Hepatocellular Carcinoma In Cirrhotic Patients Research Articles

PWE-283 Surveillance for hepatocellular carcinoma: a clinical audit

IntroductionIt is thought that mortality due to hepatocellular carcinoma (HCC) is rising in the Western world. This has been primarily attributed to the hepatitis C viral epidemic.1 HCC detected after...

Hepatectomy for hepatocellular carcinoma patients with macronodular cirrhosis

Patients with hepatocellular carcinoma (HCC) presenting with nonmicronodular or micronodular cirrhosis are usually treated by hepatectomy. The value of resection for patients with hepatitis B virus-related macronodular cirrhosis, however, remains unknown because of potentially fatal complications of this procedure. Clinicopathological data were analyzed for 85 resected HCC patients with hepatitis B virus-related macronodular cirrhosis. An additional 255 patients with nonmicronodular and micronodular cirrhosis were randomly selected during the same period as the control group. Compared with nonmicronodular and micronodular cirrhosis patients, macronodular cirrhotic patients exhibited elevated alanine aminotransferase, aspartate aminotransferase, and γ-glutamyltransferase levels, higher Child-Pugh classification, higher indocyanine green retention rate at 15 min (ICG R15), and more number of total complications. No significant differences were observed between the two groups with regard to major complications, mortality, overall survival, and recurrence-free survival. The morbidity rate was relatively low in patients exhibiting low ICG R15 (<10%). Cox analysis identified small tumors (≤ 5 cm) and radical resection as independent prognostic factors that could predict long-term overall survival. Radical resection can result in high recurrence-free survival in macronodular cirrhotic patients. Resection is safe for macronodular cirrhotic HCC patients, and radical resection provides a positive outcome. Small-sized patients are good candidates for hepatectomy. Macronodular cirrhosis should not rule out hepatectomy in patients with low ICG R15.

Saudi Guidelines for the Diagnosis and Management of Hepatocellular Carcinoma: Technical Review and Practice Guidelines

Recognizing the significant prevalence of hepatocellular carcinoma (HCC) in Saudi Arabia, and the difficulties often faced in early and accurate diagnoses, evidence-based management, and the need for appropriate referral of HCC patients, the Saudi Association for the Study of Liver diseases and Transplantation (SASLT) formed a multi-disciplinary task force to evaluate and update the previously published guidelines by the Saudi Gastroenterology Association. These guidelines were later reviewed, adopted and endorsed by the Saudi Oncology Society (SOS) as its official HCC guidelines as well. The committee assigned to revise the Saudi HCC guidelines was composed of hepatologists, oncologists, liver surgeons, transplant surgeons, and interventional radiologists. Two members of the task force served as guidelines editors. A wide based search on all published reports on all aspects of the epidemiology, natural history, risk factors, diagnosis, and management of HCC was performed. All available literature was critically examined and available evidence was then classified according to its strength. The whole document and the recommendations were then discussed in details by members and consensus was obtained. All recommendations in these guidelines were based on the best available evidence, but were tailored to the patients treated in Saudi Arabia. We hope that these guidelines will improve HCC patient care and enhance the multidisciplinary care needed for these patients.

Cost-effectiveness of semi-annual surveillance for hepatocellular carcinoma in cirrhotic patients of the Italian Liver Cancer population

It was recently shown that semi-annual surveillance for hepatocellular carcinoma (HCC) in cirrhotic patients provides a prognostic advantage over the annual program; however, its cost-effectiveness (CE) in the general cirrhotic population still needs to be defined. A Markov model was built to compare CE of these two strategies, considering literature results and treatment modalities of 918 cirrhotic patients from the Italian Liver Cancer (ITA.LI.CA) database. Results from the Markov model suggest that, compared to annual surveillance, semi-annual surveillance leads to a gain in quality-adjusted life expectancy, in an unselected cirrhotic population, of 1.35 quality-adjusted life-months (QALMs) over 10 years since surveillance start in compensated patients, and of 0.73 QALMs in decompensated patients. Semi-annual surveillance was more cost-effective in compensated than in decompensated cirrhosis, with an incremental CE ratio (ICER) of 1997 and 3814€/QALM, respectively. In compensated cirrhosis, semi-annual surveillance was more cost-effective than the annual program when the annual HCC incidence was ≥3.2% and the relative survival gain after cancer diagnosis was ≥20% with respect to the annual program. In decompensated cirrhosis, semi-annual surveillance was cost-effective in patients amenable to liver transplantation. In both groups, CE of semi-annual surveillance improved with the increase of annual incidence and the survival benefit obtainable with HCC treatment. Both surveillance strategies for HCC in cirrhotic patients can be recommended, according to the individual risk profile for HCC occurrence and the expected survival gain obtainable after tumor diagnosis and therapy.

FREQUENCY OF HEPATOCELLULAR CARCINOMA IN CIRRHOSIS

Objective: To find the frequency of hepatocellular carcinoma in cirrhotic patients of our population. Design: Prospectiveobservational study. Setting: Medical A Unit Hayat Abad Medical Complex Peshawar. Period: 1st January 2010 to 31st July 2011. Material &amp;methods: All patients were screened for presence of Hepatocellular carcinoma (HCC) by performing Alpha fetoprotein and ultra sound (U/S)abdomen. Contrast enhanced computed tomography scan (CT) of abdomen was done in selective cases. European Association for the Studyof Liver Diseases (EASLD) Noninvasive criteria (limited to patients with underlying cirrhosis) was used for diagnosis of HCC i.e. Two coincidentimaging techniques that identify a focal lesion more than 2 cm showing arterial hypervascularization or one imaging modality that identifies afocal lesion more than 2 cm in diameter showing arterial hypervascularization and serum AFP levels greater than 400 ng/Ml. Results: A total of370 patients cirrhotic patients were enrolled in this study. Thirty nine patients (10.5%) were diagnosed as having HCC. Male patients were 30(77%) and 9(23%) were female. Mean age was 49.2% (range 18 to 72 years). Abdominal discomfort was predominant symptom present in 94%patients, followed by anorexia present in 90% patients, abdominal distension in 76%, weight loss in 62%, jaundice was present in 46% patients,altered mental status was notice in 36% patients and history of upper gastrointestinal (GI) bleed and malena was extracted from 26% patients.Ultrasound abdomen and CT abdomen showed unifocal lesion in 48.7% patients, multifocal lesion in 30.7% patients and massive lesion in20.5% patients. Alpha fetoprotein ranged from 45ng/dl to 630ng/dl. Hepatitis C (HCV) was the commonest cause present in 51% patients,Hepatitis B (HBV) in 15.3% patients and HBV and HCV co-infection in 10.25% patients, history of alcoholism was revealed in 5% patients and in2.5% patients alcoholism was present along with HCV and HBV each, while in 10% cases the cause of cirrhosis remained unknown.Conclusions: Hepatocellular carcinoma is the most common primary hepatic tumor and one of the most common cancers worldwide. It isconcluded that HCC is more common in males compared to female cirrhotic patients. Hepatitis C followed by HBV are the leading causes ofHCC related cirrhosis in local Population of Khyber pakhtoonkhwa.

Surgical management of hepatocellular carcinoma in Child-Pugh class B cirrhotic patients: Hepatic resection and/or microwave coagulation therapy versus living donor liver transplantation

The surgical management of hepatocellular carcinoma (HCC) in cirrhotic patients with Child-Pugh class B remains controversial. The aim of this study was to compare the results of hepatic resection plus microwave coagulation therapy (MCT) versus living donor liver transplantation (LDLT) for HCC in cirrhotic patients with Child-Pugh class B. Between January 1998 and June 2008, 30 patients underwent hepatic resection plus MCN and 40 patients underwent LDLT for HCC with Child-Pugh class B. Univariate and multivariate Cox proportional hazard models were established. Kaplan-Meier survival curves were generated, and a log-rank test was performed to compare group survival status. There was no difference in overall survival after hepatic resection plus MCT (1-, 3-, and 5-year: 86.7%, 70.4%, and 70.4%, respectively) compared with LDLT (1-, 3-, and 5-year: 92.5%, 81.5%, and 72.6%, respectively). Disease-free survival was significantly better after LDLT compared with hepatic resection plus MCT. On multivariate analyses, the des-gamma-carboxy prothrombin (DCP) level of more 300 mAU/mL was an independent risk factor for overall survival and recurrence of HCC after LDLT. In preoperative Milan criteria met-patients, 5-year overall survival following LDLT was significantly better than that after hepatic resection plus MCT. Incidentally found hepatocellular carcinoma had higher tendency of well differentiated tumor in the explant liver after LDLT. In preoperative Milan criteria met-cirrhotic patients with Child-Pugh class B, LDLT was associated with longer disease-free and overall survival than hepatic resection plus MCN. LDLT could not be indicated in the patients with DCP level of more 300 mAU/mL.

Current concepts in hepatic resection for hepatocellular carcinoma in cirrhotic patients

Hepatocellular carcinoma (HCC) is one of the most frequent neoplasms worldwide and in most cases it is associated with liver cirrhosis. Liver resection is considered the most potentially curative therapy for HCC patients when liver transplantation is not an option or is not immediately accessible. This review is aimed at investigating the current concepts that drive the surgical choice in the treatment of HCC in cirrhotic patients; Eastern and Western perspectives are highlighted. An extensive literature review of the last two decades was performed, on topics covering various aspects of hepatic resection. Early post-operative and long-term outcome measures adopted were firstly analyzed in an attempt to define an optimal standardization useful for research comparison. The need to avoid the development of post-hepatectomy liver failure represents the "conditio sine qua non" of surgical choice and the role of the current tools available for the assessment of liver function reserve were investigated. Results of hepatic resection in relationship with tumor burden were compared with those of available competing strategies, namely, radiofrequency ablation for early stages, and trans-arterial chemoembolization for intermediate and advanced stages. Finally, the choice for anatomical versus non-anatomical, as well as the role of laparoscopic approach, was overviewed. The literature review suggests that partial hepatectomy for HCC should be considered in the context of multi-disciplinary evaluation of cirrhotic patients. Scientific research on HCC has moved, in recent years, from surgical therapy toward non-surgical approaches and most of the literature regarding topics debated in the present review is represented by observational studies, whereas very few well-designed randomized controlled trials are currently available; thus, no robust recommendations can be derived.

Diabetes Worsens the Surgical Outcomes in Cirrhotic Patients with Hepatocellular Carcinoma

Diabetes is a known risk factor for developing hepatocellular carcinoma (HCC). Reported rates of diabetes are higher in chronic hepatitis, cirrhosis and HCC patients. However, its effects on postoperative recurrence and survival with HCC are controversial. This study offers a retrospective analysis of the impacts of diabetes on postoperative recurrence and survival in patients with cirrhosis and HCC. A total of 389 cirrhotic patients who underwent curative resection for primary HCC at our institution between January 2000 and December 2008 were enrolled. Of them, 272 (70%) patients were classified into a non-diabetes group and 117 (30%) patients into the diabetes group. The diabetes group was divided into an oral hypoglycemic agent (OHA) control group (n = 100) and an insulin control group (n = 17). The result indicates that the diabetes group had a higher postoperative recurrence rate and poorer long-term survival rate (p = 0.001 vs. 0.01). There was no significant difference in recurrence-free survival rate between the OHA control group and the insulin control group (p = 0.17). The insulin control group had a poorer long-term surgical outcome than the OHA control group (p = 0.035). In conclusion, our results suggest that diabetes is an independent risk factor for postoperative recurrence and surgical survival of cirrhotic HCC patients. Cirrhotic HCC patients with diabetes who received hepatic resection should be closely followed-up for postoperative recurrence and long-term outcome. Moreover, an effective peri-operative sugar control planning in HCC patients with diabetes should be established.

Iron Load and Serum Hepcidin in Hepatitis C Virus-Related Hepatocellular Carcinoma

Background: Hepatocellular carcinoma (HCC) is a major causeof death worldwide, and chronic inflammatory stress causedby hepatitis viruses plays a major role in HCC carcinogenesis.The aim of the present study was to investigate the expressionof serum hepcidin and its correlation with iron overload in HCC.Study design: The study was carried out on 50 hepatitis Cvirus (HCV)-related HCC cirrhotic patients (Group I) and 20age-matched non-HCC liver cirrhosis patients as control(Group II). Serum hepcidin was measured in all samples with acommercial immunoassay. The extent of iron deposition wasevaluated in liver histochemically.Results: There was no relationship between the serum hepcidinlevel and the histological grade of HCC (p = 0.1492), ormultiplicity of focal lesion (p = 0.0719), however, hepatic irondeposition was significant higher in HCC than non-HCC cirrhoticpatients (p < 0.005).Conclusion: The current study suggests a positive associationof hepatic iron score, but the role of hepcidin in this contextremains to be elucidated.Abbreviations: HCC: Hepatocellular carcinoma; HCV: HepatitisC virus; ROS: Reactive oxygen species; ESR: Erythrocytessedimentation rate; TIBC: Total iron-binding capacity; HIS:Hepatocytic iron score; SIS: Sinusoidal iron score; PIS: Portaliron score; TIS: The total iron score.

How to predict the development of hepatocellular carcinoma in cirrhotic patients. Despite recent advances, the search continues

Hepatocellular carcinoma (HCC) is a major global health problem, accounting for more than 626,000 new cases worldwide each year...

How to predict the development of hepatocellular carcinoma in cirrhotic patients. Despite recent advances, the search continues

How to predict the development of hepatocellular carcinoma in cirrhotic patients. Despite recent advances, the search continues

How to predict the development of hepatocellular carcinoma in cirrhotic patients. Despite recent advances, the search continues

How to predict the development of hepatocellular carcinoma in cirrhotic patients. Despite recent advances, the search continues

Hepatocellular Carcinoma Screening Rates Vary by Etiology of Cirrhosis and Involvement of Gastrointestinal Sub-specialists

Regular screening of cirrhotic patients for hepatocellular carcinoma (HCC) has been suboptimal, but there is little data regarding specific risk factors for reduced screening. From 1996 to 2010, patients with cirrhosis were retrospectively identified from outpatient gastroenterology and primary care practices. Data was obtained from the diagnosis of cirrhosis until the time of elevated alpha-fetoprotein (AFP) or lesion suspicious for HCC, death, liver transplantation, or end of the data collection period. Recommended screening was defined as abdominal imaging (ultrasound, contrast-enhanced CT, or MRI) with or without serum alpha-fetoprotein (AFP) at least once every 12months based on professional guidelines. One hundred fifty-six patients with cirrhosis were identified. The etiologies of cirrhosis were viral hepatitis (n=65), alcohol (n=40), non-alcoholic steatohepatitis (NASH) (n=27), and non-viral, non-alcoholic, non-NASH cirrhosis (n=24). Of the 156 patients, 51% received recommended screening for HCC. Patients with NASH cirrhosis received recommended screening significantly less (p=0.016) than cirrhotics with viral hepatitis, alcoholic cirrhosis, or non-viral, non-alcoholic, non-NASH cirrhosis and were less likely to receive gastroenterology referral (p<0.001). Additionally, 20 patients were diagnosed with cirrhosis incidentally during a surgical procedure. These patients were significantly less likely to receive recommended HCC screening than those diagnosed non-surgically (10.0 vs. 56.6%; p<0.001). Screening was significantly more likely to occur in patients seen regularly by a gastrointestinal subspecialist (66.7 vs. 22.8%; p<0.001). Patients with NASH cirrhosis and incidentally discovered cirrhosis have low rates of HCC screening and are referred less often to gastroenterologists. These data suggest a need for increased education about NASH cirrhosis and better systems of communication among general practitioners, surgeons, and gastroenterologists.

Does the hepatocellular phase of gadobenate dimeglumine help to differentiate hepatocellular carcinoma in cirrhotic patients according to histological grade?

To assess the role of the hepatocellular phase on magnetic resonance imaging (MRI) following gadobenate in characterizing the grade of hepatocellular carcinoma (HCC) in cirrhotic patients. A retrospective review of the MRI database from October 2004 to February 2009, performed for this Institutional Review Board-approved and Health Insurance Portability and Accountability Act (HIPAA)-complaint study, revealed 237 cirrhotic patients with focal liver lesions. Patients who had both a hepatocellular phase after gadobenate and pathological confirmation of HCC were included. Forty-six patients with 73 HCC were analysed independently by two reviewers for signal characteristics. Absolute contrast-to-noise ratio (CNR) and enhancement ratio (ER) were calculated. Univariate analysis, stepwise logistic regression analysis, and receiver operating characteristic curves (ROC) were performed. The mean age was 61.3 years (range 45 to 78 years). There were 11 females and 35males, who had 22 well-differentiated (WD HCC), 35 moderately-differentiated (MD HCC), and 16 poorly-differentiated (PD HCC) hepatocellular carcinomas. On visual analysis of the hepatocellular phase, a hyperintense or isointense lesion had a sensitivity and specificity of 45% and 76%, respectively, for WD HCC. On quantitative analysis, the only significant predictor of the grade of HCC was the ER on the hepatocellular phase (p=0.019 and 0.001 for the two reviewers in logistic regression model). On ROC analysis, an ER of >13% was 47% sensitive and 89% specific in predicting WD HCC histology. Although the hepatocellular phase of gadobenate may help to differentiate some cases of WD HCC from the more aggressive grades, there is overlap between the different grades on qualitative and quantitative analysis.

Transcatheter arterial chemoembolization for hepatocellular carcinoma in cirrhosis

Transcatheter arterial chemoembolization (TACE) is a routine treatment for hepatocellular carcinoma in cirrhotic patients. Whether TACE influences the degree of portal hypertension remains uncertain. AIM AND PATIENTS: We retrospectively analyzed the clinical course of 283 TACE to investigate the incidence of variceal bleeding and ascites after the procedure. We also prospectively evaluated portal pressure by hepatic venous portal gradient (HVPG) before and within 3 days by TACE in a group of 15 patients. Before TACE, esophageal varices were present in 125 patients. Variceal bleeding occurred in three (1.5%) and ascites in two (1%) patients during the follow-up post-TACE. Patients with variceal bleeding were significantly older (P=0.019). In 15 patients who underwent portal pressure measurement before and within 3 days by TACE, HVPG was unchanged (mean 13.1 vs. 12.8 mmHg, P>0.05). In our series portal hypertension-related complications after TACE were rare and did not result in higher mortality. As TACE did not influence HVPG, the preventive ligation of esophageal varices before TACE does not seem justified.

Therapeutic effects of the oriental herbal medicine Sho‐saiko‐to on liver cirrhosis and carcinoma

The traditional Chinese herbal medicine Sho-saiko-to is a mixture of seven herbal preparations that has long been used in the treatment of chronic liver disease. Various clinical trials have shown that Sho-saiko-to protects against the development of hepatocellular carcinoma in cirrhotic patients. However, the mechanism by which Sho-saiko-to protects hepatocytes against hepatic fibrosis and carcinoma is not yet known. Basic science studies have demonstrated that Sho-saiko-to reduces hepatocyte necrosis and enhances liver function. Sho-saiko-to significantly inhibits hepatic fibrosis by inhibiting the activation of stellate cells, the major producers of collagen in the liver, as well as by inhibiting hepatic lipid peroxidation, promoting matrix degradation, and suppressing extracellular matrix (ECM) accumulation. Furthermore, clinical trials have shown that Sho-saiko-to lowers the rate of hepatocellular carcinoma (HCC) development in patients with cirrhosis and increases the survival of patients with HCC. Unfortunately, some case reports have shown the side effects of Sho-saiko-to. Most of the side effects were interstitial pneumonia and acute respiratory failure induced by Sho-saiko-to in Japan. As a result of analyzing these case reports, the incidence and risk are increased by co-administration of interferon, duration of medication, and, high in an elderly population. This review discusses the properties of Sho-saiko-to with regards to the treatment of chronic liver diseases and suggests the side effects of Sho-saiko-to.

A randomized controlled trial of emergency treatment of bleeding esophageal varices in cirrhosis for hepatocellular carcinoma

Background Ninety percent of patients with hepatocellular carcinoma (HCC) have cirrhosis. Bleeding esophageal varices (BEV) is a frequent complication of cirrhosis. Detection of HCC in cirrhotic patients with BEV has not been studied. Methods Two hundred eleven unselected patients with cirrhosis and BEV were randomized to endoscopic sclerotherapy (n = 106) or emergency portacaval shunt (n = 105). Diagnostic workup and treatment were initiated within 8 hours. Ninety-six percent had >10 years of follow-up. HCC screening involved serum α-fetoprotein (AFP) every 3 months, ultrasonography every 6 months, and selective computed tomography (CT). Results HCC occurred in 15 patients, all incurable, a mean of 2.94 years after entry. They died a mean 1.33 years after discovery. Serial AFP and ultrasound examinations were unrevealing over a mean of 2.3 years. The mean model of end-stage liver disease score was 12.7 at entry and 17.4 at HCC diagnosis. Conclusions Long-term screening by AFP and ultrasound plus selective CT failed to detect HCC at a curable stage. The detection of HCC in cirrhotic patients with BEV remains a serious, unsolved problem. The use of CT for routine screening warrants consideration despite increased costs.

Surveillance for hepatocellular carcinoma in cirrhotic patients: From official recommendations to the real life

COMMENTARY ON: Use of surveillance for hepatocellular carcinoma among patients with cirrhosis in the United States. Davila JA, Morgan RO, Richardson PA, Du XL, McGlynn KA, El-Serag HB. Hepatology 2010 Jul;52(1):132–41. http://www.ncbi.nlm.nih.gov/pubmed/20578139

Laparoscopic liver resection for hepatocellular carcinoma in cirrhotic patients. Feasibility of nonanatomic resection in difficult tumor locations

BACKGROUND:Surgical resection for hepatocellular carcinoma (HCC) in cirrhotic patients remains controversial because of high morbidity and recurrence rates. Laparoscopic resection of liver tumors has recently been developed and could reduce morbidity. The aim of this study was to evaluate retrospectively our results for laparoscopic liver resection (LLR) for HCC including lesions in the posterosuperior segments of the liver in terms of feasibility, outcome, recurrence and survival.MATERIALS AND METHODS:Between June 2005 and February 2009, we performed 20 LLR for HCC. Median age of the patients was 66 years. The underlying cirrhosis was staged as Child A in 17 cases and Child B in 3.RESULTS:LLR included anatomic resection in six cases and nonanatomic resection in 14. Eleven procedures were associated in nine (45%) patients. Median tumor size and surgical margins were 3.1 cm and 15 mm, respectively. A conversion to laparotomy occurred in one (5%) patient for hemorrhage. Mortality and morbidity rates were 0% and 15% (3/20). Median hospital stay was 8 days (range: 5-16 days). Over a mean follow-up period of 26 months (range: 19–62 months), 10 (50%) patients presented recurrence, mainly at distance from the surgical site. Treatment of recurrence was possible in all the patients, including orthotopic liver transplantation in three cases.CONCLUSIONS:LLR for HCC in selected patients is a safe procedure with good short-term results. It can also be proposed in tumor locations with a difficult surgical access maintaining a low morbidity rate and good oncological adequacy. This approach could have an impact on the therapeutic strategy of HCC complicating cirrhosis as a treatment with curative intent or as a bridge to liver transplantation.

Hepatocellular carcinoma in cirrhotic patients with portal hypertension: Is liver resection always contraindicated?

To analyze the outcome of hepatocellular carcinoma (HCC) resection in cirrhosis patients, related to presence of portal hypertension (PH) and extent of hepatectomy. A retrospective analysis of 135 patients with HCC on a background of cirrhosis was submitted to curative liver resection. PH was present in 44 (32.5%) patients. Overall mortality and morbidity were 2.2% and 33.7%, respectively. Median survival time in patients with or without PH was 31.6 and 65.1 mo, respectively (P = 0.047); in the subgroup with Child-Pugh class A cirrhosis, median survival was 65.1 mo and 60.5 mo, respectively (P = 0.257). Survival for patients submitted to limited liver resection was not significantly different in presence or absence of PH. Conversely, median survival for patients after resection of 2 or more segments with or without PH was 64.4 mo and 163.9 mo, respectively (P = 0.035). PH is not an absolute contraindication to liver resection in Child-Pugh class A cirrhotic patients, but resection of 2 or more segments should not be recommended in patients with PH.