Clinical Briefings | Transplant | Penn Medicine

Management of Hepatitis C

2011-09-28T07:48:00.002-04:00

From the Penn GI News

The Penn Liver Cancer team consists of hepatologists, surgeons, medical oncologists, interventional radiologists, radiologists and radiation oncologists whose primary focus is the care of patients with liver cancer and those at risk for the disease.

Diagnostic and Treatment Options

A variety of liver diseases, including Hepatitis C, can cause inflammation and progressive scar formation in the liver resulting in cirrhosis. Over time, patients with cirrhosis are at risk of developing primary liver cancer (hepatocellular carcinoma or HCC). Consequently, HCC is often the result of a process that started years before the onset of cancer.

Because HCC is present years before its manifestations appear, it is often possible to identify patients at risk of developing HCC at a stage where it is curable. Early diagnosis may be achieved, for example, with screening tests that are used to detect incipient cancer.

The primary challenge in the treatment of liver cancer emanates from the fact that HCC typically occurs in the background of a liver diseased by cirrhosis. Therefore, one has to consider that patients with HCC have two serious health problems: a cancer and a chronic liver disease.

This is important because the severity of liver disease often has a major impact on the choice of treatment options in hepatocellular carcinoma. In all cases, early detection is key, because only early cancer can be cured.

Surgical resection of the tumor can achieve cure of hepatocellular carcinoma, particularly when the tumor is small, but can only be safe and effective if liver function is nearly intact. Liver transplantation, where the entire liver – including the tumor – is removed and replaced with a normal liver from a donor, is a very effective treatment for HCC, as long as the tumor is within specific size limits.

Because the entire liver is replaced, liver transplant circumvents the strict need for a good liver function that surgical resection requires. The other major advantage of transplantation is that it results in removal of the tumor as well as removal of the rest of the liver which, if left behind, will remain at risk of developing additional cancer.

A select group of patients with small favorably located tumors can be cured with minimally invasive treatments such as radiofrequency ablation.

Effective treatment for HCC is also possible in patients with more advanced disease. Transarterial chemoembolization (TACE), in which a chemotherapy mixture is injected directly into the tumor to interrupt its blood supply, results in tumor death and is effective at controlling even larger tumors confined to the liver.

TACE is also useful to prevent tumors from growing while patients with smaller tumors are on the transplant waiting list.

Another effective modality, radioembolization kills tumor cells by injection of radiation-emitting beads into the tumor and is also an effective treatment for larger tumors. Chemotherapy in the form of the oral drug Sorafenib, or clinical trials with new drugs are also a possible effective treatment options.

Navigating the various treatment options in HCC can be complex and requires the expertise of physicians with different areas of specialization.

The Penn Liver Cancer team includes: Rajender Reddy, MD, Director of Hepatology; Thomas W. Faust, MD; Kimberly A. Forde, MD , MHS; Maarouf A. Hoteit, MD;David E. Kaplan, MD, MSc; Karen Krok, MD; and George A. Makar, MD, MSCE.

At Penn, all cases are discussed every week by a multidisciplinary team of specialists in the context of the Penn Liver Tumor Conference. Patients are then evaluated by multiple experts in a single visit to the Penn Liver Tumor Clinic where treatment options are discussed. The Liver Cancer team at Penn has the unique capability of an efficient and expert evaluation of patients, and is committed to offering convenient access to skilled medical care of a complex disease.

To refer a patient to Penn Medicine, please contact Penn PhysicianLink^TM here or at 877-937-7366.

Download a pdf of the Spring 2011 Penn GI News.

Management of Hepatocellular Carcinoma

2011-05-02T14:34:00.002-04:00

Hepatologists, surgeons, medical oncologists, interventional radiologists, radiologists and radiation oncologists at Penn Medicine are treating patients with hepatocellular carcinoma and those at risk for the disease.

Hepatocellular carcinoma (HCC) is an increasingly prevalent problem in the United States. Hepatitis C-associated HCC is likely the major culprit for a dramatic increase in HCC incidence and mortality in the past two decades.1

There are many treatment options for patients with hepatocellular carcinoma.2 Since early detection offers the best opportunity for cure, screening for HCC in patients with cirrhosis is of utmost importance and is often a key determinant of outcome.

Surgical resection of the tumor can achieve cure of HCC, particularly when the tumor is small and liver function is preserved. With partial hepatectomy, there is always concern for development of another HCC in the remaining diseased liver, which can happen in up to 50-70 percent of cases. Liver transplantation is often the most effective treatment for HCC, if the tumor is within a certain stage.

Because the entire liver is replaced, liver transplant circumvents the strict need for good liver function that surgical resection requires. The other major advantage of transplantation is that it results in removal of the tumor as well as removal of the rest of the liver which, if left behind, will remain at risk of developing additional tumors. The result is that the recurrence rate of HCC after transplantation is 10-20%, much lower than after resection. A select group of patients with small, favorably located tumors can be cured with ablative therapies, such as percutaneous or laparoscopic radiofrequency ablation.

Effective treatment for HCC is possible also in patients with more advanced disease. Trans-arterial chemoembolization (TACE), in which a chemotherapy mixture is injected directly into the tumor and its blood supply is interrupted, results in tumor death and is effective at controlling even larger tumors.

TACE is also useful to prevent tumors from growing while patients with smaller tumors are on the liver transplant waiting list. Radioembolization involves the injection of radiation-emitting beads into the tumor and is often an alternative option to TACE. Systemic chemotherapy in the form of the oral drug Sorafenib or clinical trials with newer drugs are also effective treatment options in advanced disease.

Navigating the various treatment options in HCC can be complex and requires the expertise of physicians with different areas of specialization. At Penn, patients presenting with liver tumors are discussed every week by a multidisciplinary team of specialists in the context of a conference. Patients are then evaluated by multiple physicians and surgeons with expertise in liver cancer and liver disease in a single visit to the Penn Liver Tumor Clinic where treatment options are discussed.

The liver tumor team at Penn has the unique capability of an efficient and expert evaluation of patients, and is committed to offering convenient access to skilled medical and surgical care of a complex disease.

Case Study

Mr. A is a 53-year-old teacher with chronic hepatitis C-related cirrhosis who recently failed standard therapy for hepatitis C. He has no symptoms of liver disease, and has only small varices on an upper screening endoscopy. He has no other medical history and works full time. On an ultrasound of the liver obtained for screening, a 2.5 cm mass was found. AFP was normal. An MRI of the liver was performed (Figure 1).

Mr. A’s case was discussed in the Penn Multidisciplinary Liver Tumor Conference. Review of the films confirmed a diagnosis of hepatocellular carcinoma by imaging characteristics; no biopsy for confirmation was warranted. Treatment options were discussed. Since the location of the lesion would require a right hepatectomy and the presence of varices indicated portal hypertension, it was felt that resection would carry a high risk of liver failure.

The potential for the less invasive treatment option of radiofrequency ablation was discussed, but it was felt that this would be a suboptimal treatment in his case because he would be an excellent transplant surgical candidate.

Mr. A was seen in consultation in liver tumor clinic concurrently by a hepatologist, a transplant/hepatobiliary surgeon and an interventional radiologist. The risks, benefits and alternatives of the different treatment options were discussed. After reviewing his options, the patient elected to pursue liver transplantation. He completed a liver transplant evaluation and was listed for transplantation.

To prevent the tumor from growing while waiting for transplantation, TACE was performed. Partial tumor necrosis was achieved and the lesion remained stable in size until he received a transplant, about 9 months after being listed.

Pathology of the explanted liver showed moderately differentiated HCC in the right lobe, 2.8 cm in size; about 70% of the nodule was necrotic and there was no evidence of vascular invasion. The patient was enrolled in a surveillance program for recurrent disease, with serial imaging of the chest and abdomen. At 18 months post transplant, there is no evidence of recurrent HCC and the patient is asymptomatic.
References
1. El-Serag HB, Rudolph KL. Hepatocellular carcinoma: epidemiology and
molecular carcinogenesis. Gastroenterology. 2007;132:2557-2576.
2. Mendizabal M, Reddy KR. Current management of hepatocellular carcinoma.
Med Clin Nor Am. 2009;93:885-900.

Team of Faculty
The Penn Liver Tumor Clinic brings together a multidisciplinary team of physicians, nurse specialists and hospital support staff who provide coordinated care throughout the treatment process. The goal is to meet the unique physical and emotional needs of each patient in a caring, professional environment.

Hepatologists

K. Rajender Reddy, MD,
Director of Hepatology
Medical Director of Liver Transplantation

Kimberly A Forde, MD, MHS
Assistant Professor of Medicine

Maarouf A. Hoteit, MD
Assistant Professor of Clinical Medicine

David E. Kaplan, MD, MSc
Assistant Professor of Medicine

George A. Makar, MD , MSCE
Associate Professor of Clinical Medicine

Transplant and Hepatobiliary Surgeons

Abraham Shaked, MD, PhD
Director, Penn Transplant Institute

Kim Olthoff, MD
Director, Liver Transplant Program

Peter L. Abt, MD
Associate Professor of Surgery

Matthew H. Levine, MD, PhD
Assistant Professor of Surgery

Medical Oncologists

Bruce Giantonio, MD
Associate Professor of Medicine

Nevena Damjanov, MD
Associate Professor of Clinical Medicine

Ursina R. Teitelbaum, MD
Deenie Greitzer and Daniel G. Haller Associate Professor

Radiologists

Mark A. Rosen, MD, PhD
Associate Professor of Radiology

Evan S. Siegelman, MD
Associate Professor of Radiology

Interventional Radiologists

Michael Soulen, MD
Professor of Radiology in Surgery

S. William Stavropoulos, MD
Professor of Radiology

Jeff Mondschein, MD
Associate Professor of Clinical Radiology

Mandeep S. Dagli, MD
Assistant Professor of Clinical Radiology

Radiation Oncologists

Robert Lustig, MD
Professor of Clinical Radiation Oncology

John P Plastaras, MD, PhD
Associate Professor of Radiation Oncology

Access
The Penn Transplant Institute
Liver Tumor Clinic
Perelman Center for Advanced Medicine
West Tower, 2nd Floor
Philadelphia, PA 19104

Comprehensive Care at Every Stage of Heart Failure

2010-08-09T08:20:00.002-04:00

The Heart Failure and Transplantation Program at the Hospital of the University of Pennsylvania (HUP) has developed a multidisciplinary algorithm for heart failure management that reflects the chronic, progressive nature of the disease. Thus, the program provides a seamless continuum of care to address heart failure, its effects and comorbidities from its earliest stages onward.

Case Study
Mr. W, a 58-year-old male with a two-year history of non-ischemic cardiomyopathy, was referred to the Penn Heart and Vascular Center. At presentation, his medications included carvedilol 25 mg BID, lasix 40 mg BID, enalapril 20 mg BID, and spironolactone 25 mg QD. Despite good compliance with this regimen, Mr. W was increasingly symptomatic, requiring an increase in his daily diuretic dose.

After consultation at Penn, Mr. W was electively scheduled for right heart catheterization, which revealed a markedly abnormal cardiac performance, with a cardiac index of only 1.4L/min/m2 and an elevated pulmonary capillary wedge pressure (35mmHg) with normal systemic vascular resistance. Milrinone was initiated following admission to the inpatient heart failure unit, with improvement in cardiac index.

An inpatient heart transplant evaluation was begun with the transplant team, including the nurse coordinator for transplant assessment and education, a social worker to address potential psycho-social concerns pre- and post-transplant, and a financial counselor to verify insurance and prescription coverage. A battery of lab tests was performed to more accurately determine Mr. W’s risk at the time of transplant and to aid in individualization of his post-transplant immunosuppression.

Mr. W felt much better on inotropic support, although he developed significant ventricular dysrhythmias. At the weekly multidisciplinary transplant meeting, the cardiac surgeons decided to evaluate Mr. W for a ventricular assist device (VAD) as a bridge to transplant. Subsequently, he underwent successful implantation of the HeartMate® II. His recovery was uneventful. To ensure that he would be in optimal condition for his transplant, he was followed closely by the nutritionists and physical therapists on the transplant team.

After successfully completing 6 weekly outpatient appointments with the VAD coordinators and HUP transplant cardiologists, Mr. W underwent heart transplant surgery. He has done remarkably well post-transplant. He eagerly talks about his experience and serves as an inspiration to those who are waiting on the list. He now comes in on a routine basis for his cardiac biopsies and is scheduled to start cardiac rehabilitation soon.

Our Team of Faculty
The Penn Heart and Vascular Center is comprised of a multidisciplinary team of specialists and clinicians whose experience spans the breadth and depth of heart failure care. The team includes some of the nation's finest cardiologists, cardiovascular surgeons, nurses, transplant and VAD coordinators, as well as social workers and specialists in cardiac imaging, arrhythmia management, cardiac anesthesia, infectious disease, immunology and rehabilitation medicine. Together, this team is dedicated to the management of patients with complex heart failure.

Heart Failure
Susan C. Brozena, MD
Associate Professor of Medicine
Thomas C. Cappola, MD, ScM
Herbert C. Rorer Associate Professor in Medical Sciences
Stephen M. Chrzanowski, MD
Brian M. Drachman, MD
Clinical Assistant Professor of Medicine

Lee R. Goldberg, MD, MPH
Associate Professor of Medicine

Mariell L. Jessup, MD
Professor of Medicine
Kenneth B. Margulies, MD
Professor of Medicine
Rhondalyn McLean, MD
Assistant Professor of Medicine
Anjali Tiku Owens, MD
Assistant Professor of Medicine
J. Eduardo Rame, MD
Assistant Professor of Medicine
Anjali Vaidya, MD
Assistant Professor of Medicine
Joyce W. Wald, DO
Assistant Professor of Clinical Medicine
Ross. R. Zimmer, MD
Clinical Assistant Professor of Medicine

Cardiovascular Surgery
Michael A. Acker, MD
William Maul Measey Professor of Surgery
Pavan Atluri, MD
Edward Cantu III, MD

Heart Failure Nurse Specialists
Eileen Baxter, BSN, RN
Sarah Fontana, MSN, RN, CHFN
Lauren McDevitt, BSN, RN
Patricia McGurl, MSN, RN
Judie Shilling, RN
Joann Treacy, BSN, RN
Linda Wells, MA, RN, CHFN
Mechanical Circulatory Support Device (MSD) Coordinators
Mary Lou O’Hara, MSN, RN, CCRN

Judy Marble, RN, BSN

Heart Transplant Clinical Practitioners
Susan Chambers, MSN, CRNP
Wilhelmina Maslanek, MSN, CRNP
Maria Molina, MSN, CRNP
Patricia Curry-Stutman, MSN, CRNP
Mary Williams, MSN, CRNP

Heart Transplant Nurse Coordinators
William Wynne, BSN, RN
Patricia Poderis RN

Pre-Transplant Coordinator
Nicole Hornsby, MSN, CRNP

Social Workers
Deborah L. Gordon, MSS, LCSW
Sallie Blair Smith, MSW
Julia Bruno, MSW, LSW

Financial Coordinator
Cammy McCaskill

Clinical Operations Director
Donna Chojnowski, MSN, CRNP

For more information on Heart Failure, Mechanical Assist Device and Transplantation programs and services.

To refer a patient and/or consult with a doctor: Call 800-789-PENN (7366) or visit: PennMedicine.org/referral or http://PennMedicine.org/heart.