All Publications

  • Development and validation of a biomarker index for HCC treatment response. Hepatology communications Liang, J., Li, P. Y., Norman, J., Lauzon, M., Yeo, Y. H., Trivedi, H., Ayoub, W. S., Kuo, A., Friedman, M. L., Sankar, K., Gong, J., Osipov, A., Hendifar, A., Todo, T., Kim, I., Voidonikolas, G., Brennan, T. V., Wisel, S. A., Steggarda, J., Kosari, K., Saouaf, R., Nissen, N., Yao, F., Mehta, N., Yang, J. D. 2024; 8 (7)


    Serum AFP-L3%, AFP, and DCP are useful biomarkers for HCC detection, but their utility in assessing treatment response remains unknown. We aim to evaluate the accuracy of a biomarker model in the detection of posttreatment viable tumors.For model derivation, recipients with HCC undergoing liver transplant from 2018 to 2022 who had biomarkers collected within 3 months before transplant were included. We developed a generalized linear model for detecting posttreatment viable tumors with the 3 biomarkers as covariates, which we termed the "LAD Score." An independent cohort of 117 patients with HCC was used for external validation.Among 205 recipients of transplant, 70.2% had evidence of viable tumor on explant. The median LAD score was higher among patients with viable versus nonviable tumors (1.06 vs. 0.465, p < 0.001). The LAD score had a sensitivity of 55.6% and a specificity of 85.1% at the cutoff of 0.927, which was more accurate than imaging for detecting posttreatment viable tumors (AUROC 0.736 vs. 0.643, respectively; p = 0.045). The superior performance of the LAD score over imaging is primarily driven by its greater accuracy in detecting tumors <2 cm in diameter (AUROC of the LAD score 0.721 vs. imaging 0.595, p = 0.02). In the validation data set, the LAD score had an AUROC of 0.832 (95% CI: 0.753, 0.911) with a sensitivity of 72.5% and a specificity of 89.4% at the cutoff of 0.927.Our findings suggest the utility of LAD score in treatment response assessment after locoregional therapy for HCC, particularly in detecting small tumors. A larger prospective study is in progress to validate its accuracy and evaluate its performance in recurrence monitoring.

    View details for DOI 10.1097/HC9.0000000000000466

    View details for PubMedID 38896084

    View details for PubMedCentralID PMC11186807

  • Dual Positivity for AFP-L3 and DCP Identifies Patients at Exceptionally High Risk for Post-LT HCC Recurrence. Journal of hepatology Norman, J. S., Mehta, N. 2024

    View details for DOI 10.1016/j.jhep.2024.02.006

    View details for PubMedID 38346579

  • Management of ascites and volume overload in patients with cirrhosis. Clinical liver disease Kwong, A. J., Norman, J., Biggins, S. W. 2024; 23 (1): e0115

    View details for DOI 10.1097/CLD.0000000000000115

    View details for PubMedID 38343635

    View details for PubMedCentralID PMC10857675

  • Reply to: Incorporating AFP-L3 and DCP in selecting patients with hepatocellular carcinoma for liver transplantation: what are the optimal criteria? Journal of hepatology Norman, J. S., Mehta, N. 2023

    View details for DOI 10.1016/j.jhep.2023.12.017

    View details for PubMedID 38154740

  • A NOVEL HCC WAITLIST DROPOUT SCORE: BIOMARKER INTEGRATED DROPOUT GRADIENT ESTIMATION (BRIDGE) Li, J., Liang, J., Agopian, V. G., Nunez, K., Norman, J., Kim, N., Yum, J., Gumate, S., Cohen, A. J., Kosari, K., Nissen, N., Yao, F., Thevenot, P., Yang, J., Mehta, N. LIPPINCOTT WILLIAMS & WILKINS. 2023: S354
  • Author Spotlight: Joshua Norman. Digestive diseases and sciences Norman, J. 2023

    View details for DOI 10.1007/s10620-023-08109-7

    View details for PubMedID 37713039

  • AFP-L3 and DCP Strongly Predict Early Hepatocellular Carcinoma Recurrence After Liver Transplantation. Journal of hepatology Norman, J. S., Li, P. J., Kotwani, P., Shui, A. M., Yao, F., Mehta, N. 2023


    BACKGROUND & AIMS: Alpha-fetoprotein (AFP) predicts hepatocellular carcinoma (HCC) recurrence after liver transplant (LT) but remains an imperfect biomarker. The role of DCP (des-gamma-carboxyprothrombin) and AFP-L3 (AFP bound to Lens culinaris agglutinin) in predicting HCC recurrence remains incompletely characterized. AFP-L3 and DCP could identify patients at high risk of post-transplant HCC recurrence and serve as liver transplant exclusion criteria to defer transplant until patients receive additional risk-reducing pre-transplant local regional therapy.METHODS: This prospective cohort study included consecutive HCC patients who underwent LT (within or down-staged to Milan criteria) between 2017 and 2022. Pre-transplant AFP, AFP-L3, and DCP measurements were obtained. The primary endpoint was the ability of biomarkers to predict HCC recurrence-free survival.RESULTS: This cohort included 285 patients with a median age of 67 (IQR 63-71). At LT, median biomarker values were AFP 5.0ng/mL (IQR 3.0-12.1), AFP-L3 6.7% (0.5-13.2), and DCP 1.0ng/mL (0.3-2.8). Most (94.7%) patients received pre-LT local regional therapy (LRT). After a median post-LT follow-up of 3.1 years, HCC recurrence was observed in 18 (6.3%) patients. AFP-L3 and DCP outperformed AFP with C-statistics of 0.81 and 0.86 respectively, compared with 0.74 for AFP. A dual-biomarker combination of AFP-L3 ≥15% and DCP ≥7.5 predicted 61.1% of HCC recurrences whereas among 265 patients not meeting this threshold, only 7 (2.6%) recurred. The Kaplan-Meier recurrence-free survival at 3 years post-LT was 43.7% for patients with dual-positive biomarkers compared to 97.0% for all others (p<0.001).CONCLUSIONS: Dual-positivity for AFP-L3 ≥15% and DCP ≥7.5 strongly predicted post-LT HCC recurrence. This model could refine LT selection criteria and identify high-risk HCC patients to receive additional LRT with LT on hold until biomarker reduction is achieved.

    View details for DOI 10.1016/j.jhep.2023.08.020

    View details for PubMedID 37683735

  • Milky Way: Management of Primary Intestinal Lymphangiectasia. Digestive diseases and sciences Norman, J. S., Testa, S., Wang, C. X., Savage, T. 2023

    View details for DOI 10.1007/s10620-023-08077-y

    View details for PubMedID 37634185

    View details for PubMedCentralID 7789053

  • Optimizing liver transplant prioritization for hepatocellular carcinoma through risk stratification. Current opinion in organ transplantation Norman, J., Mehta, N., Kwong, A. 2023


    In the United States, candidates with hepatocellular carcinoma (HCC) meeting standardized qualifying criteria receive similar priority on the liver transplant waiting list through Model for End-Stage Liver Disease exception points, without consideration of the dropout risk or relative expected benefit from liver transplantation. A more nuanced allocation scheme for HCC is needed to better represent the individual urgency for liver transplant and optimize organ utility. In this review, we discuss the development of HCC risk prediction models for practical use in liver allocation.HCC is a heterogenous disease that requires improved risk stratification for patients who fall within current transplant eligibility criteria. Several models have been proposed, though none have been adopted in clinical practice or liver allocation to date, due to various limitations.Improved HCC risk stratification for liver transplant candidates is needed to more accurately represent their urgency for transplant, with continued attention to the potential impact on post-liver transplant outcomes. Plans to implement a continuous distribution model for liver allocation in the United States may provide an opportunity to re-consider a more equitable allocation scheme for patients with HCC.

    View details for DOI 10.1097/MOT.0000000000001080

    View details for PubMedID 37339511