Recent Publications by CFE Educators

BACKGROUND & AIMS

Noninvasive variceal risk stratification systems have not been validated in patients with hepatocellular carcinoma (HCC), which presents logistical barriers for patients in the setting of systemic HCC therapy. We aimed to develop and validate a noninvasive algorithm for the prediction of varices in patients with unresectable HCC.

METHODS

We performed a retrospective cohort study in 21 centers in the United States including adult patients with unresectable HCC and Child-Pugh A5-B7 cirrhosis diagnosed between 2007 and 2019. We included patients who completed an esophagogastroduodonoscopy (EGD) within 12 months of index imaging but before HCC treatment. We divided the cohort into a 70:30 training set and validation set, with the goal of maximizing negative predictive value (NPV) to avoid EGD in low-risk patients.

RESULTS

We included 707 patients (median age, 64.6 years; 80.6% male; 74.0% White). Median time from HCC diagnosis to EGD was 47 (interquartile range, 114) days, with 25.0% of patients having high-risk varices. A model using clinical variables alone achieved an NPV of 86.3% in the validation cohort, whereas a model integrating clinical and imaging variables had an NPV 97.4% in validation. The clinical and imaging model would avoid EGDs in more than half of low-risk patients while misclassifying 7.7% of high-risk patients.

CONCLUSIONS

A model incorporating clinical and imaging data can accurately predict the absence of high-risk varices in patients with HCC and avoid EGD in many low-risk patients before the initiation of systemic therapy, thus expediting their care and avoiding treatment delays.

This preliminary study investigates hypoglossal nerve stimulator (HNS) amplitude changes and usage patterns during the initial HNS uptitration period to characterize when patients achieve their therapeutic amplitude. HNS therapy amplitudes, duration, and pause times were examined across the first 4 months of implant use. Average HNS therapy amplitude increased monthly from baseline (0.7 ± 0.3 V) to the first (1.1 ± 0.3 V), second (1.4 ± 0.4 V), third (1.7 ± 0.5 V), and fourth months (1.8 ± 0.5 V) (P  .001). After 4 months, 60% had reached a therapeutic amplitude. Average therapeutic amplitude was greater for patients who did not achieve therapeutic amplitude by month 4 than for those who did (2.6 vs 1.6 V; P  .05). Body mass index, baseline apnea-hypopnea index, respiratory disturbance index, and initial HNS amplitude did not differ between the 2 groups. Predictors for therapeutic amplitude and other usage patterns require further investigation.