Nathalie Goutte

Prospective evaluation of the management of hepatocellular carcinoma in the elderly.

BACKGROUND An increasing proportion of patients with hepatocellular carcinoma are older than 75 years. Previous studies suggested that ageing does not adversely impact survival but they have the drawback of being retrospective and spanning a prolonged period of time. GOALS Evaluate management and prognosis of hepatocellular carcinoma in elderly. PATIENTS AND METHODS A multidisciplinary oncology meeting prospectively evaluated all patients with hepatocellular carcinoma. Management were standardised according to European and American guidelines. Forty patients older than 75 years were matched with younger patients for tumour extension and liver function. Both groups were compared for the type of treatment and survival. RESULTS Male/female ratio was 1.2 as compared to 7 in controls. Cirrhosis was related mostly to hepatitis C virus in elderly, and equally to hepatitis C or B virus and alcohol in controls. Curative treatments were recommended in 55% of elderly and 75% of controls. Treatment actually performed was curative in 25% in elderly as compared to 63% in controls. Median survival (30 months) was identical in both groups. CONCLUSION Despite more restricted access to curative treatments, survival of elderly patients with hepatocellular carcinoma is comparable to that of younger patients.

Geographical variations in incidence, management and survival of hepatocellular carcinoma in a Western country

BACKGROUND & AIMS Information on the incidence, management, and prognosis of hepatocellular carcinoma (HCC) is derived from population samples, regional data, or registries. Comprehensive national evaluations within a given country are lacking. This study aimed to investigate regional variations in HCC care within France. METHODS This observational study analysed data from French administrative databases for more than 30,000 patients with HCC diagnosed between 2009 and 2012, and followed-up until 2013. The incidence of HCC, access to surgery, and survival, at both the national level and two geographical levels (the 21 French regions and 95 French departments into which France is divided administratively), were determined. The influence on outcome of the structure of the hospital where HCC was first managed was assessed. RESULTS At the national level, the median survival was 9.4months and only 22.8% of patients had curative treatment. There were marked variations between regions and departments in incidence, access to curative treatment (range 1.3-28.8% and 8.1-32.3% respectively), and in median survival (range 5.7-12.1 and 4.3-16.5months respectively). The administrative type and annual HCC-caseload of the hospital where patients were first admitted also had an independent influence on treatment and survival. CONCLUSION Despite full insurance coverage for all citizens, national measures to reduce inequities in the management of cancer patients, standardised recommendations for HCC surveillance and management, the percentage of patients undergoing curative treatment and their survival may vary four-fold depending on their postcode. The hospital in which patients are first managed has a clear influence on accessibility to both good care and survival. LAY SUMMARY Population-based studies have highlighted large and sometimes unexpected differences between countries in the survival of patients with malignancy. As these differences are considered to indicate the overall effectiveness of health systems, in addition to the incidence of the cancer or quality of registration, variations within a given country should be minimal. However, similar to between countries differences, this study shows differences within the same country in the incidence, curative treatment rate, and survival of patients with HCC. Evidence that access to care and survival varies within a country can strengthen the impetus for government and clinicians to address these disparities.

Standardized Care Management Ensures Similar Survival Rates in HIV-Positive and HIV-Negative Patients With Hepatocellular Carcinoma

Objective:It has been suggested that HIV infection has a detrimental impact on patients with hepatocellular carcinoma (HCC). The present study sought to test this hypothesis, while controlling for tumor extension and liver disease. Design and Setting:A case control and a cohort approach were performed in patients with HCC managed prospectively via dedicated multidisciplinary team meeting in a single tertiary institution between 2004 and 2009. Subjects:Of 473 consecutive treatment-naive patients with HCC, 23 were HIV-positive (HIV+) and 450 were HIV-negative (HIV−). HIV+ patients were matched 1:2 with a control group of HIV− patients in terms of the etiology of HCC, the severity of liver disease, tumor extension, and year of diagnosis. Intervention:Curative or palliative treatment of HCC. Main Outcome Measures:Eligibility for HCC treatment, the treatment actually administered, and the survival rate. Results:The HIV+ population was younger than the HIV− population (mean age: 49 vs. 61 years, respectively; P < 0.0001). Curative treatment was recommended by the multidisciplinary team meeting and then actually performed to a similar extent in HIV+ patients (74% and 43%, respectively) and their matched HIV− controls (74% and 56%, respectively). The HIV+ and their matched HIV− patients did not differ significantly in terms of the 3-year survival rate [44% vs. 48%, respectively; mean (95% confidence interval) hazard ratio = 0.64 (0.3–1.3); P = 0.2]. In a cohort analysis, HIV status was not an independent predictor of survival among curatively treated patients. Conclusion:In an equal-access unbiased environment, HIV status does not significantly influence treatment access, delivery, and outcome.

Laparoscopic left lateral sectionectomy: a population-based study

BACKGROUND Laparoscopic left lateral sectionectomy (LLS) has now become standard practice. However, published series are small and retrospective. The aim was to compare at a national level the use and short-term outcome of laparoscopic and open LLS. METHODS National hospital discharge databases were screened to identify all adult patients who had undergone elective LLS in France between 2007 and 2012. Outcome measurements included blood transfusion, severe morbidity, mortality and length of hospital stay. The independent influence of the laparoscopic approach on these outcomes was tested overall and after stratifying for the indication (benign condition, primary malignancy, liver metastasis). RESULTS Over the 6-year study period, 2198 patients underwent LLS, accounting for 6.9% of all elective liver resections. Some 28.5% of LLS procedures were performed laparoscopically. Among hospitals in which LLS was carried out, 33.2% of procedures were done laparoscopically (median 2 laparoscopic LLS resections per year). The laparoscopic approach was independently associated with a shorter length of hospital stay irrespective of the indication, and a lower transfusion rate in patients with benign condition or primary malignancy. CONCLUSION LLS is seldom performed and the laparoscopic approach has not been adopted widely. The potential benefit of laparoscopic LLS varies according to the indication.

The epidemiology of Budd–Chiari syndrome in France

INTRODUCTION Epidemiological data is lacking on primary Budd-Chiari syndrome (BCS) in France. METHODS Two approaches were used: (1) A nationwide survey in specialized liver units for French adults. (2) A query of the French database of discharge diagnoses screening to identify incident cases in adults. BCS associated with cancer, alcoholic/viral cirrhosis, or occurring after liver transplantation were classified as secondary. RESULTS Approach (1) 178 primary BCS were identified (prevalence 4.04 per million inhabitants (pmi)), of which 30 were incident (incidence 0.68 pmi). Mean age was 40 ± 14 yrs. Risk factors included myeloproliferative neoplasms (MPN) (48%), oral contraceptives (35%) and factor V Leiden (16%). None were identified in 21% of patients, ≥2 risk factors in 25%. BMI was higher in the group without any risk factor (25.7 kg/m2 vs 23.7 kg/m2, p < 0.001). Approach (2) 110 incident primary BCS were admitted to French hospitals (incidence 2.17 pmi). MPN was less common (30%) and inflammatory local factors predominated (39%). CONCLUSION The entity of primary BCS as recorded in French liver units is 3 times less common than the entity recorded as nonmalignant hepatic vein obstruction in the hospital discharge database. The former entity is mostly related to MPN whereas the latter with abdominal inflammatory diseases.

P998 BENEFIT OF SORAFENIB ACCORDING TO UNDERLYING LIVER DISEASE ETIOLOGY IN PATIENTS WITH ADVANCED HEPATOCELLULAR CARCINOMA (HCC)

BCLC staging when modified according to the findings of PS or disregarding it. Results: At multivariate analysis only PS≥2 vs PS0–1, beside various liver function and tumor related variables, but not PS≥1 vs PS0 resulted significant predictors of survival. We then compared the prognostic capacity of the original BCLC staging (model 1) vs a complete removal of PS (model 2) vs a model where only PS≥2 qualifies a patient to be advanced, but not PS1, according to our findings. The discrimination ability among the various BCLC stages (AvsBvsCvsD), expressed by the Akaike information criterion (AIC), was significantly better in model 2 (943) and 3 (880) than in model 1 (699, p < 0.05). Model 3 produced the best progressive discriminatory capacity among stages. Conclusions: Patients with HCC on cirrhosis and PS1 should not be considered advanced, due to the difficulty in ascribing mild symptoms, commonly observed in cirrhosis, to the tumor.