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Singal AG, Llovet JM, Yarchoan M, Mehta N, Heimbach JK, Dawson LA, Jou JH, Kulik LM, Agopian VG, Marrero JA, Mendiratta-Lala M, Brown DB, Rilling WS, Goyal L, Wei AC, Taddei TH. AASLD Practice Guidance on prevention, diagnosis, and treatment of hepatocellular carcinoma. Hepatology 2023; 78:1922-1965. [PMID: 37199193 PMCID: PMC10663390 DOI: 10.1097/hep.0000000000000466] [Citation(s) in RCA: 144] [Impact Index Per Article: 144.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 05/01/2023] [Indexed: 05/19/2023]
Affiliation(s)
- Amit G. Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Josep M. Llovet
- Liver Cancer Program, Division of Liver Diseases, Tisch Cancer Institute, Mount Sinai School of Medicine, New York, New York, USA
- Translational Research in Hepatic Oncology, Liver Unit, August Pi i Sunyer Biomedical Research Institute, Hospital Clinic, University of Barcelona, Catalonia, Spain
- Institució Catalana de Recerca i Estudis Avançats, Barcelona, Catalonia, Spain
| | - Mark Yarchoan
- Department of Medical Oncology, Johns Hopkins Sidney Kimmel Comprehensive Cancer Center, Baltimore, Maryland, USA
| | - Neil Mehta
- University of California, San Francisco, San Francisco, California, USA
| | | | - Laura A. Dawson
- Radiation Medicine Program/University Health Network, Department of Radiation Oncology, University of Toronto, Toronto, Canada
| | - Janice H. Jou
- Division of Gastroenterology and Hepatology, Oregon Health and Science University, Portland, Oregon, USA
| | - Laura M. Kulik
- Northwestern Medical Faculty Foundation, Chicago, Illinois, USA
| | - Vatche G. Agopian
- The Dumont–University of California, Los Angeles, Transplant Center, David Geffen School of Medicine, University of California, Los Angeles, Los Angeles, California, USA
| | - Jorge A. Marrero
- Division of Gastroenterology and Hepatology, University of Pennsylvania, Philadelphia, Pennsylvania, USA
| | - Mishal Mendiratta-Lala
- Department of Radiology, University of Michigan Medical Center, Ann Arbor, Michigan, USA
| | - Daniel B. Brown
- Department of Radiology, Vanderbilt University Medical Center, Nashville, Tennessee, USA
| | - William S. Rilling
- Division of Interventional Radiology, Medical College of Wisconsin, Milwaukee, Wisconsin, USA
| | - Lipika Goyal
- Department of Medicine, Stanford School of Medicine, Palo Alto, California, USA
| | - Alice C. Wei
- Memorial Sloan Kettering Cancer Center, New York City, New York, USA
| | - Tamar H. Taddei
- Department of Medicine (Digestive Diseases), Yale School of Medicine, New Haven, CT, USA
- Veterans Affairs Connecticut Healthcare System, West Haven, CT, USA
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2
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Kim H, Choi B, Mouli SK, Choi H, Harris KR, Kulik LM, Lewandowski RJ, Kim DH. Preclinical Development and Validation of Translational Temperature Sensitive Iodized Oil Emulsion Mediated Transcatheter Arterial Chemo-Immuno-Embolization for the Treatment of Hepatocellular Carcinoma. Adv Healthc Mater 2023; 12:e2300906. [PMID: 37163283 PMCID: PMC10592544 DOI: 10.1002/adhm.202300906] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2023] [Revised: 05/02/2023] [Indexed: 05/11/2023]
Abstract
Herein a practical strategy for augmenting immune activation in transcatheter arterial chemoembolization (TACE) of hepatocellular carcinoma (HCC) is presented. Pluronic F127 (PF127) is incorporated with Lipiodol (LPD) to achieve safe and effective delivery of therapeutic agents during transcatheter intra-arterial (IA) local delivery. Enhanced emulsion stability, IA infusion, embolic effect, safety, pharmacokinetics, and tumor response of Doxorubicin loaded PF127-LPD (Dox-PF127-LPD) for TACE in both in vitro and in vivo preclinical VX2 liver cancer rabbit model and N1S1 HCC rat model are demonstrated. Then, transcatheter arterial chemo-immuno-embolization (TACIE) combining TACE and local delivery of immune adjuvant (TLR9 agonist CpG oligodeoxynucleotide) is successfully performed using CpG-loaded Dox-PF127-LPD. Concurrent and safe local delivery of CpG and TACE during TACIE demonstrate leveraged TACE-induced immunogenic tumor microenvironment and augment systemic anti-tumor immunity in syngeneic N1S1 HCC rat model. Finally, the broad utility and enhanced therapeutic efficacy of TACIE are validated in the diethylnitrosamine-induced rat HCC model. TACIE using clinically established protocols and materials shall be a convenient and powerful therapeutic approach that can be translated to patients with HCC. The robust anti-cancer immunity and tumor regression of TACIE, along with its favorable safety profile, indicate its potential as a novel localized combination immunotherapy for HCC treatment.
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Affiliation(s)
- Heegon Kim
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Bongseo Choi
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Samdeep K. Mouli
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Robert H. Lurie Comprehensive Cancer Center, Chicago, IL 60611, USA
| | - Hyunjun Choi
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Department of Biomedical Engineering, University of Illinois at Chicago, Chicago, IL 60607, USA
| | - Kathleen R. Harris
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Laura M. Kulik
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
| | - Robert J. Lewandowski
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Robert H. Lurie Comprehensive Cancer Center, Chicago, IL 60611, USA
| | - Dong-Hyun Kim
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
- Department of Biomedical Engineering, University of Illinois at Chicago, Chicago, IL 60607, USA
- Robert H. Lurie Comprehensive Cancer Center, Chicago, IL 60611, USA
- Department of Biomedical Engineering, McCormick School of Engineering, Evanston, IL 60208, USA
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3
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Kelley RK, Joseph NM, Nimeiri HS, Hwang J, Kulik LM, Ngo Z, Behr SC, Onodera C, Zhang K, Bocobo AG, Benson AB, Venook AP, Gordan JD. Phase II Trial of the Combination of Temsirolimus and Sorafenib in Advanced Hepatocellular Carcinoma with Tumor Mutation Profiling. Liver Cancer 2021; 10:561-571. [PMID: 34950179 PMCID: PMC8647100 DOI: 10.1159/000518297] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [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: 03/10/2021] [Accepted: 07/01/2021] [Indexed: 02/04/2023] Open
Abstract
BACKGROUND The mammalian target of rapamycin (mTOR) pathway is upregulated in nearly half of hepatocellular carcinoma (HCC) tumors and is associated with poor prognosis. In preclinical models of HCC, the combination of mTOR pathway inhibition with the multikinase inhibitor sorafenib improves treatment efficacy. A prior phase I study of the allosteric mTOR inhibitor temsirolimus combined with sorafenib demonstrated acceptable safety at the recommended phase II dose. METHODS We conducted a single-arm, multicenter phase II trial of the combination of temsirolimus 10 mg intravenously weekly plus sorafenib 200 mg b.i.d. The primary endpoint was time to progression (TTP) with efficacy target of median TTP of at least 6 months; secondary endpoints included overall survival (OS), objective response rate, safety, and alpha-fetoprotein (AFP) tumor marker response. Next-generation tumor sequencing was performed as an exploratory endpoint. RESULTS Twenty-nine patients were enrolled, including 48% with hepatitis C virus infection and 28% with hepatitis B virus; 86% had Barcelona clinic liver cancer stage C disease. Among 28 patients evaluable for efficacy, the median TTP was 3.7 (95% confidence interval [CI]: 2.2, 5.3) months, with 14% of patients achieving TTP of at least 6 months. The median OS was 8.8 (95% CI: 6.8, 14.8) months. There were no complete or partial responses; 75% of patients had stable disease as best response. AFP decline by at least 50% was associated with prolonged TTP and OS. Serious adverse events occurred in 21%; the most common treatment-related adverse events of CTCAE grade 3 or higher were hypophosphatemia (36%), thrombocytopenia (14%), and rash (11%). There were no grade 5 events attributed to sorafenib or temsirolimus. Tumor next-generation sequencing (NGS) was performed in a subgroup of 24 patients with adequate tumor samples. Tumor mTOR pathway mutations were identified in 42%. There was no association between tumor mutation profile and OS or TTP. CONCLUSIONS The combination of temsirolimus and sorafenib demonstrated acceptable safety but did not achieve the target threshold for efficacy in this phase II study. Tumor NGS including the presence of mTOR pathway mutations was not associated with treatment response in an exploratory subgroup analysis.
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Affiliation(s)
- Robin K. Kelley
- Helen Diller Family Comprehensive Cancer Center (HDFCCC), University of California, San Francisco (UCSF), San Francisco, California, USA,*Robin K. Kelley,
| | - Nancy M. Joseph
- Department of Pathology, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Halla S. Nimeiri
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
| | - Jimmy Hwang
- Helen Diller Family Comprehensive Cancer Center (HDFCCC), University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Laura M. Kulik
- Division of Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois, USA
| | - Zoe Ngo
- Helen Diller Family Comprehensive Cancer Center (HDFCCC), University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Spencer C. Behr
- Department of Radiology, University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Courtney Onodera
- Clinical Cancer Genomics Lab, UCSF Health, San Francisco, California, USA
| | - Karen Zhang
- Helen Diller Family Comprehensive Cancer Center (HDFCCC), University of California, San Francisco (UCSF), San Francisco, California, USA,*Robin K. Kelley,
| | - Andrea G. Bocobo
- Helen Diller Family Comprehensive Cancer Center (HDFCCC), University of California, San Francisco (UCSF), San Francisco, California, USA
| | - Al B. Benson
- Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois, USA
| | - Alan P. Venook
- Helen Diller Family Comprehensive Cancer Center (HDFCCC), University of California, San Francisco (UCSF), San Francisco, California, USA
| | - John D. Gordan
- Helen Diller Family Comprehensive Cancer Center (HDFCCC), University of California, San Francisco (UCSF), San Francisco, California, USA
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4
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Fix OK, Blumberg EA, Chang KM, Chu J, Chung RT, Goacher EK, Hameed B, Kaul DR, Kulik LM, Kwok RM, McGuire BM, Mulligan DC, Price JC, Reau NS, Reddy KR, Reynolds A, Rosen HR, Russo MW, Schilsky ML, Verna EC, Ward JW, Fontana RJ. American Association for the Study of Liver Diseases Expert Panel Consensus Statement: Vaccines to Prevent Coronavirus Disease 2019 Infection in Patients With Liver Disease. Hepatology 2021; 74:1049-1064. [PMID: 33577086 PMCID: PMC8014184 DOI: 10.1002/hep.31751] [Citation(s) in RCA: 125] [Impact Index Per Article: 41.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/07/2021] [Accepted: 02/08/2021] [Indexed: 02/06/2023]
Abstract
The aim of this document is to provide a concise scientific review of the currently available COVID-19 vaccines and those in development, including mRNA, adenoviral vectors, and recombinant protein approaches. The anticipated use of COVID-19 vaccines in patients with chronic liver disease (CLD) and liver transplant (LT) recipients is reviewed and practical guidance is provided for health care providers involved in the care of patients with liver disease and LT about vaccine prioritization and administration. The Pfizer and Moderna mRNA COVID-19 vaccines are associated with a 94%-95% vaccine efficacy compared to placebo against COVID-19. Local site reactions of pain and tenderness were reported in 70%-90% of clinical trial participants, and systemic reactions of fever and fatigue were reported in 40%-70% of participants, but these reactions were generally mild and self-limited and occurred more frequently in younger persons. Severe hypersensitivity reactions related to the mRNA COVID-19 vaccines are rare and more commonly observed in women and persons with a history of previous drug reactions for unclear reasons. Because patients with advanced liver disease and immunosuppressed patients were excluded from the vaccine licensing trials, additional data regarding the safety and efficacy of COVID-19 vaccines are eagerly awaited in these and other subgroups. Remarkably safe and highly effective mRNA COVID-19 vaccines are now available for widespread use and should be given to all adult patients with CLD and LT recipients. The online companion document located at https://www.aasld.org/about-aasld/covid-19-resources will be updated as additional data become available regarding the safety and efficacy of other COVID-19 vaccines in development.
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Affiliation(s)
- Oren K Fix
- Elson S. Floyd College of MedicineWashington State UniversitySpokaneWAUSA
| | | | - Kyong-Mi Chang
- University of PennsylvaniaPhiladelphiaPAUSA.,The Corporal Michael J. Crescenz VA Medical CenterPhiladelphiaPAUSA
| | - Jaime Chu
- Icahn School of Medicine at Mount SinaiNew YorkNYUSA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | - Mark W Russo
- Atrium HealthCarolinas Medical CenterCharlotteNCUSA
| | | | | | - John W Ward
- Coalition for Global Hepatitis EliminationDecaturGAUSA
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5
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Gordon AC, Gupta AN, Gabr A, Thornburg BG, Kulik LM, Ganger DR, Maddur H, Flamm SL, Boike JR, Moore CM, Borja-Cacho D, Christopher DA, Katariya NN, Ladner DP, Caicedo-Ramirez JC, Riaz A, Salem R, Lewandowski RJ. Safety and Efficacy of Segmental Yttrium-90 Radioembolization for Hepatocellular Carcinoma after Transjugular Intrahepatic Portosystemic Shunt Creation. J Vasc Interv Radiol 2021; 32:211-219. [PMID: 33349507 DOI: 10.1016/j.jvir.2020.09.007] [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] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2020] [Revised: 08/28/2020] [Accepted: 09/08/2020] [Indexed: 01/06/2023] Open
Abstract
PURPOSE To evaluate safety and efficacy of segmental yttrium-90 (Y90) radioembolization for hepatocellular carcinoma (HCC) after transjugular intrahepatic portosystemic shunt (TIPS) placement. The hypothesis was liver sparing segmental Y90 for HCC after TIPS would provide high antitumor response with a tolerable safety profile. MATERIALS AND METHODS This single-arm retrospective study included 39 patients (16 women, 23 men) with ages 49-81 years old who were treated with Y90. Child-Pugh A/B liver dysfunction was present in 72% (28/39) with a median Model for End-stage Liver Disease score of 18 (95% confidence interval, 16.4-19.4). Primary outcomes were clinical and biochemical toxicities and antitumor imaging response by World Health Organization (WHO) and European Association for the Study of the Liver (EASL) criteria. Secondary outcomes were orthotopic liver transplantation (OLT), time to progression (TTP), and overall survival (OS) estimates by the Kaplan-Meier method. RESULTS The 30-day mortality was 0%. Grade 3+ clinical adverse events and grade 3+ hyperbilirubinemia occurred in 5% (2/39) and 0% (0/39), respectively. Imaging response was achieved in 58% (22/38, WHO criteria) and 74% (28/38, EASL criteria), respectively. Median TTP was 16.1 months for any cause and 27.5 months for primary index lesions. OLT was completed in 88% (21/24) of listed patients at a median time of 6.1 months (range, 0.9-11.7 months). Median OS was 31.6 months and 62.9 months censored and uncensored to OLT, respectively. CONCLUSIONS Segmental Y90 for HCC appears safe and efficacious in patients after TIPS. Preserved transplant eligibility suggests that Y90 is a useful tool for bridging these patients to liver transplantation.
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Affiliation(s)
- Andrew C Gordon
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Aakash N Gupta
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Ahmed Gabr
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Bartley G Thornburg
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Laura M Kulik
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois; Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Daniel R Ganger
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois; Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Haripriya Maddur
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Steven L Flamm
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois; Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Justin R Boike
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Christopher M Moore
- Division of Gastroenterology and Hepatology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Daniel Borja-Cacho
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Derrick A Christopher
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Nitin N Katariya
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Daniela P Ladner
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois; Department of Medical Social Sciences, Northwestern University, Chicago, Illinois
| | - Juan C Caicedo-Ramirez
- Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois
| | - Ahsun Riaz
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois
| | - Riad Salem
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Section of Interventional Radiology, Department of Radiology, Northwestern University, Chicago, Illinois; Division of Transplant Surgery, Department of Surgery, Northwestern University, Chicago, Illinois; Division of Hematology and Oncology, Department of Medicine, Northwestern University, Chicago, Illinois.
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6
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Abstract
Multiple systemic agents have recently been approved in the first- and second-line setting for hepatocellular carcinoma (HCC), increasing the therapeutic options for patients and treating physicians. The randomised controlled trials that led to these approvals were predominantly conducted in a population comprised of patients with advanced HCC. However, these trials also included a subset of patients who had progressed after locoregional therapies (LRTs), mostly transarterial chemoembolisation. With a greater number of systemic agents available, the role of LRTs has become a topic of debate, specifically regarding when to transition to systemic therapy in unresectable HCC and the potential opportunities for combining locoregional and systemic therapies. Trials of immuno-oncology agents (notably T cell checkpoint inhibitors) are ongoing in the advanced disease setting and these agents also present opportunities for combination therapies, both with other systemic agents and with LRTs in earlier stage disease. This article will review strategies to guide patient selection for LRT as well as the development of locoregional-systemic combinations based on scientific rationale and the challenges of clinical trial design in this setting.
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Affiliation(s)
- Daniel H Palmer
- Liverpool CR UK/NIHR Experimental Cancer Medicine Centre, University of Liverpool, Liverpool, UK.
| | - Katerina Malagari
- 2(nd) Department of Radiology, Medical School, National and Kapodistrian University of Athens, Athens, Greece
| | - Laura M Kulik
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, USA
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7
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Marrero JA, Kulik LM, Sirlin CB, Zhu AX, Finn RS, Abecassis MM, Roberts LR, Heimbach JK. Diagnosis, Staging, and Management of Hepatocellular Carcinoma: 2018 Practice Guidance by the American Association for the Study of Liver Diseases. Hepatology 2018; 68:723-750. [PMID: 29624699 DOI: 10.1002/hep.29913] [Citation(s) in RCA: 2685] [Impact Index Per Article: 447.5] [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: 03/12/2018] [Accepted: 03/13/2018] [Indexed: 12/11/2022]
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8
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Heimbach JK, Kulik LM, Finn RS, Sirlin CB, Abecassis MM, Roberts LR, Zhu AX, Murad MH, Marrero JA. AASLD guidelines for the treatment of hepatocellular carcinoma. Hepatology 2018; 67:358-380. [PMID: 28130846 DOI: 10.1002/hep.29086] [Citation(s) in RCA: 2604] [Impact Index Per Article: 434.0] [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: 01/10/2017] [Accepted: 01/10/2017] [Indexed: 12/07/2022]
Affiliation(s)
- Julie K Heimbach
- Division of Transplant Surgery, William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| | - Laura M Kulik
- Department of Medicine, Division of Gastroenterology and Hepatology, Northwestern University, Chicago, IL
| | - Richard S Finn
- Department of Medicine, Division of Hematology and Oncology, David Geffen School of Medicine at the University of California, Los Angeles, Santa Monica Geffen School of Medicine at UCLA, Los Angeles, California
| | - Claude B Sirlin
- Liver Imaging Group, Department of Radiology, University of California, San Diego
| | | | - Lewis R Roberts
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, MN
| | - Andrew X Zhu
- Massachusetts General Hospital Cancer Center, Harvard Medical School, Boston, MA
| | - M Hassan Murad
- Mayo Clinic Evidence-based Practice Center, Mayo Clinic, Rochester, MN
| | - Jorge A Marrero
- Digestive and Liver Diseases Division, Department of Internal Medicine, UT Southwestern Medical Center, Dallas, TX
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9
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Hickey RM, Kulik LM, Nimeiri H, Kalyan A, Kircher S, Desai K, Riaz A, Lewandowski RJ, Salem R. Immuno-oncology and Its Opportunities for Interventional Radiologists: Immune Checkpoint Inhibition and Potential Synergies with Interventional Oncology Procedures. J Vasc Interv Radiol 2017; 28:1487-1494. [PMID: 28912090 DOI: 10.1016/j.jvir.2017.07.018] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/11/2017] [Revised: 07/14/2017] [Accepted: 07/15/2017] [Indexed: 12/18/2022] Open
Abstract
Immunotherapy, specifically the use of immune checkpoint inhibitors, offers a new approach to fighting cancer. Although the results of treatment with immune checkpoint inhibition alone have been remarkable for certain cancers, these results are not universal. Preclinical and early clinical studies indicate the potential for synergistic effects when immune checkpoint inhibition is combined with immunogenic local therapies such as ablation and embolization. This review offers an overview of immunology as it relates to immune checkpoint inhibition and the possibilities for synergy when combined with interventional radiology treatments.
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Affiliation(s)
- Ryan M Hickey
- Department of Radiology, Section of Interventional Radiology, New York University, 560 First Ave., New York, NY 10016.
| | - Laura M Kulik
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, Illinois
| | - Halla Nimeiri
- Department of Medicine, Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Aparna Kalyan
- Department of Medicine, Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Sheetal Kircher
- Department of Medicine, Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois
| | - Kush Desai
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
| | - Riad Salem
- Department of Medicine, Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, Illinois; Department of Radiology, Section of Interventional Radiology, Northwestern University, Chicago, Illinois
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10
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Abstract
Orthotopic liver transplantation (OLT) offers the best chance for cure in the setting of unresectable hepatocellular carcinoma (HCC). A consensus statement recommends locoregional therapy (LRT) be considered in patients with HCC who are expected to wait more than 6 months for OLT to diminish dropout from the waiting list because of tumor progression. This article reviews LRT as a bridge to OLT in patients with HCC.
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Affiliation(s)
- Meena A Prasad
- From the Department of Medicine, Division of Gastroenterology/Hepatology, Northwestern University, Chicago, Illinois
| | - Laura M Kulik
- From the Department of Medicine, Division of Gastroenterology/Hepatology, Northwestern University, Chicago, Illinois
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11
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Abstract
The burden of hepatocellular carcinoma is rising and anticipated to escalate and while the best chance for long term cure remains transplantation, however the shortage of available organs remains a limitation. Liver directed therapy can serve the role of bridge/downstaging to transplant or as palliative care. Despite an improved overall survival among patients with HCC, due to advancements in surgical techniques, liver directed and systemic therapy, the 5 year overall survival remains low at 18% high-lightening the need for novel therapies. Surveillance for HCC is key to detect disease at an early stage to increase the chances for a potentially curative option.
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Affiliation(s)
- Laura M Kulik
- Kovler Organ Transplantation Center, NMH, Arkes Family Pavilion, Suite 1900, 676 North Saint Clair, Chicago, IL 60611, USA.
| | - Attasit Chokechanachaisakul
- Kovler Organ Transplantation Center, NMH, Arkes Family Pavilion, Suite 1900, 676 North Saint Clair, Chicago, IL 60611, USA
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12
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Memon K, Kulik LM, Lewandowski RJ, Wang E, Wang J, Ryu RK, Hickey R, Vouche M, Baker T, Ganger D, Gates VL, Habib A, Mulcahy MF, Salem R. Comparative study of staging systems for hepatocellular carcinoma in 428 patients treated with radioembolization. J Vasc Interv Radiol 2014; 25:1056-66. [PMID: 24613269 PMCID: PMC5097871 DOI: 10.1016/j.jvir.2014.01.010] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2013] [Revised: 12/30/2013] [Accepted: 01/11/2014] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To compare the utility of different staging systems and analyze independent predictors of survival in patients with hepatocellular carcinoma (HCC) treated with yttrium-90 ((90)Y) radioembolization. MATERIALS AND METHODS During the period 2004-2011, 428 patients with HCC were treated with (90)Y radioembolization. All patients were staged prospectively by the following staging systems: Child-Turcotte-Pugh (CTP), United Network for Organ Sharing, Barcelona Clinic Liver Cancer (BCLC), Okuda classification, Cancer of the Liver Italian Program (CLIP), Groupe d'Etude et de Traitement du Carcinome Hepatocellulaire, Chinese University Prognostic Index, and Japan Integrated Staging. The ability of the staging systems to predict survival was assessed. The staging systems were compared using Cox proportional hazards regression model, linear regression, Akaike information criterion (AIC), and concordance index (C-index). Univariate and multivariate analyses were employed to assess independent predictors of survival. RESULTS When tested independently, all staging systems exhibited significant ability to discriminate early (long survival) from advanced (worse survival) disease. CLIP provided the most accurate information in predicting survival outcomes (AIC = 2,993, C-index = 0.8503); CTP was least informative (AIC = 3,074, C-index = 0.6445). Independent predictors of survival included Eastern Cooperative Oncology Group performance status grade 0 (hazard ration [HR], 0.56; confidence interval [CI], 0.34-0.93), noninfiltrative tumors (HR, 0.62; CI, 0.44-0.89), absence of portal venous thrombosis (HR, 0.60; CI, 0.40-0.89), absence of ascites (HR, 0.56; CI, 0.40-0.76), albumin ≥ 2.8 g/dL (HR, 0.72; CI, 0.55-0.94), alkaline phosphatase ≤ 200 U/L (HR, 0.68; CI, 0.50-0.92), and α-fetoprotein ≤ 200 ng/mL (HR, 0.67; CI, 0.51-0.86). CONCLUSIONS CLIP was most accurate in predicting survival in patients with HCC. Given that not all patients receive the recommended BCLC treatment strategy, this information is relevant for clinical trial design and predicting long-term outcomes after (90)Y radioembolization.
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Affiliation(s)
- Khairuddin Memon
- Department of Radiology, Section of Interventional Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611
| | - Laura M Kulik
- Department of Medicine, Division of Hematology, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611
| | - Robert J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611
| | - Edward Wang
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611
| | - Jonathan Wang
- Department of Radiology, Section of Interventional Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611
| | - Robert K Ryu
- Department of Radiology, Section of Interventional Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611
| | - Ryan Hickey
- Department of Radiology, Section of Interventional Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611
| | - Michael Vouche
- Department of Radiology, Section of Interventional Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611
| | - Talia Baker
- Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611
| | - Daniel Ganger
- Department of Medicine, Division of Hematology, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611
| | - Vanessa L Gates
- Department of Radiology, Section of Interventional Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611
| | - Ali Habib
- Department of Radiology, Section of Interventional Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611
| | - Mary F Mulcahy
- Department of Medicine, Division of Hematology and Oncology, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611
| | - Riad Salem
- Department of Radiology, Section of Interventional Radiology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611; Department of Medicine, Division of Hematology and Oncology, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611; Department of Surgery, Division of Transplantation, Comprehensive Transplant Center, Northwestern University, 676 N. St. Clair, Suite 800, Chicago, IL 60611.
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Terrault NA, Stravitz RT, Lok AS, Everson GT, Brown RS, Kulik LM, Olthoff KM, Saab S, Adeyi O, Argo CK, Everhart JE, Rodrigo DR. Hepatitis C disease severity in living versus deceased donor liver transplant recipients: an extended observation study. Hepatology 2014; 59:1311-9. [PMID: 24677192 PMCID: PMC4118586 DOI: 10.1002/hep.26920] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [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: 06/27/2013] [Revised: 09/20/2013] [Accepted: 10/28/2013] [Indexed: 12/23/2022]
Abstract
UNLABELLED Donor factors influence hepatitis C virus (HCV) disease severity in liver transplant (LT) recipients. Living donors, because they are typically young and have short cold ischemic times, may be advantageous for HCV-infected patients. Among HCV-infected patients in the Adult-to-Adult Living Donor Liver Transplantation Cohort Study (A2ALL) surviving >90 days and followed for a median 4.7 years, advanced fibrosis (Ishak stage ≥3) and graft loss were determined. The 5-year cumulative risk of advanced fibrosis was 44% and 37% in living donor LT (LDLT) and deceased donor LT (DDLT) patients (P = 0.16), respectively. Aspartate aminotransferase (AST) activity at LT (hazard ratio [HR] = 1.38 for doubling of AST, P = 0.005) and biliary strictures (HR = 2.68, P = 0.0001) were associated with advanced fibrosis, but LDLT was not (HR = 1.11, 95% confidence interval [CI] 0.73-1.69, P = 0.63). The 5-year unadjusted patient and graft survival probabilities were 79% and 78% in LDLT, and 77% and 75% in DDLT (P = 0.43 and 0.32), with 27% and 20% of LDLT and DDLT graft losses due to HCV (P = 0.45). Biliary strictures (HR = 2.25, P = 0.0006), creatinine at LT (HR = 1.74 for doubling of creatinine, P = 0.0004), and AST at LT (HR = 1.36 for doubling of AST, P = 0.004) were associated with graft loss, but LDLT was not (HR = 0.76, 95% CI: 0.49-1.18, P = 0.23). CONCLUSION Donor type does not affect the probability of advanced fibrosis or patient and graft survival in HCV-infected recipients. Thus, while LDLT offers the advantage of shorter wait times, there is no apparent benefit for HCV disease progression. Biliary strictures have a negative effect on HCV fibrosis severity and graft survival, and a high AST at LT may be an important predictor of fibrosis risk post-LT.
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Affiliation(s)
| | | | | | | | | | | | | | - Sammy Saab
- University of California, Los Angeles, Los Angeles, CA
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14
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Wang D, Gaba RC, Jin B, Lewandowski RJ, Riaz A, Memon K, Ryu RK, Sato KT, Kulik LM, Mulcahy MF, Larson AC, Salem R, Omary RA. Perfusion reduction at transcatheter intraarterial perfusion MR imaging: a promising intraprocedural biomarker to predict transplant-free survival during chemoembolization of hepatocellular carcinoma. Radiology 2014; 272:587-97. [PMID: 24678859 DOI: 10.1148/radiol.14131311] [Citation(s) in RCA: 13] [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: 12/13/2022]
Abstract
PURPOSE To investigate the predictive value of transcatheter intraarterial perfusion (TRIP) magnetic resonance (MR) imaging-measured tumor perfusion changes during transarterial chemoembolization on transplant-free survival (TFS) in patients with unresectable hepatocellular carcinoma (HCC). MATERIALS AND METHODS This HIPAA-compliant prospective study was approved by the institutional review board. Written informed consent was obtained from all patients. Fifty-one consecutive adult patients with surgically unresectable single or multifocal measurable HCC and adequate laboratory parameters who underwent chemoembolization in a combined MR imaging-interventional radiology suite between February 2006 and June 2010 were studied. Tumor perfusion changes during chemoembolization were measured by using TRIP MR imaging with area under the time-signal intensity curve calculation. The end point of the study was TFS. The authors assessed the correlation between the percentage perfusion reduction in the tumor during chemoembolization and TFS by using univariate and multivariate analyses. RESULTS Fifty patients (mean age, 61 years; 39 men aged 42-87 years [mean age, 61 years] and 11 women aged 49-83 years [mean age, 62 years]) were eligible for the analysis. Patients with 35%-85% intraprocedural tumor area under the time-signal intensity curve reduction (n = 32) showed significantly improved median TFS compared with patients with an area under the time-signal intensity curve reduction outside this range (n = 18) (16.6 months [95% confidence interval: 11.2, 22.0 months] vs 9.3 months [95% confidence interval: 6.6, 12.0 months], respectively; P = .046; hazard ratio: 0.46; 95% confidence interval: 0.21, 1.00). The cumulative TFS rates in the 35%-85% and less than 35% or more than 85% perfusion reduction groups at 1, 2, and 5 years after chemoembolization were 66.4%, 42.2%, and 28.2% versus 33.8%, 16.9%, and 0%, respectively. CONCLUSION The study shows evidence of an association between intraprocedural tumor perfusion reduction during chemoembolization and TFS and suggests the utility of TRIP MR imaging- measured tumor perfusion reduction as an intraprocedural imaging biomarker during chemoembolization.
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Affiliation(s)
- Dingxin Wang
- From the Departments of Radiology (D.W., B.J., R.J.L., A.R., K.M., R.K.R., K.T.S., A.C.L., R.S., R.A.O.), Hepatology (L.M.K.), and Medicine (M.F.M., R.S.), Feinberg School of Medicine, Robert H. Lurie Comprehensive Cancer Center (R.J.L., L.M.K., M.F.M., A.C.L., R.S., R.A.O.), and Biomedical Engineering Department, McCormick School of Engineering (A.C.L., R.A.O.), Northwestern University, Chicago, Ill; Center for Magnetic Resonance Research, University of Minnesota, Minneapolis, Minn (D.W.); and Department of Radiology, University of Illinois Hospital and Health Sciences System, Chicago, Ill (R.C.G.)
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15
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Everson GT, Terrault NA, Lok AS, Rodrigo DR, Brown RS, Saab S, Shiffman ML, Al-Osaimi AMS, Kulik LM, Gillespie BW, Everhart JE. A randomized controlled trial of pretransplant antiviral therapy to prevent recurrence of hepatitis C after liver transplantation. Hepatology 2013; 57:1752-62. [PMID: 22821361 PMCID: PMC3510348 DOI: 10.1002/hep.25976] [Citation(s) in RCA: 98] [Impact Index Per Article: 8.9] [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: 03/08/2012] [Accepted: 06/11/2012] [Indexed: 12/13/2022]
Abstract
UNLABELLED Hepatitis C virus (HCV) infection recurs in liver recipients who are viremic at transplantation. We conducted a randomized, controlled trial to test the efficacy and safety of pretransplant pegylated interferon alpha-2b plus ribavirin (Peg-IFN-α2b/RBV) for prevention of post-transplant HCV recurrence. Enrollees had HCV and were listed for liver transplantation, with either potential living donors or Model for End-Stage Liver Disease upgrade for hepatocellular carcinoma. Patients with HCV genotypes (G) 1/4/6 (n = 44/2/1) were randomized 2:1 to treatment (n = 31) or untreated control (n = 16); HCV G2/3 (n=32) were assigned to treatment. Overall, 59 were treated and 20 were not. Peg-IFN-α2b, starting at 0.75 μg/kg/week, and RBV, starting at 600 mg/day, were escalated as tolerated. Patients assigned to treatment versus control had similar baseline characteristics. Combined virologic response (CVR) included pretransplant sustained virologic response and post-transplant virologic response (pTVR), defined as undetectable HCV RNA 12 weeks after end of treatment or transplant, respectively. In intent-to-treat analyses, 12 (19%) assigned to treatment and 1 (6%) assigned to control achieved CVR (P = 0.29); per-protocol values were 13 (22%) and 0 (0%) (P = 0.03). Among treated G1/4/6 patients, 23 of 30 received transplant, of whom 22% had pTVR; among treated G2/3 patients 21 of 29 received transplant, of whom 29% had pTVR. pTVR was 0%, 18%, and 50% in patients treated for <8, 8-16, and >16 weeks, respectively (P = 0.01). Serious adverse events (SAEs) occurred with similar frequency in treated versus untreated patients (68% versus 55%; P = 0.30), but the number of SAEs per patient was higher in the treated group (2.7 versus 1.3; P = 0.003). CONCLUSION Pretransplant treatment with Peg-IFN-α2b/RBV prevents post-transplant recurrence of HCV in selected patients. Efficacy is higher with >16 weeks of treatment, but treatment is associated with increased risk of potentially serious complications.
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Affiliation(s)
| | - Norah A. Terrault
- Division of Gastroenterology, University of California, San Francisco, CA
| | - Anna S. Lok
- Department of Internal Medicine, University of Michigan, Ann Arbor, MI
| | - Del R. Rodrigo
- Department of Surgery, University of Michigan, Ann Arbor, MI
| | - Robert S. Brown
- Department of Medicine and Surgery, Columbia University College of Physicians and Surgeons, New York, NY
| | - Sammy Saab
- Department of Medicine and Surgery, University of California, Los Angeles, CA
| | | | | | - Laura M. Kulik
- Department of Medicine and Surgery, Northwestern University, Chicago, IL
| | | | - James E. Everhart
- Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD
| | - the Adult-to-Adult Living Donor Liver Transplantation Cohort Study
- The A2ALL Study Group includes Northwestern University, Chicago, IL; University of California – Los Angeles, CA; University of California – San Francisco, CA; University of Colorado Health Sciences Center, Denver, CO; University of North Carolina, Chapel Hill, NC; Epidemiology and Clinical Trials Branch, Division of Digestive Diseases and Nutrition, National Institute of Diabetes and Digestive and Kidney Diseases, National Institutes of Health, Bethesda, MD; University of Michigan, Ann Arbor, MI; Department of Surgery, Columbia Presbyterian Medical Center, New York, NY; University of Pennsylvania, Philadelphia, PA; Department of Internal Medicine, University of Virginia, Charlottesville, VA; Virginia Commonwealth University, Richmond, VA
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16
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Darwish Murad S, Kim WR, Harnois DM, Douglas DD, Burton J, Kulik LM, Botha JF, Mezrich JD, Chapman WC, Schwartz JJ, Hong JC, Emond JC, Jeon H, Rosen CB, Gores GJ, Heimbach JK. Efficacy of neoadjuvant chemoradiation, followed by liver transplantation, for perihilar cholangiocarcinoma at 12 US centers. Gastroenterology 2012; 143:88-98.e3; quiz e14. [PMID: 22504095 PMCID: PMC3846443 DOI: 10.1053/j.gastro.2012.04.008] [Citation(s) in RCA: 350] [Impact Index Per Article: 29.2] [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: 12/15/2011] [Revised: 03/28/2012] [Accepted: 04/12/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Excellent single-center outcomes of neoadjuvant chemoradiation and liver transplantation for unresectable perihilar cholangiocarcinoma caused the United Network of Organ Sharing to offer a standardized model of end-stage liver disease (MELD) exception for this disease. We analyzed data from multiple centers to determine the effectiveness of this treatment and the appropriateness of the MELD exception. METHODS We collected and analyzed data from 12 large-volume transplant centers in the United States. These centers met the inclusion criteria of treating 3 or more patients with perihilar cholangiocarcinoma using neoadjuvant therapy, followed by liver transplantation, from 1993 to 2010 (n = 287 total patients). Center-specific protocols and medical charts were reviewed on-site. RESULTS The patients completed external radiation (99%), brachytherapy (75%), radiosensitizing therapy (98%), and/or maintenance chemotherapy (65%). Seventy-one patients dropped out before liver transplantation (rate, 11.5% in 3 months). Intent-to-treat survival rates were 68% and 53%, 2 and 5 years after therapy, respectively; post-transplant, recurrence-free survival rates were 78% and 65%, respectively. Patients outside the United Network of Organ Sharing criteria (those with tumor mass >3 cm, transperitoneal tumor biopsy, or metastatic disease) or with a prior malignancy had significantly shorter survival times (P < .001). There were no differences in outcomes among patients based on differences in surgical staging or brachytherapy. Although most patients came from 1 center (n = 193), the other 11 centers had similar survival times after therapy. CONCLUSIONS Patients with perihilar cholangiocarcinoma who were treated with neoadjuvant therapy followed up by liver transplantation at 12 US centers had a 65% rate of recurrence-free survival after 5 years, showing this therapy to be highly effective. An 11.5% drop-out rate after 3.5 months of therapy indicates the appropriateness of the MELD exception. Rigorous selection is important for the continued success of this treatment.
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Affiliation(s)
| | - W. Ray Kim
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| | - Denise M. Harnois
- Division of Gastroenterology and Hepatology, Mayo Clinic Florida, Jacksonville, FL
| | - David D. Douglas
- Division of Gastroenterology and Hepatology, Mayo Clinic Arizona, Phoenix, AZ
| | - James Burton
- Division of Gastroenterology and Hepatology, University of Colorado, Denver, CO
| | - Laura M. Kulik
- Department of Hepatology, Northwestern University, Chicago, IL
| | - Jean F. Botha
- Division of Transplantation, University of Nebraska Medical Center, Omaha, NE
| | - Joshua D. Mezrich
- Division of Transplantation, University of Wisconsin School of Medicine and Public Health, Madison, WI
| | | | - Jason J. Schwartz
- Department of Surgery, Columbia University Medical Center, New York, NY
| | - Johnny C. Hong
- Division of Transplant, University of Illinois at Chicago, Chicago, IL
| | | | | | - Charles B. Rosen
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
| | - Gregory J. Gores
- William J. von Liebig Transplant Center, Mayo Clinic, Rochester, MN
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17
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Riaz A, Memon K, Miller FH, Nikolaidis P, Kulik LM, Lewandowski RJ, Ryu RK, Sato KT, Gates VL, Mulcahy MF, Baker T, Wang E, Gupta R, Nayar R, Benson AB, Abecassis M, Omary R, Salem R. Role of the EASL, RECIST, and WHO response guidelines alone or in combination for hepatocellular carcinoma: radiologic-pathologic correlation. J Hepatol 2011; 54:695-704. [PMID: 21147504 PMCID: PMC3094725 DOI: 10.1016/j.jhep.2010.10.004] [Citation(s) in RCA: 131] [Impact Index Per Article: 10.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/15/2010] [Revised: 10/01/2010] [Accepted: 10/06/2010] [Indexed: 02/09/2023]
Abstract
BACKGROUND & AIMS We sought to study receiver-operating characteristics (ROC) of the European Association for the Study of the Liver (EASL), Response Evaluation Criteria in Solid Tumors (RECIST), and World Health Organization (WHO) guidelines for assessing response following locoregional therapies individually and in various combinations. METHODS Eighty-one patients with hepatocellular carcinoma underwent liver explantation following locoregional therapies. Response was assessed using EASL, RECIST, and WHO. Kappa statistics were used to determine inter-method agreement. Uni/multivariate logistic regression analyses were performed to determine the variables predicting complete pathologic necrosis. Numerical values were assigned to the response classes: complete response=0, partial response=1, stable disease=2, and progressive disease=3. Various mathematical combinations of EASL and WHO were tested to calculate scores and their ROCs were studied using pathological examination of the explant as the gold standard. RESULTS Median times (95% CI) to the WHO, RECIST, and EASL responses were 5.3 (4-11.5), 5.6 (4-11.5), and 1.3months (1.2-1.5), respectively. Kappa coefficients for WHO/RECIST, WHO/EASL, and RECIST/EASL were 0.78, 0.28, and 0.31, respectively. EASL response demonstrated significant odds ratios for predicting complete pathologic necrosis on uni/multivariate analyses. Calculated areas under the ROC curves were: RECIST: 0.63, WHO: 0.68, EASL: 0.82, EASL+WHO: 0.82, EASL×WHO: 0.85, EASL+(2×WHO): 0.79 and (2×EASL)+WHO: 0.85. An EASL×WHO Score of ⩽1 had 90.2% sensitivity for predicting complete pathologic necrosis. CONCLUSIONS The product of WHO and EASL demonstrated better ROC than the individual guidelines for assessment of tumor response. EASL×WHO scoring system provides a simple and clinically applicable method of response assessment following locoregional therapies for hepatocellular carcinoma.
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Affiliation(s)
- Ahsun Riaz
- Department of Radiology, Northwestern University, Chicago IL
| | | | - Frank H. Miller
- Department of Radiology, Northwestern University, Chicago IL
| | - Paul Nikolaidis
- Department of Radiology, Northwestern University, Chicago IL
| | - Laura M. Kulik
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL
| | | | - Robert K. Ryu
- Department of Radiology, Northwestern University, Chicago IL
| | - Kent T. Sato
- Department of Radiology, Northwestern University, Chicago IL
| | | | - Mary F. Mulcahy
- Department of Medicine, Division of Medical Oncology, Northwestern University, Chicago, IL
| | - Talia Baker
- Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, IL
| | - Ed Wang
- Department of Surgery, Section of Biostatistics, Northwestern University, Chicago, IL
| | - Ramona Gupta
- Department of Radiology, Northwestern University, Chicago IL
| | - Ritu Nayar
- Department of Pathology, Northwestern University, Chicago, IL
| | - Al B Benson
- Department of Medicine, Division of Medical Oncology, Northwestern University, Chicago, IL
| | - Michael Abecassis
- Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, IL
| | - Reed Omary
- Department of Radiology, Northwestern University, Chicago IL
| | - Riad Salem
- Department of Radiology, Northwestern University, Chicago IL, Department of Surgery, Division of Transplant Surgery, Northwestern University, Chicago, IL
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Wang D, Jin B, Lewandowski RJ, Ryu RK, Sato KT, Mulcahy MF, Kulik LM, Miller FH, Salem R, Li D, Omary RA, Larson AC. Quantitative 4D transcatheter intraarterial perfusion MRI for monitoring chemoembolization of hepatocellular carcinoma. J Magn Reson Imaging 2010; 31:1106-16. [PMID: 20432345 DOI: 10.1002/jmri.22155] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
PURPOSE To develop a fully quantitative 4D transcatheter intraarterial perfusion (TRIP) magnetic resonance imaging (MRI) technique and prospectively test the hypothesis that quantitative 4D TRIP-MRI can be used clinically to monitor intraprocedural liver tumor perfusion reductions during transcatheter arterial chemoembolization (TACE). MATERIALS AND METHODS TACE was performed within an x-ray digital subtraction angiography (DSA)-MRI procedure suite in 16 patients with hepatocellular carcinoma. Quantitative 4D TRIP-MRI with targeted radiofrequency field mapping and dynamic longitudinal relaxation rate mapping was used to monitor changes in tumor perfusion during TACE. First-pass perfusion analysis was performed to produce intraprocedural blood flow (Frho) maps. Mean liver tumor perfusions before and after TACE were compared with a paired t-test (alpha = 0.05). RESULTS Perfusion reductions were successfully measured with quantitative 4D TRIP-MRI in 22 separate tumors during 18 treatment sessions. Mean tumor perfusion Frho decreased from 16.3 (95% confidence interval [CI]: 10.7-21.9) before TACE to 5.0 (95% CI: 3.5-6.5) (mL/min/100 mL) after TACE. Tumor perfusion reductions were statistically significant (P < 0.0005), with a mean absolute perfusion change of 11.4 (95% CI: 5.6-17.1) (mL/min/100 mL) and a mean percentage reduction of 61.0% (95% CI: 48.3%-73.6%). CONCLUSION Quantitative 4D TRIP-MRI can be successfully performed within clinical interventional settings to monitor intraprocedural changes in liver tumor perfusion during TACE.
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Affiliation(s)
- Dingxin Wang
- Department of Radiology, Feinberg School of Medicine, Northwestern University, Chicago, IL 60611, USA
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Lewandowski RJ, Mulcahy MF, Kulik LM, Riaz A, Ryu RK, Baker TB, Ibrahim SM, Abecassis MI, Miller FH, Sato KT, Senthilnathan S, Resnick SA, Wang E, Gupta R, Chen R, Newman SB, Chrisman HB, Nemcek AA, Vogelzang RL, Omary RA, Benson AB, Salem R. Chemoembolization for hepatocellular carcinoma: comprehensive imaging and survival analysis in a 172-patient cohort. Radiology 2010; 255:955-65. [PMID: 20501733 DOI: 10.1148/radiol.10091473] [Citation(s) in RCA: 125] [Impact Index Per Article: 8.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
PURPOSE To determine comprehensive imaging and long-term survival outcome following chemoembolization for hepatocellular carcinoma (HCC). MATERIALS AND METHODS One hundred seventy-two patients with HCC treated with chemoembolization were studied retrospectively in an institutional review board approved protocol; this study was HIPAA compliant. Baseline laboratory and imaging characteristics were obtained. Clinical and laboratory toxicities following treatment were assessed. Imaging characteristics following chemoembolization were evaluated to determine response rates (size and necrosis) and time to progression (TTP). Survival from the time of first chemoembolization treatment was calculated. Subanalyses were performed by stratifying the population according to Child-Pugh, United Network for Organ Sharing, and Barcelona Clinic for Liver Cancer (BCLC) staging systems. RESULTS Cirrhosis was present in 157 patients (91%); portal hypertension was present in 139 patients (81%). Eleven patients (6%) had metastases at baseline. Portal vein thrombosis was present in 11 patients (6%). Fifty-five percent of patients experienced some form of toxicity following treatment; 21% developed grade 3 or 4 bilirubin toxicity. Post-chemoembolization response was seen in 31% and 64% of patients according to size and necrosis criteria, respectively. Median TTP was 7.9 months (95% confidence interval: 7.1, 9.4) but varied widely by stage. Median survival was significantly different between patients with BCLC stages A, B, and C disease (stage A, 40.0 months; B, 17.4 months; C, 6.3 months; P < .0001). CONCLUSION The determination of TTP and survival in patients with HCC is confounded by tumor biology and background cirrhosis; chemoembolization was shown to be a safe and effective therapy in patients with HCC.
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Affiliation(s)
- Robert J Lewandowski
- Dept of Radiology, Section of Interventional Radiology, Robert H. Lurie Comprehensive Cancer Ctr, Northwestern Memorial Hosp, 676 N St Clair St, Suite 800, Chicago, IL 60611, USA
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Chung JC, Naik NK, Lewandowski RJ, Deng J, Mulcahy MF, Kulik LM, Sato KT, Ryu RK, Salem R, Larson AC, Omary RA. Diffusion-weighted magnetic resonance imaging to predict response of hepatocellular carcinoma to chemoembolization. World J Gastroenterol 2010; 16:3161-7. [PMID: 20593501 PMCID: PMC2896753 DOI: 10.3748/wjg.v16.i25.3161] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate whether intra-procedural diffusion-weighted magnetic resonance imaging can predict response of hepatocellular carcinoma (HCC) during transcatheter arterial chemoembolization (TACE).
METHODS: Sixteen patients (15 male), aged 59 ± 11 years (range: 42-81 years) underwent a total of 21 separate treatments for unresectable HCC in a hybrid magnetic resonance/interventional radiology suite. Anatomical imaging and diffusion-weighted imaging (b = 0, 500 s/mm2) were performed on a 1.5-T unit. Tumor enhancement and apparent diffusion coefficient (ADC, mm2/s) values were assessed immediately before and at 1 and 3 mo after TACE. We calculated the percent change (PC) in ADC values at all time points. We compared follow-up ADC values to baseline values using a paired t test (α = 0.05).
RESULTS: The intra-procedural sensitivity, specificity, and positive and negative predictive values (%) for detecting a complete or partial 1-mo tumor response using ADC PC thresholds of ±5%, ±10%, and ±15% were 77, 67, 91, and 40; 54, 67, 88, and 25; and 46, 100, 100, and 30, respectively. There was no clear predictive value for the 3-mo follow-up. Compared to baseline, the immediate post-procedure and 1-mo mean ADC values both increased; the latter obtaining statistical significance (1.48 ± 0.29 mm2/s vs 1.65 ± 0.35 × 10-3 mm2/s, P < 0.014).
CONCLUSION: Intra-procedural ADC changes of > 15% predicted 1-mo anatomical HCC response with the greatest accuracy, and can provide valuable feedback at the time of TACE.
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Abstract
Primary and secondary liver tumors are common. Locoregional therapies are establishing a role in the management of liver tumors due to the limited roles of surgical and systemic therapies. Our review presents some general concepts associated with yttrium-90 radioembolization and its specific utilization in various primary and secondary liver malignancies.
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Affiliation(s)
- Ahsun Riaz
- Department of Radiology, Division of Interventional Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL, USA
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22
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Riaz A, Miller FH, Kulik LM, Nikolaidis P, Yaghmai V, Lewandowski RJ, Mulcahy MF, Ryu RK, Sato KT, Gupta R, Wang E, Baker T, Abecassis M, Benson AB, Nemcek AA, Omary R, Salem R. Imaging response in the primary index lesion and clinical outcomes following transarterial locoregional therapy for hepatocellular carcinoma. JAMA 2010; 303:1062-9. [PMID: 20233824 PMCID: PMC3117395 DOI: 10.1001/jama.2010.262] [Citation(s) in RCA: 164] [Impact Index Per Article: 11.7] [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] [Indexed: 01/04/2023]
Abstract
CONTEXT Response Evaluation Criteria in Solid Tumors (RECIST) (unidimensional), World Health Organization (WHO) (bidimensional), and European Association for Study of the Liver (EASL) (necrosis) guidelines are commonly used to assess response following therapy for hepatocellular carcinoma (HCC). No universally accepted standard exists. OBJECTIVES To evaluate intermethod agreement between these 3 imaging guidelines and to introduce the concept of the "primary index lesion" as a biomarker for response. DESIGN, SETTING, AND PARTICIPANTS Single-center comprehensive imaging analysis including 245 consecutive patients with HCC who were treated with chemoembolization or radioembolization between January 2000 and December 2008. Computed tomography and magnetic resonance imaging scans (N = 1065) were reviewed to assess response in the "primary index lesion," defined as the largest tumor targeted during first treatment. MAIN OUTCOME MEASURES Intermethod agreement (kappa statistics) between RECIST, WHO, and EASL guidelines response; correlation of WHO and EASL response in the primary index lesion with time to progression and survival. RESULTS Kappa coefficients were 0.86 (95% confidence interval [CI], 0.80-0.92) between the WHO and RECIST guidelines, 0.24 (95% CI, 0.16-0.33) between RECIST and EASL, and 0.28 (95% CI, 0.19-0.36) between WHO and EASL. Disease progressed in 96 patients; 113 died. The hazard ratio for time to progression in responders compared with nonresponders was 0.36 (95% CI, 0.23-0.57) for WHO, 0.38 (95% CI, 0.24-0.58) for RECIST, and 0.38 (95% CI, 0.22-0.64) for EASL. Hazard ratios for survival in responders compared with nonresponders in univariate and multivariate analyses were 0.46 (95% CI, 0.32-0.67) and 0.55 (95% CI, 0.35-0.84) for WHO and 0.36 (95% CI, 0.22-0.57) and 0.54 (95% CI, 0.34-0.85) for EASL. Hazard ratios for survival in responders vs nonresponders in patients with solitary and multifocal HCC were 0.39 (95% CI, 0.19-0.77) and 0.51 (95% CI, 0.32-0.82) for WHO and 0.26 (95% CI, 0.10-0.67) and 0.47 (95% CI, 0.28-0.79) for EASL. CONCLUSIONS Among a group of patients with HCC, agreement for classification of therapeutic response was high between the RECIST and WHO guidelines but low between each of these and EASL. Application of these methods to measure response in a primary index lesion resulted in statistically significant correlations with disease progression and survival.
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Affiliation(s)
- Ahsun Riaz
- Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Frank H Miller
- Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Laura M Kulik
- Department of Medicine, Division of Hepatology, Northwestern University, Chicago, IL
| | - Paul Nikolaidis
- Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Vahid Yaghmai
- Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Robert J Lewandowski
- Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Mary F Mulcahy
- Department of Medicine, Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Robert K Ryu
- Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Kent T Sato
- Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Ramona Gupta
- Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Ed Wang
- Department of Transplant Surgery, Northwestern University, Chicago, IL
| | - Talia Baker
- Department of Transplant Surgery, Northwestern University, Chicago, IL
| | - Michael Abecassis
- Department of Transplant Surgery, Northwestern University, Chicago, IL
| | - Al B Benson
- Department of Medicine, Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
| | - Albert A Nemcek
- Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Reed Omary
- Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
| | - Riad Salem
- Department of Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago IL
- Department of Medicine, Division of Hematology and Oncology, Robert H. Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL
- Department of Transplant Surgery, Northwestern University, Chicago, IL
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23
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Riaz A, Ryu RK, Kulik LM, Mulcahy MF, Lewandowski RJ, Minocha J, Ibrahim SM, Sato KT, Baker T, Miller FH, Newman S, Omary R, Abecassis M, Benson AB, Salem R. Alpha-fetoprotein response after locoregional therapy for hepatocellular carcinoma: oncologic marker of radiologic response, progression, and survival. J Clin Oncol 2009; 27:5734-42. [PMID: 19805671 DOI: 10.1200/jco.2009.23.1282] [Citation(s) in RCA: 171] [Impact Index Per Article: 11.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Alpha-fetoprotein (AFP) is considered to be an indicator of tumor activity in hepatocellular carcinoma (HCC). We present a novel correlation of AFP response to radiologic response, time-to-progression (TTP), progression-free survival (PFS), and overall survival (OS) in patients treated with locoregional therapies. PATIENTS AND METHODS Four hundred sixty-three patients with HCC were treated with chemoembolization or radioembolization at our institution. One hundred twenty-five patients with baseline AFP higher than 200 ng/mL were studied for this analysis. AFP response was defined as more than 50% decrease from baseline. One hundred nineteen patients with follow-up imaging were studied for the AFP imaging correlation analysis. AFP response was correlated to radiologic response, TTP, PFS, and OS. Multivariate analyses were performed. RESULTS Eighty-one patients (65%) showed AFP response. AFP response was seen in 26 (55%) of 47 and 55 (70%) of 78 of patients treated with chemoembolization and radioembolization, respectively (P = .12). WHO response was seen in 41 (53%) of 77 and 10 (24%) of 42 of AFP responders and nonresponders, respectively (P = .002). The hazard ratio (HR) for TTP in AFP nonresponders compared with responders was 2.8 (95% CI, 1.5 to 5.1). The HR for PFS was 4.2 (95% CI, 2.4 to 7.2) in AFP nonresponders compared with responders. The HR for OS in AFP nonresponders compared with responders was 5.5 (95% CI, 3.1 to 9.9) and 2.7 (95% CI, 1.6 to 4.6) on univariate and multivariate analyses, respectively. CONCLUSION The data presented support the use of AFP response seen after locoregional therapy as an ancillary method of assessing tumor response and survival, as well as an early objective screening tool for progression by imaging.
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Affiliation(s)
- Ahsun Riaz
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H Lurie Comprehensive Cancer Center, Northwestern University, Chicago, IL 60611, USA
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24
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Lewandowski RJ, Kulik LM, Riaz A, Senthilnathan S, Mulcahy MF, Ryu RK, Ibrahim SM, Sato KT, Baker T, Miller FH, Omary R, Abecassis M, Salem R. A comparative analysis of transarterial downstaging for hepatocellular carcinoma: chemoembolization versus radioembolization. Am J Transplant 2009; 9:1920-8. [PMID: 19552767 DOI: 10.1111/j.1600-6143.2009.02695.x] [Citation(s) in RCA: 415] [Impact Index Per Article: 27.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
Chemoembolization and other ablative therapies are routinely utilized in downstaging from United Network for Organ Sharing (UNOS) T3 to T2, thus potentially making patients transplant candidates under the UNOS model for end-stage liver disease (MELD) upgrade for hepatocellular carcinoma (HCC). This study was undertaken to compare the downstaging efficacy of transarterial chemoembolization (TACE) versus transarterial radioembolization. Eighty-six patients were treated with either TACE (n = 43) or transarterial radioembolization with Yttrium-90 microspheres (TARE-Y90; n = 43). Median tumor size was similar (TACE: 5.7 cm, TARE-Y90: 5.6 cm). Partial response rates favored TARE-Y90 versus TACE (61% vs. 37%). Downstaging to UNOS T2 was achieved in 31% of TACE and 58% of TARE-Y90 patients. Time to progression according to UNOS criteria was similar for both groups (18.2 months for TACE vs. 33.3 months for TARE-Y90, p = 0.098). Event-free survival was significantly greater for TARE-Y90 than TACE (17.7 vs. 7.1 months, p = 0.0017). Overall survival favored TARE-Y90 compared to TACE (censored 35.7/18.7 months; p = 0.18; uncensored 41.6/19.2 months; p = 0.008). In conclusion, TARE-Y90 appears to outperform TACE for downstaging HCC from UNOS T3 to T2.
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Affiliation(s)
- R J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
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25
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Lewandowski RJ, Kulik LM, Riaz A, Senthilnathan S, Mulcahy MF, Ryu RK, Ibrahim SM, Sato KT, Baker T, Miller FH, Omary R, Abecassis M, Salem R. A comparative analysis of transarterial downstaging for hepatocellular carcinoma: chemoembolization versus radioembolization. Am J Transplant 2009. [PMID: 19552767 DOI: 10.1111/j.1600-6143.2009.02695.x.] [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] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Chemoembolization and other ablative therapies are routinely utilized in downstaging from United Network for Organ Sharing (UNOS) T3 to T2, thus potentially making patients transplant candidates under the UNOS model for end-stage liver disease (MELD) upgrade for hepatocellular carcinoma (HCC). This study was undertaken to compare the downstaging efficacy of transarterial chemoembolization (TACE) versus transarterial radioembolization. Eighty-six patients were treated with either TACE (n = 43) or transarterial radioembolization with Yttrium-90 microspheres (TARE-Y90; n = 43). Median tumor size was similar (TACE: 5.7 cm, TARE-Y90: 5.6 cm). Partial response rates favored TARE-Y90 versus TACE (61% vs. 37%). Downstaging to UNOS T2 was achieved in 31% of TACE and 58% of TARE-Y90 patients. Time to progression according to UNOS criteria was similar for both groups (18.2 months for TACE vs. 33.3 months for TARE-Y90, p = 0.098). Event-free survival was significantly greater for TARE-Y90 than TACE (17.7 vs. 7.1 months, p = 0.0017). Overall survival favored TARE-Y90 compared to TACE (censored 35.7/18.7 months; p = 0.18; uncensored 41.6/19.2 months; p = 0.008). In conclusion, TARE-Y90 appears to outperform TACE for downstaging HCC from UNOS T3 to T2.
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Affiliation(s)
- R J Lewandowski
- Department of Radiology, Section of Interventional Radiology, Northwestern Memorial Hospital, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL, USA
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26
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Gaba RC, Lewandowski RJ, Kulik LM, Riaz A, Ibrahim SM, Mulcahy MF, Ryu RK, Sato KT, Gates V, Abecassis MM, Omary RA, Baker TB, Salem R. Radiation lobectomy: preliminary findings of hepatic volumetric response to lobar yttrium-90 radioembolization. Ann Surg Oncol 2009; 16:1587-96. [PMID: 19357924 DOI: 10.1245/s10434-009-0454-0] [Citation(s) in RCA: 170] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2008] [Revised: 03/13/2009] [Accepted: 03/14/2009] [Indexed: 12/11/2022]
Abstract
PURPOSE To describe volumetric changes of "radiation lobectomy," a manifestation of hepatic parenchymal response to lobar (90)Y microsphere radioembolization. METHODS Twenty patients exhibiting this phenomenon were identified. Pre- and posttreatment absolute right and left hepatic lobar volume (HLV), relative HLV (rHLV = HLV/total liver volume), and degree of lobar atrophy (DA) or hypertrophy (DH) (DA or DH = |posttreatment rHLV - pretreatment rHLV|) were determined. Laboratory toxicities, tumor response, and patient survival were also assessed. RESULTS Twenty patients with primary (HCC, n = 17; peripheral cholangiocarcinoma, n = 3) liver malignancies demonstrated findings of radiation lobectomy. Initial absolute right and left HLV was 955 cm(3) (range 644-1,842 cm(3), rHLV = 57%) and 719 cm(3) (range 328-1,387 cm(3), rHLV = 43%), respectively. Following (90)Y, absolute right HLV decreased to 460 cm(3) (range 185-948 cm(3), 52% reduction, rHLV = 31%, DA = 26%, P < 0.0001), while absolute left HLV increased to 1,004 cm(3) (range 560-1,558 cm(3), 40% increase, rHLV = 69%, DH = 26%, P < 0.0001). No grade 3 or 4 bilirubin toxicities were encountered. Tumor response ranged from 55% to 70% by size criteria. Forty-six percent 5-year survival was achieved in HCC patients. CONCLUSIONS Radiation lobectomy following (90)Y radioembolization of right lobe tumors manifests extensive contralateral lobar hypertrophy, high response rates, and prolonged survival. This phenomenon was noted in 6.4% (20/315) of the entire cohort and 19.8% (20/101) of patients with unilobar right lobe tumors. Further investigation is necessary to determine contributing factors that may predict this effect.
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Affiliation(s)
- Ron C Gaba
- Department of Radiology, University of Illinois at Chicago, USA
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27
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Shaked A, Ghobrial RM, Merion RM, Shearon TH, Emond JC, Fair JH, Fisher RA, Kulik LM, Pruett TL, Terrault NA. Incidence and severity of acute cellular rejection in recipients undergoing adult living donor or deceased donor liver transplantation. Am J Transplant 2009; 9:301-8. [PMID: 19120082 PMCID: PMC3732169 DOI: 10.1111/j.1600-6143.2008.02487.x] [Citation(s) in RCA: 119] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Living donor liver transplantation (LDLT) may have better immunological outcomes compared to deceased donor liver transplantation (DDLT). The aim of this study was to analyze the incidence of acute cellular rejection (ACR) after LDLT and DDLT. Data from the adult-to-adult living donor liver transplantation (A2ALL) retrospective cohort study on 593 liver transplants done between May 1998 and March 2004 were studied (380 LDLT; 213 DDLT). Median LDLT and DDLT follow-up was 778 and 713 days, respectively. Rates of clinically treated and biopsy-proven ACR were compared. There were 174 (46%) LDLT and 80 (38%) DDLT recipients with >/=1 clinically treated episodes of ACR, whereas 103 (27%) LDLT and 58 (27%) DDLT recipients had >/=1 biopsy-proven ACR episode. A higher proportion of LDLT recipients had clinically treated ACR (p = 0.052), but this difference was largely attributable to one center. There were similar proportions of biopsy-proven rejection (p = 0.97) and graft loss due to rejection (p = 0.16). Longer cold ischemia time was associated with a higher rate of ACR in both groups despite much shorter median cold ischemia time in LDLT. These data do not show an immunological advantage for LDLT, and therefore do not support the application of unique posttransplant immunosuppression protocols for LDLT recipients.
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Affiliation(s)
- Abraham Shaked
- Department of Surgery, University of Pennsylvania, Philadelphia, PA
| | - R. Mark Ghobrial
- Department of Surgery, University of California, Los Angeles, Los Angeles, CA
| | | | | | - Jean C. Emond
- Department of Medicine and Surgery, Columbia University College of Physicians & Surgeons, New York, NY
| | - Jeffrey H. Fair
- Department of Surgery, University of North Carolina, Chapel Hill, NC
| | - Robert A. Fisher
- Department of Surgery, Medical College of Virginia Hospitals, Virginia Commonwealth University, Richmond, VA
| | - Laura M. Kulik
- Department of Medicine, Northwestern University, Chicago, IL
| | | | - Norah A. Terrault
- Department of Medicine, University of California, San Francisco, San Francisco, CA
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Virmani S, Rhee TK, Ryu RK, Sato KT, Lewandowski RJ, Mulcahy MF, Kulik LM, Szolc-Kowalska B, Woloschak GE, Yang GY, Salem R, Larson AC, Omary RA. Comparison of hypoxia-inducible factor-1alpha expression before and after transcatheter arterial embolization in rabbit VX2 liver tumors. J Vasc Interv Radiol 2009; 19:1483-9. [PMID: 18922400 DOI: 10.1016/j.jvir.2008.06.017] [Citation(s) in RCA: 62] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/04/2008] [Revised: 06/16/2008] [Accepted: 06/29/2008] [Indexed: 12/12/2022] Open
Abstract
PURPOSE To test the hypothesis that transcatheter arterial embolization (TAE) induces expression of hypoxia-inducible factor-1alpha (HIF-1alpha) within the same rabbit VX2 liver tumor. MATERIALS AND METHODS Seven VX2 tumors were grown in the livers of five New Zealand white rabbits. Ultrasonography-guided biopsy was performed before and 10 minutes after TAE in all tumors. Pre- and post-TAE tumor biopsy specimens along with post-TAE whole liver tumor sections were stained with HIF-1alpha antibody and analyzed for percentage of HIF-1alpha-positive nuclei by using a spectral unmixing system mounted on a high-powered microscope. Statistical data comparisons were performed with the Wilcoxon signed-rank test (alpha = 0.05). RESULTS TAE of liver tumors resulted in a statistically significant increase in the mean percentage of HIF-1alpha expression. The mean percentage of HIF-1alpha-positive stained nuclei increased from 23% +/- 3.5 in pre-TAE biopsy specimens to 41% +/- 8.7 in post-TAE biopsy specimens (P < .02). The increase was even more significant when the mean percentage of HIF-1alpha-positive stained nuclei from the same pre-TAE biopsy specimens was compared with sections from post-TAE whole tumor specimens (60% +/- 8.9, P < .02). CONCLUSIONS The results of this study revealed that hypoxia caused by TAE of VX2 liver tumors activates HIF-1alpha, a transcription factor that in turn regulates other pro-angiogenic factors.
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Affiliation(s)
- Sumeet Virmani
- Department of Radiology, Northwestern University, 737 N Michigan Ave, Ste 1600, Chicago, IL 60611, USA
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29
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Larson AC, Wang D, Atassi B, Sato KT, Ryu RK, Lewandowski RJ, Nemcek AA, Mulcahy MF, Kulik LM, Miller FH, Salem R, Omary RA. Transcatheter intraarterial perfusion: MR monitoring of chemoembolization for hepatocellular carcinoma--feasibility of initial clinical translation. Radiology 2008; 246:964-71. [PMID: 18309018 DOI: 10.1148/radiol.2463070725] [Citation(s) in RCA: 43] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
PURPOSE To prospectively test the hypothesis that intraprocedural transcatheter intraarterial perfusion (TRIP) magnetic resonance (MR) imaging can be used to successfully measure reductions in perfusion to the targeted hepatocellular carcinoma (HCC) and the adjacent surrounding liver tissue during MR-interventional radiology (IR)-monitored transcatheter arterial chemoembolization (TACE). MATERIALS AND METHODS This HIPAA-compliant prospective study was approved by the institutional review board. An MR-IR unit was used to perform TACE in 10 patients with HCC (seven male, three female; eight younger than 69 years, two older than 69 years). Intraprocedural reductions in tumor perfusion before and after TACE were monitored with TRIP MR imaging. Time-signal intensity curves were derived, and semiquantitative spatially resolved area under the time-signal intensity curve maps of tumor perfusion before and after TACE were produced. Mean perfusion values before and after TACE for liver tumors and adjacent liver tissue were compared by using a mixed-model analysis, with alpha = .05. RESULTS Perfusion reductions were measured successfully with TRIP MR imaging in 18 separate tumors during 13 treatment sessions. Perfusion maps showed significant perfusion reductions for tumors (P < .013) but not for adjacent nontumorous liver tissue (P = .21). For tumors, the mean perfusion value was 193 arbitrary units (AU) +/- 223 (standard deviation) before TACE and 45.3 AU +/- 91.9 after TACE, with a mean reduction in baseline perfusion of 74.6% +/- 24.8. For adjacent liver tissue, the mean perfusion value was 124 AU +/- 93.5 before TACE and 93.2 AU +/- 72.3 after TACE, with a mean reduction in baseline perfusion of 24.2% +/- 14.5. CONCLUSION TRIP MR imaging can be used to detect intraprocedural changes in perfusion to HCC and surrounding liver parenchyma during MR-IR-monitored TACE.
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Affiliation(s)
- Andrew C Larson
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 448 E Ontario St, Suite 700, Chicago, IL 60611, USA
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30
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Kulik LM, Carr BI, Mulcahy MF, Lewandowski RJ, Atassi B, Ryu RK, Sato KT, Benson A, Nemcek AA, Gates VL, Abecassis M, Omary RA, Salem R. Safety and efficacy of 90Y radiotherapy for hepatocellular carcinoma with and without portal vein thrombosis. Hepatology 2008; 47:71-81. [PMID: 18027884 DOI: 10.1002/hep.21980] [Citation(s) in RCA: 434] [Impact Index Per Article: 27.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
UNLABELLED This study was undertaken to present data from a phase 2 study in which patients with unresectable hepatocellular carcinoma (HCC) with and without portal vein thrombosis underwent radioembolization with Yttrium ((90)Y) microspheres. Patients treated were stratified by Okuda, Child-Pugh, baseline bilirubin, tumor burden, Eastern Cooperative Oncology Group (ECOG), presence of cirrhosis and portal vein thrombosis (PVT) (none, branch, and main). Clinical and biochemical data were obtained at baseline and at 4-week intervals following treatment for up to 6 months. Tumor response was obtained using computed tomography (CT). Patients were followed for survival. One hundred eight patients were treated during the study period. Thirty-seven (34%) patients had PVT, 12 (32%) of which involved the main PV. The cumulative dose for those with and without PVT was 139.7 Gy and 131.9 Gy, respectively. The partial response rate using world Health Organization (WHO) criteria was 42.2%. Using European Association for the Study of the Liver (EASL), the response rate was 70%. Kaplan-Meier survival varied depending on location of PVT and presence of cirrhosis. The adverse event (AE) rates were highest in patients with main PVT and cirrhosis. There were no cases of radiation pneumonitis. CONCLUSION The use of minimally embolic (90)Y glass microspheres to treat patients with HCC complicated by branch/lobar PVT may be clinically indicated and appears to have a favorable toxicity profile. Further investigation is warranted in patients with main PVT.
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Affiliation(s)
- Laura M Kulik
- Department of Hepatology, Northwestern University, Chicago, IL, USA
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Abstract
The incidence of hepatocellular carcinoma (HCC) is predicted to continue to increase over the next 30 years. Surgical intervention, including resection and orthotopic liver transplantation (OLT) is offered to a limited number of patients. Novel approaches to the treatment of patients with HCC are needed. This article aims to review emerging approaches in the care of the HCC patient including systemic treatment, selection of appropriate candidates for OLT, improved imaging to follow treatment response, and management pre-OLT and post-OLT.
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Affiliation(s)
- Laura M Kulik
- Division of Hepatology, Departments of Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA.
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32
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Rhee TK, Young JY, Larson AC, Haines GK, Sato KT, Salem R, Mulcahy MF, Kulik LM, Paunesku T, Woloschak GE, Omary RA. Effect of transcatheter arterial embolization on levels of hypoxia-inducible factor-1alpha in rabbit VX2 liver tumors. J Vasc Interv Radiol 2007; 18:639-45. [PMID: 17494846 DOI: 10.1016/j.jvir.2007.02.031] [Citation(s) in RCA: 58] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
PURPOSE To test the hypothesis that transcatheter arterial embolization (TAE) of VX2 rabbit liver tumors increases the expression of hypoxia-inducible factor-1alpha (HIF-1alpha), a transcription factor that regulates the expression of pro-angiogenic genes. MATERIALS AND METHODS VX2 tumors were implanted in the livers of eight New Zealand white rabbits. Once tumor growth was seen at T2-weighted turbo spin-echo magnetic resonance (MR) imaging, four of the eight rabbits underwent TAE with 45-150-mum polyvinyl alcohol particles. The remaining four rabbits served as non-TAE controls. The TAE end point was stasis of antegrade blood flow. All rabbits were sacrificed for tumor harvest 2 hours after TAE. Tumor tissue and corresponding normal liver tissue in each rabbit liver were stained with anti-human HIF-1alpha monoclonal antibody and reviewed with light microscopy. Percentages of stained viable tumor and normal liver cells were compared by using the Mann-Whitney U test (alpha=0.05). RESULTS In eight rabbits with 24 discrete liver tumors, the mean percentage (+/-standard deviation) of positive HIF-1alpha-stained cells in the TAE group was greater than that in the control group (19%+/-7.0 vs 12%+/-8.0, respectively) (P=.05). Normal liver tissue in both the TAE and control groups showed no HIF-1alpha staining. CONCLUSION Although HIF-1alpha is not expressed in normal rabbit liver parenchyma-even after TAE-HIF-1alpha expression is present in implanted VX2 rabbit liver tumors and significantly increased in lesions that have undergone embolization.
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Affiliation(s)
- Thomas K Rhee
- Department of Radiology, Northwestern University Feinberg School of Medicine, 448 E Ontario St, Ste 700, Chicago, IL 60611, USA
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Abstract
PURPOSE OF REVIEW This review primarily focuses on new developments in the prevention and treatment of hepatocellular carcinoma. RECENT FINDINGS Molecular markers for tumor biology are still in development, but advances thus far are promising. The Barcelona Clinic Liver Cancer (BCLC) staging system offers the best prognostic information in patients with hepatocellular carcinoma. While surgery remains the gold standard for the treatment of hepatocellular carcinoma, new methods are emerging with greater potential response, lower risk and lower cost. Percutaneous local ablative therapy has proved very effective. Chemoemobolization therapy in hepatocellular carcinoma has been effective in selected patients with improved survival reported in a large cohort. SUMMARY New methods for the management of hepatocellular carcinoma need to continue to evolve. This includes more focused therapies to reduce tumor development or more effective adjuvants to promote positive pre and posttransplant response. With the advent of better treatment options due to a clearer understanding of the pathogenesis of hepatocellular carcinoma, there is hope that the seemingly insurmountable burden of this disease will come under better control.
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Affiliation(s)
- Laura M Kulik
- Division of Hepatology, Northwestern University, Feinberg School of Medicine, Chicago, Illinois 60611, USA.
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Terrault NA, Shiffman ML, Lok ASF, Saab S, Tong L, Brown RS, Everson GT, Reddy KR, Fair JH, Kulik LM, Pruett TL, Seeff LB. Outcomes in hepatitis C virus-infected recipients of living donor vs. deceased donor liver transplantation. Liver Transpl 2007; 13:122-9. [PMID: 17192908 PMCID: PMC3155862 DOI: 10.1002/lt.20995] [Citation(s) in RCA: 99] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
In this retrospective study of hepatitis C virus (HCV)-infected transplant recipients in the 9-center Adult to Adult Living Donor Liver Transplantation Cohort Study, graft and patient survival and the development of advanced fibrosis were compared among 181 living donor liver transplant (LDLT) recipients and 94 deceased donor liver transplant (DDLT) recipients. Overall 3-year graft and patient survival were 68% and 74% in LDLT, and 80% and 82% in DDLT, respectively. Graft survival, but not patient survival, was significantly lower for LDLT compared to DDLT (P = 0.04 and P = 0.20, respectively). Further analyses demonstrated lower graft and patient survival among the first 20 LDLT cases at each center (LDLT <or=20) compared to later cases (LDLT > 20; P = 0.002 and P = 0.002, respectively) and DDLT recipients (P < 0.001 and P = 0.008, respectively). Graft and patient survival in LDLT >20 and DDLT were not significantly different (P = 0.66 and P = 0.74, respectively). Overall, 3-year graft survival for DDLT, LDLT >20, and LDLT <or=20 were 80%, 79% and 55%, with similar results conditional on survival to 90 days (84%, 87% and 68%, respectively). Predictors of graft loss beyond 90 days included LDLT <or=20 vs. DDLT (hazard ratio [HR] = 2.1, P = 0.04), pretransplant hepatocellular carcinoma (HCC) (HR = 2.21, P = 0.03) and model for end-stage liver disease (MELD) at transplantation (HR = 1.24, P = 0.04). In conclusion, 3-year graft and patient survival in HCV-infected recipients of DDLT and LDLT >20 were not significantly different. Important predictors of graft loss in HCV-infected patients were limited LDLT experience, pretransplant HCC, and higher MELD at transplantation.
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Affiliation(s)
- Norah A Terrault
- Department of Medicine, Division of Gastroenterology, University of California at San Francisco, San Francisco, CA, USA
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Kulik LM. Can therapy of hepatitis C affect the development of hepatocellular carcinoma? J Natl Compr Canc Netw 2006; 4:751-7. [PMID: 16948953 DOI: 10.6004/jnccn.2006.0065] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2006] [Accepted: 05/03/2006] [Indexed: 11/17/2022]
Abstract
Chronic inflammation induced by viral infections and their role in carcinogenesis is well recognized. Two hepatotropic viruses, hepatitis B and hepatitis C (HCV), have been linked worldwide to the development of hepatocellular carcinoma (HCC). Although orthotopic liver transplant offers the best chance for cure and long-term survival, the demand for organs far outweighs the supply. The incidence of HCC in the United States has increased over the past 3 decades. HCV-induced cirrhosis is believed to play a significant role in the rising rate of HCC. Therefore, primary measures to prevent HCC in HCV-infected patients are urgently needed. Numerous studies of the HCV HCC patient have considered primary treatment with interferon-based therapy. However, secondary prevention currently seems to carry more promise. This article evaluates and assesses various treatments for primary and secondary chemoprevention in the setting of HCV.
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Affiliation(s)
- Laura M Kulik
- Feinberg School of Medicine, Northwestern University, Chicago, Illinois, 60611, USA.
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Kulik LM, Atassi B, van Holsbeeck L, Souman T, Lewandowski RJ, Mulcahy MF, Hunter RD, Nemcek AA, Abecassis MM, Haines KG, Salem R. Yttrium-90 microspheres (TheraSphere) treatment of unresectable hepatocellular carcinoma: downstaging to resection, RFA and bridge to transplantation. J Surg Oncol 2006; 94:572-86. [PMID: 17048240 DOI: 10.1002/jso.20609] [Citation(s) in RCA: 236] [Impact Index Per Article: 13.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
PURPOSE To present the clinical data of 35 patients with T3 unresectable hepatocellular carcinoma (HCC) that were treated with (90)Y with the specific intent of downstaging to resection, radiofrequency ablation (RFA) candidate, United Network for Organ Sharing (UNOS) stage T2 or liver transplantation. MATERIALS AND METHODS One hundred fifty patients with unresectable HCC were treated with (90)Y microspheres. Of these, 35 patients were UNOS stage T3 at the time of treatment. Patients were followed for clinical toxicities, alterations in model for end-stage-liver disease (MELD) score, tumor response, downstaging to RFA, resection, transplantation, and survival. RESULTS Nineteen of 34 patients (56%) were successfully downstaged from T3 to T2 following treatment. 11 of 34 (32%) patients treated were downstaged to target lesions measuring 3.0 cm or less. Twenty-three of 35 (66%) were downstaged to either T2 status, lesion < 3.0 cm (RFA candidate), or resection. Seventeen of 34 (50%) had an objective tumor response by WHO criteria. Eight patients (23%) were successfully downstaged and underwent OLT following treatment. 1, 2, and 3-year survival was 84%, 54%, and 27%, respectively. Median survival by Kaplan-Meier analysis for the entire cohort was 800 days. CONCLUSION These data suggest that intra-arterial (90)Y microspheres can be used as a bridge to transplantation, surgical resection, or RFA.
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Affiliation(s)
- Laura M Kulik
- Division of Hepatology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Chicago, Illinois, USA
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Deng J, Miller FH, Rhee TK, Sato KT, Mulcahy MF, Kulik LM, Salem R, Omary RA, Larson AC. Diffusion-weighted MR imaging for determination of hepatocellular carcinoma response to yttrium-90 radioembolization. J Vasc Interv Radiol 2006; 17:1195-200. [PMID: 16868174 DOI: 10.1097/01.rvi.0000227234.81718.eb] [Citation(s) in RCA: 97] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
Abstract
Early detection of the response of hepatocellular carcinoma (HCC) to yttrium-90 radioembolization therapy may be important to permit repeat radioembolization or alternative treatment options. Water-mobility measurements with use of diffusion-weighted (DW) magnetic resonance (MR) imaging are useful for noninvasive interrogation of microstructural tissue properties. Findings of DW MR imaging may serve as an early biomarker of HCC response. This study tested the hypothesis that DW MR imaging can detect changes in tumor tissue water diffusion in response to (90)Y therapy. In each of six patients with HCC included in the study, tumor water diffusion increased significantly after therapy. DW MR imaging is a promising technique for noninvasive assessment of tumor response to (90)Y radioembolization.
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Affiliation(s)
- Jie Deng
- Department of Radiology, Feinberg School of Medicine, Northwestern University, 448 East Ontario, Suite 700, Chicago, IL 60611, USA
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Kulik LM, Mulcahy MF, Hunter RD, Nemcek AA, Abecassis MM, Salem R. Use of yttrium-90 microspheres (TheraSphere) in a patient with unresectable hepatocellular carcinoma leading to liver transplantation: a case report. Liver Transpl 2005; 11:1127-31. [PMID: 16123954 DOI: 10.1002/lt.20514] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.6] [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] [Indexed: 01/12/2023]
Abstract
Prior to therapy, model for end stage liver disease (MELD) scoring, diagnostic imaging and tumor staging were performed in a patient with T3 HCC. The patient received an orthotopic liver transplant (OLT) 42 days after treatment. The explant specimen showed complete necrosis of the target tumor. Follow-up of this patient has demonstrated no evidence of recurrence. There was no life threatening or fatal adverse experiences related to treatment. This case report documents the natural course, history and outcome of a patient treated with yttrium-90 for unresectable HCC. The patient was downstaged from T3 to T2 and was subsequently transplanted.
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Affiliation(s)
- Laura M Kulik
- Department of Hepatology, Robert H. Lurie Comprehensive Cancer Center, Northwestern Memorial Hospital, Chicago, IL 60611, USA
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