Presence Of Portal Vein Tumor Thrombosis Research Articles

Efficacy of immune checkpoint inhibitors in patients with HIV-associated unresectable HCC (uHCC): Propensity-score matched analyses from two international consortia.

442 Background: HIV-associated HCC is an incompletely characterized disease with poor prognosis. People living with HIV (PWH) are commonly excluded from clinical trials, leading to a paucity of high-level evidence for optimal management. Whether ICIs are tolerated and effective in HIV-associated uHCC remains unclear. Methods: Using data from the CATCH-IT consortium and from a global dataset recruiting patients with HCC from 14 centers in 3 continents, we selected patients with HIV-associated uHCC treated with ICIs and compared their outcomes with a matched cohort of HIV negative (HIV-) patients. Primary endpoints were overall (OS) and progression-free survival (PFS). Propensity score matching (PSM) between the two groups was performed for the following variables: age, sex, HCC aetiology, Child-Pugh class (CP-C), ECOG-PS, BCLC stage, alpha-fetoprotein (AFP) levels, treatment line, portal vein tumor thrombosis (PVTT), and extrahepatic spread (EHS). Restricted mean survival time (RMST) difference analyses stratified by HIV status were performed for OS and PFS at 3, 6 and 9 months. Results: We accrued 46 PWH and 400 HIV-, treated mostly in the first-line setting (58.7% vs. 43.7%) with either atezolizumab plus bevacizumab (28.3% vs 17.5%) or anti-PD-1 monotherapy. Median age at ICI start was 62 (38-76) and 64 (18-87); viral hepatitis (HCV: 58.7%; HBV: 34.8%) were the prevalent aetiologies in PWH, non-viral (46%) was the most common in HIV-; most patients had BCLC-C HCC (84.8% and 82.3%). In PWH, median CD4 count was 345 cells/mm3 (IQR: 200-465); viral load was undetectable in 45 patients, all were established on combined anti-retroviral therapy. Following PSM, 44 PWH and 117 HIV- were included. Median OS was 7.5 months (95%CI: 5.2-NR) in PWH and 10.8 months (95%CI: 7.3-19.5) in HIV- (HR: 0.89; 95%CI: 0.56-1.42; p=0.58). Presence of PVTT, AFP>400 ng/mL, and ECOG-PS=1 but not HIV status were associated with worse OS in uni- and multivariable models. Median PFS was 2.8 months (95%CI: 2.6-4.8) for PWH vs 3.0 months (95%CI: 2.4-5.3) for HIV- (HR: 0.83-95%CI:0.56-1.24 ;p=0.38); HIV status was not associated with worse PFS. RMST confirmed no OS or PFS differences based on HIV status. In matched cohorts, neither ORR (21% vs. 19.1%, p=0.97) nor DCR (44.7% vs. 55.4%, p=0.19) were associated with HIV status. All grade immune-related adverse events (irAEs) were more frequent in HIV (44.0% vs 21.7%, p=0.003), with similar incidence of grade ≥3 irAEs (22.2% vs 13.0%). PWH had lower incidence of dermatological toxicities (4.3% vs 22%, p=0.003) and a trend towards lower incidence of hepatotoxicity (6.5% vs 18%, p=0.059). Conclusions: This study provides practice-informing evidence to support the use of ICIs in PWH and uHCC. Our findings encourage the inclusion of patients with well-controlled HIV in prospective clinical trials.

Refining MRI-based criteria for portal vein invasion in hepatocellular carcinoma: improving sensitivity beyond portal vein tumor thrombosis.

To investigate the imaging features indicating portal vein invasion (PVI) of hepatocellular carcinoma (HCC) on gadoxetic acid-enhanced MRI and to create more accurate diagnostic criteria than the presence of portal vein tumor thrombosis (PVTT) on MRI. This retrospective study included patients with surgically resected HCC larger than 5 cm, and the presence of PVI was investigated. On MRI, we evaluated the image findings of portal vein occlusion, the parenchymal signal change caused by hemodynamic alterations of the portal vein, and their combination showing the highest odds ratio (OR) to define the diagnostic criteria for radiological PVI detection (rPVI criteria). The diagnostic performance and recurrence-free survival were compared between the rPVI criteria and the presence of PVTT using McNemar's test and Kaplan-Meier method, respectively. Interobserver agreement was evaluated using Cohen's weighted ĸ statistics. Of 189 enrolled patients, 25 (13.2%) had PVI on histology. To diagnose PVI on MRI, either peripheral wedge-shaped arterial peritumoral hyperemia with an abrupt cut-off of a portal vein or the presence of PVTT had the highest OR (41.67, p<0.001). The sensitivity of PVI was significantly increased under this diagnostic criterion (64.0% to 88.0%; p=0.031) with comparable accuracy (95.2% vs. 94.7%; p>0.999). In terms of recurrence-free survival, the patient group with rPVI was significantly worse (p=0.017) compared with the patients without rPVI. Interobserver agreement of radiologic findings was substantial (ĸ=0.64). Diagnostic criteria for radiologically PVI detection increase the sensitivity more than the only presence of PVTT.

Creating and Testing a Model to Predict Postoperative Discomfort in Patients with Hepatocellular Carcinoma Receiving Transarterial Chemoembolisation

Background: Abdominal pain is a frequent adverse event in patients with hepatocellular carcinoma (HCC) after transarterial chemoembolisation (TACE). However, there remains uncertainty regarding the determinants of post-TACE pain. Objectives: We aimed to create and verify a prediction model for postoperative pain in patients with HCC after TACE treatment. Methods: This prospective study included all patients with HCC undergoing TACE in our hospital. According to the time of treatment, the dataset was divided into two cohorts (development and validation) in a 3: 2 ratio. After TACE, the participants used a visual analog scale to quantify their pain level at rest over a 24-hour period. The age, gender, tumor location, tumor size and number, medication administration route, and presence of portal vein tumor thrombosis (PVTT) were recorded in all patients. Results: In total, 137 (mean age: 60.3 ± 10.1 years; 78.1% male) and 91 (mean age: 61.1 ± 10.5 years; 73.6% male) patients were included in the development and validation cohorts, respectively. Furthermore, 46.0% and 39.6% of the patients experienced acute moderate to severe pain after TACE in the development and validation cohorts, respectively. The tumor location, the drug delivery method, and the presence of PVTT were independently associated with post-TACE pain, all of which were combined to develop a prediction model based on a logistic equation. The discrimination of this risk score was satisfactory in both the development (area under the curve (AUC): 0.693, 95% confidence interval (CI): 0.609 to 0.769, P &lt; 0.001) and validation (AUC: 0.652, 95% CI: 0.544 to 0.748, P = 0.002) cohorts. There was no significant difference between the two cohorts (difference: 0.042, 95% CI: -0.081 to 0.164, P = 0.506). The risk score had good specificity for predicting post-TACE pain in both the development (83.8% (95% CI: 73.4% to 91.3%)) and validation (76.4% (95% CI: 63.0% to 86.8%)) cohorts. Conclusions: The presence of PVTT, the tumor location, and the drug administration method were risk factors for post-TACE discomfort. A prediction model based on these risk factors was useful for identifying patients who were vulnerable to post-TACE pain. However, further studies are required to validate these findings and optimize the model’s performance.

A study of the clinical profile, predictors, prognostic features, and survival of patients with hepatocellular carcinoma having macroscopic portal vein tumor thrombosis.

Macroscopic portal vein tumor thrombosis (PVTT) is considered a negative prognostic factor in hepatocellular carcinoma (HCC) patients. There is divergent opinion regarding management of these patients worldwide. We aimed to evaluate the clinical profile, predictors, prognostic features, and survival of patients of HCC with PVTT. Treatment-naïve HCC patients with and without PVTT were analyzed retrospectively using a prospectively accrued dataset. Patients with PVTT were further divided as per treatment groups for survival analysis. Of 508 patients, 46.1% had radiological evidence of PVTT at presentation. On logistic regression, serum albumin (odds ratio [OR]=0.65, 95% confidence interval [CI]= 0.44-0.96; p= 0.031); international normalized ratio (OR = 3.78,95% CI = 1.42-10.00; p=0.008); alpha-feto protein >400 ng/mL (OR=3.58, 95%CI = 2.00-6.40; p <0.001); size of largest tumor nodule >5 cm (OR =6.37, 95%CI =2.03-19.99; p =0.002); and male gender (OR =1.84, 95%CI = 1.01-3.33; p = 0.045) were independent predictors for PVTT. Patients with PVTT amenable to aggressive therapies had significantly better median overall survival (in months) as compared to those receiving sorafenib or best supportive care only (13.1, 3.9, and 1.8 respectively, p<0.0001). Treatment modality received (p<0.001) and extrahepatic metastasis (p=0.006) were independent predictors of mortality in these patients. Size of largest tumor nodule >5 cm and alpha-fetoprotein >400 ng/mL are strongly associated with the presence of PVTT in patients with HCC. A multidisciplinary approach may identify a subgroup of patients who can be offered aggressive therapies like surgery and/or locoregional therapy with significant survival benefit.

Risk of Variceal Bleeding in Patients With Advanced Hepatocellular Carcinoma Receiving Atezolizumab/Bevacizumab

Risk of Variceal Bleeding in Patients With Advanced Hepatocellular Carcinoma Receiving Atezolizumab/Bevacizumab

A case of pathologically complete response after preoperative chemotherapy in a pancreatic acinar cell carcinoma patient with portal vein tumor thrombosis

Preoperative treatment is being proposed as a standard treatment for pancreatic ductal adenocarcinoma though few cases show a pathologically complete response. On the other hand, there is no consensus regarding preoperative chemotherapy for pancreatic acinar cell carcinoma (ACC). The present study described a rare case of ACC in the pancreatic head with portal vein tumor thrombosis (PVTT) treated with preoperative chemotherapy using modified FOLFIRINOX, which achieved a pathologically complete response. A 65-year-old man was referred for consideration of treatment strategy. Contrast-enhanced abdominal computed tomography revealed a pancreatic tumor and PVTT. The pancreatic tumor was diagnosed as ACC by an endoscopic ultrasound-guided fine-needle aspiration biopsy. Initially, the tumor was assessed as unresectable due to the presence of PVTT, and therefore, a chemotherapy using modified FOLFIRINOX was administered. After 14 courses of the chemotherapy, imaging studies revealed that the tumor and PVTT showed marked reduction in size; thus, the patient underwent pancreaticoduodenectomy with combined resection of the portal vein (PV). A pathological examination uncovered a complete degeneration of the primary tumor and the PV embolus without any residue of carcinoma. The patient did not receive adjuvant chemotherapy and survived with no evidence of recurrence for 33months after surgery. The chemotherapy using modified FOLFIRINOX could give a complete response in patients with pancreatic ACC with PVTT.

Transarterial Chemoembolization in Unresectable Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis: A Tertiary Care Center Experience.

Background Portal vein tumor thrombosis (PVTT) is a common complication of hepatocellular carcinoma (HCC) occurring in 30 to 40% of cases. The presence of PVTT in HCC is regarded as an advanced disease that confers poor prognosis and survival. Transarterial chemoembolization (TACE) has traditionally been considered to be contraindicated in cases of PVTT, due to the risk of hepatic infarction, and further deteriorate liver function. We evaluated safety, technical efficacy, and outcomes of TACE in HCC with PVTT. Methods From search results of the hospital database, out of 652 patients who underwent TACE for HCC, 73 patients of HCC with PVTT were retrospectively evaluated. Post-TACE tumor response by computed tomography (CT)/magnetic resonance imaging (MRI) imaging as per modified response evaluation criteria in solid tumors (mRECIST) criteria, if any occurrence of acute hepatic failure was assessed. Prognostic factors influencing survival were also determined. Results In our study population, the mean age of the patients was 58 years. The 12- and 24-month survival rates were 59 and 14%, respectively, with an overall median survival of 12.3 months. A total of 58.9% patients had branch portal vein tumor thrombus and 41.1% had tumor thrombus in the main portal vein. We did not encounter any mortality or acute liver failure following TACE in a 30-day period. Both univariate and multivariate analysis revealed Child–Pugh score ( p = 0.01) and the extent of tumoral thrombus ( p 0.004) as a significant prognostic factor. Patients with branch PVTT, no ascites, and Child–Pugh A had better survival than those having main portal vein tumor thrombus, ascites, and Child–Pugh B. Conclusion Our study concluded that TACE can achieve good disease control and improved survival in HCC with portal vein invasion despite being considered as a relative contraindication. Technical expertise, selection of patients, such as superselective catheterization and preserved liver function, are the key factors for a safe therapeutic procedure. Child–Pugh score and extent of portal vein invasion were the significant prognostic factors determining survival.

Chemoembolization for Hepatocellular Carcinoma in Patients with Extrahepatic Spread: Prognostic Determinants and Appropriate Candidates

PurposeTo investigate treatment outcome, prognostic factors for overall survival, and appropriate candidates for transarterial chemoembolization among patients with hepatocellular carcinoma (HCC) and extrahepatic spread (EHS). Materials and MethodsFrom January 2010 to June 2014, 111 consecutive patients with HCC and EHS treated by transarterial chemoembolization alone were evaluated. Factors associated with overall survival were evaluated using Cox regression analysis, and a scoring equation was established to subgroup patients with EHS. ResultsMedian follow-up was 3.8 months, and median overall survival was 3.8 months (95% confidence interval [CI], 2.9–4.7 months). Multivariate analysis demonstrated maximum tumor size ≥ 10 cm (hazard ratio [HR] 1.58; 95% CI, 1.02–2.46; P = .041), multifocal intrahepatic tumors (HR 1.55; 95% CI, 1.03–2.33; P = .037), and portal vein tumor thrombosis (PVTT) (HR 1.81; 95% CI, 1.12–2.91; P = .015) as significant predictors of overall survival. Based on these factors, a scoring equation was developed to predict treatment outcome of transarterial chemoembolization, with an area under the receiver operating characteristic curve of 0.76 in predicting 6-month survival. Using a cutoff score of 5.5, patients with HCC and EHS were divided into 2 groups with significantly different overall survival (8.1 months for EHS1 and 2.4 months for EHS2; P < .001). The described method of subgrouping remained discriminatory regardless of baseline characteristics. ConclusionsMaximum tumor size, intrahepatic tumor distribution, and presence of PVTT were significant determinants of overall survival for patients with HCC and EHS. Transarterial chemoembolization may be appropriate for patients with EHS but lower intrahepatic tumor burden.

Treatment of hepatocellular carcinoma with portal venous tumor thrombosis: A comprehensive review.

The natural history of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is dismal (approximately 2-4 mo), and PVTT is reportedly found in 10%-40% of HCC patients at diagnosis. According to the Barcelona Clinic Liver Cancer (BCLC) Staging System (which is the most widely adopted HCC management guideline), sorafenib is the standard of care for advanced HCC (i.e., BCLC stage C) and the presence of PVTT is included in this category. However, sorafenib treatment only marginally prolongs patient survival and, notably, its therapeutic efficacy is reduced in patients with PVTT. In this context, there have been diverse efforts to develop alternatives to current standard systemic chemotherapies or combination treatment options. To date, many studies on transarterial chemoembolization, 3-dimensional conformal radiotherapy, hepatic arterial chemotherapy, and transarterial radioembolization report better overall survival than sorafenib therapy alone, but their outcomes need to be verified in future prospective, randomized controlled studies in order to be incorporated into current treatment guidelines. Additionally, combination strategies have been applied to treat HCC patients with PVTT, with the hope that the possible synergistic actions among different treatment modalities would provide promising results. This narrative review describes the current status of the management options for HCC with PVTT, with a focus on overall survival.

Factors predictive for long‐term survival of male patients with hepatocellular carcinoma after curative resection

Curative hepatic resection (CHR) was a modality that provides possibility of long-term survival for hepatocellular carcinoma (HCC). So far, prognostic factors of male patients with HCC after CHR remain unclear. Purposes of the present study were to identify these factors and to compare them with those for females. Consecutive 151 male and 23 female patients with HCC undergoing CHR were enrolled in this retrospective study. Their prognostic factors were identified by uni- and multi-variate statistical analysis. One-, three- and five-year overall and disease-free survival of male patients were 82.4, 51.5, and 43.6%, and 65.8, 33.7, and 21.7%, respectively, with no significant differences compared to females. Univariate analysis showed that tumor size, TNM staging, Edmondson-Steiner grade, serum alpha-fetoprotein (AFP) level, presence of portal vein tumor thrombosis (PVTT) and satellite nodule were significant for males with HCC, but only Edmondson-Steiner grade, presence of PVTT and satellite nodule were independent. For females, Edmondson-Steiner grade was the single potential indicator for survival. Malignant degree and invasive phenotypes were main factors that independently influenced survival of male patients with HCC after CHR. Among them, histological grade, which was also potentially significant for females, was the most powerful survival predictor.