Isolated IgG4-associated autoimmune hepatitis or the first manifestation of IgG4-related disease?

To the Editor:Immunoglobulin G4(IgG4)-associated autoimmune hepatitis(IgG4-AIH)is a novel and rare disease entity,characterized by sig-nificant infiltration of IgG4-expressing plasma cells in the liver.The classification of of IgG4-AIH as a subtype of AIH or an early manifestation of IgG4-related disease(IgG4-RD)remains controversial.Herein,we discuss an interesting clinical vignette of IgG4-AIH in a gentleman with no significant past medical history,who presented with undifferentiated symptoms and elevated aminotransferases.

Clinical outcomes of patients with two small hepatocellular carcinomas

BACKGROUND Management of single small hepatocellular carcinoma(HCC)is straightforward with curative outcomes achieved by locoregional therapy or resection.Liver transplantation is often considered for multiple small or single large HCC.Management of two small HCC whether presenting synchronously or sequentially is less clear.AIM To define the outcomes of patients presenting with two small HCC.METHODS Retrospective review of HCC databases from multiple institutions of patients with either two synchronous or sequential HCC≤3 cm between January 2000 and March 2018.Primary outcomes were overall survival(OS)and transplant-free survival(TFS).RESULTS 104 patients were identified(male n=89).Median age was 63 years(interquartile range 58-67.75)and the most common aetiology of liver disease was hepatitis C(40.4%).59(56.7%)had synchronous HCC and 45(43.3%)had sequential.36 patients died(34.6%)and 25 were transplanted(24.0%).1,3 and 5-year OS was 93.0%,66.1% and 62.3% and 5-year post-transplant survival was 95.8%.1,3 and 5-year TFS was 82.1%,45.85% and 37.8%.When synchronous and sequential groups were compared,OS(1,3 and 5 year synchronous 91.3%,63.8%,61.1%,sequential 95.3%,69.5%,64.6%,P=0.41)was similar but TFS was higher in the sequential group(1,3 and 5 year synchronous 68.5%,37.3% and 29.7%,sequential 93.2%,56.6%,48.5%,P=0.02)though this difference did not remain during multivariate analysis.CONCLUSION TFS in patients presenting with two HCC≤3 cm is poor regardless of the timing of the second tumor.All patients presenting with two small HCC should be considered for transplantation.

Outcomes of microwave versus radiofrequency ablation for hepatocellular carcinoma:A systematic review and meta-analysis

BACKGROUND Studies to date comparing outcomes of microwave ablation(MWA)with radiofrequency ablation(RFA)on patients with hepatocellular carcinoma have yielded conflicting results,with no clear superiority of one technique over the other.The aim of this systematic review and meta-analysis was to compare the efficacy and safety of MWA with RFA.AIM To perform a systematic review and meta-analysis comparing the efficacy and safety of MWA with RFA.METHODS A systematic literature search was performed using Ovid Medline,Embase,PubMed,Reference Citation Analysis,Cochrane Central and Cochrane Systematic Review databases,and Web of Science.Abstracts and full manuscripts were screened for inclusion utilising predefined inclusion and exclusion criteria comparing outcomes of MWA and RFA.A random-effects model was used for each outcome.Meta-regression analysis was performed to adjust for the difference in follow-up period between the studies.Primary outcome measures included complete ablation(CA)rate,local recurrence rate(LRR),survival[local recurrence-free survival(LRFS),overall survival(OS)]and adverse events.RESULTS A total of 42 published studies[34 cohort and 8 randomised controlled trials(RCT)]with 6719 patients fulfilled the selection criteria.There was no significant difference in tumour size between the treatment groups.CA rates between MWA and RFA groups were similar in prospective cohort studies[odds ratio(OR)0.95,95%confidence interval(CI)0.28–3.23]and RCTs(OR 1.18,95%CI 0.64–2.18).However,retrospective studies reported higher rates with MWA(OR 1.29,95%CI 1.06–1.57).Retrospective cohort studies reported higher OS(OR 1.54,95%CI 1.15–2.05 and lower LRR(OR 0.67,95%CI 0.51–0.87).No difference in terms of LRFS or 30-d mortality was observed between both arms.MWA had an increased rate of adverse respiratory events when compared to RFA(OR 1.99,95%CI 1.07–3.71,P=0.03).CONCLUSION MWA achieves similar CA rates and as good or better longer-term outcomes in relation to LRR and OS compared to RFA.Apart from an increased rate of respiratory events post procedure,MWA is as safe as RFA.