Over three-quarters of patients with hepatocellular carcinoma who have hepatitis C can achieve viral cure with direct-acting antiviral drugs. Among patients with hepatocellular carcinoma who subsequently received liver transplantation, over 90% of patients can achieve viral cure.
IRE of HCC results in a large region of enhancement on immediate postprocedure MR images that, over time, involutes and is associated with decreasing signal intensity of the peripheral ablation zone. This phenomenon may represent resolution of the reversible penumbra.
We suggest that the application of multi-level analysis and missing-value analysis is a statistical necessity for this study. Firstly, in Beste et al. 1 , 426 patients with HCC were collected from 167 medical centers; therefore, small VA medical centers may have contributed few or no HCC patients. In Table 4 of the paper by Beste et al. 1 , there was no hospital or geographic information variable in the final regression model, which implies that large VA medical centers could over-represent patients or hospitals. This concern can be appropriately adjusted by a hierarchical modeling approach using multi-level analysis at patient, as well as at hospital levels. 9 Secondly, authors used an assumption of randomly missing data (11.6% of HCC patients) based on unclear multiple imputation methods. Randomness of missing data could be raised from not only the amount of missing data but also from a higher discontinuation rate in the missing group that might have resulted from these patients' intention to leave the VA health care system to receive additional or new therapy for any reason. To confirm the absence of missing not at random data, it is necessary to utilize multiple imputation methods by emerging approaches, multiple imputation using chained equations, and a visualization of Monte Carlo simulation results. 10 Conflict of interest The authors who have taken part in this study declared that they do not have anything to disclose regarding funding or conflict of interest with respect to this manuscript.
Purpose Locoregional therapy for hepatocellular carcinoma (HCC) can be challenging in patients with a transjugular intrahepatic portosystemic shunt (TIPS). This study compares safety and imaging response of ablation, chemoembolization, radioembolization, and supportive care in patients with both TIPS and HCC. Methods This retrospective study included 48 patients who had both a TIPS and a diagnosis of HCC. Twenty-nine of 48 (60 %) underwent treatment for HCC, and 19/48 (40 %) received best supportive care (i.e., symptomatic management only). While etiology of cirrhosis and indication for TIPS were similar between the two groups, treated patients had better baseline liver function (34 vs. 67 % Child-Pugh class C). Tumor characteristics were similar between the two groups. A total of 39 ablations, 17 chemoembolizations, and 10 yttrium-90 radioembolizations were performed on 29 patients.Results Ablation procedures resulted in low rates of hepatotoxicity and clinical toxicity. Post-embolization/ ablation syndrome occurred more frequently in patients undergoing chemoembolization than ablation (47 vs. 15 %). Significant hepatic dysfunction occurred more frequently in the chemoembolization group than the ablation group. Follow-up imaging response showed objective response in 100 % of ablation procedures, 67 % of radioembolization procedures, and 50 % of chemoembolization procedures (p = 0.001). When censored for OLT, patients undergoing treatment survived longer than patients receiving supportive care (2273 v. 439 days, p = 0.001). Conclusions Ablation appears to be safe and efficacious for HCC in patients with TIPS. Catheter-based approaches are associated with potential increased toxicity in this patient population. Chemoembolization appears to be associated with increased toxicity compared to radioembolization.
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