Evaluation of model for end stage liver disease (MELD)-based systems as prognostic index for hepatocellular carcinoma

Predictors of portal vein thrombosis after splenectomy in patients with cirrhosis

BACKGROUND

Portal vein thrombosis (PVT) is a commonthsn complication after splenectomy in patients with cirrhosis. However, the predictors of postoperative PVT are not known.

AIM

To investigate the predictors of PVT after splenectomy in patient with cirrhosis.

METHODS

A total of 45 patients with cirrhosis who underwent splenectomy were consecutively enrolled from January 2017 to December 2018. The incidence of PVT at 1 months, 3 months, and 12 months after splenectomy in patients with cirrhosis was observed. The hematological indicators, biochemical and coagulation parameters, and imaging features were recorded at baseline and at each observation point. The univariable, multivariable, receiver operating characteristic curve and time-dependent curve analyses were performed.

RESULTS

The cumulative incidence of PVT was 40.0%, 46.6%, and 48.9% at 1 months, 3 months, and 12 months after splenectomy. Multivariable analysis showed that portal vein diameter (PVD) ≥ 14.5 mm and monthsdel‎ end-stage liver disease (MELD) score > 10 were independent predictors of PVT at 1 months, 3 months, and 12 months after splenectomy (P < 0.05). Time-dependent curve showed that the cumulative incidence of PVT was significantly different between patients with MELD score ≤ 10 and > 10 (P < 0.05). In addition, the cumulative incidence of PVT in the PVD ≥ 14.5 mm group was significantly higher than that in the PVD < 14.5 mm group (P < 0.05).

CONCLUSION

Wider PVD and MELD score > 10 were independent predictors of PVT at 1 months, 3 months, and 12 months after splenectomy in patient with cirrhosis.

Predictors of Mortality in Patients with Advanced Cancer-A Systematic Review and Meta-Analysis

To timely initiate advance care planning in patients with advanced cancer, physicians should identify patients with limited life expectancy. We aimed to identify predictors of mortality. To identify the relevant literature, we searched Embase, MEDLINE, Cochrane Central, Web of Science, and PubMed databases between January 2000-April 2020. Identified studies were assessed on risk-of-bias with a modified QUIPS tool. The main outcomes were predictors and prediction models of mortality within a period of 3-24 months. We included predictors that were studied in ≥2 cancer types in a meta-analysis using a fixed or random-effects model and summarized the discriminative ability of models. We included 68 studies (ranging from 42 to 66,112 patients), of which 24 were low risk-of-bias, and 39 were included in the meta-analysis. Using a fixed-effects model, the predictors of mortality were: the surprise question, performance status, cognitive impairment, (sub)cutaneous metastases, body mass index, comorbidity, serum albumin, and hemoglobin. Using a random-effects model, predictors were: disease stage IV (hazard ratio [HR] 7.58; 95% confidence interval [CI] 4.00-14.36), lung cancer (HR 2.51; 95% CI 1.24-5.06), ECOG performance status 1+ (HR 2.03; 95% CI 1.44-2.86) and 2+ (HR 4.06; 95% CI 2.36-6.98), age (HR 1.20; 95% CI 1.05-1.38), male sex (HR 1.24; 95% CI 1.14-1.36), and Charlson comorbidity score 3+ (HR 1.60; 95% CI 1.11-2.32). Thirteen studies reported on prediction models consisting of different sets of predictors with mostly moderate discriminative ability. To conclude, we identified reasonably accurate non-tumor specific predictors of mortality. Those predictors could guide in developing a more accurate prediction model and in selecting patients for advance care planning.

Model for End-Stage Liver Disease and Sodium Velocity Predicts Overall Survival in Nonmetastatic Hepatocellular Carcinoma Patients

BACKGROUND & AIMS

The significance of short-term changes in model for end-stage liver disease and Sodium (MELD-Na) following hepatocellular carcinoma (HCC) diagnosis is unknown. In this report, we explore the value of the rate of short-term changes in MELD-Na as an independent predictor of mortality in patients with nonmetastatic HCC.

METHODS

We reviewed a cohort of patients diagnosed with nonmetastatic HCC at our institution between 2001 and 2011. We evaluated potential predictors of overall survival, including baseline MELD-Na and the change in MELD-Na over 90 days. We explored survival times of cohorts grouped by baseline MELD-Na and the change in MELD-Na.

RESULTS

182 patients met eligibility criteria. With a median follow-up of 21 months for surviving patients, 110 deaths were observed (60%). Median MELD-Na at the time of diagnosis was 9.7 (IQR 7.5 to 13.9). The median changes in percentage of MELD-Na over 90 days were an increase of 9% (IQR -4% to 55%). Multivariable Cox proportional hazards modeling demonstrated that both baseline MELD-Na (HR=1.07 per unit increase, 95% CI 1.03 to 1.11, p<0.001) and changes in MELD-Na exceeding 40% (HR=3.69, 95% CI 2.39 to 5.69, p<0.001) were independently associated with increased mortality risk. Median survival among patients whose changes in MELD-Na were greater than 40% was 4.5 months, and median survival among the 131 other patients was 25.8 months (p<0.001).

CONCLUSIONS

We identified a subset of HCC patients who have extremely poor prognosis by incorporating the rate of short-term change in MELD-Na to baseline MELD-Na score.

Effect of branched-chain amino acids in patients receiving intervention for hepatocellular carcinoma

AIM: To investigate the usefulness of branched-chain amino acids (BCAA) before transarterial chemoembolization (TACE) or radiofrequency ablation (RFA).

METHODS: We investigated the usefulness of pre-intervention with BCAAs by comparing patients treated with BCAAs at 12.45 g/d orally for at least 2 wk before TACE or RFA and those not receiving such pretreatment. A total of 270 patients with hepatocellular carcinoma complicated by cirrhosis were included in the study. Mean changes from baseline (Δ) in serum albumin (Alb), C-reactive protein (CRP), and transaminase levels, as well as peak body temperature were also determined and compared at days 2, 5, and 10 after the start of TACE or RFA.

RESULTS: In patients who underwent TACE or RFA, BCAA pre-intervention significantly suppressed the development of post- intervention hypoalbuminemia and reduced inflammatory reactions during the subsequent clinical course. After TACE, the ΔAlb peaked on day 2, remained constantly lower in BCAA-treated patients, compared to the control group, and was -0.13 ± 0.42 g/dL in BCAA-treated patients and -0.33 ± 0.51 g/dL in untreated patients on day 10. The ΔCRP was also significantly lower in BCAA-treated patients on days 2, 5 and 10 after TACE. Like the trends noted after TACE, a similar tendency was noted as to the ΔAlb and ΔCRP after RFA. The changes in serum Alb level were inversely correlated with CRP changes; therefore, a possible involvement of the anti-inflammatory effect of BCAAs was inferred as a factor contributory to the suppression of decrease in serum Alb level.

CONCLUSION: Pre-intervention with BCAAs may hasten the recovery of serum Alb level and mitigate post-operative complications in patients undergoing TACE or RFA.

Is transarterial chemoembolization beneficial for patients with diffuse infiltrative hepatocellular carcinoma?

PURPOSE

Diffuse infiltrative hepatocellular carcinoma (D-HCC) is an incurable disease with short survival time. Transarterial chemoembolization (TACE) was often used to alleviate patient's symptoms and reduce tumor burden. However, it remains unknown if the TACE benefits the survival of D-HCC patients.

METHODS

A hospital-based retrospective study was conducted at a large referral hospital in Taiwan for a 9-year period (2000-2008).

RESULTS

Of the 150 D-HCC patients, 106 patients were related to hepatitis B virus (HBV), 17 to hepatitis C virus (HCV), 3 to both HBV and HCV, and 24 not to HBV or HCV. Multivariate Cox regression analysis showed treatment strategy, serum alpha-fetoprotein level, model for end-stage liver disease (MELD) score, serum gamma glutamyl transferase, and serum lactic acid dehydrogenase were associated with survival time. Compared to supportive treatment, the adjusted hazard ratios of transarterial chemoembolization (TACE) and chemotherapy including oral or systemic chemotherapy were 0.383 (p < 0.001) and 0.711 (p = 0.289), respectively.

CONCLUSION

TACE is a preferred therapy for D-HCC patients.

Comparison of the Child-Turcotte-Pugh classification and the model for end-stage liver disease score as predictors of the severity of the systemic inflammatory response in patients undergoing living-donor liver transplantation

The aim of this study was to evaluate and compare the Child-Turcotte-Pugh (CTP) classification system and the model for end-stage liver disease (MELD) score in predicting the severity of the systemic inflammatory response in living-donor liver transplantation patients. Recipients of liver graft were allocated to a recipient group (n = 39) and healthy donors to a donor group (n = 42). The association between the CTP classification, the MELD scores and perioperative cytokine concentrations in the recipient group was evaluated. The pro-inflammatory cytokines measured included interleukin (IL)-1β, IL-6, and tumor necrosis factor (TNF)-α; the anti-inflammatory cytokines measured included IL-10 and IL-4. Cytokine concentrations were quantified using sandwich enzyme-linked immunoassays. The IL-6, TNF-α, and IL-10 concentrations in the recipient group were significantly higher than those in healthy donor group patients. All preoperative cytokine levels, except IL-6, increased in relation to the severity of liver disease, as measured by the CTP classification. Additionally, all cytokine levels, except IL-6, were significantly correlated preoperatively with MELD scores. However, the correlations diminished during the intraoperative period. The CTP classification and the MELD score are equally reliable in predicting the severity of the systemic inflammatory response, but only during the preoperative period.

Nonsurgical options for hepatocellular carcinoma: evolving role of external beam radiotherapy

BACKGROUND

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide and thus poses a global concern. Its incidence is expected to increase in North America secondary to the increasing incidence of patients who develop hepatitis C. Patients who ultimately develop cirrhosis have an increased risk of developing hepatocellular carcinoma.

METHODS

The authors focus on nonsurgical therapies for this disease with an exploration of how external beam radiotherapy can be used alone or with other modalities. The development of partial liver strategies secondary to an explosion in radiation treatment planning and delivery advances is reviewed. Integration of advanced technology has evolved from three-dimensional conformal treatment to intensity-modulated radiation therapy and image-guided radiation therapy, along with stereotactic body radiation therapy, tomotherapy, and proton beam therapy.

RESULTS

Current data show a promising future for treatment strategies incorporating radiation with high rates of infield tumor control and low rates of radiation-induced liver disease. Radiation can be delivered in conjunction with transarterial catheter embolization for advanced-stage patients. External beam radiotherapy also has a role in the setting of patients with macrovascular tumor thrombus.

CONCLUSIONS

Future directions include how to best synergize the effects of radiation strategies with novel agents, given the hypervascularity of HCC. Downstaging of larger lesions with these therapies to resectable or transplantable disease may lead to better outcomes for patients deemed inoperable at diagnosis, and definitive radiotherapy may offer cure to patients with smaller lesions.

Management of advanced hepatocellular carcinoma

Many patients are diagnosed with hepatocellular carcinoma (HCC) at an advanced or terminal stage. Due to hepatic decompensation, they have missed the best opportunity for treatment. Of all HCC staging systems, the Barcelona Clinic Liver Cancer (BCLC) staging classification is the only one that can satisfy the aspects of tumor progression, liver function and performance scale. Patients at each stage of BCLC are provided with different therapies. Interventional therapies for advanced HCC include transcatheter arterial chemoembolization (TACE), transcatheter arterial embolization (TAE) and hepatic arterial infusion chemotherapy (HIAC). HIAC may be a choice for patients with poor liver function and portal vein thrombosis (PVT). While systematic therapy for advanced HCC is not recommended and there are still disputes over the efficacy of biotherapies, molecular targeted therapy may become a first-line treatment for advanced HCC.

Diabetes mellitus as an independent prognostic predictor and its association with renal dysfunction in patients with hepatocellular carcinoma

BACKGROUND

Patients with hepatocellular carcinoma (HCC) often have coexisting cirrhosis, which may predispose to the development of diabetes mellitus (DM). Diabetic HCC patients may have renal insufficiency and a subsequent worse outcome. This study investigated the interaction between DM, cirrhosis and renal dysfunction and the impact of these factors on HCC.

METHODS

A prospective database of 1713 HCC patients was analysed.

RESULTS

A total of 392 (22.9%) patients were diabetic. Diabetic patients had a significantly higher Child-Turcotte-Pugh (CTP) score, model for end-stage liver disease score and serum creatinine level, but had significantly lower serum albumin, sodium, alanine aminotransferase, aspartate aminotransferase and bilirubin levels. The serum creatinine level progressively increased and correlated well with increasing CTP class in both diabetic and non-diabetic patients. After a mean follow-up of 18+/-16 months, DM was shown to be an independent predictor of mortality in the Cox proportional hazard model after adjusting for other predictors [hazard ratio (HR): 1.2, 95% confidence interval (CI): 1.02-1.42]. Diabetic patients more often had renal insufficiency, defined as serum creatinine>1.5 mg/dl (17.3 vs 8.3%, P<0.0001). Renal insufficiency was an independent prognostic predictor in diabetic patients (HR: 2.26, 95% CI: 1.57-3.24) but not in non-diabetic patients, because it was significantly associated with the severity of cirrhosis in the non-diabetic group (P<0.001) but not in the diabetic group (P=0.143).

CONCLUSIONS

DM is associated with inadequate liver reserve and independently predicts decreased survival in HCC patients. Both advanced cirrhosis and DM are associated with renal insufficiency, which is a poor prognostic predictor for HCC.

Major adverse events, pretransplant assessment and outcome prediction

Liver cirrhosis and portal hypertension pose enormous loss of lives and resources throughout the world, especially in endemic areas of chronic viral hepatitis. Although the pathophysiology of cirrhosis is not completely understood, the accumulating evidence has paved the way for better control of the complications, including gastroesophageal variceal bleeding, hepatic encephalopathy, ascites, hepatorenal syndrome, hepatopulmonary syndrome and portopulmonary hypertension. Modern pharmacological and interventional therapies have been designed to treat these complications. However, liver transplantation (LT) is the only definite treatment for patients with preterminal end-stage liver disease. To pursue successful LT, the meticulous evaluation of potential recipients and donors is pivotal, especially for living donor transplantation. The critical shortage of cadaveric donor livers is another concern. In many Asian countries, cultural and religious concerns further limit the number of the donors, which lags far behind that of the recipients. The model for end-stage liver disease (MELD) scoring system has recently become the prevailing criterion for organ allocation. Initial results showed clear benefits of moving from the Child-Turcotte-Pugh-based system toward the MELD-based organ allocation system. In addition to the MELD, serum sodium is another important prognostic predictor in patients with advanced cirrhosis. The incorporation of serum sodium into the MELD could enhance the performance of the MELD and could become an indispensable strategy in refining the priority for LT. However, the feasibility of the MELD in combination with sodium in predicting the outcome for patients on transplant waiting list awaits actual outcome data before this becomes standard practice in the Asia-Pacific region.