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Kneiseler G, Dechêne A. [Gastrointestinal bleeding in old age]. Z Gerontol Geriatr 2024; 57:59-70. [PMID: 38108897 DOI: 10.1007/s00391-023-02258-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2023] [Accepted: 07/25/2023] [Indexed: 12/19/2023]
Abstract
Gastrointestinal bleeding is a frequent symptom, with increasing age as a risk factor. Upper, middle and lower gastrointestinal bleeding are differentiated depending on the location, whereby only upper and lower gastrointestinal bleeding are elucidated in this article. The symptomatology varies depending on the localization of the bleeding. German and international clinical guidelines currently exist for the preclinical and clinical management of gastrointestinal bleeding. The main focus of the article is on pre-endoscopic management of upper gastrointestinal nonvariceal and variceal bleeding, including the risk stratification, transfusion and coagulation management as well as the initial pharmacological treatment. In addition, current developments in endoscopic and interventional treatment of gastrointestinal bleeding are highlighted.
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Affiliation(s)
- Guntje Kneiseler
- Medizinische Klinik 6 (Schwerpunkte Gastroenterologie, Hepatologie, Endokrinologie und Ernährungsmedizin) am Klinikum Nürnberg, Universitätsklinik der Paracelsus Medizinischen Privatuniversität Nürnberg, Prof.-Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland
| | - Alexander Dechêne
- Medizinische Klinik 6 (Schwerpunkte Gastroenterologie, Hepatologie, Endokrinologie und Ernährungsmedizin) am Klinikum Nürnberg, Universitätsklinik der Paracelsus Medizinischen Privatuniversität Nürnberg, Prof.-Ernst-Nathan-Str. 1, 90419, Nürnberg, Deutschland.
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Jahn M, Özçürümez MK, Dolff S, Rohn H, Heider D, Dechêne A, Canbay A, Rath PM, Katsounas A. A Multipathogen Bile Sample-based PCR Assay Can Guide Empirical Antimicrobial Strategies in Cholestatic Liver Diseases. J Clin Transl Hepatol 2022; 10:788-795. [PMID: 36304501 PMCID: PMC9547272 DOI: 10.14218/jcth.2021.00337] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/14/2021] [Revised: 10/19/2021] [Accepted: 01/29/2022] [Indexed: 12/04/2022] Open
Abstract
BACKGROUND AND OBJECTIVES Polymerase chain reaction (PCR) techniques provide rapid detection of pathogens. This pilot study evaluated the diagnostic utility and clinical impact of multiplex real-time PCR (mRT-PCR, SeptiFast) vs. conventional microbial culture (CMC) in bile samples of patients with chronic cholestatic liver diseases (cCLDs), endoscopic retrograde cholangio-pancreatography (ERCP), and peri-interventional-antimicrobial-prophylaxis (pAP). METHODS We prospectively collected bile samples from 26 patients for microbiological analysis by CMC and mRT-PCR. Concordance of the results of both methods was determined by Krippendorff's alpha (α) for inter-rater reliability and the Jaccard index of similarity. RESULTS mRT-PCRbile and CMCbile results were concordant for only Candida albicans (α=0.8406; Jaccard index=0.8181). mRT-PCRbile detected pathogens in 8/8 cases (100%), CMCbile in 7/8 (87.5%), and CMCblood in 5/8 (62.5%) with clinical signs of infection. mRT-PCRbile, CMCbile, and CMCblood had identical detection results in 3/8 (37.5%) with clinical signs of infection (two Klebsiella spp. and one Enterococcus faecium). The total pathogen count was significantly higher with mRT-PCRbile than with CMCbile (62 vs. 31; χ2=30.031, p<0.001). However, pathogens detected by mRT-PCRbile were more often susceptible to pAP according to the patient infection/colonization history (PI/CH) and surveillance data for antibiotic resistance in our clinic (DARC). Pathogens identified by mRT-PCRbile and resistant to pAP by PI/CH and DARC were likely to be clinically relevant. CONCLUSIONS mRT-PCR in conjunction with CMCs for bile analysis increased diagnostic sensitivity and may benefit infection management in patients with cholestatic diseases. Implementation of mRT-PCR in a bile sample-based diagnostic routine can support more rapid and targeted use of antimicrobial agents in cCLD-patients undergoing ERCP and reduce the rate/length of unnecessary administration of broad-spectrum antibiotics.
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Affiliation(s)
- Michael Jahn
- Department of Nephrology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Correspondence to: Michael Jahn, Department of Nephrology, University Hospital Essen, Hufelandstrasse 55, Essen 45122, Germany. Tel: +49-201-723-83840, Fax: +49-201-723-5500, E-mail:
| | - Mustafa K Özçürümez
- Department of Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Sebastian Dolff
- Department of Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Hana Rohn
- Department of Infectious Diseases, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Dominik Heider
- Department of Mathematics and Computer Science, University of Marburg, Marburg, Germany
| | - Alexander Dechêne
- Department for Internal Medicine, Nuremberg Hospital North, Paracelsus Private Medical University Nuremberg, Nuremberg, Germany
| | - Ali Canbay
- Department of Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
| | - Peter M. Rath
- Institute of Medical Microbiology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Antonios Katsounas
- Department of Medicine, Universitätsklinikum Knappschaftskrankenhaus Bochum, Ruhr-University Bochum, Bochum, Germany
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Affiliation(s)
- Martin Götz
- Medizinische Klinik IV - Gastroenterologie/Onkologie, Klinikum Sindelfingen-Böblingen, Böblingen, Deutschland
| | - Erwin Biecker
- Abteilung Innere Medizin mit Schwerpunkt Gastroenterologie, Zollernalb Klinikum Balingen, Balingen, Deutschland
| | - Alexander Dechêne
- Medizinische Klinik 6 mit Schwerpunkt Gastroenterologie, Klinikum Nord, Nürnberg, Deutschland
| | - Dieter Schilling
- Medizinische Klinik II mit Schwerpunkt Gastroenterologie, Diakonissenkrankenhaus Mannheim, Mannheim, Deutschland
| | - Alexander Zipprich
- Klinik für Innere Medizin IV Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Jena, Jena, Deutschland
| | - Jonel Trebicka
- Medizinische Klinik B für Gastroenterologie und Hepatologie, Universitätsklinikum Münster, Münster, Deutschland
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Köbler P, Krauss-Köstler EK, Stein B, Ficker JH, Wilhelm M, Dechêne A, Waller C. Specialized Biopsychosocial Care in Inpatient Somatic Medicine Units-A Pilot Study. Front Public Health 2022; 10:844874. [PMID: 35493384 PMCID: PMC9039260 DOI: 10.3389/fpubh.2022.844874] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2021] [Accepted: 03/21/2022] [Indexed: 11/13/2022] Open
Abstract
Introduction Specialized biopsychosocial care concepts are necessary to overcome the dualism between physical and psychosocial treatment in acute care hospitals. For patients with complex and chronic comorbid physical and mental health problems, neither standardized psychiatric/psychosomatic nor somatic care units alone are appropriate to their needs. The “Nuremberg Integrated Psychosomatic Acute Unit” (NIPA) has been developed to integrate treatment of both, psychosocial and physical impairments, in an acute somatic care setting. Method NIPA has been established in inpatient internal medical wards for respiratory medicine, oncology and gastroenterology. One to two patients per ward are regularly enrolled in the NIPA treatment while remaining in the same inpatient bed after completion of the somatic care. In a naturalistic study design, we evaluated treatment effects by assessment of symptom load at admission and at discharge using the Patient Health Questionnaire (PHQ) and the Generalized Anxiety Disorder Scale-7 (GAD-7). Furthermore, we assessed the severity of morbidity using diagnosis data during treatment. At discharge, we measured satisfaction with treatment through the Patient Satisfaction Questionnaire (ZUF-8). Results Data from 41 NIPA patients were analyzed (18–87 years, 76% female). Seventy-eight percent suffered from at least moderate depression and 49% from anxiety disorders. Other diagnoses were somatoform pain disorder, somatoform autonomic dysfunction, eating disorder and posttraumatic stress disorder. Hypertension, chronic lung diseases and musculoskeletal disorders as well as chronic oncological and cardiac diseases were the most common somatic comorbidities. Treatment resulted in a significant reduction of depressive mood (admission: M = 10.9, SD = 6.1, discharge: M = 7.6, SD = 5.3, d = 0.58, p = 0.001), anxiety (admission: M = 10.6, SD = 4.9, discharge: M = 7.3, SD = 4.1, d = 0.65, p< 0.001) and stress (admission: M = 6.0, SD = 3.6, discharge: M = 4.1, SD = 2.5, d = 0.70, p< 0.001). Somatic symptom burden was reduced by NIPA treatment (admission: M = 10.9, SD = 5.8, discharge: M = 9.6, SD = 5.5, d = 0.30), albeit not statistically significant (p = 0.073) ZUF-8 revealed that 89% reported large or full satisfaction and 11% partial dissatisfaction with treatment. Discussion NIPA acute care is bridging the gap for patients in need of psychosocial treatment with complex somatic comorbidity. Further long-term evaluation will show whether psychosocial NIPA care is able to reduce the course of physical illness and hospital costs by preventing hospitalization and short-term inpatient re-admissions.
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Affiliation(s)
- Paul Köbler
- Department of Psychosomatic Medicine and Psychotherapy, Paracelsus Medical Private University, Nuremberg General Hospital, Nuremberg, Germany
| | - Eva K Krauss-Köstler
- Department of Psychosomatic Medicine and Psychotherapy, Paracelsus Medical Private University, Nuremberg General Hospital, Nuremberg, Germany
| | - Barbara Stein
- Department of Psychosomatic Medicine and Psychotherapy, Paracelsus Medical Private University, Nuremberg General Hospital, Nuremberg, Germany
| | - Joachim H Ficker
- Department of Internal Medicine 3, Respiratory Medicine, Paracelsus Medical Private University, Nuremberg General Hospital, Nuremberg, Germany
| | - Martin Wilhelm
- Department of Internal Medicine 5, Oncology/Hematology, Paracelsus Medical Private University, Nuremberg General Hospital, Nuremberg, Germany
| | - Alexander Dechêne
- Department of Internal Medicine 6, Gastroenterology, Paracelsus Medical Private University, Nuremberg General Hospital, Nuremberg, Germany
| | - Christiane Waller
- Department of Psychosomatic Medicine and Psychotherapy, Paracelsus Medical Private University, Nuremberg General Hospital, Nuremberg, Germany
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Ben Khaled N, Seidensticker M, Ricke J, Mayerle J, Oehrle B, Rössler D, Teupser D, Ehmer U, Bitzer M, Waldschmidt D, Fuchs M, Reuken PA, Lange CM, Wege H, Kandulski A, Dechêne A, Venerito M, Berres ML, Luedde T, Kubisch I, Reiter FP, De Toni EN. Atezolizumab and bevacizumab with transarterial chemoembolization in hepatocellular carcinoma: the DEMAND trial protocol. Future Oncol 2022; 18:1423-1435. [PMID: 35081747 DOI: 10.2217/fon-2021-1261] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
The combination of the anti-PD-L1 antibody atezolizumab and the anti-VEGF bevacizumab is the first approved immunotherapeutic regimen for first-line therapy in patients with unresectable hepatocellular carcinoma (HCC), currently approved in more than 80 countries. The efficacy and tolerability of this regimen suggest that the use of atezolizumab + bevacizumab could be extended to the treatment of patients with intermediate-stage HCC in combination with transarterial chemoembolization (TACE). The authors describe the rationale and design of the DEMAND study. This investigator-initiated, multicenter, randomized phase II study is the first trial to evaluate the safety and efficacy of atezolizumab + bevacizumab prior to or in combination with TACE in patients with intermediate-stage HCC. The primary end point is the 24-month survival rate; secondary end points include objective response rate, progression-free survival, safety and quality of life. Clinical Trial Registration: NCT04224636 (ClinicalTrials.gov).
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Affiliation(s)
- Najib Ben Khaled
- Department of Medicine II, University Hospital, LMU Munich, Munich, 81377, Germany
| | - Max Seidensticker
- Department of Radiology, University Hospital, LMU Munich, Munich, 81377, Germany
| | - Jens Ricke
- Department of Radiology, University Hospital, LMU Munich, Munich, 81377, Germany
| | - Julia Mayerle
- Department of Medicine II, University Hospital, LMU Munich, Munich, 81377, Germany
| | - Bettina Oehrle
- Department of Medicine II, University Hospital, LMU Munich, Munich, 81377, Germany
| | - Daniel Rössler
- Department of Medicine II, University Hospital, LMU Munich, Munich, 81377, Germany
| | - Daniel Teupser
- Institute of Laboratory Medicine, University Hospital, LMU Munich, Munich, 81377, Germany
| | - Ursula Ehmer
- Internal Medicine II, Klinikum rechts der Isar, TU München, Munich, 81675, Germany
| | - Michael Bitzer
- Department for Internal Medicine I & Center for Personalized Medicine, Eberhard-Karls University, Tübingen, 72016, Germany
| | - Dirk Waldschmidt
- Department of Gastroenterology, University Hospital of Cologne, Cologne, 50937, Germany
| | - Martin Fuchs
- Department of Gastroenterology, Hepatology & GI-Oncology, Munich Hospital Bogenhausen, Munich, 81925, Germany
| | - Philipp A Reuken
- Department of Internal Medicine IV, Jena University Hospital, Jena, 07743, Germany
| | - Christian M Lange
- Department of Medicine II, University Hospital, LMU Munich, Munich, 81377, Germany
- Department of Gastroenterology & Hepatology, University Hospital Essen, Essen, 45147, Germany
| | - Henning Wege
- Cancer Center Esslingen, Medical Center Esslingen, Esslingen, 73730, Germany
| | - Arne Kandulski
- Department of Gastroenterology, University Hospital Regensburg, Regensburg, 93053, Germany
| | - Alexander Dechêne
- Department of Gastroenterology, Hepatology & Endocrinology, General Hospital Nuremberg, Nuremberg, 90419, Germany
| | - Marino Venerito
- Department of Gastroenterology, Hepatology & Infectious Diseases, Otto-von-Guericke University Hospital, Magdeburg, 39120, Germany
| | - Marie-Luise Berres
- Medical Department III, University Hospital of Aachen, Aachen, 52074, Germany
| | - Tom Luedde
- Clinic for Gastroenterology, Hepatology & Infectious Diseases, University Hospital of Düsseldorf, Düsseldorf, 40225, Germany
| | - Ilja Kubisch
- Department of Internal Medicine II, Gastroenterology, Hepatology, Endocrinology, Metabolic Disorders, Oncology, Klinikum Chemnitz gGmbH, Chemnitz, 09116, Germany
| | - Florian P Reiter
- Division of Hepatology, Department of Medicine II, University Hospital Würzburg, Würzburg, 97080, Germany
| | - Enrico N De Toni
- Department of Medicine II, University Hospital, LMU Munich, Munich, 81377, Germany
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Buechter M, Katsounas A, Saner F, Gerken G, Canbay A, Dechêne A. ERCP in critically ill patients is safe and does not increase mortality. Medicine (Baltimore) 2022; 101:e28606. [PMID: 35119004 PMCID: PMC8812702 DOI: 10.1097/md.0000000000028606] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/13/2021] [Revised: 12/14/2021] [Accepted: 12/24/2021] [Indexed: 01/04/2023] Open
Abstract
ABSTRACT Endoscopic retrograde cholangiopancreatography (ERCP) is the gold standard for minimally-invasive treatment of biliary or pancreatic tract disease. When treating patients on intensive care units (ICU) with ERCP, interventionalists are faced with considerably higher morbidity compared to patients in ambulatory settings. However, data on complications and outcome of critical ill patients undergoing emergency ERCP are limited.A retrospective analysis of 102 patients treated on ICUs undergoing 121 ERCP procedures at the University Hospital of Essen, Germany between 2002 and 2016 was performed. Indications, interventional success, outcome including survival and procedure-related complications were analyzed. Patients' condition pre-ERCP was categorized by using the "Simplified Acute Physiology Score" (SAPS 3).66/102 patients (64.7%) were referred to ERCP from surgical ICU, 36/102 (35.3%) from nonsurgical ICU. The majority of patients were male (63.7%), the mean age was 54.1 ± 14.9 [21-88] years. Indications for ERCP were biliary complications after liver transplantation (n = 34, 33.3%), biliary leakage after hepatobiliary surgery (n = 32, 31.4%), and cholangitis/biliary sepsis (n = 36; 35.3%), respectively. 117/121 (96.7%) ERCPs were successful, 1 patient (1.0%) died during ERCP. Post-ERCP pancreatitis occurred in 11.8% of interventions. The median simplified acute physiology score 3 was 65 points, predicting a risk-adjusted estimated mortality of 48.8%, corresponding to an observed mortality of 52.2% (P = n.s.).ERCP is safe in critically ill patients on ICU, it does not increase overall mortality rate and has a relatively low rate of procedure-associated complications.
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Affiliation(s)
- Matthias Buechter
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Germany
- St. Nikolaus-Stiftshospital, Andernach, Germany
| | - Antonios Katsounas
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Germany
- Department of Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Germany
| | - Fuat Saner
- Department of General, Visceral, and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Germany
- Department of Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, Germany
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Germany
- Department of Gastroenterology, Hepatology and Endocrinology, General Hospital Nuremberg, Germany
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Trojan J, Hoffmeister A, Neu B, Kasper S, Dechêne A, Jürgensen C, Schirra J, Jakobs R, Palmer D, Selbo PK, Olivecrona H, Finnesand L, Høgset A, Walday P, Sturgess R. OUP accepted manuscript. Oncologist 2022; 27:430-e433. [PMID: 35675633 PMCID: PMC9177099 DOI: 10.1093/oncolo/oyab074] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 11/30/2021] [Indexed: 11/19/2022] Open
Abstract
Background Photochemical internalization (PCI) is a novel technology for light-induced enhancement of the local therapeutic effect of cancer drugs, utilizing a specially designed photosensitizing molecule (fimaporfin). The photosensitizing molecules are trapped in endosomes along with macromolecules or drugs. Photoactivation of fimaporfin disrupts the endosomal membranes so that drug molecules are released from endosomes inside cells and can reach their therapeutic target in the cell cytosol or nucleus. Compared with photodynamic therapy, the main cytotoxic effect with PCI is disruption of the endosomal membrane resulting in delivery of chemotherapy drug, and not to the photochemical reactions per se. In this study we investigated the effect of PCI with gemcitabine in patients with inoperable perihilar cholangiocarcinoma (CCA). Methods The in vitro cytotoxic effect of PCI with gemcitabine was studied on two CCA-derived cell lines. In a fimaporfin dose-escalation phase I clinical study, we administered PCI with gemcitabine in patients with perihilar CCA (n = 16) to establish a safe and tolerable fimaporfin dose and to get early signals of efficacy. The patients enrolled in the study had tumors in which the whole length of the tumor could be illuminated from the inside of the bile duct, using an optical fiber inserted via an endoscope (Fig. 1). Fimaporfin was administered intravenously at day 0; gemcitabine (i.v.) and intraluminal biliary endoscopic laser light application on day 4; followed by standard gemcitabine/cisplatin chemotherapy. Results Preclinical experiments showed that PCI enhanced the effect of gemcitabine. In patients with CCA, PCI with gemcitabine was well tolerated with no dose-limiting toxicities, and no unexpected safety signals. Disease control was achieved in 10 of 11 evaluable patients, with a clearly superior effect in the two highest dose groups. The objective response rate (ORR) was 42%, including two complete responses, while ORR at the highest dose was 60%. Progression-free survival at 6 months was 75%, and median overall survival (mOS) was 15.4 months, with 22.8 months at the highest fimaporfin dose. Conclusion Photochemical internalization with gemcitabine was found to be safe and resulted in encouraging response and survival rates in patients with unresectable perihilar CCA.
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Affiliation(s)
- Jörg Trojan
- Corresponding author: Jörg Trojan, MD, University Hospital and Cancer Center Medical Department 1, Goethe University, Theodor-Stern-Kai 7, Frankfurt 60590, Germany. Tel: +49 69 6301 7860;
| | - Albrecht Hoffmeister
- Department of Medicine (Gastroenterology), University of Leipzig, Leipzig, Germany
| | - Bruno Neu
- Technical University, Munich, Germany (now at Krankenhaus Lanshut-Achdorf)
| | - Stefan Kasper
- Department of Medical Oncology, West German Cancer, University Hospital Essen, Essen, Germany
| | - Alexander Dechêne
- Department of Gastroenterology, Hepatology and Endocrinology, Klinikum Nuremberg, Paracelsus Medical University, Nuremburg, Germany
| | | | - Jörg Schirra
- Klinikum der Ludwig-Maximilians-Universität, Munich, Germany
| | - Ralf Jakobs
- Klinikum Ludwigshafen, Ludwigshafen, Germany
| | - Dan Palmer
- University Hospital Aintree, Liverpool, UK
| | - Pål k. Selbo
- Oslo University Hospital--The Norwegian Radium Hospital, Oslo, Norway
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Rosery V, Reis H, Savvatakis K, Kowall B, Stuschke M, Paul A, Dechêne A, Yang J, Zhao B, Borgers A, Kasper S, Schuler M, Cheung PF, Siveke JT. Antitumor immune response is associated with favorable survival in GEP-NEN G3. Endocr Relat Cancer 2021; 28:683-693. [PMID: 34472429 DOI: 10.1530/erc-21-0223] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/09/2021] [Accepted: 08/06/2021] [Indexed: 11/08/2022]
Abstract
The tumor immune microenvironment (TME) represents a key determinant for responses to cancer treatment. However, the immune phenotype of highly proliferative gastroenteropancreatic neuroendocrine neoplasms (GEP-NEN) is still largely elusive. In this retrospective study, we characterized the TME of high-grade (G3, Ki-67 > 20%) GEP-NEN. We analyzed formalin-fixed paraffin-embedded samples from 37 patients with GEP-NEN G3 by immunohistochemistry and multiplex immunofluorescence to address the abundance and spatial interaction of relevant immune subsets. We focused on the expression of immune checkpoint molecules PD-1 and PD-L1, the cytotoxic T-cell marker CD8, and the tumor-associated macrophage marker CD206. Findings were correlated with overall survival (OS) from the date of a cancer diagnosis. Patients with PD-L1-positive tumors (CPS ≥ 1) and intense PD-1+CD8+ immune cell infiltration showed the most favorable median OS. Multiplex immunofluorescence staining of ten representative tissue samples illustrated intratumoral heterogeneity of PD-L1 expression. Dense PD-1+CD8+ immune cell infiltrates were observed in PD-L1-positive tumor regions but not in PD-L1-negative regions. Proximity analysis revealed a spatial interaction between PD-1+CD8+ cells and PD-L1-positive cells. Our data suggest a pre-existing antitumor immune response in the TME in a subgroup of GEP-NEN G3. This supports a targeted clinical exploration of immunotherapeutic approaches.
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Affiliation(s)
- Vivian Rosery
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Henning Reis
- Institute of Pathology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Konstantinos Savvatakis
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK), Partner site University Hospital Essen, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Bernd Kowall
- Center of Clinical Epidemiology, Institute for Medical Informatics, Biometry and Epidemiology, Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - Martin Stuschke
- Department of Radiotherapy, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner site University Hospital Essen, Essen, Germany
| | - Andreas Paul
- German Cancer Consortium (DKTK), Partner site University Hospital Essen, Essen, Germany
- General, Visceral and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Department of Internal Medicine 6, Paracelsus Medical University, Nürnberg, Germany
| | - JiaJin Yang
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK), Partner site University Hospital Essen, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Ben Zhao
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK), Partner site University Hospital Essen, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Arianna Borgers
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK), Partner site University Hospital Essen, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Stefan Kasper
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner site University Hospital Essen, Essen, Germany
| | - Martin Schuler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner site University Hospital Essen, Essen, Germany
| | - Phyllis F Cheung
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK), Partner site University Hospital Essen, and German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Jens T Siveke
- Bridge Institute of Experimental Tumor Therapy, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
- Division of Solid Tumor Translational Oncology, German Cancer Consortium (DKTK), Partner site University Hospital Essen, and German Cancer Research Center (DKFZ), Heidelberg, Germany
- German Cancer Consortium (DKTK), Partner site University Hospital Essen, Essen, Germany
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9
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Abstract
Background Cholangiocarcinomas are relatively rare tumors most frequently arising from the epithelium of the hilar bile ducts. The diagnosis is often made in advanced (symptomatic) stages, which accounts for the infavorable prognosis with a 5-year survival of less than 10%. Identification of perihilar cholangiocarcinoma (pCCA) is often challenging because there is no single method offering sufficient diagnostic accuracy. Summary Most tumors arise in patients without specific risk factors. Clinical symptoms of pCCA are nonspecific and reliable biomarkers are lacking, with carbohydrate antigen 19-9 being the most commonly used tumor marker (but with a low accuracy). Cross-sectional imaging (CT and MRI) is used to identify and map hilar strictures and determine resectability by showing vascular involvement. Endoscopic ultrasound offers additional information on locoregional tumor spread and lymph node involvement. Endoscopic retrograde cholangiography in combination with cholangioscopy gives direct access to and imaging of hilar strictures but it does not always distinguish between pCCA and benign hilar strictures. Tissue acquisition for histological diagnosis is challenging, with frequent sampling errors regardless of the method of biopsy procurement because of the cellular paucity of tumor tissue. Key Messages In suspected perihilar malignancy, a mosaic of clinical data has to be taken into account. Histological evaluation of (endoscopically harvested) specimens is pivotal to differential diagnosis. Several new techniques to increase diagnostic accuracy are under investigation (biomarkers and genetic testing among others).
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Affiliation(s)
- Evgeny Solonitsyn
- Almasov National Medical Research Centre, Saint-Petersburg, Russian Federation
| | - Alexander Dechêne
- Department of Gastroenterology, Hepatology and Endocrinology, University Hospital, Paracelsus Medical University Nuremberg, Nuremberg, Germany
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10
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Dechêne A, Kasper S, Olivecrona H, Schirra J, Trojan J. Photochemical internalization and gemcitabine combined with first-line chemotherapy in perihilar cholangiocarcinoma: observations in three patients. Endosc Int Open 2020; 8:E1878-E1883. [PMID: 33269324 PMCID: PMC7695516 DOI: 10.1055/a-1276-6366] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 08/17/2020] [Indexed: 12/22/2022] Open
Abstract
Photochemical internalization (PCI) is a technology to induce a localized, intracellular enhancement of therapeutics that are processed through endosomal pathways, including gemcitabine in malignant cells. In addition to a direct phototoxic and tumoricidal effect, PCI specifically disrupts endosomal membranes and, thereby, the compartmentalization of certain cytotoxic compounds to enhance a drug's intended intracellular target reach within the tissue treated. Non-resectable extrahepatic cholangiocarcinoma (eCCA) is a common primary tumor and gemcitabine/cisplatin chemotherapy is widely considered standard of care for it. PCI is well suited as an endoscopic intervention, and clinical observations in three subjects participating in a phase I/IIa dose escalation safety trial are described. The trial included patients with perihilar, non-resectable CCA suitable for standard-of-care chemotherapy. Per protocol, a single endoscopic PCI procedure with gemcitabine was conducted at the initiation of standard gemcitabine/cisplatin therapy. Sixteen patients enrolled in the initial dose escalation phase of the trial, which later was extended to explore the safety of a second PCI procedure during chemotherapy. While limited to a case series, the various clinical observations described here serve to illustrate the effects of localized, perihilar tumor targeting in appropriate patients by any safe methodology, including PCI. As previously indicated by clinical data using other localized treatment modalities, adding a directed, tumor-targeting treatment to systemic therapy to ameliorate the progressively expanding extrahepatic tumor burden can have important effects on the overall outcome of systemic treatment in many patients who have incurable eCCA.
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Affiliation(s)
- Alexander Dechêne
- Dept. of Gastroenterology and Endocrinology, Klinikum Nürnberg, Paracelsus Medical University, Nürnberg, Germany
| | - Stefan Kasper
- Dept of Medical Oncology West German Cancer Center, University Hospital Essen, Germany
| | | | - Joerg Schirra
- Medical Department II, University Hospital, Ludwig Maximilians-University, Munich, Germany
| | - Joerg Trojan
- Goethe University Medical Center, Frankfurt, Germany
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11
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Sydor S, Manka P, van Buren L, Theurer S, Schwertheim S, Best J, Heegsma J, Saeed A, Vetter D, Schlattjan M, Dittrich A, Fiel MI, Baba HA, Dechêne A, Cubero FJ, Gerken G, Canbay A, Moshage H, Friedman SL, Faber KN, Bechmann LP. Hepatocyte KLF6 expression affects FXR signalling and the clinical course of primary sclerosing cholangitis. Liver Int 2020; 40:2172-2181. [PMID: 32462764 DOI: 10.1111/liv.14542] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/14/2019] [Revised: 04/26/2020] [Accepted: 05/19/2020] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Primary sclerosing cholangitis (PSC) is characterized by chronic cholestasis and inflammation, which promotes cirrhosis and an increased risk of cholangiocellular carcinoma (CCA). The transcription factor Krueppel-like-factor-6 (KLF6) is a mediator of liver regeneration, steatosis, and hepatocellular carcinoma (HCC), but no data are yet available on its potential role in cholestasis. Here, we aimed to identify the impact of hepatic KLF6 expression on cholestatic liver injury and PSC and identify potential effects on farnesoid-X-receptor (FXR) signalling. METHODS Hepatocellular KLF6 expression was quantified by immunohistochemistry (IHC) in liver biopsies of PSC patients and correlated with serum parameters and clinical outcome. Liver injury was analysed in hepatocyte-specific Klf6-knockout mice following bile duct ligation (BDL). Chromatin-immunoprecipitation-assays (ChIP) and KLF6-overexpressing HepG2 cells were used to analyse the interaction of KLF6 and FXR target genes such as NR0B2. RESULTS Based on IHC, PSC patients could be subdivided into two groups showing either low (<80%) or high (>80%) hepatocellular KLF6 expression. In patients with high KLF6 expression, we observed a superior survival in Kaplan-Meier analysis. Klf6-knockout mice showed reduced hepatic necrosis following BDL when compared to controls. KLF6 suppressed NR0B2 expression in HepG2 cells mediated through binding of KLF6 to the NR0B2 promoter region. CONCLUSION Here, we show an association between KLF6 expression and the clinical course and overall survival in PSC patients. Mechanistically, we identified a direct interaction of KLF6 with the FXR target gene NR0B2.
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Affiliation(s)
- Svenja Sydor
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke-University Hospital Magdeburg, Magdeburg, Germany.,Department of Internal Medicine, University Hospital Knappschaftskrankenhaus, Ruhr-University Bochum, Bochum, Germany
| | - Paul Manka
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Lea van Buren
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Sarah Theurer
- Department of Pathology, University Hospital of Essen, Essen, Germany
| | - Suzan Schwertheim
- Department of Pathology, University Hospital of Essen, Essen, Germany
| | - Jan Best
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke-University Hospital Magdeburg, Magdeburg, Germany
| | - Janette Heegsma
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Ali Saeed
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Diana Vetter
- Department of Surgery, University Hospital Zurich, Zurich, Switzerland
| | - Martin Schlattjan
- Department of Pathology, University Hospital of Essen, Essen, Germany
| | - Anna Dittrich
- Department of Systems Biology, Institute of Biology, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Maria I Fiel
- Division of Liver Diseases, Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Hideo A Baba
- Department of Pathology, University Hospital of Essen, Essen, Germany
| | - Alexander Dechêne
- Nürnberg Hospital, Department of Internal Medicine 6, Nürnberg, Germany
| | - Francisco J Cubero
- Department of Immunology, Opthalmology and ORL, Complutense University School of Medicine, Madrid, Spain.,de Octubre Health Research Institute (imas 12), Madrid, Spain
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Ali Canbay
- Department of Internal Medicine, University Hospital Knappschaftskrankenhaus, Ruhr-University Bochum, Bochum, Germany
| | - Han Moshage
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Scott L Friedman
- Department of Systems Biology, Institute of Biology, Otto-von-Guericke-University Magdeburg, Magdeburg, Germany
| | - Klaas Nico Faber
- Department of Gastroenterology and Hepatology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Laboratory Medicine, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Lars P Bechmann
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke-University Hospital Magdeburg, Magdeburg, Germany.,Department of Internal Medicine, University Hospital Knappschaftskrankenhaus, Ruhr-University Bochum, Bochum, Germany
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12
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Glöckner E, Wening F, Christ M, Dechêne A, Singler K. Lung Ultrasound Eight-Point Method in Diagnosing Acute Heart Failure in Emergency Patients with Acute Dyspnea: Diagnostic Accuracy and 72 h Monitoring. Medicina (Kaunas) 2020; 56:medicina56080379. [PMID: 32731477 PMCID: PMC7466324 DOI: 10.3390/medicina56080379] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/14/2020] [Revised: 07/21/2020] [Accepted: 07/24/2020] [Indexed: 12/30/2022]
Abstract
Background and Objectives: Acute dyspnea is a common chief complaint in the emergency department (ED), with acute heart failure (AHF) as a frequent underlying disease. Early diagnosis and rapid therapy are highly recommended by international guidelines. This study evaluates the accuracy of point-of-care B-line lung ultrasound in diagnosing AHF and monitoring the therapeutic success of heart failure patients. Materials and Methods: This is a prospective mono-center study in adult patients presenting with undifferentiated acute dyspnea to a German ED. An eight-zone pulmonary ultrasound was performed by experienced sonographers in the ED and 24 and 72 h after. Along with the lung ultrasound evaluation patients were asked to assess the severity of shortness of breath on a numeric rating scale. The treating ED physicians were asked to assess the probability of AHF as the underlying cause. Final diagnosis was adjudicated by two independent experts. Follow-up was done after 30 and 180 days. Results: In total, 102 patients were enrolled. Of them, 89 patients received lung ultrasound evaluation in the ED. The sensitivity of lung ultrasound evaluation in ED in diagnosing AHF was 54.2%, specificity 97.6%. As much as 96.3% of patients with a positive LUS test result for AHF in ED actually suffered from AHF. Excluding diuretically pretreated patients, sensitivity of LUS increased to 75% in ED. Differences in the sum of B-lines between admission time point, 24 and 72 h were not statistically significant. There were no statistically significant differences in the subjectively assessed severity of dyspnea between AHF patients and those with other causes of dyspnea. Of the 89 patients, 48 patients received the final adjudicated diagnosis of AHF. ED physicians assessed the probability of AHF in patients with a final diagnosis of AHF as 70%. Roughly a quarter (23.9%) of the overall cohort patients were rehospitalized within 30 days after admission, 38.6% within 180 days of follow-up. Conclusion: In conclusion, point-of-care lung ultrasound is a helpful tool for the early rule-in of acute heart failure in ED but only partially suitable for exclusion. Of note, the present study shows no significant changes in the number of B-lines after 24 and 72 h.
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Affiliation(s)
- Erika Glöckner
- Department of Gastroenterology, Hepatology, Endocrinology, Diabetology and Nutrition, Klinikum Nuernberg, Paracelsus Medical University Nuernberg, 90419 Nuernberg, Germany;
- Correspondence: ; Tel.: +49(911)-398-114402
| | - Felicitas Wening
- Department of Respiratory Medicine, Allergology and Sleep Medicine, Klinikum Nürnberg, Paracelsus Medical University Nuernberg, 90419 Nuernberg, Germany;
| | - Michael Christ
- Emergency Department, Luzerner Kantonsspital, 6000 Luzern, Switzerland;
| | - Alexander Dechêne
- Department of Gastroenterology, Hepatology, Endocrinology, Diabetology and Nutrition, Klinikum Nuernberg, Paracelsus Medical University Nuernberg, 90419 Nuernberg, Germany;
| | - Katrin Singler
- Department of Geriatrics, Klinikum Nuernberg, Paracelsus Medical University, 90419 Nuernberg, Germany;
- Institute for Biomedicine of Aging, Friedrich-Alexander University Erlangen-Nuernberg, 90419 Nuernberg, Germany
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13
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Kasper S, Meiler J, Knipp H, Höhler T, Reimer P, Steinmetz T, Berger W, Linden G, Reis H, Markus P, Paul A, Dechêne A, Schumacher B, Kostbade K, Virchow I, Ting S, Worm K, Schmid KW, Herold T, Wiesweg M, Schuler M, Trarbach T. Biweekly Cetuximab Plus FOLFOX6 as First-Line Therapy in Patients With RAS Wild-Type Metastatic Colorectal Cancer: The CEBIFOX Trial. Clin Colorectal Cancer 2020; 19:236-247.e6. [PMID: 32737003 DOI: 10.1016/j.clcc.2020.03.003] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 02/27/2020] [Accepted: 03/11/2020] [Indexed: 12/28/2022]
Abstract
BACKGROUND The multicenter, single-arm, phase II study CEBIFOX evaluated the efficacy of a biweekly cetuximab administration in combination with FOLFOX6 as first-line therapy in KRAS (exon 2) wild-type (wt) metastatic colorectal cancer (mCRC). PATIENTS AND METHODS Patients received FOLFOX6 with cetuximab (500 mg/m2) every second week. Primary endpoint was objective response rate (ORR), among others secondary endpoints were safety, progression-free survival (PFS), overall survival (OS), and patient-reported outcome (PRO). The impact on the treatment efficacy was evaluated in explorative subgroup analyses, including extended molecular profiling and primary tumor location. RESULTS In total, 57 were included in the intention-to-treat (ITT) analyses. New RAS mutations were detected in 14.0% by post hoc next-generation sequencing analysis in 43 patients. The ORR in the all RASwt population was 70.3% with a median PFS and OS of 10.9 (95% confidence interval [CI], 9.0-12.9) and 33.8 (95% CI, 21.1-45.5) months. Grade 3-5 adverse events occurred in 66.7% of the ITT, without significant impact on the PRO. Patients with right-sided primary tumors had a reduced ORR (54.5%), and median PFS and OS (10.1 and 23.8 months). BRAF mutations were detected in 11.3%. These patients had a significantly lower ORR, and median PFS and OS. Patients with RASwt/BRAFwt tumors had a notably high median PFS and OS of 14.3 and 38.9 months. CONCLUSIONS This study supports the efficacy and safety of biweekly cetuximab given in combination with FOLFOX6 in patients with RASwt/BRAFwt mCRC with left-sided primary tumor. CEBIFOX is the first trial reporting the complete dataset, including extended molecular profiling and tumor location of a biweekly administered cetuximab/FOLFOX6 in mCRC. Clinical trial number: NCT01051167.
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Affiliation(s)
- Stefan Kasper
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Heidelberg, Germany.
| | - Johannes Meiler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Heike Knipp
- Department of Medicine I, Alfried Krupp von Bohlen and Halbach Hospital, Essen, Germany
| | - Thomas Höhler
- Department of Medicine I, Prosper Hospital, Recklinghausen, Germany
| | - Peter Reimer
- Department of Hematology and Medical Oncology, Protestant Hospital, Essen-Werden, Germany
| | | | - Winfried Berger
- Department of Hematology, and Medical Oncology, Catholic Hospital, Essen, Germany
| | - Gabriele Linden
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Henning Reis
- Institute of Pathology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Peter Markus
- Department of General, Visceral and Trauma Surgery, Elisabeth Hospital, Essen, Germany
| | - Andreas Paul
- German Cancer Consortium (DKTK), Heidelberg, Germany; West German Cancer Centre, Department of General, Visceral and Transplantation Surgery, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Alexander Dechêne
- West German Cancer Centre, Department of Gastroenterology and Hepatology, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | | | - Karina Kostbade
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Isabel Virchow
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Saskia Ting
- Institute of Pathology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Karl Worm
- Institute of Pathology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Kurt W Schmid
- German Cancer Consortium (DKTK), Heidelberg, Germany; Institute of Pathology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Thomas Herold
- Institute of Pathology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Marcel Wiesweg
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
| | - Martin Schuler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany; German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Tanja Trarbach
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University of Duisburg-Essen, Essen, Germany
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14
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Best J, Bechmann LP, Sowa JP, Sydor S, Dechêne A, Pflanz K, Bedreli S, Schotten C, Geier A, Berg T, Fischer J, Vogel A, Bantel H, Weinmann A, Schattenberg JM, Huber Y, Wege H, von Felden J, Schulze K, Bettinger D, Thimme R, Sinner F, Schütte K, Weiss KH, Toyoda H, Yasuda S, Kumada T, Berhane S, Wichert M, Heider D, Gerken G, Johnson P, Canbay A. GALAD Score Detects Early Hepatocellular Carcinoma in an International Cohort of Patients With Nonalcoholic Steatohepatitis. Clin Gastroenterol Hepatol 2020; 18:728-735.e4. [PMID: 31712073 DOI: 10.1016/j.cgh.2019.11.012] [Citation(s) in RCA: 137] [Impact Index Per Article: 34.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2019] [Revised: 10/23/2019] [Accepted: 11/03/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS The prevalence of nonalcoholic steatohepatitis (NASH) associated hepatocellular carcinoma (HCC) is increasing. However, strategies for detection of early-stage HCC in patients with NASH have limitations. We assessed the ability of the GALAD score, which determines risk of HCC based on patient sex; age; and serum levels of α-fetoprotein (AFP), AFP isoform L3 (AFP-L3), and des-gamma-carboxy prothrombin (DCP), to detect HCC in patients with NASH. METHODS We performed a case-control study of 125 patients with HCC (20% within Milan Criteria) and 231 patients without HCC (NASH controls) from 8 centers in Germany. We compared the performance of serum AFP, AFP-L3, or DCP vs GALAD score to identify patients with HCC using receiver operating characteristic curves and corresponding area under the curve (AUC) analyses. We also analyzed data from 389 patients with NASH under surveillance for HCC in Japan, followed for a median of 167 months. During the 5-year screening period, 26 patients developed HCC. To compensate for irregular intervals of data points, we performed locally weighted scatterplot smoothing, linear regression, and a non-linear curve fit to assess development of GALAD before HCC development. RESULTS The GALAD score identified patients with any stage HCC with an AUC of 0.96 - significantly greater than values for serum levels of AFP (AUC, 0.88), AFP-L3 (AUC, 0.86) or DCP (AUC, 0.87). AUC values for the GALAD score were consistent in patients with cirrhosis (AUC, 0.93) and without cirrhosis (AUC, 0.98). For detection of HCC within Milan Criteria, the GALAD score achieved an AUC of 0.91, with a sensitivity of 68% and specificity of 95% at a cutoff of -0.63. In a pilot Japanese cohort study, the mean GALAD score was higher in patients with NASH who developed HCC than in those who did not develop HCC as early as 1.5 years before HCC diagnosis. GALAD scores were above -0.63 approximately 200 days before the diagnosis of HCC. CONCLUSIONS In a case-control study performed in Germany and a pilot cohort study in Japan, we found the GALAD score may detect HCC with high levels of accuracy in patients with NASH, with and without cirrhosis. The GALAD score can detect patients with early-stage HCC, and might facilitate surveillance of patients with NASH, who are often obese, which limits the sensitivity of detection of liver cancer by ultrasound.
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Affiliation(s)
- Jan Best
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Lars P Bechmann
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Jan-Peter Sowa
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Svenja Sydor
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany; Department of Gastroenterology, Hepatology and Endocrinology, Paracelsus Medical University, Klinikum Nürnberg, Nürnberg, Germany
| | - Kristina Pflanz
- Department of Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Sotiria Bedreli
- Department of Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Clemens Schotten
- Department of Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Andreas Geier
- Division of Hepatology, Department of Internal Medicine II, University Hospital Würzburg, Würzburg, Germany
| | - Thomas Berg
- Section of Hepatology, Division of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Janett Fischer
- Section of Hepatology, Division of Gastroenterology and Rheumatology, University Hospital Leipzig, Leipzig, Germany
| | - Arndt Vogel
- Clinic of Gastroenterology, Hepatology and Endocrinology, Hannover Medical High School, Hannover, Germany
| | - Heike Bantel
- Clinic of Gastroenterology, Hepatology and Endocrinology, Hannover Medical High School, Hannover, Germany
| | - Arndt Weinmann
- Department of Medicine I, University Medical Center Johannes Gutenberg University, Mainz, Germany
| | - Jörn M Schattenberg
- Department of Medicine I, University Medical Center Johannes Gutenberg University, Mainz, Germany
| | - Yvonne Huber
- Department of Medicine I, University Medical Center Johannes Gutenberg University, Mainz, Germany
| | - Henning Wege
- Department of Medicine I, University Medical Center, Hamburg-Eppendorf, Germany
| | - Johann von Felden
- Department of Medicine I, University Medical Center, Hamburg-Eppendorf, Germany
| | - Kornelius Schulze
- Department of Medicine I, University Medical Center, Hamburg-Eppendorf, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Freiburg, Germany; Berta-Ottenstein-Programme, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II, Medical Center University of Freiburg, Freiburg, Germany
| | - Friedrich Sinner
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Kerstin Schütte
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany
| | - Karl Heinz Weiss
- Department of Internal Medicine IV, University Hospital Heidelberg, Heidelberg, Germany
| | - Hidenori Toyoda
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Satoshi Yasuda
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Takashi Kumada
- Department of Nursing, Gifu Kyoritsu University, Ogaki, Japan
| | - Sarah Berhane
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Marc Wichert
- Central Laboratory, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Dominik Heider
- Department of Mathematics and Computer Science, Philipps-University Marburg, Marburg, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Philip Johnson
- Department of Molecular and Clinical Cancer Medicine, University of Liverpool, Liverpool, United Kingdom
| | - Ali Canbay
- Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Magdeburg, Germany.
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15
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Schotten C, Bechmann LP, Manka P, Theysohn J, Dechêne A, El Fouly A, Barbato F, Neumann U, Radünz S, Sydor S, Heider D, Venerito M, Canbay A, Gerken G, Herrmann K, Wedemeyer H, Best J. NAFLD-Associated Comorbidities in Advanced Stage HCC Do Not Alter the Safety and Efficacy of Yttrium-90 Radioembolization. Liver Cancer 2019; 8:491-504. [PMID: 31799206 PMCID: PMC6883476 DOI: 10.1159/000501484] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/25/2019] [Accepted: 06/12/2019] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND Patients with advanced hepatocellular carcinoma (HCC) arising in nonalcoholic fatty liver disease (NAFLD) may not be suitable for systemic therapy due to metabolic syndrome-related diseases. Recent trials did not show a survival benefit of radioembolization (RE) compared to sorafenib in advanced stage HCC but RE may represent an adequate alternative in patients with contraindications to systemic therapy due to its favorable safety profile. AIM To investigate the impact of NAFLD-related comorbidities on safety and efficacy of RE for HCC treatment in a retrospective monocentric cohort study. PATIENTS AND METHODS Safety and efficacy of RE were evaluated in patients with NAFLD-associated HCC. Hepatitis B virus (HBV)-related HCC patients served as controls, exhibiting matching Barcelona Liver Cancer Clinic (BCLC) stages while showing significantly fewer metabolic comorbidities. RESULTS Overall, 87 HCC patients with NAFLD (mean age 71.3 ± 6.9 years) and 62 HCC patients with HBV (mean age 58.8 ± 10.9 years) not amenable to surgical or conventional locoregional treatments were included. Patients with HBV-related HCC had a comparable liver function to HCC patients with NAFLD. RE treatment-related toxicity did not differ between the two groups (increase in bilirubin Common Terminology Criteria for Adverse Events grade in 29 [38.7%] NAFLD and 20 [39.2%] HBV patients, p = 0.91). Overall survival was similar in HCC patients with NAFLD and HBV (11.1 [interquartile range, IQR, 18.27] vs. 9.3 months [IQR 14.73], p = 0.38), also in the subgroup analyses of BCLC B and C stages. CONCLUSION RE showed similar survival outcomes at a comparable toxicity profile in HCC patients with NAFLD and HBV. NAFLD-associated metabolic comorbidities did not exhibit limitations for RE while offering comparable therapeutic efficacy as compared to HBV patients.
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Affiliation(s)
- Clemens Schotten
- Department of Gastroenterology and Hepatology, Essen University Hospital, Essen, Germany
| | - Lars P. Bechmann
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke University, Magdeburg, Germany
| | - Paul Manka
- Department of Gastroenterology and Hepatology, Essen University Hospital, Essen, Germany
| | - Jens Theysohn
- Institute for Diagnostic and Interventional Radiology and Neuroradiology, Essen University Hospital, Essen, Germany
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology, Essen University Hospital, Essen, Germany,Department of Internal Medicine 6, Paracelsus Medical University Nürnberg, Nürnberg, Germany
| | - Amr El Fouly
- Endemic Medicine Department, Helwan University, Cairo, Egypt
| | - Francesco Barbato
- Department of Nuclear Medicine, Essen University Hospital, Essen, Germany
| | - Ursula Neumann
- Department of Mathematics and Computer Science, Philipps University of Marburg, Marburg, Germany
| | - Sonia Radünz
- Department of General Surgery and Transplantation, Essen University Hospital, Essen, Germany
| | - Svenja Sydor
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke University, Magdeburg, Germany
| | - Dominik Heider
- Department of Mathematics and Computer Science, Philipps University of Marburg, Marburg, Germany
| | - Marino Venerito
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke University, Magdeburg, Germany
| | - Ali Canbay
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke University, Magdeburg, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, Essen University Hospital, Essen, Germany
| | - Ken Herrmann
- Department of Nuclear Medicine, Essen University Hospital, Essen, Germany
| | - Heiner Wedemeyer
- Department of Gastroenterology and Hepatology, Essen University Hospital, Essen, Germany
| | - Jan Best
- Department of Gastroenterology and Hepatology, Essen University Hospital, Essen, Germany,Department of Gastroenterology, Hepatology and Infectious Diseases, Otto von Guericke University, Magdeburg, Germany,*Jan Best, MD, Department of Gastroenterology, Hepatology and Infectious Diseases, University Hospital Magdeburg, Otto von Guericke University, Leipziger Strasse 44, DE–39120 Magdeburg (Germany), E-Mail
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16
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Pieper K, Dechêne A, Kathemann S, Pilic D, Hünseler C, Weber LT, Bergheim C, Paul A, Baba HA, Hoyer PF, Lainka E. Persistierende Transaminasenerhöhung und Hepatopathie nach schwerer Grunderkrankung im frühen Kindesalter. Monatsschr Kinderheilkd 2019. [DOI: 10.1007/s00112-019-00788-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
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17
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Goetz M, Andersen P, Bergman J, Frei N, Schmidt A, Kähler G, Martus P, Dechêne A. ERCP in babies: Low risk of post-ERCP pancreatitis - results from a multicentre survey. United European Gastroenterol J 2019; 8:77-80. [PMID: 32213056 DOI: 10.1177/2050640619874187] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
BACKGROUND AND AIMS Endoscopic retrograde cholangiopancreatography (ERCP) is rarely performed in newborns, and the risk of post-ERCP pancreatitis (PEP) has not been defined in this age group. We therefore performed a European multicentre analysis of PEP rates and risk factors in children aged ≤1 year. PATIENTS AND METHODS Based on a sample size estimation, 135 consecutive ERCPs in 126 children aged ≤1 year were evaluated from five European centres, and the first ERCP per child analysed. All ERCPs and clinical reports were reviewed manually for PEP and associated risk factors. All ERCPs were performed by endoscopists with high ERCP expertise. RESULTS No PEP was observed (0/126, 0.0%, CI 0-2.9%) despite the formal presence of multiple risk factors and despite lack of PEP prophylaxis (except one patient having received a pancreatic duct stent). The PEP rate was significantly lower than the PEP rate expected in adults with similar risk factors. CONCLUSIONS ERCP in children aged ≤1 year is safe in terms of PEP. The PEP risk is significantly lower in children aged ≤1 year than in adults, therefore no PEP prophylaxis seems to be needed in young children. Risk factors from adults may not apply to children under 1 year. Reluctance to perform diagnostic ERCP in suspected biliary anomalies should not be based on presumed PEP risk.
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Affiliation(s)
- Martin Goetz
- Innere Medizin I, Universitätsklinikum Tübingen, Tübingen, Germany.,Medizinische Klinik IV, Kliniken Böblingen, Böblingen, Germany
| | - Philipp Andersen
- Innere Medizin I, Universitätsklinikum Tübingen, Tübingen, Germany
| | - Jacques Bergman
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Nicola Frei
- Department of Gastroenterology and Hepatology, Academic Medical Center, Amsterdam, The Netherlands
| | - Arthur Schmidt
- Department of Medicine II, Faculty of Medicine, University of Freiburg; Medical Centre, Freiburg, Germany
| | - Georg Kähler
- Central Interdisciplinary Endoscopy, Medical Center Mannheim, University of Heidelberg, Mannheim, Germany
| | - Peter Martus
- Institut für Klinische Epidemiologie und Angewandte Biometrie (IKEaB), Universität Tübingen, Tübingen, Germany
| | - Alexander Dechêne
- Klinik für Innere Medizin 6, Klinikum Nürnberg, Universitätsklinik der Paracelsus Medizinischen Privatuniversität, Nürnberg, Germany.,Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Essen, Germany
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18
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Abendroth A, Noureddine R, Abramczyk M, Paul A, Gerken G, Schmid KW, Markus P, Schumacher B, Wiesweg M, Köhler J, Markus M, Mende B, Dechêne A, Schuler M, Kasper S. Long-term outcome of patients with advanced pancreatic cancer treated with sequential chemotherapies before the era of modern combination therapy protocols. J Cancer Res Clin Oncol 2018; 145:445-455. [PMID: 30430229 DOI: 10.1007/s00432-018-2789-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2018] [Accepted: 11/08/2018] [Indexed: 12/17/2022]
Abstract
INTRODUCTION Patients (pts) with locally advanced (LAPC) or metastatic pancreatic ductal adenocarcinoma (mPDAC) have a dismal prognosis. Recently, new combination chemotherapies such as FOLFIRINOX and nab-paclitaxel/gemcitabine have demonstrated superiority over gemcitabine monotherapy. However, a substantial proportion of pts cannot tolerate these intensive front-line protocols. Moreover, the long-term superiority of multiagent protocols over less intensive strategies remains to be shown. To provide a benchmark for future studies, we analyzed the outcome of patients with LAPC or mPDAC treated at the West German Cancer Center before the FOLFIRINOX/nab-paclitaxel + gemcitabine era. METHODS This retrospective analysis included 201 consecutive pts with LAPC and mPDAC treated between 2007 and 2011. Efficacy parameters were correlated with type of chemotherapy, number of treatment lines and clinicopathological parameters. RESULTS Gemcitabine monotherapy was given as first-line therapy in 51.1%, whereas 48.9% received combination chemotherapies such as gemcitabine/oxaliplatin or FOLFOX. Patients received a median of two lines of treatment, with 54.8% receiving second-line and 37.9% receiving third- and further-line therapies. There was no significant difference between gemcitabine monotherapy and combination therapies. Despite moderate activity of first-line treatment, median overall survival for LAPC was 11.3 months and 8.7 months for mPDAC. Multivariate analysis identified age and number of treatment lines as prognostic markers. CONCLUSION The long-term outcome of unselected pts with LAPC and mPDAC treated before the introduction of aggressive multiagent chemotherapy protocols compares favorably with the results of contemporary benchmark trials. This suggests a multifactorial benefit from interdisciplinary care provided over sequential treatment lines at high volume expert centers.
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Affiliation(s)
- A Abendroth
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - R Noureddine
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - M Abramczyk
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - A Paul
- Department of General, Visceral and Transplant Surgery, West German Cancer Center, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner site University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - G Gerken
- Department of Gastroenterology and Hepatology, West German Cancer Center, University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - K W Schmid
- West German Cancer Center, Institute of Pathology Essen, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner site University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - P Markus
- Department of General Surgery and Traumatology, Elisabeth Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - B Schumacher
- Department of Gastroenterology, Elisabeth Hospital Essen, Essen, Germany
| | - M Wiesweg
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - J Köhler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - M Markus
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
| | - B Mende
- Central Pharmacy, University Hospital Essen, Essen, Germany
| | - A Dechêne
- Department of Gastroenterology and Hepatology, West German Cancer Center, University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - M Schuler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany
- German Cancer Consortium (DKTK), Partner site University Hospital Essen, Essen, Germany
- Medical Faculty, University Duisburg-Essen, Essen, Germany
| | - S Kasper
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, Essen, Germany.
- Medical Faculty, University Duisburg-Essen, Essen, Germany.
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19
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Wiesweg M, Reis H, Köster T, Goetz M, Worm K, Herold T, Paul A, Dechêne A, Schumacher B, Markus P, Virchow I, Kostbade K, Wolf N, Zaun G, Metzenmacher M, Schmid KW, Schuler M, Kasper S. Phosphorylation of p70 Ribosomal Protein S6 Kinase β-1 is an Independent Prognostic Parameter in Metastatic Colorectal Cancer. Clin Colorectal Cancer 2018. [PMID: 29526493 DOI: 10.1016/j.clcc.2018.02.003] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Deregulation of signal transduction pathways plays a critical role in oncogenesis of colorectal cancer (CRC) and directly affects sensitivity to targeted therapies. Against this background we developed a comprehensive biomarker profiling program including markers of downstream signaling to study their association with clinical outcomes. PATIENTS AND METHODS A prospectively studied cohort of 160 patients with metastatic CRC was included. Standard diagnostic workup included mutational analyses of Kirsten rat sarcoma viral oncogene homolog (KRAS), neuroblastoma RAS viral oncogene homolog (NRAS), and v-Raf murine sarcoma viral oncogene homolog B (BRAF). In addition, markers of mitogen-activated protein kinase (MAPK), phosphatidylinositol 3-kinase/protein kinase B (PI3K/AKT) and mammalian target of rapamycin pathway activation (phosphorylation of extracellular signal-regulated kinase [ERK], AKT, and p70 ribosomal protein S6 kinase β-1 [p70S6K]) were studied using standardized immunohistochemistry. RESULTS There was a significant correlation between markers of ERK and AKT activation in the full cohort. In addition, phosphorylation of p70S6K correlated strongly with ERK and AKT phosphorylation and primary tumor localization in the right colon. Subgroup analyses specified these correlations to patients with all-RAS wild type tumors. In contrast, tumors harboring RAS mutations predominantly exhibited ERK phosphorylation. Interestingly, patients with CRC showing high p70S6K phosphorylation (highest quartile) had a significantly inferior overall survival (hazard ratio [HR], 2.4; P = .002) irrespective of RAS mutational status. This effect remained significant in multivariate analysis (P = .002). A patient subgroup characterized by high p70S6K phosphorylation and right-sided primary tumors had a particularly poor prognosis with a dramatically inferior overall survival (HR, 5.2; P < .001). Patients with right-sided primary tumor and low p70S6K phosphorylation had responses to anti-epidermal growth factor receptor antibody-based therapies and overall survival similar to patients with left-sided primary tumors. CONCLUSION High phosphorylation of p70S6K is a novel, independent biomarker for poor prognosis, in particular in patients with right-sided primary tumors.
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Affiliation(s)
- Marcel Wiesweg
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Henning Reis
- Institute of Pathology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Tobias Köster
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Moritz Goetz
- Institute of Pathology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Karl Worm
- Institute of Pathology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Thomas Herold
- Institute of Pathology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Andreas Paul
- Department of General, Visceral and Transplantation Surgery, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | | | - Peter Markus
- Department of General, Visceral and Trauma Surgery, Elisabeth Hospital Essen, Essen, Germany
| | - Isabel Virchow
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Karina Kostbade
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Nathalie Wolf
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Gregor Zaun
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Martin Metzenmacher
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany
| | - Kurt W Schmid
- Institute of Pathology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Martin Schuler
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany
| | - Stefan Kasper
- Department of Medical Oncology, West German Cancer Center, University Hospital Essen, University Duisburg-Essen, Essen, Germany; German Cancer Consortium, Partner Site University Hospital Essen, Essen, Germany.
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Abstract
BACKGROUND Perihilar cholangiocarcinoma (Klatskin tumor) is a rare tumor entity with an unfavorable prognosis despite optimal treatment. OBJECTIVES The aim of the study is to investigate beneficial histopathological features and recommendations for surgery in perihilar cholangiocarcinoma to improve patients' long term survival. MATERIAL AND METHODS 192 patients suffering from perihilar cholangiocarcinoma underwent attempted tumor resection between 1998 and 2008 at our clinic. 50 patients survived more than 2 years. The follow-up ended in December 2013. The resection type, the UICC stage and histopathological features were compared between three groups (2-3-year, 3-5-year and > 5-year survival groups). RESULTS The overall 5‑year survival rate of the study groups was 32 %, and even 16 % survived more than 10 years after surgery. Patients with lymph node positive tumors (p = 0.0126) and distant metastasis (p = 0.0376) had the poorest survival rate. Perineural invasion had no significant impact on the overall survival, but patients surviving more than 5 years had the lowest incidence of perineural invasion with 18.75 %. Caudate lobectomy was significantly (p = 0.011) associated with a survival of more than 5 years in our study. CONCLUSIONS Complete tumor resection with additional caudate lobe resection is associated with long-term survival. Perineural invasion seems to be a negative prognostic factor for long-term survival.
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Affiliation(s)
- B Juntermanns
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, Essen, Deutschland
| | - C D Fingas
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, Essen, Deutschland
| | - G C Sotiropoulos
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, Essen, Deutschland
| | - D Jaradat
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, Essen, Deutschland
| | - A Dechêne
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45122, Essen, Deutschland
| | - H Reis
- Institut für Pathologie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - S Kasper
- Innere Klinik (Tumorforschung), Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, 45147, Essen, Deutschland
| | - A Paul
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, Essen, Deutschland
| | - G M Kaiser
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsklinikum Essen, Universität Duisburg-Essen, Hufelandstr. 55, Essen, Deutschland.
- Klinik für Allgemein- und Viszeralchirurgie, St. Bernhard-Hospital Kamp-Lintfort, Bürgermeister-Schmelzing-Str. 90, 47475, Kamp-Lintfort, Deutschland.
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21
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Tal AO, Finkelmeier F, Filmann N, Kylänpää L, Udd M, Parzanese I, Cantù P, Dechêne A, Penndorf V, Schnitzbauer A, Friedrich-Rust M, Zeuzem S, Albert JG. Multiple plastic stents versus covered metal stent for treatment of anastomotic biliary strictures after liver transplantation: a prospective, randomized, multicenter trial. Gastrointest Endosc 2017; 86:1038-1045. [PMID: 28302527 DOI: 10.1016/j.gie.2017.03.009] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/20/2016] [Accepted: 03/05/2017] [Indexed: 02/08/2023]
Abstract
BACKGROUND AND AIMS Treatment of anastomotic biliary strictures (ABSs) after orthotopic liver transplantation by endoscopic insertion of multiple plastic stents (MPSs) is well established. The use of covered self-expandable metal stents (cSEMSs) for this indication is less investigated. METHODS In an open-label, multicenter, randomized trial, patients with confirmed ABSs were randomly assigned 1:1 to receive either an MPS or a cSEMS. The primary endpoint was the number of endoscopic interventions until ABS resolution. Secondary endpoints were frequency of adverse events, treatment success rates, and time to treatment success and recurrence of ABS during follow-up of at least 1 year. RESULTS Fifty-eight patients were included between 2012 and 2015, and 48 patients completed follow-up. Patients receiving MPS (n = 24) underwent a median of 4 (range, 3-12) endoscopic retrograde cholangiography examinations, whereas those in the cSEMS group (n = 24) underwent a median of 2 (range, 2-12) sessions until ABS resolution (P < .001). A median of 8 (range, 2-32) stents was used until ABS resolution within the MPS group and 1 (range, 1-24) in the cSEMS group (P < .0001). cSEMS migration occurred in 8 (33.3%) patients. Treatment duration did not differ significantly. Initial treatment success rates were high with 23 (95.8%) in the MPS group and 24 (100%) for cSEMSs (P = 1). Five (20.8%) patients in both groups showed stricture recurrence after a median follow-up of 500 days (range, 48-1317 days). CONCLUSIONS cSEMSs for treatment of ABSs needed less endoscopic interventions to achieve similar efficacy as MPS and might become a new treatment standard. However, the optimal duration of cSEMS therapy and cost-efficacy have to be evaluated. (Clinical trial registration number: NCT01393067.).
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Affiliation(s)
- Andrea Oliver Tal
- Department of Internal Medicine I, Frankfurt University Hospital, Frankfurt, Germany
| | - Fabian Finkelmeier
- Department of Internal Medicine I, Frankfurt University Hospital, Frankfurt, Germany
| | - Natalie Filmann
- Institute of Biostatistics and Mathematical Modeling, Frankfurt University Hospital, Frankfurt, Germany
| | - Leena Kylänpää
- Department of Gastrointestinal and General Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Marianne Udd
- Department of Gastrointestinal and General Surgery, Helsinki University Central Hospital, Helsinki, Finland
| | - Ilaria Parzanese
- Department of Gastroenterology, IRCCS Cà Granda, Ospedale Policlinico, Milan, Italy
| | - Paolo Cantù
- Department of Gastroenterology, IRCCS Cà Granda, Ospedale Policlinico, Milan, Italy
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology, Universitätsklinikum Essen, Essen, Germany
| | - Volker Penndorf
- Department of Gastroenterology and Hepatology, Universitätsklinikum Essen, Essen, Germany
| | - Andreas Schnitzbauer
- Department of General and Visceral Surgery, Frankfurt University Hospital, Frankfurt, Germany
| | - Mireen Friedrich-Rust
- Department of Internal Medicine I, Frankfurt University Hospital, Frankfurt, Germany
| | - Stefan Zeuzem
- Department of Internal Medicine I, Frankfurt University Hospital, Frankfurt, Germany
| | - Jörg G Albert
- Department of Gastroenterology, Hepatology and Endocrinology, Robert-Bosch Hospital, Stuttgart, Germany
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Götz M, Anders M, Biecker E, Bojarski C, Braun G, Brechmann T, Dechêne A, Dollinger M, Gawaz M, Kiesslich R, Schilling D, Tacke F, Zipprich A, Trebicka J. [S2k Guideline Gastrointestinal Bleeding - Guideline of the German Society of Gastroenterology DGVS]. Z Gastroenterol 2017; 55:883-936. [PMID: 29186643 DOI: 10.1055/s-0043-116856] [Citation(s) in RCA: 53] [Impact Index Per Article: 7.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Affiliation(s)
- Martin Götz
- Innere Medizin I, Gastroenterologie, Hepatologie, Infektiologie, Universitätsklinikum Tübingen
| | - Mario Anders
- Klinik für Innere Medizin, Vivantes Wenckebach-Klinikum
| | | | - Christian Bojarski
- Medizinische Klinik für Gastroenterologie, Infektiologie und Rheumatologie, Charité - Campus Benjamin Franklin
| | | | - Thorsten Brechmann
- Medizinische Klinik I, Klinikum der Ruhr-Universität Bochum, Berufsgen. Kliniken Bergmannsheil
| | - Alexander Dechêne
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen
| | | | | | | | | | - Frank Tacke
- Medizinische Klinik III, Universitätsklinikum Aachen
| | - Alexander Zipprich
- Universitätsklinik und Poliklinik Innere Medizin I, Universitätsklinikum Halle
| | - Jonel Trebicka
- Medizinische Klinik und Poliklinik I, Universitätsklinikum Bonn
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Buechter M, Kahraman A, Manka P, Gerken G, Dechêne A, Canbay A, Wetter A, Umutlu L, Theysohn JM. Partial spleen embolization reduces the risk of portal hypertension-induced upper gastrointestinal bleeding in patients not eligible for TIPS implantation. PLoS One 2017; 12:e0177401. [PMID: 28494001 PMCID: PMC5426764 DOI: 10.1371/journal.pone.0177401] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2016] [Accepted: 04/09/2017] [Indexed: 12/18/2022] Open
Abstract
Introduction Upper gastrointestinal bleeding (UGIB) is a severe and life-threatening complication among patients with portal hypertension (PH). Covered transjugular intrahepatic portosystemic shunt (TIPS) is the treatment of choice for patients with refractory or recurrent UGIB despite pharmacological and endoscopic therapy. In some patients, TIPS implantation is not possible due to co-morbidity or vascular disorders. Spleen embolization (SE) may be a promising alternative in this setting. Materials and methods We retrospectively analyzed 9 patients with PH-induced UGIB who underwent partial SE between 2012 and 2016. All patients met the following criteria: (i) upper gastrointestinal hemorrhage with primary or secondary failure of endoscopic interventions and (ii) TIPS implantation not possible. Each patient was followed for at least 6 months after embolization. Results Five patients (56%) suffered from cirrhotic PH, 4 patients (44%) from non-cirrhotic PH. UGIB occured in terms of refractory hemorrhage from gastric varices (3/9; 33%), hemorrhage from esophageal varices (3/9; 33%), and finally, hemorrhage from portal-hypertensive gastropathy (3/9; 33%). None of the patients treated with partial SE experienced re-bleeding episodes or required blood transfusions during a total follow-up time of 159 months, including both patients with cirrhotic- and non-cirrhotic PH. Discussion Partial SE, as a minimally invasive intervention with low procedure-associated complications, may be a valuable alternative for patients with recurrent PH-induced UGIB refractory to standard therapy.
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Affiliation(s)
- Matthias Buechter
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Alisan Kahraman
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Paul Manka
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany.,Institute of Hepatology London, Foundation for Liver Research, London, and Faculty of Life Sciences & Medicine, King's College London, London, United Kingdom
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Axel Wetter
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Lale Umutlu
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Jens M Theysohn
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
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Buechter M, Kahraman A, Manka P, Gerken G, Jochum C, Canbay A, Dechêne A. Spleen and Liver Stiffness Is Positively Correlated with the Risk of Esophageal Variceal Bleeding. Digestion 2017; 94:138-144. [PMID: 27756066 DOI: 10.1159/000450704] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/01/2016] [Accepted: 09/01/2016] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS Portal hypertension (PH) is a common complication of chronic liver disease and results in esophageal and gastric variceal bleeding, which is associated with a high mortality rate. Measurement of the hepatic venous pressure gradient (HVPG) is considered the gold standard for diagnosing PH and estimating the risk of varices and bleeding. In contrast, upper gastrointestinal (GI) endoscopy (UGE) can reliably demonstrate the presence of varices and bleeding. Both measures are invasive, and HVPG is mainly restricted to tertiary centers. Therefore, the development of noninvasive methods of assessing the severity of PH and the risk of variceal bleeding is warranted. METHODS We retrospectively examined the correlation of spleen stiffness (SSM) and liver stiffness measurements (LSM) with the incidence of variceal bleeding among 143 patients who underwent combined liver and spleen elastography between 2013 and 2015. RESULTS For 19 of 103 patients (16.8%), upper GI variceal bleeding was diagnosed and treated endoscopically. The median SSM of all patients was 35.3 kilopascals (kPa); the median LSM, 11.7 kPa. Patients with previous bleeding episodes had significantly higher SSM (75.0 kPa) and LSM (37.3 kPa) than those without a history of bleeding (SSM, 30.6 kPa; LSM, 8.2 kPa; p < 0.0001). Seventy-five patients (66.4%) underwent UGE in addition to SSM and LSM: 25 with no esophageal varices (EVs; SSM, 29.5 kPa; LSM, 11.4 kPa), 16 with EV grade 1 (SSM, 35.9 kPa; LSM, 33.4 kPa), 21 with EV grade 2 (SSM, 67.8 kPa; LSM, 27.0 kPa) and 13 with EV grade 3 (SSM, 75.0 kPa; LSM, 26.3 kPa). No statistically significant differences were found between respective grades of EV but were found between the presence and absence of varices. At a calculated cutoff level of 42.6 kPa (with application of 95% CI), SSM had sensitivity of 89% and specificity of 64% in determining the risk of bleeding, with a negative predictive value (NPV) of 0.97 (LSM sensitivity, 84%; LSM specificity, 80%; LSM NPV, 0.96 at LSM cutoff level of 20.8 kPa). When LSM (cutoff level, 20.8 kPa) and SSM (cutoff level, 42.6 kPa) were combined, the NPV was 1 (sensitivity, 100%; specificity, 55%). CONCLUSION SSM and LSM as determined by FibroScan (a noninvasive method of detecting PH) is positively correlated with upper GI variceal bleeding (optimal SSM cutoff level, 42.6 kPa; optimal LSM cutoff level, 20.8 kPa). No patients with both SSM and LSM below cutoff levels had a history of bleeding complications.
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Affiliation(s)
- Matthias Buechter
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
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Parohl N, Stiefenhöfer D, Heiligtag S, Reuter H, Dopadlik D, Mosel F, Gerken G, Dechêne A, Heintschel von Heinegg E, Jochum C, Buer J, Popp W. Monitoring of endoscope reprocessing with an adenosine triphosphate (ATP) bioluminescence method. GMS Hyg Infect Control 2017; 12:Doc04. [PMID: 28405542 PMCID: PMC5373681 DOI: 10.3205/dgkh000289] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 01/21/2023]
Abstract
Background: The arising challenges over endoscope reprocessing quality proposes to look for possibilities to measure and control the process of endoscope reprocessing. Aim: The goal of this study was to evaluate the feasibility of monitoring endoscope reprocessing with an adenosine triphosphate (ATP) based bioluminescence system. Methods: 60 samples of eight gastroscopes have been assessed from routine clinical use in a major university hospital in Germany. Endoscopes have been assessed with an ATP system and microbial cultures at different timepoints during the reprocessing. Findings: After the bedside flush the mean ATP level in relative light units (RLU) was 19,437 RLU, after the manual cleaning 667 RLU and after the automated endoscope reprocessor (AER) 227 RLU. After the manual cleaning the mean total viable count (TVC) per endoscope was 15.3 CFU/10 ml, and after the AER 5.7 CFU/10 ml. Our results show that there are reprocessing cycles which are not able to clean a patient used endoscope. Conclusion: Our data suggest that monitoring of flexible endoscope with ATP can identify a number of different influence factors, like the endoscope condition and the endoscopic procedure, or especially the quality of the bedside flush and manual cleaning before the AER. More process control is one option to identify and improve influence factors to finally increase the overall reprocessing quality, best of all by different methods. ATP measurement seems to be a valid technique that allows an immediate repeat of the manual cleaning if the ATP results after manual cleaning exceed the established cutoff of 200 RLU.
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Affiliation(s)
| | - Doris Stiefenhöfer
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
| | | | | | - Dana Dopadlik
- Department of Hospital Hygiene, University Hospital Essen, Germany
| | - Frank Mosel
- Department of Clinical Microbiology, University Hospital Essen, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
| | | | - Christoph Jochum
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - Jan Buer
- Department of Clinical Microbiology, University Hospital Essen, Germany
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El Fouly A, Best J, Mueller S, Theysohn J, Bockisch A, Gerken G, Canbay A, Dechêne A. C-Reactive Protein the Best Survival Predictor in 100 HCCs with Portal Vein Thrombosis after Radioembolization with Yttrium-90. Z Gastroenterol 2016. [DOI: 10.1055/s-0036-1597459] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Affiliation(s)
- A El Fouly
- Essen University Hospitals, Hepatology & Gastroenterology, Essen, Germany
| | - J Best
- Essen University Hospitals, Hepatology & Gastroenterology, Essen, Germany
| | - S Mueller
- Essen University Hospitals, Institute for Nuclear Medicine, Essen, Germany
| | - J Theysohn
- Essen University Hosptial, Institute for Diagnostic and Interventional Radiology and Neuroradiology, Essen, Germany
| | - A Bockisch
- Essen University Hospitals, Institute for Nuclear Medicine, Essen, Germany
| | - G Gerken
- Essen University Hospitals, Hepatology & Gastroenterology, Essen, Germany
| | - A Canbay
- Essen University Hospitals, Hepatology & Gastroenterology, Essen, Germany
| | - A Dechêne
- Essen University Hospitals, Hepatology & Gastroenterology, Essen, Germany
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Best J, Bilgi H, Heider D, Schotten C, Manka P, Bedreli S, Gorray M, Ertle J, van Grunsven LA, Dechêne A. The GALAD scoring algorithm based on AFP, AFP-L3, and DCP significantly improves detection of BCLC early stage hepatocellular carcinoma. Z Gastroenterol 2016; 54:1296-1305. [PMID: 27936479 DOI: 10.1055/s-0042-119529] [Citation(s) in RCA: 66] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
Background: Hepatocellular carcinoma (HCC) is one of the leading causes of death in cirrhotic patients worldwide. The detection rate for early stage HCC remains low despite screening programs. Thus, the majority of HCC cases are detected at advanced tumor stages with limited treatment options. To facilitate earlier diagnosis, this study aims to validate the added benefit of the combination of AFP, the novel biomarkers AFP-L3, DCP, and an associated novel diagnostic algorithm called GALAD. Material and methods: Between 2007 and 2008 and from 2010 to 2012, 285 patients newly diagnosed with HCC and 402 control patients suffering from chronic liver disease were enrolled. AFP, AFP-L3, and DCP were measured using the µTASWako i30 automated immunoanalyzer. The diagnostic performance of biomarkers was measured as single parameters and in a logistic regression model. Furthermore, a diagnostic algorithm (GALAD) based on gender, age, and the biomarkers mentioned above was validated. Results: AFP, AFP-L3, and DCP showed comparable sensitivities and specifities for HCC detection. The combination of all biomarkers had the highest sensitivity with decreased specificity. In contrast, utilization of the biomarker-based GALAD score resulted in a superior specificity of 93.3 % and sensitivity of 85.6 %. In the scenario of BCLC 0/A stage HCC, the GALAD algorithm provided the highest overall AUROC with 0.9242, which was superior to any other marker combination. Conclusions: We could demonstrate in our cohort the superior detection of early stage HCC with the combined use of the respective biomarkers and in particular GALAD even in AFP-negative tumors.
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Affiliation(s)
- J Best
- Universitätsklinikum Essen, Klinik für Gastroenterologie und Hepatologie, Essen, Germany
| | - H Bilgi
- Universitätsklinikum Essen, Klinik für Gastroenterologie und Hepatologie, Essen, Germany
| | - D Heider
- Straubing Center of Science, Department of Bioinformatics, Straubing, Germany
| | - C Schotten
- Universitätsklinikum Essen, Klinik für Gastroenterologie und Hepatologie, Essen, Germany
| | - P Manka
- Universitätsklinikum Essen, Klinik für Gastroenterologie und Hepatologie, Essen, Germany
| | - S Bedreli
- Universitätsklinikum Essen, Klinik für Gastroenterologie und Hepatologie, Essen, Germany
| | - M Gorray
- Universitätsklinikum Essen, Klinik für Gastroenterologie und Hepatologie, Essen, Germany
| | - J Ertle
- Universitätsklinikum Essen, Klinik für Gastroenterologie und Hepatologie, Essen, Germany
| | - L A van Grunsven
- Vrije Universiteit Brussel (VUB Jette), Liver Cell Biology Laboratory, Brussels, Belgium
| | - A Dechêne
- Universitätsklinikum Essen, Klinik für Gastroenterologie und Hepatologie, Essen, Germany
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Buechter M, Penndorf V, Canbay A, Theysohn JM, Dechêne A. Multimodal therapy of recurrent and refractory bleeding from esophageal varices - case report and review of the literature. Z Gastroenterol 2016; 54:1320-1326. [PMID: 27875848 DOI: 10.1055/s-0042-117227] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Bleeding from esophageal varices is a major cause of mortality in patients with advanced liver disease. Although standard treatment and secondary prophylaxis are effective, in some patients sustained hemostasis cannot be achieved. We report the case of a woman with alcoholic liver disease in whom pharmacological, endoscopic, and intravascular therapies failed to control variceal bleeding. Only a combination of (repeated) band ligation, insertion of a self-expanding metal stent, TIPS implantation and redilatation, transjugular variceal embolization, and finally implantation of a portocaval shunt proved to be successful. We discuss the stepwise approach to this situation and the challenges encountered in the process.
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Affiliation(s)
- M Buechter
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - V Penndorf
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - A Canbay
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - J M Theysohn
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany
| | - A Dechêne
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
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Buechter M, Theysohn JM, Kahraman A, Manka P, Gerken G, Canbay A, Dechêne A. Rescue therapy of a refractory rectal variceal bleeding in a cirrhotic patient by Linton-Nachlas tube and TIPS implantation in combination with variceal embolization. Z Gastroenterol 2016; 55:50-55. [PMID: 27706545 DOI: 10.1055/s-0042-116234] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/20/2022]
Abstract
Background Transjugular intrahepatic portosystemic shunt (TIPS) is considered the gold standard for treatment of gastrointestinal variceal bleeding refractory to endoscopic therapy in patients with portal hypertension. Clinically relevant hemorrhage from rectal varices is less frequent than from other sources, and the therapeutic role of TIPS is still ambiguous. Case report A 57-year-old female patient was referred to us in December 2015 with severe signs of decompensated alcohol-induced liver cirrhosis. During hospitalization, she presented with recurrent hematochezia from rectal varices following electrosurgical snare removal of a rectal adenoma. Endoscopic treatment with hemoclips, epinephrine and fibrin glue injections, and thermocoagulation failed to permanently stop the bleeding. Recurrent hemorrhage led to a further deterioration of liver function and clinical status of the patient. After a total of 3 endoscopic treatment attempts, hemostasis was achieved by transanal placement of a Linton-Nachlas balloon tube. Additionally, TIPS implantation with embolization of the rectal varices was performed successfully 24 hours after tube insertion, resulting in reduction of the portosystemic pressure gradient from 24 to 12 mmHg. Subsequently, the patient recovered clinically, hemopressin and catecholamine treatment was discontinued, and liver function test as well as serum hemoglobin levels improved. No further blood transfusions were required. Conclusion In this patient, rescue therapy with balloon compression and TIPS implantation in combination with variceal embolization in a cirrhotic patient with refractory rectal variceal bleeding was effective. To our knowledge, it is the first description of this specific therapeutic approach.
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Affiliation(s)
- Matthias Buechter
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - Jens M Theysohn
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Germany
| | - Alisan Kahraman
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - Paul Manka
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital Essen, Germany
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Kasper S, Meiler J, Knipp H, Höhler T, Reimer P, Steinmetz H, Berger W, Linden G, Ting S, Markus P, Paul A, Dechêne A, Schumacher B, Kostbade K, Worm K, Schmid K, Herold T, Schuler M, Trarbach T. Cetuximab biweekly (q2w) plus mFOLFOX6 as 1st line therapy in patients (pts) with KRAS wild-type (wt) (exon 2) metastatic colorectal cancer (mCRC) – Primary endpoint and subgroup analysis of the CEBIFOX trial. Ann Oncol 2016. [DOI: 10.1093/annonc/mdw370.56] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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Best J, Schotten C, Theysohn JM, Wetter A, Müller S, Radünz S, Schulze M, Canbay A, Dechêne A, Gerken G. Novel implications in the treatment of hepatocellular carcinoma. Ann Gastroenterol 2016; 30:23-32. [PMID: 28042235 PMCID: PMC5198244 DOI: 10.20524/aog.2016.0092] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/23/2016] [Accepted: 08/29/2016] [Indexed: 02/06/2023] Open
Abstract
Worldwide hepatocellular carcinoma remains one of the leading causes of cancer-related death, associated with a poor prognosis due to late diagnosis in the majority of cases. Physicians at care are frequently confronted with patients who are ineligible for curative treatment such as liver resection, transplantation or radiofrequency ablation. Besides established palliative locoregional therapies, such as ablation or chemoembolization, new treatment options, such as microwave ablation, drug-eluting bead transarterial chemoembolization or selective internal radiation therapy, are emerging; however, data from randomized controlled trials are still lacking. In order to achieve optimal tumor control, patients should receive tailored treatment concepts, considering their tumor burden, liver function and performance status, instead of strictly assigning patients to treatment modalities following algorithms that may be partly very restrictive. Palliative locoregional pretreatment might facilitate downstaging to ensure later curative resection or transplantation. In addition, the combined utilization of different locoregional treatment options or systemic co-treatment has been the subject of several trials. In cases where local tumor control cannot be achieved, or in the scenario of extrahepatic spread, sorafenib remains the only approved systemic therapy option. Alternative targeted therapies, such as immune checkpoint inhibitors have shown encouraging preliminary results, while data from phase III studies are pending.
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Affiliation(s)
- Jan Best
- Department of Gastroenterology and Hepatology (Jan Best, Clemens Schotten, Ali Canbay, Alexander Dechêne, Guido Gerken)
| | - Clemens Schotten
- Department of Gastroenterology and Hepatology (Jan Best, Clemens Schotten, Ali Canbay, Alexander Dechêne, Guido Gerken)
| | - Jens M Theysohn
- Departments of Diagnostic and Interventional Radiology and Neuroradiology (Jens M. Theysohn, Axel Wetter)
| | - Axel Wetter
- Departments of Diagnostic and Interventional Radiology and Neuroradiology (Jens M. Theysohn, Axel Wetter)
| | | | - Sonia Radünz
- Departments of Transplant and General Surgery (Sonia Radünz, Maren Schulze), University Hospital Essen, Essen, Germany
| | - Maren Schulze
- Departments of Transplant and General Surgery (Sonia Radünz, Maren Schulze), University Hospital Essen, Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology and Hepatology (Jan Best, Clemens Schotten, Ali Canbay, Alexander Dechêne, Guido Gerken)
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology (Jan Best, Clemens Schotten, Ali Canbay, Alexander Dechêne, Guido Gerken)
| | - Guido Gerken
- Department of Gastroenterology and Hepatology (Jan Best, Clemens Schotten, Ali Canbay, Alexander Dechêne, Guido Gerken)
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Schelhorn J, Best J, Dechêne A, Göbel T, Bertram S, Lauenstein T, Kinner S. Evaluation of combined Gd-EOB-DTPA and gadobutrol magnetic resonance imaging for the prediction of hepatocellular carcinoma grading. Acta Radiol 2016; 57:932-8. [PMID: 26586852 DOI: 10.1177/0284185115616293] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2015] [Accepted: 10/15/2015] [Indexed: 12/23/2022]
Abstract
BACKGROUND Tumor biopsy is not essential for the diagnosis of hepatocellular carcinoma (HCC); however, grading remains important for the prognosis. PURPOSE To investigate whether combined Gd-EOB-DTPA and gadobutrol liver magnetic resonance imaging (MRI) can predict HCC grading. MATERIAL AND METHODS Thirty patients (66.6 ± 7.3 years) with histologically confirmed HCC (grade 1, n = 5; grade 1-2, n = 6; grade 2, n = 13; grade 2-3, n = 2; grade 3, n = 4) underwent two liver MRIs, one with gadobutrol and one with Gd-EOB-DTPA, on consecutive days. Blinded to grading, two radiologists reviewed the gadobutrol and Gd-EOB-DTPA images in consensus with respect to: (i) HCC hyper-/iso-/hypointensity in the arterial, portal-venous/delayed, and Gd-EOB-DTPA hepatocellular phase; and (ii) morphologic tumor features (encapsulated growth, vessel invasion, heterogeneity, liver capsule infiltration, satellite metastases). RESULTS A significant correlation with grading was not found for either the combined dynamic information of all gadobutrol phases (r = -0.187, P = 0.331) or all the Gd-EOB-DTPA phases (r = 0.052, P = 0.802). No correlation with grading was found for a combination of arterial and hepatocellular phase in Gd-EOB-DTPA MRI (r = 0.209, P = 0.305), a combination of both arterial phases (gadobutrol and Gd-EOB-DTPA) with the Gd-EOB-DTPA hepatocellular phase (r = 0.240, P = 0.248), or a combination of all available gadobutrol and Gd-EOB-DTPA phases (r = 0.086, P = 0.691). For all gadobutrol information (dynamic phases and morphology; r = 0.049, P = 0.801) and for all Gd-EOB-DTPA information (r = 0.040, P = 0.845), no correlation with grading was found. Hepatocellular Gd-EOB-DTPA phase iso-/hyperintensity never occurred in grade 3 HCCs. CONCLUSION Histological HCC grading cannot be predicted by combined Gd-EOB-DTPA/gadobutrol MRI. However, Gd-EOB-DTPA hepatocellular phase iso-/hyperintensity was never detected in grade 3 HCCs.
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Affiliation(s)
- Juliane Schelhorn
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Jan Best
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
| | - Thomas Göbel
- Department of Gastroenterology and Hepatology, Petrus Hospital, Wuppertal, Germany
| | - Stefanie Bertram
- Department of Pathology, University Hospital Essen, Essen, Germany
| | - Thomas Lauenstein
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
| | - Sonja Kinner
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Essen, Germany
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Dechêne A, Sowa JP, Schlattjan M, Wree A, Blomeyer S, Best J, Maldonado EJ, Bechmann LP, Gerken G, Baba HA, Syn WK, Canbay A. Mini-laparoscopy guided liver biopsy increases diagnostic accuracy in acute liver failure. Digestion 2015; 90:240-7. [PMID: 25531058 DOI: 10.1159/000366517] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2014] [Accepted: 08/10/2014] [Indexed: 02/04/2023]
Abstract
BACKGROUND/AIMS For diagnosis, prognosis, and treatment of acute liver failure (ALF), macroscopic evaluation and histological assessment of the liver are important. Due to impaired coagulation in ALF, the risk of bleeding is high after a percutaneous liver biopsy. Our aims were to assess (i) safety and benefit of mini laparoscopy (ML) in patients with ALF and (ii) the potential utility of histological markers in ALF prognosis. METHODS ML was performed in 39 patients with ALF to assess liver surface and to obtain a liver biopsy. Serological markers of liver injury and immunohistochemical detection of cell death and proliferation were compared to a non-ALF group (n = 10). RESULTS Liver biopsies were successfully performed in all patients with no significant complications. All patients had markedly elevated M30 and M65 levels in the serum. In the liver, M30 and Ki67 immune-reactive cells were more abundant in those with ALF. Importantly, there were significantly more Ki67-positive cells but fewer M30-positive cells in livers of ALF patients who recovered spontaneously. CONCLUSION ML with liver biopsy in patients with ALF and severe coagulopathy is safe. Immunohistochemical detection of liver cell death and regeneration may identify individuals who would recover spontaneously or who would need a liver transplant.
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Affiliation(s)
- Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Germany
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Dechêne A, Kodde C, Kathemann S, Treckmann J, Lainka E, Paul A, Gerken G, Feldstein AE, Hoyer PF, Canbay A. Endoscopic treatment of pediatric post-transplant biliary complications is safe and effective. Dig Endosc 2015; 27:505-511. [PMID: 25545826 DOI: 10.1111/den.12420] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/17/2014] [Accepted: 12/19/2014] [Indexed: 12/13/2022]
Abstract
BACKGROUND AND AIM Biliary complications (BC) after liver transplantation (LT) are associated with significant morbidity and mortality. Incidence of BC after pediatric LT is more than 10%. In adults, treatment by endoscopic retrograde cholangiopancreaticography (ERCP) is successful. As data in pediatric patients are limited, endoscopic treatment of BC in a pediatric cohort in a German transplant center was analyzed. METHODS LT recipients <18 years of age who were endoscopically treated for BC at University Hospital Essen were retrospectively analyzed. Characteristics of LT, endoscopic treatment measures, clinical and endoscopic presentation of BC, and outcomes after endoscopic treatment were evaluated. RESULTS Seventeen patients (median age 12 years) with clinical signs of BC were treated endoscopically using ERCP. Eleven patients had received a full-size liver, and six a left-sided living-donor transplant graft. In 12 patients, the bile ducts were accessible via Vater's papilla and five patients had a bilioenteric anastomosis. Biliary sphincterotomy was done in 13 patients. Eleven patients presented with stricture of the biliary anastomosis (AST), either isolated (nine) or in combination with biliary cast syndrome (BCS) or biliary leakage (one patient each). Ischemia-type biliary lesions (ITBL) were found in two patients. Five patients suffered from BCS, either as isolated pathology (two) or in combination with AST, bile leak or ITBL. In one patient, biliary access via the major papilla was not obtainable. CONCLUSIONS BC in pediatric LT were treated safely and successfully in pediatric patients when the biliary tract was accessible. The most common complications were AST, BCS and ITBL.
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Affiliation(s)
- Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Cathrin Kodde
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Simone Kathemann
- Department of Pediatrics II, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Jürgen Treckmann
- Department of General Surgery and Transplantation, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Elke Lainka
- Department of Pediatrics II, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Andreas Paul
- Department of General Surgery and Transplantation, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Ariel E Feldstein
- Department of Pediatrics, University of California San Diego (UCSD), San Diego, USA
| | - Peter F Hoyer
- Department of Pediatrics II, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
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El Fouly A, Ertle J, El Dorry A, Shaker MK, Dechêne A, Abdella H, Mueller S, Barakat E, Lauenstein T, Bockisch A, Gerken G, Schlaak JF. In intermediate stage hepatocellular carcinoma: radioembolization with yttrium 90 or chemoembolization? Liver Int 2015; 35:627-35. [PMID: 25040497 DOI: 10.1111/liv.12637] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/28/2013] [Accepted: 07/01/2014] [Indexed: 02/13/2023]
Abstract
BACKGROUND & AIMS Transarterial chemoembolization (TACE) is one of the standard treatments recommended for intermediate stage hepatocellular carcinoma (HCC). At the same time, only little is known about the use of radioembolization with Yttrium-90 microspheres (TARE Y-90) for this subset of patients. To perform comparative analysis between both locoregional therapies in intermediate HCCs. Primary endpoint was overall survival (OS), while safety, response rate and time-to-progression (TTP) were considered as secondary endpoints. METHODS We collected data of 86 HCC patients in two university hospitals at which conventional TACE with doxorubicin or TARE Y-90 using glass microspheres were performed. The median observation period was 10 months. Patients were followed up for signs of toxicity and response. They underwent imaging analysis at baseline and follow-up at regular time intervals. RESULTS Eighty-six HCC patients with intermediate stage B (BCLC) were treated with either TACE (n = 42) or TARE Y-90 (n = 44). Despite a higher tumour burden in the TARE Y-90 group, the median OS (TACE: 18 months vs. TARE Y-90: 16.4 months) and the median TTP (TACE: 6.8 months vs. TARE Y-90: 13.3 months) were not statistically different. The number of treatment sessions, the average rate of treatment sessions per patient, total hospitalization time and rate of adverse events were significantly higher in the TACE cohort. CONCLUSION In intermediate HCC stage patients, both treatments resulted in similar survival probabilities despite more advanced disease in the TARE Y-90 group. Still, TARE Y-90 was better tolerated and associated with less hospitalization and treatment sessions.
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Affiliation(s)
- Amr El Fouly
- Department of Hepatology and Gastroenterology, University Hospital of Essen, Essen, Germany; Tropical Medicine Dep., Ain Shams University Hospital, Cairo, Egypt; Egyptian Atomic Energy Authority, Cairo, Egypt
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Lankisch T, Bektas H, Dechêne A, Ehlken H, Kirchner GI, Lang H, Schramm C. Acute and Chronic Inflammation of the Biliary System. Visc Med 2015; 31:200-3. [PMID: 26468316 PMCID: PMC4569206 DOI: 10.1159/000434663] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Tim Lankisch
- Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Hanover, Germany
- *Prof. Dr. med. Tim Lankisch, Klinik für Gastroenterologie, Hepatologie und Endokrinologie, Zentrum Innere Medizin, Medizinische Hochschule Hannover, Carl-Neuberg-Straße 1, 30625 Hannover, Germany,
| | - Hüseyin Bektas
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Medizinische Hochschule Hannover, Hanover, Germany
| | - Alexander Dechêne
- Klinik für Gastroenterologie und Hepatologie, Universitätsklinikum Essen, Essen, Germany
| | - Hanno Ehlken
- I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
| | - Gabriele I. Kirchner
- Klinik und Poliklinik für Innere Medizin I, Universitätsklinikum Regensburg, Regensburg, Germany
| | - Hauke Lang
- Klinik für Allgemein-, Viszeral- und Transplantationschirurgie, Universitätsmedizin Mainz, Mainz, Germany
| | - Christoph Schramm
- I. Medizinische Klinik und Poliklinik, Universitätsklinikum Hamburg-Eppendorf, Hamburg, Germany
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Schelhorn J, Best J, Reinboldt MP, Dechêne A, Gerken G, Ruhlmann M, Lauenstein TC, Antoch G, Kinner S. Does diffusion-weighted imaging improve therapy response evaluation in patients with hepatocellular carcinoma after radioembolization? comparison of MRI using Gd-EOB-DTPA with and without DWI. J Magn Reson Imaging 2014; 42:818-27. [DOI: 10.1002/jmri.24827] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2014] [Accepted: 12/01/2014] [Indexed: 12/29/2022] Open
Affiliation(s)
- Juliane Schelhorn
- Department of Diagnostic and Interventional Radiology and Neuroradiology; University Hospital Essen; Germany
| | - Jan Best
- Department of Gastroenterology und Hepatology; University Hospital Essen; Essen, Germany
| | - Marcus P. Reinboldt
- Department of Diagnostic and Interventional Radiology and Neuroradiology; University Hospital Essen; Germany
| | - Alexander Dechêne
- Department of Gastroenterology und Hepatology; University Hospital Essen; Essen, Germany
| | - Guido Gerken
- Department of Gastroenterology und Hepatology; University Hospital Essen; Essen, Germany
| | - Marcus Ruhlmann
- Clinic of Nuclear Medicine; University Hospital Essen; Essen, Germany
| | - Thomas C. Lauenstein
- Department of Diagnostic and Interventional Radiology and Neuroradiology; University Hospital Essen; Germany
| | - Gerald Antoch
- Department of Diagnostic and Interventional Radiology; Medical Faculty, University Dusseldorf; Dusseldorf Germany
| | - Sonja Kinner
- Department of Diagnostic and Interventional Radiology and Neuroradiology; University Hospital Essen; Germany
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Dechêne A, Jochum C, Fingas C, Paul A, Heider D, Syn WK, Gerken G, Canbay A, Zöpf T. Endoscopic management is the treatment of choice for bile leaks after liver resection. Gastrointest Endosc 2014; 80:626-633.e1. [PMID: 24796959 DOI: 10.1016/j.gie.2014.02.1028] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/09/2013] [Accepted: 02/27/2014] [Indexed: 02/08/2023]
Abstract
BACKGROUND Despite improvements in surgical techniques and postoperative patient care, bile leaks still occur postoperatively in as many as 15% of liver resections (LRs) and are associated with high mortality. There is a paucity of outcome data on endoscopic treatment of complex bile leaks. OBJECTIVE The aim of this retrospective study was to evaluate the efficacy of interventional endoscopy in the treatment of bile leaks after LR. DESIGN Retrospective interventional study. SETTING, PATIENTS, AND INTERVENTIONS Sixty patients with bile leaks after LR were treated endoscopically with or without implantation of endoprostheses by using ERCP. The characteristics of LR, effects of surgical and other nonendoscopic treatment measures, clinical and endoscopic presentation of bile leaks, and outcomes after stent placement were recorded. MAIN OUTCOME MEASURE Main outcome measure was resolution of leakage or termination of unsuccessful endoscopic leakage therapy. RESULTS The median age of the observed cohort was 58 years. Sixty-five percent of patients had central and 35% peripheral bile leaks; 55% had resection of an entire hepatic lobe, and 45% underwent segmental resection. The overall success rate of endoscopic therapy was 77%. Although endoscopic therapy was performed in all patients with a mean of 2.6 interventions, 28% underwent additional percutaneous drainage. Success of endoscopic treatment was related to stent implantation. Thirteen patients with unsuccessful endoscopic treatment underwent surgical reintervention, and 1 patient died before surgical intervention. LIMITATIONS No standardized protocol for stent placement due to retrospective nature of the study. Small sample number with uneven distribution of outcome. CONCLUSIONS Endoscopic therapy with sphincterotomy and insertion of endoprostheses is effective, even in large postoperative bile leaks and particularly for leaks proximal to the common hepatic duct. Complete resolution of the leakage often necessitates multiple treatment sessions.
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Affiliation(s)
- Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Christoph Jochum
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Christian Fingas
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany; Department of General Surgery and Transplantation, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Andreas Paul
- Department of General Surgery and Transplantation, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Dominik Heider
- Department of Bioinformatics, Center for Medical Biotechnology, University of Duisburg-Essen, Essen, Germany
| | - Wing-Kin Syn
- Regeneration and Repair Group, The Institute of Hepatology, London, United Kingdom
| | - Guido Gerken
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Ali Canbay
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany
| | - Thomas Zöpf
- Department of Gastroenterology and Hepatology, University Hospital, University Duisburg-Essen, Essen, Germany; Department of Internal Medicine and Gastroenterology, Diakonissen-Krankenhaus Rüppurr, Karlsruhe, Germany
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Lenz P, Eckelskemper F, Erichsen T, Lankisch T, Dechêne A, Lubritz G, Lenze F, Beyna T, Ullerich H, Schmedt A, Domagk D. Prospective observational multicenter study to define a diagnostic algorithm for biliary candidiasis. World J Gastroenterol 2014; 20:12260-12268. [PMID: 25232260 PMCID: PMC4161811 DOI: 10.3748/wjg.v20.i34.12260] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/11/2013] [Revised: 01/14/2014] [Accepted: 04/29/2014] [Indexed: 02/07/2023] Open
Abstract
AIM: To develop an algorithm to improve the diagnosis and treatment of patients with biliary candidiasis.
METHODS: We performed a prospective study of 127 patients who underwent endoscopic retrograde cholangiopancreatography, for various biliary disorders, at 3 tertiary referral centers in Germany from July 2011 through July 2012 (ClinicalTrials.gov: NCT01109550). Bile, buccal, and stool samples were collected. When indicated, endoscopic transpapillary bile duct biopsies were performed to clarify the etiology of bile duct strictures and to prove invasive fungal infections.
RESULTS: Candida species were detected in 38 of the 127 bile samples (29.9%). By multivariate analysis patients’ age and previous endoscopic sphincterotomy were independent risk factors for biliary candidiasis (P < 0.05). Patients with immunosuppression (P = 0.058) and recent long-term antibiotic therapy (> 7 d) (P = 0.089) tend to be at risk for biliary candidiasis. One patient was negative in mycological culture of bile fluid but invasive biliary candidiasis was diagnosed histologically. Of Candida subspecies detected, 36.7% were azole-resistant, such as C glabrata. Eight patients received anti-mycotic therapy, based on our algorithm. Of these, 3 had cancer with biliary tract involvement, 2 had secondary sclerosing cholangitis, 1 had retroperitoneal fibrosis, and 5 had septicemia. In all patients contamination was ruled out by smears of the endoscope channel.
CONCLUSION: Gastroenterologists should be aware of frequent candida colonization in patients with cholangitis and biliary disorders. Our suggested algorithm facilitates the further clinical management.
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Hoerning A, Raub S, Dechêne A, Brosch MN, Kathemann S, Hoyer PF, Gerner P. Diversity of disorders causing neonatal cholestasis - the experience of a tertiary pediatric center in Germany. Front Pediatr 2014; 2:65. [PMID: 25003101 PMCID: PMC4066316 DOI: 10.3389/fped.2014.00065] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2013] [Accepted: 06/01/2014] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND AND OBJECTIVE Rapidly establishing the cause of neonatal cholestasis is an urgent matter. The aim of this study was to report on the prevalence and mortality of the diverse disorders causing neonatal cholestasis in an academic center in Germany. METHODS Clinical chemistry and cause of disease were retrospectively analyzed in 82 infants (male n = 42, 51%) that had presented with neonatal cholestasis to a tertiary medical center from January 2009 to April 2013. RESULTS Altogether, 19 disorders causing neonatal cholestasis were identified. Biliary atresia was the most common diagnosis (41%), followed by idiopathic cases (13%), progressive familial intrahepatic cholestasis (PFIC, 10%), cholestasis in preterm infants (10%), α1AT deficiency, Alagille syndrome, portocaval shunts, mitochondriopathy, biliary sludge (all 2%), and others. Infants with biliary atresia were diagnosed with a mean age of 62 days, they underwent Kasai portoenterostomy ~66 days after birth. The majority of these children (~70%) received surgery within 10 weeks of age and 27% before 60 days. The 2-year survival with their native liver after Kasai procedure was 12%. The time span between Kasai surgery and liver transplantation was 176 ± 73 days. Six children (7%), of whom three patients had a syndromic and one a non-syndromic biliary atresia, died prior to liver transplantation. The pre- and post-transplant mortality rate for children with biliary atresia was ~12 and ~17%, respectively. CONCLUSION Neonatal cholestasis is a severe threat associated with a high risk of complications in infancy and it therefore requires urgent investigation in order to initiate life saving therapy. Although in the last 20 years new causes such as the PFICs have been identified and newer diagnostic tools have been introduced into the clinical routine biliary atresia still represents the major cause.
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Affiliation(s)
- André Hoerning
- Department for Pediatric Nephrology, Gastroenterology, Endocrinology and Transplant Medicine, Clinic for Pediatrics II, University Children's Hospital Essen, University Duisburg-Essen , Essen , Germany ; Department of Pediatrics and Adolescent Medicine, University Children's Hospital Erlangen, Friedrich-Alexander University , Erlangen , Germany
| | - Simon Raub
- Department for Pediatric Nephrology, Gastroenterology, Endocrinology and Transplant Medicine, Clinic for Pediatrics II, University Children's Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Michelle N Brosch
- Department for Pediatric Nephrology, Gastroenterology, Endocrinology and Transplant Medicine, Clinic for Pediatrics II, University Children's Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Simone Kathemann
- Department for Pediatric Nephrology, Gastroenterology, Endocrinology and Transplant Medicine, Clinic for Pediatrics II, University Children's Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Peter F Hoyer
- Department for Pediatric Nephrology, Gastroenterology, Endocrinology and Transplant Medicine, Clinic for Pediatrics II, University Children's Hospital Essen, University Duisburg-Essen , Essen , Germany
| | - Patrick Gerner
- Department of Pediatrics and Adolescent Medicine, University Children's Hospital , Freiburg , Germany
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Wiesweg M, Ting S, Reis H, Worm K, Kasper S, Tewes M, Welt A, Richly H, Meiler J, Bauer S, Hense J, Gauler TC, Köhler J, Eberhardt WE, Darwiche K, Freitag L, Stamatis G, Breitenbücher F, Wohlschlaeger J, Theegarten D, Derks C, Cortes-Incio D, Linden G, Skottky S, Lütkes P, Dechêne A, Paul A, Markus P, Schmid KW, Schuler M. Feasibility of preemptive biomarker profiling for personalised early clinical drug development at a Comprehensive Cancer Center. Eur J Cancer 2013; 49:3076-82. [DOI: 10.1016/j.ejca.2013.06.014] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2013] [Accepted: 06/13/2013] [Indexed: 12/20/2022]
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Kaiser GM, Paul A, Sgourakis G, Molmenti EP, Dechêne A, Trarbach T, Stuschke M, Baba HA, Gerken G, Sotiropoulos GC. Novel prognostic scoring system after surgery for Klatskin tumor. Am Surg 2013; 79:90-95. [PMID: 23317618] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 06/01/2023]
Abstract
Klatskin tumor is a rare hepatobiliary malignancy whose outcome and prognostic factors are not clearly documented. Between April 1998 and January 2007, 96 patients with hilar cholangiocarcinoma underwent resection. Data were collected prospectively. Thirty-one variables were evaluated for prognostic significance. There were 40 trisectionectomies, 40 hemihepatectomies, five central hepatectomies, and 11 biliary hilar resections. Thirty-seven (n = 37) patients required vascular reconstruction. There were 68 R0, 26 R1, and two R2 resections. Age (P = 0.048), pT status (P = 0.046), R class (P = 0.034), and adjuvant chemoradiation (P = 0.045) showed predictive significance by multivariate Cox proportional hazard regression analysis. A point scoring system was determined as follows: age younger than 62 years:age 62 years or older = 1:2 points; pT1:pT2 to 4 = 1:2 points; R0:R1/2 = 1:2 points; and chemoradiation yes:no = 1:2 points. The only model that reached statistical significance (P = 0.0332) described the following three groups: score 6 or less; score = 7; and score = 8. Median survival for score 6 or less, score = 7, and score = 8 was 26.5, 12, and 2.2 months, respectively (P = 0.032). The corresponding 1- and 3-year survival rates were 73 to 56 per cent, 52 to 38 per cent, and 17 to 0 per cent, respectively. We propose a scoring system predictive of long-term surgical outcome that could potentially improve patient selection for further postoperative oncologic treatment for Klatskin tumors.
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Affiliation(s)
- Gernot M Kaiser
- Department of General, Visceral and Transplantation Surgery, University Hospital Essen, Essen, Germany
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Dechêne A, El Fouly AH, Bechmann LP, Jochum C, Saner FH, Gerken G, Canbay A. Acute management of refractory variceal bleeding in liver cirrhosis by self-expanding metal stents. Digestion 2012; 85:185-91. [PMID: 22269340 DOI: 10.1159/000335081] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/08/2011] [Accepted: 11/15/2011] [Indexed: 02/04/2023]
Abstract
BACKGROUND AND AIMS Current treatment strategies of variceal bleeding (VB) include banding and sclerotherapy. However, up to 10% of bleeding events remain refractory to standard therapy with high mortality. With this study, we aimed to evaluate the implantation of self-expanding metal stents (SEMS) for the management of therapy-refractory variceal bleeding. PATIENTS AND METHODS Eight cirrhotic patients who presented to our unit with a total of 9 refractory bleeding events were treated by SEMS placement. RESULTS Stenting resulted in immediate hemostasis in all cases without recurrent bleeding with SEMS in situ. After stabilization, 1 patient was treated by transjugular intrahepatic portosystemic shunt (TIPS) and after the second bleeding episode by TIPS dilation. One patient underwent orthotopic liver transplantation (OLT). The remaining patients were treated with standard drug regimens to reduce portal pressure. The SEMS were removed after a median of 11 days. No acute hemorrhage was noted on stent retrieval. While no early rebleeding occurred in the patients after TIPS implant, TIPS dilation or OLT, 3 out of 5 patients on conservative treatment experienced recurrence of VB within 9 days after SEMS removal. CONCLUSIONS SEMS placement sufficiently stops hemorrhage in refractory VB. Due to the high rebleeding rate after conservative treatment alone following SEMS removal, this procedure may be utilized as a mere bridging method. Additional interventional and/or surgical methods to effectively reduce portal pressure (i.e. TIPS, OLT) should be considered. Further studies to evaluate the optimum treatment algorithm of refractory esophageal VB are warranted.
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Affiliation(s)
- A Dechêne
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
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45
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Iacob S, Cicinnati VR, Dechêne A, Lindemann M, Heinemann FM, Rebmann V, Ferencik S, Sotiropoulos GC, Popescu I, Horn PA, Gerken G, Paul A, Beckebaum S. Genetic, immunological and clinical risk factors for biliary strictures following liver transplantation. Liver Int 2012; 32:1253-61. [PMID: 22550960 DOI: 10.1111/j.1478-3231.2012.02810.x] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Accepted: 03/19/2012] [Indexed: 12/27/2022]
Abstract
BACKGROUND Biliary strictures after liver transplantation (LT) are a major cause of morbidity and reduced graft survival. AIMS The purpose of this study was to investigate genetic, immunological and clinical risk factors for the occurrence of post-LT ischaemic type biliary lesions (ITBLs) and biliary anastomotic strictures (AS). METHODS Clinical and laboratory data, chemokine receptor (CCR) genotypes, chemotactic cytokines and anti-major-histocompatibility complex antibodies in serum were investigated in 162 LT patients. RESULTS In the univariate analysis, older donor and recipient age, partial LT, high peak aspartate aminotransaminase (AST) levels and CC chemokine receptor 5 delta32 loss-of-function mutation (CCR5Δ32) were associated with ITBL, whereas LT for acute liver failure (ALF), ABO-compatible non-identical LT, presence of donor-specific anti-human leucocyte antigen (HLA) class II antibodies and fractalkine receptor (CX3CR1)-249II allele were associated with AS. In the multivariate analysis, CCR5Δ32 was an independent risk factor for ITBL, whereas LT for ALF, ABO-compatible non-identical LT, and CX3CR1-249II allele remained predictive for AS. Serum levels of interferon-gamma and interleukin (IL)-6 as well as IL-10 were significantly increased in patients with biliary strictures. CONCLUSION Specific chemokine receptor polymorphisms of the recipient are associated with development of post-LT biliary strictures. Altered cytokine profile may contribute to enhanced fibrotic tissue remodelling and biliary stricture formation. Screening of anti-HLA antibodies might be useful for early identification of at-risk patients who could benefit from closer surveillance and tailored immunosuppressive regimen. Our findings may have relevance for prediction and management of post-LT biliary strictures.
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Affiliation(s)
- Speranta Iacob
- Department of Gastroenterology, University Hospital Essen, Essen, Germany
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Zoepf T, Maldonado de Dechêne EJ, Dechêne A, Malágo M, Beckebaum S, Paul A, Gerken G, Hilgard P. Optimized endoscopic treatment of ischemic-type biliary lesions after liver transplantation. Gastrointest Endosc 2012; 76:556-63. [PMID: 22898414 DOI: 10.1016/j.gie.2012.04.474] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/06/2012] [Accepted: 04/30/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND Biliary strictures are the most common complication after liver transplantation. A particular problem is ischemic-type biliary lesions (ITBLs), which are often responsible for graft failure and early retransplantation. Although some encouraging results of successful endoscopic treatment have been reported, this has not yet resulted in a standardized therapeutic approach to date. OBJECTIVE To evaluate an optimized algorithm for the endoscopic treatment of ITBLs. SETTING AND PATIENTS All adult patients who underwent liver transplantation at the University of Essen between April 1998 and July 2006. DESIGN Retrospective outcome analysis. MAIN OUTCOME MEASUREMENTS Success or failure of 2 different therapeutic algorithms in terms of normalization of cholestasis parameters and graft survival. RESULTS Forty-eight patients who had undergone liver transplantation and had an endoscopically determined diagnosis of ITBL were identified. The median interval between liver transplantation and first endoscopic intervention was 242.5 (range, 16-3677) days. Patients received a median of 6 treatment sessions (range 2-13) every 8 to 10 weeks. In 16 of 48 patients, a combination of balloon dilation (BD) and implantation of a plastic endoprosthesis (BD+EP) was performed; in the remaining 32 patients, BD alone was performed. Overall, endoscopic therapy was successful in 73%. BD+EP was successful in 5 of 16 (31%) and BD alone in 30 of 32 patients (91%; P = .0027). In the BD+EP group, severe cholangitis developed in 25% of patients, but only 12% of the BD group (P = .01). The median duration of therapy was 374 (range 11-808) days. Six of 48 patients underwent retransplantation because of chronic graft rejection at a median of 1288 (range 883-4204) days after the primary liver transplantation. Six of 48 patients underwent hepaticojejunostomy because of unsuccessful endoscopic therapy, and 1 patient underwent surgery because of portal vein thrombosis. LIMITATIONS Retrospective design. CONCLUSIONS An endoscopic treatment regimen for ITBLs, preferably BD alone, could prolong the time to or could completely avoid surgical revision and early retransplantation and seems to be superior to endoscopic stenting.
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Affiliation(s)
- Thomas Zoepf
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
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Kinner S, Umutlu L, Dechêne A, Ladd SC, Barkhausen J, Gerken G, Lauenstein TC, Hunold P. Biliary complications after liver transplantation: addition of T1-weighted images to MR cholangiopancreatography facilitates detection of cast in biliary cast syndrome. Radiology 2012; 263:429-36. [PMID: 22517958 DOI: 10.1148/radiol.12111625] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
PURPOSE To evaluate the diagnostic performance of T2-weighted magnetic resonance (MR) cholangiopancreatography pulse sequences in comparison with MR cholangiopancreatography sequences combined with nonenhanced T1-weighted images in the detection of biliary cast syndrome in liver transplant recipients. MATERIALS AND METHODS This retrospective study was conducted in accordance with the declaration of Helsinki. Institutional review board approval was obtained. MR images in 95 patients who were examined after liver transplantation and who presented with symptoms of biliary obstruction were examined. Two separate sets of images, MR cholangiopancreatograms and MR cholangiopancreatograms plus T1-weighted images, were evaluated independently by three readers. Sensitivities, specificities, and positive and negative predictive values for biliary cast syndrome were calculated, and receiver operating characteristic curves were generated. The results of endoscopic retrograde cholangiopancreatography served as the reference standard. To determine interobserver agreement, κ values were calculated. RESULTS Cast appeared hyperintense on nonenhanced T1-weighted images. Sensitivities for T2-weighted MR cholangiopancreatography data alone were 0.65, 0.70, and 0.55 for the three readers. Adding unenhanced T1-weighted images resulted in sensitivities of 0.95, 0.90, and 0.90, respectively. Specificities for MR cholangiopancreatography alone and for MR cholangiopancreatography plus T1-weighted images were high on average (0.98, 0.97, and 0.97 vs 1.0 for all readers, respectively). Interobserver agreement was good for T2-weighted MR cholangiopancreatography (κ for readers 1 and 2 = 0.589, κ for readers 2 and 3 = 0.593, κ for readers 1 and 3 = 0.734) and was excellent for MR cholangiopancreatography plus T1-weighted images (κ for readers 1 and 2 = 0.806, κ for readers 2 and 3 = 0.881, κ for readers 1 and 3 = 0.848). CONCLUSION The combination of T2-weighted MR cholangiopancreatography and T1-weighted imaging yields higher diagnostic performance than MR cholangiopancreatography alone. Therefore, readers evaluating liver MR images with regard to biliary complications after liver transplantation should also look at the bile ducts on unenhanced T1-weighted images, as biliary cast might be more easily depicted on these images.
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Affiliation(s)
- Sonja Kinner
- Department of Diagnostic and Interventional Radiology, University Hospital Essen, Essen, Germany.
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Wree A, Dechêne A, Herzer K, Hilgard P, Syn WK, Gerken G, Canbay A. Steroid and ursodesoxycholic Acid combination therapy in severe drug-induced liver injury. Digestion 2011; 84:54-9. [PMID: 21304237 DOI: 10.1159/000322298] [Citation(s) in RCA: 68] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2010] [Accepted: 10/22/2010] [Indexed: 02/04/2023]
Abstract
BACKGROUND Drug-induced liver injury (DILI) is the leading cause of acute severe liver disease in Western countries. Treatment strategies for DILI are still not well defined. AIM We studied the safety and outcomes of steroid/ursodesoxycholic acid (UDCA) combination therapy in DILI patients. PATIENTS, MATERIALS AND METHODS 15 consecutive patients with severe DILI were analyzed for clinical, biochemical and histological data. Nine patients were treated with a steroid step-down therapy with reduction of the daily dose over several weeks; 6 patients received a steroid pulse therapy for 3 days. UDCA was administered for several weeks in both groups. RESULTS Patients without histological signs of preexistent liver damage (n = 10) showed the most favorable clinical course. Bilirubin and serum transaminases dropped to <50% of peak values within 2 weeks, and normalized within 4-8 weeks. In contrast, patients with positive autoimmune antibodies (anti-nuclear antibodies and/or soluble liver antigen) and/or histological features of chronic hepatitis (n = 3) exhibited a slower reduction in bilirubin and serum transaminase levels. These patients were given immunosuppressants (steroids, azathioprine) for a further 6 months. CONCLUSION Treatment of severe DILI with corticosteroids (both pulse and step-down therapy) and UDCA appears to be safe, and leads to a more rapid reduction in bilirubin and transaminases after DILI.
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Affiliation(s)
- Alexander Wree
- Department of Gastroenterolgy and Hepatology, University Hospital Essen, Essen, Germany
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Dechêne A, Jochum C, Bechmann LP, Windeck S, Gerken G, Canbay A, Zöpf T. Magnetic endoscopic imaging saves abdominal compression and patient pain in routine colonoscopies. J Dig Dis 2011; 12:364-70. [PMID: 21955429 DOI: 10.1111/j.1751-2980.2011.00524.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Magnetic endoscope imaging (MEI) is a technique for the direct visualisation of endoscope configuration within the colon. This method may prevent loop formation by giving visual feedback of endoscope movement. This study aimed to evaluate the efficacy of MEI in improving colonoscopy performance. METHODS Overall 1000 consecutive patients who underwent a complete routine colonoscopy were randomized into two groups: in group A with MEI, while in group B without MEI. Sedation was performed according to local standards. In both groups time to reach the cecum, the number of positioning maneuvers and involvement of a second assistant nurse were recorded. Abdominal compression was graded from 1 to 4 according to the duration and intensity of compression was quantified using a scale from 1-3 according to compression form and patient reaction. RESULTS Patients were randomized (group A with MEI, n = 490; group B without MEI, n = 510) and a total colonoscopy was performed. Time to cecal intubation did not differ between the groups (507 s vs 538 s; NS). The duration of abdominal compression was significantly shorter in MEI guided colonoscopy. The intensity of abdominal compression was lower in group A and fewer turn maneuvers needed per patient. A trend towards a reduced need for assistance in MEI group was seen. CONCLUSION Although MEI does not generally accelerate colonoscope advancement, it significantly reduces the force and the duration of abdominal compression by assistant personnel, thus minimizing patient discomfort and decreasing the need for additional staff.
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Affiliation(s)
- Alexander Dechêne
- Department of Gastroenterology and Hepatology, University Hospital Essen, Essen, Germany
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Wree A, Canbay A, Müller-Beissenhirtz H, Dechêne A, Gerken G, Dührsen U, Lammert F, Nückel H. Excessive bilirubin elevation in a patient with hereditary spherocytosis and intrahepatic cholestasis. Z Gastroenterol 2011; 49:977-80. [PMID: 21811948 DOI: 10.1055/s-0031-1273368] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/17/2022]
Abstract
Hereditary spherocytosis is a common hemolytic anemia with an estimated incidence of 1 / 2500 births. It is caused by a molecular defect in one or more of the proteins of the red blood cell cytoskeleton. Mutations in the ABCB11 gene, encoding the bile salt export pump, can entail progressive familial intrahepatic cholestasis and benign recurred intrahepatic cholestasis. A 18 year old Turkish patient with hereditary spherocytosis was admitted to hospital with pruritus and severe jaundice. Ultrasound examination presented stones in gallbladder and bile duct. After endoscopic retrograde cholangiography with extraction of small bile duct stones abdominal pain resolved and liver enzymes normalized within a few days, but bilirubin and bile acids remained highly elevated. Liver biopsy revealed a severe canalicular cholestasis. Genetic analysis showed the compound heterozygous variants ABCB11 A 444V and 3084A > G. Treatment with ursodesoxycholic acid and intermittent therapy with prednisone reduced pruritus and jaundice with concomitant improvement of blood test. Here we report the first case of a patient with combined hereditary spherocytosis and compound heterozygous ABCB11 gene variants predisposing to intrahepatic cholestasis. Therefore, patients with hemolytic disorders should be investigated for bile acid transporter diseases in case of hyperbilirubinemia and severe cholestasis.
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Affiliation(s)
- A Wree
- Dept. Gastroenterology and Hepatology, University Hospital Essen
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