C. Yen

The ALBI grade provides objective hepatic reserve estimation across each BCLC stage of hepatocellular carcinoma

BACKGROUND & AIMS Overall survival (OS) is a composite clinical endpoint in hepatocellular carcinoma (HCC) due to the mutual influence of cirrhosis and active malignancy in dictating patients mortality. The ALBI grade is a recently described index of liver dysfunction in hepatocellular carcinoma, based solely on albumin and bilirubin levels. Whilst accurate, this score lacks cross-validation, especially in intermediate stage HCC, where OS is highly heterogeneous. METHODS We evaluated the prognostic accuracy of the ALBI grade in estimating OS in a large, multi-centre study of 2426 patients, including a large proportion of intermediate stage patients treated with chemoembolization (n=1461) accrued from Europe, the United States and Asia. RESULTS Analysis of survival by primary treatment modality confirmed the ALBI grade as a significant predictor of patient OS after surgical resection (p<0.001), transarterial chemoembolization (p<0.001) and sorafenib (p<0.001). Stratification by Barcelona Clinic Liver Cancer stage confirmed the independent prognostic value of the ALBI across the diverse stages of the disease, geographical regions of origin and time of recruitment to the study (p<0.001). CONCLUSIONS In this large, multi-centre retrospective study, the ALBI grade satisfied the criteria for accuracy and reproducibility following statistical validation in Eastern and Western HCC patients, including those treated with chemoembolization. Consideration should be given to the ALBI grade as a stratifying biomarker of liver reserve in routine clinical practice. LAY SUMMARY Liver failure is a key determinant influencing the natural history of hepatocellular carcinoma (HCC). In this large multi-centre study we externally validate a novel biomarker of liver functional reserve, the ALBI grade, across all the stages of HCC.

On-target sorafenib toxicity predicts improved survival in hepatocellular carcinoma: a multi-centre, prospective study

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide and has high mortality despite treatment. While sorafenib has a survival benefit for patients with advanced HCC, clinical response is highly variable.

The albumin-bilirubin grade improves hepatic reserve estimation post-sorafenib failure: implications for drug development

Drug development in hepatocellular carcinoma (HCC) is limited by disease heterogeneity, with hepatic reserve being a major source of variation in survival outcomes. The albumin–bilirubin (ALBI) grade is a validated index of liver function in patients with HCC.

A comparative study of short-term outcomes of colorectal cancer surgery in the elderly population

Abstract Background: Colorectal Cancer (CRC) is a disease of the elderly, and with an ageing population, oncological surgical procedures for CRC in the elderly is expected to increase. However, the balance between surgical benefits and risks associated with age and comorbidities in elderly patients is obscure. Materials and methods: A retrospective database of consecutive patients who received CRC surgery was used to compare short-term surgical and oncological outcomes between patients aged ≥75 and <75 years old undergoing CRC resection. Results: There were 54 patients (63.5%) in the <75 group and 31 patients (36.5%) in the ≥75 group. Overall, there were no differences between the <75 and ≥75 groups in postoperative HDU/ITU stay, median hospital LOS or 30-day mortality rates. Patients ≥75 had a higher preoperative performance status (25.9% versus 71.0%, p < .001), but no difference in ASA Grade and referral pattern, proportion of emergency operations, cancer staging, resection margins, achievement of curative resection or median lymph node yield. There was a significantly higher use of adjuvant chemotherapy in the <75 age group (48.1% versus 25.8%, p = .043). Conclusions: With adequate patient selection, CRC resection in elderly patients is not associated with higher postoperative mortality or worse short-term oncological benefits.

Reply to: ‘Validating the ALBI grade: Its current and future use in HCC prognostication’

To the Editor: We thank Chan et al. for their kind comments outlined in their Letter to the Editor. A number of points are also highlighted for discussion pertaining to our manuscript ‘‘The ALBI grade provides objective hepatic reserve estimation across each BCLC stage of hepatocellular carcinoma” [1]. The evolving precision in the diagnosis and management of hepatocellular carcinoma (HCC) has led, over the past decades, to a progressive improvement in treatment allocation, such that an increasing proportion of patients are now being considered for a range of effective treatments with proven survival benefit over best supportive care [2]. With this notion in mind and given the geographical and temporal heterogeneity of our study population, we evaluated whether the prognostic ability of the ALBI grade might have been influenced by a cohort effect relating to the time of diagnosis (preor post-year 2000). This was of particular importance in our study, given the high proportion of patients treated with loco-regional therapies (n = 1461), a patient subpopulation with notorious diversity in survival outcomes [3]. The improved discriminatory ability of the ALBI grade over time, that has now also been independently observed by Chan et al., is somehow thought provoking in the biological qualification of the ALBI grade as a novel biomarker of liver functional reserve. Although emerging from retrospective studies, the mutual relationship between ALBI grade, antiviral treatment and survival highlighted by Chan et al. strongly resonates with level I evidence suggesting disease-modulating effects of nucleot(s)ide analogues following curative therapy of hepatitis B virus (HBV)-related HCC [4], where optimal control of viral replication seems more important in influencing survival than systemic anti-cancer control with adjuvant sorafenib therapy [5]. With the discriminative ability of the ALBI being highest in patients classifying within Child-Pugh A criteria [6] it is perhaps unsurprising that the wider adoption of anti-HBV treatment over time in patients with HCC might have led to improved hepatic functional reserve and therefore better survival outcomes, reflected by the superior predictive accuracy of the ALBI grade. Over time, the availability and efficacy of treatment for hepatitis C virus (HCV) has also changed significantly, and the effect of antiviral therapy on patients’ survival and discriminatory ability of the ALBI grade might extend to HCV-related chronic liver disease where highly active interferon-free regimens currently produce sustained virological responses in >95% of the patients treated with direct-acting antiviral agents [7]. In answer to the second point raised by Chan et al., we tested whether the ALBI grade maintained its prognostic accuracy in a subset of 269 patients with HCC and without cirrhosis derived from our dataset. In this subgroup, Child-Pugh score was A5 in 144 (54%), A6 in 108 (40%) and B7 in 17 (6%). In non-cirrhotic

Functional and quality of life outcomes following obstetric anal sphincter injury (OASI): does the grade of injury affect outcomes?

Introduction and hypothesisThe aim of this study was to compare functional and quality of life data in patients with increasing grades of obstetric anal sphincter injury (OASI) presenting to a tertiary colorectal pelvic floor clinic within 24 months of delivery.MethodsProspective data were collected from the patients for the period 2009–2016 and included data on functional outcomes and motor anorectal manometry parameters. The instruments used for the evaluation of functional outcomes were the Birmingham Bowel and Urinary Symptoms Questionnaire, the Wexner Incontinence Score, Short Form 36, and the Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire. OASI grade of injury was based on the postdelivery endoanal ultrasound scan. Data from patients with a grade 3a, 3b, 3c or 4 OASI were compared using one-way ANOVA for parametric data and the Kruskal-Wallis test for nonparametric data overall and for separate time periods (3–6 months, 6–12 months, 12–24 months).ResultsFunctional patient data were available in 177 patients: 29 with grade 3a, 55 with grade 3b, 77 with grade 3c and 16 with grade 4 OASI. There was no discernible trend in worsening function with increasing severity of OASI overall, nor for the specified time periods of 3–6 months 58 patients), 6–12 months (85 patients) or 12–24 months (18 patients).ConclusionsOur series demonstrated no significant differences in functional outcomes or quality of life in patients with different OASI grades. Longer-term follow-up is required to ascertain any later functional differences which may become apparent with time.

Does a missed obstetric anal sphincter injury at time of delivery affect short-term functional outcome?

INTRODUCTION This study aimed to ascertain whether missed obstetric anal sphincter injury at delivery had worse functional and quality of life outcomes than primary repair immediately following delivery. MATERIALS AND METHODS Two to one propensity matching was undertaken of patients presenting to a tertiary pelvic floor unit with ultrasound evidence of missed obstetric anal sphincter injury within 24 months of delivery with patients who underwent primary repair at the time of delivery by parity, grade of injury and time to assessment. Outcomes compared included Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ), Wexner Incontinence Score, Short Form‐36, Pelvic Organ Prolapse/Urinary Incontinence Sexual Questionnaire and anorectal physiology results. RESULTS Thirty‐two missed anal sphincter injuries were matched two to one with sixty‐two patients who underwent primary repair of an anal sphincter defect. Mean time to follow‐up was 9.31 ± 6.79 months. Patients with a missed anal sphincter injury had suffered more incontinence, as seen in higher the Birmingham Bowel, Bladder and Urinary Symptom Questionnaire (BBUSQ; 30.56% ± 14.41% vs. 19.75% ± 15.65%, P = 0.002) and Wexner scores (6.00 ± 3.76 vs. 3.67 ± 4.06, P = 0.009). They also had a worse BBUSQ urinary domain score (28.25% ± 14.9% vs. 17.01 ± 13.87%, P = 0.001) and worse physical functioning as measured by the Short Form‐36 questionnaire (P = 0.045). There were no differences in other outcomes compared, including anorectal physiology and sexual function. DISCUSSION In the short‐term, patients with a missed obstetric anal sphincter injury had significantly worse faecal incontinence and urinary function scores, however quality of life and sexual function were largely comparable between groups. CONCLUSIONS Longer‐term follow‐up is needed to assess the effects of missed obstetric anal sphincter injury over time.

Treatment-stage migration maximizes survival outcomes in patients with hepatocellular carcinoma treated with sorafenib: an observational study

Background: Level I evidence supports the use of sorafenib in patients with Barcelona Clinic Liver Cancer (BCLC) stage C hepatocellular carcinoma, where heterogen