The 58th Annual Meeting of the European Association for the Study of the Liver (EASL 2023) and the 2023 EASL Congress concluded successfully on June 24th in Vienna, Austria, three years after the pandemic disrupted in-person exchanges among experts and scholars from around the world. Dr. Guohong Han, Executive Director of the Digestive Hospital at the Xi'an International Medical Center Hospital, attended the conference in person and returned with valuable insights. Although the conference has concluded, the academic enthusiasm it generated continues to surge. Hepatology Digest reporting team invited Dr. Guohong Han to share his thoughts on the groundbreaking research he has been following, such as liver cancer immunotherapy, the application of Baveno criteria, and the use of rivaroxaban for anticoagulation, along with his overall impressions of the conference.
Hepatology Digest: Liver cancer immunotherapy has been a major focus of this year’s conference, particularly the research presented on June 23rd regarding adjuvant targeted immunotherapy for high-risk liver cancer recurrence following resection or ablation (GS-011). Can you provide some insights into this research?
Dr. Guohong Han: This is the IMbrave050 study, which included high-risk hepatocellular carcinoma (HCC) patients who had undergone resection or ablation. These patients were randomly divided into two groups: one received adjuvant atezolizumab plus bevacizumab therapy, while the other group underwent active surveillance. The primary endpoint was recurrence-free survival (RFS), and the study compared the recurrence rates between the two groups. The results showed statistically and clinically significant improvement in RFS in the group receiving atezolizumab plus bevacizumab treatment compared to the active surveillance group.
For many years, there has been no established method for adjuvant therapy after surgery or ablation. Previously, there were no drugs that could prevent or reduce postoperative recurrence in high-risk patients. However, this study has yielded positive results, confirming that the combination of targeted and immunotherapy significantly reduces postoperative recurrence in high-risk patients after surgery or ablation, offering a curative treatment option for them.
Further research is needed, as the majority of patients in the study were Asian, primarily with hepatitis B. For non-viral causes of liver cancer, such as alcohol-induced liver disease, more data and research results are required. Nevertheless, this study sends a positive message that atezolizumab plus bevacizumab combination therapy provides a solution for high-risk patients after surgery or ablation, marking a milestone in liver cancer treatment.
Hepatology Digest: During this conference, French researchers led by Allaire M presented their research on whether Baveno VI and VII criteria are applicable for screening high-risk esophageal varices and clinically significant portal hypertension in HCC patients (FRI-274). What methods are currently available to screen or predict high-risk esophageal varices or portal hypertension in HCC patients?
Dr. Guohong Han: Portal hypertension in liver cancer patients is quite common, especially in Asia or China, where hepatitis B is a predominant cause of liver cancer, and patients typically have varying degrees of portal hypertension. Therefore, it is crucial to screen for portal hypertension before treating liver cancer. In the updated Baveno VII criteria, screening for patients with common or compensated cirrhosis is a priority. Baveno VI and VII criteria are used for cirrhotic patients to exclude large size esophageal varices (EV) and clinically significant portal hypertension (CSPH).
For compensated advanced chronic liver disease (cACLD) patients, a non-invasive method for screening CSPH is used. According to Baveno VI criteria, if liver stiffness measurement (LSM) is less than 20 kPa, and platelet count is greater than 150 x 10^9/L, CSPH can be excluded, and endoscopic screening is not necessary. Baveno VII, building upon the previous criteria, also includes spleen stiffness measurement (SSM). For cirrhotic patients who do not meet Baveno VI criteria, if SSM is less than or equal to 40 kPa, CSPH can still be safely excluded, and endoscopic screening is not required. However, liver cancer-related cirrhosis differs from general cirrhosis because liver cancer can increase liver stiffness. When liver stiffness is increased, using these criteria may lead to inaccurate assessments.
Allaire M and colleagues studied the clinical performance of Baveno VI and VII criteria and evaluated whether they are suitable for liver cancer patients. The study retrospectively included 185 patients who had undergone endoscopy, liver stiffness measurement (LSM), and platelet count measurements within six months. The results indicated that using Baveno VI and VII criteria may miss some patients with esophageal varices and CSPH, suggesting that these criteria are not applicable for excluding CSPH in liver cancer patients. For such patients, the most practical clinical approach is to perform endoscopy to assess the presence of esophageal varices and provide appropriate treatment to reduce portal hypertension in patients with varices.
There are also other imaging methods such as contrast-enhanced CT or MRI. In most cases, contrast-enhanced CT can identify collateral vessels and help determine the presence of esophageal varices. Magnetic resonance can also be used to assess liver stiffness. The use of non-invasive methods to assess varices is still under research. Ultrasound or contrast-enhanced CT can partially assist in assessing varices and collateral vessels. Currently, for liver cancer patients, the most accurate method is endoscopic examination.
Hepatology Digest: Non-alcoholic fatty liver disease (NAFLD) has become the most common chronic liver disease and is gradually gaining recognition and attention from the general public. NAFLD tends to progress to liver cancer, and this conference featured numerous specialized reports on the topic of NAFLD and HCC. Could you share your thoughts or takeaways from your attendance at EASL regarding this topic?
Dr. Guohong Han: This year’s EASL conference had a continuing education program centered on NAFLD, with the theme “From Non-Alcoholic Fatty Liver Disease to Liver Cancer.” The conference extensively discussed NAFLD’s etiology, epidemiology, natural progression, screening for NAFLD-related liver cancer, and its diagnosis and treatment. We need to pay high attention to this topic. Through epidemiological studies, it is becoming increasingly clear that NAFLD is a significant contributor to liver diseases, with the prevalence in the population rising from 25% in the past to 30% today. Particularly, if a patient has diabetes, their risk of NAFLD is even higher, with nearly half of diabetic patients having NAFLD, making this an even more concerning situation.
The development of liver cancer caused by NAFLD differs from that caused by viral hepatitis, especially in cases where liver cancer arises from cirrhosis. Assessing liver fibrosis or cirrhosis non-invasively, as well as diagnosing NAFLD-related portal hypertension, is different from portal hypertension caused by viral hepatitis. These differences are crucial aspects for us to focus on in our daily work and future research.
Hepatology Digest: Lastly, could you share your thoughts on other topics or research that interested you at this year’s EASL conference, as well as your overall impressions of attending the conference?
Dr. Guohong Han: This year’s conference featured research topics related to oral anticoagulants. A randomized controlled trial (GS-003) focused on the use of rivaroxaban for anticoagulation in cirrhotic patients with moderate liver dysfunction, with the results showing that anticoagulation treatment significantly extended patients’ survival and reduced decompensation events.
Regarding the use of direct oral anticoagulants (DOACs) like rivaroxaban, it is safe for Child-Pugh A patients, but caution is advised for Child-Pugh B patients, and it is not recommended for Child-Pugh C patients. The significance of this study goes beyond demonstrating that anticoagulation can improve the course of cirrhosis in patients; more importantly, it marks a milestone by using an oral Xa factor inhibitor for cirrhotic patients, challenging previous beliefs. Additionally, with direct oral anticoagulant therapy, there is no need for subcutaneous low-molecular-weight heparin injections, which is a significant development.
Although the study had a relatively small sample size and enrolled fewer than 100 patients from 2016 to 2020, even with this limited data, there were statistically significant differences between the two groups. However, further data and research are needed to confirm whether oral anticoagulants can slow the progression of cirrhosis in patients and ultimately extend their survival.
TAG: EASL2023;Interview;HCC;Liver Cancer;Cirrhosis
