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Borhani A, Luu H, Mohseni A, Xu Z, Shaghaghi M, Tolosa C, Attari MMA, Madani SP, Shahbazian H, Khoshpouri P, Afyouni S, Zandieh G, Kamel IR, Kim AK. Screening for exclusion of high-risk bleeding features of esophageal varices in cirrhosis through CT and MRI. Clin Imaging 2024; 110:110168. [PMID: 38703476 DOI: 10.1016/j.clinimag.2024.110168] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2023] [Revised: 04/14/2024] [Accepted: 04/18/2024] [Indexed: 05/06/2024]
Abstract
BACKGROUND & AIM Esophageal varices (EV) screening guidelines have evolved with improved risk stratification to avoid unnecessary esophagogastroduodenoscopy (EGD) in individuals with low bleeding risks. However, uncertainties persist in the recommendations for certain patient groups, particularly those with hepatocellular carcinoma (HCC) and/or receiving non-selective beta-blockers (NSBB) without prior endoscopy. This study assessed the efficacy of imaging in ruling out EVs and their high-risk features associated with bleeding in patients with cirrhosis and with HCC. We also evaluated the impact of NSBB on the detection of these characteristics. METHODS A total of 119 patients undergoing EGD with CT and/or MRI within 90 days of the procedure were included. 87 patients had HCC. A new imaging grading system was developed utilizing the size of EVs and the extent of their protrusion into the esophagus lumen. The negative predictive value (NPV) of EVimaging(-) versus EVimaging (+) (grades 1-3) in ruling out the presence of EV and/or high-risk features by EGD was calculated. The predictive performance of imaging was determined by logistic regression. RESULTS The NPV of imaging for detecting EV and high-risk features was 81 % and 92 %, respectively. Among HCC patients, the NPV for EV and high-risk features was 80 % and 64 %, respectively. Being on NSBB didn't statistically impact the imaging detection of EV. Imaging was a better predictor of high-risk EGD findings than Child-Turcotte-Pugh scores. CONCLUSIONS Our results suggest that imaging can effectively rule out the presence of EV and high-risk features during EGD, even in patients with HCC and/or receiving NSBB.
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Affiliation(s)
- Ali Borhani
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Harry Luu
- Department of Medicine, Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Alireza Mohseni
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ziyi Xu
- Bloomberg School of Public Health, Johns Hopkins University, Baltimore, MD, USA
| | - Mohammadreza Shaghaghi
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Celestina Tolosa
- Department of Medicine, Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | | | - Seyedeh Panid Madani
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Haneyeh Shahbazian
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Pegah Khoshpouri
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Shadi Afyouni
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ghazal Zandieh
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Ihab R Kamel
- Department of Radiology and Radiological Sciences, School of Medicine, Johns Hopkins University, Baltimore, MD, USA.
| | - Amy K Kim
- Department of Medicine, Gastroenterology and Hepatology, School of Medicine, Johns Hopkins University, Baltimore, MD, USA
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Fujiwara K, Kondo T, Fujimoto K, Yumita S, Ogawa K, Ishino T, Nakagawa M, Iwanaga T, Tsuchiya S, Koroki K, Kanzaki H, Inoue M, Kobayashi K, Kiyono S, Nakamura M, Kanogawa N, Ogasawara S, Nakamoto S, Chiba T, Koizumi J, Kato J, Kato N. Clinical risk factors for portal hypertension-related complications in systemic therapy for hepatocellular carcinoma. J Gastroenterol 2024; 59:515-525. [PMID: 38583112 PMCID: PMC11128395 DOI: 10.1007/s00535-024-02097-9] [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: 08/24/2023] [Accepted: 03/07/2024] [Indexed: 04/08/2024]
Abstract
BACKGROUND During systemic therapy, the management of portal hypertension (PH)-related complications is vital. This study aimed to clarify factors associated with the incidence and exacerbation of PH-related complications, including the usefulness of contrast-enhanced computed tomography (CECT) in the management of PH-related complications during systemic therapy. METHODS A total of 669 patients who received systemic therapy as first-line treatment (443 patients for sorafenib, 131 for lenvatinib, and 90 for atezolizumab/bevacizumab [ATZ/BEV]) were enrolled in this retrospective study. Additionally, the lower esophageal intramural vessel diameters (EIV) on CECT and endoscopic findings in 358 patients were compared. RESULTS The cutoff values of the EIV diameter on CECT were 3.1 mm for small, 5.1 mm for medium, and 7.6 mm for large varices, demonstrating high concordance with the endoscopic findings. esophageal varices (EV) bleeding predictors include EIV ≥ 3.1 mm and portal vein tumor thrombosis (PVTT). In patients without EV before systemic therapy, factors associated with EV exacerbation after 3 months were EIV ≥ 1.9 mm and ATZ/BEV use. Predictors of hepatic encephalopathy (HE) include the ammonia level or portosystemic shunt diameter ≥ 6.8 mm. The incidence of HE within 2 weeks was significantly higher (18%) in patients with an ammonia level ≥ 73 μmol/L and a portosystemic shunt ≥ 6.8 mm. The exacerbating factors for ascites after 3 months were PVTT and low albumin levels. CONCLUSIONS Careful management is warranted for patients with risk factors for exacerbation of PH-related complications; moreover, the effective use of CECT is clinically important.
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Affiliation(s)
- Kisako Fujiwara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Takayuki Kondo
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan.
- Ultrasound Center, Chiba University Hospital, Chiba, Japan.
| | - Kentaro Fujimoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Sae Yumita
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Keita Ogawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Takamasa Ishino
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Miyuki Nakagawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Terunao Iwanaga
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Satoshi Tsuchiya
- Department of Radiology, Graduate School of Medicine, Chiba University, Chiba, Japan
| | - Keisuke Koroki
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Hiroaki Kanzaki
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Masanori Inoue
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Kazufumi Kobayashi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Soichiro Kiyono
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Masato Nakamura
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Naoya Kanogawa
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Sadahisa Ogasawara
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Shingo Nakamoto
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Tetsuhiro Chiba
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Jun Koizumi
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Jun Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
| | - Naoya Kato
- Department of Gastroenterology, Graduate School of Medicine, Chiba University, 1-8-1, Inohana, Chuo-ku, Chiba, 260-8670, Japan
- Ultrasound Center, Chiba University Hospital, Chiba, Japan
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De Gaetano V, Pallozzi M, Cerrito L, Santopaolo F, Stella L, Gasbarrini A, Ponziani FR. Management of Portal Hypertension in Patients with Hepatocellular Carcinoma on Systemic Treatment: Current Evidence and Future Perspectives. Cancers (Basel) 2024; 16:1388. [PMID: 38611066 PMCID: PMC11011056 DOI: 10.3390/cancers16071388] [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: 02/21/2024] [Revised: 03/27/2024] [Accepted: 03/28/2024] [Indexed: 04/14/2024] Open
Abstract
The management of CSPH in patients undergoing systemic treatment for HCC has emerged as a critical concern due to the absence of reliable diagnostic criteria and uncertainties surrounding therapeutic approaches. This review aims to underscore the primary pathophysiological aspects linking HCC and PH, while also addressing the current and emerging clinical strategies for the management of portal hypertension. A review of studies from January 2003 to June 2023 was conducted using the PubMed database and employing MeSH terms, such as "hepatocellular carcinoma", "immune checkpoint inhibitors", "systemic therapy", "portal hypertension", "variceal bleeding" and "tyrosine kinase inhibitors". Despite promising results of tyrosine kinase inhibitors in animal models for PH and fibrosis, only Sorafenib has demonstrated similar effects in human studies, whereas Lenvatinib appears to promote PH development. The impact of Atezolizumab/Bevacizumab on PH remains uncertain, with an increasing risk of bleeding related to Bevacizumab in patients with prior variceal hemorrhage. Given the absence of specific guidelines, endoscopic surveillance during treatment is advisable, and primary and secondary prophylaxis of variceal bleeding should adhere to the Baveno VII recommendations. Furthermore, in patients with advanced HCC, refinement of diagnostic criteria for CSPH and guidelines for its surveillance are warranted.
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Affiliation(s)
- Valeria De Gaetano
- Liver Unit, Centro Malattie dell’Apparato Digerente (CEMAD), Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario GemelliIstituto di Ricovero e Cura a Carattere Scientifico, IRCCS, 00168 Rome, Italy; (V.D.G.); (M.P.); (L.C.); (F.S.); (L.S.); (F.R.P.)
| | - Maria Pallozzi
- Liver Unit, Centro Malattie dell’Apparato Digerente (CEMAD), Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario GemelliIstituto di Ricovero e Cura a Carattere Scientifico, IRCCS, 00168 Rome, Italy; (V.D.G.); (M.P.); (L.C.); (F.S.); (L.S.); (F.R.P.)
| | - Lucia Cerrito
- Liver Unit, Centro Malattie dell’Apparato Digerente (CEMAD), Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario GemelliIstituto di Ricovero e Cura a Carattere Scientifico, IRCCS, 00168 Rome, Italy; (V.D.G.); (M.P.); (L.C.); (F.S.); (L.S.); (F.R.P.)
| | - Francesco Santopaolo
- Liver Unit, Centro Malattie dell’Apparato Digerente (CEMAD), Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario GemelliIstituto di Ricovero e Cura a Carattere Scientifico, IRCCS, 00168 Rome, Italy; (V.D.G.); (M.P.); (L.C.); (F.S.); (L.S.); (F.R.P.)
| | - Leonardo Stella
- Liver Unit, Centro Malattie dell’Apparato Digerente (CEMAD), Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario GemelliIstituto di Ricovero e Cura a Carattere Scientifico, IRCCS, 00168 Rome, Italy; (V.D.G.); (M.P.); (L.C.); (F.S.); (L.S.); (F.R.P.)
| | - Antonio Gasbarrini
- Liver Unit, Centro Malattie dell’Apparato Digerente (CEMAD), Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario GemelliIstituto di Ricovero e Cura a Carattere Scientifico, IRCCS, 00168 Rome, Italy; (V.D.G.); (M.P.); (L.C.); (F.S.); (L.S.); (F.R.P.)
- Dipartimento di Medicina e Chirurgia Traslazionale, Università Cattolica del Sacro Cuore, 00168 Rome, Italy
| | - Francesca Romana Ponziani
- Liver Unit, Centro Malattie dell’Apparato Digerente (CEMAD), Medicina Interna e Gastroenterologia, Fondazione Policlinico Universitario GemelliIstituto di Ricovero e Cura a Carattere Scientifico, IRCCS, 00168 Rome, Italy; (V.D.G.); (M.P.); (L.C.); (F.S.); (L.S.); (F.R.P.)
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Allaire M, Thabut D. Portal hypertension and variceal bleeding in patients with liver cancer: Evidence gaps for prevention and management. Hepatology 2024; 79:213-223. [PMID: 36631021 DOI: 10.1097/hep.0000000000000291] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2022] [Accepted: 12/19/2022] [Indexed: 01/13/2023]
Abstract
BACKGROUND AND AIMS Portal hypertension (PHT) and HCC are 2 major complications of cirrhosis that often coexist in the same patient and impact the prognosis, especially in patients with acute variceal bleeding. In this review, we aim to discuss the best strategy for PHT screening and primary prophylaxis, as well as the management of acute variceal bleeding, to improve the management of PHT in HCC patients. RESULTS Recent therapeutic advances observed in the management of HCC, notably through the advent of immunotherapy, have led to a clear improvement in the survival of patients. The prevention of complications related to underlying cirrhosis, such as PHT and acute variceal bleeding, is now part of the management of HCC patients. The Baveno VII conference recently redefined screening and prophylaxis in patients with cirrhosis. However, data regarding the applicability of these criteria in patients with HCC have been sparse. From our point of view, the Baveno criteria are not appropriate to exclude high-risk esophageal varices (EV) in HCC patients, and endoscopy should be performed except in HCC patients with a liver stiffness measurement (LSM) ≥25 kPa, who should benefit from nonselective beta-blockers (NSSBs) without performing endoscopy. We are also in favor of using NSBBs as primary prophylaxis in patients with EV regardless of the size and with gastric varices since these patients display clinically significant PHT. CONCLUSIONS Appropriate evaluation and treatment of PHT remain major issues in improving the outcomes of HCC patients. Many questions remain unanswered, opening the field to many areas of research.
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Affiliation(s)
- Manon Allaire
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France
- Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université de Paris, Team Proliferation Stress and Liver Physiopathology, Paris, France
| | - Dominique Thabut
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France
- Sorbonne Université, INSERM, Centre de recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), Paris, France
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5
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Zanuso V, Pirozzi A, Balsano R, Pressiani T, Rimassa L. Safety and Efficacy of Atezolizumab and Bevacizumab Combination as a First Line Treatment of Advanced Hepatocellular Carcinoma. J Hepatocell Carcinoma 2023; 10:1689-1708. [PMID: 37808223 PMCID: PMC10557510 DOI: 10.2147/jhc.s347932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2023] [Accepted: 09/20/2023] [Indexed: 10/10/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is one of the most common leading causes of cancer death worldwide. As most patients are diagnosed with advanced disease, systemic therapy remains the backbone of treatment. In recent years, we have witnessed the transformation of advanced HCC treatment landscapes from single-agent targeted therapies to immunotherapy combinations, with atezolizumab plus bevacizumab becoming the new first-line standard of care with an increase in overall survival, progression-free survival, and objective response rate compared to sorafenib, and a positive impact on quality of life. Although the efficacy and safety of this combination have been confirmed regardless of ethnicity, age, and etiology, only a subgroup of patients seems to benefit the most from this treatment. Currently, predictive serum and tissue biomarkers to select patients who are most likely to respond to atezolizumab plus bevacizumab are lacking. Moreover, the optimal subsequent therapy for patients who progress on first-line atezolizumab plus bevacizumab remains unknown, clinical trials are ongoing, and real-world data are needed to determine the most effective treatment sequence. Importantly, careful evaluation of bleeding risk and preservation of adequate liver function are fundamental to improve patients' prognosis, especially when subsequent treatments are administered.
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Affiliation(s)
- Valentina Zanuso
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Angelo Pirozzi
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Rita Balsano
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Tiziana Pressiani
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Medical Oncology and Hematology Unit, IRCCS Humanitas Research Hospital, Milan, Italy
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6
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Gordan JD, Keenan BP, Lim HC, Yarchoan M, Kelley RK. New Opportunities to Individualize Frontline Therapy in Advanced Stages of Hepatocellular Carcinoma. Drugs 2023; 83:1091-1109. [PMID: 37402062 DOI: 10.1007/s40265-023-01907-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/05/2023] [Indexed: 07/05/2023]
Abstract
Hepatocellular carcinoma (HCC) is a leading cause of cancer death globally and is rising in incidence. Until recently, treatment options for patients with advanced stages of HCC have been limited to antiangiogenic therapies with modest improvements in overall survival. The emerging role of immunotherapy with immune checkpoint inhibitors (ICI) in oncology has led to a rapid expansion in treatment options and improvements in outcomes for patients with advanced stages of HCC. Recent clinical trials have shown meaningful survival improvement in patients treated with the combination of bevacizumab and atezolizumab, as well as with the combination of tremelimumab with durvalumab, resulting in regulatory approvals of these regimens as frontline therapy. Beyond improvements in overall survival, ICI-based combination regimens achieve higher rates of durable treatment response than multikinase inhibitors and have favorable side effect profiles. With the emergence of doublet anti-angiogenic and immune checkpoint inhibitor (ICI) and dual ICI combinations, individualized therapy is now possible for patients based on co-morbidity profiles and other factors. These more potent systemic therapies are also being tested in earlier stages of disease and in combination with loco-regional therapies such as trans-arterial chemoembolization and stereotactic body radiotherapy. We summarize these advances and emerging therapeutic combinations currently in clinical trials.
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Affiliation(s)
- John D Gordan
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, UC San Francisco, San Francisco, CA, USA.
- Quantitative Biosciences Institute, UC San Francisco, San Francisco, CA, USA.
| | - Bridget P Keenan
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, UC San Francisco, San Francisco, CA, USA
- Cancer Immunotherapy Program, Helen Diller Family Comprehensive Cancer Center, UC San Francisco, San Francisco, CA, USA
| | - Huat Chye Lim
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, UC San Francisco, San Francisco, CA, USA
- Quantitative Biosciences Institute, UC San Francisco, San Francisco, CA, USA
| | - Mark Yarchoan
- Department of Oncology, Sidney Kimmel Comprehensive Cancer Center, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - R Katie Kelley
- Division of Hematology/Oncology, Helen Diller Family Comprehensive Cancer Center, UC San Francisco, San Francisco, CA, USA
- Cancer Immunotherapy Program, Helen Diller Family Comprehensive Cancer Center, UC San Francisco, San Francisco, CA, USA
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7
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Piscaglia F, La Mura V, Ravaioli F. A pragmatic strategy for the screening and treatment of portal hypertension in patients needing systemic treatment for advanced hepatocellular carcinoma. Dig Liver Dis 2023; 55:997-1000. [PMID: 37321913 DOI: 10.1016/j.dld.2023.05.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/11/2023] [Revised: 05/12/2023] [Accepted: 05/17/2023] [Indexed: 06/17/2023]
Affiliation(s)
- Fabio Piscaglia
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Italy; Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Italy.
| | - Vincenzo La Mura
- Foundation I.R.C.C.S. Ca' Granda, Ospedale Maggiore Policlinico, Angelo Bianchi Bonomi and Thrombosis center, Milan, Italy; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Federico Ravaioli
- Department of Medical and Surgical Sciences (DIMEC), University of Bologna, Italy
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Yano Y, Yamamoto A, Mimura T, Kushida S, Hirohata S, Yoon S, Hirano H, Kim SK, Hatazawa Y, Momose K, Hayashi H, Kado T, Nishi K, Tanaka H, Matsuura T, Yoshida R, Asaji N, Yasutomi E, Shiomi Y, Minami A, Komatsu S, Fukumoto T, Ueda Y, Kodama Y. Factors associated with the response to atezolizumab/bevacizumab combination therapy for hepatocellular carcinoma. JGH Open 2023; 7:476-481. [PMID: 37496817 PMCID: PMC10366485 DOI: 10.1002/jgh3.12932] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2023] [Revised: 04/26/2023] [Accepted: 06/05/2023] [Indexed: 07/28/2023]
Abstract
Background and Aim The purpose of this study was to analyze factors associated with the overall survival (OS) of atezolizumab/bevacizumab combination therapy for advanced hepatocellular carcinoma (aHCC). We also assessed the OS of patients with ineffective therapy and those who discontinued treatment owing to adverse events (AEs). Methods This retrospective multicenter study involved 139 patients with aHCC who received atezolizumab/bevacizumab combination therapy between November 2020 and September 2022. Results The median duration of treatment was 136.5 days, and the median observation period was 316 days. The overall response rate was 40%, and the disease control rate was 78% according to mRECIST criteria. Grade ≥2 AEs occurred in 63 patients (43%) and led to treatment discontinuation in 16 patients. Multivariate analysis revealed that treatment response and occurrence of grade ≥2 AEs after therapy, as well as low level of albumin-bilirubin (ALBI) grade and low level of des-gamma carboxy prothrombin (DCP) before therapy, were extracted as factors that contributed to OS. Log-rank tests with the Kaplan-Meier method showed significant differences in OS among these factors. The OS of patients who discontinued owing to AEs was significantly shorter than that of other patients. Conclusion Not only factors before therapy but also treatment response and the appearance of AEs are involved in OS for atezolizumab/bevacizumab combination therapy. Although the development of AEs also contributed to OS, appropriate management of AEs is important to avoid discontinuing treatment with this combination.
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Affiliation(s)
- Yoshihiko Yano
- Division of GastroenterologyKobe University Graduate School of MedicineKobeJapan
| | - Atsushi Yamamoto
- Division of GastroenterologyKobe University Graduate School of MedicineKobeJapan
| | | | | | | | - Seitetsu Yoon
- Hyogo Prefectural Kakogawa Medical CenterKakogawaJapan
| | | | | | | | | | | | | | | | | | - Takanori Matsuura
- Division of GastroenterologyKobe University Graduate School of MedicineKobeJapan
| | - Ryutaro Yoshida
- Division of GastroenterologyKobe University Graduate School of MedicineKobeJapan
| | - Naoki Asaji
- Division of GastroenterologyKobe University Graduate School of MedicineKobeJapan
| | - Eiichiro Yasutomi
- Division of GastroenterologyKobe University Graduate School of MedicineKobeJapan
| | - Yuuki Shiomi
- Division of GastroenterologyKobe University Graduate School of MedicineKobeJapan
| | - Akihiro Minami
- Division of GastroenterologyKobe University Graduate School of MedicineKobeJapan
| | - Shohei Komatsu
- Division of Hepato‐Biliary‐Pancreatic SurgeryKobe University Graduate School of MedicineKobeJapan
| | - Takumi Fukumoto
- Division of Hepato‐Biliary‐Pancreatic SurgeryKobe University Graduate School of MedicineKobeJapan
| | - Yoshihide Ueda
- Division of GastroenterologyKobe University Graduate School of MedicineKobeJapan
| | - Yuzo Kodama
- Division of GastroenterologyKobe University Graduate School of MedicineKobeJapan
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9
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Thabut D, Kudo M. Treatment of portal hypertension in patients with HCC in the era of Baveno VII. J Hepatol 2023; 78:658-662. [PMID: 36460163 DOI: 10.1016/j.jhep.2022.11.019] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Revised: 11/10/2022] [Accepted: 11/15/2022] [Indexed: 12/03/2022]
Abstract
Portal hypertension (PHT) and hepatocellular carcinoma (HCC) often coexist, and their association impairs the prognosis of patients with cirrhosis. The interplay between these two conditions is of major therapeutic significance, both from the perspective of offering adequate treatment for HCC and for preventing or managing the complications of PHT. Recommendations on the management of PHT were heavily revised at the last Baveno VII conference, redefining screening and extending the indications for prophylaxis. PHT can preclude locoregional therapies, and TIPS placement can be discussed in patients with HCC. New systemic therapies for HCC can influence the level of PHT and favour bleeding. Complications of PHT should be prevented and treated adequately in all patients, especially those presenting with advanced HCC. Specific aspects of the management of both conditions will be discussed in the present expert opinion, which considers very recent data in the HCC field.
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Affiliation(s)
- Dominique Thabut
- Sorbonne Université, AP-HP.Sorbonne Université, Hôpital de la Pitié-Salpêtrière, Service d'hépato-gastroentérologie, Unité de Soins Intensifs d'hépatologie, Paris, France; Brain Liver Pitié-Salpêtrière (BLIPS) Study Group, INSERM UMR_S 938, Centre de Recherche Saint-Antoine, Maladies Métaboliques, Biliaires et Fibro-inflammatoire du Foie, Institute of Cardiometabolism and Nutrition (ICAN), Paris, France.
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka-Sayama Osaka, Japan
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Allaire M, Manfredi S, Lerosey L, Ganne-Carrié N, Thabut D. Screening and management of portal hypertension in advanced hepatocellular carcinoma: A French practice survey. Clin Res Hepatol Gastroenterol 2023; 47:102059. [PMID: 36455860 DOI: 10.1016/j.clinre.2022.102059] [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] [Received: 08/17/2022] [Revised: 11/27/2022] [Accepted: 11/27/2022] [Indexed: 11/29/2022]
Abstract
BACKGROUND Portal hypertension (PHT) and hepatocellular carcinoma (HCC) are two major complications of cirrhosis that are closely linked and impact patients prognosis, particularly acute variceal bleeding (AVB). Therefore, PHT screening and AVB prophylaxis are major issues to improve the outcome of the patients, but practices may vary among physicians. METHODS We submitted hepatologists, gastroenterologists and digestive oncologists to a questionnaire of 70 items about PHT screening and management to evaluate their practice. RESULTS 95 out of 847 physicians responded to the questionnaire (hepatologists 63.2%, Oncologists/gastroenterologists 36.8%). In patients with advanced HCC, PHT was assessed by endoscopy in 80.0% of cases. HCC progression motivated a new for 12.6% of respondents while no intent to control was declared for 49.5% of them. AVB primary prophylaxis for large size esophageal varices (EV) was impacted by the presence of red marks at endoscopy. In the absence of a red mark, prophylaxis with non-selective betablockers (NSSB) was proposed in 70.5% of cases for patients undergoing TKI and 63.2% undergoing Atezolizumab/Bevacizumab, whereas the combination of endoscopic band ligation (EBL) and NSBB was preferred in 41.1% of patients undergoing TKI versus 53.7% undergoing Atezolizumab/Bevacizumab in case of a red mark. The initiation of a systemic treatment was lower in patients with an history of AVB <6 months, which was even more significant for Atezolizumab/Bevacizumab combination (51.6%) compared to tyrosine kinase inhibitors (72.6%) (p<0.001). Atezolizumab/Bevacizumab was initiated in 43% of participants in case of AVB <6 months versus 95% if >6 months (p<0.001). In case of AVB on Atezolizumab/Bevacizumab, 43.2% continued the treatment after regression of EV, 24.2% continued Atezolizumab alone and 14.7% permanently stopped the treatment. CONCLUSION Strategies for screening and management of PHT in advanced HCC remain very heterogeneous among physicians, suggesting the need to improve PHT knowledge and dedicated studies for advanced HCC.
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Affiliation(s)
- Manon Allaire
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France.
| | | | - Léa Lerosey
- Centre Hospitalier Universitaire Dijon Bourgogne, Dijon, France
| | - Nathalie Ganne-Carrié
- AP-HP Sorbonne Paris Nord, Hôpitaux Universitaire Paris Seine Saint-Denis, Service d'Hépatologie, Bobigny, France; INSERM UMR 1138, Centre de recherche des Cordeliers, 75006, Paris, France
| | - Dominique Thabut
- AP-HP Sorbonne Université, Hôpital Universitaire Pitié-Salpêtrière, Service d'Hépato-gastroentérologie, Paris, France; Sorbonne Université, INSERM, Centre de recherche Saint-Antoine (CRSA), Institute of Cardiometabolism and Nutrition (ICAN), F-75012, Paris, France
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