EASL-EORTC clinical practice guidelines : management of hepatocellular carcinoma

Since the publication of the American Association for the Study of Liver Diseases (AASLD) practice guidelines on the management of hepatocellular carcinoma (HCC) in 2005, new information has emerged that requires that the guidelines be updated. The full version of the new guidelines is available on the AASLD Web site at http://www.aasld.org/practiceguidelines/ Documents/Bookmarked%20Practice%20Guidelines/ HCCUpdate2010.pdf. Here, we briefly describe only new or changed recommendations.

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AASLD PRACTICE GUIDELINE Management of Hepatocellular Carcinoma: An Update

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.20933

Management of hepatocellular carcinoma.

Clinical Management of Hepatocellular Carcinoma. Conclusions of the Barcelona-2000 EASL Conference

https://aasldpubs.onlinelibrary.wiley.com/doi/pdf/10.1002/hep.22759

Diagnosis, management, and treatment of hepatitis C: An update

Background The role of orthotopic liver transplantation in the treatment of patients with cirrhosis and hepatocellular carcinoma is controversial, and determining which patients are likely to have a good outcome after liver transplantation is difficult. Methods We studied 48 patients with cirrhosis who had small, unresectable hepatocellular carcinomas and who underwent liver transplantation. In 94 percent of the patients, the cirrhosis was related to infection with hepatitis B virus, hepatitis C virus, or both. The presence of tumor was confirmed by biopsy or serum alpha-fetoprotein assay. The criteria for eligibility for transplantation were the presence of a tumor 5 cm or less in diameter in patients with single hepatocellular carcinomas and no more than three tumor nodules, each 3 cm or less in diameter, in patients with multiple tumors. Twenty-eight patients with sufficient hepatic function underwent treatment for the tumor, mainly chemoembolization, before transplantation. After liver transplantation...

Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis

Prevention of recurrent hepatitis C after liver transplantation with early interferon and ribavirin treatment.

The liver plays a major role in regulating glucose metabolism, and since its function is influenced by sympathetic/ parasympathetic innervation, we used liver graft as a model of denervation to study the role of CNS in modulating hepatic glucose metabolism in humans. 22 liver transplant subjects were randomly studied by means of the hyperglycemic/ hyperinsulinemic (study 1), hyperglycemic/isoinsulinemic (study 2), euglycemic/hyperinsulinemic (study 3) as well as insulin-induced hypoglycemic (study 4) clamp, combined with bolus-continuous infusion of [3-3H]glucose and indirect calorimetry to determine the effect of different glycemic/insulinemic levels on endogenous glucose production and on peripheral glucose uptake. In addition, postabsorptive glucose homeostasis was cross-sectionally related to the transplant age (range = 40 d-35 mo) in 4 subgroups of patients 2, 6, 15, and 28 mo after transplantation. 22 subjects with chronic uveitis (CU) undergoing a similar immunosuppressive therapy and 35 normal healthy subjects served as controls. The results showed that successful transplantation was associated with fasting glucose concentration and endogenous glucose production in the lower physiological range within a few weeks after transplantation, and this pattern was maintained throughout the 28-mo follow-up period. Fasting glucose (4. 55+/-0.06 vs. 4.75+/-0.06 mM; P = 0.038) and endogenous glucose production (11.3+/-0.4 vs. 12.9+/-0.5 micromol/[kg.min]; P = 0.029) were lower when compared to CU and normal patients. At different combinations of glycemic/insulinemic levels, liver transplant (LTx) patients showed a comparable inhibition of endogenous glucose production. In contrast, in hypoglycemia, after a temporary fall endogenous glucose production rose to values comparable to those of the basal condition in CU and normal subjects (83+/-5 and 92+/-5% of basal), but it did not in LTx subjects (66+/-7%; P < 0.05 vs. CU and normal subjects). Fasting insulin and C-peptide levels were increased up to 6 mo after transplantation, indicating insulin resistance partially induced by prednisone. In addition, greater C-peptide but similar insulin levels during the hyperglycemic clamp (study 1) suggested an increased hepatic insulin clearance in LTx as compared to normal subjects. Fasting glucagon concentration was higher 6 mo after transplantation and thereafter. During euglycemia/hyperinsulinemia (study 3), the insulin-induced glucagon suppression detectable in CU and normal subjects was lacking in LTx subjects; furthermore, the counterregulatory response during hypoglycemia was blunted. In summary, liver transplant subjects have normal postabsorptive glucose metabolism, and glucose and insulin challenge elicit normal response at both hepatic and peripheral sites. Nevertheless, (a) minimal alteration of endogenous glucose production, (b) increased concentration of insulin and glucagon, and (c) defective counterregulation during hypoglycemia may reflect an alteration of the liver-CNS-islet circuit which is due to denervation of the transplanted graft.

/pdf/regulation-of-glucose-homeostasis-in-humans-with-denervated-2wo2pwmvib.pdf

Regulation of glucose homeostasis in humans with denervated livers.

C IRRHOSIS caused by hepatitis C virus (HCV) accounts for at least 30% of all liver transplants (OLT) currently performed in adults’ Good survival of patients with such an indication has been described, even though the reappearance of viral genome (HCV-RNA) occurs in more than 90% of patients during the first year after transplantation‘’ The course of recurrent HCV graft infection is generally benign Nevertheless, some concerns about the long-term outcome of the disease have arisen since at least 50% of HCV-RNA positive patients develop chronic hepatitis within two years’,2 and 35% of livers are seriuosly injured (chronic active hepatitis and cirrhosis) 5 years after transplantation4 In the present study, a therapeutic attempt to prevent recurrent HCV infection was undertaken in a group of HCV-RNA positive transplant recipients, using a combination of interferon and ribavirin early after OLT The preliminary results of this pilot experience, the first of its kind, are reported herein

Prophylaxis against HCV recurrence after liver transplantation: Effect of interferon and ribavirin combination

LIVER metastases from neuroendocrine tumors (NET) is the main cause of death for patient with neuroendocrine tumors originating from the intestine and pancreas. In about 90% of patients, the distribution of liver metastases is multifocal and bilateral so that curative liver resection is feasible in no more than 20% of the referred cases. Large liver metastases often cause hormone-related symptoms (carcinoid syndrome) with severe consequences on patient quality of life. Both surgical and medical treatments have been proposed for patients with liver metastases from NET (systemic and intraarterial chemotherapy, somatostatin analogues, interferon therapy) with cumulative patient survival not exceeding 25 to 35% at five years. Resective surgery with curative intent has been associated with an improved 5 year survival in nearly 50% of cases, but the number of eligible patients is low. Total hepatectomy and liver transplantation (OLT) has been advocated for patients with bilateral unresectable symptomatic liver metastases from NET although a clear consensus on stage of disease, pathological subtypes, and patient conditions amenable of transplant candidacy are still lacking. In this report, we describe our experience with 29 patients affected by liver metastases from NET who were treated with either hepatic resections or liver transplantation. Pre-transplantation selection criteria currently applied in our centre are also proposed.

A. Pulvirenti

Papers

Liver transplantation for the treatment of small hepatocellular carcinomas in patients with cirrhosis

Prevention of recurrent hepatitis C after liver transplantation with early interferon and ribavirin treatment.

Regulation of glucose homeostasis in humans with denervated livers.

Prophylaxis against HCV recurrence after liver transplantation: Effect of interferon and ribavirin combination

Resection versus transplantation for liver metastases from neuroendocrine tumors.