Goh Eun Chung

Transarterial Chemoembolization Can Be Safely Performed in Patients with Hepatocellular Carcinoma Invading the Main Portal Vein and May Improve the Overall Survival

PURPOSE To determine the efficacy and safety of transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) and main portal vein (MPV) invasion. MATERIALS AND METHODS This study was approved by the institutional review board, and the requirement to obtain informed consent was waived. The authors retrospectively assessed the electronic medical records of patients in whom HCC with MPV invasion was newly diagnosed from January 2004 to December 2007 at a single tertiary medical center. Patients with decompensated hepatic function were excluded. Outcomes of patients treated with TACE were compared with those of patients given supportive care according to Child-Pugh class. RESULTS One hundred twenty-five patients (104 men and 21 women; mean age, 55.7 years; age range, 33.4-83.0 years) were included. The median overall survival was 3.7 months (range, 0.2-33.3 months). Eighty-three of the 125 patients (66.4%) were treated with TACE and 42 (33.6%) received supportive care. Repeated TACE showed significant survival benefits compared with supportive care in patients with Child-Pugh class A (median survival, 7.4 months vs 2.6 months, respectively; P < .001) and class B (median survival, 2.8 months vs 1.9 months, respectively; P = .002) disease. Results of multivariate analysis showed that treatment with TACE (hazard ratio, 0.263; 95% confidence interval [CI]: 0.164, 0.424; P < .001) and Child-Pugh class A status (hazard ratio, 0.550; 95% CI: 0.368, 0.822; P = .004) were independent predictive factors of a favorable outcome. There were no procedure-related deaths within 4 weeks after TACE, and patient morbidity was 28.9% (24 of 83 patients). CONCLUSION TACE can be performed safely and may improve the overall survival of patients with HCC and MPV invasion.

Non-alcoholic fatty liver disease across the spectrum of hypothyroidism

BACKGROUND & AIMS The aim of this study was to characterize the relationship between the broad spectrum of hypothyroidism and NAFLD. METHODS A cross-sectional study with 4648 health check-up subjects (2324 cases with hypothyroidism vs. age- and sex-matched controls) was conducted. The subjects were categorized as having either subclinical [thyroid-stimulating hormone (TSH) ≥4.1 mIU/L and normal free thyroixine (T(4)) level (0.7-1.8 ng/dl)] or overt hypothyroidism [free T(4)<0.7 ng/dl]. NAFLD was diagnosed on the basis of typical ultrasonographic findings, and alcohol consumption of less than 20 g/day in the absence of other causes of liver disease. RESULTS The mean age of the subjects was 48.6±11.8 years and 62.4% were female. NAFLD was significantly associated with hypothyroidism (30.2% patients vs. 19.5% control, p<0.001). The prevalence of NAFLD and abnormal liver enzyme levels (ALT>33/25 IU/L) increased steadily with increasing grades of hypothyroidism (for NAFLD, subclinical: 29.9% and overt: 36.3%; for abnormal ALT, 20.1% and 25.9%, p<0.001, respectively). Multivariate regression analysis showed that NAFLD was statistically significantly associated with hypothyroidism (odds ratio (OR) 1.38, 95% confidence interval (CI), 1.17-1.62) and the grade of hypothyroidism in a dose-dependent manner (OR 1.36, 95% CI, 1.16-1.61 in subclinical hypothyroidism and OR 1.71, 95% CI, 1.10-2.66 in overt hypothyroidism). CONCLUSIONS Subclinical hypothyroidism, even in the range of upper normal TSH levels, was found to be related to NAFLD in a dose-dependent manner. Hypothyroidism is closely associated with NAFLD independently of known metabolic risk factors, confirming a relevant clinical relationship between these two diseases.

Association of nonalcoholic fatty liver disease with components of metabolic syndrome according to body mass index in Korean adults.

OBJECTIVES:Nonalcoholic fatty liver disease (NAFLD) is the most common cause of chronic liver disease, and its prevalence is much higher in obese individuals. NAFLD is closely related to metabolic syndrome (MetS); however, most concepts about the relationship between NAFLD and MetS have emphasized obesity, although NAFLD is not a rare disease in the non-obese population. In the present study, we aim to determine the association between NAFLD and MetS and to compare this association between non-obese and obese individuals.METHODS:A total of 29,994 adults who underwent routine comprehensive health evaluations, including abdominal ultrasonography, were selected. We calculated the adjusted prevalence ratios (PRs) for components of MetS (high blood pressure (BP), impaired fasting glucose, low high-density lipoprotein cholesterol (HDL-C), and high triglycerides (TG)) according to NAFLD in non-obese and obese patients.RESULTS:NAFLD was found in 12.6% of non-obese subjects and 50.1% of obese subjects. NAFLD was associated with most components of MetS in both obese and non-obese subjects. However, non-obese NAFLD patients had significantly higher PRs for certain components of MetS than did obese patients, especially among women. Adjusted PRs (95% confidence interval) for components of MetS in non-obese women vs. obese women were as follows: (1) high BP: 1.41 (1.31–1.51) vs. 1.05 (0.89–1.22) (2) impaired fasting glucose: 2.04 (1.95–2.75) vs. 1.37 (1.21–1.53) (3) low HDL-C: 2.00 (1.92–2.08) vs. 1.40 (1.26–1.55), and (4) high TG: 3.36 (3.24–3.47) vs. 1.97 (1.76–2.17).CONCLUSIONS:NAFLD was associated with risk for components of MetS, and the association was stronger in non-obese than in obese individuals, especially in women. Therefore, NAFLD should be considered a meaningful predictor of metabolic diseases in the non-obese population.

Long-term prognosis of combined hepatocellular and cholangiocarcinoma after curative resection comparison with hepatocellular carcinoma and cholangiocarcinoma.

Goal In this study, we attempted to evaluate the prognosis of combined hepatocellular and cholangiocarcinoma (cHCC-CC) with comparison to hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (CC). Background The prognosis of cHCC-CC has not been fully elucidated. In this study, we attempted to evaluate the prognosis of cHCC-CC with comparison to HCC and CC. Study Consecutive patients who underwent curative resection for cHCC-CC at a single tertiary care center in Korea and their age, sex, and Child-Turcotte-Pugh class matched HCC and CC patients were included. We evaluated time-to-recurrence (TTR) and overall survival (OS) of cHCC-CC cases and compared them with HCC and CC patients. Results Thirty cHCC-CC, 60 HCC, and 60 CC patients were included. For cHCC-CC group, the median TTR and OS were 5.4 and 18.0 months. After adjustment for confounding factors, the cHCC-CC group had a shorter TTR than did HCC group [relative risk (RR), 2.76; P<0.001] and CC group (RR, 2.00; P=0.013), and a shorter OS than HCC group (RR, 4.70; P<0.001). Compared with the each stage I diseases, cHCC-CC had shorter TTR than HCC (RR, 4.59; P=0.001) and CC (RR, 2.74, P=0.015) and shorter OS than HCC (RR, 9.35; P=0.001). Conclusions The results of this study indicated that cHCC-CC had a significantly poorer prognosis than HCC and CC even after curative resection.

Effect of annual endoscopic screening on clinicopathologic characteristics and treatment modality of gastric cancer in a high‐incidence region of Korea

We investigated risk factors for gastric cancer (GC) and effect of annual endoscopic screening on detection and treatment modality of GC. Asymptomatic adults who underwent upper endoscopy during health checkups at Seoul National University Hospital Healthcare System Gangnam Center were enrolled. We compared clinicopathologic characteristics of GC according to screening interval (repeated vs. infrequent, annual vs. biennial). After age‐ and sex‐matching, relative risk was computed by hazard ratio (HR) using Cox proportional regression with multivariate adjustment. Of the 58,849 subjects who received screening endoscopy, 277 (0.47%) were found to have GC. Intestinal type comprised 55.4% (102/184) followed by diffuse type (n = 65, 35.3%). Age ≥50 years, family history and smoking independently increased the risk of GC for both types, whereas male gender [HR = 4.81, 95% confidence interval (CI): 2.72–8.03] and intestinal metaplasia (IM) (HR = 10.87, 95% CI: 3.36–22.30) were significant predictors for intestinal type only. Proportion of early gastric cancer (EGC) was 98.6% (71/72) in annual screening group and 80.7% (46/57) in biennial screening group (p < 0.01). In the former, tumor size was smaller (1.7 ± 1.3 vs. 2.3 ± 1.8 cm; p < 0.01] and proportion of intramucosal cancer was larger (75.0 vs. 56.1%; p = 0.04). Endoscopic resection was performed more frequently in annual screening group (56.9 vs. 33.3%; p = 0.02). IM along with male gender and older age was a strong risk factor for intestinal type GC. Annual screening group improved detection of early‐stage and endoscopically treatable GC suggesting that intensive screening and surveillance may be useful for high‐risk subpopulations with epidemiologic risk factors or premalignant lesions such as IM.

Comparison of detection and miss rates of narrow band imaging, flexible spectral imaging chromoendoscopy and white light at screening colonoscopy: a randomised controlled back-to-back study

Objective Virtual chromoendoscopy (CE) is expected to enhance adenoma yield and reduce variation in performance between colonoscopists. This study aimed to compare the efficacy of narrow band imaging (NBI), flexible spectral imaging CE (FICE) and white light (WL) colonoscopy and their impact for less experienced endoscopists. Methods We performed a randomised tandem colonoscopy trial controlling for withdrawal time and bowel preparation. Average-risk adults undergoing screening colonoscopy were enrolled and randomly assigned to first withdrawal with one of the three imaging modalities (NBI (NBI-WL group), FICE (FICE-WL group) and WL (WL-WL group)). Eight colonoscopists were categorised into expert and non-expert subgroups. Results 1650 subjects (mean age 51.4 years, 63.9% men) were included (550 in each group). Compared with WL, neither NBI nor FICE increased the mean number of adenomas detected per patient (0.37 vs 0.35 and 0.36; p=0.591) or the percentage of patients with adenoma (25.3% vs 24.5% and 23.6%; p=0.753). For all three modalities, expert subgroups had higher yields of adenomas than non-expert subgroups. Learning curves were observed only for non-expert subgroups with all three modalities. The percentage of missed adenomas did not differ between the three groups (20.8% by WL vs 22.9% by NBI and 26.0% by FICE, p=0.300) and was not affected by endoscopists’ expertise. Conclusions Neither NBI nor FICE improved adenoma detection or miss rates, with no difference in diagnostic efficacy between the two systems. Virtual CE had no additional benefits over WL for non-experts. Clinical trial registration number: KCT0000570.

Serum bilirubin levels are inversely associated with nonalcoholic fatty liver disease

Background/Aims Serum bilirubin exerts antioxidant and cytoprotective effects. In addition, elevated serum bilirubin levels are associated with a decreased risk of metabolic and cardiovascular diseases. However, few studies have evaluated whether serum bilirubin is associated with non-alcoholic fatty liver disease (NAFLD), which is closely associated with other metabolic diseases. The aim of this study was thus to elucidate the association between serum total bilirubin levels and NAFLD. Methods A cross-sectional study of 17,348 subjects undergoing a routine health check-up was conducted. Subjects positive for hepatitis B or hepatitis C virus, or with other hepatitis history were excluded. NAFLD was diagnosed on the basis of typical ultrasonographic findings and an alcohol consumption of less than 20 g/day. Results The mean age of the subjects was 49 years and 9,076 (52.3%) were men. The prevalence of NAFLD decreased steadily as the serum bilirubin level increased in both men and women (P<0.001 for both). Multivariate regression analysis adjusted for other metabolic risk factors showed that serum bilirubin level was inversely associated with the prevalence of NAFLD [odds ratio (OR)=0.88, 95% confidence interval (CI)=0.80-0.97]. Furthermore, there was an inverse, dose-dependent association between NAFLD and serum total bilirubin levels (OR=0.83, 95% CI=0.75-0.93 in the third quartile; OR=0.80, 95% CI=0.71-0.90 in the fourth quartile vs. lowest quartile, P for trend <0.001). Conclusions Serum bilirubin levels were found to be inversely associated with the prevalence of NAFLD independent of known metabolic risk factors. Serum bilirubin might be a protective marker for NAFLD.

Erratum to: Add-On Adefovir Is Superior to a Switch to Entecavir as Rescue Therapy for Lamivudine-Resistant Chronic Hepatitis B

Serum ALT levels decreased during the treatment period in both groups (Table 2). However, no significant differences were found between the two groups in the mean reduction and normalization of ALT at week 48. Among HBeAgpositive patients, HBeAg seroconversion (66.7% in the ETV group vs. 38.4% in the add-on ADV group) and the mean time to HBeAg seroconversion (11.83 ± 8.95 months in the ETV group vs. 5.40 ± 1.45 months in the add-on ADV group) were similar in the two groups (P = 0.229 and P = 0.190).

Cholecystectomy is independently associated with nonalcoholic fatty liver disease in an Asian population

AIM To investigate the relationship between gallstone disease and nonalcoholic fatty liver disease (NAFLD) in a large Asian population. METHODS A cross-sectional study including 17612 subjects recruited from general health check-ups at the Seoul National University Hospital, Healthcare System Gangnam Center between January 2010 and December 2010 was conducted. NAFLD and gallstone disease were diagnosed based on typical ultrasonographic findings. Subjects who were positive for hepatitis B or C, or who had a history of heavy alcohol consumption (> 30 g/d for men and > 20 g/d for women) or another type of hepatitis were excluded. Gallstone disease was defined as either the presence of gallstones or previous cholecystectomy, and these two entities (gallstones and cholecystectomy) were analyzed separately. Clinical parameters including body mass index, waist circumference, hypertension, diabetes, smoking status, and regular physical activity were reviewed. Laboratory parameters, including serum levels of gamma-glutamyl transpeptidase, alanine aminotransferase, aspartate aminotransferase, fasting glucose, fasting insulin, total cholesterol, triglycerides, and high-density lipoprotein, were also reviewed. RESULTS The mean age of the subjects was 48.5 ± 11.3 years, and 49.3% were male. Approximately 30.3% and 6.1% of the subjects had NAFLD and gallstone disease, respectively. The prevalence of gallstone disease (8.3% vs 5.1%, P < 0.001), including both the presence of gallstones (5.5% vs 3.4%, P < 0.001) and a history of cholecystectomy (2.8% vs 1.7%, P < 0.001), was significantly increased in the NAFLD group. In the same manner, the prevalence of NAFLD increased with the presence of gallstone disease (41.3% vs 29.6%, P < 0.001). Multivariate regression analysis showed that cholecystectomy was associated with NAFLD (OR = 1.35, 95%CI: 1.03-1.77, P = 0.028). However, gallstones were not associated with NAFLD (OR = 1.15, 95%CI: 0.95-1.39, P = 0.153). The independent association between cholecystectomy and NAFLD was still significant after additional adjustment for insulin resistance (OR = 1.45, 95%CI: 1.01-2.08, P = 0.045). CONCLUSION This study shows that cholecystectomy, but not gallstones, is independently associated with NAFLD after adjustment for metabolic risk factors. These data suggest that cholecystectomy may be an independent risk factor for NAFLD.

Role of physical activity in nonalcoholic fatty liver disease in terms of visceral obesity and insulin resistance

Limited evidence supports a role for physical activity (PA) in nonalcoholic fatty liver disease (NAFLD) independent of visceral obesity or/and insulin resistance. We investigated the association between PA and NAFLD while considering visceral adipose tissue (VAT) and insulin resistance in a large general population.