Noninvasive Predictors of High-Risk Varices in Patients with Non-Cirrhotic Portal Hypertension

Comparison of atezolizumab plus bevacizumab and lenvatinib for hepatocellular carcinoma with portal vein tumor thrombosis

BACKGROUND/AIM

Atezolizumab plus bevacizumab and lenvatinib are currently available as first-line therapy for the treatment of unresectable hepatocellular carcinoma (HCC). However, comparative efficacy studies are still limited. This study aimed to investigate the effectiveness of these treatments in HCC patients with portal vein tumor thrombosis (PVTT).

METHODS

We retrospectively included patients who received either atezolizumab plus bevacizumab or lenvatinib as first-line systemic therapy for HCC with PVTT. Primary endpoint was overall survival (OS), and secondary endpoints included progressionfree survival (PFS) and disease control rate (DCR) determined by response evaluation criteria in solid tumors, version 1.1.

RESULTS

A total of 52 patients were included: 30 received atezolizumab plus bevacizumab and 22 received lenvatinib. The median follow-up duration was 6.4 months (interquartile range, 3.9-9.8). The median OS was 10.8 months (95% confidence interval [CI], 5.7 to not estimated) with atezolizumab plus bevacizumab and 5.8 months (95% CI, 4.8 to not estimated) with lenvatinib (P=0.26 by log-rank test). There was no statistically significant difference in OS (adjusted hazard ratio [aHR], 0.71; 95% CI, 0.34-1.49; P=0.37). The median PFS was similar (P=0.63 by log-rank test), with 4.1 months (95% CI, 3.3-7.7) for atezolizumab plus bevacizumab and 4.3 months (95% CI, 2.6-5.8) for lenvatinib (aHR, 0.93; 95% CI, 0.51-1.69; P=0.80). HRs were similar after inverse probability treatment weighting. The DCRs were 23.3% and 18.2% in patients receiving atezolizumab plus bevacizumab and lenvatinib, respectively (P=0.74).

CONCLUSION

The effectiveness of atezolizumab plus bevacizumab and lenvatinib was comparable for the treatment of HCC with PVTT.

Assessment of variceal bleeding in cirrhotic patients: accuracy of multi-detector computed tomography

Background

Esophageal variceal hemorrhage (EVH) has been shown to be a leading cause of mortality in patients with portal hypertension. Our purpose was to assess the utility of multi-detector computed tomography (MDCT) features in the assessment of esophageal varices (EVs) and esophageal variceal hemorrhage (EVH). This prospective study included 85 cirrhotic patients who underwent MDCT and Upper Gastrointestinal Tract (UGIT) endoscopy within 2 weeks. Four radiologists evaluated the presence of EVs and the presence and size of different collaterals. Multivariable logistic regression analysis was calculated to investigate the significant predictors influencing EV and EVH.

Results

Findings of EV with MDCT were the best predictor of EV or EVH. The presence (and/or size) of following collaterals had significant association with both EV and EVH: paraesophageal (p < 0.001, < 0.001), short gastric (p = 0.024, 0.010), gastric varicosities (p < 0.001, < 0.001), coronary (p < 0.001, < 0.001), and main coronary vein (MCV) (p < 0.001, = 0.011). We proposed an imaging-based model (presence of coronary collaterals, main coronary vein size > 3.5 mm, presence of short gastric collaterals, presence of gastric varicosities, size > 1.5 mm) with 97% sensitivity, 91% specificity, and 94% accuracy to predict EVs. We suggested another model (presence of paraesophageal collaterals, presence of short gastric vein (SGC), SGC size > 2.5 mm, main coronary vein size > 3.5 mm, gastric varicosities size > 1.5 mm, size of EVs > 4 mm, and Child C score) to predict EVH with 98% sensitivity, 81% specificity, and 89.5% accuracy. Inter-observer agreement was high in the detection of EVs (W. Kappa = 0.71–0.88).

Conclusion

MDCT is an effective modality in the diagnosis of EVs. At MDCT, the presence and/or size of various collaterals including para-esophageal, short gastric, coronary collaterals, and gastric varicosities are accurate predictors for either EVs existence or EVH. We suggested two computed tomography imaging-based models with high reproducibility and acceptable accuracy for the prediction of EV and EVH. With cirrhotic patients, we recommend that radiologists report collaterals in their daily practice.

Noninvasive predictors of esophageal varices in patients with hepatosplenic schistosomiasis mansoni

BACKGROUND

No previous study have evaluated transient elastography for predicting esophageal varices in hepatosplenic schistosomiasis.

AIM

To investigate noninvasive methods of predicting esophageal varices in patients with hepatosplenic schistosomiasis mansoni.

METHODS

Cross-sectional multicentric study included 51 patients with hepatosplenic schistosomiasis. Patients underwent ultrasonography-dopplerfluxometry, upper endoscopy, complete blood cell count and transient elastography (Fibroscan®) for liver and spleen stiffness measurement (LSM and SSM). Noninvasive scores previously established for cirrhotic population were studied: platelet count to spleen diameter ratio (PSR), LSM-spleen diameter to platelet ratio score (LSPS) and varices risk score (VRS). We proposed a version of LSPS and VRS by replacing LSM with SSM and named them SSPS and modified-VRS, respectively.

RESULTS

Esophageal varices were detected in 42 (82.4%) subjects. Individuals with varices presented higher SSM (73.5 vs 36.3 Kpa, p = 0.001), splenic vein diameter (10.8 vs 8.0 mm, p = 0.017), SSPS (18.7 vs 6.7, p = 0.003) and modified-VRS (4.0 vs 1.4, p = 0.013), besides lower PSR (332 vs 542, p = 0.038), than those without varices. SSPS was independently associated with varices presence (OR=1.19, 95%CI 1.03-1.37, p = 0.020) after multivariate analysis. In a model excluding noninvasive scores, SSM was independently associated with varices diagnosis (OR=1.09, 95%CI 1.03-1.16, p = 0.004). AUROC was 0.856 (95%CI 0.752-0.961, p = 0.001) for SSM and 0.816 (95%CI 0.699-0.932, p = 0.003) for SSPS (p = 0.551).

CONCLUSIONS

Spleen-related variables were predictors of esophageal varices: SSM, splenic vein diameter, SSPS, modified-VRS and PSR. Multivariate models indicated that SSM and SSPS are useful tools for predicting varices in non-cirrhotic portal hypertension by hepatosplenic schistosomiasis and may be used in clinical practice.

Nomogram for predicting the risk of gastroesophageal varices after primary endoscopic prophylaxis for variceal hemorrhage in patients with cirrhosis

BACKGROUND AND AIMS

The aim of this study was to identify predictors of non-high-risk gastroesophageal varices and evaluate the probability of the residual high-risk varices in cirrhosis patients after the primary endoscopic treatment.

PATIENTS AND METHODS

Medical records of the patients with cirrhosis admitted for primary endoscopic prophylaxis gastroesophageal varices hemorrhage were retrospectively analyzed. The patients were divided into high-risk varices and non-high-risk varices groups according to the endoscopy. A nomogram was developed based on the results of multivariate Cox analyses. Accuracy of this model was validated by the concordance index (Harrell's c-index) and calibration curve.

RESULTS

Altogether 117 patients were enrolled between March 2014 and April 2018. The multivariate Cox analyses identified spleen length <140 mm [odds ratio (OR) = 2.715; P = 0.037), small or medium size of esophageal varices (OR = 4.412; P = 0.017), unaccompanied with gastric varices (OR = 7.025; P = 0.003) and frequency of endoscopic variceal ligation ≥one time per 4 months (OR = 3.834; P = 0.034) as independent factors of non-high-risk varices. All significant predictors were incorporated into a nomogram to predict the residual high-risk varices, which showed a notable accuracy with the concordance index (0.833).

CONCLUSION

The nomogram-based prediction of residual high-risk varices can be used for risk stratification in cirrhosis patients with gastroesophageal varices.

Transient splenic elastography predicts high-risk esophageal varices in patients with non-cirrhotic portal hypertension

BACKGROUND AND AIMS

Non-cirrhotic portal hypertension (NCPH) comprise a group of diseases that cause portal hypertension without cirrhosis, leading to a high risk of hemorrhage from esophageal varices. There are no non-invasive predictors of high-risk varices (HRV) described in the literature for NCPH. This study aimed to evaluate whether transient splenic elastography (TSE) can predict HRV in patients with NCPH.

METHODS

Prospective study of patients with NCPH who underwent a single timepoint evaluation with transient liver and spleen elastography, ultrasonography, upper endoscopy, and laboratory tests. The study was performed from January to September 2020. Patients were divided into two groups based on the presence of HRV. The relation between TSE, transient liver elastography (TLE), spleen size, and platelet count to the presence of HRV was evaluated.

RESULTS

Of 42 patients with NCPH, 50% (21/42) presented HRV. In univariate analysis, TSE (median, 58.4 vs. 28.3, p = 0.009) and spleen size (median, 17.5 vs. 14.5 cm, p = 0.013) were associated with HRV. No statistically significant relationship was found between the presence of HRV and platelet count or TLE. In multivariate analysis, TSE was the only variable related to HRV (OR 1.21, 95% CI 1.02-1.38). TSE had a good performance in predicting HRV in our population (AUROC 0.878; 95% CI 0.751-1000). TSE > 35.4 kPa presents 93.3% sensitivity, 60.0% specificity, and 90.9% negative predictive value.

CONCLUSION

In our population of patients with NCPH, TSE is useful in predicting HRV. TLE, spleen size, and platelet count were not related to HRV.

Esophageal variceal hemorrhage: the role of MDCT characteristics in predicting the presence of varices and bleeding risk

PURPOSE

To investigate the associated Multi-Detector Computed Tomography (MDCT) features for esophageal varices (EVs) and esophageal variceal hemorrhage (EVH), with particular emphasis on different collateral veins.

MATERIALS AND METHODS

All cirrhotic patients who had undergone both Upper Gastrointestinal Tract (UGIT) endoscopy and contrast-enhanced MDCT within 6 months from 2013 to 2019 were included in the study. MDCT of 124 patients, 76 males and 48 females, aged between 21 and 73 years old were evaluated for presence of EV and presence and size of different collaterals. The presence and size of collaterals in patients with high-risk EVs or EVH were compared with others.

RESULTS

Findings of EV in MDCT analysis were the best predictor of EV or EVH, and presence (and/or size) of following collaterals showed a significant relationship with both EV and EVH: coronary (p = 0.006, 0.002), short gastric (SGC) (p = 0.02, < 0.001), and paraesophageal (p = 0.04, 0.01). Those presenting each aforementioned collaterals or with higher collateral size were more likely to develop the EV or EVH. Yet, other collaterals indicated no similar association: para-umbilical, omental, perisplenic, and splenorenal. Main coronary vein (p = 0.02, 0.03) and fundus (p = 0.006, 0.001) varices' sizes were also significantly higher in patients with EV or EVH. Finally, we suggested an imaging-based model (presence of SGC, SGC size > 2.5 mm, presence of EV, and coronary vein size > 3.5 mm) with 75.86% sensitivity, 76.92% specificity, and 76.36% accuracy to predict the presence of EVs according to UGIT endoscopy. Furthermore, we presented another model (presence of SGC, SGC size > 2.5 mm, presence of EV, and MELD score > 11.5 mm) to predict the occurrence of EVH with 75.86% sensitivity, 76.92% specificity, and 76.36% accuracy.

CONCLUSION

We suggested imaging characteristics for predicting EV and EVH with especial emphasis on the presence and size of various collaterals; then, we recommended reliable imaging criteria with high specificity and accuracy for predicting the EV and EVH.