Improving survival of cirrhosis patients with hepatocellular carcinoma through application of standard of care
Authors: Edoardo G. Giannini, Franco Trevisani
Journal: Hepatology (2014)

We read with great interest the article by Ripoll et al.1 recently published in Hepatology. In their study the authors observed that prophylaxis of rebleeding from esophageal varices in cirrhosis patients with hepatocellular carcinoma (HCC) is associated with improved outcome. Furthermore, confirming previous findings, they observed that patients with HCC who bled had a worse outcome as compared to a matched group of bleeding cirrhosis patients without liver cancer.1-3 One of the most interesting results of this study, however, was that fewer patients with HCC received secondary prophylaxis after bleeding, and that lack of secondary prophylaxis was an independent predictor of death. We feel that this study touches upon an important issue in the management of cirrhosis patients, and more so in cirrhosis patients with HCC. In fact, despite recent evidence of improved outcome, the mortality rate associated with variceal bleeding is still as high as 20%.4, 5 Furthermore, although primary prophylaxis of variceal hemorrhage may be associated with an overall benefit that goes beyond a simple decrease in bleeding rate, and the unavailability of accurate noninvasive methods able to obviate the need for endoscopy, the proportion of patients at risk of bleeding who actually undergo screening endoscopy is low.6-9 Moreover, the proportion of patients who, after a positive screening result, actually undergo primary prophylaxis is unknown. Noteworthy, the study by Ripoll et al.1 shows that less than half (43%) of eligible patients with cirrhosis and HCC were on primary prophylaxis of bleeding. This finding is clinically meaningful, as we have previously shown that in patients with HCC the presence of varices is independently associated with death, and death due to bleeding is significantly more frequent in patients with varices.10 However, due to insufficient data our study was not able to identify whether the presence of varices simply identified patients with more advanced disease—and therefore at higher risk of bleeding and death—and which was the proportion of patients on bleeding prophylaxis. In this regard, the study by Ripoll et al. shows us that cirrhosis patients with HCC who bled received a suboptimal management, and puts forward the hypothesis that this may be due to the perception that intensive management would not result in a meaningful clinical benefit when HCC is present. Instead, their results clearly show that lack of rebleeding prophylaxis is associated with increased mortality, even after adjustment for the severity of liver disease. This information calls us to a more thorough management of these patients. All in all, we feel that studies like this are extremely useful for clinical practice, providing data that should remind us that some measures, such as primary and secondary prophylaxis of variceal bleeding, are standard of care and not options in the management of cirrhosis patients, regardless of the presence of HCC. Edoardo G. Giannini, M.D., Ph.D.1 Franco Trevisani, M.D.2 1Dipartimento di Medicina Interna Unità di Gastroenterologia IRCCS Azienda Ospedaliera Universitaria San Martino IST Università di Genova Genova, Italy 2Dipartimento di Scienze Mediche Chirurgiche Unità di Semeiotica Medica, Alma Mater Studiorum Università di Bologna Bologna, Italy