Clinical Focus

  • Gastroenterology
  • hepatology
  • Liver translant
  • Liver cancer

Academic Appointments

Administrative Appointments

  • Member and Manuscript Co-ordinator, Analysis Working Group, The Cancer Genome Atlas (TCGA), Liver Cancer (2014 - Present)
  • Associate Editor, BMC Gastroenterology Journal (2014 - Present)
  • Working group Member, AGA Young Delegates Program (2016 - Present)
  • Media Spokesperson, American Gastroenterological Association (AGA) (2016 - Present)

Honors & Awards

  • B Braun Medical Trust Foundation Scholarship, B Braun (2007)
  • Travel Bursary to present abstract, EASL HCC SUMMITGeneva, Switzerland, (Feb 2014)
  • Travel Bursary to present at the Basic science session, ILCA Liver Meeting, Austria (April 2015)
  • 2015 William H. Summerskill award for outstanding achievement in research, Mayo Clinic, Rochester (2015)

Boards, Advisory Committees, Professional Organizations

  • Member, AGA Research Advocacy Subcommittee (2016 - Present)
  • Member, AGA Practice management and Economics Committee (2016 - Present)
  • Member, AGA Young GI and Trainee Committee (2015 - Present)

Professional Education

  • Board Certification: Internal Medicine, American Board of Internal Medicine (2012)
  • Fellowship:Stanford University Gastroenterology Fellowship (2016) CA
  • Board Certification: Gastroenterology, American Board of Internal Medicine (2015)
  • Board Certification, American Board of Internal Medicine, Internal Medicine (2013)
  • Internship, University of Florida FL (2010)
  • Fellowship:Mayo Clinic (2015) MN
  • Fellowship, Stanford University, Transplant hepatology (2016)
  • Residency:University of Florida (2012) FL
  • Fellowship, Mayo Clinic, Rochester, Gastroenterology (2015)
  • Internship:University of Florida (2010) FL
  • Residency, University of Florida, Gainesville, Internal Medicine (2012)
  • MD, Madras Medical College, Internal Medicine (2008)
  • Medical Education:Bangalore Medical College (2005) India
  • MBBS, Bangalore Medical College, Medicine (2005)

Research & Scholarship

Current Research and Scholarly Interests

Clinical and translational research on hepatocellular carcinoma and cirrhosis.


All Publications

  • Clinical implications of basic research in hepatocellular carcinoma JOURNAL OF HEPATOLOGY Dhanasekaran, R., Venkatesh, S. K., Torbenson, M. S., Roberts, L. R. 2016; 64 (3): 736-745


    A 58-year old Caucasian female has compensated hepatitis C related cirrhosis. Her surveillance ultrasound showed hypodense liver nodules and subsequent triple phase CT scan showed five tumor nodules with diameters ranging from 3-5cms involving both hepatic lobes. The nodules showed characteristic radiologic findings on the CT scan and she was diagnosed with hepatocellular carcinoma (HCC) based on non-invasive criteria. There was also associated right portal vein tumor thrombosis. Her functional capacity at diagnosis was slightly limited, but she was capable of performing all activities of daily living and self-care. Her laboratory tests at diagnosis were as follows: sodium 129mmol/L, potassium 3.6mmol/L, blood urea nitrogen 22mg/dL, creatinine 1.0mg/dL, albumin 2.9g/dl, bilirubin 1.8mg/dl, alanine aminotransferase 87U/L, aspartate aminotransferase 68U/L, alkaline phosphatase 139U/L, white blood cell 3.5x10(9)/L, hemoglobin 10.4, platelet count 73x10(9)/L, international normalized ratio 1.9 and alpha-fetoprotein 5200ng/ml. An upper endoscopy was negative for esophageal or gastric varices. Based on the tumor burden, presence of macrovascular invasion, ECOG performance status of 1 and Child-Pugh class A she was classified to have BCLC stage C HCC. She was started on sorafenib therapy at 400mg oral twice daily but unfortunately this had to be discontinued since she experienced severe diarrhea and skin rash. She now returns for follow-up and requests information on the available therapeutic options. This particular case scenario is not uncommon and does raise several clinically relevant questions: This review provides a comprehensive overview of the current state of HCC management and also examines the clinical implications of recent basic research in HCC.

    View details for Web of Science ID 000370292300025

    View details for PubMedID 26450813

  • Response to Fibrosis progression in patients treated for hepatitis C recurrence LIVER INTERNATIONAL Dhanasekaran, R., Sanchez, W., Charlton, M. 2015; 35 (12): 2625-2625

    View details for DOI 10.1111/liv.12969

    View details for Web of Science ID 000367723200023

    View details for PubMedID 26386267

  • Impact of fibrosis progression on clinical outcome in patients treated for post- transplant hepatitis C recurrence LIVER INTERNATIONAL Dhanasekaran, R., Sanchez, W., Mounajjed, T., Wiesner, R. H., Watt, K. D., Charlton, M. R. 2015; 35 (11): 2433-2441


    Patients who achieve sustained virological response (SVR) following the treatment of post-liver transplant (LT) recurrence of hepatitis C virus (HCV) infection have improved outcomes. The full impact of eradication of HCV on allograft histology is, however, not clearly known.We studied allograft histology in protocol-based paired liver biopsies in consecutive LT recipients who underwent post-LT treatment of recurrence of HCV.A total of 116 patients were treated with interferon-based therapy for recurrent HCV. Paired pre-treatment baseline biopsies and post-treatment biopsies were available in 83.2% of patients. SVR was achieved in 37.9% of patients. Among the patients who achieved SVR, 20.5% had progression of fibrosis on post-treatment biopsies vs. 65.5% of patients with non-response/relapse (P < 0.001). The impact of virological response on fibrosis progression was sustained and a similar outcome was observed in the subset of patients who had 4-5 year post-treatment biopsies available. In the SVR group, 12.8% progressed to fibrosis stage ≥3 on post-treatment biopsies vs. 37.9% in the non-response/relapse group (P = 0.001). The 5-year survival in patients with progression of fibrosis 86% vs. 98% among patients who had improvement/stable fibrosis [P = 0.003; HR 3.8 (1.2-11.8)]. A small subset of patients who achieve SVR unfortunately still experience progression of fibrosis, most commonly associated with plasma cell hepatitis.In post-transplant patients treated for HCV, SVR is associated with improved graft survival and also with sustained and significant improvement in histological outcome. Importantly, progression of fibrosis still occurred in a small subset of patients who achieved SVR.

    View details for DOI 10.1111/liv.12890

    View details for Web of Science ID 000363411900012

    View details for PubMedID 26058570

  • Somatic Mutational Analysis by Next Generation RNA Sequencing Reveals Frequent Mutation of Chromatin and Chromosome Remodeling Genes in Gallbladder Cancer HEPATOLOGY Allotey, L. K., Chaiteerakij, R., Oliver, G. R., Sarangi, V., Dhanasekaran, R., Moser, C. D., Giama, N. H., O'Brien, D. R., Moore, R. M., Champion, M. D., Klee, E. W., Borad, M. J., Roberts, L. R. 2015; 62: 1165A-1165A
  • Multi-platform analysis of Telomerase Reverse Transcriptase (TERT) gene alterations in Hepatocellular Carcinoma (HCC) HEPATOLOGY Dhanasekaran, R., Covington, K., Watt, J., Cherniack, A. D., O'Brien, D. R., Lee, J., Creighton, C., Munzy, D. M., Roberts, L. R., Wheeler, D. A. 2015; 62: 274A-275A
  • Quality of Cancer Care in Patients with Cirrhosis and Hepatocellular Carcinoma. Current gastroenterology reports Dhanasekaran, R., Talwalkar, J. A. 2015; 17 (9): 34-?


    Hepatocellular carcinoma is the most common primary liver cancer in patients with cirrhosis and is the leading cause of mortality in these patients. Despite existence of robust clinical practice guidelines for surveillance, diagnosis, and management for hepatocellular carcinoma (HCC), the quality of care received by patients with HCC has been inconsistent. Several studies have reported disappointingly low surveillance rates in high-risk groups which likely contribute to most HCC cases being diagnosed at advanced stages. There is also data from large studies showing that significant under-referral to specialists and delay in initiation of treatment are linked to poor clinical outcomes. Given above circumstances, it is very important to perform studies which can identify areas in need of improvement in the care processes of HCC and design interventions to enhance quality of care. Unfortunately, data on validated quality indicators and quality metrics for HCC are non-existent. In this article, we review the existing literature pertaining to this issue and identify areas that need further research.

    View details for DOI 10.1007/s11894-015-0459-8

    View details for PubMedID 26238927

  • Activation of the Transforming Growth Factor-beta/SMAD Transcriptional Pathway Underlies a Novel Tumor-Promoting Role of Sulfatase 1 in Hepatocellular Carcinoma HEPATOLOGY Dhanasekaran, R., Nakamura, I., Hu, C., Chen, G., Oseini, A. M., Seven, E. S., Miamen, A. G., Moser, C. D., Zhou, W., van Kuppevelt, T. H., van Deursen, J. M., Mounajjed, T., Fernandez-Zapico, M. E., Roberts, L. R. 2015; 61 (4): 1269-1283


    In vitro studies have proposed a tumor suppressor role for sulfatase 1 (SULF1) in hepatocellular carcinoma (HCC); however, high expression in human HCC has been associated with poor prognosis. The reason underlying this paradoxical observation remains to be explored. Using a transgenic (Tg) mouse model overexpressing Sulf1 (Sulf1-Tg), we assessed the effects of SULF1 on the diethylnitrosamine model of liver carcinogenesis. Sulf1-Tg mice show a higher incidence of large and multifocal tumors with diethylnitrosamine injection compared to wild-type mice. Lung metastases were found in 75% of Sulf1-Tg mice but not in wild-type mice. Immunohistochemistry, immunoblotting, and reporter assays all show a significant activation of the transforming growth factor-β (TGF-β)/SMAD transcriptional pathway by SULF1 both in vitro and in vivo. This effect of SULF1 on the TGF-β/SMAD pathway is functional; overexpression of SULF1 promotes TGF-β-induced gene expression and epithelial-mesenchymal transition and enhances cell migration/invasiveness. Mechanistic analyses demonstrate that inactivating mutation of the catalytic site of SULF1 impairs the above actions of SULF1 and diminishes the release of TGF-β from the cell surface. We also show that SULF1 expression decreases the interaction between TGF-β1 and its heparan sulfate proteoglycan sequestration receptor, TGFβR3. Finally, using gene expression from human HCCs, we show that patients with high SULF1 expression have poorer recurrence-free survival (hazard ratio 4.1, 95% confidence interval 1.9-8.3; P = 0.002) compared to patients with low SULF1. We also found strong correlations of SULF1 expression with TGF-β expression and with several TGF-β-related epithelial-mesenchymal transition genes in human HCC.Our study proposes a novel role of SULF1 in HCC tumor progression through augmentation of the TGF-β pathway, thus defining SULF1 as a potential biomarker for tumor progression and a novel target for drug development for HCC.

    View details for DOI 10.1002/hep.27658

    View details for Web of Science ID 000352099700023

    View details for PubMedID 25503294

  • Undiagnosed Nonalcoholic Steatohepatitis (NASH) Is Responsible for a Significant Proportion of Cryptogenic Hepatocellular Carcinoma (HCC) GASTROENTEROLOGY Dhanasekaran, R., Rizvi, Z. H., Giama, N. H., Roberts, L. R. 2015; 148 (4): S1026-S1026
  • Comparative Efficacy of Transarterial Radioembolization (TARE) Versus Chemotherapy or Best Supportive Care for Unresectable Intrahepatic Cholangiocarcinoma (iCCA) GASTROENTEROLOGY Saffouri, G., Dhanasekaran, R., Spiceland, C. M., Lozada, M. E., Pankratz, R., Gansen, D., Gregory, W., Chad, F., Andrews, J., Chaiteerakij, R., Paz-Fumagalli, R., Harnois, D. M., Roberts, L. R. 2015; 148 (4): S986-S987
  • Next Generation Sequencing and Pathway Analysis Reveals Frequent Activation of the PI3-K/Akt Pathway in Gallbladder Cancer: Potential for Targeted Therapy GASTROENTEROLOGY Allotey, L. K., Chaiteerakij, R., Dhanasekaran, R., Moser, C. D., Giama, N. H., O'Brien, D. R., Moore, R. M., Champion, M. D., Borad, M., Roberts, L. R. 2015; 148 (4): S1019-S1019
  • Vasodilator-Stimulated Phosphoprotein Promotes Activation of Hepatic Stellate Cells by Regulating Rab11-Dependent Plasma Membrane Targeting of Transforming Growth Factor Beta Receptors HEPATOLOGY Tu, K., Li, J., Verma, V. K., Liu, C., Billadeau, D. D., Lamprecht, G., Xiang, X., Guo, L., Dhanasekaran, R., Roberts, L. R., Shah, V. H., Kang, N. 2015; 61 (1): 361-374


    Liver microenvironment is a critical determinant for development and progression of liver metastasis. Under transforming growth factor beta (TGF-β) stimulation, hepatic stellate cells (HSCs), which are liver-specific pericytes, transdifferentiate into tumor-associated myofibroblasts that promote tumor implantation (TI) and growth in the liver. However, the regulation of this HSC activation process remains poorly understood. In this study, we tested whether vasodilator-stimulated phosphoprotein (VASP) of HSCs regulated the TGF-β-mediated HSC activation process and tumor growth. In both an experimental liver metastasis mouse model and cancer patients, colorectal cancer cells reaching liver sinusoids induced up-regulation of VASP and alpha-smooth muscle actin (α-SMA) in adjacent HSCs. VASP knockdown in HSCs inhibited TGF-β-mediated myofibroblastic activation of HSCs, TI, and growth in mice. Mechanistically, VASP formed protein complexes with TGF-β receptor II (TβRII) and Rab11, a Ras-like small GTPase and key regulator of recycling endosomes. VASP knockdown impaired Rab11 activity and Rab11-dependent targeting of TβRII to the plasma membrane, thereby desensitizing HSCs to TGF-β1 stimulation.Our study demonstrates a requirement of VASP for TGF-β-mediated HSC activation in the tumor microenvironment by regulating Rab11-dependent recycling of TβRII to the plasma membrane. VASP and its effector, Rab11, in the tumor microenvironment thus present therapeutic targets for reducing TI and metastatic growth in the liver.

    View details for DOI 10.1002/hep.27251

    View details for Web of Science ID 000347005100042

    View details for PubMedID 24917558

  • Female Gender Associated With Less Aggressive Tumor Phenotype and Better Survival in HCC GASTROENTEROLOGY Dhanasekaran, R., Saffouri, G., Yang, J. D., Giama, N. H., Slettedahl, S. W., Harmsen, W. S., Therneau, T. M., Roberts, L. R. 2014; 146 (5): S918-S918
  • Challenges of recurrent hepatitis C in the liver transplant patient WORLD JOURNAL OF GASTROENTEROLOGY Dhanasekaran, R., Firpi, R. J. 2014; 20 (13): 3391-3400


    Cirrhosis secondary to hepatitis C virus (HCV) is a very common indication for liver transplant. Unfortunately recurrence of HCV is almost universal in patients who are viremic at the time of transplant. The progression of fibrosis has been shown to be more rapid in the post-transplant patients than in the transplant naïve, hence treatment of recurrent HCV needs to be considered for all patients with documented recurrent HCV. Management of recurrent HCV is a challenging situation both for patients and physicians due to multiple reasons as discussed in this review. The standard HCV treatment with pegylated interferon and Ribavarin can be considered in these patients but it leads to a lower rate of sustained virologic clearance than in the non-transplanted population. Some of the main challenges associated with treating recurrent HCV in post-transplant patients include the presence of cytopenias; need to monitor drug-drug interactions and the increased incidence of renal compromise. In spite of these obstacles all patients with recurrent HCV should be considered for treatment since it is associated with improvement in survival and a delay in fibrosis progression. With the arrival of direct acting antiviral drugs there is renewed hope for better outcomes in the treatment of post-transplant HCV recurrence. This review evaluates current literature on this topic and identifies challenges associated with the management of post-transplant HCV recurrence.

    View details for DOI 10.3748/wjg.v20.i13.3391

    View details for Web of Science ID 000334423300001

    View details for PubMedID 24707122

  • CLINICAL OUTCOMES AFTER RESECTION IN PATIENTS WITH NASH-RELATED HCC JOURNAL OF HEPATOLOGY Dhanasekaran, R., Yang, J. D., Giama, N., Slettedahl, S. W., Harmsen, W. S., Therneau, T., Roberts, L. R. 2014; 60 (1): S408-S408
  • A potential role for type XVIII collagen as a suppressor of hepatocellular carcinoma HEPATOLOGY Duncan, M., Dhanasekaran, R., Thakur, P., Roberts, L. R. 2014; 60: 642A-642A
  • Selective Internal Yttrium-90 Radioembolization Therapy (90Y-SIRT) Versus Best Supportive Care in Patients With Unresectable Metastatic Melanoma to the Liver Refractory to Systemic Therapy: Safety and Efficacy Cohort Study. American journal of clinical oncology Xing, M., Prajapati, H. J., Dhanasekaran, R., Lawson, D. H., Kokabi, N., Eaton, B. R., Kim, H. S. 2014


    To investigate survival, efficacy, and safety of selective internal yttrium-90 radioembolization therapy (Y-SIRT) in patients with unresectable metastatic melanoma (MM) to liver refractory to systemic therapy.An IRB-approved retrospective review of 58 patients diagnosed with unresectable MM to the liver, refractory to systemic therapy, between February 2003 and March 2012 was conducted. Of these, 28 received resin-based Y-SIRT (group A), and 30 patients received best supportive care (group B). Survival was calculated using the Kaplan-Meier method and Cox proportional hazard models.Groups A and B were similar for the Child-Pugh class, ECOG scores, age, sex, and race. Median overall survival (OS) from diagnosis of primary melanoma in groups A and B were 119.9 and 26.1 months, respectively (P<0.001). Median OS from hepatic metastasis in groups A and B were 19.9 and 4.8 months, respectively (P<0.0001). In group A, median OS from hepatic metastasis in the Child-Pugh A, B, and C patients was 37.7, 4.2, and 3.6 months, respectively (P<0.001). In group B, median OS from hepatic metastasis in the Child-Pugh A, B, and C patients was 7.8, 4.2, and 1.9 months, respectively (P=0.04). Within group A, median OS from first Y-SIRT was 10.1 months; median OS of the Child-Pugh A, B, and C patients from first Y-SIRT was 10.3, 1.2, and 0.9 months, respectively (P=0.04). Median OS from first Y-SIRT was significantly greater in the absence of diffuse (>10) liver metastases (15.1 vs. 4.7 mo, P=0.02), and in the absence of extrahepatic metastases (21.3 vs. 8.6 mo, P<0.001). Common clinical toxicities following Y-SIRT included abdominal pain (17.9%), fatigue (14.3%), and self-limiting grade III bilirubin toxicity (10.7%).For patients with unresectable MM to the liver refractory to systemic therapy, resin-based Y was associated with longer survival from liver metastases than best supportive care. Child-Pugh A patients with <10 metastatic lesions and absence of extrahepatic metastases demonstrated greatest survival following Y-SIRT.

    View details for DOI 10.1097/COC.0000000000000109

    View details for PubMedID 25089529

  • Response to Houlihan et al. American journal of gastroenterology Dhanasekaran, R., Kim, H. S. 2013; 108 (11): 1807-?

    View details for DOI 10.1038/ajg.2013.300

    View details for PubMedID 24192955

  • Validation of immunohistochemistry-based classification of hepatic adenomas: Different subtype distribution in a large US experience HEPATOLOGY Dhanasekaran, R., Kang, Y. N., Smoot, R., Moser, C. D., Gores, G. J., Wu, T., Mounajjed, T., Roberts, L. R. 2013; 58: 1217A-1217A
  • Internet Search Patterns for Gastroenterological Symptoms and the Relationship to Physician Visits AMERICAN JOURNAL OF GASTROENTEROLOGY Dhanasekaran, R., Oxentenko, A. 2013; 108: S477-S477
  • Analysis of Paired Biopsies to Assess Progression of Fibrosis in Patients Treated for Post-Transplant Hepatitis C Recurrence GASTROENTEROLOGY Dhanasekaran, R., Charlton, M. R., Sanchez, W. 2013; 144 (5): S1028-S1028
  • Rate and Predictors of Progression and Mortality in a Large Population Based Cohort of Be GASTROENTEROLOGY Ragunathan, K., Dhanasekaran, R., Sharma, P. K., Dunagan, K. T., Schleck, C. D., Zinsmeister, A. R., Locke, G. R., Talley, N. J., Wang, K. K., Iyer, P. G. 2013; 144 (5): S685-S685
  • Is NASH Related HCC Different From HCC Related to Other Causes GASTROENTEROLOGY Dhanasekaran, R., Yang, J. D., Giama, N. H., Slettedahl, S. W., Harmsen, W. S., Therneau, T., Kim, W. R., Roberts, L. R. 2013; 144 (5): S1038-S1038
  • Hepatic Preservation Injury: Severity of Hepatitis C Recurrence and Survival After Liver Transplantation DIGESTIVE DISEASES AND SCIENCES Michaels, A. J., Dhanasekaran, R., Foley, D. P., Alkhasawneh, A., Dixon, L., Soldevila-Pico, C., Morelli, G., Cabrera, R., Clark, V. C., Firpi, R. J. 2013; 58 (5): 1403-1409


    Preservation injury in the HCV liver transplant population has been reported to correlate with poorer survival outcomes compared to preservation injury in the non-HCV liver transplant population. However, determinants of progression to cirrhosis in HCV infection remain poorly defined in this population.This study aimed to determine if the presence and severity of preservation injury impact the acceleration of HCV recurrence and survival after liver transplant.We retrospectively reviewed liver transplant HCV patients over a 10-year period. Biopsies from postoperative day 7 were assessed for preservation injury and 4- and 12-month biopsies were assessed for fibrosis. Patients with Ishak fibrosis >0.8 Units/year were considered rapid fibrosers.Our study group consisted of 255 patients. The mean age was 49.3 years old, 180 (70.6 %) were male, and 221 (86.7 %) were Caucasian. The incidence of preservation injury on the 7-day biopsy was 69.0 %. A strong correlation between postoperative peak AST within the first week and preservation injury was found. The overall prevalence of rapid fibrosers at 4 months, 1 and 2 years was 47.4, 75.2, and 58.9 %, respectively. The prevalence of rapid fibrosers at 4 months, 1 and 2 years between patients with or without preservation injury was not statistically significant (p = 0.39, p = 0.46, and p = 0.53, respectively). No differences were seen between patients with and without PI in terms of patient and graft survival.In this study, the presence and severity of preservation injury were not associated with development of rapid HCV recurrence or worsening in survival.

    View details for DOI 10.1007/s10620-012-2521-9

    View details for Web of Science ID 000319350300037

    View details for PubMedID 23306846

  • Treatment outcomes and prognostic factors of intrahepatic cholangiocarcinoma ONCOLOGY REPORTS Dhanasekaran, R., Hemming, A. W., Zendejas, I., George, T., Nelson, D. R., Soldevila-Pico, C., Firpi, R. J., Morelli, G., Clark, V., Cabrera, R. 2013; 29 (4): 1259-1267


    The aim of the present study was to determine the treatment outcome and prognostic factors for survival in patients with peripheral intrahepatic cholangiocarcinoma (ICC). A retrospective chart review was performed for patients diagnosed with ICC between 2000 and 2009 at a single institution. We identified a total of 105 patients with ICC. Among them, 63.8% were older than 60 years of age, 50.5% were male and 88.6% were Caucasian. By preoperative imaging approximately half of the patients (50.5%) were surgical candidates and underwent resection. The other half of the patients (49.5%) were unresectable. The unresectable group received chemoradiotherapy (53%) and transarterial chemoembolization (7.7%) as palliative treatments while 23.0% of the patients (12/52) received best supportive care alone. The median survival rates were 16.1 months (13.1‑19.2) for the entire cohort, 27.6 months (17.7-37.6) for curative resection, 12.9 months (6.5-19.2) for palliative chemoradiotherapy and 4.9 months (0.4-9.6) for best supportive care (p<0.001). Independent predictors on multivariate analysis were advanced stage at diagnosis and treatment received. In those patients who underwent resection, advanced AJCC stage and presence of microvascular invasion were also independent predictors of poor survival. We concluded that surgery offers the most beneficial curative option and outcome, emphasizing the importance of resectability as a major prognostic factor. The present study also revealed that use of chemoradiotherapy in the adjuvant setting failed to improve survival but its palliative use in those patients with unresectable ICC offered a modest survival advantage over best supportive care. The overriding factors influencing outcome were stage and the presence of microvascular invasion on pathology.

    View details for DOI 10.3892/or.2013.2290

    View details for Web of Science ID 000316510600001

    View details for PubMedID 23426976

  • Safety and Efficacy of Doxorubicin Drug-eluting Bead Transarterial Chemoembolization in Patients with Advanced Hepatocellular Carcinoma JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Prajapati, H. J., Dhanasekaran, R., El-Rayes, B. F., Kauh, J. S., Maithel, S. K., Chen, Z., Kim, H. S. 2013; 24 (3): 307-315


    To investigate the safety and efficacy of transarterial chemoembolization using doxorubicin drug-eluting beads (DEBs) in patients with Barcelona Clinic Liver Cancer (BCLC) C stage hepatocellular carcinoma (HCC).Consecutive patients with initial staging of BCLC C HCC who received DEB transarterial chemoembolization over the last 5 years were studied. The study included 121 patients (mean age, 61.2 years old). Adverse events (AEs) after DEB transarterial chemoembolization were studied in detail and were recorded as per the National Cancer Institute Common Terminology Criteria for Adverse Events version 4.03 criteria. Survivals were analyzed according to parameters from the time of first DEB transarterial chemoembolization. Kaplan-Meier method by log-rank test and Cox proportional hazard model were used for survival analysis.AEs occurred in 30.2% of patients. No AEs were greater than Common Terminology Criteria for Adverse Events grade III. Grade I and II AEs included nausea and vomiting in 7.8% of patients and abdominal pain in 23.8% of patients. Grade III AEs were noted in 1.06% of patients. There were no gastrointestinal or hepatic complications. There were no deaths within 30 days after DEB transarterial chemoembolization. The overall median survival was 13.5 months. Among the Child-Pugh class A patients, those without PVT and metastasis (28.9%) had better survival when treated with DEB transarterial chemoembolization than those with PVT and metastases (9.9%) (18.8 mo versus 4.4 mo, P = .001). Ascites, performance status, Okuda stage HCC, serum alpha fetoprotein levels, and etiologic factor for chronic liver disease predicted survival.DEB transarterial chemoembolization appears to be a safe and effective treatment option for patients with BCLC C HCC. Patients with Child-Pugh class A without PVT and metastasis benefited most from DEB transarterial chemoembolization.

    View details for DOI 10.1016/j.jvir.2012.11.026

    View details for Web of Science ID 000315543600002

    View details for PubMedID 23375519

  • Chinese skullcap in move free arthritis supplement causes drug induced liver injury and pulmonary infiltrates. Case reports in hepatology Dhanasekaran, R., Owens, V., Sanchez, W. 2013; 2013: 965092-?


    Herbal medications are being increasingly used by the American population especially for common conditions like arthritis. They have been reported to cause adverse effects, including significant hepatotoxicity, but reporting remains sporadic. We report here a patient who developed drug induced liver injury following the intake of Move Free, which is an over-the-counter arthritis supplement. We propose that Chinese skullcap, which is one of the herbal ingredients of the medication, is responsible for the adverse event. There was a strong temporal association between the intake of supplement and onset of symptoms, and also there have been a few recent case reports implicating the same component. A unique observation in our case is the occurrence of pulmonary infiltrates simultaneously with the hepatotoxicity, and this side effect has not been well documented before. Both the hepatic and pulmonary complications completely resolved over few weeks after the patient stopped taking the medication. Since these supplements are readily available over the counter, we feel that it is important to document possible adverse outcomes to raise awareness in the medical community and also among patients.

    View details for DOI 10.1155/2013/965092

    View details for PubMedID 25431706

  • Liver Test Results Do Not Identify Liver Disease in Adults With alpha(1)-Antitrypsin Deficiency CLINICAL GASTROENTEROLOGY AND HEPATOLOGY Clark, V. C., Dhanasekaran, R., Brantly, M., Rouhani, F., Schreck, P., Nelson, D. R. 2012; 10 (11): 1278-1283


    Liver disease is a significant cause of death among adults with α(1)-antitrypsin (A-AT) deficiency. Age and male sex are reported risk factors for liver disease. In the absence of adequate risk stratification, current recommendations are to intermittently test A-AT-deficient adults for liver function. We evaluated this recommendation in a large group of adults with A-AT deficiency to determine the prevalence of increased levels of alanine aminotransferase (ALT) and identify risk factors for liver disease.We used the Alpha-1 Foundation DNA and Tissue Bank to identify a cross section of A-AT-deficient adults (n = 647) with and without liver disease; individuals without A-AT deficiency were used as controls (n = 152). Results from ALT tests were compared between groups.The prevalence of liver disease among individuals with A-AT deficiency was 7.9%; an increased level of ALT was observed in 7.8% of A-AT-deficient individuals, which did not differ significantly from controls. Mean levels of ALT fell within normal range for all groups. An increased level of ALT identified patients with liver disease with 11.9% sensitivity. The level of only γ-glutamyl transpeptidase was significantly higher in the A-AT-deficient group than in controls (43 vs 30 IU/mL; P < .003). A childhood history of liver disease and male sex were risk factors for adult liver disease in the multivariate analysis.An increased level of ALT does not identify adults with A-AT deficiency who have liver disease. Male sex and liver disease during childhood might help identify those at risk.

    View details for DOI 10.1016/j.cgh.2012.07.007

    View details for Web of Science ID 000310780200021

    View details for PubMedID 22835581

  • Incidentally discovered HCC (iHCC) in explant liver- Clinical and histopathologic features and outcome HEPATOLOGY Dhanasekaran, R., Pannu, D. S., Ismail, B., Zendejas, I., Firpi, R. L., Soldevila-Pico, C., Morelli, G., Clark, V. C., Suman, A., Nelson, D. R., Cabrera, R. 2012; 56: 476A-477A
  • The Impact of Pre transplant Transarterial Therapy in Hepatocellular Carcinoma HEPATOLOGY Pannu, D. S., Dhanasekaran, R., Bahaaeldeen, I., Zendejas, I., Firpi, R. J., Soldevila-Pico, C., Morelli, G., Clark, V. C., Nelson, D. R., Suman, A., Cabrera, R. 2012; 56: 458A-459A
  • Impact of Transarterial Therapy in Hepatitis C-Related Hepatocellular Carcinoma on Long-term Outcomes After Liver Transplantation AMERICAN JOURNAL OF CLINICAL ONCOLOGY-CANCER CLINICAL TRIALS Cabrera, R., Dhanasekaran, R., Caridi, J., Clark, V., Morelli, G., Soldevila-Pico, C., Magglioca, J., Nelson, D., Firpi, R. J. 2012; 35 (4): 345-350


    To evaluate the impact of long-term outcomes of transarterial embolization (TAE) therapy in patients with hepatitis C virus (HCV)-related hepatocellular carcinoma (HCC) on the waiting list for liver transplantation (LT).We retrospectively evaluated the post-LT patients with HCV-related HCC who received TAE intervention (n=33) and those who had no treatment (n=47) while on the waiting list to determine long-term outcomes.Over a 10-year period, of the 424 patients transplanted with HCV, 80 patients had HCC with a tumor burden within Milan criteria. For the entire study cohort, the mean duration of post-LT follow-up was 3.5 years; mean time of transplant waiting list was 120 days; and median post-LT survival was 8.9 years. The survival rates at 1, 3, 5, and 10 years were 82%, 70%, 55%, and 35%, respectively. From the study cohort, 33 patients received TAE and 47 patients did not while on the waiting list. The 2 groups were well matched, except, that the intervention patients received post-LT interferon more often and had a shorter time on the waiting list (56.2 d) when compared with the no treatment group (164.6 d, P<0.001). Median survival in the TAE group was 4.8 years and 8.9 years in the no treatment group. The recurrence rate was 15.6% in the treatment group and 6.9% in the no therapy group (P=0.275).Pre-LT transarterial therapy has no benefit on post-LT survival and tumor recurrence in patients with HCV-related HCC who underwent a mean waiting period of <3 months to transplant.

    View details for DOI 10.1097/COC.0b013e31821631f6

    View details for Web of Science ID 000306599200008

    View details for PubMedID 21552101

  • Tumoral and angiogenesis factors in hepatocellular carcinoma after locoregional therapy PATHOLOGY RESEARCH AND PRACTICE Farris, A. B., Dursun, N., Dhanasekaran, R., Coban, I., McIntosh, E. B., Adsay, N. V., Kim, H. S. 2012; 208 (1): 15-21


    Locoregional therapy (LRT) is used as a bridge to orthotopic liver transplant (OLT) for hepatocellular carcinoma (HCC) patients. Liver explants in OLT patients with HCC were studied regarding both tumor stage, histology, and immunohistochemical staining for cytokeratin (CK)7, CK19, P53, Ki-67, and vascular endothelial growth factor (VEGF). Patients receiving no LRT (control) (n=30) were compared with LRT treatment groups with conventional transarterial chemoembolization (cTACE) (n=25) or drug-eluting bead transarterial chemoembolization (DEB TACE) (n=17). Tumor stage and histology were similar between treatment and control groups. The mean percent necrosis was significantly higher for treatment groups versus the control group (p<0.0001 for both groups versus control) and was significantly higher in the cTACE group versus the DEB TACE group. Only the DEB TACE group showed peritumoral CK19 positivity, and tumors were all CK19-negative. Using a threshold of 50% of tumoral cells, tumoral VEGF was significantly different between groups, with the control group having the highest degree of positivity; however, peritumoral VEGF was not significantly different between the groups. The Ki-67 proliferation fraction was higher in the treated groups with a statistically significant difference between the DEB-treated group and those without treatment (p=0.02). There were no statistically significant differences in tumoral or peritumoral CK7 or p53. Percent necrosis and percent Ki-67 positivity were higher with LRT, with a significant difference between groups for percent necrosis, confirming that LRT causes necrosis and suggesting that treatment leads to increased proliferation and decreased tumoral VEGF.

    View details for DOI 10.1016/j.prp.2011.10.005

    View details for Web of Science ID 000300602900003

    View details for PubMedID 22088254

  • Rare case of adult undifferentiated (embryonal) sarcoma of the liver treated with liver transplantation: excellent long-term survival. Case reports in hepatology Dhanasekaran, R., Hemming, A., Salazar, E., Cabrera, R. 2012; 2012: 519741-?


    We present the case of a 54-year-old gentleman who presented with abdominal distension and a CT scan of his abdomen revealed a large (25 cm) left hepatic lobe tumor. He received chemotherapy for over 1.5 years. The CT scans at the completion of this therapy revealed that the tumor had actually slightly grown in size. He underwent orthotopic liver transplantation without any major complications. The explant histopathology revealed an undifferentiated embryonal cell sarcoma (UECS) composed of relatively bland spindled cells arranged in short fascicles. It is now 10 years and 3 months since his last transplant and the patient remains well with no tumor recurrence.

    View details for DOI 10.1155/2012/519741

    View details for PubMedID 25374706

  • Hepatocellular carcinoma: current trends in worldwide epidemiology, risk factors, diagnosis, and therapeutics. Hepatic medicine : evidence and research Dhanasekaran, R., Limaye, A., Cabrera, R. 2012; 4: 19-37


    Hepatocellular carcinoma (HCC) is a common malignancy in developing countries and its incidence is on the rise in the developing world. The epidemiology of this cancer is unique since its risk factors, including hepatitis C and B, have been clearly established. The current trends in the shifting incidence of HCC in different regions of the world can be explained partly by the changing prevalence of hepatitis. Early detection offers the only hope for curative treatment for patients with HCC, hence effective screening strategies for high-risk patients is of utmost importance. Liver transplantation and surgical resection remains the cornerstone of curative treatment. But major advances in locoregional therapies and molecular-targeted therapies for the treatment of advanced HCC have occurred recently. In this review, current trends in the worldwide epidemiology, surveillance, diagnosis, standard treatments, and the emerging therapies for HCC are discussed.

    View details for DOI 10.2147/HMER.S16316

    View details for PubMedID 24367230

  • Treatment Outcomes and Prognostic Factors for Intrahepatic Cholangiocarcinoma Single Center Experience GASTROENTEROLOGY Dhanasekaran, R., Hemming, A. W., Nelson, D. R., Soldevila-Pico, C., Firpi, R. J., Morelli, G., Clark, V., George, T. J., Robert, Z., Cabrera, R. 2011; 140 (5): S920-S920
  • THE IMPACT OF TRANSARTERIAL THERAPY IN RECURRENT HEPATOCELLULAR CARCINOMA AFTER LIVER TRANSPLANT HEPATOLOGY Cabrera, R., Dhanasekaran, R., Clark, V., Soldevila-Pico, C., Morelli, G. J., Caridi, J. G., Kim, R. D., Limaye, A. R., Nelson, D. R., Firpi, R. J. 2010; 52 (4): 1154A-1155A
  • THE IMPACT OF PRESERVATION INJURY ON ACCELERATED HEPATITIS C RECURRENCE AFTER LIVER TRANSPLANTATION HEPATOLOGY Michaels, A., Dhanasekaran, R., Alkhasawneh, A., Dixon, L., Soldevila-Pico, C., Morelli, G. (., Cabrera, R., Clark, V., Nelson, D. R., Firpi, R. J. 2010; 52 (4): 320A-320A
  • The Effectiveness of Locoregional Therapies versus Supportive Care in Maintaining Survival within the Milan Criteria in Patients with Hepatocellular Carcinoma JOURNAL OF VASCULAR AND INTERVENTIONAL RADIOLOGY Dhanasekaran, R., Khanna, V., Kooby, D. A., Spivey, J. R., Parekh, S., Knechtle, S. J., Carew, J. D., Kauh, J. S., Kim, H. S. 2010; 21 (8): 1197-1204


    To compare survival after treatment with either locoregional therapy (LRT) or supportive care in patients with hepatocellular carcinoma (HCC) within the Milan criteria.Patients with HCC who were classified within the Milan criteria (solitary HCC

    View details for DOI 10.1016/j.jvir.2010.04.018

    View details for Web of Science ID 000281045500008

    View details for PubMedID 20656222

  • Long-term survival after locoregional therapy in patients with unresectable hepatocellular carcinoma: Improvements over two decades. JOURNAL OF CLINICAL ONCOLOGY Dhanasekaran, R., McIntosh, E. B., Kauh, J. S., Kooby, D. A., El-rayes, B. F., Kim, H. S. 2010; 28 (15)
  • Chemoembolization with doxorubicin drug-eluting beads for unresectable hepatocelluar carcinoma with portal vein thrombosis JOURNAL OF CLINICAL ONCOLOGY McIntosh, E. B., Dhanasekaran, R., Kauh, J. S., El-rayes, B. F., Kooby, D. A., Williams, R. S., Kim, H. S. 2010; 28 (15)
  • Tumoral and angiogenesis factors in hepatocellular carcinoma (HCC) after drug eluting bead (DEB) transarterial chemoembolization (TACE) with doxorubicin JOURNAL OF CLINICAL ONCOLOGY Farris, A. B., Dhanasekaran, R., Dursun, N., Coban, I., McIntosh, E. B., Adsay, V., Kim, H. S. 2010; 28 (15)
  • Comparison of Conventional Transarterial Chemoembolization (TACE) and Chemoembolization With Doxorubicin Drug Eluting Beads (DEB) for Unresectable Hepatocelluar Carcinoma (HCC) JOURNAL OF SURGICAL ONCOLOGY Dhanasekaran, R., Kooby, D. A., Staley, C. A., Kauh, J. S., Khanna, V., Kim, H. S. 2010; 101 (6): 476-480


    Chemoembolization with doxorubicin drug eluting beads (DEB) is a novel locoregional treatment modality for unresectable hepatocellular carcinoma (HCC). Initial animal studies and clinical trials suggest that treatment with DEB may provide safer and more effective short-term outcomes than conventional chemoembolization. Current study explores long-term survival benefits.Consecutive patients who received transcatheter therapy with DEB or conventional chemoembolization as sole therapy between 1998 and 2008 were studied. Statistical analysis was performed using Kaplan-Meier estimator with log-rank testing, chi-squared, and independent t-tests.Seventy-one patients were included in this study, 45 (63.4%) received therapy with DEB (group A) and 26 (36.6%) underwent conventional chemoembolization (group B). Median survival from diagnosis of HCC in groups A and B were 610 (351-868) and 284 days (4-563; P = 0.03), respectively. In Okuda stage I, survival in groups A and B were 501 (421-528) and 354 days (148-560, P = 0.02). In Child-Pugh classes A and B, survival in groups A and B were 641 (471-810) and 323 days (161-485, P = 0.002). Median survival in patients with Cancer of Liver Italian Program (CLIP) score

    View details for DOI 10.1002/jso.21522

    View details for Web of Science ID 000277524100007

    View details for PubMedID 20213741

  • Prognostic factors for survival in patients with unresectable hepatocellular carcinoma undergoing chemoembolization with doxorubicin drug-eluting beads: a preliminary study HPB Dhanasekaran, R., Kooby, D. A., Staley, C. A., Kauh, J. S., Khanna, V., Kim, H. S. 2010; 12 (3): 174-180


    Transarterial chemoembolization (TACE) with drug-eluting beads (DEB) is a new treatment modality. Little is known about prognostic factors affecting survival after DEB TACE for patients with hepatocellular carcinoma (HCC).Patients who underwent TACE with doxorubicin DEB for unresectable HCC during 2006-2008 were studied. Survival was calculated from the day of first transcatheter therapy. Survival analysis was performed using Kaplan-Meier estimations. Survival curves were compared using the log-rank test.Fifty patients underwent chemoembolization with doxorubicin DEB. They included 39 women and 11 men, with a median age of 57.5 years (range 28-91 years). Eighteen patients died during the study period and 32 remained alive. Overall survival rates at 6 months, 1 year and 2 years from the first administration of doxorubicin DEB TACE were 71%, 65% and 51%, respectively. Prognostic factors found to be significant on univariate analysis were Child-Pugh class, Okuda staging, bilirubin > 2 mg/dl, albumin < 3.0 g/dl, Model for End-stage Liver Disease (MELD) score, serum alphafetoprotein (AFP), Cancer of the Liver Italian Programme (CLIP) score, tumour satisfying Milan criteria, Eastern Cooperative Oncology Group (ECOG) performance status (PS) and Barcelona Clinic Liver Cancer (BCLC) staging.Child-Pugh class, Okuda staging, bilirubin > 2 mg/dl, albumin < 3 g/dl, MELD score, serum AFP, CLIP score, Milan criteria, ECOG PS and BCLC staging were found to be prognostic markers of survival after treatment with doxorubicin DEB TACE in patients with unresectable HCC.

    View details for DOI 10.1111/j.1477-2574.2009.00138.x

    View details for Web of Science ID 000286435700003

    View details for PubMedID 20590884

  • Transjugular Intrahepatic Portosystemic Shunt for Symptomatic Refractory Hepatic Hydrothorax in Patients With Cirrhosis AMERICAN JOURNAL OF GASTROENTEROLOGY Dhanasekaran, R., West, J. K., Gonzales, P. C., Subramanian, R., Parekh, S., Spivey, J. R., Martin, L. G., Kim, H. S. 2010; 105 (3): 635-641


    We sought to study effectiveness, survival, and complications after transjugular intrahepatic portosystemic shunt (TIPS) in patients with cirrhosis and symptomatic refractory hepatic hydrothorax.Consecutive patients who underwent TIPS between January 1992 and December 2008 for refractory hydrothorax were reviewed retrospectively. Clinical, laboratory, and procedural data were collected for all patients by retrospective chart review. Chi-square test was used to compare categorical variables and t-test to compare continuous variables. The Kaplan-Meier method was used for survival analysis. Survival curves were compared using the log-rank test.Seventy-three patients were included in the study, and their mean age at TIPS creation was 55.62 years (s.d. 11.65). The mean pre- and post-TIPS portosystemic gradients were 18.9 (s.d. 4.7) mm Hg and 5.7 (s.d. 2.4) mm Hg (P<0.001), respectively. The rates of favorable clinical response within 1 month and at 6 months after TIPS were 79% (58/73) and 75% (30/40), respectively. Median survival of the study group was 517 days (95% CI 11-626). The short-term survival rates at 30, 60, and 90 days were 81, 78, and 72%, respectively. The long-term survival rates at 1, 3, and 5 years were 48, 26, and 15%, respectively. Multivariate analysis by Cox proportional hazards method showed that pre-TIPS model for end-stage liver disease (MELD) score (P=0.039, HR 1.9 (95% CI 1.0-3.7)) and clinical response (P=0.003, HR 2.5 (95% CI 1.4-4.5)) were significantly and independently associated with overall survival. The 30-day mortality rate was 19%. Pre-TIPS creatinine levels (P=0.024, HR 3.42 (95% CI 1.2-9.9)) were significantly associated with 30-day mortality.TIPS can be successfully used to achieve symptomatic relief in patients with refractory hepatic hydrothorax. Better clinical response after TIPS and pre-TIPS MELD score less than 15 were associated with longer survival after TIPS.

    View details for DOI 10.1038/ajg.2009.634

    View details for Web of Science ID 000275458300027

    View details for PubMedID 19904245

  • PREDICTORS OF EARLY MORTALITY AFTER TRAN-SJUGULAR INTRAHEPATIC PORTOSYSTEMIC SHUNTS (TIPS) HEPATOLOGY Dhanasekaran, R., Gonzales, P. C., West, J., Subramanian, R., Parekh, S., Spivey, J. R., Reshamwala, P., Martin, L. G., Kim, H. S. 2009; 50 (4): 436A-437A
  • Drug eluting beads versus conventional TACE for unresectable hepatocellular carcinoma: Survival benefits and safety JOURNAL OF CLINICAL ONCOLOGY Dhanasekaran, R., Kooby, D. A., Staley, C. A., Kauh, J. S., Kim, H. S. 2009; 27 (15)
  • Locoregional therapies as a bridge to transplant in patients with hepatocellular carcinoma JOURNAL OF CLINICAL ONCOLOGY Sakaria, S. S., Dhanasekaran, R., Pankonin, M., Parekh, S., Kauh, J. S., Kim, H. S. 2009; 27 (15)
  • High-risk factors affecting survival after transcatheter therapy with doxorubicin-eluting beads for unresectable hepatocellular carcinoma JOURNAL OF CLINICAL ONCOLOGY West, J. K., Dhanasekaran, R., Kooby, D. A., Staley, C. A., Kauh, J., Kim, H. S. 2009; 27 (15)