Spontaneously ruptured hepatocellular carcinoma on non-cirrhotic liver: A prospective case series.

BACKGROUND AND AIMS: Spontaneous ruptured hepatocellular carcinoma is an uncommon complication, and there are scarce data about non-cirrhotic patients. Tumor treatment is not standardized and the risk of peritoneal dissemination is unclear. AIM: we analyzed the treatment and survival in patients with rHCC on non-cirrhotic liver. METHODS: One hundred and forty-one non-cirrhotic patients with hepatocellular carcinoma diagnosed by histology were included in a multicenter prospective registry (2018-2022). Seven of them (5%) presented with hemoperitoneum due to spontaneous rupture. RESULTS: Liver disease was associated in three patients (42.9%). A single nodule was detected in three cases (42.9%). One patient had vascular invasion and none extrahepatic spread. Initial hemostatic therapy and sequential treatment was individualized. Patients with single nodule were treated: resection (one case) with recurrence at 4 months treated with TACE and sorafenib. TACE/TAE followed by surgery (two cases) one in remission 43 months later, the other had liver recurrence at 18 months and was transplanted. Patients with multiple lesions were treated: TAE/emergency surgery and subsequent systemic therapy (two cases), one received lenvatinib (1-year survival) and the other sorafenib (5-month survival). TAE and surgery with subsequent systemic therapy (one case). Initial hemostatic surgery, dying on admission (one case). No patient developed intraperitoneal metastasis. All patients with multiple lesions died by tumor. The 3-year survival rate was 42.9%. CONCLUSIONS: Initial hemostasis was achieved in all patients by TAE/TACE or surgery. Subsequent treatment was individualized, based on tumor characteristics, regardless of rupture. Long-time remission could be achieved in single nodule patients.

[Therapeutic decisions in the treatment of hepatocellular carcinoma and patterns of sorafenib use. Results of the international observational GIDEON trial in Spain]. / Decisiones terapéuticas en el tratamiento del carcinoma hepatocelular y patrones de uso de sorafenib. Resultados del estudio internacional observacional GIDEON en España.

INTRODUCTION: GIDEON is a non-interventional, prospective, international study that evaluated the safety of sorafenib in patients with unresectable hepatocellular carcinoma (HCC) in daily clinical practice, including Child-Pugh B patients. OBJECTIVES: To analyze data collected in Spain on the safety and efficacy of sorafenib and treatment patterns. METHODS: Data were collected during follow-up on demographic and disease characteristics, the initial dose used, treatment-emergent adverse events (AEs) and dose modifications. Overall survival was evaluated, as well as time to disease progression. Efficacy and safety were analyzed according to the Child-Pugh classification and the initial dose. RESULTS: We included 143 patients from 19 Spanish hospitals. A total of 24.5% of the patients were Child-Pugh B. An initial dose of 400 mg/12 h was used in 90.9% of patients. In Child-Pugh A patients, dose modifications occurred more frequently and the treatment duration was longer. The incidence of AEs and drug-related AEs were similar in Child-Pugh A and B patients, although serious AEs were more frequent in Child-Pugh B patients. The most common AEs were diarrhea, fatigue and hand-foot skin reactions. The median overall survival was 384 days and was higher in Child-Pugh A patients (593 vs. 211 days in Child-Pugh B). The median time to disease progression was 177 days, similar in both subgroups. CONCLUSION: The safety profile of sorafenib in Spanish patients with unresectable HCC is independent of liver function. Child-Pugh status does not seem to influence the approach to sorafenib dosage or time to progression but does seem to be a strong prognostic factor for survival.

Safety and diagnostic accuracy of percutaneous ultrasound-guided biopsy of the spleen: a multicenter study.

PURPOSE: To analyze the safety and accuracy of ultrasound-guided (USG) percutaneous needle biopsy of the spleen. METHODS: Sixty-two USG needle biopsies performed in 52 patients were retrospectively analyzed: there were 53 biopsies of local lesions and 9 biopsies of diffuse lesions. Fine-needle aspiration (FNA) was performed in 37 cases and core-needle biopsy (CNB) in 25 cases. The complications and diagnostic accuracy of the 2 types of biopsy were compared. RESULTS: Two patients (3.8%) had postprocedural hemorrhage after CNB; one was minor, and the other severe, requiring splenectomy. No bleeding occurred with FNA. The diagnostic accuracy was similar with FNA (86.5%) and CNB (92%), whereas in patients with lymphoma, accuracy of FNA (80%) tended to be lower than that of CNB (100%), although the difference was not statistically significant. CONCLUSION: USG needle biopsy is safe and effective for diagnosing both focal and diffuse splenic lesions. The risk of bleeding may be lower with FNA than with CNB.

Clinical characteristics of hepatocellular carcinoma in Spain. Comparison with the 2008-2009 period and analysis of the causes of diagnosis out of screening programs. Analysis of 686 cases in 73 centers. / Características clínicas del carcinoma hepatocelular en España. Comparación con el período 2008-2009 y análisis de las causas del diagnóstico fuera de cribado. Estudio de 686 casos en 73 centros.

BACKGROUND AND OBJECTIVE: In 2010 we published that 53% of cases of hepatocellular carcinoma (HCC) detected in Spain were diagnosed outside the context of standard screening programs, which consequently leads to lower survival rates. The aim of this study was to analyze the current situation and the causes of diagnosis out of screening programs. MATERIAL AND METHODS: Prospective registry of 73 second- and third-level Spanish healthcare centers carried out between October 1, 2014 and January 31, 2015. The baseline characteristics of the disease and the first treatment administered for the incidental primary liver tumors during such period were recorded. RESULTS: A total of 720 patients were included in the study: HCC (n=686), intrahepatic cholangiocarcinoma (n=29), hepatic cholangiocarcinoma (n=2), other (n=3). HCC characteristics: male 82%; mean age 67 years; cirrhosis 87%; main etiologies: alcohol 35%, HCV 30%, alcohol and HCV 15%, non-alcoholic fatty liver disease 6%; tumor stage: BCLC-0 11%, A 43%, B 19%, C 16% and D 11%; first treatment: transarterial chemoembolization (23%), percutaneous ablation (22%), symptomatic treatment (20%), resection (11%), sorafenib (11%). Three hundred and fifty-six patients (53%) were diagnosed outside of screening programs, mainly owing to the fact that they suffered from an undiagnosed liver disease (76%) and to the poor adherence to the screening program (18%). These patients were mainly male (P<.001), with an alcoholic etiology (P<.001) and active alcohol consumption (P<.001). Moreover, the disease was predominantly diagnosed at more advanced stages (P<.001) and was addressed with less radical treatments (P<.001). CONCLUSIONS: In Spain, the main cause of diagnosis of a HCC outside the context of a screening program is the absence of a prior diagnosis of a liver disease, particularly in alcohol-consuming men. Detecting a liver disease in asymptomatic populations and improving adherence to screening programs are the main areas that must be subject to improvement in order to improve the early detection of HCC.

Dilutional hyponatremia in patients with cirrhosis and ascites.

OBJECTIVES: To analyze the predisposing factors, modifications of vasoactive systems, and prognosis of patients with cirrhosis and hyponatremia. PATIENTS AND METHODS: Fifty-four patients with hyponatremia (serum sodium level of <130 mEq/L after 5 days of hyponatremic diet and no diuretic therapy). Twenty cirrhotic patients served as controls. We measured plasma renin activity and levels of plasma aldosterone, norepinephrine, and antidiuretic hormone. Follow-up identified the development of hepatorenal syndrome and death. RESULTS: A higher percentage of patients with hyponatremia had decreased liver size, higher levels of plasma renin activity, and higher serum concentrations of aldosterone and norepinephrine. Renal insufficiency was detected in 31 of them (57%). Precipitating factors (hemorrhage or infections) were detected in 27 patients (50%). Incidence of hepatorenal syndrome and death were higher in patients with spontaneous development of hyponatremia (n = 23 [85%] and n = 25 [93%], respectively) than in patients with precipitating factors (n = 15 [56%] and n = 12 [44%], respectively) and cirrhotic controls (n = 1 [5%] and n = 5 [25%], respectively) (P<.001). Results of multivariate analysis showed that Child-Pugh index, presence of hepatocarcinoma, and serum concentration of urea were associated with mortality. After excluding those patients with kidney failure at the time of admission, only Child-Pugh index and norepinephrine concentrations were independent predictors of mortality. CONCLUSIONS: Hyponatremia is an alteration in patients with advanced liver disease. Although survival is significantly reduced in patients with spontaneous development of hyponatremia, a reduced sodium concentration cannot be considered as a independent predictor of the risk for death.

Implication of inflammation-related cytokines in the natural history of liver cirrhosis.

BACKGROUND/AIMS: Increased serum concentrations of pro-inflammatory cytokines have been detected in patients with liver cirrhosis. However, their role in the natural history of cirrhosis and portal hypertension, in the absence of infection, and the prognostic significance of inflammation-related cytokines have not been reported. Our objective was the analysis of the prognostic value of inflammation-related cytokines in cirrhotic patients. PATIENTS AND METHODS: Serum concentrations of tumor necrosis factor (TNF-alpha) and its soluble receptors I and II and interleukin 6 (IL-6), as well as mean blood pressure, plasma renin activity, aldosterone, vasopressin and norepinephrine concentrations were determined in 72 cirrhotic patients (Child-Pugh score: A 50%, B 33.3%, C 16.7%), without any evidence of infection, and in 25 healthy controls. Patients were followed up for a median of 35.9 (range 6-60) months. RESULTS: Increased concentrations of soluble TNF receptors were detected in cirrhotic patients when compared with healthy controls. TNF receptors and IL-6 concentrations were both significantly more elevated in advanced phases of cirrhosis (Child-Pugh score C vs B and vs A). Sixteen patients died as a related consequence of liver cirrhosis. Multivariant analysis demonstrated that Child-Pugh score, mean blood pressure and serum levels of TNF receptor I were associated with mortality. CONCLUSIONS: In addition to the classic factors implicated in mortality (Child-Pugh score and hemodynamic parameters), alterations in inflammation-related components are of prognostic significance in cirrhotic patients.