Well-preserved Liver Function Research Articles

Potentiality and boundaries of use of sorafenib in patients with hepatocellular carcinoma: awaiting the results of ongoing clinical trials.

No systemic therapy had been proven effective in patients with advanced hepatocellular carcinoma (HCC) until 2007, when a large randomized trial with sorafenib demonstrated a clinically relevant prolongation of survival. Currently, sorafenib represents standard treatment for patients with advanced HCC and well-preserved liver function, whilst the evidence about its effectiveness in patients with more severe liver impairment is less robust. A randomized trial to demonstrate the efficacy of sorafenib in Child-Pugh B patients with advanced HCC is currently ongoing. In the meantime, several trials are testing the role of sorafenib in early HCC (as adjuvant treatment after potentially curative loco-regional therapies) and in intermediate stage (exploring different modalities of integration of sorafenib with trans-arterial chemo-embolization). The results of all these trials will better define the potentiality and the boundaries of use of sorafenib in HCC patients.

A randomized phase III trial comparing sorafenib plus best supportive care (BSC) versus BSC alone in Child-Pugh B patients (pts) with advanced hepatocellular carcinoma (HCC): The BOOST study.

TPS4151 Background: The efficacy of sorafenib in pts with advanced HCC has been demonstrated in two randomized phase III trials (Llovet JM, NEJM 2008;359:378; Cheng AL, Lancet Oncol 2009;10:25), both restricted to pts with well-preserved liver function (Child-Pugh A). Child-Pugh B (CPB) pts, that represent a relevant proportion of pts with advanced HCC in clinical practice, were not eligible. Despite this limitation, the marketing authorization of sorafenib by the main regulatory agencies was not restricted to Child A pts. CPB pts are different in terms of prognosis, and are potentially different in terms of balance between treatment efficacy and toxicity. Large observational studies [Marrero JA, ASCO 2011 (abstr 4001)] are producing quite reassuring data about sorafenib tolerability in CPB pts, but the real efficacy of the drug in this setting remains substantially unknown, due to the lack of randomized trials. Methods: BOOST (B Child HCC patients – Optimization Of Sorafenib Treatment) is a randomized phase III trial comparing sorafenib + best supportive care (BSC) vs. BSC alone in CPB pts with advanced HCC. Pts are eligible if older than 18, with ECOG performance status 0-2. Pts assigned to experimental arm receive sorafenib 400 mg twice daily, with dose reductions and interruptions according to toxicity. Overall survival (OS) is the primary endpoint. In order to demonstrate a Hazard Ratio of death 0.70 in favor of sorafenib (2-month improvement in median OS, from 4.5 to 6.5 months), with 80% power and α 0.05, 320 pts have to be randomized, 160 per arm. The BOOST trial (ClinicalTrials.gov Identifier NCT01405573; Eudract number 2009-013870-42) is approved by the Ethical Committee of the National Cancer Institute, Napoli, Italy, as coordinating centre, and is currently under evaluation by several other Institutions. BOOST is a non-profit, academic trial. The trial has received a financial support by Italian Ministry of Health (FARM84SA2X), although the support is not enough to supply sorafenib to participating centers. BOOST is partially supported by AIRC (grant IG2009-9316). The study is open to all international Centers wishing to participate.

Selective surgical shunts for treating complications of portal hypertension: 10-year experience in a single institution in eastern Taiwan

ObjectiveSurgical portosystemic shunts are safe and effective for treating rebleeding gastric varices (GV) in portal hypertensive patients with well-preserved liver function. The aim of this study is to investigate the clinical outcomes of using selected surgical shunts for managing rebleeding GV at a single institution in eastern Taiwan. Materials and MethodsWe retrospectively recruited 12 patients who received distal splenorenal shunts (DSRS) following the indication of rebleeding GV or hypersplenism from January 2001 through December 2010. Their demographic data, etiology of portal hypertension, associated treatments, perioperative complications and clinical outcomes were reviewed. ResultsAll patients received DSRS, including 10 adults and two children, and were examined for a median follow-up period of 53 months. No postoperative encephalopathy, major complications, or surgical mortality occurred. Two of the patients were waiting for liver transplants. Late rebleeding in esophageal varices developed in two patients who were successfully managed using endoscopic treatment. The etiology of portal hypertension had no significant impact on the postoperative complications. ConclusionAlthough there were a limited number of cases in this series, our results indicate that the DSRS is an effective treatment for rebleeding GV, especially for patients with well-preserved liver function and taking into account the realities of organ shortages.

Poor Prognostic Factors after Repeat Hepatectomy for Recurrent Hepatocellular Carcinoma in the Modern Era

The purpose of this study was to determine the poor prognostic factors after repeat hepatectomy (Hx) in patients with recurrent hepatocellular carcinoma (HCC). Overall survival rates and clinicopathological variables in 112 patients with repeat Hx from 1992 to 2010 were compared with those in 531 patients who underwent a primary Hx. To clarify the poor prognosis factors after repeat Hx, survival data among 112 patients were univariately and multivariately analyzed. Overall survival after repeat Hx was similar for that of the patients who underwent a primary Hx. The mean age of repeat Hx group was significantly higher, and a well-preserved liver function was recognized than the primary Hx group. Multivariate analysis revealed that: 1) indocyanine green retention rate at 15 minutes; 2) disease-free interval; 3) tumor size; 4) portal vein invasion at primary Hx; 5) gender; and 6) estimated blood loss to be an independent and significant poor prognostic factors. The overall 3-year postrecurrence overall survival rates were 100, 91.3, 59.6, and 0 per cent at risk number (R) R0, R1/2, R3, R4, respectively (P < 0.05). Repeat Hx provided a good compatible prognosis with primary Hx. In our findings, five risk factors to predict poor outcomes after repeat Hx were useful. Patients with recurrent HCC do not have universally poor outcomes, and our simple scoring system using five poor prognostic factors could serve to advise the prognosis and the potential benefit for patient selection about repeat Hx.

Risk Assessment of Development of Hepatic Decompensation in Histologically Proven Hepatitis B Viral Cirrhosis Using Liver Stiffness Measurement

Background/Aims: There are few studies regarding the predictive value of liver stiffness measurement (LSM) for development of hepatic decompensation. We assessed the risk of hepatic decompensations in B-viral compensated cirrhosis, using an LSM and LSM-based model (LSM-spleen diameter to platelet ratio score, LSPS = LSM × spleen diameter/platelet count) in a prospective, longitudinal study. Methods: We analyzed 217 patients with histologically proven B-viral cirrhosis, well-preserved liver function, and no history of decompensation. The Kaplan-Meier and Cox regression method were used to examine the major endpoint, time to the first decompensation event, defined as development of ascites, hepatic encephalopathy, variceal hemorrhage, and deterioration of liver function to Child-Pugh class B/C. Results: During follow-up, 26 patients experienced hepatic decompensation, ascites (n = 22), hepatic encephalopathy (n = 11), variceal hemorrhage (n = 9), and deterioration of liver function (n = 20). For risk stratification, patients were grouped as LSM <13, 13–18, and ≥18 kPa, and from multivariate analysis, patients with LSM 13–18 kPa [hazard ratio (HR) 4.547/ p = 0.044] and ≥18 kPa (HR 12.446/p < 0.001) retained independently higher risks than patients with LSM <13 kPa. Similarly, when patients were grouped as LSPS <1.1, 1.1–2.5, and ≥2.5, those with LSPS 1.1–2.5 (HR 5.796/p = 0.004) and ≥2.5 (HR 13.618/p < 0.001) retained independently higher risks than those with LSPS <1.1. Conclusion: LSM and LSPS are useful in risk assessment of hepatic decompensation among complication-naive B-viral cirrhotic patients.

Surgical Management of Hepatocellular Carcinoma

Hepatocellular carcinoma is the sixth most common cancer worldwide and its incidence is rising in Western countries. Liver resection is the treatment of choice in noncirrhotic patients and in cirrhotic patients with well-preserved liver function. Postresection survival rates are in the range of 41-74% at 5 years. Predictors of recurrence include tumor grade, vascular invasion, tumor size, number of tumors, presence of satellites, alpha-fetoprotein level, transfusion, and positive surgical margin. Second hepatic resection for recurrent hepatocellular carcinoma is applicable in about 15% of patients with recurrence. Liver transplantation has become an important element of the therapeutic strategy for hepatocellular carcinoma. Liver transplantation provides excellent outcomes applying the Milan criteria with 5-year survival rates of 70% and low recurrence rates. Intention-to-treat analysis has shown that wide extended indications lead to 25% 5-year survival rates. Expansion of indications beyond the Milan Criteria and use of bridging/downstaging procedures, to convert intermediate advanced stages of hepatocellular cancer within the Milan criteria limits, are counterbalanced by graft shortage and increasing use of marginal donors. Living donor transplantation is an alternative that can eliminate the waiting time and the attendant risk of drop-out.

OC-29 Terlipressin and albumin vs midodrine plus octreotide and albumin in the treatment of hepatorenal syndrome in patients with cirrhosis: results of a controlled clinical trial by A.I.S.F.

were treated with RFA (n=69), and the others underwent HR (n=63). The two groups were similar for liver disease status. The outcome was considered in terms of overall survival (OS) and disease-free survival (DFS) calculated by the Kaplan-Meier method. Differences among groups were validated by log-rank test. Results: The 1-, 3and 5-year OS rates for the RFA group and the HR group were 91%, 75%, 52%, and 97%, 92%, 74%, respectively. The corresponding DFS rates for the 2 groups were 64%, 28%, 5%, and 85%, 63%, 40%, respectively. OS and DFS were significantly lower in the RFA group than in the HR group (p=0.0210 and p=0.00001). The 5-year HCC recurrence rate was higher in the RFA group than in the HR group (87% vs. 60%; p = 0.0010). Conclusions: HR may provide better survival and lower recurrence rates than RFA for patients with VE HCC. HR should still be employed for those patients with a single small tumor and well-preserved liver function, as suggested by BCLC staging system. RFA should be chosen for patients with an unresectable single tumor for HCC position and grade of liver damage.

Efficacy and safety of sorafenib in patients with advanced hepatocellular carcinoma according to baseline status: Subset analyses of the phase III Sorafenib Asia–Pacific trial

BackgroundThe phase III Sorafenib Asia–Pacific (AP) trial—conducted in China, Taiwan and South Korea – confirmed that sorafenib improves overall survival (OS) and is safe for patients with advanced hepatocellular carcinoma (HCC). We performed a series of exploratory subset analyses to determine whether baseline status affected response to sorafenib. MethodsIn the Sorafenib AP trial, 226 patients with well-preserved liver function (>95% Child-Pugh A) were randomised 2:1 to sorafenib 400mg bid or matching placebo. Subanalyses were based on aetiology (hepatitis B virus present/absent); tumour burden (macroscopic vascular invasion and/or extrahepatic spread present/absent); presence or absence of either lung or lymph node metastasis at baseline, Eastern Cooperative Oncology Group performance status (0, 1–2); serum concentrations of alanine aminotransferase/aspartate aminotransferase (normal, mildly elevated, moderately elevated), alpha-fetoprotein (normal/elevated) and total bilirubin (normal/elevated); and whether or not there was a history of hepatectomy or transarterial chemoembolisation/embolisation. Subgroup assessments included OS, time to progression (TTP), disease control rate and safety. FindingsSorafenib consistently improved both median OS and median TTP, compared with placebo (range of hazard ratios (HR), 0.32–0.87 and 0.31–0.75, respectively). The most common grade 3/4 adverse events were hand-foot skin reaction, diarrhoea and fatigue, the incidence of which was similar between subgroups. InterpretationThe efficacy and safety profiles of sorafenib in the subpopulations described were comparable with those in the overall study population. These exploratory analyses suggest that sorafenib is effective for patients from the AP region with advanced HCC, irrespective of baseline status.

Management of cirrhotic patients with hepatocellular carcinoma treated with sorafenib

Sorafenib (Nexavar®, Bayer), a multi-targeted tyrosine kinase inhibitor, was the first systemic agent that demonstrated a significant improvement in the overall survival in patients with advanced hepatocellular carcinoma and well-preserved liver function. This drug is now recommended in patients with advanced hepatocellular carcinoma as first-line therapy and for patients not suitable for locoregional treatment. This brief article, produced by a multidisciplinary panel including specialists in gastroenterology and oncology, provides an overview of the major issues related to systemic treatment of hepatocellular carcinoma with sorafenib, including staging and prognostic strategies, assessment of liver disease and its complications, and efficacy and safety of this molecule. Particular emphasis is given on how to improve tolerability of sorafenib in difficult-to-treat patients.

Effects of Long‐term Parenteral Nutrition on Serum Lipids, Plant Sterols, Cholesterol Metabolism, and Liver Histology in Pediatric Intestinal Failure

Plant sterols (PS) in parenteral nutrition (PN) may contribute to intestinal failure-associated liver disease. We investigated interrelations between serum PS, liver function and histology, cholesterol metabolism, and characteristics of PN. Eleven patients with intestinal failure (mean age 6.3 years) receiving long-term PN were studied prospectively (mean 254 days) and underwent repeated measurements of serum lipids, noncholesterol sterols, including PS, and liver enzymes. PS contents of PN were analyzed. Liver biopsy was obtained in 8 patients. Twenty healthy children (mean age 5.7 years) served as controls. Median percentage of parenteral energy of total daily energy (PN%) was 48%, including 0.9 g · kg(-1) · day(-1) of lipids. Respective amounts of PN sitosterol, campesterol, avenasterol, and stigmasterol were 683, 71, 57, and 45 μg · kg(-1) · day(-1). Median serum concentrations of sitosterol (48 vs 7.5 μmol/L, P < 0.001), avenasterol (2.9 vs 1.9, P < 0.01), stigmasterol (1.9 vs 1.2, P < 0.005), but not that of campesterol (9.8 vs 12, P = 0.22), were increased among patients in relation to controls, and correlated with PN% (r = 0.81-0.88, P < 0.005), but not with PN fat. Serum cholesterol precursors were higher in patients than in controls. Serum liver enzymes remained close to normal range. Glutamyl transferase correlated with serum PS (r = 0.61-0.62, P < 0.05). Liver fibrosis in 5 patients reflected increased serum PS (r = 0.55-0.60, P = 0.16-0.12). Serum PS moderately increase during olive oil-based PN, and correlate positively with PN% and glutamyl transferase. Despite well-preserved liver function, histology often revealed significant liver damage.

TACE and Sorafenib: A Good Marriage?

TACE and Sorafenib: A Good Marriage?

Non-Cirrhotic Portal Hypertension in Human Immunodeficiency Virus-Infected Patients: A New Challenge in Antiretroviral Therapy Era

Non-cirrhotic portal hypertension (NCPH) has been recently reported as a liver disease in Human Immunodeficiency Virus (HIV)-infected patients under antiretroviral therapy (ART). Combination of non-exclusive mechanisms has been described: primary endothelial damage of terminal portal veins induced by HIV or immunologic disorders, mitochondrial toxicity by didanosine and prothrombotic state. It is characterized by heterogeneous liver histological findings, frequently identified as nodular regenerative hyperplasia and clinical manifestations of portal hypertension with well-preserved liver function. We describe herein two HIV-infected patients with clinical picture suggestive of NCPH. Besides the case reports, we briefly address questions to apply to patient care in clinical practice.

Abstract 4473: Sorafenib suppresses postsurgical recurrence and metastasis of hepatocellular carcinoma in an orthotopic mouse model

Abstract Surgical resection is the first-line treatment for hepatocellular carcinoma (HCC) patients with well-preserved liver function. Nevertheless, postoperative recurrences occur up to 70% at 5 years, gravely jeopardizing the therapeutic outcome. Clearly, new approaches are needed for preventing relapse of this deadly disease. Taking advantage of a luciferase-labeled orthotopic xenograft model of HCC, we examined the role of Sorafenib, the first approved systemic drug for advanced HCC patients, in prevention of HCC recurrence. We found that Sorafenib suppressed the development of postsurgical intrahepatic recurrences, as well as abdominal metastasis, consequently leading to a prolonged postoperative survival of mice in this model. Furthermore, hyperactivity of ERK signaling caused by elevated levels of growth factors associated with postoperative liver regeneration enhanced the sensitivity of HCC cells to Sorafenib, providing a plausible explanation to the observation that recurrent tumors are more responsive to growth inhibition by Sorafenib. Our results strongly suggest a potential application of Sorafenib in early stage HCC patients who have received hepatectomy with curative intention, by effectively reducing postoperative recurrences. Citation Format: {Authors}. {Abstract title} [abstract]. In: Proceedings of the 102nd Annual Meeting of the American Association for Cancer Research; 2011 Apr 2-6; Orlando, FL. Philadelphia (PA): AACR; Cancer Res 2011;71(8 Suppl):Abstract nr 4473. doi:10.1158/1538-7445.AM2011-4473

Clinical benefit of peretinoin for the suppression of hepatocellular carcinoma (HCC) recurrence in patients with Child-Pugh grade A (CP-A) and small tumor: A subgroup analysis in a phase II/III randomized, placebo-controlled trial.

165 Background: HCC has a high recurrence rate and poor prognosis; however, no effective treatment has been established for preventing recurrence after resection or ablation. Peretinoin, an acyclic retinoid, of 600 mg/day reduced HCC recurrence and a strong effect after two years suggested that it mainly suppressed de novo carcinogenesis (ASCO2010). Liver impairment causes non- HCC-related deaths or adverse events, and can potentially mask drug efficacy. The size of the main HCC nodule associates vascular invasion and intrametastasis. To evaluate peretinoin efficacy and assess its mechanism of action, we performed subgroup analysis in CP-A patients who had undergone curative therapy for a small tumor. Methods: Eligibility criteria included HCV positive, CP-A or B, and prior curative resection or ablation for conventional HCC. The patients were randomized into groups to receive peretinoin 600 mg/day (high dose, H), peretinoin 300 mg/day (low dose, L), or placebo (P). The patients were grouped according to the CP grade and the size of the major tumor &lt;20mm at the time of diagnosis. Cumulative recurrence-free survival rates were calculated. Hazard ratio (HR) was calculated using Cox regression analysis. Results: Of the 401 patients, 310 showed CP-A, and 144 showed CP-A and tumor size &lt;20 mm. In the CP-A subgroup, the HR of H group (100) vs. P group (106) was 0.603 (95% CI, 0.408-0.891); in the CP-A and tumor size &lt;20 mm subgroup, the HR of H group (49) vs. P group (49) was 0.376 (95% CI, 0.200-0.705). The common treatment-related adverse events in the CP-A subgroup were albuminuria, hypertension, and headache, which were tolerated. Conclusions: Subgroup analysis with CP-A reinforced the peretinoin efficacy in preventing HCC recurrence. In addition, the CP-A and tumor size &lt;20mm subgroup results strongly suggested that peretinoin inhibited de novo carcinogenesis. The subgroup analyses results of our phase II/II study supported the efficacy and safety of peretinoin and showed that it has early benefits for patients with well-preserved liver function and undergone curative therapy for a small tumor. [Table: see text]

Sorafenib suppresses postsurgical recurrence and metastasis of hepatocellular carcinoma in an orthotopic mouse model

Surgical resection is the first-line treatment for hepatocellular carcinoma (HCC) patients with well-preserved liver function. Nevertheless, the rate of postoperative recurrence at 5 years is as high as 70%, and this gravely jeopardizes the therapeutic outcome. Clearly, new approaches are needed for preventing the relapse of this deadly disease. Taking advantage of a luciferase-labeled orthotopic xenograft model of HCC, we examined the role of sorafenib, the first systemic drug approved for advanced HCC patients, in the prevention of HCC recurrence. We found that sorafenib suppressed the development of postsurgical intrahepatic recurrence and abdominal metastasis and consequently led to prolonged postoperative survival of mice in this model. Furthermore, hyperactivity of extracellular signal-regulated kinase signaling caused by elevated levels of growth factors associated with postoperative liver regeneration enhanced the sensitivity of HCC cells to sorafenib; this provides a plausible explanation for the observation that recurrent tumors are more responsive to growth inhibition by sorafenib. Our results strongly suggest that by effectively reducing postoperative recurrence, sorafenib has a potential application in early-stage HCC patients who have undergone hepatectomy with curative intention.

Non-cirrhotic portal fibrosis related end stage liver disease in adults: evaluation from a study on living donor liver transplant recipients

That non-cirrhotic portal fibrosis (NCPF) can lead to end stage chronic liver disease (CLD) has been convincingly demonstrated only recently after the study of explant livers from clinically cirrhosis cases. This study attempted to determine the frequency of NCPF among adults transplanted for end stage CLD and to identify parameters for a pre-transplant diagnosis of NCPF. Several parameters were analyzed in three categories of cases: pure NCPF (n=10), overlap NCPF (n=10), and NAFLD cirrhosis controls (n=44). Morphologic features of NCPF were looked for in explant livers of all these. Explant livers in the pure NCPF group were non-cirrhotic and showed histologic features of NCPF. These features were also present in all cases of overlap NCPF in the background of established cirrhosis of other etiologies but absent in the NAFLD cirrhosis controls. Values of seven objective and two subjective parameters showed significant differences between pure NCPF and NAFLD control groups. Compared to NAFLD controls, the model for end stage liver disease (MELD) score, body mass index (BMI), bilirubin, albumin, aspartate amino transferase (AST), and international normalized ratio (INR) were significantly less, whereas variceal grade was higher in the pure NCPF group. The study concludes that in our population, NCPF constitutes about 5% of the subset of end stage CLD considered eligible for liver transplantation (LT), presenting mostly as cryptogenic cirrhosis (CC). A diagnosis of NCPF should be considered when patients presumed to have cryptogenic or other cirrhosis become eligible for LT even in the presence of relatively well-preserved liver function and low MELD scores. End stage CLD manifests at earlier age, when cirrhosis of another etiology supervenes on pre-existent NCPF.

Second hepatic resection for recurrent hepatocellular cancer: A Western experience

Recurrence of hepatocellular cancer after resection is a significant problem. The optimal treatment of patients with intrahepatic recurrence after resection and well-preserved liver function is not clear. We analyzed the outcomes of patients undergoing a second hepatic resection for recurrent hepatocellular cancer at a single Western center. The records of all patients undergoing primary hepatic resection for hepatocellular cancer between January 1994 and January 2009 were reviewed. Patients with a single intrahepatic recurrence, Child's A liver function, and platelet count>100,000/μl underwent a second hepatic resection. Clinical data was recorded and analyzed. Of the 487 patients undergoing primary resection, 221 developed recurrence, and 35 underwent a second hepatic resection. There were no perioperative mortalities. There were 10 deaths during the study period; 5-year overall survival was 67% from second resection. Time to recurrence from primary resection<1 year and gross vascular invasion at second resection were predictors of survival and recurrence. Patients with recurrence>1 year from primary resection and without gross vascular invasion had a 5-year survival of 81%. There were 17 recurrences with a 3-year recurrence rate of 55%. Second hepatic resection for recurrent hepatocellular cancer is applicable in about 15% of patient with recurrence. The procedure is safe and can achieve excellent results in well-selected patients. Recurrence continues to be a significant problem.

Thermal Ablation for Primary and Metastatic Hepatic Malignancies

Abstract Surgical resection offers the best hope for long-term survival in both hepatocellular carcinoma patients and those with metastatic liver disease. Patients most likely to benefit are those with a single tumor and well-preserved liver function, who have normal serum bilirubin and normal portal flow. Patients are often ineligible for resection for a variety of reasons. Ablative options, such as cryoablation and radiofrequency ablation (RFA), are minimally invasive procedures particularly suited for those patients who are felt to be poor surgical risks. These options are based on the principle that decreasing the volume of viable tumor or preventing new tumor growth can lead to longer survival and potential cure in selected patients. Complications related to these procedures are minimal compared with open surgery. The most common complications are bleeding and infection.

Radiofrequency ablation as first-line treatment for small solitary hepatocellular carcinoma: Long-term results

Aims To evaluate long-term results of patients with small solitary hepatocellular carcinoma (HCC) and well-preserved liver function who received radiofrequency ablation (RFA) as first-line treatment. Materials and methods Between November 1999 and June 2007, 247 patients with solitary HCC ≤5 cm and liver status scored as Child-Pugh class A were enrolled. RFA was performed in 224 patients as first-line treatment; 23 patients excluded from RFA because of unfavorable tumor location or their unwillingness, and all of these patients converted to surgical resection. Results In the 224 patients treated with RFA, the overall 5-, 7-, 10-year survival rates were 59.8%, 55.2%, 33.9%, respectively, and the median of overall survival was 76.1 months. Complete ablation was achieved in 216 patients (96.4%). Major complications occurred in two patients (0.9%), with no treatment-related death or needle track seeding. Indocyanine green retention rate in 15 min (ICGR15) ( P = 0.014) and prothrombin activity ( P = 0.004) were associated with overall survival. A subgroup of patients with ICGR15 ≤ 10% and prothrombin activity >75% had 5-, 7-, 10-year survival rates of 67.1%, 64.2%, 57.1%, respectively, with a median survival of 87.7 months. The 10-year recurrence-free, tumor-free survival rates were 17.5%, 28.2%, respectively. Serum albumin was the only factor that significantly impacted recurrence-free and tumor-free survival ( P = 0.008, 0.002, respectively). Conclusion RFA is considered to be the treatment of first choice for patients with solitary HCC ≤5 cm and well-preserved liver function. Surgery can be used as second-line therapy for few patients if RFA is unfeasible.

A Single-Institution Review of Portosystemic Shunts in Children: An Ongoing Discussion

Purpose. Review the safety and long-term success with portosystemic shunts in children at a single institution. Methods. An IRB-approved, retrospective chart review of all children ages 19 and undergoing surgical portosystemic shunt from January 1990–September 2008. Results. Ten patients were identified, 8 females and 2 males, with a mean age of 15 years (range 5–19 years). Primary diagnoses were congenital hepatic fibrosis (5), hepatic vein thrombosis (2), portal vein thrombosis (2), and cystic fibrosis (1). Primary indications were repeated variceal bleeding (6), symptomatic hypersplenism (2), and significant liver dysfunction (2). Procedures performed were distal splenorenal bypass (4), side-to-side portocaval shunt (3), proximal splenorenal shunt (2), and an interposition H-graft portocaval shunt (1). There was no perioperative mortality and only minor morbidity. Seventy percent of patients had improvement of their symptoms. Eighty percent of shunts remained patent. Two were occluded at a median follow-up of 50 months (range 0.5–13.16 years). Two patients underwent subsequent liver transplantation. Two patients died at 0.5 and 12.8 years postoperatively, one from multisystem failure with cystic fibrosis and one from post-operative transplant complications. Conclusions. The need for portosystemic shunts in children is rare. However, in the era of liver transplantation, portosystemic shunts in selected patients with well-preserved liver function remains important. We conclude that portosystemic shunts are safe and efficacious in the control of variceal hemorrhage and symptoms related to hypersplenism.