Caitlin Hester

Management of hepatocellular in the United States

Hepatocellular carcinoma (HCC) is a major cause of cancer burden globally. In the United States, the incidence of HCC is forecast to continue to rise for the next 15 years. Patients with HCC vary markedly owing to heterogeneous tumor characteristics and concomitant liver dysfunction. In the United States and Europe, HCC is staged and managed according to the Barcelona Clinic Liver Cancer (BCLC) system. For very early and early stage HCC, or BCLC 0/A, liver transplant is the optimal treatment option. Liver resection and radiofrequency or microwave ablation are alternative treatment options. For intermediate stage HCC, or BCLC B, transarterial chemoembolization (TACE) is the standard of care. An alternative locoregional therapy, transarterial radioembolization using yttrium-90, has shown comparable outcomes with TACE and may be used in patients for whom TACE is contraindicated. For advanced stage HCC, or BCLC C, systemic chemotherapy with sorafenib, a multikinase inhibitor, is the only evidence-based treatment option available. Another multikinase inhibitor, regorafenib, was recently approved as a second-line therapy for this patient group. Randomized clinical trials investigating other agents in enriched patient groups and novel therapeutics including checkpoint inhibitors are underway. Patient with prohibitive performance status and/or end stage liver dysfunction are classified terminal stage HCC, or BCLC D, and are managed with best supportive care. The future direction for the management of HCC will rely on continuing efforts to uncover molecular pathways and actionable genetic aberrations in HCC.

Comprehensive review of typical and atypical pathology of the appendix on CT: cases with clinical implications

Acute appendicitis is the most common abdominal surgical emergency in the United States with approximately 250,000 cases annually. Computed Tomography (CT) has emerged as the most accurate diagnostic test to triage these patients for emergent surgery. Although the radiology search pattern is prioritized to detect an inflamed appendix, not all appearances equate to a typical surgical appendicitis. There are a select set of atypical pathologies involving the appendix that have subtle differences on CT, but can have catastrophic complications if treated with emergent appendectomy. This paper will review the spectrum of CT appearances and clinical management for typical and atypical appendiceal pathologies.

Comparative outcomes of adenosquamous carcinoma of the pancreas: An analysis of the National Cancer Database

A paucity of data exists regarding the natural history and outcome measures of adenosquamous carcinoma of the pancreas (ASCP), a histology distinct from pancreatic adenocarcinoma (PDAC). The aim of this study is to characterize the clinicopathological features of ASCP in a large cohort of patients comparing outcome measures of surgically resected patients to PDAC.

Gastric Cancer: Recent Molecular Classification Advances, Racial Disparity, and Management Implications

Gastric adenocarcinoma remains an aggressive and poorly understood malignancy with a heterogeneous presentation and tumor biology. The current histologic and anatomic classification has been ineffective in guiding therapy, with only marginal improvement in outcome over time. Furthermore, the variation in presentation and disease among racial and ethnic groups amplifies the complexity of this cancer. An understanding of the clinical and molecular variability is important for effective treatment. Recent advances in molecular biology have better defined gastric cancer subtypes. We systematically review recent literature on the molecular classification of gastric adenocarcinoma and the associated management implications, with an emphasis on Hispanic and Native American populations.

Racial and Ethnic Differences in Presentation and Outcomes of Hepatocellular Carcinoma

Background & Aims Racial and ethnic minorities are reported to have higher mortality related to hepatocellular carcinoma (HCC) than non‐Hispanic whites. However, it is not clear whether differences in tumor characteristics or liver dysfunction among racial or ethnic groups affect characterization of causes for this disparity. We aimed to characterize racial and ethnic differences in HCC presentation, treatment, and survival. Methods We performed a retrospective study of patients diagnosed with HCC from January 2008 through July 2017 at 2 large health systems in the United States. We used multivariable logistic regression and Cox proportional hazard models to identify factors associated with receipt of curative therapy and overall survival. Results Among 1117 patients with HCC (35.9% white, 34.3% black, 29.7% Hispanic), 463 (41.5%) were diagnosed with early stage HCC (Barcelona Clinic Liver Cancer stage 0/A) and 322 (28.8%) underwent curative treatment. Hispanic (odds ratio [OR], 0.75; 95% CI, 0.55–1.00) and black patients (OR, 0.74; 95% CI, 0.56–0.98) were less likely to be diagnosed with early stage HCC than white patients. Among patients with early stage HCC, Hispanics were less likely to undergo curative treatment than whites (OR, 0.58; 95% CI, 0.36–0.91). Black patients with early stage HCC were also less likely to undergo curative treatment than white patients, but this difference was not statistically significant (OR, 0.66; 95% CI, 0.43–1.03). Black and Hispanic patients had shorter median survival times than white patients (10.6 and 14.4 mo vs 16.3 mo). After adjusting for type of medical insurance, Child–Pugh class, Barcelona Clinic Liver Cancer stage, and receipt of HCC treatment, black patients had significantly higher mortality (hazard ratio, 1.12; 95% CI, 1.10–1.14) and Hispanic patients had lower mortality (hazard ratio, 0.83; 95% CI, 0.74–0.94) than white patients. Conclusions In a retrospective study of patients diagnosed with HCC, we found racial/ethnic differences in outcomes of HCC to be associated with differences in detection of tumors at early stages and receipt of curative treatment. These factors are intervention targets for improving patient outcomes and reducing disparities.

Multidisciplinary Team Management of Patients with Hepatocellular Carcinoma

Purpose of ReviewThe purposes of the current review are to (1) define multidisciplinary care and a proposed composition for a multidisciplinary team and (2) summarize process and outcome measures associated with multidisciplinary care for patients with hepatocellular carcinoma (HCC).Recent FindingsThere has been a shift from multidisciplinary tumor boards to multidisciplinary clinics, which facilitates greater provider discussion and interaction over patients’ treatment course. Although most studies examining the effect of multidisciplinary care for the management of a newly diagnosed patient with HCC rely on surrogate measures of quality cancer care, recent studies have demonstrated significant improvement of stage-stratified survival.SummaryHCC is a complex and heterogeneous disease due to the concomitant presence of underlying liver disease and cancer. Given the variety of available treatment options and data showing improved outcomes, it should be considered best practice for HCC patients to be managed by a multidisciplinary team.