2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Prognostic Significance of Volumetric Parameters on Pretreatment FDG PET/CT in Patients With Hepatocellular Carcinoma Receiving Atezolizumab Plus Bevacizumab Therapy

BACKGROUND

This study aimed to assess prognostic significance of FDG PET/CT parameters in predicting progression-free survival (PFS) and overall survival (OS) in patients with hepatocellular carcinoma (HCC) treated with atezolizumab plus bevacizumab therapy.

PATIENTS AND METHODS

We retrospectively enrolled 78 patients with HCC who underwent FDG PET/CT before atezolizumab plus bevacizumab therapy and identified intrahepatic target tumor lesions on pretreatment imaging studies. From PET/CT images, we measured SUVmax, tumor-to-normal liver uptake ratio, metabolic tumor volume, and total lesion glycolysis (TLG) for intrahepatic tumor lesions, as well as SUVmax for extrahepatic metastatic lesions (extrahepatic SUVmax).

RESULTS

In comparisons of PET/CT parameters, patients with progressive disease demonstrated significantly higher TLG values than those achieving complete or partial response ( P < 0.05). In the multivariate survival analysis, TLG independently predicted both PFS ( P = 0.019) and OS ( P = 0.003). Metabolic tumor volume was significantly associated with OS alone ( P = 0.010), and extrahepatic SUVmax was significantly associated with only PFS ( P = 0.045). Patients with high TLG values experienced poorer PFS and OS than those with low TLG values ( P < 0.05).

CONCLUSIONS

TLG in intrahepatic HCC lesions was significantly associated with treatment response and served as an independent prognostic factor for PFS and OS. TLG could be a potential imaging biomarker for predicting clinical outcomes in patients with HCC receiving atezolizumab plus bevacizumab therapy.

Association between early job loss and prognosis among hepatocellular carcinoma survivors

BACKGROUND

Early job loss after curative treatment for hepatocellular carcinoma (HCC) is associated with significant socioeconomic and health challenges, potentially worsening patient outcomes.

AIMS

To examine the impact of early job loss on all-cause mortality among HCC survivors following curative treatment.

METHODS

We conducted a retrospective cohort study using Korean National Health Insurance Service data on 4578 HCC survivors (aged 35-54) with economic activity treated between 2009 and 2015. Primary and secondary outcomes were all-cause mortality and HCC recurrence, respectively. Early job loss was defined as a shift from insurer to dependent status. Adjusted hazard ratio (HR) and 95% confidence interval (CI) were estimated using multivariable Cox regression models, and subgroup analyses were performed. Causal mediation analysis assessed early HCC recurrence as a mediator between early job loss and all-cause mortality.

RESULTS

Among 4578 patients (median follow-up, 8.3 years), 1189 (26%) died including 989 (25%) in the job-maintained group and 200 (35%) in the early job loss group (P < .001). Early job loss was significantly associated with increased risk of all-cause mortality (adjusted HR 1.52 [95% CI 1.30-1.78]), but not with HCC recurrence (adjusted HR 1.07 [95% CI 0.91-1.25]). Subgroup analyses showed prominent association among middle-income level, non-liver cirrhosis, non-alcoholism, or surgical resection group. Early HCC recurrence plays a significant mediating role on the relationship between early job loss and all-cause mortality (mediated proportion 19%, 95% CI 5-31%).

CONCLUSIONS

Early job loss may increase risk of all-cause mortality among HCC survivors undergoing curative treatment.

Advances in the treatment of hepatocellular carcinoma: An overview of the current and evolving therapeutic landscape for clinicians

Hepatocellular carcinoma (HCC) is the sixth most common malignancy and the third leading cause of cancer-related death worldwide. Contemporary advances in systemic and locoregional therapies have led to changes in peer-reviewed guidelines regarding systemic therapy as well as the possibility of downstaging disease that may enable some patients with advanced disease to ultimately undergo partial hepatectomy or transplantation with curative intent. This review focuses on all modalities of therapy for HCC, guided by modern-day practice-changing randomized data where available. The surgical management of HCC, including resection and transplantation, both of which have evolving criteria for what is considered biologically resectable and transplantable, as well as locoregional therapy (i.e., therapeutic embolization, ablation, radiation, and hepatic arterial infusion), are discussed. Historical and modern-day practice-changing trials evaluating immunotherapy with targeted therapies for advanced disease, as well as adjuvant systemic therapy, are also summarized. In addition, this article examines the critical dimension of toxicities and patient-oriented considerations to ensure a comprehensive and balanced discourse on treatment implications.

Comparative Hepatic Outcomes of SGLT2i or DPP4i Compared to GLP-1RA in CHB and T2DM Patients

BACKGROUND

The prevalence of diabetes is increasing among chronic hepatitis B (CHB) patients. However, the relative efficacy of sodium-glucose cotransporter-2 inhibitors (SGLT2i) or dipeptidyl peptidase-4 inhibitors (DPP4i), compared with glucagon-like peptide-1 receptor agonists (GLP-1RA), among such at-risk populations remains unclear in terms of reducing liver-related events (LRE).

METHODS

Using a nationwide database (2019-2022), we identified CHB patients with diabetes (age ≥ 40) and established two new-user cohorts: SGLT2i vs. GLP-1RA and DPP4i vs. GLP-1RA. LREs included hepatocellular carcinoma, cirrhosis, liver transplantation and liver-related mortality. For appropriate balancing, propensity score matching (PSM) was performed for each cohort. Multivariate Cox regression models were used to estimate LRE risk with adjusted hazard ratios (aHR) and 95% confidence intervals (CI).

RESULTS

Propensity score matching provided two separate cohorts: (1) SGLT2i (n = 2297) vs. GLP-1RA (n = 461) and (2) DPP4i (n = 803) vs. GLP-1RA (n = 165) users. The LREs risk was similar across each comparison, with aHRs of 0.82 (95% CI 0.49-1.37) for GLP-1RA (vs. SGLT2i) and 0.93 (95% CI 0.41-2.07) for GLP-1RA (vs. DPP4i), indicating no significant differences. Subgroup analyses showed a trend favouring GLP-1RA over SGLT2i in females, obese individuals, antiviral therapy (AVT) users, those with diabetes complications, longer diabetes duration and physically active individuals. Compared with DPP4i, the trend was observed in AVT users and those with a shorter diabetes duration, though none were statistically significant.

CONCLUSION

Overall LRE risk was comparable between SGLT2i or DPP4i vs. GLP-1RA users. Further prospective studies are required to identify who can benefit from specific medication.

Male preference for TERT alterations and HBV integration in young-age HBV-related HCC: implications for sex disparity

BACKGROUND/AIMS

Hepatocellular carcinoma (HCC) exhibits significant sex disparities in incidence, yet its molecular mechanisms remain unclear. We explored the role of telomerase reverse transcriptase (TERT) genetic alterations and hepatitis B virus (HBV) integration, both known major contributors to HCC, in sex-specific risk for HBV-related HCC.

METHODS

We examined 310 HBV-related HCC tissues to investigate sex-specific TERT promoter (TERT-pro) mutations and HBV integration profiles, stratified by sex and age, and validated with single-cell RNA sequencing (scRNA-seq) data.

RESULTS

Tumors predominantly exhibited TERT-pro mutations (26.0% vs. 0%) and HBV-TERT integration (37.0% vs. 3.0%) compared to non-tumorous tissues. While TERT-pro mutations increased with age in both sexes, younger males (≤60 years) showed marked predominance compared to younger females. Males had significantly more HBV integrations at younger ages, while females initially had fewer integrations that gradually increased with age. Younger males' integrations showed significantly greater enrichment in the TERT locus compared to younger females, alongside a preference for promoters, PreS/S regions, and CpG islands. Overall, TERT genetic alterations were significantly sex-differential in younger individuals (75.3% in males vs. 23.1% in females) but not in older individuals (76.9% vs. 83.3%, respectively). These alterations were associated with increased TERT expression. The skewed TERT abnormalities in younger males were further corroborated by independent scRNA-seq data.

CONCLUSION

Our findings highlight the critical role of TERT alterations and HBV integration patterns in the male predominance of HCC incidence among younger HBV carriers, offering insights for future exploration to optimize sex-specific patient care and HCC surveillance strategies.

Incorporating ALBI Grade with Geriatric Nutritional Risk Index Enhances Hepatocellular Carcinoma Risk Stratification

Introduction

Despite its prognostic impact, nutritional status has not yet been integrated into the assessment of hepatocellular carcinoma (HCC). This study investigated the association between geriatric nutritional risk index (GNRI) and overall survival (OS) in patients with HCC using a nationwide registry.

Methods

Data from the Korea Central Cancer Registry between 2008 and 2019 were analyzed. We explored the integration of the GNRI with the albumin-bilirubin (ALBI) grade for prognostic stratification. Restricted cubic spline regression was used to assess the association between GNRI and survival, stratified by ALBI grade.

Results

Among the 16,416 treatment-naïve HCC patients, the ALBI grades were distributed as follows: grade 1, 7,409; grade 2, 7,445; and grade 3, 1,562. Patients were categorized according to Barcelona Clinic Liver Cancer (BCLC) stages: 5,132 stage 0/A, 2,608 stage B, 5,289 stage C, and 968 stage D. The median OS for all patients was 3.1 years (95% CI: 3.0-3.2) and significantly differed with the inclusion of ALBI grade and GNRI (p < 0.001). The effect of combining ALBI grade and GNRI was further evaluated for each BCLC stage. This risk stratification showed a significant correlation with OS for each BCLC stage (all p < 0.001), except for stage D (p = 0.082). Multivariate analysis revealed that a combination of favorable ALBI grade and high GNRI score was independently associated with decreased mortality risk.

Conclusion

The GNRI was significantly correlated with OS across ALBI grades and BCLC stages. Integrating the GNRI into the ALBI grade may enhance risk stratification for patients with HCC.

A Machine Learning Model to Predict De Novo Hepatocellular Carcinoma Beyond Year 5 of Antiviral Therapy in Patients With Chronic Hepatitis B

BACKGROUND AND AIMS

This study aims to develop and validate a machine learning (ML) model predicting hepatocellular carcinoma (HCC) in chronic hepatitis B (CHB) patients after the first 5 years of entecavir (ETV) or tenofovir (TFV) therapy.

METHODS

CHB patients treated with ETV/TFV for > 5 years and not diagnosed with HCC during the first 5 years of therapy were selected from two hospitals. We used 36 variables, including baseline characteristics (age, sex, cirrhosis, and type of antiviral agent) and laboratory values (at baseline, at 5 years, and changes between 5 years) for model development. Five machine learning algorithms were applied to the training dataset and internally validated using a test dataset. External validation was performed.

RESULTS

In years 5-15, a total of 279/5908 (4.7%) and 25/562 (4.5%) patients developed HCC in the derivation and external validation cohorts, respectively. In the training dataset (n = 4726), logistic regression showed the highest area under the receiver operating curve (AUC) of 0.803 and a balanced accuracy of 0.735, outperforming other ML algorithms. An ensemble model combining logistic regression and random forest performed best (AUC, 0.811 and balanced accuracy, 0.754). The results from the test dataset (n = 1182) verified the good performance of the ensemble model (AUC, 0.784 and balanced accuracy, 0.712). External validation confirmed the predictive accuracy of our ensemble model (AUC, 0.862 and balanced accuracy, 0.771). A web-based calculator was developed (http://ai-wm.khu.ac.kr/HCC/).

CONCLUSIONS

The proposed ML model excellently predicted HCC risk beyond year 5 of ETV/TFV therapy and, therefore, could facilitate individualised HCC surveillance based on risk stratification.

Proton beam therapy in the management of hepatocellular carcinoma

INTRODUCTION

Hepatocellular carcinoma (HCC) is the most common form of primary liver cancer. Photon radiotherapy shows efficacy in treating HCC but carries risks of high exit dose and radiation-induced liver disease. Additionally, HCCs with portal vein tumor thrombosis (PVTT) have a poor prognosis and are associated with higher risk of death. In recent years, proton beam therapy (PBT) has emerged as a novel treatment with the ability to downstage HCC for liver transplant (LT).

AREAS COVERED

This review will provide an overview of dosimetric benefits of PBT, efficacy of PBT in treating HCC, downstaging HCC-PVTT for LT, and a comparison of PBT with other non-surgical techniques. A search of PubMed until 3 September 2024 was conducted using free search and the following keywords: hepatocellular carcinoma, proton beam therapy, portal vein tumor thrombosis, local ablative therapy, trans-arterial chemoembolization, stereotactic body radiotherapy, Y-90 radioembolization.

EXPERT OPINION

Various clinical trials using PBT have shown promising tumor local control and overall survival rates. PBT is mostly safe and efficacious for downstaging HCC-PVTT for LT. PBT has also been shown to be non-inferior to various other treatment modalities. Future research should focus on combinations of PBT with other modalities.

A Risk Prediction Model for Hepatocellular Carcinoma in the General Population Without Traditional Risk Factors for Liver Disease

BACKGROUND AND AIM

Existing hepatocellular carcinoma (HCC) prediction models for the general population without traditional risk factors for chronic liver disease are limited. This study aimed to develop an HCC prediction model for individuals lacking these traditional risk factors.

METHODS

The total of 138 452 adult participants without chronic viral hepatitis or significant alcohol intake who underwent regular health checkup at a tertiary hospital in South Korea were followed up for the development of HCC. Risk factors for HCC development were analyzed using Cox regression analysis, and prediction model was developed using the risk factors.

RESULTS

Significant predictors of HCC development included older age, male sex, higher body mass index, presence of diabetes mellitus, and levels of aspartate aminotransferase, total cholesterol, and platelet count. A new HCC prediction model using these variables was developed. Harrell's concordance index and Heagerty's integrated area under the receiver operating characteristics (AUROC) curve of the model were 0.88 (95% confidence interval [CI] 0.85-0.91) and 0.89 (95% CI 0.86-0.91), respectively. The 5- and 10-year AUROC were 0.89 (95% CI 0.88-0.89) and 0.87 (95% CI 0.87-0.88), respectively. This model significantly outperformed the FIB-4 scoring model in predicting HCC and effectively stratified individuals into low-, intermediate-, and high-risk groups with significantly different cumulative incidences of HCC.

CONCLUSIONS

The new model, based on clinical parameters, provides a valuable tool for clinicians to stratify HCC risk in the general population without risk factors for chronic liver disease.

The inhibition of endothelial DLL4-NOTCH1 signaling by 2'-hydroxyflavanone enhances anti-PD-1 therapy in melanoma

Immune checkpoint inhibitors (ICIs) have revolutionized cancer therapeutics; however limited patient responses necessitate combination strategies to improve therapeutic efficacy. Among potential combination partners, drugs targeting DLL4-NOTCH1 signaling pathway-a critical regulator of vascular function-show promise as angiogenesis modulators, but their clinical development have been hindered by safety concerns. To address this challenge, we adopted a novel approach by screening natural compounds with a long history of human consumption. Building upon our earlier findings, we identified three inhibitors of DLL4-NOTCH1 signaling: steppogenin, sanggenon F, and dehydrovomifoliol. Steppogenin inhibited both DLL4 and NOTCH1 activities, while sanggenon F and dehydrovomifoliol selectively suppressed DLL4 and NOTCH1 activity, respectively. We assessed their impact on key angiogenic processes, including endothelial cell migration, sprouting, and proliferation, and elucidated the relative contributions of selective DLL4 or NOTCH1 inhibition to the anti-angiogenic effect. By comparing structurally similar compounds, we identified the 2'-hydroxyflavanone moiety as a key element for DLL4 inhibition. Notably, combining steppogenin with an ICI demonstrated that a nature-derived angiogenesis inhibitor can boost the anti-cancer effect of ICI in a mouse melanoma allograft model. This comprehensive analysis of structure-activity relationships and in vivo therapeutic evaluation provides valuable insights into the development of novel anti-angiogenic compounds for combination therapy with ICIs in cancer treatment.

Recent advances and issues in imaging modalities for hepatocellular carcinoma surveillance

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide. Early detection via surveillance plays a crucial role in enabling curative treatment and improving survival rates. Since the initial randomized controlled trial, biannual ultrasound (US) has been established as the standard surveillance method because of its accessibility, safety, and low cost. However, US has some limitations, including operator dependency, suboptimal sensitivity for early-stage HCC, and challenges such as a limited sonic window that may result in inadequate examination. Alternative imaging modalities, including contrast-enhanced computed tomography (CT) and magnetic resonance imaging (MRI), have demonstrated higher sensitivity for detecting very early-stage HCC. Recent advancements, such as low-dose CT with deep learning-based reconstruction, have enhanced the safety and feasibility of CT-based surveillance by reducing radiation exposure and amount of contrast media. MRI, particularly with gadoxetic acid or abbreviated protocols, offers superior tissue contrast and sensitivity, although its accessibility and cost remain challenges. Tailored surveillance strategies based on individual risk profiles and integration of advanced imaging technologies have the potential to enhance the detection performance and cost-effectiveness. This review highlights the recent developments in imaging technologies for HCC surveillance, focusing on their respective strengths and limitations.

Management of hepatocellular carcinoma in elderly and adolescent/young adult populations

Hepatocellular carcinoma (HCC) presents unique challenges in both the elderly and adolescent/young adult (AYA) populations, requiring distinct management approaches. Recent epidemiological data show an increasing incidence of HCC in both age groups, with elderly cases rising significantly and AYA cases showing trends in specific regions. The clinical characteristics and treatment considerations vary substantially among these populations. Elderly patients with HCC typically present with hepatitis C virus infection, metabolic dysfunction-associated steatotic liver disease, well-differentiated tumors, and multiple comorbidities. In contrast, AYA patients with HCC often present with more aggressive tumor characteristics and predominantly with hepatitis B virus-related diseases. Treatment decisions for elderly patients with HCC require careful consideration of physiological reserves, comprehensive geriatric assessments, and potential complications. Recent studies have demonstrated that elderly patients can achieve outcomes comparable to younger patients across various treatment modalities when properly selected. While surgical outcomes are comparable to those of younger patients with proper selection, less-invasive options such as radiofrequency ablation or transarterial therapies may be more appropriate for some elderly patients. The treatment approach for AYA HCC emphasizes curative intent while considering long-term effects. AYA patients require specialized attention to their psychosocial needs, fertility preservation, and long-term health maintenance. Although data on AYA patients remain limited, they are known to have relatively favorable prognoses despite exhibiting more aggressive tumor characteristics. Management of HCC in both the elderly and AYA populations requires individualized approaches that consider age-specific factors. Both groups benefit from multidisciplinary team involvement and careful consideration of quality of life.

Hepatocellular carcinoma in Korea: an analysis of the 2016-2018 Korean Nationwide Cancer Registry

BACKGROUNDS/AIMS

Hepatocellular carcinoma (HCC) is the sixth most common cancer and second leading cause of cancer-related deaths in South Korea. This study evaluated the characteristics of Korean patients newly diagnosed with HCC in 2016-2018.

METHODS

Data from the Korean Primary Liver Cancer Registry (KPLCR), a representative database of patients newly diagnosed with HCC in South Korea, were analyzed. This study investigated 4,462 patients with HCC registered in the KPLCR in 2016-2018.

RESULTS

The median patient age was 63 years (interquartile range, 55-72). 79.7% of patients were male. Hepatitis B infection was the most common underlying liver disease (54.5%). The Barcelona Clinic Liver Cancer (BCLC) staging system classified patients as follows: stage 0 (14.9%), A (28.8%), B (7.5%), C (39.0%), and D (9.8%). The median overall survival was 3.72 years (95% confidence interval, 3.47-4.14), with 1-, 3-, and 5-year overall survival rates of 71.3%, 54.1%, and 44.3%, respectively. In 2016-2018, there was a significant shift toward BCLC stage 0-A and Child-Turcotte-Pugh liver function class A (P<0.05), although survival rates did not differ by diagnosis year. In the treatment group (n=4,389), the most common initial treatments were transarterial therapy (31.7%), surgical resection (24.9%), best supportive care (18.9%), and local ablation therapy (10.5%).

CONCLUSIONS

Between 2016 and 2018, HCC tended to be diagnosed at earlier stages, with better liver function in later years. However, since approximately half of the patients remained diagnosed at an advanced stage, more rigorous and optimized HCC screening strategies should be implemented.

Synergistic effects of L-arginine and argininosuccinate synthetase 1 in inducing apoptosis in hepatocellular carcinoma

BACKGROUNDS/AIMS

Hepatocellular carcinoma (HCC) is a malignant cancer with an increasing incidence worldwide. Although numerous efforts have been made to identify effective therapies for HCC, current strategies have limitations. We present a new approach for targeting L-arginine and argininosuccinate synthetase 1 (ASS1).

METHODS

ASS1 expression in HCC cell lines and primary hepatocytes was detected using polymerase chain reaction and western blotting. Proliferation, migration, signaling pathways, and nitric oxide production in HCC cell lines were measured using MTS, colony formation, wound healing, Western blot, and Griess assays.

RESULTS

ASS1 expression varied among the HCC cell lines, and cisplatin cytotoxicity was ASS1-dependent. L-arginine alone induced apoptosis in HCC cell lines, regardless of ASS1 expression; however, its effect was enhanced in ASS1-expressing HCC cell lines. Cisplatin cytotoxicity also increased, suggesting that L-arginine acts as a sensitizer to cisplatin in HCC cell lines. ASS1 and L-arginine produced nitric oxide and inhibited key proliferation- and survival-related signaling pathways such as PI3K/Akt and MAPK. Additionally, ASS1 and L-arginine reduced the expression of PKM1 and PKM2 in the glycolysis pathway.

CONCLUSIONS

Our study revealed that ASS1 and L-arginine exhibited anticancer effects in HCC and sensitized cisplatin-resistant HCC cells to chemotherapy. The combination of ASS1 and L-arginine significantly enhanced the anticancer effects, even in HCC cell lines with low or absent ASS1 expression. These findings highlight the critical roles of arginine and ASS1 in HCC and suggest that increasing arginine availability could be a promising therapeutic strategy.

Development and Validation of a Prediction Model for Cardiac Events in Patients With Hepatocellular Carcinoma Undergoing Stereotactic Body Radiation Therapy

PURPOSE

To develop and validate a prediction model for major adverse cardiac events (MACEs) in hepatocellular carcinoma patients treated with stereotactic body radiation therapy (SBRT).

METHODS AND MATERIALS

We retrospectively identified 1893 hepatocellular carcinoma patients who received SBRT at 2 institutions, with one serving as the development cohort (n = 1473) and the other as the validation cohort (n = 420). A MACE was defined as any cardiac event classified as grade 3 or higher according to the Common Terminology Criteria for Adverse Events, version 5.0. We evaluated 15 clinical and 88 dosimetric parameters using bootstrapped forward selection and area under the curve (AUC) to identify significant predictors for MACEs. Based on these factors, we constructed the Cardiac Event Index (CEI) model, categorizing patients into distinct risk groups. Model performance was assessed for discrimination, efficiency, and calibration.

RESULTS

The MACE occurrence rate was 5.8% in the development cohort and 6.7% in the validation cohort. Five parameters were selected for predicting MACEs and were incorporated into the CEI model using the following equation: CEI = age score + hypertension + current smoking + (2 × history of cardiac disease) + (0.05 × heart-V5 [%]), which yielded an AUC of 0.770 for MACEs and 0.750 for coronary artery disease. The CEI model stratified patients into low-, intermediate-, and high-risk groups that had MACE incidence rates of 0.4%, 4.9%, and 22.8%, respectively. The impact of heart-V5 on MACEs was minimal in low- and intermediate-risk groups but pronounced in the high-risk group. In the validation cohort, the CEI model yielded an AUC of 0.809 for MACEs and 0.793 for coronary artery disease.

CONCLUSIONS

The CEI model demonstrated robust performance in predicting MACEs, revealing the significant influence of clinical factors and the minimal impact of SBRT. This model can inform evidence-based decisions regarding cardiac dose optimization in SBRT planning.

Validation of an albumin-indocyanine green-based China liver cancer staging system to evaluating resectable hepatocellular carcinoma patients and comparison with the Child-Pugh-based China liver cancer staging system

Aim

Here, the utility of an albumin-indocyanine green-based China liver cancer (CNLC) staging system (ALICE-CNLC) as a tool for the prognostic assessment of hepatocellular carcinoma (HCC) patients was evaluated, comparing this system to the Child-Pugh score-based CNLC staging system.

Methods

The cohort for this study included 331 patients with HCC who had undergone hepatectomy at Jinhua Municipal Central Hospital Medical Group in China from April 2012-June 2021 and had postoperative pathology-confirmed HCC. Kaplan-Meier survival curves were generated, with log-rank tests used to examine prognostic factors. Univariate and multivariate analyses were used for identification of outcome predictors using Cox proportional hazards regression.

Results

The prediction of overall survival (OS) by the ALICE-CNLC system for patients with stage Ia disease was markedly better than that for patients with stage Ib and IIa disease (P=0.010, P=0.026), while the latter groups did not differ significantly (P=0.796). The ALICE-CNLC system predicted the 3-year recurrence-free survival (RFS) rates for patients with stage Ia, Ib, and IIa disease to be 50.4%, 47.7%, and 25%, respectively, with significant differences among the groups (P=0.033, P<0.001, and P=0.043). These results were similar to those of the CNLC staging system.The OS and RFS did not differ significantly between the same grades of patients evaluated with the ALICE-CNLC and CNLC staging systems.

Conclusion

The ALICE-CNLC and CNLC staging systems did not show significant differences in predicting the prognosis of patients with HCC who have undergone hepatectomy.

Hepatic artery infusion chemotherapy: A resurgence

In this manuscript, we comment on the article by Zhou et al, who assessed the efficacy of hepatic arterial infusion chemotherapy (HAIC) and its combination strategies for advanced hepatocellular carcinoma (HCC) using network meta-analysis methodology. We focus specifically on the potential advantages and role of HAIC in the treatment algorithm for advanced HCC. However, there remains numerous knowledge gaps before the role of HAIC can be established. There is significant heterogeneity of HAIC regimes with difficult interpretation of the clinical outcomes. Additionally, there is a lack of direct comparative data between HAIC, systemic chemotherapy, novel immunotherapies and targeted therapies. The underlying biochemical mechanisms that might explain the efficacy of HAIC and its effect on the HCC microenvironment requires further research. In the developing era of nanotechnology and targeted drug delivery systems, there is potential for integration of HAIC with novel technologies to effectively treat advanced HCC whilst minimising systemic complications.

Comparison of hepatocellular carcinoma incidence after long-term treatment with besifovir vs. tenofovir AF

Besifovir dipivoxil maleate (BSV) is a novel antiviral agent widely used in South Korea for treating chronic hepatitis B (CHB). This study aimed to compare the incidence of hepatocellular carcinoma (HCC) following long-term use of BSV versus tenofovir alafenamide fumarate (TAF), utilizing large-scale national data. A total of 41,949 patients were analyzed, with propensity score matching (PSM) yielding 2,239 BSV and 6,717 TAF patients. The HCC incidence rate per 1,000 person-years was 1.8 for BSV versus 2.4 for TAF before matching (P = 0.057) and 1.6 versus 2.2 after matching (P = 0.284). Multivariate Cox regression identified age, male sex, antiviral duration, Charlson Comorbidity Index (CCI) score, and decompensated cirrhosis as significant risk factors for HCC, while antiviral type was not (HR 1.12, P = 0.413). Subgroup analyses showed no significant differences in HCC incidence between BSV and TAF in cirrhotic or non-cirrhotic patients. These findings suggest that BSV offers comparable efficacy to TAF in preventing HCC and is a promising option for CHB management. Longer-term studies with larger cohorts are necessary to confirm these results and assess the full impact of BSV on HCC prevention.

Serum Ferritin Levels and Liver-Related Events in Individuals With Steatotic Liver Disease: A Longitudinal Cohort Study

BACKGROUND

Serum ferritin has been suggested as a potential biomarker associated with disease progression in metabolic dysfunction-associated steatotic liver disease (MASLD).

AIMS

We investigated the association between serum ferritin levels and liver-related events (LREs) in individuals with steatotic liver disease (SLD).

METHODS

This cohort study included 17,560 adults with SLD (MASLD [n = 15,744], MASLD with increased alcohol intake (MetALD) [n = 1103] and cryptogenic SLD [n = 713]) without LRE at baseline. A steatotic liver was diagnosed using ultrasound, and LRE was defined as the development of decompensation (ascites, variceal bleeding and hepatic encephalopathy) or hepatocellular carcinoma. Participants were categorised into high (≥ 300 μg/L for males, ≥ 200 μg/L for females) or normal to low (< 300 μg/L for males, < 200 μg/L for females) ferritin levels.

RESULTS

During 211,425 person-years of follow-up (median: 12.3 years), 74 incident LRE cases were identified, with 63 cases in MASLD, 10 in MetALD and 1 in cryptogenic SLD. The multivariable-adjusted hazard ratio (aHR) for LRE comparing individuals with high and normal-to-low ferritin level was 3.13 (95% confidence interval [CI] 1.89-5.18). Increased risk of LRE in individuals with high serum ferritin level compared to those with normal to low serum ferritin level was consistent across SLD subtypes (aHR 2.69, 95% CI 1.55-4.67 for MASLD; aHR 5.73, 95% CI 1.31-25.0 for MetALD), and SLD severity assessed by Fibrosis-4 (FIB-4) index (aHR 2.38, 95% CI 1.34-4.21 for FIB-4 ≥ 1.3; aHR 3.13, 95% CI 1.18-8.29 for FIB-4 < 1.3).

CONCLUSIONS

Serum ferritin levels correlated with the risk of LRE in patients with SLD.

Comparison of Metastasectomy and Stereotactic Body Radiation Therapy for Pulmonary Oligometastasis From Hepatocellular Carcinoma: A Propensity Score-Weighted Analysis

PURPOSE

Although there is a growing role for local therapy in patients with hepatocellular carcinoma (HCC) and pulmonary oligometastasis, it remains unclear whether metastatectomy or stereotactic body radiation therapy (SBRT) is the more effective treatment for these patients. We aimed to compare the oncologic outcomes of metastasectomy and SBRT for HCC with pulmonary oligometastasis.

METHODS AND MATERIALS

We retrospectively analyzed 209 patients with HCC with 322 metastatic lung lesions who underwent either metastasectomy (150 patients with 241 lesions) or SBRT (59 patients with 81 lesions) between January 2008 and December 2018. Propensity score-based inverse probability of treatment weighting was used to minimize potential bias between the 2 groups.

RESULTS

The median follow-up duration was 39.8 months (range, 2.3-166.9 months). The 2-year rate of freedom from local progression was 98.2% in the metastasectomy group and 97.0% in the SBRT group (P = .197). The 2-year rates of overt systemic progression-free survival (PFS) (51.0% vs 46.1%; P = .274), PFS (26.3% vs 9.1%; P = .074), and overall survival (OS, 74.0% vs 57.6%; P = .006) were higher in the metastasectomy group. After the probability of treatment weighting adjustment, the 2-year rates of overt systemic PFS (50.8% vs 52.7%; P = .396), PFS (23.0% vs 24.7%; P = .478), and OS (72.6% vs 83.0%, P = .428) were not significantly different between the 2 groups. In multivariate analysis, viable intrahepatic lesions and the number of prior liver-directed therapies were found to be significant prognostic factors for OS and PFS. The time interval between HCC diagnosis and the development of pulmonary metastases was also significantly associated with OS.

CONCLUSIONS

Both metastasectomy and SBRT demonstrated excellent local control and comparable oncologic outcomes in patients with pulmonary oligometastasis from HCC. The treatment modality for these patients could be determined based on the individual patient's condition and intrahepatic disease status.

Lower incidence of hepatocellular carcinoma with tenofovir alafenamide in chronic hepatitis B: Evidence from a large-scale cohort

Background & Aims

Tenofovir alafenamide (TAF) lacks extensive research regarding its impact on hepatocellular carcinoma (HCC). This study evaluated and compared the effects of TAF, tenofovir disoproxil fumarate (TDF), and entecavir (ETV) on HCC incidence using nationwide claim data.

Methods

In total, 75,816 patients with treatment-naïve HBV were included in the study and divided into TAF (n = 25,680), TDF (n = 26,954), and ETV (n = 23,182) groups after exclusions. Propensity score matching (1:1:1) resulted in 17,537 patients per group. HCC incidence rates were compared among the groups.

Results

Before matching, the incidence of HCC was significantly lower in the TAF group compared with the TDF and ETV groups (11.47 vs. 15.04 and 14.24 per 1,000 person-years). The incidence rate ratio (IRR) for TDF was 1.31 (1.19-1.44) and for ETV was 1.24 (1.12-1.37). Before matching, the TAF group had a significantly lower HCC compared with TDF and ETV in both patients with and without cirrhosis. After matching, the TAF group had a lower HCC incidence compared with the TDF group (12.38 vs. 15.39, IRR 1.24, p <0.001) but not with ETV group (IRR 1.08, p = 0.219). In patients with cirrhosis, TAF had lower HCC incidence compared with TDF and ETV (30.25 vs. 39.56 and 38.51, respectively). In patients without cirrhosis, the TAF group had a lower HCC incidence compared with the TDF group (IRR 1.19, p = 0.030) but not the ETV group (IRR 0.85, p = 0.066). Cox regression analysis showed that the TAF group had a significantly lower HCC incidence compared with the TDF (hazard ratio 1.335, p <0.001) and ETV groups (hazard ratio 1.162, p = 0.011), after adjusting for age, gender, and cirrhosis status.

Conclusions

The TAF group consistently demonstrated a lower incidence of HCC compared with the TDF and ETV groups, especially in patients with cirrhosis.

Impact and implications

This work aimed to fill the knowledge gap regarding the comparative efficacy of tenofovir alafenamide (TAF), tenofovir disoproxil fumarate (TDF), and entecavir (ETV) in reducing the incidence of hepatocellular carcinoma (HCC) in patients with chronic HBV. The results are particularly crucial for healthcare providers and policymakers, because they highlight the significantly lower incidence of HCC associated with TAF, especially in patients with cirrhosis. These results suggest TAF as a preferable antiviral therapy option to mitigate HCC risk, thus influencing clinical decision-making and healthcare guidelines. From a practical perspective, these findings can guide physicians in prescribing more effective treatments, assist researchers in designing further studies to explore the mechanisms behind the effectiveness of TAF, and inform policymakers to craft healthcare policies that optimize patient outcomes while considering potential limitations, such as the observational nature of the study and residual confounding factors.

Tenofovir Disoproxil Fumarate Versus Entecavir: Effects on Lipid Profiles and Cardiovascular Outcomes in People Living With Chronic Hepatitis B

While entecavir (ETV) and tenofovir disoproxil fumarate (TDF) effectively manage chronic hepatitis B, their long-term effects on lipid metabolism and cardiovascular outcomes remain unclear. This study compares the impact of ETV, TDF, and treatment-naïve (control group) on hyperlipidemia and major adverse cardiac events (MACE) in people living with chronic hepatitis B (PLWHB). We used claim data from the South Korean National Health Insurance Service. Propensity score matching was used to account for confounding factors. The 5-year cumulative incidence of dyslipidemia was 7.10% for TDF, 12.17% for ETV, and 18.55% for the control group, with incidence rates per 1000 person-years of 14.5, 25.5, and 38.9, respectively. TDF showed a significantly lower risk of dyslipidemia compared to ETV (IRR: 0.56, p < 0.001) and the control group, which was confirmed in Cox regression analysis (HR: 0.392 vs. control, p < 0.001). For MACE, the 5-year cumulative incidence was 9.11% for TDF, 10.98% for ETV, and 12.32% for the control group, with incidence rates per 1000 person-years of 18.4, 22.5, and 24.8, respectively. TDF demonstrated a reduced risk compared to ETV (IRR: 0.817, p < 0.001), which was similarly supported by Cox regression analysis (HR: 0.728 vs. control, p < 0.001). In conclusion, TDF not only reduces the risk of hyperlipidemia but is also associated with a reduced risk of MACE compared to ETV or treatment-naive group in PLWHB.

Stereotactic body radiotherapy alone versus stereotactic body radiotherapy after incomplete transarterial therapy for hepatocellular carcinoma

INTRODUCTION

We investigated the clinical outcomes of stereotactic body radiation therapy (SBRT) alone versus SBRT after incomplete transarterial chemoembolization (TACE) for a single recurrent hepatocellular carcinoma (HCC) smaller than 5 cm.

METHODS

We retrospectively reviewed the medical records of patients who underwent SBRT for a single recurrent HCC ≤5 cm, without vascular invasion or extrahepatic metastasis. Patients were divided into the SBRT-alone group and the TACE-SBRT group. The primary outcome was the local control (LC) rate, and secondary outcomes were survivals and treatment-related toxicities. We additionally conducted a propensity score matching (PSM) analysis.

RESULTS

A total of 477 patients were available for analysis. Among them, 54 patients received SBRT without prior treatment to the target lesion (SBRT-alone group), whereas 423 patients received SBRT for viable HCC after TACE (TACE-SBRT group). The 3-year LC rates did not differ between the two groups (SBRT-alone group, 88.6% vs. TACE-SBRT group, 89.6%, P = 0.918). The 3-year rates of overall survival, out-of-field intrahepatic recurrence-free survival and recurrence-free survival were also not significantly different (P = 0.479, 0.290 and 0.273, respectively). Even after PSM, LC and survival rates at 3 years were not significantly different.

CONCLUSION

SBRT alone demonstrated comparable local control and survival outcomes to SBRT following incomplete TACE. SBRT alone may be considered an alternative treatment option for a single recurrent HCC smaller than 5 cm when curative treatments or TACE are not feasible.

Multicenter, retrospective GUIDANCE001 study comparing transarterial chemoembolization with or without tyrosine kinase and immune checkpoint inhibitors as conversion therapy to treat unresectable hepatocellular carcinoma: Survival benefit in intermediate or advanced, but not early, stages

BACKGROUND AND AIMS

Various conversion therapy options have become available to patients with unresectable HCC, but which conversion therapy is optimal for which type of patient is controversial. This study compared the efficacy and safety of TACE alone or combined with immune checkpoint and tyrosine kinase inhibitors.

APPROACH AND RESULTS

Data were retrospectively compared for patients with initially unresectable HCC who underwent conversion therapy consisting of TACE alone (n=459) or combined with immune checkpoint and tyrosine kinase inhibitors (n=343). Compared to the group that received TACE alone, the group that received triple conversion therapy showed significantly higher rates of overall survival (HR 0.43, 95%CI 0.35-0.53). In addition, triple therapy was associated with significantly longer median progression-free survival (15.9 vs. 8.0 mo, p <0.001). These results were confirmed in matched subsets of patients from each group. However, subgroup analysis confirmed the results only for patients with HCC in intermediate or advanced stages, not in an early stage. Those who received triple conversion therapy had a significantly higher rate of hepatectomy after conversion therapy (36.4 vs. 23.5%, p <0.001). Among those who underwent hepatectomy after conversion therapy, triple therapy was associated with a significantly higher rate of complete tumor response (32.1 vs. 11.1%, p <0.001). However, it was also associated with a significantly higher frequency of serious adverse events (35.6 vs. 27.0%, p =0.009).

CONCLUSIONS

Combining TACE with immune checkpoint and tyrosine kinase inhibitors was associated with significantly better survival and conversion efficacy than TACE alone among patients with intermediate or advanced unresectable HCC.

Nomogram for predicting early cancer-related death due to recurrence after liver resection in hepatocellular carcinoma patients with Barcelona Clinic Liver Cancer (BCLC) stage B/C: a multicenter study

BACKGROUND

Early identification of the risk of early cancer-related death (within one year, ECRD) due to recurrence after liver resection for hepatocellular carcinoma (HCC) patients with Barcelona Clinic Liver Cancer (BCLC) stage B/C is important for surgeons to make clinical decisions. Our study aimed to establish a nomogram to predict the ECRD due to recurrence for HCC patients with BCLC stage B/C.

METHODS

A total of 672 HCC patients with BCLC stages B/C from four medical centers between January 2012 and December 2018 were included in our study. The patients were randomly divided into a training cohort (n = 404) and a validation cohort (n = 268) at a ratio of 6:4. The least absolute shrinkage and selection operator (LASSO) logistic regression model was used to establish a nomogram model.

RESULTS

In our LASSO-logistic regression model, three variables were independently associated with the ECRD due to recurrence: the alpha-fetoprotein-tumor burden score (ATS score, Odd Ratio [OR]: 1.12, p = 0.001), BCLC stage (OR: 4.39, p < 0.001) and the aspartate transaminase (AST) to alanine transaminase (ALT) ratio (AAR, OR: 1.49, p = 0.027) and we established the nomogram model based on these three variables. The nomogram model showed superior predictive ability in the training cohort (Area under the curve [AUC]: 0.754, 95%CI: 0.703-0.804) and the validation cohort (AUC: 0.741, 95%CI: 0.660-0.823). Compared with the ATS score, BCLC stage and AAR, the nomogram both had better predictive ability in both the training cohort (ATS score, AUC: 0.699, 95%CI: 0.646-0.752, p = 0.010; BCLC stage, AUC: AUC: 0.684, 95%CI: 0.637-0.732, p < 0.001; AAR, AUC: 0.593, 95%CI: 0.522-0.663, p < 0.001) and the validation cohort (ATS score, AUC: 0.659, 95%CI: 0.577-0.740, p = 0.002; BCLC stage, AUC: 0.688, 95%CI: 0.622-0.753, p = 0.009; AAR, AUC: 0.540, 95%CI: 0.436-0.645, p < 0.001).

CONCLUSIONS

We established a nomogram that had excellent predictive power for predicting the ECRD due to recurrence in HCC patients with BCLC stage B/C, which might help surgeons to avoid futile liver resection.

A comprehensive study on the feasibility and diagnostic potential of fluctuation imaging in liver tumor assessment

Ultrasound (US) is a widely used technique for liver disease but has limitations in distinguishing tumors. This study evaluates the clinical efficacy of fluctuational imaging (FLI), a new US method that detects the fluttering sign in liver tumors. We conducted a prospective exploratory study with 120 participants diagnosed with liver tumors through histopathology or standard imaging. Both FLI and US were performed, capturing approximately 100 image frames within a 10-second breath-hold to create a color-coded FLI map. The fluttering sign, shown by yellow to red area in tumors, was primarily analyzed in the largest tumor in cases with multiple tumors. Eleven participants were excluded due to non-visibility of tumor in B-mode US (n = 3), not a hepatic tumor (n = 1) or motion artifact affecting FLI map creation (n = 7). The final cohort comprised 70 hemangiomas, 17 hepatocellular carcinomas, 7 cholangiocarcinomas, 11 metastases, 3 angiomyolipomas, and 1 cortical adenoma. The fluttering sign was observed in 57.1% (40/70) of hemangiomas, significantly higher than the 12.8% (5/39) in other tumor types (P < 0.001). Mixed or hypoechoic hemangiomas showed an 86.1% incidence (31/38) of the fluttering sign, significantly more than hyperechoic hemangiomas (28.1%, 9/32) (P < 0.001). FLI significantly detects the fluttering sign in hepatic hemangiomas, especially mixed or hypoechoic types, enhancing its diagnostic value.

Evolution of Liver Resection for Hepatocellular Carcinoma: Change Point Analysis of Textbook Outcome over Twenty Years

Background and Objectives: The aim of this study was to comprehensively analyze the evolution in textbook outcome (TO) achievement after liver resection for hepatocellular carcinoma (HCC) over two decades at a single tertiary referral center. Materials and Methods: All consecutive liver resections for HCC at Seoul National University Bundang Hospital from 2003 to 2022 were analyzed. The included 1334 patients were divided into four groups by time intervals identified through change point analysis. TO was defined as no intraoperative transfusions, positive margins, major complications, 30-day readmission or mortality, and prolonged length of hospital stay (LOS). Results: Multiple change point analysis identified three change points (2006, 2012, 2017), and patients were divided into four groups. More recent time interval groups were associated with older age (59 vs. 59 vs. 61 vs. 63 years, p < 0.0001) and more comorbidities. Minimally invasive procedures were increasingly performed (open/laparoscopic/robotic 37.0%/63.0%/0%) vs. 43.8%/56.2%/0% vs. 17.1%/82.4%/0.5% vs. 22.9%/75.9%/1.2%, p < 0.0001). TO achievement improved over time (1.9% vs. 18.5% vs. 47.7% vs. 62.5%, p < 0.0001), and LOS was the greatest limiting factor. Conclusions: TO after liver resection improved with advances in minimally invasive techniques and parenchymal sparing procedures, even in older patients with more comorbidities and advanced tumors.

Risk of Bleeding in Hepatocellular Carcinoma Patients Treated with Atezolizumab/Bevacizumab: A Systematic Review and Meta-Analysis

Introduction

The combination of atezolizumab/bevacizumab has emerged as an effective first-line treatment for advanced hepatocellular carcinoma (HCC). However, this therapy is potentially associated with bleeding complications, warranting a comprehensive analysis of their incidence and severity. This meta-analysis aims to synthesize available evidence from clinical trials and observational studies to quantify the prevalence of bleeding following atezolizumab/bevacizumab administration.

Methods

This meta-analysis focused on HCC treatment using atezolizumab/bevacizumab, particularly examining bleeding complications. It determined the prevalence of bleeding post-administration and compared the risk ratio with tyrosine kinase inhibitors (sorafenib or lenvatinib). Risk factors for bleeding complications were also evaluated.

Results

From 28 studies involving 3,895 patients, the pooled prevalence of bleeding side effects was 8.42% (95% CI: 5.72-11.54). Grade III or IV bleeding occurred in 4.42% (95% CI: 2.64-6.10) of patients, with grade V bleeding observed in 2.06% (95% CI: 0.56-4.22). Gastrointestinal bleeding, predominantly variceal, was the most common, with a prevalence of 5.48% (95% CI: 3.98-7.17). Subgroup analysis indicated variability in bleeding rates based on study design and geographical location. Atezolizumab/bevacizumab treatment exhibited a 2.11 times higher prevalence of bleeding compared to tyrosine kinase inhibitors (95% CI: 1.21-3.66). Meta-regression identified high body mass index (BMI) and higher proportion of albumin-bilirubin (ALBI) grade 3 as significant risk factors for bleeding complications.

Conclusion

Atezolizumab/bevacizumab therapy for advanced HCC carries a heightened risk of gastrointestinal bleeding, exceeding that of tyrosine kinase inhibitors. High BMI and higher ALBI grade are key predictors of bleeding complications, emphasizing the need for cautious patient selection and monitoring.

Evidence-based clinical recommendations for hypofractionated radiotherapy: exploring efficacy and safety - Part 4: Liver and locally recurrent rectal cancer

In this paper, we review the use of hypofractionated radiotherapy for gastrointestinal malignancies, focusing on primary and metastatic liver cancer, and recurrent rectal cancer. Technological advancements in radiotherapy have facilitated the direct delivery of high-dose radiation to tumors, while limiting normal tissue exposure, supporting the use of hypofractionation. Hypofractionated radiotherapy is particularly effective for primary and metastatic liver cancer where high-dose irradiation is crucial to achieve effective local control. For recurrent rectal cancer, the use of stereotactic body radiotherapy offers a promising approach for re-irradiation, balancing efficacy and safety in patients who have been administered previous pelvic radiotherapy and in whom salvage surgery is not applicable. Nevertheless, the potential for radiation-induced liver disease and gastrointestinal complications presents challenges when applying hypofractionation to gastrointestinal organs. Given the lack of universal consensus on hypofractionation regimens and the dose constraints for primary and metastatic liver cancer, as well as for recurrent rectal cancer, this review aims to facilitate clinical decision-making by pointing to potential regimens and dose constraints, underpinned by a comprehensive review of existing clinical studies and guidelines.

The Efficacy and Safety of Bevacizumab Plus Anti-PD-1/PD-L1 Inhibitors in Combination with Hepatic Arterial Infusion Chemotherapy for Initially Unresectable Hepatocellular Carcinoma

Objection

To report the efficacy and safety of triple combination therapy with bevacizumab plus anti-PD-1 (BP1) or anti-PD-L1 inhibitors (BPL) combined with hepatic arterial infusion chemotherapy (HAIC) as a first-line treatment for initially unresectable hepatocellular carcinoma (uHCC).

Methods

In this retrospective study, patients with initially uHCC received either BP1-HAIC or BPL-HAIC as first-line treatment. The primary endpoint was progression-free survival (PFS); secondary endpoints included overall survival (OS), objective response rate (ORR) and disease control rate (DCR).

Results

Between January 2020 and December 2022, a total of 136 patients with initially uHCC received triple combination therapy, with 76 in the BP1-HAIC group and 60 in the BPL-HAIC group. The median PFS for the entire cohort was 11.1 months (95% CI, 8.0-13.7 months), and the median OS was 22.4 months (95% CI, 21.3- not reached). Comparative analysis revealed no significant differences in PFS (HR, 0.91, P = 0.69) or OS (HR, 0.71, P = 0.31) between the BP1-HAIC and BPL-HAIC groups. The ORR was 46.3% per RECIST v1.1 and 66.9% per mRECIST, with a DCR of 83.1% under both criteria. Common adverse events (AEs) included hypoalbuminemia and elevated aspartate/alanine aminotransferase, with 5.1% (7/136) experienced upper gastrointestinal bleeding. Multivariate Cox analysis identified tumor number and BCLC stage as independent prognostic factors for OS, and tumor number for PFS.

Conclusion

Triple combination therapy demonstrated significant therapeutic efficacy and tumor response in initially uHCC. No notable differences in outcomes were observed between the BP1-HAIC and BPL-HAIC groups. AEs were manageable in clinical practice.

A Potential Pneumothorax Induced by Immune Checkpoint Inhibitors: A Case Report and Literature Review

Background and Objectives: Immune checkpoint inhibitors (ICIs), which target immune checkpoints in cancer cells, are increasingly used as a mainstay in anticancer treatment. The combination of atezolizumab and bevacizumab is also a first-line treatment for hepatocellular carcinoma (HCC). However, ICIs can cause immune-related adverse events (IrAEs) which range from mild to severe, potentially leading to the need for discontinuing immunotherapy. We report a case of a pneumothorax, a rare side effect caused by IrAEs. Materials and Methods: This paper reports a case of a 78-year-old male HCC patient who developed a recurrent pneumothorax, suspected to be an adverse effect of ICIs. Results: The patient was a current smoker with a 30 pack-year smoking history. Prior to initiating ICIs, a chest CT scan showed mild emphysema and fibrosis attributable to smoking. Following ICI treatment, the patient developed a recurrent pneumothorax. Further tests revealed no underlying cause for the pneumothorax other than the ICIs and smoking, and there were no signs of intrapulmonary metastasis or pneumonitis. Conclusions: When a pneumothorax occurs in a patient undergoing immunotherapy, it is important to consider it as a potential adverse effect of the treatment. Special attention should be given to the possibility that immunotherapy may exacerbate underlying lung conditions. Patients should be advised on the importance of smoking cessation. As there are currently no guidelines for resuming immunotherapy after a pneumothorax, it is crucial to weigh the risks and benefits and consider dose reduction or discontinuation of the medication.

Management Consensus Guidelines for Hepatocellular Carcinoma: 2023 Update on Surveillance, Diagnosis, Systemic Treatment, and Posttreatment Monitoring by the Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan

Hepatocellular carcinoma (HCC) is the leading cause of cancer-related mortality in Taiwan. The Taiwan Liver Cancer Association and the Gastroenterological Society of Taiwan established HCC management consensus guidelines in 2016 and updated them in 2023. Current recommendations focus on addressing critical issues in HCC management, including surveillance, diagnosis, systemic treatment, and posttreatment monitoring. For surveillance and diagnosis, we updated the guidelines to include the role of protein induced by vitamin K absence or antagonist II (PIVKA-II) and gadoxetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) in detecting HCCs. For systemic treatment, the updated guidelines summarize the multiple choices available for targeted therapy, immune checkpoint inhibitors, and a combination of both, especially for those carcinomas refractory to or unsuitable for transarterial chemoembolization. We have added a new section, posttreatment monitoring, that describes the important roles of PIVKA-II and EOB-MRI after HCC therapy, including surgery, locoregional therapy, and systemic treatment. Through this update of the management consensus guidelines, patients with HCC may benefit from optimal diagnosis, therapeutic modalities, and posttreatment monitoring.

Risk of Hepatocellular Carcinoma by Steatotic Liver Disease and Its Newly Proposed Subclassification

Introduction

Steatotic liver disease (SLD) is a new overarching term proposed to replace nonalcoholic fatty liver disease and metabolic dysfunction-associated fatty liver disease. Subclassification includes metabolic dysfunction-associated SLD (MASLD), MASLD with increased alcohol intake (MetALD), and cryptogenic SLD. This study aimed to investigate whether SLD and its subclassification could stratify hepatocellular carcinoma (HCC) risk.

Methods

A cohort of 85,119 adults without viral hepatitis or heavy alcohol intake was analyzed for the risk of HCC according to SLD and its subclassification. The fibrosis-4 (FIB-4) index was used to estimate the degree of liver fibrosis.

Results

During a median follow-up of 11.9 years, HCC was diagnosed in 123 individuals. The incidence rate of HCC per 1,000 person-years was higher in individuals with SLD than in those without SLD (0.197 vs. 0.071, p < 0.001), with an adjusted hazard ratio of 2.02 (95% confidence interval: 1.40-2.92). The HCC incidence rate per 1,000 person-years was 0, 0.180, and 0.648 for cryptogenic SLD, MASLD, and MetALD, respectively. When participants with SLD was further stratified by the FIB-4 index, the HCC incidence rate per 1,000 person-years was 0.074 for SLD with FIB-4 < 1.3 and 0.673 for SLD with FIB-4 ≥ 1.3. Of note, HCC risk was substantially high (HCC incidence rate: 1.847 per 1,000 person-years) for MetALD with FIB-4 ≥ 1.3.

Conclusions

HCC risk was different by SLD and its subclassification. The utilization of SLD and its subclassification can aid in stratifying HCC risk and facilitate the identification of individuals requiring interventions to mitigate the risk of HCC.

Clinical significance of surgical resection for hepatocellular carcinoma with portal vein invasion: a nationwide cohort study

Background

Hepatocellular carcinoma (HCC) with portal vein invasion (PVI) is considered an advanced stage with a poor prognosis. Although current guidelines recommend systemic treatment for HCC with PVI, surgical resection could produce acceptable outcomes in selected patients. This study aimed to identify the clinical significance of surgical resection for HCC with PVI patients using a large-scale nationwide registry.

Methods

This retrospective, multicenter, observational cohort analyzed data from the Korean Primary Liver Cancer Registry. A total of 16,781 patients who were newly diagnosed with HCC between 2008 and 2018 were enrolled in this study. Patients with worse Child-Turcotte-Pugh scores (≥7) or performance status (≥2) were excluded. Among them, 998 patients who received treatment for HCC with PVI were included in the analysis and were divided into two groups: resection group of 151 (15.1%) and palliative group of 847 (84.9%) who received transarterial and systemic therapy according to the treatment intent. After matching the number and size of the tumors and model for end-stage liver disease (MELD) score between the groups, the final study cohort for analysis comprised 151 (26.6%) patients in the resection group and 417 (73.4%) in the palliative group. The primary endpoints were overall survival (OS) and cancer-specific survival (CSS).

Results

The number and maximum size of HCC did not differ between the resection and palliative groups after matching [1 (range, 1-5) vs. 1 (range, 1-6), P=0.11 and 5.5 (range, 1.2-20.6) vs. 6.0 (range, 1.0-20.5) cm, P=0.24, respectively]. Tumor markers, including alpha-fetoprotein (AFP) and protein induced by vitamin K absence or antagonist-II (PIVKA-II), also did not differ between the groups (P=0.29 and P=0.36, respectively). The 5-year OS and CSS rates of the resection and palliative groups were 44.8% and 17.4% (P<0.001) and 47.7% and 18.6% (P<0.001), respectively. Multivariate analysis showed that palliative treatment intent was the most significant risk factor for OS and CSS [odds ratio (OR) =2.24; 95% confidence interval (CI): 1.66-3.02; P<0.001 and OR =2.29; 95% CI: 1.68-3.12; P<0.001, respectively].

Conclusions

Surgical resection could significantly improve OS and CSS in selected HCC with PVI patients who have preserved liver function and performance status.

Local Ablation for Hepatocellular Carcinoma: 2024 Expert Consensus-Based Practical Recommendations of the Korean Liver Cancer Association

Local ablation for hepatocellular carcinoma, a non-surgical option that directly targets and destroys tumor cells, has advanced significantly since the 1990s. Therapies with different energy sources, such as radiofrequency ablation, microwave ablation, and cryoablation, employ different mechanisms to induce tumor necrosis. The precision, safety, and effectiveness of these therapies have increased with advances in guiding technologies and device improvements. Consequently, local ablation has become the first-line treatment for early-stage hepatocellular carcinoma. The lack of organized evidence and expert opinions regarding patient selection, preprocedure preparation, procedural methods, swift post-treatment evaluation, and follow-up has resulted in clinicians following varied practices. Therefore, an expert consensus-based practical recommendation for local ablation was developed by a group of experts in radiology and hepatology from the Research Committee of the Korean Liver Cancer Association in collaboration with the Korean Society of Image-Guided Tumor Ablation to provide useful information and guidance for performing local ablation and for the pre- and post-treatment management of patients.

Assessment of real-time US-CT/MR-guided percutaneous gold fiducial marker implementation in malignant hepatic tumors for stereotactic body radiation therapy

BACKGROUNDS/AIMS

This study explored the initial institutional experience of using gold fiducial markers for stereotactic body radiotherapy (SBRT) in treating malignant hepatic tumors using real-time ultrasound-computed tomography (CT)/magnetic resonance (MR) imaging fusion-guided percutaneous placement.

METHODS

From May 2021 to August 2023, 19 patients with 25 liver tumors that were invisible on pre-contrast CT received fiducial markers following these guidelines. Postprocedural scans were used to confirm their placement. We assessed technical and clinical success rates and monitored complications. The implantation of fiducial markers facilitating adequate treatment prior to SBRT, which was achieved in 96% of the cases (24 of 25 tumors), was considered technical success. Clinical success was the successful completion of SBRT without evidence of marker displacement and was achieved in 88% of cases (22 of 25 tumors). Complications included one major subcapsular hematoma and marker migration into the right atrium in two cases, which prevented SBRT.

RESULTS

Among the treated tumors, 20 of 24 (83.3%) showed a complete response, three of 24 (12.5%) remained stable, and one of 24 (4.2%) progressed during an average 11.7-month follow-up (range, 2-32 months).

CONCLUSIONS

This study confirms that percutaneous gold fiducial marker placement using real-time CT/MR guidance is effective and safe for SBRT in hepatic tumors, but warns of marker migration risks, especially near the hepatic veins and in subcapsular locations. Using fewer markers than traditionally recommended-typically two per patient, the outcomes were still satisfactory, particularly given the increased risk of migration when markers were placed near major hepatic veins.

Re-assessing the diagnostic value of the enhancing capsule in hepatocellular carcinoma imaging

BACKGROUNDS/AIMS

The enhancing capsule (EC) in hepatocellular carcinoma (HCC) diagnosis has received varying degrees of recognition across major guidelines. This study aimed to assess the diagnostic utility of EC in HCC detection.

METHODS

We retrospectively analyzed patients who underwent pre-surgical computed tomography (CT) and hepatobiliary agent-enhanced magnetic resonance imaging (HBA-MRI) between January 2016 and December 2019. A single hepatic tumor was confirmed based on the pathology of each patient. Three radiologists independently reviewed the images according to the Liver Imaging Reporting and Data System (LI-RADS) v2018 criteria and reached a consensus. Interobserver agreement for EC before reaching a consensus was quantified using Fleiss κ statistics. The impact of EC on the LI-RADS classification was assessed by comparing the positive predictive values for HCC detection in the presence and absence of EC.

RESULTS

In total, 237 patients (median age, 60 years; 184 men) with 237 observations were included. The interobserver agreement for EC detection was notably low for CT (κ=0.169) and HBA-MRI (κ=0.138). The presence of EC did not significantly alter the positive predictive value for HCC detection in LI-RADS category 5 observations on CT (94.1% [80/85] vs. 94.6% [88/93], P=0.886) or HBAMRI (95.7% [88/92] vs. 90.6% [77/85], P=0.178).

CONCLUSIONS

The diagnostic value of EC in HCC diagnosis remains questionable, given its poor interobserver agreement and negligible impact on positive predictive values for HCC detection. This study challenges the emphasis on EC in certain diagnostic guidelines and suggests the need to re-evaluate its role in HCC imaging.

Superselective ablative chemo-ethanol embolization for recurrent single hepatocellular carcinoma: a 6-month outcome analysis

BACKGROUNDS/AIMS

To evaluate the safety and effectiveness of superselective ablative chemo-ethanol embolization (SACE) for the treatment of patients with recurrent single hepatocellular carcinoma (rHCC).

METHODS

This retrospective study included 22 patients (19 men; median age, 63 years [range, 38-86]) with Child-Pugh class of A/ B/C (16/3/3) that underwent SACE between January and June 2023 for recurrent single HCCs measuring ≤5 cm in diameter using a mixture of 99% ethanol and ethiodized oil/doxorubicin emulsion. The primary endpoint was the 6-month tumor response, and the secondary endpoints were the 1-month tumor response and treatment-related safety. This study was approved by our institutional review board, and the requirement for informed consent was waived.

RESULTS

SACE was successfully performed in 22 patients (95.2%). The complete response rates at 1-month and 6-month after treatment were 100.0% and 83.3%, respectively. At 6-month, local tumor progression occurred in one patient and intrahepatic distant metastasis was found in six patients (30.0%). No 6-month mortalities were reported. No adverse events greater than grade 2 or laboratory deteriorations were observed. Biliary complications or liver abscesses were not observed.

CONCLUSIONS

SACE for a single rHCC was highly effective in achieving a favorable 6-month tumor response and showed acceptable adverse events. However, further prospective studies are required to verify these findings.

Recent update of proton beam therapy for hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUNDS/AIMS

Although access to proton beam therapy (PBT) is limited worldwide, its use for the treatment of hepatocellular carcinoma (HCC) is gradually increasing with the expansion of new facilities. Therefore, we conducted a systematic review and metaanalysis to investigate the updated evidence of PBT for HCC.

METHODS

The MEDLINE, EMBASE, Cochrane Library, and Web of Science databases were systematically searched for studies that enrolled patients with liver-confined HCC that were treated with PBT for a cure up to February 2024.

RESULTS

A total of 1,858 HCC patients receiving PBT from 22 studies between 2004 and 2023 were selected for this meta-analysis. The median proportion of Child-Pugh class A was 86% (range, 41-100), and the median tumor size was 3.6 cm (range, 1.2-9.0). The median total dose ranged from 55 GyE to 76 GyE (median, 69). The pooled rates of 3- and 5-year local progression-free survival after PBT were 88% (95% confidence interval [CI], 85-91) and 86% (95% CI, 82-90), respectively. The pooled 3- and 5-year overall rates were 60% (95% CI, 54-66) and 46% (95% CI, 38-54), respectively. The pooled rates of grade 3 hepatic toxicity, classic radiationinduced liver disease (RILD), and non-classic RILD were 1%, 2%, and 1%, respectively.

CONCLUSIONS

The current study supports PBT for HCC and demonstrates favorable long-term survival and low hepatic toxicities compared with other published studies on other radiotherapy modalities. However, further studies are needed to identify the subgroups that will benefit from PBT.

Local Ablation for Hepatocellular Carcinoma: 2024 Expert Consensus-Based Practical Recommendations of the Korean Liver Cancer Association

Local ablation for hepatocellular carcinoma (HCC), a non-surgical option that directly targets and destroys tumor cells, has advanced significantly since the 1990s. Therapies with different energy sources, such as radiofrequency ablation, microwave ablation, and cryoablation, employ different mechanisms to induce tumor necrosis. The precision, safety, and effectiveness of these therapies have increased with advances in guiding technologies and device improvements. Consequently, local ablation has become the first-line treatment for early-stage HCC. The lack of organized evidence and expert opinions regarding patient selection, pre-procedure preparation, procedural methods, swift post-treatment evaluation, and follow-up has resulted in clinicians following varied practices. Therefore, an expert consensus-based practical recommendation for local ablation was developed by a group of experts in radiology and hepatology from the Research Committee of the Korean Liver Cancer Association in collaboration with the Korean Society of Image-guided Tumor Ablation to provide useful information and guidance for performing local ablation and for the pre- and post-treatment management of patients.

Local ablation for hepatocellular carcinoma: 2024 expert consensus-based practical recommendation of the Korean Liver Cancer Association

Local ablation for hepatocellular carcinoma (HCC), a non-surgical option that directly targets and destroys tumor cells, has advanced significantly since the 1990s. Therapies with different energy sources, such as radiofrequency ablation, microwave ablation, and cryoablation, employ different mechanisms to induce tumor necrosis. The precision, safety, and effectiveness of these therapies have increased with advances in guiding technologies and device improvements. Consequently, local ablation has become the firstline treatment for early-stage HCC. The lack of organized evidence and expert opinions regarding patient selection, pre-procedure preparation, procedural methods, swift post-treatment evaluation, and follow-up has resulted in clinicians following varied practices. Therefore, an expert consensus-based practical recommendation for local ablation was developed by a group of experts in radiology and hepatology from the Research Committee of the Korean Liver Cancer Association in collaboration with the Korean Society of Image-guided Tumor Ablation to provide useful information and guidance for performing local ablation and for the pre- and posttreatment management of patients.

Atezolizumab-Induced Ulcerative Colitis in Patient with Hepatocellular Carcinoma: Case Report and Literature Review

Background and Objectives: Immune check inhibitor (ICI) colitis is one of most common and adverse side effects of ICI. However, there was no case report of ulcerative colitis (UC)-mimicking colitis after atezolizumab use in hepatocellular carcinoma (HCC) to our knowledge. Materials and Methods: We would like to introduce the case of a patient with Stage IV HCC who complained of abdominal pain, diarrhea and rectal bleeding after two cycles of atezolizumab/bevacizumab chemotherapy and was then diagnosed with UC-mimicking colitis. Results: Endoscopy revealed typical findings of UC, suggesting diagnosis of UC-mimicking colitis. The patient was treated with systemic steroids and oral mesalamine, which significantly improved his symptoms, which were also supported by endoscopic findings. The patient resumed chemotherapy with atezolizumab and bevacizumab without any interruption to the chemotherapy schedule. Conclusions: Early endoscopic evaluation is pivotal to diagnosing UC-mimicking colitis. If diagnosed, UC-based treatments such as steroids and mesalamine should be strongly considered. Given previous reports of inflammatory bowel disease (IBD) flare-ups after immunotherapy, routine lower endoscopy, performed together with upper endoscopy before atezolizumab/bevacizumab therapy, is promising to patients.

Fatal intratumoral hemorrhage in a patient with hepatocellular carcinoma following successful treatment with atezolizumab/bevacizumab: A case report

BACKGROUND

Atezolizumab/bevacizumab is emerging as the new standard for advanced hepatocellular carcinoma (HCC), with ongoing real-world implementation to study its effectiveness. As the use of atezolizumab/bevacizumab increases, various side effects have been reported in clinical practice, most notably increased bleeding caused by bevacizumab.

CASE SUMMARY

In this case report, we present a rare and fatal case of intratumoral hemorrhage in a patient with advanced HCC following successful treatment with atezolizumab/bevacizumab. A 63-year-old male diagnosed with HCC initially underwent four cycles of intra-arterial chemotherapy. However, follow-up abdominal computed tomography (CT) revealed disease progression. Subsequently, the treatment plan was modified to atezolizumab/bevacizumab. After the fifth cycle of atezolizumab/bevacizumab, CT showed partial regression of HCC. One week later, he visited the emergency room due to severe abrupt abdominal pain. Abdominal CT revealed focal rupture of HCC in the medial segment inferior portion with active bleeding and a large amount of hemoperitoneum. Angiography was performed on the same day, and embolization of A4 and A8 branches using lipiodol and gelfoam was implemented. Despite successful hemostasis, the patient subsequently developed liver failure and died.

CONCLUSION

Atezolizumab/bevacizumab for advanced HCC suggests that intratumoral hemorrhage may be crucial despite good tumor response after immunotherapy, emphasizing the continuous monitoring of this side effect.

Analysis of Immune-Related Adverse Events of Atezolizumab and Bevacizumab in Patients with Hepatocellular Carcinoma: A Multicentre Cohort Study

INTRODUCTION

Despite the emergence of atezolizumab and bevacizumab (A + B) as standard first-line systemic therapy for unresectable hepatocellular carcinoma (HCC), a comprehensive understanding of the clinical significance of immune-related adverse events (irAEs) remains limited. We aimed to assess the impact of irAEs on patients with HCC undergoing A + B treatment.

METHODS

This multicentre retrospective study included consecutive patients with HCC who were treated with the A + B regimen from September 2020 to December 2022. Patients were categorized into three groups based on the severity of irAEs, ranging from those without any experience of irAEs to those with severe irAEs.

RESULTS

This study included 150 patients with HCC, with a mean age of 63.3 years. Among them, 93.3% of patients were classified as Barcelona Clinic Liver Cancer stage C, 52.0% had portal vein tumour thrombosis (PVTT), and 60.7% extrahepatic spread. Patients were classified as follows: group 1 (n = 84) had no irAEs, group 2 (n = 37) had mild irAEs (grade 1-2), and group 3 (n = 29) had severe irAEs (grade ≥3). The median overall survival (OS), progression-free survival (PFS), and time-to-treatment discontinuation (TTD) were 13.6, 5.7, and 3.6 months, respectively. Group 2 demonstrated significantly superior OS compared to group 1 (9.5 months) and group 3 (5.6 months), with a median OS of 23.0 months (p < 0.001). Furthermore, group 2 demonstrated significantly better outcomes in terms of PFS and TTD compared to both group 1 and group 3 (p < 0.001 for both). Multivariate analysis identified mild irAEs (hazard ratio [HR], 0.353; p = 0.010), ALBI grade 1 (HR, 0.389; p = 0.006), Child-Pugh class A (HR, 0.338; p = 0.002), and the absence of PVTT (HR, 0.556; p = 0.043) as independent predictors of better OS.

CONCLUSION

Our study highlights the significant impact of irAE severity on the outcomes of patients with HCC receiving A + B. Notably, the occurrence of mild irAEs was independently associated with favourable survival, suggesting their potential role as surrogate indicators of HCC prognosis.

Consistent efficacy of hepatic artery infusion chemotherapy irrespective of PD‑L1 positivity in unresectable hepatocellular carcinoma

Atezolizumab/bevacizumab is the first line of treatment for unresectable hepatocellular carcinoma (HCC), combining immune checkpoint inhibitor and anti-VEGF monoclonal antibodies. Hepatic arterial infusion chemotherapy (HAIC) is administered when the above-described combination fails to confer sufficient clinical benefit. The present study aimed to explore the association between tumor programmed cell death-ligand 1 (PD-L1) positivity and HAIC response. A total of 40 patients with HCC who had undergone HAIC with available biopsy samples obtained between January 2020 and May 2023 were retrospectively enrolled. Tumor response, progression-free survival (PFS), disease control rate (DCR) and overall survival (OS) were evaluated. PD-L1 expression in tumor samples was assessed using a combined positivity score. The response rates of HAIC-treated patients with advanced HCC after failure of atezolizumab/bevacizumab combination therapy were recorded. OS (P=0.9717) and PFS (P=0.4194) did not differ between patients with and without PD-L1 positivity. The objective response rate (P=0.7830) and DCR (P=0.7020) also did not differ based on PD-L1 status. In conclusion, the current findings highlight the consistent efficacy of HAIC, regardless of PD-L1 positivity.

Efficacy and Safety of Surgical Resection in Elderly Patients with Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis

Background/Aims

: With increased life expectancy, the management of elderly hepatocellular carcinoma (HCC) patients became a crucial issue, yet it is still challenging due to comorbidities and high surgical risks. While surgical resection is considered as primary treatment for eligible HCC patients, systematic evidence on its outcomes in elderly patients remains scarce. In this review, we aimed to analyze the efficacy and safety outcomes of surgical resection in elderly HCC patients.

Methods

: The studies included in this meta-analysis were selected from Ovid-MEDLINE, Ovid-Embase, CENTRAL, KoreaMed, KMbase, and KISS databases following a predefined protocol. Efficacy outcomes included overall survival and disease-free survival, while the safety outcomes included postoperative mortality and complications.

Results

: Patients in the elderly group (≥65 years) who underwent surgery exhibited non-inferior overall survival (hazard ratio [HR], 1.26; 95% confidence interval [CI], 0.92 to 1.74) and disease-free survival (HR, 1.03; 95% CI, 0.99 to 1.08) compared to the non-elderly group. Overall postoperative mortality exhibited no statistical difference (odds ratio [OR], 1.07; 95% CI, 0.87 to 1.31), but 30-day, 90-day, and in-hospital mortality were higher in the elderly group. The incidence of overall complications was higher in the elderly group (OR, 1.44; 95% CI, 1.22 to 1.69). Sensitivity analysis for the super elderly group (≥80 years) showed significantly higher in-hospital mortality compared to the non-super elderly group (OR, 2.51; 95% CI, 1.16 to 5.45).

Conclusions

: The efficacy outcome of surgical resection in the elderly HCC patients was not worse than that in the non-elderly HCC patients, while in-hospital mortality and complications rates were higher. Therefore, surgical resection should be purposefully considered in the elderly population, with careful candidate selection.

Trends in alcohol use and alcoholic liver disease in South Korea: a nationwide cohort study

BACKGROUND

There is a lack of national-level research on alcohol consumption and the epidemiology of alcoholic liver disease (ALD) in South Korea. This study aims to address the critical public health issue of ALD by focusing on its trends, incidence, and outcomes, using nationwide claims data.

METHODS

Utilizing National Health Insurance Service data from 2011 to 2017, we calculated the population's overall drinking amount and the incidence of ALD based on ICD-10 diagnosis codes.

RESULTS

From 2011 to 2017 in South Korea, social drinking increased from 15.7% to 16.5%, notably rising among women. High-risk drinking remained around 16.4%, decreasing in men aged 20-39 but not decreased in men aged 40-59 and steadily increased in women aged 20-59. The prevalence of ALD in high-risk drinkers (0.97%) was significantly higher than in social drinkers (0.16%). A 3-year follow-up revealed ALD incidence of 1.90% for high-risk drinkers and 0.31% for social drinkers. Women high-risk drinkers had a higher ALD risk ratio (6.08) than men (4.18). The economic burden of ALD was substantial, leading to higher healthcare costs and increased hospitalization. Progression rates to liver cirrhosis and hepatocellular carcinoma (HCC) in ALD patients were 23.3% and 2.8%, respectively, with no gender difference in cirrhosis progression.

CONCLUSIONS

The study revealed a concerning rise in alcohol consumption among South Korean women and emphasizes the heightened health risks and economic burdens associated with high-risk drinking, especially concerning ALD and its complications.