Incidence and Predictors of Esophagogastric Varices Bleeding in Patients with Hepatocellular Carcinoma in Lenvatinib

Development and validation of a score model for predicting the risk of first esophagogastric variceal hemorrhage and mortality in patients with hepatocellular carcinoma

AIMS

Esophagogastric variceal bleeding, especially first variceal hemorrhage, represents a challenging complication in the management of patients with hepatocellular carcinoma (HCC), and its presence significantly herald poor patient prognosis. The stratification system for the risk of first variceal hemorrhage and mortality has not been validated in patients with HCC. We aimed to develop and validate a simple score for the prediction of initial variceal bleeding and mortality in patients with HCC.

METHODS

This multicenter retrospective-prospective study included HCC patients at three tertiary hospitals in China from January 2016 to December 2023. The bleeding following endoscopy for hepatocellular carcinoma (BFE-HCC) score was constructed by the least absolute contraction and selection operator (LASSO) regression combined with multivariate logistic regression analysis. The performance of the score model was evaluated using the receiver operating characteristic (ROC) curve, the calibration curve, and the decision curve analysis (DCA). Finally, the of the results was further verified in an independent external cohort.

RESULTS

We recruited 351 patients from three centers (median age 56 years, 85.5% male and 83.5% with cirrhosis), 56.6% patients presented high-risk (HR) varices, and 35% patients experienced variceal bleeding. Multivariate logistic analysis revealed that the presence of cirrhosis, a history of acute variceal bleeding (AVB), Child-Pugh score, ALBI score, tumor size and portal vein tumor thrombosis (PVTT) Vp4 were independent predictors of HR varices. The BFE-HCC is composed of six variables: white blood cell count, HR varices, Child-Pugh score, HCC therapy modality, Vp4, and tumor stage. The area under the curve (AUC) of BFE-HCC was 0.82, and the calibration plots and decision curve analysis exhibited outstanding performance compared with the MELD, ALBI, and Child-Pugh scores. In addition, Patients with BFE-HCC ≥ 4 were at increased risk of mortality (P<0.01).

CONCLUSIONS

The BFE-HCC score is hopeful to predict initial variceal bleeding and mortality in patients with HCC, offering a promising tool for prognostic assessment and treatment decisions.

Visualizing global progress and challenges in esophagogastric variceal bleeding

BACKGROUND

Esophageal and gastric variceal bleeding is a catastrophic complication of portal hypertension, most commonly caused by cirrhosis of various etiologies. Although a considerable body of research has been conducted in this area, the complexity of the disease and the lack of standardized treatment strategies have led to fragmented findings, insufficient information, and a lack of systematic investigation. Bibliometric analysis can help clarify research trends, identify core topics, and reveal potential future directions. Therefore, this study aims to use bibliometric methods to conduct an in-depth exploration of research progress in this field, with the expectation of providing new insights for both clinical practice and scientific research.

AIM

To evaluate research trends and advancements in esophagogastric variceal bleeding (EGVB) over the past twenty years.

METHODS

Relevant publications on EGVB were retrieved from the Web of Science Core Collection. VOSviewer, Pajek, CiteSpace, and the bibliometrix package were then employed to perform bibliometric visualizations of publication volume, countries, institutions, journals, authors, keywords, and citation counts.

RESULTS

The analysis focused on original research articles and review papers. From 2004 to 2023, a total of 2097 records on EGVB were retrieved. The number of relevant publications has increased significantly over the past two decades, especially in China and the United States. The leading contributors in this field, in terms of countries, institutions, authors, and journals, were China, Assistance Publique-Hôpitaux de Paris, Bosch Jaime, and World Journal of Gastroenterology, respectively. Core keywords in this field include portal hypertension, management, liver cirrhosis, risk, prevention, and diagnosis. Future research directions may focus on optimizing diagnostic methods, personalized treatment, and multidisciplinary collaboration.

CONCLUSION

Using bibliometric methods, this study reveals the developmental trajectory and trends in research on EGVB, underscoring risk assessment and diagnostic optimization as the core areas of current focus. The study provides an innovative and systematic perspective for this field, indicating that future research could center on multidisciplinary collaboration, personalized treatment approaches, and the development of new diagnostic tools. Moreover, this work offers practical research directions for both the academic community and clinical practice, driving continued advancement in this domain.

Atezolizumab/bevacizumab or lenvatinib in hepatocellular carcinoma: Multicenter real-world study with focus on bleeding and thromboembolic events

Background & Aims

Atezolizumab/bevacizumab (atezo/bev) and lenvatinib have demonstrated efficacy as first-line therapies for hepatocellular carcinoma (HCC). However, vascular endothelial growth factor (VEGF) inhibition with these therapies may be associated with the risk of bleeding and thromboembolic events. In this study, we evaluated the efficacy and safety with focus on the bleeding and thromboembolic events of atezo/bev vs. lenvatinib in a large, multicenter real-world population.

Methods

This study is based on HCC cohorts from seven centers in Germany and Austria. Incidences of bleeding or thromboembolic events and efficacy outcomes were assessed and compared.

Results

In total, 464 patients treated with atezo/bev (n = 325) or lenvatinib (n = 139) were analyzed. Both groups were balanced with respect to demographics, presence of liver cirrhosis, and variceal status. Duration of therapy did not differ between groups. Within 3 months of therapy, bleeding episodes were described in 57 (18%) patients receiving atezo/bev compared with 15 (11%) patients receiving lenvatinib (p = 0.07). Variceal hemorrhage occurred in 11 (3%) patients treated with atezo/bev compared with 4 (3%) patients treated with lenvatinib (p = 0.99). Thromboembolic events were reported in 19 (6%) of patients in the atezo/bev cohort compared with 5 (4%) patients in the lenvatinib cohort (p = 0.37). In addition, incidence of overall bleeding, variceal hemorrhage, and thromboembolic events did not differ significantly in patients who received either atezo/bev or lenvantinib for 6 months.

Conclusions

Safety considerations related to bleeding and thromboembolic events may not be helpful in guiding clinical decision-making when choosing between atezo/bev and lenvatinib.

Impact and implications

The inhibition of VEGF by current first-line therapies for HCC, such as atezolizumab/bevacizumab or lenvatinib, may be associated with the risk of bleeding and thromboembolic events. Studies comparing the incidence of these side effects between atezolizumab/bevacizumab and lenvatinib, which are preferred treatments over sorafenib for HCC, are needed. Differences in this side effect profile may influence the choice of first-line therapy by treating physicians. Because no significant differences were observed regarding bleeding or thromboembolic events between both therapies in the present study, we conclude that safety considerations related to these events may not be helpful in guiding clinical decision-making when choosing between atezolizumab/bevacizumab and lenvatinib.

Immune Checkpoint Inhibitors in Hepatocellular Carcinoma and Their Hepatic-Related Side Effects: A Review

Primary liver cancer is one of the leading causes of cancer mortality worldwide, with hepatocellular carcinoma (HCC) being the most prevalent type of liver cancer. The prognosis of patients with advanced, unresectable HCC has historically been poor. However, with the emergence of immunotherapy, specifically immune checkpoint inhibitors (ICIs), there is reason for optimism. Nevertheless, ICIs do not come without risk, especially when administered in patients with HCC, given their potential underlying poor hepatic reserve. Given their novelty in the management of HCC, there are few studies to date specifically investigating ICI-related side effects on the liver in patients with underlying HCC. This review will serve as a guide for clinicians on ICIs' role in the management of HCC and their potential side effect profile. There will be a discussion on ICI-related hepatotoxicity, the potential for hepatitis B and C reactivation with ICI use, the potential for the development of autoimmune hepatitis with ICI use, and the risk of gastrointestinal bleeding with ICI use. As ICIs become more commonplace as a treatment option in patients with advanced HCC, it is imperative that clinicians not only understand the mechanism of action of such agents but also understand and are able to identify hepatic-related side effects.