DENISE CERQUEIRA PARANAGUA VEZOZZO
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Instituto Central, Hospital das Clínicas, Faculdade de Medicina - Médico
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article 44 Citação(ões) na Scopus Epidemiology of HCC in Brazil: incidence and risk factors in a ten-year cohort(2014) PARANAGUA-VEZOZZO, Denise C.; ONO, Suzane K.; ALVARADO-MORA, Monica V.; FARIAS, Alberto Q.; CUNHA-SILVA, Marlone; FRANCA, Joao I. D.; ALVES, Venancio A. F.; SHERMAN, Morris; CARRILHO, Flair JoseBackground and aim. The lack of information about hepatocellular carcinoma (HCC) in Brazil weakens health policy in preventing deaths from the illness. The aim of this study was to establish the cumulative incidence and the risk factors for hepatocellular carcinoma development in patients under a surveillance program. Material and methods. 884 patients with compensated cirrhosis were prospectively followed up for at least five years, from August 1998 until August 2008, with at least one annual ultrasonography liver examination and serum alpha fetoprotein (AFP) measurement. Results. Among 884 patients, 72 (8.1%) developed a tumor with a median follow up of 21.4 months. In the hepatocellular carcinoma group, hepatitis C virus infection was the major etiological factor (65.3%), 56.9% (41/72) were male and the mean average age was 57 +/- 10 years. The annual incidence of hepatocellular carcinoma was 2.9%. 79.2% (57/72) of HCCs were detected within Milan Criteria, and the mean survival time was 52.3 months, significantly higher than for those outside Milan, with a mean time of 40.6 months (p = 0.0003). Conclusion. The annual incidence of HCC among this large series of Brazilian cirrhotic patients was around 2.9% with a detection rate of 8.1%, or a cumulative incidence rate over five years of 14.3%. The three variables related to HCC risk were low serum albumin [HR: 0.518 (0.46-0.78)], high AFP > 20 ng/mL [HR: 3.16 (1.86-5.38)], and ethnicity (Brazilian-East Asian descendants vs. other mixed Brazilian ethnicities) [HR: 2.86 (1.48-5.53)].- Liver elastography can predict degree of advanced fibrosis for autoimmune hepatitis in biochemical remission(2023) PARANAGUA-VEZOZZO, Denise Cerqueira; TERRABUIO, Debora Raquel Benedita; REINOSO-PEREIRA, Gleicy Luz; MOUTINHO, Renata; ONO, Suzane Kioko; SALAS, Veronica Walwyn; FRANCA, Joao Italo Dias; ALVES, Venancio Avancini Ferreira; CANCADO, Eduardo Luiz Rachid; CARRILHO, Flair JoseBackground and AimThe aim was to analyze the concordance of liver stiffness measurement (LSM) either by transient elastography (TE) or ARFI with liver biopsy in autoimmune hepatitis (AIH) patients with biochemical remission and to identify those with histological remission. Liver biopsy is still the golden standard for AIH diagnosis. However, it is an invasive procedure and these patients, most of the time, require many biopsies, so it would be valuable to search for noninvasive method that could select all these patients and keep under observation. MethodsThirty-three patients with AIH were submitted for liver biopsy to evaluate histological remission after at least 18 months of normal aminotransferases. The efficiency of LSM and fibrosis stages was tested by a receiver operating characteristic curve analysis (AUROC). ResultsOne patient (3%) was F0, 6 (18.2%) were F1, 8 (24.2%) were F2, 10 (30.3%) were F3, and 8 (24.2%) were F4, according to METAVIR. Thirteen of thirty-three (39.4%) patients did not achieve histological remission. AUROC for F4 stage was 0.83 (IC: 0.76-0.99) for TE and 0.78 (IC: 0.65-0.95) for ARFI. Optimal LSM cutoff values were 12.3 kPa (Se = 87.5%, Sp = 88%) for TE and 1.65 m/s (Se = 87.5%, Sp = 76%) for ARFI. The tests were unable to differentiate patients with histological activity from those in histological remission (P < 0.05). ConclusionTE and ARFI accurately identify liver fibrosis by METAVIR score in AIH patients with biochemical remission. No cutoff value was detected to indicate whether the patient achieved histological remission.
- Concordance of non-invasive mechanical and serum tests for liver fibrosis evaluation in chronic hepatitis C(2017) PARANAGUA-VEZOZZO, Denise C.; ANDRADE, Adriana; MAZO, Daniel F. C.; NUNES, Vinicius; GUEDES, Ana L.; RAGAZZO, Taisa G.; MOUTINHO, Renata; NACIF, Lucas S.; ONO, Suzane K.; ALVES, Venancio A. F.; CARRILHO, Flair J.AIM To determine the sensitivity and specificity of liver stiffness measurement (LSM) and serum markers (SM) for liver fibrosis evaluation in chronic hepatitis C. METHODS Between 2012 and 2014, 81 consecutive hepatitis C virus (HCV) patients had METAVIR score from liver biopsy compared with concurrent results from LSM [transient elastography (TE) [FibroScan (R)/ARFI technology (Virtual Touch (R))] and SM [FIB-4/aspartate aminotransferase-to-platelet ratio index (APRI)]. The diagnostic performance of these tests was assessed using receiver operating characteristic curves. The optimal cut-off levels of each test were chosen to define fibrosis stages F >= 2, F >= 3 and F = 4. The Kappa index set the concordance analysis. RESULTS Fifty point six percent were female and the median age was 51 years (30-78). Fifty-six patients (70%) were treatment-naive. The optimal cut-off values for predicting F >= 2 stage fibrosis assessed by TE were 6.6 kPa, for acoustic radiation force impulse (ARFI) 1.22 m/s, for APRI 0.75 and for FIB-4 1.47. For F >= 3 TE was 8.9 kPa, ARFI was 1.48 m/s, APRI was 0.75, and FIB-4 was 2. For F = 4, TE was 12.2 kPa, ARFI was 1.77 m/s, APRI was 1.46, and FIB-4 was 3.91. The APRI could not distinguish between F2 and F3, P = 0.92. The negative predictive value for F = 4 for TE and ARFI was 100%. Kappa index values for F >= 3 METAVIR score for TE, ARFI and FIB-4 were 0.687, 0.606 and 0.654, respectively. This demonstrates strong concordance between all three screening methods, and moderate to strong concordance between them and APRI (Kappa index = 0.507). CONCLUSION Given the costs and accessibility of LSM methods, and the similarity with the outcomes of SM, we suggest that FIB-4 as well as TE and ARFI may be useful indicators of the degree of liver fibrosis. This is of particular importance to developing countries.
- Hepatocellular Carcinoma Management in Nonalcoholic Fatty Liver Disease Patients Applicability of the BCLC Staging System(2016) KIKUCHI, Luciana; OLIVEIRA, Claudia P.; ALVARES-DA-SILVA, Mario R.; TANI, Claudia M.; DINIZ, Marcio A.; STEFANO, Jose T.; CHAGAS, Aline L.; ALENCAR, Regiane S. S. M.; VEZOZZO, Denise C. P.; SANTOS, Gilmar R.; CAMPOS, Priscila B.; ALVES, Venancio A. F.; RATZIU, Vlad; CARRILHO, Flair J.Background/Aims: Nonalcoholic fatty liver disease (NAFLD) has emerged as an important cause of chronic liver disease, cirrhosis, and hepatocellular carcinoma (HCC). The Barcelona Clinic Liver Cancer (BCLC) system is the preferred staging system to evaluate patients with HCC and links prognosis assessment with treatment recommendation. The aim of this retrospective study was to evaluate whether the BCLC staging system and its treatment algorithm are suitable for,patients with HCC arising from NAFLD. Methods: Forty-two patients with HCC related to either to NAFLD or cryptogenic cirrhosis were retrieved retrospectively from 2 centers in Brazil. Patients were classified according to BCLC staging system. If the proposed HCC therapy could not be applied, the case was considered to represent deviations from the recommended BCLC guideline. Causes of treatment deviations were investigated. Results: There were 4 patients without evidence of cirrhosis according to liver biopsy and/or clinical evaluation. One (2%), 21 (50%), 10 (24%), 5 (12%), and 5 patients (12%) were classified initially to the very early (0), early (A), intermediate (B), advanced (C), and terminal (D) BCLC stages, respectively. Thirty-five patients (83%) were treated according to BCLC recommendations. There were 3 cases (of 5) of protocol deviation in BCLC C patients. The 1- and 2-year overall survival rates were 81% and 66%, respectively. Conclusions: The BCLC system is applied in most cases of NAFLD-related HCC cases. Deviation of BCLC is found more frequently in BCLC C stage patients.
- BRAZILIAN SOCIETY OF HEPATOLOGY UPDATED RECOMMENDATIONS FOR DIAGNOSIS AND TREATMENT OF HEPATOCELLULAR CARCINOMA(2020) CHAGAS, Aline Lopes; MATTOS, Angelo Alves de; CARRILHO, Flair José; BITTENCOURT, Paulo Lisboa; VEZOZZO, Denise Cerqueira Paranaguá; HORVAT, Natally; ROCHA, Manoel de Souza; ALVES, Venâncio Avancini Ferreira; CORAL, Gabriela Perdomo; ALVARES-DA-SILVA, Mario Reis; BARROS, Fabio Marinho do Rego; MENEZES, Marcos Roberto; MONSIGNORE, Lucas Moretti; COELHO, Fabricio Ferreira; SILVA, Renato Ferreira da; SILVA, Rita de Cássia Martins Alves; BOIN, Ilka de Fatima Santana Ferreira; D`ALBUQUERQUE, Luiz Augusto Carneiro; GARCIA, José Huygens Parente; FELGA, Guilherme Eduardo Gonçalves; MOREIRA, Airton Mota; BRAGHIROLI, Maria Ignez Freitas Melro; HOFF, Paulo Marcelo Gehm; MELLO, Vivianne Barretto de; DOTTORI, Mariana Fonseca; BRANCO, Tiago Pugliese; SCHIAVON, Leonardo de Lucca; COSTA, Thaisa de Fátima AlmeidaABSTRACT Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related mortality worldwide. The Brazilian Society of Hepatology (SBH) published in 2015 its first recommendations about the management of HCC. Since then, new data have emerged in the literature, prompting the governing board of SBH to sponsor a single-topic meeting in August 2018 in São Paulo. All the invited experts were asked to make a systematic review of the literature reviewing the management of HCC in subjects with cirrhosis. After the meeting, all panelists gathered together for the discussion of the topics and the elaboration of updated recommendations. The text was subsequently submitted for suggestions and approval of all members of the Brazilian Society of Hepatology through its homepage. The present manuscript is the final version of the reviewed manuscript containing the recommendations of SBH.
article 2 Citação(ões) na Scopus m-RECIST at 1 month and Child A are survival predictors after percutaneous ethanol injection of hepatocellular carcinoma(2014) SILVA, Mauricio F.; CARRILHO, Flair J.; PARANAGUA-VEZOZZO, Denise C.; CAMPOS, Luciana T.; NACIF, Lucas S.; DINIZ, Marcio A.; FARIAS, Alberto Q.; ALVES, Venancio A. F.; D'ALBURQUERQUE, Luis A. C.; ONO, Suzane K.Background and aims. Percutaneous ethanol injection (PEI) is a well-established therapeutic option in patients with cirrhosis and hepatocellular carcinoma (HCC). The modified-Response Evaluation Criteria in Solid Tumors (m-RECIST) are an important tool for the assessment of HCC response to therapy. The aim was to evaluate whether HCC response according to the m-RECIST criteria could be an effective predictor of Long-term survival in Barcelona Clinic Liver Cancer (BCLC) stage 0 and A HCC patients undergoing PEI. Material and methods. 79 patients were followed-up for median time of 26.8 months. HCC diagnosis was based on the,current guidelines of the American Association for Study of the Liver Diseases (AASLD) and European Association for Study of the Liver (EASL). Patient survival was calculated from the first PEI session to the end of the follow-up. Results. The 1-, 3-, and 5-year overall survival rates were 79, 48 and 37%, respectively. In the multivariate analysis, Child-Pugh-Turcotte (CPT) (p = 0.022) and the response to m-RECIST criteria (p = 0.016) were associated with patient survival. CPT A patients who achieved Complete Response (CR) 1 month after PEI presented a 5-year survival rate of 55%. By contrast, the worst scenario, the group with CPT B but without CR had a 5-year survival rate of 9%, while the group with either CPT A or CR as a survival predictor had a 5-year survival rate of 31%. In conclusion, in BCLC stage 0 and A HCC-patients, m-RECIST at 1 month and Child A may predict survival rates after PEI.conferenceObject Transient Elastography (TE) And Acoustic Radiation Force Impulse Imaging (ARFI) Can Predict Degree Of Advanced Fibrosis For Autoimmune Hepatitis In Biochemical Remission(2017) PARANAGUA-VEZOZZO, Denise; TERRABUIO, Debora R.; MOUTINHO, Renata D.; CANCADO, Eduardo L.; ONO, Suzane; SALAS, Veronica; CARRILHO, Flair; ALVES, Venancio Ferreira- Accuracy of transient elastography-FibroScan (R), acoustic radiation force impulse (ARFI) imaging, the enhanced liver fibrosis (ELF) test, APRI, and the FIB-4 index compared with liver biopsy in patients with chronic hepatitis C(2017) RAGAZZO, Taisa Grotta; PARANAGUA-VEZOZZO, Denise; LIMA, Fabiana Roberto; MAZO, Daniel Ferraz de Campos; PESSOA, Mario Guimaraes; OLIVEIRA, Claudia Pinto; ALVES, Venancio Avancini Ferreira; CARRILHO, Flair JoseOBJECTIVES: Although liver biopsy is the gold standard for determining the degree of liver fibrosis, issues regarding its invasiveness and the small amount of liver tissue evaluated can limit its applicability and interpretation in clinical practice. Non-invasive evaluation methods for liver fibrosis can address some of these limitations. The aim of this study was to evaluate the accuracy of transient elastography-FibroScan (R), acoustic radiation force impulse (ARFI), enhanced liver fibrosis (ELF), the aspartate aminotransferase-to-platelet ratio index (APRI), and the FIB-4 index compared with liver biopsy in hepatitis C. METHODS: We evaluated chronic hepatitis C patients who were followed at the Division of Clinical Gastroenterology and Hepatology, Hospital das Clinicas, Department of Gastroenterology of University of Sao Paulo School of Medicine, Sao Paulo, Brazil, and who underwent liver biopsy. The accuracy of each method was determined by a receiver operating characteristic (ROC) curve analysis, and fibrosis was classified as significant fibrosis (>= F2), advanced fibrosis (>= F3), or cirrhosis (F4). The Obuchowski method was also used to determine the diagnostic accuracy of each method at the various stages of fibrosis. In total, 107 FibroScan (R), 51 ARFI, 68 ELF, 106 APRI, and 106 FIB-4 analyses were performed. RESULTS: A total of 107 patients were included in the study. The areas under the ROC curve (AUROCs) according to fibrosis degree were as follows: significant fibrosis (>= F2): FibroScan (R) : 0.83, FIB-4: 0.76, ELF: 0.70, APRI: 0.69, and ARFI: 0.67; advanced fibrosis (>= F3): FibroScan (R) : 0.85, ELF: 0.82, FIB-4: 0.77, ARFI: 0.74, and APRI: 0.71; and cirrhosis (F4): APRI: 1, FIB-4: 1, FibroScan (R) : 0.99, ARFI: 0.96, and ELF: 0.94. The accuracies of transient elastography, ARFI, ELF, APRI and FIB-4 determined by the Obuchowski method were F0-F1: 0.81, 0.78, 0.44, 0.72 and 0.67, respectively; F1-F2: 0.73, 0.53, 0.62, 0.60, and 0.68, respectively; F2-F3: 0.70, 0.64, 0.77, 0.60, and 0.67, respectively; and F3-F4: 0.98, 0.96, 0.82, 1, and 1, respectively. CONCLUSION: Transient elastography remained the most effective method for evaluating all degrees of fibrosis. The accuracy of all methodologies was best at F4.
- HIGHER VALUES IN LIVER ELASTOGRAPHY AND MELD SCORE ARE MORTALITY PREDICTORS ON LIVER TRANSPLANT WAITING LIST(2018) NACIF, Lucas Souto; PARANAGUA-VEZOZZO, Denise C.; MATSUDA, Alina; ALVES, Venancio Avancini Ferreira; CARRILHO, Flair J.; FARIAS, Alberto Queiroz; D'ALBUQUERQUE, Luiz Carneiro; ANDRAUS, WellingtonBackground: Liver elastography have been reported in hepatocellular carcinoma (HCC) with higher values; however, it is unclear to identify morbimortality risk on liver transplantation waiting list. Aim: To assess liver stiffness, ultrasound and clinical findings in cirrhotic patients with and without HCC on screening for liver transplant and compare the morbimortality risk with elastography and MELD score. Method: Patients with cirrhosis and HCC on screening for liver transplant were enrolled with clinical, radiological and laboratory assessments, and transient elastography. Results: 103 patients were included (without HCC n=58 (66%); HCC n=45 (44%). The mean MELD score was 14.7 +/- 6.4, the portal hypertension present on 83.9% and the mean transient elastography value was 32.73 +/- 22.5 kPa. The median acoustic radiation force impulse value of liver parenchyma was 1.98 (0.65-3.2) m/s and 2.16 (0.59-2.8) m/s in HCC group. The HCC group was significantly associated with HCV infection (OR 26.84; p<0.0001), higher levels of serum alpha-fetoprotein (OR 5.51; p=0.015), clinical portal hypertension (OR 0.25; p=0.032) and similar MELD score (p=0.693). The area under the receiver operating characteristics (AUROC) showed sensitivity and specificity for serum alpha-fetoprotein (cutoff 9.1 ng/ml), transient elastography value (cutoff value 9 kPa), and acoustic radiation force impulse value (cutoff value 2.56 m/s) of 50% and 86%, 92% and 17% and 21% and 92%, respectively. The survival group had a mean transient elastography value of 31.65 +/- 22.2 kPa vs. 50.87 +/- 20.9 kPa (p=0.098) and higher MELD scores (p=0.035). Conclusion: Elastography, ultrasound and clinical findings are important non-invasive tools for cirrhosis and HCC on screening for liver transplant. Higher values in liver elastography and MELD scores predict mortality.
- Hepatocellular Carcinoma Related to Schistosoma mansoni Infection: Case Series and Literature Review(2015) TODA, Karla Sawada; KIKUCHI, Luciana; CHAGAS, Aline Lopes; TANIGAWA, Ryan Yukimatsu; PARANAGUA-VEZOZZO, Denise Cerqueira; PFIFFER, Tulio; ROCHA, Manoel de Souza; ALVES, Venancio Avancini Ferreira; CARRILHO, Flair JoseBackground and Aims: Schistosomiasis is a major chronic disease of humans in endemic regions, and infected individuals may develop a spectrumof pathology, including hepatic fibrosis, hepatosplenomegaly, and portal hypertension. Hepatocellular carcinoma (HCC) is considered the fifth most common cancer in the world, and there is limited and controversial evidence suggesting that Schistosoma mansoni infection may be a possible risk factor for HCC. The aim of this study was to report a case series of patients with HCC and S. mansoni infection and to conduct a literature review on the topic. Methods: From January 2002 to January 2015, an institutional database was screened retrospectively to identify patients with HCC and S. mansoni infection at a single center in the Department of Gastroenterology of University of Sao Paulo School of Medicine and Hospital das Clinicas, Brazil. Results: Seven cases were included. The mean age of patients was 62.1 +/- 10.3 years; six (85.7%) were male and one (14.3%) was female. All cases had positive epidemiology, coming from endemic areas of S. mansoni infection in Brazil, and four (57.1%) had previous complications (upper gastrointestinal bleeding) related toportal hypertension or surgery intervention (splenectomy) performed more than 10 years before the HCC diagnosis. Nontumoral portal vein thrombosis was identified in five (71.4%) patients. All patients had negative serology for HCV, and four (57.1%) had positivity of HBVcore antibodies without evidence of viral replication. According to BCLC staging, one (14.3%) patient was BCLC A and received TACE instead of RFA because HCC size was >30 mm; three (42.8%) BCLC B patients received sorafenib instead of local regional treatment due to the presence of nontumoral TPV. During follow-up, all patients developed tumoral progression and died. Conclusions: It remains unclear if S. mansoni infection alone has carcinogenic potential. The available literature indicates that S. Mansoni, in the presence of HBV and HCV infections, likely acts as a cofactor for the hepatic lesion and potentiates injury.