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461 Outcome of Patients With Hepatocellular Carcinoma Beyond Milan Criteria
ascites (44% vs. 22%, p<0.0001) and encephalopathy (19% vs. 10%, p=0.002). Median Child-Turcotte-Pugh score was significantly higher in the non-Asian cohort: 7 (5-13) vs. 6 (5-12), p<0.0001. Baseline evaluation showed no significant differences in tumor characteristic using the Tumor, Node and Metastasis (TNM) and Barcelona Clinic Liver Cancer (BCLC) staging criteria. Patients in the Asian cohort were more likely to undergo partial hepatic resection (17% vs. 9%, p=0.012). The two cohorts also had similar proportion of patients eligible for liver transplantation based on both Milan criteria (47-49%) and UCSF criteria (62-67%); however, a significantly higher proportion of non-Asian patients actually underwent liver transplantation compared to Asian patients (28% vs. 12%, p<0.0001). Conclusion: Compared to non-Asian patients, HCV-related HCC Asian patients were more likely female, older, and less likely to have decompensated liver disease. Tumor staging and transplant eligibility by tumor criteria were similar in both groups, but Asians were more likely to undergo partial hepatic resection while non-Asians were more likely to undergo liver transplantation. Additional studies are needed to evaluate treatment outcomes and longterm survival in Asian Americans with HCV-related HCC.
Figure 1: Kaplan-Meier Survival in patients with HCC beyond Milan criteria
Racial Disparity in Hepatocellular Carcinoma in Presentation, Treatment, and Mortality: Analysis of a Nationwide Inpatient Database Sabeen F. Medvedev, Ali Abbas, Sofia Medvedev, Lydia Bazzano, Nathan J. Shores, Marie L. Borum, Luis A. Balart Background: Our objective was to evaluate the impact of patient race upon presentation, treatment, and post-treatment outcome of hepatocellular carcinoma (HCC). Methods: University Health Consortium is a nationwide clinical and administrative database compiled from 42 states representing 90% of the non-profit academic medical centers. Adult admissions with primary discharge diagnoses of HCC in 2002-2011 were identified using International Disease Codes 9th edition. Information about demographics, liver decompensation, comorbidities, metastases, inpatient death, geographic location, and treatment allocation were included in a multivariate model predicting metastasis at first admission (presentation) and treatment allocation. Propensity scores for receiving each treatment were calculated and included in a model predicting inpatient mortality (post-treatment outcome). Results are presented as odd ratios with their corresponding p values. Results: We identified 27,741 patients with a median age of 60.8 years. The population was composed of Caucasians 53.9%, African-Americans (AA) 16.2%, Hispanic 9.3%, Asians 10.7%, and others 9.9%. Compared to Caucasians, AA (1.2, p<0.001) and Asians (1.23, p=0.001) were more likely to present with metastasis and AA were less likely to receive invasive procedures: transplant (0.46, p<0.001), resection (0.53, p<0.001), and ablation (0.67, p<0.001). Compared to Caucasians, Asians were as likely to receive transplant and ablation and more likely to receive resection (1.35, p<0.001). Compared to Caucasians, AA (1.62, p<0.001) and Asians (1.27, p<0.001) had higher inpatient mortality from HCC in univariate analysis. However, after controlling for the aforementioned confounders and treatment allocation factors using propensity scores, AA have lower (1.29, p<0.001) mortality than Asians (1.63, p<0.001). Conclusion: Compared to Caucasians, Asians and AA presented with more metastasis, yet AA did not receive as many invasive treatments as Asians. In addition, AA and Asians had higher inpatient mortality than Caucasians. While we observed a difference in mortality that favors Asians when compared to AA on a univariate level, once the disparity in treatment allocation was evaluated using the propensity score, the mortality trend reversed in favor of AA. More importantly, after using propensity scores to mimic randomization of treatment options, inpatient mortality (62% excess in AA compared to Caucasians) was reduced to 29% indicating that the observed disparity in mortality might extend beyond disproportionate treatment allocation. Further research should be directed towards understanding the basis of this significant racial disparity.
461 Outcome of Patients With Hepatocellular Carcinoma Beyond Milan Criteria Achuthan Sourianarayanane, Federico N. Aucejo, Charles M. Miller, Carlos RomeroMarrero, Nizar N. Zein, Arthur J. McCullough, KV Narayanan Menon Background and Aim: Liver transplantation (LT) is considered the treatment of choice for hepatocellular carcinoma (HCC) within Milan criteria (MC) complicating cirrhosis. However, only a small proportion of patients with HCC are eligible for LT. The outcome of patients with HCC beyond Milan criteria is not well known. The aim of our study was to determine the outcome of patients with HCC beyond Milan criteria. Methods: Consecutive patients with HCC seen at our tertiary care center from May 2007 to Dec 2009 were included. Demographic data, ethnicity, etiology and severity of underlying liver disease, tumor criteria (number and size of lesions, within or outside Milan criteria), therapy and their outcomes were obtained by chart review. Patients were stratified into three groups based on whether they underwent surgery (resection or LT following downstaging to MC), non-surgical therapy (loco-regional therapy and / or sorafenib) or no treatment. The outcomes were compared for multiple variables and a survival analysis was performed after adjusting for potential confounders. Results: Two hundred and forty seven patients (80% male) were evaluated for HCC during this study period with a mean age was 64 years. One hundred and twenty seven patients (51%) who were beyond MC were included in the study. The mean age was 64.9 years and 81% were men. Hepatitis C was prevalent in 48% and 19% were African Americans. Therapy included surgical interventions (n=40) with resection in 23 and liver transplantation following downstaging in 17, locoregional therapy and/or sorafenib (n=60) or no treatment (n=29). The mean follow up was 13.3 ± 11 months. There was no difference in age, gender, race or prevalence of HCV infection between the three groups. The MELD and CTP scores were lower in patients able to undergo any form of therapy compared to patients who could not undergo therapy. Survival was significantly better (p<0.001) in patients undergoing surgical therapy (72.5%, 22 months) compared to patient undergoing other forms of therapy (25%, 11.5 months) and no therapy (6.9%, 4.9 months) [Figure 1] during the follow up. On multivariate analysis surgical therapy was an independent factor associated with survival (p=0.0009). Non surgical therapy was also associated with better survival compared to patients on no therapy (p=0.002). Conclusion: Surgical resection of HCC outside Milan criteria is superior to locoregional therapy and / or soafenib. Patients undergoing locoregional therapy and / or sorafenib have significantly better survival compared to patients on no therapy. All patients with HCC beyond Milan criteria should be offered therapy whenever possible.
463 The Impact of HIV Serologic Status on Clinical Presentation, Treatment and Survival in Patients With Hepatocellular Carcinoma Adam Yopp, Madhu Subramanian, Mamta K. Jain, John C. Mansour, Glen C. Balch, Amit G. Singal Background: Liver disease has emerged as a major cause of morbidity and mortality in individuals infected with HIV, particularly in those co-infected with hepatitis C (HCV) and hepatitis B virus (HBV). Hepatocellular carcinoma (HCC), which is increasing among patients with cirrhosis, is anticipated to become an increasingly significant problem among HIVpositive patients. There is a lack of consensus if HIV co-infection has a significant effect on clinical presentation or survival in patients with HCC. Aims: To compare the clinical presentation, treatment, and survival of HIV-positive (HIV-pos) and HIV-negative (HIV-neg) patients with HCC. Methods: We conducted a retrospective cohort study of cirrhotic patients diagnosed with HCC at a large safety net hospital between January 2005 and June 2011. Patients without known HIV serologic status were excluded. Demographic features, tumor characteristics, treatments, and survival were compared between HIV-pos and HIV-neg patients. Survival curves were generated using Kaplan-Meier plots and compared using log rank test. Results: Of 190 patients with HCC, 26 were HIV-pos and 164 were HIV-neg. HIV-pos patients had a median CD4 count of 247/mm3 (range 17-813), with 73% being on HAART therapy. HIV-pos and HIV-neg patients did not differ by age (mean 56, p=0.73) or gender (83% male, p=0.40) but were more likely to be Caucasian (38% vs. 21%, p= 0.05). Viral liver disease was present in 96% (14 HCV, 11 HBV) of HIV-pos patients, compared to 82% (124 HCV, 10 HBV) of HIV-neg patients (p=0.08). HIV-pos patients were more likely to present with unifocal HCC (65% vs. 40%, p=0.02) but with no significant difference in maximum tumor diameter (2.6 vs. 4.7 cm respectively, p=0.69), portal vein
S-915
AASLD Abstracts
AASLD Abstracts
462
Figure 1: Kaplan-Meier Survival in patients with HCC beyond Milan criteria
Racial Disparity in Hepatocellular Carcinoma in Presentation, Treatment, and Mortality: Analysis of a Nationwide Inpatient Database Sabeen F. Medvedev, Ali Abbas, Sofia Medvedev, Lydia Bazzano, Nathan J. Shores, Marie L. Borum, Luis A. Balart Background: Our objective was to evaluate the impact of patient race upon presentation, treatment, and post-treatment outcome of hepatocellular carcinoma (HCC). Methods: University Health Consortium is a nationwide clinical and administrative database compiled from 42 states representing 90% of the non-profit academic medical centers. Adult admissions with primary discharge diagnoses of HCC in 2002-2011 were identified using International Disease Codes 9th edition. Information about demographics, liver decompensation, comorbidities, metastases, inpatient death, geographic location, and treatment allocation were included in a multivariate model predicting metastasis at first admission (presentation) and treatment allocation. Propensity scores for receiving each treatment were calculated and included in a model predicting inpatient mortality (post-treatment outcome). Results are presented as odd ratios with their corresponding p values. Results: We identified 27,741 patients with a median age of 60.8 years. The population was composed of Caucasians 53.9%, African-Americans (AA) 16.2%, Hispanic 9.3%, Asians 10.7%, and others 9.9%. Compared to Caucasians, AA (1.2, p<0.001) and Asians (1.23, p=0.001) were more likely to present with metastasis and AA were less likely to receive invasive procedures: transplant (0.46, p<0.001), resection (0.53, p<0.001), and ablation (0.67, p<0.001). Compared to Caucasians, Asians were as likely to receive transplant and ablation and more likely to receive resection (1.35, p<0.001). Compared to Caucasians, AA (1.62, p<0.001) and Asians (1.27, p<0.001) had higher inpatient mortality from HCC in univariate analysis. However, after controlling for the aforementioned confounders and treatment allocation factors using propensity scores, AA have lower (1.29, p<0.001) mortality than Asians (1.63, p<0.001). Conclusion: Compared to Caucasians, Asians and AA presented with more metastasis, yet AA did not receive as many invasive treatments as Asians. In addition, AA and Asians had higher inpatient mortality than Caucasians. While we observed a difference in mortality that favors Asians when compared to AA on a univariate level, once the disparity in treatment allocation was evaluated using the propensity score, the mortality trend reversed in favor of AA. More importantly, after using propensity scores to mimic randomization of treatment options, inpatient mortality (62% excess in AA compared to Caucasians) was reduced to 29% indicating that the observed disparity in mortality might extend beyond disproportionate treatment allocation. Further research should be directed towards understanding the basis of this significant racial disparity.
461 Outcome of Patients With Hepatocellular Carcinoma Beyond Milan Criteria Achuthan Sourianarayanane, Federico N. Aucejo, Charles M. Miller, Carlos RomeroMarrero, Nizar N. Zein, Arthur J. McCullough, KV Narayanan Menon Background and Aim: Liver transplantation (LT) is considered the treatment of choice for hepatocellular carcinoma (HCC) within Milan criteria (MC) complicating cirrhosis. However, only a small proportion of patients with HCC are eligible for LT. The outcome of patients with HCC beyond Milan criteria is not well known. The aim of our study was to determine the outcome of patients with HCC beyond Milan criteria. Methods: Consecutive patients with HCC seen at our tertiary care center from May 2007 to Dec 2009 were included. Demographic data, ethnicity, etiology and severity of underlying liver disease, tumor criteria (number and size of lesions, within or outside Milan criteria), therapy and their outcomes were obtained by chart review. Patients were stratified into three groups based on whether they underwent surgery (resection or LT following downstaging to MC), non-surgical therapy (loco-regional therapy and / or sorafenib) or no treatment. The outcomes were compared for multiple variables and a survival analysis was performed after adjusting for potential confounders. Results: Two hundred and forty seven patients (80% male) were evaluated for HCC during this study period with a mean age was 64 years. One hundred and twenty seven patients (51%) who were beyond MC were included in the study. The mean age was 64.9 years and 81% were men. Hepatitis C was prevalent in 48% and 19% were African Americans. Therapy included surgical interventions (n=40) with resection in 23 and liver transplantation following downstaging in 17, locoregional therapy and/or sorafenib (n=60) or no treatment (n=29). The mean follow up was 13.3 ± 11 months. There was no difference in age, gender, race or prevalence of HCV infection between the three groups. The MELD and CTP scores were lower in patients able to undergo any form of therapy compared to patients who could not undergo therapy. Survival was significantly better (p<0.001) in patients undergoing surgical therapy (72.5%, 22 months) compared to patient undergoing other forms of therapy (25%, 11.5 months) and no therapy (6.9%, 4.9 months) [Figure 1] during the follow up. On multivariate analysis surgical therapy was an independent factor associated with survival (p=0.0009). Non surgical therapy was also associated with better survival compared to patients on no therapy (p=0.002). Conclusion: Surgical resection of HCC outside Milan criteria is superior to locoregional therapy and / or soafenib. Patients undergoing locoregional therapy and / or sorafenib have significantly better survival compared to patients on no therapy. All patients with HCC beyond Milan criteria should be offered therapy whenever possible.
463 The Impact of HIV Serologic Status on Clinical Presentation, Treatment and Survival in Patients With Hepatocellular Carcinoma Adam Yopp, Madhu Subramanian, Mamta K. Jain, John C. Mansour, Glen C. Balch, Amit G. Singal Background: Liver disease has emerged as a major cause of morbidity and mortality in individuals infected with HIV, particularly in those co-infected with hepatitis C (HCV) and hepatitis B virus (HBV). Hepatocellular carcinoma (HCC), which is increasing among patients with cirrhosis, is anticipated to become an increasingly significant problem among HIVpositive patients. There is a lack of consensus if HIV co-infection has a significant effect on clinical presentation or survival in patients with HCC. Aims: To compare the clinical presentation, treatment, and survival of HIV-positive (HIV-pos) and HIV-negative (HIV-neg) patients with HCC. Methods: We conducted a retrospective cohort study of cirrhotic patients diagnosed with HCC at a large safety net hospital between January 2005 and June 2011. Patients without known HIV serologic status were excluded. Demographic features, tumor characteristics, treatments, and survival were compared between HIV-pos and HIV-neg patients. Survival curves were generated using Kaplan-Meier plots and compared using log rank test. Results: Of 190 patients with HCC, 26 were HIV-pos and 164 were HIV-neg. HIV-pos patients had a median CD4 count of 247/mm3 (range 17-813), with 73% being on HAART therapy. HIV-pos and HIV-neg patients did not differ by age (mean 56, p=0.73) or gender (83% male, p=0.40) but were more likely to be Caucasian (38% vs. 21%, p= 0.05). Viral liver disease was present in 96% (14 HCV, 11 HBV) of HIV-pos patients, compared to 82% (124 HCV, 10 HBV) of HIV-neg patients (p=0.08). HIV-pos patients were more likely to present with unifocal HCC (65% vs. 40%, p=0.02) but with no significant difference in maximum tumor diameter (2.6 vs. 4.7 cm respectively, p=0.69), portal vein
S-915
AASLD Abstracts
AASLD Abstracts
462