1
|
Jachs M, Hartl L, Simbrunner B, Semmler G, Balcar L, Hofer BS, Schwarz M, Bauer D, Stättermayer AF, Pinter M, Trauner M, Reiberger T, Mandorfer M. Prognostic performance of non-invasive tests for portal hypertension is comparable to that of hepatic venous pressure gradient. J Hepatol 2024; 80:744-752. [PMID: 38218352 DOI: 10.1016/j.jhep.2023.12.028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/06/2023] [Revised: 12/08/2023] [Accepted: 12/20/2023] [Indexed: 01/15/2024]
Abstract
BACKGROUND & AIMS Non-invasive tests to assess the probability of clinically significant portal hypertension (CSPH) - including the ANTICIPATE±NASH models based on liver stiffness measurement and platelet count±BMI, and the von Willebrand factor antigen to platelet count ratio (VITRO) - have fundamentally changed the management of compensated advanced chronic liver disease (cACLD). However, their prognostic utility has not been compared head-to-head to the gold standard for prognostication in cACLD, i.e. the hepatic venous pressure gradient (HVPG). METHODS Patients with cACLD (liver stiffness measurement ≥10 kPa) who underwent advanced characterization via same-day HVPG/non-invasive test assessment from 2007-2022 were retrospectively included. Long-term follow-up data on hepatic decompensation was recorded. RESULTS Four hundred and twenty patients with cACLD of varying etiologies, with a CSPH prevalence of 67.6%, were included. The cumulative incidence of hepatic decompensation at 1 and 2 years was 4.7% and 8.0%, respectively. HVPG, VITRO, and ANTICIPATE±NASH-CSPH-probability showed similar time-dependent prognostic value (AUROCs 0.683-0.811 at 1 year and 0.699-0.801 at 2 years). In competing risk analyses adjusted for MELD score and albumin, HVPG (adjusted subdistribution hazard ratio [aSHR] 1.099 [95% CI 1.054-1.150] per mmHg; p <0.001), or VITRO (aSHR 1.134 [95% CI 1.062-1.211] per unit; p <0.001), or ANTICIPATE±NASH-CSPH-probability (aSHR 1.232 [95% CI 1.094-1.387] per 10%; p <0.001) all predicted first decompensation during follow-up. Previously proposed cut-offs (HVPG ≥10 mmHg vs. <10 mmHg, VITRO ≥2.5 vs. <2.5, and ANTICIPATE-CSPH probability ≥60% vs. <60%) all accurately discriminated between patients at negligible risk and those at substantial risk of hepatic decompensation. CONCLUSIONS The prognostic performance of ANTICIPATE±NASH-CSPH-probability and VITRO is comparable to that of HVPG, supporting their utility for identifying patients who may benefit from medical therapies to prevent first hepatic decompensation. IMPACT AND IMPLICATIONS Non-invasive tests have revolutionized the diagnosis and management of clinically significant portal hypertension in patients with compensated advanced chronic liver disease (cACLD). However, limited data exists regarding the prognostic utility of non-invasive tests in direct comparison to the gold standard for prognostication in cACLD, i.e. the hepatic venous pressure gradient. In our study including 420 patients with cACLD, the ANTICIPATE±NASH model and VITRO yielded similar AUROCs to hepatic venous pressure gradient for hepatic decompensation within 1 to 2 years. Thus, non-invasive tests should be applied and updated in yearly intervals in clinical routine to identify patients at short-term risk, thereby identifying patients who may benefit from treatment aimed at preventing hepatic decompensation.
Collapse
Affiliation(s)
- Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Hartl
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Benedikt Silvester Hofer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Michael Schwarz
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - David Bauer
- Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Department of Internal Medicine IV, Klinik Ottakring, Vienna, Austria
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Hepatic Hemodynamic Lab, Division of Gatroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
2
|
Celsa C, Cabibbo G, Fulgenzi CAM, Scheiner B, D'Alessio A, Manfredi GF, Nishida N, Ang C, Marron TU, Saeed A, Wietharn B, Pinter M, Cheon J, Huang YH, Lee PC, Phen S, Gampa A, Pillai A, Vivaldi C, Salani F, Masi G, Roehlen N, Thimme R, Vogel A, Schönlein M, von Felden J, Schulze K, Wege H, Galle PR, Kudo M, Rimassa L, Singal AG, El Tomb P, Ulahannan S, Parisi A, Chon HJ, Hsu WF, Stefanini B, Verzoni E, Giusti R, Veccia A, Catino A, Aprile G, Guglielmini PF, Di Napoli M, Ermacora P, Antonuzzo L, Rossi E, Verderame F, Zustovich F, Ficorella C, Di Pietro FR, Battelli N, Negrini G, Grossi F, Bordonaro R, Pipitone S, Banzi M, Ricciardi S, Laera L, Russo A, De Giorgi U, Cavanna L, Sorarù M, Montesarchio V, Bordi P, Brunetti L, Pinto C, Bersanelli M, Cammà C, Cortellini A, Pinato DJ. Characteristics and outcomes of immunotherapy-related liver injury in patients with hepatocellular carcinoma versus other advanced solid tumours. J Hepatol 2024; 80:431-442. [PMID: 37972660 DOI: 10.1016/j.jhep.2023.10.040] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/29/2023] [Revised: 10/26/2023] [Accepted: 10/30/2023] [Indexed: 11/19/2023]
Abstract
BACKGROUND & AIMS Immune-related liver injury (irLI) is commonly observed in patients with cancer treated with immune checkpoint inhibitors (ICIs). We aimed to compare the incidence, clinical characteristics, and outcomes of irLI between patients receiving ICIs for hepatocellular carcinoma (HCC) vs. other solid tumours. METHODS Two separate cohorts were included: 375 patients with advanced/unresectable HCC, Child-Pugh A class treated with first-line atezolizumab+bevacizumab from the AB-real study, and a non-HCC cohort including 459 patients treated with first-line ICI therapy from the INVIDIa-2 multicentre study. IrLI was defined as a treatment-related increase of aminotransferase levels after exclusion of alternative aetiologies of liver injury. The incidence of irLI was adjusted for the duration of treatment exposure. RESULTS In patients with HCC, the incidence of any grade irLI was 11.4% over a median treatment exposure of 4.4 months (95% CI 3.7-5.2) vs. 2.6% in the INVIDIa-2 cohort over a median treatment exposure of 12.4 months (95% CI 11.1-14.0). Exposure-adjusted-incidence of any grade irLI was 22.1 per 100-patient-years in patients with HCC and 2.1 per 100-patient-years in patients with other solid tumours (p <0.001), with median time-to-irLI of 1.4 and 4.7 months, respectively. Among patients who developed irLI, systemic corticosteroids were administered in 16.3% of patients with HCC and 75.0% of those without HCC (p <0.001), and irLI resolution was observed in 72.1% and 58.3%, respectively (p = 0.362). In patients with HCC, rates of hepatic decompensation and treatment discontinuation due to irLI were 7%. Grade 1-2 irLI was associated with improved overall survival only in patients with HCC (hazard ratio 0.53, 95% CI 0.29-0.96). CONCLUSIONS Despite higher incidence and earlier onset, irLI in patients with HCC is characterised by higher rates of remission and lower requirement for corticosteroid therapy (vs. irLI in other solid tumours), low risk of hepatic decompensation and treatment discontinuation, not negatively affecting oncological outcomes. IMPACT AND IMPLICATIONS Immune-related liver injury (irLI) is common in patients with cancer receiving immune checkpoint inhibitors (ICIs), but whether irLI is more frequent or it is associated with a worse clinical course in patients with hepatocellular carcinoma (HCC), compared to other tumours, is not known. Herein, we compared characteristics and outcomes of irLI in two prospective cohorts including patients treated with ICIs for HCC or for other oncological indications. irLI is significantly more common and it occurs earlier in patients with HCC, also after adjustment for duration of treatment exposure. However, outcomes of patients with HCC who developed irLI are not negatively affected in terms of requirement for corticosteroid therapy, hepatic decompensation, treatment discontinuation and overall survival.
Collapse
Affiliation(s)
- Ciro Celsa
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, W120HS London, UK; Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, Italy
| | - Giuseppe Cabibbo
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, Italy
| | - Claudia A M Fulgenzi
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, W120HS London, UK; Operative Research Unit of Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy
| | - Bernhard Scheiner
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, W120HS London, UK; Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Antonio D'Alessio
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, W120HS London, UK; Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Giulia F Manfredi
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, W120HS London, UK; Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Naoshi Nishida
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Celina Ang
- Department of Medicine, Division of Hematology/Oncology, Tisch Cancer Institute, Mount Sinai Hospital, New York, NY, USA
| | - Thomas U Marron
- Department of Medicine, Division of Hematology/Oncology, Tisch Cancer Institute, Mount Sinai Hospital, New York, NY, USA
| | - Anwaar Saeed
- Department of Medicine, Division of Hematology & Oncology, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Brooke Wietharn
- Department of Medicine, Division of Medical Oncology, Kansas University Cancer Center, Kansas City, Kansas, USA
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Jaekyung Cheon
- Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Yi-Hsiang Huang
- Healthcare and Services Center, Taipei Veterans General Hospital, Taipei, Taiwan; Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, Taipei, Taiwan; Institute of Clinical Medicine, Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, Taipei, Taiwan; Faculty of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Samuel Phen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Anuhya Gampa
- Section of Gastroenterology, Hepatology & Nutrition, the University of Chicago Medicine 5841 S. Maryland Ave, 60637 Chicago, IL, USA
| | - Anjana Pillai
- Unit of Medical Oncology 2, Azienda Ospedaliero- Universitaria Pisana, Pisa, Italy
| | - Caterina Vivaldi
- Scuola Superiore Sant'Anna Pisa, interdisciplinary research center "Health Science", Pisa, Italy
| | - Francesca Salani
- Unit of Medical Oncology 2, Azienda Ospedaliero- Universitaria Pisana, Pisa, Italy; Scuola Superiore Sant'Anna Pisa, interdisciplinary research center "Health Science", Pisa, Italy
| | - Gianluca Masi
- Unit of Medical Oncology 2, Azienda Ospedaliero- Universitaria Pisana, Pisa, Italy
| | - Natascha Roehlen
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases), Freiburg University Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Robert Thimme
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases), Freiburg University Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Arndt Vogel
- Hannover Medical School, Hannover, Germany; Longo Family Chair in Liver Cancer Research, Division of Gastroenterology and Hepatology, Toronto General Hospital, Medical Oncology, Princess Margaret Cancer Centre, Schwartz Reisman Liver Research Centre, Toronto, Canada
| | - Martin Schönlein
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johann von Felden
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kornelius Schulze
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henning Wege
- Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Peter R Galle
- University Medical Center Mainz, Department of Internal Medicine I, Mainz, Germany
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele, Milan, Italy; Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano, Milan, Italy
| | - Amit G Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, Texas, USA
| | - Paul El Tomb
- Medical Oncology/TSET Phase 1 Program, Stephenson Cancer Center, University of Oklahoma, Oklahoma City
| | - Susanna Ulahannan
- Medical Oncology/TSET Phase 1 Program, Stephenson Cancer Center, University of Oklahoma, Oklahoma City
| | - Alessandro Parisi
- Department of Oncology, Università Politecnica delle Marche, Azienda Ospedaliero-Universitaria delle Marche, 60126 Ancona, Italy
| | - Hong Jae Chon
- Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam, South Korea
| | - Wei-Fan Hsu
- Center for Digestive Medicine, Department of Internal Medicine, China Medical University Hospital, Taichung, Taiwan
| | - Bernardo Stefanini
- Department of Medical and Surgical Sciences, University of Bologna, Italy
| | - Elena Verzoni
- SS. Oncologia Genitourinaria, Fondazione IRCCS Istituto Nazionale dei Tumori, Milano, Italy
| | | | | | - Annamaria Catino
- Medical Thoracic Oncology Unit, IRCCS Istituto Tumori "Giovanni Paolo II", Bari, Italy
| | - Giuseppe Aprile
- Department of Oncology, San Bortolo General Hospital, Vicenza, Italy
| | | | - Marilena Di Napoli
- UC Oncologia Medica Uro-Ginecologica, Istituto Nazionale Tumori "Fondazione G. Pascale", IRCCS, Napoli, Italy
| | - Paola Ermacora
- Dipartimento di Oncologia, Presidio Ospedaliero Universitario Santa Maria della Misericordia, Azienda sanitaria universitaria Integrata Friuli Centrale, Udine, Italy
| | | | - Ernesto Rossi
- Medical Oncology, Fondazione Policlinico Universitario A. Gemelli IRCCS, Rome, Italy
| | | | - Fable Zustovich
- UOC Oncologia di Belluno, Dipartimento di Oncologia Clinica, AULSS 1 Dolomiti, Ospedale S.Martino, Belluno, Italy
| | - Corrado Ficorella
- Department of Biotechnological and Applied Clinical Sciences, St Salvatore Hospital, University of L'Aquila, L'Aquila, Italy
| | | | - Nicola Battelli
- UOC Oncologia, Ospedale Generale Provinciale di Macerata, ASUR Marche Area Vasta 3, Macerata, Italy
| | - Giorgia Negrini
- Medical Oncology Unit, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Grossi
- Medical Oncology Department, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | | | - Stefania Pipitone
- Medical Oncology Unit, University Hospital of Modena e Reggio Emilia, Italy
| | - Maria Banzi
- Medical Oncology Unit, AUSL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | | | - Letizia Laera
- Medical Oncology, Ospedale Generale Regionale F Miulli, Acquaviva delle Fonti, Puglia, Italy
| | - Antonio Russo
- Dipartimento di Discipline Chirurgiche, Oncologiche e Stomatologiche, Università degli Studi di Palermo, Palermo, Italy
| | - Ugo De Giorgi
- Department of Medical Oncology, Istituto Scientifico Romagnolo per lo Studio e la Cura dei Tumori (IRST) IRCCS, Meldola, Italy
| | | | - Mariella Sorarù
- Medical Oncology, Camposampiero Hospital, AULSS 6 Euganea, Padova, Italy
| | - Vincenzo Montesarchio
- UOC Oncologia, Ospedale Monaldi, Azienda Ospedaliera Specialistica dei Colli, Napoli, Italy
| | - Paola Bordi
- Medical Oncology Unit, Medicine and Surgery Department, University of Parma, Parma, Italy
| | - Leonardo Brunetti
- Operative Research Unit of Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy
| | - Carmine Pinto
- Medical Oncology Unit, AUSL-IRCCS of Reggio Emilia, Reggio Emilia, Italy
| | - Melissa Bersanelli
- Medical Oncology Unit, Medicine and Surgery Department, University of Parma, Parma, Italy
| | - Calogero Cammà
- Gastroenterology and Hepatology Unit, Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, University of Palermo, Italy
| | - Alessio Cortellini
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, W120HS London, UK; Operative Research Unit of Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy
| | - David J Pinato
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, W120HS London, UK; Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy.
| |
Collapse
|
3
|
Dekervel J, Casadei-Gardini A, Pinter M. Controversies in upper GI oncology: first-line systemic treatment in MASLD-associated HCC. ESMO Open 2024; 9:102245. [PMID: 38335903 PMCID: PMC10867617 DOI: 10.1016/j.esmoop.2024.102245] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/12/2024] Open
Affiliation(s)
- J Dekervel
- Digestive Oncology, University Hospitals Leuven, Leuven, Belgium.
| | - A Casadei-Gardini
- Department of Medical Oncology, IRCCS San Raffaele Hospital, Milan, Italy
| | - M Pinter
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
4
|
Balcar L, Scheiner B, Fulgenzi CAM, D’Alessio A, Pomej K, Roig MB, Meyer EL, Che J, Nishida N, Lee PC, Wu L, Ang C, Krall A, Saeed A, Stefanini B, Cammarota A, Pressiani T, Abugabal YI, Chamseddine S, Wietharn B, Parisi A, Huang YH, Phen S, Vivaldi C, Salani F, Masi G, Bettinger D, Vogel A, von Felden J, Schulze K, Silletta M, Trauner M, Samson A, Wege H, Piscaglia F, Galle PR, Stauber R, Kudo M, Singal AG, Itani A, Ulahannan SV, Parikh ND, Cortellini A, Kaseb A, Rimassa L, Chon HJ, Pinato DJ, Pinter M. A meta-analysis and real-world cohort study on the sex-related differences in efficacy and safety of immunotherapy for hepatocellular carcinoma. JHEP Rep 2024; 6:100982. [PMID: 38274490 PMCID: PMC10809085 DOI: 10.1016/j.jhepr.2023.100982] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/19/2023] [Revised: 11/15/2023] [Accepted: 11/30/2023] [Indexed: 01/27/2024] Open
Abstract
Background & Aims Sex-related differences in the immune pathogenesis of hepatocellular carcinoma (HCC), particularly related to oestrogen-dependent secretion of pro-tumourigenic cytokines, are well-known. Whether sex influences the efficacy and safety of immunotherapy is not known. Methods We performed a restricted maximum likelihood random effects meta-analysis of five phase III trials that evaluated immune checkpoint inhibitors (ICIs) in advanced HCC and reported overall survival (OS) hazard ratios (HRs) stratified by sex to evaluate sex-related differences in OS. In a real-world cohort of 840 patients with HCC from 22 centres included between 2018 and 2023, we directly compared the efficacy and safety of atezolizumab + bevacizumab (A+B) between sexes. Radiological response was reported according to RECIST v1.1. Uni- and multivariable Cox regression analyses were performed for OS and progression-free survival (PFS). Results In the meta-analysis, immunotherapy was associated with a significant OS benefit only in male (pooled HR 0.79; 95% CI 0.73-0.86) but not in female (pooled HR 0.85; 95% CI 0.70-1.03) patients with HCC. When directly comparing model estimates, no differences in the treatment effect between sexes were observed. Among 840 patients, 677 (81%) were male (mean age 66 ± 11 years), and 163 (19%) were female (mean age 67 ± 12 years). Type and severity of adverse events were similar between the two groups. OS and PFS were comparable between males and females upon uni- and multivariable analyses (aHR for OS and PFS: 0.79, 95% CI 0.59-1.04; 1.02, 95% CI 0.80-1.30, respectively). Objective response rates (24%/22%) and disease control rates (59%/59%) were also similar between sexes. Conclusion Female phase III trial participants experienced smaller OS benefit following ICI therapy for advanced HCC, while outcomes following A+B treatment were comparable between sexes in a large real-world database. Based on the ambiguous sex-related differences in survival observed here, further investigation of sex-specific clinical and biologic determinants of responsiveness and survival following ICIs are warranted. Impact and implications While immune checkpoint inhibitors have emerged as standard of care for the treatment of hepatocellular carcinoma, there are conflicting reports on whether the efficacy of cancer immunotherapy differs between females and males. Our study suggests ambiguous sex-related differences in outcomes from immunotherapy in hepatocellular carcinoma. Further investigation of sex-specific clustering in clinicopathologic and immunologic determinants of responsiveness to immune checkpoint inhibitor therapy should be prioritised. Systematic review registration PROSPERO CRD42023429625.
Collapse
Affiliation(s)
- Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | - Claudia Angela Maria Fulgenzi
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Operative Research Unit of Medical Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy
| | - Antonio D’Alessio
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Katharina Pomej
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Marta Bofill Roig
- Section for Medical Statistics, Center for Medical Data Science, Medical University of Vienna, Vienna, Austria
| | - Elias Laurin Meyer
- Section for Medical Statistics, Center for Medical Data Science, Medical University of Vienna, Vienna, Austria
- Berry Consultants, Vienna, Austria
| | - Jaekyung Che
- Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Centre, CHA University, Seongnam, Republic of Korea
| | - Naoshi Nishida
- Department of Gastroenterology and Hepatology, Kindai University, Faculty of Medicine, Osaka, Japan
| | - Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Linda Wu
- Department of Medicine, Division of Hematology/Oncology, Tisch Cancer Institute, Mount Sinai Hospital, New York, NY, USA
| | - Celina Ang
- Department of Medicine, Division of Hematology/Oncology, Tisch Cancer Institute, Mount Sinai Hospital, New York, NY, USA
| | - Anja Krall
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Anwaar Saeed
- Division of Hematology/Oncology, Department of Medicine, University of Pittsburgh (UPMC), Pittsburgh, PA, USA
| | - Bernardo Stefanini
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Antonella Cammarota
- Drug Development Unit, Sarah Cannon Research Institute UK, London, UK
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (Milan), Italy
| | - Tiziana Pressiani
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Rozzano (Milan), Italy
| | - Yehia I. Abugabal
- Dept of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Shadi Chamseddine
- Dept of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Brooke Wietharn
- Division of Medical Oncology, Department of Medicine, University of Kansas Cancer Center, Westwood, KS, USA
| | - Alessandro Parisi
- Department of Oncology, Università Politecnica delle Marche, Azienda Ospedaliero-Universitaria delle Marche, Ancona, Italy
| | - Yi-Hsiang Huang
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University School of Medicine, Taipei, Taiwan; Healthcare and Services Center, Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Samuel Phen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Caterina Vivaldi
- Unit of Medical Oncology 2, University Hospital of Pisa, Pisa, Italy
| | - Francesca Salani
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Gianluca Masi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, Pisa, Italy
| | - Dominik Bettinger
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology, and Infectious Diseases), Freiburg University Medical Centre, Freiburg, Germany
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Johann von Felden
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Kornelius Schulze
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Marianna Silletta
- Operative Research Unit of Medical Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Adel Samson
- Leeds Institute of Medical Research at St. James's (LIMR), School of Medicine, Faculty of Medicine and Health, University of Leeds, St James's University Hospital, Leeds, UK
| | - Henning Wege
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Hamburg, Germany
| | - Fabio Piscaglia
- Division of Internal Medicine, Hepatobiliary and Immunoallergic Diseases, IRCCS Azienda Ospedaliero-Universitaria di Bologna, Bologna, Italy
| | - Peter R. Galle
- I. Medical Department, University Medical Centre Mainz, Mainz, Germany
| | - Rudolf Stauber
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Medical University of Graz, Graz, Austria
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University, Faculty of Medicine, Osaka, Japan
| | - Amit G. Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Aleena Itani
- Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Susanna V. Ulahannan
- Stephenson Cancer Center, University of Oklahoma Health Sciences Center, Oklahoma City, OK, USA
| | - Neehar D. Parikh
- Department of Internal Medicine, University of Michigan, Ann Arbor, Michigan, USA
| | - Alessio Cortellini
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Operative Research Unit of Medical Oncology, Fondazione Policlinico Universitario Campus Bio-Medico, Via Alvaro del Portillo, 200 - 00128 Roma, Italy
| | - Ahmed Kaseb
- Dept of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, USA
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (Milan), Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Rozzano (Milan), Italy
| | - Hong Jae Chon
- Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Centre, CHA University, Seongnam, Republic of Korea
| | - David J. Pinato
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, London, United Kingdom
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
5
|
Balcar L, Mrekva A, Scheiner B, Pomej K, Meischl T, Mandorfer M, Reiberger T, Trauner M, Tamandl D, Pinter M. Management of varices but not anticoagulation is associated with improved outcome in patients with HCC and macrovascular tumour invasion. Cancer Imaging 2024; 24:9. [PMID: 38217049 PMCID: PMC10787425 DOI: 10.1186/s40644-024-00657-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2023] [Accepted: 01/07/2024] [Indexed: 01/14/2024] Open
Abstract
BACKGROUND & AIMS The value of bleeding prophylaxis and anticoagulation in patients with hepatocellular carcinoma (HCC) and macrovascular tumour invasion (MVI) is unclear. We evaluated the impact of anticoagulation on thrombosis progression, bleeding events, and overall mortality, and assessed the efficacy of adequate management of varices as recommended for patients with cirrhosis. METHODS HCC patients with MVI who had Child-Turcotte-Pugh A-B7 were included between Q4/2002 and Q2/2022. Localization of the tumour thrombus and changes at 3-6 months were evaluated by two radiologists. Univariable and multivariable logistic/Cox regression analyses included time-dependent variables (i.e., anticoagulation, systemic therapy, non-selective beta blocker treatment). RESULTS Of 124 patients included (male: n = 110, 89%), MVI involved the main portal vein in 47 patients (38%), and 49 individuals (40%) had additional non-tumorous thrombus apposition. Fifty of 80 patients (63%) with available endoscopy had varices. Twenty-four individuals (19%) received therapeutic anticoagulation and 94 patients (76%) were treated with effective systemic therapies. The use of therapeutic anticoagulation did not significantly affect the course of the malignant thrombosis at 3-6 months. Systemic therapy (aHR: 0.26 [95%CI: 0.16-0.40]) but not anticoagulation was independently associated with reduced all-cause mortality. In patients with known variceal status, adequate management of varices was independently associated with reduced risk of variceal bleeding (aHR: 0.12 [95%CI: 0.02-0.71]). In the whole cohort, non-selective beta blockers were independently associated with reduced risk of variceal bleeding or death from any cause (aHR: 0.69 [95%CI: 0.50-0.96]). CONCLUSION Adequate bleeding prophylaxis and systemic anti-tumour therapy but not anticoagulation were associated with improved outcomes in patients with HCC and MVI.
Collapse
Affiliation(s)
- Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Arpad Mrekva
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Katharina Pomej
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Tobias Meischl
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
- 3rd Medical Department (Hematology & Oncology), Hanusch Krankenhaus, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria
| | - Dietmar Tamandl
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, Vienna, 1090, Austria.
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
6
|
Pinter M, Reig M, Cabibbo G. Analysis of individual patient data in patients with HCC treated with immunotherapy: A step forward for clinical trial design. Hepatology 2023; 78:1684-1687. [PMID: 37300382 DOI: 10.1097/hep.0000000000000511] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2023] [Accepted: 06/05/2023] [Indexed: 06/12/2023]
Affiliation(s)
- Matthias Pinter
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Maria Reig
- Barcelona Clinic Liver Cancer (BCLC) Group, Liver Oncology Unit, Liver Unit, Hospital Clinic of Barcelona, Barcelona, Spain
- Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Barcelona, Spain
- Centro de Investigación Biomédica en Red en Enfermedades Hepáticas y Digestivas (CIBEREHD), Madrid, Spain
| | - Giuseppe Cabibbo
- Department of Health Promotion, Mother & Child Care, Internal Medicine & Medical Specialties, PROMISE, Gastroenterology & Hepatology Unit, University of Palermo, Palermo, Italy
| |
Collapse
|
7
|
Simbrunner B, Villesen IF, Scheiner B, Paternostro R, Schwabl P, Stättermayer AF, Marculescu R, Pinter M, Quehenberger P, Trauner M, Karsdal M, Lisman T, Reiberger T, Leeming DJ, Mandorfer M. Von Willebrand factor processing in patients with advanced chronic liver disease and its relation to portal hypertension and clinical outcome. Hepatol Int 2023; 17:1532-1544. [PMID: 37605068 PMCID: PMC10661794 DOI: 10.1007/s12072-023-10577-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/05/2023] [Accepted: 07/27/2023] [Indexed: 08/23/2023]
Abstract
BACKGROUND AND AIMS Endothelial dysfunction and portal hypertension (PH) are reflected by increased von Willebrand factor antigen (VWF-Ag) levels in advanced chronic liver disease (ACLD). This study investigated VWF release and cleavage and their association with PH and clinical outcomes. METHODS Levels of VWF-Ag, VWF-N (VWF-propeptide), and VWF-A (VWF processed by the main VWF-cleaving protease ADAMTS13) were assessed in 229 patients with clinically stable ACLD (hepatic venous pressure gradient [HVPG] ≥ 6 mmHg; absence of bacterial infections or acute decompensation) undergoing HVPG-measurement. Liver-healthy individuals served as controls (n = 24). RESULTS VWF-Ag and VWF-N were similarly accurate for the identification of clinically significant PH (CSPH; HVPG ≥ 10 mmHg) in compensated ACLD (AUROC: VWF-Ag 0.748; VWF-N 0.728). ADAMTS13 activity was similar between patients with ACLD and controls and did not correlate with PH and disease severity, whereas VWF cleavage decreased in patients with CSPH (i.e., VWF-Ag/-A-ratio increased). In vitro VWF activity strongly reflected VWF-Ag levels (Spearman's r = 0.874, p < 0.001), but decreased (vs. controls) in patients with CSPH when normalized to VWF-Ag levels (VWF-activity/-Ag-ratio). VWF-Act/-Ag ratio correlated negatively with ADAMTS13 activity (r =- 0.256, p < 0.001). ADAMTS13 activity was independently predictive for (i) portal vein thrombosis (PVT) and (ii) hepatic decompensation or liver-related death. CONCLUSIONS VWF-Ag levels and its propeptide are similarly suitable surrogates of PH in patients with compensated ACLD. ADAMTS13-Act was not linked to disease and PH severity, however, when normalized to VWF-Ag, both VWF cleavage and VWF activity were decreased in patients with CSPH, as compared to liver-healthy individuals. Low ADAMTS13-Act was associated with presumably more procoagulant VWF and adverse outcomes. CLINICAL TRIAL NUMBER NCT03267615.
Collapse
Affiliation(s)
- Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases (LBI-RUD), Vienna, Austria
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Ida Falk Villesen
- Nordic Bioscience, Herlev, Denmark
- University of Copenhagen, Copenhagen, Denmark
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases (LBI-RUD), Vienna, Austria
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Rodrig Marculescu
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | - Peter Quehenberger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
| | | | - Ton Lisman
- Surgical Research Laboratory, Department of Surgery, University of Groningen, University Medical Centre Groningen, Groningen, The Netherlands
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
- Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases (LBI-RUD), Vienna, Austria
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | | | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Waehringer Guertel 18-20, 1090, Vienna, Austria.
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
8
|
Zeng Q, Klein C, Caruso S, Maille P, Allende DS, Mínguez B, Iavarone M, Ningarhari M, Casadei-Gardini A, Pedica F, Rimini M, Perbellini R, Boulagnon-Rombi C, Heurgué A, Maggioni M, Rela M, Vij M, Baulande S, Legoix P, Lameiras S, Bruges L, Gnemmi V, Nault JC, Campani C, Rhee H, Park YN, Iñarrairaegui M, Garcia-Porrero G, Argemi J, Sangro B, D'Alessio A, Scheiner B, Pinato DJ, Pinter M, Paradis V, Beaufrère A, Peter S, Rimassa L, Di Tommaso L, Vogel A, Michalak S, Boursier J, Loménie N, Ziol M, Calderaro J. Artificial intelligence-based pathology as a biomarker of sensitivity to atezolizumab-bevacizumab in patients with hepatocellular carcinoma: a multicentre retrospective study. Lancet Oncol 2023; 24:1411-1422. [PMID: 37951222 DOI: 10.1016/s1470-2045(23)00468-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Revised: 09/13/2023] [Accepted: 09/14/2023] [Indexed: 11/13/2023]
Abstract
BACKGROUND Clinical benefits of atezolizumab plus bevacizumab (atezolizumab-bevacizumab) are observed only in a subset of patients with hepatocellular carcinoma and the development of biomarkers is needed to improve therapeutic strategies. The atezolizumab-bevacizumab response signature (ABRS), assessed by molecular biology profiling techniques, has been shown to be associated with progression-free survival after treatment initiation. The primary objective of our study was to develop an artificial intelligence (AI) model able to estimate ABRS expression directly from histological slides, and to evaluate if model predictions were associated with progression-free survival. METHODS In this multicentre retrospective study, we developed a model (ABRS-prediction; ABRS-P), which was derived from the previously published clustering-constrained attention multiple instance learning (or CLAM) pipeline. We trained the model fit for regression analysis using a multicentre dataset from The Cancer Genome Atlas (patients treated by surgical resection, n=336). The ABRS-P model was externally validated on two independent series of samples from patients with hepatocellular carcinoma (a surgical resection series, n=225; and a biopsy series, n=157). The predictive value of the model was further tested in a series of biopsy samples from a multicentre cohort of patients with hepatocellular carcinoma treated with atezolizumab-bevacizumab (n=122). All samples in the study were from adults (aged ≥18 years). The validation sets were sampled between Jan 1, 2008, to Jan 1, 2023. For the multicentre validation set, the primary objective was to assess the association of high versus low ABRS-P values, defined relative to cross-validation median split thresholds in the first biopsy series, with progression-free survival after treatment initiation. Finally, we performed spatial transcriptomics and matched prediction heatmaps with in situ expression profiles. FINDINGS Of the 840 patients sampled, 641 (76%) were male and 199 (24%) were female. Across the development and validation datasets, hepatocellular carcinoma risk factors included alcohol intake, hepatitis B and C virus infections, and non-alcoholic steatohepatitis. Using cross-validation in the development series, the mean Pearson's correlation between ABRS-P values and ABRS score (mean expression of ABRS genes) was r=0·62 (SD 0·09; mean p<0·0001, SD<0·0001). The ABRS-P generalised well on the external validation series (surgical resection series, r=0·60 [95% CI 0·51-0·68], p<0·0001; biopsy series, r=0·53 [0·40-0·63], p<0·0001). In the 122 patients treated with atezolizumab-bevacizumab, those with ABRS-P-high tumours (n=74) showed significantly longer median progression-free survival than those with ABRS-P-low tumours (n=48) after treatment initiation (12 months [95% CI 7-not reached] vs 7 months [4-9]; p=0·014). Spatial transcriptomics showed significantly higher ABRS score, along with upregulation of various other immune effectors, in tumour areas with high ABRS-P values versus areas with low ABRS-P values. INTERPRETATION Our study indicates that AI applied on hepatocellular carcinoma digital slides is able to serve as a biomarker for progression-free survival in patients treated with atezolizumab-bevacizumab. This approach could be used in the development of inexpensive and fast biomarkers for targeted therapies. The combination of AI heatmaps with spatial transcriptomics provides insight on the molecular features associated with predictions. This methodology could be applied to other cancers or diseases and improve understanding of the biological mechanisms that drive responses to treatments. FUNDING Institut National du Cancer, Fondation ARC, China Scholarship Council, Ligue Contre le Cancer du Val de Marne, Fondation de l'Avenir, Ipsen, and Fondation Bristol Myers Squibb Pour la Recherche en Immuno-Oncologie.
Collapse
Affiliation(s)
- Qinghe Zeng
- Centre d'Histologie, d'Imagerie et de Cytométrie, Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université Paris Cité, Paris, France; Laboratoire d'Informatique Paris Descartes, Université Paris Cité, Paris, France
| | - Christophe Klein
- Centre d'Histologie, d'Imagerie et de Cytométrie, Centre de Recherche des Cordeliers, INSERM, Sorbonne Université, Université Paris Cité, Paris, France
| | - Stefano Caruso
- Université Paris Est Créteil, INSERM, IMRB, Créteil, France; Department of Pathology, Henri Mondor-Albert Chenevier University Hospital, AP-HP, Créteil, France
| | - Pascale Maille
- Université Paris Est Créteil, INSERM, IMRB, Créteil, France; Department of Pathology, Henri Mondor-Albert Chenevier University Hospital, AP-HP, Créteil, France
| | - Daniela S Allende
- Pathology Department and Robert J Tomsich Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, OH, USA
| | - Beatriz Mínguez
- Liver Unit, Hospital Universitario Vall d'Hebron, Barcelona, Spain; Liver Cancer Research Group, Liver Diseases, Vall d'Hebron Institut de Recerca, Barcelona, Spain; Department of Medicine, Universitat Autònoma de Barcelona, Bellaterra, Spain; Centro de Investigación Biomédica en Red de Enfermedades Hepáticas y Digestivas, Instituto de Salud Carlos III, Madrid, Spain
| | - Massimo Iavarone
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Massih Ningarhari
- Centre Hospitalier Universitaire de Lille, Hôpital Huriez, Maladies de l'Appareil Digestif, Lille, France; Université de Lille, INSERM, INFINITE, Lille, France
| | - Andrea Casadei-Gardini
- Department of Oncology, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy
| | | | - Margherita Rimini
- Department of Oncology, Vita-Salute San Raffaele University, IRCCS San Raffaele Scientific Institute Hospital, Milan, Italy
| | - Riccardo Perbellini
- Division of Gastroenterology and Hepatology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Camille Boulagnon-Rombi
- Reims University Hospital, Department of Pathology, Reims, France; Research Unit CNRS UMR 7369 MEDyC, Université de Reims Champagne-Ardenne, Faculté de Médecine de Reims, Reims, France
| | | | - Marco Maggioni
- Department of Pathology, Foundation IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Mohamed Rela
- The Institute of Liver Disease and Transplantation, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Mukul Vij
- Department of Pathology, Dr Rela Institute and Medical Centre, Bharath Institute of Higher Education and Research, Chennai, India
| | - Sylvain Baulande
- Institut Curie Genomics of Excellence NGS Platform, Institut Curie, Paris, France
| | - Patricia Legoix
- Institut Curie Genomics of Excellence NGS Platform, Institut Curie, Paris, France
| | - Sonia Lameiras
- Institut Curie Genomics of Excellence NGS Platform, Institut Curie, Paris, France
| | - Léa Bruges
- Centre Hospitalier Universitaire de Lille, Hôpital Huriez, Maladies de l'Appareil Digestif, Lille, France; Université de Lille, INSERM, INFINITE, Lille, France
| | - Viviane Gnemmi
- Service d'Anatomie Pathologique, Centre de Biologie Pathologique, CHU Lille, Lille, France; JPARC-Jean-Pierre Aubert Research Center, Lille, France
| | - Jean-Charles Nault
- AP-HP Paris Nord, Hôpital Universitaire Avicenne, Service d'Hépatologie, Paris, France; Centre de Recherche des Cordeliers, Sorbonne Université, Paris, France; INSERM, Université de Paris Cité, Functional Genomics of Solid Tumors, Paris, France
| | - Claudia Campani
- Centre de Recherche des Cordeliers, Sorbonne Université, Paris, France; INSERM, Université de Paris Cité, Functional Genomics of Solid Tumors, Paris, France
| | - Hyungjin Rhee
- Department of Radiology, Research Institute of Radiological Science, Center for Clinical Imaging Data Science, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea
| | - Young Nyun Park
- Department of Pathology, Severance Hospital, Yonsei University College of Medicine, Seoul, South Korea; Graduate School of Medical Science, Brain Korea 21 Project, Yonsei University College of Medicine, Seoul, South Korea
| | - Mercedes Iñarrairaegui
- Liver Unit, Clínica Universidad de Navarra, Pamplona, Spain; Department of Internal Medicine, Clínica Universidad de Navarra, Pamplona, Spain; Instituto de Investigación Sanitaria de Navarra, Pamplona, Spain; Centro de Investigación Sanitaria en Red de Enfermedades Hepáticas y Digestivas, Madrid, Spain
| | | | - Josepmaria Argemi
- Liver Unit and HPB Oncology Area, Clínica Universidad de Navarra and CIBEREHD, Pamplona, Spain; Hepatology Program, Centro de Investigación Médica Aplicada, Universidad de Navarra, Pamplona, Spain
| | - Bruno Sangro
- Liver Unit and HPB Oncology Area, Clínica Universidad de Navarra and CIBEREHD, Pamplona, Spain; Hepatology Program, Centro de Investigación Médica Aplicada, Universidad de Navarra, Pamplona, Spain
| | - Antonio D'Alessio
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK; Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - David James Pinato
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK; Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale "A Avogadro", Novara, Italy
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Valérie Paradis
- Centre de Recherche sur l'Inflammation, INSERM 1149, Université Paris Cité, Paris, France; Pathology Department, Beaujon Hospital, AP-HP Nord, Clichy, France
| | - Aurélie Beaufrère
- Centre de Recherche sur l'Inflammation, INSERM 1149, Université Paris Cité, Paris, France; Pathology Department, Beaujon Hospital, AP-HP Nord, Clichy, France
| | - Simon Peter
- Department of Gastroenterology, Hepatology and Endocrinology and Center for Personalized Medicine, Hannover Medical School, Hannover, Germany
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Medical Oncology and Hematology Unit, Humanitas Cancer Center IRCCS Humanitas Research Hospital, Milan, Italy
| | - Luca Di Tommaso
- Department of Biomedical Sciences, Humanitas University, Milan, Italy; Pathology Unit, Humanitas Cancer Center IRCCS Humanitas Research Hospital, Milan, Italy
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology and Center for Personalized Medicine, Hannover Medical School, Hannover, Germany
| | - Sophie Michalak
- Laboratoire HIFIH, EA 3859, Université d'Angers, Angers, France; Angers University Hospital, Department of Pathology, Angers, France
| | - Jérôme Boursier
- Service d'Hépato-Gastroentérologie et Oncologie Digestive, Centre Hospitalier Universitaire d'Angers, Angers, France; Laboratoire Hémodynamique, Interaction Fibrose et Invasivité Tumorales Hépatiques, University Paris Research, Structure Fédérative de Recherche, Interactions Cellulaires et Applications Thérapeutiques 4208, University of Angers, Angers, France
| | - Nicolas Loménie
- Laboratoire d'Informatique Paris Descartes, Université Paris Cité, Paris, France
| | - Marianne Ziol
- Centre de Ressources Biologiques (BB-0033-00027) Hôpitaux Universitaires Paris-Seine-Saint-Denis, AP-HP, Bobigny, France; Service d'Anatomie Pathologique, Hôpital Avicenne, Hôpitaux Universitaires Paris-Seine-Saint-Denis, AP-HP, Bobigny, France
| | - Julien Calderaro
- Université Paris Est Créteil, INSERM, IMRB, Créteil, France; Department of Pathology, Henri Mondor-Albert Chenevier University Hospital, AP-HP, Créteil, France.
| |
Collapse
|
9
|
Dharmapuri S, Özbek U, Jethra H, Jun T, Marron TU, Saeed A, Huang YH, Muzaffar M, Pinter M, Balcar L, Fulgenzi C, Amara S, Weinmann A, Personeni N, Scheiner B, Pressiani T, Navaid M, Bengsch B, Paul S, Khan U, Bettinger D, Nishida N, Mohamed YI, Vogel A, Gampa A, Korolewicz J, Cammarota A, Kaseb A, Galle PR, Pillai A, Wang YH, Cortellini A, Kudo M, D’Alessio A, Rimassa L, Pinato DJ, Ang C. Baseline neutrophil-lymphocyte ratio and platelet-lymphocyte ratio appear predictive of immune treatment related toxicity in hepatocellular carcinoma. World J Gastrointest Oncol 2023; 15:1900-1912. [DOI: 10.4251/wjgo.v15.i11.1900] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/21/2023] [Revised: 09/14/2023] [Accepted: 10/23/2023] [Indexed: 11/15/2023] Open
Abstract
BACKGROUND A well-recognized class effect of immune checkpoint inhibitors (ICI) is immune-related adverse events (IrAEs) ranging from low grade toxicities to life-threatening end organ damage requiring permanent discontinuation of ICI. Deaths are reported in < 5% of patients treated with ICI. There are, however, no reliable markers to predict the onset and severity of IrAEs. We tested the association between neutrophil-lymphocyte ratio (NLR) and platelet-lymphocyte ratio (PLR) at baseline with development of clinically significant IrAEs (grade ≥ 2) in hepatocellular carcinoma (HCC) patients treated with ICI.
AIM To test the association between NLR and PLR at baseline with development of clinically significant IrAEs (grade ≥ 2) in HCC patients treated with ICI.
METHODS Data was extracted from an international database from a consortium of 11 tertiary-care referral centers. NLR = absolute neutrophil count/absolute lymphocyte count (ALC) and PLR = platelet count/ALC. Cutoff of 5 was used for NLR and 300 for PLR based on literature. We also tested the association between antibiotic and steroid exposure to IrAEs.
RESULTS Data was collected from 361 patients treated between 2016-2020 across the United States (67%), Asia (14%) and Europe (19%). Most patients received Nivolumab (n = 255, 71%). One hundred sixty-seven (46%) patients developed at least one IrAE, highest grade 1 in 80 (48%), grade ≥ 2 in 87 (52%) patients. In a univariable regression model PLR > 300 was significantly associated with a lower incidence of grade ≥ 2 IrAEs (OR = 0.40; P = 0.044). Similarly, a trend was observed between NLR > 5 and lower incidence of grade ≥ 2 IrAEs (OR = 0.58; P = 0.097). Multivariate analyses confirmed PLR > 300 as an independent predictive marker of grade ≥ 2 IrAEs (OR = 0.26; P = 0.011), in addition to treatment with programmed cell death ligand 1 (PD-1)/cytotoxic T lymphocyte-associated protein-4 (OR = 2.57; P = 0.037) and PD-1/tyrosine kinase inhibitor (OR = 3.39; P = 0.01) combinations. Antibiotic use was not associated with IrAE incidence (OR = 1.02; P = 0.954). Patients treated with steroids had a > 2-fold higher incidence of grade ≥ 2 IrAEs (OR = 2.74; P < 0.001), although 74% were prescribed steroids for the treatment of IrAEs.
CONCLUSION Given that high baseline NLR and PLR are associated with a decreased incidence of IrAEs, lower baseline NLR and PLR may be predictive biomarkers for the appearance of IrAEs in HCC treated with ICI. This finding is in keeping with several studies in solid tumors that have shown that baseline NLR and PLR appear predictive of IrAEs.
Collapse
Affiliation(s)
- Sirish Dharmapuri
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Umut Özbek
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Hiren Jethra
- Department of Data Analytics Harrisburg, Harrisburg University of Science and Technology, Harrisburd, PA 17101, United States
| | - Tomi Jun
- SEMA4, Stamford, CT 06902, United States
| | - Thomas U Marron
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| | - Anwaar Saeed
- Division of Medical Oncology Kansas, University of Kansas Cancer Center, Kansas, MO 66160, United States
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Mahvish Muzaffar
- Department of Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC 27858, United States
| | - Matthias Pinter
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna 1090, Austria
| | - Lorenz Balcar
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna 1090, Austria
| | - Claudia Fulgenzi
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital London, London W12 0HS, United Kingdom
| | - Suneetha Amara
- Department of Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC 27858, United States
| | - Arndt Weinmann
- Department of Hepatology, Johannes Gutenberg-University Medical Centre, Niedersachsen 30625, Germany
| | - Nicola Personeni
- Medical Oncology Unit, ASST Garda, Via Lungomella Valsecchi, Brescia, Manerbio 25025, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Milan, Rozzano 20089, Italy
| | - Bernhard Scheiner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna 1090, Austria
| | - Tiziana Pressiani
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Milan, Rozzano 20089, Italy
| | - Musharraf Navaid
- Department of Internal Medicine, Brody School of Medicine, East Carolina University, Greenville, NC 27858, United States
| | - Bertram Bengsch
- Department of Medicine II, Univ Med Ctr Freiburg, Hugstetter Str 55, University Hospital Freiburg, Freiburg D-79106, Germany
| | - Sonal Paul
- Department of Oncology Baltimore, LifeBridge Health, Baltimore, MD 21215, United States
| | - Uqba Khan
- Division of Hematology and Oncology, Weill Cornell Medical College, NY 10065, United States
| | - Dominik Bettinger
- Department of Medicine II, Univ Med Ctr Freiburg, Hugstetter Str 55, University Hospital Freiburg, Freiburg D-79106, Germany
| | - Naoshi Nishida
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka 577-8502, Japan
| | - Yehia Ibrahim Mohamed
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Arndt Vogel
- Department of Gastroenterology Hepatology and Endocrinology, HannoverArndt Vogel, Medical School Hannover, Carl-Neubergstr., Hannover 30659, Germany
| | - Anuhya Gampa
- Department of Hepatology, Rush University Medical Group 1725 W Harrison St Ste 158, Chicago, IL 60612, United States
| | - James Korolewicz
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital London, London W12 0HS, United Kingdom
| | - Antonella Cammarota
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Milan, Rozzano 20089, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Milan, Pieve Emanuele 20072, Italy
| | - Ahmed Kaseb
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Peter R Galle
- Department of Internal Medicine I and Cirrhosis Center Mainz, University Medical Center Mainz, Johannes Gutenberg Univ Mainz, Med Klin and Poliklin, Mainz D-55131, Germany
| | - Anjana Pillai
- Department of Gastroenterology, Hepatology, and Nutrition, University of Chicago Medical Center, Chicago, IL 60637, United States
| | - Ying-Hong Wang
- Department of Gastroenterology, Hepatology and Nutrition, The University of Texas MD Anderson Cancer Center, Houston, TX 77030, United States
| | - Alessio Cortellini
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital London, London W12 0HS, United Kingdom
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka 577-8502, Japan
| | - Antonio D’Alessio
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital London, London W12 0HS, United Kingdom
| | - Lorenza Rimassa
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Milan, Rozzano 20089, Italy
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Milan, Pieve Emanuele 20072, Italy
| | - David James Pinato
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital London, London W12 0HS, United Kingdom
| | - Celina Ang
- Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, United States
| |
Collapse
|
10
|
Manfredi GF, Celsa C, John C, Jones C, Acuti N, Scheiner B, Fulgenzi CAM, Korolewicz J, Pinter M, Gennari A, Mauri FA, Pirisi M, Minisini R, Vincenzi F, Burlone M, Rigamonti C, Donadon M, Cabibbo G, D’Alessio A, Pinato DJ. Mechanisms of Resistance to Immunotherapy in Hepatocellular Carcinoma. J Hepatocell Carcinoma 2023; 10:1955-1971. [PMID: 37941812 PMCID: PMC10629523 DOI: 10.2147/jhc.s291553] [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] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2023] [Accepted: 10/24/2023] [Indexed: 11/10/2023] Open
Abstract
Systemic treatment for advanced hepatocellular carcinoma (HCC) has been revolutionized over the last few years following the approval of immune checkpoint inhibitors (ICI). Despite the promising survival extension seen with ICI combination regimens, responses are not universally seen and the optimal partner for programmed cell death 1 pathway inhibitors remains to be identified. Even fewer encouraging results have been demonstrated with ICI used for monotherapy. Several mechanisms of resistance have been described so far, involving characteristics of cancer cells (intrinsic mechanisms) and of the surrounding tumor microenvironment (extrinsic mechanisms). Factors related to therapy may also contribute to the development of resistance. Increasing research efforts are being dedicated to the discovery of novel approaches and targets to overcome resistance, some of which may be introduced into clinic in the future. Herein we describe a selection of resistance mechanisms that have been involved in impairing response to ICI and propose potential therapeutic approaches to overcome resistance.
Collapse
Affiliation(s)
- Giulia Francesca Manfredi
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London, UK
- Department of Translational Medicine, Università Del Piemonte Orientale, Novara, Italy
| | - Ciro Celsa
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London, UK
- Section of Gastroenterology & 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
| | - Chloe John
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London, UK
| | - Charlotte Jones
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London, UK
| | - Nicole Acuti
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London, UK
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Claudia Angela Maria Fulgenzi
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London, UK
- Department of Medical Oncology, University Campus Bio-Medico of Rome, Rome, Italy
| | - James Korolewicz
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London, UK
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alessandra Gennari
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Francesco A Mauri
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London, UK
| | - Mario Pirisi
- Department of Translational Medicine, Università Del Piemonte Orientale, Novara, Italy
- Division of Internal Medicine, AOU Maggiore della Carità, Novara, Italy
| | - Rosalba Minisini
- Department of Translational Medicine, Università Del Piemonte Orientale, Novara, Italy
| | - Federica Vincenzi
- Department of Translational Medicine, Università Del Piemonte Orientale, Novara, Italy
| | - Michela Burlone
- Division of Internal Medicine, AOU Maggiore della Carità, Novara, Italy
| | - Cristina Rigamonti
- Department of Translational Medicine, Università Del Piemonte Orientale, Novara, Italy
- Division of Internal Medicine, AOU Maggiore della Carità, Novara, Italy
| | - Matteo Donadon
- Department of Health Science, Università Del Piemonte Orientale, Novara, Italy
- Department of Surgery, University Maggiore Hospital della Carità, Novara, Italy
| | - Giuseppe Cabibbo
- Section of Gastroenterology & Hepatology, Department of Health Promotion, Mother and Child Care, Internal Medicine and Medical Specialties, PROMISE, University of Palermo, Palermo, Italy
| | - Antonio D’Alessio
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London, UK
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - David James Pinato
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London, UK
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| |
Collapse
|
11
|
Joerg V, Scheiner B, D´Alessio A, Fulgenzi CA, Schönlein M, Kocheise L, Lohse AW, Huber S, Wege H, Kaseb A, Wang Y, Mathew A, Kuang A, Muzaffar M, Abugabal YI, Chamseddine S, Phen S, Cheon J, Lee PC, Balcar L, Krall A, Ang C, Wu L, Saeed A, Huang YH, Bengsch B, Rimassa L, Weinmann A, Stauber R, Korolewicz J, Pinter M, Singal AG, Chon HJ, Pinato DJ, Schulze K, von Felden J. Efficacy and safety of atezolizumab/bevacizumab in patients with HCC after prior systemic therapy: A global, observational study. Hepatol Commun 2023; 7:e0302. [PMID: 37889520 PMCID: PMC10615429 DOI: 10.1097/hc9.0000000000000302] [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] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/27/2023] [Accepted: 08/03/2023] [Indexed: 10/28/2023] Open
Abstract
BACKGROUND Since the introduction of the combination treatment of anti-programmed death-ligand 1 antibody atezolizumab and anti-VEGF antibody bevacizumab (AB), median overall survival in HCC has drastically improved. However, evidence on the efficacy and safety of the novel treatment standard in patients with prior exposure to systemic treatment is scarce. The aim of this global, multicenter, observational study was to evaluate the efficacy and safety of AB in patients after previous systemic therapy. METHODS We screened our global, multicenter, prospectively maintained registry database for patients who received any systemic therapy before AB. The primary end point was overall survival; secondary end points were time-to-progression, progression-free survival, objective response rate, and safety (rate and severity of adverse events). RESULTS Among 493 patients who received AB for unresectable HCC, 61 patients received prior systemic therapy and were included in this analysis. The median age of the study population was 66 years, with 91.8% males. Predominant risk factors for HCC were viral hepatitis (59%) and alcohol (23%). Overall survival for AB was 16.2 (95% CI, 14.5-17.9) months, time-to-progression and progression-free survival were 4.1 (95% CI, 1.5-6.6) and 3.1 (95% CI, 1.1-5.1) months, respectively. The objective response rate was 38.2% (7.3% with complete and 30.9% with partial response). Overall survival was not influenced by treatment line (2nd vs. >2nd) or previous systemic treatment modality (tyrosine kinase inhibitors vs. immune checkpoint inhibitors). Treatment-related adverse events of all grades according to Common Terminology Criteria for Adverse Events were documented in 42.6% of patients, with only 13.1% of grade ≥3, including one death. CONCLUSION In this observational study, AB emerges as a safe and efficacious treatment option in patients with HCC previously treated with other systemic therapy.
Collapse
Affiliation(s)
- Vincent Joerg
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Bernhard Scheiner
- Department of Surgery & Cancer, Imperial College London, UK
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Austria
| | | | - Claudia A.M. Fulgenzi
- Department of Surgery & Cancer, Imperial College London, UK
- Division of Medical Oncology, Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Martin Schönlein
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Lorenz Kocheise
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ansgar W. Lohse
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Samuel Huber
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henning Wege
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Ahmed Kaseb
- Department of Gastrointestinal Medical Oncology, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology & Nutrition, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Antony Mathew
- Department of Internal Medicine, University of Texas Health Science Center, Houston, Texas, USA
| | - Andrew Kuang
- Department of Internal Medicine, Baylor College of Medicine, Houston, Texas, USA
| | - Mahvish Muzaffar
- Division of Hematology and Oncology, East Carolina University, Greenville, North Carolina, USA
| | - Yehia I. Abugabal
- Department of Gastrointestinal Medical Oncology, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Shadi Chamseddine
- Department of Gastrointestinal Medical Oncology, MD Anderson Cancer Center, University of Texas, Houston, Texas, USA
| | - Samuel Phen
- Department of Internal Medicine, Southwestern Medical Center, University of Texas, USA
| | - Jaekyung Cheon
- Department of Internal Medicine, Medical Oncology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - Pei-Chang Lee
- Department of Medicine, Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, Taipei
| | - Lorenz Balcar
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Austria
| | - Anja Krall
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Austria
| | - Celina Ang
- Department of Medicine, Division of Hematology/Oncology, Tisch Cancer Institute, Mount Sinai Hospital, New York, New York, USA
| | - Linda Wu
- Department of Medicine, Division of Hematology/Oncology, Tisch Cancer Institute, Mount Sinai Hospital, New York, New York, USA
| | - Anwaar Saeed
- Department of Medicine, Division of Hematology/Oncology, University of Pittsburgh (UPMC), Pittsburgh, Pennsylvania, USA
| | - Yi-Hsiang Huang
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University School of Medicine; Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Bertram Bengsch
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases), Freiburg University Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
- Partner Site Freiburg, German Cancer Consortium (DKTK), Heidelberg, Germany
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Milan, Italy
| | - Arndt Weinmann
- Department of Internal Medicine I, University Medical Centre of the Johannes Gutenberg University, Mainz, Germany
| | - Rudolf Stauber
- Department of Internal Medicine, Division of Gastroenterology and Hepatology, Medical University of Graz, Austria
| | | | - Matthias Pinter
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Austria
| | - Amit G. Singal
- Department of Internal Medicine, Southwestern Medical Center, University of Texas, USA
| | - Hong Jae Chon
- Department of Internal Medicine, Medical Oncology, CHA Bundang Medical Center, CHA University, Seongnam, Republic of Korea
| | - David J. Pinato
- Department of Surgery & Cancer, Imperial College London, UK
- Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Kornelius Schulze
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johann von Felden
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| |
Collapse
|
12
|
Scheiner B, Lampichler K, Pomej K, Beer L, Balcar L, Sartoris R, Bouattour M, Sidali S, Trauner M, Mandorfer M, Reiberger T, Scharitzer M, Tamandl D, Pinato DJ, Ronot M, Pinter M. Transversal psoas muscle thickness measurement is associated with response and survival in patients with HCC undergoing immunotherapy. Hepatol Commun 2023; 7:e0261. [PMID: 37708441 PMCID: PMC10503692 DOI: 10.1097/hc9.0000000000000261] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/23/2023] [Accepted: 07/18/2023] [Indexed: 09/16/2023] Open
Abstract
BACKGROUND Sarcopenia is a common problem in patients with HCC. We aimed to evaluate the prognostic and predictive value of baseline transversal psoas muscle thickness (TPMT) measurement in patients with HCC undergoing immunotherapy. METHODS HCC patients treated with programmed death ligand 1-based therapies between June 2016 and October 2022 at the Vienna General Hospital (n = 80) and the Hôpital Beaujon Clichy (n = 96) were included and followed until April 2023. TPMT at the level of the third lumbar vertebra was measured independently by 2 radiologists to evaluate interreader reliability. TPMT <12 mm/m in men and <8 mm/m in women indicated sarcopenia. RESULTS Overall, 176 patients (age: 66.3±11.7 y; male: n=143, 81%, Barcelona-Clinic Liver Cancer C: n=121, 69%) were included, of which 131 (74%) exhibited cirrhosis. Interreader agreement for the diagnosis of sarcopenia based on TPMT was 92.6%, and Cohen κ showed a "strong agreement" [κ = 0.84 (95% CI: 0.75-0.92)]. Sarcopenia, present in 58 patients (33%), was associated with shorter median overall survival [7.2 (95% CI: 5.0-9.5) vs. 22.6 (95% CI: 16.4-28.8 months); p < 0.001] and median progression-free survival [3.4 (95% CI: 0.2-6.8) vs. 7.9 (95% CI: 5.8-9.9 months), p = 0.001], and an independent predictor of overall [adjusted HR: 1.63 (95% CI: 1.07-2.48)] and progression-free mortality [adjusted HR: 1.54 (95% CI: 1.06-2.23)] in multivariable analyses. The objective response rate [evaluable in 162 subjects (92.0%)] per modified Response Evaluation Criteria In Solid Tumors (mRECIST) in patients with and without sarcopenia was 22% and 39%, respectively (p = 0.029). Survival and radiological responses were worse in patients with sarcopenia and systemic inflammation [median overall survival: 6.1 (95% CI: 3.6-8.6) mo; median progression-free survival: 2.8 (95% CI: 2.1-3.4) mo; objective response rate=16%; disease control rate=39%]. CONCLUSIONS Evaluation of sarcopenia using TPMT measurement is reliable and identifies HCC patients with a dismal prognosis and response to immunotherapy.
Collapse
Affiliation(s)
- Bernhard Scheiner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Department of Surgery and Cancer, Imperial College London, London, UK
| | - Katharina Lampichler
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Katharina Pomej
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Lucian Beer
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Lorenz Balcar
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Riccardo Sartoris
- Department of Radiology, Beaujon Hospital, APHP.Nord, Hôpital Beaujon, Clichy, France
| | - Mohamed Bouattour
- Department of Digestive Oncology, APHP.Nord, Hôpital Beaujon, Clichy, France
| | - Sabrina Sidali
- Department of Digestive Oncology, APHP.Nord, Hôpital Beaujon, Clichy, France
| | - Michael Trauner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Martina Scharitzer
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - Dietmar Tamandl
- Department of Biomedical Imaging and Image-Guided Therapy, Medical University of Vienna, Vienna, Austria
| | - David J. Pinato
- Department of Surgery and Cancer, Imperial College London, London, UK
- Department of Translational Medicine, Division of Oncology, University of Piemonte Orientale, Novara, Italy
| | - Maxime Ronot
- Department of Radiology, Beaujon Hospital, APHP.Nord, Hôpital Beaujon, Clichy, France
- Université Paris Cité, CRI INSERM U1149, Paris, France
| | - Matthias Pinter
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
13
|
Xie E, Yeo YH, Scheiner B, Zhang Y, Hiraoka A, Tantai X, Fessas P, de Castro T, D’Alessio A, Fulgenzi CAM, Xu S, Tsai HM, Kambhampati S, Wang W, Keenan BP, Gao X, Xing Z, Pinter M, Lin YJ, Guo Z, Vogel A, Tanaka T, Kuo HY, Kelley RK, Kudo M, Yang JD, Pinato DJ, Ji F. Immune Checkpoint Inhibitors for Child-Pugh Class B Advanced Hepatocellular Carcinoma: A Systematic Review and Meta-Analysis. JAMA Oncol 2023; 9:1423-1431. [PMID: 37615958 PMCID: PMC10450588 DOI: 10.1001/jamaoncol.2023.3284] [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] [Received: 02/27/2023] [Accepted: 05/24/2023] [Indexed: 08/25/2023]
Abstract
Importance Immune checkpoint inhibitors (ICIs) are increasingly used in patients with advanced hepatocellular carcinoma (HCC). However, data on ICI therapy in patients with advanced HCC and impaired liver function are scarce. Objective To conduct a systematic review and meta-analysis to determine the efficacy and safety of ICI treatment for advanced HCC with Child-Pugh B liver function. Data Sources PubMed, Embase, Web of Science, and Cochrane Library were searched for relevant studies from inception through June 15, 2022. Study Selection Randomized clinical trials, cohort studies, or single-group studies that investigated the efficacy or safety of ICI therapy for Child-Pugh B advanced HCC were included. Data Extraction and Synthesis The Preferred Reporting Items for Systematic Reviews and Meta-Analysis guideline was followed to extract data. A random-effects model was adopted if the heterogeneity was significant (I2 > 50%); otherwise, a fixed-effect model was used. Main Outcomes and Measures The objective response rate (ORR) and overall survival (OS) were considered to be the primary efficacy outcomes of ICI treatment for Child-Pugh B advanced HCC, and the incidence of treatment-related adverse events (trAEs) was set as the primary measure for the safety outcome. Results A total of 22 studies including 699 patients with Child-Pugh B and 2114 with Child-Pugh A advanced HCC comprised the analytic sample (median age range, 53-73 years). Upon pooled analysis, patients treated with ICIs in the Child-Pugh B group had an ORR of 14% (95% CI, 11%-17%) and disease control rate (DCR) of 46% (95% CI, 36%-56%), with a median OS of 5.49 (95% CI, 3.57-7.42) months and median progression-free survival of 2.68 (95% CI, 1.85-3.52) months. The rate of any grade trAEs in the Child-Pugh B group was 40% (95% CI, 34%-47%) and of grade 3 or higher trAEs was 12% (95% CI, 6%-23%). Compared with the Child-Pugh A group, the ORR (odds ratio, 0.59; 95% CI, 0.43-0.81; P < .001) and DCR (odds ratio, 0.64; 95% CI, 0.50-0.81; P < .001) were lower in the Child-Pugh B group. Child-Pugh B was independently associated with worse OS in patients with advanced HCC treated with ICIs (hazard ratio, 2.72 [95% CI, 2.34-3.16]; adjusted hazard ratio, 2.33 [95% CI, 1.81-2.99]). However, ICIs were not associated with increased trAEs in the Child-Pugh B group. Conclusions and Relevance The findings of this systematic review and meta-analysis suggest that although the safety of ICI treatment was comparable between patients with HCC with vs without advanced liver disease and the treatment resulted in a significant number of radiologic responses, survival outcomes are still inferior in patients with worse liver function. More study is needed to determine the effectiveness of ICI treatment in this population.
Collapse
Affiliation(s)
- Enrui Xie
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Yee Hui Yeo
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California
| | - Bernhard Scheiner
- Department of Surgery and Cancer, Imperial College London, United Kingdom
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Yue Zhang
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- The Eighth Hospital of Xi’an City, Xi’an Jiaotong University, Shaanxi, China
| | - Atsushi Hiraoka
- Gastroenterology Center, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Xinxing Tantai
- Department of Gastroenterology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Petros Fessas
- Department of Surgery and Cancer, Imperial College London, United Kingdom
| | - Tiago de Castro
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Antonio D’Alessio
- Department of Surgery and Cancer, Imperial College London, United Kingdom
| | | | - Shuo Xu
- Department of Rheumatology and Immunology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Hong-Ming Tsai
- Department of Diagnostic Radiology, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Swetha Kambhampati
- Department of Hematology and Hematopoietic Stem Cell Transplantation, City of Hope National Medical Center, Duarte, California
| | - Wenjun Wang
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Bridget P. Keenan
- Division of Hematology/Oncology, Department of Medicine, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco
| | - Xu Gao
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Department of Gastroenterology, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Zixuan Xing
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria
| | - Yih-Jyh Lin
- Department of Surgery, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Zhanjun Guo
- Department of Rheumatology and Immunology, The Fourth Hospital of Hebei Medical University, Shijiazhuang, China
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology, Infectious Diseases and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Takaaki Tanaka
- Gastroenterology Center, Ehime Prefectural Central Hospital, Matsuyama, Japan
| | - Hsin-Yu Kuo
- Department of Internal Medicine, National Cheng Kung University Hospital, College of Medicine, National Cheng Kung University, Tainan, Taiwan
- Institute of Clinical Medicine, College of Medicine, National Cheng Kung University, Tainan, Taiwan
| | - Robin K. Kelley
- Division of Hematology/Oncology, Department of Medicine, Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Ju Dong Yang
- Karsh Division of Gastroenterology and Hepatology, Cedars-Sinai Medical Center, Los Angeles, California
- Samuel Oschin Comprehensive Cancer Institute, Cedars-Sinai Medical Center, Los Angeles, California
| | - David J. Pinato
- Department of Surgery and Cancer, Imperial College London, United Kingdom
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale “A Avogadro,” Novara, Italy
| | - Fanpu Ji
- Department of Infectious Diseases, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- National and Local Joint Engineering Research Center of Biodiagnosis and Biotherapy, The Second Affiliated Hospital of Xi’an Jiaotong University, Xi’an, China
- Shaanxi Provincial Clinical Medical Research Center of Infectious Diseases, Xi’an, China
- Key Laboratory of Surgical Critical Care and Life Support (Xi’an Jiaotong University), Ministry of Education, Xi’an, China
| |
Collapse
|
14
|
Breitenecker K, Hedrich V, Pupp F, Chen D, Řezníčková E, Ortmayr G, Huber H, Weber G, Balcar L, Pinter M, Mikulits W. Synergism of the receptor tyrosine kinase Axl with ErbB receptors mediates resistance to regorafenib in hepatocellular carcinoma. Front Oncol 2023; 13:1238883. [PMID: 37746265 PMCID: PMC10514905 DOI: 10.3389/fonc.2023.1238883] [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] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2023] [Accepted: 08/22/2023] [Indexed: 09/26/2023] Open
Abstract
Introduction Hepatocellular carcinoma (HCC) patients at advanced stages receive immunotherapy or treatment with tyrosine kinase inhibitors (TKIs) such as Sorafenib (Sora) or Lenvatinib in frontline as well as Regorafenib (Rego) or Cabozantinib in second-line. A major hindrance of TKI therapies is the development of resistance, which renders drug treatment futile and results in HCC progression. Methods In this study, we addressed the impact of the receptor tyrosine kinase Axl binding to its ligand Gas6 in acquiring refractoriness to TKIs. The initial responses of Axl-positive and Axl-negative cell lines to different TKIs were assessed. Upon inducing resistance, RNA-Seq, gain- and loss-of-function studies were applied to understand and intervene with the molecular basis of refractoriness. Secretome analysis was performed to identify potential biomarkers of resistance. Results We show that HCC cells exhibiting a mesenchymal-like phenotype were less sensitive to drug treatment, linking TKI resistance to changes in epithelial plasticity. Gas6/Axl expression and activation were upregulated in Rego-resistant HCC cells together with the induction of ErbB receptors, whereas HCC cells lacking Axl failed to stimulate ErbBs. Treatment of Rego-insensitive HCC cells with the pan-ErbB family inhibitor Afatinib rather than with Erlotinib blocking ErbB1 reduced cell viability and clonogenicity. Genetic intervention with ErbB2-4 but not ErbB1 confirmed their crucial involvement in refractoriness to Rego. Furthermore, Rego-resistant HCC cells secreted basic fibroblast growth factor (bFGF) depending on Axl expression. HCC patients treated with Sora in first-line and with Rego in second-line displayed elevated serum levels of bFGF, emphasizing bFGF as a predictive biomarker of TKI treatment. Discussion Together, these data suggest that the inhibition of ErbBs is synthetic lethal with Rego in Axl-expressing HCC cells, showing a novel vulnerability of HCC.
Collapse
Affiliation(s)
- Kristina Breitenecker
- Center for Cancer Research, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Viola Hedrich
- Center for Cancer Research, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Franziska Pupp
- Center for Cancer Research, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Doris Chen
- Department of Chromosome Biology, Max Perutz Labs Vienna, University of Vienna, Vienna, Austria
| | - Eva Řezníčková
- Center for Cancer Research, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
- Department of Experimental Biology, Faculty of Science, Palacký University Olomouc, Olomouc, Czechia
| | - Gregor Ortmayr
- Center for Cancer Research, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Heidemarie Huber
- Center for Cancer Research, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Gerhard Weber
- Center for Cancer Research, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| | - Lorenz Balcar
- Department of Internal Medicine III, Division of Gastroenterology & Hepatology, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Department of Internal Medicine III, Division of Gastroenterology & Hepatology, Medical University of Vienna, Vienna, Austria
| | - Wolfgang Mikulits
- Center for Cancer Research, Comprehensive Cancer Center, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
15
|
Vithayathil M, D'Alessio A, Fulgenzi CAM, Nishida N, Schönlein M, von Felden J, Schulze K, Wege H, Saeed A, Wietharn B, Hildebrand H, Wu L, Ang C, Marron TU, Weinmann A, Galle PR, Bettinger D, Bengsch B, Vogel A, Balcar L, Scheiner B, Lee PC, Huang YH, Amara S, Muzaffar M, Naqash AR, Cammarota A, Zanuso V, Pressiani T, Pinter M, Cortellini A, Kudo M, Rimassa L, Pinato DJ, Sharma R. Impact of body mass index in patients receiving atezolizumab plus bevacizumab for hepatocellular carcinoma. Hepatol Int 2023; 17:904-914. [PMID: 37005953 PMCID: PMC10386929 DOI: 10.1007/s12072-023-10491-3] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2022] [Accepted: 01/16/2023] [Indexed: 04/04/2023]
Abstract
BACKGROUND Atezolizumab plus bevacizumab (Atezo/Bev) is first line-treatment for unresectable hepatocellular carcinoma (HCC). Body mass index (BMI) has demonstrated predictive value for response to immunotherapy in non-HCC cancer types. Our study investigated the effect of BMI on safety and efficacy of real-life use of Atezo/Bev for unresectable HCC. METHODS 191 consecutive patients from seven centres receiving Atezo/Bev were included in the retrospective study. Overall survival (OS), progression-free survival (PFS), overall response rate (ORR) and disease control rate (DCR) defined by RECIST v1.1 were measured in overweight (BMI ≥ 25) and non-overweight (BMI < 25) patients. Treatment-related adverse events (trAEs) were evaluated. RESULTS Patients in the overweight cohort (n = 94) had higher rates of non-alcoholic fatty liver disease (NAFLD) and lower rates of Hepatitis B compared to non-overweight cohort (n = 97). Baseline Child-Pugh class and Barcelona Clinic Liver Cancer stage were similar between cohorts, with lower rates of extrahepatic spread in the overweight group. Overweight patients had similar OS compared to non-overweight (median OS 15.1 vs. 14.9 months; p = 0.99). BMI did not influence median PFS (7.1 vs. 6.1 months; p = 0.42), ORR (27.2% vs. 22.0%; p = 0.44) and DCR (74.1% vs. 71.9%; p = 0.46). There were higher rates of atezolizumab-related fatigue (22.3% vs. 10.3%; p = 0.02) and bevacizumab-related thrombosis (8.5% vs. 2.1%; p = 0.045) in the overweight patients, but overall trAEs and treatment discontinuation were comparable between cohorts. CONCLUSION Atezo/Bev has comparable efficacy in overweight HCC patients, with an increase in treatment-related fatigue and thrombosis. Combination therapy is safe and efficacious to use in overweight patients, including those with underlying NAFLD.
Collapse
Affiliation(s)
- Mathew Vithayathil
- Department of Surgery & Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0HS, UK
| | - Antonio D'Alessio
- Department of Surgery & Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0HS, UK
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
| | - Claudia Angela Maria Fulgenzi
- Department of Surgery & Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0HS, UK
- Division of Medical Oncology, Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Naoshi Nishida
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Martin Schönlein
- Department of Oncology, Hematology and Bone Marrow Transplantation With Section of Pneumology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johann von Felden
- Department of Gastroenterology and Hepatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kornelius Schulze
- Department of Gastroenterology and Hepatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Henning Wege
- Department of Gastroenterology and Hepatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anwaar Saeed
- Division of Medical Oncology, Department of Medicine, Kansas University Cancer Center, Kansas City, KS, USA
| | - Brooke Wietharn
- Division of Medical Oncology, Department of Medicine, Kansas University Cancer Center, Kansas City, KS, USA
| | - Hannah Hildebrand
- Division of Medical Oncology, Department of Medicine, Kansas University Cancer Center, Kansas City, KS, USA
| | - Linda Wu
- Division of Hematology/Oncology, Department of Medicine, Tisch Cancer Institute, Mount Sinai Hospital, New York, NY, USA
| | - Celina Ang
- Division of Hematology/Oncology, Department of Medicine, Tisch Cancer Institute, Mount Sinai Hospital, New York, NY, USA
| | - Thomas U Marron
- Division of Hematology/Oncology, Department of Medicine, Tisch Cancer Institute, Mount Sinai Hospital, New York, NY, USA
| | - Arndt Weinmann
- I. Medical Department, University Medical Center Mainz, Mainz, Germany
| | - Peter R Galle
- I. Medical Department, University Medical Center Mainz, Mainz, Germany
| | - Dominik Bettinger
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases), Faculty of Medicine, Freiburg University Medical Center, University of Freiburg, Freiburg, Germany
| | - Bertram Bengsch
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases), Faculty of Medicine, Freiburg University Medical Center, University of Freiburg, Freiburg, Germany
- University of Freiburg, Signalling Research Centers BIOSS and CIBSS, Freiburg, Germany
- German Cancer Consortium (DKTK), Partner Site, Freiburg, Germany
| | | | - Lorenz Balcar
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
- Institute of Clinical Medicine, School of Medicine, National Yang Ming Chiao Tung University, Taipei, Taiwan
| | - Suneetha Amara
- Division of Hematology/Oncology, East Carolina University, Greenville, NC, USA
| | - Mahvish Muzaffar
- Division of Hematology/Oncology, East Carolina University, Greenville, NC, USA
| | - Abdul Rafeh Naqash
- Division of Hematology/Oncology, East Carolina University, Greenville, NC, USA
- Medical Oncology/TSET Phase 1 Program, Stephenson Cancer Center, University of Oklahoma, Norman, OK, USA
| | - Antonella Cammarota
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Valentina Zanuso
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Tiziana Pressiani
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - Matthias Pinter
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alessio Cortellini
- Department of Surgery & Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0HS, UK
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka, Japan
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele, Milan, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Rozzano, Milan, Italy
| | - David J Pinato
- Department of Surgery & Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0HS, UK
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Rohini Sharma
- Department of Surgery & Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, London, W12 0HS, UK.
| |
Collapse
|
16
|
Balcar L, Scheiner B, Urheu M, Weinberger P, Paternostro R, Simbrunner B, Semmler G, Willheim C, Pinter M, Ferenci P, Trauner M, Reiberger T, Stättermayer AF, Mandorfer M. The impact of transmembrane 6 superfamily 2 (TM6SF2) rs58542926 on liver-related events in patients with advanced chronic liver disease. Dig Liver Dis 2023; 55:1072-1080. [PMID: 36863929 DOI: 10.1016/j.dld.2023.02.012] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/27/2022] [Revised: 02/09/2023] [Accepted: 02/11/2023] [Indexed: 03/04/2023]
Abstract
BACKGROUND & AIMS Genetic factors such as the transmembrane 6 superfamily 2 (TM6SF2) rs58542926 single nucleotide variant(SNV) modulate the susceptibility for (advanced) chronic liver disease ([A]CLD). However, the impact of this variant in patients who have already progressed to ACLD is unknown. METHODS The association between TM6SF2-rs58542926 genotype and liver-related events was evaluated in 938 ACLD patients undergoing hepatic venous pressure gradient (HVPG) measurement. RESULTS Mean HVPG was 15±7 mmHg and mean UNOS MELD (2016) 11±5 points. Viral hepatitis (n = 495, 53%) was the most common cause of ACLD, followed by alcohol-related (ARLD; n = 342, 37%) and non-alcoholic fatty liver disease (NAFLD; n = 101, 11%). While 754 (80%) patients harboured the TM6SF2 wild-type (C/C), 174 (19%) and 10 (1%) patients had one or two T-alleles. At baseline, patients with at least one TM6SF2 T-allele had more pronounced portal hypertension (HVPG: 16±7 vs. 15±7 mmHg; p = 0.031), higher gamma-glutamyl transferase levels (123 [63-229] vs. 97 [55-174] UxL-1; p = 0.002), and more commonly hepatocellular carcinoma (17% vs. 12%; p = 0.049). Harbouring the TM6SF2 T-allele was associated with the composite endpoint hepatic decompensation/liver transplantation/liver-related death (SHR: 1.44 [95%CI: 1.14-1.83]; p = 0.003). This was confirmed in multivariable competing risk regression analyses that were adjusted for severity of portal hypertension and hepatic dysfunction at baseline. CONCLUSION The TM6SF2 variant modulates liver disease progression beyond the development of ACLD, as it modifies the risks of hepatic decompensation and liver-related death, independently of baseline liver disease severity.
Collapse
Affiliation(s)
- Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Markus Urheu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Patrick Weinberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Claudia Willheim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Peter Ferenci
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
17
|
Jachs M, Hartl L, Simbrunner B, Bauer D, Paternostro R, Balcar L, Hofer B, Pfisterer N, Schwarz M, Scheiner B, Stättermayer AF, Pinter M, Trauner M, Mandorfer M, Reiberger T. Carvedilol Achieves Higher Hemodynamic Response and Lower Rebleeding Rates Than Propranolol in Secondary Prophylaxis. Clin Gastroenterol Hepatol 2023; 21:2318-2326.e7. [PMID: 35842118 DOI: 10.1016/j.cgh.2022.06.007] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [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: 03/03/2022] [Revised: 05/11/2022] [Accepted: 06/05/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Carvedilol induces stronger decreases in hepatic venous pressure gradient (HVPG) than conventional nonselective β-blockers (ie, propranolol). Limited data exist on the efficacy of carvedilol in secondary prophylaxis of variceal bleeding. METHODS Patients undergoing paired HVPG measurements for guiding secondary prophylaxis with either carvedilol or propranolol were included in this retrospective analysis. All patients also underwent band ligation. Changes in HVPG and systemic hemodynamics were compared between the 2 groups. Long-term follow-up data on rebleeding, acute kidney injury, nonbleeding decompensation, and liver-related death were analyzed applying competing risk regression. RESULTS Eighty-seven patients (carvedilol/propranolol, n = 45/42) were included in our study. The median baseline HVPG was 21 mm Hg (interquartile range, 18-24 mm Hg), and 39.1%/48.3%/12.6% had Child-Turcotte-Pugh A/B/C cirrhosis, respectively. Upon nonselective β-blocker initiation, HVPG decreased more strongly in carvedilol users (median relative decrease, -20% [interquartile range: -29% to -10%] vs -11% [-22% to -5%] for propranolol; P = .027), who also achieved chronic HVPG response more often (53.3% vs 28.6%; P = .034). Cumulative incidences for rebleeding (Gray test, P = .027) and liver-related death (P = .036) were significantly lower in patients taking carvedilol compared with propranolol. Notably, ascites development/worsening also was observed less commonly in carvedilol patients (P = .012). Meanwhile, acute kidney injury rates did not differ between the 2 groups (P = .255). Stratifying patients by HVPG response status yielded similar results. The prognostic value of carvedilol intake was confirmed in competing risk regression models. CONCLUSIONS Carvedilol induces more marked reductions in HVPG than propranolol in secondary prophylaxis of variceal bleeding, and thus is associated with lower rates of rebleeding, liver-related death, and further nonbleeding decompensation.
Collapse
Affiliation(s)
- Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Hartl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - David Bauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Benedikt Hofer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - Nikolaus Pfisterer
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Department of Internal Medicine IV, Klinik Landstraße, Vienna, Austria
| | - Michael Schwarz
- Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Department of Internal Medicine IV, Klinik Ottakring, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Albert F Stättermayer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
18
|
Pinter M, Scheiner B, Pinato DJ. Immune checkpoint inhibitors in hepatocellular carcinoma: emerging challenges in clinical practice. Lancet Gastroenterol Hepatol 2023:S2468-1253(23)00147-4. [PMID: 37327807 DOI: 10.1016/s2468-1253(23)00147-4] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [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: 02/08/2023] [Revised: 04/13/2023] [Accepted: 04/25/2023] [Indexed: 06/18/2023]
Abstract
Systemic therapy for advanced hepatocellular carcinoma has expanded at an unprecedented pace over the past 5 years. After tyrosine kinase inhibitors dominated the field for more than a decade, immune checkpoint inhibitor (ICI)-based therapies have become the main component in systemic first-line treatment of this cancer. Delivery of immunotherapy in routine clinical practice recognises several challenges. In this Viewpoint, we discuss the major gaps in knowledge around the role of ICI-based therapies in patients with Child-Pugh class B. We discuss the challenges in individuals with rare histological subtypes of primary liver cancer, including combined hepatocellular-cholangiocarcinoma, fibrolamellar hepatocellular carcinoma, and sarcomatoid hepatocellular carcinoma. We also review data on ICI rechallenge in patients previously treated with ICIs, and discuss atypical patterns of progression related to immunotherapy (ie, hyperprogressive disease and pseudoprogression).
Collapse
Affiliation(s)
- Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London, UK
| | - David J Pinato
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London, UK; Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| |
Collapse
|
19
|
Pinato DJ, Li X, Mishra-Kalyani P, D’Alessio A, Fulgenzi CA, Scheiner B, Pinter M, Wei G, Schneider J, Rivera DR, Pazdur R, Theoret MR, Casak S, Lemery S, Fashoyin-Aje L, Cortellini A, Pelosof L. Association between antibiotics and adverse oncological outcomes in patients receiving targeted or immune-based therapy for hepatocellular carcinoma. JHEP Rep 2023; 5:100747. [PMID: 37197442 PMCID: PMC10183666 DOI: 10.1016/j.jhepr.2023.100747] [Citation(s) in RCA: 8] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/21/2023] [Revised: 03/08/2023] [Accepted: 03/08/2023] [Indexed: 05/19/2023] Open
Abstract
Background & Aims Immune checkpoint inhibitors (ICIs) alone or in combination with other ICIs or vascular endothelial growth factor pathway inhibitors are therapeutic options in unresectable/metastatic hepatocellular carcinoma (HCC). Whether antibiotic (ATB) exposure affects outcome remains unclear. Methods This study retrospectively analysed an FDA database including 4,098 patients receiving ICI (n = 842) either as monotherapy (n = 258) or in combination (n = 584), tyrosine kinase inhibitor (TKI) (n = 1,968), vascular endothelial growth factor pathway inhibitors (n = 480), or placebo (n = 808) as part of nine international clinical trials. Exposure to ATB within 30 days before or after treatment initiation was correlated with overall survival (OS) and progression-free survival (PFS) across therapeutic modality before and after inverse probability of treatment weighting (IPTW). Results Of 4,098 patients with unresectable/metastatic HCC, of which 39% were of hepatitis B aetiology and 21% were of hepatitis C aetiology, 83% were males with a median age of 64 years (range 18-88), a European Collaborative Oncology Group performance status of 0 (60%), and Child-Pugh A class (98%). Overall, ATB exposure (n = 620, 15%) was associated with shorter median PFS (3.6 months in ATB-exposed vs. 4.2 months; hazard ratio [HR] 1.29; 95% CI 1.22, 1.36) and OS (8.7 months in ATB-exposed vs. 10.6 months; HR 1.36; 95% CI 1.29, 1.43). In IPTW analyses, ATB was associated with shorter PFS in patients treated with ICI (HR 1.52; 95% CI 1.34, 1.73), TKI (HR 1.29; 95% CI 1.19, 1.39), and placebo (HR 1.23; 95% CI 1.11, 1.37). Similar results were observed in IPTW analyses of OS in patients treated with ICI (HR 1.22; 95% CI 1.08, 1.38), TKI (HR 1.40; 95% CI 1.30, 1.52), and placebo (HR 1.40; 95% CI 1.25, 1.57). Conclusions Unlike other malignancies where the detrimental effect of ATB may be more prominent in ICI recipients, ATB is associated with worse outcomes in this study across different therapies for HCC including placebo. Whether ATB is causally linked to worse outcomes through disruption of the gut-liver axis remains to be demonstrated in translational studies. Impact and Implications A growing body of evidence suggests the host microbiome, frequently altered by antibiotic treatment, as an important outcome predictor in the context of immune checkpoint inhibitor therapy. In this study, we analysed the effects of early antibiotic exposure on outcomes in almost 4,100 patients with hepatocellular carcinoma treated within nine multicentre clinical trials. Interestingly, early exposure to antibiotic treatment was associated with worse outcomes not only in patients treated with immune checkpoint inhibitors but also in those treated with tyrosine kinase inhibitors and placebo. This is in contrast to data published in other malignancies, where the detrimental effect of antibiotic treatment may be more prominent in immune checkpoint inhibitor recipients, highlighting the uniqueness of hepatocellular carcinoma given the complex interplay between cirrhosis, cancer, risk of infection, and the pleiotropic effect of molecular therapies for this disease.
Collapse
Affiliation(s)
- David J. Pinato
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
- Corresponding authors. Addresses: Imperial College London Hammersmith Campus, Du Cane Road, W12 0HS, London, UK. Tel.: +44-20-83833720.
| | - Xiaoxue Li
- Office of Biostatistics, Center for Drug Evaluation and Research (CDER), US FDA, Silver Spring, MD, USA
| | - Pallavi Mishra-Kalyani
- Office of Biostatistics, Center for Drug Evaluation and Research (CDER), US FDA, Silver Spring, MD, USA
| | - Antonio D’Alessio
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Claudia A.M. Fulgenzi
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
- Department of Medical Oncology, University Campus Bio-Medico of Rome, Rome, Italy
| | - Bernhard Scheiner
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Guo Wei
- Oncology Center of Excellence, US FDA, Silver Spring, MD, USA
| | - Julie Schneider
- Oncology Center of Excellence, US FDA, Silver Spring, MD, USA
| | - Donna R. Rivera
- Oncology Center of Excellence, US FDA, Silver Spring, MD, USA
| | - Richard Pazdur
- Oncology Center of Excellence, US FDA, Silver Spring, MD, USA
- Office of Oncologic Diseases, Center for Drug Evaluation and Research (CDER), US FDA, Silver Spring, MD, USA
| | - Marc R. Theoret
- Oncology Center of Excellence, US FDA, Silver Spring, MD, USA
- Office of Oncologic Diseases, Center for Drug Evaluation and Research (CDER), US FDA, Silver Spring, MD, USA
| | - Sandra Casak
- Office of Oncologic Diseases, Center for Drug Evaluation and Research (CDER), US FDA, Silver Spring, MD, USA
| | - Steven Lemery
- Office of Oncologic Diseases, Center for Drug Evaluation and Research (CDER), US FDA, Silver Spring, MD, USA
| | - Lola Fashoyin-Aje
- Office of Oncologic Diseases, Center for Drug Evaluation and Research (CDER), US FDA, Silver Spring, MD, USA
| | - Alessio Cortellini
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London, UK
| | - Lorraine Pelosof
- Office of Oncologic Diseases, Center for Drug Evaluation and Research (CDER), US FDA, Silver Spring, MD, USA
- Office of Oncologic Diseases, Center for Drug Evaluation and Research (CDER), US Food and Drug Administration (FDA), 10903 New Hampshire Avenue, White Oak Building 22, Silver Spring, MD 20993, USA. Tel.: +1-240-402-6469.
| |
Collapse
|
20
|
Fulgenzi CAM, Scheiner B, Korolewicz J, Stikas CV, Gennari A, Vincenzi B, Openshaw MR, Silletta M, Pinter M, Cortellini A, Scotti L, D’Alessio A, Pinato DJ. Efficacy and safety of frontline systemic therapy for advanced HCC: A network meta-analysis of landmark phase III trials. JHEP Rep 2023; 5:100702. [PMID: 37025943 PMCID: PMC10070142 DOI: 10.1016/j.jhepr.2023.100702] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Revised: 01/11/2023] [Accepted: 02/02/2023] [Indexed: 04/08/2023] Open
Abstract
Background & Aims Direct comparisons across first-line regimens for advanced hepatocellular carcinoma are not available. We performed a network metanalysis of phase III of trials to compare first-line systemic treatments for hepatocellular carcinoma in terms of overall survival (OS), progression-free survival (PFS), objective response rate, disease control rate, and incidence of adverse events (AEs). Methods After performing a literature review from January 2008 to September 2022, we screened 6,329 studies and reviewed 3,009 studies, leading to identification of 15 phase III trials for analysis. We extracted odds ratios for objective response rate and disease control rate, relative risks for AEs, and hazard ratios (HRs) with 95% CIs for OS and PFS, and used a frequentist network metanalysis, with fixed-effect multivariable meta-regression models to estimate the indirect pooled HRs, odds ratios, relative risks, and corresponding 95% CIs, considering sorafenib as reference. Results Of 10,820 included patients, 10,444 received active treatment and 376 placebo. Sintilimab + IBI350, camrelizumab + rivoceranib, and atezolizumab + bevacizumab provided the greatest reduction in the risk of death compared with sorafenib, with HRs of 0.57 (95% CI 0.43-0.75), 0.62 (95% CI 0.49-0.79), and 0.66 (95% CI 0.52-0.84), respectively. Considering PFS, camrelizumab + rivoceranib and pembrolizumab + lenvatinib were associated with the greatest reduction in the risk of PFS events compared with sorafenib, with HRs of 0.52 (95% CI 0.41-0.65) and 0.52 (95% CI 0.35-0.77), respectively. Immune checkpoint inhibitor (ICI) monotherapies carried the lowest risk for all-grade and grade ≥3 AEs. Conclusions The combinations of ICI + anti-vascular endothelial growth factor, and double ICIs lead to the greatest OS benefit compared with sorafenib, whereas ICI + kinase inhibitor regimens are associated with greater PFS benefit at the cost of higher toxicity rates. Impact and Implications In the last few years, many different therapies have been studied for patients with primary liver cancer that cannot be treated with surgery. In these cases, anticancer drugs (alone or in combination) are given with the intent to keep the cancer at bay and, ultimately, to prolong survival. Among all the therapies that have been investigated, the combination of immunotherapy (drugs that boost the immune system against the cancer) and anti-angiogenic agents (drugs that act on tumoural vessels) has appeared the best to improve survival. Similarly, the combination of two types of immunotherapies that activate the immune system at different levels has also shown positive results. Systematic Review Registration PROSPERO CRD42022366330.
Collapse
Affiliation(s)
- Claudia Angela Maria Fulgenzi
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK
- Medical Oncology Department, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Bernhard Scheiner
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - James Korolewicz
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK
| | | | - Alessandra Gennari
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Bruno Vincenzi
- Medical Oncology Department, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | | | - Marianna Silletta
- Medical Oncology Department, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alessio Cortellini
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK
- Medical Oncology Department, Fondazione Policlinico Universitario Campus Bio-Medico, Rome, Italy
| | - Lorenza Scotti
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy
| | - Antonio D’Alessio
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - David J. Pinato
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK
- Department of Translational Medicine, Università del Piemonte Orientale UPO, Novara, Italy
- Corresponding author. Address: Department of Surgery and Cancer, Imperial College London, Hammersmith Campus, Du Cane Road, W12 0HS, London, UK. Tel.: +44-020-83833720
| |
Collapse
|
21
|
Semmler G, Scheiner B, Balcar L, Paternostro R, Simbrunner B, Pinter M, Trauner M, Bofill Roig M, Meyer EL, Hofer BS, Mandorfer M, Pinato DJ, Zauner C, Reiberger T, Funk GC. Disturbances in sodium and chloride homeostasis predict outcome in stable and critically ill patients with cirrhosis. Aliment Pharmacol Ther 2023. [PMID: 37016513 DOI: 10.1111/apt.17507] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/25/2022] [Revised: 11/12/2022] [Accepted: 03/24/2023] [Indexed: 04/06/2023]
Abstract
BACKGROUND Hyponatremia has prognostic implications in patients with cirrhosis, and thus, has been incorporated in the 2016 MELD-UNOS update. Changes in serum chloride (Cl) are commonly perceived as 'just' parallel to changes in serum sodium, however, are less well-studied in the context of cirrhosis. AIMS To investigate whether serum chloride independently predicts outcomes in patients with advanced chronic liver disease (ACLD) and stable clinical course or with critical illness. METHODS In total, 891 patients with ACLD (defined by hepatic venous pressure gradient [HVPG] ≥6 mm Hg) were followed after HVPG measurement between 2003 and 2020 (ACLD-cohort). In total, 181 critically ill patients with cirrhosis admitted to the ICU between 2004 and 2007 were recruited for the ICU-cohort. Hypo-/hypernatremia (normal: 136-145 mmol/L) and hypo-/hyperchloremia (normal: 98-107 mmol/L) at baseline were assessed. RESULTS ACLD-cohort: 68% of male patients with a median MELD (adjusted for Na) of 11 (9-17) were included (Child-Pugh-stages-A/B/C: 46%/38%/16%) and followed for a median of 60 months. Lower serum chloride (adjusted average HR per mmol/L: 0.965 [95% confidence interval (95% CI): 0.945-0.986], p = 0.001) showed a significant association with hepatic decompensation/liver-related mortality on multivariable Cox regression analysis adjusted for age, HVPG, albumin and MELD. In line, hypochloremia was significantly associated with hepatic decompensation/liver-related mortality (adjusted average HR: 1.656 [95% CI:1.267-2.163], p < 0.001). ICU-cohort: 70% of patients were male, median MELD was 31(22-39) at ICU admission (92% with Child-Pugh-stage-C). After adjusting for hypo-/hypernatremia, MELD, and blood pH, hypochloremia remained independently associated with ICU-mortality (aOR Cl: 3.200 [95%CI: 1.209-8.829], p = 0.021). CONCLUSION Hypochloremia is associated with increased mortality in clinically stable and critically ill patients with cirrhosis independently of MELD including serum sodium.
Collapse
Affiliation(s)
- Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK
| | - Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Marta Bofill Roig
- Institute for Medical Statistics, Center for Medical Data Science, Medical University of Vienna, Vienna, Austria
| | - Elias Laurin Meyer
- Institute for Medical Statistics, Center for Medical Data Science, Medical University of Vienna, Vienna, Austria
| | - Benedikt Silvester Hofer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - David James Pinato
- Division of Cancer, Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK
| | - Christian Zauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
- CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Georg-Christian Funk
- 2nd Medical Department with Pneumology, Klinik Ottakring, Vienna, Austria
- Karl-Landsteiner-Institute for Lung Research and Pulmonary Oncology, Vienna, Austria
| |
Collapse
|
22
|
Balcar L, Krawanja J, Scheiner B, Paternostro R, Simbrunner B, Semmler G, Jachs M, Hartl L, Stättermayer AF, Schwabl P, Pinter M, Szekeres T, Trauner M, Reiberger T, Mandorfer M. Impact of ammonia levels on outcome in clinically stable outpatients with advanced chronic liver disease. JHEP Rep 2023; 5:100682. [PMID: 36873421 PMCID: PMC9976454 DOI: 10.1016/j.jhepr.2023.100682] [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] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/18/2022] [Revised: 12/28/2022] [Accepted: 01/10/2023] [Indexed: 01/24/2023] Open
Abstract
Background & Aims Ammonia levels predicted hospitalisation in a recent landmark study not accounting for portal hypertension and systemic inflammation severity. We investigated (i) the prognostic value of venous ammonia levels (outcome cohort) for liver-related outcomes while accounting for these factors and (ii) its correlation with key disease-driving mechanisms (biomarker cohort). Methods (i) The outcome cohort included 549 clinically stable outpatients with evidence of advanced chronic liver disease. (ii) The partly overlapping biomarker cohort comprised 193 individuals, recruited from the prospective Vienna Cirrhosis Study (VICIS: NCT03267615). Results (i) In the outcome cohort, ammonia increased across clinical stages as well as hepatic venous pressure gradient and United Network for Organ Sharing model for end-stage liver disease (2016) strata and were independently linked with diabetes. Ammonia was associated with liver-related death, even after multivariable adjustment (adjusted hazard ratio [aHR]: 1.05 [95% CI: 1.00-1.10]; p = 0.044). The recently proposed cut-off (≥1.4 × upper limit of normal) was independently predictive of hepatic decompensation (aHR: 2.08 [95% CI: 1.35-3.22]; p <0.001), non-elective liver-related hospitalisation (aHR: 1.86 [95% CI: 1.17-2.95]; p = 0.008), and - in those with decompensated advanced chronic liver disease - acute-on-chronic liver failure (aHR: 1.71 [95% CI: 1.05-2.80]; p = 0.031). (ii) Besides hepatic venous pressure gradient, venous ammonia was correlated with markers of endothelial dysfunction and liver fibrogenesis/matrix remodelling in the biomarker cohort. Conclusions Venous ammonia predicts hepatic decompensation, non-elective liver-related hospitalisation, acute-on-chronic liver failure, and liver-related death, independently of established prognostic indicators including C-reactive protein and hepatic venous pressure gradient. Although venous ammonia is linked with several key disease-driving mechanisms, its prognostic value is not explained by associated hepatic dysfunction, systemic inflammation, or portal hypertension severity, suggesting direct toxicity. Impact and implications A recent landmark study linked ammonia levels (a simple blood test) with hospitalisation/death in individuals with clinically stable cirrhosis. Our study extends the prognostic value of venous ammonia to other important liver-related complications. Although venous ammonia is linked with several key disease-driving mechanisms, they do not fully explain its prognostic value. This supports the concept of direct ammonia toxicity and ammonia-lowering drugs as disease-modifying treatment.
Collapse
Key Words
- ACLD, advanced chronic liver disease
- ACLF, acute-on-chronic liver failure
- ARLD, alcohol-related liver disease
- AUROC, area under the receiver operating characteristic curve
- Acute-on-chronic liver failure
- BAs, Bile acids
- CRP, C-reactive protein
- CTP, Child–Turcotte–Pugh score
- Cirrhosis
- Death
- Decompensation
- ELF®-test, enhanced liver fibrosis-test
- HE, hepatic encephalopathy
- HSC, hepatic stellate cell
- HVPG, hepatic venous pressure gradient
- Hepatic encephalopathy
- MAFLD, metabolic-associated fatty liver disease
- MAP, mean arterial pressure
- NAFLD, non-alcoholic fatty liver disease
- NH3-ULN, ammonia-adjusted for the upper limit of normal
- PCT, procalcitonin
- SHR, subdistribution hazard ratio
- UNOS MELD (2016), United Network for Organ Sharing model for end-stage liver disease (2016)
- aHR, adjusted hazard ratio
- vWF, von Willebrand factor
Collapse
Affiliation(s)
- Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Julia Krawanja
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Hartl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Szekeres
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
23
|
Talbot T, D'Alessio A, Pinter M, Balcar L, Scheiner B, Marron TU, Jun T, Dharmapuri S, Ang C, Saeed A, Hildebrand H, Muzaffar M, Fulgenzi CAM, Amara S, Naqash AR, Gampa A, Pillai A, Wang Y, Khan U, Lee P, Huang Y, Bengsch B, Bettinger D, Mohamed YI, Kaseb A, Pressiani T, Personeni N, Rimassa L, Nishida N, Kudo M, Weinmann A, Galle PR, Muhammed A, Cortellini A, Vogel A, Pinato DJ. Progression patterns and therapeutic sequencing following immune checkpoint inhibition for hepatocellular carcinoma: An international observational study. Liver Int 2023; 43:695-707. [PMID: 36577703 PMCID: PMC10947007 DOI: 10.1111/liv.15502] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/12/2022] [Revised: 12/11/2022] [Accepted: 12/18/2022] [Indexed: 12/30/2022]
Abstract
BACKGROUND AND AIMS Different approaches are available after the progression of disease (PD) to immune checkpoint inhibitors (ICIs) for hepatocellular carcinoma (HCC), including the continuation of ICI, treatment switching to tyrosine kinase inhibitors (TKIs) and cessation of anticancer therapy. We sought to characterise the relationship between radiological patterns of progression and survival post-ICI, also appraising treatment strategies. METHODS We screened 604 HCC patients treated with ICIs, including only those who experienced PD by data cut-off. We evaluated post-progression survival (PPS) according to the treatment strategy at PD and verified its relationship with radiological patterns of progression: intrahepatic growth (IHG), new intrahepatic lesion (NIH), extrahepatic growth (EHG), new extrahepatic lesion (NEH) and new vascular invasion (nVI). RESULTS Of 604 patients, 364 (60.3%) experienced PD during observation. Median PPS was 5.3 months (95% CI: 4.4-6.9; 271 events). At the data cut-off, 165 patients (45%) received no post-progression anticancer therapy; 64 patients (17.6%) continued ICI beyond PD. IHG (HR 1.64 [95% CI: 1.21-2.22]; p = .0013) and nVI (HR 2.15 [95% CI: 1.38-3.35]; p = .0007) were associated with shorter PPS. Multivariate models adjusted for progression patterns, treatment line and albumin-bilirubin grade and Eastern Cooperative Oncology Group performance status at PD confirmed receipt of ICI beyond PD with (HR 0.17, 95% CI: 0.09-0.32; p < .0001) or without subsequent TKI (HR 0.39, 95% CI: 0.26-0.58; p < .0001) as predictors of prolonged PPS versus no anticancer therapy. CONCLUSIONS ICI-TKI sequencing is a consolidated option in advanced HCC. nVI and IHG predict a poorer prognosis. Despite lack of recommendation, the continuation of ICI beyond progression in HCC is adopted clinically: future efforts should appraise which patients benefit from this approach.
Collapse
Affiliation(s)
- Thomas Talbot
- Department of Surgery & Cancer, Imperial College LondonHammersmith HospitalLondonUK
| | - Antonio D'Alessio
- Department of Surgery & Cancer, Imperial College LondonHammersmith HospitalLondonUK
- Department of Biomedical SciencesHumanitas UniversityMilanItaly
| | - Matthias Pinter
- Division of Gastroenterology & Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Lorenz Balcar
- Division of Gastroenterology & Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Bernhard Scheiner
- Division of Gastroenterology & Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Thomas U. Marron
- Division of Hematology/Oncology, Department of Medicine, Tisch Cancer InstituteMount Sinai HospitalNew YorkNew YorkUSA
| | | | - Sirish Dharmapuri
- Division of Hematology/Oncology, Department of Medicine, Tisch Cancer InstituteMount Sinai HospitalNew YorkNew YorkUSA
| | - Celina Ang
- Division of Hematology/Oncology, Department of Medicine, Tisch Cancer InstituteMount Sinai HospitalNew YorkNew YorkUSA
| | - Anwaar Saeed
- Division of Medical Oncology, Department of MedicineKansas University Cancer CenterWestwoodKansasUSA
| | - Hannah Hildebrand
- Division of Medical Oncology, Department of MedicineKansas University Cancer CenterWestwoodKansasUSA
| | - Mahvish Muzaffar
- Division of Hematology/OncologyEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Claudia A. M. Fulgenzi
- Department of Surgery & Cancer, Imperial College LondonHammersmith HospitalLondonUK
- Department of Medical OncologyUniversity Campus Bio‐MedicoRomeItaly
| | - Suneetha Amara
- Division of Hematology/OncologyEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Abdul Rafeh Naqash
- Division of Hematology/OncologyEast Carolina UniversityGreenvilleNorth CarolinaUSA
- Division of Cancer Treatment and DiagnosisNational Cancer InstituteBethesdaMarylandUSA
| | - Anuhya Gampa
- Section of GastroenterologyHepatology & Nutrition, the University of Chicago MedicineChicagoIllinoisUSA
| | - Anjana Pillai
- Section of GastroenterologyHepatology & Nutrition, the University of Chicago MedicineChicagoIllinoisUSA
| | - Yinghong Wang
- Department of Gastroenterology, Hepatology & NutritionThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Uqba Khan
- Division of Hematology and OncologyWeill Cornell Medicine/New York Presbyterian HospitalNew YorkNew YorkUSA
| | - Pei‐Chang Lee
- Division of Gastroenterology and Hepatology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
| | - Yi‐Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
- Institute of Clinical MedicineNational Yang Ming Chiao Tung University School of MedicineTaipeiTaiwan
| | - Bertram Bengsch
- Department of Medicine II, Faculty of MedicineMedical Center University of Freiburg, University of FreiburgFreiburgGermany
| | - Dominik Bettinger
- Department of Medicine II, Faculty of MedicineMedical Center University of Freiburg, University of FreiburgFreiburgGermany
| | - Yehia I. Mohamed
- Department of Gastrointestinal Medical OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Ahmed Kaseb
- Department of Gastrointestinal Medical OncologyThe University of Texas MD Anderson Cancer CenterHoustonTexasUSA
| | - Tiziana Pressiani
- Medical Oncology and Hematology Unit, Humanitas Cancer CenterIRCCS Humanitas Research HospitalMilanItaly
| | - Nicola Personeni
- Department of Biomedical SciencesHumanitas UniversityMilanItaly
- Medical Oncology and Hematology Unit, Humanitas Cancer CenterIRCCS Humanitas Research HospitalMilanItaly
| | - Lorenza Rimassa
- Department of Biomedical SciencesHumanitas UniversityMilanItaly
- Medical Oncology and Hematology Unit, Humanitas Cancer CenterIRCCS Humanitas Research HospitalMilanItaly
| | - Naoshi Nishida
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsaka‐SayamaJapan
| | - Masatoshi Kudo
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsaka‐SayamaJapan
| | - Arndt Weinmann
- 1st Department of Internal Medicine, Gastroenterology and HepatologyUniversity Medical Center of the Johannes Gutenberg‐University MainzMainzGermany
| | - Peter R. Galle
- 1st Department of Internal Medicine, Gastroenterology and HepatologyUniversity Medical Center of the Johannes Gutenberg‐University MainzMainzGermany
| | - Ambreen Muhammed
- Department of Surgery & Cancer, Imperial College LondonHammersmith HospitalLondonUK
| | - Alessio Cortellini
- Department of Surgery & Cancer, Imperial College LondonHammersmith HospitalLondonUK
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and EndocrinologyHannover Medical SchoolHannoverGermany
| | - David J. Pinato
- Department of Surgery & Cancer, Imperial College LondonHammersmith HospitalLondonUK
- Division of Oncology, Department of Translational MedicineUniversity of Piemonte Orientale “A. Avogadro”NovaraItaly
| |
Collapse
|
24
|
Wu YL, van Hyfte G, Özbek U, Reincke M, Gampa A, Mohamed YI, Nishida N, Wietharn B, Amara S, Lee PC, Scheiner B, Balcar L, Pinter M, Vogel A, Weinmann A, Saeed A, Pillai A, Rimassa L, Naqash AR, Muzaffar M, Huang YH, Kaseb AO, Kudo M, Pinato DJ, Ang C. Outcomes of beta blocker use in advanced hepatocellular carcinoma treated with immune checkpoint inhibitors. Front Oncol 2023; 13:1128569. [PMID: 36865801 PMCID: PMC9971987 DOI: 10.3389/fonc.2023.1128569] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Accepted: 01/30/2023] [Indexed: 02/16/2023] Open
Abstract
Background In patients with cirrhosis, portal hypertension increases intestinal permeability, dysbiosis, and bacterial translocation, promoting an inflammatory state that can lead to the progression of liver disease and development of hepatocellular carcinoma (HCC). We aimed to investigate whether beta blockers (BBs), which can mediate portal hypertension, conferred survival benefits in patients treated with immune checkpoint inhibitors (ICIs). Methods We conducted a retrospective, observational study of 578 patients with unresectable HCC treated with ICI from 2017 to 2019 at 13 institutions across three continents. BB use was defined as exposure to BBs at any time during ICI therapy. The primary objective was to assess the association of BB exposure with overall survival (OS). Secondary objectives were to evaluate the association of BB use with progression-free survival (PFS) and objective response rate (ORR) according to RECIST 1.1 criteria. Results In our study cohort, 203 (35%) patients used BBs at any point during ICI therapy. Of these, 51% were taking a nonselective BB. BB use was not significantly correlated with OS (hazard ratio [HR] 1.12, 95% CI 0.9-1.39, P = 0.298), PFS (HR 1.02, 95% CI 0.83-1.26, P = 0.844) or ORR (odds ratio [OR] 0.84, 95% CI 0.54-1.31, P = 0.451) in univariate or multivariate analyses. BB use was also not associated with incidence of adverse events (OR 1.38, 95% CI 0.96-1.97, P = 0.079). Specifically, nonselective BB use was not correlated with OS (HR 0.94, 95% CI 0.66-1.33, P = 0.721), PFS (HR 0.92, 0.66-1.29, P = 0.629), ORR (OR 1.20, 95% CI 0.58-2.49, P = 0.623), or rate of adverse events (OR 0.82, 95% CI 0.46-1.47, P = 0.510). Conclusion In this real-world population of patients with unresectable HCC treated with immunotherapy, BB use was not associated with OS, PFS or ORR.
Collapse
Affiliation(s)
- Y. Linda Wu
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Grace van Hyfte
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Umut Özbek
- Department of Population Health Science and Policy, Icahn School of Medicine at Mount Sinai, New York, NY, United States
| | - Marlene Reincke
- Department of Medicine II, Faculty of Medicine, Medical Center University of Freiburg, Freiburg, Germany
| | - Anuhya Gampa
- Section of Gastroenterology, Hepatology and Nutrition, The University of Chicago Medical Center, Chicago, IL, United States
| | - Yehia I. Mohamed
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Naoshi Nishida
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - Brooke Wietharn
- Division of Medical Oncology, Department of Medicine, Kansas University Cancer Center, Kansas City, KS, United States
| | - Suneetha Amara
- Division of Hematology/Oncology, East Carolina University, Greenville, NC, United States
| | - Pei-Chang Lee
- Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Arndt Weinmann
- Department of Internal Medicine, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Anwaar Saeed
- Division of Medical Oncology, Department of Medicine, Kansas University Cancer Center, Kansas City, KS, United States
| | - Anjana Pillai
- Section of Gastroenterology, Hepatology and Nutrition, The University of Chicago Medical Center, Chicago, IL, United States
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, Pieve Emanuele (Milan), Italy,Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Clinical and Research Hospital, Rozzano (Milan), Italy
| | - Abdul Rafeh Naqash
- Division of Cancer Treatment and Diagnosis, National Cancer Institute, Bethesda, MD, United States
| | - Mahvish Muzaffar
- Division of Hematology/Oncology, East Carolina University, Greenville, NC, United States
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, National Yang-Ming University, Taipei, Taiwan
| | - Ahmed O. Kaseb
- Department of Gastrointestinal Medical Oncology, The University of Texas MD Anderson Cancer Center, Houston, TX, United States
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Kindai University Faculty of Medicine, Osaka, Japan
| | - David J. Pinato
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital London, London, United Kingdom
| | - Celina Ang
- Division of Hematology and Medical Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY, United States,*Correspondence: Celina Ang,
| |
Collapse
|
25
|
Pomej K, Balcar L, Shmanko K, Welland S, Himmelsbach V, Scheiner B, Mahyera A, Mozayani B, Trauner M, Finkelmeier F, Weinmann A, Vogel A, Pinter M. Clinical characteristics and outcome of patients with combined hepatocellular-cholangiocarcinoma-a European multicenter cohort. ESMO Open 2023; 8:100783. [PMID: 36753993 PMCID: PMC10024130 DOI: 10.1016/j.esmoop.2023.100783] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Revised: 12/16/2022] [Accepted: 01/03/2023] [Indexed: 02/08/2023] Open
Abstract
BACKGROUND There is no clear consensus on the optimal systemic treatment regimen in combined hepatocellular-cholangiocarcinoma (cHCC-CCA) patients. We describe clinical characteristics and outcome of cHCC-CCA patients, with a special focus on patients receiving palliative systemic therapy, including immune checkpoint inhibitors (ICIs). METHODS In this European retrospective, multicenter study, patients with histologically proven cHCC-CCA treated at four institutions between April 2003 and June 2022 were included. In patients receiving palliative systemic therapy, outcome was compared between cytotoxic chemotherapy (CHT)- and non-cytotoxic CHT (nCHT)-treated patients. RESULTS Of 101 patients, the majority were male (n = 70, 69%) with a mean age of 64.6 ± 10.6 years. Only type of first-line treatment was independently associated with overall survival (OS). Palliative systemic therapy was administered to 44 (44%) patients. Of those, 25 (57%) patients received CHT and 19 (43%) had nCHT (n = 16 of them sorafenib) in systemic first line. Although there was no significant difference in overall response rate (ORR; CHT versus nCHT: 8% versus 5%), disease control rate (24% versus 21%), and median progression-free survival {3.0 months [95% confidence interval (CI) 1.4-4.6 months] versus 3.2 months (95% CI 2.8-3.6 months), P = 0.725}, there was a trend towards longer median OS in the CHT group [15.5 months (95% CI 8.0-23.0 months) versus 5.3 months (95% CI 0-12.5 months), P = 0.052]. However, in multivariable analysis, type of first-line regimen (CHT versus sorafenib) was not associated with OS. ORR in patients receiving ICIs (n = 7) was 29%. CONCLUSIONS In patients with cHCC-CCA, OS, progression-free survival, ORR, and disease control rate were not significantly different between individuals receiving CHT and patients receiving nCHT. Immunotherapy may be effective in a subset of patients. Prospective studies are needed to identify optimal systemic treatment regimens in cHCC-CCA.
Collapse
Affiliation(s)
- K Pomej
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - L Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - K Shmanko
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz
| | - S Welland
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover
| | - V Himmelsbach
- Department of Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - B Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Division of Cancer, Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, UK
| | - A Mahyera
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - B Mozayani
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - M Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna
| | - F Finkelmeier
- Department of Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - A Weinmann
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz
| | - A Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover
| | - M Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
26
|
Pinter M, Pinato DJ, Ramadori P, Heikenwalder M. NASH and Hepatocellular Carcinoma: Immunology and Immunotherapy. Clin Cancer Res 2023; 29:513-520. [PMID: 36166660 PMCID: PMC9890137 DOI: 10.1158/1078-0432.ccr-21-1258] [Citation(s) in RCA: 25] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/29/2022] [Revised: 06/29/2022] [Accepted: 09/20/2022] [Indexed: 02/05/2023]
Abstract
The last 10 years have revolutionized our basic understanding of nonalcoholic fatty liver disease and consequent liver cancer. It has become clear that several innate and adaptive immune cells play an important role in initiating, maintaining, or exacerbating nonalcoholic steatohepatitis (NASH)-a disease that has been recently defined as autoaggressive. Despite improved disease management aimed at reducing the progression of fibrosis, NASH is set to become a leading cause for hepatocellular carcinoma (HCC). Preliminary data from preclinical studies suggest that immunotherapy efficacy may be reduced in NASH-related HCC compared with viral HCC; however, conclusive evidence supporting clinical translation of these findings is lacking. Comprehensive clinical and immunologic phenotyping of mechanisms linking NASH progression with carcinogenesis and therapeutic resistance is key to prevent progression to cirrhosis, improve monitoring and stratification of NASH according to predicted cancer risk, and ultimately increase survival of patients with NASH-HCC. In this review, we summarize the state of the art in the field of NASH and NASH-HCC with focus on immunobiology. We discuss preclinical and clinical findings underpinning NASH as an immunologically distinct pro-tumorigenic disease entity, and explore areas of potential therapeutic vulnerabilities in NASH-associated HCC.
Collapse
Affiliation(s)
- Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - David J. Pinato
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London, United Kingdom
- Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Pierluigi Ramadori
- Division of Chronic Inflammation and Cancer, German Cancer Research Center, Heidelberg, Germany
| | - Mathias Heikenwalder
- Division of Chronic Inflammation and Cancer, German Cancer Research Center, Heidelberg, Germany
| |
Collapse
|
27
|
Finn RS, Merle P, Ikeda M, Klümpen HJ, Masi G, Granito A, Lim HY, Kudo M, Qin S, Gerolami R, Huang YH, Kim DY, Pinter M, Kato N, Kurosaki M, Numata K, Khan J, Ozgurdal K, Kim YJ. Real-world dosing of regorafenib in patients with unresectable hepatocellular carcinoma (uHCC): Final analysis of the prospective, observational REFINE study. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.4_suppl.518] [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: 01/25/2023] Open
Abstract
518 Background: Final results from the real-world REFINE study confirmed the safety and effectiveness of regorafenib (REG) in a broad population of patients (pts) with uHCC that was consistent with the results from RESORCE, in which REG prolonged overall survival (OS) vs placebo in pts with uHCC who progressed on prior sorafenib. Here we evaluate baseline characteristics and outcomes according to the initial REG dose. Methods: REFINE (NCT03289273), an international, prospective, multicenter study, enrolled pts with uHCC for whom a decision to treat with REG was made by the treating physician prior to enrollment according to the local health authority approved label (160 mg/day, 3 weeks on/1 week off). The primary objective was safety (NCI-CTCAE v4.03); secondary endpoints included OS and progression-free survival (PFS). Results: Of 1005 pts eligible for analysis, 47%, 11%, 40%, and 3% initiated REG at 160 mg, 120 mg, 80 mg, and 40 mg, respectively. A higher proportion of pts from Asia initiated REG at 160 mg (51%) vs non-Asian countries (42%), and 67% were Child–Pugh A in Asia vs 54% in non-Asian countries at study entry. Pts initiating REG at 160 mg were more likely to be Child–Pugh A and albumin–bilirubin (ALBI) grade 1 vs pts initiating REG at <160 mg (Table). A higher proportion of pts (53%) who initiated REG at 160 mg ended prior sorafenib at 800 mg/day. Of the pts intolerant to prior sorafenib (n=91), more pts started REG at 80 mg (49%), followed by 160 mg (32%) and 120 mg (9%). Median duration of REG treatment was similar across initial dose levels (overall 3.7 months). Any-grade TEAEs were reported for 90%, 93%, and 93% of pts initiating REG at 160 mg, 120 mg, and 80 mg, respectively. TEAEs led to dose modifications in 49%, 51%, and 38% and to dose reductions in 34%, 26%, and 17% of pts. Median OS was 15.8 months in pts who initiated REG at 160 mg, 13.3 months at 120 mg, and 11.1 months at 80 mg. Median PFS was similar across doses (overall 3.9 months). Conclusions: In this real-world study, most pts with uHCC initiated REG at 160 mg or 80 mg/day. A higher proportion of pts from Asia initiated REG at the recommended dose, and a higher proportion of pts initiating REG at 160 mg had relatively better liver function at study entry. Safety was generally similar regardless of initial dose, and OS was observed to be longer in pts initiating REG at 160 mg vs lower doses. Clinical trial information: NCT03289273 . [Table: see text]
Collapse
Affiliation(s)
- Richard S. Finn
- David Geffen School of Medicine at UCLA, UCLA Medical Center, Los Angeles, CA
| | - Philippe Merle
- Groupement Hospitalier Lyon Nord, Hepatology Unit, Lyon, France
| | | | - Heinz-Josef Klümpen
- Amsterdam University Medical Centers, University of Amsterdam, Amsterdam, Netherlands
| | - Gianluca Masi
- Azienda Ospedaliera-Universitaria Pisana, Pisa, Italy
| | | | - Ho Yeong Lim
- Samsung Medical Center, Sungkyunkwan University School of Medicine, Seoul, South Korea
| | | | - Shukui Qin
- Chinese People’s Liberation Army Cancer Center of Nanjing Bayi Hospital, Nanjing, China
| | | | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Taipei Veterans General Hospital, Taipei, Taiwan
| | | | | | | | | | - Kazushi Numata
- Yokohama City University Medical Center, Yokohama, Japan
| | | | | | - Yoon Jun Kim
- Seoul National University Hospital, Seoul, South Korea
| |
Collapse
|
28
|
Fulgenzi CA, Murphy C, D'Alessio A, Scheiner B, Pinter M, Cortellini A, Pinato DJJ. Effect of early antibiotic exposure on survival of patients receiving atezolizumab plus bevacizumab but not sorafenib for unresectable HCC: A sub-analysis of the phase III IMbrave150 study. J Clin Oncol 2023. [DOI: 10.1200/jco.2023.41.4_suppl.597] [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: 01/25/2023] Open
Abstract
597 Background: The combination of atezolizumab plus bevacizumab (A+B) is the standard of care for patients (pts) with unresectable/advanced hepatocellular carcinoma (HCC). Emerging evidence suggest a detrimental role of early antibiotics (ATB) exposure in immunotherapy recipients. However, it is unclear whether ATB affect outcomes of pts receiving A+B. Methods: We conducted a patient-level analysis of subjects receiving either A+B or Sorafenib (Sor) within the IMbrave150 trial to assess the impact of early ATB exposure (ATB+, i.e. +/-30 from treatment initiation) on overall (OS) and progression-free survival (PFS). Differences in median (m) OS and mPFS were estimated by the Kaplan-Meier method. Cox proportional regression models were used to assess the prognostic impact of ATB+ adjusting for race, age, baseline AFP, baseline ALBI grade, continent of origin and neutrophil-to-lymphocyte ratio, a measure of systemic inflammation. Results: Data of 420 IMbrave150 participants were made available by Vivli. Among them, 278 received A+B and 142 Sor. Most pts were of ECOG performance status 0 (65%); 47% had extrahepatic spread, 40% had macrovascular invasion and 35% had AFP>400 ng/mL. Viral aetiology (39% HBV and 24% HCV) was the most common risk factor for HCC. Overall, 60 pts in the A+B arm (21.5%) and 31 (21.8%) in the Sor group were ATB+. Baseline characteristics were well balanced across ATB groups, except for region of origin, with a higher proportion of Asian pts in ATB+ (60% vs 45%; p=0.01). After a median follow-up of 10.38 months (95%CI:8.6-12.5), OS and PFS rates at 12 months were 72.3% and 9.7% in A+B; 64.8%, and 1.4% in Sor, respectively. ATB+ exposure was associated with increased risk of death both in univariate (HR 1.67; 95%CI 1.04-2.69) and multivariate models (HR 1.62; 95%CI 1.40-1.89) in the A+B (p for interaction <0.001), but not in the Sor arm (univariate HR 0.63; 95%CI 0.32-1.25; multivariate HR 0.70; 95%CI 0.31-1.60). Similarly, the risk of progression was increased for ATB+ pts in the A+B arm (univariate HR 1.68; 95%CI 1.03-2.71; multivariate HR 1.59; 95%CI 1.40-1.81), but not in the Sor arm (univariate HR 0.51;95%CI 0.26-1.01; multivariate HR 0.53; 95%CI 0.21-1.30) with positive p for interaction (p=0.002). Objective response rate (ORR) according to RECIST v.1.1 did not differ between ATB+ (28.0%) and ATB- (30.0%) in A+B (p=0.68). Conclusions: In a post-hoc sub-analysis of IMbrave150 we demonstrate for the first time the negative impact of early antibiotics exposure on outcomes of patients receiving A+B but not in those treated with Sor. Prospective translational studies should evaluate the role of ATB-mediated gut dysbiosis as a proposed mechanism underlying the adverse outcome in immunotherapy-recipients.
Collapse
Affiliation(s)
- Claudia A.M. Fulgenzi
- Department of Surgery and Cancer, Imperial College London, Hammersmith Hospital, London, United Kingdom
| | | | | | - Bernhard Scheiner
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | | | - Alessio Cortellini
- Department of Surgery and Cancer, Imperial College London, London, United Kingdom
| | | |
Collapse
|
29
|
Affiliation(s)
- Matthias Pinter
- Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, 1090 Vienna, Austria.
| | - David J Pinato
- Department of Surgery & Cancer, Hammersmith Hospital, Imperial College London, London, UK; Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| |
Collapse
|
30
|
Balcar L, Bauer D, Pomej K, Meischl T, Mandorfer M, Reiberger T, Trauner M, Scheiner B, Pinter M. Early changes in immunoglobulin G levels during immune checkpoint inhibitor treatment are associated with survival in hepatocellular carcinoma patients. PLoS One 2023; 18:e0282680. [PMID: 37027398 PMCID: PMC10081755 DOI: 10.1371/journal.pone.0282680] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/15/2022] [Accepted: 02/21/2023] [Indexed: 04/08/2023] Open
Abstract
BACKGROUND & AIMS Immunotherapy represents the new standard of care in systemic first-line treatment of hepatocellular carcinoma (HCC). Biomarkers that predict treatment response and survival remain an unmet clinical need. METHODS Patients with HCC treated with immune-checkpoint inhibitors (ICI) between 10/2017 and 03/2022 were retrospectively evaluated. Immunoglobulin levels (IgG, IgM, IgA) were measured at baseline and six weeks after initiation of ICI treatment. Impact of relative changes on overall survival (OS), progression-free survival (PFS), and time to progression (TTP) were evaluated. RESULTS Seventy-two patients with HCC receiving ICI (mostly atezolizumab/bevacizumab n = 54,75%) were included (mean age: 68±12 years, cirrhosis: 72%, mean Child-Turcotte-Pugh [CTP] score: 7±2 points). Most patients had a preserved performance status (ECOG-PS 0, n = 45, 63%), 25 (35%) showed macrovascular invasion, and 32 (44%) had extrahepatic spread. Baseline immunoglobulin values (median, IgG: 1395mg/dL, IgM: 337mg/dL, IgA: 89mg/dL) were not different between responders and non-responders, and neither baseline nor follow-up immunoglobulin values correlated with OS, PFS, and TTP. However, the relative change in IgG (Δ-IgG) independently predicted OS in multivariable Cox regression analysis after adjusting for severity of liver disease, baseline AFP and CRP as well as for Δ-IgA and Δ-IgM. Patients could be stratified into high (Δ-IgG≥+14%) vs. low (Δ-IgG<+14%) risk groups (median OS: 6.4 vs. 15.9 months; p = 0.001). Importantly, Δ-IgG was also associated with PFS and TTP on adjusted multivariable Cox regression analyses. CONCLUSION Our study proposes a higher increase of Δ-IgG upon ICI treatment as a negative prognostic marker in patients with HCC, independent of underlying liver disease severity. These results require independent validation.
Collapse
Affiliation(s)
- Lorenz Balcar
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - David Bauer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Katharina Pomej
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Tobias Meischl
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
- 3rd Medical Department (Hematology & Oncology), Hanusch Krankenhaus, Vienna, Austria
| | - Mattias Mandorfer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
31
|
Sinner F, Pinter M, Scheiner B, Ettrich TJ, Sturm N, Gonzalez-Carmona MA, Waidmann O, Finkelmeier F, Himmelsbach V, De Toni EN, Ben Khaled N, Mohr R, Fründt TW, Kütting F, van Bömmel F, Lieb S, Krug S, Bettinger D, Schultheiß M, Jochheim LS, Best J, Müller C, Keitel V, Venerito M. Atezolizumab Plus Bevacizumab in Patients with Advanced and Progressing Hepatocellular Carcinoma: Retrospective Multicenter Experience. Cancers (Basel) 2022; 14:5966. [PMID: 36497447 PMCID: PMC9737362 DOI: 10.3390/cancers14235966] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2022] [Revised: 11/24/2022] [Accepted: 11/30/2022] [Indexed: 12/11/2022] Open
Abstract
Atezolizumab plus bevacizumab is the standard of care for first-line systemic therapy for advanced hepatocellular carcinoma (aHCC). Data on the efficacy and safety of atezolizumab plus bevacizumab in patients with aHCC who have received prior systemic therapy are not available. Methods: Patients with aHCC who received atezolizumab plus bevacizumab after at least one systemic treatment between December 2018 and March 2022 were retrospectively identified in 13 centers in Germany and Austria. Patient characteristics, tumor response rates, progression-free survival (PFS), overall survival (OS), and adverse events (AE) were analyzed. Results: A total of 50 patients were identified; 41 (82%) were male. The median age at initiation of treatment with atezolizumab plus bevacizumab was 65 years, 41 (82%) patients had cirrhosis, 30 (73%) Child A, 9 (22%) B, and 2 (5%) C. A total of 34 patients (68%) received atezolizumab plus bevacizumab in the second-line setting and 16 (32%) in later lines. The best radiologic tumor responses were complete remission (2%), partial remission (30%), stable disease (36%), and progressive disease (18%), resulting in an objective response rate of 32% and a disease control rate of 68%. Median OS was 16.0 months (95% confidence interval 5.6-26.4 months), and median PFS was 7.1 months (95% confidence interval 4.4-9.8 months). AE grades 3-4 were observed in seven (14%) and resulted in death in three patients (6%). There were five (10%) bleeding events with a grade ≥ 3, including one (2%) with a fatal outcome. Conclusions: Atezolizumab plus bevacizumab is effective in patients with aHCC who did not have access to this option as first-line therapy. The safety profile was consistent with previous reports.
Collapse
Affiliation(s)
- Friedrich Sinner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Matthias Pinter
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, A-1090 Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, A-1090 Vienna, Austria
| | - Bernhard Scheiner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, A-1090 Vienna, Austria
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, A-1090 Vienna, Austria
| | - Thomas Jens Ettrich
- Ulm University Hospital, Department of Internal Medicine I, 89081 Ulm, Germany
| | - Niklas Sturm
- Ulm University Hospital, Department of Internal Medicine I, 89081 Ulm, Germany
| | | | - Oliver Waidmann
- Department of Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, 60590 Frankfurt, Germany
- University Cancer Center Frankfurt, University Hospital Frankfurt, 60590 Frankfurt, Germany
- Center for Hematology and Oncology Bethanien, 60389 Frankfurt, Germany
| | - Fabian Finkelmeier
- Department of Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, 60590 Frankfurt, Germany
- University Cancer Center Frankfurt, University Hospital Frankfurt, 60590 Frankfurt, Germany
- Frankfurt Cancer Institute, Goethe University Frankfurt/Main, 60590 Frankfurt, Germany
| | - Vera Himmelsbach
- Department of Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, 60590 Frankfurt, Germany
| | - Enrico N. De Toni
- Department of Medicine II, University Hospital, LMU Munich, 81377 Munich, Germany
| | - Najib Ben Khaled
- Department of Medicine II, University Hospital, LMU Munich, 81377 Munich, Germany
- German Cancer Consortium (DKTK), Partner Site Munich, and German Cancer Research Center, 69120 Heidelberg, Germany
| | - Raphael Mohr
- Department of Hepatology & Gastroenterology, Campus Virchow Klinikum and Campus Charité Mitte, Charité University Medicine Berlin, 10117 Berlin, Germany
| | - Thorben Wilhelm Fründt
- Department of Internal Medicine, Gastroenterology & Hepatology, University Medical Center Hamburg-Eppendorf, 20246 Hamburg, Germany
| | - Fabian Kütting
- Clinic for Gastroenterology and Hepatology, Faculty of Medicine and University Hospital Cologne, University of Cologne, 50937 Cologne, Germany
| | - Florian van Bömmel
- Department of Medicine II, Division of Hepatology, Leipzig University Medical Center, 04103 Leipzig, Germany
| | - Sabine Lieb
- Department of Medicine II, Division of Hepatology, Leipzig University Medical Center, 04103 Leipzig, Germany
| | - Sebastian Krug
- Department of Internal Medicine I, Martin-Luther-University Halle-Wittenberg, 06120 Halle, Germany
| | - Dominik Bettinger
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Michael Schultheiß
- Department of Medicine II, Medical Center University of Freiburg, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Leonie S. Jochheim
- Department of Gastroenterology and Hepatology, University Hospital Essen, 45147 Essen, Germany
| | - Jan Best
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital Magdeburg, 39120 Magdeburg, Germany
- Department of Internal Medicine, University Hospital Knappschaftskrankenhaus Bochum, Ruhr University Bochum, 44892 Bochum, Germany
| | - Christian Müller
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Verena Keitel
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital Magdeburg, 39120 Magdeburg, Germany
| | - Marino Venerito
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-von-Guericke University Hospital Magdeburg, 39120 Magdeburg, Germany
| |
Collapse
|
32
|
Wu YL, Fulgenzi CAM, D’Alessio A, Cheon J, Nishida N, Saeed A, Wietharn B, Cammarota A, Pressiani T, Personeni N, Pinter M, Scheiner B, Balcar L, Huang YH, Phen S, Naqash AR, Vivaldi C, Salani F, Masi G, Bettinger D, Vogel A, Schönlein M, von Felden J, Schulze K, Wege H, Galle PR, Kudo M, Rimassa L, Singal AG, Sharma R, Cortellini A, Gaillard VE, Chon HJ, Pinato DJ, Ang C. Neutrophil-to-Lymphocyte and Platelet-to-Lymphocyte Ratios as Prognostic Biomarkers in Unresectable Hepatocellular Carcinoma Treated with Atezolizumab plus Bevacizumab. Cancers (Basel) 2022; 14:cancers14235834. [PMID: 36497316 PMCID: PMC9737420 DOI: 10.3390/cancers14235834] [Citation(s) in RCA: 23] [Impact Index Per Article: 11.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2022] [Revised: 11/22/2022] [Accepted: 11/23/2022] [Indexed: 11/29/2022] Open
Abstract
Systemic inflammation is a key risk factor for hepatocellular carcinoma (HCC) progression and poor outcomes. Inflammatory markers such as the neutrophil-to-lymphocyte ratio (NLR) and platelet-to-lymphocyte ratio (PLR) may have prognostic value in HCC treated with standard of care atezolizumab plus bevacizumab (Atezo-Bev). We conducted a multicenter, international retrospective cohort study of patients with unresectable HCC treated with Atezo-Bev to assess the association of NLR and PLR with overall survival (OS), progression-free survival (PFS), and objective response rates. Patients with NLR ≥ 5 had a significantly shorter OS (9.38 vs. 16.79 months, p < 0.001) and PFS (4.90 vs. 7.58 months, p = 0.03) compared to patients with NLR < 5. NLR ≥ 5 was an independent prognosticator of worse OS (HR 2.01, 95% CI 1.22−3.56, p = 0.007) but not PFS. PLR ≥ 300 was also significantly associated with decreased OS (9.38 vs. 15.72 months, p = 0.007) and PFS (3.45 vs. 7.11 months, p = 0.04) compared to PLR < 300, but it was not an independent prognosticator of OS or PFS. NLR and PLR were not associated with objective response or disease control rates. NLR ≥ 5 independently prognosticated worse survival outcomes and is worthy of further study and validation.
Collapse
Affiliation(s)
- Yue Linda Wu
- Department of Medicine, Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
| | - Claudia Angela Maria Fulgenzi
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
- Division of Medical Oncology, Policlinico Universitario Campus Bio-Medico, 00128 Rome, Italy
| | - Antonio D’Alessio
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
| | - Jaekyung Cheon
- Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam 46371, Republic of Korea
| | - Naoshi Nishida
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka 589-8511, Japan
| | - Anwaar Saeed
- Department of Medicine, Division of Medical Oncology, Kansas University Cancer Center, Kansas City, KS 66160, USA
| | - Brooke Wietharn
- Department of Medicine, Division of Medical Oncology, Kansas University Cancer Center, Kansas City, KS 66160, USA
| | - Antonella Cammarota
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Tiziana Pressiani
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Nicola Personeni
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, 1090 Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, 1090 Vienna, Austria
| | - Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, 1090 Vienna, Austria
| | - Yi-Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei 11217, Taiwan
- Institute of Clinical Medicine, National Yang Ming Chiao Tung University, Taipei 71150, Taiwan
- School of Medicine, National Yang Ming Chiao Tung University, Taipei 11217, Taiwan
| | - Samuel Phen
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Abdul Rafeh Naqash
- Medical Oncology/TSET Phase 1 Program, Stephenson Cancer Center, University of Oklahoma, Oklahoma City, OK 73104, USA
| | - Caterina Vivaldi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56124 Pisa, Italy
| | - Francesca Salani
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy
- Sant’Anna School of Advanced Studies, 56127 Pisa, Italy
| | - Gianluca Masi
- Department of Translational Research and New Technologies in Medicine and Surgery, University of Pisa, 56124 Pisa, Italy
- Unit of Medical Oncology 2, Azienda Ospedaliero-Universitaria Pisana, 56126 Pisa, Italy
| | - Dominik Bettinger
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases), Freiburg University Medical Center, Faculty of Medicine, University of Freiburg, 79106 Freiburg, Germany
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, 30625 Hannover, Germany
| | - Martin Schönlein
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of Pneumology, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Johann von Felden
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Kornelius Schulze
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Henning Wege
- I. Department of Medicine, University Medical Center Hamburg-Eppendorf, 20251 Hamburg, Germany
| | - Peter R. Galle
- I. Department of Internal Medicine, University Medical Center Mainz, 55131 Mainz, Germany
| | - Masatoshi Kudo
- Department of Gastroenterology and Hepatology, Faculty of Medicine, Kindai University, Osaka 589-8511, Japan
| | - Lorenza Rimassa
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, Pieve Emanuele, 20072 Milan, Italy
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, Rozzano, 20089 Milan, Italy
| | - Amit G. Singal
- Department of Internal Medicine, University of Texas Southwestern Medical Center, Dallas, TX 75390, USA
| | - Rohini Sharma
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Alessio Cortellini
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | | | - Hong Jae Chon
- Medical Oncology, Department of Internal Medicine, CHA Bundang Medical Center, CHA University, Seongnam 46371, Republic of Korea
| | - David J. Pinato
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, London W12 0HS, UK
| | - Celina Ang
- Department of Medicine, Division of Hematology/Oncology, Tisch Cancer Institute, Icahn School of Medicine at Mount Sinai, New York, NY 10029, USA
- Correspondence: ; Tel.: +1-(212)-824-8551
| |
Collapse
|
33
|
Vithayathil M, D'Alessio A, Fulgenzi CAM, Nishida N, Schönlein M, von Felden J, Schulze K, Wege H, Saeed A, Wietharn B, Hildebrand H, Wu L, Ang C, Marron TU, Weinmann A, Galle PR, Bettinger D, Bengsch B, Vogel A, Balcar L, Scheiner B, Lee P, Huang Y, Amara S, Muzaffar M, Naqash AR, Cammarota A, Personeni N, Pressiani T, Pinter M, Cortellini A, Kudo M, Rimassa L, Pinato DJ, Sharma R. Impact of older age in patients receiving atezolizumab and bevacizumab for hepatocellular carcinoma. Liver Int 2022; 42:2538-2547. [PMID: 35986902 PMCID: PMC9825835 DOI: 10.1111/liv.15405] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Revised: 08/01/2022] [Accepted: 08/09/2022] [Indexed: 01/18/2023]
Abstract
BACKGROUND AND AIMS Combination atezolizumab/bevacizumab is the gold standard for first-line treatment of unresectable hepatocellular carcinoma (HCC). Our study investigated the efficacy and safety of combination therapy in older patients with HCC. METHODS 191 consecutive patients from eight centres receiving atezolizumab and bevacizumab were included. Overall survival (OS), progression-free survival (PFS), overall response rate (ORR) and disease control rate (DCR) defined by RECIST v1.1 were measured in older (age ≥ 65 years) and younger (age < 65 years) age patients. Treatment-related adverse events (trAEs) were evaluated. RESULTS The elderly (n = 116) had higher rates of non-alcoholic fatty liver disease (19.8% vs. 2.7%; p < .001), presenting with smaller tumours (6.2 cm vs 7.9 cm, p = .02) with less portal vein thrombosis (31.9 vs. 54.7%, p = .002), with fewer patients presenting with BCLC-C stage disease (50.9 vs. 74.3%, p = .002). There was no significant difference in OS (median 14.9 vs. 15.1 months; HR 1.15, 95% CI 0.65-2.02 p = .63) and PFS (median 7.1 vs. 5.5 months; HR 1.11, 95% CI 0.54-1.92; p = .72) between older age and younger age. Older patients had similar ORR (27.6% vs. 20.0%; p = .27) and DCR (77.5% vs. 66.1%; p = .11) compared to younger patients. Atezolizumab-related (40.5% vs. 48.0%; p = .31) and bevacizumab-related (44.8% vs. 41.3%; p = .63) trAEs were comparable between groups. Rates of grade ≥3 trAEs and toxicity-related treatment discontinuation were similar between older and younger age patients. Patients 75 years and older had similar survival and safety outcomes compared to younger patients. CONCLUSIONS Atezolizumab and bevacizumab therapy is associated with comparable efficacy and tolerability in older age patients with unresectable HCC.
Collapse
Affiliation(s)
- Mathew Vithayathil
- Department of Surgery & Cancer, Imperial College LondonHammersmith HospitalLondonUK
| | - Antonio D'Alessio
- Department of Surgery & Cancer, Imperial College LondonHammersmith HospitalLondonUK,Department of Biomedical SciencesHumanitas UniversityPieve EmanueleItaly
| | - Claudia A. M. Fulgenzi
- Department of Surgery & Cancer, Imperial College LondonHammersmith HospitalLondonUK,Division of Medical OncologyPoliclinico Universitario Campus Bio‐MedicoRomeItaly
| | - Naoshi Nishida
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Martin Schönlein
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of PneumologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Johann von Felden
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Kornelius Schulze
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Henning Wege
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Anwaar Saeed
- Division of Medical Oncology, Department of MedicineKansas University Cancer CenterKansas CityKansasUSA
| | - Brooke Wietharn
- Division of Medical Oncology, Department of MedicineKansas University Cancer CenterKansas CityKansasUSA
| | - Hannah Hildebrand
- Division of Medical Oncology, Department of MedicineKansas University Cancer CenterKansas CityKansasUSA
| | - Linda Wu
- Division of Hematology/Oncology, Department of MedicineTisch Cancer Institute, Mount Sinai HospitalNew YorkNew YorkUSA
| | - Celina Ang
- Division of Hematology/Oncology, Department of MedicineTisch Cancer Institute, Mount Sinai HospitalNew YorkNew YorkUSA
| | - Thomas U. Marron
- Division of Hematology/Oncology, Department of MedicineTisch Cancer Institute, Mount Sinai HospitalNew YorkNew YorkUSA
| | - Arndt Weinmann
- I. Medical DepartmentUniversity Medical Center MainzMainzGermany
| | - Peter R. Galle
- I. Medical DepartmentUniversity Medical Center MainzMainzGermany
| | - Dominik Bettinger
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases), Faculty of Medicine, Freiburg University Medical CenterUniversity of FreiburgFreiburgGermany
| | - Bertram Bengsch
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases), Faculty of Medicine, Freiburg University Medical CenterUniversity of FreiburgFreiburgGermany,University of FreiburgSignalling Research Centers BIOSS and CIBSSFreiburgGermany,German Cancer Consortium (DKTK), Partner SiteFreiburgGermany
| | | | - Lorenz Balcar
- Division of Gastroenterology & Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Bernhard Scheiner
- Division of Gastroenterology & Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Pei‐Chang Lee
- Division of Gastroenterology and Hepatology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan
| | - Yi‐Hsiang Huang
- Division of Gastroenterology and Hepatology, Department of MedicineTaipei Veterans General HospitalTaipeiTaiwan,Institute of Clinical Medicine, School of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Suneetha Amara
- Division of Hematology/OncologyEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Mahvish Muzaffar
- Division of Hematology/OncologyEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Abdul Rafeh Naqash
- Division of Hematology/OncologyEast Carolina UniversityGreenvilleNorth CarolinaUSA,Medical Oncology/TSET Phase 1 Program, Stephenson Cancer CenterUniversity of OklahomaNormanOklahomaUSA
| | - Antonella Cammarota
- Department of Biomedical SciencesHumanitas UniversityPieve EmanueleItaly,Medical Oncology and Hematology Unit, Humanitas Cancer CenterIRCCS Humanitas Research HospitalRozzanoItaly
| | - Nicola Personeni
- Department of Biomedical SciencesHumanitas UniversityPieve EmanueleItaly,Medical Oncology and Hematology Unit, Humanitas Cancer CenterIRCCS Humanitas Research HospitalRozzanoItaly
| | - Tiziana Pressiani
- Medical Oncology and Hematology Unit, Humanitas Cancer CenterIRCCS Humanitas Research HospitalRozzanoItaly
| | - Matthias Pinter
- Division of Gastroenterology & Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Alessio Cortellini
- Department of Surgery & Cancer, Imperial College LondonHammersmith HospitalLondonUK
| | - Masatoshi Kudo
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Lorenza Rimassa
- Department of Biomedical SciencesHumanitas UniversityPieve EmanueleItaly,Medical Oncology and Hematology Unit, Humanitas Cancer CenterIRCCS Humanitas Research HospitalRozzanoItaly
| | - David J. Pinato
- Department of Surgery & Cancer, Imperial College LondonHammersmith HospitalLondonUK,Division of Oncology, Department of Translational MedicineUniversity of Piemonte OrientaleNovaraItaly
| | - Rohini Sharma
- Department of Surgery & Cancer, Imperial College LondonHammersmith HospitalLondonUK
| |
Collapse
|
34
|
Simbrunner B, Villesen IF, Königshofer P, Scheiner B, Bauer D, Paternostro R, Schwabl P, Timelthaler G, Ramazanova D, Wöran K, Stift J, Eigenbauer E, Stättermayer AF, Marculescu R, Pinter M, Møller S, Trauner M, Karsdal M, Leeming DJ, Reiberger T, Mandorfer M. Systemic inflammation is linked to liver fibrogenesis in patients with advanced chronic liver disease. Liver Int 2022; 42:2501-2512. [PMID: 35822301 PMCID: PMC9804351 DOI: 10.1111/liv.15365] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2021] [Revised: 05/18/2022] [Accepted: 07/09/2022] [Indexed: 01/05/2023]
Abstract
BACKGROUND & AIMS Experimental evidence indicates that systemic inflammation (SI) promotes liver fibrogenesis. This study investigated the potential link between SI and fibrogenesis in patients with advanced chronic liver disease (ACLD). METHODS Serum biomarkers of SI (CRP, IL-6, procalcitonin [PCT]) and extracellular matrix (ECM) turnover (i.e., fibrogenesis/fibrolysis) were analysed in 215 prospectively recruited patients with ACLD (hepatic venous pressure gradient [HVPG] ≥6 mm Hg) undergoing hepatic vein catheterization. Patients with non-elective hospitalization or bacterial infection were excluded. Histological alpha-smooth muscle actin (α-SMA) area was quantified on full biopsy scans by automated morphometric quantification in a subset of 34 patients who underwent concomitant transjugular liver biopsy. RESULTS Histological α-SMA proportionate area correlated with enhanced liver fibrosis (ELF) score (Spearman's ρ = 0.660, p < .001), markers of collagen formation (PRO-C3, ρ = 0.717, p < .001; PRO-C6, ρ = 0.526, p = .002) and tissue inhibitor of metalloproteinases-1 (TIMP1; ρ = 0.547, p < .001), indicating that these blood biomarkers are capable of reflecting the dynamic process of ECM turnover. CRP, IL-6 and PCT levels correlated with ELF, biomarkers of collagen synthesis/degradation and TIMP1, both in compensated and decompensated patients. Multivariate linear regression models (adjusted for HVPG) confirmed that CRP, IL-6 and PCT were independently linked to markers of liver fibrogenesis and ECM turnover. CONCLUSION Systemic inflammation is linked to both liver fibrogenesis and ECM turnover in ACLD and this association is not confounded by the severity of liver disease, as evaluated by HVPG. Our study confirms experimental data on the detrimental impact of SI on ECM deposition and fibrosis progression in a thoroughly characterized cohort of patients with ACLD.
Collapse
Affiliation(s)
- Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases (LBI-RUD), Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Ida Falk Villesen
- Nordic Bioscience, Herlev, Denmark.,University of Copenhagen, Copenhagen, Denmark
| | - Philipp Königshofer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases (LBI-RUD), Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - David Bauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Philipp Schwabl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases (LBI-RUD), Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Gerald Timelthaler
- Institute of Cancer Research, Department of Medicine I, Medical University of Vienna, Vienna, Austria
| | - Dariga Ramazanova
- Section for Medical Statistics, CeMSIIS, Medical University of Vienna, Vienna, Austria
| | - Katharina Wöran
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Judith Stift
- Department of Pathology, Medical University of Vienna, Vienna, Austria
| | - Ernst Eigenbauer
- IT Systems and Communications, Medical University of Vienna, Vienna, Austria
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rodrig Marculescu
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Søren Møller
- Department of Clinical Physiology and Nuclear Medicine, Center for Functional and Diagnostic Imaging and Research, Copenhagen University Hospital, Hvidovre, Denmark.,Department of Clinical Medicine, University of Copenhagen, Copenhagen, Denmark
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | | | | | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases (LBI-RUD), Vienna, Austria.,CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
35
|
Balcar L, Scheiner B, Urheu M, Weinberger P, Paternostro R, Simbrunner B, Hartl L, Jachs M, Bauer D, Semmler G, Willheim C, Pinter M, Ferenci P, Trauner M, Reiberger T, Stättermayer AF, Mandorfer M. Alpha-1 antitrypsin Pi∗Z allele is an independent risk factor for liver transplantation and death in patients with advanced chronic liver disease. JHEP Rep 2022; 4:100562. [PMID: 36176936 PMCID: PMC9513767 DOI: 10.1016/j.jhepr.2022.100562] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/05/2022] [Revised: 07/21/2022] [Accepted: 08/09/2022] [Indexed: 11/28/2022] Open
Abstract
Background & Aims Alpha-1 antitrypsin (AAT) deficiency causes/predisposes individuals to advanced chronic liver disease (ACLD). However, the role of the SERPINA1 Pi∗Z allele in patients who have already progressed to ACLD is unclear. Thus, we aimed to evaluate the impact of the Pi∗Z allele on the risk of liver transplantation/liver-related death in patients with ACLD, while adjusting for the severity of liver disease at inclusion. Methods A total of 1,118 patients with ACLD who underwent hepatic venous pressure gradient (HVPG) measurement and genotyping for the Pi∗Z/Pi∗S allele at the Vienna Hepatic Hemodynamic Lab were included in this retrospective analysis. The outcome of interest was liver transplantation/liver-related death, while non-liver-related death and removal/suppression of the primary etiological factor were considered as competing risks. Results Viral hepatitis was the most common etiology (44%), followed by alcohol-related (31%) and non-alcoholic fatty liver disease (11%). Forty-two (4%) and forty-six (4%) patients harboured the Pi∗Z and Pi∗S variants, respectively. Pi∗Z carriers had more severe portal hypertension (HVPG: 19±6 vs.15±7 mmHg; p <0.001) and hepatic dysfunction (Child-Turcotte-Pugh: 7.1±1.9 vs. 6.5±1.9 points; p = 0.050) at inclusion, compared to non-carriers. Contrarily, the Pi∗S allele was unrelated to liver disease severity. In competing risk regression analysis, harbouring the Pi∗Z allele was significantly associated with an increased probability of liver transplantation/liver-related death, even after adjusting for liver disease severity at inclusion. The detrimental impact of the common Pi∗MZ genotype (adjusted subdistribution hazard ratio: ≈1.56 vs. Pi∗MM) was confirmed in a fully adjusted subgroup analysis. In contrast, Pi∗S carriers had no increased risk of events. Conclusion Genotyping for the Pi∗Z allele identifies patients with ACLD at increased risk of adverse liver-related outcomes, thereby improving prognostication. Therapies targeting the accumulation of abnormal AAT should be evaluated as disease-modifying treatments in Pi∗Z allele carriers with ACLD. Lay summary Alpha-1 antitrypsin deficiency is a genetic disease that affects the lung and the liver. Carrying two dysfunctional copies of the gene causes advanced liver disease. Harbouring one dysfunctional copy increases disease severity in patients with other liver illness. However, the significance of this genetic defect in patients who already suffer from advanced liver disease is unclear. Our study found that harbouring at least one dysfunctional copy of the alpha-1 antitrypsin gene increases the risk of requiring a liver transplantation or dying from a liver disease. This indicates the need for medical therapies aimed at treating the hepatic consequences of this genetic defect. Pi∗Z allele is significantly associated with liver-related events in patients with ACLD. This finding extends to patients harbouring the Pi∗MZ genotype. Genotyping for the Pi∗Z allele might improve prognostication in patients with ACLD. Therapies targeting accumulation of abnormal AAT should be assessed in Pi∗Z carriers with ACLD.
Collapse
Key Words
- (a[S])HR, (Adjusted [subdistribution]) hazard ratio
- AAT, Alpha-1 antitrypsin
- AATD
- AATD, Alpha-1 antitrypsin deficiency
- ACLD, Advanced chronic liver disease
- CTP, Child-turcotte-pugh score
- ER, Endoplasmic reticulum
- GWAS, Genome wide association studies
- HCC, Hepatocellular carcinoma
- HVPG, Hepatic venous pressure gradient
- NAFLD, Non-alcoholic fatty liver disease
- SERPINA1, Serpin family a member 1
- UNOS MELD (2016), United network for organ sharing model for end-stage liver disease
- cirrhosis
- genetic risk
- prognostication
- rare disease
Collapse
Affiliation(s)
- Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Markus Urheu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Patrick Weinberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Lukas Hartl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - David Bauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Claudia Willheim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Peter Ferenci
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.,Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
36
|
Scheiner B, Roessler D, Phen S, Lim M, Pomej K, Pressiani T, Cammarota A, Fründt TW, von Felden J, Schulze K, Himmelsbach V, Finkelmeier F, Deibel A, Siebenhüner AR, Shmanko K, Radu P, Schwacha-Eipper B, Ebert MP, Teufel A, Djanani A, Hucke F, Balcar L, Philipp AB, Hsiehchen D, Venerito M, Sinner F, Trauner M, D'Alessio A, Fulgenzi CA, Pinato DJ, Peck-Radosavljevic M, Dufour JF, Weinmann A, Kremer AE, Singal AG, De Toni EN, Rimassa L, Pinter M. Efficacy and safety of immune checkpoint inhibitor rechallenge in individuals with hepatocellular carcinoma. JHEP Rep 2022; 5:100620. [PMID: 36578451 PMCID: PMC9791167 DOI: 10.1016/j.jhepr.2022.100620] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Revised: 10/13/2022] [Accepted: 10/14/2022] [Indexed: 11/07/2022] Open
Abstract
Background & Aims We investigated the efficacy and safety of immune checkpoint inhibitor (ICI) rechallenge in patients with hepatocellular carcinoma (HCC) who received ICI-based therapies in a previous systemic line. Methods In this international, retrospective multicenter study, patients with HCC who received at least two lines of ICI-based therapies (ICI-1, ICI-2) at 14 institutions were eligible. The main outcomes included best overall response and treatment-related adverse events. Results Of 994 ICI-treated patients screened, a total of 58 patients (male, n = 41; 71%) with a mean age of 65.0±9.0 years were included. Median systemic treatment lines of ICI-1 and ICI-2 were 1 (range, 1-4) and 3 (range, 2-9), respectively. ICI-based therapies used at ICI-1 and ICI-2 included ICI alone (ICI-1, n = 26, 45%; ICI-2, n = 4, 7%), dual ICI regimens (n = 1, 2%; n = 12, 21%), or ICI combined with targeted therapies/anti-VEGF (n = 31, 53%; n = 42, 72%). Most patients discontinued ICI-1 due to progression (n = 52, 90%). Objective response rate was 22% at ICI-1 and 26% at ICI-2. Responses at ICI-2 were also seen in patients who had progressive disease as best overall response at ICI-1 (n = 11/21; 52%). Median time-to-progression at ICI-1 and ICI-2 was 5.4 (95% CI 3.0-7.7) months and 5.2 (95% CI 3.3-7.0) months, respectively. Treatment-related adverse events of grade 3-4 at ICI-1 and ICI-2 were observed in 9 (16%) and 10 (17%) patients, respectively. Conclusions ICI rechallenge was safe and resulted in a treatment benefit in a meaningful proportion of patients with HCC. These data provide a rationale for investigating ICI-based regimens in patients who progressed on first-line immunotherapy in prospective trials. Impact and implications Therapeutic sequencing after first-line immune checkpoint inhibitor (ICI)-based therapy for advanced hepatocellular carcinoma (HCC) remains a challenge as no available second-line treatment options have been studied in immunotherapy-pretreated patients. Particularly, the role of ICI rechallenge in patients with HCC is unclear, as data from prospective trials are lacking. We investigated the efficacy and safety of ICI-based regimens in patients with HCC pretreated with immunotherapy in a retrospective, international, multicenter study. Our data provide the rationale for prospective trials investigating the role of ICI-based regimens in patients who have progressed on first-line immunotherapy.
Collapse
Key Words
- BOR, best overall response
- CR, complete response
- DCR, disease control rate
- HCC, hepatocellular carcinoma
- ICI, immune checkpoint inhibitor
- Immune checkpoint blocker
- Immunotherapy
- Liver cancer
- NE, not evaluable
- ORR, objective response rate
- OS, overall survival
- PD, progressive disease
- PR, partial response
- SD, stable disease
- Systemic therapy
- TRAEs, treatment-related adverse events
- TTP, time-to-progression
Collapse
Affiliation(s)
- Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria,Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Daniel Roessler
- Department of Medicine II, University Hospital, LMU Munich, Munich, 81377, Germany
| | - Samuel Phen
- Department of Medicine, UT Southwestern Medical Center, Dallas TX, USA
| | - Mir Lim
- Department of Medicine, UT Southwestern Medical Center, Dallas TX, USA
| | - Katharina Pomej
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria,Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Tiziana Pressiani
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano (Milan), Italy
| | - Antonella Cammarota
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano (Milan), Italy,Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele (Milan), Italy
| | - Thorben W. Fründt
- 1. Department of Internal Medicine, Gastroenterology & Hepatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johann von Felden
- 1. Department of Internal Medicine, Gastroenterology & Hepatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kornelius Schulze
- 1. Department of Internal Medicine, Gastroenterology & Hepatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Vera Himmelsbach
- Department of Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Fabian Finkelmeier
- Department of Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Ansgar Deibel
- Department of Hepatology and Gastroenterology, University Hospital Zurich and University Zurich, Zurich, Switzerland
| | - Alexander R. Siebenhüner
- Department of Medical Oncology and Hematology, University Hospital Zurich and University Zurich, Zurich, Switzerland,Department of Medical Oncology and Hematology, Cantonal Hospital Schaffhausen, Schaffhausen, Switzerland
| | - Kateryna Shmanko
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Pompilia Radu
- Hepatology-Department of Biomedical Research, University of Bern, Bern, Switzerland,Department of Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Birgit Schwacha-Eipper
- Department of Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Matthias P. Ebert
- Department of Internal Medicine II, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany,Clinical Cooperation Unit Healthy Metabolism, Center for Preventive Medicine and Digital Health Baden-Württemberg (CPDBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany,DKFZ-Hector Cancer Institute at University Medical Center Mannheim, Mannheim, Germany
| | - Andreas Teufel
- Clinical Cooperation Unit Healthy Metabolism, Center for Preventive Medicine and Digital Health Baden-Württemberg (CPDBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany,Department of Internal Medicine II, Division of Hepatology, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Angela Djanani
- Department of Internal Medicine I, Division of Gastroenterology, Hepatology, Endocrinology and Metabolism, Medical University of Innsbruck, Innsbruck, Austria
| | - Florian Hucke
- Internal Medicine and Gastroenterology (IMuG), Including Centralized Emergency Service (ZAE), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria,Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alexander B. Philipp
- Department of Medicine II, University Hospital, LMU Munich, Munich, 81377, Germany
| | - David Hsiehchen
- Department of Medicine, UT Southwestern Medical Center, Dallas TX, USA
| | - Marino Venerito
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-Von Guericke University Hospital, 39120 Magdeburg, Germany
| | - Friedrich Sinner
- Department of Gastroenterology, Hepatology and Infectious Diseases, Otto-Von Guericke University Hospital, 39120 Magdeburg, Germany
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Antonio D'Alessio
- Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele (Milan), Italy,Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London, UK
| | - Claudia A.M. Fulgenzi
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London, UK,Department of Medical Oncology, University Campus Bio-Medico of Rome, Italy
| | - David J. Pinato
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, London, UK,Division of Oncology, Department of Translational Medicine, University of Piemonte Orientale, Novara, Italy
| | - Markus Peck-Radosavljevic
- Internal Medicine and Gastroenterology (IMuG), Including Centralized Emergency Service (ZAE), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Jean-François Dufour
- Hepatology-Department of Biomedical Research, University of Bern, Bern, Switzerland
| | - Arndt Weinmann
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Andreas E. Kremer
- Department of Hepatology and Gastroenterology, University Hospital Zurich and University Zurich, Zurich, Switzerland,Department of Medicine 1, Friedrich-Alexander-University Erlangen-Nürnberg, Erlangen, Germany
| | - Amit G. Singal
- Department of Medicine, UT Southwestern Medical Center, Dallas TX, USA
| | - Enrico N. De Toni
- Department of Medicine II, University Hospital, LMU Munich, Munich, 81377, Germany
| | - Lorenza Rimassa
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano (Milan), Italy,Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20072 Pieve Emanuele (Milan), Italy
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria,Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria,Corresponding author. Address: Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090 Vienna, Austria. Tel.: +43 1 40400 47440, fax: +43 1 40400 47350.
| |
Collapse
|
37
|
Jachs M, Hartl L, Simbrunner B, Bauer D, Paternostro R, Scheiner B, Balcar L, Semmler G, Stättermayer AF, Pinter M, Quehenberger P, Trauner M, Reiberger T, Mandorfer M. The Sequential Application of Baveno VII Criteria and VITRO Score Improves Diagnosis of Clinically Significant Portal Hypertension. Clin Gastroenterol Hepatol 2022:S1542-3565(22)00957-0. [PMID: 36244661 DOI: 10.1016/j.cgh.2022.09.032] [Citation(s) in RCA: 18] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/01/2022] [Revised: 09/14/2022] [Accepted: 09/19/2022] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS Baveno VII proposed liver stiffness measurement (LSM)/platelet count (PLT)-based criteria ('ruled out,' LSM ≤15 kPa plus PLT ≥150 G/L; 'ruled in': LSM ≥25 kPa) for clinically significant portal hypertension (CSPH) in compensated advanced chronic liver disease (cACLD). However, a substantial proportion of patients remains 'unclassified.' METHODS Patients with evidence of cACLD (LSM ≥10 kPa) undergoing hepatic venous pressure gradient (HVPG) measurement at the Vienna General Hospital 2004 to 2021 (derivation [2004-2016], n = 221; validation [2017-2021], n = 81) were included. The performance of noninvasive tests (NITs) including von Willebrand factor antigen to PLT ratio (VITRO) for the detection of CSPH (HVPG ≥10 mmHg) were evaluated. RESULTS Overall, viral hepatitis was the predominant (50.7%) etiology, followed by alcoholic liver disease (15.2%) and nonalcoholic steatohepatitis (13.2%); CSPH prevalence was 62.3%. In the derivation cohort, 45.7% were 'unclassified' according to Baveno VII criteria; in this group, VITRO showed an excellent diagnostic performance for the detection of CSPH (area under the receiver operating curve, 0.909; 95% confidence interval, 0.823-0.965). VITRO ≤1.5 and ≥2.5 ruled out (sensitivity, 97.7%; negative predictive value, 97.5%) and ruled in (specificity, 94.7%; positive predictive value, 91.2%), respectively, CSPH in patients who were 'unclassifiable' by Baveno VII criteria. The application of a sequential Baveno VII-VITRO algorithm reallocated 73% and 70% of 'unclassified' patients to the 'ruled in' and 'ruled out' group, respectively, while maintaining high sensitivity and negative predictive value and specificity and positive predictive value in the derivation and validation cohort, respectively. No patient allocated to the 'CSPH ruled out' group by the Baveno VII-VITRO algorithm developed decompensation within 5 years, whereas 5-year decompensation rates were negligible (4%) and substantial (23.9%) among 'unclassified' and 'CSPH ruled in' patients, respectively. CONCLUSIONS The sequential application of VITRO in patients with cACLD who were 'unclassifiable' with regard to CSPH by Baveno VII criteria substantially decreased the number of 'unclassifiable' patients to <15% and refined prognostication.
Collapse
Affiliation(s)
- Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Hartl
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Christian Doppler Lab for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - David Bauer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Peter Quehenberger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Christian Doppler Lab for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria.
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Medicine III, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
38
|
D’Alessio A, Fulgenzi CAM, Nishida N, Schönlein M, von Felden J, Schulze K, Wege H, Gaillard VE, Saeed A, Wietharn B, Hildebrand H, Wu L, Ang C, Marron TU, Weinmann A, Galle PR, Bettinger D, Bengsch B, Vogel A, Balcar L, Scheiner B, Lee P, Huang Y, Amara S, Muzaffar M, Naqash AR, Cammarota A, Personeni N, Pressiani T, Sharma R, Pinter M, Cortellini A, Kudo M, Rimassa L, Pinato DJ. Preliminary evidence of safety and tolerability of atezolizumab plus bevacizumab in patients with hepatocellular carcinoma and Child-Pugh A and B cirrhosis: A real-world study. Hepatology 2022; 76:1000-1012. [PMID: 35313048 PMCID: PMC9790703 DOI: 10.1002/hep.32468] [Citation(s) in RCA: 95] [Impact Index Per Article: 47.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/27/2022] [Revised: 02/25/2022] [Accepted: 03/10/2022] [Indexed: 12/31/2022]
Abstract
BACKGROUND AND AIMS Atezolizumab plus bevacizumab (AtezoBev) is the standard of care for first-line treatment of unresectable HCC. No evidence exists as to its use in routine clinical practice in patients with impaired liver function. APPROACH AND RESULTS In 216 patients with HCC who were consecutively treated with AtezoBev across 11 tertiary centers, we retrospectively evaluated treatment-related adverse events (trAEs) graded (G) according to Common Terminology Criteria for Adverse Events v5.0, including in the analysis all patients treated according to label (n = 202, 94%). We also assessed overall survival (OS), progression-free survival (PFS), overall response (ORR), and disease control rates (DCR) defined by Response Evaluation Criteria in Solid Tumors v1.1. Disease was mostly secondary to viral hepatitis, namely hepatitis C (n = 72; 36%) and hepatitis B infection (n = 35, 17%). Liver function was graded as Child-Pugh (CP)-A in 154 patients (76%) and CP-B in 48 (24%). Any grade trAEs were reported by 143 patients (71%), of which 53 (26%) were G3 and 3 (2%) G4. Compared with CP-A, patients with CP-B showed comparable rates of trAEs. Presence and grade of varices at pretreatment esophagogastroduodenoscopy did not correlate with bleeding events. After a median follow-up of 9.0 months (95% CI, 7.8-10.1), median OS was 14.9 months (95% CI, 13.6-16.3), whereas median PFS was 6.8 months (95% CI, 5.2-8.5). ORR and DCR were respectively 25% and 73%, with no difference across CP classes. CONCLUSIONS This study confirms reproducible safety and efficacy of AtezoBev in routine practice. Patients with CP-B reported similar tolerability compared with CP-A, warranting prospective evaluation of AtezoBev in this treatment-deprived population.
Collapse
Affiliation(s)
- Antonio D’Alessio
- Department of Surgery & CancerImperial College LondonHammersmith HospitalLondonUK,Department of Biomedical SciencesHumanitas UniversityPieve Emanuele, MilanItaly
| | - Claudia Angela Maria Fulgenzi
- Department of Surgery & CancerImperial College LondonHammersmith HospitalLondonUK,Division of Medical OncologyPoliclinico Universitario Campus Bio‐MedicoRomeItaly
| | - Naoshi Nishida
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Martin Schönlein
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of PneumologyUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Johann von Felden
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Kornelius Schulze
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | - Henning Wege
- Department of MedicineUniversity Medical Center Hamburg‐EppendorfHamburgGermany
| | | | - Anwaar Saeed
- Division of Medical OncologyDepartment of MedicineKansas University Cancer CenterKansas CityKansasUSA
| | - Brooke Wietharn
- Division of Medical OncologyDepartment of MedicineKansas University Cancer CenterKansas CityKansasUSA
| | - Hannah Hildebrand
- Division of Medical OncologyDepartment of MedicineKansas University Cancer CenterKansas CityKansasUSA
| | - Linda Wu
- Division of Hematology/OncologyDepartment of MedicineTisch Cancer InstituteMount Sinai HospitalNew YorkNew YorkUSA
| | - Celina Ang
- Division of Hematology/OncologyDepartment of MedicineTisch Cancer InstituteMount Sinai HospitalNew YorkNew YorkUSA
| | - Thomas U. Marron
- Division of Hematology/OncologyDepartment of MedicineTisch Cancer InstituteMount Sinai HospitalNew YorkNew YorkUSA
| | | | | | - Dominik Bettinger
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases)Faculty of MedicineFreiburg University Medical CenterUniversity of FreiburgFreiburgGermany
| | - Bertram Bengsch
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases)Faculty of MedicineFreiburg University Medical CenterUniversity of FreiburgFreiburgGermany,University of FreiburgSignalling Research Centres BIOSS and CIBSSFreiburgGermany,German Cancer Consortium (DKTK), partner siteFreiburgGermany
| | | | - Lorenz Balcar
- Division of Gastroenterology & HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Bernhard Scheiner
- Division of Gastroenterology & HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Pei‐Chang Lee
- Division of Gastroenterology and HepatologyDepartment of MedicineTaipei Veterans General HospitalTaipeiTaiwan
| | - Yi‐Hsiang Huang
- Division of Gastroenterology and HepatologyDepartment of MedicineTaipei Veterans General HospitalTaipeiTaiwan,Institute of Clinical MedicineSchool of MedicineNational Yang Ming Chiao Tung UniversityTaipeiTaiwan
| | - Suneetha Amara
- Division of Hematology/OncologyEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Mahvish Muzaffar
- Division of Hematology/OncologyEast Carolina UniversityGreenvilleNorth CarolinaUSA
| | - Abdul Rafeh Naqash
- Division of Hematology/OncologyEast Carolina UniversityGreenvilleNorth CarolinaUSA,Medical Oncology/TSET Phase 1 ProgramStephenson Cancer CenterUniversity of OklahomaNormanOklahomaUSA
| | - Antonella Cammarota
- Department of Biomedical SciencesHumanitas UniversityPieve Emanuele, MilanItaly,Medical Oncology and Hematology UnitHumanitas Cancer CenterIRCCS Humanitas Research HospitalRozzanoMilanItaly
| | - Nicola Personeni
- Department of Biomedical SciencesHumanitas UniversityPieve Emanuele, MilanItaly,Medical Oncology and Hematology UnitHumanitas Cancer CenterIRCCS Humanitas Research HospitalRozzanoMilanItaly
| | - Tiziana Pressiani
- Medical Oncology and Hematology UnitHumanitas Cancer CenterIRCCS Humanitas Research HospitalRozzanoMilanItaly
| | - Rohini Sharma
- Department of Surgery & CancerImperial College LondonHammersmith HospitalLondonUK
| | - Matthias Pinter
- Division of Gastroenterology & HepatologyDepartment of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Alessio Cortellini
- Department of Surgery & CancerImperial College LondonHammersmith HospitalLondonUK
| | - Masatoshi Kudo
- Department of Gastroenterology and HepatologyKindai University Faculty of MedicineOsakaJapan
| | - Lorenza Rimassa
- Department of Biomedical SciencesHumanitas UniversityPieve Emanuele, MilanItaly,Medical Oncology and Hematology UnitHumanitas Cancer CenterIRCCS Humanitas Research HospitalRozzanoMilanItaly
| | - David J. Pinato
- Department of Surgery & CancerImperial College LondonHammersmith HospitalLondonUK,Division of OncologyDepartment of Translational MedicineUniversity of Piemonte OrientaleNovaraItaly
| |
Collapse
|
39
|
Pomej K, Scheiner B, Balcar L, Nussbaumer RJ, Weinzierl J, Paternostro R, Simbrunner B, Bauer D, Pereyra D, Starlinger P, Stättermayer AF, Pinter M, Trauner M, Quehenberger P, Reiberger T, Mandorfer M. Clinical significance of substantially elevated von Willebrand factor antigen levels in patients with advanced chronic liver disease. Dig Liver Dis 2022; 54:1376-1384. [PMID: 35871985 DOI: 10.1016/j.dld.2022.06.010] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [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: 05/12/2022] [Revised: 06/01/2022] [Accepted: 06/15/2022] [Indexed: 12/29/2022]
Abstract
BACKGROUND Von Willebrand factor antigen (VWF) is a non-invasive marker for clinically significant portal hypertension (HVPG≥10 mmHg) and confers HVPG-independent prognostic information. While quantification of increased VWF-levels is not relevant in the context of von Willebrand disease, highly elevated VWF may be of clinical significance in ACLD. Thus, we have modified our analytical approach to quantify very high VWF-levels (i.e.,>420%) and investigated their prognostic value. METHODS Patients undergoing HVPG-measurement at the Vienna Hepatic Hemodynamic Lab with evidence of ACLD and information on VWF were considered. Clinical stages (CS) were defined as follows: Probable compensated ACLD (cACLD): LSM≥10kPa&HVPG<6 mmHg; 0: cACLD&6-9 mmHg; 1: cACLD&HVPG≥10 mmHg; 2: bleeding; 3: non-bleeding decompensation; 4: ≥2 decompensations. RESULTS 124 (16%) of 793 patients had VWF>420%. The proportion of VWF>420% increased with disease severity (probable cACLD-0: 5(4%) vs. 1: 22(10%) vs. 2-4: 97(23%),p ≤ 0.001) as well as across HVPG (<6mmHg: 1(2%) vs. 6-9: 6(6%) vs. 10-15: 17(9%) vs. ≥16: 100(22%),p ≤ 0.001) and MELD (<10: 17(6%) vs. 10-14: 27(10%) vs. ≥15: 79(32%),p ≤ 0.001) strata. In patients with VWF>420%, median VWF was 533 (IQR:466-611)% and VWF was unrelated to HVPG (Spearman's ρ=0.139,p = 0.123), but showed direct correlations of weak/moderate strength with MELD (ρ=0.336,p < 0.001) and CRP (ρ=0.286,p = 0.001). In the subgroup with VWF>420%, VWF was predictive of decompensation/liver-related mortality (VWF per 10%; hazard ratio (HR): 1.02(95% confidence interval (95%CI): 1.01-1.04),p = 0.008, even after adjusting for other factors (VWF per 10%; adjusted HR: 1.02(95%CI: 1.00-1.05),p = 0.031). CONCLUSION The proportion of patients with substantially elevated VWF values steadily increases with disease progression. While VWF is not reflective of HVPG in these patients, it is correlated with hepatic dysfunction and systemic inflammation. Importantly, quantification of high values provides prognostic information.
Collapse
Affiliation(s)
- Katharina Pomej
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Lorenz Balcar
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Rosa Johanna Nussbaumer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Johanna Weinzierl
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria
| | - David Bauer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - David Pereyra
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Patrick Starlinger
- Department of General Surgery, Division of Visceral Surgery, Medical University of Vienna, Vienna, Austria
| | - Albert Friedrich Stättermayer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| | - Peter Quehenberger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria; Christian Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria.
| | - Mattias Mandorfer
- Department of Internal Medicine III, Division of Gastroenterology and Hepatology, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
40
|
Samadaei M, Senfter D, Madlener S, Uranowska K, Hafner C, Trauner M, Rohr‐Udilova N, Pinter M. Targeting DNA repair to enhance the efficacy of sorafenib in hepatocellular carcinoma. J Cell Biochem 2022; 123:1663-1673. [PMID: 36271841 PMCID: PMC9828257 DOI: 10.1002/jcb.30340] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2021] [Revised: 09/23/2022] [Accepted: 10/07/2022] [Indexed: 01/12/2023]
Abstract
The multityrosine kinase inhibitor sorafenib remains an important systemic treatment option for hepatocellular carcinoma (HCC). Signaling pathways, which are targeted by sorafenib, are involved in checkpoint and DNA repair response, RAD51 being a candidate protein. Here, we aim to evaluate the effect of the human RAD51 inhibitor B02 in combination with sorafenib in human HCC cells. Impact of RAD51 expression on HCC patient survival was evaluated by an in silico approach using Human Protein Atlas dataset. Cell viability of HUH7, AKH12, AKH13, and 3P was assessed by neutral red assay. To measure the cytotoxicity, we quantified loss of membrane integrity by lactate dehydrogenase release. We also employed colony formation assay and hanging drop method to assess clonogenic and invasive ability of HCC cell lines upon sorafenib and B02 treatment. Cell cycle distribution and characterization of apoptosis was evaluated by flow cytometry. In silico approach revealed that HCC patients with higher expression of RAD51 messenger RNA had a significantly shorter overall survival. The RAD51 inhibitor B02 alone and in combination with sorafenib significantly reduced viability, colony formation ability, and invasion capacity of HCC cells. Cell cycle analysis revealed that the combination of both agents reduces the proportion of cells in the G2/M phase while leading to an accumulating in the subG1 phase. The RAD51 inhibitor B02 seems to be a promising agent for HCC treatment and enhances the antitumor effects of sorafenib in vitro.
Collapse
Affiliation(s)
- Mahzeiar Samadaei
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria,Liver Cancer (HCC) Study Group ViennaDepartment of Internal Medicine III, Medical University of ViennaViennaAustria
| | - Daniel Senfter
- Department of Pediatrics and Adolescent MedicineMolecular Neuro‐Oncology, Medical University of ViennaViennaAustria
| | - Sibylle Madlener
- Department of Pediatrics and Adolescent MedicineMolecular Neuro‐Oncology, Medical University of ViennaViennaAustria
| | - Karolina Uranowska
- Department of Dermatology, University Hospital St. PoeltenKarl Landsteiner University of Health SciencesSt. PoeltenAustria,Center for Pathophysiology, Infectiology and Immunology, Institute of Pathophysiology and Allergy ResearchMedical University of ViennaViennaAustria
| | - Christine Hafner
- Department of Dermatology, University Hospital St. PoeltenKarl Landsteiner University of Health SciencesSt. PoeltenAustria,Karl Landsteiner Institute of Dermatological ResearchKarl Landsteiner GesellschaftSt. PoeltenAustria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria
| | - Nataliya Rohr‐Udilova
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria,Liver Cancer (HCC) Study Group ViennaDepartment of Internal Medicine III, Medical University of ViennaViennaAustria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine IIIMedical University of ViennaViennaAustria,Liver Cancer (HCC) Study Group ViennaDepartment of Internal Medicine III, Medical University of ViennaViennaAustria
| |
Collapse
|
41
|
Bauer D, Kozbial K, Schwabl P, Chromy D, Simbrunner B, Stättermayer AF, Pinter M, Steindl-Munda P, Trauner M, Ferenci P, Reiberger T, Mandorfer M. Angiopoietin 2 levels decrease after HCV-cure and reflect the evolution of portal hypertension. Dig Liver Dis 2022; 54:1222-1229. [PMID: 35382974 DOI: 10.1016/j.dld.2022.02.013] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/27/2021] [Revised: 12/18/2021] [Accepted: 02/19/2022] [Indexed: 12/14/2022]
Abstract
BACKGROUND Portal hypertension (PH) does not resolve in a considerable proportion of patients who achieved HCV-cure. AIMS To investigate (i)whether HCV-cure impacts cytokines that orchestrate angiogenesis (i.e.,Ang1/Ang2/VEGF) and fibrogenesis (i.e.,PDGF/TGF-β) and (ii)whether their changes reflect PH-evolution and its complications. METHODS We measured plasma levels of cytokines and von Willebrand factor (VWF) and assessed hepatic venous pressure gradient (HVPG) before/after HCV-cure in 66 patients with pre-treatment PH and 23 patients without advanced disease, who served as controls. RESULTS Following HCV-cure, we observed a decrease in Ang2/TGF-β, but no changes in the other cytokines. The differences in circulating cytokine profiles in PH patients persisted after removing the primary etiological factor. Patients with pre-treatment HVPG≥10 mmHg with HVPG-reduction≥10% had a more pronounced relative decrease in Ang2. Finally, post-treatment Ang2 predicted FU-HVPG≥16 mmHg/decompensation with AUROC-values of 0.804/0.835. CONCLUSIONS HCV-cure decreases circulating Ang2 - a mediator/indicator of dysangiogenesis/endothelial dysfunction, as well as TGF-β - a profibrogenic cytokine. The dynamics of Ang2 mirrored those of PH, rendering FU-Ang2 a non-invasive test for pronounced PH at FU that also predicts hepatic decompensation. The pathophysiological significance of the persistently altered cytokine levels for mechanisms that hinder the PH-regression warrants further study.
Collapse
Affiliation(s)
- David Bauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Karin Kozbial
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Philipp Schwabl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Lazarettgasse 14, 1090, Vienna, Austria; CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Lazarettgasse 14, 1090, Vienna, Austria.
| | - David Chromy
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Albert F Stättermayer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Petra Steindl-Munda
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Peter Ferenci
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Lazarettgasse 14, 1090, Vienna, Austria; CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Lazarettgasse 14, 1090, Vienna, Austria.
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Währinger Gürtel 18-20, 1090, Vienna, Austria.
| |
Collapse
|
42
|
Scheiner B, Pinter M. Reply to: "The CRAFITY score: a promising prognostic predictor for patients with hepatocellular carcinoma treated with tyrosine kinase inhibitor and immunotherapy combinations". J Hepatol 2022; 77:576-577. [PMID: 35526786 DOI: 10.1016/j.jhep.2022.04.030] [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: 04/27/2022] [Accepted: 04/28/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
43
|
Jachs M, Scheiner B, Pinter M. Immunotherapy for hepatocellular carcinoma in a patient with hepatitis B virus and hepatitis delta virus coinfection. J Hepatol 2022; 77:256-257. [PMID: 35124108 DOI: 10.1016/j.jhep.2022.01.017] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/05/2022] [Revised: 01/17/2022] [Accepted: 01/25/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
44
|
Hucke F, Pinter M, Hucke M, Bota S, Bolf D, Hackl M, Peck-Radosavljevic M. Changing Epidemiological Trends of Hepatobiliary Carcinomas in Austria 2010–2018. Cancers (Basel) 2022; 14:cancers14133093. [PMID: 35804861 PMCID: PMC9264900 DOI: 10.3390/cancers14133093] [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] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2022] [Revised: 06/13/2022] [Accepted: 06/20/2022] [Indexed: 12/04/2022] Open
Abstract
Simple Summary Primary liver cancer is currently the sixth most common cancer and the third common cause of cancer-related mortality worldwide. Incidences have increased in recent year, especially in high-income countries. The epidemiology of predisposing risk factors for hepatobiliary carcinomas have changed significantly, while treatment and therapeutic options have markedly improved. Here, we provide an update of incidence, mortality, and survival trends in recent years, in Austria. While age-adjusted incidence rates remained stable in almost all hepatobiliary carcinoma subtypes—except for gall-bladder cancer—the overall survival improved significantly. Abstract Using national registries, we investigated the epidemiological trends of hepatobiliary carcinomas in Austria between 2010 and 2018 and compared them to those reported for the periods of 1990–1999 and 2000–2009. In total, 12,577 patients diagnosed with hepatocellular carcinoma (n = 7146), intrahepatic cholangiocarcinoma (n = 1858), extrahepatic cholangiocarcinoma (n = 1649), gallbladder carcinoma (n = 1365), and ampullary carcinoma (n = 559), between 2010 and 2018, were included. The median overall survival of all patients was 9.0 months. The best median overall survival was observed in patients with ampullary carcinoma (28.5 months) and the worst median overall survival was observed in patients with intrahepatic carcinoma (5.6 months). The overall survival significantly improved in all entities over the period 2010–2018 as compared with over the periods of 2000–2009 and 1990–1999. Age-adjusted incidence and mortality rates remained stable for most entities in both, men and women; only in gallbladder carcinoma, the incidence and mortality rates significantly decreased in women, whereas, in men, the incidence rates remained stable and mortality rates showed a decreasing trend. We showed that age-adjusted incidence and mortality rates were stable in most entities, except in gallbladder carcinoma. The overall survival improved in almost all entities as compared with those during 1990–2009.
Collapse
Affiliation(s)
- Florian Hucke
- Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology and Nephrology Including Centralized Emergency Department (ZAE), Klinikum Klagenfurt am Wörthersee, 9020 Klagenfurt, Austria; (M.H.); (S.B.); (D.B.); (M.P.-R.)
- Correspondence:
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, 1090 Vienna, Austria;
| | - Miriam Hucke
- Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology and Nephrology Including Centralized Emergency Department (ZAE), Klinikum Klagenfurt am Wörthersee, 9020 Klagenfurt, Austria; (M.H.); (S.B.); (D.B.); (M.P.-R.)
| | - Simona Bota
- Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology and Nephrology Including Centralized Emergency Department (ZAE), Klinikum Klagenfurt am Wörthersee, 9020 Klagenfurt, Austria; (M.H.); (S.B.); (D.B.); (M.P.-R.)
| | - Dajana Bolf
- Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology and Nephrology Including Centralized Emergency Department (ZAE), Klinikum Klagenfurt am Wörthersee, 9020 Klagenfurt, Austria; (M.H.); (S.B.); (D.B.); (M.P.-R.)
| | - Monika Hackl
- Austrian National Cancer Registry, Statistics Austria, 1110 Vienna, Austria;
| | - Markus Peck-Radosavljevic
- Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology and Nephrology Including Centralized Emergency Department (ZAE), Klinikum Klagenfurt am Wörthersee, 9020 Klagenfurt, Austria; (M.H.); (S.B.); (D.B.); (M.P.-R.)
| |
Collapse
|
45
|
Scheiner B, Pinter M. Reply to: "The CRAFITY score: A new guidepost for prognosis prediction in patients with hepatocellular carcinoma undergoing immunotherapy". J Hepatol 2022; 76:1233-1234. [PMID: 35176440 DOI: 10.1016/j.jhep.2022.02.002] [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: 01/31/2022] [Accepted: 02/02/2022] [Indexed: 12/04/2022]
Affiliation(s)
- Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
46
|
Scheiner B, Balcar L, Nussbaumer RJ, Weinzierl J, Paternostro R, Simbrunner B, Hartl L, Jachs M, Bauer D, Stättermayer AF, Semmler G, Pinter M, Ay C, Quehenberger P, Trauner M, Reiberger T, Lisman T, Mandorfer M. Factor VIII/protein C ratio independently predicts liver-related events but does not indicate a hypercoagulable state in ACLD. J Hepatol 2022; 76:1090-1099. [PMID: 35066090 DOI: 10.1016/j.jhep.2021.12.038] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [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: 05/30/2021] [Revised: 12/09/2021] [Accepted: 12/28/2021] [Indexed: 12/11/2022]
Abstract
BACKGROUND & AIMS It has been suggested that the ratio of procoagulant factor VIII to anticoagulant protein C (FVIII/PC) reflects the hemostatic equilibrium. Moreover, FVIII/PC predicted decompensation/death in a small study not accounting for portal hypertension severity. We investigated (i) the prognostic value of FVIII/PC (outcome-cohort) and (ii) whether FVIII/PC reflects the hypercoagulable state (assessed by thrombomodulin-modified thrombin generation assay [TM-TGA]) or the risk of bleeding/thrombotic events in patients undergoing hepatic venous pressure gradient (HVPG) measurement during follow-up. METHODS (i) The outcome-cohort comprised 576 patients with evidence of advanced chronic liver disease (liver stiffness measurement ≥10 kPa and/or HVPG ≥6 mmHg). (ii) TM-TGA-cohort patients (n = 142) were recruited from the prospective VIenna CIrrhosis Study (VICIS: NCT03267615). RESULTS (i) FVIII/PC significantly increased across clinical stages (p <0.001) as well as HVPG (p <0.001) and MELD score (p <0.001) strata and remained independently associated with decompensation/liver-related death (adjusted hazard ratio 1.06; 95% CI 1.01-1.11; p = 0.013), even after multivariable adjustment. It was also associated with acute-on-chronic liver failure (ACLF) development (adjusted hazard ratio 1.10; 95% CI 1.02-1.19; p = 0.015) in patients with decompensated cirrhosis. (ii) FVIII/PC showed a weak positive correlation with endogenous thrombin potential (Spearman's ρ = 0.255; p = 0.002), but this association disappeared after adjusting for the severity of liver disease. FVIII/PC was not associated with the development of bleeding (p = 0.272) or thrombotic events (p = 0.269). However, FVIII/PC correlated with biomarkers of different pathophysiological mechanisms that promote liver disease progression. CONCLUSION FVIII/PC provides prognostic information regarding hepatic decompensation/death and ACLF, independently of established prognostic indicators. However, this is not evidence that hypercoagulability drives disease progression, as the correlation between FVIII/PC and thrombin generation is confounded by liver disease severity and FVIII/PC was not associated with thrombosis. Therefore, FVIII/PC does not reflect coagulation and results from previous studies on FVIII/PC require re-interpretation. CLINICAL TRIAL NUMBER NCT03267615 (in part). LAY SUMMARY A balanced coagulation system is essential for preventing bleeding episodes and blood clot formation (thrombosis). Blood of patients with advanced liver disease may have increased coagulation potential, possibly promoting the worsening of liver disease via thrombosis in the blood vessels of the liver. The ratio between the results of 2 blood tests (procoagulant factor VIII to anticoagulant protein C) has been suggested to reflect these increases in coagulation potential. Our study demonstrates, on the one hand, that this ratio is a versatile predictor of the development of complications of cirrhosis, yet on the other hand, that it is unrelated to coagulation.
Collapse
Affiliation(s)
- Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rosa Johanna Nussbaumer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Johanna Weinzierl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Rafael Paternostro
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Benedikt Simbrunner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Lukas Hartl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Mathias Jachs
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - David Bauer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Albert Friedrich Stättermayer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Georg Semmler
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Cihan Ay
- Clinical Division of Haematology and Haemostaseology, Department of Internal Medicine I, Medical University of Vienna, Vienna, Austria; I. M. Sechenov First Moscow State Medical University, Moscow, Russia
| | - Peter Quehenberger
- Department of Laboratory Medicine, Medical University of Vienna, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Ton Lisman
- Surgical Research Laboratory and Section of Hepatobiliary Surgery and Liver Transplantation, Department of Surgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Lab, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| |
Collapse
|
47
|
Scheiner B, Pinter M. Reply to: "Prognostic prediction for patients with hepatocellular carcinoma receiving immunotherapy: Are we there yet?". J Hepatol 2022; 76:988-989. [PMID: 34979133 DOI: 10.1016/j.jhep.2021.12.025] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/16/2021] [Accepted: 12/22/2021] [Indexed: 12/22/2022]
Affiliation(s)
- Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|
48
|
de Castro T, Jochheim LS, Bathon M, Welland S, Scheiner B, Shmanko K, Roessler D, Khaled NB, Jeschke M, Ludwig JM, Marquardt JU, Weinmann A, Pinter M, Lange CM, Vogel A, Saborowski A. Atezolizumab and bevacizumab in patients with advanced hepatocellular carcinoma with impaired liver function and prior systemic therapy: a real-world experience. Ther Adv Med Oncol 2022; 14:17588359221080298. [PMID: 35251317 PMCID: PMC8891886 DOI: 10.1177/17588359221080298] [Citation(s) in RCA: 31] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2021] [Accepted: 01/28/2022] [Indexed: 12/13/2022] Open
Abstract
Objective: Evaluation of the efficacy and safety of atezolizumab/bevacizumab in a
real-world HCC cohort, including patients with impaired liver function and
prior systemic therapy. Methods: Retrospective analysis of 147 HCC patients treated with
atezolizumab/bevacizumab at six sites in Germany and Austria. Results: The overall response rate and disease control rate were 20.4% and 51.7%,
respectively. Seventy-three patients (49.7%) met at least one major
exclusion criterion of the IMbrave150 trial (IMbrave-OUT), whereas 74
patients (50.3%) were eligible (IMbrave-IN). Median overall survival (mOS)
as well as median progression-free survival (mPFS) was significantly longer
in IMbrave-IN versus IMbrave-OUT patients [mOS: 15.0 months
(95% confidence interval (CI): 10.7–19.3] versus 6.0 months
(95% CI: 3.2–8.9; p < 0.001) and mPFS: 8.7 months (95%
CI: 5.9–11.5) versus 3.7 months (95% CI: 2.7–4.7;
p < 0.001)]. Prior systemic treatment did not
significantly affect mOS [hazard ratio (HR): 1.32 (95% CI: 0.78–2.23;
p = 0.305)]. mOS according to ALBI grades 1/2/3 were
15.0 months (95% CI: not estimable), 8.6 months (95% CI: 5.4–11.7), and
3.2 months (95% CI: 0.3–6.1), respectively. ALBI grade and ECOG score were
identified as independent prognostic factors [ALBI grade 2
versus 1; HR: 2.40 (95% CI: 1.34 – 4.30;
p = 0.003), ALBI grade 3 versus 1; HR:
7.28 (95% CI: 3.30–16.08; p < 0.001), and ECOG ⩾2
versus 0; HR: 2.09 (95% CI: 1.03 – 4.23;
p = 0.042)], respectively. Sixty-seven patients (45.6%)
experienced an adverse event classified as CTCAE grade ⩾3. Patients in the
IMbrave-OUT group were at increased risk of hepatic decompensation with
encephalopathy (13.7% versus 1.4%,
p = 0.004) and/or ascites (39.7% versus
9.5%; p < 0.001). Conclusion: In this real-world cohort, efficacy was comparable to the results of the
IMbrave150 study and not affected by prior systemic treatment. ALBI grade
and ECOG score were independently associated with survival. IMbrave-OUT
patients were more likely to experience hepatic decompensation.
Collapse
Affiliation(s)
- Tiago de Castro
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Leonie S. Jochheim
- Department of Gastroenterology and Hepatology, Essen University Hospital, Essen, Germany
| | - Melanie Bathon
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Sabrina Welland
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Bernhard Scheiner
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Kateryna Shmanko
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Daniel Roessler
- Department of Medicine II, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Najib Ben Khaled
- Department of Medicine II, University Hospital of the Ludwig-Maximilians-University Munich, Munich, Germany
| | - Matthias Jeschke
- Department of Gastroenterology and Hepatology, Essen University Hospital, Essen, Germany
| | - Johannes M. Ludwig
- Institute of Diagnostic and Interventional Radiology and Neuroradiology, Faculty of Medicine, Essen University Hospital, Essen, Germany
| | - Jens U. Marquardt
- Department of Medicine I, University Hospital Schleswig-Holstein, Lübeck, Germany
| | - Arndt Weinmann
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Matthias Pinter
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Christian M. Lange
- Department of Gastroenterology and Hepatology, Essen University Hospital, Essen, Germany
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Carl-Neuberg-Straße 1, 30625 Hannover, Germany
| | - Anna Saborowski
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| |
Collapse
|
49
|
D'Alessio A, Weinmann A, Galle PR, Fulgenzi CAM, Bettinger D, Bengsch B, Vogel A, Balcar L, Scheiner B, Navaid M, Naqash AR, Personeni N, Pressiani T, Sharma R, Pinter M, Cortellini A, Rimassa L, Pinato DJ. Real-world use of atezolizumab plus bevacizumab in patients with hepatocellular carcinoma and Child-Pugh A and B cirrhosis. J Clin Oncol 2022. [DOI: 10.1200/jco.2022.40.4_suppl.393] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022] Open
Abstract
393 Background: Atezolizumab plus bevacizumab (A+B) is the new standard of care for first-line treatment of advanced hepatocellular carcinoma (HCC). No evidence exists as to its use in routine clinical practice in patients (pts) with impaired liver function. Methods: This retrospective, multi-center observational study was conducted across 7 tertiary academic referral centres and collected 64 HCC pts consecutively treated with A+B. Efficacy outcome measures included overall (OS) and progression-free survival (PFS) calculated from time of A+B commencement and overall response rates (ORR) and disease control rates (DCR) defined by Response Evaluation Criteria in Solid Tumors (RECIST, v1.1). Safety outcomes included treatment-related adverse events (trAEs) graded (G) according to CTCAE v5.0. Results: Of 64 eligible pts, 54 had BCLC C stage HCC (84%), secondary to hepatitis C cirrhosis (n = 24; 37%), hepatitis B (n = 10; 16%), and non-viral etiologies (n = 40; 47%). Liver function was classified as Child-Pugh (CP) A in 46 patients (72%), B7 in 7 (11%), B8 in 8 (12%), and B9 in 3 (5%). Patients were of performance status (PS) ECOG 0 (n = 39; 61%) and 1 (n = 25; 39%). Pre-treatment upper-gastrointestinal endoscopy was performed in 44 patients (69%), with gastro-esophageal varices found in 18 pts (40%) and graded as 1 (n = 12, 27%), 2 (n = 4, 9%) and 3 (n = 2, 4%) respectively. After a median follow-up of 6.8 months (m) (95% confidence interval [CI], 5.5-8.0), median OS (mOS) was 11.7m (95% CI, 6.2-17.3) whereas median progression-free survival (mPFS) was 6.97m (95% CI, 2.9-11.0). ORR and DCR were 26% and 62% respectively. TrAEs of any grade were documented in 43 pts (67%): 12 pts (18%) had trAEs of G≥3: 7 (11%) atezolizumab-related and 5 (8%) bevacizumab-related. Toxicity led to treatment discontinuation in 3 pts (5%). Compared to CP-A, CP-B pts achieved shorter OS (11.7m [95% CI, 10.3-13.2] vs 6.5m (95% CI, 3.5-9.5), p = 0.029) and PFS (9.1m [95% CI, 5.4-12.8] vs 2.3m [95% CI, 1.7-2.9], p = 0.001) with no differences in ORR nor in DCR. The rate of trAEs did not significantly differ across CP classes. Median OS was significantly longer in patients achieving a radiologic response (12.7m [95% CI, not reached] vs 11.0m [95% CI, 5.5-16.5], p = 0.04). Presence and grade of varices was not associated to bevacizumab-related trAEs. Conclusions: This study confirms reproducible efficacy and safety of A+B in routine practice. Despite inferior OS and PFS compared to CP-A, A+B was associated with similar tolerability and radiologic response in CP-B patients, warranting prospective evaluation of A+B in this treatment deprived population.
Collapse
Affiliation(s)
| | | | - Peter R. Galle
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | | | - Dominik Bettinger
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases), Freiburg University Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | - Bertram Bengsch
- Department of Medicine II (Gastroenterology, Hepatology, Endocrinology and Infectious Diseases), Freiburg University Medical Center, Faculty of Medicine, University of Freiburg, Freiburg, Germany
| | | | - Lorenz Balcar
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Bernhard Scheiner
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Musharraf Navaid
- Division of Hematology/Oncology, East Carolina University, Greenville, NC
| | - Abdul Rafeh Naqash
- Division of Hematology/Oncology, East Carolina University, Greenville, NC
| | - Nicola Personeni
- Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | | | | | - Matthias Pinter
- Division of Gastroenterology & Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Alessio Cortellini
- Department of Biotechnological and Applied Clinical Sciences, University of L’Aquila, L'Aquila, Italy
| | | | - David James Pinato
- Department of Surgery and Cancer, Imperial College, London, United Kingdom
| |
Collapse
|
50
|
Scheiner B, Pomej K, Kirstein MM, Hucke F, Finkelmeier F, Waidmann O, Himmelsbach V, Schulze K, von Felden J, Fründt TW, Stadler M, Heinzl H, Shmanko K, Spahn S, Radu P, Siebenhüner AR, Mertens JC, Rahbari NN, Kütting F, Waldschmidt DT, Ebert MP, Teufel A, De Dosso S, Pinato DJ, Pressiani T, Meischl T, Balcar L, Müller C, Mandorfer M, Reiberger T, Trauner M, Personeni N, Rimassa L, Bitzer M, Trojan J, Weinmann A, Wege H, Dufour JF, Peck-Radosavljevic M, Vogel A, Pinter M. Prognosis of patients with hepatocellular carcinoma treated with immunotherapy - development and validation of the CRAFITY score. J Hepatol 2022; 76:353-363. [PMID: 34648895 DOI: 10.1016/j.jhep.2021.09.035] [Citation(s) in RCA: 117] [Impact Index Per Article: 58.5] [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: 01/14/2021] [Revised: 09/20/2021] [Accepted: 09/26/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND & AIMS Immunotherapy with atezolizumab plus bevacizumab represents the new standard of care in systemic front-line treatment of hepatocellular carcinoma (HCC). However, biomarkers that predict treatment success and survival remain an unmet need. METHODS Patients with HCC put on PD-(L)1-based immunotherapy were included in a training set (n = 190; 6 European centers) and a validation set (n = 102; 8 European centers). We investigated the prognostic value of baseline variables on overall survival using a Cox model in the training set and developed the easily applicable CRAFITY (CRP and AFP in ImmunoTherapY) score. The score was validated in the independent, external cohort, and evaluated in a cohort of patients treated with sorafenib (n = 204). RESULTS Baseline serum alpha-fetoprotein ≥100 ng/ml (hazard ratio [HR] 1.7; p = 0.007) and C-reactive protein ≥1 mg/dl (HR, 1.7; p = 0.007) were identified as independent prognostic factors in multivariable analysis and were used to develop the CRAFITY score. Patients who fulfilled no criterion (0 points; CRAFITY-low) had the longest median overall survival (27.6 (95% CI 19.5-35.8) months), followed by those fulfilling 1 criterion (1 point; CRAFITY-intermediate; 11.3 (95% CI 8.0-14.6) months), and patients meeting both criteria (2 points; CRAFITY-high; 6.4 (95% CI 4.8-8.1) months; p <0.001). Additionally, best radiological response (complete response/partial response/stable disease/progressive disease) was significantly better in patients with lower CRAFITY score (CRAFITY-low: 9%/20%/52%/20% vs. CRAFITY-intermediate: 3%/25%/36%/36% vs. CRAFITY-high: 2%/15%/22%/61%; p = 0.003). These results were confirmed in the independent validation set and in different subgroups, including Child-Pugh A and B, performance status 0 and ≥1, and first-line and later lines. In the sorafenib cohort, CRAFITY was associated with survival, but not radiological response. CONCLUSIONS The CRAFITY score is associated with survival and radiological response in patients receiving PD-(L)1 immunotherapy. The score may help with patient counseling but requires prospective validation. LAY SUMMARY The immunotherapy-based regimen of atezolizumab plus bevacizumab represents the new standard of care in systemic first-line therapy of hepatocellular carcinoma (HCC). Biomarkers to predict treatment outcome are an unmet need in patients undergoing immunotherapy for HCC. We developed and externally validated a score that predicts outcome in patients with HCC undergoing immunotherapy with immune checkpoint blockers.
Collapse
Affiliation(s)
- Bernhard Scheiner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Katharina Pomej
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Martha M Kirstein
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany; Department of Medicine I, University Medical Center Schleswig-Holstein, Lübeck, Germany
| | - Florian Hucke
- Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology and Nephrology including Centralized Emergency Department (ZAE), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Fabian Finkelmeier
- Department of Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Oliver Waidmann
- Department of Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Vera Himmelsbach
- Department of Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Kornelius Schulze
- 1. Department of Internal Medicine, Gastroenterology & Hepatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Johann von Felden
- 1. Department of Internal Medicine, Gastroenterology & Hepatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Thorben W Fründt
- 1. Department of Internal Medicine, Gastroenterology & Hepatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marc Stadler
- Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria; Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Harald Heinzl
- Center for Medical Statistics, Informatics and Intelligent Systems, Medical University of Vienna, Vienna, Austria
| | - Kateryna Shmanko
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Stephan Spahn
- Department of Internal Medicine I, Eberhard-Karls University, Tuebingen, Germany
| | - Pompilia Radu
- Hepatology-Department of Biomedical Research, University of Bern, Bern, Switzerland; University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Alexander R Siebenhüner
- Department of Medical Oncology and Hematology, University Hospital Zurich and University Zurich, Zurich, Switzerland; Department of Medical Oncology and Hematology, Cantonal Hospital Schaffhausen, Schaffhausen, Switzerland
| | - Joachim C Mertens
- Department of Hepatology and Gastroenterology, University Hospital Zurich and University Zurich, Zurich, Switzerland
| | - Nuh N Rahbari
- Department of Surgery at University Hospital Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Fabian Kütting
- Department of Gastroenterology and Hepatology, University of Cologne, Cologne, Germany
| | | | - Matthias P Ebert
- Department of Internal Medicine II, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; Clinical Cooperation Unit Healthy Metabolism, Center for Preventive Medicine and Digital Health Baden-Württemberg (CPDBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Andreas Teufel
- Clinical Cooperation Unit Healthy Metabolism, Center for Preventive Medicine and Digital Health Baden-Württemberg (CPDBW), Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany; Department of Internal Medicine II, Division of Hepatology, University Medical Center Mannheim, Medical Faculty Mannheim, Heidelberg University, Mannheim, Germany
| | - Sara De Dosso
- Department of Medical Oncology, Oncology Institute of Southern Switzerland, Bellinzona, Switzerland; Faculty of Biomedical Sciences, Università della Svizzera italiana (USI), Lugano, Switzerland
| | - David J Pinato
- Department of Surgery & Cancer, Imperial College London, Hammersmith Hospital, Du Cane Road, W120HS London, UK; Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Tiziana Pressiani
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano (Milan), Italy
| | - Tobias Meischl
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Lorenz Balcar
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Christian Müller
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria
| | - Mattias Mandorfer
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Thomas Reiberger
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Vienna Hepatic Hemodynamic Laboratory, Medical University of Vienna, Vienna, Austria; Christian-Doppler Laboratory for Portal Hypertension and Liver Fibrosis, Medical University of Vienna, Vienna, Austria; Ludwig Boltzmann Institute for Rare and Undiagnosed Diseases, Vienna, Austria; CeMM Research Center for Molecular Medicine of the Austrian Academy of Sciences, Vienna, Austria
| | - Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria
| | - Nicola Personeni
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano (Milan), Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele (Milan), Italy
| | - Lorenza Rimassa
- Medical Oncology and Hematology Unit, Humanitas Cancer Center, IRCCS Humanitas Research Hospital, Via Manzoni 56, 20089 Rozzano (Milan), Italy; Department of Biomedical Sciences, Humanitas University, Via Rita Levi Montalcini 4, 20090 Pieve Emanuele (Milan), Italy
| | - Michael Bitzer
- Department of Internal Medicine I, Eberhard-Karls University, Tuebingen, Germany
| | - Jörg Trojan
- Department of Gastroenterology, Hepatology and Endocrinology, University Hospital Frankfurt, Frankfurt/Main, Germany
| | - Arndt Weinmann
- Department of Internal Medicine I, University Medical Center of the Johannes Gutenberg University Mainz, Mainz, Germany
| | - Henning Wege
- 1. Department of Internal Medicine, Gastroenterology & Hepatology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany; Cancer Center Esslingen, Klinikum Esslingen, 73730 Esslingen am Neckar, Germany
| | - Jean-François Dufour
- Hepatology-Department of Biomedical Research, University of Bern, Bern, Switzerland; University Clinic for Visceral Surgery and Medicine, Inselspital, University of Bern, Bern, Switzerland
| | - Markus Peck-Radosavljevic
- Internal Medicine and Gastroenterology (IMuG), Hepatology, Endocrinology, Rheumatology and Nephrology including Centralized Emergency Department (ZAE), Klinikum Klagenfurt am Wörthersee, Klagenfurt, Austria
| | - Arndt Vogel
- Department of Gastroenterology, Hepatology and Endocrinology, Hannover Medical School, Hannover, Germany
| | - Matthias Pinter
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Vienna, Austria; Liver Cancer (HCC) Study Group Vienna, Medical University of Vienna, Vienna, Austria.
| |
Collapse
|