Baveno VI and VII criteria are not suitable for screening for large varices or clinically significant portal hypertension in patients with hepatocellular carcinoma

Abstract

Summary Background Baveno VI and VII criteria are used in patients with cirrhosis to rule out large size oesophageal varices (EV) and rule in/out clinically significant portal hypertension (CSPH). Aim To evaluate their diagnostic performance in these patients. Methods We retrospectively included all patients with Child‐Pugh A cirrhosis and HCC who had endoscopy, liver stiffness measurement (LSM) and platelet count within 6 months. They were classified according to the BCLC stage. Favourable Baveno VI criteria were defined by LSM < 20 kPa and platelets > 150 G/L (to rule out large EV), favourable Baveno VII criteria if LSM ≤ 15 kPa and platelets ≥ 150 G/L (to rule out CSPH, which was defined by a HVPG ≥ 10 mm Hg. Results We included 185 patients; 46% were BCLC‐0/A, 28% BCLC‐B and 26% BCLC‐C. EV were present in 44% (23% large), and HVPG ≥ 10 mm Hg in 42% (mean 8 mm Hg). In patients with favourable Baveno VI criteria, 8% of the whole cohort (Se 93%, NPV 92%), 11% of BCLC‐0‐A (Se 89%, NPV 89%) and 10.0% of BCLC‐C patients (Se 91%, NPV 90%) had large EV. Among patients with HVPG < 10 mm Hg, 6% had large EV and 17% small. CSPH was present in 23% of patients with favourable Baveno VII criteria among the whole cohort, and in 25% of those with BCLC‐0/A. The specificity of LSM ≥ 25 kPa to rule in CSPH was 48%. Conclusions Favourable Baveno VI criteria are not appropriate to rule out the presence of high‐risk EV, or Baveno VII criteria to rule CSPH in/out in patients with HCC.

Editorial: The use of Baveno VI and VII criteria in patients with hepatocellular carcinoma

“…Further, Baveno VII criteria for CSPH resulted in a PPV of 64% and NPV of 50%. 4 These results are somewhat at odds with previous studies showing an adequate performance of liver stiffness measurement by transient elastography or the actual Baveno VII criteria to diagnose CSPH. [4][5][6] Some factors that may have led to this discrepancy may be the inclusion of patients with tumour thrombus, patients who were already on a NSBB, and patients with previous resection, and not considering in the analysis the presence of bland thrombosis.…”

“…4 These results are somewhat at odds with previous studies showing an adequate performance of liver stiffness measurement by transient elastography or the actual Baveno VII criteria to diagnose CSPH. [4][5][6] Some factors that may have led to this discrepancy may be the inclusion of patients with tumour thrombus, patients who were already on a NSBB, and patients with previous resection, and not considering in the analysis the presence of bland thrombosis. Finally, distinct from previous studies, this one included a number of patients with hepatitis C virus (HCV) infection with sustained viral response.…”

“…7,8 Thus, there is still a need to further determine if these criteria can be applied in the absence of factors, such as portal vein thrombosis, infiltrative HCCs, bulky HCCs or patients with tumour-driven biliary obstruction, that can alter the relationship between elastography and portal hypertension.In the present study, subgroup analysis was limited by the sample size, but the data strongly suggest that infiltrative tumours and/or tumour thrombosis should trigger an endoscopy in patients who are not already on a NSBB. 4 Not surprisingly, the latter seem to be at increased risk of bleeding on atezolizuamb/bevacizumab. 9 Whether elastography is modified by the presence of an HCC within the targeted zone is still not clear, as current evidence is discordant.…”

“…In the present study, subgroup analysis was limited by the sample size, but the data strongly suggest that infiltrative tumours and/or tumour thrombosis should trigger an endoscopy in patients who are not already on a NSBB. 4 Not surprisingly, the latter seem to be at increased risk of bleeding on atezolizuamb/bevacizumab. 9 Whether elastography is modified by the presence of an HCC within the targeted zone is still not clear, as current evidence is discordant.…”

Editorial: The use of Baveno VI and VII criteria for portal hypertension and varices in patients with hepatocellular carcinoma—Authors' reply

“…Drs. Moctezuma‐Velazquez and Abraldes have raised valid concerns regarding our study on the applicability of Baveno VI and VII criteria in patients with hepatocellular carcinoma (HCC), which we would like to address 1,2 . Notably, our study's population diverged from those typically included in Baveno consensus trials, as we deliberately incorporated patients with HCC 3,4 .…”