Browsing by Subject "Carcinoma, Hepatocellular"
Now showing 1 - 19 of 19
- Results Per Page
- Sort Options
Item Demographics, Clinical Presentation, and Outcomes of HIV Infected and Uninfected Patients with Hepatocellular Carcinoma(2023-01-31) Zhang, Lucia; Chang, Gloria; Rich, Nicole; Singal, Amit; Yopp, AdamWith highly active antiretroviral therapy (HAART), HIV infected individuals have seen longer survival, which is associated with increased mortality and morbidity from chronic liver diseases (CLD). Patients with HIV are 7 times more likely to develop HCC. To date, the clinical course and outcomes of patients with HIV and HCC is not well defined. We compared the survival of HCC patients with and without HIV infection, and we expected demographic factors, clinical presentation, and treatment patterns to impact survival differently between the two groups. We performed a retrospective cohort study of HCC patients at two hospitals within the same system in Dallas between January 2010 and June 2022. We excluded patients without a known HIV diagnosis status. Demographics, prognostic measures, tumor characteristics, treatment modalities, and survival were compared between patients with and without HIV infection. Survival curves were generated using Kaplan- Meier plots and compared with the log rank test. Of the 1,391 patients with HCC, 43 (3.1%) were HIV infected. HIV infected patients were more likely to have Medicare (51% vs 29%; P=0.012) and less likely to be uninsured (0% vs 9.9%; P=0.012). CLD etiologies differed between the groups with HIV infected patients less likely to have alcohol-related liver disease (4.7% vs 17.6%; P<0.001) and more likely to have HBV infection (32.6% vs 5.1%, P<0.001). There were no significant differences in the prognostic measures and tumor characteristics between the two groups. Median overall survival (OS) was similar between HIV infected and uninfected patients (17.2 months vs 21.1 months; P=.318). Median OS was also compared between controlled and poorly controlled HIV infected patients and found to be similar (19.2 months vs 16.0 months; P=.521). On multivariable analysis, factors associated with worse OS included underlying fatty liver disease (HR 1.533, 95% CI 1.1-2.1) and HBV (HR 1.703, 95% CI 1.2-2.5). ECOG functional status>=2 (HR 1.331, 95% CI 1.0-1.7), Child Pugh class B (HR 1.278, 95% CI 1.1-1.5), and having multiple lesions at time of diagnosis (HR 1.213, 95% CI 1.1-1.4) were also associated with worse survival. HIV infection was not independently associated with worse survival (HR 1.295, 95% CI .858-1.955). The relationship between HIV infection and HCC in affecting clinical outcomes remains complex. HIV infected patients present with different underlying liver disease but similar prognostic and tumor characteristics. Overall survival was ultimately found to be similar between HIV infected and uninfected patients with HCC.Item Donald W. Seldin, M.D., Research Symposium finalist presentations(2021-04-23) Arvind, Ashwini; Elias, Roy; McAdams, Meredith; Salazar, Alonso Pezo; Rao, Shreya; Sheth, RahulThis edition of the UT Southwestern Internal Medicine Grand Rounds features presentations by the six Foster Fellows selected as finalists from the Sixth Annual Donald W. Seldin, M.D. Research Symposium, which was held on April 23, 2021. These Foster Fellows presented work that spanned the breadth and depth of scholarly activity across the department, and at the close of Grand Rounds, one will be selected as the 2021 Seldin Scholar, in honor of Dr. Donald W. Seldin. The Grand Rounds presentation also includes additional awards honoring Clinical Vignettes and an award for work in Quality and Education at Parkland Hospital.Item Donald W. Seldin, M.D., Research Symposium finalist presentations(2022-04-29) Almonte, Matthew; Duvalyan, Angela; McAdams, Meredith; Onyirioha, Kristeen; Saez-Calveras, Nil; Triana, TaylorThis edition of the UT Southwestern Internal Medicine Grand Rounds features presentations by the six Foster Fellows selected as finalists from the Seventh Annual Donald W. Seldin, M.D. Research Symposium, which was held on April 21, 2022. These Foster Fellows presented work that spanned the breadth and depth of scholarly activity across the department, and at the close of Grand Rounds, one will be selected as the 2022 Seldin Scholar, in honor of Dr. Donald W. Seldin. The Grand Rounds presentation includes additional award presentations recognizing Clinical Vignettes, as well as the Award for Research in Quality and Education at Parkland Hospital and the Social Impact Award.Item Donald W. Seldin, M.D., Research Symposium finalist presentations(2020-05-29) Adomako, Emmanuel; Hinkamp, Colin; Liu, Po-Hong (Stuart); McAdams, Meredith; Omar, Wally; Segar, MatthewThis edition of the UT Southwestern Internal Medicine Grand Rounds features presentations by the six Foster Fellows selected as finalists from the Fifth Annual Donald W. Seldin, M.D. Research Symposium, which was held on May 21, 2020. These Foster Fellows presented work that spanned the breadth and depth of scholarly activity across the department, and at the close of Grand Rounds, one will be selected as the 2020 Seldin Scholar, in honor of Dr. Donald W. Seldin. The Grand Rounds presentation also includes additional awards honoring Clinical Vignettes and an award for work in Quality and Education at Parkland Hospital.Item Effect of Fragmentation of Cancer Care on Treatment Use and Survival in Hepatocellular Carcinoma(2020-05-01T05:00:00.000Z) Karbhari, Nishika; Yopp, Adam; Mansour, John; Porembka, Matthew R.BACKGROUND: Fragmentation of care (FC) refers to treatment received at multiple facilities. Implications of FC include increased health care costs and amplification of existing healthcare disparities. This study aimed to identify patient and hospital-level factors associated with FC and analyze the effect of FC on patient outcome measures (overall survival and time to treatment). OBJECTIVE: Fragmented care in HCC patients is associated with worse overall survival and increased time to treatment compared to patients receiving non-fragmented care. METHODS: The Texas Cancer Registry (TCR) was queried from 2004-2015 for a 12-year study span. Patient- and hospital-level factors were characterized within 2 groups: patients receiving fragmented care (FC) and those receiving non-fragmented care (NFC). Cox proportional hazards regression models were used to identify those factors that were independently and significantly associated with overall survival and time to treatment. Kaplan-Meier curves were generated to evaluate differences in overall survival between the FC and NFC groups, as well as between every type of transition within the FC group (stratified on the basis of safety net hospital status or volume status). All statistical analyses were performed with SPSS. RESULTS: Of our cohort (n = 4329), 72.6% received NFC, and 27.4% received FC. In comparison to patients receiving NFC, patients receiving FC had larger median tumor sizes at diagnosis (≥4 cm, 52.6% vs 35.2%; p < .001). NFC patients also tended to present with regional or metastatic disease (35.9% vs 26.7%; P < .001). A subset analysis of patients with localized stage HCC who received curative therapy showed that FC was associated with decreased odds of curative therapy (odds ratio, 0.83; 95% confidence interval [CI], 0.7-0.9). In this subgroup analysis, FC was associated with worse OS (median survival, 67 vs 43 months; HR, 1.2; 95% CI, 1.0-1.4) and increased TTT (HR, 0.74; 95% CI, 0.7-0.8). Ultimately, in our global cohort, FC was associated with worse OS (hazard ratio [HR], 1.14; 95% CI, 1.05-1.24) and increased TTT (HR, 0.76; 95% CI, 0.7-0.8). CONCLUSION: Patients receiving FC had worse OS and increased TTT compared to patients receiving NFC. Several patient and hospital-level factors were found to be associated with FC, including age, insurance, non-safety net hospital status, accreditation, and disease stage. This work has implications for encouraging initiatives geared toward increasing care coordination, especially when managing cancer. Future work may aim to elucidate the reasons for the associations described and delineate steps by which to mitigate FC in the context of these factors.Item The Efficacy of Immunotherapy in Preventing Liver Cancer and the Role of Metabolic Zonation in Its Development(August 2021) Chung, Andrew Seungjae; McFadden, David G.; DeBerardinis, Ralph J.; Mani, Ram; Zhu, HaoIn order to study the development and progression of liver cancer, as well as the efficacy of novel therapeutic strategies, accurate models of human disease are needed. In particular, in vivo mouse models capture critical characteristics that are relevant to human hepatocellular carcinoma (HCC). There is a diverse array of mouse HCC models available, falling into three major categories: transplantation-based models, chemically-induced models, and genetically-induced models. Within these categories, models differ in factors such as the source of the tumor cells and the chemicals or genetic drivers used to induce tumorigenesis. All of these models offer specific advantages over the others but also have some disadvantages as well. Thus, the utility of any model is dependent on the specific investigatory aims of the study. In our case, we used two types of models to try to address two questions about HCC. First, we asked if immune checkpoint inhibition could prevent tumorigenesis in a chemically-induced mouse model of HCC. We found that initiation of anti-PD-1 immunotherapy prior to tumorigenesis could prevent up to 46% of liver tumors. This reduction in tumor burden was accompanied by infiltration of CD4+ T helper and CD8+ cytotoxic T cells into the liver parenchyma. Importantly, anti-PD-1 therapy did not exacerbate liver dysfunction or worsen overall health in this model. Given the safety and preservation of quality of life observed with long-term immunotherapy use, an immunotherapy chemoprevention strategy is likely associated with a low risk-to-benefit ratio and high value care in select patients. Along the portal-to-central axis within the hepatic lobule, there are profound differences in gene expression, metabolic processes, oxygen tension, and ploidy. Whether or not these differences reflect any differences in neoplastic potential is unclear. To address this, we turned to genetically-induced HCC models. We used various hepatic zone-specific CreERT2 mouse lines to induce activating mutations in Ctnnb1 and to delete Arid2. We found that mutant clones arising from zone 1 gradually expanded and persisted, while mutant clones arising from Zone 3 rapidly disappeared over time. However, more tumors ultimately developed in the zone 3 livers than in the zone 1 livers, suggesting that expression of some zonated metabolic genes may influence the fate of mutant hepatocytes. This could have major implications for prevention and treatment of HCC, as these metabolic genes could represent actionable preventive or therapeutic targets.Item HCC Surveillance Is Associated with Potential Harms(2015-01-26) Muffler, Adam; Atiq, Omair; Yopp, Adam; Singal, Amit G.BACKGROUND: Hepatocellular carcinoma (HCC) is the 3rd leading cause of cancer death worldwide and leading cause of death in patients with cirrhosis. HCC surveillance is recommended in patients with cirrhosis to improve early detection rates. A comprehensive assessment of HCC surveillance should weigh both benefits and harms; however, no study to date has assessed potential harms. Although ultrasound and alpha fetoprotein (AFP) have minimal direct harms, there are potential downstream harms from follow-up tests that should be considered. Objective: To quantify and characterize potential harms of HCC surveillance among a large cohort of patients with cirrhosis METHODS: We conducted a retrospective cohort study among patients with cirrhosis followed at a large safety-net health system. We recorded all surveillance abdominal imaging and/or alpha fetoprotein (AFP) testing between January 2010 and December 2013. We defined a false positive surveillance test as a suspicious liver mass on ultrasound or AFP >20 ng/mL, without HCC development during follow-up. We recorded CT or MRI scans, biopsies, or any procedures performed as a direct result of surveillance testing. Predictors of harm were identified using logistic regression, with significance being defined as p<0.05. RESULTS: We identified 571 patients with cirrhosis, with median follow-up of 2.8 years. HCC surveillance was performed at least once in 551 (96%) patients. Surveillance testing led to diagnostic CT or MRI testing in 123 (21.5%) patients - 74 with one CT/MRI and 49 with multiple studies. Rates of unnecessary diagnostic testing increased from 15% if followed for ≤1 year to 25% if followed for 1-2 years to 37% if followed for ≥2 years. An additional two patients had a biopsy and one patient angiogram for false positive surveillance tests. Follow-up tests were performed due to false positive ultrasound in 47 cases, false positive AFP in 35 cases, and indeterminate ultrasound results in 41 cases. In multivariate analysis, surveillance harm was associated with viral liver disease (OR 1.60, 95%CI 1.04-2.46), receipt of hepatology subspecialty care (OR 2.32, 95%CI 1.52-3.59), and coverage by Parkland Health Plus (OR 2.21, 95%CI 1.45- 3.40). CONCLUSION: This study is the first to demonstrate HCC surveillance can be associated with potential harms. One in five patients have at least one unnecessary diagnostic test, and nearly 10% have multiple tests. Better HCC surveillance tools, with a higher positive predictive value, are urgently needed.Item Hepatocellular carcinoma: new insights into pathogenesis and management(1992-10-01) Thiele, Dwain L.Item Hepatocellular carcinoma: No longer an exotic disease(2002-06-20) Thiele, Dwain L.Item Liver transplantation: what an internist needs to know(2018-07-06) Kerr, Thomas A.Item Management of advanced hepatocellular carcinoma(2016-02-05) Zhu, HaoItem New insights into hepatocellular carcinoma(2007-01-26) Brown, GeriItem Quality of Life Is Associated with Survival in Patients with Cirrhosis and Hepatocellular Carcinoma(2014-04-11) Meier, Adam Thomas; Singal, Amit G.; Yopp, Adam; Beg, MuhammadBACKGROUND: Prior studies assessing quality of life (QOL) in patients with hepatocellular carcinoma (HCC) primarily included patients with preserved liver function and/or early HCC, leading to overestimation of QOL. OBJECTIVE: To characterize QOL among a diverse cohort of cirrhotic patients with HCC and evaluate its association with survival. METHODS: We conducted a prospective cohort study among cirrhotic patients with HCC from a large urban safety-net hospital between April 2011 and September 2013. Patients completed two self-administered surveys, the EORTC QLQ-C30, and QLQ-HCC18, prior to HCC-directed treatment. We used generalized linear models to identify correlates of QOL. Survival curves were generated using Kaplan-Meier analysis and compared using log rank test to determine if QOL is associated with survival. RESULTS: 130 treatment-naïve patients were enrolled and completed both surveys. Patients reported fair global QOL (median score 50%), high cognitive and social function (median scores 67%), but poor role function (median score 50%). QOL was associated with both cirrhosis-related (p=0.02) and tumor-related (p=0.02) components of Barcelona Clinic Liver Cancer (BCLC) stage. QOL was associated with survival on univariate analysis (HR 0.37, 95%CI 0.16-0.85) but became non-significant (HR 0.82, 95%CI 0.37-1.80) after adjusting for BCLC stage and treatment. Role functioning was significantly associated with survival (HR 0.40, 95%CI 0.20-0.81), after adjusting for Caucasian race (HR 0.31, 95%CI 0.16-0.59), BCLC stage (HR 1.51, 95%CI 0.21-1.89), and treatment (HR 0.57, 95%CI 0.33-0.97). CONCLUSION: QOL and role function have prognostic significance and are important to assess in cirrhotic patients with HCC.Item Safety of Drug-Eluting Beads Chemoembolization in Patients with Pre-Exisiting Transjugular Intrahepatic Portosystemic Shunt(2015-01-26) Rief, Katherine M.; Pirasteh, Ali; Shenoy-Bhangle, Anu; Ganguli, Shoey; Kalva, SanjeevaSTUDY AIM: To assess the safety of transarterial chemoembolization (TACE) for unresectable hepatocellular carcinoma (HCC) in patients with a pre-existing transjugular intrahepatic portosystemic shunt (TIPS). METHODS: A multi-institutional, IRB approved, retrospective review was conducted of patients with a pre-existing patent TIPS who underwent TACE to treat unresectable HCC between 2009 and 2014. Patients (7 male, 4 female) ranging from 39 to 74 years of age (mean 61, SD 11) were included. Parameters of interest included type of TACE (drug-eluting beads or traditional), number of TACE procedures, 30-day mortality from last TACE procedure, and any complications or toxicity following TACE. RESULTS:Ten of the eleven patients underwent super-selective drug-eluting bead TACE, using doxorubicin at a dosage ranging from 50mg to 150mg (Median 100mg). Number of TACE procedures per patient ranged from 1 to 4 (Median 1). Three of the patients (3/11, 27%) experienced toxicity (CTAE v4) grade 2 or higher immediately following the TACE procedure. Two of these patients experienced Grade 2 Albumin Toxicity. Another had Grade 3 Toxicity of AST, ALT and bilirubin. 73% of patients were discharged within 24 hours. The remaining 3 patients were hospitalized for pain, edema, or acute pancreatitis for 3, 5 and 20 days respectively. All eleven patients were alive and discharged from the hospital 30 days after the most recent TACE procedure. DISCUSSION: TACE can be well tolerated by patients with a patent TIPS given adequate liver function. As additional cases are performed we hope to clarify the efficacy and most appropriate TIPS patient population for TACE.Item Sensitivity of Ultrasound and Alpha Fetoprotein for Detection of Hepatocellular Carcinoma in Patients with Cirrhosis(2017-01-17) Sasiponganan, Chayanit; Singal, Amit G.BACKGROUND: Hepatocellular carcinoma (HCC) is the fastest growing cause of cancer related mortality in the United States. Prognosis is strongly tied to early detection, which facilitates curative treatment and long-term survival. Therefore, HCC screening is recommended in at risk patients, i.e. those with cirrhosis. Although ultrasonography is routinely used to screen at-risk patients for HCC, it is operator dependent and its sensitivity outside of prospective cohort studies is poorly described. Further, the benefit of adding serum biomarkers, such as alpha fetoprotein, has also been poorly studied. The aim of our study was to quantify the effectiveness of ultrasound and AFP for HCC detection in patients with cirrhosis. METHODS: We performed a retrospective chart review of patients newly diagnosed with HCC at UT Southwestern and Parkland Health and Hospital System between January 2009 and December 2015. We excluded patients who did not have at least one ultrasound within 12 months prior to HCC diagnosis. Ultrasounds were categorized as positive if there was a suspicious mass > 1 cm and AFP as positive if ≥20 ng/mL, the most common cut-off in clinical practice. Sensitivity was compared between ultrasound alone and combination of ultrasound + AFP using the chi-square test, with statistical significance defined as p<0.05. RESULTS: Of the 925 patients diagnosed with HCC between January 2009 and December 2015, 521 patients had an ultrasound within 12 months prior to HCC diagnosis. The overall sensitivity of ultrasound for HCC detection was 77.5% n=404/521). Of the 521 included patients, 400 had at least one AFP within 12 months of HCC diagnosis. There were 154 patients who had both positive ultrasound and AFP, 143 with positive ultrasound alone, 59 with positive AFP alone, and 44 with negative ultrasound and AFP. The sensitivity of ultrasound alone was 74.3% compared to 89.0% with ultrasound and AFP p<0.001). CONCLUSION: Ultrasound alone has suboptimal sensitivity for HCC detection in clinical practice, highlighting the need for better screening tools. Adding serum biomarkers, such as AFP, can significantly improve HCC detection in clinical practice.Item Treatment and prevention of hepatocellular carcinoma(2021-12-10) Hoshida, YujinItem Treatment of advanced hepatocellular carcinoma: updates and unmet needs(2020-08-21) Zhu, HaoItem Treatment of hepatocellular carcinoma(2013-02-01) Marrero, JorgeItem Turning the tide on the liver cancer epidemic in Texas(2018-01-12) Singal, Amit