Cholangiocarcinoma (CCA) is a rare malignancy of the biliary tract. The goals of endoscopy in CCA are to (a) provide an accurate diagnosis (tissue acquisition) and staging of disease and (b) relieve biliary obstruction and associated symptoms such as pruritis (stent placement). This then facilitates optimal treatment to occur; be this surgical resection, uninterrupted chemotherapy or improvement in symptoms. Endoscopy can involve endoscopic retrograde cholangiopancreatography with or without cholangioscopy, or endoscopic ultrasound with fine-needle aspiration to support these goals of making surgery safer and chemotherapy possible while avoiding endoscopy compilations such as pancreatitis and sepsis.
The number of effective systemic therapies for the treatment of unresectable hepatocellular carcinoma (uHCC) is rapidly increasing and the advent of immunotherapy changed the treatment paradigm for these patients, leading to a significant improvement in survival outcomes. While sorafenib, a tyrosine-kinase inhibitor monotherapy, remained the only effective treatment for almost a decade, the combination of atezolizumab, an immune checkpoint inhibitor (ICI) targeting programmed death-ligand 1, plus bevacizumab, an antiangiogenic agent targeting vascular endothelial growth factor, now represents the new standard of care for patients with uHCC. Moreover, several further clinical trials are ongoing to evaluate novel combinations between ICIs with other drugs, belonging to the same class or to other classes. As HCC occurs in most cases in the setting of cirrhosis, the evaluation of the risk/benefit ratio of systemic treatments represents a critical point. The underlying liver disease significantly influences the safety and the effectiveness of current and future systemic treatments for uHCC. For this reason, the hepatotoxicity profile and impact on liver function of these molecules should be carefully assessed in both clinical trials and in the real-world setting. Here, we review hepatotoxicity data on systemic treatments for uHCC and offer suggestions on monitoring and managing liver-related adverse events occurring during the treatment.
A simple score combining clinical and biochemical parameters (general evaluation score (GES)) has shown value in predicting hepatocellular carcinoma (HCC) risk after hepatitis C virus (HCV) eradication in Egyptian patients with HCV genotype 4. We aimed to apply the GES to predict HCC risk in Japanese HCV patients who achieved sustained virological response (SVR) following direct-acting antivirals (DAAs). This multicentre retrospective cohort study included 187 HCV patients without a history of HCC treatment who achieved SVR. The GES was calculated using pre- and post-treatment data. The median age of the patients was 66 years; 49% were male, 89% had cirrhosis and 69% had HCV genotype 1. During the mean 36-month follow-up, 19 (10.2%) developed HCC. Regarding the pretreatment scores, 75 (40.1%), 58 (31.0%) and 54 (28.9%) patients had low-, intermediate- and high-risk scores, respectively. The 4-year cumulative incidence (CumI) was 1.64% in the low-risk group, 2.82% in the intermediate-risk group and 6.88% in the high-risk group (log-rank P = .029). In patients with cirrhosis, 60 (36.1%), 57 (34.3%) and 49 (29.5%) had low-, intermediate- and high-risk scores respectively. The 4-year CumI was 0.98% in the low-risk group, 2.86% in the intermediate-risk group and 6.67% in the high-risk group (log-rank P = .02). The GES calculated with pretreatment data was more useful than that calculated with post-treatment data (Harrell's C statistic: 0.670 vs 0.587). This tool incorporates changes over time to estimate variations in HCC risk and could help identify low-risk patients for whom HCC surveillance can be discontinued.
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