Impact of endoscopic ultrasound-guided radiofrequency ablation in managing pancreatic malignancy

Pancreatic malignancy is still the most lethal gastrointestinal malignancy.It has a very poor prognosis with low survival rate.Surgery is still the main treatment option for pancreatic malignancy.Most patients already have locally advanced and even late stage disease due to non-specific abdominal symptoms.Even though some cases are still suitable for surgical treatment,due to its aggressiveness adjuvant chemotherapy is becoming the standard treatment for controlling the disease.Radiofrequency ablation(RFA)is a thermal therapy that has been used as one of the standard treatments for liver malignancy.It can also be performed intraoperatively.There are several reports on percutaneous RFA treatment for pancreatic malignancy using transabdominal ultrasound and guided by computed tomography scan.However,due to its anatomical location and the risk of high radiation exposure,these methods seem to be very limited.Endoscopic ultrasound(EUS)has been widely used for pancreatic abnormality evaluation due to its ability to detect more accurately,especially small pancreatic lesions,compared to other imaging modalities.By the EUS approach,it is easier to achieve good visualization of tumor ablation and necrosis as the echoendoscope position is closer to the tumor area.Based on studies and a recent meta-analysis,EUS-guided RFA is a promising treatment approach for most pancreatic malignancy cases,but most studies only collected data from a small sample size.Larger studies are needed before clinical recommendations can be made.

Endoscopic ultrasound-guided portal pressure gradient measurement in managing portal hypertension

Portal hypertension(PH)is still a challenging clinical condition due to its silent manifestations in the early stage and needs to be measured accurately for early detection.Hepatic vein pressure gradient measurement has been considered as the gold standard measurement for PH;however,it needs special skill,experience,and high expertise.Recently,there has been an innovative development in using endoscopic ultrasound(EUS)for the diagnosis and management of liver diseases,including portal pressure measurement,which is commonly known as EUS-guided portal pressure gradient(EUS-PPG)mea-surement.EUS-PPG measurement can be performed concomitantly with EUS evaluation for deep esophageal varices,EUS-guided liver biopsy,and EUS-guided cyanoacrylate injection.However,there are still major issues,such as different etiologies of liver disease,procedural training,expertise,availability,and cost-effectiveness in several situations with regard to the standard management.

Role of endoscopic ultrasound in non-variceal upper gastrointestinal bleeding management

Non-variceal upper gastrointestinal bleeding(NVUGIB)is one of the challenging situations in clinical practice.Despite that gastric ulcer and duodenal ulcer are still the main causes of acute NVUGIB,there are other causes of bleeding which might not always be detected through the standard endoscopic evaluation.Standard endoscopic management of UGIB consists of injection,thermal coagulation,hemoclips,and combination therapy.However,these methods are not always successful for rebleeding prevention.Endoscopic ultrasound(EUS)has been used recently for portal hypertension management,especially in managing acute variceal bleeding.EUS has been considered a better tool to visualize the bleeding vessel in gastroesophageal variceal bleeding.There have been studies looking at the role of EUS for managing NVUGIB;however,most of them are case reports.Therefore,it is important to review back to see the evolution and innovation of endoscopic treatment for NVUGIB and the role of EUS for possibility to replace the standard endoscopic haemostasis management in daily practice.

Peri-operative score for elderly patients with resectable hepatocellular carcinoma

BACKGROUND Liver resection is the mainstay for a curative treatment for patients with resectable hepatocellular carcinoma(HCC),also in elderly population.Despite this,the evaluation of patient condition,liver function and extent of disease remains a demanding process with the aim to reduce postoperative morbidity and mortality.AIM To identify new perioperative risk factors that could be associated with higher 90-and 180-d mortality in elderly patients eligible for liver resection for HCC considering traditional perioperative risk scores and to develop a risk score.METHODS A multicentric,retrospective study was performed by reviewing the medical records of patients aged 70 years or older who electively underwent liver resection for HCC;several independent variables correlated with death from all causes at 90 and 180 d were studied.The coefficients of Cox regression proportional-hazards model for sixmonth mortality were rounded to the nearest integer to assign risk factors'weights and derive the scoring algorithm.RESULTS Multivariate analysis found variables(American Society of Anesthesiology score,high rate of comorbidities,Mayo end stage liver disease score and size of biggest lesion)that had independent correlations with increased 90-and 180-d mortality.A clinical risk score was developed with survival profiles.CONCLUSION This score can aid in stratifying this population in order to assess who can benefit from surgical treatment in terms of postoperative mortality.

亚太地区慢性乙型肝炎治疗共识(2012最新版)

自2008年至今,有大量关于慢性HBV感染的自然史和治疗的最新数据不断涌现。其中包括慢性HBV感染的无症状感染者,以社区为基础的队列研究,HBV基因型的作用,非药物诱导的自然HBV变异型毒株,无创性肝纤维化评估方法的应用,HBsAg定量在临床中的应用,更有效的新治疗药物和新治疗方案等等。来自亚太地区的专家审查和评估了相关数据,并共同商讨了近年来报道的最有意义的发现,基于此,对2008年版的亚太地区慢性乙型肝炎治疗共识进行修订,同时对2008年版治疗指南定义的关键词组进行了修订。修订后的指南包括以下几方面内容:一般治疗,肝纤维化评价适应证,何时开始治疗或停药,初始抗病毒治疗药物的选择,如何监测治疗中和治疗后的患者。关于特殊人群的治疗建议中包括了对妊娠妇女,已发生耐药,合并其他病毒感染,肝功能失代偿,接受免疫抑制治疗、化疗,肝移植或肝细胞癌患者的具体治疗建议。

Innovation of endoscopic management in difficult common bile duct stone in the era of laparoscopic surgery

Common bile duct(CBD)stone is a common biliary problem,which often requires endoscopic approach as the initial treatment option.Roughly,7%-12%of the subjects who experience cholecystectomy were subsequently referred to biliary endoscopist for further management.In general,there are three classifications of difficult CBD stone,which are based on the characteristics of the stone(larger than 15 mm,barrel or square-shaped stones,and hard consistency),accessibility to papilla related to anatomical variations,and other clinical conditions or comorbidities of the patients.Currently,endoscopic papillary large balloon dilation(EPLBD)of a previous sphincterotomy and EPLBD combined with limited sphincterotomy performed on the same session is still recommended by the European Society of Gastrointestinal Endoscopy as the main approach in difficult CBD stones with history of failed sphincterotomy and balloon and/or basket attempts.If failed extraction is still encountered,mechanical lithotripsy or cholangioscopy-assisted lithotripsy or extracorporeal shockwave lithotripsy can be considered.Surgical approach can be considered when stone extraction is still failed or the facilities to perform lithotripsy are not available.To our knowledge,conflicting evidence are still found from previous studies related to the comparison between endoscopic and surgical approaches.The availability of experienced operator and resources needs to be considered in creating individualized treatment strategies for managing difficult biliary stones.

Co-infection of SENV-D among chronic hepatitis C patients treated with combination therapy with high-dose interferon-alfa and ribavirin

AIM: The clinical significance of co-infection of SENV-D among patients with chronic hepatitis C (CHC) and response of both viruses to combination therapy with high-dose interferon-alfa (IFN) plus ribavirin remain uncertain and are being investigated.METHODS: Total 164 (97 males and 67 females, the mean age 48.1±11.4 years, range: 20-73 years, 128histologically proved) naive CHC patients were enrolled in this study. SENV-D DNA was tested by PCR method.Detection of serum HCV RNA was performed using a standardized automated qualitative RT-PCR assay (COBAS AMPLICOR HCV Test, version 2.0). HCV genotypes 1a,1b, 2a, 2b, and 3a were determined by using genotypespecific primers. Pretreatment HCV RNA levels were determined by using the branched DNA assay (Quantiplex HCV RNA 3.0). There are 156 patients receiving combination therapy with IFN 6 MU plus ribavirin for 24 wk and the response to therapy is determined.RESULTS: Sixty-one (37.2%) patients were positive for SENV-D DNA and had higher mean age than those who were negative (50.7±10.6 years vs46.6±11.6 years,P = 0.026). The rate of sustained viral response (SVR)for HCV and SENV-D were 67.3% (105/156) and 56.3%(27/48), respectively. By univariate analysis, the higher rate of SVR was significantly related to HCV genotype non-1b (P＜0.001), younger ages (P = 0.014), lower pretreatment levels of HCV RNA (P = 0.019) and higher histological activity index (HAI) score for intralobular regeneration and focal necrosis (P = 0.037). By multivariate analyses, HCV genotype non-1b, younger age and lower pretreatment HCV RNA levels were significantly associated with HCV SVR (odds ratio (OR)/95% confidence interval (CI): 12.098/0.02-0.19, 0.936/0.890-0.998, and 3.131/1.080-9.077, respectively). The SVR of SENV-D was higher among patients clearing SENV-D than those who had viremia at the end of therapy (P = 0.04).CONCLUSION: Coexistent SENV-D infection, apparently associated with higher ages, is found in more than onethird Taiwan Residents CHC patients. Both HCV and SENV-D are highly susceptible to combination therapy with high-dose IFN and ribavirin and SENV-D co-infection does not affect the HCV response. HCV genotype, pretreatment HCV RNA levels and age are predictive factors for HCV SVR.

Carvedilol vs endoscopic variceal ligation for primary and secondary prevention of variceal bleeding: Systematic review and metaanalysis

BACKGROUND Variceal hemorrhage is associated with high mortality and is the cause of death for 20–30%of patients with cirrhosis.Nonselectiveβblockers(NSBBs)or endoscopic variceal ligation(EVL)are recommended for primary prevention of variceal bleeding in patients with medium to large esophageal varices.Meanwhile,combination of EVL and NSBBs is the recommended approach for the secondary prevention.Carvedilol has greater efficacy than other NSBBs as it decreases intrahepatic resistance.We hypothesized that there was no difference between carvedilol and EVL intervention for primary and secondary prevention of variceal bleeding in cirrhosis patients.AIM To evaluate the efficacy of carvedilol compared to EVL for primary and secondary prevention of variceal bleeding in cirrhotic patients METHODS We searched relevant literatures in major journal databases(CENTRAL,MEDLINE,and EMBASE)from March to August 2018.Patients with cirrhosis and portal hypertension,regardless of aetiology and severity,with or without a history of variceal bleeding,and aged≥18 years old were included in this review.Only randomized controlled trials(RCTs)that compared the efficacy of carvedilol and that of EVL for primary and secondary prevention of variceal bleeding and mortality in patients with cirrhosis and portal hypertension were considered,irrespective of publication status,year of publication,and language.RESULTS Seven RCTs were included.In four trials assessing the primary prevention,no significant difference was found on the events of variceal bleeding(RR:0.74,95%CI:0.37-1.49),all-cause mortality(RR:1.10,95%CI:0.76-1.58),and bleedingrelated mortality(RR:1.02,95%CI:0.34-3.10)in patients who were treated with carvedilol compared to EVL.In three trials assessing secondary prevention,there was no difference between two interventions for the incidence of rebleeding(RR:1.10,95%CI:0.75-1.61).The fixed-effect model showed that,compared to EVL,carvedilol decreased all-cause mortality by 49%(RR:0.51,95%CI:0.33-0.79),with little or no evidence of heterogeneity.CONCLUSION Carvedilol had similar efficacy to EVL in preventing the first variceal bleeding in cirrhosis patients with esophageal varices.It was superior to EVL alone for secondary prevention of variceal bleeding in regard to all-cause mortality reduction.

Genome-wide DNA hypermethylation and homocysteine increase a risk for myopia

AIM: To test for the association between genome-wide methylation and myopia in human and mice. METHODS: Long interspersed nucleotide element 1(LINE-1) methylation levels were used to surrogate genome-wide methylation level. We first tested for the association between high myopia(<-6 D) and LINE-1 methylation in leukocytes in 220 cases and 220 control subjects. Secondly, we validated the results of LINE-1 methylation in eyes from the form deprivation myopia(FDM) mice. Furthermore,we calculated the correlation of LINE-1 methylation levels between leukocyte DNA and ocular DNA in the mice. We also tested whether dopamine can alter LINE-1 methylation levels. RESULTS: The LINE-1 methylation level was significantly higher in the myopic human subjects than controls. The upper and middle tertiles of the methylation levels increased an approximately 2-fold(P≤0.002) risk for myopia than the lower tertile. Similarly, FDM mice had high LINE-1 methylation levels in the leukocyte, retina and sclera, and furthermore the methylation levels detected from these three tissues were significantly correlated. Immunohistochemical staining revealed higher levels of homocysteine and methionine in the rodent myopic eyes than normal eyes. Dopamine treatment to the cells reduced both LINE-1 methylation and DNA methyltransferase levels. CONCLUSION: LINE-1 hypermethylation may be associated with high myopia in human and mice. Homocysteine and methionine are accumulated in myopic eyes, which may provide excess methyl group for genome-wide methylation.

Dynamics of cytokines predicts risk of hepatocellular carcinoma among chronic hepatitis C patients after viral eradication

BACKGROUND Chronic hepatitis C virus(HCV)infection induces profound alterations in the cytokine and chemokine signatures in peripheral blood.Clearance of HCV by antivirals results in host immune modification,which may interfere with immune-mediated cancer surveillance.Identifying HCV patients who remain at risk of hepatocellular carcinoma(HCC)following HCV eradication remains an unmet need.We hypothesized that antiviral therapy-induced immune reconstruction may be relevant to HCC development.AIM To investigate the impact of differential dynamics of cytokine expression on the development of HCC following successful antiviral therapy.METHODS One hundred treatment-naïve HCV patients with advanced fibrosis(F3/4)treated with direct-acting antivirals(DAAs)or peginterferon/ribavirin who achieved sustained virologic response[SVR,defined as undetectable HCV RNA throughout 12 wk(SVR12)for the DAA group or 24 wk(SVR24)for the interferon group after completion of antiviral therapy]were enrolled since 2003.The primary endpoint was the development of new-onset HCC.Standard HCC surveillance(abdominal ultrasound andα-fetoprotein)was performed every six months during the followup.Overall,64 serum cytokines were detected by the multiplex immunoassay at baseline and 24 wk after end-of-treatment.RESULTS HCC developed in 12 of the 97 patients over 459 person-years after HCV eradication.In univariate analysis,the Fibrosis-4 index(FIB-4),hemoglobin A1c(HbA1c),the dynamics of tumor necrosis factor-α(TNF-α),and TNF-like weak inducer of apoptosis(TWEAK)after antiviral therapy were significant HCC predictors.The multivariate Cox regression model showed thatΔTNF-α(≤-5.7 pg/mL)was the most important risk factor for HCC(HR=11.54,95%CI:2.27-58.72,P=0.003 in overall cases;HR=9.98,95%CI:1.88-52.87,P=0.007 in the interferon group).An HCC predictive model comprising FIB-4,HbA1c,ΔTNF-α,andΔTWEAK had excellent performance,with 3-,5-,10-,and 13-year areas under the curve of 0.882,0.864,0.903,and 1.000,respectively.The 5-year accumulative risks of HCC were 0%,16.9%,and 40.0%in the low-,intermediate-,and high-risk groups,respectively.CONCLUSION Downregulation of serum TNF-αsignificantly increases the risk of HCC after HCV eradication.A predictive model consisting of cytokine kinetics could ameliorate personalized HCC surveillance strategies for post-SVR HCV patients.

Therapeutic interventional endoscopic ultrasound in pancreatobiliary disorders:Does it really replace the surgical/percutaneous approach?

Pancreato-biliary disorders are still incredibly challenging in the field of gastroenterology,as they would sometimes require multi-approach interventional procedures.Recently,therapeutic interventional endoscopic ultrasound(EUS)has emerged as a potential alternative to surgical or percutaneous approaches.Unfortunately,considering the high cost of EUS,lack of facility and expertise,most gastroenterologists still often refer cases to undergo surgical interventions without contemplating the possibility of utilizing EUS first.EUS-guided biliary drainage has become one of the best choices for establishing access to biliary system,given the clear visualization of pancreas,gallbladder,and common bile duct.Although there are still only a few studies which directly compare EUSguided and surgical approaches for biliary drainage,current evidence demonstrated the superiority of EUS-guided approach in terms of adverse events and reintervention rates,with similarly high technical and clinical success rates compared to percutaneous and surgical approaches,especially in patients with history of failed endoscopic retrograde cholangiopancreatography attempt.Comparable success rates with shorter length of hospital stay between endoscopic and surgical approaches have also been exhibited for pancreatic pseudocysts and walled-off necrosis.Recent findings about the progress of EUS approach in gastroenterostomy/jejunostomy also indicated a promising potential of EUS,as a less invasive approach,for managing gastric outlet obstruction.

Impact of endoscopic ultrasound elastography in pancreatic lesion evaluation

Pancreatic malignancy still becomes a major global problem and is considered as one of the most lethal cancers in the field of gastroenterology.Most patients come in the late stage of the disease due to organ’s location,and until now the treatment result is still far away from satisfaction.Early detection is still the main key for good,prolonged survival.However,discerning from other types of tumor sometimes is not easy.Endoscopic ultrasound(EUS)is still the best tool for pancreatic assessment,whereas fine-needle aspiration biopsy(FNAB)is considered as the cornerstone for further management of pancreatic malignancy.Several conditions have become a concern for EUS-FNAB procedure,such as risk of bleeding,pancreatitis,and even needle track-seeding.Recently,an artificial intelligence innovation,such as EUS elastography has been developed to improve diagnostic accuracy in pancreatic lesions evaluation.Studies have shown the promising results of EUS elastography in improving diagnostic accuracy,as well as discerning from other tumor types.However,more studies are still needed with further considerations,such as adequate operator training,expertise,availability,and its cost-effectiveness in comparison to other imaging options.

Laparoscopic liver resections at the gates of 2020: a stand-alone field of hepatobiliary surgery

We read with interest the review entitled"Laparoscopic liver resection:the current status and the future"written by Dr.Xiujun Cai and published in Hepatobiliary Surgery and Nutrition(1).

Improving performance of robotic liver resections with high technical complexity by Robo-Lap approach

Introduction The hybrid robotic-laparoscopic technique has been described-in the field of hepatic surgery-in order to overcome procedural challenges related to the lack of the robotic ultrasonic dissector(1-4):Robo-Lap approach hence combines the use of the robotic platform(specifically robotic bipolar forceps for coagulation and scissors)with the laparoscopic dissector handled by the surgeon at the table.

Community-centered Disease Severity Assessment of Metabolic Dysfunction-associated Fatty Liver Disease

Background and Aims:Disease severity across the different diagnostic categories of metabolic dysfunction-associated fatty liver disease(MAFLD)remains elusive.This study assessed the fibrosis stages and features of MAFLD between different items.We also aimed to investigate the associations between advanced fibrosis and risk factors.Methods:This multicenter cross-sectional study enrolled adults participating in liver disease screening in the community.Patients were stratified following MAFLD diagnostic criteria,to group A(395 patients)for type 2 diabetes,group B(1,818 patients)for body mass index(BMI)>23 kg/m^(2),and group C(44 patients)for BMI≤23kg/m^(2) with at least two metabolic factors.Advanced fibrosis was defined as a fibrosis-4 index>2.67.Results:Between 2009 and 2020,1,948 MAFLD patients were recruited,including 478 with concomitant liver diseases.Advanced fibrosis was observed in 125 patients.A significantly larger proportion of patients in group C(25.0%)than in group A(7.6%)and group B(5.8%)had advanced fibrosis (p<0.01).Logistic regression analysis found that hepatitis B virus(HBV)/hepatitis C virus(HCV)coinfection(odds ratio[OR]:12.14,95%confidence interval[CI]:4.04-36.52;p<0.01),HCV infection(OR:7.87,95%CI:4.78-12.97;p<0.01),group C(OR:6.00,95%CI:2.53-14.22;p<0.01),and TC/LDL-C(OR:1.21,95%CI:1.06-1.38;p<0.01)were significant predictors of advanced fibrosis.Conclusions:A higher proportion of lean MAFLD patients with metabolic abnormalities had advanced fibrosis.HCV infection was significantly associated with advanced fibrosis.

Robotic versus laparoscopic liver resection for huge (≥10 cm) liver tumors: an international multicenter propensity-score matched cohort study of 799 cases

Background:The use of laparoscopic(LLR)and robotic liver resections(RLR)has been safely performed in many institutions for liver tumours.A large scale international multicenter study would provide stronger evidence and insight into application of these techniques for huge liver tumours≥10 cm.Methods:This was a retrospective review of 971 patients who underwent LLR and RLR for huge(≥10 cm)tumors at 42 international centers between 2002-2020.Results:One hundred RLR and 699 LLR which met study criteria were included.The comparison between the 2 approaches for patients with huge tumors were performed using 1:3 propensity-score matching(PSM)(73 vs.219).Before PSM,LLR was associated with significantly increased frequency of previous abdominal surgery,malignant pathology,liver cirrhosis and increased median blood.After PSM,RLR and LLR was associated with no significant difference in key perioperative outcomes including media operation time(242 vs.290 min,P=0.286),transfusion rate rate(19.2%vs.16.9%,P=0.652),median blood loss(200 vs.300 mL,P=0.694),open conversion rate(8.2%vs.11.0%,P=0.519),morbidity(28.8%vs.21.9%,P=0.221),major morbidity(4.1%vs.9.6%,P=0.152),mortality and postoperative length of stay(6 vs.6 days,P=0.435).Conclusions:RLR and LLR can be performed safely for selected patients with huge liver tumours with excellent outcomes.There was no significant difference in perioperative outcomes after RLR or LLR.

Portal Hypertension in Nonalcoholic Fatty Liver Disease:From Pathogenesis to Clinical Practice

Portal hypertension in nonalcoholic fatty liver disease(NAFLD)mostly occur in cirrhotic stage.However,several experimental and clinical studies showed evidence of portal hypertension in NAFLD without significant or advance fibrosis.This early development of portal hypertension in NAFLD is associated with liver sinusoidal contraction by hepatocellular lipid accumulation and ballooning,which is also accompanied by capillarization and dysfunction of liver sinusoidal endothelial cells.Both of these impaired mechanical and molecular components can cause an increase in intrahepatic vascular resistance which lead to the increase of portal pressure in the absence of significant liver fibrosis.Extrahepatic factors such as insulin resistance and gut dysbiosis may also contribute to liver sinusoidal endothelial dysfunction and early portal hypertension in NAFLD.The clinical impact of early portal hypertension in NAFLD is still unclear.However,clinical tools for diagnosis and monitoring of portal hypertension in NAFLD are being investigated to predict high-risk patients and to guide therapy.

Have we really understood when the efforts of laparoscopic liver resection are justified?-a complexity-based appraisal of the differential benefit

Background:The implementation of minimally invasive liver resection surgery(MILS)programs starts from procedures with a low degree of technical difficulty.Data regarding the real short-term advantage of laparoscopy according to technical difficulty are still lacking.The aim of the present study is to evaluate the differential benefit of laparoscopic over open technique according to the technical difficulty of the procedures and to investigate if efforts associated with laparoscopic approach are always justified.Methods:Nine hundred and thirty-six MILS resections performed between 2005 and 2018 were stratified according to technical complexity(low,intermediate and high difficulty)and to approach(MILS or open)and matched in a 1:1 ratio using propensity scores to obtain three pairs of groups(Pair 1:Low-MILS and Low-Open,including 274 cases respectively;Pair 2:Int-MILS and Int-Open,including 237 patients respectively;Pair 3:High-MILS and High-Open,including 226 patients respectively).Results:MILS approach resulted in a statistically significant lower blood loss,reduced morbidity,reduced and shorter time for functional recover and length of stay within all pairs.The evaluation of the differential benefit showed a greater advantage of laparoscopic approach in high degree procedures compared with intermediate and low degree,both in terms of blood loss(-250 and-200 mL respectively)and morbidity rate(-5.7%and-4.1%respectively).Conclusions:The favorable biological scenario associated with laparoscopic approach allows to obtain significant benefits in the setting of technically complex procedures.The commitment towards MILS approach should be therefore stronger in this setting,where the advantage of laparoscopy seems to be enhanced.

Role of Granulocyte Colony-stimulating Factor Therapy in Cirrhosis,'Inside Any Deep Asking Is the Answering'

Liver cirrhosis progresses through multiple clinical stages which culminate in either death or liver transplantation.Availability of organs,timely listing and prompt receipt of donor-livers pose difficulties in improving transplant-listed and transplant outcomes.In this regard,regenerative therapies,particularly with granulocyte colony-stimulating factor(GCSF),has become a lucrative option for improving transplant-free survival.However,the literature is confusing with regards to patient selection and real outcomes.In this exhaustive review,we describe the basics of liver fibrosis and cirrhosis through novel insights from a therapeutic point of view,discuss preclinical studies on GCSF in advanced liver disease to improve on clinical utility,shed light on the pertinent literature of GCSF in advanced cirrhosis,and provide astute inputs on growth factor therapy in decom-pensated cirrhosis.

Treatment efficacy for patients with chronic hepatitis C and preexisting hepatocellular carcinoma by directly acting antivirals

Aim:Despite the high cure rate of interferon-free directly acting antivirals(DAAs)for chronic hepatitis C(CHC)patients,the treatment efficacy for patients with preexisting hepatocellular carcinoma(HCC)remains undefined.We aimed in the present study to address the issue by using novel DAAs in treating CHC patients who were adherent to treatment in Taiwan.Methods:CHC patients with or without HCC were consecutively enrolled.The primary objective was sustained virological response(SVR)defined as undetectable HCV RNA throughout 12 weeks of a post-treatment follow-up period(SVR12).Only patients with available SVR12 were enrolled for final analysis.Results:A total of 1237 patients(1113 non-HCC,101 inactive HCC and 23 active HCC)were enrolled.The overall SVR12 rate was 98.9%,and was similar between HCV patients with and without pre-existing HCC(98.4%vs.98.9%,P=0.64).While HCC patients were classified as those who had active or inactive HCC,the SVR12 was also similar between patients with and without active HCC(95.7%vs.99.0%,P=0.34).Among the 101 patients without viable HCC at the time of DAA initiation,eighty-four patients exhibited curative therapy and the other 17 ;patients experienced HCC recurrence before DAAs.Among the 23 patients with viable HCC at the time of DAA treatment,10 patients had received curative therapy for HCC whereas the remaining 13 patients had HCC that was never cured.The SVR12 rates were also similar among the four subpopulations,being 98.8%(83/84),100%(17/17),90%(9/10)and 100%(13/13)respectively.Conclusion:CHC patients with HCC who were adherent to potent DAAs achieved similar SVR12 rate compared to those without HCC and could be effectively treated.