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A Reduction of Calcineurin Inhibitors May Improve Survival in Patients with De Novo Colorectal Cancer after Liver Transplantation. MEDICINA (KAUNAS, LITHUANIA) 2022; 58:medicina58121755. [PMID: 36556957 PMCID: PMC9785597 DOI: 10.3390/medicina58121755] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 11/25/2022] [Accepted: 11/28/2022] [Indexed: 12/04/2022]
Abstract
Background and Objectives: After liver transplantation (LT), long-term immunosuppression (IS) is essential. IS is associated with de novo malignancies, and the incidence of colorectal cancer (CRC) is increased in LT patients. We assessed course of disease in patients with de novo CRC after LT with focus of IS and impact on survival in a retrospective, single-center study. Materials and Methods: All patients diagnosed with CRC after LT between 1988 and 2019 were included. The management of IS regimen following diagnosis and the oncological treatment approach were analyzed: Kaplan−Meier analysis as well as univariate and multivariate analysis were performed. Results: A total of 33 out of 2744 patients were diagnosed with CRC after LT. Two groups were identified: patients with restrictive IS management undergoing dose reduction (RIM group, n = 20) and those with unaltered regimen (maintenance group, n = 13). The groups did not differ in clinical and oncological characteristics. Statistically significant improved survival was found in Kaplan−Meier analysis for patients in the RIM group with 83.46 (8.4−193.1) months in RIM and 24.8 (0.5−298.9) months in the maintenance group (log rank = 0.02) and showed a trend in multivariate cox regression (p = 0.054, HR = 14.3, CI = 0.96−213.67). Conclusions: Immunosuppressive therapy should be reduced further in patients suffering from CRC after LT in an individualized manner to enable optimal oncological therapy and enable improved survival.
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Minimization of Immunosuppressive Therapy Is Associated with Improved Survival of Liver Transplant Patients with Recurrent Hepatocellular Carcinoma. Cancers (Basel) 2021; 13:cancers13071617. [PMID: 33807392 PMCID: PMC8037838 DOI: 10.3390/cancers13071617] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2021] [Revised: 03/23/2021] [Accepted: 03/24/2021] [Indexed: 12/12/2022] Open
Abstract
Simple Summary Liver transplantation is a curative treatment option for a subset of patients with hepatocellular carcinoma (HCC). However, about twenty percent of patients develop recurrence in the graft or at extrahepatic sites, which is associated with limited therapeutic options and poor survival. To date, management of the immunosuppressive regimen after recurrence and its impact on survival are unknown. In this retrospective study, we analyzed a cohort of liver recipients with HCC recurrence. Our findings indicate that reduction of immunosuppressive therapy after diagnosis of recurrence has a beneficial impact on patient survival. Therefore, we propose further investigation into the management of immunosuppressive therapy following recurrence. Abstract Introduction: Recurrence of hepatocellular carcinoma (rHCC) after liver transplantation (LT) is associated with limited survival. Therefore, identification of factors that prolong survival in these patients is of great interest. Surgical resection, radiotherapy, and transarterial chemoembolization (TACE) are established interventions to improve outcomes in these patients; however, the impact of immunosuppression is unknown. Methods: All patients diagnosed with rHCC in the follow-up after LT were identified from a database of liver recipients transplanted between 1988 and 2019 at our institution (Charité Universitätsmedizin Berlin, Germany). Based on the immunosuppressive regimen following diagnosis of rHCC and the oncological treatment approach, survival analysis was performed. Results: Among 484 patients transplanted for HCC, 112 (23.1%) developed rHCC in the follow-up. Recurrent HCC was diagnosed at a median interval of 16.0 months (range 1.0–203.0), with the majority presenting early after transplantation (63.0%, <2 years). Median survival after rHCC diagnosis was 10.6 months (0.3–228.7). Reduction of immunosuppression was associated with improved survival, particularly in patients with palliative treatment (8.4 versus 3.0 months). In addition, greater reduction of immunosuppression seemed to be associated with greater prolongation of survival. Graft rejection after reduction was uncommon (n = 7, 6.8%) and did not result in any graft loss. Patients that underwent surgical resection showed improved survival rates (median 19.5 vs. 8.7 months). Conclusion: Reduction of immunosuppressive therapy after rHCC diagnosis is associated with prolonged survival in LT patients. Therefore, reduction of immunosuppression should be an early intervention following diagnosis. In addition, surgical resection should be attempted, if technically feasible and oncologically meaningful.
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Abdelsameea E, Alsebaey A, Ehsan N, Elrefaey A, Aboelela K, Ibrahim ES, Elsabaawy M. Liver biopsy is still needed in liver transplantation recipients: a single center experience. EGYPTIAN LIVER JOURNAL 2020. [DOI: 10.1186/s43066-020-00031-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Abstract
Background
Liver transplantation is a final treatment for decompensated liver disease.
Aim
Description of post-liver transplant histopathology. We enrolled 89 patients divided into two groups according to if they underwent on demand liver biopsy (n = 34; 38.2%) or not (n = 55; 61.8%). Albumin-bilirubin (ALBI) score and model for end-stage liver disease (MELD) assessed the degree of liver dysfunction.
Results
Patient underwent liver biopsy (LB) was 44.65 ± 8.46 years old, mainly males (88.2%) with average MELD of 8.74 ± 4.71. Most patients were positive pre-transplant for HCV (91.2%) and 29.4% had hepatocellular carcinoma on top of hepatitis C. Patients underwent LB had worse liver dysfunction by ALBI score (− 2.62 ± 0.6 vs. − 2.96 ± 0.5; p = 0.014) but comparable MELD. The time till first biopsy was 19.88 ± 11.22 (4-44) months. It was not different statistically with various histopathology (p > 0.05). Histopathology of first biopsy was viral chronic hepatitis (50%), acute rejection (20.6%), steatohepatitis (11.8%), chronic rejection (5.9%), chronic hepatitis (5.9%), biliary obstruction (2.9%), and cytomegalovirus hepatitis (2.9%). Most patients were F1 (38.2%) and A1 (35.3%). The immunosuppressive drug regimen had no impact on the histopathology (p > 0.05). Patients with hepatitis C pre-transplant had in a descending manner the following histological diagnosis (p = 0.001): viral chronic hepatitis 16 (51.6%), acute rejection 7 (22.6%), steatohepatitis 4 (12.9%), chronic rejection 2 (6.5%), biliary obstruction 1 (3.2%), and CMV hepatitis 1(3.2%). Some patients required on demand second (n = 9) and third biopsied (n = 5) that were the same as the first biopsy or completely different.
Conclusion
Liver biopsy is a useful tool for diagnosis of liver transplantation complications.
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Hong SK, Lee K, Yoon KC, Kim H, Ahn S, Kim H, Lee J, Cho J, Yi N, Suh K. Different prognostic factors and strategies for early and late recurrence after adult living donor liver transplantation for hepatocellular carcinoma. Clin Transplant 2019; 33:e13703. [DOI: 10.1111/ctr.13703] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2019] [Accepted: 08/23/2019] [Indexed: 12/15/2022]
Affiliation(s)
- Suk Kyun Hong
- Department of Surgery Seoul National University College of Medicine Seoul Korea
| | - Kwang‐Woong Lee
- Department of Surgery Seoul National University College of Medicine Seoul Korea
| | - Kyung Chul Yoon
- Department of Surgery Division of HBP Surgery & Liver Transplantation Anam Hospital Korea University College of Medicine Seoul Korea
| | - Hyo‐Sin Kim
- Department of Surgery Chonnam National University Medical School and Hospital Gwangju Korea
| | - Sung‐Woo Ahn
- Department of Surgery Chonbuk National University College of Medicine Jeonju Korea
| | - Hyeyoung Kim
- Department of Surgery Eulji University Hospital Eulji University College of Medicine Daejeon Korea
| | - Jeong‐Moo Lee
- Department of Surgery Seoul National University College of Medicine Seoul Korea
| | - Jae‐Hyung Cho
- Department of Surgery Seoul National University College of Medicine Seoul Korea
| | - Nam‐Joon Yi
- Department of Surgery Seoul National University College of Medicine Seoul Korea
| | - Kyung‐Suk Suh
- Department of Surgery Seoul National University College of Medicine Seoul Korea
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Grigg SE, Sarri GL, Gow PJ, Yeomans ND. Letter: mechanistic target of rapamycin inhibitors-do they impact on recurrence of hepatocellular carcinoma after liver transplantation? Authors' reply. Aliment Pharmacol Ther 2019; 50:117-120. [PMID: 31184392 DOI: 10.1111/apt.15324] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Affiliation(s)
- Sam E Grigg
- University of Melbourne, Parkville, Vic., Australia
| | - Gino L Sarri
- University of Melbourne, Parkville, Vic., Australia
| | - Paul J Gow
- Liver Transplant Unit, Austin Health, Heidelberg, Vic., Australia
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Grigg SE, Sarri GL, Gow PJ, Yeomans ND. Systematic review with meta-analysis: sirolimus- or everolimus-based immunosuppression following liver transplantation for hepatocellular carcinoma. Aliment Pharmacol Ther 2019; 49:1260-1273. [PMID: 30989721 DOI: 10.1111/apt.15253] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2018] [Revised: 01/20/2019] [Accepted: 03/17/2019] [Indexed: 12/14/2022]
Abstract
BACKGROUND Calcineurin-inhibitor immunosuppressants (tacrolimus and ciclosporin) have been associated with an exposure-related increase in tumour recurrence following liver transplantation for hepatocellular carcinoma (HCC). Conversely, mechanistic target of rapamycin (mTOR) inhibitors (sirolimus and everolimus) have been suggested to reduce recurrence rates and improve survival in this patient group. AIM To clarify the potential benefit of mTOR-inhibitors in HCC transplant patients by comparing recurrence and survival outcomes with calcineurin-inhibitor-based immunosuppression. METHODS A systematic review and meta-analysis was performed. The inclusion criteria were observational or interventional studies reporting the effect of early-initiated (<6 months post-transplant) mTOR-inhibitor-based immunosuppression on survival or tumour recurrence in patients transplanted with HCC, compared to a control of calcineurin-inhibitor-based therapy. RESULTS Meta-analysis demonstrated that compared with calcineurin-inhibitor controls, recurrence-free-survival was significantly increased with mTOR-inhibitor-based therapy at 1-year (Risk-Ratio (RR): 1.09, 95% CI: 1.01-1.18) and 3-years (RR: 1.1, 95% CI: 1.01-1.21) post-transplant, with a nonsignificant increase at 5-years (RR: 1.15, 95% CI: 0.99-1.35). Overall survival was improved at 1-year (RR: 1.07, 95% CI: 1.02-1.12), 3-years (RR: 1.1, 95% CI: 1.02-1.19), and 5-years (RR: 1.18, 95% CI: 1.08-1.29). Recurrence-rate was lower in the mTOR-inhibitor arm (RR: 0.67, 95% CI: 0.56-0.82), with no significant increase in acute rejection (RR: 1.1, 95% CI: 0.94-1.28). CONCLUSIONS mTOR-inhibitor-based immunosuppression may be a preferable option in patients transplanted with HCC. It improves recurrence-free-survival over at least three years and reduces the recurrence rate compared with standard calcineurin-inhibitor-based therapy, with no significant increase in the rate of acute rejection. Future research should clarify the effect in higher vs lower risk cohorts.
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Affiliation(s)
- Sam E Grigg
- University of Melbourne, Parkville, Vic., Australia
| | - Gino L Sarri
- University of Melbourne, Parkville, Vic., Australia
| | - Paul J Gow
- Liver Transplant Unit, Austin Health, Heidelberg, Vic., Australia
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Kang SH, Hwang S, Ha TY, Song GW, Jung DH, Ahn CS, Moon DB, Kim KH, Park GC, Yoon YI, Park YH, Cho HD, Kwon JH, Chung YK, Choi JU, Lee SG. Cross-sectional analysis of immunosuppressive regimens focused on everolimus after liver transplantation in a Korean high-volume transplantation center. KOREAN JOURNAL OF TRANSPLANTATION 2019; 33:98-105. [PMID: 35769980 PMCID: PMC9188937 DOI: 10.4285/jkstn.2019.33.4.98] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/07/2019] [Revised: 09/16/2019] [Accepted: 10/11/2019] [Indexed: 12/13/2022] Open
Abstract
Background The mammalian target of the rapamycin inhibitor has dual inhibitory effects on cell growth and angiogenesis. This study aimed to analyze the usage of everolimus on actual immunosuppression (IS) regimens through a cross-sectional study in a high-volume liver transplantation (LT) center. Methods Our institutional LT database was searched for adult patients who underwent primary LT surgery between January 2010 and December 2016. We identified 2,093 LT recipients with observation periods of 1 to 8 years. Results We divided the 2,093 recipients into three groups according to the posttransplant follow-up period as follows: group A (12–36 months; n=680), group B (37–60 months; n=560), and group C (>60 months; n=853). The individual IS agents were tacrolimus in 1,807 patients (86.3%), cyclosporine in 169 patients (8.1%), mycophenolate mofetil (MMF) in 1,310 patients (62.6%), and everolimus in 115 patients (5.5%). The most common IS regimens were tacrolimus-MMF combination and tacrolimus monotherapy, regardless of the posttransplant period. Patients with pretransplant malignancies were administered everolimus more frequently than those without pretransplant malignancies (P<0.001). In 102 patients with hepatocellular carcinoma recurrence or de novo malignancies, IS regimens included everolimus-tacrolimus in 41 patients (40.2%), tacrolimus-MMF in 27 patients (26.4%), tacrolimus in 20 patients (19.6%), MMF in 10 patients (9.8%), cyclosporine in three patients (2.9%), and cyclosporine-MMF in one patient (1.0%). Conclusions Administration of everolimus after LT has been gradually increasing with the expansion of indications in our institutional practice. Currently, the role of everolimus is minimal and not comparable to that of tacrolimus, but it has a unique position in the field of IS after LT.
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Affiliation(s)
- Sang-Hyun Kang
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Young-In Yoon
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yo-Han Park
- Department of Surgery, Busan Paik Hospital, Inje University College of Medicine, Busan, Korea
| | - Hui-Dong Cho
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Hyun Kwon
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yong-Kyu Chung
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Uk Choi
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Liver Transplantation and Hepatobiliary Surgery, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Jung DH, Tak E, Hwang S, Song GW, Ahn CS, Kim KH, Moon DB, Ha TY, Park GC, Ryoo BY, Lee KJ, Kim N, Kwon JH, Jwa EK, Lee SG. Antitumor effect of sorafenib and mammalian target of rapamycin inhibitor in liver transplantation recipients with hepatocellular carcinoma recurrence. Liver Transpl 2018; 24:932-945. [PMID: 29710388 DOI: 10.1002/lt.25191] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/31/2017] [Revised: 12/23/2017] [Accepted: 04/13/2018] [Indexed: 12/12/2022]
Abstract
Both sorafenib and mammalian target of rapamycin inhibitor (mTORi) have antitumor effects. This study aimed to evaluate their antitumor effects in liver transplantation (LT) recipients with hepatocellular carcinoma (HCC) recurrence. We performed a laboratory study using sorafenib and mTORi and subsequently validated their survival benefit in a clinical LT setting. In the laboratory study, the HepG2.2.15 liver tumor cell line and 5 patient-derived graft HCC cell lines were used for in vitro cytotoxic studies. After treatment with everolimus and sorafenib, cell viability and apoptosis assays revealed noticeable cytotoxic effects with individual agents and augmented effects by combination therapy. An in vivo mouse study also demonstrated similar cytotoxic outcomes. In the clinical study including 232 LT recipients with HCC recurrence, the 3-month medication drop-out rate was 35.6% for sorafenib administration and 23.5% for mTORi administration. Postrecurrence survival rates were not different according to sorafenib administration (P = 0.17) but were significantly improved following mTORi administration (P < 0.001). In mTORi subgroups with and without sorafenib, there was no difference in the overall postrecurrence patient survival period (P = 0.26), indicating an absence of synergistic or additional antitumor effect from sorafenib. The median progression-free and overall survival period was 6.4 and 11.8 months, respectively, after sorafenib administration. Time of tumor recurrence and use of mTORi were independent risk factors. In conclusion, our laboratory study demonstrated synergistic antitumor effects of sorafenib and mTORi, but this was not reproduced in our clinical LT study. Our clinical result of mTORi administration showed improved postrecurrence survival, thus administering mTORi in LT recipients with HCC recurrence appears worthwhile. However, the antitumor effect of sorafenib on posttransplant recurrence was not determined in this retrospective study, thus requiring further studies with early start of sorafenib administration. Liver Transplantation 24 932-945 2018. © 2018 AASLD.
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Affiliation(s)
- Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Departments of Surgery
| | - Eunyoung Tak
- Asan Institute of Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Departments of Surgery
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Departments of Surgery
| | - Chul-Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Departments of Surgery
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Departments of Surgery
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Departments of Surgery
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Departments of Surgery
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Departments of Surgery
| | | | - Kyung Jin Lee
- Asan Institute of Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Nayoung Kim
- Asan Institute of Life Sciences, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jae-Hyeon Kwon
- Division of Hepatobiliary Surgery and Liver Transplantation, Departments of Surgery
| | - Eun-Kyoung Jwa
- Division of Hepatobiliary Surgery and Liver Transplantation, Departments of Surgery
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Departments of Surgery
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Alshahrani AA, Hwang S, Song GW, Moon DB, Jung DH, Ahn CS, Kim KH, Ha TY, Park GC, Ha SM, Park YH, Lee SG. Management of very late peritoneal metastasis of hepatocellular carcinoma 10 years after liver transplantation: Lessons from two cases. Ann Hepatobiliary Pancreat Surg 2018; 22:136-143. [PMID: 29896574 PMCID: PMC5981143 DOI: 10.14701/ahbps.2018.22.2.136] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Revised: 03/20/2018] [Accepted: 04/10/2018] [Indexed: 12/12/2022] Open
Abstract
Recurrence of hepatocellular carcinoma (HCC) 10 years after liver transplantation (LT) is very rare. Here, we present two cases of peritoneal metastasis of HCC that occurred 10 and 12 years after LT. A 77-year-old male who had undergone deceased-donor LT 10 years earlier showed slow progressive elevation of tumor marker levels over 6 months. Close observation with frequent imaging studies and monthly tumor marker analyses revealed a solitary peritoneal seeding mass. Imaging studies revealed that the mass was highly likely to be metastatic HCC. After excision of the mass, all tumor markers returned to the normal range. Over past 10 months, the patient has received everolimus monotherapy and half-dose sorafenib, and has shown no evidence of HCC recurrence. In the second case, marginally elevated tumor marker levels were detected in a 65-year-old male who had undergone living-donor LT 12 years earlier. After observation for 3 months, follow-up studies revealed a peritoneal seeding mass. Thorough imaging studies revealed that the mass was highly likely to be metastatic HCC. Two mass lesions were excised, and the patient was administered low-dose calcineruin inhibitor, sirolimus, and full-dose sorafenib. Subsequently, the tumor marker levels increased again and growth of new peritoneal seeding nodules was observed; therefore, sorafenib was stopped after 2 years of administration. During 6 years since HCC recurrence diagnosis, the patient has experienced slowly growing tumors, but has been doing well. For very late peritoneal metastasis of HCC, the therapeutic modalities include surgical resection if possible, everolimus monotherapy, and long-term use of sorafenib.
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Affiliation(s)
- Abdulwahab A Alshahrani
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea.,Multi Organ Transplant Center, King Fahad Specialist University Hospital, Dammam, Saudi Arabia
| | - Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Su-Min Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Yo-Han Park
- Department of Surgery, College of Medicine Inje University, Busan Paik Hospital, Busan, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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Cholongitas Ε, Goulis I, Theocharidou E, Antoniadis N, Fouzas I, Imvrios G, Giouleme O, Angelaki A, Vasiliadis T, Papanikolaou V, Akriviadis E. Everolimus with or without mycophenolate mofetil in a liver transplantation setting: a single-center experience. Ann Gastroenterol 2018; 31:613-620. [PMID: 30174399 PMCID: PMC6102469 DOI: 10.20524/aog.2018.0278] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2018] [Accepted: 04/11/2018] [Indexed: 12/16/2022] Open
Abstract
Background This study evaluated the efficacy, safety, and impact on renal function of everolimus in patients after liver transplantation (LT) with or without mycophenolate mofetil (MMF). Methods We evaluated LT recipients with calcineurin inhibitor (CNI)-related renal dysfunction after everolimus initiation. Laboratory data, including evaluation of renal function based on glomerular filtration rate (GFR) at baseline (i.e., everolimus initiation) and at the end of follow up, were analyzed. Results Fifty consecutive patients started taking everolimus at 30 months post-LT (range: 1-240), 6 as monotherapy and 44 in combination with MMF. After 30.5 months (range: 6-112), all patients were alive, without any biochemical evidence of a rejection episode or recurrence of hepatocellular carcinoma. The mean GFR, based on the Modification of Diet in Renal Disease equation, was 53±13 mL/min at baseline and 59±12 mL/min at the end of follow up (P=0.031). Eleven (22%) of the patients had GFR <60 mL/min at baseline but returned to GFR >60 mL/min by the end of follow up. In multivariate analysis, the time between the development of renal dysfunction and everolimus initiation was the only factor independently associated with GFR improvement (odds ratio [OR] 0.85, 95% confidence interval [95%CI] 0.76-0.96; P=0.007). Everolimus was stopped in 11 patients (22%) at the end of follow up because of adverse events. Conclusion A CNI-free everolimus-based regimen was effective in LT recipients with renal dysfunction and was associated with an improvement in GFR.
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Affiliation(s)
- Εvangelos Cholongitas
- 4 Department of Internal Medicine, Medical School of Aristotle University, Hippokration General Hospital of Thessaloniki (Evangelos Cholongitas, Ioannis Goulis, Aliki Angelaki, Evangelos Akriviadis), Greece.,1 Department of Internal Medicine, Medical School of National & Kapodistrian University, Athens (Evangelos Cholongitas), Greece
| | - Ioannis Goulis
- 4 Department of Internal Medicine, Medical School of Aristotle University, Hippokration General Hospital of Thessaloniki (Evangelos Cholongitas, Ioannis Goulis, Aliki Angelaki, Evangelos Akriviadis), Greece
| | - Eleni Theocharidou
- 2 Propedeutic Department of Internal Medicine, Medical School of Aristotle University, Hippokration Hospital, Thessaloniki (Eleni Theocharidou, Olga Giouleme), Greece
| | - Nikolaos Antoniadis
- Department of Transplant Surgery, Aristotle University of Thessaloniki (Nikolaos Antoniadis, Ioannis Fouzas, George Imvrios, Vasilios Papanikolaou), Greece
| | - Ioannis Fouzas
- Department of Transplant Surgery, Aristotle University of Thessaloniki (Nikolaos Antoniadis, Ioannis Fouzas, George Imvrios, Vasilios Papanikolaou), Greece
| | - George Imvrios
- Department of Transplant Surgery, Aristotle University of Thessaloniki (Nikolaos Antoniadis, Ioannis Fouzas, George Imvrios, Vasilios Papanikolaou), Greece
| | - Olga Giouleme
- 2 Propedeutic Department of Internal Medicine, Medical School of Aristotle University, Hippokration Hospital, Thessaloniki (Eleni Theocharidou, Olga Giouleme), Greece
| | - Aliki Angelaki
- 4 Department of Internal Medicine, Medical School of Aristotle University, Hippokration General Hospital of Thessaloniki (Evangelos Cholongitas, Ioannis Goulis, Aliki Angelaki, Evangelos Akriviadis), Greece
| | - Themistoklis Vasiliadis
- 3 Department of Internal Medicine, Papageorgiou General Hospital, Aristotle University of Thessaloniki (Themistoklis Vasiliadis), Greece
| | - Vasilios Papanikolaou
- Department of Transplant Surgery, Aristotle University of Thessaloniki (Nikolaos Antoniadis, Ioannis Fouzas, George Imvrios, Vasilios Papanikolaou), Greece
| | - Evangelos Akriviadis
- 4 Department of Internal Medicine, Medical School of Aristotle University, Hippokration General Hospital of Thessaloniki (Evangelos Cholongitas, Ioannis Goulis, Aliki Angelaki, Evangelos Akriviadis), Greece
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11
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Hwang S, Ahn CS, Kim KH, Moon DB, Ha TY, Song GW, Jung DH, Park GC, Lee SG. A cross-sectional analysis of long-term immunosuppressive regimens after liver transplantation at Asan Medical Center: Increased preference for mycophenolate mofetil. Ann Hepatobiliary Pancreat Surg 2018. [PMID: 29536052 PMCID: PMC5845607 DOI: 10.14701/ahbps.2018.22.1.19] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Backgrounds/Aims Long-term immunosuppression regimens after liver transplantation (LT) are rarely reported in detail. We aimed to provide information on actual long-term immunosuppression regimens through this cross-sectional study. Methods Our institutional LT database was searched for adult patients who underwent primary LT operation from 2000 to 2016. We identified 3620 live recipients with actual information on immunosuppressive agent use for 1-17 years. Results The study cohort was divided into 7 groups according to posttransplantation period. The immunosuppressive agents used at the cross-sectional review period were tacrolimus in 2884 (79.7%), cyclosporine in 445 (12.3%), mycophenolate mofetil in 2007 (55.4%), and everolimus in 138 (3.8%) recipients. There was no marked difference in immunosuppressive agent use according to pretransplantation liver malignancy or type of LT operation. Tacrolimus, cyclosporine, mycophenolate mofetil, and everolimus were used in 97.4%, 1.8%, 60.9%, and 9.2%, respectively, in the year 2 group; 94.1%, 3.9%, 51.6%, and 8.3%, respectively, in the year 3 group; 87.3%, 8.4%, 68.9%, and 4.8%, respectively, in the year 4-5 group; 78.2%, 12.9%, 64.6%, and 3.0%, respectively, in the year 6-7 group; 76.9%, 10.8%, 58.8%, and 2.4%, respectively, in the year 8-10 group; 66.7%, 22.4%, 43.4%, and 1.5%, respectively, in the year 11-15 group; and 73.8%, 15.4%, 32.9%, and 1.7%, respectively, in the year ≥15 group. Conclusions Tacrolimus and mycophenolate mofetil are the primary immunosuppressive agents after LT, and the indications for everolimus have started to increase at our institution. We believe our results will help establish tailored long-term immunosuppression regimens.
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Affiliation(s)
- Shin Hwang
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Chul-Soo Ahn
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ki-Hun Kim
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Deok-Bog Moon
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Tae-Yong Ha
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gi-Won Song
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong-Hwan Jung
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Gil-Chun Park
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Sung-Gyu Lee
- Division of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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12
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Lerut J, Iesari S, Foguenne M, Lai Q. Hepatocellular cancer and recurrence after liver transplantation: what about the impact of immunosuppression? Transl Gastroenterol Hepatol 2017; 2:80. [PMID: 29167827 DOI: 10.21037/tgh.2017.09.06] [Citation(s) in RCA: 30] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2017] [Accepted: 09/05/2017] [Indexed: 12/12/2022] Open
Abstract
Liver transplantation (LT) has originally been designed to treat hepatobiliary malignancies. The initial results of LT for hepatocellular cancer (HCC) were, however, dismal this mainly due to the poor patient selection procedure. Better surgical and perioperative care and, especially, the refinement of selection criteria led to a major improvement of results, making HCC nowadays (again!) one of the leading indications for LT. This evolution is clearly shown by the innumerable reports aiming to further extend inclusion criteria for LT in HCC patients. Nonetheless, the vast majority of papers only deals with morphologic (tumour diameter and number) and (only recently) biologic (tumour markers and response to locoregional treatment) parameters to do so. Curiously enough, the role of both the immune competent state of the recipient as well as the impact of both immunosuppression (IS) type and load has been very poorly addressed in this context, even if it has been shown for a long time, based on both basic and clinical research, that they all play a key role in the outcome of any oncologic treatment and in the development of de novo as well as recurrent tumours. This chapter aims to give, after a short introductive note about the currently used inclusion criteria of HCC patients for LT and about the role of IS in carcinogenesis, a comprehensive overview of the actual literature related to the impact of different immunosuppressive drugs and schemes on outcome of LT in HCC recipients. Unfortunately, up to now solid conclusions cannot be drawn due to the lack of high-level evidence studies caused by the heterogeneity of the studied patient cohorts and the lack of prospectively designed and randomized studies. Based on long-term personal experience with immunosuppressive handling in LT some proposals for further clinical research and practice are put forward. The strategy of curtailing and minimising IS should be explored in the growing field of transplant oncology taking thereby into account the immunological privilege of the liver allograft. These strategies will become more and more compelling when further extending the indications in which adjuvant chemotherapy will probably become an inherent part of the therapeutic scheme of HCC liver recipients.
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Affiliation(s)
- Jan Lerut
- Starzl Unit Abdominal Transplantation, University Hospitals Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Samuele Iesari
- General Surgery and Organ Transplantation, Department of Biotechnological and Applied Clinical Sciences, University of L'Aquila, L'Aquila, Italy
| | - Maxime Foguenne
- Starzl Unit Abdominal Transplantation, University Hospitals Saint Luc, Université Catholique de Louvain, Brussels, Belgium
| | - Quirino Lai
- Hepato-bilio-pancreatic and Liver Transplant Unit, Department of Surgery, La Sapienza University, Rome, Italy
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13
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Cholongitas E. Everolimus-Based Immunosuppression in Liver Transplant Recipients. Am J Transplant 2017; 17:2488. [PMID: 28556427 DOI: 10.1111/ajt.14375] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2017] [Revised: 04/11/2017] [Accepted: 05/11/2017] [Indexed: 01/25/2023]
Affiliation(s)
- E Cholongitas
- Fourth Department of Internal Medicine, Medical School of Aristotle University, Hippokration General Hospital of Thessaloniki, Thessaloniki, Greece
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14
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Yee ML, Tan HH. Use of everolimus in liver transplantation. World J Hepatol 2017; 9:990-1000. [PMID: 28878864 PMCID: PMC5569278 DOI: 10.4254/wjh.v9.i23.990] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Revised: 05/20/2017] [Accepted: 06/12/2017] [Indexed: 02/06/2023] Open
Abstract
In recent years, the use of mammalian target of rapamycin inhibitors has gained traction in their use as alternative or adjunct immunosuppressants in the post-liver transplantation (LT) setting. The efficacy of everolimus (EVR) in de novo LT is established and a reasonable time to initiate EVR is 30 d from LT surgery. Initiating EVR early post-LT allows for calcineurin inhibitor (CNI) reduction, thus reducing nephrotoxicity in LT recipients. However, data is inadequate on the appropriate timing for conversion from CNI to EVR maintenance in order to achieve optimal renoprotective effect without compromising drug efficacy. Adverse effects of proteinuria, hypercholesterolemia and hyperlipidemia are significantly higher as compared to standard CNI and long-term implications on graft and patient survival in LT is still unclear. Future research to explore strategies to minimise EVR adverse effects will be crucial for the success of EVR as an important alternative or adjunct immunosuppressive therapy in LT.
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Affiliation(s)
- Mei-Ling Yee
- Department of Pharmacy, Singapore General Hospital, Singapore 169608, Singapore.
| | - Hui-Hui Tan
- Department of Gastroenterology and Hepatology, Singapore General Hospital, Singapore 169608, Singapore
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15
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Giakoustidis AE, Giakoustidis DE. Immunosuppression strategies in liver transplantation patient; patients with hepatocellular carcinoma. Immunotherapy 2017; 9:197-206. [PMID: 28128716 DOI: 10.2217/imt-2016-0110] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Hepatocellular carcinoma (HCC) consists the main primary malignant tumor of the liver. There is an underlining liver cirrhosis mainly attributed to chronic hepatitis B virus or hepatitis C virus, alcoholic liver disease, nonalcoholic steatohepatitis and other pathologic conditions. Liver transplantation consists a radical management, treating both cancer and cirrhosis. By introducing the Milan Criteria for liver transplantation in HCC patients there was a 5-year survival escalation. Even though there is a careful selection of patients with HCC for transplantation, recurrent disease is still high. The role of immusuppression therapy is of paramount importance, in order to avoid acute and chronic graft rejection while protecting the patient from tumor recurrence. In recent years newer immunosuppressive agents such as the mTOR inhibitors are proposed, having dual properties, as both immunosuppressive and antitumors agents.
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Affiliation(s)
- Alexander E Giakoustidis
- Hepato-Pancreato-Biliary Surgery Department, The Royal London Hospital, Barts Health, Whitechapel Road, London E1 1BB, UK
| | - Dimitrios E Giakoustidis
- Division of Transplant Surgery, Department of Surgery, School of Health Sciences, Aristotle University of Thessaloniki & Hippokration General Hospital, Thessaloniki, Greece
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16
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Tarantino G, Magistri P, Ballarin R, Di Francia R, Berretta M, Di Benedetto F. Oncological Impact of M-Tor Inhibitor Immunosuppressive Therapy after Liver Transplantation for Hepatocellular Carcinoma: Review of the Literature. Front Pharmacol 2016; 7:387. [PMID: 27818634 PMCID: PMC5073152 DOI: 10.3389/fphar.2016.00387] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2016] [Accepted: 10/04/2016] [Indexed: 12/12/2022] Open
Abstract
Background: Hepatocellular Carcinoma (HCC) represents the fifth most common malignancy and the third cancer-related cause of death worldwide. Hepatitis B (HBV) and C (HCV) viral infections and alcohol abuse are the principal etiological factors for HCC. Liver transplantation (LT) is oncologically the preferable approach to HCC, as it can remove all the intrahepatic tumor foci, and also the oncogenic cirrhotic liver. The use of mTOR inhibitors (mTORi) for immunosuppression after LT for HCC has been proposed due to rapamycin antitumor activity. We decided to review the literature to clarify the oncological role of mTORi after liver transplantation for HCC, analyzing both present condition and future perspectives. Material and Methods: A systematic literature search was performed using PubMed, EMBASE, Scopus, and the Cochrane Library Central. The search was limited to studies in humans and to those reported in the English language in the period of time between January 2005 and December 2015. Results: The literature search yielded 93 articles; after duplicates were removed, 77 titles and abstracts were reviewed. Most relevant data and papers are herein reported and discussed. Conclusions: So far, the use of mTORi is encouraging in terms of oncological outcomes for patients underwent LT for HCC, both for prevention and treatment of HCC recurrence although definitive data are still awaited.
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Affiliation(s)
- Giuseppe Tarantino
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia Modena, Italy
| | - Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio EmiliaModena, Italy; Department of Medical and Surgical Sciences and Translational Medicine, Sapienza - University of RomeRome, Italy
| | - Roberto Ballarin
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia Modena, Italy
| | - Raffaele Di Francia
- Hematology, National Cancer Institute, Fondazione "G. Pascale" Napoli, Italy
| | | | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia Modena, Italy
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17
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Bilbao I, Guilera M. Reply. Liver Transpl 2016; 22:134-5. [PMID: 26439432 DOI: 10.1002/lt.24354] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/22/2015] [Accepted: 09/23/2015] [Indexed: 01/13/2023]
Affiliation(s)
- Itxarone Bilbao
- Hospital Vall d'Hebrón Network Center for Biomedical Research in Hepatic and Digestive Disease, Barcelona, Spain
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18
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Cholongitas E, Antoniadis N, Goulis I, Fouzas I, Vasiliadis T, Akriviadis E, Papanikolaou V. Renal function improvement in liver transplant recipients after early everolimus conversion: A clinical practice cohort study in Spain. Liver Transpl 2016; 22:132-3. [PMID: 26389717 DOI: 10.1002/lt.24345] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2015] [Accepted: 09/11/2015] [Indexed: 01/13/2023]
Affiliation(s)
- Evangelos Cholongitas
- 4th Department of Internal Medicine, Medical School of Aristotle University Hippokration General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Nikolaos Antoniadis
- Department of Transplant Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Goulis
- 4th Department of Internal Medicine, Medical School of Aristotle University Hippokration General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Ioannis Fouzas
- Department of Transplant Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Themistoklis Vasiliadis
- Department of Transplant Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
| | - Evangelos Akriviadis
- 4th Department of Internal Medicine, Medical School of Aristotle University Hippokration General Hospital of Thessaloniki, Thessaloniki, Greece
| | - Vasilios Papanikolaou
- Department of Transplant Surgery, Aristotle University of Thessaloniki, Thessaloniki, Greece
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