Outcome of liver cancer patients with SARS-CoV-2 infection: An International, Multicentre, Cohort Study.

BACKGROUND & AIMS: Information about the impact of severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) in patients with liver cancer is lacking. This study characterizes the outcomes and mortality risk in this population. METHODS: Multicentre retrospective, cross-sectional, international study of liver cancer patients with SARS-CoV-2 infection registered between February and December 2020. Clinical data at SARS-CoV-2 diagnosis and outcomes were registered. RESULTS: Two hundred fifty patients from 38 centres were included, 218 with hepatocellular carcinoma (HCC) and 32 with intrahepatic cholangiocarcinoma (iCCA). The median age was 66.5 and 64.5 years, and 84.9% and 21.9% had cirrhosis in the HCC and iCCA cohorts respectively. Patients had advanced cancer stage at SARS-CoV-2 diagnosis in 39.0% of the HCC and 71.9% of the iCCA patients. After a median follow-up of 7.20 (IQR: 1.84-11.24) months, 100 (40%) patients have died, 48% of the deaths were SARS-CoV-2-related. Forty (18.4%) HCC patients died within 30-days. The death rate increase was significantly different according to the BCLC stage (6.10% [95% CI 2.24-12.74], 11.76% [95% CI 4.73-22.30], 20.69% [95% CI 11.35-31.96] and 34.52% [95% CI 17.03-52.78] for BCLC 0/A, B, C and D, respectively; p = .0017). The hazard ratio was 1.45 (95% CI 0.49-4.31; p = .5032) in BCLC-B versus 0/A, and 3.13 (95% CI 1.29-7.62; p = .0118) in BCLC-C versus 0/A in the competing risk Cox regression model. Nineteen out of 32 iCCA (59.4%) died, and 12 deaths were related to SARS-CoV-2 infection. CONCLUSIONS: This is the largest cohort of liver cancer patients infected with SARS-CoV-2. It characterizes the 30-day mortality risk of SARS-CoV-2 infected patients with HCC during this period.

International and multicenter real-world study of sorafenib-treated patients with hepatocellular carcinoma under dialysis.

BACKGROUND & AIMS: Information on safety and efficacy of systemic treatment in patients with hepatocellular carcinoma (HCC) under dialysis are limited due to patient exclusion from clinical trials. Thus, we aimed to evaluate the rate, prevalence, tolerability, and outcome of sorafenib in this population. METHODS: We report a multicenter study comprising patients from Latin America and Europe. Patients treated with sorafenib were enrolled; demographics, dose modifications, adverse events (AEs), treatment duration, and outcome of patients undergoing dialysis were recorded. RESULTS: As of March 2018, 6156 HCC patients were treated in 44 centres and 22 patients were concomitantly under dialysis (0.36%). The median age was 65.5 years, 40.9% had hepatitis C, 75% had Child-Pugh A, and 85% were Barcelona Clinic Liver Cancer-C. The median time to first dose modification, treatment duration and overall survival rate were 2.4 months (interquartile ranges [IQR], 0.8-3.8), 10.8 months (IQR, 4.5-16.9), and 17.5 months (95% CI, 7.2-24.5), respectively. Seventeen patients required at least 1 dose modification. The main causes of first dose modification were asthenia/worsening of Eastern Cooperative Oncology Group-Performance Status and diarrhoea. At the time of death or last follow-up, four patients were still on treatment and 18 had discontinued sorafenib: 14 were due to tumour progression, 2 were sorafenib-related, and 2 were non-sorafenib-related AE. CONCLUSIONS: The outcomes observed in this cohort seem comparable to those in the non-dialysis population. Thus, to the best of our knowledge, this is the largest and most informative dataset regarding systemic treatment outcomes in HCC patients undergoing dialysis.

Phytase and xylanase in diets with nutritional adjustments and their effects on serum biochemistry, morphometry and intestinal health of broilers.

To examine the association between phytase and xylanase in diets with nutritional adjustments on intestinal morphometry, serum biochemistry and microbiology of broilers, 250 broilers were evaluated in a completely randomized design with five treatments and five replicates. The following treatments were tested: positive control diet - without phytase or xylanase; negative control diet - with an energy reduction of 100 kcal/kg, without phytase or xylanase; and three diets containing xylanase and phytase and energy reductions of 50, 100 and 150 Kcal/kg. For all energy-reduced diets, the nutritional matrix of phytase with phosphorus (0.15%), calcium (0.165%) and sodium (0.035%) was considered. An effect of the association between enzyme inclusion and metabolizable energy reduction in the diets was observed only by contrast analysis, for villus height. Intestinal health was not changed. Only the serum phosphorus concentration was altered by the treatments at the different evaluated ages. The association of phytase (500 FTU/kg) with xylanase (16000 BXU/kg) in diets with reductions of up to 150 Kcal/kg metabolizable energy, 0.15% digestible P, 0.165% Ca and 0.035% Na does not alter the intestinal morphometry, serum biochemistry or microbiology of broilers.

Antimicrobial Potential of Essential Oils from Cerrado Plants against Multidrug-Resistant Foodborne Microorganisms.

Foodborne pathogens are a real public health concern in an escalating antimicrobial resistance scenario. Natural products represent a promising source of bioactive molecules, and essential oils have attracted much attention due to their myriad of biological properties, including antibacterial activities. In this context, essential oils obtained from the leaves of Chromolaena squalida, Campomanesia sessiliflora, Myrsine guianensis, Matayba guianensis, Siparuna guianensis, Ocotea minarum and Endlicheria paniculata-species from the Cerrado biome of Midwest Brazil-were extracted and evaluated for their antibacterial activity against a panel of four standard and three clinical multidrug-resistant bacterial strains. All tested oils showed moderate to good activity against at least four bacterial strains, including Salmonella Typhi and oxacillin-resistant Staphylococcus. The essential oils from C. squalida, C. sessiliflora, My. guianensis and Ma. guianensis showed strong inhibition of clinical Staphylococcus strains, which cause bovine mastitis and are related to milk-borne diseases. Their chemical profiles were investigated by gas chromatography coupled to mass spectrometry (GC/MS), which revealed a predominance of mono- and sesquiterpene hydrocarbons, some of which with well-known antimicrobial properties. The essential oil from Cerrado plants proved active against resistant Gram-positive and Gram-negative bacteria, revealing their potentialities for the development of new alternative agents to prevent the spreading of resistant bacterial contamination.

Risk of recurrence of hepatocellular carcinoma in patients treated with interferon-free antivirals. / Riesgo de recurrencia del carcinoma hepatocelular en pacientes tratados con antivirales libres de interferón.

Eradication of the hepatitis C virus (HCV) with interferon-free therapies (DAAs) has modified the course of the disease, as the rate of patients with compensated cirrhosis who achieve a sustained virological response exceeds 95%. However, the impact on development of hepatocellular carcinoma (HCC) is currently in dispute. This argument could be divided into different key points: the impact of DAA on rate of HCC recurrence, the temporal link between starting DAAs and HCC recurrence, and finally, the aggressive pattern of HCC. Therefore, the aim of this review is to analyse the available results in this population of patients from a clinical perspective where the risks and benefits of HCV eradication with DAA therapies are evaluated in patients with complete response of HCC.

Survival and tolerance to sorafenib in Child-Pugh B patients with hepatocellular carcinoma: a prospective study.

Sorafenib has been widely used to treat unresectable hepatocellular carcinoma (HCC) but most studies have been done in Child-Pugh A (CP-A) patients with well-preserved liver function. We evaluated the overall survival (OS) and tolerance to sorafenib in a large cohort of Child-Pugh B (CP-B) HCC patients as compared to CP-A HCC patients. We prospectively studied 130 patients with advanced HCC who started sorafenib between January 2011 and December 2015. Patients were classified as CP-A (n = 65) or CP-B (n = 65). The average OS for all 130 patients was 10 months. CP-A patients had a median survival rate significantly longer than CP-B patients: 12 months vs. 6 months. The OS found in our group of CP-B patients was 6.5 months, which is higher than that found in most studies done so far. When stratified, our CP-B patients had better OS than ever reported. The dose of the drug was interrupted due to adverse events (AEs) in 38 (29%) of the patients, of whom 20 (30%) were CP-A patients and 18 (28%) were CP-B patients. This real-life cohort of CP-B HCC patients treated with sorafenib had a higher survival than that described in the literature, with a satisfactory safety profile. Despite the high prevalence of severe AEs in CP-B patients, there were fewer treatment interruptions in this group, indicating that Child-Pugh B patients can tolerate treatment and may benefit from sorafenib.

Photoinactivation effect of eosin methylene blue and chlorophyllin sodium-copper against Staphylococcus aureus and Escherichia coli.

The use of eosin methylene blue according to Giemsa as photosensitizer is presented for the first time in this paper. The present study evaluated the potential application of chlorophyllin sodium copper salt (CuChlNa) and eosin methylene blue according to Giemsa (EMB) as antimicrobial photosensitizers (aPS) for photodynamic inactivation (PDI) of Staphylococcus aureus (gram-positive) and Escherichia coli (gram-negative) bacteria. The experiments were performed using S. aureus stain ATCC 25923 and E. coli ATCC 25922 in which five aPS concentrations (0.0, 1.0, 2.5, 5.0, 10.0, and 20.0 µM for S. aureus and 0.0, 5.0, 10.0, 20.0, 40.0, and 50.0 µM for E. coli) were prepared and added in 2 mL of a saline solution containing the bacterial inoculum. After aPS incubation, the samples were divided into two groups, one kept in the dark and another submitted to the illumination. Then, the bacterial inactivation was determined 18 h after the incubation at 37 °C by counting the colony-forming units (CFU). The results revealed that both EMB and CuChlNa can be used as aPS for the photoinactivation of S. aureus, while only EMB was able to photoinactivate E. coli. Nevertheless, a more complex experimental setup was needed for photoinactivation of E. coli. The data showed that EMB and CuChlNa presented similar photoinactivation effects on S. aureus, in which bacterial growth was completely inhibited at photosensitizer (PS) concentrations over 5 µM, when samples were previously incubated for 30 min and irradiated by a light dose of 30 J cm-2 as a result of an illumination of 1 h at 8.3 mW cm-2 by using a red light at 625 nm with a 1 cm beam diameter and output power of 6.5 mW. In the case of E. coli, bacterial growth was completely inhibited only when combining a PS incubation period of 120 min with concentrations over 20 µM.

Incidence and Risk Factors of Hepatocellular Carcinoma in Patients with Chronic Hepatitis C Treated with Direct-Acting Antivirals.

BACKGROUND: Conflicting data regarding the incidence of hepatocellular carcinoma (HCC) after cure of HCV infection with direct-acting antivirals (DAAs) remains. We investigated the incidence and risk factors to HCC after treatment with DAAs followed up for five years. METHODS: A total of 1075 HCV patients ≥ 18 years were treated with DAAs from 2015 to 2019 and followed until 2022. Ultrasonography was performed before DAAs and each 6 months thereafter. RESULTS: Of the total, 51/1075 (4.7%) developed HCC in the median of 40 (IQR 25-58) months: 26/51 (51%) male, median age 60 (IQR 54-66) years, alpha-fetoprotein (AFP) 12.2 (IQR 6.1-18.8) ng/mL, 47/51 (92.1%) cirrhotic 78.7%, 8/51 (15.7%) without sustained virological response (SVR). Seventeen percent had non-characterized nodules before DAAs. Cumulative HCC incidence was 5.9% in 5 years. Overall incidence was 1.46/100 patient-years (PY) (95% CI = 1.09-1.91), being 2.31/100 PY (95% CI = 1.70-3.06), 0.45/100 PY (95% CI = 0.09-1.32) and 0.20/100 PY (95% CI 0.01-1.01) in METAVIR F4, F3 and F2, respectively, and the main risks to HCC were non-characterized nodule, cirrhosis, high AFP values and non-SVR. CONCLUSION: HCV cure reduced risk for HCC, but it still occurred particularly in cirrhotic patients. Some risk factors can be identified to predict early HCC diagnosis.

Multi-resistant diarrheagenic Escherichia coli identified by FTIR and machine learning: a feasible strategy to improve the group classification.

The identification of multidrug-resistant strains from E. coli species responsible for diarrhea in calves still faces many laboratory limitations and is necessary for adequately monitoring the microorganism spread and control. Then, there is a need to develop a screening tool for bacterial strain identification in microbiology laboratories, which must show easy implementation, fast response, and accurate results. The use of FTIR spectroscopy to identify microorganisms has been successfully demonstrated in the literature, including many bacterial strains; here, we explored the FTIR potential for multi-resistant E. coli identification. First, we applied principal component analysis to observe the group formation tendency; the first results showed no clustering tendency with a messy sample score distribution; then, we improved these results by adequately selecting the main principal components which most contribute to group separation. Finally, using machine learning algorithms, a predicting model showed 75% overall accuracy, demonstrating the method's viability as a screaming test for microorganism identification.

Surgical gowns as a safety barrier under non-standard environmental conditions.

In this prospective study, we aimed to investigate whether surgical gowns become contaminated during surgery. Samples from the gowns of five surgeons during 19 surgeries were collected using sterile swabs in circular standard delimited areas on both wrists and the mid-chest at three time-points: immediately before surgical incision (t=0), 30 min (t=30), and 60 min (t=60) later. Additionally, at t=0 and t=60, three settle plates of plate count agar were positioned at 1.5 m from the ground and remained open for 20 min. The operating room temperature and relative humidity were monitored. The swabs were cultivated and incubated, and colony-forming units per gram (CFU/g) counts were measured. The CFU/g counts for bacteria or fungi did not differ among the three sampling sites. The surgeons' lateral dominance in manual dexterity did not influence the gowns' contamination. There were significant variations in the temperature and relative humidity over time, but not in the CFU/g counts. In conclusion, during the first hour of surgery, surgical gowns did not become a source of contamination and are an effective barrier against bacterial and fungal contamination even under non-standard surgical environmental conditions.

BRAZILIAN SOCIETY OF HEPATOLOGY UPDATED RECOMMENDATIONS FOR SYSTEMIC TREATMENT OF HEPATOCELLULAR CARCINOMA.

Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related mortality worldwide. The Brazilian Society of Hepatology (SBH) published in 2020 the updated recommendations for the diagnosis and treatment of HCC. Since then, new data have emerged in the literature, including new drugs approved for the systemic treatment of HCC that were not available at the time. The SBH board conducted an online single-topic meeting to discuss and review the recommendations on the systemic treatment of HCC. The invited experts were asked to conduct a systematic review of the literature on each topic related to systemic treatment and to present the summary data and recommendations during the meeting. All panelists gathered together for discussion of the topics and elaboration of the updated recommendations. The present document is the final version of the reviewed manuscript containing the recommendations of SBH and its aim is to assist healthcare professionals, policy-makers, and planners in Brazil and Latin America with systemic treatment decision-making of patients with HCC.

Molecular and phenotypic characterization of Escherichia coli from calves in an important meat-producing region in Brazil.

INTRODUCTION: Escherichia coli strains that lead to enteritis are considered an important cause of diarrhea in calves. For correct identification, these microorganisms must be differentiated from non-pathogenic members of the intestinal microbiota. The aim of the present work was to characterize E. coli isolates in calves regarding the presence of virulence genes that cause enteritis and evaluate the sensitivity of the isolates to different antimicrobials. METHODOLOGY: One hundred forty-nine samples from beef cattle and 27 samples from dairy cattle were evaluated. All samples were submitted to microbiological identification and the disk diffusion antibiogram test. The polymerase chain reaction method was used to detect virulence genes. RESULTS: A hundred seventy-six samples were biochemically identified as E. coli and antibiograms were determined. The samples were then submitted to PCR; 35 were positive for the eae gene (19.88%), 135 (76.70%) for the stx1 gene, 62 (35.22%) for the stx2 gene, 159 (90.34%) for the sta gene and 35 (19.88%) for the ltII gene. No samples were positive for the cnf gene. Based on these results, the E. coli isolates were classified into pathotypes: enteropathogenic (n = 3), enterohemorrhagic (n = 32), Shiga toxin-producing (n = 122) and enterotoxigenic (n = 163). The antimicrobial sensitivity tests revealed that 77.2% of the isolates were resistant to three or more pharmacological groups, characterizing these isolates as multidrug resistant. CONCLUSIONS: Enterotoxigenic E. coli was the predominant pathotype. Moreover, the prevalence of multidrug-resistant isolates was very high, accounting for the vast majority of isolates.

Outbreaks of Brachiaria ruziziensis and Brachiaria brizantha intoxications in Brazilian experienced cattle.

Brachiaria species are some of the most used forage species for raising Brazilian cattle because of their great nutritional value and adaptability to the tropical climate. However, cases of animal intoxication have been described. Animal species, age, genetic resistance, and previous adaptation to the forage can influence the susceptibility to intoxication. Cattle (young or adults), other adult ruminants and animals adapted to consumption (experienced flocks) are considered more resistant. The main clinical presentation is that of hepatogenous photosensitization. Brachiaria brizantha and Brachiaria ruziziensis are considered less toxic. The aim of this study is to describe three outbreaks of intoxication by B. brizantha and B. ruziziensis in experienced cattle, as well as to compare the concentrations of protodioscin in paddocks with and without clinical cases. It was observed that the two forage species are toxic to all age groups of cattle adapted to their consumption, and the concentrations of protodioscin present in the plant cannot be used as the only criterion for determining the occurrence of intoxication.

Mutational profile of skin lesions in hepatocellular carcinoma patients under tyrosine kinase inhibition: a repercussion of a wide-spectrum activity.

BACKGROUND/AIM: Dermatological adverse events (DAE) in hepatocellular carcinoma (HCC) patients treated with sorafenib predicts better outcome. Some turn into skin lesions (SL) requiring pathology examination. We describe incidence, characteristics and molecular profile of SL in HCC patients treated with sorafenib. MATERIALS AND METHODS: SL were prospectively collected in 311 HCC patients who started sorafenib. SL from sorafenib cohort were compared to those from a control patient group selected to match SL type and demographics. HRAS, KRAS and BRAF mutations were analyzed by CAST-PCR, mutated p53 and MAPK pathway activation by immunohistochemistry and immune infiltration by hematoxylin-eosin staining. RESULTS: Eighty-eight out of 311 patients developed DAE and 7.4% SL required histological assessment. Most frequent lesions were keratoacanthomas (n = 4), squamous-cell carcinomas (SCC)(n = 5), basal-cell carcinomas (BCC)(n = 3) and seborrheic keratosis (n = 5). HRAS and KRAS mutations were detected in 4 SL, while no mutations showed in control SL. Nuclear pERK immunostaining was identified in 33.3% of cases versus 5.3% of controls. Most SL (90%) from patients with DAE were proliferative with intense immune infiltration (73%). CONCLUSIONS: The onset of SL and their molecular profile did not impact negatively on patient's prognosis, but intense proliferation of SL may reflect compensatory activation of MAPK pathway and warrants their close monitoring.

Assessing the impact of COVID-19 on liver cancer management (CERO-19).

BACKGROUND & AIMS: The coronavirus disease 2019 (COVID-19) pandemic has posed unprecedented challenges to healthcare systems and it may have heavily impacted patients with liver cancer (LC). Herein, we evaluated whether the schedule of LC screening or procedures has been interrupted or delayed because of the COVID-19 pandemic. METHODS: An international survey evaluated the impact of the COVID-19 pandemic on clinical practice and clinical trials from March 2020 to June 2020, as the first phase of a multicentre, international, and observational project. The focus was on patients with hepatocellular carcinoma or intrahepatic cholangiocarcinoma, cared for around the world during the first COVID-19 pandemic wave. RESULTS: Ninety-one centres expressed interest to participate and 76 were included in the analysis, from Europe, South America, North America, Asia, and Africa (73.7%, 17.1%, 5.3%, 2.6%, and 1.3% per continent, respectively). Eighty-seven percent of the centres modified their clinical practice: 40.8% the diagnostic procedures, 80.9% the screening programme, 50% cancelled curative and/or palliative treatments for LC, and 41.7% modified the liver transplantation programme. Forty-five out of 69 (65.2%) centres in which clinical trials were running modified their treatments in that setting, but 58.1% were able to recruit new patients. The phone call service was modified in 51.4% of centres which had this service before the COVID-19 pandemic (n = 19/37). CONCLUSIONS: The first wave of the COVID-19 pandemic had a tremendous impact on the routine care of patients with liver cancer. Modifications in screening, diagnostic, and treatment algorithms may have significantly impaired the outcome of patients. Ongoing data collection and future analyses will report the benefits and disadvantages of the strategies implemented, aiding future decision-making. LAY SUMMARY: The coronavirus disease 2019 (COVID-19) pandemic has posed unprecedented challenges to healthcare systems globally. Herein, we assessed the impact of the first wave pandemic on patients with liver cancer and found that routine care for these patients has been majorly disrupted, which could have a significant impact on outcomes.

The gynecological examination in Pantaneiro mares.

Gynecological examination is essential to assess the reproductive tract of mares and can provide important information about the uterine environment. It includes physical, vaginal, and rectal examination, ultrasound, cytology, culture, and endometrial biopsy. The present study aimed to perform gynecological examination and fertility to assess the fertility prognosis of Pantaneiro mares that have not been reproductively active and to determine their reproductive ability. Eight mares underwent ultrasound and gynecological examination and artificial insemination. Ultrasound revealed changes only in one mare. Histopathological findings were mild, such as periglandular and perivascular inflammatory cell infiltrates, fibrotic areas, glandular dilation, glandular island formation, and edema due to the phase of the estrous cycle. One animal was classified in category I and the others in category IIA. Cytological changes were found in only one mare. Endometrial culture from five mares resulted in isolation of Pseudomonas sp., Bacillus sp., Escherichia coli and Candida sp. Only four mares resulted pregnant through artificial insemination, using the same stallion with fresh semen, which has been proving fertility. Thus, mares with better uterine conditions will not always become pregnant and those with mild changes will not always be barren.

SALMONELLA SPP. INFECTION IN PSITTACIDAE AT A WILDLIFE REHABILITATION CENTER IN THE STATE OF MATO GROSSO DO SUL, BRAZIL.

The growing interest in wild birds as pets and the increasingly complex interspecific relationships due to human activities in wild environments underscore the need for better knowledge about the health of these animals. Salmonella stands out among the infectious agents of considerable importance to both animal and human health. The importance of these enterobacteria to the health of humans and livestock animals has long been known. In wild birds in countries such as Brazil, however, little is known regarding the frequency of infection and the main serotypes of occurrence. In the present study, the frequency of infection and the main serotypes of Salmonella spp. were investigated in 258 birds at a wild animal rehabilitation center using conventional microbiological methods and molecular diagnostic techniques. Four birds infected with Salmonella enterica were identified using PCR. The birds were of the species Brotogeris chiriri, Ara ararauna, and Eupsittula aurea. Sequencing of DNA revealed identity with the Javiana, Newport, and Arizonae serotypes. These results are of considerable importance to the implementation of management and control measures directed at human and animal health.

Outbreak investigation of septicemic salmonellosis in calves.

INTRODUCTION: An early and accurate diagnosis of septicemic salmonellosis is critical for implementing timely and proper treatment, prevention, and control measures. METHODOLOGY: Here, we report a study on three outbreaks of septicemic salmonellosis in calves from Midwestern Brazil. RESULTS: the morbidity, mortality and lethality rates were of 10.55%, 2.79%, and 26.4%, respectively. Higher susceptibility was detected in Bos taurus than in Bos indicus cattle. Clinical manifestations consisted of apathy, hyperthermia, difficulty breathing and panting, and pallor of the mucous membranes. Chronic cases had necrosis of the tail tip and ears. Gross findings included enlarged liver, non-collapsed edematous lungs and diphtheritic enteritis. Significant histopathological changes included paratyphoid nodules in the liver and acute interstitial pneumonia. Salmonella enterica subsp. enterica serotype Dublin was detected by culture and by PCR from the blood of live calves, and from the spleen, liver, bile, mesenteric lymph node and lung samples of necropsied calves. CONCLUSIONS: We suggest that in clinical cases of septicemic salmonellosis, blood samples are better than fecal samples for detection of the agent, being a sound test to identify animal carriers in the herd.

Hepatocellular Carcinoma Recurrence in HCV Patients Treated with Direct Antiviral Agents.

The risk of hepatocellular carcinoma recurrence is universal regardless of the treatment modality applied, and secondary prevention is still an unmet issue even though the elimination of hepatitis C (HCV) with direct antiviral agents (DAAs) was expected to be one of the new options. Unfortunately, the impact of DAAs on hepatocellular carcinoma (HCC) development (de novo and recurrence) is still controversial. Since the first publication on the subject in 2016, almost all groups worldwide have carried out research in this field with hundreds of publications now available. This revision is focused on the impact of DAAs on HCC recurrence and aims to discuss the potential underlying mechanisms and host factors pointing out the time association phenomenon between DAA treatment and HCC recurrence. Moreover, we comment on the methodological issues that could affect the different interpretations of the published results. In conclusion, this is an area of research with potential in the understanding of the impact of factors not previously considered, and may also help change hepatocarcinogenesis tenets, such as the belief that the elimination of HCV should be used as a second prevention treatment.

Atualização das Recomendações da Sociedade Brasileira de Hepatologia para o Tratamento Sistêmico do Carcinoma Hepatocelular / Brazilian society of hepatology updated recommendations for systemic treatment of hepatocellular carcinoma

ABSTRACT Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related mortality worldwide. The Brazilian Society of Hepatology (SBH) published in 2020 the updated recommendations for the diagnosis and treatment of HCC. Since then, new data have emerged in the literature, including new drugs approved for the systemic treatment of HCC that were not available at the time. The SBH board conducted an online single-topic meeting to discuss and review the recommendations on the systemic treatment of HCC. The invited experts were asked to conduct a systematic review of the literature on each topic related to systemic treatment and to present the summary data and recommendations during the meeting. All panelists gathered together for discussion of the topics and elaboration of the updated recommendations. The present document is the final version of the reviewed manuscript containing the recommendations of SBH and its aim is to assist healthcare professionals, policy-makers, and planners in Brazil and Latin America with systemic treatment decision-making of patients with HCC.

RESUMO O carcinoma hepatocelular (CHC) é uma das principais causas de mortalidade relacionada a câncer no Brasil e no mundo. A Sociedade Brasileira de Hepatologia (SBH) publicou em 2020 a atualização das recomendações da SBH para o diagnóstico e tratamento do CHC. Desde então, novas evidências científicas sobre o tratamento sistêmico do CHC foram relatadas na literatura médica, incluindo novos medicamentos aprovados que não estavam disponíveis na época do último consenso, levando a diretoria da SBH a promover uma reunião monotemática on-line para discutir e rever as recomendações sobre o tratamento sistêmico do CHC. Um grupo de experts foi convidado para realizar uma revisão sistemática da literatura e apresentar uma atualização, baseada em evidências científicas, sobre cada tópico relacionado ao tratamento sistêmico e a apresentar os dados e recomendações resumidas durante a reunião. Todos os painelistas se reuniram para discutir os tópicos e elaborar as recomendações atualizadas. O presente documento é a versão final do manuscrito revisado, contendo as recomendações da SBH, e seu objetivo é auxiliar os profissionais de saúde, formuladores de políticas e planejadores no Brasil e na América Latina na tomada de decisões sobre o tratamento sistêmico de pacientes com CHC.