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Trevisani F, Vitale A, Kudo M, Kulik L, Park JW, Pinato DJ, Cillo U. Merits and boundaries of the BCLC staging and treatment algorithm: Learning from the past to improve the future with a novel proposal. J Hepatol 2024; 80:661-669. [PMID: 38266658 DOI: 10.1016/j.jhep.2024.01.010] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 12/03/2023] [Accepted: 01/04/2024] [Indexed: 01/26/2024]
Abstract
In this Expert Opinion, we thoroughly analyse the Barcelona Clinic Liver Cancer (BCLC) staging and treatment algorithm for hepatocellular carcinoma (HCC) that, since 1999, has standardised HCC management, offering a structured approach for the prognostic evaluation and treatment of patients with HCC. The first part of the article presents the strengths and evolutionary improvements of the BCLC staging system. Nevertheless, both patient characteristics and available treatments have changed in the last two decades, limiting the role of the BCLC criteria for treatment allocation in a growing number of patients. As therapeutic options expand and become more effective, the stage-linked treatment decision-making algorithm may lead to undertreatment and suboptimal outcomes for patients with disease beyond early-stage HCC. Consequently, strict adherence to BCLC criteria is limited in expert centres, particularly for patients diagnosed beyond early-stage HCC. Although the BCLC system remains the benchmark against which other therapeutic frameworks must be judged, the era of precision medicine calls for patient-tailored therapeutic decision-making (by a multidisciplinary tumour board) rather than stage-dictated treatment allocation. Acknowledging this conceptual difference in clinical management, the second part of the article describes a novel "multiparametric therapeutic hierarchy", which integrates a comprehensive assessment of clinical factors, biomarkers, technical feasibility, and resource availability. Lastly, considering the increasing efficacy of locoregional and systemic treatments, the concept of "converse therapeutic hierarchy" is introduced. These treatments can increase the feasibility (conversion approach) and effectiveness (adjuvant approach of systemic therapy) of potentially curative approaches to greatly improve clinical outcomes.
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Affiliation(s)
- Franco Trevisani
- Unit of Semetiotics, Liver and Alcohol-related Disease, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy; Units of Semetiotics, Liver and Alcohol-related disease, Alma Mater Studiorum - University of Bologna, Bologna, Italy
| | - Alessandro Vitale
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy.
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | | | - Joon-Won Park
- Center for Liver and Pancreatobiliary Cancer, National Cancer Center, Goyang, Korea
| | - David J Pinato
- Department of Surgery & Cancer, Imperial College London, London, UK; Division of Oncology, Department of Translational Medicine (DIMET), The University of Piemonte Orientale "A. Avogadro", Novara, Italy
| | - Umberto Cillo
- Department of Surgical, Oncological and Gastroenterological Sciences, University of Padova, Padova, Italy
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Arvind A, Seif El Dahan K, Malhotra R, Daher D, Rich NE, Patel MS, VanWagner LB, Lieber SR, Cotter TG, Louissaint J, Mufti AR, Kulik L, Pillai A, Parikh ND, Singal AG. Association between bridging therapy and posttransplant outcomes in patients with HCC within Milan criteria: A systematic review and meta-analysis. Liver Transpl 2024:01445473-990000000-00339. [PMID: 38466889 DOI: 10.1097/lvt.0000000000000357] [Citation(s) in RCA: 0] [Impact Index Per Article: 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: 09/19/2023] [Accepted: 01/15/2024] [Indexed: 03/13/2024]
Abstract
Liver transplantation is the curative therapy of choice for patients with early-stage HCC. Locoregional therapies are often employed as a bridge to reduce the risk of waitlist dropout; however, their association with posttransplant outcomes is unclear. We conducted a systematic review using Ovid MEDLINE and EMBASE to identify studies published between database inception and August 2, 2023, which reported posttransplant recurrence-free survival and overall survival among patients transplanted for HCC within Milan criteria, stratified by receipt of bridging therapy. Pooled HRs were calculated for each outcome using the DerSimonian and Laird method for a random-effects model. We identified 38 studies, including 19,671 patients who received and 20,148 patients who did not receive bridging therapy. Bridging therapy was not associated with significant differences in recurrence-free survival (pooled HR: 0.91, 95% CI: 0.77-1.08; I2 =39%) or overall survival (pooled HR: 1.09, 95% CI: 0.95-1.24; I2 =47%). Results were relatively consistent across subgroups, including geographic location and study period. Studies were discordant regarding the differential strength of association by pretreatment tumor burden and pathologic response, but potential benefits of locoregional therapy were mitigated in those who received 3 or more treatments. Adverse events were reported in a minority of studies, but when reported occurred in 6%-15% of the patients. Few studies reported loss to follow-up and most had a risk of residual confounding. Bridging therapy is not associated with improvements in posttransplant recurrence-free or overall survival among patients with HCC within Milan criteria. The risk-benefit ratio of bridging therapy likely differs based on the risk of waitlist dropout.
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Affiliation(s)
- Ashwini Arvind
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Karim Seif El Dahan
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Riya Malhotra
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Darine Daher
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Nicole E Rich
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Madhukar S Patel
- Department of Surgery, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Lisa B VanWagner
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Sarah R Lieber
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Thomas G Cotter
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Jeremy Louissaint
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Arjmand R Mufti
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
| | - Laura Kulik
- Department of Internal Medicine, Northwestern Medicine, Chicago, Illinois, USA
| | - Anjana Pillai
- Department of Internal Medicine, University of Chicago, Chicago, Illinois, USA
| | - Neehar D Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Amit G Singal
- Department of Internal Medicine, UT Southwestern Medical Center, Dallas, Texas, USA
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Kalas V, Nguyen J, Wan AW, Dietch ZC, Kulik L, Hughes DL. Acute-on-Chronic Liver Failure Incited by Cyclin-Dependent Kinase Inhibitor Therapy for Breast Cancer Effectively Treated With Liver Transplantation. ACG Case Rep J 2024; 11:e01253. [PMID: 38274302 PMCID: PMC10810594 DOI: 10.14309/crj.0000000000001253] [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: 04/18/2023] [Accepted: 12/07/2023] [Indexed: 01/27/2024] Open
Abstract
Cyclin-dependent kinase 4/6 inhibitors are targeted therapies demonstrated to significantly improve overall survival as adjuvant treatment of estrogen receptor-positive breast cancers. Although intended to preferentially arrest cell cycle transitions in tumor cells, these agents can have undesirable systemic side effects, including hepatotoxicity. We report the first case of cyclin-dependent kinase 4/6 inhibitor therapy leading to acute-on-chronic liver failure requiring liver transplantation. Our case highlights the multidisciplinary approach required to manage acute-on-chronic liver failure induced by cancer-directed therapies in those with extrahepatic malignancies.
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Affiliation(s)
- Vasilios Kalas
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, IL
| | - Jessica Nguyen
- Department of Pathology, Northwestern University, Chicago, IL
| | - Alan W. Wan
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, IL
| | - Zachary C. Dietch
- Department of Transplant Surgery, Northwestern University, Chicago, IL
| | - Laura Kulik
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, IL
| | - Dempsey L. Hughes
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, IL
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4
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Kulik L. Untangling the web of waitlist dropout in HCC. Liver Transpl 2023; 29:1019-1020. [PMID: 37368024 DOI: 10.1097/lvt.0000000000000195] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2023] [Accepted: 06/08/2023] [Indexed: 06/28/2023]
Affiliation(s)
- Laura Kulik
- Department of Surgery (Organ Transplantation) and Interventional Radiology, Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Ranganathan S, Gabr A, Entezari P, Riaz A, Desai K, Thornburg B, Kulik L, Kalyan A, Salem R, Lewandowski RJ. Radioembolization for Intermediate Stage Hepatocellular Carcinoma Maintains Liver Function and Permits Systemic Therapy at Progression. J Vasc Interv Radiol 2023; 34:968-975. [PMID: 36791957 DOI: 10.1016/j.jvir.2022.11.036] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2022] [Revised: 11/02/2022] [Accepted: 11/19/2022] [Indexed: 02/16/2023] Open
Abstract
PURPOSE To assess the liver function trends in intermediate-stage (BCLC B) patients undergoing Y90-radioembolization (TARE) in response to a growing concern that that liver-directed therapies negatively impact liver function and prevent HCC patients from systemic therapy candidacy. METHODS A prospectively acquired HCC/TARE database (2004-2017) was retrospectively reviewed. BCLC B/Child-Pugh (CP)-A patients with laboratory tests/imaging at baseline and for at least 1-month post-TARE were included. Follow-ups were at 3-month intervals. CP was assessed at each timepoint. Endpoints included time-to-persistent CP-B, time-to-CP-C, and median overall survival (OS). Time-to-endpoint analyses were performed using Kaplan-Meier method. RESULTS 74 patients (80% males with mean age 63 years) with mostly (62%) bilobar disease underwent 186 TARE treatments (median 2 (range[r]: 1-8)). Median time-to-2nd TARE was 2.3 months (r: 1.7-6.4), median time-to-3rd and 4th TARE was 11.7 (r: 7.5 - 15) and 17.3 (r: 11.5-23.1) months, respectively. 43 patients (58%) developed persistent CP-B at median time-to-persistent CP-B of 15.4 Months (CI: 9.2 - 25.3) months. 17 (23%) became CP-C at a median time-to-CP-C of 87.2 (CI: 39.8 - 136.1) months. Median OS censored to transplantation was 30.4 (CI: 22.7-37.4) months. On univariate and multivariate analyses baseline albumin was significant prognosticator of OS, while baseline albumin and bilirubin were significant prognosticators of time-to-persistent CP-B, and time-to-CP-C. CONCLUSION In CP-A patients undergoing TARE for BCLC B HCC, the median time-to persistent CP-B is 15.4 months. These findings indicate that patients would be candidates for systemic therapy at progression if indicated.
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Affiliation(s)
- Srirajkumar Ranganathan
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Ahmed Gabr
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Pouya Entezari
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Kush Desai
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Bartley Thornburg
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Laura Kulik
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL; Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL; Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | - Aparna Kalyan
- Department of Medicine, Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL; Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL; Department of Medicine, Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL; Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL; Department of Medicine, Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL.
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6
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Riaz A, Entezari P, Malik A, Badar W, Scheller S, Gabr A, Thornburg B, Seedial S, Boike J, Resnick S, Sato K, Ladner D, Moore C, Ganger D, Donaldson J, Kulik L, Lewandowski RJ, Funaki BS, Ahmed O, Caicedo JC, Salem R. Impact of Portal Hypertension on Adverse Events after Splenic Arterial Aneurysm Embolization. J Vasc Interv Radiol 2022; 33:1519-1526.e1. [PMID: 35985557 DOI: 10.1016/j.jvir.2022.08.014] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2022] [Revised: 08/01/2022] [Accepted: 08/10/2022] [Indexed: 11/17/2022] Open
Abstract
PURPOSE To evaluate the outcomes of splenic artery aneurysm (SAA) embolization and compare adverse event (AE) rates after embolization in patients with and without portal hypertension (PHTN). MATERIALS AND METHODS A retrospective review of all patients who underwent embolization of SAAs at 2 institutions was performed (34 patients from institution 1 and 7 patients from institution 2). Baseline demographic characteristics, preprocedural imaging, procedural techniques, and postprocedural outcomes were evaluated. Thirty-day postprocedural severe and life-threatening AEs were evaluated using the Society of Interventional Radiology guidelines. Thirty-day mortality and readmission rates were also evaluated. t test, χ2 test, and/or Fisher exact test were used for the statistical analysis. RESULTS There was no statistically significant difference between patients with and without PHTN in the location, number, and size of SAA(s). All procedures were technically successful. There were 13 (32%) patients with and 28 (68%) patients without PHTN. The 30-day mortality rate (31% vs 0%; P = .007), readmission rates (61% vs 7%; P < .001), and severe/life-threatening AE rates (69% vs 0%; P < .001) were significantly higher in patients with PHTN than in those without PHTN. CONCLUSIONS There was a significantly higher mortality and severe/life-threatening AE rate in patients with PHTN than in those without PHTN. SAAs in patients with PHTN need to be managed very cautiously, given the risk of severe/life-threatening AEs after embolization.
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Affiliation(s)
- Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Chicago, Illinois.
| | - Pouya Entezari
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Asad Malik
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Wali Badar
- Department of Radiology, Section of Interventional Radiology, University of Chicago, Chicago, Illinois
| | - Stephen Scheller
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Ahmed Gabr
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Bartley Thornburg
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Stephen Seedial
- Department of Radiology, St Joseph Mercy Oakland Hospital, Pontiac, Michigan
| | - Justin Boike
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, Illinois
| | - Scott Resnick
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Kent Sato
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Daniela Ladner
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - Christopher Moore
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, Illinois
| | - Daniel Ganger
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, Illinois
| | - James Donaldson
- Department of Radiology, Section of Interventional Radiology, Lurie Children's Hospital, Chicago, Illinois
| | - Laura Kulik
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Chicago, Illinois
| | - Brian S Funaki
- Department of Radiology, Section of Interventional Radiology, University of Chicago, Chicago, Illinois
| | - Osman Ahmed
- Department of Radiology, Section of Interventional Radiology, University of Chicago, Chicago, Illinois
| | - Juan Carlos Caicedo
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Chicago, Illinois
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7
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Wong RJ, Jayasekera C, Jones P, Kanwal F, Singal AG, Ahmed A, Taglienti R, Younossi Z, Kulik L, Mehta N. An Open-Access, Interactive Decision-Support Tool to Facilitate Guideline-Driven Care for Hepatocellular Carcinoma. Gastroenterology Res 2022; 15:297-307. [PMID: 36660470 PMCID: PMC9822660 DOI: 10.14740/gr1573] [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: 09/28/2022] [Accepted: 11/07/2022] [Indexed: 12/23/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is increasing in incidence and is a leading cause of cancer-related mortality worldwide. Adherence to HCC surveillance guidelines and appropriate treatment triage of liver lesions may improve receipt of curative-intent treatment and improved survival. Late-stage HCC diagnosis reflects sub-optimal implementation of effective HCC surveillance, whereas inappropriate treatment triage or linkage to care accounts for the non-receipt of curative-intent in close to half of early-stage HCC in the USA. A free, open-access decision-support tool for liver lesions that incorporates current guideline recommendations in a user-friendly interface could improve appropriate and timely triage of patients to appropriate care. This review provides a summary of gaps and disparities in linkage to HCC care and introduces a free, internet-based, interactive decision-support tool for managing liver lesions. This tool has been developed by the HCC Steering Committee of the Chronic Liver Disease Foundation and is targeted toward clinicians across specialties who may encounter liver lesions during routine care or as part of dedicated HCC surveillance.
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Affiliation(s)
- Robert J. Wong
- Veterans Affairs Palo Alto Healthcare System, Stanford University School of Medicine, Palo Alto, CA, USA,Corresponding Author: Robert J. Wong, Veterans Affairs Palo Alto Healthcare System, Stanford University School of Medicine, Palo Alto, CA 94304, USA.
| | | | | | - Fasiha Kanwal
- Michael E. DeBakey Veterans Affairs Medical Center and Baylor College of Medicine, Houston, TX, USA
| | - Amit G. Singal
- University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Aijaz Ahmed
- Stanford University School of Medicine, Stanford, CA, USA
| | | | | | | | - Neil Mehta
- University of California, San Francisco, CA, USA
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Ranganathan S, Entezari P, Gabr A, Gordon A, Kulik L, Desai K, Thornburg B, Riaz A, Salem R, Lewandowski R. Abstract No. 309 Evaluating liver function status trends in hepatocellular carcinoma patients with intermediate-stage disease undergoing radioembolization: a longitudinal study. J Vasc Interv Radiol 2022. [DOI: 10.1016/j.jvir.2022.03.390] [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: 10/18/2022] Open
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Gordon A, Thornburg B, Savoor R, Riaz A, Caicedo-Ramirez J, Kulik L, Boike J, Borhani A, Salem R, Lewandowski R. Abstract No. 229 Does spontaneous portosystemic shunt embolization improve liver transplantation outcomes? A propensity-score matched analysis. J Vasc Interv Radiol 2022. [DOI: 10.1016/j.jvir.2022.03.310] [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: 11/27/2022] Open
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10
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Shroff H, Kulik L. Telemedicine for Liver Transplant Evaluations: The Benefits and Risks. Clin Liver Dis (Hoboken) 2022; 19:157-160. [PMID: 35505918 PMCID: PMC9053678 DOI: 10.1002/cld.1175] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [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: 02/14/2021] [Revised: 05/27/2021] [Accepted: 09/22/2021] [Indexed: 02/04/2023] Open
Abstract
Content available: Author Interview and Author Audio Recording.
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Affiliation(s)
- Hersh Shroff
- Division of Gastroenterology and HepatologyDepartment of MedicineMcGaw Medical Center at Northwestern UniversityChicagoIL
| | - Laura Kulik
- Division of Gastroenterology and HepatologyDepartment of MedicineMcGaw Medical Center at Northwestern UniversityChicagoIL
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11
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Swersky A, Kulik L, Kalyan A, Grace K, Caicedo JC, Lewandowski RJ, Salem R. Contemporary Algorithm for the Management of Hepatocellular Carcinoma in 2021: The Northwestern Approach. Semin Intervent Radiol 2021; 38:432-437. [PMID: 34629710 DOI: 10.1055/s-0041-1735528] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Hepatocellular carcinoma (HCC) is the most common primary liver cancer and a major cause of cancer-related morbidity and mortality around the world. Frequently, concurrent liver dysfunction and variations in tumor burden make it difficult to design effective and standardized treatment pathways. Contemporary treatment guidelines designed for an era of personalized medicine should consider these features in a more clinically meaningful way to improve outcomes for patients across the HCC spectrum. Given the heterogeneity of HCC, we propose a detailed clinical algorithm for selecting optimal treatment using an evidence-based and practical approach, incorporating liver function, tumor burden, the extent of disease, and ultimate treatment intent, with the goal of individualizing clinical decision making.
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Affiliation(s)
- Adam Swersky
- Section of Interventional Radiology, Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Laura Kulik
- Division of Hepatology, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Aparna Kalyan
- Division of Medical Oncology, Department of Medicine, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Karen Grace
- Section of Interventional Radiology, Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Juan Carlos Caicedo
- Division of Transplantation, Department of Surgery, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Robert J Lewandowski
- Section of Interventional Radiology, Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois
| | - Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern Feinberg School of Medicine, Chicago, Illinois
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12
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Martin MT, Patel S, Kulik L, Chan C. Glecaprevir/pibrentasvir + sofosbuvir + ribavirin offers high cure rate for hepatitis C virus retreatment in real-world settings. J Hepatol 2021; 75:251-254. [PMID: 33652031 DOI: 10.1016/j.jhep.2021.02.024] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/12/2021] [Accepted: 02/22/2021] [Indexed: 02/06/2023]
Affiliation(s)
- Michelle T Martin
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA; University of Illinois at Chicago College of Pharmacy, Chicago, IL, USA.
| | | | | | - Christine Chan
- University of Illinois Hospital and Health Sciences System, Chicago, IL, USA
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13
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Fenton SE, Kircher SM, Mulcahy MF, Mahalingam D, Salem R, Lewandowski R, Kulik L, Benson AB, Kalyan A. A phase I study of nivolumab (NIVO) in combination with TheraSphere (Yttrium-90) in patients with advanced hepatocellular cancer. J Clin Oncol 2021. [DOI: 10.1200/jco.2021.39.15_suppl.e16183] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
e16183 Background: Significant advances have been made in the management of hepatocellular carcinoma (HCC) with the introduction of locoregional therapies including Theraspere, a treatment utilizing glass microspheres coated in radioactive yttrium-90 (Y-90). Hepatocyte exposure to Y-90 results in immunogenic cell death and tumor-specific immunity, suggesting this treatment may synergize with checkpoint inhibitor therapies to improve response rates and disease control. This abstract presents the results of combination therapy with Y-90 and NIVO in patients with advanced HCC. Methods: This study is a prospective, open-label, phase I clinical trial of NIVO plus Y-90. Eligible patients were diagnosed with advanced HCC (CP A6-B7) and were not transplant or resection candidates. Patients were treated with Y-90 following institutional procedures. The NIVO dose was escalated in a standard 3+3 format. Patients at DL1 began therapy 4 weeks after Y90 administration and received 80 mg of NIVO every two weeks. Patients at DL2 began therapy 2 weeks after Y90 administration and received 240 mg of NIVO every two weeks. The primary objective was to determine a maximum tolerated dose (MTD) of NIVO in combination with Y-90 therapy. Secondary objectives included objective response rate (RECIST v1.1), toxicity evaluation, disease control rate and progression free survival. Results: Fifteen patients were registered to DL1, 8 received Y90 and 6 were eligible and received NIVO. Twelve patients were registered to DL2, 9 were eligible for Y90, 7 were eligible for NIVO and 6 completed therapy. Patients that did not complete therapy either withdrew consent, had a decline in performance status or a worsening in hepatic function. Fifty-nine percent of patients were male (N = 10), 82% were Caucasian (N = 14), 12% were Hispanic or Latino (N = 2) and 6% were African American (N = 1). Of the patients who received both Y90 and NIVO, 82% patients were CP B7. The MTD of NIVO is 240mg given 2 weeks after Y90. The disease control rate was 82% (N = 9/11 with stable disease). Forty-six percent of patients (N = 6) had a decrease in circulating levels of AFP, the most significant change was a decrease from 11,080 ng/mL to 260 ng/mL following cycle 2 of NIVO and normalization by cycle 4 of NIVO. The most common toxicities in both treatment groups were Grade 1-2 elevations in ALT/AST, frequency of these side effects was not higher than expected given this patient population. Conclusions: Therapy with Y-90 and NIVO in advanced HCC was tolerable and a maximum tolerated dose of NIVO was established. Combination therapy resulted in a clinical benefit rate of 82%, with 9 patients achieving stable disease. In a notably sick patient population with advanced CP scores this combination offered good disease control without increasing the adverse event rate. Study was stopped early due to lack of funding. Clinical trial information: NCT02837029.
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Affiliation(s)
| | | | - Mary Frances Mulcahy
- Northwestern University, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | | | - Riad Salem
- Northwestern University Feinberg School of Medicine, Chicago, IL
| | | | - Laura Kulik
- Northwestern University Feinberg School of Medicine, Chicago, IL
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14
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Llovet JM, De Baere T, Kulik L, Haber PK, Greten TF, Meyer T, Lencioni R. Locoregional therapies in the era of molecular and immune treatments for hepatocellular carcinoma. Nat Rev Gastroenterol Hepatol 2021; 18:293-313. [PMID: 33510460 DOI: 10.1038/s41575-020-00395-0] [Citation(s) in RCA: 370] [Impact Index Per Article: 123.3] [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] [Accepted: 11/25/2020] [Indexed: 12/14/2022]
Abstract
Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related mortality and has an increasing incidence worldwide. Locoregional therapies, defined as imaging-guided liver tumour-directed procedures, play a leading part in the management of 50-60% of HCCs. Radiofrequency is the mainstay for local ablation at early stages and transarterial chemoembolization (TACE) remains the standard treatment for intermediate-stage HCC. Other local ablative techniques (microwave ablation, cryoablation and irreversible electroporation) or locoregional therapies (for example, radioembolization and sterotactic body radiation therapy) have been explored, but have not yet modified the standard therapies established decades ago. This understanding is currently changing, and several drugs have been approved for the management of advanced HCC. Molecular therapies dominate the adjuvant trials after curative therapies and combination strategies with TACE for intermediate stages. The rationale for these combinations is sound. Local therapies induce antigen and proinflammatory cytokine release, whereas VEGF inhibitors and tyrosine kinase inhibitors boost immunity and prime tumours for checkpoint inhibition. In this Review, we analyse data from randomized and uncontrolled studies reported with ablative and locoregional techniques and examine the expected effects of combinations with systemic treatments. We also discuss trial design and benchmarks to be used as a reference for future investigations in the dawn of a promising new era for HCC treatment.
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Affiliation(s)
- Josep M Llovet
- Mount Sinai Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA. .,Translational Research in Hepatic Oncology, Liver Unit, IDIBAPS, Hospital Clinic, University of Barcelona, Catalonia, Spain. .,Institució Catalana d'Estudis Avançats (ICREA), Barcelona, Catalonia, Spain.
| | - Thierry De Baere
- Radiology Department Gustave Roussy Cancer Center, Vilejuif, France.,University Paris-Saclay, Saint-Aubin, France
| | - Laura Kulik
- Division of Gastroenterology and Hepatology, Surgery and Interventional Radiology in Northwestern University, Chicago, IL, USA
| | - Philipp K Haber
- Mount Sinai Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Tim F Greten
- Gastrointestinal Malignancy Section, Thoracic and Gastrointestinal Oncology Branch, Center for Cancer Research, National Cancer Institute, National Institutes of Health, Bethesda, MD, USA
| | - Tim Meyer
- Deptartment of Oncology, University College London Cancer Institute, London, UK.,Deptartment of Oncology, Royal Free Hospital, London, UK
| | - Riccardo Lencioni
- Department of Radiology, University of Pisa School of Medicine, Pisa, Italy.,Miami Cancer Institute, Miami, FL, USA
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15
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Matsumoto MM, Mouli S, Saxena P, Gabr A, Riaz A, Kulik L, Ganger D, Maddur H, Boike J, Flamm S, Moore C, Kalyan A, Desai K, Thornburg B, Abecassis M, Hickey R, Caicedo J, Grace K, Lewandowski RJ, Salem R. Comparing Real World, Personalized, Multidisciplinary Tumor Board Recommendations with BCLC Algorithm: 321-Patient Analysis. Cardiovasc Intervent Radiol 2021; 44:1070-1080. [PMID: 33825060 DOI: 10.1007/s00270-021-02810-8] [Citation(s) in RCA: 20] [Impact Index Per Article: 6.7] [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: 01/14/2021] [Accepted: 02/17/2021] [Indexed: 02/07/2023]
Abstract
PURPOSE To evaluate hepatocellular carcinoma (HCC) treatment allocation, deviation from BCLC first-treatment recommendation, and outcomes following multidisciplinary, individualized approach. METHODS Treatment-naïve HCC discussed at multidisciplinary tumor board (MDT) between 2010 and 2013 were included to allow minimum 5 years of follow-up. MDT first-treatment recommendation (resection, transplant, ablation, transarterial radioembolization (Y90), transarterial chemoembolization, sorafenib, palliation) was documented, as were subsequent treatments. Overall survival (OS) analyses were performed on an intention-to-treat (ITT) basis, stratified by BCLC stage. RESULTS Three hundred and twenty-one patients were treated in the 4-year period. Median age was 62 years, predominantly male (73%), hepatitis C (41%), and Y90 initial treatment (52%). There was a 76% rate of BCLC-discordant first-treatment. Median OS was not reached (57% alive at 10 years), 51.0 months, 25.4 months and 13.4 months for BCLC stages A, B, C and D, respectively. CONCLUSION Deviation from BCLC guidelines was very common when individualized, MDT treatment recommendations were made. This approach yielded expected OS in BCLC A, and exceeded general guideline expectations for BCLC B, C and D. These results suggest that while guidelines are helpful, implementing a more personalized approach that incorporates center expertise, patient-specific characteristics, and the known multi-directional treatment allocation process, improves patient outcomes.
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Affiliation(s)
- Monica M Matsumoto
- Section of Interventional Radiology, Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA.,Pritzker School of Medicine, University of Chicago, Chicago, IL, USA
| | - Samdeep Mouli
- Section of Interventional Radiology, Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA
| | - Priyali Saxena
- Section of Interventional Radiology, Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA
| | - Ahmed Gabr
- Section of Interventional Radiology, Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA
| | - Ahsun Riaz
- Section of Interventional Radiology, Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA
| | - Laura Kulik
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Daniel Ganger
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Haripriya Maddur
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Justin Boike
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Steven Flamm
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Christopher Moore
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Aparna Kalyan
- Division of Medical Oncology, Department of Medicine, Northwestern University, Chicago, IL, USA
| | - Kush Desai
- Section of Interventional Radiology, Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA
| | - Bartley Thornburg
- Section of Interventional Radiology, Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA
| | | | - Ryan Hickey
- Section of Interventional Radiology, Department of Radiology, New York University, New York, NY, USA
| | - Juan Caicedo
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Karen Grace
- Section of Interventional Radiology, Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA
| | - Robert J Lewandowski
- Section of Interventional Radiology, Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA.,Division of Medical Oncology, Department of Medicine, Northwestern University, Chicago, IL, USA.,Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, IL, USA
| | - Riad Salem
- Section of Interventional Radiology, Department of Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL, 60611, USA. .,Division of Medical Oncology, Department of Medicine, Northwestern University, Chicago, IL, USA. .,Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, IL, USA.
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16
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Gabr A, Kulik L, Mouli S, Riaz A, Ali R, Desai K, Mora RA, Ganger D, Maddur H, Flamm S, Boike J, Moore C, Thornburg B, Alasadi A, Baker T, Borja-Cacho D, Katariya N, Ladner DP, Caicedo JC, Lewandowski RJ, Salem R. Liver Transplantation Following Yttrium-90 Radioembolization: 15-Year Experience in 207-Patient Cohort. Hepatology 2021; 73:998-1010. [PMID: 32416631 DOI: 10.1002/hep.31318] [Citation(s) in RCA: 51] [Impact Index Per Article: 17.0] [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: 01/31/2020] [Revised: 03/31/2020] [Accepted: 05/03/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS Radioembolization (yttrium-90 [Y90]) is used in hepatocellular carcinoma (HCC) as a bridging as well as downstaging liver-directed therapy to curative liver transplantation (LT). In this study, we report long-term outcomes of LT for patients with HCC who were bridged/downstaged by Y90. APPROACH AND RESULTS Patients undergoing LT following Y90 between 2004 and 2018 were included, with staging by United Network for Organ Sharing (UNOS) tumor-node-metastasis criteria at baseline pre-Y90 and pre-LT. Post-Y90 toxicities were recorded. Histopathological data of HCC at explant were recorded. Long-term outcomes, including overall survival (OS), recurrence-free survival (RFS), disease-specific mortality (DSM), and time-to-recurrence, were reported. Time-to-endpoint analyses were estimated using Kaplan-Meier. Univariate and multivariate analyses were performed using a log-rank test and Cox proportional-hazards model, respectively. During the 15-year period, 207 patients underwent LT after Y90. OS from LT was 12.5 years, with a median time to LT of 7.5 months [interquartile range, 4.4-10.3]. A total of 169 patients were bridged, whereas 38 were downstaged to LT. Respectively, 94 (45%), 60 (29%), and 53 (26%) patients showed complete, extensive, and partial tumor necrosis on histopathology. Three-year, 5-year, and 10-year OS rates were 84%, 77%, and 60%, respectively. Twenty-four patients developed recurrence, with a median RFS of 120 (95% confidence interval, 69-150) months. DSM at 3, 5, and 10 years was 6%, 11%, and 16%, respectively. There were no differences in OS/RFS for patients who were bridged or downstaged. RFS was higher in patients with complete/extensive versus partial tumor necrosis (P < 0.0001). For patients with UNOS T2 treated during the study period, 5.2% dropped out because of disease progression. CONCLUSIONS Y90 is an effective treatment for HCC in the setting of bridging/downstaging to LT. Patients who achieved extensive or complete necrosis had better RFS, supporting the practice of neoadjuvant treatment before LT.
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Affiliation(s)
- Ahmed Gabr
- Department of RadiologySection of Interventional RadiologyNorthwestern Memorial HospitalRobert H. Lurie Comprehensive Cancer CenterChicagoIL
| | - Laura Kulik
- Department of MedicineDivision of HepatologyNorthwestern UniversityChicagoIL
| | - Samdeep Mouli
- Department of RadiologySection of Interventional RadiologyNorthwestern Memorial HospitalRobert H. Lurie Comprehensive Cancer CenterChicagoIL
| | - Ahsun Riaz
- Department of RadiologySection of Interventional RadiologyNorthwestern Memorial HospitalRobert H. Lurie Comprehensive Cancer CenterChicagoIL
| | - Rehan Ali
- Department of RadiologySection of Interventional RadiologyNorthwestern Memorial HospitalRobert H. Lurie Comprehensive Cancer CenterChicagoIL
| | - Kush Desai
- Department of RadiologySection of Interventional RadiologyNorthwestern Memorial HospitalRobert H. Lurie Comprehensive Cancer CenterChicagoIL
| | - Ronald A Mora
- Department of RadiologySection of Interventional RadiologyNorthwestern Memorial HospitalRobert H. Lurie Comprehensive Cancer CenterChicagoIL
| | - Daniel Ganger
- Department of MedicineDivision of HepatologyNorthwestern UniversityChicagoIL
| | - Haripriya Maddur
- Department of RadiologySection of Interventional RadiologyNorthwestern Memorial HospitalRobert H. Lurie Comprehensive Cancer CenterChicagoIL
| | - Steven Flamm
- Department of MedicineDivision of HepatologyNorthwestern UniversityChicagoIL
| | - Justin Boike
- Department of MedicineDivision of HepatologyNorthwestern UniversityChicagoIL
| | - Christopher Moore
- Department of MedicineDivision of HepatologyNorthwestern UniversityChicagoIL
| | - Bartley Thornburg
- Department of RadiologySection of Interventional RadiologyNorthwestern Memorial HospitalRobert H. Lurie Comprehensive Cancer CenterChicagoIL
| | - Ali Alasadi
- Department of RadiologySection of Interventional RadiologyNorthwestern Memorial HospitalRobert H. Lurie Comprehensive Cancer CenterChicagoIL
| | - Talia Baker
- Department of SurgeryDivision of TransplantationUniversity of ChicagoChicagoIL
| | - Daniel Borja-Cacho
- Department of SurgeryDivision of TransplantationComprehensive Transplant CenterNorthwestern UniversityChicagoIL
| | - Nitin Katariya
- Department of SurgeryDivision of TransplantationComprehensive Transplant CenterNorthwestern UniversityChicagoIL
| | - Daniela P Ladner
- Department of SurgeryDivision of TransplantationComprehensive Transplant CenterNorthwestern UniversityChicagoIL
| | - Juan Carlos Caicedo
- Department of SurgeryDivision of TransplantationComprehensive Transplant CenterNorthwestern UniversityChicagoIL
| | - Robert J Lewandowski
- Department of RadiologySection of Interventional RadiologyNorthwestern Memorial HospitalRobert H. Lurie Comprehensive Cancer CenterChicagoIL.,Department of SurgeryDivision of TransplantationComprehensive Transplant CenterNorthwestern UniversityChicagoIL
| | - Riad Salem
- Department of RadiologySection of Interventional RadiologyNorthwestern Memorial HospitalRobert H. Lurie Comprehensive Cancer CenterChicagoIL.,Department of SurgeryDivision of TransplantationComprehensive Transplant CenterNorthwestern UniversityChicagoIL
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17
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Kulik L, da Fonseca LG, He AR, Rimola J, Wilson Woods A, Zöllner YF, Galle PR. Potential Impact of IMbrave150 Results in the Evolving Treatment Landscape of Advanced Hepatocellular Carcinoma: A Multidisciplinary Expert Opinion. J Hepatocell Carcinoma 2020; 7:423-433. [PMID: 33376711 PMCID: PMC7762763 DOI: 10.2147/jhc.s274930] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2020] [Accepted: 11/10/2020] [Indexed: 12/22/2022] Open
Abstract
A virtual expert roundtable was convened on April 16, 2020, to discuss the evolving landscape of care for treating patients with advanced hepatocellular carcinoma (HCC) and discuss questions related to patient care and treatment selection. This commentary presents highlights from this discussion and provides an expert opinion about approaches to treatment for HCC in the Americas and the European Union. We anticipate that atezolizumab plus bevacizumab will become the standard of care for advanced HCC patients. However, this approach will make decisions regarding the sequencing of treatments for second-line therapies and beyond more challenging. Therapy will require individualization based on patient characteristics and preferences, while insurance coverage decisions and requirements may also impact the options that patients can access. Additional research regarding prognostic and predictive biomarkers is needed to help better identify optimal treatment approaches for specific patient populations. Multidisciplinary tumor boards will continue to play a critical role in guiding treatment selection for individual patients. Atezolizumab plus bevacizumab offers a promising new first-line therapeutic option for patients with advanced HCC, but more research is needed to optimize and individualize patient therapy.
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Affiliation(s)
| | | | | | - Jordi Rimola
- Radiology Department, Hospital Clínic de Barcelona, Barcelona, Catalonia, Spain
| | - Andrea Wilson Woods
- Blue Faery: The Adrienne Wilson Liver Cancer Association, Birmingham, AL, USA
| | - York F Zöllner
- Hamburg University of Applied Sciences, Competence Center Health, Hamburg, Germany
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18
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Abstract
The evolution of locoregional therapies in the last decade has been refined with improved patient selection and a development of a more personalized approach. In doing so, there has been associated improved outcomes and less toxicity. With the rapidly changing landscape of systemic therapy, the role of locoregional therapies alone or in combination for downstaging and curative intent will continue to evolve.
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Affiliation(s)
- Anjana A Pillai
- Department of Internal Medicine, University of Chicago Medicine, 5841 South Maryland Avenue, Chicago, IL 60687, USA
| | - Meera Ramanathan
- Department of Internal Medicine, Northwestern Memorial Hospital, 676 North St. Clair 19(th) Floor, Chicago, IL 60611, USA
| | - Laura Kulik
- Department of Internal Medicine, Northwestern Memorial Hospital, 676 North St. Clair 19(th) Floor, Chicago, IL 60611, USA.
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19
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Gabr A, Ranganathan S, Mouli SK, Riaz A, Gates VL, Kulik L, Ganger D, Maddur H, Moore C, Hohlastos E, Katariya N, Caicedo JC, Kalyan A, Lewandowski RJ, Salem R. Streamlining radioembolization in UNOS T1/T2 hepatocellular carcinoma by eliminating lung shunt estimation. J Hepatol 2020; 72:1151-1158. [PMID: 32145255 DOI: 10.1016/j.jhep.2020.02.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [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: 12/09/2019] [Revised: 02/04/2020] [Accepted: 02/09/2020] [Indexed: 12/18/2022]
Abstract
BACKGROUND & AIMS Pre-treatment Tc-99m macroaggregated albumin (MAA) scans are routinely performed prior to transarterial radioembolization (TARE) to estimate lung shunt fraction (LSF) and lung dose. In this study, we investigate LSF observed in early hepatocellular carcinoma (HCC) and provide the scientific rationale for eliminating this step from routine practice. METHODS Patients with HCC who underwent Y90 from 2004 to 2018 were reviewed. Inclusion criteria were early stage HCC (UNOS T1/T2/Milan criteria: solitary ≤5 cm, 3 nodules ≤3 cm). LSF was determined using MAA in all patients. Associations between LSF and baseline characteristics were investigated. A "no-MAA" paradigm was then proposed based on a homogenous group that expressed very low LSF. RESULTS Of 1,175 patients with HCC treated with TARE, 448 patients met inclusion criteria. Mean age was 65.6 years and 303 (68%) were males. A total of 352 (79%) had solitary lesions and 406 (91%) unilobar disease. Two-hundred and forty-three (54%), 178 (40%) and 27 (6%) patients were Child-Pugh class A, B and C, respectively. Median LSF was 3.9% (IQR 2.4-6%). Median administered activity was 0.9 GBq (IQR 0.6-1.4), for a median segmental volume of 170 cm3 (range: 60-530). Median lung dose was 1.9 Gy (IQR: 1.0-3.3). The presence of a transjugular intrahepatic portosystemic shunt (TIPS; n = 38) was associated with LSF >10% (odds ratio 12.2; 95% CI 5.2-28.6; p <0.001). Median LSF was 3.8% (IQR: 2.4-5.7%) and 6% (IQR: 3.8-15.3%) in no-TIPS vs. TIPS patients (p <0.001). CONCLUSION LSF is clinically negligible in patients with UNOS T1/T2 HCC without TIPS. When segmental injections are planned, this step can be eliminated, thereby reducing time-to-treatment, number of procedures, and improving convenience for patients traveling from faraway. LAY SUMMARY Transarterial radioembolization is a microembolic transarterial treatment for hepatocellular carcinoma. In our study, we found that early stage patients, where segmental injections are planned, exhibited low lung shunting, effectively eliminating the risk of radiation pneumonitis. We propose that the lung shunt study be eliminated in this subgroup, thus leading to fewer procedures, a cost reduction and improved convenience for patients.
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Affiliation(s)
- Ahmed Gabr
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Srirajkumar Ranganathan
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Samdeep K Mouli
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Vanessa L Gates
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Laura Kulik
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL
| | - Daniel Ganger
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL
| | - Haripriya Maddur
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL
| | - Christopher Moore
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL
| | - Elias Hohlastos
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Nitin Katariya
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL
| | - Juan Carlos Caicedo
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL
| | - Aparna Kalyan
- Department of Medicine, Division of Medical Oncology, Northwestern University, Chicago, IL
| | - Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL; Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL; Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL; Department of Medicine, Division of Medical Oncology, Northwestern University, Chicago, IL.
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20
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Rich NE, Yang JD, Perumalswami PV, Alkhouri N, Jackson W, Parikh ND, Mehta N, Salgia R, Duarte-Rojo A, Kulik L, Rakoski M, Said A, Oloruntoba O, Ioannou GN, Hoteit MA, Moon AM, Rangnekar AS, Eswaran SL, Zheng E, Jou JH, Hanje J, Pillai A, Hernaez R, Wong R, Scaglione S, Samant H, Kapuria D, Chandna S, Rosenblatt R, Ajmera V, Frenette CT, Satapathy SK, Mantry P, Jalal P, John BV, Fix OK, Leise M, Lindenmeyer CC, Flores A, Patel N, Jiang ZG, Latt N, Dhanasekaran R, Odewole M, Kagan S, Marrero JA, Singal AG. Provider Attitudes and Practice Patterns for Direct-Acting Antiviral Therapy for Patients With Hepatocellular Carcinoma. Clin Gastroenterol Hepatol 2020; 18:974-983. [PMID: 31357028 PMCID: PMC8174017 DOI: 10.1016/j.cgh.2019.07.042] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/27/2019] [Revised: 07/13/2019] [Accepted: 07/23/2019] [Indexed: 12/15/2022]
Abstract
BACKGROUND & AIMS Direct-acting antivirals (DAAs) are effective against hepatitis C virus and sustained virologic response is associated with reduced incidence of hepatocellular carcinoma (HCC). However, there is controversy over the use of DAAs in patients with active or treated HCC and uncertainty about optimal management of these patients. We aimed to characterize attitudes and practice patterns of hepatology practitioners in the United States regarding the use of DAAs in patients with HCC. METHODS We conducted a survey of hepatology providers at 47 tertiary care centers in 25 states. Surveys were sent to 476 providers and we received 279 responses (58.6%). RESULTS Provider beliefs about risk of HCC recurrence after DAA therapy varied: 48% responded that DAAs reduce risk, 36% responded that DAAs do not change risk, and 16% responded that DAAs increase risk of HCC recurrence. However, most providers believed DAAs to be beneficial to and reduce mortality of patients with complete response to HCC treatment. Accordingly, nearly all providers (94.9%) reported recommending DAA therapy to patients with early-stage HCC who received curative treatment. However, fewer providers recommended DAA therapy for patients with intermediate (72.9%) or advanced (57.5%) HCC undergoing palliative therapies. Timing of DAA initiation varied among providers based on HCC treatment modality: 49.1% of providers reported they would initiate DAA therapy within 3 months of surgical resection whereas 45.9% and 5.0% would delay DAA initiation for 3-12 months and >1 year post-surgery, respectively. For patients undergoing transarterial chemoembolization (TACE), 42.0% of providers would provide DAAs within 3 months of the procedure, 46.7% would delay DAAs until 3-12 months afterward, and 11.3% would delay DAAs more than 1 year after TACE. CONCLUSIONS Based on a survey sent to hepatology providers, there is variation in provider attitudes and practice patterns regarding use and timing of DAAs for patients with HCC. Further studies are needed to characterize the risks and benefits of DAA therapy in this patient population.
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Affiliation(s)
- Nicole E Rich
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas.
| | - Ju Dong Yang
- Division of Digestive and Liver Diseases, Comprehensive Transplant Center and Samuel Oschin Comprehensive Cancer Institute, Cedars Sinai Medical Center, Los Angeles, California
| | - Ponni V Perumalswami
- Division of Liver Diseases, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Naim Alkhouri
- Texas Liver Institute, University of Texas Health San Antonio, San Antonio, Texas
| | - Whitney Jackson
- Division of Gastroenterology and Hepatology, University of Colorado Denver School of Medicine, Denver, Colorado
| | - Neehar D Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Neil Mehta
- Division of Gastroenterology, University of California San Francisco, San Francisco, California
| | - Reena Salgia
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan
| | - Andres Duarte-Rojo
- T.E. Starzl Transplantation Institute and Center for Liver Disease, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania
| | - Laura Kulik
- Division of Hepatology, Northwestern University, Chicago, Illinois
| | - Mina Rakoski
- Transplantation Institute and Division of Gastroenterology, Loma Linda University Health, Loma Linda, California
| | - Adnan Said
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Omobonike Oloruntoba
- Division of Gastroenterology and Hepatology, Duke University Health Center, Durham, North Carolina
| | - George N Ioannou
- Division of Gastroenterology and Research and Development, Veterans Affairs Puget Sound Healthcare System and University of Washington, Seattle, Washington
| | - Maarouf A Hoteit
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew M Moon
- Division of Gastroenterology and Hepatology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Amol S Rangnekar
- Division of Gastroenterology, Georgetown University Hospital, Washington, DC
| | - Sheila L Eswaran
- Division of Gastroenterology, Rush Medical College, Chicago, Illinois
| | - Elizabeth Zheng
- Division of Digestive and Liver Diseases, Columbia University, New York, New York
| | - Janice H Jou
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | - James Hanje
- Division of Gastroenterology, Hepatology and Nutrition, The Ohio State University Wexner Medical Center, Columbus, Ohio
| | - Anjana Pillai
- Division of Gastroenterology, Hepatology and Nutrition, University of Chicago, Chicago, Illinois
| | - Ruben Hernaez
- Section of Gastroenterology and Hepatology, Baylor College of Medicine and Michael E. Debakey Veterans Affairs Medical Center, Houston, Texas
| | - Robert Wong
- Division of Gastroenterology and Hepatology, Alameda Health System, Oakland, California
| | - Steven Scaglione
- Division of Hepatology, Loyola University Medical Center and Edward Hines Veterans Affairs, Chicago, Illinois
| | - Hrishikesh Samant
- Division of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, New Orleans, Louisiana
| | - Devika Kapuria
- Division of Gastroenterology and Hepatology, University of New Mexico, Albuquerque, New Mexico
| | - Shaun Chandna
- Division of Gastroenterology, Hepatology and Nutrition, University of Utah, Salt Lake City, Utah
| | - Russell Rosenblatt
- Division of Gastroenterology and Hepatology, Weill Cornell Medicine - New York-Presbyterian Hospital, New York, New York
| | - Veeral Ajmera
- Division of Gastroenterology and Hepatology, University of California San Diego, San Diego, California
| | - Catherine T Frenette
- Division of Organ Transplantation, Scripps Green Hospital, San Diego, California
| | - Sanjaya K Satapathy
- Division of Transplant Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | | | - Prasun Jalal
- Division of Abdominal Transplantation, Baylor College of Medicine, Houston, Texas
| | - Binu V John
- Division of Gastroenterology and Hepatology, McGuire Veterans Affairs Medical Center, Richmond, Virginia
| | - Oren K Fix
- Organ Transplant Department, Swedish Medical Center, Seattle, Washington
| | - Michael Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | | | - Avegail Flores
- Division of Gastroenterology, Washington University School of Medicine, St. Louis, Missouri
| | - Nayan Patel
- Banner Transplant Institute, Banner - University Medical Center Phoenix, Phoenix, Arizona
| | - Z Gordon Jiang
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical Center, Boston, Massachusetts
| | - Nyan Latt
- Oschner Multi-Organ Transplant Institute, Oschner Health System, New Orleans, Louisiana
| | | | - Mobolaji Odewole
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Sofia Kagan
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Jorge A Marrero
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
| | - Amit G Singal
- Division of Digestive and Liver Diseases, UT Southwestern Medical Center, Dallas, Texas
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Joh M, Mutonga M, Li E, Riaz A, Mouli S, Kulik L, Lewandowski R, Salem R, Thornburg B. 4:03 PM Abstract No. 324 Survival comparison of patients undergoing elective transjugular intrahepatic portosystemic shunt creation with intermediate and high Model End Stage Liver Disease scores. J Vasc Interv Radiol 2020. [DOI: 10.1016/j.jvir.2019.12.379] [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: 11/16/2022] Open
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22
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Assalino M, Terraz S, Grat M, Lai Q, Vachharajani N, Gringeri E, Bongini MA, Kulik L, Tabrizian P, Agopian V, Mehta N, Brustia R, Vitali GC, Andres A, Berney T, Mazzaferro V, Compagnon P, Majno P, Cillo U, Chapman W, Zieniewicz K, Scatton O, Toso C. Liver transplantation for hepatocellular carcinoma after successful treatment of macrovascular invasion - a multi-center retrospective cohort study. Transpl Int 2020; 33:567-575. [PMID: 31994238 DOI: 10.1111/tri.13586] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [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: 07/25/2019] [Revised: 09/04/2019] [Accepted: 01/23/2020] [Indexed: 12/19/2022]
Abstract
Macrovascular invasion is considered a contraindication to liver transplantation for hepatocellular carcinoma (HCC) due to a high risk of recurrence. The aim of the present multicenter study was to explore the outcome of HCC patients transplanted after a complete radiological regression of the vascular invasion by locoregional therapies and define sub-groups with better outcomes. Medical records of 45 patients were retrospectively reviewed, and imaging was centrally assessed by an expert liver radiologist. In the 30 patients with validated diagnosis of macrovascular invasion, overall survival was 60% at 5 years. Pretransplant alpha-fetoprotein (AFP) value was significantly different between patients with and without recurrence (P = 0.019), and the optimal AFP cutoff was 10ng/ml (area under curve = 0.78). Recurrence rate was 11% in patients with pretransplant AFP < 10ng/ml. The number of viable nodules (P = 0.008), the presence of residual HCC (P = 0.036), and satellite nodules (P = 0.001) on the explant were also significantly different between patients with and without recurrence. Selected HCC patients with radiological signs of vascular invasion could be considered for transplantation, provided that they previously underwent successful treatment of the macrovascular invasion resulting in a pretransplant AFP < 10 ng/ml. Their expected risk of post-transplant HCC recurrence is 11%, and further prospective validation is needed.
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Affiliation(s)
- Michela Assalino
- Division of Transplantation, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Sylvain Terraz
- Department of Radiology, Geneva University Hospitals, Geneva, Switzerland
| | - Michal Grat
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Quirino Lai
- Department of General Surgery and Organ Transplantation, Sapienza University Hospital of Rome, Rome, Italy
| | - Neeta Vachharajani
- Section of Abdominal Organ Transplant, Department of General Surgery, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Enrico Gringeri
- Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Padua University Hospital, Padua, Italy
| | - Marco Angelo Bongini
- Division of Surgery and Hepatology, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), University of Milan, Milan, Italy
| | - Laura Kulik
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern Memorial Hospital, Chicago, IL, USA
| | - Parissa Tabrizian
- Recanati-Miller Transplantation Institute, Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Vatche Agopian
- Division of Liver and Pancreas Transplantation, Department of Surgery, David Geffen School of Medicine, University of California at Los Angeles, Los Angeles, CA, USA
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California at San Francisco, San Francisco, CA, USA
| | - Raffaele Brustia
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Giulio Cesare Vitali
- Division of Transplantation, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland
| | - Axel Andres
- Division of Transplantation, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland.,Division of Abdominal Surgery, Department of Surgery, Hepato-Pancreato-Biliary Center, Geneva University Hospitals, Geneva, Switzerland
| | - Thierry Berney
- Division of Transplantation, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland.,Division of Abdominal Surgery, Department of Surgery, Hepato-Pancreato-Biliary Center, Geneva University Hospitals, Geneva, Switzerland
| | - Vincenzo Mazzaferro
- Division of Surgery and Hepatology, Fondazione IRCCS Istituto Nazionale Tumori (National Cancer Institute), University of Milan, Milan, Italy
| | - Philippe Compagnon
- Division of Transplantation, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland.,Division of Abdominal Surgery, Department of Surgery, Hepato-Pancreato-Biliary Center, Geneva University Hospitals, Geneva, Switzerland
| | - Pietro Majno
- Division of General Surgery, Department of surgery, Regional Hospital of Lugano, Lugano, Switzerland
| | - Umberto Cillo
- Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, Padua University Hospital, Padua, Italy
| | - William Chapman
- Section of Abdominal Organ Transplant, Department of General Surgery, Washington University in Saint Louis, Saint Louis, MO, USA
| | - Krzysztof Zieniewicz
- Department of General, Transplant and Liver Surgery, Medical University of Warsaw, Warsaw, Poland
| | - Olivier Scatton
- Department of Hepatobiliary and Liver Transplantation Surgery, Pitié-Salpêtrière University Hospital, Assistance Publique-Hôpitaux de Paris, Sorbonne University, Paris, France
| | - Christian Toso
- Division of Transplantation, Department of Surgery, Geneva University Hospitals, Geneva, Switzerland.,Division of Abdominal Surgery, Department of Surgery, Hepato-Pancreato-Biliary Center, Geneva University Hospitals, Geneva, Switzerland
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23
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Gao R, Gabr A, Mouli S, Riaz A, Kulik L, Lewandowski RJ, Salem R. Toxicity and Survival of Hepatocellular Carcinoma Patients with Hepatitis B Infection Treated with Yttrium-90 Radioembolization: An Updated 15-Year Study. J Vasc Interv Radiol 2020; 31:401-408.e1. [PMID: 31983593 DOI: 10.1016/j.jvir.2019.08.033] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2019] [Revised: 08/01/2019] [Accepted: 08/08/2019] [Indexed: 01/27/2023] Open
Abstract
PURPOSE To evaluate the toxicity and survival of hepatocellular carcinoma (HCC) secondary to hepatitis B virus (HBV) infection treated with yttrium-90 transarterial radioembolization (TARE) over a 15-year period. MATERIALS AND METHODS This study retrospectively analyzed 93 consecutive patients with HBV HCC-all derived from an original cohort of 1,000 patients-who were treated with TARE via standard radiation segmentectomy/lobectomy between December 2003 and December 2018. This group comprised 80 males and 13 females, with 79 having only HBV and 14 having additional liver comorbidities. Toxicity grades were determined by Common Terminology Criteria for Adverse Events, version 5.0. Overall survival (OS) was reported using intention-to-treat (ITT), censored, or competing risk. Univariate/multivariate analyses were used to evaluate predictors of OS. RESULTS Posttreatment grade 3/4 toxicities included albumin (1.1%), bilirubin (4.3%), aspartate transaminase (6.5%), and alanine transaminase (3.2%). Median censored OS was 16.9 months (95% confidence interval [CI], 11.8-23.5): 17.5 months (95% CI, 11.5-86.9) for Child-Pugh (CP) A and 14.5 months (95% CI, 5.2-22.5) for CP B; not reached, 16.9 months (95% CI, 11.2-68.7), and 11.5 months (95% CI, 8.6-17.5) for Barcelona Clinic Liver Cancer (BCLC) A, B, and C, respectively. Multivariate analysis revealed albumin, alpha-fetoprotein, and portal vein thrombosis as independent predictors of ITT OS and albumin and tumor size as predictors when curative therapy was assigned as a competing risk. CONCLUSIONS This retrospective study showed that TARE therapy resulted in minimal toxicity in patients with HBV-derived HCC. Patients with CP A or BCLC A disease had superior survival outcomes compared to patients with CP B and BCLC B/C disease. These findings suggest that TARE is a viable treatment option for certain patient groups with HCC tumors secondary to HBV infection.
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Affiliation(s)
- Ruoqi Gao
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 800, Chicago, IL, 60611
| | - Ahmed Gabr
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 800, Chicago, IL, 60611
| | - Samdeep Mouli
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 800, Chicago, IL, 60611
| | - Ahsun Riaz
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 800, Chicago, IL, 60611
| | - Laura Kulik
- Department of Medicine, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 800, Chicago, IL, 60611
| | - Robert J Lewandowski
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 800, Chicago, IL, 60611
| | - Riad Salem
- Department of Radiology, Northwestern University Feinberg School of Medicine, 676 N St Clair, Suite 800, Chicago, IL, 60611.
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Singal AG, Rich NE, Mehta N, Branch AD, Pillai A, Hoteit M, Volk M, Odewole M, Scaglione S, Guy J, Said A, Feld JJ, John BV, Frenette C, Mantry P, Rangnekar AS, Oloruntoba O, Leise M, Jou JH, Bhamidimarri KR, Kulik L, Ioannou GN, Huang A, Tran T, Samant H, Dhanasekaran R, Duarte-Rojo A, Salgia R, Eswaran S, Jalal P, Flores A, Satapathy SK, Kagan S, Gopal P, Wong R, Parikh ND, Murphy CC. Direct-Acting Antiviral Therapy for Hepatitis C Virus Infection Is Associated With Increased Survival in Patients With a History of Hepatocellular Carcinoma. Gastroenterology 2019; 157:1253-1263.e2. [PMID: 31374215 PMCID: PMC6815711 DOI: 10.1053/j.gastro.2019.07.040] [Citation(s) in RCA: 115] [Impact Index Per Article: 23.0] [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: 03/24/2019] [Revised: 06/24/2019] [Accepted: 07/22/2019] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS There is controversy regarding the benefits of direct-acting antiviral (DAA) therapy for hepatitis C virus (HCV) infection for patients with a history of hepatocellular carcinoma (HCC). We performed a multicenter cohort study to compare overall survival between patients with HCV infection treated with DAAs and patients who did not receive DAA treatment for their HCV infection after complete response to prior HCC therapy. METHODS We conducted a retrospective cohort study of patients with HCV-related HCC who achieved a complete response to resection, local ablation, transarterial chemo- or radioembolization, or radiation therapy, from January 2013 through December 2017 at 31 health care systems throughout the United States and Canada. We used Cox proportional hazards regression to determine the association between receipt of DAA therapy, modeled as a time-varying covariate, and all-cause mortality, accounting for informative censoring and confounding using inverse probability weighting. RESULTS Of 797 patients with HCV-related HCC, 383 (48.1%) received DAA therapy and 414 (51.9%) did not receive treatment for their HCV infection after complete response to prior HCC therapy. Among DAA-treated patients, 43 deaths occurred during 941 person-years of follow-up, compared with 103 deaths during 526.6 person-years of follow-up among patients who did not receive DAA therapy (crude rate ratio, 0.23; 95% confidence interval [CI], 0.16-0.33). In inverse probability-weighted analyses, DAA therapy was associated with a significant reduction in risk of death (hazard ratio, 0.54; 95% CI, 0.33-0.90). This association differed by sustained virologic response to DAA therapy; risk of death was reduced in patients with sustained virologic response to DAA therapy (hazard ratio, 0.29; 95% CI, 0.18-0.47), but not in patients without a sustained virologic response (hazard ratio, 1.13; 95% CI, 0.55-2.33). CONCLUSIONS In an analysis of nearly 800 patients with complete response to HCC treatment, DAA therapy was associated with a significant reduction in risk of death.
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Affiliation(s)
- Amit G. Singal
- Division of Digestive and Liver Disease, UT Southwestern Medical Center
| | - Nicole E. Rich
- Division of Digestive and Liver Disease, UT Southwestern Medical Center
| | - Neil Mehta
- Division of Gastroenterology, University of California San Francisco
| | | | - Anjana Pillai
- Division of Gastroenterology, Hepatology and Nutrition, University of Chicago
| | - Maarouf Hoteit
- Division of Gastroenterology and Hepatology, University of Pennsylvania
| | - Michael Volk
- Transplantation Institute and Division of Gastroenterology, Loma Linda University Health
| | - Mobolaji Odewole
- Division of Digestive and Liver Disease, UT Southwestern Medical Center
| | - Steven Scaglione
- Division of Hepatology, Loyola University Medical Center and Edward Hines Veterans Affairs
| | - Jennifer Guy
- Department of Transplantation, California Pacific Medical Center
| | - Adnan Said
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine
| | - Jordan J. Feld
- Toronto Center for Liver Disease, Toronto General Hospital
| | - Binu V. John
- Division of Gastroenterology and Hepatology, McGuire VA Medical Center
| | | | | | | | | | - Michael Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic
| | - Janice H. Jou
- Division of Gastroenterology and Hepatology, Oregon Health and Science University
| | | | - Laura Kulik
- Division of Hepatology, Northwestern University
| | - George N. Ioannou
- Division of Gastroenterology and Research and Development, Veterans Affairs Puget Sound Healthcare System and University of Washington
| | - Annsa Huang
- Division of Gastroenterology, University of California San Francisco
| | - Tram Tran
- Liver Disease and Transplant Center, Cedars-Sinai Medical Center
| | - Hrishikesh Samant
- Division of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center
| | | | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences
| | - Reena Salgia
- Division of Gastroenterology and Hepatology, Henry Ford Hospital
| | | | - Prasun Jalal
- Division of Abdominal Transplantation, Baylor College of Medicine
| | - Avegail Flores
- Division of Gastroenterology, Washington University School of Medicine
| | - Sanjaya K. Satapathy
- Division of Hepatology, Donald and Barbara Zucker School of Medicine, Northshore University Hospital, Northwell Health, Manhasset, New York
| | - Sofia Kagan
- Division of Digestive and Liver Disease, UT Southwestern Medical Center
| | - Purva Gopal
- Department of Pathology, UT Southwestern Medical Center
| | - Robert Wong
- Division of Gastroenterology and Hepatology, Alameda Health System
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Antkowiak M, Gabr A, Das A, Ali R, Kulik L, Ganger D, Moore C, Abecassis M, Katariya N, Mouli S, Mahalingam D, Lewandowski RJ, Salem R, Riaz A. Prognostic Role of Albumin, Bilirubin, and ALBI Scores: Analysis of 1000 Patients with Hepatocellular Carcinoma Undergoing Radioembolization. Cancers (Basel) 2019; 11:cancers11060879. [PMID: 31238514 PMCID: PMC6627853 DOI: 10.3390/cancers11060879] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [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: 05/16/2019] [Revised: 05/31/2019] [Accepted: 06/19/2019] [Indexed: 02/08/2023] Open
Abstract
Introduction: We compared the efficacy of the ALBI (albumin-bilirubin) score to the established Child-Pugh (CP) grade in hepatocellular carcinoma (HCC) patients treated with yttrium-90 radioembolization (Y90). We further assessed the individual contributions of albumin and bilirubin to survival prediction. Methods: 1000 consecutive HCC patients treated with Y90 were included. Overall survival (OS) was assessed using Kaplan Meier analysis. Sub-stratification analyses were performed using CP and ALBI and in subgroups determined by United Network for Organ Sharing (UNOS) or Barcelona Clinic Liver Cancer (BCLC) staging. The independent impact (hazard ratio (HR)) of ALBI, CP, albumin, and bilirubin on survival was assessed using Cox proportional hazards analysis. Results: Median OS for ALBI 1, 2, and 3 grades was 46.7, 19.1, and 8.8 months, respectively. The HR for death for ALBI 2 vs. ALBI 1 was 3.39 (1.75-6.57); ALBI 3 vs. ALBI 1 was 7.58 (3.89-14.79); and the c-index was 0.623. Median OS for CP A, B, and C was 21.7, 11.3, and 6.0 months, respectively. The HR for death for CP B vs. CP A was 2.04 (1.71-2.43); CP C vs. CP A was 3.27 (2.08-5.14); and the c-index was 0.616. Stratified OS showed unique prognostic groups identified by ALBI within CP-B and CP-C. Median OS for albumin grades 1, 2, and 3 was 46.0, 17.1, and 9.1 months, respectively. Median OS for bilirubin grades 1, 2, and 3 was 15.6, 21.0, and 5.8 months, respectively. The HR for death for albumin 2 vs. 1 was 2.48 (1.81-3.41); albumin 3 vs. 1 was 4.74 (3.44-6.54); and the c-index was 0.640. The HR for death for bilirubin 2 vs. 1 was 1.09 (0.82-1.44); bilirubin 3 vs. 1 was 2.37 (1.66-3.40); and the c-index was 0.533. Conclusions: ALBI outperforms CP in survival prognosis in Y90 treated patients. On sub-analyses, serum albumin (not bilirubin) appears to be the main driver of survival prediction. Our study supports the prognostic ability of ALBI and may suggest a role of albumin alone as a biomarker for patients with HCC.
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Affiliation(s)
- Mark Antkowiak
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL 60611, USA; (M.A.); (A.G.); (A.D.); (R.A.); (S.M.); (R.L.); (R.S.)
| | - Ahmed Gabr
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL 60611, USA; (M.A.); (A.G.); (A.D.); (R.A.); (S.M.); (R.L.); (R.S.)
| | - Arighno Das
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL 60611, USA; (M.A.); (A.G.); (A.D.); (R.A.); (S.M.); (R.L.); (R.S.)
| | - Rehan Ali
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL 60611, USA; (M.A.); (A.G.); (A.D.); (R.A.); (S.M.); (R.L.); (R.S.)
| | - Laura Kulik
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, IL 60611, USA; (L.K.); (D.G.); (C.M.)
| | - Daniel Ganger
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, IL 60611, USA; (L.K.); (D.G.); (C.M.)
| | - Christopher Moore
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, IL 60611, USA; (L.K.); (D.G.); (C.M.)
| | - Michael Abecassis
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, IL 60611, USA; (M.A.); (N.K.)
| | - Nitin Katariya
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, IL 60611, USA; (M.A.); (N.K.)
| | - Samdeep Mouli
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL 60611, USA; (M.A.); (A.G.); (A.D.); (R.A.); (S.M.); (R.L.); (R.S.)
| | - Devalingam Mahalingam
- Division of Oncology, Department of Medicine, Northwestern University, Chicago, IL 60611, USA;
| | - Robert J. Lewandowski
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL 60611, USA; (M.A.); (A.G.); (A.D.); (R.A.); (S.M.); (R.L.); (R.S.)
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, IL 60611, USA; (L.K.); (D.G.); (C.M.)
| | - Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL 60611, USA; (M.A.); (A.G.); (A.D.); (R.A.); (S.M.); (R.L.); (R.S.)
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, IL 60611, USA; (L.K.); (D.G.); (C.M.)
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, IL 60611, USA; (M.A.); (N.K.)
| | - Ahsun Riaz
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL 60611, USA; (M.A.); (A.G.); (A.D.); (R.A.); (S.M.); (R.L.); (R.S.)
- Correspondence: ; Tel.: +312-330-2227
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26
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Singal AG, Rich NE, Mehta N, Branch A, Pillai A, Hoteit M, Volk M, Odewole M, Scaglione S, Guy J, Said A, Feld JJ, John BV, Frenette C, Mantry P, Rangnekar AS, Oloruntoba O, Leise M, Jou JH, Bhamidimarri KR, Kulik L, Tran T, Samant H, Dhanasekaran R, Duarte-Rojo A, Salgia R, Eswaran S, Jalal P, Flores A, Satapathy SK, Wong R, Huang A, Misra S, Schwartz M, Mitrani R, Nakka S, Noureddine W, Ho C, Konjeti VR, Dao A, Nelson K, Delarosa K, Rahim U, Mavuram M, Xie JJ, Murphy CC, Parikh ND. Direct-Acting Antiviral Therapy Not Associated With Recurrence of Hepatocellular Carcinoma in a Multicenter North American Cohort Study. Gastroenterology 2019; 156:1683-1692.e1. [PMID: 30660729 PMCID: PMC6598433 DOI: 10.1053/j.gastro.2019.01.027] [Citation(s) in RCA: 104] [Impact Index Per Article: 20.8] [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] [Received: 10/04/2018] [Revised: 12/15/2018] [Accepted: 01/09/2019] [Indexed: 12/26/2022]
Abstract
BACKGROUND & AIMS There is controversy over the effects of direct-acting antiviral (DAA) therapies for hepatitis C virus (HCV) infection on hepatocellular carcinoma (HCC) recurrence and tumor aggressiveness. We compared HCC recurrence patterns between DAA-treated and untreated HCV-infected patients who had achieved a complete response to HCC treatment in a North American cohort. METHODS We conducted a retrospective cohort study of patients with HCV-related HCC with a complete response to resection, local ablation, transarterial chemo- or radioembolization, or radiation therapy from January 2013 through December 2017 at 31 health systems throughout the United States and Canada. Cox regression was used to examine the association between DAA therapy and time to recurrence after a complete response, with DAA therapy analyzed as a time-varying exposure. We also estimated the association between DAA therapy and risk of early HCC recurrence (defined as 365 days after complete response). RESULTS Of 793 patients with HCV-associated HCC, 304 (38.3%) received DAA therapy and 489 (61.7%) were untreated. HCC recurred in 128 DAA-treated patients (42.1%; early recurrence in 52 patients) and 288 untreated patients (58.9%; early recurrence in 227 patients). DAA therapy was not associated with HCC recurrence (hazard ratio 0.90, 95% confidence interval 0.70-1.16) or early HCC recurrence (hazard ratio 0.96, 95% confidence interval 0.70-1.34) after we adjusted for study site, age, sex, Child-Pugh score, α-fetoprotein level, tumor burden, and HCC treatment modality. In DAA-treated and untreated patients, most recurrences were within the Milan criteria (74.2% vs 78.8%; P = .23). A larger proportion of DAA-treated than untreated patients received potentially curative HCC therapy for recurrent HCC (32.0% vs 24.6%) and achieved a complete or partial response (45.3% vs 41.0%) but this did not achieve statistical significance. CONCLUSION In a large cohort of North American patients with complete response to HCC treatment, DAA therapy was not associated with increased overall or early HCC recurrence. HCC recurrence patterns, including treatment response, were similar in DAA-treated and untreated patients.
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Affiliation(s)
- Amit G. Singal
- Division of Digestive and Liver Disease, UT Southwestern Medical Center Dallas, Texas
| | - Nicole E. Rich
- Division of Digestive and Liver Disease, UT Southwestern Medical Center Dallas, Texas
| | - Neil Mehta
- Division of Gastroenterology, University of California San Francisco, San Francisco, California
| | - Andrea Branch
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Anjana Pillai
- Division of Gastroenterology, Hepatology and Nutrition, University of Chicago, Chicago, Illinois
| | - Maarouf Hoteit
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael Volk
- Transplantation Institute and Division of Gastroenterology, Loma Linda University Health, Loma Linda, California
| | - Mobolaji Odewole
- Division of Digestive and Liver Disease, UT Southwestern Medical Center Dallas, Texas
| | - Steven Scaglione
- Division of Hepatology, Loyola University Medical Center, Chicago, Illinois,Edward Hines Veterans Affairs, Chicago, Illinois
| | - Jennifer Guy
- Department of Transplantation, California Pacific Medical Center, San Francisco, California
| | - Adnan Said
- Division of Gastroenterology and Hepatology, University of Wisconsin School of Medicine, Madison, Wisconsin
| | - Jordan J. Feld
- Toronto Center for Liver Disease, Toronto General Hospital, Toronto, Ontario, Canada
| | - Binu V. John
- Division of Gastroenterology and Hepatology, McGuire VA Medical Center, Richmond, Virginia
| | - Catherine Frenette
- Division of Organ Transplantation, Scripps Green Hospital, San Diego, California
| | | | - Amol S. Rangnekar
- Division of Gastroenterology, Georgetown University Hospital, Washington, DC
| | - Omobonike Oloruntoba
- Division of Gastroenterology and Hepatology, Duke University Health Center, Durham, North Carolina
| | - Michael Leise
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Janice H. Jou
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon
| | | | - Laura Kulik
- Division of Hepatology, Northwestern University, Chicago, Illinois
| | - Tram Tran
- Liver Disease and Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Hrishikesh Samant
- Division of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, Baton Rouge, Louisiana
| | | | - Andres Duarte-Rojo
- Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Reena Salgia
- Division of Gastroenterology and Hepatology, Henry Ford Hospital, Detroit, Michigan
| | - Sheila Eswaran
- Division of Gastroenterology, Rush Medical College, Chicago, Illinois
| | - Prasun Jalal
- Division of Abdominal Transplantation, Baylor College of Medicine, Dallas, Texas
| | - Avegail Flores
- Division of Gastroenterology, Washington University School of Medicine, Louis, Missouri
| | - Sanjaya K. Satapathy
- Division of Transplant Surgery, University of Tennessee Health Science Center, Memphis, Tennessee
| | - Robert Wong
- Division of Gastroenterology and Hepatology, Alameda Health System, Oakland, California
| | - Annsa Huang
- Division of Gastroenterology, University of California San Francisco, San Francisco, California
| | - Suresh Misra
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Myron Schwartz
- Department of Medicine, Icahn School of Medicine at Mount Sinai, New York, New York
| | - Robert Mitrani
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Sasank Nakka
- Transplantation Institute and Division of Gastroenterology, Loma Linda University Health, Loma Linda, California
| | - Wassim Noureddine
- Transplantation Institute and Division of Gastroenterology, Loma Linda University Health, Loma Linda, California
| | - Chanda Ho
- Department of Transplantation, California Pacific Medical Center, San Francisco, California
| | - Venkata R. Konjeti
- Division of Gastroenterology and Hepatology, McGuire VA Medical Center, Richmond, Virginia
| | - Alexander Dao
- Division of Gastroenterology, Georgetown University Hospital, Washington, DC
| | - Kevin Nelson
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota
| | - Kelly Delarosa
- Liver Disease and Transplant Center, Cedars-Sinai Medical Center, Los Angeles, California
| | - Usman Rahim
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California
| | - Meher Mavuram
- Division of Gastroenterology and Hepatology, Louisiana State University Health Sciences Center, Baton Rouge, Louisiana
| | - Jesse J. Xie
- Division of Gastroenterology and Hepatology, University of Arkansas for Medical Sciences, Little Rock, Arkansas
| | - Caitlin C. Murphy
- Division of Digestive and Liver Disease, UT Southwestern Medical Center Dallas, Texas
| | - Neehar D. Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
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Joh M, Mutonga M, Li E, Mouli S, Riaz A, Kulik L, Lewandowski R, Salem R, Thornburg B. 03:18 PM Abstract No. 171 Predictors of survival after transjugular intrahepatic portosystemic shunt (TIPS) creation with covered stents. J Vasc Interv Radiol 2019. [DOI: 10.1016/j.jvir.2018.12.224] [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: 10/27/2022] Open
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28
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Mutonga M, Joh M, Li E, Liu D, Riaz A, Kulik L, Lewandowski R, Thornburg B. 03:54 PM Abstract No. 175 Transjugular intrahepatic portosystemic shunt (TIPS) outcomes in orthotopic liver transplant versus native liver. J Vasc Interv Radiol 2019. [DOI: 10.1016/j.jvir.2018.12.228] [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: 11/25/2022] Open
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29
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Kulik L. Locoregional Therapy for Hepatocellular Carcinoma: Transarterial Chemoembolization Versus Transarterial Radioembolization Versus Stereotactic Body Radiotherapy. Clin Liver Dis (Hoboken) 2019; 13:26-28. [PMID: 31168362 PMCID: PMC6465782 DOI: 10.1002/cld.801] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/23/2018] [Accepted: 12/20/2018] [Indexed: 02/04/2023] Open
Affiliation(s)
- Laura Kulik
- Department of MedicineNorthwestern UniversityChicagoIL
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Abstract
The major risk factors for hepatocellular carcinoma (HCC) in contemporary clinical practice are becoming increasingly related to sustained virological response after hepatitis C, suppressed hepatitis B virus during treatment, and alcoholic and nonalcoholic fatty liver disease. We review the emerging data on the risk and determinants of HCC in these conditions and the implications of HCC surveillance. However, from a public health perspective, active hepatitis C and B continue to drive most of the global burden of HCC. In United States, the age-adjusted incidence rates of HCC in Hispanics have surpassed those of HCC in Asians. Prognosis in HCC is complex because of the competing risk imposed by underlying cirrhosis and presence of malignancy. In addition to tumor burden, liver function and performance status; additional parameters including tumor biopsy, serum markers, and subclassification of current staging systems; and taking into account patterns of tumor progression may improve patient selection for therapy. Advancements in the treatment of HCC have included identification of patients who are most likely to derive a clinically significant benefit from the available therapeutic options. Additionally, the combination strategies of locoregional therapies and/or systemic therapy are being investigated.
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Affiliation(s)
- Laura Kulik
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Chicago, Illinois, USA
| | - Hashem B. El-Serag
- Section of Gastroenterology and Hepatology, Department of Medicine, Baylor College of Medicine and Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
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31
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Salem R, Gabr A, Riaz A, Mora R, Ali R, Abecassis M, Hickey R, Kulik L, Ganger D, Flamm S, Atassi R, Atassi B, Sato K, Benson AB, Mulcahy MF, Abouchaleh N, Asadi AA, Desai K, Thornburg B, Vouche M, Habib A, Caicedo J, Miller FH, Yaghmai V, Kallini JR, Mouli S, Lewandowski RJ. Institutional decision to adopt Y90 as primary treatment for hepatocellular carcinoma informed by a 1,000-patient 15-year experience. Hepatology 2018; 68:1429-1440. [PMID: 29194711 DOI: 10.1002/hep.29691] [Citation(s) in RCA: 141] [Impact Index Per Article: 23.5] [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: 10/26/2017] [Revised: 11/15/2017] [Accepted: 11/26/2017] [Indexed: 12/12/2022]
Abstract
UNLABELLED Yttrium-90 transarterial radioembolization (TARE) is a locoregional therapy (LRT) for hepatocellular carcinoma (HCC). In this study, we present overall survival (OS) outcomes in a 1,000-patient cohort acquired over a 15-year period. Between December 1, 2003 and March 31, 2017, 1,000 patients with HCC were treated with TARE as part of a prospective cohort study. A comprehensive review of toxicity and survival outcomes was performed. Outcomes were stratified by baseline Child-Pugh (CP) class, United Network for Organ Sharing (UNOS), and Barcelona Clinic Liver Cancer (BCLC) staging systems. Albumin and bilirubin laboratory toxicities were compared to baseline. OS outcomes were reported using censoring and intention-to-treat methodologies. All treatments were outpatient, with a median one treatment per patient. Five hundred six (51%) were CP A, 450 (45%) CP B, and 44 (4%) CP C. Two hundred sixty-three (26%) patients were BCLC A, 152 (15%) B, 541 (54%) C, and 44 (4%) D. Three hundred sixty-eight (37%) were UNOS T1/T2, 169 (17%) T3, 147 (15%) T4a, 223 (22%) T4b, and 93 (9%) N/M. In CP A patients, censored OS for BCLC A was 47.3 (confidence interval [CI], 39.5-80.3) months, BCLC B 25.0 (CI, 17.3-30.5) months, and BCLC C 15.0 (CI, 13.8-17.7) months. In CP B patients, censored OS for BCLC A was 27 (CI, 21-30.2) months, BCLC B 15.0 (CI, 12.3-19.0) months, and BCLC C 8.0 (CI, 6.8-9.5) months. Forty-nine (5%) and 110 (11%) patients developed grade 3/4 albumin and bilirubin toxicities, respectively. CONCLUSION Based on our experience with 1,000 patients over 15 years, we have made a decision to adopt TARE as the first-line transarterial LRT for patients with HCC. Our decision was informed by prospective data and incrementally reported demonstrating outcomes stratified by BCLC, applied as either neoadjuvant or definitive treatment. (Hepatology 2017).
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Affiliation(s)
- Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL.,Department of Medicine, Division of Hematology and Oncology, Northwestern University, Chicago, IL.,Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, IL
| | - Ahmed Gabr
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Ronald Mora
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Rehan Ali
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Michael Abecassis
- Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, IL
| | - Ryan Hickey
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Laura Kulik
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL
| | - Daniel Ganger
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL
| | - Steven Flamm
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL
| | - Rohi Atassi
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Bassel Atassi
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Kent Sato
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Al B Benson
- Department of Medicine, Division of Hematology and Oncology, Northwestern University, Chicago, IL
| | - Mary F Mulcahy
- Department of Medicine, Division of Hematology and Oncology, Northwestern University, Chicago, IL
| | - Nadine Abouchaleh
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Ali Al Asadi
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Kush Desai
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Bartley Thornburg
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Michael Vouche
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Ali Habib
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Juan Caicedo
- Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, IL
| | - Frank H Miller
- Department of Radiology, Section of Body Imaging, Northwestern University, Chicago, IL
| | - Vahid Yaghmai
- Department of Radiology, Section of Body Imaging, Northwestern University, Chicago, IL
| | - Joseph R Kallini
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Samdeep Mouli
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL
| | - Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL.,Department of Medicine, Division of Hematology and Oncology, Northwestern University, Chicago, IL.,Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, IL
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Chauhan N, Bukovcan J, Boucher E, Cosgrove D, Edeline J, Hamilton B, Kulik L, Master F, Salem R. Intra-Arterial TheraSphere Yttrium-90 Glass Microspheres in the Treatment of Patients With Unresectable Hepatocellular Carcinoma: Protocol for the STOP-HCC Phase 3 Randomized Controlled Trial. JMIR Res Protoc 2018; 7:e11234. [PMID: 30111528 PMCID: PMC6115595 DOI: 10.2196/11234] [Citation(s) in RCA: 28] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2018] [Accepted: 07/09/2018] [Indexed: 12/19/2022] Open
Abstract
BACKGROUND Globally, hepatocellular carcinoma is the second most common cause of cancer deaths. It remains challenging to intensify cancer treatment without impairing liver function. OBJECTIVE The objective of the TheraSphere in the Treatment of Patients with Unresectable Hepatocellular Carcinoma (STOP-HCC) study is to examine the hypothesis that transarterial radioembolization (TheraSphere yttrium-90 glass microspheres) combined with standard first-line treatment with sorafenib will improve outcomes over treatment with sorafenib alone in unresectable hepatocellular carcinoma. The STOP-HCC study is the largest international, multicenter, prospective study of intra-arterial treatment in combination with sorafenib in unresectable hepatocellular carcinoma. Here we report the study design. METHODS STOP-HCC is a prospective, phase 3, open-label, randomized controlled study conducted across up to 105 sites in North America, Europe, and Asia. Eligible adults have unresectable hepatocellular carcinoma and a life expectancy of at least 12 weeks, 1 or more unidimensional measurable lesions, Child-Pugh score 7 points or less, and Eastern Cooperative Oncology Group Performance Status score 1 or lower, and are candidates for treatment with sorafenib. Presence of branch portal vein tumor thrombosis is permitted. Patients were randomly assigned in a 1:1 ratio to receive either sorafenib alone or transarterial radioembolization followed by sorafenib within 2 to 6 weeks. The primary outcome is overall survival. Secondary outcomes are time to progression, time to untreatable progression, time to symptomatic progression, tumor response, quality of life, and adverse event occurrence. The study is an adaptive trial, comprising a group-sequential design with 2 interim analyses with 520 patients, and an option to increase the sample size to 700 patients at the second interim analysis. The sample size of 520 patients allows for 417 deaths to give 80% power to detect an increase in median overall survival from 10.7 months for the sorafenib group (based on the Sorafenib Hepatocellular Carcinoma Assessment Randomized Protocol [SHARP] trial) to 14.2 months for the transarterial radioembolization+sorafenib group (hazard ratio 0.754) with 2-sided alpha of .05. The increased sample size of 700 patients allows for 564 deaths to give 80% power to detect a smaller difference in median overall survival from 10.7 months for the sorafenib group to 13.7 months for the transarterial radioembolization+sorafenib group (hazard ratio 0.781). RESULTS Enrollment for the study completed in September 2017. Results of the first and second interim analyses were reviewed by the Independent Data Monitoring Committee. The recommendation of the committee, at both interim analyses, was to continue the study without any changes. CONCLUSIONS The STOP-HCC study will contribute toward the establishment of the role of combination therapy with transarterial radioembolization and sorafenib in the treatment of unresectable hepatocellular carcinoma with and without branch portal vein tumor thrombosis. TRIAL REGISTRATION ClinicalTrials.gov NCT01556490; https://clinicaltrials.gov/ct2/show/NCT01556490 (Archived by WebCite at http://www.webcitation.org/7188iygKs). REGISTERED REPORT IDENTIFIER RR1-10.2196/11234.
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Affiliation(s)
- Nikhil Chauhan
- Research and Development, BTG International Group Companies, London, United Kingdom
| | - Janet Bukovcan
- Research and Development, BTG International Group Companies, London, United Kingdom
| | - Eveline Boucher
- Research and Development, BTG International Group Companies, London, United Kingdom
| | - David Cosgrove
- Division of Medical Oncology, Compass Oncology, Vancouver Cancer Center, Vancouver, WA, United States
| | - Julien Edeline
- Department of Oncology, Centre Eugene Marquis, Rennes, France
| | - Bonnie Hamilton
- Research and Development, BTG International Group Companies, London, United Kingdom
| | - Laura Kulik
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern Memorial Hospital, Chicago, IL, United States
| | - Fayaz Master
- Research and Development, BTG International Group Companies, London, United Kingdom
| | - Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, IL, United States.,Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, IL, United States.,Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, IL, United States
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33
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Lewandowski RJ, Gabr A, Abouchaleh N, Ali R, Al Asadi A, Mora RA, Kulik L, Ganger D, Desai K, Thornburg B, Mouli S, Hickey R, Caicedo JC, Abecassis M, Riaz A, Salem R. Radiation Segmentectomy: Potential Curative Therapy for Early Hepatocellular Carcinoma. Radiology 2018; 287:1050-1058. [PMID: 29688155 DOI: 10.1148/radiol.2018171768] [Citation(s) in RCA: 142] [Impact Index Per Article: 23.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
Purpose To report long-term outcomes of radiation segmentectomy (RS) for early hepatocellular carcinoma (HCC). The authors hypothesized that outcomes are comparable to curative treatments for patients with solitary HCC less than or equal to 5 cm and preserved liver function. Materials and Methods This retrospective study included 70 patients (median age, 71 years; range, 22-96 years) with solitary HCC less than or equal to 5 cm not amenable to percutaneous ablation who underwent RS (dose of >190 Gy) between 2003 and 2016. Patients who underwent subsequent curative liver transplantation were excluded to eliminate this confounding variable affecting survival. Radiologic response of time to progression and median overall survival were estimated by using the Kaplan-Meier method per the guidelines of the European Association for the Study of the Liver (EASL) and the World Health Organization (WHO). Results Seventy patients were treated with RS over 14 years. Sixty-three patients (90%) showed response by using EASL criteria, of which 41 (59%) showed complete response. Fifty patients (71%) achieved response by using WHO criteria, of which 11 (16%) achieved complete response. Response rates at 6 months were 86% and 49% by using EASL and WHO criteria, respectively. Median time to progression was 2.4 years (95% confidence interval: 2.1, 5.7), with 72% of patients having no target lesion progression at 5 years. Median overall survival was 6.7 years (95% confidence interval: 3.1, 6.7); survival probability at 1, 3, and 5 years was 98%, 66%, and 57%, respectively. Overall survival probability at 1, 3, and 5 years was 100%, 82%, and 75%, respectively, in patients with baseline tumor size less than or equal to 3 cm (n = 45) and was significantly longer than in patients with tumors greater than 3 cm (P = .026). Conclusion RS provides response rates, tumor control, and survival outcomes comparable to curative-intent treatments for selected patients with early-stage HCC who have preserved liver function. © RSNA, 2018 Online supplemental material is available for this article.
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Affiliation(s)
- Robert J Lewandowski
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
| | - Ahmed Gabr
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
| | - Nadine Abouchaleh
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
| | - Rehan Ali
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
| | - Ali Al Asadi
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
| | - Ronald A Mora
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
| | - Laura Kulik
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
| | - Daniel Ganger
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
| | - Kush Desai
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
| | - Bartley Thornburg
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
| | - Samdeep Mouli
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
| | - Ryan Hickey
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
| | - Juan Carlos Caicedo
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
| | - Michael Abecassis
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
| | - Ahsun Riaz
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
| | - Riad Salem
- From the Department of Radiology, Section of Interventional Radiology (R.J.L., A.G., N.A., R.A., A.A., R.A.M., K.D., B.T., S.M., R.H., A.R., R.S.), Department of Medicine, Division of Hepatology (L.K., D.G.), Department of Surgery, Division of Transplantation (J.C.C., M.A., R.S.), and Department of Medicine, Division of Hematology and Oncology (R.S.), Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, 676 N St. Clair St, Suite 800, Chicago IL 60611
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Gabr A, Ali R, Mora R, Al Asadi A, Abouchaleh N, Kulik L, Mouli S, Riaz A, Lewandowski R, Salem R. 4:03 PM Abstract No. 268 Role of Y90 radioembolization in BCLC D patients. J Vasc Interv Radiol 2018. [DOI: 10.1016/j.jvir.2018.01.299] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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Riaz A, Gabr A, Abouchaleh N, Ali R, Al Asadi A, Mora R, Kulik L, Desai K, Thornburg B, Mouli S, Hickey R, Miller FH, Yaghmai V, Ganger D, Lewandowski RJ, Salem R. Radioembolization for hepatocellular carcinoma: Statistical confirmation of improved survival in responders by landmark analyses. Hepatology 2018; 67:873-883. [PMID: 28833344 DOI: 10.1002/hep.29480] [Citation(s) in RCA: 40] [Impact Index Per Article: 6.7] [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: 05/10/2017] [Revised: 08/07/2017] [Accepted: 08/14/2017] [Indexed: 12/22/2022]
Abstract
UNLABELLED Does imaging response predict survival in hepatocellular carcinoma (HCC)? We studied the ability of posttherapeutic imaging response to predict overall survival. Over 14 years, 948 patients with HCC were treated with radioembolization. Patients with baseline metastases, vascular invasion, multifocal disease, Child-Pugh > B7, and transplanted/resected were excluded. This created our homogeneous study cohort of 134 patients with Child-Pugh ≤ B7 and solitary HCC. Response (using European Association for Study of the Liver [EASL] and Response Evaluation Criteria in Solid Tumors 1.1 [RECIST 1.1] criteria) was associated with survival using Landmark and risk-of-death methodologies after reviewing 960 scans. In a subanalysis, survival times of responders were compared to those of patients with stable disease (SD) and progressive disease (PD). Uni/multivariate survival analyses were performed at each Landmark. At the 3-month Landmark, responders survived longer than nonresponders by EASL (hazard ratio [HR], 0.46; confidence interval [CI], 0.26-0.82; P = 0.002) but not RECIST 1.1 criteria (HR, 0.70; CI, 0.37-1.32; P = 0.32). At the 6-month Landmark, responders survived longer than nonresponders by EASL (HR, 0.32; CI, 0.15-0.77; P < 0.001) and RECIST 1.1 criteria (HR, 0.50; CI, 0.29-0.87; P = 0.021). At the 12-month Landmark, responders survived longer than nonresponders by EASL (HR, 0.34; CI, 0.15-0.77; P < 0.001) and RECIST 1.1 criteria (HR, 0.52; CI 0.27-0.98; P = 0.049). At 6 months, risk of death was lower for responders by EASL (P < 0.001) and RECIST 1.1 (P = 0.0445). In subanalyses, responders lived longer than patients with SD or PD. EASL response was a significant predictor of survival at 3-, 6-, and 12-month Landmarks on uni/multivariate analyses. CONCLUSION Response to radioembolization in patients with solitary HCC can prognosticate improved survival. EASL necrosis criteria outperformed RECIST 1.1 size criteria in predicting survival. The therapeutic objective of radioembolization should be radiologic response and not solely to prevent progression. (Hepatology 2018;67:873-883).
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Affiliation(s)
- Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Ahmed Gabr
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Nadine Abouchaleh
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Rehan Ali
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Ali Al Asadi
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Ronald Mora
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Laura Kulik
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL
| | - Kush Desai
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Bartley Thornburg
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Samdeep Mouli
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Ryan Hickey
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Frank H Miller
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Vahid Yaghmai
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Daniel Ganger
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL
| | - Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL.,Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, IL.,Department of Medicine, Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
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Wagener EDA, Souma N, Hodakowski A, Martinez C, Fox P, Mehta R, O'Brien MJ, Bolon M, Kulik L, Yang GY, Isakova T. A Patient With CKD Develops Cholestatic Liver Injury During a Clinical Trial. Kidney Int Rep 2018; 3:5-10. [PMID: 29340307 PMCID: PMC5762939 DOI: 10.1016/j.ekir.2017.07.012] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
Affiliation(s)
- Emma D A Wagener
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Nao Souma
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Alexander Hodakowski
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Carlos Martinez
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Patrick Fox
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Rupal Mehta
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Matthew J O'Brien
- Division of General Internal Medicine and Geriatrics, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Maureen Bolon
- Division of Infectious Diseases, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Laura Kulik
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Guang-Yu Yang
- Department of Pathology, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
| | - Tamara Isakova
- Center for Translational Metabolism and Health, Institute for Public Health and Medicine, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA.,Division of Nephrology and Hypertension, Northwestern University Feinberg School of Medicine, Chicago, Illinois, USA
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Kulik L, Heimbach JK, Zaiem F, Almasri J, Prokop LJ, Wang Z, Murad MH, Mohammed K. Therapies for patients with hepatocellular carcinoma awaiting liver transplantation: A systematic review and meta-analysis. Hepatology 2018; 67:381-400. [PMID: 28859222 DOI: 10.1002/hep.29485] [Citation(s) in RCA: 187] [Impact Index Per Article: 31.2] [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: 01/10/2017] [Revised: 04/03/2017] [Accepted: 06/02/2017] [Indexed: 12/11/2022]
Abstract
UNLABELLED Patients with hepatocellular carcinoma (HCC) who are listed for liver transplantation (LT) are often treated while on the waiting list with locoregional therapy (LRT), which is aimed at either preventing progression of HCC or reducing the measurable disease burden of HCC in order to receive increased allocation priority. We aimed to synthesize evidence regarding the effectiveness of LRT in the management of patients with HCC who were on the LT waitlist. We conducted a comprehensive search of multiple databases from 1996 to April 25, 2016, for studies that enrolled adults with cirrhosis awaiting LT and treated with bridging or down-staging therapies before LT. Therapies included transcatheter arterial chemoembolization, transarterial radioembolization, ablation, and radiotherapy. We included both comparative and noncomparative studies. There were no randomized controlled trials identified. For adults with T1 HCC and waiting for LT, there were only two nonrandomized comparative studies, both with a high risk of bias, which reported the outcome of interest. In one series, the rate of dropout from all causes at 6 months in T1 HCC patients who underwent LRT was 5.3%, while in the other series of T1 HCC patients who did not receive LRT, the dropout rate at median follow-up of 2.4 years and the progression rate to T2 HCC were 30% and 88%, respectively. For adults with T2 HCC awaiting LT, transplant with any bridging therapy showed a nonsignificant reduction in the risk of waitlist dropout due to progression (relative risk [RR], 0.32; 95% confidence interval [CI], 0.06-1.85; I2 = 0%) and of waitlist dropout from all causes (RR, 0.38; 95% CI, 0.060-2.370; I2 = 85.7%) compared to no therapy based on three comparative studies. The quality of evidence is very low due to high risk of bias, imprecision, and inconsistency. There were five comparative studies which reported on posttransplant survival rates and 10 comparative studies which reported on posttransplant recurrence, and there was no significant difference seen in either of these endpoints. For adults initially with stage T3 HCC who received LRT, there were three studies reporting on transplant with any down-staging therapy versus no downstaging, and this showed a significant increase in 1-year (two studies, RR, 1.11; 95% CI, 1.01-1.23) and 5-year (1 study, RR, 1.17; 95% CI, 1.03-1.32) post-LT survival rates for patients who received LRT. The quality of evidence is very low due to serious risk of bias and imprecision. CONCLUSION In patients with HCC listed for LT, the use of LRT is associated with a nonsignificant trend toward improved waitlist and posttransplant outcomes, though there is a high risk of selection bias in the available evidence. (Hepatology 2018;67:381-400).
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Affiliation(s)
- Laura Kulik
- Division of Gastroenterology and Hepatology, Northwestern School of Medicine, Chicago, IL
| | | | - Feras Zaiem
- Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Jehad Almasri
- Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Larry J Prokop
- Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Zhen Wang
- Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - M Hassan Murad
- Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
| | - Khaled Mohammed
- Evidence-Based Practice Center, Mayo Clinic Robert D. and Patricia E. Kern Center for the Science of Health Care Delivery, Mayo Clinic, Rochester, MN
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Thornburg B, Desai K, Hickey R, Hohlastos E, Kulik L, Ganger D, Baker T, Abecassis M, Caicedo JC, Ladner D, Fryer J, Riaz A, Lewandowski RJ, Salem R. Pretransplantation Portal Vein Recanalization and Transjugular Intrahepatic Portosystemic Shunt Creation for Chronic Portal Vein Thrombosis: Final Analysis of a 61-Patient Cohort. J Vasc Interv Radiol 2017; 28:1714-1721.e2. [PMID: 29050854 DOI: 10.1016/j.jvir.2017.08.005] [Citation(s) in RCA: 82] [Impact Index Per Article: 11.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/04/2017] [Revised: 07/27/2017] [Accepted: 08/08/2017] [Indexed: 12/13/2022] Open
Abstract
PURPOSE To report the final analysis of the safety and efficacy of portal vein (PV) recanalization (PVR) and transjugular intrahepatic portosystemic shunt (TIPS) creation (PVR-TIPS) in patients with PV thrombosis (PVT) in need of liver transplantation. MATERIALS AND METHODS Sixty-one patients with cirrhosis and PVT underwent PVR-TIPS to improve transplantation candidacy. Median patient age was 58 years (range, 22-75 y), and median pre-TIPS Model for End-Stage Liver Disease score was 14 (range, 7-42). The most common etiologies of cirrhosis were nonalcoholic fatty liver disease in 18 patients (30%) and hepatitis C in 13 patients (21%). Twenty-seven patients (44%) had partial PVT, and 34 patients (56%) had complete thrombosis. Forty-nine patients (80%) had Yerdel grade 2 PVT, and 12 (20%) had Yerdel grade 3 PVT. Twenty-nine patients (48%) had cavernous transformation of the PV. RESULTS PVR-TIPS was technically successful in 60 of 61 patients (98%). PV/TIPS patency was maintained in 55 patients (92%) at a median follow-up of 19.2 months (range, 0-105.9 mo). Recurrent PV/TIPS thrombosis occurred in 5 patients (8%), all of whom initially presented with complete PVT. The most common adverse events were TIPS stenosis in 13 patients (22%) and transient encephalopathy in 11 patients (18%). Twenty-four patients (39%) underwent transplantation, 23 of whom (96%) received an end-to-end anastomosis. There were no cases of recurrent PVT following transplantation, with a median imaging follow-up of 32.5 months (range, 0.4-75.4 mo). Five-year overall survival rate was 82%. CONCLUSIONS PVR-TIPS is a safe, effective, and durable treatment option for patients with chronic PVT who need liver transplantation.
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Affiliation(s)
- Bartley Thornburg
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Kush Desai
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Ryan Hickey
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Elias Hohlastos
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Laura Kulik
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, Illinois
| | - Daniel Ganger
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, Illinois
| | - Talia Baker
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - Michael Abecassis
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - Juan C Caicedo
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - Daniela Ladner
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - Jonathan Fryer
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois
| | - Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, Illinois; Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, Chicago, Illinois; Department of Medicine, Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611.
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Prenner S, Kulik L. Reply to: "Treatment failure after interferon-free treatment of hepatitis C as a clue of a yet undetected hepatocellular carcinoma". J Hepatol 2017; 68:S0168-8278(17)32283-3. [PMID: 28918130 DOI: 10.1016/j.jhep.2017.09.004] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/31/2017] [Accepted: 09/01/2017] [Indexed: 12/04/2022]
Affiliation(s)
- Stacey Prenner
- Department of Medicine, Division of Gastroenterology and Hepatology, Hospital of the University of Pennsylvania, Philadelphia, PA, USA.
| | - Laura Kulik
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
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Gabr A, Abouchaleh N, Ali R, Vouche M, Atassi R, Memon K, Asadi AA, Baker T, Caicedo JC, Desai K, Fryer J, Hickey R, Abeccassis M, Habib A, Hohlastos E, Ganger D, Kulik L, Lewandowski RJ, Riaz A, Salem R. Comparative study of post-transplant outcomes in hepatocellular carcinoma patients treated with chemoembolization or radioembolization. Eur J Radiol 2017; 93:100-106. [DOI: 10.1016/j.ejrad.2017.05.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/18/2017] [Accepted: 05/19/2017] [Indexed: 02/08/2023]
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Affiliation(s)
- Aparana Kalyan
- Division of Hematology Oncology, Developmental Therapeutics Program, Northwestern University Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center of Northwestern University, Chicago, Illinois
| | - Laura Kulik
- Department of Medicine, Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, Illinois.
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Prenner SB, VanWagner LB, Flamm SL, Salem R, Lewandowski RJ, Kulik L. Hepatocellular carcinoma decreases the chance of successful hepatitis C virus therapy with direct-acting antivirals. J Hepatol 2017; 66:1173-1181. [PMID: 28161470 PMCID: PMC5776681 DOI: 10.1016/j.jhep.2017.01.020] [Citation(s) in RCA: 118] [Impact Index Per Article: 16.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/15/2016] [Revised: 01/11/2017] [Accepted: 01/17/2017] [Indexed: 12/14/2022]
Abstract
BACKGROUND & AIMS The approval of all-oral direct-acting antiviral (DAA) regimens for the treatment of hepatitis C virus (HCV) has led to the expansion of therapy to include patients with cirrhosis who have hepatocellular carcinoma (HCC). Data on the use of DAAs in HCV+ patients with HCC is limited. The aim of this study was to assess the efficacy of all-oral-DAA regimens in HCV+ cirrhotic patients who have or had HCC compared to those without HCC. METHODS A retrospective cohort study was conducted on all cirrhotic patients who were treated for HCV with DAAs at our institution between January 2014 and November 2015. RESULTS A total of 421 HCV+ patients with cirrhosis were identified, of whom 33% had active or a history of HCC. Failure to achieve sustained virologic response (SVR) occurred in 21% of patients with HCC compared to 12% of patients without HCC (p=0.009). Of the 29 patients with HCC who did not achieve SVR, 27 (93%) occurred when an active tumor was present. DAA therapy in the presence of an inactive tumor or after removal of tumor (resection/transplant) resulted in excellent SVR rates, similar to those without HCC (p<0.0001). In multivariable analysis, the primary predictor of DAA treatment failure was the presence of active HCC at the time of HCV treatment initiation (adjusted odds ratio=8.5, 95% confidence interval=3.90-18.49). CONCLUSIONS The presence of active HCC tumor at the initiation of HCV therapy is significantly associated with all-oral DAA treatment failure. HCV treatment after curative therapies for HCC resulted in excellent SVR. LAY SUMMARY The new medications for hepatitis C have excellent cure rates. However, our study shows that in patients with both liver cancer and hepatitis C, they do not achieve these cure rates. Patients with liver cancer are almost 8 times more likely to fail hepatitis C treatment than patients without liver cancer.
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Affiliation(s)
- Stacey B Prenner
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Lisa B VanWagner
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA; Department of Preventive Medicine, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Steven L Flamm
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, IL, USA
| | - Laura Kulik
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL, USA.
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Salem R, Gordon AC, Mouli S, Hickey R, Kallini J, Gabr A, Mulcahy MF, Baker T, Abecassis M, Miller FH, Yaghmai V, Sato K, Desai K, Thornburg B, Benson AB, Rademaker A, Ganger D, Kulik L, Lewandowski RJ. Y90 Radioembolization Significantly Prolongs Time to Progression Compared With Chemoembolization in Patients With Hepatocellular Carcinoma. Gastroenterology 2016; 151:1155-1163.e2. [PMID: 27575820 DOI: 10.1053/j.gastro.2016.08.029%' and 2*3*8=6*8 and 'jyor'!='jyor%] [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] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/18/2016] [Accepted: 08/23/2016] [Indexed: 01/29/2024]
Abstract
BACKGROUND & AIMS Conventional transarterial chemoembolization (cTACE) is used to treat patients with hepatocellular carcinoma (HCC). Radioembolization is a minimally invasive procedure that involves implantation of radioactive micron-sized particles loaded with yttrium-90 (Y90) inside the blood vessels that supply a tumor. We performed a randomized, phase 2 study to compare the effects of cTACE and Y90 radioembolization in patients with HCC. METHODS From October 2009 through October 2015, we reviewed patients with HCC of all Barcelona Clinic Liver Cancer (BCLC) stages for eligibility. Of these, 179 patients with BCLC stages A or B met our enrollment criteria and were candidates for cTACE or Y90 therapy. Patients were assigned randomly to groups that received Y90 therapy (n = 24; 50% Child-Pugh A) or cTACE (n = 21; 71% Child-Pugh A). The primary outcome was time to progression (TTP), evaluated by intention-to-treat analysis. Secondary outcomes included safety, rate of response (based on tumor size and necrosis criteria), and Kaplan-Meier survival time. We performed inverse probability of censoring weighting and competing risk analyses. RESULTS Patients in the Y90 radioembolization group had significant longer median TTP (>26 mo) than patients in the cTACE group (6.8 mo; P = .0012) (hazard ratio, 0.122; 95% confidence interval [CI], 0.027-0.557; P = .007). This was confirmed by competing risk and inverse probability of censoring weighting analyses accounting for transplantation or death. A significantly greater proportion of patients in the cTACE group developed diarrhea (21%) than in the Y90 group (0%; P = .031) or hypoalbuminemia (58% in the cTACE group vs 4% in the Y90 group; P < .001). Similar proportions of patients in each group had a response to therapy, marked by necrosis (74% in the cTACE group vs 87% in the Y90 group) (P = .433). The median survival time, censored to liver transplantation, was 17.7 months for the cTACE group (95% CI, 8.3-not calculable) vs 18.6 months for the Y90 group (95% CI, 7.4-32.5) (P = .99). CONCLUSIONS In a randomized phase 2 study of patients with HCC of BCLC stages A or B, we found Y90 radioembolization to provide significantly longer TTP than cTACE. Y90 radioembolization provides better tumor control and could reduce drop-out from transplant waitlists. ClinicalTrials.gov no. NCT00956930.
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Affiliation(s)
- Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois; Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois.
| | - Andrew C Gordon
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Samdeep Mouli
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ryan Hickey
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Joseph Kallini
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ahmed Gabr
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Mary F Mulcahy
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Talia Baker
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Michael Abecassis
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Frank H Miller
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Vahid Yaghmai
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kent Sato
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kush Desai
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Bartley Thornburg
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Al B Benson
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Alfred Rademaker
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Daniel Ganger
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Laura Kulik
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
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Salem R, Gordon AC, Mouli S, Hickey R, Kallini J, Gabr A, Mulcahy MF, Baker T, Abecassis M, Miller FH, Yaghmai V, Sato K, Desai K, Thornburg B, Benson AB, Rademaker A, Ganger D, Kulik L, Lewandowski RJ. Y90 Radioembolization Significantly Prolongs Time to Progression Compared With Chemoembolization in Patients With Hepatocellular Carcinoma. Gastroenterology 2016; 151:1155-1163.e2. [PMID: 27575820 DOI: 10.1053/j.gastro.2016.08.029' and 2*3*8=6*8 and 'ebrd'='ebrd] [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] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/18/2016] [Accepted: 08/23/2016] [Indexed: 01/29/2024]
Abstract
BACKGROUND & AIMS Conventional transarterial chemoembolization (cTACE) is used to treat patients with hepatocellular carcinoma (HCC). Radioembolization is a minimally invasive procedure that involves implantation of radioactive micron-sized particles loaded with yttrium-90 (Y90) inside the blood vessels that supply a tumor. We performed a randomized, phase 2 study to compare the effects of cTACE and Y90 radioembolization in patients with HCC. METHODS From October 2009 through October 2015, we reviewed patients with HCC of all Barcelona Clinic Liver Cancer (BCLC) stages for eligibility. Of these, 179 patients with BCLC stages A or B met our enrollment criteria and were candidates for cTACE or Y90 therapy. Patients were assigned randomly to groups that received Y90 therapy (n = 24; 50% Child-Pugh A) or cTACE (n = 21; 71% Child-Pugh A). The primary outcome was time to progression (TTP), evaluated by intention-to-treat analysis. Secondary outcomes included safety, rate of response (based on tumor size and necrosis criteria), and Kaplan-Meier survival time. We performed inverse probability of censoring weighting and competing risk analyses. RESULTS Patients in the Y90 radioembolization group had significant longer median TTP (>26 mo) than patients in the cTACE group (6.8 mo; P = .0012) (hazard ratio, 0.122; 95% confidence interval [CI], 0.027-0.557; P = .007). This was confirmed by competing risk and inverse probability of censoring weighting analyses accounting for transplantation or death. A significantly greater proportion of patients in the cTACE group developed diarrhea (21%) than in the Y90 group (0%; P = .031) or hypoalbuminemia (58% in the cTACE group vs 4% in the Y90 group; P < .001). Similar proportions of patients in each group had a response to therapy, marked by necrosis (74% in the cTACE group vs 87% in the Y90 group) (P = .433). The median survival time, censored to liver transplantation, was 17.7 months for the cTACE group (95% CI, 8.3-not calculable) vs 18.6 months for the Y90 group (95% CI, 7.4-32.5) (P = .99). CONCLUSIONS In a randomized phase 2 study of patients with HCC of BCLC stages A or B, we found Y90 radioembolization to provide significantly longer TTP than cTACE. Y90 radioembolization provides better tumor control and could reduce drop-out from transplant waitlists. ClinicalTrials.gov no. NCT00956930.
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Affiliation(s)
- Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois; Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois.
| | - Andrew C Gordon
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Samdeep Mouli
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ryan Hickey
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Joseph Kallini
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ahmed Gabr
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Mary F Mulcahy
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Talia Baker
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Michael Abecassis
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Frank H Miller
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Vahid Yaghmai
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kent Sato
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kush Desai
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Bartley Thornburg
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Al B Benson
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Alfred Rademaker
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Daniel Ganger
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Laura Kulik
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
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45
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Salem R, Gordon AC, Mouli S, Hickey R, Kallini J, Gabr A, Mulcahy MF, Baker T, Abecassis M, Miller FH, Yaghmai V, Sato K, Desai K, Thornburg B, Benson AB, Rademaker A, Ganger D, Kulik L, Lewandowski RJ. Y90 Radioembolization Significantly Prolongs Time to Progression Compared With Chemoembolization in Patients With Hepatocellular Carcinoma. Gastroenterology 2016; 151:1155-1163.e2. [PMID: 27575820 DOI: 10.1053/j.gastro.2016.08.029����%2527%2522\'\"] [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] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/18/2016] [Accepted: 08/23/2016] [Indexed: 01/29/2024]
Abstract
BACKGROUND & AIMS Conventional transarterial chemoembolization (cTACE) is used to treat patients with hepatocellular carcinoma (HCC). Radioembolization is a minimally invasive procedure that involves implantation of radioactive micron-sized particles loaded with yttrium-90 (Y90) inside the blood vessels that supply a tumor. We performed a randomized, phase 2 study to compare the effects of cTACE and Y90 radioembolization in patients with HCC. METHODS From October 2009 through October 2015, we reviewed patients with HCC of all Barcelona Clinic Liver Cancer (BCLC) stages for eligibility. Of these, 179 patients with BCLC stages A or B met our enrollment criteria and were candidates for cTACE or Y90 therapy. Patients were assigned randomly to groups that received Y90 therapy (n = 24; 50% Child-Pugh A) or cTACE (n = 21; 71% Child-Pugh A). The primary outcome was time to progression (TTP), evaluated by intention-to-treat analysis. Secondary outcomes included safety, rate of response (based on tumor size and necrosis criteria), and Kaplan-Meier survival time. We performed inverse probability of censoring weighting and competing risk analyses. RESULTS Patients in the Y90 radioembolization group had significant longer median TTP (>26 mo) than patients in the cTACE group (6.8 mo; P = .0012) (hazard ratio, 0.122; 95% confidence interval [CI], 0.027-0.557; P = .007). This was confirmed by competing risk and inverse probability of censoring weighting analyses accounting for transplantation or death. A significantly greater proportion of patients in the cTACE group developed diarrhea (21%) than in the Y90 group (0%; P = .031) or hypoalbuminemia (58% in the cTACE group vs 4% in the Y90 group; P < .001). Similar proportions of patients in each group had a response to therapy, marked by necrosis (74% in the cTACE group vs 87% in the Y90 group) (P = .433). The median survival time, censored to liver transplantation, was 17.7 months for the cTACE group (95% CI, 8.3-not calculable) vs 18.6 months for the Y90 group (95% CI, 7.4-32.5) (P = .99). CONCLUSIONS In a randomized phase 2 study of patients with HCC of BCLC stages A or B, we found Y90 radioembolization to provide significantly longer TTP than cTACE. Y90 radioembolization provides better tumor control and could reduce drop-out from transplant waitlists. ClinicalTrials.gov no. NCT00956930.
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Affiliation(s)
- Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois; Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois.
| | - Andrew C Gordon
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Samdeep Mouli
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ryan Hickey
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Joseph Kallini
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ahmed Gabr
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Mary F Mulcahy
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Talia Baker
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Michael Abecassis
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Frank H Miller
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Vahid Yaghmai
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kent Sato
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kush Desai
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Bartley Thornburg
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Al B Benson
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Alfred Rademaker
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Daniel Ganger
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Laura Kulik
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
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46
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Salem R, Gordon AC, Mouli S, Hickey R, Kallini J, Gabr A, Mulcahy MF, Baker T, Abecassis M, Miller FH, Yaghmai V, Sato K, Desai K, Thornburg B, Benson AB, Rademaker A, Ganger D, Kulik L, Lewandowski RJ. Y90 Radioembolization Significantly Prolongs Time to Progression Compared With Chemoembolization in Patients With Hepatocellular Carcinoma. Gastroenterology 2016; 151:1155-1163.e2. [PMID: 27575820 DOI: 10.1053/j.gastro.2016.08.029z38hphcs] [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] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/18/2016] [Accepted: 08/23/2016] [Indexed: 01/29/2024]
Abstract
BACKGROUND & AIMS Conventional transarterial chemoembolization (cTACE) is used to treat patients with hepatocellular carcinoma (HCC). Radioembolization is a minimally invasive procedure that involves implantation of radioactive micron-sized particles loaded with yttrium-90 (Y90) inside the blood vessels that supply a tumor. We performed a randomized, phase 2 study to compare the effects of cTACE and Y90 radioembolization in patients with HCC. METHODS From October 2009 through October 2015, we reviewed patients with HCC of all Barcelona Clinic Liver Cancer (BCLC) stages for eligibility. Of these, 179 patients with BCLC stages A or B met our enrollment criteria and were candidates for cTACE or Y90 therapy. Patients were assigned randomly to groups that received Y90 therapy (n = 24; 50% Child-Pugh A) or cTACE (n = 21; 71% Child-Pugh A). The primary outcome was time to progression (TTP), evaluated by intention-to-treat analysis. Secondary outcomes included safety, rate of response (based on tumor size and necrosis criteria), and Kaplan-Meier survival time. We performed inverse probability of censoring weighting and competing risk analyses. RESULTS Patients in the Y90 radioembolization group had significant longer median TTP (>26 mo) than patients in the cTACE group (6.8 mo; P = .0012) (hazard ratio, 0.122; 95% confidence interval [CI], 0.027-0.557; P = .007). This was confirmed by competing risk and inverse probability of censoring weighting analyses accounting for transplantation or death. A significantly greater proportion of patients in the cTACE group developed diarrhea (21%) than in the Y90 group (0%; P = .031) or hypoalbuminemia (58% in the cTACE group vs 4% in the Y90 group; P < .001). Similar proportions of patients in each group had a response to therapy, marked by necrosis (74% in the cTACE group vs 87% in the Y90 group) (P = .433). The median survival time, censored to liver transplantation, was 17.7 months for the cTACE group (95% CI, 8.3-not calculable) vs 18.6 months for the Y90 group (95% CI, 7.4-32.5) (P = .99). CONCLUSIONS In a randomized phase 2 study of patients with HCC of BCLC stages A or B, we found Y90 radioembolization to provide significantly longer TTP than cTACE. Y90 radioembolization provides better tumor control and could reduce drop-out from transplant waitlists. ClinicalTrials.gov no. NCT00956930.
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Affiliation(s)
- Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois; Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois.
| | - Andrew C Gordon
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Samdeep Mouli
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ryan Hickey
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Joseph Kallini
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ahmed Gabr
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Mary F Mulcahy
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Talia Baker
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Michael Abecassis
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Frank H Miller
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Vahid Yaghmai
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kent Sato
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kush Desai
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Bartley Thornburg
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Al B Benson
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Alfred Rademaker
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Daniel Ganger
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Laura Kulik
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
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47
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Salem R, Gordon AC, Mouli S, Hickey R, Kallini J, Gabr A, Mulcahy MF, Baker T, Abecassis M, Miller FH, Yaghmai V, Sato K, Desai K, Thornburg B, Benson AB, Rademaker A, Ganger D, Kulik L, Lewandowski RJ. Y90 Radioembolization Significantly Prolongs Time to Progression Compared With Chemoembolization in Patients With Hepatocellular Carcinoma. Gastroenterology 2016; 151:1155-1163.e2. [PMID: 27575820 DOI: 10.1053/j.gastro.2016.08.029'"] [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] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/18/2016] [Accepted: 08/23/2016] [Indexed: 01/29/2024]
Abstract
BACKGROUND & AIMS Conventional transarterial chemoembolization (cTACE) is used to treat patients with hepatocellular carcinoma (HCC). Radioembolization is a minimally invasive procedure that involves implantation of radioactive micron-sized particles loaded with yttrium-90 (Y90) inside the blood vessels that supply a tumor. We performed a randomized, phase 2 study to compare the effects of cTACE and Y90 radioembolization in patients with HCC. METHODS From October 2009 through October 2015, we reviewed patients with HCC of all Barcelona Clinic Liver Cancer (BCLC) stages for eligibility. Of these, 179 patients with BCLC stages A or B met our enrollment criteria and were candidates for cTACE or Y90 therapy. Patients were assigned randomly to groups that received Y90 therapy (n = 24; 50% Child-Pugh A) or cTACE (n = 21; 71% Child-Pugh A). The primary outcome was time to progression (TTP), evaluated by intention-to-treat analysis. Secondary outcomes included safety, rate of response (based on tumor size and necrosis criteria), and Kaplan-Meier survival time. We performed inverse probability of censoring weighting and competing risk analyses. RESULTS Patients in the Y90 radioembolization group had significant longer median TTP (>26 mo) than patients in the cTACE group (6.8 mo; P = .0012) (hazard ratio, 0.122; 95% confidence interval [CI], 0.027-0.557; P = .007). This was confirmed by competing risk and inverse probability of censoring weighting analyses accounting for transplantation or death. A significantly greater proportion of patients in the cTACE group developed diarrhea (21%) than in the Y90 group (0%; P = .031) or hypoalbuminemia (58% in the cTACE group vs 4% in the Y90 group; P < .001). Similar proportions of patients in each group had a response to therapy, marked by necrosis (74% in the cTACE group vs 87% in the Y90 group) (P = .433). The median survival time, censored to liver transplantation, was 17.7 months for the cTACE group (95% CI, 8.3-not calculable) vs 18.6 months for the Y90 group (95% CI, 7.4-32.5) (P = .99). CONCLUSIONS In a randomized phase 2 study of patients with HCC of BCLC stages A or B, we found Y90 radioembolization to provide significantly longer TTP than cTACE. Y90 radioembolization provides better tumor control and could reduce drop-out from transplant waitlists. ClinicalTrials.gov no. NCT00956930.
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Affiliation(s)
- Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois; Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois.
| | - Andrew C Gordon
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Samdeep Mouli
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ryan Hickey
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Joseph Kallini
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ahmed Gabr
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Mary F Mulcahy
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Talia Baker
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Michael Abecassis
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Frank H Miller
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Vahid Yaghmai
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kent Sato
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kush Desai
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Bartley Thornburg
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Al B Benson
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Alfred Rademaker
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Daniel Ganger
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Laura Kulik
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
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48
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Salem R, Gordon AC, Mouli S, Hickey R, Kallini J, Gabr A, Mulcahy MF, Baker T, Abecassis M, Miller FH, Yaghmai V, Sato K, Desai K, Thornburg B, Benson AB, Rademaker A, Ganger D, Kulik L, Lewandowski RJ. Y90 Radioembolization Significantly Prolongs Time to Progression Compared With Chemoembolization in Patients With Hepatocellular Carcinoma. Gastroenterology 2016; 151:1155-1163.e2. [PMID: 27575820 PMCID: PMC5124387 DOI: 10.1053/j.gastro.2016.08.029] [Citation(s) in RCA: 423] [Impact Index Per Article: 52.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/18/2016] [Accepted: 08/23/2016] [Indexed: 12/02/2022]
Abstract
BACKGROUND & AIMS Conventional transarterial chemoembolization (cTACE) is used to treat patients with hepatocellular carcinoma (HCC). Radioembolization is a minimally invasive procedure that involves implantation of radioactive micron-sized particles loaded with yttrium-90 (Y90) inside the blood vessels that supply a tumor. We performed a randomized, phase 2 study to compare the effects of cTACE and Y90 radioembolization in patients with HCC. METHODS From October 2009 through October 2015, we reviewed patients with HCC of all Barcelona Clinic Liver Cancer (BCLC) stages for eligibility. Of these, 179 patients with BCLC stages A or B met our enrollment criteria and were candidates for cTACE or Y90 therapy. Patients were assigned randomly to groups that received Y90 therapy (n = 24; 50% Child-Pugh A) or cTACE (n = 21; 71% Child-Pugh A). The primary outcome was time to progression (TTP), evaluated by intention-to-treat analysis. Secondary outcomes included safety, rate of response (based on tumor size and necrosis criteria), and Kaplan-Meier survival time. We performed inverse probability of censoring weighting and competing risk analyses. RESULTS Patients in the Y90 radioembolization group had significant longer median TTP (>26 mo) than patients in the cTACE group (6.8 mo; P = .0012) (hazard ratio, 0.122; 95% confidence interval [CI], 0.027-0.557; P = .007). This was confirmed by competing risk and inverse probability of censoring weighting analyses accounting for transplantation or death. A significantly greater proportion of patients in the cTACE group developed diarrhea (21%) than in the Y90 group (0%; P = .031) or hypoalbuminemia (58% in the cTACE group vs 4% in the Y90 group; P < .001). Similar proportions of patients in each group had a response to therapy, marked by necrosis (74% in the cTACE group vs 87% in the Y90 group) (P = .433). The median survival time, censored to liver transplantation, was 17.7 months for the cTACE group (95% CI, 8.3-not calculable) vs 18.6 months for the Y90 group (95% CI, 7.4-32.5) (P = .99). CONCLUSIONS In a randomized phase 2 study of patients with HCC of BCLC stages A or B, we found Y90 radioembolization to provide significantly longer TTP than cTACE. Y90 radioembolization provides better tumor control and could reduce drop-out from transplant waitlists. ClinicalTrials.gov no. NCT00956930.
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Affiliation(s)
- Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois; Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois.
| | - Andrew C Gordon
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Samdeep Mouli
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ryan Hickey
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Joseph Kallini
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ahmed Gabr
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Mary F Mulcahy
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Talia Baker
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Michael Abecassis
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Frank H Miller
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Vahid Yaghmai
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kent Sato
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kush Desai
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Bartley Thornburg
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Al B Benson
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Alfred Rademaker
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Daniel Ganger
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Laura Kulik
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
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49
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Salem R, Gordon AC, Mouli S, Hickey R, Kallini J, Gabr A, Mulcahy MF, Baker T, Abecassis M, Miller FH, Yaghmai V, Sato K, Desai K, Thornburg B, Benson AB, Rademaker A, Ganger D, Kulik L, Lewandowski RJ. Y90 Radioembolization Significantly Prolongs Time to Progression Compared With Chemoembolization in Patients With Hepatocellular Carcinoma. Gastroenterology 2016; 151:1155-1163.e2. [PMID: 27575820 DOI: 10.1053/j.gastro.2016.08.029" and 2*3*8=6*8 and "wbge"="wbge] [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] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/18/2016] [Accepted: 08/23/2016] [Indexed: 01/29/2024]
Abstract
BACKGROUND & AIMS Conventional transarterial chemoembolization (cTACE) is used to treat patients with hepatocellular carcinoma (HCC). Radioembolization is a minimally invasive procedure that involves implantation of radioactive micron-sized particles loaded with yttrium-90 (Y90) inside the blood vessels that supply a tumor. We performed a randomized, phase 2 study to compare the effects of cTACE and Y90 radioembolization in patients with HCC. METHODS From October 2009 through October 2015, we reviewed patients with HCC of all Barcelona Clinic Liver Cancer (BCLC) stages for eligibility. Of these, 179 patients with BCLC stages A or B met our enrollment criteria and were candidates for cTACE or Y90 therapy. Patients were assigned randomly to groups that received Y90 therapy (n = 24; 50% Child-Pugh A) or cTACE (n = 21; 71% Child-Pugh A). The primary outcome was time to progression (TTP), evaluated by intention-to-treat analysis. Secondary outcomes included safety, rate of response (based on tumor size and necrosis criteria), and Kaplan-Meier survival time. We performed inverse probability of censoring weighting and competing risk analyses. RESULTS Patients in the Y90 radioembolization group had significant longer median TTP (>26 mo) than patients in the cTACE group (6.8 mo; P = .0012) (hazard ratio, 0.122; 95% confidence interval [CI], 0.027-0.557; P = .007). This was confirmed by competing risk and inverse probability of censoring weighting analyses accounting for transplantation or death. A significantly greater proportion of patients in the cTACE group developed diarrhea (21%) than in the Y90 group (0%; P = .031) or hypoalbuminemia (58% in the cTACE group vs 4% in the Y90 group; P < .001). Similar proportions of patients in each group had a response to therapy, marked by necrosis (74% in the cTACE group vs 87% in the Y90 group) (P = .433). The median survival time, censored to liver transplantation, was 17.7 months for the cTACE group (95% CI, 8.3-not calculable) vs 18.6 months for the Y90 group (95% CI, 7.4-32.5) (P = .99). CONCLUSIONS In a randomized phase 2 study of patients with HCC of BCLC stages A or B, we found Y90 radioembolization to provide significantly longer TTP than cTACE. Y90 radioembolization provides better tumor control and could reduce drop-out from transplant waitlists. ClinicalTrials.gov no. NCT00956930.
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Affiliation(s)
- Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois; Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois.
| | - Andrew C Gordon
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Samdeep Mouli
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ryan Hickey
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Joseph Kallini
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ahmed Gabr
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Mary F Mulcahy
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Talia Baker
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Michael Abecassis
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Frank H Miller
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Vahid Yaghmai
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kent Sato
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kush Desai
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Bartley Thornburg
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Al B Benson
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Alfred Rademaker
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Daniel Ganger
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Laura Kulik
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
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50
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Salem R, Gordon AC, Mouli S, Hickey R, Kallini J, Gabr A, Mulcahy MF, Baker T, Abecassis M, Miller FH, Yaghmai V, Sato K, Desai K, Thornburg B, Benson AB, Rademaker A, Ganger D, Kulik L, Lewandowski RJ. Y90 Radioembolization Significantly Prolongs Time to Progression Compared With Chemoembolization in Patients With Hepatocellular Carcinoma. Gastroenterology 2016; 151:1155-1163.e2. [PMID: 27575820 DOI: 10.1053/j.gastro.2016.08.029'||'] [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] [Grants] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/22/2016] [Revised: 08/18/2016] [Accepted: 08/23/2016] [Indexed: 01/29/2024]
Abstract
BACKGROUND & AIMS Conventional transarterial chemoembolization (cTACE) is used to treat patients with hepatocellular carcinoma (HCC). Radioembolization is a minimally invasive procedure that involves implantation of radioactive micron-sized particles loaded with yttrium-90 (Y90) inside the blood vessels that supply a tumor. We performed a randomized, phase 2 study to compare the effects of cTACE and Y90 radioembolization in patients with HCC. METHODS From October 2009 through October 2015, we reviewed patients with HCC of all Barcelona Clinic Liver Cancer (BCLC) stages for eligibility. Of these, 179 patients with BCLC stages A or B met our enrollment criteria and were candidates for cTACE or Y90 therapy. Patients were assigned randomly to groups that received Y90 therapy (n = 24; 50% Child-Pugh A) or cTACE (n = 21; 71% Child-Pugh A). The primary outcome was time to progression (TTP), evaluated by intention-to-treat analysis. Secondary outcomes included safety, rate of response (based on tumor size and necrosis criteria), and Kaplan-Meier survival time. We performed inverse probability of censoring weighting and competing risk analyses. RESULTS Patients in the Y90 radioembolization group had significant longer median TTP (>26 mo) than patients in the cTACE group (6.8 mo; P = .0012) (hazard ratio, 0.122; 95% confidence interval [CI], 0.027-0.557; P = .007). This was confirmed by competing risk and inverse probability of censoring weighting analyses accounting for transplantation or death. A significantly greater proportion of patients in the cTACE group developed diarrhea (21%) than in the Y90 group (0%; P = .031) or hypoalbuminemia (58% in the cTACE group vs 4% in the Y90 group; P < .001). Similar proportions of patients in each group had a response to therapy, marked by necrosis (74% in the cTACE group vs 87% in the Y90 group) (P = .433). The median survival time, censored to liver transplantation, was 17.7 months for the cTACE group (95% CI, 8.3-not calculable) vs 18.6 months for the Y90 group (95% CI, 7.4-32.5) (P = .99). CONCLUSIONS In a randomized phase 2 study of patients with HCC of BCLC stages A or B, we found Y90 radioembolization to provide significantly longer TTP than cTACE. Y90 radioembolization provides better tumor control and could reduce drop-out from transplant waitlists. ClinicalTrials.gov no. NCT00956930.
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Affiliation(s)
- Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois; Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois.
| | - Andrew C Gordon
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Samdeep Mouli
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ryan Hickey
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Joseph Kallini
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ahmed Gabr
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Mary F Mulcahy
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Talia Baker
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Michael Abecassis
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Frank H Miller
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Vahid Yaghmai
- Section of Body Imaging, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kent Sato
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Kush Desai
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Bartley Thornburg
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Al B Benson
- Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Alfred Rademaker
- Department of Preventive Medicine, Northwestern University, Chicago, Illinois
| | - Daniel Ganger
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Laura Kulik
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
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