Análisis obsevacional para evaluar la eficacia y seguridad de los mTORi en la esfera oncológica en el paciente trasplantado hepático

1 UNIVERSIDAD DE SEVILLA FACULDAD DE MEDICINA Departamento de Cirugía Tesis doctoral Análisis obsevacional para evaluar la eficacia y seguridad de los mTORi en la esfera oncológica en el paciente trasplantado hepático Presentada por XI DANG Tutor： Luis Cristóbal Capitán Morales Directores: José María Álamo Martínez Miguel Ángel Gómez Bravo SEVILLA, 2019 2 3 D. LUIS CRISTÓBAL CAPITÁN MORALES, PROFESOR TITULAR DEL DEPARTAMENTO DE CIRUGÍA DE LA UNIVERSIDAD DE SEVILLA, DECANO DE FACULTAD DE MEDICINA CERTIFICA: Que la Tesis Doctoral que lleva por título: “Análisis obsevacional para evaluar la eficacia y seguridad de los mTORi en la esfera oncológica en el paciente trasplantado hepático”, presentada por D. XI DANG para optar al grado de Doctor, ha sido realizada en el Departamento de Cirugía de la Facultad de Medicina de la Universidad de Sevilla. Revisado el texto, doy mi conformidad para su presentación y defensa para optar al grado de Doctor por la Universidad de Sevilla. Fdo. Dr. Luis Critóbal Capitán Morales Tutor de la Tesis 3 de Junio de 2018 4 5 D. MIGUEL ÁNGEL GÓMEZ BRAVO, PROFESOR ASOCIADO DEL DEPARTAMENTO DE CIRUGÍA DE LA UNIVERSIDAD DE SEVILLA CERTIFICA: Que la Tesis Doctoral que lleva por título: “Análisis obsevacional para evaluar la eficacia y seguridad de los mTORi en la esfera oncológica en el paciente trasplantado hepático”, presentada por D. XI DANG para optar al grado de Doctor, ha sido realizada en el Departamento de Cirugía de la Facultad de Medicina de la Universidad de Sevilla. Revisado el texto, doy mi conformidad para su presentación y defensa para optar al grado de Doctor por la Universidad de Sevilla. Fdo. Dr. Miguel Ángel Gómez Bravo Director de la Tesis 3 de Junio de 2018 6 7 D. JOSÉ MARÍA ÁLAMO MARTÍNEZ, PROFESOR ASOCIADO DEL DEPARTAMENTO DE CIRUGÍA DE LA UNIVERSIDAD DE SEVILLA CERTIFICA: Que la Tesis Doctoral que lleva por título: “Análisis obsevacional para evaluar la eficacia y seguridad de los mTORi en la esfera oncológica en el paciente trasplantado hepático”, presentada por D. XI DANG para optar al grado de Doctor, ha sido realizada en el Departamento de Cirugía de la Facultad de Medicina de la Universidad de Sevilla. Revisado el texto, doy mi conformidad para su presentación y defensa para optar al grado de Doctor por la Universidad de Sevilla. Fdo. Dr. José María Álamo Martínez Director de la Tesis 3 de Junio de 2018 8 9 Agradecimiento A Dr. Luis Cristóbal Capitán Morales, tutor de esta tesis, por haberme brindado la oportunidad de este estudio, por su apoyo incondicional y motivación. A Dr. José María Álamo Martínez, director de esta tesis, por su gran paciencia y enorme capacidad de esfuerzo, por sus ganas de aprender y enseñar al mismo tiempo. A Dr. Miguel Ángel Gómez Bravo, director de esta tesis, por su apoyo y su implicación en mi formación médica e investigadora. A Dres. Luis Miguel Marín, Ganzalo Suarez, Carmen Bernal, Carmen cepeda, integrantes de la Unidad de Cirugía Hepatobiliopancreática y Trasplante. Por sus introducción y enseñanza en la cirugia hepatobiliopancreática, por su confianza y apoyo. A mi familia. 16 17 Index 1. Introduction-------------------------------------------------------- 21 1.1. History of liver transplantation-------------------------------------- 23 1.2. Indication and contraindication of liver transplant------------- 26 1.2.1. Indication of liver transplant-------------------------------------------------- 26 1.2.2. Liver transplant procedure--------------------------------------------------- 30 1.3. Surgical technique of liver transplantation----------------------- 33 1.4. Complication of liver transplantation------------------------------ 35 1.4.1. Complication postoperative immediately--------------------------------- 36 1.5. Basic notions oncology-------------------------------------------- 43 1.5.1. Hepatocellular carcinoma (HCC)------------------------------------------- 43 1.5.2. Lung cancer--------------------------------------------------------------------- 47 1.5.3. Colorectal cancer-------------------------------------------------------------- 50 1.5.4. Kidney cancer------------------------------------------------------------------- 53 1.5.5. Prostate cancer----------------------------------------------------------------- 56 1.6. Immunosuppression in liver transplantation-------------------- 60 1.6.1. Calcineurin inhibitors---------------------------------------------------------- 61 1.6.1.1. Tacrolimus--------------------------------------------------------------------------- 61 1.6.1.2. Toxicity of calcineurin inhibitors------------------------------------------------ 62 1.6.2. Mycophenolate-mofetil------------------------------------------------------- 64 1.6.3. mTORi---------------------------------------------------------------------------- 65 1.6.3.1. Pharmacokinetics of Sirolimus------------------------------------------------- 67 1.6.3.2. Pharmacokinetics of Everolimus----------------------------------------------- 68 1.6.3.3. Adverse effects--------------------------------------------------------------------- 69 1.6.3.4. mTORi in the field of oncology-------------------------------------------------- 70 1.6.3.4.1. Hepatocellular carcinoma recurrence---------------------------------------------- 71 1.6.3.4.2. De novo neoplasia---------------------------------------------------------------------- 72 18 2. Hypothesis--------------------------------------------------------- 87 3. Objective----------------------------------------------------------- 91 4. Methods------------------------------------------------------------ 95 5. Results------------------------------------------------------------ 107 5.1. Hepatocellular carcinoma (HCC)--------------------------------- 109 5.1.1.Influence of smoking and alcohol consumption------------------------ 109 5.1.2. Histoligical Finding----------------------------------------------------------- 110 5.1.3. Tumor recurrence------------------------------------------------------------ 116 5.1.4. Immunosuppressant scheme---------------------------------------------- 120 5.2. De novo neoplasia (NN)-------------------------------------------- 129 6. Discussion-------------------------------------------------------- 175 6.1. Hepatocellular carcinoma (HCC)--------------------------------- 178 6.1.1. Is there influence in survival about smoking and alcohol?---------- 178 6.1.2. Do histological characteristics affects survival?----------------------- 179 6.1.3. Survival in the patients with recurrence of HCC----------------------- 180 6.1.4. Is there influence of survival about Immunosuppressant scheme?--- -------------------------------------------------------------------------------------------------- 180 6.2. mTORi in “de novo” neoplasia after LT-------------------------- 183 6.2.1. Do smoking and alcohol have influence on survival?---------------- 183 6.2.2. Is there influence in survival about treatment method?-------------- 184 6.2.3. The influence in survival about stage of cancer------------------------ 184 6.2.4. The influence of immunosuppressant treatment in neoplasia de novo-------------------------------------------------------------------------------------------- 185 7. Conclusions------------------------------------------------------ 193 19 8. References------------------------------------------------------- 197 20 21 1. INTRODUCTION 22 23 1. INTRODUCTION 1.1. History of liver transplantation Liver transplantation (LT) is considered to be the treatment used in patients with acute or chronic liver disease when other alternative therapy has been exhausted and it is the best treatment for end-stage chronic liver disease and is associated with a oneyear survival rate that ranges from 78% to 85%1. The research possibility of LT began in the 1960s. In 1955, Dr. Welch was the first to describe liver transplantation as a treatment and proposed ectopic liver transplantation in the abdominal cavity. However, modern liver transplantation is orthotopic liver transplant (OLT), which consists of excision of the diseased liver followed by placement in the same anatomical location of a healthy liver from an organ donor, constituted by grafting the entire or a part of a liver2. A few later, in 1963, Starzl et al attempted the first human LT in the world, the patient was a 3-year-old boy with biliary atresia, who died during surgery due to coagulation disorder and uncontrolled bleeding3,4. Especially, using the same immunosuppressive regimen, at the University of Cambridge, United Kingdom, 138 cases of OLT were performed between 1968 and 1984, and the results were so disappointing5,6,7. In 1990, Starzl et al.8. reported the first use of the new tacrolimus as imunosupressant agent in patients submitted to liver transplantation who suffered a rejection even using conventional immunosuppressive treatment. Tacrolimus, which is similar to CsA but with greater potency. The success of cyclosporine conversion by tracrolimus in these patients and by showing it safety and effectiveness of rejection control, lots of new clinical studies were conducted with using tacrolimus as the main immunosuppressor in liver transplantation8910. Until then, the CNIs (Cyclosporine A and Tacmolimus) had been the basis immunosuppressor in OLT. At the end of the 1990s, 24 a new purine synthesis inhibitor was introduced, mycophenolate mofetil (MMF), which was presented as a more selective alternative and with greater immunosuppressive capacity than azathioprine (AZA). In fact, CNIs presents nephrotoxic effects, which are an important source of mortality in OLT. Almost 20% of OLT recipients have chronic renal failure after 5 years of the transplantation11. Everolimus (EVE) and Sirolimus (SRL), two new immunosuppressant of the mammalian Target Of Rapamycin Inhibitor (mTORi), could potentially satisfy this adverse effect. The chief advantage sirolimus has over calcineurin inhibitors is its low toxicity toward kidneys. Transplant patients maintained on calcineurin inhibitors long-term tend to develop impaired kidney function or even chronic renal failure; this can be avoided by using sirolimus instead. It is particularly advantageous in patients with kidney transplants for hemolytic-uremic syndrome, the SRL was approved by the Food Drug Administration (FDA), USA, for kidney transplantation, because it has ability to protect kidney function1213. And in the year 2010, the EVE was approved by the FDA being used together with TAC, and reduced dose of TAC and steroid in the OLT recipients to decrease the nephrotoxicity of the CNIs. The SRL has been used in several OLT centers in the world for prophylaxis and to decrease the nephrotoxicity of CNIs. In Europe, the OLT was widely applied in the 1980s, where the countries that made their first OLT succeeded. (Figure 1.1) According to the information of the European Liver Transplant Registry (ELTR), until the present time, 174 transplant centers from 32 European countries are participating to ELTR. By comparison with the official data Transplant Observatory, More than 98% of European liver transplantation’s data are continuously updated, analyzed and published by ELTR. 25 Fig.1.1: Evolution of 93,634 LTs performed in Europe since May 1968. Arrows indicate the year the first LT was performed in indicated countries. This decrease is owed to the fact that some centers did not yet send their updating further to the recent changes of the questionnaire. In Spain, the first OLT was successfully carried out in 1984 in Barcelona. The annual number of OLT performed has progressively increased, reaching 1,000 cases per year in the last 10 years. The high activity of OLT is associated with a high rate of liver donation. Spain has an index of 14 donors per million inhabitants, which is the highest, not only in Europe but also in the world. For now, almost 50 years after the first OLT, the survival rates of 1 and 5 years are 85% and 73%, respectively14. This success is related to advances in surgical technique, progress in immunosuppression, progress in graft conservation and anesthetic technique, and advances in perioperative care. 32 The result is multiplied by 10 and rounded to the nearest whole number. The value ranges from 6 to 40, in direct proportion to the severity of the disease. The MELD model includes the impact of the variations of the evaluation of the components analysis in the laboratory, a lack of recognition of the differences between the creatinine in male and female and a potential disadvantage in certain groups of receptors, such as those with hyponatremia or those with primary sclerosing cholangitis1718. Encephalopathy, tumors and metabolic diseases are risk factors not correlated with the MELD, and it would be quite difficult to determine the priority of a patient with cirrhosis related complications and a low MELD score19. MELD is used in the age of patients older than 12 years. The best way to use of MELD in the OLT is as an index to prioritize the patients on the waiting list and obtain a fair distribution of the organs obtained. A Child-Pugh score greater than 7 (stages B and C), or an MELD score greater than 15, and that is the indication for a transplantation. However, there are circumstances in some patients in which survival decreases drastically, which are either should be deterioration of quality of life (like intractable pruritus), or because of a greater complication (such as ascites, encephalopathy, refractory digestive bleeding from portal hypertension, hepatorenal syndrome, spontaneous bacterial peritonitis). In fact, the number of donor livers is not sufficient for the candidates of the recipient, and the number of patients on the waiting list is increasing, with the consequent increase in mortality on the waiting list. Some researchers suggest that the allocation of organ resources should be based primarily on the access of cadaveric donor organs to those recipients whose quality of life is unacceptable but without terminal disease, such as those with intractable pruritus, polycystic hepatis or intractable 33 encephalopathy18. It is necessary to choose well both the donors and the recipients, optimize the candidates and determine the appropriate time for the transplant, in order to obtain the best possible performance of the organs transplantation. 1.3. Surgical technique of liver transplantation There are three steps of the surgical OLT of recipient: 1. Total hepatectomy; 2. Liver implant (vascular and biliary reconstruction); 3. Hemostasis and abdominal closure. The traditional technique "veno-venous bypass" was replaced by the technique "piggyback", which is not necessary to replace the vena cava, and make the hepatectomy with preservation of native retrohepatic vena cava. The ‘piggy-back’ technique with temporary portocaval shunt allows one to choose the order of graft revascularization. We prefer to do the portal anastomosis first and then the arterial anastomosis 20,21. 34 Figure 1.3. The piggyback technique for OLT. Diagram shows the confluence of donor hepatic veins that are anastomosed to the recipient suprahepatic IVC. End-to-end hepatic artery anastomosis, common bile duct anastomosis, and anastomosis of the donor and recipient portal veins are performed, although the exact technique may vary from case to case The "piggyback" technique of liver transplantation had been described by Calne et al. in 1968 and had been routine used in clinical by Tzakis 20 years later22. The character is keeping the continuity of the vena cava of the recipient to implant in it a segment of the vena cava of the graft that contains the ostia of the hepatic veins. The technique offers the advantage of this technique are that they contain a reduction in the risk of stenosis, technical failures associated with the fabrication of two anastomoses with IVC, both reduction in the time of operation and bleeding23. In the technique, the suprahepatic veins are sectioned intrahepatic, in order to gain the largest possible segment of vein to anastomosis. In general, the common trunk of the middle and left hepatic veins are very short, so for the anastomosis of the 35 suprahepatic cava easier, the anastomosis area of the vena cava must be prepared. During the liver removing, The impermeability of the stump of the infrahepatic cava is ensured by obliterating the implantation holes of the caudate lobe veins, sectioned222425. 1.4. Complication of liver transplantation Liver transplantation (LT) is widely accepted as an effective therapeutic modality for a variety of irreversible acute and chronic liver disease. But for the patient followup with OLT, there are several complication frequent in postoperative immediately and the long-term. As we know, LT is the treatment complicated, any complication is related to the mortality of the OLT26.(Tab.1.3) 36 Tab.1.3 Complication of liver transplantation 1.4.1. Complication postoperative immediately Immediate postoperative complication l Postoperative hemorrhage It happens mainly during the first 24-48 h after completion of the OLT, with a variable prevalence that, in some series, has reached 20%26. Preexisting coagulopathy, significant hemorrhage during surgery, imperfect hemostasis and/or 37 immediate poor synthetic function are some of the factors associated with this complication. It has been considered a complication and a major problem, and due to its severity, up to 12% of the causes of post-transplant mortality have been reached in some series2627. l Liver graft dysfunction The transplanted liver can have a normal postoperative course, manifested by progressive decrease of transaminases, increase of factor V, prothrombin and platelets, control of acidosis, normalization of ammonium, good biliary production, and absence of encephalopathy. Dysfunction of the graft may occur in the immediate postoperative period or late during the follow-up of the patient. The reason of early dysfunction of the graft can be: 1. problems of the graft itself (primary dysfunction/malfunction, nonspecific cholestatic syndrome, rejection), 2. complications of the surgical technique [vascular (arterial, portal thrombosis, poor drainage of the suprahepatic veins), or biliary], and 3. other causes such as drugrelated liver toxicity. Primary graft failure is defined as the clinical situation in which there is poor liver function to maintain the individual’s life leading to death of the patient or retransplantation during the first seven postoperative days. It constitutes between 20 and 30% of the causes of retransplantation. The mortality of the primary dysfunction of graft without retransplantation approaches 80% of the patients, reducing between 30% and 50% after performing the retransplant2628. It is one of the most serious situations in the early post-transplant setting. The exact cause of this severe complication is unknown, although there are some of factors conditions: donor age, hemodynamic instability, suboptimal donors, cold ischemia time, reperfusion damage and the temperature of the preservation solution262729. l Arterial complication 38 This complications including thrombosis and stenosis of the hepatic artery, which cause high morbidity and mortality when they cause severe graft dysfunction. Particularly the thrombosis of the hepatic artery (prevalence ranging from 1.5 to 25%) are the most frequent ones. The most frequent cause including poor arterial flow, increased sinusoidal resistance, preservation injury, stenosis of the anastomosis and a state of hypercoagulability26273031. It usually manifests as a sudden and progressive deterioration of liver function, unlike primary graft dysfunction, it occurs after a variable period of normal hepatic function. l Portal vein complication Portal vein thrombosis is an infrequent complication with an overall prevalence of 2-3%. It is related to pre-transplantation portal thrombosis, splenectomy, and prior portal hypertension surgery. The most frequent cause are technical errors related to venous redundancy and torsion and / or stenosis of the anastomosis. Clinically, it has been classified as early form(in the first week of the postoperative period) and late form(as of the first week). The clinical picture is dominated by symptoms/signs of hepatic failure in the early form; and in the late form, the typical presentation was manifested portal hypertension, obviously, it is also accompanied by ascites, esophagogastric varices and other symptoms2631. l Caval vein complication It is uncommon and rare complication following liver transplantation “thrombosis of the vena cava” with an reported incidence of less than 3%. The main risk factor leading to caval anastomosis complications is represented by technical errors in the connection of caval anastomoses, and usually realized with stenosis anastomosis. Clinical presentation ranges from hepatomegaly, ascites, Budd-Chiari syndrome, lower limb edema, liver and renal failure to hypotension leading to allograft loss and multiorgan failure31. 39 l Biliary complication Anastomotic leaks and Biliary strictures stenosis are the very frequency in Biliary complication after liver transplantation. With an overall incidence of 5% to 25%32. The most common is biliary strictures or called biliary stenosis. Biliary strictures usually can be divided into two categories and they are anastomotic strictures and nonanastomotic strictures3233. Anastomotic strictures usually involve the anastomotic site, is more commonly associated with biliary reconstruction by hepaticojejunostomy and the main cause responsible can be inadequate anastomoses. The mechanism of nonanastomotic strictures remains unclear, but it is often related to ischemic events. It has a worse prognosis and a significant proportion of patients who require retransplantation3334. As we know, the rejection after liver transplantation can be divided acute rejection and chronic rejection. Due to chronic rejection belongs to the complication long-term, it will be introduce sooner. l Acute rejection The acute cellular rejection (ACR) as the frequency rejection after the liver transplantation, and showed incidence of 10-30% in recipients during the first month after liver transplantation35. ACR is generally associated with the high-level of hepatic enzymes (such as: serum aminotransferases, alkaline phosphatase, gamma-glutamyl transpeptidase) and/or bilirubin, especially the gamma-glutamyl transpeptidase (GGT). Moreover, for the younger patient (age<40 years) and the recipient of LT without renal dysfunction, have the ACR with high possible. But it just can be achieved only with histologic analysis of a liver biopsy353637. l Infection complication 40 Infections continue to be one of the main complications that can contribute to the recipient’s death during the first year26. There are series source of the infecting, such as the donor organ, transfused blood products and the reactivation of previous infection et.al. The most common is the bacterial infections. For the viral infections, the source of infecting are cytomegalovirus, Epstein-Barr virus, herpesvirus, hepatitis-B and hepatitis-C virus. Without doubt, Fungal also is one of the source of infecting. But the incidence of fungal is not high, most of these episodes were caused by Candida or Aspergillus3839. l Respiratory complication The lung is one mainly organ, in order of frequency, that presents greater infectious problems in the immediate postoperative period of OLT. The complications such as pneumonia and acute respiratory distress syndrome (ARDS) are associated with higher mortality rates despite advanced diagnosis and treatment options. Among those with pneumonia and acute respiratory failure, mortality rates were 43.75% and 50%, respectively40. Pulmonary effusion also occurs frequently with the mortality rates were 35.7%, in most cases, caused by intraoperative diaphragmatic manipulation. Pulmonary effusion has associated with the higher MELD scores. On the other hand, Several preoperative factors combined with a high MELD increase the incidence of respiratory failure postoperative, such factors as: perioperative blood transfusion, fluid retention, severe restrictive lung patterns, and muscle atrophy related to poor nutritional status41. l Neurological complication The neurological complications in the OLT are frequent, during the postoperative period varies widely from 10 to 42%. The most common CNS complications are confusion, seizures, posterior leuco-encephalopathy syndrome and the neurotoxic 41 side-effects of immunosuppressive drugs. Neurological complications are a significant cause of morbidity and mortality in patients who undergo liver transplantation, which in some series reach a mortality rate is close to 50%. They may happened immediately after the operation of OLT or later (a month, three o four months)424344. Long-term complication l Chronic rejection Pathogenesis of CR is not well characterized. The pathogenesis of CR is multifactorial and includes vascular occlusion, antibodies and cell mediated pathways. Pathophysiology of CR is not entirely clear but immune mechanisms are involved as changes of CR does not appear in isografts and sometimes it is extension and result of ACR35. With the improvement in immunosuppression regimen, it has been achieved to reduce the frequency of episodes of acute rejection, as well as the consequent beneficial effect on CR control. In some series, chronic rejection currently occurs in less than 5% of transplants45. l Renal dysfunction Renal dysfunction (acute o chronic) is one important complication after LT, and it occurs in 17-95% of patients46. The alteration of renal function can affect directly morbidity and mortality. There are approximate 10-20% patients after LT occur renal dysfunction in the medium or long-term. It is close to 20% that the patients occur chronic renal dysfunction after OLT 5-10 years47. Some research present many preoperative factors may favour the occurrence of renal dysfunction after OLT, such as preoperative renal dysfunction, hepatorenal syndrome (HRS), pre-OLT low serum 48 The mainly way to diagnosis lung cancer is chest radiograph, obviously, there are some others technique can help us to discriminate lung cancer, like CT image and biopsy. Same to HCC, in the TNM stage, T means size of primary tumor, N means node and M means metastasis to other organ60. Stage TNM: Tx : Tumor cells present in sputum or bronchial washing, but tumor not seen with imaging or bronchoscopy T0 : No evidence of primary tumor Tis : Carcinoma in situ T1 : Tumor size less than or equal to 3 cm across, surrounded by lung or visceral pleura, without invasion proximal to the lobar bronchus T1mi : Minimally invasive adenocarcinoma T1a : Tumor size ≤ 1 cm T1b : Tumor size > 1 cm, but ≤ 2 cm T1c : Tumor size > 2 cm but ≤ 3 cm T2 : Any of: Tumor size> 3 cm but ≤ 5 cm; Involvement of the main bronchus but not the carina; Invasion of visceral pleura; Atelectasis or obstructive pneumonitis extending to the hilum T2a : Tumor size > 3 cm but ≤ 4 cm T2b : Tumor size > 4 cm but ≤ 5 cm T3 : Any of: Tumor size > 5 cm but ≤ 7 cm; Invasion into the chest wall, phrenic nerve, or parietal pericardium; Separate tumor nodule in the same lobe T4 : Any of: Tumor size > 7 cm; Invasion of the diaphragm, mediastinum, heart, great vessels, trachea, carina, recurrent laryngeal nerve, esophagus, or vertebral body or Separate tumor nodule in a different lobe of the same lung NX : Regional lymph nodes cannot be assessed N0 : No regional lymph node metastasis 49 N1 : Metastasis to ipsilateral peribronchial and/or hilar lymph nodes N1a : Metastasis to a single N1 nodal station N1b : Metastasis to two or more N1 nodal stations N2 : Metastasis to ipsilateral mediastinal and/or subcarinal lymph nodes N2a1 : Metastasis to one N2 nodal station with no involvement of N1 nodes N2a2 : Metastasis to one N2 nodal station and at least one N1 nodal station N2b : Metastasis to two or more N2 nodal stations N3 : Any of : Metastasis to scalene or supraclavicular lymph nodes or Metastasis to contralateral hilar or mediastinal lymph nodes MX : Distant metastasis cannot be assessed M0 : No distant metastasis M1a : Any of : Separate tumor nodule in the other lung, Tumor with pleural or pericardial nodules or Malignant pleural or pericardial effusion M1b: A single metastasis outside the chest M1c: Two or more metastases outside the chest Tab. 1.5: Stage I-IV of lung cancer Treatment for lung cancer depends on the cancer's specific cell type, how far it has spread, and the person's performance status. Common treatments include palliative care, surgery, chemotherapy, and radiation therapy. 50 The lung cancer five-year survival rate is 18.6% and the five-year survival rate for lung cancer is 56% for cases detected when the disease is still localized (within the lungs). Only 16% of lung cancer cases are diagnosed at an early stage. For distant tumors (spread to other organs) the five-year survival rate is only 5%. More than half of people with lung cancer die within one year of being diagnosed. 1.5.3. Colorectal cancer Colorectal cancer (CRC) is the development of cancer from the colon or rectum (parts of the large intestine). A cancer is the abnormal growth of cells that have the ability to invade or spread to other parts of the body. More than 75–95% of colorectal cancer occurs in people with little or no genetic risk. Risk factors include advanced age, male sex, high intake of fat, sugar, alcohol, red meat, processed meats, obesity, smoking, and a lack of physical exercise6162. Colorectal cancer diagnosis is performed by sampling of areas of the colon suspicious for possible tumor development, typically during colonoscopy or sigmoidoscopy, depending on the location of the lesion61. It is confirmed by microscopical examination of a tissue sample. Stage is typically made according to the TNM staging system from the WHO organization. TX : The primary tumor cannot be evaluated. T0 : No evidence of cancer in the colon or rectum. 51 Tis : carcinoma in situ (also called cancer in situ). Cancer cells are found only in the epithelium or lamina propria, which are the top layers lining the inside of the colon or rectum. T1 : The tumor has grown into the submucosa, which is the layer of tissue underneath the mucosa or lining of the colon. T2 : The tumor has grown into the muscularis propria, a deeper, thick layer of muscle that contracts to force along the contents of the intestines. T3 : The tumor has grown through the muscularis propria and into the subserosa, which is a thin layer of connective tissue beneath the outer layer of some parts of the large intestine, or it has grown into tissues surrounding the colon or rectum. T4a : The tumor has grown into the surface of the visceral peritoneum, which means it has grown through all layers of the colon. T4b : The tumor has grown into or has attached to other organs or structures. NX : The regional lymph nodes cannot be evaluated. N0 : No spread to regional lymph nodes. N1a : There are tumor cells found in 1 regional lymph node. N1b : There are tumor cells found in 2 or 3 regional lymph nodes. N1c : There are nodules made up of tumor cells found in the structures near the colon that do not appear to be lymph nodes. N2a : There are tumor cells found in 4 to 6 regional lymph nodes. N2b : There are tumor cells found in 7 or more regional lymph nodes. M0 : The disease has not spread to a distant part of the body. M1a : The cancer has spread to 1 other part of the body beyond the colon or rectum. M1b : The cancer has spread to more than 1 part of the body other than the colon or rectum. M1c : The cancer has spread to the peritoneal surface. 52 Stage I-IV of colorectal cancer is complicated. ( Tab. 1.6) Tab. 1.6: Stage I-IV of colorectal cancer In general, the treatment of colorectal cancer is cure or palliation. However, the decision on which aim to adopt depends on factors, including the health situation of patient, preferences and the stage of the tumor. When colorectal cancer is early stage, surgery can be curative. However, when it is detected at later stages (metastases are present), the treatment is usually directed at palliation, to relieve symptoms caused by the tumor and keep the person as comfortable as possible6163. According stage TNM, without N or M(N0 and M0): The colon cancer five-year survival rate is 90% and the five-year survival rate for rectal cancer is 89%; without M or written M0: The colon cancer five-year survival rate is 71% and the five-year survival rate for rectal cancer is 70%; once the situation of tumor reach to late stage (M1), the five-year survival rate reduce to 14%(colon cancer) and 15%(rectal cancer)64. 53 1.5.4. Kidney cancer The kidney cancer, or named renal cancer is the abnormal cell of kidney growth without limited, and affect renal function. Commonly, the causes of kidney cancer include smoking, obesity, faulty genes, family history with kidney cancer, with kidney disease and need dialysis, being infected with hepatitis C and previous treatment for testicular cancer or cervical cancer. Obviously, there are other cause, like kidney stone and artery hypertension et. al. that are researching. According the pathophysiology and the tumor location, kidney cancer can be divide a several type. The most commonly types are renal cell carcinoma (RCC) and transitional cell carcinoma (TCC, also named urothelial carcinoma). Normally, blood and urine tests, biopsy and imagen tests (CT, X-Ray, MRI, IVP and Cystoscopy and nephro-ureteroscopy) are the way to diagnosis kidney cancer. In additional, the different type of kidney cancer develop with different way, that means there are different long-term outcomes. So, needs to make different treatment depend the stage and the type65. Stage TNM TX : The primary tumor cannot be evaluated. T0 : No evidence of a primary tumor. T1 : The tumor is found only in the kidney and ≤ 7 cm at its largest area. There has been much discussion among doctors about whether this classification should only include a tumor that ≤ 5 cm. T1a : The tumor is found only in the kidney and ≤ 4 cm at its largest area. T1b : The tumor is found only in the kidney and 4-7 cm at its largest area. T2 : The tumor is found only in the kidney and > 7 cm at its largest area. T2a : The tumor is only in the kidney and is > 7 cm but ≤ 10 cm at its largest area. 54 T2b : The tumor is only in the kidney and is > 10 cm at its largest area. T3 : The tumor has grown into major veins within the kidney or perinephric tissue, which is the connective, fatty tissue around the kidneys. However, it has not grown into the adrenal gland on the same side of the body as the tumor. The adrenal glands are located on top of each kidney and produce hormones and adrenaline to help control heart rate, blood pressure, and other bodily functions. In addition, the tumor has not spread beyond Gerota's fascia, an envelope of tissue that surrounds the kidney. T3a : The tumor has spread to the large vein leading out of the kidney, called the renal vein, or the branches of the renal vein; the fat surrounding and/or inside the kidney; or the pelvis and calyces of the kidney, which collect urine before sending it to the bladder. The tumor has not grown beyond Gerota's fascia. T3b : The tumor has grown into the large vein that drains into the heart, called the inferior vena cava, below the diaphragm. The diaphragm is the muscle under the lungs that helps breathing. T3c : The tumor has spread to the vena cava above the diaphragm and into the right atrium of the heart or to the walls of the vena cava. T4 : The tumor has spread to areas beyond Gerota's fascia and extends into the adrenal gland on the same side of the body as the tumor. NX : The regional lymph nodes cannot be evaluated. N0 : The cancer has not spread to the regional lymph nodes. N1 : The cancer has spread to regional lymph nodes. M0 : The disease has not metastasized. M1 : The cancer has spread to other parts of the body beyond the kidney area. 55 Tab.1.7: Stage I-IV of kidney cancer Surgery is the most common treatment as kidney cancer does not often respond to chemotherapy and radiotherapy. It usually be removed by surgery, if the cancer without metastasis. In some special cases, may remove the whole kidney. However most tumors are amenable to partial removal to eradicate the tumor and preserve the remaining normal portion of the kidney. If the cancer cannot be treated with surgery, other techniques such as freezing the tumor or treating it with high temperatures may be used. Certainly there are some new treatment opinion with the technique developed, like biological therapies and immunotherapy66. Although the new technique developed fast, but the survival rate of end-stage also lower (Tab.1.8). Tab.1.8: Survival rate of kidney cancer 56 1.5.5. Prostate cancer The prostate is a little-sized gland with peculiar of male, and the main function is making seminal fluid. With the men get older, prostate increase it’s size and lead benign prostatic hypertrophy(BPH). BPH is a common in old male people and the symptoms likes the cancer. In fact, BPH is not related with prostate cancer. The prostate cancer is not clear symptoms in early stage. However, there are several symptoms that are similar with BHP caused by prostate cancer, such as, frequent urination, nocturia, difficulty starting and maintaining a steady stream of urine, hematuria, and dysuria67. As known, obesity, age and family history are the major risk factors caused prostate cancer. The morbidity of prostate cancer is variational rate that is increasing with the age get older. It’s uncommon to see a patient who has been diagnosis prostate cancer under 45 years old. The age of diagnosis is approximately 75 years old. The main method of diagnosis are digital rectal examination (DRE), cystoscopy, transrectal ultrasonography and tumor marker (PSA), but the most important method to diagnosis and confirmation the cancer is biopsy68. Obviously, for make the treatment regimen, know stage of cancer is necessary. Due to the DRE and PSA can make sure that the cancer is activity, there are several different stage to describe prostate cancer such as Stage TNM, Gleason score and Stage groping69(Tab. 1.9). Stage TNM Clinical T TX: The primary tumor cannot be evaluated. T0: There is no evidence of a tumor in the prostate. 57 T1: The tumor cannot be felt during a DRE and is not seen during imaging tests. It may be found when surgery is done for another reason, usually for BPH or an abnormal growth of noncancerous prostate cells. T1a: The tumor is in 5% or less of the prostate tissue removed during surgery. T1b: The tumor is in more than 5% of the prostate tissue removed during surgery. T1c: The tumor is found during a needle biopsy, usually because the patient has an elevated PSA level. T2: The tumor is found only in the prostate, not other parts of the body. It is large enough to be felt during a DRE. T2a: The tumor involves one-half of 1 side of the prostate. T2b: The tumor involves more than one-half of 1 side of the prostate but not both sides. T2c: The tumor has grown into both sides of the prostate. T3: The tumor has grown through the prostate on 1 side and into the tissue just outside the prostate. T3a: The tumor has grown through the prostate either on 1 or both sides of the prostate. This called extraprostatic extension (EPE). T3b: The tumor has grown into the seminal vesicle(s), the tube(s) that carry semen. T4: The tumor is fixed, or it is growing into nearby structures other than the seminal vesicles, such as the external sphincter, the part of the muscle layer that helps to control urination; the rectum; the bladder; levator muscles; or the pelvic wall. Pathological T (there is not TX, T0 and T1 in pathological T) T2: The tumor is found only in the prostate. T3: There is EPE. The tumor has grown through the prostate on 1 or both sides of the prostate. T3a: There is EPE or the tumor has invaded the neck of the bladder. T3b: The tumor has grown into the seminal vesicle(s). 64 growth.18 Moreover, cyclosporine interferes with DNA repair among in vitro cultured white blood cells from renal transplant recipients76. 1.6.2. Mycophenolate-mofetil Mycophenolate-mofetil (MMF) is an immunosuppressive agent used to prevent rejection in organ transplantation. Discovered by Italian medical scientist Bartolomeo Gosio in 1893, mycophenolic acid was the first antibiotic to be synthesised in pure and crystalline form. MMF was approved by the FDA in 1995. Mechanism of action MMF was the observations that suggested that the de novo pathway of purine synthesis, and not the recovery pathway, was crucial for the proliferative response of human T and B lymphocytes. Mycophenolate mofetil (MMF) undergo immediate first-pass metabolism in the liver into the active compound mycophenolic acid (MPA). MPA inhibits inosine-5'- monophosphate dehydrogenase (IMPDH). IMPDH inhibition particularly affects lymphocytes since they rely almost exclusively on de novo purine synthesis. Clinical use In general, it has been used mainly associated with anti-calcineurin or as a drug to be added in case of toxicity to CyA or tacrolimus given the need to reduce the dose of these due to the side effects they cause73. 65 It has also been observed that the use of MMF has a beneficial effect in the prevention of chronic graft nephropathy, which is in part independent of the reduction of the acute or chronic rejection rate. Adverse effects Because of the mechanism of action, it alters other types of dividing cells, so fundamentally its side effects include gastrointestinal disorders, spinal toxicity and to a lesser extent opportunistic infections and respiratory tract disorders. First, the digestive disorders include diarrhea, nausea, vomiting and joint pain. These usually involve the suppression of treatment in only 5% of cases. Opportunistic infections: All transplant patients are at the situation that increasing risk of opportunistic infections, the most common in patients treated with MMF (2 or 3 g / day, but patients may tolerate the drug better if started at 500mg twice a day or four times a day73.) in OLT are fungal (mainly Candida) and viral (viremia / CMV disease and Herpes simplex). Unlike other immunosuppressive agents used in the OLT, no clinically significant adverse effects have been found as a direct consequence of the use of MMF such as nephrotoxicity, hepatotoxicity. 1.6.3. mTORi Sirolimus, or called rapamycin, is a macrolide compound, and it is produced by the bacterium Streptomyces hygroscopicus and was isolated for the first time in 1972 by Surendra Nath Sehgal and colleagues from samples of Streptomyces hygroscopicus 66 found on Easter Island77, where it received its initial name. Sirolimus was initially developed as an antifungal agent in 1975, later demonstrating its immunosuppressive activity in vitro. However, this use was abandoned when it was discovered to have potent immunosuppressive and antiproliferative properties due to its ability to inhibit mTOR. In recent years, there is other inhibitor was developed with the similar mechanism of sirolimus, called Everolimus that is the 40-O-(2-hydroxyethyl) derivative of sirolimus and works similarly to sirolimus as an inhibitor of mammalian target of rapamycin (mTOR). Mechanism action of mTORi This therapeutic group has also been called Proliferation Signal Inhibitors (ISP) and has some advantages over classical immunosuppressants that have aroused great interest. It acts through blocking signal 3 of cell activation from IL-2 receptors in T-cells and B-cells. Interestingly, despite binding to the same cell receptor, sirolimus and tacrolimus do not compete with each other and act synergistically70. The mTOR protein forms two structurally and functionally distinct complexes, mTORC1 and mTORC2, both of which play different roles downstream. mTORC1 is activated by growth factors, amino acids and controls of cell proliferation, promoting processes such as DNA translation, RNA transcription, ribosomal biogenesis, and cell cycle progression7778. Because the antiproliferative effects, it is useful in the artery of chronic rejection. In addition to blocking the cell cycle progression induced by IL-2, it facilitates apoptosis, acting synergistically with the blocking of the costimulatory signal in the reduction of alloreactive lymphocytes, which also differentiates it from anti-calcineurins, which block apoptosis. This is relevant because apoptosis has been related to the development of allograft tolerance mechanisms. 67 1.6.3.1. Pharmacokinetics of Sirolimus Absorption Sirolimus is absorbed quickly that means whole-blood sirolimus concentrations (Cmax) occur 1 hour after administration of single doses and 2 hours after multiple doses in stable renal transplant patients, The bioavailability of sirolimus is 14%. Coadministration with fatty foods delays the rate of absorption, in this way the Cmax decreases by 34%, the tmax increases 3.5 times, and the area under the curve of plasma concentrations vs. Time (AUC) is also increased by 35% when compared to the values obtained in fasting79. Metabolism Sirolimus undergoes extensive oxidative metabolism at the liver level, after incubation with human liver ,icrosomes to yield multiple demethylation and hydroxylation reactions. It originates a large number of metabolites, and in appearance these partially preserve the activity of the original molecule79. Excretion According to the result of the health volunteers intake labeled sirolimus with single oral dose, The excretion is mostly fecal (91.1%), with urinary elimination being low (2.2%). After the administration of multiple doses to kidney transplant patients, the elimination half-life (t1 / 2) was 62 hours and mean oral-dose clearance (Cl / F) 210 ml / h / kg79. 68 1.6.3.2. Pharmacokinetics of Everolimus Absorption The oral bioavailability of everolimus is 16%, little higher than sirolimus. Everolimus reaches the maximum concentration after 1 or 2 hours after intake with oral administration. Based on the ratio of areas under the concentration / time curve (AUC ratio), the relative bioavailability of the dispersible tablet versus the conventional tablet is 0.90 (90% CI 0.76 - 1.07)80. Distribution The blood / plasma rate of everolimus depends on the concentration. The binding to plasma proteins is approximately 74% in healthy individuals and in patients with moderate hepatic insufficiency. Metabolism Everolimus is one of the substrates of CYP3A4 and P-glycoprotein. The main metabolic pathways identified in humans are monohydroxylations and 0-dealkylations. Two major metabolites are formed by hydrolysis of the cyclic lactone. Everolimus is the predominant form in blood circulation. None of the major metabolites contribute significantly to the immunosuppressive activity of everolimus81. Excretion Same to the experimentation of Sirolimus. After the administration of a single dose of radioactive everolimus to patients treated with ciclosporin after transplantation, most of the radioactivity (80%) was found in the faeces and only a small proportion (5%) in the urine82. And researcher undetected the original compound in urine and faeces. 69 1.6.3.3. Adverse effects The main side effect is hyperlipidemia, present in approximately 44% of patients, a higher percentage than other immunosuppressive drugs. The presence of thrombopenia and leukopenia is also very frequent, although both are reversible in 90% of cases83. Some studies have shown a higher survival of the graft while others have described a relative myelosuppression. mTORi is regulated in eukaryotic cells by the PI3K / Akt metabolic pathway. Those cells with a mutation in the PTEN and PI3K genes present a release of the control of this pathway, so that the inhibition of mTOR would act effectively in the neoplastic control. It should be noted that there is an initial work that describes an increased risk of arterial thrombosis in patients who received sirolimus, although this finding has not been reproduced in other studies82. Use of these drugs in liver transplantation for malignancies (hepatocellular carcinoma, cholangiocarcinoma, neuroendocrine tumors metastatic), malignant tumors de novo (cutaneous carcinomas, gastric cancer, breast cancer, etc), renal failure associated with CNI, previous renal failure that does not improve after transplantation and immunosuppression in patients with acute or chronic corticoresistant rejection84. The potential risks of mTOR inhibitors, including hypercholesterolemia, thrombosis and problems in wound healing, have also been highlighted in this population segment. No controlled study has examined these critical endpoints in the OLT setting. 70 1.6.3.4. mTORi in the field of oncology The incidence of de novo neoplasia that occur after OLT is higher than that of malignant tumors developed in the general population, because of the recipient must administration immunosuppressive agent for lifelong85. Immunosuppressive therapy decreases the immune response against malignant cells and against a large variety of viruses with oncogenic properties. Likewise, it has been described in a recently published randomized trial that cirrhotic patients of enolic origin had a much higher risk of non-hepatic neoplasia in the case of having been transplanted, in contrast to those who did not receive a transplant and followed a treatment standard for their pathology (at 5 years, the risk of neoplasia was 37% versus 6%). This increased risk is especially high in neoplasms related to viral infections, such as non-Hodgkin's lymphoma, Kaposi's sarcoma and cervical cancer. The risk of skin cancer is also greatly increased in these patients8687. The incidence of other common cancers seems to be increased too, but this risk is not high. Some studies shown that the incidence of colorectal, lung, head and neck, urological, and hepatocellular carcinomas increases after receiving lifelong immunosuppressive therapy888990. In some cases, the cause of this increased risk may be a specific association between certain causes of liver disease and risk factors for the development of certain types of neoplasia in the general population: there is an association between primary sclerosing cholangitis and ulcerative colitis, which markedly increases the risk of colorectal cancer. In patients with alcoholic liver disease, the risk of esophageal cancer and cancer of the head and neck is increased of tumors diagnosed most frequently in patients posttransplant. And it may have the association with high alcohol intaking and smoking, which is a very important risk factor for some patients. 71 mTOR, a protein of the group of kinases, is involved in cellular metabolic regulation PI3K / Akt. Its activation, in response to growth, nutrient and energy signals, leads to an increase in the synthesis of proteins necessary for the development and growth of tumors. This feature makes mTOR an important target for cancer therapy77. The first generation of mTORi, sirolimus and its derivatives, everolimus have been widely evaluated in patients with cancer. On the other hand, the second generation mTORi, small molecules with action in the field of kinases, are also in full clinical development. Clinical trials are under way to identify additional malignancies that respond to mTORi, either in single or combined therapy. Future research should evaluate the most appropriate terpeutic regimes as well as target populations. Same to all immunosuppressive agents, the sirolimus also decreases the antioncogenic activity of the organism and allows the proliferation of some cancers which would normally be destroyed. Immunosuppressed patients have a cancer risk 10 to 100 times higher than the general population. In addition, patients who currently have or have been treated for cancer, develop a higher rate of tumor progression as well as recurrence in relation to patients with an intact immune system909192. 1.6.3.4.1. Hepatocellular carcinoma recurrence HCC is the most common in primary liver cancer with(70-85%), and it had been the third most frequent cause of death-related-cancer in the world93. As we know, liver transplantation is the ultimate treatment of end-stage HCC. Due to against reaction rejection of organ, from AZA to CNIs, and to mTORi, many regimens were be chosen for reduce the complications post-LT to lower. As mentioned above, mTORi has been used as anticancer drug. The exact mechanism for this increased risk is unknown, although preclinical data suggest that CNIs may actually promote tumor growth. In contrast, other data suggest 72 that immunosuppression regimens that include rapamycin (sirolimus) or its analogs reduce the risk of HCC recurrence as well as the development of de novo malignancies after orthotopic liver transplantation, while successfully avoiding allograft rejection and improving overall survival93. The rate of HCC recurrence post-LT is between 13-27%. A meta-analysis indicated the risk factors on pre-transplant risk for HCC recurrence showed significant correlations for the presence of vascular invasion, level of differentiation, tumor size, and tumor stage outside the Milan criteria. As vascular invasion and a tumor size >5 cm are included in a tumor stage considered exceeding the Milan criteria, the only risk factor identified within this meta-analysis for patients with a tumor stage within the Milan criteria was a moderate or poorly differentiated HCC94. Theoretically, HCC recurrence can use all modalities for treating HCC. However, HCC recurrence after LT is considered a “systemic disease”, and the efficacy of locoregional treatment for a systemic disease is doubtful. Because for the recipient, use immunosuppressive agent can affect wound healing and increace the rate of infection. And the operation of liver transplantation may damage or change the structures of vascular in anatomy. Due to these reasons, it may be difficult in interventional radiological procedures like TACE. So, some studies present a new treatment for intrahepatic recurrent, High-intensity focused ultrasound (HIFU) ablation. And on the other hand, change the inhibitor non-mTORi to mTORi is a regimen can be used95. 1.6.3.4.2. De novo neoplasia Due to the more prolonged exposure to immunosuppression is associated with an increased frequency of developing neoplasms, the rate of De novo neoplasia almost reached 30% at 10 years in patient after liver transplantation and it is the most common cause to death in 1-year of recipient after liver transplantation. Compare with general 73 population, same level of the age and gender, there are 2-4 times higher of risk to occur malignancy96. De novo malignancy after liver transplantation has become a major source of morbidity and mortality97. As mentioned above, used inhibitor is the most important factor that can increase risk to occur malignancy. Obviously, there are the association factors with cancer risk such as: age, gender, race, alcohol intake, smoking and history of cancer et.al.91 Age: Advanced age as a risk factor for almost all disease, as the well described risk factor for de novo neoplasia after LT. This suggests that other factors may supersede age in cancer risk, though some caveats are notable with the extremes of age. A study reported, LT recipients older than 60 years had > 2 times higher 5-year incidence of new cancers (> 40%) compared to younger LT recipients (< 20%), with significantly higher cancer related mortality91. Gender and race: There is conflicting data on the relative risk of de novo malignancy according to gender, with slightly higher sirolimus of cancers in females in one registry study, and in males in another, limiting any meaningful conclusion. A study indicate that Non-Caucasian race was associated with a significantly increased risk of de novo malignancy, but the small size of that subgroup was limiting9192. Indication for LT: Patients who receive LT and conform to one of indications are more prone to occur malignancies. There are some research of multicenter in USA discovered that the patient with primary sclerosing cholangitis exhibited an increased risk for lymphoproliferative disorder (PTLD), skin malignancies and solid organ malignancies. And the highest cumulative incidence of non-skin cancer of 5.5%, 10.4%, and 21.9% at 1, 5, and 10 years, respectively. 80 N2c: Cancer has spread to more than 1 lymph node on either side of the body, and none measures larger than 6 cm. There is no ENE. N3a: The cancer is found in a lymph node and is larger than 6 cm. There is no ENE. N3b: There is ENE in any lymph node. M: M0: Cancer has not spread to other parts of the body. M1: Cancer has spread to other parts of the body. Tab. 1.10: Stage Group (I-IV) For the patient of LT, the diagnosis is same to general population. Usually used imagen test such as X-Ray, CT and MRI; endoscopy and biopsy also are the test diagnosis for oropharyngeal cancer107. Depend the stage, the regimen of therapy can be chosen surgical, radiation therapy o expectant therapy. The survival rate of oropharyngeal cancer is not bad that the rate of 5-years is 66.67% and 10-years is 44.44%.108 81 l Esophageal and gastric cancer Although their incidence is increased with respect to the general population, gastric and esophageal cancers are reported infrequently in most series of LT recipients96. Esophageal cancer following liver transplant is closely associated with history of alcohol intake and smoking chewing109. The factor risk of gastric cancer mainly is prolong time using immunosuppressive agent. Stage TNM of gastric cancer TX: The primary tumor cannot be evaluated. T0: There is no evidence of a primary tumor in the stomach. Tis: This stage describes a condition called carcinoma (cancer) in situ. The cancer is found only in cells on the surface of the inner lining of the stomach called the epithelium and has not spread to any other layers of the stomach. T1: The tumor has grown into the lamina propria, muscularis mucosae, or the submucosa, which are the inner layers of the wall of the stomach. T1a: The tumor has grown into the lamina propria or muscularis mucosae. T1b: The tumor has grown into the submucosa. T2: The tumor has grown into the muscularis propria, the muscle layer of the stomach. T3: The tumor has grown through all of the layers of the muscle into the connective tissue outside the stomach. It has not grown into the lining of the abdomen, called the peritoneal lining, or into the serosa, which is the outer layer of the stomach. T4: The tumor has grown through all of the layers of the muscle into the connective tissue outside the stomach. It has also grown into the peritoneal lining or serosa or the organs surrounding the stomach. T4a: The tumor has grown into the serosa. T4b: The tumor has grown into organs surrounding the stomach. 82 NX: Regional lymph nodes cannot be evaluated. N0: The cancer has not spread to the regional lymph nodes. N1: The cancer has spread to 1 to 2 regional lymph nodes. N2: The cancer has spread to 3 to 6 regional lymph nodes. N3: The cancer has spread to 7 or more regional lymph nodes. N3a: The cancer has spread to 7 to 15 regional lymph nodes. N3b: The cancer has spread to 16 or more regional lymph nodes. MX: Distant metastasis cannot be evaluated. M0: The cancer has not spread to other parts of the body. M1: The cancer has spread to another part or parts of the body. About stage group, stage 0 (Tis N0 M0); stage IA (T1 N0 M0); stage IB(T1 N1 M0), (T2 N0 M0); stage IIA (T1 N2 M0), (T2 N1 M0), (T3 N0 M0); stage IIB (T1 N3a M0), (T2 N2 M0), (T3 N1 M0), (T4b N0 M0); stage IIIA (T2 N3a M0), (T3 N2 M0), (T4a N1 M0), (T4b N0 M0); stage IIIB (T1 or T2 N3b M0), (T3 N3a M0), (T4a N3a M0), (T4b N1 or N1 M0); stage IIIC (T3 or T4a N3b M0), (T4b N3a or N3b M0); stage IV (any T or N, M1) Stage TNM and stage group of esophageal cancer110 T, N, and M status, histologic grade and stage group definitions for esophagus and esophagogastric junction cancer in the 7th edition of the American Joint Committee on Cancer Staging Manual 83 Tab. 1.11: TNM stage of Gastric cancer Tab. 1.12: Stage group of Gastric cancer Depend the stage, tumor location and situation of patient, therapy options include local mucosal resection or ablation therapies, esophagectomy, chemotherapy, and radiation therapy110. For gastric cancer, also can use regimen of therapy by surgical, chemotherapy and radiation therapy111. The survival of novo esophageal cancer is not high, with a mortality (combined for esophageal and gastric cancer of 62.5%) being second only to that of lung cancer96. 84 l Others novo neoplasia Although it seems that breast cancer is no more frequent in LT compared to the general population, however, other studies have evidence that breast cancer incidence is in fact elevated in the transplant population, with the advantage, however, that early detection is more common, and this has also resulted in decreased mortality compared to that of the general population upon similar diagnose. The stage of breast cancer is complicated, including stage TNM and stage group96,112. TX: The primary tumor cannot be evaluated. T0: There is no evidence of cancer in the breast. Tis: Refers to carcinoma in situ. The cancer is confined within the ducts or lobules of the breast tissue and has not spread into the surrounding tissue of the breast. There are 2 types of breast carcinoma in situ: Tis (DCIS): DCIS is a noninvasive cancer, but if not removed it may develop into an invasive breast cancer later. DCIS means that cancer cells have been found in breast ducts and have not spread past the layer of tissue where they began. Tis (Paget’s): Paget’s disease of the nipple is a rare form of early, noninvasive cancer that is only in the skin cells of the nipple. Sometimes Paget’s disease is associated with another, invasive breast cancer. If there is another invasive breast cancer, it is classified according to the stage of the invasive tumor. T1: The tumor in the breast is 20 mm or smaller in size at its widest area. This is a little less than an inch. This stage is then broken into 4 substages depending on the size of the tumor: T1mi is a tumor that is 1 mm or smaller T1a is a tumor that is larger than 1 mm but 5 mm or smaller T1b is a tumor that is larger than 5 mm but 10 mm or smaller T1c is a tumor that is larger than 10 mm but 20 mm or smaller 85 T2: The tumor is larger than 20 mm but not larger than 50 mm. T3: The tumor is larger than 50 mm. T4: The tumor falls into 1 of the following groups: T4a means the tumor has grown into the chest wall. T4b is when the tumor has grown into the skin. T4c is cancer that has grown into the chest wall and the skin. T4d is inflammatory breast cancer. NX: The lymph nodes were not evaluated. N0: Either of the following: No cancer was found in the lymph nodes. Only areas of cancer smaller than 0.2 mm are in the lymph nodes. N1: The cancer has spread to 1 to 3 axillary lymph nodes and/or the internal mammary lymph nodes. N2: The cancer has spread to 4 to 9 axillary lymph nodes. Or it has spread to the internal mammary lymph nodes, but not the axillary lymph nodes. N3: The cancer has spread to 10 or more axillary lymph nodes. Or it has spread to the lymph nodes located under the clavicle, or collarbone. It may have also spread to the internal mammary lymph nodes. Cancer that has spread to the lymph nodes above the clavicle, called the supraclavicular lymph nodes, is also described as N3. MX: Distant spread cannot be evaluated. M0: The disease has not metastasized. M0 (i+): There is no clinical or radiographic evidence of distant metastases. Microscopic evidence of tumor cells is found in the blood, bone marrow, or other lymph nodes that are no larger than 0.2 mm. M1: There is evidence of metastasis to another part of the body, meaning there are breast cancer cells growing in other organs. 86 Tab. 1.13: Stage group of Breast cancer Due to the mentioned above, the stage TNM and stage group of kidney cancer and prostate cancer are not more detailed description. The incidence of prostate cancer does not seem to be increased in LT recipients, but the other genitourinary cancers (especially the renal cancer) seem to be higher than that of the general population. Mean time to diagnosis of non-prostate genitourinary cancer ranges from 20 to 55.3 months, while in cases of prostate cancer the diagnosis is often performed between 5.8 and 18.4 months after LT. In LT recipients, prostate cancer is more often diagnosed at earlier stages and has a good prognosis, whereas renal and bladder cancers have a poor prognosis96. 87 2. HYPOTHESIS 88 89 2. Hypothesis l The use of mTORi in patients with liver transplantation caused by HCC reduces the incidence of recurrence and increases the survival rate. l The use of mTORi in the patient after liver transplantation with de novo neoplasia reduces the incidence of recurrence and increasing the survival rate. 96 97 4. Methods Clinical study with liver transplant recipients operated between 1990 and 2017 because of HCC or liver transplants recipients with “de novo” neoplasia. The methodology of the work has followed the order of the hypotheses and objectives of the same. l To analyze if the use of mTORi in the patient with liver transplantation caused by HCC reduces the incidence of recurrence of HCC and increase the survival rate. l To analyze if the use of mTORi in the patient with liver transplantation and “de novo” neoplasia reduces the incidence of recurrence and increase the survival rate. This was an observational, retrospective cohort study, using a sample of patients drawn from all 1273 liver transplant patients at the Virgen del Rocío Hospital between March 1990 and July 2017. Of these, 433 patients were selected. Tab. 4.1. The patients selection The patients' data were conformed to analysis (n=392) The patients with HCC recurrent(n=247) The patients with de novo neoplasia(n=171) The patients were conformed the conditions inclusion (n=433) The patient died cause by posttransplantation(n=41) The patients were living after transplantation(n=392) All patients with OLT between 1990 and 2017 en HBPT (n= 1273) 98 The table 1. describes how to conformed the patients and the types of patients for analysis. The patients conformed the conditions inclusion were 433. More than 90% of these patients were selected. 41 patients died post-transplantation, so were excluded. In these 392 patients, 247 patients were diagnosis with HCC and recurrent HCC. And there are 171 patients with de novo neoplasia. About patients In the tables below is shown the distribution of patients Gender of patients Gender Frequency Percentage Male 371 85.70% Female 62 14.30% The male patients were 6 times of female patients, it may caused because of alcohol intaking and smoke usually happens in the population male. Gender of patients whit HCC and de novo neoplasia(NN) Gender Frequency(HCC) Percentage(HCC) Frequency(NN) Percentage(NN) Male 211 85.40% 148 86.55% Female 36 14.60% 23 13.45% Total 247 100% 171 100% Tab. 4.2. and Table 4.3. The distribution of gender of patients 99 Without the patients exclusion, the proportion of male/female in the patients with HCC and the patients de novo neoplasia are almost same that the male patients are 7 times of female. And the p > 0,05. Cirrhosis etiology Type Frequency Percentage Alcoholic Cirrhosis 245 56.60% CHVC 93 21.46% CHVB 57 13.16% Others 38 8.78% Total 433 100% Cirrhosis etiology of patients with HCC and the patients with de novo neoplasia(NN) Type Frequency(HCC) Percentage(HCC) Frequency(NN) Percentage(NN) p Alcoholic Cirrhosis 134 54.25% 112 65.50% >0,05 CHVC 66 26.72% 18 10.52% >0,05 CHVB 33 13.36% 19 11.11% >0,05 Others 14 5.67% 22 12.87% >0,05 Tab. 4.4. and Table 4.5. The distribution of diagnosis Most of HCC were caused by alcoholic cirrhosis, also hepatitis virus B and C can affect HCC too. Obviously, there are some other cause in the table. 4, but there are rare cases which were less than 10% of it. 100 Distribution of age of the patients Age Frequency Percentage 20-50 75 19.40% 51-60 197 49.90% 61-70 120 30.70% Tab. 4.6. The distribution of age of patients at the moment of liver transplant Most patients who make the operation of transplantation were between 51-60 years, and the mean was 56.04 years old. Blood group Type Frequency Percentage O 162 37.40% A 187 43.20% B 60 13.80% AB 24 5.60% 101 Fig. 4.1 Tab. 4.7. and Fig 4.1. The distribution of Blood Group Blood group of the patients with HCC and patients with de novo neoplasia(NN) Type Frequency(HCC) Percentage(HCC) Frequency(NN) Percentage(NN) p O 97 39.27% 61 35.68% >0,05 A 106 42.91% 71 41.52% >0,05 B 34 13.77% 28 16.37% >0,05 AB 10 4.05% 11 6.43% >0,05 Tab. 4.7-8. and Fig. 4.1. The distribution of Blood group Smoke Type of smoke Frequency Percentage Yes 287 66.30% No 146 33.70% O 37% A 43% B 14% AB 6% Blood group O A B AB 102 Fig. 4.2 Tab. 4.9 and Fig 4.2. Distribution of smoking in patients of study Distribution of smoke in patients with HCC and NN Type Frequency(HCC) Percentage(HCC) Frequency(NN) Percentage(NN) Yes 170 68.80% 121 70.80% No 77 31.20% 50 29.20% Tab. 4.9-10. and Fig. 4.2. The distribution of smoke in patients In general, the patients with smoke is 2 times higher than without it. There are no difference between HCC and de novo neoplasia patient. Yes 66% No 34% Smoke Yes No 103 Alcohol Type Frequency Percentage Yes 278 64.20% No 154 35.60% Distribution of alcohol in patients with HCC and NN Type Frequency(HCC) Percentage(HCC) Frequency(NN) Percentage(NN) p Yes 168 68% 116 67.80% >0,05 No 79 32% 55 32.20% >0,05 Tab. 4.11-12. The distribution of alcohol in patients As mentioned above, the patient who smoking always intaking alcohol. There are no difference between HCC and de novo neoplasia. Organ appearance Type Frequency Percentage Optimum 303 70% Suboptimal 130 30% Tab. 4.13. The organ appearance of donor 104 En these patients, there are 247 patients with HCC recurrent, and 171 patients with de novo neoplasia after liver transplantation. Including colorectal cancer, lung cancer, kidney cancer et.al. The distribution of de novo neoplasia Type of cancer Frequency Percentage Lung cancer 28 16.37% Colorectal cancer 8 4.68% Urothelial cancer 4 2.34% Esophagus cancer 1 0.58% Pancreatic cancer 2 1.17% Small bowel cancer 2 1.17% Hepatic sarcoma 1 0.58% Otorhinolaryngologic cancer 31 18.13% Lymphoproliferative syndrome 14 8.19% Breast cancer 6 3.51% Prostate cancer 10 5.85% Kidney cancer 4 2.34% Skin cancer 55 32.16% Gastric cancer 3 1.75% Central nervous cancer 1 0.58% Cholangiocarcinoma 1 0.58% Tab. 4.14. The types of cancer in de novo neoplasia In the patients with de novo neoplasia, there are 69 patients with tumor recurrence. 105 Immunosuppressive agent Frequency Percentage mTORi 152 35.1% CNI 255 58.9% MMF 26 6% Tab. 4.15. Distribution of immunosuppressive agent Immunosuppressive agent Frequency Percentage mTORi 86 34.8% CNI 158 1.2% MMF 3 64% Tab. 4.16. Immunosuppressive agent use in HCC Immunosuppressive agent Frequency Percentage mTORi 77 45% CNI 69 14.6% MMF 25 40.4% Tab. 4.17. Immunosuppressive agent use in “de novo” neoplasia Clinical study variables The criteria of safety assessment, and efficacy were determined after the follow-up many years. We record the side effects of mTORi. 112 Figure 5.4. The survival rate of Vascular invasion in patients with HCC (unit: month) With the test (p<0.0001, p<0.05) Kaplan-Meier, known about the related between survival time and the vascular invasion, almost 80% patients without vascular invasion reach 50 months, and more than 60% patients reach 150 months. However, just 40% patients can reach 220 months. Other side, less than 50% patients with vascular invasion can reach 50 months, and the largest time of survival is 183 months, just 3 (7.3%)patients’ survival are more than 150 months. 113 Capsule appearance Frequency Percentage Percentage valid Percentage accumulated Valid NO 215 87.0 87.0 87.0 SI 32 13.0 13.0 100.0 Total 247 100.0 100.0 Table 5.2. The distribution of capsule appearance in patients with HCC Figure 5.5. capsule appearance of HCC With the table 2. and the figure 5. Just 32 patients with capsule appearance. In the figure 6. (Test Kaplan-Meier, with p<0.0001, <0.05)shown the patients without capsule appearance, the survival time is much better than the patients with capsule Yes 13% No 87% Capsule appearance Yes No 114 appearance. More than 60% patients without it achieve 150 months after liver transplantation, however, the patients with it just 1 patient’s (3.12%) survival time more than 150 months. Most of these patients with it, the survival time is about 50 months Figure 5.6. The survival rate of Capsule appearance in patients with HCC (unit: month) 115 Edmondson Frequenc y Percentag e Percentage valid Percentage accumulated Valid High differentiated 36 14.6 14.6 14.6 Moderately differentiated 189 76.5 76.5 91.1 Poorly differentiated 22 8.9 8.9 100.0 Total 247 100.0 100.0 Table 5.3. The differentiated of HCC Figure 5.7. The percentage of Edmondson of HCC Highly differentiated 15% Moderately differentiated 76% Poorly differentiated 9% Edmonson Highly differentiated Moderately differentiated Poorly differentiated 116 Figure 5.8. The survival rate of Edmondson in patients with HCC(unit: month) With the table. 3 and figure. 7, can shown directly the distribution of the differentiated of cancer in patients. The figure 8. is the test Kaplan-Meier with p=0.090 (p>0.05). In general, the tumor with highly differentiated is much better than poorly differentiated. The moderately differentiated is between those. 5.1.3. Tumor recurrence 247 patients with the diagnosis HCC, and there are 42 patients occur HCC recurrent, 26 of it were metastasis. 117 Tumor recurrence Frequency Percentag e Percentage valid Percentage accumulated Valid NO 205 83.0 83.0 83.0 SI 42 17.0 17.0 100.0 Total 247 100.0 100.0 Table 5.4. HCC recurrence in patients Figure 5.9. The percentage of HCC Yes 17% No 83% HCC recurrence Yes No 118 Figure 5.10. Survival rate of patients with and without recurrence.(unit: month) We use test Kaplan-Meier to confirm the survival rate of recurrence tumor (p<0.0001, p<0.05). The survival rate of patients without HCC recurrent is higher than the patients with HCC recurrent. And 40% of these can achieve 300 months. 119 Figure 5.11. The distribution of location of recurrent Figure 5.12. The survival rate of the location of recurrent tumor (unit: month) No 83% Local 7% Metastasis 10% Location of recurrent No Local Metastasis 120 Due to the figure 11. Most recurrence are metastasis. But in the figure 12 (test with p<0.0001, p<0.05), the patients without recurrence and the survival time are much better than other two. About 70% patients reach 150 months (12.5 years), more than 80% patients achieve 50 months, 40% patients’ survival time more than 200 months. 60% patients with recurrent tumor in location local can reach 50 months, but the patients with metastasis just 30% of these can reach 50 months. 5.1.4. Immunosuppressant scheme There are 158 patients use CNI, 86 patients with mTORi (37 patients use Sirolimus and 49 patients use Everolimus) and 3 patients with mycophenolate. mTORi, CNI, MMF Frequency Percentage Percentage valid Percentage accumulated Valid mTORI 86 34.8 34.8 34.8 CNI 158 64.0 64.0 98.8 MMF 3 1.2 1.2 100.0 Total 247 100.0 100.0 Table 5.5. The use of immunosuppressive inhibitor 121 Figure 5.13. The survival of patients transplanted because of HCC in function of immunosuppressant regimen Figure 5.14. The survival rate of patients with CNI, mTORi and MMF. (unit: month) mTORi 35% CNI 64% MMF 1% mTORi-CNI-MMF mTORi CNI MMF 128 Figure. 5.20 CAUSE OF DEATH Frequency Percentage Percentage valid Percentage accumulated Valid 171 69.2 69.2 69.2 CANCER 34 13.8 13.8 83.0 POST-OLT 1 .4 .4 83.4 CARDIOVASCUL AR 6 2.4 2.4 85.8 OTHERS 35 14.2 14.2 100.0 Total 247 100.0 100.0 Tab. 5.9 No 66% Si 34% Exitus No Si 129 5.2. De novo neoplasia (NN) Figure 5.21. The survival rate of smoke in patients de novo neoplasia. (unit: month) We use the test survival (Kaplan-Meier, with p=0.001) to check the related of smoke and survival time in patients de novo neoplasia. Different with related HCC and smoke, the smoke and the novo neoplasia is clearly that without smoke is much better than smoker. 130 Figure 5.22. The survival rate of alcohol in patients with de novo neoplasia. (unit: month) Use the test Kaplan-Meier, with the p=0.020. Intaking alcohol has bad effect for patients. Tumor recurrence Frequency Percentage Percentage valid Percentage accumulated Valid NO 102 59.6 59.6 59.6 YES 69 40.4 40.4 100.0 Total 171 100.0 100.0 Table 5.10. Recurrent tumor in patients with de novo neoplasia 131 Figure 5.23. The distribution of recurrent tumor in the patients with NN. In figure 5.24. we can observe the survival of patient in case of tumor recurrence in patients with NN. Figure 5.24. The survival rate of recurrent tumor in patients with NN. (unit: month) Yes 40% No 60% Recurrent tumor Yes No 132 There are 69 patients (40%) occur tumor recurrence. And use the survival test to check the related with recurrence and survival time, the Kaplan-Meier test (p<0.0001) shown the survival time. Without recurrence is more than 4 times than with it in the point 50 months. And in the point 200 months, without recurrence is almost 6 times than with it. In next table we can see what treatment was offered to patients with NN: surgical resection or chemotherapy/radiotherapy. Treatment way Type of treatment Frequency Percentage Resection 89 52.05% QT or RT 47 27.49% No treatment 35 20.46% Total 171 100% Table 5.11. The frequency and percentage of treatment way in patients with NN. Figure 5.25. The distribution of treatment way (QT-RT means: Chemotherapy or Radiotherapy) No treatment 20% Resection 52% QT or RT 28% Treatment way No treatment Resection QT or RT 133 We have studied (figure 5.26) the survival of patients with NN in case of treatment way (QT-RT means: Chemotherapy or Radiotherapy). Figure 5.26. The survival rate of the treatment way in patients with NN. (unit: month) In the table 2 and figure 5, described the distribution of treatment way in patients with NN. With the survival test (p<0.0001), the resection is the best way to treatment tumor in NN. Chemotherapy or Radiotherapy and without treatment is similar, but Chemotherapy or Radiotherapy is little better than without treatment in the short-term. In next figure we can observe survival of transplanted patients with NN in function of tumor size (T stage). 134 Figure 5.27. The survival rate of Stage T in patients with NN. (unit: month) (p<0.0001) Obviously, the survival time of stage 1 of T is best. As we know, the stage 4 is severe, so the worst is stage 4, the stage 2 and stage 3 are similar but the stage 2 is better than stage 3. Next figure shows the same in case of metastatic nodes (N stage) and distance metastasis (M stage). 135 Figure 5.28. The survival rate of Stage M in patients with NN. (unit: month) (p<0.0001) 136 Figure 5.29. The survival rate of Stage M in patients with NN. (unit: month) (p<0.0001) The figure 5.28. is shown clearly that stage 0 of N is the best. And the figure 5.29. show the without metastasis distal, the survival time is larger. 137 Figure 5.30. The survival rate of Stage group in patients with NN. (unit: month) (p<0.0001) In the general, the stage 1 is better than others, although the rate of stage 2 higher than stage 1 twice. 144 Figure 5.37. The distribution of patient used immunosuppressant with or without tumor recurrence.(p=0.590) There are 22 patients with skin cancer used immunosuppressant mTORi, the survival of with tumor recurrence is higher. But only 2 patients with tumor recurrence, and this test dose not has statistical significance. (p=0.440) 145 Figure 5.38. The survival rate of CNI used in patients with skin cancer. (unit: month) (p=0.883) Also, there is no difference in survival in case of CNI treatment. 146 Figure 5.39. The survival rate of steroid used in patients with skin cancer. (unit: month) (p=0.003) Without steroid therapy is much better than patient with the steroid therapy. 147 ORL cancer In next figure we can observe survival of ORL cancer patients depending of treatment used, surgical resection VS chemotherapy/radiotherapy. Figure 5.40. The survival rate of treatment way in patients with Otorhinolaryngologic cancer. (unit: month) (p=0.030) As we can observe, surgical resection gives a better survival in patients with ORL cancer. Next figure shows survival in function of immunosuppressant regimen we used in these patients, mTORi, CNI or MMF. 148 Figure 5.41. The survival rate of CNI, mTORi and MMF used in patients with Otorhinolaryngologic cancer. (unit: month) (p=0.018) The MMF treatment is better than mTORi and CNI. Also, mTORi is better than CNI. (p<0.05) 149 Figure 5.42. The distribution of patient used immunosuppressant with or without tumor recurrence. There are 22 patients without tumor recurrence (11 patients with mTORi, 9 patients with CNI and 2 patients with MMF), and 9 patients with tumor recurrence. (p=0.020) 150 Figure 5.43. The survival rate of CNI used in patients with Otorhinolaryngologic cancer. (unit: month) (p=0.086) Without CNI’s therapy is better than CNI therapy. 151 Figure 5.44. The survival rate of CNI used in patients with Otorhinolaryngologic cancer. (unit: month) (p=0.159) Everolimus seems to be better than Sirolimus, but it is only a clinical observation without statistical significance. (p>0.05) 152 Lung cancer In figure 5.45. we can see survival of lung cancer depending no treatment offered: palliative, chemotherapy/radiotherapy or surgical resection. Figure 5.45. The survival rate of treatment way in patients with lung cancer. (unit: month) (p=0.005) The resection is the best than others 2 treatment way. Without treatment is the worst way, and cannot reach 15 months. Next figures show survival of patients with lung cancer depending of inmunosupressant regimen. 153 Figure 5.46. The survival rate of CNI,mTORi and MMF used in patients with lung cancer. (unit: month) (p=0.067) mTORi is better than others 2 drugs CNI and MMF, although it is only a clinical observation with a little statistical signification (p<0,05). Survival time is largest that almost reach 50 months.