Lamivudine (LAM) is a nucleoside analogue widely used for the treatment of chronic hepatitis B virus (HBV) infection. Emergence of resistant strains with amino acid substitutions in the tyrosine-methionine-aspartate-aspartate (YMDD) motif of reverse transcriptase is a serious problem in patients on LAM therapy. The amount of covalently closed circular DNA in the serum is reported to be higher in patients who develop YMDD mutants than in those without mutants. However, there is no useful serum marker that can predict early emergence of mutants during LAM therapy. Analysis of patients who were treated with entecavir (n ‫؍‬ 7) and LAM (n ‫؍‬ 36) showed some patients had high serum levels of HBV RNA. Median serum levels of HBV RNA were significantly higher in patients in whom the YMDD mutant had emerged within 1 year (n ‫؍‬ 6, 1.688 log copies/ml) than in those in whom the YMDD mutant emerged more than 1 year after treatment (n ‫؍‬ 12, 0.456 log copies/ml, P ‫؍‬ 0.0125) or in whom the YMDD mutant never emerged (n ‫؍‬ 18, 0.688 log copies/ml, P ‫؍‬ 0.039). Our results suggest that HBV RNA is a valuable predictor of early occurrence of viral mutation during LAM therapy. (HEPATOLOGY 2007;45:1179-1186 T he hepatitis B virus (HBV) is a member of the hepadnaviridae family. Worldwide, approximately 350 million people are estimated to be chronically infected with HBV. 1 Patients with chronic HBV infection develop chronic hepatitis, cirrhosis, and hepatocellular carcinoma, accounting for approximately 1 million deaths per year. 2 Recently, inhibitors of reverse transcriptase have been developed and widely used for patients with chronic HBV infection. Lamivudine (LAM), a cytosine nucleoside analogue, was first developed as an antiviral agent against HIV and later was used effectively against HBV because HBV also uses reverse transcriptase for replication. 3,4 Because LAM suppresses HBV replication, patients who are treated with LAM show a decreased level or disappearance of HBV DNA in serum and hepatitis B e antigen, normalization of serum alanine aminotransferase (ALT) level, and histological improvement. [5][6][7][8][9][10][11][12] However, discontinuation of therapy often leads to reactivation of HBV. 6,8,13,14 Therefore, long-term therapy is necessary for many patients with chronic HBV infection. During long-term LAM therapy, drug-resistant mutants with amino acid substitutions in the tyrosine-methionine-aspartate-aspartate (YMDD) motif emerge, resulting in expression of HBV DNA increasing again and in worsening of hepatitis. 6,10,[15][16][17][18] Moreover, some patients develop a severe flare-up of hepatitis that could lead to fatal hepatic failure. Therefore, prediction of the emergence of YMDD mutants is an important issue.In our hunt for useful serum markers to detect the early emergence of YMDD mutants, we noticed some patients who showed a discrepancy in the expression of HBV DNA measured by the transcription-mediated amplifica-

<b><i>Introduction:</i></b> We evaluated the efficacy and safety of lenvatinib-transcatheter arterial chemoembolization (LEN-TACE) sequential therapy for patients (<i>n</i> = 88) with intermediate-stage hepatocellular carcinoma (HCC). <b><i>Methods:</i></b> Eighty-eight patients who obtained tumor control by LEN treatment were analyzed; 30 received LEN followed by TACE (LEN-TACE sequential therapy), and 58 received LEN monotherapy. Propensity score matching was performed, and the outcomes of 19 patients in the LEN-TACE group and 19 patients in the LEN-alone group were compared. Objective response rate (ORR), progression-free survival (PFS), overall survival (OS), incidence of adverse events (AEs), and change in albumin-bilirubin (ALBI) score were evaluated. <b><i>Results:</i></b> After matching, baseline characteristics were similar between the groups. The ORR was 63.2% with LEN-TACE group and 63.2% with the LEN-alone group. Multivariate analysis showed that addition of TACE during LEN treatment (hazard ratio [HR] 0.264, 95% confidence interval [CI] 0.087–0.802, <i>p</i> =  0.019) and Child-Pugh score 5 (HR 0.223, 95% CI 0.070–0.704, <i>p</i> = 0.011) were the significant factors for PFS. Median PFS was 11.6 months with LEN-TACE and 10.1 months with LEN-alone. The survival rate of the LEN-TACE group was significantly higher than that of the LEN-alone group (median survival time; not reached vs. 16.9 months, <i>p</i> = 0.007). The incidence of common LEN-associated AEs was similar between groups. Although elevated aspartate aminotransferase/alanine aminotransferase and fever were more frequent with LEN-TACE group, these events were manageable. <b><i>Conclusion:</i></b> For patients with intermediate-stage HCC, LEN-TACE sequential therapy may provide a deep response and favorable prognosis.

Objective: To compare the outcome of hepatic arterial infusion chemotherapy combined with radiotherapy (HAIC + RT) versus sorafenib monotherapy in patients with advanced hepatocellular carcinoma (HCC) and major portal vein tumor thrombosis (PVTT). Methods: This retrospective study included 108 HCC patients with PVTT of the main trunk or first branch and Child-Pugh ≤7. Sixty-eight received HAIC + RT and 40 received sorafenib. Patients were then assigned to the HAIC + RT group (n = 36) and the sorafenib group (n = 36) through case-control matching. The decision to treat with HAIC + RT or sorafenib was left to the attending physician. Results: The median overall, progression-free, and postprogression survival were significantly longer in the HAIC + RT group than in the sorafenib group (9.9 vs. 5.3, p = 0.002; 3.9 vs. 2.1, p = 0.048; and 3.7 vs. 1.9 months, p = 0.02, respectively). Multivariate analysis identified HAIC + RT (hazard ratio = 2.02; 95% confidence interval, 1.14–3.57; p = 0.01) as a significant and independent determinant of overall survival. Conclusions: In patients with advanced HCC and major PVTT, survival was significantly longer in those treated with HAIC + RT than with sorafenib.

Transcatheter arterial chemoembolization refractory status with HAIC and MVI with sorafenib were factors for poor prognosis. In particular, HAIC was significantly better than sorafenib as primary treatment in MVI and non-TACE refractory cases. It is necessary to consider these factors in treatment selection.

Aim: Combination therapy with sofosbuvir (SOF) plus velpatasvir (VEL) is approved for patients with hepatitis C virus (HCV)-related decompensated cirrhosis. We analyzed the real-world efficacy of SOF/VEL therapy. Methods: Thirty-three patients with HCV-related decompensated cirrhosis (25 and eight patients with Child B and C, respectively) were treated with SOF/VEL for 12 weeks. The HCV non-structural protein (NS)5A and NS5B drug resistance-associated substitutions (RASs) were determined by direct sequencing. Result: Thirty-two of 33 patients completed the treatment, but the remaining patient discontinued the therapy during third week of the treatment due to aggravation of hepatic encephalopathy. Serum HCV-RNA became negative during the treatment in all patients but relapsed after the end of therapy in five patients. In total, 28 out of 33 patients (85%) achieved sustained vi-rological response 12 weeks following completion of treatment (SVR12). The SVR12 rate was 96% in patients with Child B, but significantly lower, at 50%, in patients with Child C (P<0.05). In genotype 1b HCV-infected patients, all eight patients without baseline NS5A RASs, but only three of seven patients with RASs, achieved SVR12. Multivariate analysis identified Child B (odds ratio, 35.8 for Child C; P=0.045) as an independent predictor of SVR12. Median serum albumin levels significantly increased only in patients who achieved SVR12. Child-Pugh scores improved in 16 of 28 patients (57%) following achievement of SVR12. Conclusion: The effect of SOF/VEL therapy is lower for patients with Child C. Improvement of hepatic function is expected after viral eradication with SOF/VEL therapy in patients with decompensated cirrhosis.