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

Current topics in the surgical treatments for hepatocellular carcinoma

Treatment strategy for hepatocellular carcinoma (HCC) requires optimal selection of therapies based on various factors related to tumor condition and liver functional reserve. Although several evidence-based guidelines have been proposed for the treatment of HCC, the criteria and range of indications differ among these guidelines according to the circumstances of each country. In European nations and the USA, patients with the Barcelona Clinic Liver Cancer stage 0-A are subjects for surgical resection, whereas in Asian countries, even those with the intermediate stage are regarded as surgical candidates. Furthermore, since the recent introduction and rapidly widely spreading use of laparoscopic liver resection, this technique has become an important treatment option for surgical resection. In this review article, we overview the current topics of treatment of HCC with a special focus on surgical therapy.

Transjugular intrahepatic portosystemic shunt placement before abdominal intervention in cirrhotic patients with portal hypertension: lessons from a pilot study

BACKGROUND

Abdominal interventions are usually contraindicated in patients with cirrhosis and portal hypertension because of increased morbidity and mortality. Decreasing portal pressure with transjugular intrahepatic portosystemic shunt (TIPS) may improve patient outcomes. We report our experience with patients treated by neoadjuvant TIPS to identify those who would most benefit from this two-step procedure.

PATIENTS AND METHODS

All patients treated by dedicated neoadjuvant TIPS between 2005 and March 2013 in two tertiary referral hospitals were included. The primary endpoint was the rate of failure, defined by the inability to proceed to the planned intervention after TIPS placement or persistent liver decompensation 3 months after intervention. The secondary endpoints were the rate of complications, parameters associated with failure, and 1-year survival.

RESULTS

Twenty-eight consecutive patients were included, with a mean age of 61.2±6.6 years, mean Child-Pugh score of 6.6±1.5, and mean model for end-stage liver disease score of 10.4±3.3. Procedures were digestive (43%) or liver (25%) resections, abdominal wall surgery (21%), or interventional gastrointestinal endoscopies (11%). The scheduled procedure was performed in 24 (86%) patients within a median of 25 days after TIPS. Procedure failures occurred in six (21%) patients: four did not undergo surgery and two experienced persistent liver decompensation. Seven (25%) patients had postoperative complications, mainly local. Viral origin of cirrhosis, history of encephalopathy, and hepatic surgery were found to be associated with failure. One-year survival in the whole cohort was 70%.

CONCLUSION

In selected patients, extrahepatic surgery or interventional endoscopies can be safely performed after portal hypertension has been controlled by TIPS.

Benefits of laparoscopic liver resection in patients with hepatocellular carcinoma and portal hypertension: a case-matched study

BACKGROUND

The advantages of laparoscopy over open liver resection in patients with cirrhosis have been widely demonstrated. On the other hand, information on the role of minimally invasive liver surgery in the presence of clinically significant portal hypertension (CSPH) is scarce. The aim of this study was to evaluate the role of laparoscopic liver resection in selected cirrhotic patients with CSPH.

METHODS

A retrospective case-control study of cirrhotic patients with hepatocellular carcinoma who were treated with laparoscopic liver resection was conducted from December 2005 to April 2016. A total of 45 patients were included. Patients were divided into two groups according to the presence or absence of clinically significant portal hypertension. Fifteen cirrhotic patients with CSPH were matched with 30 patients without CSPH.

RESULTS

Overall, there were no differences in intraoperative results. No conversion to open surgery occurred in the CSPH group, and 3 patients were converted in the Non-CSPH group (0 vs. 10% p = 0.57). Only 2 (7%) patients in the Non-CSPH group and 1 (7%) in the CSPH group had relevant complications (modified Clavien-Dindo classification III). Two patients in the Non-CSPH group and one in the CSPH group developed transient ascites (7 vs. 7%). Postoperative hospital stay was similar in both groups, with a median of 4 days in the CSPH group and 3 days in the Non-CSPH group (p = 0.37). The median follow-up of the entire cohort was 38 months (range 7-100). Overall survival rates at 1 and 3 years were 100 and 87%, respectively. There was no significant difference between the groups in terms of survival (p = 0.8).

CONCLUSION

This initial study showed that laparoscopic resection in patients with CSPH can be performed safely in well-selected patients and expand the current surgical indications in patients with CSPH. Prospective trials with a larger sample size are necessary to confirm these results.

Liver resection for HCC outside the BCLC criteria

PURPOSE

Surgical resection still remains the mainstay of management of hepatocellular carcinoma (HCC). At present, Barcelona clinic liver cancer (BCLC) staging is the most widely used tool to guide treatment; however, criteria for offering surgery as curative treatment are restrictive. We aimed to evaluate short-term and long-term outcomes of HCC after resection, even for patients outside BCLC criteria for resection.

METHODS

Data was collected from a prospective database from GI and HPB Department, Tata Memorial Hospital, Mumbai. Study period was from June 2010 to June 2015.

RESULTS

One hundred three patients of HCC were operated during this period, of which 100 underwent complete resection. Patients were staged according to the BCLC classification (BCLC stage A-25, B-64, C-11). Preoperative therapy was administered in 36 (36%) patients. At median follow-up of 21 months, overall 3-year survival for BCLC stages A, B, and C was 55.2, 62.7, and 37.5%, respectively.

CONCLUSION

In today's era of liver transplantation, resection (especially for larger tumors) may still be the preferred treatment option, considering problems and difficulties in donor availability, cost, and long waiting list for liver transplant. With evolving modern surgical technique, long-term survival benefit can be achieved with acceptable safety in most BCLC stage B and selected BCLC stage C patients and those who either do not fit into the transplant criteria or cannot afford transplant. Carefully designed trials are required to further elucidate these results.

Advances and challenges in cirrhosis and portal hypertension

BACKGROUND

Liver cirrhosis is the fourth cause of death in adults in Western countries, with complications of portal hypertension being responsible for most casualties. In order to reduce mortality, development of accurate diagnostic methods for early diagnosis, effective etiologic treatment, improved pharmacological therapy for portal hypertension, and effective therapies for end-stage liver failure are required.

DISCUSSION

Early detection of cirrhosis and portal hypertension is now possible using simple non-invasive methods, leading to the advancement of individualized risk stratification in clinical practice. Despite previous assumptions, cirrhosis can regress if its etiologic cause is effectively removed. Nevertheless, while this is now possible for cirrhosis caused by chronic hepatitis C, the incidence of cirrhosis due to non-alcoholic steatohepatitis has increased dramatically and effective therapies are not yet available. New drugs acting on the dynamic component of hepatic vascular resistance are being studied and will likely improve the future management of portal hypertension.

CONCLUSION

Cirrhosis is now seen as a dynamic disease able to progress and regress between the compensated and decompensated stages. This opinion article aims to provide the author's personal view of the current major advances and challenges in this field.

Hepatocellular carcinoma: Present and future

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide with over 740,000 new cases per year and the third leading cause of cancer-related death, with a growing incidence in recent years. This tumor usually arises in patients with an underlying chronic liver disease. The management of this tumor has improved over the past 2 decades: patients at risk are included in a surveillance program, a prognostic staging system has been created and, finally, new treatments particularly aimed at patients with advanced HCC have been developed. This fact has resulted in a greater interest in this tumor and several scientific societies have developed clinical practice guidelines for the management of patients with this disease. In this article, we review the current and future prospects of this tumor.

Management consensus guideline for hepatocellular carcinoma: 2016 updated by the Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related mortality in Taiwan. To help clinical physicians to manage patients with HCC, the Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan produced the management consensus guideline for HCC.

METHODS

The recommendations focus on nine important issues on management of HCC, including surveillance, diagnosis, staging, surgery, local ablation, transarterial chemoembolization/transarterial radioembolization/hepatic arterial infusion chemotherapy, systemic therapy, radiotherapy, and prevention.

RESULTS

The consensus statements were discussed, debated and got consensus in each expert team. And then the statements were sent to all of the experts for further discussion and refinement. Finally, all of the experts were invited to vote for the statements, including the level of evidence and recommendation.

CONCLUSION

With the development of the management consensus guideline, HCC patients could benefit from the optimal therapeutic modality.

The portal hypertension syndrome: etiology, classification, relevance, and animal models

BACKGROUND

Portal hypertension is a key complication of portal hypertension, which is responsible for the development of varices, ascites, bleeding, and hepatic encephalopathy, which, in turn, cause a high mortality and requirement for liver transplantation.

AIM

This review deals with the present day state-of-the-art preventative treatments of portal hypertension in cirrhosis according to disease stage. Two main disease stages are considered, compensated and decompensated cirrhosis, the first having good prognosis and being mostly asymptomatic, and the second being heralded by the appearance of bleeding or non-bleeding complications of portal hypertension.

RESULTS

The aim of treatment in compensated cirrhosis is preventing clinical decompensation, the more frequent event being ascites, followed by variceal bleeding and hepatic encephalopathy. Complications are mainly driven by an increase of hepatic vein pressure gradient (HVPG) to values ≥10 mmHg (defining the presence of Clinically Significant Portal Hypertension, CSPH). Before CSPH, the treatment is limited to etiologic treatment of cirrhosis and healthy life style (abstain from alcohol, avoid/correct obesity…). When CSPH is present, association of a non-selective beta-blocker (NSBB), including carvedilol should be considered. NSBBs are mandatory if moderate/large varices are present. Patients should also enter a screening program for hepatocellular carcinoma. In decompensated patients, the goal is to prevent further bleeding if the only manifestation of decompensation was a bleeding episode, but to prevent liver transplantation and death in the common scenario where patients have manifested first non-bleeding complications. Treatment is based on the same principles (healthy life style..) associated with administration of NSBBs in combination if possible with endoscopic band ligation if there has been variceal bleeding, and complemented with simvastatin administration (20-40 mg per day in Child-Pugh A/B, 10-20 mg in Child C). Recurrence shall be treated with TIPS. TIPS might be indicated earlier in patients with: 1) Difficult/refractory ascites, who are not the best candidates for NSBBs, 2) patients having bleed under NSBBs or showing no HVPG response (decrease in HVPG of at least 20% of baseline or to values equal or below 12 mmHg). Decompensated patients shall all be considered as potential candidates for liver transplantation.

CONCLUSION

Treatment of portal hypertension has markedly improved in recent years. The present day therapy is based on accurate risk stratification according to disease stage.

Impact of alcohol & smoking on the surgical management of gastrointestinal patients

Alcohol and smoking are repeatedly described as modifiable risk factors in clinical studies across all surgical specialities. These lifestyle choices impart a sub-optimal physiology via multiple processes and play an important role in the surgical management of the gastrointestinal patient. Cessation is imperative to optimise the patient's fitness for surgery with surgery itself being a prime opportunity for sustained cessation. A consistent, planned and integrated management involving surgical, anaesthetic, medical, and primary care facets will aid in successful cessation and perioperative care. This review highlights the pathological processes which contribute to perioperative complications and details the current practices to detect, predict and appropriately manage the perioperative gastrointestinal patient who smokes and consumes alcohol.

Liver Stiffness Assessed by Shear Wave Elastography Predicts Postoperative Liver Failure in Patients with Hepatocellular Carcinoma

BACKGROUND

Cirrhosis increases a patient's risk of developing postoperative liver failure (PLF). Liver stiffness (LS), assessed by two-dimensional shear wave elastography (SWE), indicates liver fibrosis with high accuracy. Whether LS is superior to portal hypertension (PHT) in predicting PLF remains to be studied.

METHODS

The study enrolled 280 patients who underwent hepatectomy for hepatocellular carcinoma from July 2015 to July 2016. All patients received preoperative assessments for LS, PHT, and serum markers of liver fibrosis in addition to other clinicopathological tests. Risk factors for grade A and grade B (or greater) PLF were subjected to univariate and multivariate analysis and receiver operating characteristic curve analysis.

RESULTS

Fifty-five patients (19.6%) experienced PLF. The cutoff value of LS for predicting cirrhosis was 10.1 kPa. Multivariate analysis identified LS, hyaluronic acid, IV collagen, and the presence of splenomegaly as independent predictors of PLF. The cutoff value of LS for predicting PLF and grade B (or greater) PLF was 11.75 and 11.9 kPa, respectively. LS was superior to PHT in predicting PLF or greater than grade B PLF (0.72 vs. 0.60, 0.76 vs. 0.59, P < 0.05).

CONCLUSION

LS measured by SWE can predict risk of PLF with greater accuracy than PHT.

Non-invasive evaluation of portal hypertension using ultrasound elastography

Portal hypertension (PH) leads to serious complications, such as bleeding from gastroesophageal varices, ascites and portosystemic encephalopathy in patients with chronic liver disease (CLD). Gold standard methods for assessing PH and its complications include the measurement of hepatic venous pressure gradient and endoscopy; however, these are invasive, expensive and not available at all centres. Therefore, non-invasive alternatives have been the subject of extensive investigation over the last 20years. The present review focuses on the role of ultrasound elastography - a novel group of non-invasive techniques used to measure stiffness in target organs. In the context of CLD these methods are used to identify the presence of PH, its severity, and the risk of PH-related complications. The rationale, accumulated evidence, advantages and limitations of liver and spleen stiffness measurements evaluated by different ultrasound elastography techniques in patients with advanced CLD is discussed. Recent data regarding the use of ultrasound elastography techniques in patients with non-cirrhotic forms of PH are also described.

LncRNA GHET1 activated by H3K27 acetylation promotes cell tumorigenesis through regulating ATF1 in hepatocellular carcinoma

BACKGROUND

GHET1 is one of tumor-related lncRNAs. We aimed to explore the functional involvement of GHET1 in hepatocellular carcinoma (HCC).

METHODS

In this study, HCC tissues and the paired normal tissues were collected for the detection of target molecules. The expression level of target molecules in HCC tissues or cell lines was determined by qRT-PCR and western blot, respectively. The expression of endogenous GHET1 and ATF1 was modulated by using cell transfection. RNA pull down assay was performed to examine the interaction between GHET1 and ATF1. ChIP assay was conducted to determine the H3K27Ac acetylation of GHET1 promoter.

RESULTS

H3K27 acetylation activated-GHET1 was upregulated in HCC tissues and cell lines. Moreover, GHET1 silencing could inhibit the proliferation, migration, invasion and EMT of HCC cells in vitro. GHET1 could regulate the expression of ATF1 mRNA and protein; RNA pull-down assays supported that GHET1 could bind to ATF1 protein. Furthermore, overexpression of ATF1 almost completely reversed the GHET1 knockdown mediated inhibition on the proliferation, migration, invasion and EMT of HCC cells.

CONCLUSION

LncRNA GHET1 was intimately involved in the occurrence and development of HCC through regulating ATF1.

Factors associated with contralateral liver hypertrophy after unilateral radioembolization for hepatocellular carcinoma

INTRODUCTION

Radioembolization for the treatment of hepatocellular carcinoma (HCC) induces liver volume changes referred to as "atrophy-hypertrophy complex". The aim of this study was to investigate lobar liver volume changes after unilateral radioembolization and to search for factors associated with hypertrophy of the untreated lobe.

MATERIALS AND METHODS

Seventy-five patients were retrospectively evaluated. Inclusion criteria were: (1) right-lobar radioembolization for unresectable unilateral HCC, (2) available liver computed tomography scans before, 1, 3, and at least 6 months after radioembolization. Baseline patient characteristics included clinical features, laboratory results, spleen volume, and liver computed tomography. Absolute and relative (referred to the whole liver volume) liver lobe volumes (LLV) as well as relative LLV (rLLV) change per month were evaluated and compared.

RESULTS

Absolute and relative contralateral LLV continuously increased after radioembolization (p<0.001). Mean relative contralateral LLV increased from 36±11.6% before radioembolization to 50±15.3% 6 months after radioembolization. Median contralateral rLLV increase/month (within first 6 months) was 2.5%. Contralateral rLLV increase/month was significantly lower in patients with ascites (p = 0.017) or platelet count <100/nl (p = 0.009). An inverse correlation of contralateral rLVV increase/month with spleen volume (p = 0.017), patient age (p = 0.024), Child Pugh score (p = 0.001), and tumor burden (p = 0.001) was found.

CONCLUSIONS

Significant contralateral hypertrophy and ipsilateral atrophy were common after unilateral radioembolization. Small spleen volume, low patient age, low Child Pugh score, absence of ascites, platelet count ≥100/nl, and low tumor burden were associated with increased contralateral hypertrophy, indicating that younger patients with compensated cirrhosis might benefit most from radioembolization in a "bridge-to-resection" setting.

Hepatocellular carcinoma: early-stage management challenges

Hepatocellular carcinoma (HCC) is a major cause of cancer death and is increasing in incidence. This review focuses on HCC surveillance and treatment of early-stage disease, which are essential to improving outcomes. Multiple societies have published HCC surveillance guidelines, but screening efforts have been limited by noncompliance and overall lack of testing for patients with undiagnosed chronic liver disease. Treatment of early-stage HCC has become increasingly complex due to expanding therapeutic options and better outcomes with established treatments. Surgical indications for HCC have broadened with improved preoperative liver testing, neoadjuvant therapy, portal vein embolization, and perioperative care. Advances in post-procedural monitoring have improved efficacies of transarterial chemoembolization and radiofrequency ablation, and novel therapies involving delivery of radiochemicals are being studied in small trials. Finally, advances in liver transplantation have allowed for expanded indications beyond Milan criteria with non-inferior outcomes. More clinical trials evaluating new therapies and multimodal regimens are necessary to help clinicians design better treatment algorithms and improve outcomes.

Diagnosis of cirrhosis and portal hypertension: imaging, non-invasive markers of fibrosis and liver biopsy

The concept of ‘cirrhosis’ is evolving and it is now clear that compensated and decompensated cirrhosis are completely different in terms of prognosis. Furthermore, the term ‘advanced chronic liver disease (ACLD)’ better reflects the continuum of histological changes occurring in the liver, which continue to progress even after cirrhosis has developed, and might regress after removing the etiological factor causing the liver disease. In compensated ACLD, portal hypertension marks the progression to a stage with higher risk of clinical complication and requires an appropriate evaluation and treatment. Invasive tests to diagnose cirrhosis (liver biopsy) and portal hypertension (hepatic venous pressure gradient measurement and endoscopy) remain of crucial importance in several difficult clinical scenarios, but their need can be reduced by using different non-invasive tests in standard cases. Among non-invasive tests, the accepted use, major limitations and major benefits of serum markers of fibrosis, elastography and imaging methods are summarized in the present review.

Cone Beam CT-Guided Chemoembolization of Probable Hepatocellular Carcinomas Smaller than 1 cm in Patients at High Risk of Hepatocellular Carcinoma

PURPOSE

To evaluate the effectiveness and safety of cone-beam computed tomography (CT)-guided chemoembolization for probable hepatocellular carcinomas (HCCs) smaller than 1 cm in patients at high risk for HCC.

MATERIALS AND METHODS

From December 2009 to May 2014, 57 patients (43 male and 14 female; mean age, 61.1 y) at high risk for HCC underwent cone-beam CT-guided conventional chemoembolization for 79 treatment-naive probable HCCs < 1 cm. Probable HCCs were diagnosed when hepatic nodules showed arterial enhancement and washout on dynamic CT or magnetic resonance images. The Kaplan-Meier method and Cox proportional-hazards regression were used to evaluate the time to local progression (TTLP), time to progression (TTP), and overall survival (OS).

RESULTS

Initial follow-up images obtained 2-3 months after chemoembolization showed complete response in all 79 tumors. The 1-, 2-, and 3-year local progression rates were 10.4%, 21.7%, and 35.7%, respectively. Subsegmental catheterization (P < .001; hazard ratio [HR] = .041) and segmental catheterization (P = .001; HR = .049) were significantly associated with longer TTLP. The 1-, 2-, and 3-year progression rates were 40.5%, 66.7%, and 78.6%, respectively. Tumor multiplicity (P = .004; HR = 2.612) was a significant risk factor for shorter TTP. The 1-, 2-, and 3-year OS rates were 100%, 98.2%, and 88.5%, respectively. Child-Turcotte-Pugh class B disease (P = .029; HR = 5.989) was significantly associated with shorter OS. No complications occurred after chemoembolization.

CONCLUSIONS

Cone-beam CT-guided chemoembolization can be a useful and safe option for probable HCCs < 1 cm in patients at high risk for HCC.

Perioperative Care of Patients With Liver Cirrhosis: A Review

The incidence of cirrhosis is rising, and identification of these patients prior to undergoing any surgical procedure is crucial. The preoperative risk stratification using validated scores, such as Child-Turcotte-Pugh (CTP) and Model for End-Stage Liver Disease, perioperative optimization of hemodynamics and metabolic derangements, and postoperative monitoring to minimize the risk of hepatic decompensation and complications are essential components of medical management. The advanced stage of cirrhosis, emergency surgery, open surgeries, old age, and coexistence of medical comorbidities are main factors influencing the clinical outcome of these patients. Perioperative management of patients with cirrhosis warrants special attention to nutritional status, fluid and electrolyte balance, control of ascites, excluding preexisting infections, correction of coagulopathy and thrombocytopenia, and avoidance of nephrotoxic and hepatotoxic medications. Transjugular intrahepatic portosystemic shunt may improve the CTP class, and semielective surgeries may be feasible. Emergency surgery, whenever possible, should be avoided.

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.

Personalized treatment of patients with very early hepatocellular carcinoma

Hepatocellular carcinoma (HCC), in its very early stage, is heterogeneous both in terms of liver function (i.e., presence or absence of portal hypertension, model for end-stage liver disease score, Child-Pugh score 5 or 6, bilirubin level) and tumor characteristics (i.e., location, alpha-fetoprotein values, pathological features such as microvascular invasion, tumor grade and satellitosis). Existing evidence in comparing different curative options for patients with very early HCC is poor due to small sample sizes and lack of solid subgroup analyses. Large observational studies are available, with the potential to identify effective interventions in different subgroup of patients and to discover which treatments work "in a real world setting". These studies suggest some important treatment selection strategies in very early HCC patients. According to extent of liver resection, and liver function, percutaneous ablation or liver resection are the recommended first line therapies in these patients. Laparoscopic surgery (resection or ablation) is the preferable strategy when the tumor is in the surface of the liver or close to extra-hepatic organs. Due to scarce donor resources and competition with patients at high transplant benefit (HCC patients unsuitable for non-transplant radical therapies and non-HCC patients with decompensated cirrhosis), transplantation is recommended only as second line therapy in patients with very early stage HCC in case of tumor recurrence or liver failure after ablation or liver resection.

Noninvasive tools and risk of clinically significant portal hypertension and varices in compensated cirrhosis: The "Anticipate" study

In patients with compensated advanced chronic liver disease (cACLD), the presence of clinically significant portal hypertension (CSPH) and varices needing treatment (VNT) bears prognostic and therapeutic implications. Our aim was to develop noninvasive tests-based risk prediction models to provide a point-of-care risk assessment of cACLD patients. We analyzed 518 patients with cACLD from five centers in Europe/Canada with paired noninvasive tests (liver stiffness measurement [LSM] by transient elastography, platelet count, and spleen diameter with calculation of liver stiffness to spleen/platelet score [LSPS] score and platelet-spleen ratio [PSR]) and endoscopy/hepatic venous pressure gradient measurement. Risk of CSPH, varices, and VNT was modeled with logistic regression. All noninvasive tests reliably identified patients with high risk of CSPH, and LSPS had the highest discrimination. LSPS values above 2.65 were associated with risks of CSPH above 80%. None of the tests identified patients with very low risk of all-size varices, but both LSPS and a model combining TE and platelet count identified patients with very low risk (<5%) risk of VNT, suggesting that they could be used to triage patients requiring screening endoscopy. LSPS values of <1.33 were associated with a <5% risk of VNT, and 26% of patients had values below this threshold. LSM combined with platelet count predicted a risk <5% of VNT in 30% of the patients. Nomograms were developed to facilitate point-of-care risk assessment.

CONCLUSION

A significant proportion of patients with a very high risk of CSPH, and a population with a very low risk of VNT can be identified with simple, noninvasive tests, suggesting that these can be used to individualize medical care. (Hepatology 2016;64:2173-2184).

Liver failure after hepatectomy: A risk assessment using the pre-hepatectomy shear wave elastography technique

OBJECTIVE

To determine the efficacy of liver stiffness (LS) measurements utilizing the Shear Wave Elastography (SWE) technique for predicting post-hepatectomy liver failure (PHLF) among patients with hepatocellular carcinoma (HCC).

METHODS

Data from eighty consecutive patients who were undergoing hepatectomy for HCC were prospectively identified and evaluated with preoperative SWE. The SWE was measured with advanced ultrasound equipment (Philips EPIQ7; Philips Healthcare, Seattle, WA, USA). PHLF classification was defined according to the International Study Group of Liver Surgery Recommendations (ISGLS).

RESULTS

SWE was successfully performed in 77 patients. According to the ISGLS criteria, PHLF occurred in 35.1% of patients (27 patients), including 2/25 patients with Grade A/B, respectively. Elevated SWE values (P=0.002) and histological cirrhosis (P=0.003) were independent predictors of PHLF according to the multivariate analysis. Patients with SWE values higher than or equal to 6.9kPa were identified at higher risk of PHLF (area under the curve: 0.843, sensitivity: 77.8% and specificity: 78.0%). Postoperative dynamic course of the median the Model For End-stage Liver Disease (MELD) score showed irregular changes among patients with an SWE >6.9kPa. Patients with an SWE <6.9kPa, postoperative dynamic course of the median MELD score gradually decreased.

CONCLUSION

LS measured with SWE is a valid and reliable method for the prediction of PHLF grade A/B among patients with HCC. SWE could become a routine examination for the preoperative evaluation of PHLF.

Controversies and evidence of hepatic resection for hepatocellular carcinoma

Symptoms of early hepatocellular carcinoma (HCC) often go unnoticed, so more than half of patients with primary HCC are diagnosed after their disease has already reached an intermediate or advanced stage, or after portal hypertension has appeared. While hepatic resection is widely recognized as a first-line therapy to treat very early or early HCC, its use in treating intermediate or advanced HCC or HCC involving portal hypertension remains controversial. Here we review PubMed-indexed literature covering the use of hepatic resection for such patients. The available evidence strongly suggests that, as a result of improvements in surgical techniques and perioperative care, hepatic resection can benefit many patients with intermediate or advanced HCC or with HCC associated with portal hypertension.

Novel implications in the treatment of hepatocellular carcinoma

Worldwide hepatocellular carcinoma remains one of the leading causes of cancer-related death, associated with a poor prognosis due to late diagnosis in the majority of cases. Physicians at care are frequently confronted with patients who are ineligible for curative treatment such as liver resection, transplantation or radiofrequency ablation. Besides established palliative locoregional therapies, such as ablation or chemoembolization, new treatment options, such as microwave ablation, drug-eluting bead transarterial chemoembolization or selective internal radiation therapy, are emerging; however, data from randomized controlled trials are still lacking. In order to achieve optimal tumor control, patients should receive tailored treatment concepts, considering their tumor burden, liver function and performance status, instead of strictly assigning patients to treatment modalities following algorithms that may be partly very restrictive. Palliative locoregional pretreatment might facilitate downstaging to ensure later curative resection or transplantation. In addition, the combined utilization of different locoregional treatment options or systemic co-treatment has been the subject of several trials. In cases where local tumor control cannot be achieved, or in the scenario of extrahepatic spread, sorafenib remains the only approved systemic therapy option. Alternative targeted therapies, such as immune checkpoint inhibitors have shown encouraging preliminary results, while data from phase III studies are pending.

The impact of clinically significant portal hypertension on the prognosis of patients with hepatocellular carcinoma after radiofrequency ablation: a propensity score matching analysis

OBJECTIVES

To assess the impact of clinically significant portal hypertension (CSPH) on the prognosis of patients with hepatocellular carcinoma (HCC) undergoing radiofrequency ablation (RFA).

METHODS

We retrospectively enrolled 280 treatment-naïve early-stage HCC patients who had Child-Pugh grade A or B and received upper gastrointestinal endoscopy at the time of HCC diagnosis. CSPH was defined as (1) a platelet count < 100,000/mm³ associated with splenomegaly and/or (2) the presence of oesophageal/gastric varices by endoscopy. Factors determining poor overall survival and recurrence after RFA were analysed by Cox proportional hazards model and propensity score matching analysis.

RESULTS

A total of 192 (68.6 %) patients had CSPH. The cumulative 5-year survival rates were 50.6 % and 76.7 % in patients with and without CSPH, respectively (p = 0.015). Based on multivariate analysis, age > 65 years (hazard ratio (HR) 1.740, p = 0.025), serum albumin levels ≤ 3.5 g/dL (HR 3.268, p < 0.001) and multiple tumours (HR 1.693, p = 0.046), but not CSPH, were independent risk factors associated with poor overall survival after RFA. Moreover, the overall survival rates were comparable between patients with and without CSPH after adjusting for confounding factors via propensity score matching analysis.

CONCLUSIONS

CSPH was not associated with poor outcomes after RFA.

KEY POINTS

• CSPH was common in HCC patients who underwent RFA therapy. • CSPH was not an independent risk factor in determining poor prognosis. • Serum albumin level was more important to determine the outcomes.

HVPG signature: A prognostic and predictive tool in hepatocellular carcinoma

Hepatic venous pressure gradient (HVPG) measurement provides independent prognostic value in patients with cirrhosis, and the prognostic and predictive role of HVPG in hepatocellular carcinoma (HCC) also has been explored. The management of HCC is limited to the European Association for the Study of the Liver (EASL) and American Association for the Study of Liver Diseases (AASLD) guidelines that consider that HVPG≥10 mmHg to be a contraindication for hepatic resection (HR), otherwise other treatment modalities are recommended. Current studies show that a raised HVPG diagnosed directly or indirectly leads to a negative prognosis of patients with HCC and cirrhosis, but HVPG greater than 10 mmHg should not be regarded as an absolute contraindication for HR. Selecting direct or surrogate measurement of HVPG is still under debate. Only several studies reported the impact of HVPG in negative prognosis of HCC patients after liver transplantation (LT) and the value of HVPG in the prediction of HCC development, which need to be further validated.

Assessment of Preoperative Liver Function in Patients with Hepatocellular Carcinoma - The Albumin-Indocyanine Green Evaluation (ALICE) Grade

BACKGROUND

Most patients with hepatocellular carcinoma (HCC) have underlying liver disease, therefore, precise preoperative evaluation of the patient's liver function is essential for surgical decision making.

METHODS

We developed a grading system incorporating only two variables, namely, the serum albumin level and the indocyanine green retention rate at 15 minutes (ICG R15), to assess the preoperative liver function, based on the overall survival of 1868 patients with HCC who underwent liver resection. We then tested the model in a European cohort (n = 70) and analyzed the predictive power for the postoperative short-term outcome.

RESULTS

The Albumin-Indocyanine Green Evaluation (ALICE) grading system was developed in a randomly assigned training cohort: linear predictor = 0.663 × log10ICG R15 (%)-0.0718 × albumin (g/L) (cut-off value: -2.20 and -1.39). This new grading system showed a predictive power for the overall survival similar to the Child-Pugh grading system in the validation cohort. Determination of the ALICE grade in Child-Pugh A patients allowed further stratification of the postoperative prognosis. This result was reproducible in the European cohort. Determination of the ALICE grade allowed better prediction of the risk of postoperative liver failure and mortality (ascites: grade 1, 2.1%; grade 2, 6.5%; grade 3, 16.0%; mortality: grade 1, 0%; grade 2, 1.3%; grade 3, 5.3%) than the previously reported model based on the presence/absence of portal hypertension.

CONCLUSIONS

This new grading system is a simple method for prediction of the postoperative long-term and short-term outcomes.

Treatment of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) represents the most frequent primary liver cancer. This disease usually arises as a result of a chronic liver disease, but may appear without any underlying disease. In most units, the staging and treatment decision in patients with HCC follows the Barcelona Clínic Liver Cancer (BCLC) strategy. Following this approach, patients diagnosed with HCC are classified according to tumour burden, liver function and ECOG-Performance Status (PS). This stratifies patients according to prognosis and links each stage with the evidence-based treatment approach to be first considered. Patients correspond to BCLC stage 0 (very early) when the tumour burden accounts for just one nodule and it measures 2 cm or less. BCLC stage A includes patients with just one nodule or 3 nodules under 3 cm. Both stages 0 and A gather patients with preserved liver function according to Child-Pugh score, being Child-Pugh A. Patients in BCLC B stage (intermediate stage) are patients with multinodular liver cancer confined to the liver, without extrahepatic disease, ECOG-PS 0 and preserved liver function (Child-Pugh A or B). Patients with portal venous invasion, extrahepatic disease or cancer-related symptoms measured by PS (1-2) and still with preserved liver function correspond to BCLC C (advanced) stage. Finally, patients classified in BCLC stage D are those with a severe alteration of liver function (Child-Pugh C) or severe cancer-related symptoms with PS above 2. In very early and early stages (BCLC 0 and A), treatment options include surgical treatment, ablation and liver transplantation. Intermediate stage (BCLC B) patients should be considered for transarterial chemoembolization. At advanced stage (BCLC C), the recommended treatment is sorafenib. Finally, at the end stage (BCLC D), symptomatic treatment is the suggested option. The treatment stage migration concept refers to patients who at first glance would be treated with the option that corresponds to their BCLC stage but, because of any coexisting comorbidity, technical issue or even treatment failure/progression but still within the original stage cannot be treated by the initial suggested treatment. These patients then move to the treatment that would correspond to the next stage/s.

Evidence-Based Diagnosis, Staging, and Treatment of Patients With Hepatocellular Carcinoma

Evidence-based management of patients with hepatocellular carcinoma (HCC) is key to their optimal care. For individuals at risk for HCC, surveillance usually involves ultrasonography (there is controversy over use of biomarkers). A diagnosis of HCC is made based on findings from biopsy or imaging analyses. Molecular markers are not used in diagnosis or determination of prognosis and treatment for patients. The Barcelona Clinic Liver Cancer algorithm is the most widely used staging system. Patients with single liver tumors or as many as 3 nodules ≤3 cm are classified as having very early or early-stage cancer and benefit from resection, transplantation, or ablation. Those with a greater tumor burden, confined to the liver, and who are free of symptoms are considered to have intermediate-stage cancer and can benefit from chemoembolization if they still have preserved liver function. Those with symptoms of HCC and/or vascular invasion and/or extrahepatic cancer are considered to have advanced-stage cancer and could benefit from treatment with the kinase inhibitor sorafenib. Patients with end-stage HCC have advanced liver disease that is not suitable for transplantation and/or have intense symptoms. Studies now aim to identify molecular markers and imaging techniques that can detect patients with HCC at earlier stages and better predict their survival time and response to treatment.

Long-term impact of liver function on curative therapy for hepatocellular carcinoma: application of the ALBI grade

BACKGROUND

Application of curative therapy for hepatocellular carcinoma is crucially dependent on underlying liver function. Using the recently described ALBI grade we examined the long-term impact of liver dysfunction on survival of early-stage hepatocellular carcinoma (HCC) patients.

METHODS

This cohort study comprised 2559 HCC patients from different geographic regions, all treated with curative intent. We also examined the relation between indocyanine green (ICG) clearance and ALBI score. Survival was measured from the date of treatment to the date of death or last follow-up.

RESULTS

The ALBI score correlated well with ICG clearance. Among those undergoing surgical resection, patients with ALBI grade-1 (good liver function) survived approximately twice as long as those with ALBI grade-2 (less good liver function), although more than 90% of these patients were classified as Child-Pugh (C-P) grade A. In the cohort receiving ablative therapies, there was a similar difference in survival between ALBI grade-1 and grade-2. Cox regression analysis confirmed that the ALBI score along with age, gender, aetiology and tumour factors (AFP, tumour size/number and vascular invasion) independently influenced survival in HCC patients receiving curative treatments.

CONCLUSIONS

The ALBI score represents a simple approach to the assessment of liver function in patients with HCC. After potentially curative therapy, those with ALBI grade-1 survived approximately twice as long as those with ALBI grade-2. These data suggest that ALBI grade-1 patients are appropriately treated with surgical resection whereas ALBI grade-2 patients may, where the option exists, be more suitable for liver transplantation or the less invasive curative ablative therapies.

Albumin–bilirubin versus Child–Pugh score as a predictor of outcome after liver resection for hepatocellular carcinoma

Background

The Child–Pugh (CP) score is used widely to assess liver function and predict postoperative outcomes in patients with hepatocellular carcinoma (HCC). Recently, the albumin–bilirubin (ALBI) score has been validated as a predictor of overall survival in these patients. This study aimed to compare the ability of the ALBI and CP scores to predict outcomes in patients with HCC after liver resection with curative intent.

Methods

Consecutive patients who underwent liver resection with curative intent for HCC between January 2007 and July 2013 were included in this retrospective study. The performance of the ALBI score in predicting postoperative liver failure (PHLF) and long-term survival was compared with that of the CP score.

Results

A total of 1242 patients were enrolled. Of these, 166 (13·4 per cent) experienced PHLF. The area under the receiver operating characteristic (ROC) curve of the ALBI score for predicting PHLF was greater than that of the CP score (0·723 versus 0·607; P &lt; 0·001). Similar to findings for CP grade, the incidence and severity of PHLF increased with increasing ALBI grade. The ALBI grade stratified patients into at least two distinct overall survival cohorts (P &lt; 0·001), whereas the CP grade did not. The ALBI grade also classified patients with CP grade A disease into two distinct overall survival cohorts (P &lt; 0·001), and overall survival rates in the group with poorer survival were similar to those in the majority of patients with CP grade B disease. Both CP and ALBI scores had low power in predicting disease-free survival.

Conclusion

The ALBI grade predicted PHLF and overall survival in patients with HCC undergoing liver resection with curative intent more accurately than the CP grade.

Cancer and liver cirrhosis: implications on prognosis and management

Liver cirrhosis, the end-stage of every chronic liver disease, is not only the major risk factor for the development of hepatocellular carcinoma but also a limiting factor for anticancer therapy of liver and non-hepatic malignancies. Liver cirrhosis may limit surgical and interventional approaches to cancer treatment, influence pharmacokinetics of anticancer drugs, increase side effects of chemotherapy, render patients susceptible for hepatotoxicity, and ultimately result in a competitive risk for morbidity and mortality. In this review, we provide a concise overview about the impact of liver cirrhosis on the management and prognosis of patients with primary liver cancer or non-hepatic malignancies.

[Diagnosis and treatment of hepatocellular carcinoma. Update consensus document from the AEEH, SEOM, SERAM, SERVEI and SETH]

Hepatocellular carcinoma is the most common primary malignancy of the liver and one of the most frequent causes of death in patients with liver cirrhosis. Simultaneously with the recognition of the clinical relevance of this neoplasm, in recent years there have been important developments in the diagnosis, staging and treatment of HCC. Consequently, the Asociación Española para el Estudio del Hígado has driven the need to update clinical practice guidelines, continuing to invite all the societies involved in the diagnosis and treatment of this disease to participate in the drafting and approval of the document (Sociedad Española de Trasplante Hepático, Sociedad Española de Radiología Médica, Sociedad Española de Radiología Vascular e Intervencionista y Sociedad Española de Oncología Médica). The clinical practice guidelines published in 2009 accepted as Clinical Practice Guidelines of the National Health System has been taken as reference document, incorporating the most important advances that have been made in recent years. The scientific evidence for the treatment of HCC has been evaluated according to the recommendations of the National Cancer Institute (www.cancer.gov) and the strength of recommendation is based on the GRADE system.

Therapeutic efficacy of percutaneous microwave coagulation versus liver resection for single hepatocellular carcinoma ≤3 cm with Child-Pugh A cirrhosis

AIMS

This study aimed to compare the therapeutic efficacy of liver resection (LR) and percutaneous microwave coagulation therapy (PMCT) for single hepatocellular carcinoma ≤3 cm (HCC) in cirrhotic livers.

METHODS

In this study, 190 patients with single HCC ≤3 cm and Child-Pugh A cirrhosis were retrospectively reviewed. Among these patients, 122 patients underwent LR, and 68 patients received PMCT. The therapeutic efficacy and complications were compared between the two procedures.

RESULTS

There was no treatment-related hospital mortality in either group. Major complications were significantly more frequent in the LR group compared to the PMCT group (22.1% vs 5.9%, p = 0.004). The 1-, 3-, and 5-year OS rates for the LR group and PMCT group were 98.4%, 93.6%, 55.2% and 97.1%, 87.7%, 51%, respectively. There was no significant difference in OS rates between the LR group and PMCT group (p = 0.153). The 1-, 3-, and 5-year DFS rates were 96.7%, 70.5% and 43.7%, respectively, in the LR group, which were significantly higher compared to the PMCT group (92.6%, 50.5% and 26.3%, p = 0.006). Subgroup analyses revealed that HCC patients with portal hypertension (PH), OS and DFS were similar between the two groups.

CONCLUSIONS

LR may provide better DFS and lower recurrence rates than PMCT for single HCC ≤3 cm and Child-Pugh A cirrhosis. For HCC patients with PH, PMCT may provide therapeutic effects that are similar to LR.

Liver surgery in cirrhosis and portal hypertension

The prevalence of hepatic cirrhosis in Europe and the United States, currently 250 patients per 100000 inhabitants, is steadily increasing. Thus, we observe a significant increase in patients with cirrhosis and portal hypertension needing liver resections for primary or metastatic lesions. However, extended liver resections in patients with underlying hepatic cirrhosis and portal hypertension still represent a medical challenge in regard to perioperative morbidity, surgical management and postoperative outcome. The Barcelona Clinic Liver Cancer classification recommends to restrict curative liver resections for hepatocellular carcinoma in cirrhotic patients to early tumor stages in patients with Child A cirrhosis not showing portal hypertension. However, during the last two decades, relevant improvements in preoperative diagnostic, perioperative hepatologic and intensive care management as well as in surgical techniques during hepatic resections have rendered even extended liver resections in higher-degree cirrhotic patients with portal hypertension possible. However, there are few standard indications for hepatic resections in cirrhotic patients and risk stratifications have to be performed in an interdisciplinary setting for each individual patient. We here review the indications, the preoperative risk-stratifications, the morbidity and the mortality of extended resections for primary and metastatic lesions in cirrhotic livers. Furthermore, we provide a review of literature on perioperative management in cirrhotic patients needing extrahepatic abdominal surgery and an overview of surgical options in the treatment of hepatic cirrhosis.

Perioperative blood transfusion does not influence recurrence-free and overall survivals after curative resection for hepatocellular carcinoma: A Propensity Score Matching Analysis

BACKGROUND & AIMS

Whether perioperative blood transfusions (PBTs) negatively impact oncologic outcomes after curative resection for HCC remains controversial. We aimed to identify the independent predictive factors of PBT for curative resection of hepatocellular carcinoma (HCC), and to investigate the impact of PBT on long-term recurrence and survivals after resection.

METHODS

Of 1103 patients who underwent curative liver resection for HCC between 1999 and 2010, 285 (25.8%) patients received PBT. Univariable and multivariable regression analyses were used to identify independent predictive factors of PBT. Propensity scores and Cox regression analyses were used to compare the overall survival (OS) and recurrence-free survival (RFS) between patients who did and did not receive PBT.

RESULTS

Multivariable regression analysis revealed that performance status, preoperative hemoglobin, cirrhosis, portal hypertension, tumor rupture, tumor size, macroscopic vascular invasion, and intraoperative blood loss were independent predictive factors of PBT for HCC resection. Propensity score matching analysis created 234 pairs of patients. Before propensity matching, PBT was significantly associated with increased risks of OS (HR: 2.455, 95% CI: 2.077-2.901, p<0.001) and RFS (HR: 2.018, 95% CI: 1.718-2.370, p<0.001) in the entire cohort. After propensity matching, PBT was not significantly associated with increased risks of OS (HR: 1.229, 95% CI: 0.988-1.527, p=0.063) and RFS (HR: 1.188, 95% CI: 0.960-1.469, p=0.113). After adjustment for other prognostic variables in the propensity matched cohort, PBT was still found not to be associated with OS and RFS after HCC resection.

CONCLUSIONS

The present study identified that PBT did not influence RFS and OS after curative resection of HCC.

Hepatic venous pressure gradient in the preoperative assessment of patients with resectable hepatocellular carcinoma

BACKGROUNDS & AIMS

To assess the relationship existing between hepatic venous pressure gradient (HVPG) and the occurrence of post-hepatectomy liver failure (PHLF) grade B/C after resection of hepatocellular carcinoma (HCC) and persistent worsening of liver function.

METHODS

Data from 70 consecutive prospectively enrolled HCC patients undergoing resection were collected and analysed. PHLF grade B/C was defined by the International Study Group of Liver Surgery recommendations. The appearance of unresolved decompensation was also analysed.

RESULTS

Postoperative and 90-day mortality were null. The median HVPG value was 9mmHg (range: 4-18) and the median Model for End-stage Liver Disease (MELD) score was 8 (range: 6-14); 34 patients had an HVPG ⩾10mmHg (48.6%). Forty-nine patients had an uneventful (Grade A) postoperative course, including 17 with an HVPG ⩾10mmHg (24.2% of 70 patients). Grade B complications occurred in 20 patients (3 with an HVPG <10mmHg and 17 with an HVPG ⩾10mmHg; p<0.001); only one grade C complication occurred in a patient with an HVPG <10mmHg, subsequently successfully undergoing liver transplantation. Median MELD score returned to preoperative values after a transient postoperative increase, regardless of the HVPG values; after three months, it returned to the preoperative of 8 in patients with an HVPG <10mmHg and of 9 in patients with an HVPG ⩾10mmHg (p=0.077 and 0.076 at paired test, respectively).

CONCLUSIONS

The hepatic venous pressure gradient can be used before surgery to stratify the risk of PHLF but the proposed cut-off of 10mmHg excludes approximately one-quarter of the patients who would benefit from surgery without short to mid-term postoperative sequelae.

Surgery for hepatocellular carcinoma presenting with variceal bleeding: The eastern experience

BACKGROUND

Variceal bleeding can be the first manifestation of patients with newly diagnosed hepatocellular carcinoma (HCC), and effective treatments deserve to be explored for these patients.

METHODS

A prospectively collected database of HCC patients undergoing hepatectomy identified 75 patients who presented with variceal bleeding. Among them, 31 patients underwent concomitant Hassab's operation. The clinical variables and outcomes were compared between the Hassab and non-Hassab groups.

RESULTS

The postoperative morbidity and 90-days mortality were 44.0% and 6.7% respectively. Variceal re-bleeding and tumor recurrence occurred in 28.8% and 52.1% of surviving patients after surgery, and the 1-, 3-, and 5-year overall survival rates were 87.7, 66.8, and 50.3%. There were no significant differences in morbidity, mortality and postoperative recurrence between the Hassab and non-Hassab groups. However, patients in the Hassab group had significantly higher 1-, 3-, and 5-year overall survival rates (P = 0.038), and significantly lower rate of re-bleeding (13.3% vs. 39.5%, P = 0.014) than those in the non-Hassab group. On multivariable analysis, concomitant Hassab's operation was independently predicted longer overall survival.

CONCLUSION

Liver resection could safely be performed in selected patients with HCC who presented with variceal bleeding, and concomitant Hassab's operation may improve long-term prognosis for these patients.

Systematic review of peri-operative nutritional support for patients undergoing hepatobiliary surgery

BACKGROUND

Malnutrition is prevalent among peri-operative patients undergoing hepatobiliary surgery and is an important prognostic factor. Both hepatobiliary disease and surgical trauma significantly affects body's metabolism and environment. Therefore, it is very important for patients with liver diseases undergoing hepatobiliary surgery to receive essential nutritional support during peri-operative period.

METHODS

We summarized our clinical experience and reviewed of related literature to find the way for implementing the appropriate nutritional strategy.

RESULTS

We found after comprehensively evaluating nutrition status, function of liver and gastrointestinal tract, nutritional strategy would be selected correctly. In severe malnutrition, initiation of enteral nutrition (EN) and/or parenteral nutrition (PN) with essential or special formulae is often recommended. Especially nasojejunal feeding is indicated that early application can improve nutritional status and liver function, reduce complications and prolong survival.

CONCLUSIONS

The reasonable peri-operative nutritional support therapy can improve the effect of surgical treatment and promote the patients' recovery.

The long-term benefits of nucleos(t)ide analogs in compensated HBV cirrhotic patients with no or small esophageal varices: A 12-year prospective cohort study

BACKGROUND & AIMS

Esophageal varices (EV) are a marker of disease severity in compensated cirrhosis due to hepatitis B virus (HBV) which predicts also the risk of hepatocellular carcinoma (HCC), clinical decompensation and anticipated liver related death. The dynamics and prognostic significance of EV in patients under long-term HBV suppression by nucleos(t)ide analogs (NUC), are poorly known.

METHODS

A standardized protocol (Baveno) including 414 upper gastrointestinal (GI) endoscopies was applied to 107 HBeAg-negative compensated cirrhotic patients (93% Child-Pugh A) during a median of 12 (range 2 to 17) years of NUC therapy. Patients who initially started on lamivudine (LMV) and then developed resistance (LMV-R), were rescued by early administration of adefovir, or were switched to tenofovir. Surveillance included serum HBV DNA every three months and abdominal ultrasound every six months.

RESULTS

Twenty-seven patients had baseline F1 EV which regressed in 18, remained unchanged in eight and progressed in one patient; the 12-year cumulative incidence of EV regression was 83% (95% CI: 52-92%). De novo F1/F2 EV developed in 6/80 patients with a 12-year cumulative incidence of 10% (95% CI: 5-20%). Six of seven patients with de novo varices or progression of pre-existing varices had either a clinical breakthrough due to LMV-R and/or developed a HCC. No bleedings from ruptured EV occurred, 12 patients died (9 HCC) and 15 were transplanted (13 HCC): the 12-year cumulative incidence of HCC and overall survival was 33% (95% CI: 24-42%) and 76% (95% CI: 67-83%), respectively.

CONCLUSIONS

Long-term pharmacological suppression of HBV in HBeAg-seronegative patients with compensated cirrhosis leads to a significant regression of pre-existing EV accompanied by a negligible risk of developing de novo EV.

Angiotensin receptor blockers improve survival outcomes after radiofrequency ablation in hepatocarcinoma patients

BACKGROUND AND AIM

Inhibition of angiotensin II synthesis seems to decrease hepatocellular carcinoma recurrence after radical therapies; however, data on the adjuvant role of angiotensin II receptor 1 blockers (sartans) are still lacking. The aim of the study was to evaluate whether sartans delay time to recurrence and prolong overall survival in hepatocellular carcinoma patients after radiofrequency ablation.

METHODS

Data on 153 patients were reviewed. The study population was classified into three groups: 73 (47.8%) patients who received neither angiotensin-converting enzyme inhibitors nor sartans (group 1), 49 (32%) patients treated with angiotensin-converting enzyme inhibitors (group 2), and 31 (20.2%) patients treated with sartans (group 3). Survival outcomes were analysed by means of Kaplan-Meier analysis and compared with log-rank test.

RESULTS

In the whole study population, 85.6% of patients were in Child-Pugh A class and 89.6% in Barcelona Clinic Liver Cancer A stage. Median maximum tumor diameter was 30 mm (10-40) and alpha fetoprotein was 25 (1.1-2100) UI/mL. No differences in baseline characteristics among the three groups were reported. Median overall survival was 48 months (95% confidence interval: 31-58) in group 1, 72 months (49-89) in group 2, and 84 months (58-92) in group 3 (P = 0.02). Median time to recurrence was 26 (15-42), 44 (33-72), and 69 (44-74) months in the three groups, respectively (P = 0.02). Sartan therapy was a significant predictor of longer overall survival and delayed time to recurrence on multivariate analysis.

CONCLUSION

Sartans significantly improved overall survival and time to recurrence after radiofrequency ablation in hepatocellular carcinoma patients.

Prognosis of Early-Stage Hepatocellular Carcinoma: The Clinical Implications of Substages of Barcelona Clinic Liver Cancer System Based on a Cohort of 1265 Patients

The prognostic implication of Barcelona Clinic Liver Cancer (BCLC) substages in Asian patients with hepatocellular carcinoma (HCC) is still obscure.The aim to this study is to compare the prognoses among HCC patients in different substages of the BCLC stage 0 and A.We enrolled 1265 treatment-naive HCC patients with BCLC stage 0 or A from 2007 to 2014. Factors in terms of prognoses were analyzed by multivariate analysis.There were 184, 446, 271, 92, and 272 patients in substage 0, A1, A2, A3, and A4, respectively. After a median follow-up period of 21.0 months, patients in stages 0 and A1 had comparable prognoses (P = 0.136). Both of them had significantly higher overall survival rates than those in stages A2-A4 (all P < 0.001). Multivariate analysis revealed that the factors associated with mortality were serum albumin ≤3.5 g/dL (hazard ratio [HR] 1.459), alpha-fetoprotein >20 ng/mL (HR 1.863), tumor size >3 cm (HR 1.542), BCLC stage A2-A4 (HR 1.488), and treatment modality. Surgical resection had the highest overall survival rate followed by radiofrequency ablation (RFA) (HR 1.598), transarterial chemoembolization (HR 2.224), and other treatments (HR 3.707). Verus patients receiving RFA, those who underwent resection had a higher overall survival rate and lower recurrence rate especially in BCLC stages A2-A4.The BCLC-staging system provided good prognostic stratification for early-stage HCC. Patients with a single tumor >2 cm but without portal hypertension or jaundice had similar prognosis to those in BCLC stage 0. Curative therapies-especially hepatic resection-are suggested in early-stage HCC.