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Natarajan B, Tabrizian P, Hoteit M, Frenette C, Parikh N, Ghaziani T, Dhanasekaran R, Guy J, Shui A, Florman S, Yao FY, Mehta N. Downstaging hepatocellular carcinoma before liver transplantation: A multicenter analysis of the "all-comers" protocol in the Multicenter Evaluation of Reduction in Tumor Size before Liver Transplantation (MERITS-LT) consortium. Am J Transplant 2023; 23:1771-1780. [PMID: 37532179 PMCID: PMC10998692 DOI: 10.1016/j.ajt.2023.07.021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Revised: 06/27/2023] [Accepted: 07/27/2023] [Indexed: 08/04/2023]
Abstract
Patients with hepatocellular carcinoma meeting united network for organ sharing (UNOS)-downstaging (DS) criteria have excellent liver transplantation (LT) outcomes after DS. However, outcomes for "all-comers" (AC) patients with tumors initially exceeding UNOS-DS are poorly understood. Patients meeting AC (n = 82) or UNOS-DS (n = 229) at 7 LT centers in 4 UNOS regions were prospectively followed from 2015-2020. AC patients had a lower probability of successful DS (67% vs 83% within 12 months; P < .001). The 3-year survival was 69% for UNOS-DS vs 58% for AC (P = .05) and reduced to 30% in patients with Child-Pugh B/C cirrhosis or alpha-fetoprotein (AFP) ≥ 500. Five-year LT probability was 42% for AC vs 74% in UNOS-DS (P = .10). Thirty-eight percent were understaged on explant, with the increasing sum of the largest tumor diameter plus the number of lesions before LT (odds ratio 1.3; P = .01) and AFP ≥ 20 (odds ratio 5.9; P = .005) associated with understaging. Post-LT 3-year survival was 91% for AC vs 81% for UNOS-DS (P = .67). In this first prospective multiregional study of AC patients from the multicenter evaluation of reduction in tumor size before liver transplantation (MERITS-LT) consortium, we observed a 65% probability of successful DS. Three-year survival in AC was nearly 60%, though AC with Child-Pugh B/C or AFP ≥ 500 had poor survival. Explant pathology and 3-year post-LT outcomes were similar between cohorts, suggesting that LT is a reasonable goal in selected AC patients.
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Affiliation(s)
- Brahma Natarajan
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California, USA
| | - Parissa Tabrizian
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Maarouf Hoteit
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Catherine Frenette
- Center for Organ and Cell Transplantation, Scripps Green Hospital, La Jolla, California, USA
| | - Neehar Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan, USA
| | - Tara Ghaziani
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California, USA
| | - Renu Dhanasekaran
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California, USA
| | - Jennifer Guy
- Department of Transplantation, California Pacific Medical Center, San Francisco, California, USA
| | - Amy Shui
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California, USA
| | - Sander Florman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York, New York, USA
| | - Francis Y Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California, USA
| | - Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California, USA.
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Tran BV, Moris D, Markovic D, Zaribafzadeh H, Henao R, Lai Q, Florman SS, Tabrizian P, Haydel B, Ruiz RM, Klintmalm GB, Lee DD, Taner CB, Hoteit M, Levine MH, Cillo U, Vitale A, Verna EC, Halazun KJ, Tevar AD, Humar A, Chapman WC, Vachharajani N, Aucejo F, Lerut J, Ciccarelli O, Nguyen MH, Melcher ML, Viveiros A, Schaefer B, Hoppe-Lotichius M, Mittler J, Nydam TL, Markmann JF, Rossi M, Mobley C, Ghobrial M, Langnas AN, Carney CA, Berumen J, Schnickel GT, Sudan DL, Hong JC, Rana A, Jones CM, Fishbein TM, Busuttil RW, Barbas AS, Agopian VG. Development and validation of a REcurrent Liver cAncer Prediction ScorE (RELAPSE) following liver transplantation in patients with hepatocellular carcinoma: Analysis of the US Multicenter HCC Transplant Consortium. Liver Transpl 2023; 29:683-697. [PMID: 37029083 DOI: 10.1097/lvt.0000000000000145] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2022] [Accepted: 01/31/2023] [Indexed: 04/09/2023]
Abstract
HCC recurrence following liver transplantation (LT) is highly morbid and occurs despite strict patient selection criteria. Individualized prediction of post-LT HCC recurrence risk remains an important need. Clinico-radiologic and pathologic data of 4981 patients with HCC undergoing LT from the US Multicenter HCC Transplant Consortium (UMHTC) were analyzed to develop a REcurrent Liver cAncer Prediction ScorE (RELAPSE). Multivariable Fine and Gray competing risk analysis and machine learning algorithms (Random Survival Forest and Classification and Regression Tree models) identified variables to model HCC recurrence. RELAPSE was externally validated in 1160 HCC LT recipients from the European Hepatocellular Cancer Liver Transplant study group. Of 4981 UMHTC patients with HCC undergoing LT, 71.9% were within Milan criteria, 16.1% were initially beyond Milan criteria with 9.4% downstaged before LT, and 12.0% had incidental HCC on explant pathology. Overall and recurrence-free survival at 1, 3, and 5 years was 89.7%, 78.6%, and 69.8% and 86.8%, 74.9%, and 66.7%, respectively, with a 5-year incidence of HCC recurrence of 12.5% (median 16 months) and non-HCC mortality of 20.8%. A multivariable model identified maximum alpha-fetoprotein (HR = 1.35 per-log SD, 95% CI,1.22-1.50, p < 0.001), neutrophil-lymphocyte ratio (HR = 1.16 per-log SD, 95% CI,1.04-1.28, p < 0.006), pathologic maximum tumor diameter (HR = 1.53 per-log SD, 95% CI, 1.35-1.73, p < 0.001), microvascular (HR = 2.37, 95%-CI, 1.87-2.99, p < 0.001) and macrovascular (HR = 3.38, 95% CI, 2.41-4.75, p < 0.001) invasion, and tumor differentiation (moderate HR = 1.75, 95% CI, 1.29-2.37, p < 0.001; poor HR = 2.62, 95% CI, 1.54-3.32, p < 0.001) as independent variables predicting post-LT HCC recurrence (C-statistic = 0.78). Machine learning algorithms incorporating additional covariates improved prediction of recurrence (Random Survival Forest C-statistic = 0.81). Despite significant differences in European Hepatocellular Cancer Liver Transplant recipient radiologic, treatment, and pathologic characteristics, external validation of RELAPSE demonstrated consistent 2- and 5-year recurrence risk discrimination (AUCs 0.77 and 0.75, respectively). We developed and externally validated a RELAPSE score that accurately discriminates post-LT HCC recurrence risk and may allow for individualized post-LT surveillance, immunosuppression modification, and selection of high-risk patients for adjuvant therapies.
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Affiliation(s)
- Benjamin V Tran
- Department of Surgery, David Geffen School of Medicine at UCLA, Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Los Angeles, California, USA
| | - Dimitrios Moris
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Daniela Markovic
- Department of Medicine, Statistics Core, University of California, Los Angeles, USA
| | - Hamed Zaribafzadeh
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Ricardo Henao
- Department of Biostatistics and Bioinformatics, Duke University School of Medicine, Durham, North Carolina, USA
| | - Quirino Lai
- General Surgery and Organ Transplantation Unit, Sapienza University, AOU Policlinico Umberto I, Rome, Italy
| | - Sander S Florman
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, New York, USA
| | - Parissa Tabrizian
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, New York, USA
| | - Brandy Haydel
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, New York, USA
| | - Richard M Ruiz
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - Goran B Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, Texas, USA
| | - David D Lee
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - C Burcin Taner
- Department of Transplantation, Mayo Clinic, Jacksonville, Florida, USA
| | - Maarouf Hoteit
- Penn Transplant Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Matthew H Levine
- Penn Transplant Institute, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Umberto Cillo
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- New York-Presbyterian Hospital, Weill Cornell, New York, New York, USA
| | - Alessandro Vitale
- Department of Surgery, Oncology and Gastroenterology, University of Padua, Padua, Italy
- New York-Presbyterian Hospital, Weill Cornell, New York, New York, USA
| | - Elizabeth C Verna
- New York-Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Karim J Halazun
- New York-Presbyterian Hospital, Columbia University, New York, New York, USA
| | - Amit D Tevar
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Abhinav Humar
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - William C Chapman
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | - Neeta Vachharajani
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, Missouri, USA
| | | | - Jan Lerut
- Department of Abdominal and Transplantation Surgery, Institute for Experimental and Clinical Research, Universite Catholique Louvain, Brussels, Belgium
| | - Olga Ciccarelli
- Department of Abdominal and Transplantation Surgery, Institute for Experimental and Clinical Research, Universite Catholique Louvain, Brussels, Belgium
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California, USA
| | - Marc L Melcher
- Department of Surgery, Stanford University, Palo Alto, California, USA
| | - Andre Viveiros
- Department of Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Benedikt Schaefer
- Department of Medicine I, Medical University of Innsbruck, Innsbruck, Austria
| | - Maria Hoppe-Lotichius
- Clinic for General, Visceral and Transplantation Surgery, Universitatsmedizin Mainz, Mainz, Germany
| | - Jens Mittler
- Clinic for General, Visceral and Transplantation Surgery, Universitatsmedizin Mainz, Mainz, Germany
| | - Trevor L Nydam
- Department of Surgery, Division of Transplant Surgery, University of Colorado School of Medicine, Denver, Colorado, USA
| | - James F Markmann
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, Massachusetts, USA
| | - Massimo Rossi
- General Surgery and Organ Transplantation Unit, Sapienza University, AOU Policlinico Umberto I, Rome, Italy
| | - Constance Mobley
- Sherrie & Alan Conover Center for Liver Disease & Transplantation, Houston Methodist Hospital, Houston, Texas, USA
| | - Mark Ghobrial
- Sherrie & Alan Conover Center for Liver Disease & Transplantation, Houston Methodist Hospital, Houston, Texas, USA
| | - Alan N Langnas
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Carol A Carney
- Department of Surgery, University of Nebraska Medical Center, Omaha, Nebraska, USA
| | - Jennifer Berumen
- Department of Surgery, Division of Transplantation and Hepatobiliary Surgery, University of California, San Diego, San Diego, California, USA
| | - Gabriel T Schnickel
- Department of Surgery, Division of Transplantation and Hepatobiliary Surgery, University of California, San Diego, San Diego, California, USA
| | - Debra L Sudan
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Johnny C Hong
- Department of Hepatobiliary Surgery & Transplantation, Division of Transplantation, Penn State College of Medicine, Hershey, Pennsylvania, USA
| | - Abbas Rana
- Department of Surgery, Baylor College of Medicine, Houston, Texas, USA
| | - Christopher M Jones
- Section of Hepatobiliary and Transplant Surgery, University of Louisville School of Medicine, Louisville, Kentucky, USA
| | - Thomas M Fishbein
- Medstar Georgetown Transplant Institute, Georgetown University, Washington, District of Columbia, USA
| | - Ronald W Busuttil
- Department of Surgery, David Geffen School of Medicine at UCLA, Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Los Angeles, California, USA
| | - Andrew S Barbas
- Department of Surgery, Duke University Medical Center, Durham, North Carolina, USA
| | - Vatche G Agopian
- Department of Surgery, David Geffen School of Medicine at UCLA, Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Los Angeles, California, USA
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3
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Kim YY, Nyman A, Rosenthal B, Lluri G, Haeffele C, Defreitas A, Lubert A, Krasuski RA, Wu F, Krieger EV, Saraf A, Earing M, Lewis MJ, Rodriguez FH, Zaidi AN, Bradley E, Cedars AM, Franklin WJ, Ginde S, Grewal J, Schluger C, Min J, Hilscher M, Hoteit M. CLINICAL CHARACTERISTICS AND OUTCOMES OF HEPATOCELLULAR CARCINOMA FOLLOWING FONTAN PALLIATION. J Am Coll Cardiol 2023. [DOI: 10.1016/s0735-1097(23)01984-8] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
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Mettikanont P, Kalluri A, Bittermann T, Phillips N, Loza BL, Rosen M, Siegelman E, Furth E, Abt P, Olthoff K, Shaked A, Hoteit M, Reddy KR. The Course of LIRADS 3 and 4 Hepatic Abnormalities as Correlated With Explant Pathology: A Single Center Experience. J Clin Exp Hepatol 2022; 12:1048-1056. [PMID: 35814502 PMCID: PMC9257948 DOI: 10.1016/j.jceh.2022.02.005] [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] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/26/2021] [Accepted: 02/23/2022] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND AND AIMS The Liver Reporting and Data System (LI-RADS) is the standard classification of imaging findings of hepatic abnormalities for hepatocellular carcinoma (HCC) surveillance. We aimed to study the course of LI-RADS 3 and 4 (LR-3 and LR-4) abnormalities through correlations with explant pathology. METHODS A single center retrospective study of liver transplant recipients between January 2016 and September 2019 with HCC on explant pathology was conducted. Eligible patients were divided into three subgroups based on their LI-RADS classification: LR-3/4, LR-5 only, and combination of LR-3/4/5. RESULTS There were 116 eligible patients with 99 LR-3/4 observations (60 LR-3 and 39 LR-4); the rest had LR-5 lesions. LR-4 more often than LR-3 observations progressed to LR-5 (36% vs 12%) and with shorter duration during follow-up (median 175 days and 196 days). Mean size growth of LR-3 and LR-4 abnormalities were 2.6 and 3.8 mm; median growth rates were 0.2 and 0.4 mm/month, respectively. Numbers of HCC lesions per explant, largest HCC lesion size, and cumulative size were higher in LR-3/4/5 subgroup than LR-5 subgroup (P = 0.007, 0.007 and 0.006, respectively); 68% of LR-3 and 82% of LR-4 abnormalities were confirmed HCC on explant (P = 0.09). CONCLUSION Compared to LR-3, more LR-4 abnormalities progressed to LR-5 (12% and 36%, respectively) in a shorter time and with faster growth rate. A high proportion of LR-3 and LR-4 lesions (68% and 82%, respectively) were confirmed HCC on explant, raising the question of whether excluding HCC based on radiologic criteria alone is adequate in those with LR-3/4 abnormalities.
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Key Words
- AFP, alpha-fetoprotein
- BMI, body mass index
- CT, computed tomography
- HBV, hepatitis b virus
- HCC, hepatocellular carcinoma
- HCV, hepatitis c virus
- LI-RADS, liver reporting and data system
- LIRADS classification
- LR-3, LI-RADS 3
- LR-4, LI-RADS4
- LR-5, LI-RADS 5
- LT, liver transplantation
- MELD-Na, model for end stage liver disease sodium
- MRI, magnetic resonance imaging
- explant pathology
- hepatocellular carcinoma
- liver transplant
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Affiliation(s)
| | | | | | | | | | | | | | | | | | | | | | | | - K. Rajender Reddy
- Address for correspondence: K. Rajender Reddy, Professor of Medicine, Director of Hepatology, University of Pennsylvania, 2 Dulles, 3400 Spruce Street, Philadelphia, PA, 19104, United States.
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5
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Mehta N, Frenette C, Tabrizian P, Hoteit M, Guy J, Parikh N, Ghaziani TT, Dhanasekaran R, Dodge JL, Natarajan B, Holzner ML, Frankul L, Chan W, Fobar A, Florman S, Yao FY. Downstaging Outcomes for Hepatocellular Carcinoma: Results From the Multicenter Evaluation of Reduction in Tumor Size before Liver Transplantation (MERITS-LT) Consortium. Gastroenterology 2021; 161:1502-1512. [PMID: 34331914 PMCID: PMC8545832 DOI: 10.1053/j.gastro.2021.07.033] [Citation(s) in RCA: 54] [Impact Index Per Article: 18.0] [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: 01/21/2021] [Revised: 05/30/2021] [Accepted: 07/20/2021] [Indexed: 12/16/2022]
Abstract
BACKGROUND & AIMS United Network of Organ Sharing (UNOS) has adopted uniform criteria for downstaging (UNOS-DS) of hepatocellular carcinoma (HCC) before liver transplantation (LT), but the downstaging success rate and intention-to-treat outcomes across broad geographic regions are unknown. METHODS In this first multiregional study (7 centers, 4 UNOS regions), 209 consecutive patients with HCC undergoing downstaging based on UNOS-DS criteria were prospectively evaluated from 2016 to 2019. RESULTS Probability of successful downstaging to Milan criteria and dropout at 2 years from the initial downstaging procedure was 87.7% and 37.3%, respectively. Pretreatment with lectin-reactive α-fetoprotein ≥10% (hazard ratio, 3.7; P = .02) was associated with increased dropout risk. When chemoembolization (n = 132) and yttrium-90 radioembolization (n = 62) were compared as the initial downstaging treatment, there were no differences in Modified Response Evaluation Criteria In Solid Tumors response, probability of or time to successful downstaging, waiting list dropout, or LT. Probability of LT at 3 years was 46.6% after a median of 17.2 months. In the explant, 17.5% had vascular invasion, and 42.8% exceeded Milan criteria (understaging). The only factor associated with understaging was the sum of the number of lesions plus largest tumor diameter on the last pre-LT imaging, and the odds of understaging increased by 35% per 1-unit increase in this sum. Post-LT survival at 2 years was 95%, and HCC recurrence occurred in 7.9%. CONCLUSION In this first prospective multiregional study based on UNOS-DS criteria, we observed a successful downstaging rate of >80% and similar efficacy of chemoembolization and yttrium-90 radioembolization as the initial downstaging treatment. A high rate of tumor understaging was observed despite excellent 2-year post-LT survival of 95%. Additional LRT to reduce viable tumor burden may reduce tumor understaging.
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Affiliation(s)
- Neil Mehta
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco, California.
| | | | - Parissa Tabrizian
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York
| | - Maarouf Hoteit
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania
| | - Jennifer Guy
- Department of Transplantation, California Pacific Medical Center
| | - Neehar Parikh
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - T. Tara Ghaziani
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California
| | - Renu Dhanasekaran
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, California
| | - Jennifer L. Dodge
- Division of Transplant Surgery, Department of Surgery, University of California, San Francisco
| | - Brahma Natarajan
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco
| | - Matthew L. Holzner
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York
| | - Leana Frankul
- Center for Organ and Cell Transplantation, Scripps Green Hospital
| | - Wesley Chan
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco
| | - Austin Fobar
- Division of Gastroenterology and Hepatology, University of Michigan, Ann Arbor, Michigan
| | - Sander Florman
- Department of Surgery, Icahn School of Medicine at Mount Sinai, New York
| | - Francis Y. Yao
- Division of Gastroenterology, Department of Medicine, University of California, San Francisco,Division of Transplant Surgery, Department of Surgery, University of California, San Francisco
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6
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Krumeich LN, Mancinelli J, Cucchiara A, Eddinger K, Aufhauser D, Goldberg DW, Siegelman ES, Rosen M, Reddy KR, Hoteit M, Furth EE, Olthoff KM, Shaked A, Levine M, Abt P. Occult Hepatocellular Carcinoma Associated With Transjugular Intrahepatic Portosystemic Shunts in Liver Transplant Recipients. Liver Transpl 2021; 27:1248-1261. [PMID: 33853207 PMCID: PMC8429178 DOI: 10.1002/lt.26073] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/13/2020] [Revised: 03/21/2021] [Accepted: 03/29/2021] [Indexed: 01/17/2023]
Abstract
Transplant eligibility for hepatocellular carcinoma (HCC) is determined by the imaging identification of tumor burden within the Milan criteria. Transjugular intrahepatic portosystemic shunt(s) (TIPS) reduce portal hypertension but may impact HCC visualization. It was hypothesized that the presence of pretransplant TIPS would correlate with occult HCC and reduced survival. A single-center, retrospective, case control study was performed among liver transplant recipients with HCC (2000-2017). The primary endpoint was occult disease on explant pathology. Backward stepwise logistic regression was performed. The secondary endpoints disease-free survival (DFS) and overall survival (OS) were evaluated with Kaplan-Meier curves and Cox regression analysis. Of 640 patients, 40 had TIPS and more frequently exhibited occult disease (80.0% versus 43.1%; P < 0.001; odds ratio [OR], 4.16; P < 0.001). Portal vein thrombosis (PVT) similarly correlated with occult disease (OR, 1.97; P = 0.02). Explant tumor burden was equivalent between TIPS subgroups; accordingly, TIPS status was not independently associated with reduced DFS or OS. However, exceeding the Milan criteria was associated with reduced DFS (hazard ratio, 3.21; P = 0.001), and TIPS status in patients with a single suspected lesion (n = 316) independently correlated with explant tumor burdens beyond these criteria (OR, 13.47; P = 0.001). TIPS on pretransplant imaging are associated with occult HCC on explant pathology. Comparable occult disease findings in patients with PVT suggest that the mechanism may involve altered hepatic perfusion, obscuring imaging diagnosis. TIPS are not independently associated with reduced DFS or OS but are associated with exceeding the Milan criteria for patients with a single suspected lesion. The presence of TIPS may necessitate a higher index of suspicion for occult HCC.
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Affiliation(s)
- Lauren N. Krumeich
- Hospital of the University of Pennsylvania, Department of Surgery, Philadelphia PA
| | - Jenna Mancinelli
- Hospital of the University of Pennsylvania, Department of Surgery, Philadelphia PA
| | - Andy Cucchiara
- Hospital of the University of Pennsylvania, Department of Biostatistics, Philadelphia PA
| | - Kevin Eddinger
- Hospital of the University of Pennsylvania, Department of Surgery, Philadelphia PA
| | - David Aufhauser
- University of Wisconsin School of Medicine and Public Health, Department of Surgery, Madison, WI
| | - Drew W. Goldberg
- Hospital of the University of Pennsylvania, Department of Surgery, Philadelphia PA
| | - Evan S. Siegelman
- Hospital of the University of Pennsylvania, Department of Radiology, Philadelphia PA
| | - Mark Rosen
- Hospital of the University of Pennsylvania, Department of Radiology, Philadelphia PA
| | - K. Rajender Reddy
- Hospital of the University of Pennsylvania, Department of Hepatology, Philadelphia PA
| | - Maarouf Hoteit
- Hospital of the University of Pennsylvania, Department of Hepatology, Philadelphia PA
| | - Emma E. Furth
- Hospital of the University of Pennsylvania, Department of Pathology and Laboratory Medicine, Philadelphia PA
| | - Kim M. Olthoff
- Hospital of the University of Pennsylvania, Department of Surgery, Philadelphia PA
| | - Abraham Shaked
- Hospital of the University of Pennsylvania, Department of Surgery, Philadelphia PA
| | - Matthew Levine
- Hospital of the University of Pennsylvania, Department of Surgery, Philadelphia PA
| | - Peter Abt
- Hospital of the University of Pennsylvania, Department of Surgery, Philadelphia PA
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7
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Kardashian A, Florman SS, Haydel B, Ruiz RM, Klintmalm GB, Lee DD, Taner CB, Aucejo F, Tevar AD, Humar A, Verna EC, Halazun KJ, Chapman WC, Vachharajani N, Hoteit M, Levine MH, Nguyen MH, Melcher ML, Langnas AN, Carney CA, Mobley C, Ghobrial M, Amundsen B, Markmann JF, Sudan DL, Jones CM, Berumen J, Hemming AW, Hong JC, Kim J, Zimmerman MA, Nydam TL, Rana A, Kueht ML, Fishbein TM, Markovic D, Busuttil RW, Agopian VG. Liver Transplantation Outcomes in a U.S. Multicenter Cohort of 789 Patients With Hepatocellular Carcinoma Presenting Beyond Milan Criteria. Hepatology 2020; 72:2014-2028. [PMID: 32124453 DOI: 10.1002/hep.31210] [Citation(s) in RCA: 58] [Impact Index Per Article: 14.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/12/2019] [Revised: 12/29/2019] [Accepted: 02/05/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND AIMS The Organ Procurement and Transplantation Network recently approved liver transplant (LT) prioritization for patients with hepatocellular carcinoma (HCC) beyond Milan Criteria (MC) who are down-staged (DS) with locoregional therapy (LRT). We evaluated post-LT outcomes, predictors of down-staging, and the impact of LRT in patients with beyond-MC HCC from the U.S. Multicenter HCC Transplant Consortium (20 centers, 2002-2013). APPROACH AND RESULTS Clinicopathologic characteristics, overall survival (OS), recurrence-free survival (RFS), and HCC recurrence (HCC-R) were compared between patients within MC (n = 3,570) and beyond MC (n = 789) who were down-staged (DS, n = 465), treated with LRT and not down-staged (LRT-NoDS, n = 242), or untreated (NoLRT-NoDS, n = 82). Five-year post-LT OS and RFS was higher in MC (71.3% and 68.2%) compared with DS (64.3% and 59.5%) and was lowest in NoDS (n = 324; 60.2% and 53.8%; overall P < 0.001). DS patients had superior RFS (60% vs. 54%, P = 0.043) and lower 5-year HCC-R (18% vs. 32%, P < 0.001) compared with NoDS, with further stratification by maximum radiologic tumor diameter (5-year HCC-R of 15.5% in DS/<5 cm and 39.1% in NoDS/>5 cm, P < 0.001). Multivariate predictors of down-staging included alpha-fetoprotein response to LRT, pathologic tumor number and size, and wait time >12 months. LRT-NoDS had greater HCC-R compared with NoLRT-NoDS (34.1% vs. 26.1%, P < 0.001), even after controlling for clinicopathologic variables (hazard ratio [HR] = 2.33, P < 0.001) and inverse probability of treatment-weighted propensity matching (HR = 1.82, P < 0.001). CONCLUSIONS In LT recipients with HCC presenting beyond MC, successful down-staging is predicted by wait time, alpha-fetoprotein response to LRT, and tumor burden and results in excellent post-LT outcomes, justifying expansion of LT criteria. In LRT-NoDS patients, higher HCC-R compared with NoLRT-NoDS cannot be explained by clinicopathologic differences, suggesting a potentially aggravating role of LRT in patients with poor tumor biology that warrants further investigation.
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Affiliation(s)
- Ani Kardashian
- Vatche and Tamar Manoukian Division of Digestive Diseases, University of California, Los Angeles, Los Angeles, CA
| | - Sander S Florman
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - Brandy Haydel
- Recanati/Miller Transplantation Institute, Mount Sinai Medical Center, New York, NY
| | - Richard M Ruiz
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - Goran B Klintmalm
- Annette C. and Harold C. Simmons Transplant Institute, Baylor University Medical Center, Dallas, TX
| | - David D Lee
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
| | - C Burcin Taner
- Department of Transplantation, Mayo Clinic, Jacksonville, FL
| | | | - Amit D Tevar
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | - Abhinav Humar
- Thomas E. Starzl Transplantation Institute, University of Pittsburgh Medical Center, Pittsburgh, PA
| | | | | | - William C Chapman
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | - Neeta Vachharajani
- Section of Transplantation, Department of Surgery, Washington University in St. Louis, St. Louis, MO
| | - Maarouf Hoteit
- Penn Transplant Institute, University of Pennsylvania, Philadelphia, PA
| | - Matthew H Levine
- Penn Transplant Institute, University of Pennsylvania, Philadelphia, PA
| | - Mindie H Nguyen
- Division of Gastroenterology and Hepatology, Stanford University, Palo Alto, CA
| | - Marc L Melcher
- Department of Surgery, Stanford University, Palo Alto, CA
| | - Alan N Langnas
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Carol A Carney
- Department of Surgery, University of Nebraska Medical Center, Omaha, NE
| | - Constance Mobley
- Sherrie & Alan Conover Center for Liver Disease & Transplantation, Houston Methodist Hospital, Houston, TX
| | - Mark Ghobrial
- Sherrie & Alan Conover Center for Liver Disease & Transplantation, Houston Methodist Hospital, Houston, TX
| | - Beth Amundsen
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - James F Markmann
- Division of Transplant Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA
| | - Debra L Sudan
- Department of Surgery, Duke University Medical Center, Durham, NC
| | - Christopher M Jones
- Section of Hepatobiliary and Transplant Surgery, University of Louisville School of Medicine, Louisville, KY
| | - Jennifer Berumen
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of California, San Diego, San Diego, CA
| | - Alan W Hemming
- Division of Transplantation and Hepatobiliary Surgery, Department of Surgery, University of California, San Diego, San Diego, CA
| | - Johnny C Hong
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Joohyun Kim
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Michael A Zimmerman
- Division of Transplant Surgery, Department of Surgery, Medical College of Wisconsin, Milwaukee, WI
| | - Trevor L Nydam
- Division of Transplant Surgery, Department of Surgery, University of Colorado School of Medicine, Denver, CO
| | - Abbas Rana
- Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Michael L Kueht
- Department of Surgery, Baylor College of Medicine, Houston, TX
| | - Thomas M Fishbein
- Medstar Georgetown Transplant Institute, Georgetown University, Washington, DC
| | - Daniela Markovic
- Department of Biomathematics, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Ronald W Busuttil
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
| | - Vatche G Agopian
- Dumont-UCLA (University of California, Los Angeles) Transplant and Liver Cancer Centers, Department of Surgery, David Geffen School of Medicine at UCLA, Los Angeles, CA
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8
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Mohiuddin J, Manjunath S, Williams G, Grandhi N, Han X, Nadolski G, Hoteit M, Karasic T, Hunt S, Prenner S, Ben-Josef E, Wojcieszynski A. ALBI Grade vs. Child-Pugh (CP) Score For Stratification Of Survival And Liver Function Decline In Patients With Hepatocellular Carcinoma (HCC) Treated With Radiotherapy (RT). Int J Radiat Oncol Biol Phys 2020. [DOI: 10.1016/j.ijrobp.2020.07.1814] [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: 10/23/2022]
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9
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Serper M, Shaked A, Olthoff KM, Hoteit M, Appolo B, Reddy KR. A local response to COVID-19 for advanced liver disease: Current model of care, challenges and opportunities. J Hepatol 2020; 73:708-709. [PMID: 32450089 PMCID: PMC7242929 DOI: 10.1016/j.jhep.2020.05.022] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2020] [Accepted: 05/07/2020] [Indexed: 12/11/2022]
Affiliation(s)
- Marina Serper
- Division of Gastroenterology & Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA; Leonard Davis Institute of Health Economics, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA.
| | - Abraham Shaked
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kim M. Olthoff
- Department of Surgery, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Maarouf Hoteit
- Division of Gastroenterology & Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Brenda Appolo
- Division of Gastroenterology & Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - K. Rajender Reddy
- Division of Gastroenterology & Hepatology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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10
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Patel B, Serper M, Ruckdeschel E, Partington SL, Andrade L, Tobin L, Kim Y, Hoteit M. PREDICTORS OF ADVERSE LIVER-RELATED OUTCOMES IN ADULTS AFTER THE FONTAN OPERATION. J Am Coll Cardiol 2020. [DOI: 10.1016/s0735-1097(20)31264-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022]
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11
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Siddique SM, Porges S, Lane-Fall M, Mehta S, Schweickert W, Kinniry J, Taylor A, Lewis JD, Iqbal S, Goldberg D, Shea JA, Stetson R, Coniglio M, Hoteit M, Fishman N, Khungar V. Reducing Hospital Admissions for Paracentesis: A Quality Improvement Intervention. Clin Gastroenterol Hepatol 2019; 17:2630-2633.e2. [PMID: 31518719 PMCID: PMC6874893 DOI: 10.1016/j.cgh.2019.09.001] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Affiliation(s)
- Shazia Mehmood Siddique
- Division of Gastroenterology, University of Pennsylvania, Philadelphia, Pennsylvania; Leonard Davis Institute of Health Economics, University of Pennsylvania, Philadelphia, Pennsylvania; Center for Healthcare Improvement and Patient Safety, University of Pennsylvania, Philadelphia, Pennsylvania.
| | - Stefanie Porges
- Department of Emergency Medicine, University of Pennsylvania
| | - Meghan Lane-Fall
- Leonard Davis Institute of Health Economics, University of Pennsylvania,Center for Healthcare Improvement and Patient Safety, University of Pennsylvania,Department of Anesthesiology and Critical Care, University of Pennsylvania
| | - Shivan Mehta
- Division of Gastroenterology, University of Pennsylvania,Leonard Davis Institute of Health Economics, University of Pennsylvania,Center for Healthcare Improvement and Patient Safety, University of Pennsylvania
| | | | - Joan Kinniry
- Division of Pulmonary & Critical Care, University of Pennsylvania
| | - April Taylor
- Center for Healthcare Improvement and Patient Safety, University of Pennsylvania
| | - James D. Lewis
- Division of Gastroenterology, University of Pennsylvania
| | - Shaz Iqbal
- Division of Gastroenterology, Johns Hopkins University
| | - David Goldberg
- Division of Gastroenterology, University of Pennsylvania,Leonard Davis Institute of Health Economics, University of Pennsylvania
| | - Judy A. Shea
- Leonard Davis Institute of Health Economics, University of Pennsylvania,Division of General Internal Medicine, University of Pennsylvania
| | - Robert Stetson
- Department of Strategic Support, University of Pennsylvania
| | - Mary Coniglio
- Division of Gastroenterology, University of Pennsylvania
| | - Maarouf Hoteit
- Division of Gastroenterology, University of Pennsylvania
| | - Neil Fishman
- Division of Infectious Diseases, University of Pennsylvania
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12
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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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13
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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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Reiss KA, Ben-Josef E, Damjanov N, Hoteit M, Karasic TB, Carpenter E, DiCicco L, Garcia-Marcano LA, Mick R, Vonderheide RH. A pilot study of galunisertib (LY2157299 monohydrate) plus stereotactic body radiotherapy (SBRT) in advanced hepatocellular carcinoma (HCC). J Clin Oncol 2019. [DOI: 10.1200/jco.2019.37.4_suppl.270] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
270 Background: TGF-β, the strongest known immunosuppressive cytokine, modulates the hepatic immune response to various antigens and to ionizing radiation. When activated, TGF-β blocks the effector T-cell response to cellular destruction and the release of tumor-specific antigens. Preclinical data demonstrate that neutralizing TGF-β during radiation effectively generates a CD8+ T-cell response to multiple endogenous tumor antigens, thereby generating an in-situ vaccine against a tumor. We hypothesized that the combination of TGF-β receptor inhibition plus SBRT would produce a potent and clinically effective antitumor immune response against HCC. Methods: Patients received galunisertib (LY2157299 monohydrate) on days 1-14 of each 28 day cycle. SBRT was delivered in a single fraction of 18 Gy between days 15-28 of C1. Pre-treatment and on-treatment biopsies were obtained, as well as serial blood collections for CTCs, ctDNA and PBMCs. Results: 15 patients with advanced HCC and Child’s Pugh A cirrhosis were treated. 9/15 (60%) had a prior history of infectious hepatitis, three of whom had active viremia at time of enrollment. 6/15 (40%) had received prior systemic therapy for HCC and 12/15 (80%) had received prior liver directed therapy. The most common treatment-related toxicities were: fatigue (53%), nausea (47%), increased alkaline phosphatase (33%), abdominal pain (33%), vomiting (20%), decreased white blood cell count (20%). All drug-related toxicities were grade 1 or 2, with the exception of one patient who had grade 3 achalasia, thought possibly to be related to study drug. Median PFS was 3.68mo. There were two confirmed partial responses (PRs) and six additional patients had stable disease (SD) for at least four months, resulting in a disease control rate (DCR) of 53%. Both PRs included shrinkage of lesions that had not been radiated. Translational studies are currently underway. Conclusions: The combination of galunisertib with SBRT in patients with advanced HCC is a well-tolerated regimen. In this small pilot study, we observe a DCR of 53% including two PRs. These results warrant further study of this therapeutic combination in advanced HCC. Clinical trial information: NCT02906397.
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Affiliation(s)
| | | | - Nevena Damjanov
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA
| | | | | | | | - Lisa DiCicco
- University of Pennsylvania Health System, Philadelphia, PA
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Chan C, Schiano T, Agudelo E, Paul Haydek J, Hoteit M, Laurito MP, Norvell JP, Terrault N, Verna EC, Yang A, Levitsky J. Immune-mediated graft dysfunction in liver transplant recipients with hepatitis C virus treated with direct-acting antiviral therapy. Am J Transplant 2018; 18:2506-2512. [PMID: 30075485 DOI: 10.1111/ajt.15053] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [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: 04/23/2018] [Revised: 07/10/2018] [Accepted: 07/29/2018] [Indexed: 01/25/2023]
Abstract
Interferon treatment of hepatitis C virus (HCV) infection after liver transplantation (LT) can result in immune-mediated graft dysfunction (IGD). The occurrence of, risk factors for, and outcomes of IGD with direct-acting antiviral (DAA) therapy have not been reported. We conducted a multicenter study of HCV+LT recipients who did or did not develop DAA-IGD (1 case: 2 controls-33 vs 66). Among all treated between 2014 and 2016, DAA-IGD occurred in 3.4% (33/978). IGD occurred only after treatment completion (76.0 [IQR, 47.0;176]). Among those treated, 48% had plasma cell hepatitis, 36% acute cellular rejection, 6% chronic rejection, and 9% combined findings. Median time to liver enzyme resolution was 77.5 days (IQR, 31.5;126). After diagnosis, hospitalizations, steroid-induced hyperglycemia, and infection occurred in a higher percentage of cases vs controls (33% vs 7.5%, 21% vs 1.5%, 9% vs 0%; all P < .05). Only one IGD patient died and none required retransplant. A multivariate regression analysis found that liver enzyme elevations during and soon after DAA therapy completion correlated with subsequent IGD. In conclusion, while DAA-IGD is uncommon, liver enzyme elevations during or after DAA therapy may be a sign of impending IGD. These indicators should guide clinicians to diagnose and treat IGD early before the more deleterious later clinical presentation.
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Affiliation(s)
- Christine Chan
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Thomas Schiano
- Recanati/ Miller Transplantation Institute and the Division of Liver Diseases, Mount Sinai Medical Center, New York, NY, USA
| | - Eliana Agudelo
- UCSF Medical Center Division of Liver Transplant, San Francisco, CA, USA
| | - John Paul Haydek
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Maarouf Hoteit
- Division of Gastroenterology and Hepatology, Penn Transplant Institute, University of Pennsylvania, Philadelphia, PA, USA
| | - Marcela P Laurito
- Department of Medicine, Center for Liver Disease and Transplantation, Columbia University, New York, NY, USA
| | - John P Norvell
- Department of Medicine, Emory University School of Medicine, Atlanta, GA, USA
| | - Norah Terrault
- UCSF Medical Center Division of Liver Transplant, San Francisco, CA, USA
| | - Elizabeth C Verna
- Department of Medicine, Center for Liver Disease and Transplantation, Columbia University, New York, NY, USA
| | - Amy Yang
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - Josh Levitsky
- Division of Gastroenterology and Hepatology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
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Nadolski G, Kalbasi A, Soulen M, Hunt S, Dagli M, Mondschein J, Sudheendra D, Stavropoulos S, Apisarnthanarax S, Hoteit M, Ben-Josef E. 4:12 PM Abstract No. 41 Interim analysis of pilot randomized trial of transarterial chemoembolization with or without stereotactic body radiation therapy for hepatocellular carcinoma patients awaiting liver transplantation. J Vasc Interv Radiol 2018. [DOI: 10.1016/j.jvir.2018.01.049] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022] Open
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17
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Windon AL, Tondon R, Singh N, Abu-Gazala S, Porter DL, Russell JE, Cook C, Lander E, Smith G, Olthoff KM, Shaked A, Hoteit M, Furth EE, Serper M. Erythropoietic protoporphyria in an adult with sequential liver and hematopoietic stem cell transplantation: A case report. Am J Transplant 2018; 18:745-749. [PMID: 29116687 DOI: 10.1111/ajt.14581] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2017] [Revised: 10/18/2017] [Accepted: 10/28/2017] [Indexed: 01/25/2023]
Abstract
Erythropoietic protoporphyria (EPP) is a rare inherited disorder of the heme biosynthesis pathway resulting in the accumulation of protoporphyrins in the blood, erythrocytes, and other tissues. Because of a gene mutation in the FECH gene, ferrochelatase, the enzyme involved in the final step of heme synthesis, is deficient in these patients. Although the major symptom of this disorder is photosensitivity, rarely, it can cause progressive liver disease requiring liver transplantation (LT). However, LT is not curative and only bone marrow transplantation (BMT) can correct the underlying enzymatic defect. Because liver disease results from accumulation of protoporphyrin in the liver, LT without hematopoietic stem cell transplantation leaves the new liver at risk for similar EPP-related damage. A handful of pediatric patients undergoing sequential LT and stem cell transplantation have been described in the literature; however, to date none has been described in detail in adults. We report a case of an adult male with EPP and liver failure who successfully underwent a sequential liver and hematopoietic stem cell transplantation (HSCT).
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Affiliation(s)
- Annika L Windon
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Rashmi Tondon
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Nathan Singh
- Department of Medicine, Blood and Marrow Transplant Program and Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Samir Abu-Gazala
- Transplant Unit, Surgery Department, Hadassah Hebrew University Medical Center, Jerusalem, Israel
| | - David L Porter
- Department of Medicine, Blood and Marrow Transplant Program and Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - J Eric Russell
- Department of Medicine, Division of Hematology/Oncology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Colleen Cook
- Department of Surgery, Division of Transplantation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Elaine Lander
- Department of Surgery, Division of Transplantation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Georgeine Smith
- Department of Surgery, Division of Transplantation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Kim M Olthoff
- Department of Surgery, Division of Transplantation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Abraham Shaked
- Department of Surgery, Division of Transplantation, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Maarouf Hoteit
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Emma E Furth
- Department of Pathology and Laboratory Medicine, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Marina Serper
- Department of Medicine, Division of Gastroenterology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
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18
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Hoteit M, Hsu CCS, Levine MH, Forde KA, Reiss KA, Nadolski G, Soulen MC, Kron L, Helmke S, Everson GT, Ben-Josef E. Deterioration of hepatic function after locoregional therapy (LRT) for hepatocellular carcinoma (HCC) measured by hepatic cholate clearance: A pilot study. J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.4_suppl.468] [Citation(s) in RCA: 3] [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] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
468 Background: LRT is used in treating HCC, but is associated with a risk of hepatotoxicity, which is not accurately predicted by traditional measures of liver function. In this pilot study, we evaluated the change in liver function after LRT as measured by a test using dual, oral and IV, cholate clearances (HepQuantSHUNT). Our hypothesis is that LRT would impose a significant reduction in the disease severity index (DSI) measured in the HepQuant SHUNT test, as an indicator of reduced liver function. Methods: We conducted a prospective cohort study of 11 subjects undergoing LRT for HCC. HepQuantSHUNT was performed at baseline (T0) and 4-10 weeks after LRT (T1). Clinical assessment was performed at T0 and T1, and at 12-18 weeks after LRT (T2). Decompensation was defined as either a new complication of cirrhosis or an increase in Child-Pugh (CP) score by ≥2 points. Results: Median age was 61 years, 73% were men, 55% had hepatitis C. Median CP score was 7[5-8], including 36%CP A and 64%CP B. Subjects had a BCLC stage A(64%) or BCLC stage B(36%) HCC. LRT modalities were TACE (45%) or SBRT (55%). From T0 to T1, there was a reduction in oral cholate clearance(422[235-768] vs 339[208-362], p = 0.03) and in IV cholate clearance(210[150-300] vs 191[144-203],p = 0.04) as well as a trend towards a worsening disease severity index (DSI) (32.0[19.5-37.8] vs 33.0[29.7-38.0],p = 0.10); however, there was no significant change in MELD(12[9-13]vs 11[10-12],p = 0.72) or CP score(7[5-8] vs 7[6-8],p = 0.15). 89% of the subjects had a reduction in oral and IV cholate clearance, and 78% had a worsening DSI; while 44% subjects had increase in CP score, and 56% had an increase in MELD. Decompensation was observed in 43% of CP B patients and none of CP A patients; and in 60% patients with a DSI > 35, and none of the patients with DSI < 35. Conclusions: The dual cholate clearance assay HepQuant-SHUNT detects a deterioration in liver function after LRT for HCC more frequently than clinical measures of liver function. DSI 35 might be a cutoff for risk of clinical decompensation after LRT for HCC. Additional research is needed to evaluate the role of the HepQuant SHUNT test in improving the selection of Child B patients for LRT.
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Affiliation(s)
| | | | | | | | | | | | | | - Laura Kron
- University of Pennsylvania, Philadelphia, PA
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19
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Reiss KA, Ben-Josef E, Damjanov N, Hoteit M, O'Hara MH, Karasic TB, Teitelbaum UR, Schneider C, O'Dwyer PJ, Carpenter EL, Mick R, Vonderheide RH. A pilot study of galunisertib (LY2157299) plus stereotactic body radiotherapy (SBRT) in advanced hepatocellular carcinoma (HCC). J Clin Oncol 2018. [DOI: 10.1200/jco.2018.36.4_suppl.tps528] [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] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
TPS528 Background: Hepatocellular carcinoma (HCC) is a common and lethal malignancy with few effective treatment options. Inherently aggressive disease biology combined with the immunosuppressive hepatic microenvironment creates a unique therapeutic challenge. TGF-β, the strongest known immunosuppressive cytokine [1, 2], modulates the hepatic immune response to various antigens and to ionizing radiation [3, 4]. TGF-β is constitutively released by liver cells and plays a key role in the early and late pathogenesis of HCC [5-7] by dampening the local T-cell response to the oncogenic hepatitis B and –C viruses [4, 8-11]. TGF-β is activated by ionizing radiation, where it blocks the effector T-cell response to cellular destruction and the release of tumor-specific antigens [4]. Preclinical data demonstrate that neutralizing TGF-β during radiation therapy effectively generates a CD8+ T-cell response to multiple endogenous tumor antigens [4], thereby generating an in-situ vaccine against a tumor [12-17]. We hypothesize that the combination of TGF-β receptor inhibition plus radiation therapy will produce a potent and clinically effective antitumor immune response against HCC. Methods: We have enrolled 9 of 15 planned patients on study NCT02906397. Eligibility criteria include inoperable HCC, Childs Pugh score of ≤7, and either failure of or refusal to take sorafenib. Patients must be 4 weeks from prior therapy and may not be taking immunosuppressants. Patients with major cardiac disease or abnormalities or a predisposition toward aneurysm development are excluded. Patients receive galunisertib on days 1-14 of 28 day cycles. SBRT will be delivered in a single fraction of 18 Gy between days 15-28 of C1. Pre-treatment and on-treatment biopsies are obtained, as well as serial blood collections for circulating tumor material. Immunologic evaluation will include TCR deep sequencing to track T-cell receptor clones, analysis of serum inflammatory cytokines, analysis of myeloid and B cell activation, multiplex flow cytometry of PBMCs to measure percentages and absolute counts of T-cell subsets and tissue assessment of immune markers. Peripheral and tissue levels of TGF-β will be assessed. Clinical trial information: NCT02906397.
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Affiliation(s)
| | | | - Nevena Damjanov
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA
| | | | - Mark H. O'Hara
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA
| | | | | | - Charles Schneider
- Helen F. Graham Cancer Center, Christiana Care Health System, Newark, DE
| | - Peter J. O'Dwyer
- University of Pennsylvania Abramson Cancer Center, Philadelphia, PA
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20
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Arabi A, Khoueiry-Zgheib N, Awada Z, Mahfouz R, Al-Shaar L, Hoteit M, Rahme M, Baddoura R, Halabi G, Singh R, El Hajj Fuleihan G. CYP2R1 polymorphisms are important modulators of circulating 25-hydroxyvitamin D levels in elderly females with vitamin insufficiency, but not of the response to vitamin D supplementation. Osteoporos Int 2017; 28:279-290. [PMID: 27473187 DOI: 10.1007/s00198-016-3713-5] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/30/2016] [Accepted: 07/19/2016] [Indexed: 11/26/2022]
Abstract
UNLABELLED We studied the association between CYP2R1 genetic polymorphisms and circulating 25-hydroxyvitamin D [25(OH)D] before and after supplementation with vitamin D3 in 218 elderly. We found differences between 3 and 8 ng/ml in circulating levels at baseline in women but not in the response after 1 year of supplementation. INTRODUCTION This study evaluated the association between polymorphisms in four single nucleotide polymorphisms (SNPs) of the CYP2R1 gene and 25(OH)D levels before and 1 year after supplementation with two different doses of vitamin D3 (600 IU daily or a dose equivalent to 3750 IU daily), in a cohort of 218 (96 men and 122 women) Lebanese elderly overweight subjects. METHODS Genotyping was performed for rs12794714, rs10741657, rs1562902, and rs10766197 SNPs using real-time PCR. The 25(OH)D levels were measured by liquid chromatography tandem mass spectrometry. RESULTS At baseline, the mean ± SD age was 71.0 ± 4.7 years, BMI 30.3 ± 4.6 kg/m2, and 25(OH)D level was 20.5 ± 7.6 ng/ml. There were significant differences in mean 25(OH)D levels between genotypes in women, but not in men. After adjustment for age, season, and BMI, the homozygous for the low frequency gene variant (HLV) of rs1562902 and rs10741657 SNPs had the highest mean 25(OH)D levels with difference of 7.6 ng/ml for rs1562902 SNP (p < 0.01) and of 5.9 ng/ml for rs10741657 (p = 0.05) compared to the homozygous for the major polymorphisms (HMPs). Conversely, for rs10766197 and rs12794714 SNPs, HMP had the highest mean 25(OH)D levels with difference of 6 ng/ml for rs10766197 (p = 0.003) and of 4.8 ng/ml (p = 0.02) for rs12794714, compared to the HLV. CYP2R1 genetic polymorphisms explained 4.8 to 9.8 % of variability in 25(OH)D in women. After 1 year, there was no difference in the response to vitamin D3 supplementation between genotypes in either gender. CONCLUSION This study showed a difference in 25(OH)D levels between CYP2R1 genotypes that equates a daily supplementation of 400-800 IU vitamin D, depending on genotype. It underscores possible important genetic contributions for the high prevalence of hypovitaminosis D in the Middle East.
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Affiliation(s)
- A Arabi
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Department of Internal Medicine, American University of Beirut-Medical Center, P.O. Box 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon.
| | - N Khoueiry-Zgheib
- Department of Pharmacology and Toxicology, American University of Beirut, Beirut, Lebanon
| | - Z Awada
- Department of Pharmacology and Toxicology, American University of Beirut, Beirut, Lebanon
| | - R Mahfouz
- Division of Molecular Diagnostics, Department of Pathology and Laboratory Medicine, American University of Beirut, Beirut, Lebanon
| | - L Al-Shaar
- Vascular Medicine Program and Scholars in Health Research Program, American University of Beirut, Beirut, Lebanon
| | - M Hoteit
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Department of Internal Medicine, American University of Beirut-Medical Center, P.O. Box 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon
| | - M Rahme
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Department of Internal Medicine, American University of Beirut-Medical Center, P.O. Box 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon
| | - R Baddoura
- Department of Rheumatology, Saint Joseph University, Philadelphia, PA, USA
| | - G Halabi
- Department of Endocrinology, Saint Joseph University, Beirut, Lebanon
| | - R Singh
- Mayo Clinic Foundation, Rochester, MN, USA
| | - G El Hajj Fuleihan
- Calcium Metabolism and Osteoporosis Program, WHO Collaborating Center for Metabolic Bone Disorders, Department of Internal Medicine, American University of Beirut-Medical Center, P.O. Box 11-0236, Riad El-Solh, Beirut, 1107 2020, Lebanon.
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El Hajj F, Hoteit M, Ouaknine M. Elbow arthroscopy: An alternative to anteromedial portals. Orthop Traumatol Surg Res 2015; 101:411-4. [PMID: 25910702 DOI: 10.1016/j.otsr.2015.03.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/21/2013] [Revised: 02/28/2015] [Accepted: 03/09/2015] [Indexed: 02/02/2023]
Abstract
BACKGROUND Elbow arthroscopy is considered to be a difficult procedure with a high complication rate. These two disadvantages are due to the proximity of neurovascular structures. HYPOTHESIS The aim of our study was to evaluate the efficacy and complication rate of a new elbow arthroscopy technique without anteromedial portals. This approach was taken because of the high rate of ulnar nerve damage using the medial portal, and the difficulty of performing triangulation of opposite portals in a patient in the lateral decubitus position. MATERIAL AND METHODS Fifteen patients were operated on by the same surgeon between 2010 and 2012. Range of motion and the "MEPS" elbow score were calculated preoperatively and at the final postoperative follow-up. The average age of patients was 38.3 years. The follow-up was 11.1 months. Personal portals (high anterolateral and intermediate anterolateral portals) were used instead of the anteromedial portals. RESULTS Elbow flexion increased from 113° preoperatively to 129° at the final follow-up (P=0.009). Extension increased from -33° to -10° (P<0.0001). The preoperative and final postoperative "MEPS" scores were 56.3 and 94 respectively (P<0.0001). Two patients (13.3%) had radial nerve palsy with complete recovery 6 and 9 months after surgery. DISCUSSION The rate of nerve complications following elbow arthroscopy varies from 0 to 14%. The rate in our series (13.3%) is comparable to the results of the literature. This rate should be placed in perspective (since one patient had multiple open surgery elbow operations before arthroscopy). All complications were transient. Improved elbow range of motion in our study is consistent with the results in literature.
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Affiliation(s)
- F El Hajj
- Service de chirurgie orthopédique, hôpital Cochin, 47-83, boulervard de l'Hôpital, 75013 Paris, France.
| | - M Hoteit
- Faculté de santé publique, université libanaise, Hadath, Lebanon
| | - M Ouaknine
- Service de chirurgie orthopédique, hôpital Cochin, 47-83, boulervard de l'Hôpital, 75013 Paris, France
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Levine M, Enestvedt K, Porrett P, Cui R, Hoteit M, Mu Y, Siegelman E, Sonnad S, Abt P, Shaked A, Olthoff K. Incidental Hepatocellular Carcinoma in Liver Transplant Recipients is Associated With Fatty Liver Disease and Conveys a Low Risk of Recurrent Malignancy After Transplant. J Surg Res 2012. [DOI: 10.1016/j.jss.2011.11.204] [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: 10/14/2022]
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Baddoura R, Hoteit M, El-Hajj Fuleihan G. Osteoporotic fractures, DXA, and fracture risk assessment: meeting future challenges in the Eastern Mediterranean Region. J Clin Densitom 2011; 14:384-94. [PMID: 21839659 DOI: 10.1016/j.jocd.2011.03.009] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/07/2011] [Revised: 03/24/2011] [Accepted: 03/28/2011] [Indexed: 10/17/2022]
Abstract
The purpose was to report on the burden of osteoporotic fractures in the Eastern Mediterranean Region (EMR) and the use of bone mineral density (BMD) dual-energy X-ray absorptiometry (DXA) databases for osteoporosis diagnosis. PubMed electronic database was reviewed using the following MeSH terms: "Hip fractures," "Fractures, Compression," "Radius Fractures," "Osteoporosis," "Bone density," and "Middle East" up to July 2009. Incidence of hip fractures varied across the EMR between 100 and 295 per 100,000 person-years in women and 71 and 200 per 100,000 person-years in men. No data were found on other nonvertebral osteoporotic fractures. Prevalence of radiographic vertebral fractures older than 65 yr ranged between 15% and 25% in women and 7.3% and 18% in men. By 2020, the number of hip fractures older than 50 yr would increase by 20%. DXA manufacturer's reference curves for the spine were higher than population-specific ones. At the hip, National Health and Nutrition Examination Survey (NHANES) and population-based curves were comparable. Estimates of the relative risk of vertebral fracture per SD decrease in BMD using NHANES and local data set were similar, that is, 1.61 (1.17-2.23) and 1.49 (1.14-1.95), respectively. The EMR is similar to southern Europe regarding incidence rates of hip fracture, suggesting the health burden to be significant. Using DXA at the hip, population-specific reference databases did not perform better than NHANES on which the FRAX model has been developed highlighting the need for reviewing fracture risk assessment strategies in the EMR.
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Affiliation(s)
- R Baddoura
- Division of Rheumatology, Hotel Dieu de France Hospital, Beirut, Lebanon.
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24
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Edge MD, Hoteit M, Patel AP, Wang X, Baumgarten DA, Cai Q. Clinical significance of main pancreatic duct dilation on computed tomography: Single and double duct dilation. World J Gastroenterol 2007; 13:1701-5. [PMID: 17461473 PMCID: PMC4146949 DOI: 10.3748/wjg.v13.i11.1701] [Citation(s) in RCA: 35] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the patients with main pancreatic duct dilation on computed tomography (CT) and thereby to provide the predictive criteria to identify patients at high risk of significant diseases, such as pancreatic cancer, and to avoid unnecessary work up for patients at low risk of such diseases.
METHODS: Patients with dilation of the main pancreatic duct on CT at Emory University Hospital in 2002 were identified by computer search. Clinical course and ultimate diagnosis were obtained in all the identified patients by abstraction of their computer database records.
RESULTS: Seventy-seven patients were identified in this study. Chronic pancreatitis and pancreatic cancer were the most common causes of the main pancreatic duct dilation on CT. Although the majority of patients with isolated dilation of the main pancreatic duct (single duct dilation) had chronic pancreatitis, one-third of patients with single duct dilation but without chronic pancreatitis had pancreatic malignancies, whereas most of patients with concomitant biliary duct dilation (double duct dilation) had pancreatic cancer.
CONCLUSION: Patients with pancreatic double duct dilation need extensive work up and careful follow-up since a majority of these patients are ultimately diagnosed with pancreatic cancer. Patients with single duct dilation, especially such patients without any evidence of chronic pancreatitis, also need careful follow-up since the possibility of pancreatic malignancy, including adenocarcinoma and intraductal papillary mucinous tumors, is still high.
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Affiliation(s)
- Mark-D Edge
- Division of Digestive Diseases, 1365 Clifton Road, NE, Suite B1262, Emory University School of Medicine, Atlanta, GA 30322, USA
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Obideen K, Wehbi M, Hoteit M, Cai Q. Nocturnal hydration--an effective modality to reduce recurrent abdominal pain and recurrent pancreatitis in patients with adult-onset cystic fibrosis. Dig Dis Sci 2006; 51:1744-8. [PMID: 16957999 DOI: 10.1007/s10620-006-9185-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2005] [Accepted: 12/18/2005] [Indexed: 12/09/2022]
Abstract
Recurrent abdominal pain and recurrent pancreatitis are common problems associated with some patients with cystic fibrosis (CF). There is no known effective method to prevent recurrent abdominal pain and recurrent pancreatitis in such patients. The objective of this study was to determine whether nocturnal hydration (NH) prevents recurrent abdominal pain and recurrent acute pancreatitis in patients with adult-onset CF. Adult CF patients who were referred to our Pancreatic Diseases Clinic for recurrent abdominal pain and pancreatitis were enrolled in the study. Each patient was encouraged to drink plenty of water during the night and established a 6-month diary (3 months before and 3 months after NH was initiated), recording the frequency and severity of their abdominal pain, the amount of pain medication taken, and the volume of their water intake. We also reviewed the number of doctor's clinic visits, emergency room visits, and hospitalizations for about 1 year before and 1 year after the initiation of the NH. The frequency and the severity of abdominal pain in this group of patients were significantly reduced. The amount of pain medication and the number of emergency room visits and hospitalizations for abdominal pain and acute pancreatitis were reduced. NH is a simple and cost-effective method to prevent recurrent abdominal pain and pancreatitis in patients with adult-onset CF.
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Affiliation(s)
- Kamil Obideen
- Division of Digestive Diseases, Emory University School of Medicine, 1365 Clifton Road, Suite B 1262, Atlanta, GE 30322, USA
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