Reverse time-dependent effect of alphafetoprotein and disease control on survival of patients with Barcelona Clinic Liver Cancer stage C hepatocellular carcinoma

AIM To characterize the survival of cirrhotic patients with Barcelona Clinic Liver Cancer(BCLC) stage C hepatocellular carcinoma(HCC) and to ascertain the factors predicting the achievement of disease control(DC).METHODS The cirrhotic patients with BCLC stage C HCC evaluated by the Hepatocatt multidisciplinary group were subjected to the investigation. Demographic, clinical and tumor features, along with the best tumor response and overall survival were recorded. RESULTS One hundred and ten BCLC stage C patients were included in the analysis; the median overall survival was 13.4 mo(95%CI: 10.6-17.0). Only alphafetoprotein(AFP) serum level > 200 ng/m L and DC could independently predict survival but in a time dependent manner, the former was significantly associated with increased risk of mortality within the first 6 mo of follow-up(HR = 5.073, 95%CI: 2.159-11.916, P = 0.0002), whereas the latter showed a protective effect against death after one year(HR = 0.110, 95%CI: 0.038-0.314, P < 0.0001). Only patients showing microvascular invasion and/or extrahepatic spread recorded lower chances of achieving DC(OR = 0.263, 95%CI: 0.111-0.622, P = 0.002).CONCLUSION The BCLC stage C HCC includes a wide heterogeneous group of cirrhotic patients suitable for potentially curative treatments. The reverse and time dependent effect of AFP serum level and DC on patients' survival confers them as useful predictive tools for treatment management and clinical decisions.

Transjugular portosystemic shunt for early-onset refractory ascites after liver transplantation

Liver transplantation(LT)is the most effective treatment for end-stage liver disease and complications of portal hypertension(PHT).However,PHT can relapse as a consequence of viral,alcoholic or metabolic chronic liver disease(CLD)recurrence,rejection,vascular abnormalities,small-for-size syndrome and technical complications(e.g.,portal or hepatic veins stenosis and/or thrombosis)[1].LT recipients with PHT may suffer from com plications similarly to non-transplanted cirrhotic patients(e.g.,refractory ascites,variceal hemorrhages and hydrothorax)although with higher morbidity and mortality due to their postoperative status and concomitant immunosuppressive therapy[2].

Pediatric T-tube in adult liver transplantation:Technical refinements of insertion and removal

BACKGROUND With the increasing use of extended-criteria donor organs,the interest around Ttubes in liver transplantation(LT)was restored whilst concerns regarding T-tuberelated complications persist.AIM To describe insertion and removal protocols implemented at our institution to safely use pediatric rubber 5-French T-tubes and subsequent outcomes in a consecutive series of adult patients.METHODS Data of consecutive adult LT patients from brain-dead donors,treated from March 2017 to December 2019,were collected(i.e.,biliary complications,adverse events,treatment after T-Tube removal).Patients with upfront hepaticojejunostomy,endoscopically removed T-tubes,those who died or received retransplantation before T-tube removal were excluded.RESULTS Seventy-two patients were included in this study;T-tubes were removed 158 d(median;IQR 128-206 d)after LT.In four(5.6%)patients accidental T-tube removal occurred requiring monitoring only;in 68(94.4%)patients Nelaton drain insertion was performed according to our protocol,resulting in 18(25%)patients with a biliary output,subsequently removed after 2 d(median;IQR 1-4 d).Three(4%)patients required endoscopic retrograde cholangiopancreatography(ERCP)due to persistent Nelaton drain output.Three(4%)patients developed suspected biliary peritonitis,requiring ERCP with sphincterotomy and nasobiliary drain insertion(only one revealing contrast extravasation);no patient required percutaneous drainage or emergency surgery.CONCLUSION The use of pediatric rubber 5-French T-tubes in LT proved safe in our series after insertion and removal procedure refinements.

Development and validation of an artificial intelligence model for predicting post-transplant hepatocellular cancer recurrence

Dear Editor,In recent years,criteria based on the combinationof morphology and biology have been proposed forimproving the selection of hepatocellular cancer(HCC)patients waiting for liver transplantation(LT)[1,2].Since all the proposed models showed suboptimalresults in predicting the risk of postLT recurrence,aprediction model constructed using artificial intelligence(Al)could be an attractive way to surpass this limit[3,4].Therefore,the Time_Radiological-response_Alpha-fetoproteIN_Artificial-Intelligence(TRAIN-AI)modelwas developed,combining morphology and biology tumorvariables.

Frequency of and reasons behind non-listing in adult patients referred for liver transplantation: Results from a retrospective study

BACKGROUND Few studies have evaluated the frequency of and the reasons behind the refusal of listing liver transplantation candidates.AIM To assess the ineligibility rate for liver transplantation and its motivations.METHODS A single-center retrospective study was conducted on adult patients which entailed a formal multidisciplinary assessment for liver transplantation eligibility.The predictors for listing were evaluated using multivariable logistic regression.RESULTS In our center,314 patients underwent multidisciplinary work-up before liver transplantation enlisting over a three-year period.The most frequent reasons for transplant evaluation were decompensated cirrhosis(51.6%)and hepatocellular carcinoma(35.7%).The non-listing rate was 53.8%and the transplant rate was 34.4%for the whole cohort.Two hundred and five motivations for ineligibility were collected.The most common contraindications were psychological(9.3%),cardiovascular(6.8%),and surgical(5.9%).Inappropriate or premature referral accounted for 76(37.1%)cases.On multivariable analysis,a referral from another hospital(OR:2.113;95%CI:1.259–3.548)served as an independent predictor of non-listing.CONCLUSION A non-listing decision occurred in half of our cohort and was based on an inappropriate or premature referral in one case out of three.The referral from another hospital was taken as a strong predictor of non-listing.

Breast cancer liver metastasis:time to resection and criteria

A manuscript recently published by Grazi pools outcomes from data on patients undergoing surgical resection for breast cancer liver metastases(BCLMs).In the manuscript,Grazi shows no definitive proof of liver resections(LR)effectiveness for BCLM.However,the author suggests surgery may be possible in selected patients(1-3).Several retrospective case series have been published evaluating patients’survival following resection for BCLM,reporting results for 5-year overall and disease-free survivals.Grazi tries to make recommendations based on the data that show which patients have a good prognosis following liver surgery.However,the conclusion that surgical treatment is an option with a survival advantage for selected patients is not evident in the current literature as the criteria for surgery are not well established.