We thank Floreani and Farinati for their valuable comments on our article, whose remarks we read with great interest. We thought that the majority of the points they highlighted were reasonable and helpful to better understand primary biliary cirrhosis (PBC). For example, several risk factors may influence the PBC process and correlate with hepatocellular carcinoma (HCC) development, such as smoking, drinking, ursodeoxycholic acid (UDCA) therapy, etc. However, due to too small number of studies, we could not draw firm conclusions by meta-analysis. This is a limitation of our study that was discussed in the article.
Meanwhile, we also thought some points by Floreani and Farinati were worthy of being discussed. First, just as described by Floreani and Farinati, some studies investigated the association between HCC and PBC histological stage. However, not all of the studies demonstrated that advanced histological stages of PBC significantly increases HCC risk. For example, one study found that advanced histological stages were not significantly associated with increased risk of HCC in Barcelona patients with PBC. The same result was also revealed by Shibuya et al. in Japanese patients with PBC. Due to the limited available data, we were not able to carry out a high-quality meta-analysis to assess the relationship between HCC and PBC histological stage. Therefore, we think it remains to be further elucidated whether the association between PBC and the increased risk of HCC is attributed to advanced PBC histological stages. Despite this, we agree that regular screening for HCC with imaging with or without alpha fetoprotein at 6-month to 12-month intervals should be advised for PBC patients. Second, since the incidence of PBC is far lower than that of liver diseases with other etiologies, including viral hepatitis, it is reasonable that PBC-related HCC accounts for only a small proportion of patients presenting with HCC. However, for a PBC patient early prevention and screening for HCC appear to be necessary and important.
ZAIXING YANG, M.D.
YAN LIANG, M.D.
RENQIAN ZHONG, M.D.
Department of Laboratory Diagnostics Changzheng Hospital, Second Military Medical University, Shanghai, China