Letter to the Editor: Portal hypertension and variceal bleeding in patients with liver cancer: Evidence gaps for prevention and management

Abstract

To the editor, We read with interest the article by Allaire and Thabut on the management of portal hypertension (PH) in patients with HCC. [1] We would like to clarify some important aspects of the Baveno VII recommendations [2] for starting nonselective beta-blockers (NSBBs).The authors correctly mentioned that Baveno VII focuses on clinically significant portal hypertension (CSPH) to select patients with compensated advanced chronic liver disease for NSBB regardless of varices. [3,4] Evidence supports using liver stiffness measurement (LSM) ≥ 25 kPa through vibrationcontrolled transient elastography as a CSPH surrogate in patients with hepatitis C or hepatitis B infection, or alcohol-associated liver disease, and nonobese NASH-but not for other etiologies or for obese NASH. However, the PREDESCI trial [3] showed LSM to be a flawed predictor of decompensation (optimal LSM cutoff at 22 kPa). Moreover, LSM is subject to confounders, which can result in falsely elevated results. [5] As mentioned by the authors, in patients with HCC, the tumor mass can also lead to imprecise LSM, impacting its correlation with HVPG, and LSM could rule in or rule out CSPH in only half of the real-world cases. Vibration-controlled transient elastography-LSM is likely to be of limited value in patients with HCC when the technique seems so inefficient.In contrast to author's advice, we would not recommend selecting patients with HCC for NSBB solely based on LSM criteria for CSPH without an endoscopy (Figure 2 in the original manuscript), since (outside of HCC) the benefit of NSBB was only seen in patients with varices. [3,4] Baveno VII does not universally recommend NSBB for all patients with compensated advanced chronic liver disease with LSM ≥ 25 kPa, and in HCC, this strategy seems particularly problematic. The only evidence for starting NSBB without an endoscopy is if CSPH is confirmed by a baseline HVPG ≥ 10 mm Hg.In conclusion, we agree that sufficient treatment of CSPH improves the survival of patients with HCC. However, we advise caution in deciding to start NSBB in all patients with compensated cirrhosis (regardless of HCC) if CSPH diagnosis is based only on vibrationcontrolled transient elastography-LSM ≥ 25 kPa. We would strongly recommend a position of clinical equipoise and wait for the evidence to be generated for this strategy.

Reply: Portal hypertension and variceal bleeding in patients with liver cancer: Evidence gaps for prevention and management

“…So, we are not in favor of prescribing NSBB without endoscopy, only in patients with baseline HVPG ≥ 10 mm Hg. Other techniques need to be developed, such as spleen stiffness measurement or imaging score for the proper diagnosis of PHT in HCC patients.Although Tripathi et al [5] raised pertinent questions about the uncertainty of the literature regarding the use of NSBB in HCC patients, we still believe that the use of NSBB in patients with liver stiffness measurement of ≥ 25 kPa might improve their outcome and to date, no performant technique exists to diagnose PHT in this population of patients who appears as a major research issue.…”

“…Although Tripathi et al [5] raised pertinent questions about the uncertainty of the literature regarding the use of NSBB in HCC patients, we still believe that the use of NSBB in patients with liver stiffness measurement of ≥ 25 kPa might improve their outcome and to date, no performant technique exists to diagnose PHT in this population of patients who appears as a major research issue.…”