Cabozantinib in Advanced Hepatocellular Carcinoma: Efficacy and Safety Data from an International Multicenter Real-Life Cohort

Background and Aims: The multikinase inhibitor cabozantinib has been approved for hepatocellular carcinoma (HCC) previously treated with sorafenib. We report safety and efficacy data of an international, multicenter, real-life cohort of patients with advanced HCC treated with cabozantinib. Methods: Patients with HCC who were treated with cabozantinib were retrospectively identified across 11 centers in Austria, Switzerland, and Germany. Patients’ characteristics, adverse events, duration of treatment and overall survival (OS) data were analyzed until April 1, 2020. Results: Eighty-eight patients from 11 centers were included. The predominant underlying liver diseases were NAFLD/NASH in 26 (30%) and hepatitis C infection in 21 (24%) patients. Seventy-eight patients (89%) were classified as Barcelona clinic liver cancer (BCLC) stage C. Sixty patients (68%) were Child-Pugh A, whereas 22 (25%) were Child-Pugh B, respectively. Cabozantinib was used as systemic second- and third-line or later treatment in 41 (47%) and 46 (52%) patients, respectively. The following best responses under cabozantinib were documented: partial response in 6 (7%), stable disease in 28 (32%), and progressive disease in 28 (32%) patients, respectively. Fifty-two patients (59%) died during follow-up. The median OS from start of cabozantinib treatment was 7.0 months in the entire cohort and 9.7 months in Child-Pugh A patients, while Child-Pugh B patients had a median OS of 3.4 months, respectively. Thirty-seven (42%) patients fulfilled the CELESTIAL inclusion and exclusion criteria, showing a median OS of 11.1 months. Most common adverse events were fatigue (15.6%) and diarrhea (15.6%). Conclusion: Cabozantinib treatment was effective, safe, and feasible in patients with advanced HCC in patients with compensated cirrhosis. Patients in the real-life setting had more advanced liver disease – in which 25% of patients were Child-Pugh B. However, OS in patients with Child-Pugh A cirrhosis was similar to that reported in the phase 3 trial (CELESTIAL)

siRNA-based studies regarding physiological function of transcription factor Runx2 in human osteoblasts

Die physiologische Osteoblastendifferenzierung ist ein hoch komplexer Prozess, in dem der Transkriptionsfaktor Runx2 essentiell ist und über multiple Mechanismen seine Wirkung entfaltet. Da die meisten Erkenntnisse über die physiologische Funktion von Runx2 in murinen Zellmodellen erlangt worden sind, haben wir uns mit der Frage beschäftigt, ob die bisher gefundenen Gesetzmäßigkeiten auch im humanen Modell Gültigkeit besitzen. Hierfür wurden siRNA-basierte Runx2 knock-down Studien in primären Zellen (pHOB) aus dem menschlichen Knochen durchgeführt, welche in osteogenen Kulturbedingungen als ein Modell für die Osteoblastendifferenzierung etabliert worden waren. Für einen transienten und auch stabilen Runx2 knock-down wurde ein siRNA-Expressionsplasmid kloniert, welches ein Vorläufermolekül (shRNA) der gewünschten Runx2-siRNA in der transfizierten Zielzelle exprimiert und so die RNA-Interferenz induziert. Zusätzlich wurde ein transienter knock-down in pHOB Zellen über 4 Tage mit konventioneller, exogen synthetisierter siRNA induziert und mit einem RNA-Microarray analysiert. Für die Transfektion des siRNA-Expressionsplasmids in pHOB wurde mit einer ca. 90-prozentigen Transfektionsrate die Nukleofektion als potente Transfektionsmethode etabliert. In einer RNA-Microarray Analyse zeigte sich eine hohe shRNA-Syntheserate durch das siRNA-Expressionsplasmid in pHOB-Zellen, was allerdings nicht in einer Suppression des Zielgens Runx2 resultierte. Ungenügende oder fehlerhafte enzymatische Reaktionen in der Zielzelle für die shRNA-Prozessierung (Drosha, Pasha) bzw. den intrazellulären Transport (Exportin5) scheinen dafür verantwortlich zu sein, dass das siRNA-Expressionsplasmid in pHOB-Zellen keine Gensuppression von Runx2 erreicht. Durch den mit konventioneller, exogen synthetisierter siRNA vermittelten knock-down von Runx2 wurden viele Erkenntnisse über die Funktion von Runx2 in pHOB erlangt. Die regulative Tätigkeit von Runx2 auf die osteoblastentypischen Gene Osteocalcin, Osteopontin und sehr wahrscheinlich Kollagen Typ 1 und Bone Sialoprotein in pHOB wurden abermals bestätigt. Es zeigte sich weiterhin eine bisher nicht beschriebene Beziehung von Runx2 zu dem Schlüsselmolekül des canonical Wnt-Signalweges β-Catenin. Nach unseren Ergebnissen könnte Runx2 eine direkt induzierende Wirkung auf β-Catenin haben, welches wiederum selbst als Effektorprotein des canonicals Wnt-Signalweges für die Osteoblastendifferenzierung regulative Funktion besitzt. Zudem konnten andere Faktoren des canonicals Wnt-Signalweges wie das secreted frizzled-related protein-1, das frizzled homolog 6 und der WNT inhibitory factor 1 als potentielle Regulatorproteine dieser hochkomplexen Regulationsvorgänge identifiziert werden. Der knock-down zeigte weiterhin eine bisher nicht beschriebene regulative Tätigkeit von Runx2 auf die Expression der 11β-Hydroxisteroid-Dehydrogenase-1 (HSD11B1). Hiermit scheint Runx2 beeinflussend in der Steuerung hormoneller Regelkreisläufe zu agieren, indem es die Menge von in Osteoblasten synthetisierten aktiven Kortisol zumindest zum Teil reguliert

Treatment of hepatitis C infections in the era of direct-acting antivirals (DAAs)

Die chronische Hepatitis-C-Infektion kann unbehandelt zu schwerwiegenden und potenziell lebensbedrohlichen leberassoziierten Komplikationen führen. Grundsätzlich stellt damit jede chronische Infektion mit dem Hepatitis-C-Virus (HCV) eine Indikation zur antiviralen Therapie dar. Besonders dringlich ist sie jedoch bei Patient*innen mit fortgeschrittener Lebererkrankung. In diesem Beitrag werden Indikation, Therapieziele und Grundprinzipien der direkt antiviralen Therapie beschrieben. Verschiedene Therapieregime und Möglichkeiten der Überwachung von Therapie und Therapieerfolg werden vorgestellt. Heutzutage wird die chronische HCV-Infektion interferonfrei mit direkt antiviral wirksamen Medikamenten („direct acting antivirals“ – DAA) behandelt, wobei die Wahl der Medikamente von HCV-Genotyp, Vortherapie und Fibrosestatus abhängt. Patient*innen mit kompensierter Leberzirrhose und solche ohne Leberzirrhose weisen unter Behandlung vergleichbar hohe Viruseradikationsraten auf. Auch bei dekompensierter Leberzirrhose oder dialysepflichtiger Niereninsuffizienz und selbst bei Kindern ab einem Alter von 3 Jahren ist heutzutage eine sichere und hocheffiziente antivirale Behandlung möglich. Medikamenteninteraktionen sind zu beachten, können aber einfach und schnell im Internet überprüft werden. Auch wenn sich die Prognose nach HCV-Eradikation deutlich verbessert, sollten Patient*innen mit fortgeschrittener Leberfibrose bzw. einer Leberzirrhose lebenslang weiterbeobachtet werden, um die Entstehung eines hepatozellulären Karzinoms rechtzeitig zu erkennen (HCC-Surveillance).Untreated chronic hepatitis C infection can lead to severe and potentially fatal liver-associated complications. Therefore, every hepatitis C virus (HCV) infection represents an indication for antiviral treatment. In particular, patients with progressive liver disease should be treated urgently. Here, we review indication for treatment as well as goals and basic principles of antiviral therapy. In addition, different treatment regimens and monitoring of the treatment course and outcome are discussed. Today, the treatment of chronic HCV infection is based on interferon-free regimens combining different direct-acting antivirals (DAAs), where the choice of DAA-regimen depends on the viral genotype, previous treatments, and the state of liver fibrosis. With these regimens, equally high virus eradication rates are achievable in patients with compensated liver cirrhosis and in patients without advanced liver disease. In addition, patients with decompensated liver cirrhosis or patients with end-stage renal failure requiring renal replacement therapy, as well as children from an age of 3 years, can be treated safely and highly efficiently with DAA-containing regimens. Physicians should be aware of possible drug interactions of the DAAs with concomitant administered drugs. However, possible interactions can be checked easily online. Although, there is an improvement of prognosis after HCV eradication, patients with advanced liver fibrosis or liver cirrhosis must be included in a lifelong HCC surveillance program

Absence of HBV reactivation in patients with resolved HBV infection following DAA therapy for hepatitis C : a 1-year follow-up study

Background: Patients with chronic hepatitis C virus (HCV) infection and active or previous hepatitis B virus (HBV) are at risk of HBV reactivation (HBV-R) during direct-acting antiviral (DAA) therapy. Recent reports suggest that HBV-R may even occur several months after completion of DAA therapy. The aim of this study was to assess the risk of HBV-R in patients with resolved HBV after successful DAA therapy during long-term follow-up (FU). Methods: Among 848 patients treated for chronic HCV, all patients with resolved HBV and long-term FU data were eligible for inclusion. Patients were HBV DNA/hepatitis B surface antigen (HBsAg)–negative at the end of therapy (EOT) and were followed for up to 52 weeks thereafter. Patients underwent regular alanine transaminase (ALT) testing, and additional HBV DNA/HBsAg testing was performed at FU week 12, end of FU, and in case of an ALT increase above the upper limit of normal (>ULN). Results: A total of 108 patients were followed up for a mean (range) of 41.5 (24–52) weeks after EOT. None of the patients experienced reverse HBsAg seroconversion or reappearance of HBV DNA. One patient received a liver transplantation; 1 patient was diagnosed with de novo hepatocellular carcinoma, and 2 patients died. Eighteen patients (16.7%) had increased ALT levels (grade 0/1). Of those, the majority were male (72.2%) and significantly more patients had cirrhosis (66.7% vs 36.2%, P = .015) or received ribavirin as part of their treatment regimen (86.7% vs 46.8%, P = .041). None of these were associated with HBV-R. Conclusions: Our results indicate that the risk of HBV-R in patients with resolved HBV treated with DAAs for HCV is low during long-term follow-up

Impact of colonization with multidrug-resistant organisms on antibiotic prophylaxis in patients with cirrhosis and variceal bleeding.

BackgroundThe efficacy of antibiotic prophylaxis to prevent rebleeding or infection after variceal bleeding in patients with liver cirrhosis colonized with multidrug-resistant organisms (MDROs) is unknown.MethodsIn this retrospective study, patients with liver cirrhosis and endoscopically confirmed variceal bleeding who were treated at a tertiary care center in Germany and were screened for MDROs at the time of bleeding were eligible for inclusion. Efficacy of antibiotic prophylaxis was evaluated in patients stratified according to microbiological susceptibility testing.ResultsFrom 97 patients, the majority had decompensated liver cirrhosis (median MELD Score 17) and ACLF was present in half of the patients (47.4%). One third of patients were colonized with MDRO at baseline. De-novo infection until day 10 or the combination of de-novo infection or rebleeding were comparable among both groups (p = 0.696 and p = 0.928, log-rank-test). Risk of de-novo infection or rebleeding was not significantly increased in patients who received antibiotic prophylaxis that did not cover the MDRO found upon baseline screening. Acute-on-chronic liver failure at baseline was the strongest and only independent risk factor that was associated with both outcomes (OR 5.52, 95%-CI 1.48-20.61, p = 0.011 and OR 11.5, 95%-CI 2.70-48.62, pConclusionIn this study, MDRO colonization did not increase the risk of rebleeding, infections nor death, even if antibiotic prophylaxis administered did not cover all MDRO detected at MDRO screening. Patients with ACLF had an increased risk of bleeding, infections and death

The N-terminus makes the difference: impact of genotype-specific disparities in the N-terminal part of the hepatitis B virus large surface protein on morphogenesis of viral and subviral particles

The N-terminus of the hepatitis B virus (HBV) large surface protein (LHB) differs with respect to genotypes. Compared to the amino terminus of genotype (Gt)D, in GtA, GtB and GtC, an additional identical 11 amino acids (aa) are found, while GtE and GtG share another similar 10 aa. Variants of GtB and GtC affecting this N-terminal part are associated with hepatoma formation. Deletion of these amino-terminal 11 aa in GtA reduces the amount of LHBs and changes subcellular accumulation (GtA-like pattern) to a dispersed distribution (GtD-like pattern). Vice versa, the fusion of the GtA-derived N-terminal 11 aa to GtD causes a GtA-like phenotype. However, insertion of the corresponding GtE-derived 10 aa to GtD has no effect. Deletion of these 11aa decreases filament size while neither the number of released viral genomes nor virion size and infectivity are affected. A negative regulatory element (aa 2–8) and a dominant positive regulatory element (aa 9–11) affecting the amount of LHBs were identified. The fusion of this motif to eGFP revealed that the effect on protein amount and subcellular distribution is not restricted to LHBs. These data identify a novel region in the N-terminus of LHBs affecting the amount and subcellular distribution of LHBs and identify release-promoting and -inhibiting aa residues within this motive

Serum sphingolipid levels associate with upcoming virologic events and HBV genotype D in a cohort of patients with HBeAg-negative HBV infection.

OBJECTIVES:Sphingolipids (SLs) have been implicated as potent regulators of the hepatitis B virus (HBV) life cycle. We investigated the SL biomarker potential regarding virologic endpoints in a prospective subgroup of patients with HBeAg-negative chronic HBV infection. METHODS:From 2009-2016 98 patients with HBeAg-negative HBV infection were prospectively followed over four years. Clinical, laboratory and imaging data were evaluated annually. SLs were assessed in available serum probes via liquid chromatography coupled to tandem mass spectrometry. RESULTS:Of those 98 patients, 10 (10.2%) showed HBV reactivation, 13 (13.2%) lost HBsAg and 9 (9.1%) gained status of HBsAg-/HBsAb-coexistence, whereas 66 (67.3%) had no events. Within the four-year analysis sphingosine (p = 0.020), sphinganine (p<0.001), dhS1P (p<0.001), C16DHC (p<0.01) and C20Cer (p<0.001) showed a significant upregulation in patients without virologic events, C18Cer significantly decreased (p<0.001). At baseline decreased S1P-, dhS1P- and C16Cer-levels were observed in patients with upcoming status of HBsAg-/HBsAb-coexistence. S1P and dhS1P levels were elevated HBV genotype D infected patients. CONCLUSIONS:In a prospective cohort of patients with a HBeAg-negative HBV infection, serum SLs associated with the virologic course and HBV genotype D. Further studies are required to elucidate SLs as potential novel predictors of the course of HBeAg-negative HBV infection

Serum sphingolipid levels associate with upcoming virologic events and HBV genotype D in a cohort of patients with HBeAg-negative HBV infection

Objectives: Sphingolipids (SLs) have been implicated as potent regulators of the hepatitis B virus (HBV) life cycle. We investigated the SL biomarker potential regarding virologic endpoints in a prospective subgroup of patients with HBeAg-negative chronic HBV infection. Methods: From 2009–2016 98 patients with HBeAg-negative HBV infection were prospectively followed over four years. Clinical, laboratory and imaging data were evaluated annually. SLs were assessed in available serum probes via liquid chromatography coupled to tandem mass spectrometry. Results: Of those 98 patients, 10 (10.2%) showed HBV reactivation, 13 (13.2%) lost HBsAg and 9 (9.1%) gained status of HBsAg-/HBsAb-coexistence, whereas 66 (67.3%) had no events. Within the four-year analysis sphingosine (p = 0.020), sphinganine (p<0.001), dhS1P (p<0.001), C16DHC (p<0.01) and C20Cer (p<0.001) showed a significant upregulation in patients without virologic events, C18Cer significantly decreased (p<0.001). At baseline decreased S1P-, dhS1P- and C16Cer-levels were observed in patients with upcoming status of HBsAg-/HBsAb-coexistence. S1P and dhS1P levels were elevated HBV genotype D infected patients. Conclusions: In a prospective cohort of patients with a HBeAg-negative HBV infection, serum SLs associated with the virologic course and HBV genotype D. Further studies are required to elucidate SLs as potential novel predictors of the course of HBeAg-negative HBV infection