Neoadjuvant and adjuvant treatment strategies for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common liver malignancy worldwide and a major cause of cancer-related mortality for which liver resection is an important curative-intent treatment option. However, many patients present with advanced disease and with underlying chronic liver disease and/or cirrhosis, limiting the proportion of patients who are surgical candidates. In addition, the development of recurrent or de novo cancers following surgical resection is common. These issues have led investigators to evaluate the benefit of neoadjuvant and adjuvant treatment strategies aimed at improving resectability rates and decreasing recurrence rates. While high-level evidence to guide treatment decision making is lacking, recent advances in locoregional and systemic therapies, including antiviral treatment and immunotherapy, raise the prospect of novel approaches that may improve the outcomes of patients with HCC. In this review, we evaluate the evidence for various neoadjuvant and adjuvant therapies and discuss opportunities for future clinical and translational research.

Call for action:Increased healthcare utilization with growing use of percutaneous cholecystectomy tube over initial cholecystectomy in cirrhotics

Background:Acute calculous cholecystitis(ACC)is frequently seen in cirrhotics,with some being poor candidates for initial cholecystectomy.Instead,these patients may undergo percutaneous cholecystostomy tube(PCT)placement.We studied the healthcare utilization and predictors of cholecystectomy and PCT in patients with ACC.Methods:The National Database was queried to study all cirrhotics and non-cirrhotics with ACC between 2010-2014 who underwent initial PCT(with or without follow-up cholecystectomy)or cholecystectomy.Cirrhotic patients were divided into compensated and decompensated cirrhosis.Independent predictors and outcomes of initial PCT and failure to undergo subsequent cholecystectomy were studied.Results:Out of 919189 patients with ACC,13283(1.4%)had cirrhosis.Among cirrhotics,cholecystec-tomy was performed in 12790(96.3%)and PCT in the remaining 493(3.7%).PCT was more frequent in cirrhotics(3.7%)than in non-cirrhotics(1.4%).Multivariate analyses showed increased early readmis-sions[odds ratio(OR)=2.12,95%confidence interval(CI):1.43-3.13,P<0.001],length of stay(effect ratio=1.39,95%CI:1.20-1.61,P<0.001),calendar-year hospital cost(effect ratio=1.34,95%CI:1.28-1.39,P<0.001)and calendar-year mortality(hazard ratio=1.89,95%CI:1.07-3.29,P=0.030)in cir-rhotics undergoing initial PCT compared to cholecystectomy.Decompensated cirrhosis(OR=2.25,95%CI:1.67-3.03,P<0.001)had the highest odds of getting initial PCT.Cirrhosis,regardless of compensated(OR=0.56,95%CI:0.34-0.90,P=0.020)or decompensated(OR=0.28,95%CI:0.14-0.59,P<0.001),reduced the chances of getting a subsequent cholecystectomy.Conclusions:Cirrhotic patients undergo fewer cholecystectomy incurring initial PCT instead.Moreover,the rates of follow-up cholecystectomy are lower in cirrhotics.Increased healthcare utilization is seen with initial PCT amongst cirrhotic patients.This situation reflects suboptimal management of ACC in cirrhotics and a call for action.

Women receive more inpatient resections and ablations for hepatocellular carcinoma than men

AIM To evaluate disparities in the treatment of hepatocellular carcinoma(HCC) based on gender.METHODS A retrospective database analysis using the Nationwide Inpatient Sample(NIS) was performed between 2010 and 2013. Adult patients with a primary diagnosis of hepatocellular carcinoma determined by International Classification of Disease 9(ICD-9) codes were included. Univariate analysis and multivariate logistic regressions were performed to analyze differences in treatment, mortality, features of decompensation, and metastatic disease based on the patient's gender.RESULTS The analysis included 62582 patients with 45908 men and 16674 women. Women were less likely to present with decompensated liver disease(OR = 0.84, P < 0.001) and had less risk of inpatient mortality when compared to men(OR = 0.75, P < 0.001). Women were more likely to receive inpatient resection(OR = 1.31, P < 0.001) or an ablation(OR = 1.22, P = 0.028) than men. There was no significant difference between men and women in regard to liver transplantation and transcatheter arterial chemoembolization(TACE).CONCLUSION Gender impacts treatment for hepatocellular carcinoma. Women are more likely to undergo an ablation or resection then men. Gender disparities in transplantation have resolved.