COVID-19 pandemic: Impact on the management of patients with hepatocellular carcinoma at a tertiary care hospital

Effects of the COVID-19 Pandemic and Post-Pandemic Changes on the Diagnosis, Treatment, and Mortality of Hepatocellular Carcinoma in a Tertiary Center in Western Romania

BACKGROUND/OBJECTIVES

Access to healthcare services was significantly restricted during the COVID-19 pandemic, leading to changes in the management of hepatocellular carcinoma (HCC). However, limited research has examined how these changes evolved post-pandemic. This study evaluated the impact of the pandemic at a tertiary center in Romania, focusing on diagnosis rates, treatments, and survival outcomes.

METHODS

A retrospective study conducted at Timișoara County Hospital divided patients into three equal cohorts of 23 months each: the pre-pandemic period (PreP: 1 May 2018-31 March 2020), the pandemic period (PandP: 1 April 2020-28 February 2022), and the post-pandemic period (PostP: 1 March 2022-31 January 2024). Newly diagnosed HCC cases were evaluated for the tumor stage, biological markers, and treatment received during each period. A survival census was conducted nine months after the diagnosis.

RESULTS

During the PandP and PostP periods, the numbers of newly diagnosed HCC cases decreased to 58 cases (p < 0.001) and 64 cases (p < 0.005), respectively, representing reductions of 38.3% and 31.9% compared to the PreP period, which had 94 cases. The proportion of patients in the BCLC-B stage increased from 31.9% in the PreP period to 50% during the PandP period (p = 0.0401), with fewer BCLC-A-0 cases (17% vs 5.1%; p = 0.059) during PandP. The tumor characteristics, BCLC classification, and TNM staging showed no significant differences between the PreP and PostP periods. Systemic therapy was the most commonly used treatment (39.7-50%). No significant differences were observed across treatment types when comparing all three periods (p > 0.05). The median follow-up times in the PreP, PandP, and PostP periods were 157.5, 159.5, and 183.5 days, respectively, with no statistically significant differences. The survival curve showed no statistically significant differences in survival between the groups at the nine-month follow-up (p > 0.05).

CONCLUSIONS

The COVID-19 pandemic decreased HCC diagnoses, with only a partial rebound in the PostP period that did not reach PreP levels. While the PandP period showed worsening BCLC staging and an increase in tumor numbers, the tumor stage and treatment in the PostP period were similar to those in the PreP period. Similarly, the nine-month survival rates remained similar across all three periods.

Post COVID Condition and Long-Term COVID-19 Impact on Hepatic Decompensation and Survival in Cirrhosis: A Propensity Matched Observational Study

Aims

Patients with cirrhosis are susceptible to decompensation events, including ascites, variceal bleeding (VB), hepatic encephalopathy, or death after COVID-19 infection. Patients may experience post-COVID condition (PCC) with multisystem involvement that persists for at least 2 months.

Methods

Hospitalized patients with cirrhosis and COVID-19 between January 2021 and January 2023 were assessed for decompensation events and mortality and compared to a propensity-matched cohort of cirrhosis and non-COVID-19 sepsis. Both groups were followed for outcomes over 1 year.

Results

Of 252 patients with Cirrhosis+ COVID-19 (73% men, aged 48.9 ± 13.7 years, 31%-diabetes, 44%-hypertension, 35%-alcohol-associated, 34.5%-metabolic dysfunction-associated steatotic liver disease; MASLD), 72 (28.6%) died in hospital and 180 (71.4%) recovered, similar to Cirrhosis+ non-COVID-sepsis (58/214, 27.1%). Finally,60 (33.3%) met criteria for PCC, 19 (10.5%) had no post COVID-19 sequelae and 101 (56.1%) patients died (N = 45) or were lost to follow up (N = 56). Late Mortality was higher in Cirrhosis+ COVID-19 than non-COVID-sepsis (56.1% vs. 35.3%, p = 0.026). Patients with PCC were aged 47.6 years, 63.3%-men, Charlson Comorbidity Index > 4 (51.7%), 45%-diabetes, 56.7%-hypertension, with 33.3%, 23.3%, and 43.3% in Child-Turcotte-Pugh class A, B and C, respectively. PCC symptoms included persistent dyspnea (34, 43%), cognitive impairment (20, 25.3%), and anxiety (47, 59.4%). On multivariable analysis, predictors of the development of PCC were baseline MELDNa (HR 1.12, 95% CI: 1.05-1.17, p < 0.001) and age (HR 0.9, 95% CI: 0.91-0.99, p = 0.012). Predictors of mortality following COVID-19 recovery were MELDNa (HR 1.03, 95% CI: 1.01-1.05, p = 0.008), age (HR 1.2, 95% CI: 1.1-1.5, p = 0.002) and hypertension (HR 1.63, 95% CI: 1.07-2.49, p = 0.025).

Conclusion

COVID-19 is associated with long-term mortality in cirrhosis even after recovery from respiratory infection. Long COVID is seen in a third of COVID-19 survivors in patients with cirrhosis.

ELIMINATE: a PCR record-based macroelimination project for systematic recall of HCV-RNA-positive persons in Austria

BACKGROUND AND AIMS

Micro-elimination projects targeted to specific hepatitis C virus (HCV) risk populations have been successful. Systematic identification of persons with HCV viremia, regardless of risk group, based on already available laboratory records may represent an effective macroelimination approach to achieve global HCV elimination.

METHODS

Persons with a last positive HCV-RNA PCR result between 2008-2020 in the reference virology laboratories in eastern Austria were identified. First, (i) we described their demographic characteristics, (ii) we systematically recalled persons to the respective centers and (iii) started antiviral treatment if HCV-RNA viremia was confirmed, and (iv) recorded sustained virologic response (SVR). This interim report includes the preliminary results from 8 participating centers.

RESULTS

During the study period 22,682 persons underwent HCV-RNA PCR testing, 11,216 (49.4%) were positive at any point in time, and 6006 (26.5%) showed detectable HCV-RNA at the last PCR test, suggesting ongoing HCV viremia. At the time of this interim report, 2546/6006 HCV-RNA PCR(+) persons were evaluated: 443/2546 (17.4%) had died, 852/2546 (33.5%) had invalid contact data, and 547/2546 (21.5%) had achieved SVR between data retrieval and recall. Contact could be established in 236/704 (33.5%) of the remaining target population with 97/236 (41.1%) presenting at the clinic for treatment evaluation. Ultimately, 71/236 (30.1%) started antiviral treatment and SVR was documented in 47/71 (66.2%).

CONCLUSION

This ELIMINATE project based on systematic assessment of HCV-RNA PCR-records, identified 6006 persons with potential persisting HCV viremia. Invalid contact data and missed visits for treatment evaluation were the main barriers towards HCV elimination within this project. Importantly, many subjects with HCV viremia lost to follow-up were successfully linked to care and started antiviral treatment.

Impact of Coronavirus Disease 2019 on Unresectable Hepatocellular Carcinoma Treated with Atezolizumab/Bevacizumab

(1) Background: The coronavirus disease 2019 (COVID-19) pandemic has proven challenging to the management of patients with cancer, particularly those receiving systemic therapy. This study aimed to evaluate the impact of COVID-19 on patients with unresectable hepatocellular carcinoma (HCC) treated with atezolizumab/bevacizumab. (2) Methods: Patients with unresectable HCC who started atezolizumab/bevacizumab treatment between June 2020 and December 2021 at a tertiary cancer center in Korea were included (n = 241) and classified according to their COVID-19 status and severity. (3) Results: Thirty-five (14.5%) patients with unresectable HCC were diagnosed with COVID-19 during atezolizumab/bevacizumab treatment; 26 (74.2%) and nine (25.7%) in the low- and high-severity groups, respectively. The high-severity group showed higher neutrophil-to-lymphocyte ratios and lactate dehydrogenase levels. Liver and kidney injuries were observed in 31.4% and 17.1% of total patients, respectively. Liver injury was more prominent in patients with pre-existing liver dysfunction at baseline, who were more prevalent in the high-severity group. Atezolizumab/bevacizumab treatment was delayed by a median of 0 (range, 0-21) day in the low-severity group and 12 (range, 0-35) days in the high-severity group. The high-severity group showed worse post-infection progression-free survival (1.1 vs. 4.8 months, p = 0.017) and overall survival (2.2 months vs. not reached, p = 0.004). (4) Conclusions: Patients with impaired liver function at baseline are more susceptible to high-severity COVID-19, which affects atezolizumab/bevacizumab treatment outcomes.

COVID-19 Pandemic Impact on Diagnosis, Stage, and Treatment of Hepatocellular Carcinoma in the United States

Background and Aims

The change in hepatocellular carcinoma (HCC) care continuum during the coronavirus disease 2019 (COVID-19) pandemic remains unknown at a national level in the United States. We sought to determine the impact of the pandemic on incident HCC cases, clinical characteristics, and treatment in the United States.

Methods

Using the National Cancer Database, we analyzed incident HCC cases from 2010 to 2020. The incidence rate was calculated using the population data for each year from the census bureau. Joinpoint regression analysis was applied for trend analysis, and a polynomial regression model estimated the number of projected HCC cases in 2020 according to the trend of rates from 2010 to 2019. The distribution of cancer stage and treatment modality were assessed.

Results

The pandemic led to a significant reduction in reported HCC cases, from 19,597 in 2019 to 16,188 in 2020. The projected number of HCC for 2020 was 19,011, corresponding to a 14.8% reduction in 2020. Extent of reduction in the number of incident HCC cases relative to estimated cases remains consistent in racial and ethnic subgroups. Despite underdiagnosis of HCC in 2020, proportion of patients with early tumor stage (30.5% for Tumour, Node, Metastasis stage 1) and curative treatment receipt (9.1% for surgical resection, 13% for ablation, 4.2% for liver transplant) for HCC remained stable in the first year of the COVID-19 pandemic.

Conclusion

There was a significant reduction in HCC cases in 2020 compared to pre-COVID years. While tumor stage and proportion of patients receiving curative treatment remained stable, continued follow-up is needed to assess potential changes during subsequent years.

Effect of coronavirus disease 2019 on diagnosis and treatment of hepatocellular carcinoma: a systematic review

Aim

Changes in strategies in the coronavirus disease 2019 (COVID-19) crisis and the imposing of restrictions have isolated many vulnerable patients including those with hepatocellular carcinoma (HCC) from routine medical care. This study investigated how the COVID-19 pandemic is affecting the diagnosis and treatment of HCC.

Methods

An extensive search was conducted in the PubMed, Scopus, and Web of Science databases by using the appropriate keywords: COVID-19, hepatocellular carcinoma, hepatocellular cancer, and MeSH. Studies in English related to the purpose of the study were included in the analysis, and review studies, case reports, letters to editors, comments, and reports were excluded. The quality of the studies was assessed by the "Adapted Newcastle-Ottawa Quality Assessment Scales" checklist. The Endnote X7 software has been used for managing items.

Results

The final qualitative analysis consisted of 27 articles. During the COVID-19 crisis, HCC diagnosis decreased from 20% to 34.13% compared to pre-crisis. The impact of the COVID-19 pandemic on HCC treatment encompasses a wide range of aspects. Generally, delays in treatment for patients with HCC ranged from more than one month for 21.5% of patients in France, to two months for 26% of patients in Italy, up to 30% in Austria, and 66.7% in Asia-Pacific countries.

Conclusions

According to the findings, developing and implementing appropriate diagnostic and therapeutic strategies and developing low-cost and high-precision screening programs among high-risk populations seem to be effective in reducing the impact of the COVID-19 pandemic on HCC management.

CHIME - A tailored HCV microelimination project in Viennese people who inject drugs at drug centralized substitution centers

Background

Hepatitis C remains highly prevalent among people who inject drugs (PWIDs). We propose an integrated approach for screening/diagnostic testing and treatment in 6,665 Viennese PWIDs registered to access opioid agonist therapy (OAT).

Methods

OAT prescriptions were required monthly at one of nine approved authorities, making them ideal platforms for hepatitis C virus (HCV) screening. All PWIDs attending these authorities between January 2019 and March 2020 were offered on-site HCV screening, and consecutive HCV RNA PCR in case of positive HCV serology. In HCV viremic PWIDs, offsite referral to HCV care and treatment according to directly observed therapy (DOT) alongside OAT were performed.

Results

4,327/6,665 (64.9%) individuals were contacted before the COVID-19-related project discontinuation. There were 1,538/4,327 (35.5%) individuals who had participated in the study. HCV serology was available in 1,510/1,538 (98.2%): 795/1,519 (52.6%) had a positive serology, among whom 632 (79.5%) were followed-up with a PCR test. In 8/1,538 (0.5%) additional study participants HCV RNA PCR was assessed without prior serological screening. 239/640 (37.3%) individuals were HCV viremic with 51 (21.3%) having started on direct-acting antivirals (DAAs). 48/51 (94.1%) had completed treatment, among whom 42 (87.5% according to ITT) had achieved sustained virologic response at 12 weeks after completing treatment (SVR12) and 6 (12.5%) had been lost to follow-up after completion of therapy (SVR12 according to mITT: 42/42, 100%). No treatment failures had occurred.

Conclusion

Providing integrated point-of-care HCV screening/diagnostic testing at central OAT approved centers, followed by DOT with DAAs, represents an effective HCV microelimination strategy. While some PWIDs were lost in the cascade to cure and the absolute number of SVR was limited by the COVID-19 pandemic, our approach will allow linkage to care in a large proportion of Viennese PWIDs.

Screening, Surveillance, and Management of Hepatocellular Carcinoma During the COVID-19 Pandemic: a Narrative Review

PURPOSE

The COVID-19 pandemic has been a burden to the global community as a whole but the healthcare community had bore the brunt of it. The pandemic resulted in policy changes that interfered with effective healthcare delivery. The healthcare community attempted to cope with the pandemic by triaging and prioritizing emergency conditions especially COVID related, ahead of elective conditions like cancer care. There was also fear that patients with cancer were at an increased risk of sever COVID-19 with increased mortality. Hepatocellular carcinoma (HCC) was also affected by these policies.

METHODS

We reviewed the modified measures adopted in screening, surveillance, and management of HCC during the pandemic using PubMed, Medline, Index Medicus, EMBASE, SCOPUS, and Google Scholar databases.

RESULT

The main modification in surveillance and screening for HCC during the pandemic includes limiting the surveillance to those with very high risk of HCC. The interval between surveillan was also delayed by few months in some cases. The adoption of teleconferencing for multidisciplinary team meetings and patient consultation is one of the highlights of this pandemic all in an effort to reduce contact and spread of the virus. The treatment of early-stage HCC was also modified as needed. The role of ablative therapy in the management of early HCC was very prominent during the pandemic as the surgical therapy was significantly affected by the lacks of ventilators and intensive care unit space resulting from the pandemic. Transplantation, especially living donor liver transplantation, was suspended in few centers because of the risk of infection to the living donors.

CONCLUSION

As we gradually recover from the pandemic, we should prepare for the fallout from the pandemic as we may encounter increased presentation of those patients deferred from screening during the pandemic.

Surgical management of primary liver cancers during the COVID-19 pandemic: overcoming the dilemma with standardization

BACKGROUND

The present study evaluates the impact of the pandemic on outcomes after surgical treatment for primary liver cancer in a high-volume hepatopancreatobiliary surgery center.

METHODS

Patients, who underwent liver resection for primary liver resection between January 2019 and February 2020, comprised pre-pandemic control group. The pandemic period was divided into two timeframes: early pandemic (March 2020-January 2021) and late pandemic (February 2021-December 2021). Liver resections during 2022 were considered as the post-pandemic period. Peri-, and postoperative patient data were gathered from a prospectively maintained database.

RESULTS

Two-hundred-eighty-one patients underwent liver resection for primary liver cancer. The number of procedures decreased by 37.1% during early phase of pandemic, but then increased by 66.7% during late phase, which was comparable to post-pandemic phase. Postoperative outcomes were similar between four phases. The duration of hospital stay was longer during the late phase, but not significantly different compared to other groups.

CONCLUSION

Despite an initial reduction in number of surgeries, COVID-19 pandemic had no negative effect on outcomes of surgical treatment for primary liver cancer. The structured standard operating protocol in a high-volume and highly specialized surgical center can withstand negative effects, a pandemic may have on treatment of patients.

COVID-19 und Lebererkrankungen

Bis zu 53 % der PatientInnen mit Coronavirus Disease 2019 (COVID-19) weisen eine hepatische Beteiligung auf. Durch die Expression der Hauptzielstruktur für „severe acute respiratory syndrome coronavirus type 2“ (SARS-CoV-2), des Angiotensin-converting-Enzym-2(ACE2)-Rezeptors, auch auf Cholangiozyten, sinusoidalen Endothelzellen und Hepatozyten kann es zu einer direkten Schädigung der Leber kommen. Ferner spielt eine indirekte (nicht durch Rezeptoren vermittelte) Schädigung der Leber im Rahmen von COVID-19 durch eine schwere systemische Inflammation mit Zytokinsturm, hepatischen Thrombosen und einer systemischen Hypoxie eine wichtige Rolle. Bei COVID-19 gelten Leberwerte als wichtige Prädiktoren für die Prognose der PatientInnen. Wichtig ist es hierbei Differenzialdiagnosen für die Leberwerterhöhung, wie andere Virusinfektionen, medikamentös-toxisch induzierte Leberschädigung sowie autoimmune, metabolische und andere Lebererkrankungen, abzuklären. Von hoher klinischer Relevanz für die Behandlung kritisch kranker PatientInnen auf der Intensivstation ist das Krankheitsbild der „secondary sclerosing cholangitis in critically ill patients“ (SSC-CIP). Hierfür sind unter anderem hochdosierte Katecholamine, eine Beatmung mit hohem positivem endexspiratorischem Druck (PEEP) und die extrakorporale Membranoxygenierung (ECMO) Risikofaktoren. Eine frühe Diagnose dieser Erkrankung und Behandlung mittels interventioneller endoskopischer retrograder Cholangiographie (ERC) ist hierbei von entscheidender Bedeutung. Auch sollte eine Lebertransplantation evaluiert werden. Bei einer COVID-19-Erkrankung treten Fälle mit SSC, sog. COVID-SSC, auf. Die COVID-SSC und die SSC-CIP sind im klinischen Phänotyp, Risikofaktoren, Prognose und transplantatfreien Überleben vergleichbar. PatientInnen mit vorbestehender Lebererkrankung haben kein erhöhtes Risiko für eine Infektion mit SARS-CoV‑2, erkranken jedoch schwerer an COVID-19 als PatientInnen ohne Lebervorerkrankungen. Bei PatientInnen mit einer vorbestehenden Leberzirrhose kann eine SARS-CoV-2-Infektion ein akut-auf-chronisches Leberversagen (ACLF) induzieren. Hierbei handelt es sich um ein Krankheitsbild mit einer sehr hohen Mortalität, das im Rahmen einer intensivmedizinischen Behandlung therapiert werden muss.

Hepatic manifestations of coronavirus disease 2019 infection: Clinical and laboratory perspective

The novel coronavirus disease 2019 (COVID-19) pandemic, caused by severe acute respiratory syndrome coronavirus 2, has become a global challenge of unprecedented nature since December 2019. Although most patients with COVID-19 exhibit mild clinical manifestations and upper respiratory tract involvement, in approximately 5%-10% of patients, the disease is severe and involves multiple organs, leading to multi-organ dysfunction and failure. The liver and gastrointestinal tract are also frequently involved in COVID-19. In the context of liver involvement in patients with COVID-19, many key aspects need to be addressed in both native and transplanted organs. This review focuses on the clinical presentations and laboratory abnormalities of liver function tests in patients with COVID-19 with no prior liver disease, patients with pre-existing liver diseases and liver transplant recipients. A brief overview of the history of COVID-19 and etiopathogenesis of the liver injury will also be described as a prelude to better understanding the above aspects.

COVID-19 and liver disease

Knowledge on SARS-CoV-2 infection and its resultant COVID-19 in liver diseases has rapidly increased during the pandemic. Hereby, we review COVID-19 liver manifestations and pathophysiological aspects related to SARS-CoV-2 infection in patients without liver disease as well as the impact of COVID-19 in patients with chronic liver disease (CLD), particularly cirrhosis and liver transplantation (LT). SARS-CoV-2 infection has been associated with overt proinflammatory cytokine profile, which probably contributes substantially to the observed early and late liver abnormalities. CLD, particularly decompensated cirrhosis, should be regarded as a risk factor for severe COVID-19 and death. LT was impacted during the pandemic, mainly due to concerns regarding donation and infection in recipients. However, LT did not represent a risk factor per se of worse outcome. Even though scarce, data regarding COVID-19 specific therapy in special populations such as LT recipients seem promising. COVID-19 vaccine-induced immunity seems impaired in CLD and LT recipients, advocating for a revised schedule of vaccine administration in this population.

Outcome of liver cancer patients with SARS-CoV-2 infection: An International, Multicentre, Cohort Study

BACKGROUND & AIMS

Information about the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in patients with liver cancer is lacking. This study characterizes the outcomes and mortality risk in this population.

METHODS

Multicentre retrospective, cross-sectional, international study of liver cancer patients with SARS-CoV-2 infection registered between February and December 2020. Clinical data at SARS-CoV-2 diagnosis and outcomes were registered.

RESULTS

Two hundred fifty patients from 38 centres were included, 218 with hepatocellular carcinoma (HCC) and 32 with intrahepatic cholangiocarcinoma (iCCA). The median age was 66.5 and 64.5 years, and 84.9% and 21.9% had cirrhosis in the HCC and iCCA cohorts respectively. Patients had advanced cancer stage at SARS-CoV-2 diagnosis in 39.0% of the HCC and 71.9% of the iCCA patients. After a median follow-up of 7.20 (IQR: 1.84-11.24) months, 100 (40%) patients have died, 48% of the deaths were SARS-CoV-2-related. Forty (18.4%) HCC patients died within 30-days. The death rate increase was significantly different according to the BCLC stage (6.10% [95% CI 2.24-12.74], 11.76% [95% CI 4.73-22.30], 20.69% [95% CI 11.35-31.96] and 34.52% [95% CI 17.03-52.78] for BCLC 0/A, B, C and D, respectively; p = .0017). The hazard ratio was 1.45 (95% CI 0.49-4.31; p = .5032) in BCLC-B versus 0/A, and 3.13 (95% CI 1.29-7.62; p = .0118) in BCLC-C versus 0/A in the competing risk Cox regression model. Nineteen out of 32 iCCA (59.4%) died, and 12 deaths were related to SARS-CoV-2 infection.

CONCLUSIONS

This is the largest cohort of liver cancer patients infected with SARS-CoV-2. It characterizes the 30-day mortality risk of SARS-CoV-2 infected patients with HCC during this period.

Impact of SARS-CoV-2 Pandemic on the Management of Patients with Hepatocellular Carcinoma

Worldwide, the severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) significantly increases mortality and morbidity. The Coronavirus Disease 2019 (COVID-19) outbreak has had a considerable impact on healthcare systems all around the world, having a significant effect on planned patient activity and established care pathways, in order to meet the difficult task of the global pandemic. Patients with hepatocellular carcinoma (HCC) are considered a particularly susceptible population and conceivably at increased risk for severe COVID-19 because of two combined risk factors: chronic advanced liver disease and HCC itself. In these challenging times, it is mandatory to reshape clinical practice in a prompt way to preserve the highest standards of patient care and safety. However, due to the stay-at-home measures instituted to stop the spread of COVID-19, HCC surveillance has incurred a dramatic drop, and care for HCC patients has been rearranged by refining the algorithm for HCC treatment to the COVID-19 pandemic, permitting these patients to be safely managed by identifying those most at risk of neoplastic disease progression.

COVID-19 and Liver Surgery: How the Pandemic Affected an Italian Medium-Volume HBP Center

INTRODUCTION

While the COVID-19 pandemic is still ongoing, it is even more evident that victims of the pandemic are not only those who contract the virus, but also the countless patients suffering from other serious diseases (i.e., tumor) who have undergone delayed potentially life-saving surgery due to a lack of beds. Like many hospitals, ours also initially blocked all elective oncologic surgery, but these operations were "recovered" and reintegrated in a relatively short time, thanks to the establishment of COVID-free wards and operating rooms with staff dedicated to oncological surgery. In tis context, our aim is to assess whether and how the severe acute respiratory syndrome Coronavirus-2 (SARS-CoV-2) pandemic has impacted our hepatobiliary surgery unit.

METHODS

From our prospective database, we retrospectively took data from patients undergoing liver surgery in 2018-2019 (pre-COVID) and 2020-2021 (COVID period). Patients admitted to COVID-free wards must necessarily have a negative nasal swab from the previous 24 h.

RESULTS

Between January 1, 2018, and December 31, 2019 (Group 1), 101 patients were treated; during the pandemic [January 1, 2020, and December 31, 2021 (Group 2)], 126 patients were treated. There was no statistical difference between the groups. The median postoperative hospital stay was 7 days for both groups; 7 patients had major complications (Clavien-Dindo > 3) in Group 1 and 11 in Group 2 (p = 0.795). A total of 4 patients died in Group 1 and 6 during the pandemic (p = 0.754). Tumor burden was significantly greater in Group 2 where nodule size, lymphadenectomy, and extrahepatic disease were significantly greater (p = 0.011, p = 0.004, and p = 0.026, respectively).

CONCLUSION

During the COVID pandemic, our HPB unit managed to offer a volume of tertiary-center hepatobiliary surgery without a significant impact in terms of length of stay, morbidity, or mortality despite the increase in tumor burden during the pandemic years.

COVID-19 and liver cancer: lost patients and larger tumours

BACKGROUND

Northern England has been experiencing a persistent rise in the number of primary liver cancers, largely driven by an increasing incidence of hepatocellular carcinoma (HCC) secondary to alcohol-related liver disease and non-alcoholic fatty liver disease. Here we review the effect of the COVID-19 pandemic on primary liver cancer services and patients in our region.

OBJECTIVE

To assess the impact of the COVID-19 pandemic on patients with newly diagnosed liver cancer in our region.

DESIGN

We prospectively audited our service for the first year of the pandemic (March 2020-February 2021), comparing mode of presentation, disease stage, treatments and outcomes to a retrospective observational consecutive cohort immediately prepandemic (March 2019-February 2020).

RESULTS

We observed a marked decrease in HCC referrals compared with previous years, falling from 190 confirmed new cases to 120 (37%). Symptomatic became the the most common mode of presentation, with fewer tumours detected by surveillance or incidentally (% surveillance/incidental/symptomatic; 34/42/24 prepandemic vs 27/33/40 in the pandemic, p=0.013). HCC tumour size was larger in the pandemic year (60±4.6 mm vs 48±2.6 mm, p=0.017), with a higher incidence of spontaneous tumour haemorrhage. The number of new cases of intrahepatic cholangiocarcinoma (ICC) fell only slightly, with symptomatic presentation typical. Patients received treatment appropriate for their cancer stage, with waiting times shorter for patients with HCC and unchanged for patients with ICC. Survival was associated with stage both before and during the pandemic. 9% acquired COVID-19 infection.

CONCLUSION

The pandemic-associated reduction in referred patients in our region was attributed to the disruption of routine healthcare. For those referred, treatments and survival were appropriate for their stage at presentation. Non-referred or missing patients are expected to present with more advanced disease, with poorer outcomes. While protective measures are necessary during the pandemic, we recommend routine healthcare services continue, with patients encouraged to engage.

Effect of COVID-19 Pandemic on Hepatocellular Carcinoma Diagnosis: Results from a Tertiary Care Center in North-West Italy

The COVID-19 pandemic has forced us to direct most of the available resources towards its management. This has led to the neglect of all other pathologies, including cancer. The aim of this study was to verify whether the difficulty in accessing the health system has led to a reduction in new diagnoses of hepatocellular carcinoma (HCC) and whether this has already been reflected in a more advanced stage of the cancer. A single-center, retrospective study including adult patients with a new diagnosis of HCC was performed. Patients were divided into three groups: the prelockdown phase (May 2019-February 2020), the lockdown phase (March 2020-December 2020), and the postlockdown phase (January 2021-October 2021); 247 patients were included. The number of patients diagnosed with HCC distinctly diminished in the periods March 2020-December 2020 (n = 69; -35%) and January 2021-October 2021 (n = 72; -32%) as compared to the period May 2019-February 2020 (n = 106). Noteworthy was the reduced surveillance in the period January 2021-October 2021 as compared to May 2019-February 2020 (22.9% vs. 36.6%, p = 0.056). No significant changes have yet been observed in tumor characteristics (BCLC staging distribution remained unvaried, p = 0.665). In conclusion, the number of new HCC diagnoses decreased sharply in the first 2 years of the pandemic, with no worsening of the stage. A more advanced stage of the disease could be expected in the next few years in patients who have escaped diagnosis.