Management and patient survival in hepatocellular carcinoma: does the physician's level of experience matter?

INTRODUCTION: The prognostic determinants of hepatocellular carcinoma (HCC) depend on tumor stage, liver function reserve, and treatments offered. The clinical impact of the physician's experience on HCC management and the survival outcome is unknown. METHODS: A total of 103 patients were managed by one high-volume physician and 249 patients by seven low-volume physicians. The experience of high-volume physician in HCC management was five times more than that of low-volume physicians. Patient survival was the single end point for this study. RESULTS: Compared to the low-volume physician group, more of the patients allocated to the high-volume physician had early stage HCC on the date of diagnosis (66/103, 64.1%; vs 119/249, 47.8%; P = 0.008), and they received curative therapies including radiofrequency ablation or liver resection (66/103, 64.1% vs 54/249, 21.7%, P < 0.001), and had significantly better survival outcome (median survival of 34 months, 95% confidence interval [CI], 17.6-50.4; vs 6 months, 95% CI, 4.3-7.7; P < 0.001) with a multivariable-adjusted hazard ratio (HR) for survival of 1.94 (95%, CI, 1.31-2.87, P < 0.001). A multivariate analysis of the pretreatment prognostic factors for these two groups identified alpha-fetoprotein (AFP) level (HR, 1.42; 95% CI, 1.01-1.99; P = 0.042), ascites (HR, 1.68; 95% CI, 1.15-2.46; P = 0.007), maximum tumor diameter (HR, 1.78; 95% CI, 1.16-2.74; P = 0.009), and portal vein thrombosis (PVT) (HR, 2.17; 95% CI, 1.49-3.17; P < 0.001) as independent factors for the low-volume physician group. However, only maximum tumor diameter (HR, 4.54; 95% CI, 1.77-11.67; P < 0.001) and PVT (HR, 5.73; 95% CI, 2.30-14.22; P = 0.002) were independent factors for the high-volume physician group. CONCLUSION: The survival of HCC patients was dependent on the level of experience of the physicians who oversaw these patients.

Predictors of alpha-fetoprotein elevation in patients with chronic hepatitis C, but not hepatocellular carcinoma, and its normalization after pegylated interferon alfa 2a-ribavirin combination therapy.

BACKGROUND AND AIM: Elevated serum alpha-fetoprotein (AFP) levels are noted in patients with chronic hepatitis C (CHC) without hepatocellular carcinoma (HCC). The change in AFP levels after treatment with pegylated interferon and ribavirin (Peg-IFN/RBV) combination therapy is still unknown. The aim of this study was to investigate the predictors of elevated serum AFP in patients with CHC, and its change after Peg-IFN/RBV therapy. METHODS: A total of 123 patients, intended to receive pegylated interferon alfa-2a plus ribavirin therapy, were enrolled. Eighty-three patients had complete treatment and received follow up for and additional 24 weeks. The factors that may affect the elevation of pretreatment AFP and the normalization of post-treatment AFP were determined. RESULTS: The mean AFP level was 18.5 +/- 63.0 ng/mL (range, 1.3-676.0 ng/mL); 41 (33.3%) of the 123 patients had elevated serum AFP (more than 10 ng/mL) at baseline. A multivariate logistic regression analysis disclosed that older age (odds ratio [OR], 1.093; 95% confidence interval [CI], 1.015-1.177; P = 0.018), more advanced METAVIR fibrosis stage (OR, 5.237; 95% CI, 1.244-22.037; P = 0.024), a higher aspartate aminotransferase (AST) level (IU/L) (OR, 1.020; 95% CI, 1.008-1.033; P = 0.001), and lower platelet count (x10(9)/L, OR, 0.985; 95% CI, 0.968-0.994; P = 0.003) were independent determinants of pretreatment AFP elevation. After treatment, 72 of 83 (86.7%) cases were found to have normal post-treatment AFP levels (<10 ng/mL) at the end of follow up (EOF). Post-treatment negativity of the chronic hepatitis C virus (HCV)-RNA (OR, 10.014; 95% CI, 1.000-100.329; P = 0.050) and the post-treatment platelet count (x10(9)/L) (OR, 1.025; 95% CI, 1.001-1.050; P = 0.040) were associated with normal AFP at EOF. AFP progressively decreased with significant differences starting from the 12th week after treatment to the end of treatment, and was lowest at the EOF date for the sustained viral response (SVR) group. On the contrary, the non-SVR group did not have an AFP change during and after treatment. CONCLUSION: Older age, low platelet count, higher AST levels, and advanced fibrosis predisposed chronic hepatitis C patients without HCC to have elevated serum AFP levels. After Peg-IFN/RBV combination therapy, a higher platelet count and HCV viral eradication were determinants of normal AFP at EOF. Serial AFP levels decreased after treatment, presenting in a time-dependent manner, specifically for the SVR group.

Biliary stenting with puncturing technique using Baron aspiration needle in ulcerative papillary carcinoma.

A 60 year-old man with obstructive jaundice due to an ulcerative papillary carcinoma underwent endoscopic retrograde cholangiopancreatography. Owing to the totally destroyed papilla of Vater, access to the biliary tract was impossible. Instead of needle knife fistulotomy, puncturing with an 18-G aspiration needle on the supra-papillary bulge followed by biliary stenting was performed successfully. To our knowledge, this technique has not been reported before in the English literature and probably can have fewer complications of bleeding and perforations produced by needle knife fistulotomy.

Hemoclip treatment for post-endoscopic sphincterotomy bleeding.

BACKGROUND: The incidence of bleeding after endoscopic sphincterotomy (EST) ranges from 2%-12.1%. Endoscopic treatments include injection and thermal therapy, which can have recurrent bleeding and potential complications of chemical and thermal injuries. There is only 1 case report of post-EST bleeding managed by hemoclipping in the literature. Treatment of post-EST bleeding with hemoclip is reported in this study. METHODS: From March 1999 to May 2003, a retrospective analysis of 162 cases of EST was made. Nine cases (5.5%) of post EST bleeding, 7 male and 2 female patients, with a mean age of 58 +/- 16 (37-82) years, were treated with hemoclipping. Four cases of recurrent bleeding were treated with secondary clipping when previous local epinephrine injection was ineffective, and the remaining 5 cases were managed with primary hemoclipping. RESULTS: Six cases were of major bleeding; 3 needed blood transfusion (mean: 7.3 units: 6-8 units) and 3 had a reduction of hemoglobin > 2 g/dL but without blood transfusion. The location of bleeder was 5 on the left side, 2 on the right side and 1 in both flaps of post-EST papilla. The median clips used were 2 (1-7), and the median missed clips were 0.5 (0-3). The success rate hemostasis was 88.8%, including 4 recurrent major bleeding after previous local epinephrine injection. Some technical difficulties were encountered. The failed case that underwent operation was due to total inability to get a visual field because of massive bleeding. There were no complications related to hemoclipping. CONCLUSIONS: Hemoclipping can be an alternative method for hemostasis in post-EST bleeding.

Guidewire technique for endoscopic transpapillary procurement of bile duct biopsy specimens without endoscopic sphincterotomy.

BACKGROUND: Endoscopic sphincterotomy may be required when endoscopic transpapillary bile duct biopsy specimens are needed for tissue diagnosis. However, endoscopic sphincterotomy has potential complications. A guidewire technique for obtaining transpapillary biopsy specimens without endoscopic sphincterotomy was evaluated. METHODS: A total of 13 patients (11 men, 2 women; mean age 67.5 years) with biliary stricture or obstruction underwent endoscopic retrograde cholangiography. A guidewire was then inserted across the stricture or obstruction and into an intrahepatic duct. Alongside the guidewire, the biopsy forceps (1.5 mm diameter) was introduced into the papillary orifice with the duodenoscope extremely close to the papilla. OBSERVATIONS: Tissue was obtained in 92.3% of the cases for histopathologic evaluation without difficulty or complication. The single failure occurred in a patient who had undergone a partial gastrectomy with Billroth I anastomosis. CONCLUSIONS: The guidewire technique for endoscopic transpapillary procurement of biopsy specimens of the bile duct obviates the need for endoscopic sphincterotomy.