Diagnosis and treatment of hepatocellular carcinoma

Efficient detection of hepatocellular carcinoma by a hybrid blood test of epigenetic and classical protein markers

BACKGROUND

There are few blood tests for an efficient detection of hepatocellular carcinoma (HCC) associated with hepatitis C virus (HCV) infection.

METHODS

The abilities of quantitative analyses of 7 genes hypermethylation in serum DNA, α-fetoprotein (AFP) and prothrombin-induced vitamin K absence II (PIVKA-II), and various combinations to detect HCC were evaluated in a training cohort of 164 HCV-infected patients (108 HCCs; 56 non-HCCs). An optimal hybrid detector, built using data for 2 methylated genes (SPINT2 and SRD5A2), AFP, and PIVKA-II, achieved the most satisfactory ability to detect HCC in the training cohort. We evaluated the ability of the optimal hybrid detector to detect HCC in an independent validation cohort of 258 consecutive HCV-infected patients (112 HCCs; 146 non-HCCs) who were newly enrolled in 4 distinct institutes.

RESULTS

In the validation cohort of 258 patients, accuracy, sensitivity, and specificity of the hybrid detector for detection of HCC were 81.4%, 73.2%, and 87.7%, respectively. Notably, even when detecting HCC ≤ 2 cm in diameter, the hybrid detector maintained markedly high abilities (84.6% accuracy, 72.2% sensitivity, 87.7% specificity). Youden's index (sensitivity+specificity - 1) for HCC ≤ 2cm was 0.60, vastly much superior to the 0.39 for AFP at a cut-off value of 20 ng/ml and the 0.28 for PIVKA-II at a cut-off value of 40 mAU/ml.

CONCLUSIONS

These results show that the optimal hybrid blood detector can detect HCV-related HCC more accurately.

Involvement of 14-3-3γ overexpression in extrahepatic metastasis of hepatocellular carcinoma

The 14-3-3γ protein is an important regulator of various cellular and physiologic functions. Overexpression promotes cell proliferation and induces cancer cell polyploidization. Production is up-regulated in human hepatocellular carcinoma. However, the clinical significance of 14-3-3γ for human hepatocellular carcinoma metastasis and survival has not been clarified. In this study, 55 patients with human hepatocellular carcinoma were enrolled; and 18 of them were identified as having extrahepatic metastases. Expression of 14-3-3γ in these primary and metastatic samples was measured with semiquantitative immunohistochemistry analysis. Overexpression of 14-3-3γ was observed in 38 (69.1%) of the primary tumors, correlated significantly with a high α-fetoprotein concentration (P = .003), and predicted a higher probability of extrahepatic metastasis (cumulative probabilities at 5 years: 42.2% ± 8.0% versus 5.9% ± 5.7%, 14-3-3γ positive versus negative; P = .012). Furthermore, 14-3-3γ overexpression was associated with a worse 5-year overall survival rate (81.6% ± 9.6% versus 59.5% ± 8.1%, respectively) and a worse 5-year progression-free survival rate (75.6% ± 10.6% versus 48.6% ± 8.2%, respectively). Elevated expression of 14-3-3γ in human hepatocellular carcinoma predicts extrahepatic metastasis and worse survival. The protein thus is a candidate biomarker and a potential target for novel therapies against human hepatocellular carcinoma progression and metastasis.

Fibrosis and AST to platelet ratio index predict post-operative prognosis for solitary small hepatitis B-related hepatocellular carcinoma

PURPOSE

Although advanced liver fibrosis is crucial in the development of hepatocellular carcinoma (HCC) for patients with chronic hepatitis B, whether it is associated with the recurrence of HCC after resection remains obscure. This study was aimed to compare the outcomes for patients with minimal or advanced fibrosis in solitary small hepatitis B virus (HBV)-related HCC.

METHODS

This study enrolled 76 patients with small (<5 cm) solitary HBV-related HCC who underwent resection. The outcomes of patients with minimal and advanced fibrosis in non-tumor areas were compared. Serum markers were tested to assess the stage of hepatic fibrosis and to predict prognosis.

RESULTS

Fourteen patients with an Ishak fibrosis score of 0 or 1 were defined as having minimal fibrosis; the remaining 62 patients were defined as having advanced fibrosis. During a follow-up period of 77.0 ± 50.7 months, 41 patients died. The overall survival rate was significantly higher (P = 0.018) and recurrence rate was lower (P = 0.018) for patients in the minimal fibrosis group. Aspartate aminotransferase-platelet ratio index (APRI) exhibited the most reliable discriminative ability for predicting advanced fibrosis. The overall survival rate was significantly higher (P = 0.003) and recurrence rate was lower (P = 0.005) for patients with an APRI of 0.47 or less.

CONCLUSIONS

For patients with solitary small HBV-related HCC who underwent resection, minimal fibrosis is associated with a lower incidence of recurrence and with better survival. APRI could serve as a reliable marker for assessing hepatic fibrosis and predicting survival.

Bleeding gastric ulcer after prophylactic coiling of transarterial chemoembolization

Transarterial chemoembolization is standard treatment for unresectable hepatocellular carcinoma. Prophylactic embolization of variant hepatic or gastric arteries before treatment of liver tumors reduces inadvertent injury to adjacent organs. This report presents a patient with multiple hepatocellular carcinomas, who developed an episode of acute gastric ulcer bleeding because of coil migration into the stomach 2 years after prophylactic embolization of the accessory right gastric artery for transarterial chemoembolization. This report discusses the purpose of prophylactic embolization, complications of coil embolization, various presentations and possible mechanisms of coil migration, and treatment of gastrointestinal bleeding. It also reviews pertinent literature.

Transarterial chemoembolization in patients with hepatocellular carcinoma and renal insufficiency

BACKGROUND

Renal dysfunction is often present in patients with cirrhosis and hepatocellular carcinoma (HCC). Acute renal failure (ARF) may occur after transarterial chemoembolization (TACE) owing to radiocontrast agent. This study investigated the incidence and risk factors of ARF and prognostic predictors in HCC patients with preexisting renal insufficiency undergoing TACE.

METHODS

A total of 566 HCC patients undergoing TACE were enrolled. Renal insufficiency was defined as an estimated glomerular filtration rate less than 60 mL/min/1.73 m.

RESULTS

In a mean follow-up duration of 18+/-16 months, 231 (40.8%) patients undergoing TACE died. Renal insufficiency that was present in 134 (23.7%) patients at baseline, independently predicted a poor prognosis in the Cox proportional hazards model [risk ratio (RR): 1.47, P=0.012]. Of them, 13 (10%) and 6 (5%) patients had transient and prolonged ARF after TACE, respectively. Post-TACE gastrointestinal bleeding [odds ratio (OR): 16.54, P=0.001] and higher Cancer of the Liver Italian Program (CLIP) scores (> or =2; OR: 4.22, P=0.02) were independent risk factors for ARF in the multivariate logistic regression analysis. In the Cox model, prolonged ARF (RR: 3.28, P<0.001) and higher CLIP scores (> or =2; RR: 2.13, P<0.001) were independent poor prognostic predictors for HCC patients with renal insufficiency receiving TACE.

CONCLUSIONS

Gastrointestinal bleeding and higher CLIP scores are associated with the development of ARF in patients with HCC and renal insufficiency undergoing TACE. Higher CLIP scores and renal insufficiency, either preexisting before TACE or as a complication of TACE, are poor prognostic predictors in HCC patients receiving TACE.

Epithelial-to-mesenchymal transition of murine liver tumor cells promotes invasion

Epithelial-to-mesenchymal transition (EMT) is predicted to play a critical role in metastatic disease in hepatocellular carcinoma. In this study, we used a novel murine model of EMT to elucidate a mechanism of tumor progression and metastasis. A total of 2 x 10(6) liver cells isolated from Pten(loxp/loxp)/Alb-Cre(+) mice, expanded from a single CD133(+)CD45(-) cell clone, passage 0 (P0), were sequentially transplanted to obtain two passages of tumor cells, P1 and P2. Cells were analyzed for gene expression using microarray and real-time polymerase chain reaction. Functional analysis included cell proliferation, migration, and invasion in vitro and orthotopic tumor metastasis assays in vivo. Although P0, P1, and P2 each formed tumors consistent with mixed liver epithelium, within the P2 cells, two distinct cell types were clearly visible: cells with epithelial morphology similar to P0 cells and cells with fibroblastoid morphology. These P2 mesenchymal cells demonstrated increased locomotion on wound healing; increased cell invasion on Matrigel basement membrane; increased EMT-associated gene expression of Snail1, Zeb1, and Zeb2; and down-regulated E-cadherin. P2 mesenchymal cells demonstrated significantly faster tumor growth in vivo compared with P2 epithelial counterparts, with invasion of intestine, pancreas, spleen, and lymph nodes. Furthermore, P2 mesenchymal cells secreted high levels of hepatocyte growth factor (HGF), which we propose acts in a paracrine fashion to drive epithelial cells to undergo EMT. In addition, a second murine liver cancer stem cell line with methionine adenosyltransferase 1a deficiency acquired EMT after sequential transplantations, indicating that EMT was not restricted to Pten-deleted tumors.

CONCLUSION

EMT is associated with a high rate of liver tumor proliferation, invasion, and metastasis in vivo, which is driven by HGF secreted from mesenchymal tumor cells in a feed-forward mechanism.

Role of microRNA-199a-5p and discoidin domain receptor 1 in human hepatocellular carcinoma invasion

Background

Micro-ribonucleic acid (miRNA)-199a-5p has been reported to be decreased in hepatocellular carcinoma (HCC) compared to normal tissue. Discoidin domain receptor-1 (DDR1) tyrosine kinase, involved in cell invasion-related signaling pathway, was predicted to be a potential target of miR-199a-5p by the use of miRNA target prediction algorithms. The aim of this study was to investigate the role of miR-199a-5p and DDR1 in HCC invasion.

Methods

Mature miR-199a-5p and DDR1 expression were evaluated in tumor and adjacent non-tumor liver tissues from 23 patients with HCC undergoing liver resection and five hepatoma cell lines by the use of real-time quantitative RT-PCR (qRT-PCR) analysis. The effect of aberrant miR-199a-5p expression on cell invasion was assessed in vitro using HepG2 and SNU-182 hepatoma cell lines. Luciferase reporter assay was employed to validate DDR1 as a putative miR-199a-5p target gene. Regulation of DDR1 expression by miR-199a-5p was assessed by the use qRT-PCR and western blotting analysis.

Results

A significant down-regulation of miR-199a-5p was observed in 65.2% of HCC tissues and in four of five cell lines. In contrast, DDR1 expression was significantly increased in 52.2% of HCC samples and in two of five cell lines. Increased DDR1 expression in HCC was associated with advanced tumor stage. DDR1 was shown to be a direct target of miR-199a-5p by luciferase reporter assay. Transfection of miR-199a-5p inhibited invasion of HepG2 but not SNU-182 hepatoma cells.

Conclusions

Decreased expression of miR-199a-5p contributes to increased cell invasion by functional deregulation of DDR1 activity in HCC. However, the effect of miR-199a-5p on DDR1 varies among individuals and hepatoma cell lines. These findings may have significant translational relevance for development of new targeted therapies as well as prognostic prediction for patients with HCC.

Detection and characterization of liver lesions using gadoxetic acid as a tissue-specific contrast agent

The value of cross-sectional liver imaging is evaluated by the accuracy, sensitivity, and specificity of the specific imaging technique. Magnetic resonance imaging (MRI) has become a key technique for the characterization and detection of focal and diffuse liver disease. More recently, gadoxetic acid, the hepatocyte-specific MR contrast agent, was clinically approved and introduced in many countries. Gadoxetic acid may be considered a "molecular imaging" probe because the compound is actively taken into hepatocytes via the ATP-dependent organic anion transport system in the plasma membrane for the hepatic uptake. The transport of gadoxetic acid from the cytoplasm to the bile is mainly determined by the capacity of the transport protein glutathione-S-transferase. Gadoxetic acid enhances hepatocyte-containing lesions and improves detection of lesions devoid of normal hepatocytes, such as metastases. Innovative rapid MR acquisition techniques with near isotropic 3D pulse sequences with fat saturation parallel the technical progress made by multidetector computed tomography combined with an impressive improvement in tumor-liver contrast when used for gadoxetic acid-enhanced MRI. The purpose of this review is to provide an overview of the development, clinical testing, and applications of this novel MR contrast agent.

Chronic hepatitis B and hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world and the third leading cause of cancer-related deaths. More than 80% of HCC cases are from the Asian and African continents, and more than 50% of cases are from mainland China. Approximately 350 million to 400 million persons are chronically infected with hepatitis B virus (HBV), and this virus is the most common cause of HCC worldwide. It is estimated that more than 50% of liver cancers worldwide are attributable to HBV and up to 89% of HBV-related HCC are from developing countries. Recently, increasing trends in HCC incidence have been reported from several Western countries, including France, Australia, and the United States.

Hepatitis C virus infection, age, and Hispanic ethnicity increase mortality from liver cancer in the United States

BACKGROUND & AIMS

We performed a population-based study to assess factors that are associated independently with hepatocellular carcinoma (HCC)-related mortality.

METHODS

We evaluated clinicodemographic, laboratory, and mortality data collected from 15,866 individuals in the Third National Health and Nutrition Examination Survey from 1988 to 1994. The etiology of chronic liver disease was determined using serologic tests to measure hepatitis C virus (HCV) RNA, hepatitis B surface antigen, and iron; excessive alcohol consumption and nonalcoholic fatty liver disease (NAFLD) were determined. Cohorts were compared with controls using a stratum-specific chi-square test. The Cox proportional hazard model was used to identify independent predictors of HCC-related mortality.

RESULTS

After a follow-up period of 160 months, 14.55% of the individuals died; 83 deaths were liver-related (25 HCC and 58 non-HCC liver related). Factors that independently predicted HCC-related mortality were age (hazard ratio [HR], 1.10; 95% confidence interval [CI], 1.04-1.16; P = .0021), Hispanic ethnicity (HR, 5.14; 95% CI, 1.75-15.06; P = .0036), and HCV infection (HR, 18.12; 95% CI, 3.57-91.98; P = .0008). Factors that independently predicted non-HCC liver-related mortality included age (HR, 1.07; 95% CI, 1.04-1.10; P < .0001), male sex (HR, 3.29; 95% CI, 1.15-9.42; P = .0277), alcoholic liver disease (HR, 10.81; 95% CI, 1.32-88.26; P = .0271), HCV (HR, 27.00; 95% CI, 4.70-155.1; P = .0004), iron overload (HR, 6.18; 95% CI, 1.82-20.97; P = .0043), or NAFLD (HR, 11.56; 95% CI, 3.21-41.67; P = .0004).

CONCLUSIONS

This population-based study showed that HCV infection and Hispanic ethnicity independently increase the risk for HCC-related mortality. All liver diseases, including NAFLD, increase the risk for non-HCC liver-related mortality.

Treatment of hepatocellular carcinoma with adeno-associated virus encoding interleukin-15 superagonist

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide, but effective therapies are still needed. The liver has been identified as an important immune organ and is heavily populated with various lymphocyte subsets known to play important roles in cancer immunosurveillance. We hypothesized that activation of hepatic lymphocytes by interleukin (IL)-15, a cytokine known for its ability to trigger proliferation and activation of natural killer (NK) cells, natural killer T cells, and memory CD8(+) T cells, might offer an alternative therapy for HCC. We employed hepatotropic adeno-associated virus serotype 8 (AAV8) to deliver an IL-15 superagonist (IL-15-IL-15RalphaS), consisting of IL-15 covalently linked to the N-terminal sushi domain of the IL-15 receptor alpha chain, to achieve local sustained cytokine expression in the liver environment. We observed that a single injection of AAV8 expressing IL-15-IL-15RalphaS, but not IL-15 alone, greatly expanded the number of hepatic mononuclear cells, mainly NK cells, for at least 21 days. AAV8/IL-15-IL-15RalphaS treatment generated potent antitumor activity in a liver metastatic murine HCC model (BNL cells), and significantly prolonged the survival time of treated animals. The antitumor effect depended mainly on NK cells, not on CD8(+) and CD4(+) T cells, because AAV8/IL-15-IL-15RalphaS treatment greatly enhanced the cytolytic activity of hepatic NK cells and depletion of NK cells abrogated the therapeutic effect. Importantly, no apparent liver toxicity was observed during AAV8/IL-15-IL-15RalphaS treatment. Together, our data demonstrate that AAV8-delivered IL-15-IL-15RalphaS provides an effective and safe therapy against metastatic HCC.

Chemoembolization for hepatocellular carcinoma: comprehensive imaging and survival analysis in a 172-patient cohort

PURPOSE

To determine comprehensive imaging and long-term survival outcome following chemoembolization for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

One hundred seventy-two patients with HCC treated with chemoembolization were studied retrospectively in an institutional review board approved protocol; this study was HIPAA compliant. Baseline laboratory and imaging characteristics were obtained. Clinical and laboratory toxicities following treatment were assessed. Imaging characteristics following chemoembolization were evaluated to determine response rates (size and necrosis) and time to progression (TTP). Survival from the time of first chemoembolization treatment was calculated. Subanalyses were performed by stratifying the population according to Child-Pugh, United Network for Organ Sharing, and Barcelona Clinic for Liver Cancer (BCLC) staging systems.

RESULTS

Cirrhosis was present in 157 patients (91%); portal hypertension was present in 139 patients (81%). Eleven patients (6%) had metastases at baseline. Portal vein thrombosis was present in 11 patients (6%). Fifty-five percent of patients experienced some form of toxicity following treatment; 21% developed grade 3 or 4 bilirubin toxicity. Post-chemoembolization response was seen in 31% and 64% of patients according to size and necrosis criteria, respectively. Median TTP was 7.9 months (95% confidence interval: 7.1, 9.4) but varied widely by stage. Median survival was significantly different between patients with BCLC stages A, B, and C disease (stage A, 40.0 months; B, 17.4 months; C, 6.3 months; P < .0001).

CONCLUSION

The determination of TTP and survival in patients with HCC is confounded by tumor biology and background cirrhosis; chemoembolization was shown to be a safe and effective therapy in patients with HCC.

Recombinant adenovirus IL-24-Bax promotes apoptosis of hepatocellular carcinoma cells in vitro and in vivo

Gene therapy promises to become an alternative choice for the treatment of hepatic cancer. In many cancers, the delivery of chimeric proteins by adenovirus vector has been reported to induce apoptosis. This study was performed to evaluate whether the recombinant adenovirus interleukin (IL)-24-Bax can induce apoptosis in hepatocellular carcinoma cells in vitro and in vivo. Several recombinant adenoviruses were constructed, and the expression of their encoded proteins was measured. The effects of the recombinant adenovirus on hepatocellular carcinoma cells and the normal hepatocyte cell line were investigated through cell viability and apoptosis assays after the cells were treated with Ad.Luc, Ad.IL-24, Ad.Bax or Ad.IL-24-Bax. The mechanism involved was also explored. A tumor-bearing mouse model was used to evaluate the effects of the adenovirus on tumor volume and cell apoptosis in vivo. Ad.IL-24-Bax selectively suppressed growth of hepatocellular carcinoma cells and induced apoptosis, but it had little influence on the normal hepatocytes. The mechanism of this response may include the effect of the 10HRE/VEGF385 promoter and the synergistic effect of IL-24 and Bax. Ad.IL-24-Bax also suppressed tumor growth in nude mice and induced apoptosis. Ad.IL-24-Bax may be a useful tool for gene therapy of hepatic cancer.

Intermediate hepatobiliary cells predict an increased risk of hepatocarcinogenesis in patients with hepatitis C virus-related cirrhosis

BACKGROUND & AIMS

The expression of biliary lineage markers such as cytokeratin (K) 7 by hepatocytes is thought to reflect an altered regeneration pathway recruiting a stem cell compartment, more prone to carcinogenesis. We aimed to investigate the presence of these so-called intermediate hepatobiliary cells (IHC) in liver biopsies of patients with hepatitis C-related cirrhosis and their potential influence on the subsequent occurrence of hepatocellular carcinoma (HCC).

METHODS

From a cohort of patients with hepatitis C-related cirrhosis, prospectively screened for HCC, we retrospectively selected those with a liver biopsy performed for the initial diagnosis of cirrhosis. Presence of IHC was recorded when foci of K7-positive, intermediate-sized hepatocytes were detected.

RESULTS

A total of 150 patients were included (87 men; mean age, 57 y; range, 19-84 y; body mass index, 25 kg/m(2)). After a median follow-up period of 4.85 years, HCC was diagnosed in 36 patients (24%). Baseline liver biopsy showed intermediate hepatobiliary cell foci in 61 patients (41%). Intermediate cells co-expressed both hepatocytes markers and the progenitor cell markers Ep-CAM and K19. The presence of intermediate hepatobiliary cells was associated independently with HCC occurrence (Fine and Gray model; hazard ratio, 2.48; 95% confidence interval, 1.24-4.96; P = .01). Other predictors of HCC were diabetes and low platelet count. The HCC annual incidence rate was significantly higher in patients with IHC compared with patients without (8.14% vs 3.12%, Gray's test, P = .003).

CONCLUSIONS

The aberrant expression of biliary K by hepatocytes in patients with hepatitis C virus-related cirrhosis is related independently to HCC occurrence.

Health-related quality of life in patients with hepatocellular carcinoma: a systematic review

BACKGROUND & AIMS

This systematic review was conducted to identify the following: (1) generic and disease-specific measures used to assess health-related quality of life (HRQOL) in patients with hepatocellular carcinoma (HCC); (2) HRQOL in patients with HCC compared with those with chronic liver disease and the general population; (3) effects of treatment (liver surgery, hepatic artery transcatheter treatment, and radiotherapy) on HRQOL; (4) relationships between physical variables, symptoms, and HRQOL; (5) relationships between demographic characteristics, psychological variables, and HRQOL; and (6) effects of psychological interventions on HRQOL.

METHODS

Computerized databases including British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, Cochrane library, PsychoINFO, and Pubmed were searched.

RESULTS

Thirty-six articles were identified. The results suggested the following. Four original articles described the development of standardized measures to assess liver cancer-specific HRQOL. Patients with HCC reported worse physical, emotional, and functional HRQOL, but better social/family HRQOL compared with the general population. HRQOL improved after liver surgery, hepatic artery transcatheter treatment, and radiotherapy. Better liver function, early stage of disease, and no recurrence were correlated positively with better HRQOL; and pain, fatigue, nausea, and performance status were associated with worse HRQOL. HRQOL was correlated negatively with depression, uncertainty, chance health locus of control, and positively with satisfaction with medical services. Psychosocial interventions may reduce negative feelings and enhance HRQOL.

CONCLUSIONS

Future work should explore the effects of psychological variables on HRQOL and the interaction between physical and psychological variables in relation to HRQOL.

Effects of HSP70 antisense oligonucleotide on the proliferation and apoptosis of human hepatocellular carcinoma cells

The study investigated the effects of heat shock protein 70 (HSP70) antisense oligonucleotide (ASODN) on the proliferation and apoptosis of a human hepatocellular carcinoma cell line (SMMC-7721 cells) in vitro. HSP70 oligonucleotide was transfected into SMMC-7721 cells by the mediation of Sofast transfection reagent. Inhibition rate of SMMC-7721 cells was determined by using MTT method. Apoptosis rate and cell cycle distribution were measured by flow cytometry. Immunocytochemistry staining was used to observe the expression of HSP70, Bcl-2 and Bax. The results showed that HSP70 ASODN at various concentrations could significantly inhibit the growth of SMMC-7721 cells, and the inhibition effect peaked 48 h after transfection with 400-nmol/L HSP70 ASODN. Cytometric analysis showed the apoptotic rate was increased in a dose- and time-dependent manner in the HSP70 ASODN-treated cells. The percentage of cells in the G2/M and S phases was significantly decreased and that in the G0/G1 phase increased as the HSP70 ASODN concentration was elevated and the exposure time prolonged. Immunocytochemistry showed that treatment of SMMC-7721 cells with HSP70 ASODN resulted in decreased expressions of HSP70 and Bcl-2 proteins, and an increased expression of Bax protein. It was concluded that the HSP70 ASODN can inhibit the growth of the SMMC-7721 cells and increase cell apoptosis by down-regulating the expression of HSP70. HSP70 ASODN holds promise for the treatment of hepatocellular carcinoma.

Long-term clinical outcomes of hepatic arterial infusion chemotherapy with cisplatin with or without 5-fluorouracil in locally advanced hepatocellular carcinoma

PURPOSE

Hepatic arterial infusion chemotherapy (HAIC) has often been used as a therapeutic option for patients with advanced hepatocellular carcinoma (HCC). This study aimed to evaluate the efficacy and safety of HAIC using cisplatin with or without 5-fluorouracil in patients with advanced HCC.

METHODS

Between January 2002 and December 2007, we enrolled patients with advanced HCC who underwent HAIC via implantable port systems with cisplatin (60 mg/m(2) on Day 1) with or without 5-fluorouracil (500 mg/m(2) on Days 1-3) every 4 weeks. Tumor response was assessed every two cycles.

RESULTS

During follow-up (median 9.5 months), we recorded patient (n = 138) and disease characteristics including median age (53 years), Child-Pugh class A/B (n = 103/35, respectively), portal vein thrombosis (n = 115), and death (n = 121). In total, 561 cycles of HAIC were administered (median four cycles, range 1-14). Ninety-one patients received cisplatin plus 5-fluorouracil, while 47 received only cisplatin. The median progression-free survival (PFS) and overall survival (OS) were 6.0 and 9.5 months, respectively, while the overall disease control rate was 62.3% (3 complete responses, 29 partial responses and 54 stable diseases). Patients treated with cisplatin plus 5-fluorouracil had longer median PFS (7.0 vs. 4.6 months in those given cisplatin only; p = 0.004) and OS (12.0 vs. 7.5 months in those given cisplatin only; p = 0.001). Adverse reactions were tolerable and successfully managed with conservative treatment.

CONCLUSIONS

Repetitive HAIC seems well-tolerated and effective in treating advanced HCC, with more therapeutic benefit when treated with cisplatin plus 5-fluorouracil. Future randomized comparative studies are warranted for its efficacy.

Immunotherapy of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) represents the third most common cause of cancer-related death worldwide and efficient treatment options are urgently needed. Based on its pathogenesis, in addition to a number of correlative studies, immunotherapy represents a potential therapeutic option for patients with HCC. However, tumors have also evolved numerous immune escape mechanisms, including the generation of cells with immune suppressor functions, such as Tregs and myeloid-derived suppressor cells. It has been shown that these suppressor cells mask tumor-specific immune responses in patients with HCC. Different immunotherapeutic approaches including peptide- and dendritic cell-based therapies have demonstrated promising results in patients with HCC. However, we propose that any of these immunotherapeutic approaches needs to be combined with a therapy specifically targeting suppressor cells in HCC.

Genetic inactivation of the Fanconi anemia gene FANCC identified in the hepatocellular carcinoma cell line HuH-7 confers sensitivity towards DNA-interstrand crosslinking agents

Background

Inactivation of the Fanconi anemia (FA) pathway through defects in one of 13 FA genes occurs at low frequency in various solid cancer entities among the general population. As FA pathway inactivation confers a distinct hypersensitivity towards DNA interstrand-crosslinking (ICL)-agents, FA defects represent rational targets for individualized therapeutic strategies. Except for pancreatic cancer, however, the prevalence of FA defects in gastrointestinal (GI) tumors has not yet been systematically explored.

Results

A panel of GI cancer cell lines was screened for FA pathway inactivation applying FANCD2 monoubiquitination and FANCD2/RAD51 nuclear focus formation and a newly identified FA pathway-deficient cell line was functionally characterized. The hepatocellular carcinoma (HCC) line HuH-7 was defective in FANCD2 monoubiquitination and FANCD2 nuclear focus formation but proficient in RAD51 focus formation. Gene complementation studies revealed that this proximal FA pathway inactivation was attributable to defective FANCC function in HuH-7 cells. Accordingly, a homozygous inactivating FANCC nonsense mutation (c.553C > T, p.R185X) was identified in HuH-7, resulting in partial transcriptional skipping of exon 6 and leading to the classic cellular FA hypersensitivity phenotype; HuH-7 cells exhibited a strongly reduced proliferation rate and a pronounced G2 cell cycle arrest at distinctly lower concentrations of ICL-agents than a panel of non-isogenic, FA pathway-proficient HCC cell lines. Upon retroviral transduction of HuH-7 cells with FANCC cDNA, FA pathway functions were restored and ICL-hypersensitivity abrogated. Analyses of 18 surgical HCC specimens yielded no further examples for genetic or epigenetic inactivation of FANCC, FANCF, or FANCG in HCC, suggesting a low prevalence of proximal FA pathway inactivation in this tumor type.

Conclusions

As the majority of HCC are chemoresistant, assessment of FA pathway function in HCC could identify small subpopulations of patients expected to predictably benefit from individualized treatment protocols using ICL-agents.

Hepatocellular carcinoma in thalassemia: A critical review

Due to blood transfusions, thalassemics are often infected with either hepatitis C virus (HCV) or hepatitis B virus and often have hemochromatosis. Hepatocellular carcinoma (HCC) has emerged in thalassemics only recently as a result of the improvement in thalassemia outcomes. In fact, a prospective study estimated an HCC incidence in β-thalassemia of about 2%. Although data are scanty, HCC screening in thalassemics with risk factors for HCC should be carried out. HCV treatments have some efficacy in HCV infected thalassemics despite partial contraindication to ribavirin and iron overload. However, there are no data on how HCV treatment translates into HCC prevention. Preliminary data suggest that HCC treatment in thalassemics should generally have the same outcomes as in non-thalassemics. Although coexistence of severe comorbidities makes liver transplantation challenging, this therapeutic possibility should not be precluded for well selected HCC β-thalassemia patients. In fact, 2 transfusion dependent adult HCC β-thalassemia patients have recently undergone successful liver transplantation with a good outcome. In conclusion, HCC seems to be a developing issue in thalassemia and HCC screening should be carried out. HCC treatment, including liver transplantation, can be performed in selected patients. A multidisciplinary effort is needed for management.

Automated retrieval of CT images of liver lesions on the basis of image similarity: method and preliminary results

PURPOSE

To develop a system to facilitate the retrieval of radiologic images that contain similar-appearing lesions and to perform a preliminary evaluation of this system with a database of computed tomographic (CT) images of the liver and an external standard of image similarity.

MATERIALS AND METHODS

Institutional review board approval was obtained for retrospective analysis of deidentified patient images. Thereafter, 30 portal venous phase CT images of the liver exhibiting one of three types of liver lesions (13 cysts, seven hemangiomas, 10 metastases) were selected. A radiologist used a controlled lexicon and a tool developed for complete and standardized description of lesions to identify and annotate each lesion with semantic features. In addition, this software automatically computed image features on the basis of image texture and boundary sharpness. Semantic and computer-generated features were weighted and combined into a feature vector representing each image. An independent reference standard was created for pairwise image similarity. This was used in a leave-one-out cross-validation to train weights that optimized the rankings of images in the database in terms of similarity to query images. Performance was evaluated by using precision-recall curves and normalized discounted cumulative gain (NDCG), a common measure for the usefulness of information retrieval.

RESULTS

When used individually, groups of semantic, texture, and boundary features resulted in various levels of performance in retrieving relevant lesions. However, combining all features produced the best overall results. Mean precision was greater than 90% at all values of recall, and mean, best, and worst case retrieval accuracy was greater than 95%, 100%, and greater than 78%, respectively, with NDCG.

CONCLUSION

Preliminary assessment of this approach shows excellent retrieval results for three types of liver lesions visible on portal venous CT images, warranting continued development and validation in a larger and more comprehensive database.

Role of cadherin-17 in oncogenesis and potential therapeutic implications in hepatocellular carcinoma

Cadherin is an important cell adhesion molecule that plays paramount roles in organ development and the maintenance of tissue integrity. Dysregulation of cadherin expression is often associated with disease pathology including tissue dysplasia, tumor formation, and metastasis. Cadherin-17 (CDH17), belonging to a subclass of 7D-cadherin superfamily, is present in fetal liver and gastrointestinal tract during embryogenesis, but the gene becomes silenced in healthy adult liver and stomach tissues. It functions as a peptide transporter and a cell adhesion molecule to maintain tissue integrity in epithelia. However, recent findings from our group and others have reported aberrant expression of CDH17 in major gastrointestinal malignancies including hepatocellular carcinoma (HCC), stomach and colorectal cancers, and its clinical association with tumor metastasis and advanced tumor stages. Furthermore, alternative splice isoforms and genetic polymorphisms of CDH17 gene have been identified in HCC and linked to an increased risk of HCC. CDH17 is an attractive target for HCC therapy. Targeting CDH17 in HCC can inhibit tumor growth and inactivate Wnt signaling pathway in concomitance with activation of tumor suppressor genes. Further investigation on CDH17-mediated oncogenic signaling and cognate molecular mechanisms would shed light on new targeting therapy on HCC and potentially other gastrointestinal malignancies.

RhoGTPases and Rho-effectors in hepatocellular carcinoma metastasis: ROCK N'Rho move it

Hepatocellular carcinoma (HCC) is an intractable disease with an extremely high mortality rate. Metastasis is the major factor of liver failure, tumour recurrence and death in HCC patients. Unfortunately, no promising curative therapy for HCC metastasis is available as yet; therefore, treatment for advanced HCC still remains a formidable challenge. A large body of evidence has demonstrated that the RhoGTPases/Rho-effector pathway plays important roles in mediating HCC metastasis based on their foremost functions in orchestrating the cell cytoskeletal reorganization. This review will first discuss the general principles of cancer metastasis and cancer cell movement with a particular focus on HCC.We will then summarize the implications of various members in the RhoGTPases/Rho-effectors signalling cascade including the upstream RhoGTPase regulators RhoGTPases and Rho-effectors and their downstream targets in HCC metastasis. Finally, we will discuss the therapeutic insight of targeting the RhoGTPases/Rho-effector pathway in HCC. Taken together, the literature demonstrates the importance of the RhoGTPases/Rho-effector signalling pathway in HCC metastasis and marks the necessity to have a more thorough knowledge of this complicated signalling network in order to develop novel therapeutic strategies for HCC patients.

Phase II Study of Pegylated Arginine Deiminase for Nonresectable and Metastatic Hepatocellular Carcinoma

Purpose

It is well known that hepatocellular carcinoma (HCC) is an arginine auxotroph due to argininosuccinate synthetase I deficiency. This study's purpose was to evaluate the effects of pegylated arginine deiminase (ADI) in terms of toxicity, tumor response, α-fetoprotein (AFP) levels, and serum arginine levels.

Patients and Methods

Eighty patients were randomly assigned to receive either 80 IU/m2 or 160 IU/m2 of ADI weekly for up to 6 months. Adverse events, serum arginine, AFP levels, and antibody production against ADI were measured on a regular basis. In addition, disease response and time to progression according to the Response Evaluation Criteria in Solid Tumors (RECIST) and survival rates were evaluated.

Results

Four patients were excluded from the survival analysis because they developed exclusion criteria after randomization, but before first treatment. The number of patients in the two cohorts were similar (n = 37 in the low-dose cohort, n = 39 in the high-dose cohort). Mean (±SE) survival for all subjects was 15.8 months (474 days ± 39 days) from time of diagnosis of unresectable disease. Arginine levels remained below baseline for 50 days while antibodies against ADI reached a plateau at approximately the same time. There were no deaths attributed to ADI treatment. Only two patients were withdrawn for immunogenic-related adverse events. Grade 2, 3, or 4 toxicities were recorded in 92, 19, and 0 patients, respectively.

Conclusion

Pegylated ADI is a promising drug that capitalizes on a significant enzymatic deficiency in HCC. It is safe, well tolerated, and may benefit patients with unresectable HCC.

Cinobufacini, an aqueous extract from Bufo bufo gargarizans Cantor, induces apoptosis through a mitochondria-mediated pathway in human hepatocellular carcinoma cells

AIM OF THE STUDY

Cinobufacini (Huachansu), an aqueous extract from the skin and parotid venom glands of Bufo bufo gargarizans Cantor, is a traditional Chinese medicine widely used in clinical cancer therapy in China. The present study sought to investigate the possible signaling pathway implicated in cinobufacini-induced apoptosis in the hepatocellular carcinoma cell lines HepG(2) and Bel-7402.

MATERIALS AND METHODS

The effects of cinobufacini on cell proliferation of HepG(2) and Bel-7402 cells were evaluated by 3-[4,5-dimethylthiazol-2-yl]-2,5-diphenyl-tetrazolium bromide (MTT) assays. Cell apoptosis was detected by Hoechst 33258 staining and flow cytometry analysis. The mitochondrial membrane potential (Deltapsim) and caspase-9 and -3 activity were detected using MitoCapture reagent staining and colorimetric assays, respectively. The expression of apoptosis-related proteins and release of cytochrome c were assessed by Western blot analysis.

RESULTS

Cinobufacini significantly inhibited cell proliferation of both cell lines in a dose- and time-dependent manner. Marked changes in apoptotic morphology and apoptosis rates were clearly observed after cinobufacini treatment. The protein expression of Bax increased whereas that of Bcl-2 decreased, leading to an increase in the Bax/Bcl-2 ratio. Subsequently, cinobufacini disrupted the mitochondrial membrane potential (Deltapsim) and resulted in the release of cytochrome c, activation of both caspase-9 and -3, and cleavage of poly (ADP-ribose) polymerase (PARP).

CONCLUSION

The present study indicated that cinobufacini can induce apoptosis of HepG(2) and Bel-7402 cells through a mitochondria-mediated apoptosis pathway.

Quantitative proteomics identification of phosphoglycerate mutase 1 as a novel therapeutic target in hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide with poor prognosis due to resistance to conventional chemotherapy and limited efficacy of radiotherapy. There is an urgent need to develop novel biomarkers for early diagnosis, as well as to identify new drug targets for therapeutic interventions.

PATIENTS AND METHODS

54 paired HCC samples and 21 normal liver tissues were obtained from West China Hospital of Sichuan University. Informed consent was obtained from all the patients or their relatives prior to analysis, and the project was approved by the Institutional Ethics Committee of Sichuan University. Stable Isotope Labeling with Amino Acids in Cell Culture (SILAC)-based proteomics was employed to profile the differentially expressed proteins between a HepG2 human hepatoma cell line and an immortal hepatic cell line L02. Validation of PGAM1 expression was performed by semi-quantitative RT-PCR, immunoblot and immunohistochemistry using clinical samples. shRNA expressing plasmids specifically targeting PGAM1 were designed and constructed by GenePharma Corporation (Shanghai, China), and were utilized to silence expression of PGAM1 in vitro and in vivo. Cell proliferation was measured by a combination of colony formation assay and Ki67 staining. Apoptosis was examined by flow cytometry and TUNEL assay.

RESULTS

A total of 63 dysregulated proteins were identified, including 51 up-regulated proteins, and 12 down-regulated proteins (over 2-fold, p < 0.01). Phosphoglycerate mutase 1 (PGAM1) was found markedly upregulated. Clinico-pathological analysis indicated that overexpression of PGAM1 was associated with 66.7% HCC, and strongly correlated with poor differentiation and decreased survival rates (p < 0.01). shRNAs-mediated repression of PGAM1 expression resulted in significant inhibition in liver cancer cell growth both in vitro and in vivo.

CONCLUSION

Our studies suggested that PGAM1 plays an important role in hepatocarcinogenesis, and should be a potential diagnostic biomarker, as well as an attractive therapeutic target for hepatocellular carcinoma.

Regional liver therapy using oncolytic virus to target hepatic colorectal metastases

The mortality of colorectal carcinoma often results from the progression of metastatic disease, which is predominantly hepatic. Although recent advances in surgical, locoregional, and systemic therapies have yielded modest improvements in survival, treatment of these aggressive lesions is limited to palliation for the vast majority of patients. Oncolytic viral therapy represents a promising novel therapeutic modality that has achieved tumor regression in several preclinical and clinical models. Evidence further suggests that locoregional viral administration may improve viral efficacy while minimizing toxicity. This study will review the theories behind hepatic arterial infusion of oncolytic virus, as well as herpes viral design, preclinical data, and clinical progress in regional liver therapy using oncolytic virus to treat hepatic colorectal carcinoma metastases.

Enhanced detection of early hepatocellular carcinoma by serum SELDI-TOF proteomic signature combined with alpha-fetoprotein marker

Background

Biomarkers for accurate diagnosis of early hepatocellular carcinoma (HCC) are limited in number and clinical validation. We applied SELDI-TOF-MS ProteinChip technology to identify serum profile for distinguishing HCC and liver cirrhosis (LC) and to compare the accuracy of SELDI-TOF-MS profile and alpha-fetoprotein (AFP) level in HCC diagnosis.

Patients and Methods

Serum samples were obtained from 120 HCC and 120 LC patients for biomarker discovery and validation studies. ProteinChip technology was employed for generating SELDI-TOF proteomic features and analyzing serum proteins/peptides.

Results

A diagnostic model was established by CART algorithm, which is based on 5 proteomic peaks with m/z values at 3324, 3994, 4665, 4795, and 5152. In the training set, the CART algorithm could differentiate HCC from LC subjects with a sensitivity and specificity of 98% and 95%, respectively. The results were assessed in blind validation using separate cohorts of 60 HCC and 60 LC patients, with an accuracy of 83% for HCC and 92% for LC patients. The diagnostic odd ratio (DOR) indicated that SELDI-TOF proteomic signature could achieve better diagnostic performance than serum AFP level at a cutoff of 20 ng/mL (AFP₂₀) (92.72 vs 9.11), particularly superior for early-stage HCC (87% vs 54%). Importantly, a combined use of both tests could enhance the detection of HCC (sensitivity, 95%; specificity, 98%; DOR, 931).

Conclusion

Serum SELDI-TOF proteomic signature, alone or in combination with AFP marker, promises to be a good tool for early diagnosis and/screening of HCC in at-risk population with liver cirrhosis.

Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma

INTRODUCTION

The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on the management of hepatocellular carcinoma (HCC) in December 2008 to develop consensus recommendations.

METHODS

The working party consisted of expert hepatologist, hepatobiliary surgeon, radiologist, and oncologist from Asian-Pacific region, who were requested to make drafts prior to the consensus meeting held at Bali, Indonesia on 4 December 2008. The quality of existing evidence and strength of recommendations were ranked from 1 (highest) to 5 (lowest) and from A (strongest) to D (weakest), respectively, according to the Oxford system of evidence-based approach for developing the consensus statements.

RESULTS

Participants of the consensus meeting assessed the quality of cited studies and assigned grades to the recommendation statements. Finalized recommendations were presented at the fourth APASL single topic conference on viral-related HCC at Bali, Indonesia and approved by the participants of the conference.

Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma

INTRODUCTION

The Asian Pacific Association for the Study of the Liver (APASL) convened an international working party on the management of hepatocellular carcinoma (HCC) in December 2008 to develop consensus recommendations.

METHODS

The working party consisted of expert hepatologist, hepatobiliary surgeon, radiologist, and oncologist from Asian-Pacific region, who were requested to make drafts prior to the consensus meeting held at Bali, Indonesia on 4 December 2008. The quality of existing evidence and strength of recommendations were ranked from 1 (highest) to 5 (lowest) and from A (strongest) to D (weakest), respectively, according to the Oxford system of evidence-based approach for developing the consensus statements.

RESULTS

Participants of the consensus meeting assessed the quality of cited studies and assigned grades to the recommendation statements. Finalized recommendations were presented at the fourth APASL single topic conference on viral-related HCC at Bali, Indonesia and approved by the participants of the conference.

Imaging response in the primary index lesion and clinical outcomes following transarterial locoregional therapy for hepatocellular carcinoma

CONTEXT

Response Evaluation Criteria in Solid Tumors (RECIST) (unidimensional), World Health Organization (WHO) (bidimensional), and European Association for Study of the Liver (EASL) (necrosis) guidelines are commonly used to assess response following therapy for hepatocellular carcinoma (HCC). No universally accepted standard exists.

OBJECTIVES

To evaluate intermethod agreement between these 3 imaging guidelines and to introduce the concept of the "primary index lesion" as a biomarker for response.

DESIGN, SETTING, AND PARTICIPANTS

Single-center comprehensive imaging analysis including 245 consecutive patients with HCC who were treated with chemoembolization or radioembolization between January 2000 and December 2008. Computed tomography and magnetic resonance imaging scans (N = 1065) were reviewed to assess response in the "primary index lesion," defined as the largest tumor targeted during first treatment.

MAIN OUTCOME MEASURES

Intermethod agreement (kappa statistics) between RECIST, WHO, and EASL guidelines response; correlation of WHO and EASL response in the primary index lesion with time to progression and survival.

RESULTS

Kappa coefficients were 0.86 (95% confidence interval [CI], 0.80-0.92) between the WHO and RECIST guidelines, 0.24 (95% CI, 0.16-0.33) between RECIST and EASL, and 0.28 (95% CI, 0.19-0.36) between WHO and EASL. Disease progressed in 96 patients; 113 died. The hazard ratio for time to progression in responders compared with nonresponders was 0.36 (95% CI, 0.23-0.57) for WHO, 0.38 (95% CI, 0.24-0.58) for RECIST, and 0.38 (95% CI, 0.22-0.64) for EASL. Hazard ratios for survival in responders compared with nonresponders in univariate and multivariate analyses were 0.46 (95% CI, 0.32-0.67) and 0.55 (95% CI, 0.35-0.84) for WHO and 0.36 (95% CI, 0.22-0.57) and 0.54 (95% CI, 0.34-0.85) for EASL. Hazard ratios for survival in responders vs nonresponders in patients with solitary and multifocal HCC were 0.39 (95% CI, 0.19-0.77) and 0.51 (95% CI, 0.32-0.82) for WHO and 0.26 (95% CI, 0.10-0.67) and 0.47 (95% CI, 0.28-0.79) for EASL.

CONCLUSIONS

Among a group of patients with HCC, agreement for classification of therapeutic response was high between the RECIST and WHO guidelines but low between each of these and EASL. Application of these methods to measure response in a primary index lesion resulted in statistically significant correlations with disease progression and survival.

National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines for use of tumor markers in liver, bladder, cervical, and gastric cancers

BACKGROUND

Updated National Academy of Clinical Biochemistry Laboratory Medicine Practice Guidelines for the use of tumor markers in the clinic have been developed.

METHODS

Published reports relevant to use of tumor markers for 4 cancer sites--liver, bladder, cervical, and gastric--were critically reviewed.

RESULTS

Alpha-fetoprotein (AFP) may be used in conjunction with abdominal ultrasound for early detection of hepatocellular carcinoma (HCC) in patients with chronic hepatitis or cirrhosis associated with hepatitis B or C virus infection. AFP concentrations >200 microg/L in cirrhotic patients with typical hypervascular lesions >2 cm in size are consistent with HCC. After a diagnosis of HCC, posttreatment monitoring with AFP is recommended as an adjunct to imaging, especially in the absence of measurable disease. Although several urine markers have been proposed for bladder cancer, none at present can replace routine cystoscopy and cytology in the management of patients with this malignancy. Some may, however, be used as complementary adjuncts to direct more effective use of clinical procedures. Although carcinoembryonic antigen and CA 19-9 have been proposed for use gastric cancer and squamous cell carcinoma antigen for use in cervical cancer, none of these markers can currently be recommended for routine clinical use.

CONCLUSIONS

Implementation of these recommendations should encourage optimal use of tumor markers for patients with liver, bladder, cervical, or gastric cancers.

Survival in Asian Americans after treatments for hepatocellular carcinoma: a seven-year experience at UCLA

BACKGROUND/RATIONALE

Hepatocellular carcinoma (HCC) is a common malignancy in Asians and is related to the high incidence of chronic viral hepatitis in this ethnic population. The aims of this study were to examine the tumor characteristics and liver disease status in HCC patients of Asian ancestry and determine their survival after treatments for HCC.

RESULTS

Between September 2000 and December 2007, 278 patients, mean age 61.5 years, presented with HCC to the University of California Los Angeles (UCLA) Liver Cancer Center. Hepatitis B (HBV) infection was detected in up to 68% of Chinese, Korean, and Vietnamese patients, whereas 60% of Japanese patients had Hepatitis C (HCV) infection. Compared with HCC patients who presented with symptoms, those detected by surveillance had more tumors within the Milan and University of California, San Francisco (UCSF) criteria and more patients in Child-Turcotte-Pugh class A. On the basis of a predefined UCLA treatment algorithm, 83% of patients received surgical and/or loco-regional therapies. Compared with other treatments, orthotopic liver transplantation (OLT), and radiofrequency ablation had the highest overall patient survival (P<0.0001) and OLT has the highest disease free survival rates (P<0.0001). Independent baseline predictors for: (1) patient survival were HBV [hazard ratio (HR) 0.62, P=0.005], UCSF criteria (HR 0.46, P<0.0001), Child Turcotte Pugh class A (HR 0.57, P=0.005), alphafetoprotein per log10 increase (HR 1.26, P=0.0012), and alkaline phosphatase per log10 increase (HR 2.32, P=0.02); and for (2) disease free survival were UCSF criteria (HR 0.66 P=0.007), aspartate aminotransferase per log10 increase (HR 1.50, P=0.04), and age per year increase (HR=1.02, P=0.04). The 4 Asian subgroups had similar survival rates.

CONCLUSIONS

HBV and Hepatitis C were associated with over 90% of HCC cases in Asian Americans. HCC detected by surveillance identified more patients eligible for surgical and loco-regional therapies, which improved the overall and disease free survival.

dUTP pyrophosphatase expression correlates with a poor prognosis in hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is a malignancy with a poor prognosis, partly owing to the lack of biomarkers that support its classification in line with its malignant nature. To discover a novel molecular marker that is related to the efficacy of treatment for HCC and its biological nature, we performed serial analysis of gene expression (SAGE) in HCC, normal liver and cirrhotic liver tissues.

METHODS

Gene expression profiles of HCC tissues and non-cancerous liver tissues were obtained by SAGE. Suppression of the target gene by RNA interference was used to evaluate its role in HCC in vitro. The relation of the identified marker and prognosis was statistically examined in surgically resected HCC patients.

RESULTS

We identified significant overexpression of DUT, which encodes dUTP pyrophosphatase (dUTPase), in HCC tissue, and this was confirmed in about two-thirds of the HCC samples by reverse-transcription polymerase chain reaction (n=20). Suppression of dUTPase expression using short interfering RNAs inhibited cell proliferation and sensitized HuH7 cells to 5-fluorouracil treatment. Nuclear dUTPase expression was observed in 36.6% of surgically resected HCC samples (n=82) evaluated by immunohistochemistry, and its expression was significantly correlated with the histological grades (P=0.0099). Notably, nuclear dUTPase expression correlated with a poor prognosis with statistical significance (HR, 2.47; 95% CI, 1.08-5.66; P=0.032).

CONCLUSION

Taken together, these results suggest that nuclear dUTPase may be a good biomarker for predicting prognosis in HCC patients after surgical resection. Development of novel dUTPase inhibitors may facilitate the eradication of HCC.

Favorable alpha-fetoprotein decrease as a prognostic surrogate in patients with hepatocellular carcinoma after radiofrequency ablation

BACKGROUND AND AIM

To assess the significance of adequate alpha-fetoprotein decrease in monitoring the treatment effects of radiofrequency ablation (RFA) in hepatocellular carcinoma (HCC) patients.

METHODS

A total of 72 RFA treatments in 54 HCC patients were analyzed. The favorable alpha-fetoprotein decrease was defined as the alpha-fetoprotein half-life of less than 7 days. The efficacy of the ablation response is assessed by standard imaging modality, a computed tomography scan 1 month after RFA. We assessed the correlation between different alpha-fetoprotein decreases and treatment outcomes by standard imaging modality.

RESULTS

Of the 72 therapies, 15 (21%) were favorable alpha-fetoprotein decreases. Fifty-one (71%) therapies showed concordant results through standard image modality and alpha-fetoprotein decrease, including 14 (27%) therapies with a complete radiological response and favorable alpha-fetoprotein decrease, and the remaining 37 (73%) therapies with an incomplete radiological response and unfavorable alpha-fetoprotein decrease. The accuracy was 70.8% by using alpha-fetoprotein decrease in the detection treatment response based on a complete radiological response. Among the 34 therapies with a complete radiological response, 14 therapies with a favorable alpha-fetoprotein decrease had a better disease-free survival curve than 20 therapies with an unfavorable alpha-fetoprotein decrease (P = 0.003). Only one case had a favorable alpha-fetoprotein decrease, but incomplete radiological response, with massive necrosis, with the exception of a small residual tumor.

CONCLUSIONS

A favorable alpha-fetoprotein decrease has better predictive power for disease-free survival than for an unfavorable alpha-fetoprotein decrease. HCC patients after RFA with an unfavorable alpha-fetoprotein decrease should be considered to have undergone incomplete treatment, despite the complete response by standard image modality post-RFA.

Hepatitis C virus proteins modulate microRNA expression and chemosensitivity in malignant hepatocytes

PURPOSE

Hepatocellular cancer (HCC) is highly resistant to chemotherapy and is associated with poor prognosis. Chronic hepatitis C virus (HCV) infection is a major cause of HCC. However, the effect of viral proteins in mediating chemosensitivity in tumor cells is unknown. We postulated that HCV viral proteins could modulate therapeutic responses by altering host cell microRNA (miRNA) expression.

EXPERIMENTAL DESIGN

HepG2 malignant hepatocytes were stably transfected with full-length HCV genome (Hep-394) or an empty vector (Hep-SWX). MiRNA profiling was done by using a custom microarray, and the expression of selected miRNAs was validated by real-time PCR. Protein expression was assessed by Western blotting, whereas caspase activation was assessed by a luminometric assay.

RESULTS

The IC(50) to sorafenib was lower in Hep-394 compared with Hep-SWX control cells. Alterations in miRNA expression occurred with 10 miRNAs downregulated >2-fold and 23 miRNAs upregulated >2-fold in Hep-394 cells compared with controls. Of these, miR-193b was overexpressed by 5-fold in Hep-394 cells. miR-193b was predicted to target Mcl-1, an antiapoptotic protein that can modulate the response to sorafenib. The expression of Mcl-1 was decreased, and basal caspase-3/7 activity and poly ADP ribose polymerase cleavage were increased in Hep-394 cells compared with controls. Moreover, transfection with precursors to miR-193b decreased both Mcl-1 expression and the IC(50) to sorafenib.

CONCLUSIONS

Cellular expression of full-length HCV increases sensitivity to sorafenib by the miRNA-dependent modulation of Mcl-1 and apoptosis. Modulation of miRNA responses may be a useful strategy to enhance response to chemotherapy in HCC.

Reduced expression of fibroblast growth factor receptor 2IIIb in hepatocellular carcinoma induces a more aggressive growth

Fibroblast growth factor receptor 2 isoform b (FGFR2-IIIb) is highly expressed in hepatocytes and plays an important role in liver homeostasis and regeneration. Here, we analyzed the expression and function of FGFR2-IIIb in hepatocellular carcinoma (HCC). FGFR2-IIIb expression in HCC tissues and cell lines was lower than in primary human hepatocytes and nontumorous tissue. FGFR2-IIIb-negative HCCs showed a significantly higher Ki-67 labeling index, and loss of FGFR2-IIIb expression correlated significantly with vascular invasion and more advanced tumor stages. A decrease in FGFR-2IIIb expression in HCC cell lines was not related to promoter hypermethylation. However, PCR analysis indicated that chromosomal deletion at 10q accounted for the loss of FGFR2 expression in a subset of HCC cells. FGFR2-IIIb re-expression in stable transfected HCC cell lines induced a higher basal apoptosis rate and a significantly reduced proliferation and migratory potential in vitro. In nude mice, FGFR2-IIIb re-expressing HCC cells grew significantly slower, and terminal deoxynucleotidyl transferase-mediated dUTP nick-end labeling assay revealed higher apoptosis rates. The antitumorigenic effects of FGFR2-IIIb expression in HCC cells were not affected by keratinocyte growth factor or an inhibitor of FGFR-phosphorylation, indicating that they are independent of tyrosine kinase activation. In conclusion, our data indicate that FGFR2-IIIb inhibits tumorigenicity of HCC cells. Identification of the molecular mechanisms promoting regeneration in normal tissue while suppressing malignancy may lead to novel therapeutic targets of this highly aggressive tumor.

Liver tumor ablation: percutaneous and open approaches

The global incidence of liver cancer is greater than a million cases a year. Surgical resection where applicable is still the standard of care for these patients. Various liver-directed regional therapies have been developed in an effort to treat the vast majority of unresectable liver tumors. This article reviews the principles behind various ablation therapies currently available for malignant liver tumors and their outcomes.

Multiphasic MDCT enhancement pattern of hepatocellular carcinoma smaller than 3 cm in diameter: tumor size and cellular differentiation

OBJECTIVE

The purpose of this study was to evaluate according to size and degree of cellular differentiation the multiphasic MDCT enhancement pattern of hepatocellular carcinoma (HCC) smaller than 3 cm in diameter in patients with cirrhosis.

MATERIALS AND METHODS

In 155 consecutively registered patients (126 men, 29 women; mean age, 58.4 years), 204 pathologically proven HCCs smaller than 3 cm were detected at multiphasic MDCT. Three radiologists in consensus classified the relative attenuation of the tumors compared with the surrounding liver parenchyma as hyperattenuation, isoattenuation, or hypoattenuation on biphasic (n = 86) and triphasic (n = 69) CT scans.

RESULTS

The prevalent enhancement patterns of HCC differed depending on tumor size. The prevalent pattern of HCC measuring 20-29 mm was arterial hyperattenuation with venous washout (47%, 47/101). The prevalent enhancement patterns of HCC smaller than 10 mm and HCC measuring 10-19 mm were isoattenuation during the arterial and portal venous phases (29%, 6/21) and hyperattenuation and isoattenuation during the arterial and portal venous phases (33%, 27/82). The typical HCC enhancement pattern (arterial hyperattenuation with venous washout) was identified in 48% (67/141) of the moderately and poorly differentiated HCCs and in 13% (8/63) of well-differentiated HCCs.

CONCLUSION

The prevalent enhancement patterns of HCC smaller than 3 cm on multiphasic MDCT scans differed depending on tumor size and cellular differentiation. HCCs smaller than 2 cm and well-differentiated HCCs frequently had atypical enhancement patterns.

Hepatocellular carcinoma metastases to the epidural space

Hepatocellular carcinoma (HCC) is relatively uncommon in the United States, although hepatitis C, one of the known risk factors for disease, is currently showing burgeoning growth in the country. Hence, it is possible that the incidence of HCC also will increase. Clinicians and pathologists in the United States are relatively unfamiliar with the patterns of metastatic spread for HCC. We report 2 US-native patients with cirrhosis and HCC who developed epidural space metastasis, a pattern of disease spread seen infrequently, even in endemic areas. Diagnostic testing was delayed in both patients because of the lowered suspicion for metastasis and the fact that neither patient had recognized metastatic spread to more common sites, such as lung or lymph nodes. New-onset neck or back pain-especially with symptoms of paresthesia, radiculopathy, or cord compression-in the setting of HCC warrants prompt investigation for metastases to the spine and epidural space.

Hepatocellular carcinoma: review of current treatment with a focus on targeted molecular therapies

The treatment of hepatocellular carcinoma (HCC) remains a challenge, with 1- and 3-year survival rates of 20% and 5%, respectively, and a median survival of 8 months. However, a better understanding of the pathogenesis of HCC, and advances in targeted molecular therapies provide physicians treating this disease with new hope. The treatment of HCC is multidisciplinary, requiring surgeons, hepatologists, interventional radiologists and oncologists. Thus, there is enormous potential to combine various treatment modalities to improve survival for patients. This review will describe what is currently known about the molecular pathogenesis of HCC, explore current and future treatments based on these pathways, and describe how these new therapies fit into existing approaches to HCC treatment.

CT findings of completely regressed hepatocellular carcinoma with main portal vein tumor thrombosis after transcatheter arterial chemoembolization

Objective

The objective of this study was to determine the sequential CT findings of controlled hepatocellular carcinoma (HCC) with main portal vein (MPV) thrombosis with the use of transcatheter arterial chemoembolization and additional intra-arterial cisplatin infusion.

Materials and Methods

From January 2004 to September 2006, 138 patients with HCC invading MPV were referred to the angiography unit of our institution for chemoembolization and additional intra-arterial cisplatin infusion. Until August 2008, seven (5%) of 138 patients were followed-up and found not to have tumor recurrence. CT scans were retrospectively reviewed by two radiologists, focusing on the following parameters: the extent of portal vein thrombosis, the diameter of the affected portal vein, and enhancement of portal vein thrombosis.

Results

The extent of portal vein thrombosis at the initial presentation was variable: left portal vein (LPV) and MPV (n = 1), right portal vein (RPV) and MPV (n = 3), as well as RPV, LPV and MPV (n = 3). The extent and diameter of the affected portal vein decreased during follow-up examinations. In addition, the degree of enhancement for tumor thrombi and serum alpha-feto-protein levels decreased after the transcatheter arterial chemoembolization. Portal vein thrombosis was found to be completely resolved in one patient, whereas residual thrombus without viability was persistent in six patients.

Conclusion

If chemoembolization is effective in patients with HCC that invades the portal vein, the extent and enhancement of portal vein thrombosis is reduced, but residual thrombosis frequently persists for months or years, without evidence of a viable tumor.

Nuclear beta-catenin induces an early liver progenitor phenotype in hepatocellular carcinoma and promotes tumor recurrence

Transforming growth factor-beta cooperates with oncogenic Ras to activate nuclear beta-catenin during the epithelial to mesenchymal transition of hepatocytes, a process relevant in the progression of hepatocellular carcinoma (HCC). In this study we investigated the role of beta-catenin in the differentiation of murine, oncogene-targeted hepatocytes and in 133 human HCC patients scheduled for orthotopic liver transplantation. Transforming growth factor-beta caused dissociation of plasma membrane E-cadherin/beta-catenin complexes and accumulation of nuclear beta-catenin in Ras-transformed, but otherwise normal hepatocytes in p19(ARF)-/- mice. Both processes were inhibited by Smad7-mediated disruption of transforming growth factor-beta signaling. Overexpression of constitutively active beta-catenin resulted in high levels of CK19 and M2-PK, whereas ablation of beta-catenin by axin overexpression caused strong expression of CK8 and CK18. Therefore, nuclear beta-catenin resulted in dedifferentiation of neoplastic hepatocytes to immature progenitor cells, whereas loss of nuclear beta-catenin led to a differentiated HCC phenotype. Poorly differentiated human HCC showed cytoplasmic redistribution or even loss of E-cadherin, suggesting epithelial to mesenchymal transition. Analysis of 133 HCC patient samples revealed that 58.6% of human HCC exhibited strong nuclear beta-catenin accumulation, which correlated with clinical features such as vascular invasion and recurrence of disease after orthotopic liver transplantation. These data suggest that activation of beta-catenin signaling causes dedifferentiation to malignant, immature hepatocyte progenitors and facilitates recurrence of human HCC after orthotopic liver transplantation.

Radiologic-pathologic correlation of hepatocellular carcinoma treated with chemoembolization

To correlate posttreatment radiologic and pathologic findings in patients who underwent transarterial chemoembolization before transplantation or resection. Thirty-five patients with postchemoembolization follow-up imaging underwent liver transplantation/resection. Pre- and posttreatment contrast-enhanced magnetic resonance imaging were used to evaluate radiologic findings. Imaging characteristics using World Health Organization (WHO) and European Association for the Study of the Liver (EASL) criteria after treatment were evaluated. Treated lesions were examined by pathology (gold standard) for the assessment of necrosis. Radiologic findings on magnetic resonance imaging were correlated to pathologic findings to assess the predictability by imaging of actual necrosis. Kappa (κ) statistics were used to determine intermethod agreement between WHO and EASL criteria. Fourteen (40%) of 35 lesions had biopsy-proven hepatocellular carcinoma. Thirteen (37%) of 35 target lesions showed complete pathologic necrosis. Complete pathologic necrosis was seen in 35% of lesions with pretreatment size <3 cm. Complete pathologic necrosis was seen in 1 (100%) of 1, 6 (67%) of 9, 6 (33%) of 18, and 0 (0%) of 7 of the lesions that exhibited complete response (CR), partial response (PR), stable disease (SD), or progressive disease (PD) by WHO criteria, respectively. Complete pathologic necrosis was seen in 9 (82%) of 11, 4 (36%) of 11, 0 (0%) of 8, and 0 (0%) of 5 of the lesions that showed CR, PR, SD, or PD by EASL criteria, respectively. EASL CR and WHO response were shown to have ≥85% specificity for predicting complete pathologic necrosis. The κ coefficient for agreement between WHO and EASL was 0.29. EASL and WHO criteria had minimal intermethod agreement. EASL CR and WHO response were able to predict pathologic necrosis.

Stereotactic Radiotherapy of the Liver: A Bridge to Transplantation

Patients with hepatocellular carcinoma (HCC) have limited curative therapeutic options. In North America, liver transplantation is one of the most commonly used curative therapies. Many potential transplant patients will be treated with another therapeutic modality to prevent local disease progression while awaiting organ donation.

We present the case of 60-years old male diagnosed with HCC and awaiting liver transplantation. Prior to registration on the transplant list, the patient had a significant increase of his serum alpha-fetoprotein level. Due to his vascular anatomy and tumor location, he was not a candidate for more standard local ablative therapies. He was thus offered stereotactic radiotherapy as a bridge to liver transplantation. He received 50Gy in 5 fractions using respiratory gating. Following this, he had a complete radiological and serological response without worsening of his baseline Child-Pugh class C cirrhosis. Following transplant, 13 months later, pathological examination of the liver explant revealed only scarring at the site of radiation. This case illustrated the fact that hepatic stereotactic radiotherapy is a promising and safe treatment for patients with HCC. In selected patients, it can be a bridge to transplantation and, on its own, has the potential to induce complete pathological response in non-surgical candidates.

AAV3-mediated transfer and expression of the pyruvate dehydrogenase E1 alpha subunit gene causes metabolic remodeling and apoptosis of human liver cancer cells

Most cancers rely disproportionately on glycolysis for energy even in the presence of adequate oxygen supply, a condition known as "aerobic glycolysis", or the Warburg effect. Pharmacological reversal of the Warburg effect has been shown to cause selective apoptosis of tumor cells, presumably by stimulating mitochondrial respiratory chain activity and production of reactive oxygen species that, in turn, induce a caspase-mediated series of reactions leading to cell death. We reasoned that a similar effect on tumor cells might result from up-regulation of the E1alpha subunit gene (pda1) of the pyruvate dehydrogenase complex (PDC) that catalyzes the rate-limiting step in aerobic glucose oxidation and thus plays a major role in the control of oxidative phosphorylation. To test this postulate, we employed a self-complementary adeno-associated virus (scAAV)-based delivery and expression system for targeting pda1 to the mitochondria of primary cultures of human hepatoblastoma (HB) and hepatocellular carcinoma (HCC) cells. Serotypes 1-10 scAAV vectors that included enhanced green fluorescent (egfp) reporter gene driven by either cytomegalovirus (CMV) or chicken beta-actin (CBA) promoters were analyzed for transduction ability of HB (Huh-6) and HCC (Huh-7 and HepG2) cell lines and primary cultures of normal human hepatocytes. Serotype 3 scAAV-egfp (scAAV3-egfp) vector was the most efficient and transduced up to 90% of cells. We limited the transgene expression primarily to liver cancer cells by generating scAAV3 vectors that contained the human alpha-fetoprotein promoter (AFP)-driven reporter gene (scAAV3.AFP-egfp) and the potentially therapeutic gene scAAV3.AFP-pda1. Infection of Huh-6 cells by the scAAV3.AFP-pda1 vector increased protein expression of E1alpha, PDC catalytic activity, and late-stage apoptotic cell death. Apoptosis was also associated with increased protein expression of Bcl-X/S, an early marker of apoptosis, and release of cytochrome c into the cytosol of infected HB cells. These data indicate that molecular targeting of mitochondrial oxidative metabolism in liver cancer cells by AAV3-mediated delivery of pda1 holds promise as a novel and effective therapeutic approach for human hepatic tumors.