Pharmacological treatment of hepatocellular carcinoma with cavoatrial tumor thrombus - case series and literature review.

Hepatocellular carcinomas (HCC) that extend into the vena cava and the right atrium have a poor prognosis. Surgical approaches including partial hepatectomy and thrombectomy are the most frequently reported treatment options. However, most patients with advanced HCC are not eligible for complex surgical interventions due to reduced liver function, comorbidities, and metastases. At the same time, systemic treatment options of HCC have expanded in recent years. Here, we report 3 cases of patients with advanced HCC who developed a cavoatrial tumor thrombus (CATT) after initial surgical or interventional therapy. The patients were consequently treated with sorafenib or nivolumab. In all cases, the tumor responded to systemic treatment with disease stabilization or partial regression. Overall survival after diagnosis of CATT was 3 and 17 months for sorafenib and 7 + months for nivolumab. Compared to survival rates of alternative treatment options, systemic therapies demonstrated comparable outcomes. In summary, pharmacotherapy is an efficient and well worth option to treat patients with HCC and CATT and should be an integral part of a multimodal therapy concept.

The diagnosis and treatment of minimal hepatic encephalopathy.

BACKGROUND: The subtype of hepatic encephalopathy (HE) called minimal hepatic encephalopathy (MHE) is highly prevalent (22-74%) among patients with liver dysfunction. MEH is defined as HE without grossly evident neurologic abnormalities, but with cognitive deficits that can be revealed by psychometric testing. METHODS: This article is based on relevant original publications and reviews in English and German (1970-2011) that were retrieved by a selective key-word-based search in the Medline and PubMed databases. RESULTS: Despite its mild manifestations, MHE impairs patients' quality of life and their ability to work. It impairs driving ability and is associated with a higher rate of motor vehicle accidents. Furthermore, patients with MHE fall more often and are more likely to undergo progression to overt HE. The main pathophysiological mechanism of MHE is hyperammonemia leading to astrocyte dysfunction. Psychometric tests are the standard instruments for establishing the diagnosis; further, supportive diagnostic tools include neurophysiological tests and imaging studies. Recent randomized and controlled trials have revealed that treatment with lactulose or rifaximin therapy improves the quality of life of patients with MHE. Rifaximin was also found to improve driving performance in a simulator. A combination of these two drugs prevents the recurrence of episodic HE over a 6-months follow-up period. Moreover, small-scale trials have revealed that some dietary supplements can improve the cognitive deficits of MHE. CONCLUSION: Clinical trials have shown that patients with MHE and patients who have had an episode of overt HE in the past can benefit from drug treatment.