Hepatocellular carcinomas are aggressive tumors with a high dissemination power. An early diagnosis of these tumors is of great importance in order to offer the possibility of curative treatment. For an early diagnosis, abdominal ultrasound and serum alpha-fetoprotein determinations at 6-month intervals are suggested for all patients with cirrhosis of the liver, since this disease is considered to be the main risk factor for the development of the neoplasia. Helicoidal computed tomography, magnetic resonance and/or hepatic arteriography are suggested for diagnostic confirmation and tumor staging. The need to obtain a fragment of the focal lesion for cytology and/or histology for a diagnosis of hepatocellular carcinoma depends on the inability of imaging methods to diagnose the lesion. Several classifications are currently available for tumor staging in order to determine patient prognosis. All take into consideration not only the stage of the tumor but also the degree of hepatocellular dysfunction, which is known to be the main factor related to patient survival. Classifications, however, fail to correlate treatment with prognosis and cannot suggest the ideal treatment for each tumor stage. The Barcelona Classification (BCLC) attempts to correlate tumor stage with treatment but requires prospective studies for validation. For single tumors smaller than 5 cm or up to three nodules smaller than 3 cm, surgical resection, liver transplantation and percutaneous treatment may offer good anti-tumoral results, as well as improved patient survival. Embolization or chemoembolization are therapeutic alternatives for patients who do not benefit from curative therapies. Correspondence
Intrapulmonary vascular dilatations (IPVD), diagnosed by transthoracic contrast-enhanced echocardiography (CEE), can be observed in 13% to 47% of individuals with liver cirrhosis. 1,2 Despite the presence of IPVD, most patients are not characterized as having hepatopulmonary syndrome (HPS), since the diagnosis of this syndrome requires the presence of abnormal arterial oxygenation (partial pressure of arterial oxygen Ͻ 70 mm Hg, or alveolar arterial oxygen gradient Ͼ 20 mm Hg). 3,4 One of the major controversies is whether cirrhotic individuals with IPVD but without changes in arterial oxygenation are affected by HPS in the early phase and whether these alterations would appear during followup. 5 To our knowledge, there are no prospective studies of the evolution of pulmonary parameters in cirrhotic individuals with IPVD but without changes in arterial oxygenation. Would these patients fulfill HPS criteria during follow-up?In our series 6 of 56 cirrhotic patients on a waiting list for orthotopic liver transplantation, the frequency of IPVD was 45% (25 patients). Among these patients, 16 (64%) did not fulfill the criteria for HPS, confirming the high frequency of IPVD in cirrhotic subjects without HPS. These patients were followed prospectively to assess the evolution of pulmonary parameters. Of 16 cirrhotic patients with IPVD without changes in arterial oxygenation, 12 were excluded from the study, 11 due to death (after exploratory laparotomy [1], cancer of the larynx [1], digestive hemorrhage [5], spontaneous bacterial peritonitis [2], orthotopic liver transplantation [1 sepsis and 1 hemorrhage]) and 1 because he was submitted to orthotopic liver transplantation. Mean follow-up of the excluded patients was 13.8 months (2-28 months). The complementary tests were not repeated in any of the excluded patients. Thus, the final series consisted of 4 patients with a mean follow-up of 24 months (21-30 months). All patients were submitted to contrastenhanced echocardiography and measurement of arterial blood gases at the beginning and at the end of follow-up. The results are presented in Table 1. The contrast-enhanced echocardiography remained positive in all patients. No patient presented significant changes in arterial oxygenation that would characterize him as having HPS. The present data suggest stability of the pulmonary parameters during the 2-year follow-up period.The causes of the high mortality rate of our patients did not seem to be related to the presence of HPS, both because of the absence of pulmonary causes and because of the short period of time between the diagnosis of IPVD and death. Schenk et al. 7 demonstrated that not only the presence but also the severity of HPS are related to the survival of cirrhotic patients. It should be emphasized that our patients did not have HPS nor did they present alterations in gas exchanges. In addition, our patients with HPS 6 tend to have mild degrees of the syndrome, in contrast to the data reported by Schenk et al. 7 However, although this is unlikely, we cann...
The hepatopulmonary syndrome is a frequent disease that requires blood gas measurements for diagnosis. Liver transplantation is the treatment of choice for patients with the syndrome.
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