Is de novo hepatocellular carcinoma after transjugular intrahepatic portosystemic shunt increased?

Abstract

Background: Portal hypertension is a major complication of liver cirrhosis. Transjugular intrahepatic portosystemic shunt is effective in treatment of portal hypertension. However, decreased parenchymal portal venous flow after transjugular intrahepatic portosystemic shunt insertion favours ischaemic liver injury which has been discussed to induce hepatocarcinogenesis causing hepatocellular cancer. Aim: This study aimed to explore the association between transjugular intrahepatic portosystemic shunt placement and the development of hepatocellular cancer. Methods: A total of 1338 consecutive liver cirrhosis patients were included in this retrospective study between January 2004-December 2015. Data were analysed with regard to development of hepatocellular cancer during follow-up. Binary logistic regression and Kaplan-Meier analyses were conducted for the assessment of risk factors for hepatocellular cancer development. In a second step, to rule out confounders of group heterogeneity, case-control matching was performed based on gender, age, model of end-stage liver disease score and underlying cause of cirrhosis (non-alcoholic steatohepatitis, alcoholic liver disease and viral hepatitis). Results: Besides established risk factors such as older age, male gender and underlying viral hepatitis, statistical analysis revealed the absence of transjugular intrahepatic portosystemic shunt insertion as a risk factor for hepatocellular cancer development. Furthermore, matched-pair analysis of 432 patients showed a significant difference (p ¼ 0.003) in the emergence of hepatocellular cancer regarding transjugular intrahepatic portosystemic shunt placement versus the nontransjugular intrahepatic portosystemic shunt cohort. Conclusion: In patients with end-stage liver disease, transjugular intrahepatic portosystemic shunt insertion is significantly associated with reduced rates of hepatocellular cancer development.

Occult Hepatocellular Carcinoma Associated With Transjugular Intrahepatic Portosystemic Shunts in Liver Transplant Recipients

“…TIPS were not associated with an increase in the summed diameter of lesions on explant minus the summed diameter of lesions on imaging when comparing patients with the same number of explant lesions, suggesting that TIPS impact the identification of lesions more than they underestimate the size of identified lesions. Prior studies have not demonstrated a higher incidence of occult malignancy in patients with TIPS, but diagnoses have been made based on imaging modalities, (22)(23)(24) which we now suggest may be of decreased utility in these patients.…”

“…They also did not differ in terms of the incidence of PVT, extent of PVT into the splenic and/or mesenteric veins, presence of occlusive PVT, or thrombotic involvement of both the portal trunk and its branches (Table 1). A significant difference between subgroups included a higher biochemical MELD score in patients with TIPS (17 [IQR, [15][16][17][18][19][20][21][22] versus 12 [IQR, [9][10][11][12][13][14][15][16][17][18]; P < 0.001). Allocation MELD scores were not dissimilar between groups (24 [IQR, [21][22][23][24][25][26][27][28] versus 25 [IQR, [22][23][24][25][26][27][28][29]), as fewer exception points were granted to the TIPS group given their less frequent identification of pretransplant HCC.…”

“…A significant difference between subgroups included a higher biochemical MELD score in patients with TIPS (17 [IQR, [15][16][17][18][19][20][21][22] versus 12 [IQR, [9][10][11][12][13][14][15][16][17][18]; P < 0.001). Allocation MELD scores were not dissimilar between groups (24 [IQR, [21][22][23][24][25][26][27][28] versus 25 [IQR, [22][23][24][25][26][27][28][29]), as fewer exception points were granted to the TIPS group given their less frequent identification of pretransplant HCC. Patients were equally dispersed over time, such that the allocation systems used were consistent between groups.…”

Transjugular Intrahepatic Portosystemic Shunts in High-Risk Patients

“…Several subsequent studies did not detect an association between TIPS and HCC. [60][61][62][63] To date, there is no convincing evidence that the presence of TIPS by itself increases the risk for developing HCC or results in delay in its diagnosis.…”

Predictive value of spleen stiffness in hepatocellular carcinoma

“…The positive correlation between (the degree of) PH, carcinogenesis and thus HCC development was pointed out in different publications. Conversely, reduction of portal pressure by insertion of transjugular intrahepatic portosystemic shunt (TIPS) is significantly associated with reduced rates of de novo HCC (6). The results of Marasco and colleagues are therefore not exceedingly surprising: severity of liver fibrosis or cirrhosis, mirrored by spleen stiffness as indicator of PH, is closely related to HCC development.…”