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• W2130306003 abstract "Hepatocellular carcinoma (HCC) is responsible for significant morbidity and mortality in cirrhosis. It commonly leads to decompensation of cirrhosis and is the cause of death in up to 25% of cirrhotic patients.1D’Amico G. Garcia-Tsao G. Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies.J Hepatol. 2006; 44: 217-231Abstract Full Text Full Text PDF PubMed Scopus (2034) Google Scholar In a systematic review of 118 studies analyzing predictors of death in cirrhosis, HCC and parameters of liver and renal dysfunction were independent predictors of death in decompensated cirrhosis.1D’Amico G. Garcia-Tsao G. Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies.J Hepatol. 2006; 44: 217-231Abstract Full Text Full Text PDF PubMed Scopus (2034) Google Scholar Determining prognosis is essential in the evaluation of any disease because it allows the provider to counsel individual patients and forms the basis for any decision-making process. However, applying such prognostic information is frequently unsatisfactory because the individual patient might be different from the patient population from which the information was derived. In HCC, the presence or absence of cirrhosis will make a significant difference in prognosis and treatment. In the West, most cases of HCC occur in the setting of cirrhosis, and although many studies have been performed to predict mortality in HCC, most combine patients with and without cirrhosis. Among more than 80 studies that investigate predictors of death in patients with HCC, only about one fifth have been limited to patients with cirrhosis (P. Tandon and G. Garcia-Tsao, unpublished observation). In these studies, the most consistent predictors of death can be divided into those related to the severity of cirrhosis and those related to the severity of the tumor. In fact, staging systems such as the Cancer of the Liver Italian Program (CLIP),2The Cancer of the Liver Italian Program (CLIP) InvestigatorsA new prognostic system for hepatocellular carcinoma: a retrospective study of 435 patients—the Cancer of the Liver Italian Program (CLIP) investigators.Hepatology. 1998; 28: 751-755Crossref PubMed Scopus (1213) Google Scholar the Okuda,3Okuda K. Ohtsuki T. Obata H. et al.Natural history of hepatocellular carcinoma and prognosis in relation to treatment: study of 850 patients.Cancer. 1985; 56: 918-928Crossref PubMed Scopus (1796) Google Scholar and the more accepted Barcelona Clinic Liver Cancer (BCLC) staging systems4Llovet J.M. Bru C. Bruix J. Prognosis of hepatocellular carcinoma: the BCLC staging classification.Sem Liv Dis. 1999; 19: 329-338Crossref PubMed Scopus (3014) Google Scholar include parameters of liver dysfunction and parameters related to HCC. Notably, the Okuda system includes a complication related to portal hypertension, ie, ascites, and the BCLC system includes portal pressure to determine tumor resectability. In this issue of Clinical Gastroenterology and Hepatology, Giannini et al5Giannini E.G. Risso D. Testa R. et al.Prevalence and prognostic meaning of the presence of oesophageal varices in patients with hepatocellular carcinoma.Clin Gastroenterol Hepatol. 2006; 4: 1378-1384Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar evaluate the presence of esophageal varices, a direct consequence of portal hypertension, as a predictor of death in patients with HCC and underlying chronic liver disease, 95% with cirrhosis and 5% with “advanced” fibrosis. Although the study is based on prospectively collected data from 1834 consecutive patients with HCC, almost 40% of the patients were excluded because the database was missing important prognostic information. It is still one of the largest studies evaluating predictors of death in HCC (1153 evaluated patients) and one of few studies that meet many of the accepted quality criteria for prognostic studies.1D’Amico G. Garcia-Tsao G. Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies.J Hepatol. 2006; 44: 217-231Abstract Full Text Full Text PDF PubMed Scopus (2034) Google Scholar Specifically, inclusion and exclusion criteria are well defined; the number of excluded patients is specified; candidate variables are identified a priori and include most previously identified predictors of death; relevant baseline data, length of follow-up, and number of deaths are reported; and the common problem of overfitting (ie, when the ratio of number of deaths/number of variables in model is <10) is avoided. Giannini et al5Giannini E.G. Risso D. Testa R. et al.Prevalence and prognostic meaning of the presence of oesophageal varices in patients with hepatocellular carcinoma.Clin Gastroenterol Hepatol. 2006; 4: 1378-1384Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar find that esophageal varices are predictors of death in patients with HCC, independent of the severity of liver disease and independent of HCC stage, even in a model in which only known predictors were introduced, specifically Child-Pugh class, HCC staging, treatment (curative, palliative, or none), and comorbidity. Esophageal varices had been previously found to be independently predictive of death in HCC in a smaller study by Ueno et al6Ueno S. Tanabe G. Nuruki K. et al.Prognosis of hepatocellular carcinoma associated with Child class B and C cirrhosis in relation to treatment: a multivariate analysis of 411 patients at a single center.J Hepatobiliary Pancreat Surg. 2002; 9: 469-477Crossref PubMed Scopus (45) Google Scholar that included only patients with Child-Pugh class B and C cirrhosis. Contrary to the study by Ueno et al,6Ueno S. Tanabe G. Nuruki K. et al.Prognosis of hepatocellular carcinoma associated with Child class B and C cirrhosis in relation to treatment: a multivariate analysis of 411 patients at a single center.J Hepatobiliary Pancreat Surg. 2002; 9: 469-477Crossref PubMed Scopus (45) Google Scholar whose objective was to compare different treatment modalities in HCC, Giannini et al specifically evaluate the prognostic value of the presence of esophageal varices. Its rationale was based on important studies that show that portal pressure, assessed by the hepatic venous pressure gradient (HVPG), predicts postoperative hepatic decompensation (jaundice, ascites, or encephalopathy, 3 months after surgery)7Bruix J. Castells A. Bosch J. et al.Surgical resection of hepatocellular carcinoma in cirrhotic patients: prognostic value of preoperative portal pressure.Gastroenterology. 1996; 111: 1018-1022Abstract Full Text PDF PubMed Scopus (769) Google Scholar and 5-year survival8Llovet J.M. Fuster J. Bruix J. Intention-to-treat analysis of surgical treatment for early hepatocellular carcinoma: resection versus transplantation.Hepatology. 1999; 30: 1434-1440Crossref PubMed Scopus (1498) Google Scholar in patients subjected to hepatic resection for HCC. The predictive value of measurements of HVPG in the natural history of cirrhosis is undeniable. After all, most of the complications that mark the transition from compensated to decompensated cirrhosis (ascites, variceal hemorrhage, encephalopathy, and jaundice) are related to portal hypertension. An HVPG of 10–12 mm Hg is related to the presence of varices and ascites and has been termed “clinically significant” portal hypertension9D’Amico G. Garcia-Tsao G. Cales P. et al.Diagnosis of portal hypertension: how and when.in: De Franchis R. Portal hypertension III. Blackwell Science, Oxford2001: 36-64Google Scholar (normal HVPG is 3–5 mm Hg). More importantly, an HVPG >10 mm Hg is the strongest predictor of the development of varices10Groszmann R.J. Garcia-Tsao G. Bosch J. et al.Beta-blockers to prevent gastroesophageal varices in patients with cirrhosis.N Engl J Med. 2005; 353: 2254-2261Crossref PubMed Scopus (755) Google Scholar and of clinical decompensation (ie, development of ascites, encephalopathy, and variceal hemorrhage)11Ripoll C. Groszmann R. Garcia-Tsao G. et al.Hepatic venous pressure gradient (HVPG) predicts clinical decompensation in patients with compensated cirrhosis.Hepatology. 2006; 44 (abstract): 203AGoogle Scholar in compensated cirrhosis. In the absence of HVPG measurements, Giannini et al5Giannini E.G. Risso D. Testa R. et al.Prevalence and prognostic meaning of the presence of oesophageal varices in patients with hepatocellular carcinoma.Clin Gastroenterol Hepatol. 2006; 4: 1378-1384Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar consider the presence of varices as a surrogate marker of clinically significant portal hypertension. The presence of varices is, in fact, indicative of a poorer prognosis in cirrhosis.1D’Amico G. Garcia-Tsao G. Pagliaro L. Natural history and prognostic indicators of survival in cirrhosis: a systematic review of 118 studies.J Hepatol. 2006; 44: 217-231Abstract Full Text Full Text PDF PubMed Scopus (2034) Google Scholar Unfortunately, Giannini et al do not provide critical information regarding the causes of death of the 611 patients with HCC. This deficiency does not allow us to determine whether the presence of varices is simply an indicator of more advanced cirrhosis that led to decompensation and death from liver disease, or whether the presence of portal hypertension and varices led to a worsening in tumor stage and death from HCC itself. Evidence indicates that both could occur; that is, HCC can lead to worsening portal hypertension, and portal hypertension can lead to worsening HCC. HCC can lead to an increase in HVPG (sinusoidal pressure) through the presence of arteriovenous shunting within the tumor. Also, the presence of varices can be an indicator of pre-hepatic portal hypertension through macroscopic or even microscopic invasion of the portal vein and/or its branches. In fact, portal vein thrombosis is an independent predictor of death in HCC.2The Cancer of the Liver Italian Program (CLIP) InvestigatorsA new prognostic system for hepatocellular carcinoma: a retrospective study of 435 patients—the Cancer of the Liver Italian Program (CLIP) investigators.Hepatology. 1998; 28: 751-755Crossref PubMed Scopus (1213) Google Scholar Unfortunately, Giannini et al did not include portal vein thrombosis in their model even though its prevalence was higher in patients with varices. In portal hypertension, the development of both the hyperdynamic splanchnic circulation and portal-systemic collateral vessels (of which esophageal varices are the most important clinically) depends on vascular endothelial growth factor (VEGF).12Fernandez M. Vizzutti F. Garcia-Pagan J.C. et al.Anti-VEGF receptor-2 monoclonal antibody prevents portal-systemic collateral vessel formation in portal hypertensive mice.Gastroenterology. 2004; 126: 886-894Abstract Full Text Full Text PDF PubMed Scopus (196) Google Scholar, 13Fernandez M. Mejias M. Angermayr B. et al.Inhibition of VEGF receptor-2 decreases the development of hyperdynamic splanchnic circulation and portal-systemic collateral vessels in portal hypertensive rats.J Hepatol. 2005; 43: 98-103Abstract Full Text Full Text PDF PubMed Scopus (171) Google Scholar Mild increases in portal pressure are sufficient to up-regulate VEGF.14Abraldes J.G. Iwakiri Y. Loureiro-Silva M. et al.Mild increases in portal pressure upregulate vascular endothelial growth factor and endothelial nitric oxide synthase in the intestinal microcirculatory bed, leading to a hyperdynamic state.Am J Physiol Gastrointest Liver Physiol. 2006; 290: G980-G987Crossref PubMed Scopus (146) Google Scholar VEGF is expressed in HCC and has been implicated in tumor growth, invasion, and metastasis through its angiogenic potential and also by increasing endothelial permeability and HCC spread.15Schmitt M. Horbach A. Kubitz R. et al.Disruption of hepatocellular tight junctions by vascular endothelial growth factor (VEGF): a novel mechanism for tumor invasion.J Hepatol. 2004; 41: 274-283Abstract Full Text Full Text PDF PubMed Scopus (82) Google Scholar High serum VEGF levels are independent predictors of death in patients with HCC.16Poon R.T. Ho J.W. Tong C.S. et al.Prognostic significance of serum vascular endothelial growth factor and endostatin in patients with hepatocellular carcinoma.Br J Surg. 2004; 91: 1354-1360Crossref PubMed Scopus (200) Google Scholar Interestingly, the presence of esophageal varices in patients with cirrhosis is predictive of the development of HCC,17Ganne-Carrie N. Chastang C. Chapel F. et al.Predictive score for the development of hepatocellular carcinoma and additional value of liver large cell dysplasia in Western patients with cirrhosis.Hepatology. 1996; 23: 1112-1118Crossref PubMed Google Scholar, 18Nakayama H. Masuda H. Miyake H. et al.Endoscopic prediction of hepatocellular carcinoma by evaluation of bleeding esophageal varices.Digestion. 2004; 70: 233-239Crossref PubMed Scopus (7) Google Scholar and more recent data indicate that an HVPG >10 mm Hg is predictive of the development of HCC, independent of severity and duration of cirrhosis.19Ripoll C. Groszmann R. Garcia-Tsao G. et al.Hepatic venous pressure gradient (HVPG) predicts the development of hepatocellular carcinoma (HCC) independent of duration and severity of cirrhosis.Hepatology. 2006; 44 (abstract): 245AGoogle Scholar The study by Giannini et al5Giannini E.G. Risso D. Testa R. et al.Prevalence and prognostic meaning of the presence of oesophageal varices in patients with hepatocellular carcinoma.Clin Gastroenterol Hepatol. 2006; 4: 1378-1384Abstract Full Text Full Text PDF PubMed Scopus (60) Google Scholar raises important issues. It reinforces the recommendation that patients with cirrhosis should be screened for the presence of varices. If results of this study are validated prospectively in consecutive patients, who would ideally have HVPG measured at the time of diagnosis of HCC, the impact of portal hypertension in HCC would go beyond determining tumor resectability but could impact transplant organ allocation and risk stratification for other HCC therapies. Even beyond that, confirming the relationship between portal pressure and HCC in cirrhosis will have important pathophysiologic implications that could ultimately play a role in the prevention and treatment of this deadly tumor." @default.
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• W2130306003 title "Portal Hypertension and Hepatocellular Carcinoma: Prognosis and Beyond" @default.
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