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Nardelli S, Riggio O, Marra F, Gioia S, Saltini D, Bellafante D, Adotti V, Guasconi T, Ridola L, Rosi M, Caporali C, Fanelli F, Roccarina D, Bianchini M, Indulti F, Spagnoli A, Merli M, Vizzutti F, Schepis F. Episodic overt hepatic encephalopathy after transjugular intrahepatic portosystemic shunt does not increase mortality in patients with cirrhosis. J Hepatol 2024; 80:596-602. [PMID: 38097113 DOI: 10.1016/j.jhep.2023.11.033] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/04/2023] [Revised: 11/30/2023] [Accepted: 11/30/2023] [Indexed: 01/09/2024]
Abstract
BACKGROUND & AIMS Overt hepatic encephalopathy (OHE) is a major complication of transjugular intrahepatic portosystemic shunt (TIPS) placement, given its high incidence and possibility of refractoriness to medical treatment. Nevertheless, the impact of post-TIPS OHE on mortality has not been investigated in a large population. METHODS We designed a multicenter, non-inferiority, observational study to evaluate the mortality rate at 30 months in patients with and without OHE after TIPS. We analyzed a database of 614 patients who underwent TIPS in three Italian centers and estimated the cumulative incidence of OHE and mortality with competitive risk analyses, setting the non-inferiority limit at 0.12. RESULTS During a median follow-up of 30 months (IQR 12-30), 293 patients developed at least one episode of OHE. Twenty-seven (9.2%) of them experienced recurrent/persistent OHE. Patients with OHE were older (64 [57-71] vs. 59 [50-67] years, p <0.001), had lower albumin (3.1 [2.8-3.5] vs. 3.25 [2.9-3.6] g/dl, p = 0.023), and had a higher prevalence of pre-TIPS OHE (15.4% vs. 9.0%, p = 0.023). Child-Pugh and MELD scores were similar. The 30-month difference in mortality between patients with and without post-TIPS OHE was 0.03 (95% CI -0.042 to 0.102). Multivariable analysis showed that age (subdistribution hazard ratio 1.04, 95% CI 1.02-1.05, p <0.001) and MELD score (subdistribution hazard ratio 1.09, 95% CI 1.05-1.13, p <0.001), but not post-TIPS OHE, were associated with a higher mortality rate. Similar results were obtained when patients undergoing TIPS for variceal re-bleeding prophylaxis (n = 356) or refractory ascites (n = 258) were analyzed separately. The proportion of patients with persistent OHE after TIPS was significantly higher in the group of patients who died. The robustness of these results was increased following propensity score matching. CONCLUSION Episodic OHE after TIPS is not associated with mortality in patients undergoing TIPS, regardless of the indication. IMPACT AND IMPLICATIONS Overt hepatic encephalopathy (OHE) is a common complication in patients with advanced liver disease and it is particularly frequent following transjugular intrahepatic portosystemic shunt (TIPS) placement. In patients with cirrhosis outside the setting of TIPS, the development of OHE negatively impacts survival, regardless of the severity of cirrhosis or the presence of acute-on-chronic liver failure. In this multicenter, non-inferiority, observational study we demonstrated that post-TIPS OHE does not increase the risk of mortality in patients undergoing TIPS, irrespective of the indication. This finding alleviates concerns regarding the weight of this complication after TIPS. Intensive research to improve patient selection and risk stratification remains crucial to enhance the quality of life of patients and caregivers and to avoid undermining the positive effects of TIPS on survival.
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Affiliation(s)
- Silvia Nardelli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy.
| | - Oliviero Riggio
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Stefania Gioia
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Dario Saltini
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Daniele Bellafante
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Valentina Adotti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Tomas Guasconi
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Lorenzo Ridola
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Martina Rosi
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Cristian Caporali
- Department of Radiology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Fabrizio Fanelli
- Interventional Radiology Unit, Azienda Ospedaliero-Universitaria Careggi, Florence, Italy
| | - Davide Roccarina
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Marcello Bianchini
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Federica Indulti
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandra Spagnoli
- Department of Public Health and Infectious Diseases, Sapienza University of Rome, Italy
| | - Manuela Merli
- Department of Translational and Precision Medicine, Sapienza University of Rome, Italy
| | - Francesco Vizzutti
- Department of Experimental and Clinical Medicine, University of Florence, Italy
| | - Filippo Schepis
- Division of Gastroenterology, Modena Hospital, University of Modena and Reggio Emilia, Modena, Italy
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Saltini D, Indulti F, Guasconi T, Bianchini M, Cuffari B, Caporali C, Casari F, Prampolini F, Senzolo M, Colecchia A, Schepis F. Transjugular Intrahepatic Portosystemic Shunt: Devices Evolution, Technical Tips and Future Perspectives. J Clin Med 2023; 12:6758. [PMID: 37959225 PMCID: PMC10650044 DOI: 10.3390/jcm12216758] [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: 09/30/2023] [Revised: 10/18/2023] [Accepted: 10/20/2023] [Indexed: 11/15/2023] Open
Abstract
Portal hypertension (PH) constitutes a pivotal factor in the progression of cirrhosis, giving rise to severe complications and a diminished survival rate. The transjugular intrahepatic portosystemic shunt (TIPS) procedure has undergone significant evolution, with advancements in stent technology assuming a central role in managing PH-related complications. This review aims to outline the progression of TIPS and emphasizes the significant influence of stent advancement on its effectiveness. Initially, the use of bare metal stents (BMSs) was limited due to frequent dysfunction. However, the advent of expanding polytetrafluoroethylene-covered stent grafts (ePTFE-SGs) heralded a transformative era, greatly enhancing patency rates. Further innovation culminated in the creation of ePTFE-SGs with controlled expansion, enabling precise adjustment of TIPS diameters. Comparative analyses demonstrated the superiority of ePTFE-SGs over BMSs, resulting in improved patency, fewer complications, and higher survival rates. Additional technical findings highlight the importance of central stent placement and adequate stent length, as well as the use of smaller calibers to reduce the risk of shunt-related complications. However, improving TIPS through technical means alone is inadequate for optimizing patient outcomes. An extensive understanding of hemodynamic, cardiac, and systemic factors is required to predict outcomes and tailor a personalized approach. Looking forward, the ongoing progress in SG technology, paired with the control of clinical factors that can impact outcomes, holds the promise of reshaping the management of PH-related complications in cirrhosis.
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Affiliation(s)
- Dario Saltini
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Federica Indulti
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Tomas Guasconi
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Marcello Bianchini
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Biagio Cuffari
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Cristian Caporali
- Division of Radiology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy; (C.C.)
| | - Federico Casari
- Division of Radiology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy; (C.C.)
| | - Francesco Prampolini
- Division of Radiology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy; (C.C.)
| | - Marco Senzolo
- Multivisceral Transplant Unit-Gastroenterology, Department of Surgery, Oncology and Gastroenterology, Padua University Hospital, 35128 Padua, Italy;
| | - Antonio Colecchia
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
| | - Filippo Schepis
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena, and University of Modena and Reggio Emilia, 41121 Modena, Italy (F.I.); (T.G.); (M.B.); (B.C.); (A.C.)
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Di Marco L, Pivetti A, Foschi FG, D’Amico R, Schepis F, Caporali C, Casari F, Lasagni S, Critelli RM, Milosa F, Romanzi A, Marcelli G, De Maria N, Romagnoli D, Catellani B, Scianò F, Magistri P, Colecchia A, Sighinolfi P, Di Benedetto F, Martinez-Chantar ML, Villa E. Feasibility, safety, and outcome of second-line nivolumab/bevacizumab in liver transplant patients with recurrent hepatocellular carcinoma. Liver Transpl 2023; 29:559-563. [PMID: 36747351 PMCID: PMC10106106 DOI: 10.1097/lvt.0000000000000087] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2022] [Accepted: 12/06/2022] [Indexed: 02/08/2023]
Affiliation(s)
- Lorenza Di Marco
- Department of Medical Specialties, Gastroenterology Unit, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Alessandra Pivetti
- Department of Medical Specialties, Gastroenterology Unit, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
| | | | - Roberto D’Amico
- Unit of statistical and methodological support to clinical research, University of Modena and Reggio Emilia, AOU Modena, Italy
| | - Filippo Schepis
- Department of Medical Specialties, Gastroenterology Unit, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
| | - Cristian Caporali
- Radiology Department, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Federico Casari
- Radiology Department, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Simone Lasagni
- Department of Medical Specialties, Gastroenterology Unit, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Rosina Maria Critelli
- Department of Medical Specialties, Gastroenterology Unit, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
| | - Fabiola Milosa
- Department of Medical Specialties, Gastroenterology Unit, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
| | - Adriana Romanzi
- Department of Medical Specialties, Gastroenterology Unit, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
- Clinical and Experimental Medicine PhD Program, University of Modena and Reggio Emilia, Modena, Italy
| | - Gemma Marcelli
- Department of Medical Specialties, Gastroenterology Unit, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
| | - Nicola De Maria
- Department of Medical Specialties, Gastroenterology Unit, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
| | - Dante Romagnoli
- Department of Medical Specialties, Gastroenterology Unit, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
| | - Barbara Catellani
- Liver Transplant Center, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
| | - Filippo Scianò
- Department of Medical Specialties, Gastroenterology Unit, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
| | - Paolo Magistri
- Liver Transplant Center, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
| | - Antonio Colecchia
- Department of Medical Specialties, Gastroenterology Unit, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
| | - Pamela Sighinolfi
- Pathology Unit, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Fabrizio Di Benedetto
- Liver Transplant Center, University of Modena and Reggio Emilia, Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
| | - Maria-Luz Martinez-Chantar
- Liver Disease Laboratory, Center for Cooperative Research in Biosciences (CIC bioGUNE), Basque Research and Technology Alliance (BRTA), and Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd), Derio, Bizkaia, Spain
| | - Erica Villa
- Department of Medical Specialties, Gastroenterology Unit, University of Modena & Reggio Emilia and Azienda Ospedaliero-Universitaria di Modena, Via del Pozzo 71, Modena, Italy
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Vizzutti F, Celsa C, Battaglia S, Miraglia R, Enea M, Marra F, Caporali C, Cammà C, Schepis F. Reply. Hepatology 2023; 77:E76-E77. [PMID: 36177688 DOI: 10.1002/hep.32813] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/21/2022] [Accepted: 09/22/2022] [Indexed: 12/08/2022]
Affiliation(s)
- Francesco Vizzutti
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Ciro Celsa
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE , University of Palermo , Palermo , Italy
- Department of Surgical, Oncological, and Oral Sciences (Di.Chir.On.S.) , University of Palermo , Palermo , Italy
| | - Salvatore Battaglia
- Department of Economics, Business, and Statistics (SEAS) , University of Palermo , Palermo , Italy
| | - Roberto Miraglia
- Radiology Unit, Diagnostic and Therapeutic Services , IRCCS ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies) , Palermo , Italy
| | - Marco Enea
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE , University of Palermo , Palermo , Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
- Center for Research, High Education and Transfer DENOThe , University of Florence , Florence , Italy
| | | | - Calogero Cammà
- Section of Gastroenterology and Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE , University of Palermo , Palermo , Italy
| | - Filippo Schepis
- Division of Gastroenterology, Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
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Vizzutti F, Celsa C, Calvaruso V, Enea M, Battaglia S, Turco L, Senzolo M, Nardelli S, Miraglia R, Roccarina D, Campani C, Saltini D, Caporali C, Indulti F, Gitto S, Zanetto A, Di Maria G, Bianchini M, Pecchini M, Aspite S, Di Bonaventura C, Citone M, Guasconi T, Di Benedetto F, Arena U, Fanelli F, Maruzzelli L, Riggio O, Burra P, Colecchia A, Villa E, Marra F, Cammà C, Schepis F. Mortality after transjugular intrahepatic portosystemic shunt in older adult patients with cirrhosis: A validated prediction model. Hepatology 2023; 77:476-488. [PMID: 35921493 DOI: 10.1002/hep.32704] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 07/22/2022] [Accepted: 07/31/2022] [Indexed: 01/28/2023]
Abstract
BACKGROUND AND AIMS Implantation of a transjugular intrahepatic portosystemic shunt (TIPS) improves survival in patients with cirrhosis with refractory ascites and portal hypertensive bleeding. However, the indication for TIPS in older adult patients (greater than or equal to 70 years) is debated, and a specific prediction model developed in this particular setting is lacking. The aim of this study was to develop and validate a multivariable model for an accurate prediction of mortality in older adults. APPROACH AND RESULTS We prospectively enrolled 411 consecutive patients observed at four referral centers with de novo TIPS implantation for refractory ascites or secondary prophylaxis of variceal bleeding (derivation cohort) and an external cohort of 415 patients with similar indications for TIPS (validation cohort). Older adult patients in the two cohorts were 99 and 76, respectively. A cause-specific Cox competing risks model was used to predict liver-related mortality, with orthotopic liver transplant and death for extrahepatic causes as competing events. Age, alcoholic etiology, creatinine levels, and international normalized ratio in the overall cohort, and creatinine and sodium levels in older adults were independent risk factors for liver-related death by multivariable analysis. CONCLUSIONS After TIPS implantation, mortality is increased by aging, but TIPS placement should not be precluded in patients older than 70 years. In older adults, creatinine and sodium levels are useful predictors for decision making. Further efforts to update the prediction model with larger sample size are warranted.
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Affiliation(s)
- Francesco Vizzutti
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Ciro Celsa
- Department of Health Promotion, Mother and Child Care , Internal Medicine and Medical Specialties , PROMISE, Gastroenterology and Hepatology Unit , University of Palermo , Palermo , Sicilia , Italy.,Department of Surgical, Oncological, and Oral Sciences (Di.Chir.On.S.) , University of Palermo , Palermo , Italy
| | - Vincenza Calvaruso
- Department of Health Promotion, Mother and Child Care , Internal Medicine and Medical Specialties , PROMISE, Gastroenterology and Hepatology Unit , University of Palermo , Palermo , Sicilia , Italy
| | - Marco Enea
- Department of Health Promotion, Mother and Child Care , Internal Medicine and Medical Specialties , PROMISE, Gastroenterology and Hepatology Unit , University of Palermo , Palermo , Sicilia , Italy
| | - Salvatore Battaglia
- Department of Economics, Business, and Statistics (SEAS) , University of Palermo , Palermo , Italy
| | - Laura Turco
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy.,Internal Medicine Unit for the Treatment of Severe Organ Failure , Dipartimento medico chirurgico delle malattie digestive, epatiche ed endocrino-metaboliche , Istituto di Ricovero e Cura a Carattere Scientifico, Azienda Ospedaliero-Universitaria di Bologna , Policlinico di Sant'Orsola , Italy
| | - Marco Senzolo
- Multivisceral Transplant Unit-Gastroenterology , Department of Surgery, Oncology, and Gastroenterology , Padua University Hospital , Padua , Italy
| | - Silvia Nardelli
- Department of Translational and Precision Medicine , Sapienza University of Rome , Rome , Italy
| | - Roberto Miraglia
- Radiology Unit, Diagnostic and Therapeutic Services , IRCCS ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies) , Palermo , Italy
| | - Davide Roccarina
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Claudia Campani
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Dario Saltini
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Cristian Caporali
- Radiology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Federica Indulti
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Stefano Gitto
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Alberto Zanetto
- Multivisceral Transplant Unit-Gastroenterology , Department of Surgery, Oncology, and Gastroenterology , Padua University Hospital , Padua , Italy
| | - Gabriele Di Maria
- Department of Health Promotion, Mother and Child Care , Internal Medicine and Medical Specialties , PROMISE, Gastroenterology and Hepatology Unit , University of Palermo , Palermo , Sicilia , Italy
| | - Marcello Bianchini
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Maddalena Pecchini
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Silvia Aspite
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Chiara Di Bonaventura
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Michele Citone
- Department of Radiology, Interventional Radiology Unit , Careggi Hospital , Florence , Italy
| | - Tomas Guasconi
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit , University of Modena and Reggio Emilia , Modena , Italy
| | - Umberto Arena
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy
| | - Fabrizio Fanelli
- Department of Radiology, Interventional Radiology Unit , Careggi Hospital , Florence , Italy
| | - Luigi Maruzzelli
- Radiology Unit, Diagnostic and Therapeutic Services , IRCCS ISMETT (Mediterranean Institute for Transplantation and Advanced Specialized Therapies) , Palermo , Italy
| | - Oliviero Riggio
- Department of Translational and Precision Medicine , Sapienza University of Rome , Rome , Italy
| | - Patrizia Burra
- Multivisceral Transplant Unit-Gastroenterology , Department of Surgery, Oncology, and Gastroenterology , Padua University Hospital , Padua , Italy
| | - Antonio Colecchia
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Erica Villa
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
| | - Fabio Marra
- Department of Experimental and Clinical Medicine , University of Florence , Florence , Italy.,Center for Research, High Education and Transfer DENOThe , University of Florence , Florence , Italy
| | - Calogero Cammà
- Department of Health Promotion, Mother and Child Care , Internal Medicine and Medical Specialties , PROMISE, Gastroenterology and Hepatology Unit , University of Palermo , Palermo , Sicilia , Italy
| | - Filippo Schepis
- Division of Gastroenterology , Modena Hospital , University of Modena and Reggio Emilia , Modena , Italy
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Di Marco L, Pivetti A, De Maria N, Foschi FG, Romagnoli D, Casari F, Caporali C, Magistri P, Catellani B, Di Benedetto F, Villa E. Abstract PO003: Combination therapy with Nivolumab/Bevacizumab is safe and effective in patients with recurrent hepatocellular carcinoma after liver transplant. Clin Cancer Res 2022. [DOI: 10.1158/1557-3265.liverca22-po003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Abstract
Recurrent hepatocellular carcinoma (HCC-R) after Liver Transplant (LT) is difficult to manage and often characterized by relevant aggressiveness and extrahepatic localizations. Currently TKIs are the only therapeutic option, but results in term of overall survival (OS) and progression-free survival are disappointing. Immune checkpoint inhibitors in association with recombinant humanized monoclonal antibody to VEGF were to be proved effective in non-LT patients with metastatic hepatocellular carcinoma in determining tumor stabilization and improved survival. However, as in LT patients immunotherapy may increase the risk of acute liver rejection, such combination therapy has not been used so far. We designed a proof-of-concept study to analyze safety and efficacy of Nivolumab and Bevacizumab in LT patients as treatment for HCC-R after LT. Combination therapy received nominal authorization from the Provincial Medicines Commission. Candidate patients underwent routine blood test (hepatic, renal, and cardiac function), echocardiogram and a total body CT as baseline assessment. Patients with creatinine higher than 1.5 ULN or with ejection fraction lower than 45% were excluded. Five patients who experienced HCC-R 2 to 8 years after LT with pulmonary, lymph node, adrenal, bones, and hepatic localization and were either intolerant to TKIs or had had progression on TKIs, were included. All recurrent tumors and extra-hepatic localizations were characterized by high biologic aggressiveness. Patients received Nivolumab infusion every 14 days at a dose of 240 mg. Total body CT scan was performed every 8 weeks. When progression disease (PD) was detected at CT scan, Bevacizumab was added at a dose of 5 mg/kg every 14 days. One patient received a single Nivolumab infusion but was withdrawn because of rapid tumor progression, eventually followed by death. Another patient experienced moderate/severe rejection, which resolved with 1g/day Methylprednisolone e.v. for 3[EV1] days followed by Prednisone 50mg/day for 1 week then tapered and stopped. This patient was maintained on double therapy without residual problems. The 4 alive patients are still on double therapy after a mean period of treatment of 36±21 weeks. Disease stability with the combination of Nivolumab/Bevacizumab has been achieved in all patients at hepatic and all extra-hepatic HCC localization but bone, where 2/2 patients experienced progression. It should be underlined, however, that progression was very slow and mean survival of these two patients on combination therapy is 54±2 weeks. Combination therapy was very well tolerated, with few side effects throughout treatment period. These results indicate that the combination Nivolumab/Bevacizumab can be safely used in liver transplant patients. The risk of acute allograft rejection is minimal and manageable. Bone metastases remain an unsolved issue and need further alternative therapeutic approach. For patients with hepatic or other extra-hepatic localization, this combination obtained a relevant and protracted stabilization of disease.
Citation Format: Lorenza Di Marco, Alessandra Pivetti, Nicola De Maria, Francesco Giuseppe Foschi, Dante Romagnoli, Federico Casari, Cristian Caporali, Paolo Magistri, Barbara Catellani, Fabrizio Di Benedetto, Erica Villa. Combination therapy with Nivolumab/Bevacizumab is safe and effective in patients with recurrent hepatocellular carcinoma after liver transplant [abstract]. In: Proceedings of the AACR Special Conference: Advances in the Pathogenesis and Molecular Therapies of Liver Cancer; 2022 May 5-8; Boston, MA. Philadelphia (PA): AACR; Clin Cancer Res 2022;28(17_Suppl):Abstract nr PO003.
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Affiliation(s)
- Lorenza Di Marco
- 1Clinical and Experimental Medicine PhD Program, Unimore, Modena, Italy,
| | | | | | | | | | | | | | | | | | | | - Erica Villa
- 6University of Modena and Reggio Emilia, Modena, Italy
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Caporali C, Turco L, Prampolini F, Quaretti P, Bianchini M, Saltini D, Miceli F, Casari F, Felaco D, Garcia‐Pagan JC, Trebicka J, Senzolo M, Guerrini GP, Di Benedetto F, Torricelli P, Villa E, Schepis F. Proximal Splenic Artery Embolization to Treat Refractory Ascites in a Patient With Cirrhosis. Hepatology 2021; 74:3534-3538. [PMID: 34218452 PMCID: PMC9292732 DOI: 10.1002/hep.32037] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/05/2020] [Revised: 06/12/2021] [Accepted: 06/28/2021] [Indexed: 12/21/2022]
Affiliation(s)
- Cristian Caporali
- Division of RadiologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Laura Turco
- Division of GastroenterologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Francesco Prampolini
- Division of RadiologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Pietro Quaretti
- Unit of Interventional Radiology ‐ Radiology DepartmentIRCCS Policlinico San Matteo FoundationPaviaItaly
| | - Marcello Bianchini
- Division of GastroenterologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Dario Saltini
- Division of GastroenterologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Francesca Miceli
- Division of GastroenterologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Federico Casari
- Division of RadiologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Davide Felaco
- Division of RadiologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Juan Carlos Garcia‐Pagan
- Hepatic Hemodynamic Laboratory, Liver Unit, Hospital Clinic, IDIBAPS and CIBERehdHealth Care Provider of the European Reference Network on Rare Liver Disorders (ERN‐Liver)BarcelonaSpain
| | - Jonel Trebicka
- Department of Internal Medicine IUniversity of FrankfurtFrankfurtGermany
| | - Marco Senzolo
- Multivisceral Transplant Unit, Gastroenterology, Department of Surgery, Oncology and GastroenterologyPadova University HospitalPadovaItaly
| | - Gian Piero Guerrini
- Hepato‐Pancreato‐Biliary Surgery and Liver Transplantation UnitUniversity of Modena and Reggio EmiliaModenaItaly
| | - Fabrizio Di Benedetto
- Hepato‐Pancreato‐Biliary Surgery and Liver Transplantation UnitUniversity of Modena and Reggio EmiliaModenaItaly
| | - Pietro Torricelli
- Division of RadiologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Erica Villa
- Division of GastroenterologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
| | - Filippo Schepis
- Division of GastroenterologyAzienda Ospedaliero‐Universitaria di Modena and University of Modena and Reggio EmiliaModenaItaly
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Nardelli S, Riggio O, Turco L, Gioia S, Puzzono M, Bianchini M, Ridola L, Aprile F, Gitto S, Pelle G, Di Martino M, Marzocchi G, Caporali C, Spagnoli A, Di Rocco A, Schepis F. Relevance of Spontaneous Portosystemic Shunts Detected with CT in Patients with Cirrhosis. Radiology 2021; 299:133-140. [PMID: 33529134 DOI: 10.1148/radiol.2021203051] [Citation(s) in RCA: 31] [Impact Index Per Article: 10.3] [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
Background Cirrhosis leads to portal hypertension and to the consequent formation of spontaneous portosystemic shunts (SPSSs), leading to complications related to the diversion of portal blood into the systemic circulation, which is called portosystemic shunt syndrome. Purpose To investigate the characteristics of patients with cirrhosis and an SPSS and secondarily to assess the prognostic impact of SPSSs on portal hypertension-related complications and transplant-free survival. Materials and Methods A retrospective database review of patients with cirrhosis (observed from March 2015 to July 2019) was performed to identify patients with CT imaging and outcomes data. For each patient, clinical and biochemical data were collected, and the presence, types, and sizes of SPSSs were investigated with CT. Patients were followed for a mean of 27.5 months ± 22.8. Multivariable logistic analysis was used to identify the clinical characteristics associated with the presence of SPSSs (any size) and presence of SPSSs 1 cm or larger. Competitive risk analysis (Fine and Gray model) was used to identify the association between SPSSs and complications and mortality. Results Two hundred twenty-two patients with cirrhosis (157 male, 65 female; mean age, 62 years ± 12 [standard deviation]) were evaluated. An SPSS was found in 141 of 222 patients (63.5%), and 40 of 222 (18%) had a shunt diameter of at least 1 cm. At presentation, variables independently associated with the presence of SPSSs (any size) were portal vein thrombosis (odds ratio, 5.5; P = .008) and Child-Pugh class C (odds ratio, 3.0; P = .03). Previous hepatic encephalopathy (odds ratio, 4.4; P = .001) and portal vein thrombosis (odds ratio, 5.3; P = .001) were the only variables associated with SPSSs larger than 1 cm. Patients with SPSSs of any size had higher mortality (subdistribution hazard ratio, 1.9; P < .001) and higher frequency of hepatic encephalopathy (subdistribution hazard ratio, 2.3; P = .023), gastrointestinal bleeding (subdistribution hazard ratio, 2.9; P = .039), and portal vein thrombosis (subdistribution hazard ratio, 7.6; P = .005). Conclusion The presence of spontaneous portosystemic shunts on CT images in patients with cirrhosis was associated with higher mortality and complications, including portal vein thrombosis, hepatic encephalopathy, and gastrointestinal bleeding. © RSNA, 2021 See also the editorial by Reeder in this issue.
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Affiliation(s)
- Silvia Nardelli
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Oliviero Riggio
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Laura Turco
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Stefania Gioia
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Marta Puzzono
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Marcello Bianchini
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Lorenzo Ridola
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Francesca Aprile
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Stefano Gitto
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Giuseppe Pelle
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Michele Di Martino
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Guido Marzocchi
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Cristian Caporali
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Alessandra Spagnoli
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Arianna Di Rocco
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
| | - Filippo Schepis
- From the Department of Translational and Precision Medicine (S.N., O.R., S. Gioia, M.P., L.R., F.A.), Department of Radiological Sciences, Oncology, and Anatomical Pathology (M.D.M.), and Department of Public Health and Infectious Diseases (A.S., A.D.R.), Sapienza University of Rome, Viale dell'Università 37, 00161 Rome, Italy; Departments of Gastroenterology (L.T., M.B., S. Gitto, F.S.) and Radiology (G.M., C.C.), University of Modena and Reggio Emilia, Modena, Italy; Department of Interventional Radiology, Santa Maria Goretti Hospital, Latina, Italy (G.P.); and Department of Experimental and Clinical Medicine, University of Florence, Florence, Italy (S. Gitto)
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Magistri P, Catellani B, Frassoni S, Guidetti C, Olivieri T, Assirati G, Caporali C, Pecchi A, Serra V, Ballarin R, Guerrini GP, Bagnardi V, Di Sandro S, Di Benedetto F. Robotic Liver Resection Versus Percutaneous Ablation for Early HCC: Short- and Long-Term Results. Cancers (Basel) 2020; 12:cancers12123578. [PMID: 33266096 PMCID: PMC7761404 DOI: 10.3390/cancers12123578] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2020] [Accepted: 11/20/2020] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND The correct approach for early hepatocellular carcinoma (HCC) is debatable, since multiple options are currently available. Percutaneous ablation (PA) is associated in some series to reduced morbidity compared to liver resection (LR); therefore, minimally invasive surgery may play a significant role in this setting. METHODS All consecutive patients treated by robotic liver resection (RLR) or PA between January 2014 and October 2019 for a newly diagnosed single HCC, less than 3 cm in size (very early/early stages according to the Barcelona Clinic Liver Cancer (BCLC)) on chronic liver disease or liver cirrhosis, were enrolled in this retrospective study. The aim of this study was to compare short- and long-term outcomes to define the best approach in this specific cohort. RESULTS 60 patients fulfilled the inclusion criteria: 24 RLR and 36 PA. The two populations were homogeneous in terms of baseline characteristics. There were no statistically significant differences regarding the incidence of postoperative morbidity (RLR 38% vs. PA 19%, p = 0.15). The cumulative incidence of recurrence (CIR) was significantly higher in patients who underwent PA, with the one, two, and three years of CIR being 42%, 69%, and 73% in the PA group and 17%, 27%, and 27% in the RLR group, respectively. CONCLUSIONS RLR provides a significantly higher potential of cure and tumor-related free survival in cases of newly diagnosed single HCCs smaller than 3 cm. Therefore, it can be considered as a first-line approach for the treatment of patients with those characteristics in high-volume centers with extensive experience in the field of hepatobiliary surgery and minimally invasive approaches.
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Affiliation(s)
- Paolo Magistri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy; (P.M.); (B.C.); (C.G.); (T.O.); (G.A.); (V.S.); (R.B.); (G.P.G.); (S.D.S.)
| | - Barbara Catellani
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy; (P.M.); (B.C.); (C.G.); (T.O.); (G.A.); (V.S.); (R.B.); (G.P.G.); (S.D.S.)
| | - Samuele Frassoni
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, 20126 Milan, Italy; (S.F.); (V.B.)
| | - Cristiano Guidetti
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy; (P.M.); (B.C.); (C.G.); (T.O.); (G.A.); (V.S.); (R.B.); (G.P.G.); (S.D.S.)
| | - Tiziana Olivieri
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy; (P.M.); (B.C.); (C.G.); (T.O.); (G.A.); (V.S.); (R.B.); (G.P.G.); (S.D.S.)
| | - Giacomo Assirati
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy; (P.M.); (B.C.); (C.G.); (T.O.); (G.A.); (V.S.); (R.B.); (G.P.G.); (S.D.S.)
| | - Cristian Caporali
- Department of Radiology, Policlinico University Hospital of Modena, 41124 Modena, Italy; (C.C.); (A.P.)
| | - Annarita Pecchi
- Department of Radiology, Policlinico University Hospital of Modena, 41124 Modena, Italy; (C.C.); (A.P.)
| | - Valentina Serra
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy; (P.M.); (B.C.); (C.G.); (T.O.); (G.A.); (V.S.); (R.B.); (G.P.G.); (S.D.S.)
| | - Roberto Ballarin
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy; (P.M.); (B.C.); (C.G.); (T.O.); (G.A.); (V.S.); (R.B.); (G.P.G.); (S.D.S.)
| | - Gian Piero Guerrini
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy; (P.M.); (B.C.); (C.G.); (T.O.); (G.A.); (V.S.); (R.B.); (G.P.G.); (S.D.S.)
| | - Vincenzo Bagnardi
- Department of Statistics and Quantitative Methods, University of Milan-Bicocca, 20126 Milan, Italy; (S.F.); (V.B.)
| | - Stefano Di Sandro
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy; (P.M.); (B.C.); (C.G.); (T.O.); (G.A.); (V.S.); (R.B.); (G.P.G.); (S.D.S.)
| | - Fabrizio Di Benedetto
- Hepato-Pancreato-Biliary Surgery and Liver Transplantation Unit, University of Modena and Reggio Emilia, 41124 Modena, Italy; (P.M.); (B.C.); (C.G.); (T.O.); (G.A.); (V.S.); (R.B.); (G.P.G.); (S.D.S.)
- Correspondence: ; Tel.: +39-059-422-4328
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Fiocchi F, Monelli F, Besutti G, Casari F, Petrella E, Pecchi A, Caporali C, Bertucci E, Busani S, Botticelli L, Facchinetti F, Torricelli P. MRI of placenta accreta: diagnostic accuracy and impact of interventional radiology on foetal-maternal delivery outcomes in high-risk women. Br J Radiol 2020; 93:20200267. [PMID: 32706979 DOI: 10.1259/bjr.20200267] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022] Open
Abstract
OBJECTIVE To assess accuracy and reproducibility of MRI diagnosis of invasive placentation (IP) in high-risk patients and to evaluate reliability of MRI features. Secondary aim was to evaluate impact of interventional radiology (IR) on delivery outcomes in patients with IP at MRI. METHODS 26 patients (mean age 36.24 y/o,SD 6.16) with clinical risk-factors and echographic suspicion of IP underwent 1.5 T-MRI. Two readers reviewed images. Gold-standard was histology in hysterectomised patients and obstetric evaluation at delivery for patients with preserved uterus. Accuracy and reproducibility of MRI findings were calculated. RESULTS Incidence of IP was 50% (13/26) and of PP was 11.54% (3/26). MRI showed 100% sensitivity (95% CI = 75.3-100%) and 92.3% specificity (95% CI = 64.0-100%) in the diagnosis of IP. Gold-standard was histology in 10 cases and obstetric evaluation in 16. MRI findings with higher sensitivity were placental heterogeneity, uterine bulging and black intraplacental bands. Uterine scarring, placental heterogeneity, myometrial interruption and tenting of the bladder showed better specificity. MRI inter-rater agreement with Cohen's K was 1. 11 patients among 14 with MRI diagnosis of IP received IR assistance with positive impact on delivery outcomes in terms of blood loss, red cells count, intense care unit length of stay, days of hospitalisation and risk of being transfused. CONCLUSION MRI is an accurate and reproducible technique in prenatal diagnosis of IP. MRI helps planning a safe and appropriate delivery eventually assisted by IR, which positively affects foetal and maternal outcomes. ADVANCES IN KNOWLEDGE The adoption of MRI evaluation in patients with high risk of invasive placentation allows a more accurate diagnosis in terms of both presence of the disease and its extension to or through or even beyond the myometrium. This led to a better dedicated delivery management with eventual adoption of interventional radiology with a global positive effect on foetal and maternal outcomes.
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Affiliation(s)
- Federica Fiocchi
- Department of Radiology, Azienda ospedaliero- universitaria Policlinico di Modena, Modena, Italy
| | - Filippo Monelli
- Department of Radiology, Azienda ospedaliero- universitaria Policlinico di Modena, Modena, Italy
| | - Giulia Besutti
- University of Modena and Reggio Emilia, Clinical and Experimental Medicine PhD program, Modena, Italy
| | - Federico Casari
- Department of Radiology, Azienda ospedaliero- universitaria Policlinico di Modena, Modena, Italy
| | - Elisabetta Petrella
- Department of Medical and SurgicaSciences for Mothers, Children and Adults, Azienda ospedaliero - universitaria Policlinico di Modena, Modena, Italy
| | - Annarita Pecchi
- Department of Radiology, Azienda ospedaliero- universitaria Policlinico di Modena, Modena, Italy
| | - Cristian Caporali
- Department of Radiology, Azienda ospedaliero- universitaria Policlinico di Modena, Modena, Italy
| | - Emma Bertucci
- Department of Medical and SurgicaSciences for Mothers, Children and Adults, Azienda ospedaliero - universitaria Policlinico di Modena, Modena, Italy
| | - Stefano Busani
- Departement of intensive care medicine, Azienda ospedaliero - universitaria Policlinico di Modena, Modena, Italy
| | - Laura Botticelli
- Departement of Pathology, Azienda ospedaliero - universitaria Policlinico di Modena, Modena, Italy
| | - Fabio Facchinetti
- Department of Medical and SurgicaSciences for Mothers, Children and Adults, Azienda ospedaliero - universitaria Policlinico di Modena, Modena, Italy
| | - Pietro Torricelli
- Department of Radiology, Azienda ospedaliero- universitaria Policlinico di Modena, Modena, Italy
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11
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Todesca P, Marzi L, Critelli RM, Cuffari B, Caporali C, Turco L, Pinelli G, Schepis F, Carulli L, de Maria N, Casari F, Scaglioni R, Villa E. Angiopoietin-2/Tie2 Inhibition by Regorafenib Associates With Striking Response in a Patient With Aggressive Hepatocellular Carcinoma. Hepatology 2019; 70:745-747. [PMID: 30802985 DOI: 10.1002/hep.30588] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/30/2018] [Accepted: 02/14/2019] [Indexed: 12/07/2022]
Affiliation(s)
- Paola Todesca
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy.,WomenInHepatology Network
| | - Luca Marzi
- Division of Gastroenterology, Azienda Sanitaria dell'Alto Adige, Bolzano, Italy
| | - Rosina Maria Critelli
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy.,WomenInHepatology Network
| | - Biagio Cuffari
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Cristian Caporali
- Division of Radiology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Laura Turco
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy.,WomenInHepatology Network
| | - Giovanni Pinelli
- Division of Internal Medicine, Azienda Ospedaliero-Universitaria di Modena, Modena, Italy
| | - Filippo Schepis
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Lucia Carulli
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy.,WomenInHepatology Network
| | - Nicola de Maria
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Federico Casari
- Division of Radiology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Riccardo Scaglioni
- Division of Radiology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy
| | - Erica Villa
- Division of Gastroenterology, Azienda Ospedaliero-Universitaria di Modena and University of Modena and Reggio Emilia, Modena, Italy.,WomenInHepatology Network
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12
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Faillaci F, Marzi L, Critelli R, Milosa F, Schepis F, Turola E, Andreani S, Vandelli G, Bernabucci V, Lei B, D'Ambrosio F, Bristot L, Cavalletto L, Chemello L, Sighinolfi P, Manni P, Maiorana A, Caporali C, Bianchini M, Marsico M, Turco L, de Maria N, Del Buono M, Todesca P, di Lena L, Romagnoli D, Magistri P, di Benedetto F, Bruno S, Taliani G, Giannelli G, Martinez‐Chantar M, Villa E. Liver Angiopoietin-2 Is a Key Predictor of De Novo or Recurrent Hepatocellular Cancer After Hepatitis C Virus Direct-Acting Antivirals. Hepatology 2018; 68:1010-1024. [PMID: 29604220 PMCID: PMC6175123 DOI: 10.1002/hep.29911] [Citation(s) in RCA: 90] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/20/2017] [Revised: 02/19/2018] [Accepted: 03/25/2018] [Indexed: 12/14/2022]
Abstract
Recent reports suggested that direct acting antivirals (DAAs) might favor hepatocellular carcinoma (HCC). In study 1, we studied the proangiogenic liver microenvironment in 242 DAA-treated chronic hepatitis C patients with advanced fibrosis. Angiopoietin-2 (ANGPT2) expression was studied in tissue (cirrhotic and/or neoplastic) from recurrent, de novo, nonrecurrent HCC, or patients never developing HCC. Circulating ANGPT2,vascular endothelial growth factor (VEGF), and C-reactive protein (CRP) were also measured. In study 2, we searched for factors associated with de novo HCC in 257 patients with cirrhosis of different etiologies enrolled in a dedicated prospective study. Thorough biochemical, clinical, hemodynamic, endoscopic, elastographic, and echo-Doppler work-up was performed in both studies. In study 1, no patients without cirrhosis developed HCC. Of 183 patients with cirrhosis, 14 of 28 (50.0%) with previous HCC recurred whereas 21 of 155 (13.5%) developed de novo HCC. Patients with recurrent and de novo HCCs had significantly higher liver fibrosis (LF) scores, portal pressure, and systemic inflammation than nonrecurrent HCC or patients never developing HCC. In recurrent/de novo HCC patients, tumor and nontumor ANGPT2 showed an inverse relationship with portal vein velocity (PVv; r = -0.412, P = 0.037 and r = -0.409, P = 0.047 respectively) and a positive relationship with liver stiffness (r = 0.526, P = 0.007; r = 0.525, P = 0.003 respectively). Baseline circulating VEGF and cirrhotic liver ANGPT2 were significantly related (r = 0.414, P = 0.044). VEGF increased during DAAs, remaining stably elevated at 3-month follow-up, when it significantly related with serum ANGPT2 (r = 0.531, P = 0.005). ANGPT2 expression in the primary tumor or in cirrhotic tissue before DAAs was independently related with risk of HCC recurrence (odds ratio [OR], 1.137; 95% confidence interval [CI], 1.044-1.137; P = 0.003) or occurrence (OR, 1.604; 95% CI, 1.080-2.382; P = 0.019). In study 2, DAA treatment (OR, 4.770; 95% CI, 1.395-16.316; P = 0.013) and large varices (OR, 3.857; 95% CI, 1.127-13.203; P = 0.032) were independent predictors of de novo HCC. CONCLUSION Our study indicates that DAA-mediated increase of VEGF favors HCC recurrence/occurrence in susceptible patients, that is, those with more severe fibrosis and splanchnic collateralization, who already have abnormal activation in liver tissues of neo-angiogenetic pathways, as shown by increased ANGPT2. (Hepatology 2018; 00:000-000).
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Affiliation(s)
- Francesca Faillaci
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Luca Marzi
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Rosina Critelli
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Fabiola Milosa
- National Institute of Gastroenterology, “S. de Bellis” Research HospitalCastellana GrotteBariItaly
- WomenInHepatology Network
| | - Filippo Schepis
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Elena Turola
- National Institute of Gastroenterology, “S. de Bellis” Research HospitalCastellana GrotteBariItaly
- WomenInHepatology Network
| | - Silvia Andreani
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Gabriele Vandelli
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Veronica Bernabucci
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Barbara Lei
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Federica D'Ambrosio
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Laura Bristot
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Luisa Cavalletto
- Department of MedicineUniversity of PaduaPaduaItaly
- WomenInHepatology Network
| | - Liliana Chemello
- Department of MedicineUniversity of PaduaPaduaItaly
- WomenInHepatology Network
| | - Pamela Sighinolfi
- Department of PathologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Paola Manni
- Department of PathologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Antonino Maiorana
- Department of PathologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Cristian Caporali
- Department of RadiologyUniversity of Modena and Reggio EmiliaModenaItaly
| | - Marcello Bianchini
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Maria Marsico
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Laura Turco
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Nicola de Maria
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Mariagrazia Del Buono
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Paola Todesca
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
| | - Luca di Lena
- National Institute of Gastroenterology, “S. de Bellis” Research HospitalCastellana GrotteBariItaly
| | - Dante Romagnoli
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
| | - Paolo Magistri
- Liver and Multivisceral Transplant CenterUniversity of Modena and Reggio EmiliaModenaItaly
| | - Fabrizio di Benedetto
- Liver and Multivisceral Transplant CenterUniversity of Modena and Reggio EmiliaModenaItaly
| | - Savino Bruno
- Humanitas University and Humanitas Research Hospital RozzanoMilanItaly
| | - Gloria Taliani
- Department of Clinical MedicineUniversity of Rome ‘La Sapienza’RomeItaly
- WomenInHepatology Network
| | - Gianluigi Giannelli
- National Institute of Gastroenterology, “S. de Bellis” Research HospitalCastellana GrotteBariItaly
| | - Maria‐Luz Martinez‐Chantar
- CIC bioGUNE, Centro de Investigación Cooperativa en Biociencias. Technology Park of Bizkaia, Bizkaia, Spain. Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas (CIBERehd)Instituto de Salud Carlos IIIMadridSpain
- WomenInHepatology Network
| | - Erica Villa
- Gastroenterology Unit, Department of Internal MedicineUniversity of Modena and Reggio EmiliaModenaItaly
- WomenInHepatology Network
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13
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Villa E, Critelli R, Lei B, Marzocchi G, Cammà C, Giannelli G, Pontisso P, Cabibbo G, Enea M, Colopi S, Caporali C, Pollicino T, Milosa F, Karampatou A, Todesca P, Bertolini E, Maccio L, Martinez-Chantar ML, Turola E, Del Buono M, De Maria N, Ballestri S, Schepis F, Loria P, Enrico Gerunda G, Losi L, Cillo U. Neoangiogenesis-related genes are hallmarks of fast-growing hepatocellular carcinomas and worst survival. Results from a prospective study. Gut 2016; 65:861-9. [PMID: 25666192 DOI: 10.1136/gutjnl-2014-308483] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2014] [Accepted: 01/16/2015] [Indexed: 12/11/2022]
Abstract
OBJECTIVE The biological heterogeneity of hepatocellular carcinoma (HCC) makes prognosis difficult. We translate the results of a genome-wide high-throughput analysis into a tool that accurately predicts at presentation tumour growth and survival of patients with HCC. DESIGN Ultrasound surveillance identified HCC in 78 (training set) and 54 (validation set) consecutive patients with cirrhosis. Patients underwent two CT scans 6 weeks apart (no treatment in-between) to determine tumour volumes (V0 and V1) and calculate HCC doubling time. Baseline-paired HCC and surrounding tissue biopsies for microarray study (Agilent Whole Human Genome Oligo Microarrays) were also obtained. Predictors of survival were assessed by multivariate Cox model. RESULTS Calculated tumour doubling times ranged from 30 to 621 days (mean, 107±91 days; median, 83 days) and were divided into quartiles: ≤53 days (n=19), 54-82 days (n=20), 83-110 days (n=20) and ≥111 days (n=19). Median survival according to doubling time was significantly lower for the first quartile versus the others (11 vs 41 months, 42, and 47 months, respectively) (p<0.0001). A five-gene transcriptomic hepatic signature including angiopoietin-2 (ANGPT2), delta-like ligand 4 (DLL4), neuropilin (NRP)/tolloid (TLL)-like 2 (NETO2), endothelial cell-specific molecule-1 (ESM1), and nuclear receptor subfamily 4, group A, member 1 (NR4A1) was found to accurately identify rapidly growing HCCs of the first quartile (ROC AUC: 0.961; 95% CI 0.919 to 1.000; p<0.0001) and to be an independent factor for mortality (HR: 3.987; 95% CI 1.941 to 8.193, p<0.0001). CONCLUSIONS The hepatic five-gene signature was able to predict HCC growth in individual patient and the consequent risk of death. This implies a role of this molecular tool in the future therapeutic management of patients with HCC. TRIAL REGISTRATION NUMBER ClinicalTrials.gov Identifier: NCT01657695.
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Affiliation(s)
- Erica Villa
- Division of Gastroenterology, AOU Modena, Modena, Italy
| | | | - Barbara Lei
- Division of Gastroenterology, AOU Modena, Modena, Italy
| | | | - Calogero Cammà
- Division of Gastroenterology, DiBiMIS, University of Palermo, Palermo, Italy
| | | | | | - Giuseppe Cabibbo
- Division of Gastroenterology, DiBiMIS, University of Palermo, Palermo, Italy
| | - Marco Enea
- Dipartimento di Scienze Statistiche e Matematiche 'S. Vianelli', University of Palermo, Palermo, Italy
| | | | | | - Teresa Pollicino
- Department of Internal Medicine, Clinical and Molecular Hepatology, University of Messina, Messina, Italy
| | | | | | - Paola Todesca
- Division of Gastroenterology, AOU Modena, Modena, Italy
| | | | - Livia Maccio
- Department of Pathology, AOU Modena, Modena, Italy
| | | | - Elena Turola
- Division of Gastroenterology, AOU Modena, Modena, Italy
| | | | | | | | | | - Paola Loria
- Medicina Metabolica, Nuovo Ospedale S. Agostino, Modena, Italy
| | | | - Luisa Losi
- Department of Pathology, AOU Modena, Modena, Italy
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14
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Villa E, Cammà C, Marietta M, Luongo M, Critelli R, Colopi S, Tata C, Zecchini R, Gitto S, Petta S, Lei B, Bernabucci V, Vukotic R, De Maria N, Schepis F, Karampatou A, Caporali C, Simoni L, Del Buono M, Zambotto B, Turola E, Fornaciari G, Schianchi S, Ferrari A, Valla D. Enoxaparin prevents portal vein thrombosis and liver decompensation in patients with advanced cirrhosis. Gastroenterology 2012; 143:1253-1260.e4. [PMID: 22819864 DOI: 10.1053/j.gastro.2012.07.018] [Citation(s) in RCA: 466] [Impact Index Per Article: 38.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/15/2012] [Revised: 07/05/2012] [Accepted: 07/09/2012] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS We performed a randomized controlled trial to evaluate the safety and efficacy of enoxaparin, a low-molecular-weight heparin, in preventing portal vein thrombosis (PVT) in patients with advanced cirrhosis. METHODS In a nonblinded, single-center study, 70 outpatients with cirrhosis (Child-Pugh classes B7-C10) with demonstrated patent portal veins and without hepatocellular carcinoma were assigned randomly to groups that were given enoxaparin (4000 IU/day, subcutaneously for 48 weeks; n = 34) or no treatment (controls, n = 36). Ultrasonography (every 3 months) and computed tomography (every 6 months) were performed to check the portal vein axis. The primary outcome was prevention of PVT. Radiologists and hepatologists that assessed outcomes were blinded to group assignments. Analysis was by intention to treat. RESULTS At 48 weeks, none of the patients in the enoxaparin group had developed PVT, compared with 6 of 36 (16.6%) controls (P = .025). At 96 weeks, no patient developed PVT in the enoxaparin group, compared with 10 of 36 (27.7%) controls (P = .001). At the end of the follow-up period, 8.8% of patients in the enoxaparin group and 27.7% of controls developed PVT (P = .048). The actuarial probability of PVT was lower in the enoxaparin group (P = .006). Liver decompensation was less frequent among patients given enoxaparin (11.7%) than controls (59.4%) (P < .0001); overall values were 38.2% vs 83.0%, respectively (P < .0001). The actuarial probability of liver decompensation was lower in the enoxaparin group (P < .0001). Eight patients in the enoxaparin group and 13 controls died. The actuarial probability of survival was higher in the enoxaparin group (P = .020). No relevant side effects or hemorrhagic events were reported. CONCLUSIONS In a small randomized controlled trial, a 12-month course of enoxaparin was safe and effective in preventing PVT in patients with cirrhosis and a Child-Pugh score of 7-10. Enoxaparin appeared to delay the occurrence of hepatic decompensation and to improve survival.
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Affiliation(s)
- Erica Villa
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy.
| | - Calogero Cammà
- Sezione di Gastroenterologia, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | - Marco Marietta
- Department of Haematology, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Monica Luongo
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Rosina Critelli
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Colopi
- Department of Radiology, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Cristina Tata
- Department of Radiology, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Ramona Zecchini
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Stefano Gitto
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Salvatore Petta
- Sezione di Gastroenterologia, Dipartimento Biomedico di Medicina Interna e Specialistica, University of Palermo, Palermo, Italy
| | - Barbara Lei
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Veronica Bernabucci
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Ranka Vukotic
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Nicola De Maria
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Filippo Schepis
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Aimilia Karampatou
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Cristian Caporali
- Department of Radiology, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Luisa Simoni
- Haematology Laboratory, Azienda Ospedaliero-Universitaria, Modena, Italy
| | - Mariagrazia Del Buono
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Beatrice Zambotto
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Elena Turola
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | | | | | - Anna Ferrari
- Department of Gastroenterology, Azienda Ospedaliero-Universitaria and University of Modena and Reggio Emilia, Modena, Italy
| | - Dominique Valla
- Service d'Hépatologie, Hôpital Beaujon, APHP, Clichy, France; Université Paris-Diderot, Paris, France; INSERM U773-CRB3, Paris, France
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15
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Michelini E, Lonardo A, Ballestri S, Costantini M, Caporali C, Bonati ME, Bertolotti M, Iori R, Loria P. Is cholangiocarcinoma another complication of insulin resistance: a report of three cases. Metab Syndr Relat Disord 2012; 5:194-202. [PMID: 18370827 DOI: 10.1089/met.2006.0018] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Cholangiocarcinoma is the second most common primary liver cancer, and the number of cases of intrahepatic cholangiocarcinoma (ICC) have been steadily increasing worldwide. Although the reasons for this surge are unknown, insulin resistance (IR) could be a risk factor, similar to what has been reported for other cancers. CASE REPORT We report on 3 cases of ICC arising in subjects sharing IR as an underlying risk factor. Case 1 was an obese and dyslipidemic patient with NAFLD. The second and the third patients were affected by type 2 diabetes. CONCLUSIONS Evidence for a link between IR and onset of cholangiocarcinoma in our patients rests on three lines of evidence: epidemiological, biological, and exclusion of others risk factors. Studies are needed to confirm our hypothesis that IR is a risk factor for the development of ICC.
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Affiliation(s)
- E Michelini
- Dipartimento Integrato di Medicina, Endocrinologia, Metabolismo, e Geriatria-Nuovo Ospedale Civile S. Agostino-Estense di Baggiovara, Modena, Italy
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16
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Laitano RF, Guerra AS, Pimpinella M, Caporali C, Petrucci A. Charge collection efficiency in ionization chambers exposed to electron beams with high dose per pulse. Phys Med Biol 2006; 51:6419-36. [PMID: 17148826 DOI: 10.1088/0031-9155/51/24/009] [Citation(s) in RCA: 66] [Impact Index Per Article: 3.7] [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: 11/12/2022]
Abstract
The correction for charge recombination was determined for different plane-parallel ionization chambers exposed to clinical electron beams with low and high dose per pulse, respectively. The electron energy was nearly the same (about 7 and 9 MeV) for any of the beams used. Boag's two-voltage analysis (TVA) was used to determine the correction for ion losses, k(s), relevant to each chamber considered. The presence of free electrons in the air of the chamber cavity was accounted for in determining k(s) by TVA. The determination of k(s) was made on the basis of the models for ion recombination proposed in past years by Boag, Hochhäuser and Balk to account for the presence of free electrons. The absorbed dose measurements in both low-dose-per-pulse (less than 0.3 mGy per pulse) and high-dose-per-pulse (20-120 mGy per pulse range) electron beams were compared with ferrous sulphate chemical dosimetry, a method independent of the dose per pulse. The results of the comparison support the conclusion that one of the models is more adequate to correct for ion recombination, even in high-dose-per-pulse conditions, provided that the fraction of free electrons is properly assessed. In this respect the drift velocity and the time constant for attachment of electrons in the air of the chamber cavity are rather critical parameters because of their dependence on chamber dimensions and operational conditions. Finally, a determination of the factor k(s) was also made by zero extrapolation of the 1/Q versus 1/V saturation curves, leading to the conclusion that this method does not provide consistent results in high-dose-per-pulse beams.
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Affiliation(s)
- R F Laitano
- Istituto Nazionale di Metrologia delle Radiazioni Ionizzanti, ENEA Centro Ricerche Casaccia, c.p. 2400 Roma, Italy
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Bagni B, Palazzi G, Bagni I, Caporali C, Froehlich W, Casolo A, Caputo C, Rossi S, Garetti E, Pansini F, Corazzari T, De Sanctis V, Massolo F. pQCT (quantitative peripheral tomography) and data evaluation of phosphocalcic metabolism in thalassaemic patients. J Pediatr Endocrinol Metab 1998; 11 Suppl 3:791-4. [PMID: 10091148] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
pQCT is a method which allows the separate determination of cortical and trabecular bone mineral density in the peripheral skeleton. 21 thalassaemic patients (8 females, 13 males) aged from 10 to 32 years, were examined using pQCT at the ultra distal radius to evaluate SSI (Stress-Strain Index). ALP, serum calcium, hydroxyproline, magnesium, IGF-I, and body surface were determined. The results show a good correlation between cortical BMD and age, concentration of hydroxyproline in urine, serum bone Gla protein, body surface index, bone density of trabecular bone and SSI. Good correlation was found between trabecular bone density and age, IGF-I, BGP and PTH, and between SSI and cortical BMD, age and BSI. The linear relationships between age and cortical and trabecular density show an increase of cortical BMD with age and a decrease of trabecular density with age. The same results were obtained considering trabecular and cortical density versus SSI.
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Affiliation(s)
- B Bagni
- Department of Nuclear Medicine, University of Modena, Italy
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Caporali C, Guerra A, Laitano R, Pimpinella M. New basic dosimetry procedure for photon beams used in stereotactic radiotherapy. Radiother Oncol 1995. [DOI: 10.1016/0167-8140(96)80570-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
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Cognetti F, Carlini P, Pinnarò P, Ruggeri EM, Caporali C. Maintenance of antiemetic effect of a metoclopramide-dexamethasone combination during subsequent cisplatin courses. Oncology 1986; 43:292-4. [PMID: 3763123 DOI: 10.1159/000226385] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
In two previous consecutive studies on antiemetic combination of metoclopramide and dexamethasone was found to be very active against nausea and vomiting induced by cisplatin (DDP; 50 mg/m2) alone or in combination with other cytotoxic emetogenic drugs. In the present study the activity of the same antiemetic combination has been followed in 18 patients during subsequent DDP courses. Twelve out of 18 patients (67%) had a complete control of the side effect after the first course of chemotherapy. No statistically significant differences were found as regards the intensity of nausea and vomiting, the patients' overall opinions and preference and the emesis duration. In conclusion this antiemetic combination can guarantee a high degree and long-term control of DDP-induced emesis at a dose of 50 mg/m2 given alone or in combination.
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Cognetti F, Pinnaro P, Carlini P, Caporali C, Ruggeri EM, Pollera CF. Improved control of cisplatin-induced emesis with a metoclopramide-dexamethasone combination. Cancer Chemother Pharmacol 1984; 13:235-7. [PMID: 6541533 DOI: 10.1007/bf00269037] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Twenty-four patients receiving combination chemotherapy including cisplatin at a dosage of 50 mg/m2 were entered on this antiemetic randomized open cross-over study. High-dose dexamethasone (DXM) (regimen A) was compared with the combination of DXM and high doses of metoclopramide (MCP) (regimen B). Five patients (20%) treated with regimen A and 13 (54%) treated with regimen B suffered neither nausea nor vomiting (P less than 0.05). Regimen B was found to be significantly more effective than regimen A for all the parameters of evaluation considered. No severe side-effects were observed.
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Guarneri G, Caporali C, Savoldi R. [Case of protracted apnea due to succinylcholine (duration: 7 hours)]. Minerva Anestesiol 1975; 41:232-8. [PMID: 1134647] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
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