Provider Attitudes Toward Risk-Based Hepatocellular Carcinoma Surveillance in Patients With Cirrhosis in the United States.

BACKGROUND & AIMS: Hepatocellular carcinoma (HCC) surveillance rates are suboptimal in clinical practice. We aimed to elicit providers' opinions on the following aspects of HCC surveillance: preferred strategies, barriers and facilitators, and the impact of a patient's HCC risk on the choice of surveillance modality. METHODS: We conducted a web-based survey among gastroenterology and hepatology providers (40% faculty physicians, 21% advanced practice providers, 39% fellow-trainees) from 26 US medical centers in 17 states. RESULTS: Of 654 eligible providers, 305 (47%) completed the survey. Nearly all (98.4%) of the providers endorsed semi-annual HCC surveillance in patients with cirrhosis, with 84.2% recommending ultrasound ± alpha fetoprotein (AFP) and 15.4% recommending computed tomography (CT) or magnetic resonance imaging (MRI). Barriers to surveillance included limited HCC treatment options, screening test effectiveness to reduce mortality, access to transportation, and high out-of-pocket costs. Facilitators of surveillance included professional society guidelines. Most providers (72.1%) would perform surveillance even if HCC risk was low (≤0.5% per year), while 98.7% would perform surveillance if HCC risk was ≥1% per year. As a patient's HCC risk increased from 1% to 3% to 5% per year, providers reported they would be less likely to order ultrasound ± AFP (83.6% to 68.9% to 57.4%; P < .001) and more likely to order CT or MRI ± AFP (3.9% to 26.2% to 36.1%; P < .001). CONCLUSIONS: Providers recommend HCC surveillance even when HCC risk is much lower than the threshold suggested by professional societies. Many appear receptive to risk-based HCC surveillance strategies that depend on patients' estimated HCC risk, instead of our current "one-size-fits all" strategy.

Management of hepatocellular carcinoma recurrence after liver transplantation.

Despite careful selection for liver transplantation (LT) of patients with hepatocellular carcinoma (HCC), HCC may still recur after LT and is frequently associated with dismal outcome. Tumor factors, including serum alpha-fetoprotein (AFP), the presence of microvascular invasion, tumor grade/differentiation, and largest tumor size are amongst the most important predictors of recurrence after transplantation. The nature of recurrence can be highly variable, but often presents with extra-hepatic involvement. As such, management of patients with HCC can be challenging, and consensus guidelines are lacking. Curative options, with surgery or ablation, which may be applicable in patients with isolated intra-or extrahepatic metastases, offer the best chance for improved long-term outcome in patients with HCC recurrence after transplantation. Most patients with recurrence have unresectable disease, and may benefit from palliative treatments, including intra-arterial therapies and/or systemic therapy.

Genetic Variations Linked to Hepatocellular Carcinoma: Personalized Medicine Takes a Step Forward.

: There are strong associations between candidate genetic polymorphisms associated with intrahepatocyte lipid droplet accumulation and the development of cirrhosis, via a common sequence in which lipid accumulation is followed by chronic inflammatory injury and fibrogenesis. Hepatocellular carcinoma (HCC) has also been linked to genetic polymorphisms associated with intracellular lipid trafficking, although, as shown in the present study, not all the candidate polymorphisms implicated in fibrogenesis are also tied to HCC. Genetic analysis may identify at-risk persons who would most benefit from modifying life-style factors linked to cirrhosis and HCC, and also persons most likely to benefit from HCC surveillance.

Multidisciplinary Management of Hepatocellular Carcinoma Improves Access to Therapy and Patient Survival.

BACKGROUND: Given the complexity of managing hepatocellular carcinoma (HCC), it is widely accepted that a multidisciplinary team approach (tumor boards) offers the best approach to individualize therapy. The aim of this study was to determine utilization of therapies and outcomes for patients with HCC, comparing those managed through our multidisciplinary tumor board (MDTB) to those who were not. METHODS: A database analysis of all patients with HCC managed through our MDTB, from 2007 until 2011, was performed. A database of all patients with HCC from 2002 to 2011, not managed through MDTB, was similarly created. RESULTS: A total of 306 patients with HCC, from 2007 to 2011 were managed through our MDTB, in comparison with 349 patients, from 2002 to 2011 who were not. There were no significant differences in baseline demographic data or model for end-stage liver disease at presentation. Patients managed through MDTB were more likely to present at an earlier tumor stage and with lower serum alpha fetoprotein (AFP) (P=0.007). The odds of receiving any treatment for HCC was higher in patients managed through MDTB (odds ratio, 2.80; 95% confidence interval, 1.71-4.59; P<0.0001) independent of model for end-stage liver disease score, serum AFP, and tumor stage. There was significantly greater survival of patients managed through MDTB (19.1±2.5 vs. 7.6±0.9 mo, P<0.0001). Independent predictors for improved survival included management through MDTB, receipt of any HCC treatment, lower serum AFP, receipt of liver transplant, and T2 tumor stage. CONCLUSIONS: Patients with HCC managed through a MDTB had significantly higher rates of receipt of therapy and improved survival compared with those who were not.

The Utilization of Palliative Care Services in Patients with Cirrhosis who have been Denied Liver Transplantation: A Single Center Retrospective Review.

INTRODUCTION AND AIM: Utilization of palliative care services in patients dying of end-stage liver disease (ESLD) is understudied. We performed a retrospective review of palliative care services among patients with ESLD unsuitable for liver transplantation (LT) at a tertiary care center. MATERIAL AND METHODS: Deceased ESLD patients considered unsuitable for LT from 2007-2012 were identified. Patients were excluded if they received a transplant, had an incomplete workup, were lost to follow up or whose condition improved so LT was not needed. Of the 1,175 patients reviewed, 116 met inclusion criteria. RESULTS: Forty patients (34.4%) received an inpatient palliative care (PC) consultation and forty-one patients (35.3%) were referred directly to hospice. Thirty-three patients (28.4%) transitioned to comfort measures without PC consultation (median survival < 1 day). The median interval between LT denial and PC consultation or hospice was 28 days. Median survival after PC consult or hospice referral was 15 days. In conclusion, in a single center retrospective review of ESLD patients, palliative care services, when utilized, were for care at the very end of life. Without consultation, aggressive interventions continued until hours before death. We propose that ESLD patients could benefit from PC consultation at time of LT evaluation or based on MELD scores.

Psychosocial Barriers and Their Impact on Hepatocellular Carcinoma Care in US Veterans: Tumor Board Model of Care.

Background: Psychosocial barriers, including low socioeconomic status, homelessness, alcohol and substance use disorders, and psychiatric disorders are prevalent in US veterans. Our study aims to identify the prevalence of psychosocial barriers in veterans diagnosed with hepatocellular carcinoma (HCC), and their impact on receipt of cancer care. Methods: A retrospective cohort study was performed of all veterans diagnosed with HCC at the William S. Middleton Memorial Veterans' Hospital in Madison, Wisconsin, whose tumor care was coordinated through a multidisciplinary tumor board. Outcomes included receipt of any HCC-specific therapy and overall survival. Results: From January 1, 2007, through December 31, 2016, 149 veterans were diagnosed with HCC. Substance use disorders were reported in 124 (83%) patients, psychiatric illness was documented in 55 (37%) patients, 23 (15%) patients had incomes below the poverty threshold, and 7 (5%) were experiencing homelessness. The mean (SD) distance traveled for care was 207.1 (277.9) km; travel and lodging assistance were accessed by 50 (34%) and 33 (22%) veterans, respectively. Seventy-one patients (48%) had HCC exceeding T2 stage at diagnosis. Curative treatment was offered to 78 (52%) patients, with 127 (85%) receiving any HCC-specific care. Median survival from diagnosis was 727 days (95% CI, 488-966). Conclusions: Psychosocial barriers were common in our veteran cohort. Individualizing care, and coordination of travel and lodging, assisted in enabling high rates of receipt of HCC-specific therapy and improving patient survival.

A case of syphilitic hepatitis in an HIV-infected patient.

While the incidence of syphilis has been persistently on the rise in the United States, hepatitis as a complication of early syphilis is relatively uncommon. We present a case of a 51-year-old homosexual, HIV-positive man who presented with acute cholestatic hepatitis with a predominantly elevated alkaline phosphatase. After laboratory studies and imaging were unrevealing, a liver biopsy was performed that showed expanded portal tracts with a predominantly lymphoplasmacytic infiltrate and prominent bile ductular proliferation with periductal neutrophils. Testing revealed a positive rapid plasma reagin, and a subsequent Warthin-Starry stain of the liver tissue demonstrated the presence of scattered spirochetes, confirmed as Treponema pallidum spirochetes on immunohistochemistry testing. These findings confirmed a diagnosis of syphilitic hepatitis. With therapy, symptoms and liver enzymes rapidly normalized. Given the persistent rise in syphilis incidence along with the morbidity and mortality associated with a missed diagnosis, keen suspicion, early identification, and treatment are crucial.

The Utilization of Palliative Care Services in Patients with Cirrhosis who have been Denied Liver Transplantation: A Single Center Retrospective Review

ABSTRACT Introduction and aim. Utilization of palliative care services in patients dying of end-stage liver disease (ESLD) is understudied. We performed a retrospective review of palliative care services among patients with ESLD unsuitable for liver transplantation (LT) at a tertiary care center. Material and methods. Deceased ESLD patients considered unsuitable for LT from 2007-2012 were identified. Patients were excluded if they received a transplant, had an incomplete workup, were lost to follow up or whose condition improved so LT was not needed. Of the 1,175 patients reviewed, 116 met inclusion criteria. Results. Forty patients (34.4%) received an inpatient palliative care (PC) consultation and forty-one patients (35.3%) were referred directly to hospice. Thirty-three patients (28.4%) transitioned to comfort measures without PC consultation (median survival < 1 day). The median interval between LT denial and PC consultation or hospice was 28 days. Median survival after PC consult or hospice referral was 15 days. In conclusion, in a single center retrospective review of ESLD patients, palliative care services, when utilized, were for care at the very end of life. Without consultation, aggressive interventions continued until hours before death. We propose that ESLD patients could benefit from PC consultation at time of LT evaluation or based on MELD scores.