Prognostic Value of Alpha-Fetoprotein in Patients Who Achieve a Complete Response to Transarterial Chemoembolization for Hepatocellular Carcinoma

Purpose@#Alpha-fetoprotein (AFP) is a prognostic marker for hepatocellular carcinoma (HCC). We investigated the prognostic value of AFP levels in patients who achieved complete response (CR) to transarterial chemoembolization (TACE) for HCC. @*Materials and Methods@#Between 2005 and 2018, 890 patients with HCC who achieved a CR to TACE were recruited. An AFP responder was defined as a patient who showed elevated levels of AFP (>10 ng/mL) during TACE, but showed normalization or a >50% reduction in AFP levels after achieving a CR. @*Results@#Among the recruited patients, 569 (63.9%) with naïve HCC and 321 (36.1%) with recurrent HCC after complete resection were treated. Before TACE, 305 (34.3%) patients had multiple tumors, 219 (24.6%) had a maximal tumor size >3 cm, and 22 (2.5%) had portal vein tumor thrombosis. The median AFP level after achieving a CR was 6.36 ng/mL. After a CR, 473 (53.1%) patients experienced recurrence, and 417 (46.9%) died [median progression-free survival (PFS) and overall survival (OS) of 16.3 and 62.8 months, respectively]. High AFP levels at CR (>20 ng/mL) were independently associated with a shorter PFS [hazard ratio (HR)=1.403] and OS (HR=1.284), together with tumor multiplicity at TACE (HR=1.518 and 1.666, respectively). AFP non-responders at CR (76.2%, n=359 of 471) showed a shorter PFS (median 10.5 months vs. 15.5 months, HR=1.375) and OS (median 41.4 months vs. 61.8 months, HR=1.424) than AFP responders (all p=0.001). @*Conclusion@#High AFP levels and AFP non-responders were independently associated with poor outcomes after TACE. AFP holds clinical implications for detailed risk stratification upon achieving a CR after TACE.

Association between hepatic steatosis and the development of hepatocellular carcinoma in patients with chronic hepatitis B

BACKGROUND/AIMS: Nonalcoholic fatty liver disease (NAFLD) is becoming a worldwide epidemic, and is frequently found in patients with chronic hepatitis B (CHB). We investigated the impact of histologically proven hepatic steatosis on the risk for hepatocellular carcinoma (HCC) in CHB patients without excessive alcohol intake. METHODS: Consecutive CHB patients who underwent liver biopsy from January 2007 to December 2015 were included. The association between hepatic steatosis (≥ 5%) and subsequent HCC risk was analyzed. Inverse probability weighting (IPW) using the propensity score was applied to adjust for differences in patient characteristics, including metabolic factors. RESULTS: Fatty liver was histologically proven in 70 patients (21.8%) among a total of 321 patients. During the median (interquartile range) follow-up of 5.3 (2.9–8.3) years, 17 of 321 patients (5.3%) developed HCC: 8 of 70 patients (11.4%) with fatty liver and 9 of 251 patients (3.6%) without fatty liver. The five-year cumulative incidences of HCC among patients without and with fatty liver were 1.9% and 8.2%, respectively (P=0.004). Coexisting fatty liver was associated with a higher risk for HCC (adjusted hazards ratio [HR], 3.005; 95% confidence interval [CI], 1.122–8.051; P=0.03). After balancing with IPW, HCC incidences were not significantly different between the groups (P=0.19), and the association between fatty liver and HCC was not significant (adjusted HR, 1.709; 95% CI, 0.404–7.228; P=0.47). CONCLUSIONS: Superimposed NAFLD was associated with a higher HCC risk in CHB patients. However, the association between steatosis per se and HCC risk was not evident after adjustment for metabolic factors.

Sarcopenia Predicts Prognosis in Patients with Newly Diagnosed Hepatocellular Carcinoma, Independent of Tumor Stage and Liver Function / Journal of the Korean Cancer Association, 대한암학회지

PURPOSE: The purpose of this study was to demonstrate the prognostic significance of changes in body composition in patients with newly diagnosed hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Patients (n=178) newly diagnosed with HCC participated in the study between 2007 and 2012. Areas of skeletal muscle and abdominal fat were directly measured using a three-dimensional workstation. Cox proportional-hazards modes were used to estimate the effect of baseline variables on overall survival. The inverse probability of treatmentweighting (IPTW) method was used to minimize confounding bias. RESULTS: Cutoff values for sarcopenia, obtained from receiver-operating characteristic curves, were defined as skeletal muscle index at the third lumbar vertebra of ≤ 45.8 cm/m2 for males and ≤ 43.0 cm/m2 for females. Sarcopenia patients were older, more likely to be female, and had lower body mass index. Univariable analysis showed that the presence of sarcopenia and visceral to subcutaneous fat area ratio (VSR) were significantly associatedwith prognosis. The multivariable analyses revealed that VSR was predictive of overall survival. However, in the multivariable Cox model adjusted by IPTW, sarcopenia, not VSR, were associated with overall survival. CONCLUSION: The presence of sarcopenia at HCC diagnosis is independently associated with survival.

Understanding Acute Liver Failure: A Basic Overview of Definition and Treatment / 대한내과학회지

Acute liver failure is a rare but fatal condition characterized by rapid deterioration of liver function resulting in coagulopathy and altered mentation in patients without known liver disease. The three most common causes of liver failure in Korea are hepatitis B virus, exposure to certain herbs, and hepatitis A virus. Because the cause of liver failure is the most important prognostic factor, the etiology of liver failure should be evaluated as the initial step in the assessment of affected patients. Patients with acute liver failure should be intensively monitored and treated for various secondary conditions that may occur or have already developed, including cerebral edema, seizures, hemodynamic instability, renal failure, infection, bleeding, and metabolic disturbances. Although treatment with N-acetylcysteine has shown a survival benefit in patients with mild hepatic encephalopathy, the overall mortality rate associated with acute liver failure is high unless patients undergo liver transplantation, prompting patients and physicians to be prepared for transplantation. Therefore, patients who are suspected to have, or who have been diagnosed with, acute liver failure should be transferred to a transplant facility and be prepared for liver transplantation while they undergo intensive monitoring and medical treatment.

Portal Vein Cannulation During Endoscopic Retrograde Cholangiopancreatography / 대한내과학회지

A 68-year-old woman was admitted to our hospital with obstructive jaundice. Abdominal CT scan demonstrated a mass at the head of the pancreas. The patient was diagnosed as having obstructive jaundice caused by pancreatic cancer. We tried to relieve the bile duct obstruction by ERCP (endoscopic retrograde cholangiopancreatography). After several cannulation attempts, we thought that we had achieved deep cannulation of the bile duct and tried to place a biliary plastic stent. During ERCP, however, we noticed massive air in the portal venous system, indicating possible cannulation of the portal vein. The procedure was terminated immediately and abdominal computed tomography revealed air in the portal venous system. Fortunately, there were no subsequent complications. The air in the portal vein had disappeared, ascertained by CT scan taken 5 days later. The patient underwent surgical resection for pancreatic cancer. Isolated portal vein cannulation per se does not usually result in mortality or serious morbidity.

Clinical Usefulness of Bile Cytology Obtained from Biliary Drainage Tube for Diagnosing Cholangiocarcinoma / 대한소화기학회지

BACKGROUND/AIMS: Biliary drainage is performed in many patients with cholangiocarcinoma (CCA) to relieve obstructive jaundice. For those who have undergone biliary drainage, bile cytology can be easily performed since the access is already achieved. This study aims to determine the clinical usefulness of bile cytology for the diagnosis of CCA and to evaluate factors affecting its diagnostic yield. METHODS: A total of 766 consecutive patients with CCA underwent bile cytology via endoscopic nasobiliary drainage or percutaneous transhepatic biliary drainage from January 2000 to June 2012. Data were collected by retrospectively reviewing the medical records. We evaluated the diagnostic yield of bile cytology with/without other sampling methods including brush cytology and endobiliary forcep biopsy, and the optimal number of repeated bile sampling. Several factors affecting diagnostic yield were then analyzed. RESULTS: The sensitivity of bile cytology, endobiliary forceps biopsy, and a combination of both sampling methods were 24.7% (189/766), 74.4% (259/348), and 77.9% (271/348), respectively. The cumulative positive rate of bile sampling increased from 40.7% (77/189) at first sampling to 93.1% (176/189) at third sampling. On multivariate analysis, factors associated with positive bile cytology were perihilar tumor location, intraductal growing tumor type, tumor extent > or =20 mm, poorly differentiated grade tumor, and three or more samplings. CONCLUSIONS: Although bile cytology itself has a low sensitivity in diagnosing CCA, it has an additive role when combined with endobiliary forceps biopsy. Due to the relative ease and low cost, bile cytology can be considered a reasonable complementary diagnostic tool for diagnosing CCA.

Comparison of Clinical Outcomes Associated with Pull-Type and Introducer-Type Percutaneous Endoscopic Gastrostomies

BACKGROUND/AIMS: Percutaneous endoscopic gastrostomy (PEG) is a method of providing enteral nutrition using endoscopy. The PEG techniques differ according to the insertion method, and include the pull type, push type, and introducer type. The aim of this study was to compare the clinical outcomes associated with the pull-type and introducer-type PEG insertion techniques, which included the adverse events, at our tertiary care center in Korea. METHODS: We retrospectively reviewed 141 cases that had undergone PEG insertion at our center from January 2009 to June 2012. The indications for PEG insertion and the acute and chronic complications caused by each type of PEG insertion were analyzed. RESULTS: The indications for PEG insertion in our cohort included neurologic disease (58.7%), malignancy (21.7%), and other indications (19.6%). Successful PEG insertions were performed on 136 cases (96.5%), and there were no PEG-associated deaths. Bleeding was the most frequent acute complication (12.8%), and wound problems were the most frequent chronic complications (8.8%). There were no statistically significant differences between the pull-type and introducer-type PEG insertion techniques in relation to complication rates in our study population. CONCLUSIONS: PEG insertion is considered a safe procedure. The pull-type and introducer-type PEG insertion techniques produce comparable outcomes, and physicians may choose either of these approaches according to the circumstances.