Winter 2017 - Liver
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Winter 2017 - Liver

Spotlight: Montefiore Multidisciplinary Liver Tumor Program

The incidence of hepatobiliary or liver cancer continues to rise in the United States--over 27,000 deaths are anticipated this year nationwide with more than 1,500 deaths occurring in New York. Yet long-term patient survival is possible if curative therapies including liver resection and liver transplantation are performed in the early stages of the disease. Advanced technology is also producing emerging modalities such as ablation and stereotactic radiotherapy, techniques which may also be curative. There have also been significant recent advances for intermediate and advanced stages of liver cancer using transcatheter embolic and systemic therapies. The Liver Tumor Team at Montefiore employs all of these technologies and also participates in advanced clinical trials for patients with liver cancer.

The Montefiore-Einstein Liver Tumor Program is among the largest in the New York region in the treatment of hepatobiliary cancers, including cholangiocarcinoma, and benign tumors of the liver. Our multidisciplinary team of specialists includes hepatology, advanced endoscopy, medical oncology, radiation oncology, and hepatobiliary surgery, advanced body imaging and interventional radiology. All new liver tumor patients are reviewed at twice weekly multidisciplinary conferences.

This coordinated approach includes a full evaluation and an individualized treatment plan for every patient. An important goal of any patient’s cancer treatment is to ensure close surveillance and follow up as well as seamless communication with the referring physician about treatment decisions and progress.

The Liver Tumor Program employs a dedicated physician liaison who can assist in arranging expeditious appointments. The team is available for phone consultation with referring doctors 24/7. In most cases, a patient can be seen at the office within 24 hours if necessary. Films and slides are not required for patients to be evaluated.

Contact our Administrative Director, Tina Block at 718-920-6659.

LI-RADS Classification gains traction.

In order to improve conformity of reporting CT and MRI findings, the American College of Radiology has developed a standardized system of imaging features of liver nodules in patients at risk for hepatocellular carcinoma. LI-RADS identifies five categories of liver nodules criteria including 1) tumor size; 2) arterial phase enhancement; 3) portal venous phase washout following initial enhancement; 4) capsule appearance and 5) threshold growth compared to previous imaging (See figures).

The LI-RADS criteria have been adapted by the United Network of Organ Sharing (UNOS) to assign waiting list priority for patients with HCC who meet the Milan Criteria. Patients must satisfy LI-RADS 5 criteria to receive a MELD exception for hepatocellular carcinoma.

- CT LR5: 4.8 cm lesion which is hyperenhancing on arterial phase , washes out on portal venous phase and has a capsule

- ME LR5: 3.7 cm lesion which is hyperenhancing on arterial phase , washes out on portal venous phase and is mildly hyperintense on T2-weighted sequences

- CT LR4: 1.1 cm lesion which is hyperenhancing on arterial phase and washes out on portal venous phase. It does not meet criteria for LR5 since lesions <2 cm need washout AND capsule to qualify for LR5 (in concordance with UNOS criteria)

- MR LR4: 0.8 cm lesion which is hyperenhancing on arterial phase , washes out on portal venous phase, is mildly hyperintense on T2-weighted sequences, demonstrates restricted diffusion and is hypointense on hepatobiliary phase. Cannot qualify for LR5 since it is <1cm, and lesions <1cm cannot be LR5 (again, in concordance with UNOS criteria)

United Network of Organ Sharing (UNOS) modifies transplant priority for liver cancer patients in an effort to equalize organ access for tumor and non-tumor patients.

These changes include:

  • Patients are registered at their calculated MELD scores for the first six months as long as they meet transplant criteria*
  • MELD score priority increases to 28 after six months and then increases by 10% every three months to a maximal score of 34 points.

Journal Club:

Atorvastatin and Fluvastatin are associated with dose-dependent reductions in cirrhosis and hepatocellular carcinoma, among patients with Hepatitis C Virus: Results from ERCHIVES. Simon TG et al. Hepatology. 2016 Jul; 64(1):47-57

Statins have known to have a cardio-protective and promising anti-fibrotic effect with some studies showing clinically significant reductions in portal pressures after use. This non-randomized observation study evaluated the Veterans Affairs database of 9135 patients with HCV mono-infection treated for HCV. Clinical parameters along with FIB-4 score along with exposure to dose dependent Statin medications were assessed during the study observation period from 2001-2014.

Results: Statin use was associated with a 44% reduction in development of cirrhosis and 49% reduction in incident of HCC.

Gadoxetic Acid (Eovist) Enhanced MRI improves HCC detection and results in increased patient survival (Kim et al. Gastroenterology 2015;158).

A retrospective analysis of 700 Korean patients with a single liver tumor on CT observed that patients who also had Gadoxetic acid enhanced MRI had additional tumors detected and treated. Detection of additional tumors resulted in improved overall and recurrence free survival.

Clinical Trials

CONFIRM Trial-A Multi-Center, Randomized, Placebo Controlled, Double-Blind Study to Confirm Efficacy and Safety of Terlipressin in Subjects With Hepatorenal Syndrome Type 1 (The CONFIRM Study). PI – Dr. Sam Sigal

REGENERATE Trial- A Global, Multi-Center, double-blind, placebo-controlled Phase 3 Trial to evaluate the Impact on NASH with Fibrosis of Obeticholic Acid Treatment. PI – Dr. Sam Sigal

A Multicenter, Randomized, Double-Blind, Placebo-Controlled Trial of Emricasan (IDN-6556), an Oral Caspase Inhibitor, in Subjects with Non-alcoholic Steatohepatitis (NASH) Fibrosis. PI- Dr. Harmit Kalia

VTL-308 Clinical Study-VTL-308: A Randomized, Open-Label, Multicenter, Controlled, Pivotal Study to Assess Safety and Efficacy of ELAD® in Subjects with Alcohol-Induced Liver Decompensation (AILD). PI- Dr. Kristina Chacko

A Supportive Family Before, During, and After Transplant

The Helping Hands Program at Montefiore is a resource network that helps patients navigate and better manage their health and their lives as they go through the transplantation process. Comprised of doctors, nurses, a nutritionist, social workers and administrators, the Helping Hands Program focuses on helping patients meet the challenges that arise during the transplant process by promoting healthy lifestyle changes.

Helping Hands represents what is best about Montefiore, an organic and altruistic approach to meeting the needs of our patients.

Lend your helping hand today. Call Kristin Waller-Donovan at 718-920-6629 or kwaller@montefiore.org to become involved.