Simple new clinical score to predict hepatocellular carcinoma after sustained viral response with direct-acting antivirals

The time point of the most precise predictor of hepatocellular carcinoma (HCC) development after viral eradication with direct-acting antiviral (DAA) therapy is unclear. In this study we developed a scoring system that can accurately predict the occurrence of HCC using data from the optimal time point. A total of 1683 chronic hepatitis C patients without HCC who achieved sustained virological response (SVR) with DAA therapy were split into a training set (999 patients) and a validation set (684 patients). The most accurate predictive scoring system to estimate HCC incidence was developed using each of the factors at baseline, end of treatment, and SVR at 12 weeks (SVR12). Multivariate analysis identified diabetes, the fibrosis-4 (FIB-4) index, and the α-fetoprotein level as independent factors at SVR12 that contributed to HCC development. A prediction model was constructed with these factors that ranged from 0 to 6 points. No HCC was observed in the low-risk group. Five-year cumulative incidence rates of HCC were 1.9% in the intermediate-risk group and 15.3% in the high-risk group. The prediction model at SVR12 most accurately predicted HCC development compared with other time points. This simple scoring system combining factors at SVR12 can accurately evaluate HCC risk after DAA treatment.

Patients with Chronic Liver Disease under Surveillance for Hepatocellular Carcinoma Have a Favorable Long-Term Outcome for Pancreatic Cancer Due to Early Diagnosis and High Resection Rate

Patients with viral hepatitis-related chronic liver disease (CLD) under surveillance for hepatocellular carcinoma (HCC) are often diagnosed with pancreatic cancer (PC) at an early stage. However, the long-term outcomes of these patients are unclear. We aimed to clarify the long-term outcomes of patients with PC with viral hepatitis-related CLD using a chart review. Data collection included the Union for International Cancer Control (UICC) stage at PC diagnosis, hepatitis B virus and hepatitis C virus status, and long-term outcomes. The distribution of the entire cohort (N = 552) was as follows: early stage (UICC 0-IB; n = 52, 9.5%) and non-early stages (UICC IIA-IV; n = 500, 90.5%). At diagnosis, the HCC surveillance group (n = 18) had more patients in the early stages than the non-surveillance group (n = 534) (50% vs. 8.0%), leading to a higher indication rate for surgical resection (72.2% vs. 29.8%) and a longer median survival time (19.0 months vs. 9.9 months). We confirmed that patients with viral hepatitis-related CLD under HCC surveillance were diagnosed with PC at an early stage. Because of the higher indication rate for surgical resection in these patients, they had favorable long-term outcomes for PC.

AFP and eGFR are related to early and late recurrence of HCC following antiviral therapy

Background

An unexpected recurrence of hepatocellular carcinoma (HCC) sometimes occurs in patients with hepatitis C virus (HCV) after treatment with direct-acting antivirals (DAAs). However, the characteristics of patients with HCC recurrence may differ depending on time after DAA treatment. We aimed to identify risk factors related to HCC recurrence according to time after DAA treatment.

Methods

Of 1663 patients with HCV treated with a DAA, 199 patients had a previous history of HCC. We defined HCC recurrence within 1 year after DAA treatment as ‘early recurrence’, and recurrence more than 1 year after as ‘late recurrence’. The different risk factors between the early and late phases of HCC recurrence after the end of DAA therapy were investigated.

Results

Ninety-seven patients experienced HCC recurrence during the study period. Incidences of recurrence were 29.8, 41.0, and 53.4% at 1, 2, and 3 years, respectively, after the end of DAA therapy. Multivariate analysis identified post-treatment α-fetoprotein (AFP) as an independent factor contributing to HCC recurrence in the early phase (hazard ratio, 1.056; 95% confidence interval, 1.026–1.087, p < 0.001) and post-treatment estimated glomerular filtration rate (eGFR) (hazard ratio, 0.98; 95% confidence interval, 0.96–0.99, p = 0.032) as a predictor of HCC recurrence in the late phase.

Conclusion

Patients with higher post-treatment AFP in the early phase and those with lower post-treatment eGFR in the late phase had a high risk of HCC recurrence. The risk factors associated with HCC recurrence after DAA treatment were different between the early and late phases.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12885-021-08401-7.

Sex difference in the development of hepatocellular carcinoma after direct-acting antiviral therapy in patients with HCV infection

Sex differences in the predictors for hepatocellular carcinoma (HCC) development after direct-acting antiviral (DAA) therapy was investigated. DAA therapy was given to 1438 (663 male, 775 female) patients. Sex differences in the HCC development rate and the factors contributing to HCC development after DAA therapy were investigated. Male patients had a significantly higher cumulative HCC incidence (log-rank test, P =  .007). On multivariate analysis, the fibrosis-4 index (HR = 1.11; 95%CI, 1.042-1.202, P =  .002) and posttreatment α-fetoprotein (AFP) (HR = 1.11; 95%CI, 1.046-1.197, P  =  .001) were found to be independent factors that contributed to HCC development following DAA therapy in female patients, whereas only posttreatment AFP (HR  =  1.090; 95%CI, 1.024-1.160, P  = .007) was an independent factor in male patients. The optimal posttreatment AFP cut-off values were set based on receiver operating characteristic curve analyses. The optimal posttreatment AFP cut-off value was much higher in females (6.0 ng/mL) than in male (3.5 ng/mL) patients. In conclusion both in male and female patients, posttreatment AFP was an independent predictor of HCC development after DAA therapy. However, the cut-off values differed between the sexes. In male patients, HCC could be seen in patients with relatively low posttreatment AFP levels; more careful observation might be needed in such patients.

ABO Blood Type and the Long-term Outcomes of Pancreatic Cancer

Objective The long-term effect of the ABO blood type on the clinical course of patients with pancreatic cancer (PC) is inconclusive. This study aimed to determine whether or not the ABO blood type influences the long-term outcomes of PC in Japanese patients. Methods The medical records of Japanese patients with PC were reviewed. Data, including the age, sex, and outcomes, from the Ehime Pancreato-Cholangiology Study Group were analyzed. Results The mean age of the 406 patients was 71.0±10.5 years, and 220 (54.2%) were men. A total of 44.6%, 20.7%, 22.4%, and 12.3% had blood type A, B, O, and AB, respectively. The median survival time (MST) of patients with A alleles was shorter than that of patients with non-A alleles (p=0.048), especially among those who underwent resection (p=0.031). In contrast, no marked difference in the MST was noted among those who underwent chemotherapy and palliative care. Finally, a multivariate analysis confirmed A alleles as an independent factor associated with the long-term outcome of PC (p<0.05 in 2 different models). Conclusion The ABO blood type influenced the long-term outcomes of Japanese patients with PC, presumably due to its impact on disease onset and tumor behavior.

Early Detection of Pancreatic Cancer in Patients With Chronic Liver Disease Under Hepatocellular Carcinoma Surveillance

OBJECTIVE

To evaluate whether patients with hepatitis B virus (HBV)- and hepatitis C virus (HCV)-related chronic liver disease were diagnosed as having pancreatic cancer (PC) at an early stage during abdominal imaging surveillance for hepatocellular carcinoma (HCC).

PATIENTS AND METHODS

We retrospectively examined 447 patients with PC diagnosed at Ehime University Hospital and affiliated centers (2011-2013). Data were collected regarding HBV and HCV status, likelihood of PC diagnosis, and Union for International Cancer Control (UICC) stage. Intergroup comparisons were performed using the χ² test.

RESULTS

The UICC stage distribution in the HCC surveillance group (n=16) was stage 0 (n=2, 12.5%), stage IA (n=3, 18.8%), stage IB (n=2, 12.5%), stage IIA (n=2, 12.5%), stage IIB (n=2, 12.5%), stage III (n=1, 6.3%), and stage IV (n=4, 25%). The UICC stage distribution in the nonsurveillance group (n=431) was stage 0 (n=4, 0.9%), stage IA (n=28, 6.5%), stage IB (n=27, 6.3%), stage IIA (n=86, 20.0%), stage IIB (n=48, 11.1%), stage III (n=56, 13.0%), and stage IV (n=182, 42.2%). The HCC surveillance group had significantly more patients with stage 0 disease than with stages IA through IV (P=.02). Similar results were observed when including stages IA (P=.007) and IB (P=.004) as early stages but not stage IIA (P=.10). A dilated pancreatic duct led to a PC diagnosis in all 6 patients with stage 0 disease.

CONCLUSION

Patients with HBV- and HCV-related chronic liver disease had an early PC diagnosis during HCC surveillance. Careful evaluation of the pancreas is warranted during HCC surveillance.

Predictors of hepatocellular carcinoma occurrence after direct-acting antiviral therapy in patients with hepatitis C virus infection

AIM

The predictors for the development of hepatocellular carcinoma (HCC) after direct-acting antiviral (DAA) treatment were investigated.

METHODS

A total of 1174 patients with chronic hepatitis C virus infection were treated with DAA therapy (sofosbuvir and ledipasvir [n = 615], sofosbuvir and ribavirin [n = 380], and daclatasvir and asunaprevir [n = 179]) and achieved sustained virologic response (SVR). The HCC development rate and the factors that might contribute to the development of HCC after the end of DAA treatment were analyzed.

RESULTS

During the median observation period of 537 days, HCC developed in 33 cases. The incidence of HCC was 1.9%, 3.2%, and 4.1% at 1, 1.5, and 2 years after the end of DAA therapy, respectively. Multivariate analysis with pre- and post-treatment factors identified the Fibrosis-4 (FIB-4) index (hazard ratio [HR] = 1.09; 95% confidence interval [CI], 1.021-1.178; P = 0.011) and post-treatment α-fetoprotein (AFP) (HR = 1.11; 95% CI, 1.054-1.172; P < 0.001) as independent factors that contributed to the development of HCC after DAA therapy. Using these identified parameters, a new scoring system (0 to 2 points) was established. Patients in the high-score group (2 points) could be identified as having a significantly higher risk of HCC development, and the respective 1- and 2-year cumulative incidence rates of HCC were 6.1% and 14.4%.

CONCLUSIONS

A high FIB-4 index and a high post-treatment AFP at the end of DAA treatment were the independent predictors for developing HCC after DAA treatment. For patients with these risk factors, extra attention to the possibility of HCC development is needed.

Characteristics and Prognosis of Hepatocellular Carcinoma in Japanese Patients Undergoing Dialysis

Patients with end-stage renal disease who are undergoing dialysis may be at high risk of developing hepatocellular carcinoma (HCC). We investigated the characteristics and prognosis of HCC in patients undergoing dialysis in Japan. Patients characteristics, progression of HCC at diagnosis, and survival rates after diagnosis were compared between 108 HCC patients undergoing dialysis and 526 non-dialysis patients followed up at liver center. The comparisons were also performed after adjusting for patient age, gender, platelet count, and etiology using propensity-score matching. HCC was more advanced in patients undergoing dialysis than in non-dialysis controls. The 3- and 5-year survival rates of patients undergoing dialysis were 56.3% and 38.3%, respectively, which were lower than those of non-dialysis controls (66.5% and 52.7%, respectively, P = 0.0026). The results were the same after propensity score matching (P = 0.0014). In Japan, HCC was more advanced at diagnosis in patients undergoing dialysis in comparison to HCC in patients at liver centers, resulting in a lower survival rate after diagnosis.

Predictors of treatment efficacy and ALT non-normalization with sofosbuvir/ribavirin therapy for patients with hepatitis C virus genotype 2

The tolerability and efficacy of sofosbuvir and ribavirin in patients infected with hepatitis C virus (HCV) genotype 2 were investigated under actual clinical conditions. A total of 208 patients with chronic HCV genotype 2 infection were treated with sofosbuvir 400 mg and ribavirin (weight-based dosing) for 12 weeks. Treatment discontinuation and sustained virological response 12 (SVR12) were evaluated. Moreover, factors associated with SVR12, hemoglobin decreasing to less than 10 g/dL during treatment, and alanine aminotransferase (ALT) non-normalization after treatment were evaluated. In all patients, SVR12 responses were 96.1% (200/208). About 6 of 8 patients (3.8%) who did not achieve SVR12 were re-treatment patients, and eight patients who did not achieve SVR all had liver cirrhosis. Multivariate analysis also identified body mass index (OR = 0.79; P < 0.001), platelet count (OR = 0.88; P = 0.003), and estimated glomerular filtration rate (eGFR) (OR = 0.96; P = 0.007) as independent contributing factors associated with hemoglobin decreasing to less than 10 g/dL during treatment, and only Mac-2 Binding Protein Glycosylation isomer (M2BpGi) (OR = 2.46; P = 0.017) as an independent contributing factor associated with ALT non-normalization after treatment. Cirrhotic patients may have a relatively high rate of treatment failure. In patients whose M2BpGi levels are elevated, their ALT tended to not normalize after treatment completion. These patients who did not achieve normalization of ALT after sofosbuvir plus RBV treatment need more careful observation for emergence of hepatocellular carcinoma even after achievement of SVR.

Clinical features of hemodialysis patients treated for hepatocellular carcinoma: Comparison between resection and radiofrequency ablation

There is no consensus regarding which therapeutic option is better and/or safer for treating hemodialysis (HD) patients with hepatocellular carcinoma (HCC). The present study compared surgical resection (Hx) and radiofrequency ablation (RFA) with regard to therapeutic efficacy in HD patients with HCC. Of 108 HD patients with naïve HCC treated at 15 institutions between 1988 and 2014 enrolled in the present study, 58 fulfilled the up-to-7 criteria [7 as the sum of the size of the largest tumor (cm) and the number of tumors] and were treated with Hx (n=23) or RFA (n=35); their clinical features, complications and prognosis were assessed. The frequency of hepatitis C virus was higher in the RFA group compared with that in the Hx group (P=0.002), whereas there were no differences between the groups with regard to the average time from the first HD (P=0.953), tumor-nodes-metastasis (TNM) stage (Union for International Cancer Control 7th edition) (P=0.588), TNM stage (Liver Cancer Study Group of Japan 5th edition) (P=0.095), Child-Pugh classification (P=0.094), and Japan Integrated Scoring system (P=0.489). There were no significant differences in overall survival (OS) and disease-free survival (DFS) rates between the Hx and RFA groups [1-, 3- and 5-year OS rates: 81.7, 55.6 and 43.3% vs. 89.9, 67.1 and 56.3%, respectively (P=0.454); 1-, 3- and 5-year DFS rates: 71.1, 30.5 and 18.3% vs. 63.8, 31.6 and 21.1%, respectively (P=0.911)] Complications were observed in 4 patients (11.4%) in the RFA group (2 with subcapsular hemorrhage, 1 with intraperitoneal bleeding and 1 with tardive intrahepatic hematoma) and in 4 patients (17.4%) in the Hx group (2 with postoperative infection, 1 with liver failure and 1 with pleural effusion) (P=0.700). In conclusion, Hx and RFA have a similar therapeutic efficacy in HD patients with naïve HCC who fulfilled the up-to-7 criteria.

Simeprevir with peginterferon/ribavirin for patients with hepatitis C virus genotype 1: high frequency of viral relapse in elderly patients

Purpose

The tolerability and efficacy of simeprevir in combination with peginterferon and ribavirin in patients infected with hepatitis C virus (HCV) genotype 1 under actual clinical conditions were investigated.

Methods

A total of 176 patients with chronic HCV genotype 1 infection were treated with simeprevir for 12 weeks plus Peg-IFN/RBV for 24 weeks. Overall, 107 (60.7 %) patients were aged 60 years or more, and 16 (9 %) patients were aged 70 years or more. Treatment discontinuation, sustained virological response 12 (SVR12), and viral relapse were evaluated and compared between younger patients and elderly patients.

Results

The rates of undetectable HCV RNA at the end of treatment were 95.8, 100 and 93.1 % in treatment-naïve, prior relapse, and prior non-responders, respectively. However, the rates of SVR12 were 82.4, 88.2 and 69.2 %, respectively. Especially in prior non-responders, viral relapse was relatively frequent. Treatment discontinuation and SVR12 were not different between patients aged <70 and ≥70 years, but viral relapse after completing treatment was significantly more frequent in patients aged ≥70 years (p = 0.012).

Conclusions

In simeprevir with peginterferon and ribavirin therapy, viral relapse was relatively frequent. Especially in elderly patients, the relapse rate was high after completing treatment, instead of low frequency of discontinuation by the adverse events.

[Mucoepidermoid carcinoma of the intrahepatic bile duct with metastasis to the cranial skin]

Mucoepidermoid carcinoma of the intrahepatic bile duct is a rare variant of cholangiocarcinoma: it is composed of mucus-secreting squamous cells and glandular cells within the same nests. This tumor is very aggressive, with high-grade malignancy, and has a poor prognosis. In the international literature, only 17 cases of mucoepidermoid carcinoma originating in the hepatic bile duct system have been reported until now. We report an autopsy case of mucoepidermoid carcinoma of the intrahepatic bile duct with metastasis to the cranial skin in a Japanese man who was more than 70 years old. This cancer metastasizes to many organs, but skin metastasis is extremely rare.

Splenic elasticity measured with real-time tissue elastography is a marker of portal hypertension

PURPOSE

To prospectively correlate spleen elasticity and degree of portal hypertension estimated with the hepatic venous pressure gradient (HVPG) and to evaluate splenic elasticity as a predictor of gastroesophageal varices.

MATERIALS AND METHODS

The institutional review board approved this study, and patients provided written informed consent. In a pilot study of 60 patients with chronic liver damage, the authors measured liver and spleen elasticity with real-time tissue elastography (RTE), obtained serum markers related to fibrosis, examined hepatic and splenic blood flow with duplex Doppler ultrasonography, estimated HVPG, and performed upper gastrointestinal endoscopy. Then, with use of thresholds determined in the pilot study, the authors conducted a validation trial with another 210 patients, performing all studies except the measurement of HPVG. The relationship between HVPG and the other parameters was analyzed. Sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) in the diagnosis of gastroesophageal varices were calculated by using cutoff values obtained from receiver operating characteristic curves.

RESULTS

Among the parameters associated with HVPG, correlation was closest with splenic elasticity (R = 0.854, P < .0001). When 8.24 was selected as the cutoff of splenic elasticity for predicting HVPG of more than 10 mm Hg, the accuracy of diagnosing gastroesophageal varix was 90% (sensitivity, 96%; specificity, 85%; PPV, 83%; NPV, 97%). The results of the validation trial showed that the 8.24 cutoff for splenic elasticity was associated with a diagnostic accuracy of 94.8% (sensitivity, 98%; specificity, 93.8%; PPV, 82.1%; NPV, 99.4%) for gastroesophageal varices.

CONCLUSION

Splenic elasticity determined with RTE is the most closely associated parameter for evaluating HVPG and is useful as a clinical marker of portal hypertension and a predictive marker of gastroesophageal varices.

Liver fibrosis in patients with chronic hepatitis C: noninvasive diagnosis by means of real-time tissue elastography--establishment of the method for measurement

PURPOSE

To prospectively measure liver stiffness with real-time tissue elastography in patients with chronic hepatitis C and to compare the results with those of clinical assessment of fibrosis by using histologic stage as the reference standard.

MATERIALS AND METHODS

All subjects gave informed consent, and the study was approved by the institutional ethics committee. Seventy hospitalized patients (46 men, 24 women; mean age, 65.5 years ± 11.7 [standard deviation]; age range, 33-87 years) with chronic hepatitis C underwent real-time elastography between January 2009 and September 2009. Elastography was performed at four liver locations by two independent observers. The elastic ratio (ratio of the value in the intrahepatic venous small vessels divided by the value in the hepatic parenchyma) was calculated and was compared with histologic fibrosis stage at liver biopsy. The elastic ratio and clinical fibrosis markers were assessed by using receiver operating characteristic (ROC) analysis. The differences between body site and observers were assessed with κ statistics and intraclass correlation coefficients (ICCs).

RESULTS

Real-time tissue elastography cutoff values were 2.73 for F of 2 or greater, 3.25 for F of 3 or greater, and 3.93 for F of 4. No site differences were observed (κ = 0.835, ICC = 0.966), and the elastic ratio measurement was correlated between the two examiners (r(2) = 0.869, P < .0001). The areas under the ROC curves for elastic ratio, hyaluronic acid, type IV collagen, aspartate aminotransferase-to-platelet ratio index, FibroIndex, Forns score, and Hepascore were 0.95, 0.32, 0.73, 0.76, 0.76, 0.87, and 0.70, respectively; the elastic ratio performed better than the serum fibrosis markers and other scores.

CONCLUSION

Real-time tissue elastography is not invasive and could be used to evaluate liver fibrosis in patients with chronic hepatitis C.

SUPPLEMENTAL MATERIAL

http://radiology.rsna.org/lookup/suppl/doi:10.1148/radiol.10100319/-/DC1.

Transcatheter arterial chemoembolization with fine-powder cisplatin-lipiodol for HCC

BACKGROUND/AIMS

Fine-powder cisplatin has recently been developed, allowing the easy manufacture of high-density cisplatin-lipiodol suspensions. The aim of this study is to evaluate the efficacy and toxicity of transcatheter arterial chemoembolization (TACE) with fine-powder cisplatin and lipiodol suspension against advanced hepatocellular carcinoma (HCC).

METHODOLOGY

We prospectively analyzed 20 patients (16 men, 4 women) with inoperative advanced HCC without extrahepatic metastases who underwent TACE with fine-powder cisplatin and lipiodol suspension in our hospital between August 2006 and December 2008. All patients were administered a suspension of fine-powder cisplatin at 10 mg/1 cm of tumor diameter.

RESULTS

Partial response was seen in 10 cases, with stable disease in 7 cases and progressive disease in 3 cases. Overall response rate was 50%. The 1-year survival rate was 90%. Adverse effects (> or = grade 3) occurred in 40%, with vomiting in 5%, thrombocytopenia in 15%, elevated serum bilirubin in 20%, decreased serum albumin in 5%, fever in 65%, general fatigue in 15% and anorexia in 30%. However, no other life-threatening, adverse events were observed.

CONCLUSION

TACE with fine-powder cisplatin suspended in lipiodol provides better therapeutic efficacy, suggesting the potential usefulness of this agent in the treatment of advanced HCC.

Congenital hepatic fibrosis without any symptoms as diagnosed by laparoscopy

The present report represents the case of a 36-year-old woman with congenital hepatic fibrosis (CHF). She was admitted to our hospital because of gastric varices. She was asymptomatic and her liver function tests were within normal limits. Computed tomography showed hepatomegaly, splenomegaly and collateral circulation, but no evidence of liver cirrhosis. Real-time tissue elastography suggested severe fibrosis of the liver. Laparoscopy showed wide and discrete white markings on the surface of the liver and she was diagnosed with CHF based on the histological examination. The findings obtained from elastography and laparoscopy were useful for making the diagnosis of CHF.

Contrast-enhanced sonography with abdominal virtual sonography in monitoring radiofrequency ablation of hepatocellular carcinoma

BACKGROUND

Contrast-enhanced CT is regarded as the gold standard for monitoring radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC). Recently, 3-dimensional volume data from CT have been used to create cross-sectional multiplanar reconstruction images. Using this technique, we can reconstruct 2-dimensional CT images identical in orientation to ultrasound (US) images, which we call virtual sonographic (VUS) images. The present prospective randomized control trial compared the number of CT scans needed to assess the efficacy of RFA of HCC using VUS-contrast-enhanced ultrasonography (CEUS) versus CT.

METHOD

Subjects comprised 50 patients (50 HCCs) treated with US-guided RFA between May 2005 and August 2006, randomized to undergo assessment by CT (Group 1; 25 HCC nodules) or VUS-CEUS (Group 2; 25 HCC nodules). All patients were followed for 1 year. Primary endpoint was whether the number of CT scans could be reduced using VUS-CEUS.

RESULT

Mean number of CT scans required was 1.64 +/- 0.7 in Group 1 and 1.1 +/- 0.2 in Group 2 (p < 0.001).

CONCLUSION

VUS-CEUS can be used to assess the efficacy of HCC of RFA, with the potential to reduce the number of CT scans required for that purpose.

Usefulness of the hyperechoic rim for assessing the therapeutic efficacy of radiofrequency ablation in hepatocellular carcinoma patients

AIM

During radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC), a hyperechoic rim develops around the HCC nodules. The usefulness of the hyperechoic rim to guide treatment was assessed.

METHODS

RFA was first performed in pig livers to determine the significance of the hyperechoic rim. Fifty-five patients with 75 HCC nodules had received RFA for the treatment of HCC. For those patients, we evaluated whether conventional ultrasonography (US) could be used instead of contrast-enhanced computed tomography (CECT) and contrast-enhanced ultrasonography (CEUS) using virtual imaging. Finally, 31 patients with 45 HCC nodules received RFA, and the degree of ablation was assessed based on the hyperechoic rim. Repeated RFA was done when ablation appeared incomplete.

RESULTS

In the pig livers, the hyperechoic rim was found to be related to the presence of dead cells. The preliminary study showed that US could be used instead of CECT and CEUS to evaluate the degree of ablation caused by RFA. Because hepatic vessels in the back side of the hyperechoic rim were not clear by the artifact, we used the distance from the surface of the liver to the hyperechoic rim for evaluation. By analyzing the extent of the hyperechoic rim, it was noted that incomplete ablation was achieved in 17 of 31 patients (21 of 45 HCC nodules). These patients were re-treated with RFA within 5-15 min of the first RFA.

CONCLUSION

This study shows that the hyperechoic rim is related to the presence of dead and necrotic tissues. Thus, assessment of the hyperechoic rim's characteristics allows one to evaluate the efficacy of RFA.

Efficacy of laparoscopic radiofrequency ablation for hepatocellular carcinoma compared to percutaneous radiofrequency ablation with artificial ascites

AIM

Hepatocellular carcinoma (HCC) nodules close to the liver surface exhibit high recurrence compared to those in distal parts of the liver. Moreover, when nodules remain adjacent to the gastrointestinal tract or gallbladder, severe complications such as perforation of those organs may occur due to invasive therapy. Percutaneous radiofrequency ablation (PRFA) with artificial ascites or laparoscopic radiofrequency ablation (LRFA) are used to treat these patients to avoid complications. The purpose of the present study was to assess the efficacy and safety of these two methods.

METHODS

Subjects comprised 74 patients (48 men, 26 women; mean age, 68.5 +/- 8.0 years; range, 46-89 years) with 86 HCC nodules. PRFA with artificial ascites was carried out for 37 patients (44 nodules) and LRFA was used for 37 patients (42 nodules). Clinical profiles were compared between groups.

RESULTS

No significant differences in clinical profiles were found between patients treated by PRFA or LRFA. Mean number of treatments was significantly lower for LRFA (1.0 +/- 0.0) than for PRFA (2.1 +/- 1.0, P < 0.001). Mean number of PRFA treatments was 2.2 +/- 1.0 in patients with HCC nodules >2 cm in diameter, whereas all tumors were completely ablated with only one session of LRFA. The safety margin was significantly wider for LRFA than for PRFA.

CONCLUSION

LRFA is a better treatment option for ablation of HCC nodules >2.0 cm in diameter.

Efficacy of splenectomy for hypersplenic patients with advanced hepatocellular carcinoma

AIM

Chemotherapy for advanced hepatocellular carcinoma (HCC) patients with hypersplenism is generally unsatisfactory, as a lower-dose therapy is usually administered. Splenectomy may represent a better approach to overcoming the complication due to hypersplenism in patients with advanced HCC. This retrospective study was conducted to evaluate whether HCC patients who undergo splenectomy show improved prognosis.

METHODS

We examined 34 HCC patients. Twenty-two had thrombocytopenia and/or leucopenia and underwent laparoscopic splenectomy. The completion rate of full-dose drug regimens, the response rate, the toxicity of chemotherapy and the cumulative survival rate were compared between the splenectomy and non-splenectomy groups.

RESULTS

The response rate and the cumulative survival rate in the splenectomy group were significantly better than that in the non-splenectomy group.

CONCLUSIONS

Splenectomy is an efficient method for advanced HCC patients with hypersplenism treated by chemotherapy.

Neuropsychiatric dysfunction in patients with chronic hepatitis and liver cirrhosis

AIM

The aim of this study is to clarify the cerebral functions in patients with chronic hepatitis (CH) as well as those with liver cirrhosis (LC).

METHODS

We studied 58 patients with CH (20 in fibrosis stage F1, 20 in F2, 18 in F3), 77 with LC (46 rated as Child-Pugh class A, 24 as B, 7 as C), and 20 healthy volunteers (HV). Computer-aided quantitative neuropsychiatric function test systems, including eight neuropsychiatric tests were performed.

RESULTS

Subjects with results over the cut-off value for healthy subjects ranged from 11.1-28.6% in CH and 19.5-36.4% in LC. The percentages with abnormality in at least one test in CH and LC were 72.4% and 80.6%, respectively, which were significantly higher than that in the HV group (35.0%) (P = 0.003, P = 0.0003, respectively). Among CH subjects, those with three or more abnormal results in the F1, F2 and F3 subgroups were 15.0%, 20.0% and 38.9%, respectively. Among LC subjects, those with three or more abnormal results in the Child-Pugh class A, B and C subgroups comprised 30.4%, 50.0% and 57.1%, respectively. The rate in the CH F3 subgroup (P = 0.011) and in all three LC subgroups (P = 0.023, P = 0.001, P = 0.002, respectively) were significantly higher than that in the HV group.

CONCLUSION

The percentage of patients with neuropsychiatric function impairment was high in both LC and CH, especially in stage F3. Neuropsychiatric dysfunction may initiate in CH in a considerable number of patients.

Doppler waveform pattern changes in a patient with primary Budd-Chiari syndrome before and after angioplasty

A 34-year-old woman was admitted for treatment of esophageal varices. Seven years earlier, she had been diagnosed with Budd-Chiari syndrome, and percutaneous transluminal angioplasty (PTA) for right hepatic vein (RHV) stenosis was done. On admission, Doppler sonography showed a flat waveform in the RHV. RHV re-stenosis was confirmed on X-ray sonography. After PTA, the stenosis improved. Heterogeneous liver enhancement on enhanced computed tomography became homogeneous, her esophageal varices became inconspicuous, and the flat Doppler waveform pattern changed to a triphasic pattern. Doppler sonography was very useful for evaluating the effect of angioplasty and to diagnose re-stenosis.

Percutaneous ultrasound-guided radiofrequency ablation of hepatocellular carcinoma with artificially induced pleural effusion and ascites

BACKGROUND

Ultrasound-guided procedures are sometimes of limited use because the tumor is located under the diaphragm or near the surface of the liver. We investigated the safety and efficacy of radiofrequency ablation (RFA) with artificial pleural effusion and/or artificial ascites.

METHODS

Between January 2002 and May 2006, 43 lesions in 36 patients with hepatocellular carcinoma (HCC) were treated by RFA with artificial pleural effusion and/or artificial ascites.

RESULTS

Artificial pleural effusion allowed visualization of the whole tumor for 36 (83.7%) of the 43 lesions that were otherwise not detectable or poorly visible. Artificial ascites was also helpful in visualizing whole tumors that could not be visualized with only artificial pleural effusion. In all lesions, artificial pleural effusion and/or artificial ascites were helpful in performing percutaneous RFA. Artificial ascites was useful for creating a space between the liver's surface and the skin or diaphragm to avoid burns. Adverse effects after the induction of artificial pleural effusion included pneumonia in one patient and temporary atelectasis in another patient. Severe side effects were not observed. Complete necrosis after RFA was obtained in 43 (100%) of the 43 lesions. During a mean follow-up period of 31.8 +/- 5.8 months, local recurrence at the ablation site was found in none of the 43 lesions.

CONCLUSIONS

Percutaneous RFA with artificial pleural effusion and/or artificial ascites was a safe and useful treatment that resulted in good local control of HCC.

Usefulness of contrast-enhanced ultrasonography with abdominal virtual ultrasonography in assessing therapeutic response in hepatocellular carcinoma treated with radiofrequency ablation

OBJECTIVE

Contrast-enhanced computed tomography (CECT) is regarded as the gold standard for assessing the efficacy of radiofrequency ablation (RFA) against hepatocellular carcinoma (HCC). We evaluated the efficacy of virtual ultrasonography (VUS) with contrast-enhanced ultrasonography (CEUS) vs. CECT for assessing the response to RFA.

MATERIALS AND METHODS

Study 1: The therapeutic responses in 22 patients with 26 HCC nodules were assessed by CEUS with VUS as well as by CECT. The efficacy of treatment was based on whether the safety margin was greater than 5 mm after RFA. Study 2: In seven patients with seven HCC nodules, the nodules were treated by RFA and the therapeutic efficacy was assessed by CEUS with VUS. The number of RFA sessions was assessed.

RESULTS

Compared with CECT, CEUS with VUS had a specificity of 77%, a sensitivity of 91.6%, and an accuracy of 84%. When the therapeutic response to RFA was analyzed by CECT only, 1.86 +/- 0.69 assessments (mean) were required, while when response was assessed by CEUS with VUS, 1.14 +/- 0.38 CECT assessments were required (P = 0.03).

CONCLUSION

CEUS with VUS is effective in assessing the therapeutic response to RFA of HCC. Moreover, the number of CECT scans required is reduced by this approach.

[Basic and clinical studies on cefminox in obstetrics and gynecology]

Fundamental and clinical studies on cefminox (CMNX, MT-141), a new cephamycin antibiotic, were carried out and the results were as follows. After the intravenous one shot administration of 1 g CMNX to 17 cases, serum concentrations, tissue concentrations in pelvic organs and protein binding capacities in serum were measured. Blood concentrations ranged between 100-200 micrograms/immediately after the injection and declined gradually. Half-life (T1/2) was 75 minutes. Tissue concentrations were 30-70 micrograms/g (tissue weight) 10 minutes after injection and declined. Half-life was 90 minutes. The average serum protein binding rate was 66.3 +/- 8.4%. Correlation between tissue concentration (Y) and free serum concentration (X) was expressed as Y = 0.42 + 7.14X. Correlation coefficient (r) was 0.80 (r = 0.80). Correlation coefficient in serum concentrations between HPLC and bioassay was 0.83 and that in free concentration was 0.97. In clinical studies, CMNX was administered to 19 cases of obstetric and gynecological infections. The patients were constituted of 3 with puerperal endometritis, 3 with pyometra, 3 with pelvic peritonitis, 3 with parametritis, 3 with adnexitis, 2 with BARTHOLIN's abscess and 1 with retroperitoneal abscess and vulva abscess. Overall clinical efficacy was 89.5% (17/19). Bacteriologically 26 strains were isolated, 6 strains of E. coli, 4 strains of B. fragilis, 2 strains of P. anaerobius and P. asaccharolyticus and each one of E. faecalis, S. epidermidis, N. gonorrhoeae, S. marcescens, P. maltophilia, A. calcoaceticus, K. pneumoniae, P. mirabilis, H. influenzae, S. intermedius, E. lentum and F. varium. Twenty of these 24 strains were eliminated after the administration, K. pneumoniae was decreased, E. faecalis, S. marcescens and P. maltophilia remained unaffected. No side effects were observed but 1 case showed mild elevation of transaminases which normalized 1 week after CMNX was stopped.

[Clinical use of ticarcillin in the field of obstetrics and gynecology. Efficacy of ticarcillin in single administration and in combination therapy with S-sulfonated human immunoglobulin]

Single use of ticarcillin (TIPC, Monapen) was administered in 57 cases and combination therapy of TIPC and S-sulfonated human immunoglobulin (Venilon) was carried out in 23 patients who were either with severe infection, very old or in poor general conditions. The results obtained were as follows. Effective rate of single use of TIPC was 100% (3/3) in cases with infection, 50% (3/6) in cases with infection in which prior antibiotics therapy was poorly effective and 100% (48/48) in post operative cases. Effective rate of combination therapy of TIPC with S-sulfonated human immunoglobulin was 85.7% (6/7) in cases with infection, 71.4% (5/7) in cases with infection in which prior antibiotics therapy was poorly effective and 100% (9/9) in post operative cases. In laboratory findings, mild elevations of transaminase were recognized in 6 cases but restored to normal values without specific therapy. Side effect such as diarrhea, exanthema, fever, nausea and vomiting was not found in our cases.

[Clinical evaluation of BRL 25000 (clavulanic acid-amoxicillin) in the fields of obstetrics and gynecology]

BRL 25000 was administered to 37 cases with infections in the fields of obstetrics and gynecology, and the following results were obtained. The drug was administered to 17 cases with adnexitis, 13 cases with intrauterine infection and 7 cases with parametritis and/or inflammation of pelvic dead space, etc. The percentage of efficacy (excellent and good) was 74.3%. Of 7 cases where no therapeutic effect was obtained with other drugs, the percentage of efficacy was 57.1%. Antibacterial effect of BRL 25000 was studied in terms of percentage of eradication (including replacement) of clinical isolates. A high percentage of eradication (94.4% or 17/18) was obtained. Among all clinical isolates, 37.9% or 11/29 were beta-lactamase producing organisms. Eradication or replacement by BRL 25000 was noted in all these 9 strains, and BRL 25000 was proved to have a high efficacy also against penicillin or cephalosporin resistant organisms. No abnormality was noted in any patient in hematological, hepatic and renal function before and after administration of BRL 25000. As adverse reaction, diarrhea was found in 1 of 37 cases (2.7%), but it reduced after off-dose.