Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dimprognosis. The role of preoperative and palliative biliary drainage has long beendebated. The most common techniques are endoscopic retrogr...Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dimprognosis. The role of preoperative and palliative biliary drainage has long beendebated. The most common techniques are endoscopic retrograde cholangiopancreatography(ERCP) and percutaneous transhepatic biliary drainage (PTBD);however, recently developed endoscopic ultrasound-assisted methods are gainingmore atention. Selecting the best available method in any specific scenario iscrucial, yet sometimes challenging. Thus, this review aimed to discuss theavailable techniques, indications, perks, pitfalls, and timing-related issues in themanagement of hCCA. In a preoperative setting, PTBD appears to have someadvantages: low risk of postprocedural complications (namely cholangitis) andbetter priming for surgery. For palliative purposes, we propose ERCP/PTBDdepending on the experience of the operators, but also on other factors: the levelof bilirubin (if very high, rather PTBD), length of the stenosis and the presence ofcholangitis (PTBD), ERCP failure, or altered biliary anatomy.展开更多
Hemostasis is a complex physiological process based on the balance between procoagulant and anticoagulant systems to avoid pathological bleeding or thrombosis.The changes in standard coagulation tests in liver disease...Hemostasis is a complex physiological process based on the balance between procoagulant and anticoagulant systems to avoid pathological bleeding or thrombosis.The changes in standard coagulation tests in liver disease were assumed to reflect an acquired bleeding disorder,and cirrhotic patients were considered naturally anticoagulated.In the light of the new evidence,the theory of rebalanced hemostasis replaced the old concept.According to this model,the hemostatic alteration leads to a unique balance between pro-coagulant,anticoagulant,and fibrinolytic systems.But the balance is fragile and may prone to bleeding or thrombosis depending on various risk factors.The standard coagulation tests[INR(international normalized ratio),platelet count and fibrinogen]only explore parts of the hemostasis,not offering an entire image of the process.Rotational thromboelastometry(ROTEM)and thromboelastography(TEG)are both point of care viscoelastic tests(VET)that provide real-time and dynamic information about the entire hemostasis process,including clot initiation(thrombin generation),clot kinetics,clot strength,and clot stability(lysis).Despite prolonged PT/INR(international normalized ratio of prothrombin time)and low platelet counts,VET is within the normal range in many patients with both acute and chronic liver disease.However,bleeding remains the dominant clinical issue in patients with liver diseases,especially when invasive interventions are required.VET has been shown to asses more appropriately the risk of bleeding than conventional laboratory tests,leading to decrial use of blood products transfusion.Inappropriate clotting is common but often subtle and may be challenging to predict even with the help of VET.Although VET has shown its benefit,more studies are needed to establish cut-off values for TEG and ROTEM in these populations and standardization of transfusion guidelines before invasive interventions in cirrhotic patients/orthotopic liver transplantation.展开更多
The time for battling cancer has never been more suitable than nowadays and fortunately against hepatocellular carcinoma(HCC)we do have a far-reaching arsenal.Moreover,because liver cancer comprises a plethora of stag...The time for battling cancer has never been more suitable than nowadays and fortunately against hepatocellular carcinoma(HCC)we do have a far-reaching arsenal.Moreover,because liver cancer comprises a plethora of stages-from very early to advanced disease and with many treatment options–from surgery to immunotherapy trials–it leaves the clinician a wide range of options.The scope of our review is to throw light on combination treatments that seem to be beyond guidelines and to highlight these using evidence-based analysis of the most frequently used combination therapies,discussing their advantages and flaws in comparison to the current standard of care.One particular combination therapy seems to be in the forefront:Transarterial chemoembolization plus ablation for medium-size non-resectable HCC(3-5 cm),which is currently at the frontier between Barcelona Clinic Liver Cancer classification A and B.Not only does it improve the outcome in contrast to each individual therapy,but it also seems to have similar results to surgery.Also,the abundance of immune checkpoint inhibitors that have appeared lately in clinical trials are bringing promising results against HCC.Although the path of combination therapies in HCC is still filled with uncertainty and caveats,in the following years the hepatology and oncology fields could witness an HCC guideline revolution.展开更多
Cholangiocarcinoma(CCA)arises from the ductular epithelium of the biliary tree,either within the liver(intrahepatic CCA)or more commonly from the extrahepatic bile ducts(extrahepatic CCA).This disease has a poor progn...Cholangiocarcinoma(CCA)arises from the ductular epithelium of the biliary tree,either within the liver(intrahepatic CCA)or more commonly from the extrahepatic bile ducts(extrahepatic CCA).This disease has a poor prognosis and a growing worldwide prevalence.The poor outcomes of CCA are partially explained by the fact that a final diagnosis is challenging,especially the differential diagnosis between hepatocellular carcinoma and intrahepatic CCA,or distal CCA and pancreatic head adenocarcinoma.Most patients present with an advanced disease,unresectable disease,and there is a lack in non-surgical therapeutic modalities.Not least,there is an acute lack of prognostic biomarkers which further complicates disease management.Therefore,there is a dire need to find alternative diagnostic and follow-up pathways that can lead to an accurate result,either singlehandedly or combined with other methods.In the"-omics"era,this goal can be attained by various means,as it has been successfully demonstrated in other primary tumors.Numerous variants can reach a biomarker status ranging from circulating nucleic acids to proteins,metabolites,extracellular vesicles,and ultimately circulating tumor cells.However,given the relatively heterogeneous data,extracting clinical meaning from the inconsequential noise might become a tall task.The current review aims to navigate the nascent waters of the non-invasive approach to CCA and provide an evidence-based input to aid clinical decisions and provide grounds for future research.展开更多
文摘Hilar cholangiocarcinoma (hCCA) is a primary liver tumor associated with a dimprognosis. The role of preoperative and palliative biliary drainage has long beendebated. The most common techniques are endoscopic retrograde cholangiopancreatography(ERCP) and percutaneous transhepatic biliary drainage (PTBD);however, recently developed endoscopic ultrasound-assisted methods are gainingmore atention. Selecting the best available method in any specific scenario iscrucial, yet sometimes challenging. Thus, this review aimed to discuss theavailable techniques, indications, perks, pitfalls, and timing-related issues in themanagement of hCCA. In a preoperative setting, PTBD appears to have someadvantages: low risk of postprocedural complications (namely cholangitis) andbetter priming for surgery. For palliative purposes, we propose ERCP/PTBDdepending on the experience of the operators, but also on other factors: the levelof bilirubin (if very high, rather PTBD), length of the stenosis and the presence ofcholangitis (PTBD), ERCP failure, or altered biliary anatomy.
文摘Hemostasis is a complex physiological process based on the balance between procoagulant and anticoagulant systems to avoid pathological bleeding or thrombosis.The changes in standard coagulation tests in liver disease were assumed to reflect an acquired bleeding disorder,and cirrhotic patients were considered naturally anticoagulated.In the light of the new evidence,the theory of rebalanced hemostasis replaced the old concept.According to this model,the hemostatic alteration leads to a unique balance between pro-coagulant,anticoagulant,and fibrinolytic systems.But the balance is fragile and may prone to bleeding or thrombosis depending on various risk factors.The standard coagulation tests[INR(international normalized ratio),platelet count and fibrinogen]only explore parts of the hemostasis,not offering an entire image of the process.Rotational thromboelastometry(ROTEM)and thromboelastography(TEG)are both point of care viscoelastic tests(VET)that provide real-time and dynamic information about the entire hemostasis process,including clot initiation(thrombin generation),clot kinetics,clot strength,and clot stability(lysis).Despite prolonged PT/INR(international normalized ratio of prothrombin time)and low platelet counts,VET is within the normal range in many patients with both acute and chronic liver disease.However,bleeding remains the dominant clinical issue in patients with liver diseases,especially when invasive interventions are required.VET has been shown to asses more appropriately the risk of bleeding than conventional laboratory tests,leading to decrial use of blood products transfusion.Inappropriate clotting is common but often subtle and may be challenging to predict even with the help of VET.Although VET has shown its benefit,more studies are needed to establish cut-off values for TEG and ROTEM in these populations and standardization of transfusion guidelines before invasive interventions in cirrhotic patients/orthotopic liver transplantation.
文摘The time for battling cancer has never been more suitable than nowadays and fortunately against hepatocellular carcinoma(HCC)we do have a far-reaching arsenal.Moreover,because liver cancer comprises a plethora of stages-from very early to advanced disease and with many treatment options–from surgery to immunotherapy trials–it leaves the clinician a wide range of options.The scope of our review is to throw light on combination treatments that seem to be beyond guidelines and to highlight these using evidence-based analysis of the most frequently used combination therapies,discussing their advantages and flaws in comparison to the current standard of care.One particular combination therapy seems to be in the forefront:Transarterial chemoembolization plus ablation for medium-size non-resectable HCC(3-5 cm),which is currently at the frontier between Barcelona Clinic Liver Cancer classification A and B.Not only does it improve the outcome in contrast to each individual therapy,but it also seems to have similar results to surgery.Also,the abundance of immune checkpoint inhibitors that have appeared lately in clinical trials are bringing promising results against HCC.Although the path of combination therapies in HCC is still filled with uncertainty and caveats,in the following years the hepatology and oncology fields could witness an HCC guideline revolution.
基金Supported by The Romanian National Ministry of Research,Innovation and Digitalization,CNCS-UEFISCDI:Postdoctoral Research Project PN-Ⅲ-P1-1.1-PD-2019-0852/PD113 within PNCDIⅢ,awarded to Maria Ilie?。
文摘Cholangiocarcinoma(CCA)arises from the ductular epithelium of the biliary tree,either within the liver(intrahepatic CCA)or more commonly from the extrahepatic bile ducts(extrahepatic CCA).This disease has a poor prognosis and a growing worldwide prevalence.The poor outcomes of CCA are partially explained by the fact that a final diagnosis is challenging,especially the differential diagnosis between hepatocellular carcinoma and intrahepatic CCA,or distal CCA and pancreatic head adenocarcinoma.Most patients present with an advanced disease,unresectable disease,and there is a lack in non-surgical therapeutic modalities.Not least,there is an acute lack of prognostic biomarkers which further complicates disease management.Therefore,there is a dire need to find alternative diagnostic and follow-up pathways that can lead to an accurate result,either singlehandedly or combined with other methods.In the"-omics"era,this goal can be attained by various means,as it has been successfully demonstrated in other primary tumors.Numerous variants can reach a biomarker status ranging from circulating nucleic acids to proteins,metabolites,extracellular vesicles,and ultimately circulating tumor cells.However,given the relatively heterogeneous data,extracting clinical meaning from the inconsequential noise might become a tall task.The current review aims to navigate the nascent waters of the non-invasive approach to CCA and provide an evidence-based input to aid clinical decisions and provide grounds for future research.
