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Wang D, Li X, Jin JL, Hu YL, Wang C. [Analysis of severe liver injury in a patient treated with oxaliplatin, capecitabine, and a PD-1 inhibitor: a case report]. Zhonghua Gan Zang Bing Za Zhi 2023; 31:1329-1331. [PMID: 38253079 DOI: 10.3760/cma.j.cn501113-20220216-00068] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/30/2023]
Affiliation(s)
- D Wang
- Department of Hepatology, Center of Infectious Diseases and Pathogen Biology, the First Hospital of Jilin University, Changchun 130021, China
| | - X Li
- Department of Hepatology, Center of Infectious Diseases and Pathogen Biology, the First Hospital of Jilin University, Changchun 130021, China
| | - J L Jin
- Department of Hepatology, Center of Infectious Diseases and Pathogen Biology, the First Hospital of Jilin University, Changchun 130021, China
| | - Y L Hu
- Department of Hepatology, Center of Infectious Diseases and Pathogen Biology, the First Hospital of Jilin University, Changchun 130021, China
| | - C Wang
- Department of Hepatology, Center of Infectious Diseases and Pathogen Biology, the First Hospital of Jilin University, Changchun 130021, China
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Alouani E, Laparra A, Perret A, Sakkal M, Messayke S, Danlos FX, Ouali K, Hollebecque A, Even C, Ammari S, Baldini C, Champiat S, Besse B, Robert C, Guettier C, Samuel D, Lambotte O, De Martin E, Michot JM. Immunosuppressant mycophenolate mofetil for patients with steroid-refractory immune-related hepatitis induced by checkpoint inhibitors in oncology. Eur J Cancer 2023; 193:113313. [PMID: 37748398 DOI: 10.1016/j.ejca.2023.113313] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/25/2023] [Revised: 08/11/2023] [Accepted: 08/22/2023] [Indexed: 09/27/2023]
Abstract
BACKGROUND Immune-checkpoint inhibitor (ICI) hepatitis, which does not improve with steroids and requires additional immunosuppressant, is defined as steroid-refractory ICI hepatitis. The outcome of patients with steroid-refractory ICI hepatitis remains poorly determined. Herein, we investigated the incidence, clinical features, and outcome of patients treated with second-line immunosuppressant for steroid-refractory ICI hepatitis. METHODS This is a retrospective analysis of patients who presented ICI hepatitis from 1st June 2016 to 30th September 2022. Steroid-refractory ICI hepatitis was defined as no clinical and biological improvement after systemic steroid therapy ≥1 mg/kg/d. Main objectives were to assess the frequency and risk factors associated with steroid-refractory ICI hepatitis and to evaluate the efficacy of second-line immunosuppressants. RESULTS In total, 130 patients with grade ≥3 ICI hepatitis were screened, of them 60 (46.2%) were treated with systemic steroids. In total, 11/130 (8.5%) had steroid-refractory hepatitis. Statistically significant factors associated with steroid-refractory hepatitis included previous liver comorbidities (54.5% versus 11.6%; p < 0.01), hyperbilirubinemia (p < 0.001), and general symptoms (fever, jaundice, ascites, and/or encephalopathy) associated with hepatitis (72.7% versus 30.8%; p = 0.015). The 11 patients with steroid-refractory hepatitis were treated with mycophenolate mofetil. In total, resolution or return to grade ≤1 for hepatitis was observed in 81.8% (9/11) of patients. CONCLUSIONS Steroid-refractory ICI hepatitis accounted for 8.5% of patients with grade ≥3 immune-related hepatitis and was statistically associated with previous liver comorbidities, hyperbilirubinemia, and general symptoms. Mycophenolate mofetil was a suitable option of therapy for steroid-refractory ICI hepatitis.
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Affiliation(s)
- Emily Alouani
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France; Digestive Medical Oncology Department, IUCT-Rangueil, Toulouse Hospital University, Toulouse, France
| | - Ariane Laparra
- Département Interdisciplinaire d'Organisation des Parcours Patients, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Audrey Perret
- Département Interdisciplinaire d'Organisation des Parcours Patients, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Madonna Sakkal
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Sabine Messayke
- Pharmacovigilance Unit, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Francois-Xavier Danlos
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France; INSERM U1015 and CIC1428 BIOTHERIS, Gustave Roussy, Villejuif, France
| | - Kaissa Ouali
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Antoine Hollebecque
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Caroline Even
- Department of Medical Oncology, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Samy Ammari
- ELSAN Department of Radiology, Institut de Cancérologie Paris Nord, Sarcelles, France; Department of Radiology, Gustave Roussy Cancer Campus, Biomaps, UMR1281 INSERM, CEA, CNRS, Université Paris-Saclay, Villejuif, France
| | - Capucine Baldini
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Stéphane Champiat
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Benjamin Besse
- Department of Medical Oncology, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Caroline Robert
- Department of Medical Oncology, Gustave Roussy - Paris-Saclay University, Villejuif, France
| | - Catherine Guettier
- Department of Pathology, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, Paris-Saclay University, UMR-S 1193, Le Kremlin Bicêtre, France
| | - Didier Samuel
- Department of Hepatology, Paul-Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Centre Hépato-Biliaire, INSERM 1193, Villejuif, France
| | - Olivier Lambotte
- Internal Médecine Department, Bicêtre Hospital, Assistance Publique - Hôpitaux de Paris, Paris-Saclay University, Le Kremlin-Bicêtre, France; IDMIT Department, IBFJ, Centre Immunology of Viral Infections and Autoimmune Diseases, INSERM, CEA, Université Paris Saclay, Le Kremlin Bicêtre, France
| | - Eleonora De Martin
- Department of Hepatology, Paul-Brousse Hospital, Assistance Publique - Hôpitaux de Paris, Centre Hépato-Biliaire, INSERM 1193, Villejuif, France
| | - Jean-Marie Michot
- Département d'Innovation Thérapeutique et Essais Précoces, Gustave Roussy - Paris-Saclay University, Villejuif, France; INSERM U1170, Université Paris-Saclay, Gustave Roussy, Villejuif, France.
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Abstract
Various vaccines against severe acute respiratory syndrome coronavirus 2 have been developed in response to the coronavirus disease 2019 (COVID-19) global pandemic, several of which are highly effective in preventing COVID-19 in the general population. Patients with chronic liver diseases (CLDs), particularly those with liver cirrhosis, are considered to be at a high risk for severe COVID-19 and death. Given the increased rates of disease severity and mortality in patients with liver disease, there is an urgent need to understand the efficacy of vaccination in this population. However, the data regarding efficacy and safety of COVID-19 vaccination in patients with CLDs is limited. Indeed, several organ-specific or systemic immune-mediated side effects following COVID-19 vaccination, including liver injury similar to autoimmune hepatitis, have been recently reported. Although the number of cases of vaccine-related liver injury is increasing, its frequency, clinical course, and mechanism remain unclear. Here, we review the current findings on COVID-19 vaccination and liver disease, focusing on: (1) The impact of COVID-19 in patients with CLD; (2) The efficacy, safety, and risk-benefit profiles of COVID-19 vaccines in patients with CLD; and (3) Liver injury following COVID-19 vaccination.
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Affiliation(s)
- Sotaro Ozaka
- Department of Gastroenterology, Faculty of Medicine, Oita University, Yufu 879-5593, Oita, Japan
- Department of Infectious Disease Control, Faculty of Medicine, Oita University, Yufu 879-5593, Oita, Japan
| | - Takashi Kobayashi
- Department of Infectious Disease Control, Faculty of Medicine, Oita University, Yufu 879-5593, Oita, Japan
| | - Kazuhiro Mizukami
- Department of Gastroenterology, Faculty of Medicine, Oita University, Yufu 879-5593, Oita, Japan
| | - Kazunari Murakami
- Department of Gastroenterology, Faculty of Medicine, Oita University, Yufu 879-5593, Oita, Japan
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Gauci ML, Baroudjian B, Bédérède U, Zeboulon C, Delyon J, Allayous C, Madelaine I, Eftekhari P, Resche-Rigon M, Poté N, Paradis V, Durand F, Lebbé C, Roux O, Bouattour M. Severe immune-related hepatitis induced by immune checkpoint inhibitors: Clinical features and management proposal. Clin Res Hepatol Gastroenterol 2021; 45:101491. [PMID: 32773362 DOI: 10.1016/j.clinre.2020.06.016] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [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: 04/25/2020] [Revised: 06/12/2020] [Accepted: 06/22/2020] [Indexed: 02/04/2023]
Abstract
BACKGROUND Immune-related hepatitis (IRH) occurs in 1 to 18% of immune checkpoint inhibitor (ICI)-treated patients. Steroids are usually recommended for grade≥3 IRH, but their impact on IRH resolution and patient survival remains unclear. METHODS We retrospectively analyzed a prospective cohort of 339 patients treated at Saint-Louis Hospital (Paris, France) with ICIs for advanced melanoma. Cases of grade≥3 IRH were collected and analyzed. Two groups were compared for their biological features and time for IRH resolution and survival: patients who received steroids (steroids group: SG) and patients who did not (nonsteroids group: NSG). FINDINGS Grade≥3 IRH was observed in 21 patients. Thirteen were treated with steroids (SG), and 8 were not (NSG). The median time for toxicity resolution was 49 days in SG and 24 days in NSG (P=0.62). All but one patient showed a favorable outcome. Two-year survival was 56% in SG and 54% in NSG (P=0.83). Higher transaminase (P=0.002) and bilirubin (P=0.008) and lower prothrombin (P=0.035) levels were observed in SG than in NSG. For 8 (4 SG/4 NSG) patients, ICI was resumed without any hepatitis relapse. INTERPRETATION Favorable outcomes may be achieved spontaneously and with no steroids in patients with severe IRH. Steroid initiation should be discussed in cases of high bilirubin levels and decreased prothrombin levels. ICI could be resumed without hepatitis relapse. We propose a management algorithm for grade≥3 IRH that should be validated in larger and prospective cohorts.
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Affiliation(s)
- Marie-Léa Gauci
- AP-HP, Département de Dermatologie, Hôpital Saint-Louis, Paris, France; INSERM U976, Paris, France; Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Barouyr Baroudjian
- AP-HP, Département de Dermatologie, Hôpital Saint-Louis, Paris, France; INSERM U976, Paris, France; Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Ulysse Bédérède
- Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France; AP-HP, Service de Biostatistiques, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Hôpital Saint-Louis, Paris, France
| | - Charlotte Zeboulon
- AP-HP, Département de Dermatologie, Hôpital Saint-Louis, Paris, France; INSERM U976, Paris, France; Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Julie Delyon
- AP-HP, Département de Dermatologie, Hôpital Saint-Louis, Paris, France; INSERM U976, Paris, France; Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Clara Allayous
- AP-HP, Département de Dermatologie, Hôpital Saint-Louis, Paris, France; INSERM U976, Paris, France; Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Isabelle Madelaine
- Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France; AP-HP, Service de Pharmacologie,Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Hôpital Saint-Louis, Paris, France
| | - Pirayeh Eftekhari
- Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France; AP-HP, Centre Régional de Pharmacovigilance, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Fernand Widal Hospital Paris, Paris, France
| | - Matthieu Resche-Rigon
- Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France; AP-HP, Service de Biostatistiques, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Hôpital Saint-Louis, Paris, France
| | - Nicolas Poté
- Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France; AP-HP, Département d'Anatomopathologie, Hôpital Beaujon Clichy, Clichy, France; INSERM UMR 1149, Paris, France
| | - Valerie Paradis
- Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France; AP-HP, Département d'Anatomopathologie, Hôpital Beaujon Clichy, Clichy, France; INSERM UMR 1149, Paris, France
| | - François Durand
- Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France; INSERM UMR 1149, Paris, France; AP-HP, Service d'Hépatologie et Réanimation Hépatique, Pôle des maladies de l'appareil digestif, Hôpital Beaujon, Clichy, France
| | - Céleste Lebbé
- AP-HP, Département de Dermatologie, Hôpital Saint-Louis, Paris, France; INSERM U976, Paris, France; Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France
| | - Olivier Roux
- Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France; AP-HP, Service d'Hépatologie et Réanimation Hépatique, Pôle des maladies de l'appareil digestif, Hôpital Beaujon, Clichy, France
| | - Mohamed Bouattour
- AP-HP, Département d'Oncologie Digestive, Pôle des maladies de l'appareil digestif, Hôpital Beaujon, Clichy, France.
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- AP-HP, Département de Dermatologie, Hôpital Saint-Louis, Paris, France; INSERM U976, Paris, France; Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Paris, France; AP-HP, Service de Biostatistiques, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Hôpital Saint-Louis, Paris, France; AP-HP, Centre Régional de Pharmacovigilance, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, Fernand Widal Hospital Paris, Paris, France; AP-HP, Département d'Anatomopathologie, Hôpital Beaujon Clichy, Clichy, France; INSERM UMR 1149, Paris, France; AP-HP, Service d'Hépatologie et Réanimation Hépatique, Pôle des maladies de l'appareil digestif, Hôpital Beaujon, Clichy, France; AP-HP, Département d'Oncologie Digestive, Pôle des maladies de l'appareil digestif, Hôpital Beaujon, Clichy, France
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Rizell M, Åberg F, Perman M, Ny L, Stén L, Hashimi F, Svanvik J, Lindnér P. Checkpoint Inhibition Causing Complete Remission of Metastatic Combined Hepatocellular-Cholangiocarcinoma after Hepatic Resection. Case Rep Oncol 2020; 13:478-484. [PMID: 32508620 PMCID: PMC7250374 DOI: 10.1159/000507320] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2020] [Accepted: 03/17/2020] [Indexed: 12/14/2022] Open
Abstract
Combined hepatocellular-cholangiocarcinoma (CHC) is a rare type of primary liver cancer, speculated to arise from hepatic progenitor cells, and with a worse prognosis than hepatocellular carcinoma (HCC). Serum alpha-fetoprotein (AFP) levels may be one prognostic factor. It has been suggested that checkpoint inhibition might be useful in the treatment of HCC where there is an increased expression of PD-1 and PD-L1 in the microenvironment. Its effect on CHC is unknown. We report a case with a large CHC, which was radically resected, but the 53-year-old female patient subsequently developed pulmonary metastases. Histology demonstrated low-differentiated CHC without microsatellite instability. Treatment with sorafenib was started but was stopped due to angioedema. Under subsequent gemcitabine/cisplatin treatment, the metastatic disease progressed with rising AFP levels. A third-line treatment with pembrolizumab was then started, 2 mg/kg b.w. i.v. every third week for 6 months. This resulted in a radiologically complete remission of the pulmonary metastases and AFP levels were normalized (<10 μg/L) from a level of 1,790 μg/L before treatment. The patient developed immune-related adverse events (AEs) including diarrhea and hepatitis. These AEs were successfully treated with prednisolone and mycophenolate mofetil, and they were eventually resolved. There are no signs of cancer recurrence neither in the liver nor in the lungs at 33 months after the start of the checkpoint inhibition treatment, and the patient is doing well. Further study is urgently needed on the role of checkpoint inhibition therapy in liver cancer.
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Affiliation(s)
- Magnus Rizell
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Fredrik Åberg
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Mats Perman
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Lars Ny
- Department of Oncology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Liselotte Stén
- Department of Pathology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Farida Hashimi
- Department of Radiology, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Joar Svanvik
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
| | - Per Lindnér
- Transplant Institute, Sahlgrenska University Hospital, Gothenburg, Sweden
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Romanski NA, Holmstroem RB, Ellebaek E, Svane IM. Characterization of risk factors and efficacy of medical management of immune-related hepatotoxicity in real-world patients with metastatic melanoma treated with immune checkpoint inhibitors. Eur J Cancer 2020; 130:211-218. [PMID: 32229418 DOI: 10.1016/j.ejca.2020.02.041] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/27/2019] [Revised: 02/01/2020] [Accepted: 02/13/2020] [Indexed: 12/31/2022]
Abstract
INTRODUCTION Immune-related hepatitis (ir-hepatitis) is a common side-effect of checkpoint inhibitors (CPIs). Here, we characterise ir-hepatitis in a large cohort of patients with metastatic melanoma (MM) treated with CPIs and describe potential risk factors and efficacy of medical management. METHODS The retrospective study included a large cohort of patients with MM treated with CPIs between 2010 and 2019. Patients were retrieved from the national Danish Metastatic Melanoma Database. RESULTS Five hundred twenty one patients were included. Ir-hepatitis was found in 6.8% of patients. Combination therapy was associated with a significantly greater risk than monotherapy. Of all patients, 34.9% with hepatitis had a different hepatitis grading, when based on either alanine transaminase (ALT) or aspartate transaminase (AST) levels. Of all patients, 72.1% with hepatitis received steroid treatment, and two patients received additional second-line immunosuppressants. Of all patients, 35.5% experienced hepatitis relapse during steroid tapering. Of all patients, 18.6% and 25% of patients with grade ≥2 and ≥ III3, respectively, developed hepatitis within 7 days after finishing an antibiotic treatment for infection. Patients (62.5%) who received a cumulative dose of >4000 mg steroid experienced cancer progression, compared with 22.7% of patients treated with <4000 mg. CONCLUSION Several observations of clinical importance were made. Infection and antibiotic treatment during CPIs could be a possible risk factor for developing ir-hepatitis. Severity of ir-hepatitis is potentially underestimated in a significant number of patients, if only one liver enzyme is measured. The role of second-line immunosuppressants needs to be further investigated because of the high risk of hepatitis relapse during steroid tapering and the potential negative impact of cumulative steroid dose on response to CPIs.
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Affiliation(s)
- Nicole A Romanski
- Department of Oncology, Copenhagen University Hospital, Herlev, Denmark.
| | | | - Eva Ellebaek
- Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
| | - Inge Marie Svane
- National Center for Cancer Immune Therapy, Department of Oncology, Copenhagen University Hospital, Herlev, Denmark
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Gauci ML, Baroudjian B, Zeboulon C, Pages C, Poté N, Roux O, Bouattour M, Lebbé C. Immune-related hepatitis with immunotherapy: Are corticosteroids always needed? J Hepatol 2018; 69:548-550. [PMID: 29747956 DOI: 10.1016/j.jhep.2018.03.034] [Citation(s) in RCA: 60] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/09/2018] [Revised: 03/22/2018] [Accepted: 03/26/2018] [Indexed: 12/13/2022]
Affiliation(s)
- Marie-Léa Gauci
- AP-HP, Département de Dermatologie Hôpital Saint-Louis, Paris, France; INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, France
| | - Barouyr Baroudjian
- AP-HP, Département de Dermatologie Hôpital Saint-Louis, Paris, France; INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, France
| | - Charlotte Zeboulon
- AP-HP, Département de Dermatologie Hôpital Saint-Louis, Paris, France; INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, France
| | - Cécile Pages
- AP-HP, Département de Dermatologie Hôpital Saint-Louis, Paris, France; INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, France
| | - Nicolas Poté
- AP-HP, Département d'Anatomopathologie, Hôpital Beaujon Clichy, France; INSERM UMR 1149, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, France
| | - Olivier Roux
- AP-HP, Département d'Hépatologie et Réanimation Hépatique, Hôpital Beaujon, Clichy, France
| | - Mohamed Bouattour
- AP-HP, Département d'Oncologie Digestive, Hôpital, Beaujon Clichy, France.
| | - Céleste Lebbé
- AP-HP, Département de Dermatologie Hôpital Saint-Louis, Paris, France; INSERM U976, Université Paris Diderot-Paris VII, Sorbonne Paris Cité, France
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