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Primary Prophylaxis for High-Risk Varices in Patients with Hepatocellular Carcinoma and Portal Vein Tumor Thrombus
Yu-Jen Chen1,2,3, Ming-Chih Hou1,2,3, Tsung-Chieh Yang1,2,3
1Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan.
Insights
Primary prophylaxis significantly reduces hepatic decompensation and esophageal variceal bleeding in patients with hepatocellular carcinoma and portal vein tumor thrombus. This intervention improves decompensation-free survival but does not impact overall survival.
Area of Science:
- Hepatology
- Gastroenterology
- Oncology
Background:
- Clinically significant portal hypertension (CSPH) is common in hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT).
- The benefit of primary prophylaxis for hepatic decompensation in this patient group remains unclear.
Purpose of the Study:
- To evaluate the efficacy of primary prophylaxis in reducing hepatic decompensation and esophageal variceal bleeding (EVB) in HCC patients with PVTT and high-risk varices (HRV).
Main Methods:
- Retrospective review of 142 HCC patients with PVTT and HRV.
- Comparison between a prophylaxis group and a non-prophylaxis group using propensity score matching.
- Primary endpoint: decompensation-free survival (DFS); Secondary endpoints: EVB incidence and overall survival (OS).
Main Results:
- The prophylaxis group showed significantly lower EVB incidence (21% vs 46.8%) and longer DFS (84 days vs 66 days) compared to the non-prophylaxis group.
- Multivariate analysis confirmed primary prophylaxis is associated with longer DFS.
- First-line immunotherapy (IO) was linked to improved DFS and OS, while BCLC stage D correlated with worse outcomes.
Conclusions:
- Primary prophylaxis effectively delays hepatic decompensation and reduces EVB in HCC patients with PVTT.
- Non-selective beta-blockers (NSBB) appear particularly beneficial for EVB prevention.
- First-line IO treatment is an independent predictor of better survival outcomes.
Background And Aims:
The prevalence of clinically significant portal hypertension (CSPH) is high in patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT). There was no evidence of whether primary prophylaxis is beneficial in reducing hepatic decompensation in these patients.
Methods:
Clinical records of 445 patients with pathology or radiology-confirmed HCC and PVTT from January 2013 to December 2022 were reviewed, 142 patients having concurrent high-risk varices (HRV) without hepatic decompensation were enrolled. Patients were divided into the prophylaxis group and non-prophylaxis group. Propensity score matching was used for group comparison. The primary endpoint was decompensation-free survival (DFS), and the secondary endpoints were the incidence of esophageal variceal bleeding (EVB) and overall survival (OS).
Results:
The incidence of EVB was higher in the non-prophylaxis group than in the prophylaxis group (46.8% VS 21%, p = 0.001). DFS was longer in the prophylaxis group than in the non-prophylaxis group (84 days vs 66 days, p = 0.009). There was no difference in OS between two groups. In multivariate analysis, primary prophylaxis was associated with longer DFS (HR 0.806, p = 0.017); Immunotherapy (IO) was associated with longer DFS and OS; Barcelona Clinic Liver Cancer (BCLC) stage D was associated with shorter DFS and OS.
Conclusion:
Primary prophylaxis delays hepatic decompensation in HCC patients with PVTT. The incidence of EVB was also lower in the prophylaxis group, particularly in those treated with NSBB. First-line IO treatment is independently associated with better DFS and OS.
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