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Anbarasu CR, Williams-Perez S, Camp ER, Erstad DJ. Surgical Implications for Nonalcoholic Steatohepatitis-Related Hepatocellular Carcinoma. Cancers (Basel) 2024; 16:2773. [PMID: 39199546 PMCID: PMC11352989 DOI: 10.3390/cancers16162773] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/25/2024] [Revised: 07/27/2024] [Accepted: 07/31/2024] [Indexed: 09/01/2024] Open
Abstract
Hepatocellular carcinoma (HCC) is an aggressive form of liver cancer that arises in a background of chronic hepatic injury. Metabolic syndrome-associated fatty liver disease (MAFLD) and its severe form, nonalcoholic steatohepatitis (NASH), are increasingly common mechanisms for new HCC cases. NASH-HCC patients are frequently obese and medically complex, posing challenges for clinical management. In this review, we discuss NASH-specific challenges and the associated implications, including benefits of minimally invasive operative approaches in obese patients; the value of y90 as a locoregional therapy; and the roles of weight loss and immunotherapy in disease management. The relevant literature was identified through queries of PubMed, Google Scholar, and clinicaltrials.gov. Provider understanding of clinical nuances specific to NASH-HCC can improve treatment strategy and patient outcomes.
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Affiliation(s)
| | | | - Ernest R. Camp
- Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Surgery, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
| | - Derek J. Erstad
- Department of Surgery, Baylor College of Medicine, Houston, TX 77030, USA
- Department of Surgery, Michael E. DeBakey VA Medical Center, Houston, TX 77030, USA
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Watanabe Y, Aikawa M, Oshima Y, Kato T, Takase K, Watanabe Y, Okada K, Okamoto K, Koyama I. Outcomes after laparoscopic or open liver resection for nonalcoholic fatty liver disease-associated hepatocellular carcinoma: a propensity score-matching study. Surg Endosc 2024; 38:3887-3904. [PMID: 38831217 DOI: 10.1007/s00464-024-10937-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2024] [Accepted: 05/17/2024] [Indexed: 06/05/2024]
Abstract
BACKGROUND Laparoscopic liver resection (LLR) is rapidly gaining popularity; however, its efficacy for nonalcoholic fatty liver disease (NAFLD)-associated hepatocellular carcinoma (HCC) (NAFLD-HCC) has been not evaluated. The purpose of this study was to compare short- and long-term outcomes between LLR and open liver resection (OLR) among patients with NAFLD-HCC. METHODS We used a single-institution database to analyze data for patients who underwent LLR or OLR for NAFLD-HCC from January 2007 to December 2022. We performed propensity score-matching analyses to compare overall postoperative complications, major morbidities, duration of surgery, blood loss, transfusion, length of stay, recurrence, and survival between the two groups. RESULTS Among 210 eligible patients, 46 pairs were created by propensity score matching. Complication rates were 28% for OLR and 11% for LLR (p = 0.036). There were no significant differences in major morbidities (15% vs. 8.7%, p = 0.522) or duration of surgery (199 min vs. 189 min, p = 0.785). LLR was associated with a lower incidence of blood transfusion (22% vs. 4.4%, p = 0.013), less blood loss (415 vs. 54 mL, p < 0.001), and shorter postoperative hospital stay (9 vs. 6 days, p < 0.001). Differences in recurrence-free survival and overall survival between the two groups were not statistically significant (p = 0.222 and 0.301, respectively). CONCLUSIONS LLR was superior to OLR for NAFLD-HCC in terms of overall postoperative complications, blood loss, blood transfusion, and postoperative length of stay. Moreover, recurrence-free survival and overall survival were comparable between LLR and OLR. Although there is a need for careful LLR candidate selection according to tumor size and location, LLR can be regarded as a preferred treatment for NAFLD-HCC over OLR.
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Affiliation(s)
- Yukihiro Watanabe
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan.
| | - Masayasu Aikawa
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Yuhei Oshima
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Tomotaka Kato
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Kenichiro Takase
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Yuichiro Watanabe
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Katsuya Okada
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Kojun Okamoto
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
| | - Isamu Koyama
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama, 350-1298, Japan
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3
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Berardi G, Cucchetti A, Sposito C, Ratti F, Nebbia M, D’Souza DM, Pascual F, Dogeas E, Tohme S, Vitale A, D’Amico FE, Alessandris R, Panetta V, Simonelli I, Colasanti M, Russolillo N, Moro A, Fiorentini G, Serenari M, Rotellar F, Zimitti G, Famularo S, Ivanics T, Donando FG, Hoffman D, Onkendi E, Essaji Y, Giuliani T, Lopez Ben S, Caula C, Rompianesi G, Chopra A, Abu Hilal M, Sapisochin G, Torzilli G, Corvera C, Alseidi A, Helton S, Troisi RI, Simo K, Conrad C, Cescon M, Cleary S, Kwon DCH, Ferrero A, Ettorre GM, Cillo U, Geller D, Cherqui D, Serrano PE, Ferrone C, Aldrighetti L, Kingham TP, Mazzaferro V. Recurrence and tumor-related death after resection of hepatocellular carcinoma in patients with metabolic syndrome. JHEP Rep 2024; 6:101075. [PMID: 38961853 PMCID: PMC11220535 DOI: 10.1016/j.jhepr.2024.101075] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/23/2024] [Revised: 03/19/2024] [Accepted: 03/20/2024] [Indexed: 07/05/2024] Open
Abstract
Background & Aims Metabolic syndrome (MS) is a growing epidemic and a risk factor for the development of hepatocellular carcinoma (HCC). This study investigated the long-term outcomes of liver resection (LR) for HCC in patients with MS. Rates, timing, patterns, and treatment of recurrences were investigated, and cancer-specific survivals were assessed. Methods Between 2001 and 2021, data from 24 clinical centers were collected. Overall survival (OS), recurrence-free survival (RFS), and cancer-specific survival were analyzed as well as recurrence patterns and treatment. The analysis was conducted using a competing-risk framework. The trajectory of the risk of recurrence over time was applied to a competing risk analysis. For post-recurrence survival, death resulting from tumor progression was the primary endpoint, whereas deaths with recurrence relating to other causes were considered as competing events. Results In total, 813 patients were included in the study. Median OS was 81.4 months (range 28.1-157.0 months), and recurrence occurred in 48.3% of patients, with a median RFS of 39.8 months (range 15.7-174.7 months). Cause-specific hazard of recurrence showed a first peak 6 months (0.027), and a second peak 24 months (0.021) after surgery. The later the recurrence, the higher the chance of receiving curative intent approaches (p = 0.001). Size >5 cm, multiple tumors, microvascular invasion, and cirrhosis were independent predictors of recurrence showing a cause-specific hazard over time. RFS was associated with death for recurrence (hazard ratio: 0.985, 95% CI: 0.977-0.995; p = 0.002). Conclusions Patients with MS undergoing LR for HCC have good long-term survival. Recurrence occurs in 48% of patients with a double-peak incidence and time-specific hazards depending on tumor-related factors and underlying disease. The timing of recurrence significantly impacts survival. Surveillance after resection should be adjusted over time depending on risk factors. Impact and implications Metabolic syndrome (MS) is a growing epidemic and a significant risk factor for the development of hepatocellular carcinoma (HCC). The present study demonstrated that patients who undergo surgical resection for HCC on MS have a good long-term survival and that recurrence occurs in almost half of the cases with a double peak incidence and time-specific hazards depending on tumor-related factors and underlying liver disease. Also, the timing of recurrence significantly impacts survival. Clinicians should therefore adjust follow-up after surgery accordingly, considering timing of recurrence and specific risk factors. Also, the results of the present study might help design future trials on the use of adjuvant therapy following resection.
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Affiliation(s)
- Giammauro Berardi
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgery, San Camillo Forlanini Hospital, Rome, Italy
| | - Alessandro Cucchetti
- Department of Medical and Surgical Sciences-DIME, Alma Mater Studiorum, University of Bologna, Italy
- Department of General and Oncologic Surgery, Morgagni-Pierantoni Hospital, Ausl Romagna, Forlì, Italy
| | - Carlo Sposito
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Department of Surgery, HPB Surgery and Liver Transplantation, Istituto Nazionale Tumori IRCCS, Milan, Italy
| | - Francesca Ratti
- Hepatobiliary Surgery Division, San Raffaele Hospital Department of Surgery, Milan, Italy
| | - Martina Nebbia
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | | | - Franco Pascual
- Department of Surgery, Paul Brousse Hospital, Villejuif, Paris, France
| | - Epameinondas Dogeas
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Samer Tohme
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Alessandro Vitale
- Department of Surgical Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, Padua, Italy
| | - Francesco Enrico D’Amico
- Department of Surgical Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, Padua, Italy
| | - Remo Alessandris
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
- Department of Surgical Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, Padua, Italy
| | - Valentina Panetta
- Laltrastatistica Consultancy and Training, Biostatistics Department, Rome, Italy
| | - Ilaria Simonelli
- Laltrastatistica Consultancy and Training, Biostatistics Department, Rome, Italy
| | - Marco Colasanti
- Department of Surgery, San Camillo Forlanini Hospital, Rome, Italy
| | | | - Amika Moro
- Department of Surgery, Cleveland Clinic, Cleveland, OH, USA
| | | | - Matteo Serenari
- Hepato-biliary and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | | | - Giuseppe Zimitti
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Simone Famularo
- Department of General Surgery, Humanitas University and Research Hospital, IRCCS, Milan, Italy
| | - Tommy Ivanics
- Department of Surgery, University of Toronto, Toronto, ON, Canada
| | | | - Daniel Hoffman
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Edwin Onkendi
- Department of Surgery, Texas Tech University Health Sciences Center, Lubbock, TX, USA
| | - Yasmin Essaji
- Department of Surgery, Virginia Mason Hospital, Seattle, WA, USA
- Department of Surgery, Seattle Medical Center, Seattle, WA, USA
| | - Tommaso Giuliani
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Santiago Lopez Ben
- Department of Surgery, Hospital Universitari Dr Josep Trueta de Girona, Girona, Spain
| | - Celia Caula
- Department of Surgery, Hospital Universitari Dr Josep Trueta de Girona, Girona, Spain
| | - Gianluca Rompianesi
- Department of Clinical Medicine and Surgery, Università Federico Secondo, Naples, Italy
| | | | - Mohammed Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | | | - Guido Torzilli
- Department of General Surgery, Humanitas University and Research Hospital, IRCCS, Milan, Italy
| | - Carlos Corvera
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Adnan Alseidi
- Department of Surgery, University of California San Francisco, San Francisco, CA, USA
| | - Scott Helton
- Department of Surgery, Virginia Mason Hospital, Seattle, WA, USA
| | - Roberto I. Troisi
- Department of Clinical Medicine and Surgery, Università Federico Secondo, Naples, Italy
| | - Kerri Simo
- Department of Surgery, Hospital, Toledo, OH, USA
| | - Claudius Conrad
- Department of Surgery, Saint Elizabeth Medical Center, Boston, MA, USA
| | - Matteo Cescon
- Hepato-biliary and Transplant Unit, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Sean Cleary
- Department of Surgery, Mayo Clinic, Rochester, MN, USA
| | | | | | | | - Umberto Cillo
- Department of Surgical Oncological and Gastroenterological Sciences (DiSCOG), University of Padova, Padua, Italy
| | - David Geller
- Department of Surgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Daniel Cherqui
- Department of Surgery, Paul Brousse Hospital, Villejuif, Paris, France
| | - Pablo E. Serrano
- Department of Surgery, McMaster University, Hamilton, ONT, Canada
| | - Cristina Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, MA, USA
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, San Raffaele Hospital Department of Surgery, Milan, Italy
| | - T. Peter Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, NY, USA
| | - Vincenzo Mazzaferro
- Department of Oncology and Hemato-Oncology, University of Milan, Milan, Italy
- Department of Surgery, HPB Surgery and Liver Transplantation, Istituto Nazionale Tumori IRCCS, Milan, Italy
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Shi Y, Taherifard E, Saeed A, Saeed A. MASLD-Related HCC: A Comprehensive Review of the Trends, Pathophysiology, Tumor Microenvironment, Surveillance, and Treatment Options. Curr Issues Mol Biol 2024; 46:5965-5983. [PMID: 38921027 PMCID: PMC11202630 DOI: 10.3390/cimb46060356] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/11/2024] [Revised: 06/07/2024] [Accepted: 06/11/2024] [Indexed: 06/27/2024] Open
Abstract
Hepatocellular carcinoma (HCC) represents a significant burden on global healthcare systems due to its considerable incidence and mortality rates. Recent trends indicate an increase in the worldwide incidence of metabolic dysfunction-associated steatotic liver disease (MASLD) and a shift in the etiology of HCC, with MASLD replacing the hepatitis B virus as the primary contributor to new cases of HCC. MASLD-related HCC exhibits distinct characteristics compared to viral HCC, including unique immune cell profiles resulting in an overall more immunosuppressive or exhausted tumor microenvironment. Furthermore, MASLD-related HCC is frequently identified in older age groups and among individuals with cardiometabolic comorbidities. Additionally, a greater percentage of MASLD-related HCC cases occur in noncirrhotic patients compared to those with viral etiologies, hindering early detection. However, the current clinical practice guidelines lack specific recommendations for the screening of HCC in MASLD patients. The evolving landscape of HCC management offers a spectrum of therapeutic options, ranging from surgical interventions and locoregional therapies to systemic treatments, for patients across various stages of the disease. Despite ongoing debates, the current evidence does not support differences in optimal treatment modalities based on etiology. In this study, we aimed to provide a comprehensive overview of the current literature on the trends, characteristics, clinical implications, and treatment modalities for MASLD-related HCC.
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Affiliation(s)
- Yuming Shi
- Department of Medicine, Division of Hematology & Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA; (Y.S.); (E.T.)
| | - Erfan Taherifard
- Department of Medicine, Division of Hematology & Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA; (Y.S.); (E.T.)
| | - Ali Saeed
- Department of Medicine, Ochsner Lafayette General Medical Center, Lafayette, LA 70503, USA;
| | - Anwaar Saeed
- Department of Medicine, Division of Hematology & Oncology, University of Pittsburgh Medical Center, Pittsburgh, PA 15232, USA; (Y.S.); (E.T.)
- UPMC Hillman Cancer Center, Pittsburgh, PA 15232, USA
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5
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Phoolchund AGS, Khakoo SI. MASLD and the Development of HCC: Pathogenesis and Therapeutic Challenges. Cancers (Basel) 2024; 16:259. [PMID: 38254750 PMCID: PMC10814413 DOI: 10.3390/cancers16020259] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/27/2023] [Revised: 12/29/2023] [Accepted: 01/02/2024] [Indexed: 01/24/2024] Open
Abstract
Metabolic-dysfunction-associated steatotic liver disease (MASLD, previously known as non-alcoholic fatty liver disease (NAFLD)) represents a rapidly increasing cause of chronic liver disease and hepatocellular carcinoma (HCC), mirroring increasing rates of obesity and metabolic syndrome in the Western world. MASLD-HCC can develop at an earlier stage of fibrosis compared to other causes of chronic liver disease, presenting challenges in how to risk-stratify patients to set up effective screening programmes. Therapeutic decision making for MASLD-HCC is also complicated by medical comorbidities and disease presentation at a later stage. The response to treatment, particularly immune checkpoint inhibitors, may vary by the aetiology of the disease, and, in the future, patient stratification will be key to optimizing the therapeutic pathways.
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Affiliation(s)
- Anju G. S. Phoolchund
- Faculty of Medicine, University of Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
| | - Salim I. Khakoo
- Faculty of Medicine, University of Southampton, Southampton General Hospital, Tremona Road, Southampton SO16 6YD, UK
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Singal AG, Llovet JM, Yarchoan M, Mehta N, Heimbach JK, Dawson LA, Jou JH, Kulik LM, Agopian VG, Marrero JA, Mendiratta-Lala M, Brown DB, Rilling WS, Goyal L, Wei AC, Taddei TH. AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma. Hepatology 2023; 78:1922-1965. [PMID: 37199193 PMCID: PMC10663390 DOI: 10.1097/hep.0000000000000466] [Citation(s) in RCA: 269] [Impact Index Per Article: 269.0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/19/2023]
Affiliation(s)
- Amit G. Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Josep M. Llovet
- Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Mount Sinai School of Medicine, New York, New York, USA
- Translational Research in Hepatic Oncology, Liver Unit, August Pi i Sunyer Biomedical Research Institute, Hospital Clinic, University of Barcelona, Catalonia, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Catalonia, Spain
| | - Mark Yarchoan
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Neil Mehta
- University of California, San Francisco, San Francisco, California, USA
| | | | - Laura A. Dawson
- Radiation Medicine Program/University Health Network, Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Janice H. Jou
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Laura M. Kulik
- Northwestern Medical Faculty Foundation, Chicago, Illinois, USA
| | - Vatche G. Agopian
- The Dumont–University of California, Los Angeles, Transplant Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Jorge A. Marrero
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mishal Mendiratta-Lala
- Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Daniel B. Brown
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William S. Rilling
- Division of Interventional Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lipika Goyal
- Department of Medicine, Stanford School of Medicine, Palo Alto, California, USA
| | - Alice C. Wei
- Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Tamar H. Taddei
- Department of Medicine (Digestive Diseases), Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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7
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Watanabe Y, Aikawa M, Oshima Y, Kato T, Takase K, Watanabe Y, Okada K, Okamoto K, Koyama I. Short- and long-term outcomes of laparoscopic liver resection for non-alcoholic fatty liver disease-associated hepatocellular carcinoma: a retrospective cohort study. HPB (Oxford) 2023; 25:1573-1586. [PMID: 37758580 DOI: 10.1016/j.hpb.2023.09.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2023] [Revised: 08/22/2023] [Accepted: 09/04/2023] [Indexed: 09/29/2023]
Abstract
BACKGROUND We compared the recurrence-free survival (RFS), overall survival (OS), and safety of laparoscopic liver resection (LLR) between non-alcoholic fatty liver disease (NAFLD) and non-NAFLD hepatocellular carcinoma (HCC) patients. METHODS Patients with HCC (n = 349) were divided into four groups based on the HCC etiology (NAFLD [n = 71], hepatitis B [n = 27], hepatitis C [n = 187], alcohol/autoimmune hepatitis [AIH] [n = 64]). RFS and OS were assessed by multivariate analysis after adjustment for clinicopathological variables. A subgroup analysis was performed based on the presence (n = 248) or absence (n = 101) of cirrhosis. RESULTS Compared with the NAFLD group, the hazard ratios (95% confidence intervals) for RFS in the hepatitis B, hepatitis C, and alcohol/AIH groups were 0.49 (0.22-1.09), 0.90 (0.54-1.48), and 1.08 (0.60-1.94), respectively. For OS, the values were 0.28 (0.09-0.84), 0.52 (0.28-0.95), and 0.59 (0.27-1.30), respectively. With cirrhosis, NAFLD was associated with worse OS than hepatitis C (P = 0.010). Without cirrhosis, NAFLD had significantly more complications (P = 0.034), but comparable survival than others. DISCUSSION Patients with NAFLD-HCC have some disadvantages after LLR. In patients with cirrhosis, LLR is safe, but survival is poor. In patients without cirrhosis, the complication risk is high.
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Affiliation(s)
- Yukihiro Watanabe
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama 350-1298, Japan.
| | - Masayasu Aikawa
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama 350-1298, Japan
| | - Yuhei Oshima
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama 350-1298, Japan
| | - Tomotaka Kato
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama 350-1298, Japan
| | - Kenichiro Takase
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama 350-1298, Japan
| | - Yuichiro Watanabe
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama 350-1298, Japan
| | - Katsuya Okada
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama 350-1298, Japan
| | - Kojun Okamoto
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama 350-1298, Japan
| | - Isamu Koyama
- Department of Gastroenterological Surgery, Saitama Medical University International Medical Center, 1397-1 Yamane, Hidaka, Saitama 350-1298, Japan
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8
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Berardi G, Ivanics T, Sapisochin G, Ratti F, Sposito C, Nebbia M, D’Souza DM, Pascual F, Tohme S, D’Amico F, Alessandris R, Panetta V, Simonelli I, Del Basso C, Russolillo N, Fiorentini G, Serenari M, Rotellar F, Zimitti G, Famularo S, Hoffman D, Onkendi E, Lopez Ben S, Caula C, Rompianesi G, Chopra A, Abu Hilal M, Torzilli G, Corvera C, Alseidi A, Helton S, Troisi RI, Simo K, Conrad C, Cescon M, Cleary S, Kwon CHD, Ferrero A, Ettorre GM, Cillo U, Geller D, Cherqui D, Serrano PE, Ferrone C, Mazzaferro V, Aldrighetti L, Kingham PT. Minimally Invasive Versus Open Liver Resections for Hepatocellular Carcinoma in Patients With Metabolic Syndrome. Ann Surg 2023; 278:e1041-e1047. [PMID: 36994755 PMCID: PMC11218006 DOI: 10.1097/sla.0000000000005861] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/31/2023]
Abstract
OBJECTIVE To compare minimally invasive (MILR) and open liver resections (OLRs) for hepatocellular carcinoma (HCC) in patients with metabolic syndrome (MS). BACKGROUND Liver resections for HCC on MS are associated with high perioperative morbidity and mortality. No data on the minimally invasive approach in this setting exist. MATERIAL AND METHODS A multicenter study involving 24 institutions was conducted. Propensity scores were calculated, and inverse probability weighting was used to weight comparisons. Short-term and long-term outcomes were investigated. RESULTS A total of 996 patients were included: 580 in OLR and 416 in MILR. After weighing, groups were well matched. Blood loss was similar between groups (OLR 275.9±3.1 vs MILR 226±4.0, P =0.146). There were no significant differences in 90-day morbidity (38.9% vs 31.9% OLRs and MILRs, P =0.08) and mortality (2.4% vs 2.2% OLRs and MILRs, P =0.84). MILRs were associated with lower rates of major complications (9.3% vs 15.3%, P =0.015), posthepatectomy liver failure (0.6% vs 4.3%, P =0.008), and bile leaks (2.2% vs 6.4%, P =0.003); ascites was significantly lower at postoperative day 1 (2.7% vs 8.1%, P =0.002) and day 3 (3.1% vs 11.4%, P <0.001); hospital stay was significantly shorter (5.8±1.9 vs 7.5±1.7, P <0.001). There was no significant difference in overall survival and disease-free survival. CONCLUSIONS MILR for HCC on MS is associated with equivalent perioperative and oncological outcomes to OLRs. Fewer major complications, posthepatectomy liver failures, ascites, and bile leaks can be obtained, with a shorter hospital stay. The combination of lower short-term severe morbidity and equivalent oncologic outcomes favor MILR for MS when feasible.
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Affiliation(s)
- Giammauro Berardi
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
- Department of Surgery, San Camillo Forlanini Hospital, Rome, Italy
| | - Tommy Ivanics
- Department of Surgery, University of Toronto, Canada
| | | | - Francesca Ratti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy
| | - Carlo Sposito
- Department of Oncology and Hemato-Oncology, University of Milan and Department of Surgery, HPB Surgery and Liver Transplantation; Istituto Nazionale Tumori IRCCS, Milan, Italy
| | - Martina Nebbia
- Department of Surgery, Massachusetts General Hospital, Boston, USA
| | | | - Franco Pascual
- Department of Surgery, Paul Brousse Hospital, Villejuif, Paris, France
| | - Samer Tohme
- Department of Surgery, University of Pittsburgh Medical Center, USA
| | | | | | - Valentina Panetta
- Laltrastatistica Consultancy and Training, Biostatistics Department, Rome, Italy
| | - Ilaria Simonelli
- Laltrastatistica Consultancy and Training, Biostatistics Department, Rome, Italy
| | | | | | - Guido Fiorentini
- Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy
- Department of Surgery, Mayo Clinic, Rochester, USA
| | - Matteo Serenari
- Hepato-biliary Surgery and Transplant Unit, IRCCS Sant’Orsola Hospital, University of Bologna, Italy
| | | | - Giuseppe Zimitti
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Simone Famularo
- Department of General Surgery, Humanitas University and Research Hospital, IRCCS, Milan, Italy
| | - Daniel Hoffman
- Department of Surgery, University of California San Francisco, USA
| | - Edwin Onkendi
- Department of Surgery, Texas Tech University Health Sciences Center, USA
| | - Santiago Lopez Ben
- Department of Surgery, Hospital Universitari Dr Josep Trueta de Girona, Spain
| | - Celia Caula
- Department of Surgery, Hospital Universitari Dr Josep Trueta de Girona, Spain
| | - Gianluca Rompianesi
- Department of Clinical Medicine and Surgery, Università Federico Secondo, Naples, Italy
| | | | - Mohammed Abu Hilal
- Department of Surgery, Poliambulanza Foundation Hospital, Brescia, Italy
| | - Guido Torzilli
- Department of General Surgery, Humanitas University and Research Hospital, IRCCS, Milan, Italy
| | - Carlos Corvera
- Department of Surgery, University of California San Francisco, USA
| | - Adnan Alseidi
- Department of Surgery, University of California San Francisco, USA
| | - Scott Helton
- Department of Surgery, Virginia Mason Hospital and Seattle Medical Center, USA
| | - Roberto I. Troisi
- Department of Clinical Medicine and Surgery, Università Federico Secondo, Naples, Italy
| | - Kerri Simo
- Department of Surgery, Promedica Toledo Ohio, USA
| | - Claudius Conrad
- Department of Surgery, Saint Elizabeth Medical Center, Boston, USA
| | - Matteo Cescon
- Hepato-biliary Surgery and Transplant Unit, IRCCS Sant’Orsola Hospital, University of Bologna, Italy
| | - Sean Cleary
- Department of Surgery, Mayo Clinic, Rochester, USA
| | | | | | | | | | - David Geller
- Department of Surgery, University of Pittsburgh Medical Center, USA
| | - Daniel Cherqui
- Department of Surgery, Paul Brousse Hospital, Villejuif, Paris, France
| | | | - Cristina Ferrone
- Department of Surgery, Massachusetts General Hospital, Boston, USA
| | - Vincenzo Mazzaferro
- Department of Oncology and Hemato-Oncology, University of Milan and Department of Surgery, HPB Surgery and Liver Transplantation; Istituto Nazionale Tumori IRCCS, Milan, Italy
| | - Luca Aldrighetti
- Hepatobiliary Surgery Division, San Raffaele Hospital, Milan, Italy
| | - Peter T. Kingham
- Department of Surgery, Memorial Sloan Kettering Cancer Center, New York, USA
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9
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He Z, Tang D. Perioperative predictors of outcome of hepatectomy for HBV-related hepatocellular carcinoma. Front Oncol 2023; 13:1230164. [PMID: 37519791 PMCID: PMC10373594 DOI: 10.3389/fonc.2023.1230164] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2023] [Accepted: 06/28/2023] [Indexed: 08/01/2023] Open
Abstract
Hepatitis B virus (HBV) is identified as a major risk factor for hepatocellular carcinoma (HCC), resulting in so-called hepatitis B virus-related hepatocellular carcinoma (HBV-related HCC). Hepatectomy for HCC is acknowledged as an efficient treatment strategy, especially for early HCC. Furthermore, patients with advanced HCC can still obtain survival benefits through surgical treatment combined with neoadjuvant therapy, adjuvant therapy, transcatheter arterial chemoembolization, and radiofrequency ablation. Therefore, preoperative and postoperative predictors of HBV-related HCC have crucial indicative functions for the follow-up treatment of patients with feasible hepatectomy. This review covers a variety of research results on preoperative and postoperative predictors of hepatectomy for HBV-related HCC over the past decade and in previous landmark studies. The relevant contents of Hepatitis C virus-related HCC, non-HBV non-HCV HCC, and the artificial intelligence application in this field are briefly addressed in the extended content. Through the integration of this review, a large number of preoperative and postoperative factors can predict the prognosis of HBV-related HCC, while most of the predictors have no standardized thresholds. According to the characteristics, detection methods, and application of predictors, the predictors can be divided into the following categories: 1. serological and hematological predictors, 2. genetic, pathological predictors, 3. imaging predictors, 4. other predictors, 5. analysis models and indexes. Similar results appear in HCV-related HCC, non-HBV non-HCV HCC. Predictions based on AI and big biological data are actively being applied. A reasonable prediction model should be established based on the economic, health, and other levels in specific countries and regions.
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Nonalcoholic steatohepatitis-related hepatocellular carcinoma: pathogenesis and treatment. Nat Rev Gastroenterol Hepatol 2023:10.1038/s41575-023-00754-7. [PMID: 36932227 DOI: 10.1038/s41575-023-00754-7] [Citation(s) in RCA: 75] [Impact Index Per Article: 75.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 02/03/2023] [Indexed: 03/19/2023]
Abstract
Nonalcoholic fatty liver disease (NAFLD), including its more severe manifestation, nonalcoholic steatohepatitis (NASH), has a global prevalence of 20-25% and is a major public health problem. Its incidence is increasing in parallel to the rise in obesity, diabetes and metabolic syndrome. Progression from NASH to NASH-related hepatocellular carcinoma (HCC) (~2% of cases per year) is influenced by many factors, including the tissue and immune microenvironment, germline mutations in PNPLA3, and the microbiome. NASH-HCC has unique molecular and immune traits compared with other aetiologies of HCC and is equally prevalent in men and women. Comorbidities associated with NASH, such as obesity and diabetes mellitus, can prevent the implementation of potentially curative therapies in certain patients; nonetheless, outcomes are similar in patients who receive treatment. NASH-HCC at the early to intermediate stages is managed with surgery and locoregional therapies, whereas advanced HCC is treated with systemic therapies, including anti-angiogenic therapies and immune-checkpoint inhibitors. In this Review, we present the latest knowledge of the pathogenic mechanisms and clinical management of NASH-HCC. We discuss data highlighting the controversy over varying responses to immune-checkpoint inhibitors according to underlying aetiology and suggest that the future of NASH-HCC management lies in improved surveillance, targeted combination therapies to overcome immune evasion, and identifying biomarkers to recognize treatment responders.
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Teng YX, Xie S, Guo PP, Deng ZJ, Zhang ZY, Gao W, Zhang WG, Zhong JH. Hepatocellular Carcinoma in Non-alcoholic Fatty Liver Disease: Current Progresses and Challenges. J Clin Transl Hepatol 2022; 10:955-964. [PMID: 36304509 PMCID: PMC9547250 DOI: 10.14218/jcth.2021.00586] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Revised: 01/24/2022] [Accepted: 04/18/2022] [Indexed: 01/27/2023] Open
Abstract
The rising global prevalence of metabolic diseases has increased the prevalence of non-alcoholic fatty liver disease (NAFLD), leading to an increase in cases of NAFLD-related hepatocellular carcinoma (HCC). To provide an updated literature review detailing epidemiology, risk factors, pathogenic pathways, and treatment strategies linked to NAFLD-related HCC, we conducted a literature search on PubMed from its inception to December 31, 2021. About 25% of the global population suffers from NAFLD. The annual incidence of HCC among NAFLD patients is approximately 1.8 per 1,000 person-years. Older age, male sex, metabolic comorbidities, unhealthy lifestyle habits (such as smoking and alcohol consumption), physical inactivity, genetic susceptibility, liver fibrosis, and degree of cirrhosis in NAFLD patients are important risk factors for NAFLD-related HCC. Therefore, low-calorie diet, moderate-intensity exercise, treatment of metabolic comorbidities, and cessation of smoking and alcohol are the main measures to prevent NAFLD-related HCC. In addition, all patients with advanced NAFLD-related fibrosis or cirrhosis should be screened for HCC. Immune suppression disorders and changes in the liver microenvironment may be the main pathogenesis of NAFLD-related HCC. Hepatic resection, liver transplantation, ablation, transarterial chemoembolization, radiotherapy, targeted drugs, and immune checkpoint inhibitors are used to treat NAFLD-related HCC. Lenvatinib treatment may lead to better overall survival, while immune checkpoint inhibitors may lead to worse overall survival. Given the specific risk factors for NAFLD-related HCC, primary prevention is key. Moreover, the same treatment may differ substantially in efficacy against NAFLD-related HCC than against HCC of other etiologies.
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Affiliation(s)
- Yu-Xian Teng
- Hepatobiliary Surgery Department, Guangxi Liver Cancer Diagnosis and Treatment Engineering and Technology Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi, China
| | - Si Xie
- Hepatobiliary Surgery Department, Guangxi Liver Cancer Diagnosis and Treatment Engineering and Technology Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi, China
| | - Ping-Ping Guo
- Hepatobiliary Surgery Department, Guangxi Liver Cancer Diagnosis and Treatment Engineering and Technology Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi, China
| | - Zhu-Jian Deng
- Hepatobiliary Surgery Department, Guangxi Liver Cancer Diagnosis and Treatment Engineering and Technology Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi, China
| | - Zi-Yi Zhang
- Hepatobiliary Surgery Department, Guangxi Liver Cancer Diagnosis and Treatment Engineering and Technology Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi, China
| | - Wei Gao
- Hepatobiliary Surgery Department, Guangxi Liver Cancer Diagnosis and Treatment Engineering and Technology Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi, China
| | - Wan-Guang Zhang
- Hepatic Surgery Center, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan, Hubei, China
| | - Jian-Hong Zhong
- Hepatobiliary Surgery Department, Guangxi Liver Cancer Diagnosis and Treatment Engineering and Technology Research Center, Guangxi Medical University Cancer Hospital, Nanning, Guangxi, China
- Key Laboratory of Early Prevention and Treatment for Regional High Frequency Tumor (Guangxi Medical University), Ministry of Education; Guangxi Key Laboratory of Early Prevention and Treatment for Regional High Frequency Tumor, Nanning, Guangxi, China
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12
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Yun B, Ahn SH, Oh J, Yoon JH, Kim BK. Prognostic Impact of MAFLD Following Surgical Resection of Hepatitis B Virus-Related Hepatocellular Carcinoma: A Nationwide Cohort Study. Cancers (Basel) 2022; 14:cancers14205002. [PMID: 36291786 PMCID: PMC9599346 DOI: 10.3390/cancers14205002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/12/2022] [Accepted: 10/12/2022] [Indexed: 11/16/2022] Open
Abstract
The association between the metabolic effects of hepatic steatosis as a part of postoperative outcomes of hepatitis B virus (HBV)-related hepatocellular carcinoma (HCC) has rarely been studied. This study aimed to assess the relationship between metabolic dysfunction-associated fatty liver disease (MAFLD) and patients’ prognoses following curative resection of HBV-related HCC. Patients who underwent surgical resection for HBV-related HCC between 2009 and 2015 were recruited. The study endpoints were postoperative hepatocellular carcinoma (HCC) recurrence and all-cause mortality. Adjusted hazard ratios (aHRs) for the outcomes were estimated using multivariate Cox regression models. The mean age of the 2032 enrolled patients was 55.0 years, and 77.9% were men. During follow-up (median 5.3 years), HCC recurrence and all-cause mortality occurred in 954 (47.0%) and 422 (20.8%) patients, respectively. HCC recurrence and all-cause mortality were significantly associated with MAFLD, with aHRs of 1.22 (p = 0.003) and 1.44 (p < 0.001), respectively. Propensity score matching and inverse probability treatment weighting analyses confirmed similar results (p < 0.05). MAFLD was associated with significantly poor prognoses in terms of HCC recurrence and all-cause mortality following surgical resection of HBV-related HCC. Further studies are needed to develop an effective preventive strategy through the management of metabolic health.
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Affiliation(s)
- Byungyoon Yun
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
| | - Sang Hoon Ahn
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Korea
- Yonsei Liver Centre, Severance Hospital, Yonsei University Health System, Seoul 03722, Korea
| | - Juyeon Oh
- Department of Public Health, Yonsei University Graduate School, Seoul 03722, Korea
| | - Jin-Ha Yoon
- Department of Preventive Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
- The Institute for Occupational Health, Yonsei University College of Medicine, Seoul 03722, Korea
- Correspondence: (J.-H.Y.); (B.K.K.); Tel.: +82-2-2228-5179 (J.-H.Y.); +82-2-2228-1930 (B.K.K.); Fax: +82-2-392-8622 (J.-H.Y.); +82-2-393-6884 (B.K.K.)
| | - Beom Kyung Kim
- Department of Internal Medicine, Yonsei University College of Medicine, Seoul 03722, Korea
- Institute of Gastroenterology, Yonsei University College of Medicine, Seoul 03722, Korea
- Yonsei Liver Centre, Severance Hospital, Yonsei University Health System, Seoul 03722, Korea
- Correspondence: (J.-H.Y.); (B.K.K.); Tel.: +82-2-2228-5179 (J.-H.Y.); +82-2-2228-1930 (B.K.K.); Fax: +82-2-392-8622 (J.-H.Y.); +82-2-393-6884 (B.K.K.)
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13
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Ahmad MI, Khan MU, Kodali S, Shetty A, Bell SM, Victor D. Hepatocellular Carcinoma Due to Nonalcoholic Fatty Liver Disease: Current Concepts and Future Challenges. J Hepatocell Carcinoma 2022; 9:477-496. [PMID: 35673598 PMCID: PMC9167599 DOI: 10.2147/jhc.s344559] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2022] [Accepted: 05/14/2022] [Indexed: 12/24/2022] Open
Abstract
Obesity has been labeled as the global pandemic of the 21st century, resulting from a sedentary lifestyle and caloric excess. Nonalcoholic fatty liver disease (NAFLD), characterized by excessive hepatic steatosis, is strongly associated with obesity and metabolic syndrome and is estimated to be present in one-quarter of the world population, making it the most common cause of the chronic liver disease (CLD). NAFLD spectrum varies from simple steatosis to nonalcoholic steatohepatitis (NASH) and cirrhosis. The burden of NAFLD has been predicted to increase in the coming decades resulting in increased rates of decompensated cirrhosis, hepatocellular carcinoma (HCC), and liver-related deaths. In the current review, we describe the pathophysiology of NAFLD and NASH, risk factors associated with disease progression, related complications, and mortality. Later, we have discussed the changing epidemiology of HCC, with NAFLD emerging as the most common cause of CLD and HCC. We have also addressed the risk factors of HCC development in the NAFLD population (including demographic, metabolic, genetic, dietary, and lifestyle factors), presentation of NAFLD-associated HCC, its prognosis, and the issue of HCC development in non-cirrhotic NAFLD. Lastly, the problems related to HCC screening in the NAFLD population, the remaining challenges, and future directions, especially the need to identify the high-risk individuals, will be discussed. We will conclude the review by summarizing the clinical evidence for treating fibrosis and preventing HCC in those at risk with NAFLD-associated HCC.
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Affiliation(s)
- Muhammad Imran Ahmad
- Lynda K and David M Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital Houston, Houston, TX, USA
| | - Muhammad Umair Khan
- Department of Gastroenterology and Hepatology, Hamad Medical Corporation, Doha, Qatar
- ECPE- Executive and Continuing Professional Education, Harvard T.H Chan School of Public Health, Boston, MA, 02115-5810, USA
| | - Sudha Kodali
- Lynda K and David M Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital Houston, Houston, TX, USA
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, TX, USA
| | - Akshay Shetty
- Lynda K and David M Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital Houston, Houston, TX, USA
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, TX, USA
| | - S Michelle Bell
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, TX, USA
| | - David Victor
- Lynda K and David M Underwood Center for Digestive Disorders, Division of Gastroenterology and Hepatology, Houston Methodist Hospital Houston, Houston, TX, USA
- Sherrie and Alan Conover Center for Liver Disease and Transplantation, Houston Methodist Hospital, Houston, TX, USA
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14
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Long-term surgical outcomes of Non alcoholic fatty liver disease associated hepatocellular carcinoma. Surg Oncol 2022; 41:101730. [DOI: 10.1016/j.suronc.2022.101730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Revised: 02/04/2022] [Accepted: 02/22/2022] [Indexed: 11/24/2022]
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