TIPS improves outcomes in patients with HCC and symptomatic portal hypertension: a multi-institution experience

Abstract

Background: Hepatocellular carcinoma (HCC) with symptomatic portal hypertension (SPH) has poor prognosis. A transjugular intrahepatic portosystemic shunt (TIPS) relieves SPH, but its application in HCC remains unclear. We evaluated TIPS efficacy in patients with HCC and SPH.

Methods: Pre- and post-TIPS Child-pugh(C-P) scores and stages in 123 HCC patients with SPH from three centers were compared. The impact of postoperative C-P stage indicators on overall survival (OS) was explored.

Results: Post-TIPS responses to SPH included complete response (CR) (92 [74.8%]), partial response (PR) (23 [18.7%]), and nonresponse (NR) (8 [6.5%]). The control (proportion of CR and PR) for SPH was 93.5%. Median C-P scores pre-TIPS and at one month post-TIPS were 8 (IQR 6-9) and 7 (IQR 6-8), respectively (P < 0.001). Forty-one (33.3%) patients had C-P downstaging; 73 (59.3%) had lowered C-P scores; and 73 (59.3%) received intrahepatic local therapy post-TIPS. The median OS was 10.7 (1.1-55.2) months. Among the five indicators of C-P stage, lower post-TIPS ascites grading [(0/1)/(2/3); P = 0.014, HR = 0.31 (95% CI: 0.12-0.79)] and bilirubin [< 34/ ≥ 34 µmol/L; P = 0.022, HR = 0.47 (95% CI: 0.23-0.82)] and prothrombin time prolongation < 6 s [< 6/ ≥ 6 s; P = 0.001, HR = 0.17 (95% CI: 0.06-0.47)] were independent protective indicators of OS. These three indicators were included in the nomogram model to predict survival probabilities.

Conclusions: TIPS is safe and effective for HCC with SPH. This procedure can relieve the symptoms, enable subsequent antitumor therapy, and bring survival benefits, possibly through improved liver function by reducing C-P stage.

Keywords: Child–Pugh stage; Hepatocellular carcinoma; Portal hypertension; TIPS.

Fig. 1

Overall survival (Kaplan–Meier analysis). a Postoperative Child–Pugh stage. b Bilirubin. c Prolonged prothrombin time (PT). d Alpha-fetoprotein (AFP)

Fig. 2

Nomogram for predicting the probability of overall survival. A simple model based on the Child–Pugh stage was used to visually predict the overall survival probability. This model includes postoperative grading of ascites, postoperative level of bilirubin, and prothrombin time (PT). The total scores of the three indicators correspond to the predicted survival probabilities at 6, 12, 18, 24, and 36 months

Fig. 3

Case of TIPS. A 53-year-old male patient with a primary hepatocellular carcinoma (HCC) with a diameter of 3 cm. He had experienced a repeated diuretic therapy because of his refractory ascites. a, b Ascites and tumor before transjugular intrahepatic portosystemic shunt (TIPS). The Child–Pugh score and Child–Pugh stage were 9 and (B), respectively. c TIPS was completed. d Two weeks after TIPS, a microwave ablation treatment was implemented. e, f One month after TIPS, the reevaluated Child–Pugh score and Child–Pugh stage were 7 and (B) respectively. The overall survival of the patient exceeded four years, and he is still alive