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Park SY, Shin J, Jeon YJ, Lee J, Cho JH, Kim HK, Choi YS, Zo JI, Shim YM. Surgical outcomes and survival following esophagectomy for squamous cell carcinoma with or without liver cirrhosis: retrospective cohort study. Int J Surg 2024; 110:2894-2901. [PMID: 38349217 DOI: 10.1097/js9.0000000000001179] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2024] [Accepted: 01/29/2024] [Indexed: 05/16/2024]
Abstract
BACKGROUND AND AIMS Esophageal squamous cell carcinoma (ESCC) shares common risk factors with liver cirrhosis (LC). The influence of LC in patients with ESCC has not been fully investigated. This study aimed to investigate the postoperative and long-term survival outcomes of esophagectomy for ESCC according to LC presence. METHODS Among patients who underwent curative-intent surgery for ESCC between 1994 and 2018, 121 patients with Child-Pugh class A LC and 2810 patients without LC were compared. RESULTS Among the LC patients, 73 (60.3%) were diagnosed with LC before surgery and 48 (39.7%) were diagnosed intraoperatively. There were no significant differences in baseline characteristics between patients with LC and those without LC. However, intraoperative blood loss was higher, and operation time, hospital stay, and ICU stay were longer in patients with LC than in those without LC. Moreover, the reoperation, 30-day morbidity (60.6 vs. 73.6%, P =0.006) and 90-day mortality (2.2 vs. 4.9%, P =0.049) were significantly higher in patients with LC. The 5-year overall survival (OS) rate was significantly higher in patients without LC than in those with LC. After adjusting the confounding variables, LC was an adverse risk factor of OS (hazard ratio 1.402, P =0.004). Among patients with LC, the Model of End-Stage Liver Disease score was related to the development of complications of grade more than III (odds ratio 1.459, P =0.013). CONCLUSION ESCC patients with Child-Pugh class A LC have high incidences of postoperative morbidity and mortality, and poor OS. Thus, careful patient selection, meticulous operation, and careful postoperative care are needed.
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Affiliation(s)
| | - Jaeseung Shin
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, Republic of Korea
| | | | - Junghee Lee
- Department of Thoracic and Cardiovascular Surgery
| | - Jong Ho Cho
- Department of Thoracic and Cardiovascular Surgery
| | | | | | - Jae Il Zo
- Department of Thoracic and Cardiovascular Surgery
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Ningarhari M, Bertez M, Ploquin A, Bertrand N, Desauw C, Cattan S, Catala P, Vandamme H, Cheymol C, Truant S, Lassailly G, Louvet A, Mathurin P, Dharancy S, Turpin A. Conventional cytotoxic chemotherapy for gastrointestinal cancer in patients with cirrhosis: A multicentre case-control study. Liver Int 2024; 44:682-690. [PMID: 38031969 DOI: 10.1111/liv.15813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2023] [Revised: 11/08/2023] [Accepted: 11/23/2023] [Indexed: 12/01/2023]
Abstract
BACKGROUND & AIMS Progresses in management make a higher proportion of cirrhotic patients with gastrointestinal (GI) cancer candidates to chemotherapy. Data are needed on the safety and liver-related events associated with the use of chemotherapy in these patients. METHODS Forty-nine patients with cirrhosis receiving chemotherapy against GI cancer from 2013 to 2018 were identified in the French Health Insurance Database using ICD-10 codes K70-K74, and matched 1:2 to non-cirrhotic controls (n = 98) on age, tumour type and type of treatment. Adverse events (AE), dose tapering, discontinuation rate, liver-related events and survival rate were compared. RESULTS Patients with cirrhosis (Child-Pugh A 91%) more often received lower doses (38.8% vs 7.1%, p < .001), without significant differences in terms of grade 3/4 AE or dose tapering rates (29.6% vs. 36.7%; 22.3% vs 24.4%, respectively). Treatment discontinuation rate was higher in patients with cirrhosis (23.3% vs. 11.3%, p = .005). Child-Pugh (p = .007) and MELD (p = .025) scores increased under chemotherapy. Five patients with cirrhosis (10.2%) had liver decompensation within 12 months, and 17.2% of deaths in the cirrhosis group were liver-related versus 0% in matched controls. WHO-PS stage > 1 (HR 3.74, CI95%: 2.13-6.57, p < .001), TNM-stage M1 (HR 3.61, CI 95%: 1.82-7.16, p < .001), non-colorectal cancer (HR 1.73, CI 95%: 1.05-2.86, p = .032) and bilirubin higher than 5 mg/dL (HR 2.26, CI 95%: 1.39-3.70, p < .001) were independent prognostic factors of 2-year mortality, whereas cirrhosis was not. CONCLUSIONS Chemotherapy should be proposed only in patients with compensated cirrhosis with close monitoring of liver function. Dose management remains challenging. Multidisciplinary management is warranted to improve these patients' outcomes.
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Affiliation(s)
- Massih Ningarhari
- CHU Lille, Hôpital Huriez, Maladies de l'Appareil Digestif, Lille, France
| | - Marlène Bertez
- CHU Lille, Hôpital Huriez, Maladies de l'Appareil Digestif, Lille, France
| | - Anne Ploquin
- Université de Lille, CNRS INSERM UMR9020-U1277, CANTHER Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
- CHU Lille, Hôpital Huriez, Medical Oncology Department, Lille, France
| | - Nicolas Bertrand
- Université de Lille, CNRS INSERM UMR9020-U1277, CANTHER Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
- CHU Lille, Hôpital Huriez, Medical Oncology Department, Lille, France
| | - Christophe Desauw
- Université de Lille, CNRS INSERM UMR9020-U1277, CANTHER Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
- CHU Lille, Hôpital Huriez, Medical Oncology Department, Lille, France
| | - Stéphane Cattan
- CHU Lille, Hôpital Huriez, Maladies de l'Appareil Digestif, Lille, France
| | - Pascale Catala
- Centre Hospitalier de Béthune, Hépato-Gastro-Entérologie, Beuvry, France
| | - Hélène Vandamme
- Centre Hospitalier de Béthune, Hépato-Gastro-Entérologie, Beuvry, France
| | - Claire Cheymol
- GHICL Hôpital Saint-Vincent, Oncologie Médicale, Lille, France
| | - Stéphanie Truant
- CHU Lille, Hôpital Huriez, Chirurgie Digestive et Transplantation, Lille, France
| | | | - Alexandre Louvet
- CHU Lille, Hôpital Huriez, Maladies de l'Appareil Digestif, Lille, France
| | - Philippe Mathurin
- CHU Lille, Hôpital Huriez, Maladies de l'Appareil Digestif, Lille, France
| | - Sébastien Dharancy
- CHU Lille, Hôpital Huriez, Maladies de l'Appareil Digestif, Lille, France
| | - Anthony Turpin
- Université de Lille, CNRS INSERM UMR9020-U1277, CANTHER Cancer Heterogeneity Plasticity and Resistance to Therapies, Lille, France
- CHU Lille, Hôpital Huriez, Medical Oncology Department, Lille, France
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Jelicic J, Larsen TS, Fialla AD, Bukumiric Z, Andjelic B. Clinical Characteristics and Management of Patients With Concomitant Liver Cirrhosis and Lymphoma: A Systematic Review. CLINICAL LYMPHOMA, MYELOMA & LEUKEMIA 2022; 22:e981-e991. [PMID: 35948478 DOI: 10.1016/j.clml.2022.07.006] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/15/2022] [Revised: 07/07/2022] [Accepted: 07/14/2022] [Indexed: 06/15/2023]
Abstract
Over the years, a rising incidence of liver cirrhosis and lymphoma has been observed. Therefore, the risk of having cirrhosis as a comorbidity increases, thus challenging treatment approaches as data on the management of these patients is lacking. We performed a systematic review to summarize papers that analyzed patients with liver cirrhosis that occurred before and/or concomitantly to lymphoma. We identified 153 papers (230 patients) through Pubmed and/or Embase search. Publications comprised predominantly of case reports and/or case series. Most patients had HCV-related cirrhosis (62.6%), and aggressive lymphoma histology (59.6%). Data on liver status was available in 55.7% of all patients, with 46.1% having decompensated liver cirrhosis. These patients experienced more often treatment reductions and/or modifications, treatment side effects, and inferior survival than those with compensated cirrhosis (median 18 months vs. median not reached). Dose reductions and/or treatment modifications primarily due to concomitant liver disease were common. Moreover, liver toxicity was observed in 33.6% of patients with provided information on treatment side effects, ranging from mild toxicity to liver failure with fatal outcomes. Again, despite treatment modification/reduction, patients with decompensated liver cirrhosis developed hepatic toxicity more frequently than patients with compensated liver disease. Although patients suffering from cirrhosis and lymphoma can tolerate standard chemoimmunotherapy, a cautious multidisciplinary approach is needed to evaluate the risks and benefits.
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Affiliation(s)
- Jelena Jelicic
- Department of Hematology, Sygehus Lillebaelt, Vejle, Denmark; Department of Hematology, Odense University Hospital, Odense, Denmark.
| | - Thomas Stauffer Larsen
- Department of Hematology, Odense University Hospital, Odense, Denmark; Department of Clinical Research, University of Southern Denmark, Odense, Denmark
| | - Annette Dam Fialla
- Department of Gastroenterology and Hepatology, Odense University Hospital, Odense, Denmark
| | - Zoran Bukumiric
- Department of Statistics, Faculty of Medicine, University of Belgrade, Belgrade, Serbia
| | - Bosko Andjelic
- Department of Hematology, Blackpool Victoria Hospital, Lancashire Haematology Centre, Blackpool
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Xiang Z, Li Y, Zhu C, Hong T, He X, Zhu H, Jiang D. Gastrointestinal Cancers and Liver Cirrhosis: Implications on Treatments and Prognosis. Front Oncol 2021; 11:766069. [PMID: 34746008 PMCID: PMC8567751 DOI: 10.3389/fonc.2021.766069] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2021] [Accepted: 10/04/2021] [Indexed: 12/12/2022] Open
Abstract
Liver cirrhosis tends to increase the risk in the management of gastrointestinal tumors. Patients with gastrointestinal cancers and liver cirrhosis often have serious postoperative complications and poor prognosis after surgery. Multiple studies have shown that the stage of gastrointestinal cancers and the grade of cirrhosis can influence surgical options and postoperative complications. The higher the stage of cancer and the poorer the degree of cirrhosis, the less the surgical options and the higher the risk of postoperative complications. Therefore, in the treatment of patients with gastrointestinal cancer and liver cirrhosis, clinicians should comprehensively consider the cancer stage, cirrhosis grade, and possible postoperative complications. This review summarizes the treatment methods of patients with different gastrointestinal cancer complicated with liver cirrhosis.
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Affiliation(s)
- Ze Xiang
- Department of Gastroenterology, Yancheng Third People’s Hospital, Yancheng, China
- School of Medicine, Zhejiang University, Hangzhou, China
- Chu Kochen Honors College, Zhejiang University, Hangzhou, China
| | - Yiqi Li
- School of Medicine, Zhejiang University, Hangzhou, China
- Chu Kochen Honors College, Zhejiang University, Hangzhou, China
| | - Chaojie Zhu
- School of Medicine, Zhejiang University, Hangzhou, China
- Chu Kochen Honors College, Zhejiang University, Hangzhou, China
- Department of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, School of Medicine, Zhejiang University, Hangzhou, China
| | - Tu Hong
- School of Medicine, Zhejiang University, Hangzhou, China
- Chu Kochen Honors College, Zhejiang University, Hangzhou, China
| | - Xianglin He
- Chu Kochen Honors College, Zhejiang University, Hangzhou, China
| | - Hua Zhu
- Department of Gastroenterology, Yancheng Third People’s Hospital, Yancheng, China
| | - Danbin Jiang
- Department of Gastroenterology, Yancheng Third People’s Hospital, Yancheng, China
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5
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Kim J, Randhawa H, Sands D, Lambe S, Puglia M, Serrano PE, Pinthus JH. Muscle-Invasive Bladder Cancer in Patients with Liver Cirrhosis: A Review of Pertinent Considerations. Bladder Cancer 2021; 7:261-278. [PMID: 38993608 PMCID: PMC11181825 DOI: 10.3233/blc-211536] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/15/2021] [Accepted: 06/09/2021] [Indexed: 11/15/2022]
Abstract
The incidence of liver cirrhosis is increasing worldwide. Patients with cirrhosis are generally at a higher risk of harbouring hepatic and non-hepatic malignancies, including bladder cancer, likely due to the presence of related risk factors such as smoking. Cirrhosis can complicate both the operative and non-surgical management of bladder cancer. For example, cirrhotic patients undergoing abdominal surgery generally demonstrate worse postoperative outcomes, and chemotherapy in patients with cirrhosis often requires dose reduction due to its direct hepatotoxic effects and reduced hepatic clearance. Multiple other considerations in the peri-operative management for cirrhosis patients with muscle-invasive bladder cancer must be taken into account to optimize outcomes in these patients. Unfortunately, the current literature specifically related to the treatment of cirrhotic bladder cancer patients remains sparse. We aim to review the literature on treatment considerations for this patient population with respect to perioperative, surgical, and adjuvant management.
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Affiliation(s)
- John Kim
- Michael G. DeGroote School of Medicine, McMaster University, Hamilton, ON, Canada
| | | | - David Sands
- Division of Urology, McMaster University, Hamilton, ON, Canada
| | - Shahid Lambe
- Division of Urology, McMaster University, Hamilton, ON, Canada
- McMaster Institute of Urology, St. Joseph’s Hospital, Hamilton, ON, Canada
| | - Marco Puglia
- Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada
| | | | - Jehonathan H. Pinthus
- Division of Urology, McMaster University, Hamilton, ON, Canada
- Juravinski Hospital and Cancer Centre, Hamilton, ON, Canada
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Alsmadi MM, Al-Daoud NM, Jaradat MM, Alzughoul SB, Abu Kwiak AD, Abu Laila SS, Abu Shameh AJ, Alhazabreh MK, Jaber SA, Abu Kassab HT. Physiologically-based pharmacokinetic model for alectinib, ruxolitinib, and panobinostat in the presence of cancer, renal impairment, and hepatic impairment. Biopharm Drug Dispos 2021; 42:263-284. [PMID: 33904202 DOI: 10.1002/bdd.2282] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2020] [Revised: 03/18/2021] [Accepted: 04/11/2021] [Indexed: 12/24/2022]
Abstract
Renal (RIP) and hepatic (HIP) impairments are prevalent conditions in cancer patients. They can cause changes in gastric emptying time, albumin levels, hematocrit, glomerular filtration rate, hepatic functional volume, blood flow rates, and metabolic activity that can modify drug pharmacokinetics. Performing clinical studies in such populations has ethical and practical issues. Using predictive physiologically-based pharmacokinetic (PBPK) models in the evaluation of the PK of alectinib, ruxolitinib, and panobinostat exposures in the presence of cancer, RIP, and HIP can help in using optimal doses with lower toxicity in these populations. Verified PBPK models were customized under scrutiny to account for the pathophysiological changes induced in these diseases. The PBPK model-predicted plasma exposures in patients with different health conditions within average 2-fold error. The PBPK model predicted an area under the curve ratio (AUCR) of 1, and 1.8, for ruxolitinib and panobinostat, respectively, in the presence of severe RIP. On the other hand, the severe HIP was associated with AUCR of 1.4, 2.9, and 1.8 for alectinib, ruxolitinib, and panobinostat, respectively, in agreement with the observed AUCR. Moreover, the PBPK model predicted that alectinib therapeutic cerebrospinal fluid levels are achieved in patients with non-small cell lung cancer, moderate HIP, and severe HIP at 1-, 1.5-, and 1.8-fold that of healthy subjects. The customized PBPK models showed promising ethical alternatives for simulating clinical studies in patients with cancer, RIP, and HIP. More work is needed to quantify other pathophysiological changes induced by simultaneous affliction by cancer and RIP or HIP.
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Affiliation(s)
- Mo'tasem M Alsmadi
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Nour M Al-Daoud
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Mays M Jaradat
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Saja B Alzughoul
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Amani D Abu Kwiak
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Salam S Abu Laila
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Ayat J Abu Shameh
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Mohammad K Alhazabreh
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Sana'a A Jaber
- Department of Clinical Pharmacy, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
| | - Hala T Abu Kassab
- Department of Pharmaceutical Technology, Faculty of Pharmacy, Jordan University of Science and Technology, Irbid, Jordan
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Alvarado-Muñoz JF, Falco A, Morales AR, Sánchez NC, Reynoso G, Barillas A, Moreno J, López K, Prestol R, Cabreja A, Nuñez C. Platinum ineligibility in squamous cell carcinoma of the head and neck: consensus from Central America and the Caribbean. Future Oncol 2021; 17:1963-1971. [PMID: 33559505 DOI: 10.2217/fon-2020-0931] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
The high incidence of head and neck cancer in Central America and the Caribbean, together with limitations in the healthcare system for patients with locally advanced squamous cell carcinoma of the head and neck (LA SCCHN) in this region necessitate a consensus of opinion based on a review of the literature on therapy with cisplatin plus radiation. Such an approach will ensure appropriate selection of patients who can benefit from therapy and reduce the incidence of related adverse events. Therefore, we recorded the opinion of experts in the region in order to identify needs and challenges in the treatment of LA SCCHN.
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Affiliation(s)
| | - Agustín Falco
- Alexander Fleming Institute of Oncology, Buenos Aires, Argentina
| | | | - Noé C Sánchez
- Guatemalan Social Security Institute, Guatemala City, Guatemala
| | | | - Allan Barillas
- Guatemalan Social Security Institute, Guatemala City, Guatemala
| | | | - Kreilin López
- Heriberto Pieter Cancer Institute, Santo Domingo, Dominican Republic
| | - Rogelio Prestol
- Heriberto Pieter Cancer Institute, Santo Domingo, Dominican Republic
| | - Angela Cabreja
- Regional Oncological Institute Cibao, Santiago de los Caballeros, Dominican Republic
| | - César Nuñez
- Regional Oncological Institute Cibao, Santiago de los Caballeros, Dominican Republic
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Wang S, Guo XZ, Xu SX, Qi XS. Risk and treatment of non-hepatic cancers in patients with cirrhosis. Shijie Huaren Xiaohua Zazhi 2020; 28:655-659. [DOI: 10.11569/wcjd.v28.i15.655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Patients with cirrhosis are at a high risk for hepatocellular carcinoma. However, it remains controversial about whether or not there is a high risk for non-hepatic cancers in patients with liver cirrhosis. Additionally, the management of non-hepatic cancers in cirrhotic patients is a clinical challenge, because the use of surgery and anticancer drugs is often compromised by the presence of liver dysfunction. This editorial aims to briefly summarize the findings on the risk and management of non-hepatic cancers in patients with cirrhosis.
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Affiliation(s)
- Shuo Wang
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China,Postgraduate College, China Medical University, Shenyang 110122, Liaoning Province, China
| | - Xiao-Zhong Guo
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
| | - Shi-Xue Xu
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China,Postgraduate College, China Medical University, Shenyang 110122, Liaoning Province, China
| | - Xing-Shun Qi
- Department of Gastroenterology, General Hospital of Northern Theater Command, Shenyang 110840, Liaoning Province, China
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9
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Azar A, Devcic Z, Paz-Fumagalli R, Vidal LLC, McKinney JM, Frey G, Lewis AR, Ritchie C, Starr JS, Mody K, Toskich B. Albumin-bilirubin grade as a prognostic indicator for patients with non-hepatocellular primary and metastatic liver malignancy undergoing Yttrium-90 radioembolization using resin microspheres. J Gastrointest Oncol 2020; 11:715-723. [PMID: 32953155 DOI: 10.21037/jgo.2020.04.01] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
Background Studies have shown that the albumin-bilirubin (ALBI) grade can be a superior prognosticator for patients undergoing Yttrium-90 (Y90) glass microsphere radioembolization for hepatocellular carcinoma (HCC) compared to the Child-Pugh (CP) scoring system. Less is known about the applicability of this score in non-hepatocellular malignancies using Y90 resin microspheres. This study evaluates the ALBI grade's ability to predict overall survival and biochemical toxicity in patients undergoing resin Y90 radioembolization and body surface area dosimetry (BSA) for non-hepatocellular primary and metastatic liver malignancies compared to the CP class and Model for End-Stage Liver Disease (MELD) score. Methods A retrospective review of patients with intrahepatic metastatic colorectal and neuroendocrine cancers and cholangiocarcinoma undergoing resin radioembolization from 2006-2015 at a single tertiary medical center was performed. ALBI, MELD, and CP scores were compared and correlated with biochemical toxicity and overall survival. Results There was a significant difference in overall survival between CP class A and class B liver function (P=0.04) for the entire patient cohort. ALBI grade (P=0.36) and MELD score (P=0.19) were not independently associated with survival. When stratified by CP class, the ALBI grade revealed a trend for survival difference in CP class B (P=0.05). Baseline ALBI grade was associated with post-procedural albumin reduction (P=0.01) and bilirubin elevation (P=0.007). Conclusions ALBI grade predicted post-procedural biochemical toxicity, but did not predict survival after resin radioembolization of non-hepatocellular liver malignancies using BSA dosimetry. Given the heterogeneity of this study population, dedicated prospective analyses are required.
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Affiliation(s)
- Antoine Azar
- Division of Diagnostic Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Zlatko Devcic
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | | | | | - J Mark McKinney
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Gregory Frey
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Andrew R Lewis
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Charles Ritchie
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Jason S Starr
- Division of Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Kabir Mody
- Division of Oncology, Mayo Clinic Florida, Jacksonville, FL, USA
| | - Beau Toskich
- Division of Interventional Radiology, Mayo Clinic Florida, Jacksonville, FL, USA
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10
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Asti E, Sozzi M, Bonitta G, Bernardi D, Bonavina L. Esophagectomy in patients with liver cirrhosis: a systematic review and Bayesian meta-analysis. J Visc Surg 2018; 155:453-464. [DOI: 10.1016/j.jviscsurg.2018.03.014] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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11
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Han EC, Ryoo SB, Park JW, Yi JW, Oh HK, Choe EK, Ha HK, Park BK, Moon SH, Jeong SY, Park KJ. Oncologic and surgical outcomes in colorectal cancer patients with liver cirrhosis: A propensity-matched study. PLoS One 2017; 12:e0178920. [PMID: 28586376 PMCID: PMC5460849 DOI: 10.1371/journal.pone.0178920] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/16/2017] [Accepted: 05/22/2017] [Indexed: 02/06/2023] Open
Abstract
The management of colorectal cancer in patients with liver cirrhosis requires a thorough understanding of both diseases. This study evaluated the effect of liver cirrhosis on oncologic and surgical outcomes and prognostic factors in colorectal cancer patients. Fifty-five consecutive colorectal cancer patients with liver cirrhosis underwent colorectal resection (LC group). Using a prospectively maintained database, these patients were matched 1:4 using propensity scoring with R programming language, package "MatchIt" and "optmatch" by sex, age, cancer location, and tumor stage with 220 patients without liver cirrhosis (non-LC group), resulting in 275 patients. The 5-year overall survival (OS) was significantly worse in the LC group than in the non-LC group (46.7% vs. 76.2% respectively, P < 0.001); however, the 5-year proportion of recurrence free (PRF) rates were similar (73.1% vs. 84.5% respectively, P = 0.094). On multivariate analysis of the LC group, tumor-node-metastasis (TNM) stage ≥III disease, venous invasion, and a model for end-stage liver disease plus serum sodium (MELD-Na) score >10 were prognostic factors for OS. However, the OS was not different between the LC group with MELD-Na score ≤10 and the non-LC group (5-year OS rate, TNM stage ≤II, 85.7 vs 89.5%, p = 0.356; TNM stage ≥III, 41.1 vs 66.2%, p = 0.061). Colorectal cancer patients with liver cirrhosis have poorer OS compared to those without liver cirrhosis; however, the PRF rates are similar. It might be due to the mortality from the liver, and surgical treatment should be actively considered for patients with MELD-Na score <10.
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Affiliation(s)
- Eon Chul Han
- Department of Surgery, Dongnam Institute of Radiological and Medical Sciences, Busan, Korea
| | - Seung-Bum Ryoo
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
- * E-mail:
| | - Ji Won Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Jin Wook Yi
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Heung-Kwon Oh
- Department of Surgery, Seoul National University Bundang Hospital, Seoul National University College of Medicine, Seongnam, Korea
| | - Eun Kyung Choe
- Seoul National University Hospital Gangnam Center, Seoul, Korea
| | - Heon-Kyun Ha
- Department of Surgery, Seonam University College of Medicine Myongji Hospital, Goyang, Gyeonggi Province, Korea
| | - Byung Kwan Park
- Department of Surgery, Chung-Ang University Hospital, Seoul, Korea
| | - Sang Hui Moon
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Seung-Yong Jeong
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
| | - Kyu Joo Park
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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Pinter M, Trauner M, Peck-Radosavljevic M, Sieghart W. Cancer and liver cirrhosis: implications on prognosis and management. ESMO Open 2016; 1:e000042. [PMID: 27843598 PMCID: PMC5070280 DOI: 10.1136/esmoopen-2016-000042] [Citation(s) in RCA: 166] [Impact Index Per Article: 20.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2016] [Accepted: 02/06/2016] [Indexed: 12/11/2022] Open
Abstract
Liver cirrhosis, the end-stage of every chronic liver disease, is not only the major risk factor for the development of hepatocellular carcinoma but also a limiting factor for anticancer therapy of liver and non-hepatic malignancies. Liver cirrhosis may limit surgical and interventional approaches to cancer treatment, influence pharmacokinetics of anticancer drugs, increase side effects of chemotherapy, render patients susceptible for hepatotoxicity, and ultimately result in a competitive risk for morbidity and mortality. In this review, we provide a concise overview about the impact of liver cirrhosis on the management and prognosis of patients with primary liver cancer or non-hepatic malignancies.
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Affiliation(s)
- Matthias Pinter
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Edwin L. Steele Laboratories for Tumor Biology, Department of Radiation Oncology, Harvard Medical School & Massachusetts General Hospital, Boston, USA
| | - Michael Trauner
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III , Medical University of Vienna , Vienna , Austria
| | - Markus Peck-Radosavljevic
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Department of Gastroenterology & Hepatology, Endocrinology and Nephrology, Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Wolfgang Sieghart
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Austrian Society of Gastroenterology & Hepatology, Working Group GI-Oncology
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Chiou WY, Chang CM, Tseng KC, Hung SK, Lin HY, Chen YC, Su YC, Tseng CW, Tsai SJ, Lee MS, Li CY. Effect of liver cirrhosis on metastasis in colorectal cancer patients: a nationwide population-based cohort study. Jpn J Clin Oncol 2014; 45:160-8. [PMID: 25378650 DOI: 10.1093/jjco/hyu178] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
OBJECTIVE The aim of this study is to evaluate the liver metastasis risk among colorectal cancer patients with liver cirrhosis. METHODS This was a nationwide population-based cohort study of 2973 newly diagnosed colorectal cancer patients with liver cirrhosis and 11 892 age-sex matched controls enrolled in Taiwan between 2000 and 2010. The cumulative risk by Kaplan-Meier method, hazard ratio by the multivariate Cox proportional model and the incidence density were evaluated. RESULTS The median time interval from the colorectal cancer diagnosis to the liver metastasis event was 7.42 months for liver cirrhosis group and 7.67 months for non-liver cirrhosis group. The incidence density of liver metastasis was higher in the liver cirrhosis group (61.92/1000 person-years) than in the non-liver cirrhosis group (47.48/1000 person-years), with a significantly adjusted hazard ratio of 1.15 (95% CI = 1.04-1.28, P = 0.007). The 10-year cumulative risk of liver metastasis for the liver cirrhosis and the non-liver cirrhosis group was 27.1 and 23.6%, respectively (P = 0.006). For early cancer stage with locoregional disease patients receiving surgery alone without adjuvant anti-cancer treatments, patients with liver cirrhosis (10-year cumulative risk 23.9 vs. 15.7%, P < 0.001) or cirrhotic symptoms (10-year cumulative risk 25.6 vs. 16.6%, P = 0.009) both still had higher liver metastasis risk compared with their counterparts. For etiologies of liver cirrhosis, the 10-year cumulative risk for hepatitis B virus and hepatitis C virus, hepatitis B virus, hepatitis C virus, other causes and non-liver cirrhosis were 29.5, 28.9, 27.5, 26.7 and 23.4%, respectively, (P = 0.03). CONCLUSIONS Our study found that liver metastasis risk was underestimated and even higher in colorectal cancer patients with liver cirrhosis.
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Affiliation(s)
- Wen-Yen Chiou
- Department of Radiation Oncology, Buddhist Dalin Tzu Chi Hospital, Chiayi School of Medicine, Tzu Chi University, Hualien Department of Public Health, College of Medicine, National Cheng Kung University, Tainan
| | - Chun-Ming Chang
- School of Medicine, Tzu Chi University, Hualien Department of Surgery, Buddhist Dalin Tzu Chi Hospital, Chiayi
| | - Kuo-Chih Tseng
- School of Medicine, Tzu Chi University, Hualien Division of Gastroenterology, Department of Internal Medicine, Buddhist Dalin Tzu Chi Hospital, Chiayi
| | - Shih-Kai Hung
- Department of Radiation Oncology, Buddhist Dalin Tzu Chi Hospital, Chiayi School of Medicine, Tzu Chi University, Hualien
| | - Hon-Yi Lin
- Department of Radiation Oncology, Buddhist Dalin Tzu Chi Hospital, Chiayi School of Medicine, Tzu Chi University, Hualien
| | - Yi-Chun Chen
- School of Medicine, Tzu Chi University, Hualien Division of Nephrology, Department of Internal Medicine, Buddhist Dalin Tzu Chi Hospital, Chiayi
| | - Yu-Chieh Su
- School of Medicine, Tzu Chi University, Hualien Division of Hematology-Oncology, Department of Internal Medicine, Buddhist Dalin Tzu Chi Hospital, Chiayi, Taiwan
| | - Chih-Wei Tseng
- School of Medicine, Tzu Chi University, Hualien Division of Gastroenterology, Department of Internal Medicine, Buddhist Dalin Tzu Chi Hospital, Chiayi
| | - Shiang-Jiun Tsai
- Department of Radiation Oncology, Buddhist Dalin Tzu Chi Hospital, Chiayi
| | - Moon-Sing Lee
- Department of Radiation Oncology, Buddhist Dalin Tzu Chi Hospital, Chiayi School of Medicine, Tzu Chi University, Hualien
| | - Chung-Yi Li
- Department of Public Health, College of Medicine, National Cheng Kung University, Tainan
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Abstract
Cirrhosis patients’ comorbidities are their other diseases than cirrhosis. Comorbidities are neither causes nor consequences of cirrhosis, but they can increase mortality and are therefore clinically important. They are also an important source of confounding in epidemiologic studies. Comorbidity scoring systems have been developed as tools to measure the cirrhosis patient’s total burden of comorbidity, and they are useful in the clinic and for epidemiologic studies. The recently developed CirCom score is the only comorbidity scoring system developed specifically for cirrhosis patients, and it may be preferred over the older, generic, and more complex Charlson comorbidity index. Studies of individual comorbid diseases can provide insight into the interactions between cirrhosis and other diseases and thus into the pathophysiology of cirrhosis. This article reviews the literature on comorbidity in cirrhosis.
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Maida M, Macaluso FS, Galia M, Cabibbo G. Hepatocellular carcinoma and synchronous liver metastases from colorectal cancer in cirrhosis: A case report. World J Hepatol 2013; 5:696-700. [PMID: 24409337 PMCID: PMC3879692 DOI: 10.4254/wjh.v5.i12.696] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/18/2013] [Revised: 11/05/2013] [Accepted: 11/19/2013] [Indexed: 02/06/2023] Open
Abstract
A 68-year-old Caucasian man with hepatitis C virus-related cirrhosis was admitted to our Unit in February 2010 for a diagnostic evaluation of three centimetric hypoechoic focal liver lesions detected by regular surveillance ultrasound. The subsequent computer tomography (CT) led to a diagnosis of unifocal hepatocellular carcinoma (HCC) in VI hepatic segment, defined the other two nodules in the VI and VII segment as suspected metastases, and showed a luminal narrowing with marked segmental circumferential thickening of the hepatic flexure of the colon. Colonoscopy detected an ulcerated, bleeding and stricturing lesion at the hepatic flexure, which was subsequently defined as adenocarcinoma with a moderate degree of differentiation at histological examination. Finally, ultrasound-guided liver biopsy of the three focal liver lesions confirmed the diagnosis of HCC for the nodule in the VI segment, and characterized the other two lesions as metastases from colorectal cancer. The patient underwent laparotomic right hemicolectomy with removal of thirty-nine regional lymph nodes (three of them tested positive for metastasis at histological examination), and simultaneous laparotomic radio-frequency ablation of both nodule of HCC and metastases. The option of adjuvant chemotherapy was excluded because of the post-surgical onset of ascites. Abdomen CT and positron emission tomography/CT scans performed after 1, 6 and 12 mo highlighted a complete response to treatments without any radiotracer accumulation. After 18 mo, the patient died due to progressive liver failure. Our experience emphasizes the potential coexistence of two different neoplasms in a cirrhotic liver and the complexity in the proper diagnosis and management of the two tumours.
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Cabibbo G, Maida M, Cammà C, Craxì A. Is the efficacy of sorafenib treatment in patients with hepatocellular carcinoma affected by age? Expert Rev Anticancer Ther 2013; 13:1355-61. [PMID: 24224926 DOI: 10.1586/14737140.2013.859989] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Cancer is a prevalent disease in the elderly population and hepatocellular carcinoma (HCC) is a major health problem among all tumors. Curative treatments for early-stage include liver transplantation, resection and percutaneous ablation. Transarterial chemoembolization (TACE) and sorafenib, classified as non-curative treatments, can improve survival for patients with intermediate and advanced tumors, respectively. Even if the incidence of HCC progressively increases with advanced age in all populations, reaching a peak at 70 years, few reports concerning correct management of HCC in elderly patients exist. Moreover, data from large randomized controlled trials (RCT) poorly reflect the elderly population that is often quantitatively and qualitatively underrepresented, as a result of the presence of tight enrolment criteria. The aim of this brief review is to highlight the main concerns, pitfalls and warnings regarding the management of HCC in elderly patients, with particular focus on systemic therapy with sorafenib.
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Affiliation(s)
- Giuseppe Cabibbo
- Section of Gastroenterology, Di.Bi.Mi.S., University of Palermo, Italy
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Genco C, Cabibbo G, Maida M, Brancatelli G, Galia M, Alessi N, Butera G, Genova C, Romano P, Raineri M, Giarratano A, Midiri M, Cammà C. Treatment of hepatocellular carcinoma: present and future. Expert Rev Anticancer Ther 2013; 13:469-79. [PMID: 23560841 DOI: 10.1586/era.13.21] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
Hepatocellular carcinoma is a major health problem. It is the sixth most common cancer worldwide and the third most common cause of cancer-related death. Despite the availability of several treatment opportunities, diagnosis is still made in an advanced phase, limiting application of most therapeutic choices that currently are based on the Barcelona Clinic Cancer Liver Classification and include surgical resection, orthotopic liver transplantation and ablative methods for very early and early disease, arterial chemoembolization for intermediate stages and systemic therapy with sorafenib for advanced hepatocellular carcinoma. Thanks to novel advancements in knowledge of molecular pathogenesis of this tumor, many new systemic agents and locoregional treatments are in different stages of clinical development and they represent an important promise of further improvements in patients' survival.
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Affiliation(s)
- Chiara Genco
- Section of Gastroenterology, DIBIMIS, University of Palermo, Palermo, Italy
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Cabibbo G, Maida M, Genco C, Parisi P, Peralta M, Antonucci M, Brancatelli G, Cammà C, Craxì A, Di Marco V. Natural history of untreatable hepatocellular carcinoma: A retrospective cohort study. World J Hepatol 2012; 4:256-61. [PMID: 23060970 PMCID: PMC3468702 DOI: 10.4254/wjh.v4.i9.256] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/21/2012] [Revised: 07/20/2012] [Accepted: 08/23/2012] [Indexed: 02/06/2023] Open
Abstract
AIM To investigate the clinical course of untreatable hepatocellular carcinoma (HCC) identified at any stage and to identify factors associated with mortality. METHODS From January 1999 to December 2010, 320 out of 825 consecutive patients with a diagnosis of HCC and not appropriate for curative or palliative treatments were followed and managed with supportive therapy. Cirrhosis was diagnosed by histological or clinical features and liver function was evaluated according to Child-Pugh score. The diagnosis of HCC was performed by Ultra-Sound guided biopsy or by multiphasic contrast-enhanced computed tomography or gadolinium-enhanced magnetic resonance imaging. Data were collected for each patient including all clinical, laboratory and imaging variables necessary for the outcome prediction staging systems considered. HCC staging was performed according Barcelona Clinic Liver Cancer (BCLC) and Cancer of the Liver Italian Program scores. Follow-up time was defined as the number of months from the diagnosis of HCC to death. Prognostic baseline variables were analyzed by multivariate Cox analysis to identify the independent predictors of survival. RESULTS Seventy-five per cent of patients had hepatitis C. Ascites was present in 169 patients (53%), while hepatic encephalopathy was present in 49 patients (15%). The Child-Pugh score was class A in 105 patients (33%), class B in 142 patients (44%), and class C in 73 patients (23%). One hundred patients (31%) had macroscopic vascular invasion and/or extra-hepatic spread of the tumor. A single lesion > 10 cm was observed in 34 patients (11%), while multinodular HCC was present in 189 patients (59%). Thirty nine patients (12%) were BCLC early (A) stage, 55 (17%) were BCLC intermediate (B) stage, 124 (39%) were BCLC advanced (C) stage, and 102 (32%) were end-stage BCLC (D). At the time of this analysis (July 2011), 28 (9%) patients were still alive. Six (2%) patients who were lost during follow-up were censored at the last visit. The overall median survival was 6.8 mo, and the 1-year survival was 32%. The 1-year survival according to BCLC classes was 100%, 79%, 12% and 0%, for BCLC A, B, C and D, respectively. There was a significant difference in survival between each BCLC class. The median survival of patients of BCLC stages A, B, C and D was 33, 17.4, 6.9, and 1.8 mo, respectively (P < 0.05 for comparison between stages). The median survival of Child-Pugh A, B and C classes were 9.8 mo (range 6.4-13), 6.1 (range 4.9-7.3), and 3.7 (range 1.5-6), respectively (P < 0.05 for comparison between stages). By univariate analysis, the variables significantly associated to an increased liklihood of mortality were Eastern Cooperative Oncology Group performance status (PS), presence of ascites, low level of albumin, elevated level of bilirubin, international normalized ratio (INR) and Log-[(α fetoprotein (AFP)]. At multivariate analysis, mortality was independently predicted by bad PS (P < 0.0001), high INR values (P = 0.0001) and elevated Log-(AFP) levels (P = 0.009). CONCLUSION This study confirms the heterogeneous behavior of untreated HCC. BCLC staging remains an important prognostic guide and may be important in decision-making for palliative treatment.
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Affiliation(s)
- Giuseppe Cabibbo
- Giuseppe Cabibbo, Marcello Maida, Chiara Genco, Pietro Parisi, Marco Peralta, Michela Antonucci, Giuseppe Brancatelli, Calogero Cammà, Antonio Craxì, Vito Di Marco, Section of Gastroenterology, Department of Internal Medicine and Biomedical Specialist, University of Palermo, Palermo 90127, Italy
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Scandurra G, Aiello RA, Alì M, Taibi E, Sanò MV, Todaro FM, La Rocca R, Licciardello P, Caruso M. Appropriate management of cutaneous adverse events maximizes compliance with sorafenib treatment: a single-center experience. Future Oncol 2012; 8:609-15. [DOI: 10.2217/fon.12.35] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023] Open
Abstract
Aims: This report describes a positive experience of adverse event (AE) management of a multidisciplinary clinical team and 18 patients with late-stage renal cell carcinoma and hepatocellular carcinoma attending the Day Hospital Unit of the ‘Centro Catanese di Oncologia Humanitas’ (Italy) over a 2-year period. Methods: The management strategy was based on preventive measures for reducing the development of cutaneous AEs, including pain, risk of infection and patient discomfort, while avoiding the discontinuation or the reduction of the sorafenib dosage. Results: As of July 2011, eight patients were still under treatment with sorafenib; seven patients experienced cutaneous AEs and two reported severe cutaneous AEs. Conclusion: Our treatment approach seemed to reduce the incidence and/or severity of AEs, keeping patients in treatment, which is essential for good treatment outcomes.
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Affiliation(s)
- Giuseppa Scandurra
- Day Hospital – UF Oncologia Medica, Humanitas Centro Catanese di Oncologia, via E. Dabormida 64 95126 Catania, Italy
| | - Rosa Anna Aiello
- Day Hospital – UF Oncologia Medica, Humanitas Centro Catanese di Oncologia, via E. Dabormida 64 95126 Catania, Italy
| | - Marco Alì
- Day Hospital – UF Oncologia Medica, Humanitas Centro Catanese di Oncologia, via E. Dabormida 64 95126 Catania, Italy
| | - Eleonora Taibi
- Day Hospital – UF Oncologia Medica, Humanitas Centro Catanese di Oncologia, via E. Dabormida 64 95126 Catania, Italy
| | - Maria Vita Sanò
- Day Hospital – UF Oncologia Medica, Humanitas Centro Catanese di Oncologia, via E. Dabormida 64 95126 Catania, Italy
| | - Francesco Maurizio Todaro
- Day Hospital – UF Oncologia Medica, Humanitas Centro Catanese di Oncologia, via E. Dabormida 64 95126 Catania, Italy
| | - Rosaria La Rocca
- Day Hospital – UF Oncologia Medica, Humanitas Centro Catanese di Oncologia, via E. Dabormida 64 95126 Catania, Italy
| | - Paolo Licciardello
- Day Hospital – UF Oncologia Medica, Humanitas Centro Catanese di Oncologia, via E. Dabormida 64 95126 Catania, Italy
| | - Michele Caruso
- Day Hospital – UF Oncologia Medica, Humanitas Centro Catanese di Oncologia, via E. Dabormida 64 95126 Catania, Italy
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