delay progression and to treat complications of portal hypertension as they arise. This review will focus on the clinical assessment and management of portal hypertension.

Combination of albumin-bilirubin grade and platelets to predict a compensated patient with hepatocellular carcinoma who does not require endoscopic screening for esophageal varices

BACKGROUNDS AND AIMS

There is no consensus on screening for high-risk esophageal varices (HRV) in patients with hepatocellular carcinoma (HCC). Here, we aimed to investigate the prevalence and risk factors of HRV in patients with HCC and to assess the combination of albumin-bilirubin grade and platelet count (ALBI-PLT score) for predicting compensated patients who do not need unnecessary endoscopic screening for HRV.

METHODS

The ALBI-PLT score was calculated by adding the ALBI grade and points for platelet count (1 point if platelet count >150,000/mm³ and 2 points if ≤150,000/mm³). The predictive value of the ALBI-PLT score for HRV was analyzed in 887 compensated patients enrolled from October 2007 to April 2014 (study cohort). This was validated in 215 compensated patients from May 2014 to December 2015 (validation cohort).

RESULTS

In the study cohort, the rates of HRV were 2.9% and 21.1% in compensated HCC patients with an ALBI-PLT score of 2 and >2, respectively. The negative predictive values of the ALBI-PLT score for predicting HRV were 97.1% and 98.1% in the study and validation cohorts, respectively. For compensated patients who did not receive endoscopic screening at the time of HCC diagnosis, the 5-year cumulative variceal hemorrhage rate was lower in patients with an ALBI-PLT score of 2 than in those with an ALBI-PLT score >2 (1.7% vs 9.1%, P = .007).

CONCLUSION

In patients with HCC with compensated liver function, an ALBI-PLT score of 2 predicted a very low risk of HRV and variceal hemorrhage; therefore, endoscopic screening for esophageal varices is not recommended for these patients.

Impact of clinically evident portal hypertension on clinical outcome of patients with hepatocellular carcinoma treated by transarterial chemoembolization

BACKGROUND AND AIM

The aim of this study is to determine the impact of clinically evident portal hypertension (CEPH) on prognosis of hepatocellular carcinoma (HCC) patients with Child-Pugh A cirrhosis who underwent transarterial chemoembolization (TACE).

METHODS

A retrospective data analysis was performed for a total of 388 treatment-naïve HCC patients with Child-Pugh A cirrhosis who underwent TACE as first-line treatment from January 2000 to June 2014. Cumulative occurrence rate of complete response (CR), progression-free survival (PFS), and overall survival (OS) were compared between patients with CEPH and those without CEPH (esophageal/gastric varices or low platelet count [< 100 000 per mm³ ] associated with splenomegaly).

RESULTS

Among 388 patients, 252 (64.9%) had CEPH, while 136 (35.1%) had no evidence of CEPH at the time of HCC diagnosis. Cumulative probability of the occurrence of CR was significantly lower in patients with CEPH than that in patients without CEPH (P < 0.001). Median PFS was significantly shorter in patients with CEPH than that in patients without CEPH (5 vs 31 months, P < 0.001). Five-year OS rate was significantly lower in patients with CEPH than that in patients without CEPH (41.5% vs 77.5%, P < 0.001). Multivariate analysis indicated that the presence of CEPH was the most powerful poor prognostic factor for the occurrence of CR (adjusted hazard ratio [aHR], 0.16; 95% confidence interval [CI], 0.09-0.28; P < 0.001), PFS (aHR, 5.01; 95% CI, 3.08-8.12; P < 0.001), and OS (aHR, 2.95; 95% CI, 1.66-5.23; P < 0.001).

CONCLUSIONS

The presence of CEPH should be considered as a major negative prognostic factor for patients with HCC who will undergo TACE.

Neddylation, a novel paradigm in liver cancer

Liver cancer is the sixth most prevailing cancer worldwide. Hepatocellular carcinoma (HCC), the most common form of primary liver cancer, has a rather heterogeneous pathogenesis making it highly refractive to current therapeutic approaches. Hence, HCC patients have a poor and gloomy prognosis making liver cancer the second leading cause of global cancer-related deaths. On this basis, a more global mechanism, such as post-translational modifications (PTMs) of proteins, may provide a valuable therapeutic approach for HCC clinical management by simultaneously regulating multiple disrupted signaling pathways. In the last years, the ubiquitin-like molecule NEDD8 (Neural precursor cell-expressed developmentally downregulated-8) conjugation pathway, neddylation, was shown to be aberrant in HCC patients with a significant positive correlation found among global levels of neddylation and poorer prognosis. Even though the best-established role for NEDD8 is the activation of ubiquitin E3 ligase family of cullin-RING ligases, the putative role for other NEDD8 substrates has been explored in recent years leading to the identification of novel neddylation targets in HCC. Importantly, treatment with the small pharmacological inhibitor Pevonedistat (MLN4924) (Millennium Pharmaceuticals, Takeda Pharmaceutical), currently in clinical trials for the treatment of some types of leukemias and other advanced solid tumors, was shown to suppress the outgrowth of hepatoma cells and liver cancer in pre-clinical mouse models. Overall, considering that the neddylation inhibitor Pevonedistat was well-tolerated and displayed a significant antitumor effect in pre-clinical models, combinatory pharmacological treatment based on Pevonedistat are highly recommended to enter clinical trials targeting advanced HCC.

Noninvasive Assessment of Portal Hypertension in Advanced Chronic Liver Disease: An Update

The assessment of portal hypertension is a relevant step in the evaluation of newly diagnosed advanced chronic liver disease (ACLD). The current gold standard includes the invasive evaluation of hepatic venous pressure gradient (HVPG) and endoscopy. However, noninvasive or minimally invasive techniques to assess portal hypertension have been proposed and well established. In the present manuscript, we review clinical studies on the use of noninvasive or minimally invasive techniques to assess portal hypertension in ACLD patients.

A Predictive Formula for Portal Venous Pressure Prior to Liver Resection Using Directly Measured Values

Purpose: Despite refinements in surgical techniques for liver resection, evaluation of hepatic reserve disparity remains one of the most common problems in liver surgery, especially for hepatic malignancies such as hepatocellular carcinoma (HCC). Portal venous pressure (PVP) is regarded one of the important factors in selecting treatment strategy, although its measurement can be invasive and complex. Methods: To establish a formula for calculating PVP preoperatively, intraoperative directly measured PVP was used in 177 patients with preoperative factors and liver function tests such as age, sex, virus status, platelet count, prothrombin time, albumin, total bilirubin, alanine aminotransferase (ALT), Child-Pugh grade, liver damage defined by the Liver Cancer Study Group of Japan, indocyanine green retention rate at 15 min (ICG-R15), and the aspartate transaminase (AST)-platelet ratio index (APRI). Results: Although 90% of the patients were classified as Child-Pugh A, median direct PVP was 16.5 cm H₂O (5.5-37.0) and the percentage of PVP greater than 20 cm H₂O was 27.1%, reflecting portal hypertension due to liver damage. After multiple regression analysis, the formula PVP (cmH₂O) = EXP[2.606 + 0.01 × (ICG-R15) + 0.015 × APRI] was established from the measured data. Conclusion: Considering its simplicity of use, we have adopted this formula for predicting PVP in determining treatment strategy for HCC and other hepatic malignancies.

VI consensus document by the Spanish Liver Transplantation Society

The goal of the Spanish Liver Transplantation Society (La Sociedad Española de Trasplante Hepático) is to promote and create consensus documents about current topics in liver transplantation with a multidisciplinary approach. To this end, on October 20, 2016, the 6th Consensus Document Meeting was held, with the participation of experts from the 24 authorized Spanish liver transplantation programs. This Edition discusses the following subjects, whose summary is offered below: 1) limits of simultaneous liver-kidney transplantation; 2) limits of elective liver re-transplantation; and 3) liver transplantation after resection and hepatocellular carcinoma with factors for a poor prognosis. The consensus conclusions for each of these topics is provided below.

Surgical Treatment of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a major cause of cancer-related death worldwide. In select patients, surgical treatment in the form of either resection or transplantation offers a curative option. The aims of this review are to (1) review the current American Association for the Study of Liver Diseases/European Association for the Study of the Liver guidelines on the surgical management of HCC and (2) review the proposed changes to these guidelines and analyze the strength of evidence underlying these proposals. Three authors identified the most relevant publications in the literature on liver resection and transplantation for HCC and analyzed the strength of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification. In the United States, the liver allocation system provides priority for liver transplantation to patients with HCC within the Milan criteria. Current evidence suggests that liver transplantation may also be indicated in certain patient groups beyond Milan criteria, such as pediatric patients with large tumor burden or adult patients who are successfully downstaged. Patients with no underlying liver disease may also benefit from liver transplantation if the HCC is unresectable. In patients with no or minimal (compensated) liver disease and solitary HCC ≥2 cm, liver resection is warranted. If liver transplantation is not available or contraindicated, liver resection can be offered to patients with multinodular HCC, provided that the underlying liver disease is not decompensated. Many patients may benefit from surgical strategies adapted to local resources and policies (hepatitis B prevalence, organ availability, etc). Although current low-quality evidence shows better overall survival with aggressive surgical strategies, this approach is limited to select patients. Larger and well-designed prospective studies are needed to better define the benefits and limits of such approach.

Radiation Segmentectomy: Potential Curative Therapy for Early Hepatocellular Carcinoma

Purpose To report long-term outcomes of radiation segmentectomy (RS) for early hepatocellular carcinoma (HCC). The authors hypothesized that outcomes are comparable to curative treatments for patients with solitary HCC less than or equal to 5 cm and preserved liver function. Materials and Methods This retrospective study included 70 patients (median age, 71 years; range, 22-96 years) with solitary HCC less than or equal to 5 cm not amenable to percutaneous ablation who underwent RS (dose of >190 Gy) between 2003 and 2016. Patients who underwent subsequent curative liver transplantation were excluded to eliminate this confounding variable affecting survival. Radiologic response of time to progression and median overall survival were estimated by using the Kaplan-Meier method per the guidelines of the European Association for the Study of the Liver (EASL) and the World Health Organization (WHO). Results Seventy patients were treated with RS over 14 years. Sixty-three patients (90%) showed response by using EASL criteria, of which 41 (59%) showed complete response. Fifty patients (71%) achieved response by using WHO criteria, of which 11 (16%) achieved complete response. Response rates at 6 months were 86% and 49% by using EASL and WHO criteria, respectively. Median time to progression was 2.4 years (95% confidence interval: 2.1, 5.7), with 72% of patients having no target lesion progression at 5 years. Median overall survival was 6.7 years (95% confidence interval: 3.1, 6.7); survival probability at 1, 3, and 5 years was 98%, 66%, and 57%, respectively. Overall survival probability at 1, 3, and 5 years was 100%, 82%, and 75%, respectively, in patients with baseline tumor size less than or equal to 3 cm (n = 45) and was significantly longer than in patients with tumors greater than 3 cm (P = .026). Conclusion RS provides response rates, tumor control, and survival outcomes comparable to curative-intent treatments for selected patients with early-stage HCC who have preserved liver function. ^© RSNA, 2018 Online supplemental material is available for this article.

Hepatocellular carcinoma

Hepatocellular carcinoma appears frequently in patients with cirrhosis. Surveillance by biannual ultrasound is recommended for such patients because it allows diagnosis at an early stage, when effective therapies are feasible. The best candidates for resection are patients with a solitary tumour and preserved liver function. Liver transplantation benefits patients who are not good candidates for surgical resection, and the best candidates are those within Milan criteria (solitary tumour ≤5 cm or up to three nodules ≤3 cm). Image-guided ablation is the most frequently used therapeutic strategy, but its efficacy is limited by the size of the tumour and its localisation. Chemoembolisation has survival benefit in asymptomatic patients with multifocal disease without vascular invasion or extrahepatic spread. Finally, sorafenib, lenvatinib, which is non-inferior to sorafenib, and regorafenib increase survival and are the standard treatments in advanced hepatocellular carcinoma. This Seminar summarises the scientific evidence that supports the current recommendations for clinical practice, and discusses the areas in which more research is needed.

Preoperative platelet-albumin-bilirubin grades predict the prognosis of patients with hepatitis B virus-related hepatocellular carcinoma after liver resection: A retrospective study

Minimal information is available concerning platelet-albumin-bilirubin (PALBI) grades in patients with hepatocellular carcinoma (HCC) following liver resection. This study aimed to investigate the predictive ability of PALBI grades in patients with a Child-Pugh class A score and hepatitis B virus-related (HBV-related) HCC after liver resection.The data of patients with HBV-related HCC who underwent liver resection from 2010 to 2017 at our center were reviewed (n = 785). Cox regression was used to determine factors independently associated with postoperative recurrence and mortality. The area under the receiver operating characteristic curve (AUC) was used to estimate the predictive accuracy of different tools.During the follow-up period, 505 (64.3%) patients experienced recurrence, and 374 (47.6%) patients died. Multivariate analysis revealed that the tumor-node-metastasis (TNM) stage (HR = 1.591, 95%CI = 1.414-1.789, P < .001), PALBI grade (HR = 1.326, 95%CI = 1.139-1.544, P < .001), a high AFP level (HR = 1.382, 95%CI = 1.158-1.649, P < .001) and transfusion (HR = 1.364, 95%CI = 1.087-1.712, P = 0.007) were independently associated with recurrence. Additionally, microvascular invasion (HR = 1.674, 95%CI = 1.292-2.169, P < .001), beyond the Milan criteria (HR = 0.477, 95%CI = 0.346-0.657, P < .001), PALBI grade (HR = 1.356, 95%CI = 1.151-1.598, P < .001), a high AFP level (HR = 1.542, 95%CI = 1.252-1.900, P < .001), and transfusion (HR = 1.548, 95%CI = 1.199-1.999, P = 0.001) adversely impacted the overall survival. The AUCs of the PALBI grades for postoperative recurrence and mortality were significantly higher than the albumin-bilirubin grade and Child-Pugh score. The prognostic significance of the PALBI grade for postoperative recurrence and mortality was maintained when stratified by the TNM stage.The preoperative PALBI grade is a surrogate marker for the postoperative prognosis in patients with HBV-related HCC after liver resection.

Liver Stiffness Measured by Two-Dimensional Shear-Wave Elastography: Prognostic Value after Radiofrequency Ablation for Hepatocellular Carcinoma

PURPOSE

To evaluate the prognostic value of liver stiffness (LS) measured using two-dimensional (2D) shear-wave elastography (SWE) in patients with hepatocellular carcinoma (HCC) treated by radiofrequency ablation (RFA).

METHODS

The Institutional Review Board approved this retrospective study and informed consent was obtained from all patients. A total of 134 patients with up to 3 HCCs ≤5 cm who had undergone pre-procedural 2D-SWE prior to RFA treatment between January 2012 and December 2013 were enrolled. LS values were measured using real-time 2D-SWE before RFA on the procedural day. After a mean follow-up of 33.8 ± 9.9 months, we analyzed the overall survival after RFA using the Kaplan-Meier method and Cox proportional hazard regression model. The optimal cutoff LS value to predict overall survival was determined using the minimal p value approach.

RESULTS

During the follow-up period, 22 patients died, and the estimated 1- and 3-year overall survival rates were 96.4 and 85.8%, respectively. LS measured by 2D-SWE was found to be a significant predictive factor for overall survival after RFA of HCCs, as was the presence of extrahepatic metastases. As for the optimal cutoff LS value for the prediction of overall survival, it was determined to be 13.3 kPa. In our study, 71 patients had LS values ≥13.3 kPa, and the estimated 3-year overall survival was 76.8% compared to 96.3% in 63 patients with LS values <13.3 kPa. This difference was statistically significant (hazard ratio = 4.30 [1.26-14.7]; p = 0.020).

CONCLUSION

LS values measured by 2D-SWE was a significant predictive factor for overall survival after RFA for HCC.

Non-invasive evaluation of portal hypertension using shear-wave elastography: analysis of two algorithms combining liver and spleen stiffness in 191 patients with cirrhosis

BACKGROUND

Two algorithms based on sequential measurements of liver and spleen stiffness using two-dimensional shearwave elastography (2D-SWE) have been recently proposed to estimate clinically significant portal hypertension (hepatic venous pressure gradient [HVPG] ≥10 mm Hg) in patients with cirrhosis, with excellent diagnostic accuracy.

AIM

To validate externally these algorithms in a large cohort of patients with cirrhosis.

METHODS

One hundred and ninety-one patients with stable cirrhosis (Child-Pugh class A 39%, B 29% and C 31%) who underwent liver and spleen stiffness measurements using 2D-SWE at the time of HVPG measurement were included. Diagnostic accuracy of the 2 algorithms was assessed by calculating sensitivity, specificity, positive and negative predictive values.

RESULTS

The first algorithm, using liver stiffness <16.0 kilopascals (kPa) and then spleen stiffness <26.6 kPa, was used to rule-out HVPG ≥10 mm Hg. In our population, its sensitivity and negative predictive value were 95% and 63% respectively. The second algorithm, using liver stiffness >38.0 kPa, or liver stiffness ≤38.0 kPa but spleen stiffness >27.9 kPa, was used to rule-in HVPG ≥10 mm Hg. In our population, its specificity and positive predictive value were 52% and 83% respectively. Restricting the analyses to the 74 patients without any history of decompensation of cirrhosis or to the 65 patients with highly reliable liver stiffness measurement did not improve the results.

CONCLUSION

In our population, diagnostic accuracies of non-invasive algorithms based on sequential measurements of liver and spleen stiffness using 2D-SWE were acceptable, but not good enough to replace HVPG measurement or to base clinical decisions.