Treatment of hepatocellular carcinoma with adriamycin. Preliminary communication

Epirubicin and etoposide combination chemotherapy to treat hepatocellular carcinoma patients: a phase II study

Approximately half the patients affected with hepatocellular carcinoma (HCC) present with unresectable disease, so that efficacious systemic chemotherapy protocols are badly needed. We report the results of a phase-II study aimed at testing the efficacy and toxicity of a combination of epirubicin and VP-16. Thirty six patients (80 men and 6 women) received epirubicin (40 mg/m2, on day 1) and VP-16 (120 mg/m2, on days 1, 3 and 5) every 28th day. Chemotherapy was stopped in case of disease progression, while the patients who achieved an objective response or who had stable disease continued treatment for a maximum of 10 cycles. One patient (3%) achieved a complete response, while 13 patients (36%) achieved partial response, i.e. 14 objective responses in all (39%, 95% CI: 23-55%). 11 patients (31%) exhibited stable disease, while in the other 11 patients (31%) the disease progressed. Median overall survival time was 10 months and 13.5 months in the subgroup of patients responding to treatment. Significant, especially haematological, toxicity was documented, but in no case was it so severe as to require discontinuation of treatment or reduction of the dosage. In conclusion, this combination appears to be an active and tolerable therapeutic option for HCC patients who are not candidates for surgical or locoregional procedures, and in our opinion it deserves further exploration within a randomised controlled trial versus best supportive therapy.

Non-surgical treatment of hepatocellular carcinoma

A decade ago, surgery was the only satisfactory treatment modality for hepatocellular carcinoma (HCC), but it was limited only to selected cases. For the majority of cases of HCC, systemic chemotherapy was one of the few treatment alternatives, but provided only marginal benefit. In the past 20 years, diagnostic methods have improved to an extent that small HCC less than 1 cm can be detected. Moreover, non-surgical treatment is available, of which regional therapy has been shown to prolong patients' survival, and may even replace surgical resection in some cases. Regional therapy is indicated for the treatment of HCC when there is no extrahepatic metastasis and the patient has adequate liver function reserve, thus permitting repeated therapy. Transcatheter hepatic arterial embolization (TAE) using various embolizers has been well documented to include controlled studies. However, it is not indicated for patients with thrombosed main portal veins. Its therapeutic effect is also doubtful when the tumour is infiltrative in nature or is hypovascular, too large or too small. Additional chemotherapeutic agents mixed into the embolizer with lipiodol and degraded starch microspheres or styrene-maleic acid-neocarzinostatin in which chemotherapeutic agents are embedded, are used with a better response, but the survival rate has not shown significant improvement. Ultrasound-guided local injection therapy is another new method of treatment of HCC. Of these techniques, percutaneous ethanol injection therapy (PEIT) is widely used with excellent results for small, encapsulated tumours in livers with less than three HCC. Percutaneous ethanol injection therapy can also be used in cases with portal vein thrombosis, but it is not suitable for patients having coagulopathy or ascites. Using acetic acid, OK-432, interferon or anti-cancer drugs in the injection therapy shows no further benefit over ethanol alone. Transcatheter echoguided thermotherapy or cryotherapy has been reported in small series of patients, as has target therapy with immune or radiotherapy and conformal radiotherapy. Preliminary studies show encouraging results. Systemic therapy with either single drug or multidrugs is ineffective, with a response rate of less than 20%. Immunotherapy, such as with interferon or other cytokines, is not beneficial. Hormone therapy has not been promising, except for treatment with tamoxifen, which has been reported to show some beneficial effect. Gene therapy is still in its infancy. In summary, recent progress in non-surgical treatment of HCC has resulted in a breakthrough of regional therapy looking quite promising. Moreover, a combination of different types of regional therapies may yield better outcomes in selected individuals.

Nonresectional therapies for hepatocellular carcinoma

BACKGROUND

Surgical resection is generally accepted as the first choice of treatment for hepatocellular carcinoma (HCC). However, due to its multifocal nature, association with chronic liver disease, and frequent postresectional recurrence, nonresectional therapies are important in the management of a significant proportion of patients with HCC.

DATA SOURCES

A literature review was performed on the current status of different nonresectional treatment modalities commonly employed for HCC. They include direct ablation methods, systemic chemotherapy, transcatheter arterial chemoembolization, external and targeting radiotherapy, hormonal therapy, and immunotherapy. Multidisciplinary therapy resulting in preoperative cytoreduction has also been reported with improvement of therapeutic results.

CONCLUSION

Nonresectional therapies play an essential role in the treatment of inoperable HCC as they lead to satisfactory survival. Percutaneous ethanol injection and transcatheter arterial chemoembolization are the most frequently employed modalities, and they result in a 3-year survival rate of 55% to 70% and about 20%, respectively. Multidisciplinary therapy appears to be the current trend of management and improved survival is achieved especially when unresectable tumors are converted to resectable ones.

Combined cis-platinum and alpha interferon therapy of advanced hepatocellular carcinoma

To evaluate the clinical efficacy of alpha-interferon(IFN-alpha) plus cis-platinum in hepatocellular carcinoma(HCC). 56 inoperable patients with HCC were divided into IFN-alpha plus cis-platinum treated group (n = 30) and no antitumor therapy group (n = 26). The survival of IFN-alpha plus cis-platinum treated patients was significantly better than that of patients who received no antitumor therapy (p = 0.001). Median survival time was 33 weeks and 14.0 weeks, respectively. The cumulative estimated survival rates of our IFN-alpha plus cis-platinum treated group (93.5% at 3mo, 75.0% at 6mo) were for longer than that of the no antitumor therapy group (84.6% at 3mo, 57.7% at 6mo). Objective tumor regression, greater than 50% was observed in 13.3% (4 of 30) of patients receiving IFN-alpha plus cis-platinum. By the univariate analysis, the absence of portal vein thrombus (p < 0.05), alkaline phosphatase lesser than 280 U/L (p = 0.001), total bilirubin less than 2.0 mg% (p < 0.05), serum triglyceride less than 155 mg/dl (p < 0.05) were shown to be the factors most significantly favoring a better survival. By the multivariate analysis, using Cox proportional hazards model, IFN-alpha plus cis-platinum treated group (p = 0.0001), alkaline phosphatase less than 280 mg/dl (p = 0.005), the absence of portal vein thrombus (p = 0.020) were independent favorable prognostic factors. We conclude that IFN-alpha plus cis-platinum is useful in patients with inoperable HCC and the above favorable prognostic factors may also be useful in the design and analysis of future clinical trials of systemic chemotherapy for HCC.

No synergistic activity of epirubicin and interferon-alpha 2b in the treatment of hepatocellular carcinoma

Single-agent activity for anthracyclines reflected by response rates of 10%-30% has been reported in patients with advanced hepatocellular carcinoma (HCC). Preclinical data indicate that alpha-interferon could enhance the cytotoxic activity of the anthracycline Adriamycin or its analog epirubicin. In a phase I/II study, 31 patients with biopsy-proven inoperable HCC were treated with interferon-alpha 2b given s.c. at a dose of 3 x 10(6) units/m2 per day for 5 days per week plus weekly epirubicin given at 25 mg/m2 as an i.v. bolus. The protocol called for 4 consecutive weeks of treatment followed by 1 week off treatment. In all, 15 patients had been previously treated; 6 patients had failed hormonal therapy (tamoxifen), 5 patients had failed prior anthracycline treatment, and 4 patients had received chemoembolization of the tumor and had subsequently progressed. A total of 30 patients were evaluable for response. In all, 1 patient (3%) achieved a partial response for 8+ months and 11 patients (35%) achieved stabilization of disease. Six patients had a fall in alphafetoprotein (AFP) values of > 50% during therapy. The median survival for all patients was 9.5 months (range, 3-34+ months). The main side effects were hematological toxicity and fever, both of which were considered tolerable. As an indicator of the immunostimulatory effects of interferon, an elevation in serum markers of inflammation [C-reactive protein (CRP), beta 2-microglobulin] was found in 15%-20% of patients. All patients had measurable Mx protein production during therapy, but these effects were not correlated to the clinical response. The clinical response rate achieved in this trial indicates that the combination of interferon and epirubicin, at least when used on the schedule reported herein, is not superior to treatment with either agent alone for patients with advanced HCC. However, single patients achieved a prolonged progression-free interval (8-10+ months) on this therapy, and it may therefore be an option for patients who have failed prior hormonal or single-agent anthracycline therapy.

Complete hepatic venous isolation and extracorporeal chemofiltration as treatment for human hepatocellular carcinoma: a phase I study

BACKGROUND

We performed a phase I study of a novel system of complete hepatic venous isolation and extracorporeal chemofiltration in patients with unresectable hepatocellular carcinoma (HCC) to determine (a) whether systemic exposure to doxorubicin could be limited after high-dose hepatic arterial infusion (HAI), and (b) the hepatic maximum tolerated dose (MTD) of doxorubicin.

METHODS

Ten patients with biopsy-proven HCC were treated with 20-min HAI of doxorubicin (17 total treatments). Two patients were treated with doxorubicin 60 mg/m2, three patients were treated at 90 mg/m2, and five patients received 120 mg/m2. A newly developed dual-balloon vena cava catheter was advanced from the femoral vein, and the balloons were inflated to isolate and capture total hepatic venous outflow. The hepatic venous blood was pumped through extracorporeal carbon chemofilters before return of the blood to the systemic circulation.

RESULTS

Peak systemic doxorubicin levels were an average 85.6% lower than were peak prefilter levels (p < 0.01). Because all catheters were placed percutaneously and because the chemofiltration markedly limited systemic chemotherapy exposure, patients were discharged 1 day after 16 of the 17 treatments. The hepatic and systemic MTD of doxorubicin in this treatment protocol was 120 mg/m2.

CONCLUSIONS

This novel system of complete hepatic venous isolation and chemofiltration limits systemic chemotherapy toxicity and will allow use of higher doses of chemotherapeutic agents to treat HCC.

Treatment of unresectable hepatocellular carcinoma with a combination of human recombinant alpha-2b interferon and doxorubicin: results of a pilot study

Based on the in vitro and in vivo potentiation of the cytotoxic activity of chemotherapeutic agents by the interferons, a pilot study combining human recombinant alpha-2b interferon (IFN) and doxorubicin was conducted for the treatment of unresectable, histologically proven hepatocellular carcinoma. Between March 1988 and May 1990, 21 patients (median age: 60 years, range: 29-76) entered the study. The dose of doxorubicin was fixed at 35 mg/m2, every 3 weeks. The dose of alpha-2b IFN was 6 million U/m2 per day, 5 days a week. 3 patients (14%) obtained a partial response lasting 11, 16 and 30 months, and 1 had a stable disease during 8 months. The other 17 patients died within a median survival time of 4 months. All patients experienced flu-like symptoms. 7 patients experienced WHO grade III-IV haematological toxicity. We conclude that the association of alpha-2b IFN and doxorubicin is feasible, with respect to the use of doxorubicin at an inferior dose level than the same agent used without IFN. The response rate is comparable to that observed with doxorubicin used alone. Further phase I studies and randomised trials are required to confirm the role of this regimen in the treatment of unresectable hepatocellular carcinoma.

Epirubicin in hepatocellular carcinoma: pharmacokinetics and clinical activity

The pharmacokinetics and clinical activity of epirubicin were investigated in 16 patients with hepatocellular carcinoma (HCC) who received epirubicin at 75 mg/m2; the drug was given intravenously to 7 patients and via the hepatic artery to 9 patients (7 of whom also underwent embolisation). Lignocaine (1 mg/kg) was also given intravenously to 15 patients, and the metabolite monoethylglycinexylidide (MEGX) was measured as an indicator of liver function. Epirubicin clearance correlated with serum aspartate aminotransferase (AST), albumin and bilirubin values in patients treated intravenously or intraarterially. Although the route of administration did not affect the median total plasma clearance of epirubicin, early- and intermediate-phase clearance was higher following intraarterial administration. MEGX levels correlated with serum bilirubin levels but there was no correlation with albumin or AST values or epirubicin clearance. The rate of response to epirubicin was 3/13 (23%; 95% confidence interval, 8%-50%). Intravenous epirubicin was tolerated well, but intraarterial treatment was associated with significant morbidity. These data confirm that although current recommended dose adjustments are based primarily on serum bilirubin levels, altered epirubicin pharmacokinetics correlate more strongly with AST and albumin values than with serum bilirubin concentrations. However, at this dose and schedule, epirubicin has only modest activity against HCC.

Management of hepatic epithelial malignancy in childhood and adolescence

This review addresses the management of epithelial liver tumors of childhood and adolescence (hepatoblastoma and hepatocellular carcinoma), which constitute approximately 90% of primary liver malignancy in this age group. The epidemiology, pathology, clinical presentation, and diagnosis are given in order to appreciate differences in biological behavior of these two neoplasms and the need for a distinct therapeutic approach to each. The multidisciplinary treatment of hepatoblastoma has become increasingly refined and long-term survival can be expected in approximately 80% of patients. Where survival once depended solely on complete surgical resection, it is now also possible in patients with initially unresectable tumors due to effective cytoreductive chemotherapy. The problem of systemic relapse following complete surgical resection has been reduced although not eliminated by adjuvant chemotherapy programs. To date, the biological behavior of hepatocellular carcinoma prohibits complete resection in the majority of children and chemotherapy has not been effective. Early detection, development of new agents and techniques such as monoclonal antibodies and total hepatectomy with autologous transplantation in selected cases may offer hope for the future.

Combined doxorubicin and alpha-interferon therapy of advanced hepatocellular carcinoma

BACKGROUND

Modest activity for doxorubicin has been detected repeatedly for the therapy of advanced hepatocellular carcinoma. Variable activity in this disease also has been documented for alpha-interferon. Preclinical data indicated the possibility that alpha-interferon could enhance or add to the cytotoxic effect of doxorubicin.

METHODS

The authors evaluated the use of alpha-interferon at a dose of 12 x 10(6) units/m2/day for 5 days given by intramuscular injection plus doxorubicin 25-40 mg/m2 given intravenously on day 3 (both repeated every 4 weeks) for the treatment of advanced hepatocellular carcinoma.

RESULTS

Among 31 eligible patients treated, there was only one instance of objective tumor regression. The median survival for all patients was 10 months. Both hematologic and nonhematologic toxicity were significant but tolerable to the patients.

CONCLUSIONS

The 3% response rate indicated that, by the method used, the addition of alpha-interferon to doxorubicin does not improve the clinical effectiveness. This combination cannot be recommended for further study.

Clinical efficacy and toxicity of standard dose adriamycin in hyperbilirubinaemic patients with hepatocellular carcinoma: relation to liver tests and pharmacokinetic parameters

A standard dose of Adriamycin (60 mg m-2) was administered to 30 patients with inoperable hepatocellular carcinoma, 16 of whom were hyperbilirubinaemic (18-37 mumol l-1). The hyperbilirubinaemic patients experienced marked myelosuppression, but only minor symptomatic side-effects. The degree of neutropenia was directly related to the serum bilirubin concentration, but not to any other standard liver test, presence or absence of cirrhosis, or any pharmacokinetic parameter studied including the area under the Adriamycin or adriamycinol concentration-time curve to 48 h or infinity, or the terminal half-life of Adriamycin. The area under the log concentration-time curve was significantly greater for both Adriamycin and adriamycinol in patients who were hyperbilirubinaemic compared to those with normal bilirubin. Whilst hyperbilirubinaemic patients may tolerate a full dose of Adriamycin, we found no evidence that this was associated with a better response rate, which was disappointingly low at only 18%.

Transcatheter arterial chemoembolization for hepatocellular carcinoma

The factors relating to the duration of survival were analyzed for 329 cases of hepatocellular carcinoma (HCC) treated by transcatheter arterial chemoembolization (TACE) between January 1, 1983, and December 31, 1990. The cumulative survival value obtained was slightly higher but not statistically significantly higher in these 329 cases as compared with the 129 cases reported in 1989. This improvement was probably attributable to careful selection of the patients on the basis of the clinical Child's status and to improvement of the superselective angiotechnique used in the present study. The overall cumulative 1-, 2-, and 3-year survival values in this series were 50%, 25%, and 15%, respectively. The median duration of survival was 12.7 months (Kaplan-Meier method). The 1-, 2-, and 3-year survival values determined for 190 patients in Child's group A, for 95 patients in Child's group B, and for 44 patients in Child's group C were 60%, 30%, and 20%; 35%, 20%, and 10%; and 35%, 20%, and 10%, respectively. Analyses were also carried out according to the tumor's type and size, the integrity of the tumor capsule, and the patency of the portal vein. Our results disclosed that a better outcome in terms of the median survival period and the survival value was favored by the following factors: a single lesion measuring less than 5 cm in diameter, an intact capsule, a patent portal vein, and a good clinical status. It is also essential that all patients who have undergone TACE be periodically evaluated by ultrasonography, CT, and angiography to determine whether repeated chemoembolization is necessary.

Pharmacokinetics and toxicity of intraarterial adriamycin for hepatocellular carcinoma: effect of coadministration of lipiodol

To determine the effect of coadministration of lipiodol on the pharmacokinetics and systemic toxicity of intraarterial Adriamycin in patients with hepatocellular carcinoma, nine patients were studied in detail. Each received two courses of a bolus injection of Adriamycin (60 mg/m2), in one of which the Adriamycin was mixed with 10 ml of lipiodol. Analysis of the paired data, and additional 'non-paired' data from a further seven patients, showed that there was no significant difference in the area under the concentration-time curve for Adriamycin or adriamycinol or, in the case of Adriamycin, the terminal half-life. Likewise the fall in haemoglobin concentration, white cell count and platelet count following treatment, and the degree of nausea and vomiting were not significantly different. Comparison with a series of 12 patients receiving intravenous Adriamycin, in the same dose schedule, revealed no difference in terms of pharmacokinetic parameters or toxicity with intraarterial administration of Adriamycin, with or without lipiodol.

Doxorubicin for unresectable hepatocellular carcinoma. A prospective study on the addition of verapamil

A prospective study was conducted to assess the safety and efficacy of the addition of oral verapamil to intravenous Adriamycin (doxorubicin) for the management of patients with unresectable hepatocellular carcinoma (HCC). All 28 patients studied had histologically verified disease, and cirrhosis was present in 20 of the 21 patients with adequate tissue sampling. The overall median survival was 57 days. Chemotherapy was terminated in seven patients after one course of treatment. Partial response and complete response were noted in four patients (19%) and one patient (4.8%), respectively, among the 21 patients evaluated. Side effects related to the chemotherapy were present in all patients studied. Death from fulminating sepsis occurred in three of the 13 patients with leukopenia. Symptomatic myocardial dysfunction developed in one patient. The addition of verapamil apparently did not potentiate the tumoricidal effect of systemic Adriamycin on HCC but probably did increase its complications.

Hepatic arterial embolization with microencapsulated mitomycin C for unresectable hepatocellular carcinoma in cirrhosis

From 1986 to 1988, 35 patients with a hepatoma judged either inoperable or unresectable because of coexistent cirrhosis were treated with hepatic arterial embolization of mitomycin C microcapsules. Five of these 35 patients (14.5%) could not be treated because of inability to selectively cannulate the hepatic artery and were therefore excluded from the evaluation (feasibility rate, 86%). There were 24 men and six women with a median age of 57 years (range, 47 to 79) who could be classified as Okuda I (14 pts) or Okuda II (16 pts) and Child Class A:18 and Child Class B:12 in the remaining patients. A median dose of 0.5 mg mitomycin C/kg was administered to each subject and the treatment was repeated at 5 to 6 week intervals. Seventy courses were administered to these 30 patients (median, two courses/patient; range, 1 to 4). Minor complications were frequent (63%) but always either resolved spontaneously or after appropriate medical treatment. Neither severe renal nor hepatic toxicity was observed. No specific treatment related mortality was observed. When alpha-fetoprotein levels and tumor volume were assessed to evaluate the response to treatment using established criteria for identifying a response, an objective response was found in 43% of the cases treated. The actuarial median survival was 7 months and the 1-year actuarial survival was 36% (51% for those rated as Child Class A and 0% for those identified as Child Class B, P = 0.04 and 78% rated as Okuda Types I and 0% Okuda type II, P = 0.0001). The excellent quality of life and the increased survival rate experienced after mitomycin C microcapsule embolization suggest that this treatment modality can be used successfully in patients seen in the West who have unresectable hepatoma.

Spontaneous regression of hepatocellular carcinoma

A 63 year old white woman presented with abdominal discomfort, anorexia, and weight loss. Investigations showed hepatocellular carcinoma with pulmonary metastases. The primary and secondary tumours resolved without specific treatment.

Regional treatment of hepatic metastases and hepatocellular carcinoma

Hepatic metastases represent a common site of dissemination for a number of primary malignancies related in part to the dual blood supply, large blood flow, and receptive environment of the hepatic parenchyma. Although this review focuses on regional therapy, we have included sections on systemic therapy to better interpret the results with intrahepatic therapy. We will also discuss the efficiency of hepatic arterial ligation, embolization, and radiotherapy of hepatic metastases. Primary gastrointestinal neoplasms are particularly prone to produce hepatic metastases. Because colorectal carcinoma metastasizes to the liver in up to 70% of patients with advanced disease, the treatment of hepatic metastases is a relevant topic. We will discuss the systemic and regional therapy of colorectal, gastric, and gallbladder cancers. Breast carcinoma and malignant melanoma frequently metastasize to the liver, and we have described systemic and regional treatments of these diseases. Because sarcomas are often treated by regional therapy, we have included a section on the treatment of hepatic sarcomas. Neuroendocrine tumors (carcinoid and islet cell), although often slow growing, frequently metastasize to the liver and then cause symptomatic problems. Much of the work done with embolization and hepatic ligation in the treatment of hepatic metastases has been performed in neuroendocrine tumors, and these studies, as well as the systemic and regional chemotherapy of hepatic metastases, will be described. The last section concerns the treatment of hepatocellular carcinoma. We have outlined the staging systems used. We then detail the results of systemic and intrahepatic therapy, embolization, and hepatic ligation in the treatment of hepatocellular carcinoma. Because hepatic metastases are a frequent problem, many patients are available for clinical investigation. It is hoped that newer strategies for the treatment of liver metastases will lead to higher response rates and perhaps control of local disease. These therapeutic approaches may also give us leads to the treatment of systemic disease.

Transcatheter arterial chemoembolization for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) was treated with transcatheter arterial chemoembolization (TACE) in a sample of 129 patients. The cumulative survival rate was 49% at 1 year and 22% at 2 years. The median survival time was 11.9 months. The survival rates at 1 year of 84 patients in Child's group A and 27 in Child's group B were 56% and 40%; out of 52 HCC patients with portal vein patent and 77 with portal vein invasion 75% and 40% survived, and the 1-year survival rates for 33 HCC patients with capsule intact, 14 with capsule broken and 82 with no capsule were 85%, 65% and 40% respectively. From the above results there were statistically significant differences in survival time in those with good clinical performance status by Child's classification, those showing patency of the portal vein and those where the capsule was present. Therefore, we would like to recommend, TACE of HCC in well-selected patients presenting with good clinical status, patency of the portal vein and without broken capsule, in order to achieve better clinical results.

Chemotherapy of malignant hepatomas with sequential intraarterial doxorubicin and systemic 5-fluorouracil and semustine

Twenty patients with malignant hepatoma were treated with sequential intraarterial doxorubicin (72-hour continuous infusion) followed by systemic 5-fluorouracil (5-FU) and semustine (methyl CCNU). Objective tumor responses were seen in three patients (15%). The durations of response were 6, 19, and 27+ months, respectively. Median patient survival was 7 months. A variety of problems were encountered with the use of transcutaneous angiographic catheters for doxorubicin administration, including inability to adequately perfuse the liver, sepsis, and catheter dislodgement during chemotherapy infusion. Although some patients experienced palliation of reasonable duration, we do not believe that the overall results warrant further studies of this regimen.

Doxorubicin versus no antitumor therapy in inoperable hepatocellular carcinoma. A prospective randomized trial

To assess the efficacy and safety of Adriamycin (Adria Laboratories, Columbus, OH) in inoperable hepatocellular carcinoma (HCC), 60 patients were randomized to receive Adriamycin 60 to 75 mg/m2 at 3-week intervals and 46 patients to receive no antitumor therapy. The median survival rate of the Adriamycin group was 10.6 weeks; that of the group receiving no antitumor therapy was 7.5 weeks (P = 0.036). Adriamycin induced tumor regression of 25% to 50% in 5% of patients and of over 50% in only 3.3% of patients. It caused fatal complications (septicemia and cardiotoxicity) in 25% of patients. The severity of neutropenia leading to septicemia for a particular dose was unpredictable. Four of eight patients who developed cardiotoxicity received less than 500 mg/m2 of Adriamycin. We conclude that Adriamycin is not an ideal drug for the treatment of inoperable HCC.

Review: the treatment of hepatocellular carcinoma

Surgical resection offers the only realistic hope of cure in hepatocellular carcinoma (HCC) but is usually not possible, either because the tumour is widespread throughout the liver at diagnosis, or because liver function is adversely affected by concomitant cirrhosis. The results of operation in early asymptomatic disease are, however, encouraging and efforts should be made to screen regularly the cirrhotic population at risk of HCC development. The prognosis for inoperable patients remains gloomy, though exciting new treatment methods exist which require extensive evaluation. An anthracycline given as single agent intravenous therapy is probably the current treatment of choice for inoperable patients, though only 20-30% will show a response. Intra-arterial therapy has not yet been convincingly shown to have any advantages over intravenous therapy. The evaluation of clinical trials in HCC would be made easier if response criteria were standardized and universally adopted, and if trials were properly controlled and of sufficient sample size to test adequately the hypothesis in question. This review deals only with the specific treatment of HCC. HCC prevention, the early diagnosis of HCC, and the relief of symptoms in HCC, though areas of obvious importance, are outside the scope of this review.

Intrahepatic chemotherapy for unresectable hepatocellular carcinoma

From 1976 to 1983, 28 patients (24 male and four female) with unresectable hepatocellular carcinoma (HCC) were treated by intraarterial chemotherapy at the Istituto Nazionale Tumori of Milan, Milan, Italy. Tumors were retrospectively classified by a previously proposed staging system. Two patients were classified as Stage I and 26 as Stage II. Liver cirrhosis was present only in the males (in 50% of them). Nineteen patients were treated with doxorubicin (Adriamycin [Adria Laboratories, Columbus, OH]) and nine with 5-fluorouracil. Systemic toxicity was mild, but the treatment induced hepatic toxicity (ascites, clinical jaundice, or biochemical impairment) in 18% of noncirrhotic and 66% of cirrhotic patients. Clinical reduction of hepatomegaly was observed in 50% of noncirrhotic versus 16% of cirrhotic patients. Doxorubicin was effective in 66% of noncirrhotic patients and 20% of cirrhotic patients, with an overall response rate of 42%. 5-fluorouracil was effective only in patients without cirrhosis, with an overall response rate of 22%. Overall median actuarial survival was 3.5 months, with a significant difference between noncirrhotic and cirrhotic patients (6 versus 2 months, respectively). Overall median survival of patients who responded to the treatment was 13 versus 2 months for nonresponders (P less than 0.001). Liver cirrhosis was the most important prognostic factor in terms of liver toxicity, response rate, and survival. This study emphasized the negative impact of the treatment on cirrhotic patients. Also, the real value of intraarterial administration of doxorubicin was investigated.

Hepatocellular carcinoma. A retrospective analysis of treatments to manage disease confined to the liver

The histories of 73 patients with hepatocellular carcinoma (HCC) confined to the liver who were seen at M. D. Anderson Hospital between January 1976 and December 1983 were reviewed. In 18 patients the tumor was resected either at the outset or after the patients' response to chemotherapy; nonsurgical treatments consisted of hepatic arterial infusion (HAI) in 10 patients and intravenous (IV) therapy in four patients. Patients who had resection were younger, and their liver functions and performance status were better than the IV and HAI groups. Their median survival was 46 months. Of the patients who had nonresectable tumors, 28 received chemotherapy by HAI and 27 received IV therapy. Of the 28 patients in the HAI treatment group, 25 received uniform infusion of floxuridine (FUDR, Roche, Australia), doxorubicin (Adriamycin), and mitomycin C (FUDRAM). Of the 27 patients in the IV treatment group, 15 received 5-fluorouracil (5-FU) and doxorubicin-containing regimens; in 11 patients 5-FU was combined with other agents. The HAI and IV treatment groups were similar in age and ethnicity, performance status, serum alpha-fetoprotein levels, liver function, presence of hepatitis B antigen, and presence or absence of cirrhosis. The median survival was 9 months for HAI-treated patients and 5 months for the IV-treated group. The statistical differences were resection versus HAI, P less than 0.01; resection versus IV, P less than 0.01; HAI versus IV, P less than 0.01. Thirteen of 18 patients who had resections, six of 28 patients treated with HAI, and two of 27 IV-treated patients survived 2 years or more. It is concluded that for patients with hepatocellular carcinoma confined to the liver, the option of tumor resection either at the beginning of treatment or after chemotherapy offers the best chances for long-term survival. The overall prognosis is poor for patients with nonresectable hepatocellular carcinoma, but arterial infusion chemotherapy may double the median survival as compared to IV chemotherapy.

Recombinant leukocyte A interferon with doxorubicin. A phase I study in advanced solid neoplasms and implications for hepatocellular carcinoma

A pilot study was performed on seven patients with advanced solid neoplasms. They received recombinant leukocyte interferon A (rIFN-alpha A) 12 X 10(6) U/m2 intramuscularly daily for 5 days plus doxorubicin, 25 mg/m2 IV on day 3 of each monthly cycle (Roferon-A, Hoffman-LaRoche, Nutley, NJ). Because of side effects, the dose was not increased above the initial level. There was a striking partial response of biopsy-confirmed hepatocellular carcinoma for 6+ months along with a decrease in alpha-fetoprotein from 39,000 to 202 ng/mL. The doxorubicin dose is approximately 33% to 42% of the typical single-agent dose, thus suggesting that the clinical toxicity from these two agents is additive.

Chemotherapy and radiotherapy of malignant hepatic tumours

Cure of primary liver tumours remains possible only by surgery and early diagnosis will therefore continue to be important; the value of regular screening of cirrhotic patients for development of HCC by ultrasound scanning and estimation of AFP is now established. Prognosis of irresectable HCC depends largely on the general condition of the patient at the time of diagnosis and is better in the absence of cirrhosis. Radiotherapy has little role in the management of patients with HCC, but benefit with acceptable morbidity may be obtained from parenteral chemotherapy, with doxorubicin or its derivatives used as single agents, or with a combination of 5-FU and methyl-CCNU. There may be advantage from regional therapy given via the hepatic artery and early results from the combination of embolization with arterial doxorubicin are encouraging. The use of radiolabelled antibodies to tumour-related determinants of hormonal manipulation show promise. Worthwhile results from the non-surgical management of peripheral (intrahepatic) cholangiocarcinoma and primary hepatic sarcoma remain scarce. Isolated hepatic metastases from colorectal primaries may be resectable; for those that are not, results from regional chemotherapy with 5-FU or FUDR are encouraging, but cost and high morbidity currently limit more general application.

Clinical evaluation of palliative therapy for unresectable primary liver cancer

Ninety-nine patients with unresectable primary liver cancer were treated with ligation of the hepatic artery (LHA), intra-arterial infusion chemotherapy (IAIC) or transcatheter arterial embolization (TAE) between 1960 and 1983. A statistical study was made of therapeutic effects and prognosis. The results are as follows: The mean survival time of 14 patients treated with LHA was about 5 months. The survival time of the LHA + IAIC with mitomycin C group was not prolonged as compared with that of the LHA group, but LHA + IAIC with Adriamycin (doxorubicin) group showed a significant prolongation of survival time over the LHA group. In the LHA + IAIC with Adriamycin group, the mean survival time was 12.8 months and the 1-year survival rate was 37.5%. Factors including age, presence of liver cirrhosis, number of involved segments, and degree of anaplasia graded on Edmondson's criteria did not influence survival time.

Significance of serum bilirubin level in response of hepatocellular carcinoma to doxorubicin

To determine which of several clinical and laboratory features could be of significance in the response of hepatocellular carcinoma to doxorubicin we have analysed the frequency of remission in 143 patients treated with this drug. Of those features investigated including age, sex, presence and aetiology of underlying cirrhosis, duration of symptoms, performance grade and liver function tests, a normal serum bilirubin level was shown to be the only one on logistic regression analysis to predict a greater change of response (response rate = 46% with serum bilirubin less than 20 mumol/l and 10% with bilirubin greater than 20 mumol/l). The most likely explanation is that reduction in doxorubicin dosage according to the serum bilirubin level, based on the view that the risk of myelosuppression is thereby lessened, may lead to suboptimal dose administration.

Adriamycin treatment for hepatocellular carcinoma. Experience with 109 patients

One hundred nine patients with hepatocellular carcinoma were treated with intravenous (IV) Adriamycin (doxorubicin). Cumulative survival rate was 34% at 6 months and 13% at 1 year. Survival was positively related to a good performance status and to alpha-fetoprotein less than 50 ng/ml, not influenced by hepatitis B surface antigen (HBsAg) and by presence of clear cells in the tumor. Partial response (alpha-fetoprotein decrease by greater than or equal to 50% of the initial value) was observed in 10 patients and complete response in 1 patient, always within the fourth dose, with a 10% response rate. Twenty of 75 symptomatic patients (27%) achieved improvement in performance and/or pain reduction. Withdrawal of treatment became necessary for side effects in six patients. In conclusion, IV Adriamycin in hepatocellular carcinoma has only limited efficacy. Because of its early activity, treatment can be stopped after three doses if there is no evidence of response.

Hepatocellular carcinoma in Italy: report of a clinical trial with intravenous doxorubicin

Sixty-six patients with hepatocellular carcinoma (HCC) in various stages of hepatic involvement were studied prospectively. Of these, 50 (75%) had associated cirrhosis and 19 (28%) had serum hepatitis B surface antigen (HBsAg). Six (9%) patients were eligible for tumor resection, 34 were selected for doxorubicin chemotherapy (60 mg/m2, i.v., given every 3 weeks, up to a maximum dose of 550 mg/m2), and 26 were followed up without treatment. Untreated patients survived 1-18 months (median 1) after diagnosis. Surgically treated patients survived 1-14 months (median 4.5). In the doxorubicin group, six patients died soon after the first course of treatment, leaving 28 patients to be evaluated. Seven (24.5%) responded to therapy, surviving 2-26 months (median 8.0). Twenty-one (75.5%) did not respond to chemotherapy and had a median survival of 3.5 months (range: 2-12). Initial performance status and the degree of hepatic impairment were found to be covariates of prognostic significance. The type and severity of drug-related side-effects appeared to be comparable to those reported by others. In accordance with previous reports, our patients with HCC often had non-resectable tumors or responded poorly to chemotherapy. The association between this tumor and cirrhosis might partially account for treatment failure.

Clinical, serologic, and immunologic effects of human leukocyte interferon in HBsAg-positive primary hepatocellular carcinoma

Five patients with hepatitis B surface antigen (HBsAg) positive chronic hepatitis and histologically confirmed primary hepatocellular carcinoma (PHC) were treated with 3 X 10(6) units/day of partially purified human leukocyte interferon intramuscularly for 2 consecutive months. During interferon therapy, one patient had stable disease, while the remaining four patients had progressive disease. Following interferon therapy no changes were noted in the hepatitis B viral markers or in serum alphafetoprotein levels. Data on the effects of human leukocyte interferon on lymphocyte subpopulations and on the cytotoxic activity of peripheral blood mononuclear cells against a hepatitis B surface antigen expressing primary hepatocellular carcinoma cell line are presented.

Mitozantrone as single agent therapy in hepatocellular carcinoma. A phase II study

Thirty-five patients with hepatocellular carcinoma (HCC) have been treated with the Anthracenedione derivative, Mitozantrone. One complete and 5 partial responses were seen in 22 evaluable patients and in a further 4 patients tumour size remained static for lengths of time ranging from 13 to 42 weeks. Therapy was well tolerated. Bone marrow suppression was dose-limiting but easily managed by dose reduction. Other acute toxicity was rare, vomiting and hair loss being reported only once each. Cardiac 'events' occurred in 5 patients, 3 of whom had received high total cumulative doses of Mitozantrone. We conclude that Mitozantrone is of clinical benefit in HCC and that its usage is compatible with a good quality of survival. Its cardiotoxic potential requires further evaluation.

Infusion-embolization

Transcatheter intra-arterial therapy for the cancer patient encompasses infusion of chemotherapy and embolization. Intra-arterial infusion of chemotherapeutic agents has been resurrected because of the availability of new drugs, combinations of drugs, and the capability of percutaneous selective catheter placement. Intra-arterial infusion has been effective in patients with carcinomas of the liver, bladder, prostate, uterus, ovary, and lung and in bone and soft tissue sarcomas, melanomas, and tumors of the brain. Embolization of the arterial supply, creating ischemia of the neoplasm, has been employed in the therapeutic management of patients with primary and secondary neoplasms of the liver, kidney, and bone. The median survival of 100 patients with neoplasms of the liver from the time of hepatic artery embolization was 11.5 months. In 100 patients with pulmonary metastases from carcinoma of the kidney, 28 experienced a response to renal artery embolization, a therapeutic delay of 4 to 7 days, nephrectomy, and Depo-Provera (medroxyprogesterone). Seven of 12 patients with giant cell tumor of the pelvis and lumbar spine responded to arterial embolization after all other therapy failed. Chemoembolization, the combination of arterial infusion of chemotherapy and embolization, can be accomplished by the use of microencapsulated agents, liposomes, and particulate emboli with drugs. This approach integrates the advantages of infusion and occlusion, and has considerable potential. Intra-arterial immunotherapy has been initiated with bacillus Calmette-Guerin (BCG) administration into renal neoplasms in patients with metastatic disease.

The natural history of hepatocellular carcinoma. A study of 100 untreated cases

The natural course of hepatocellular carcinoma (HCC) was evaluated in 100 untreated patients who were seen during recent 13 years. There were 80 males and 20 females. The macroscopic type of tumor was massive in 58, nodular in 35, and diffuse in 7 cases. Liver cirrhosis was associated with in 80% of patients. The mean survival time of overall patients was 4 months from the onset of initial symptoms to death and 2 months from admission to death. Occult and cirrhotic types of HCC showed a longer survival than frank and febrile types that had a mean survival time of all patients. The prognosis of icteric and metastatic types was poorest. Sex, tumor type, or associated cirrhosis did not substantially affect the natural course of HCC. The tumor stage and clinical stage were grossly correlated to the prognosis. In terms of symptoms, severe jaundice and ascites were the most dismal prognostic signs.

Selective effects of Lipiodolized antitumor agents

Lipiodol Ultra-Fluid (Lipiodol) remains selectively in the tumor for an extended time when applied through arteries feeding the tumor. Although lipophilic antitumor drugs are selective when combined with Lipiodol, wide application of common hydrophilic agents is limited, as these compounds are insoluble in oil. We propose "Lipiodolization" of water-soluble agents using as an intermediate Urografin, a water-soluble contrast medium. Thirteen patients with primary hepatocellular carcinoma were treated with this Lipiodol-Urografin system containing antitumor agents. Marked decrease in serum alpha-fetoprotein (AFP) levels, decrease in tumor size in the hepatic imaging, and histologic studies of the resected specimen revealed this mode of therapy to be effective in 10 of 13 patients (77%) with hepatocellular carcinoma. Lipiodolization of antitumor agents is a new approach to selective cancer chemotherapy.

Chemotherapy for advanced hepatocellular carcinoma. Adriamycin versus quadruple chemotherapy

In a prospective clinical trial, 39 patients with advanced hepatocellular carcinoma were randomized to receive either Adriamycin (20 patients) or a combination of 5-fluorouracil, methotrexate, cyclophosphamide, and vincristine (19 patients). Five patients receiving Adriamycin and none receiving quadruple chemotherapy responded (P less than 0.05 in favor of Adriamycin). A further 25 patients were treated with Adriamycin, making a total of 45. The overall objective response rate was 24% (11 patients), with 3 complete remissions and 8 partial remissions. The median survival for Adriamycin-treated patients (13.0 weeks for the first 20 patients and 14.4 weeks for all patients) was longer than those treated by quadruple chemotherapy (6.5 weeks). The difference, however, was not significant by the Wilcoxan test as modified by Gehan. Patients with positive HbsAg had a significantly higher chance of having a response, while serum alpha-fetoprotein levels did not correlate with response.

Primary hepatocellular cancer--present results and future prospects

Hepatocellular cancer is an enormously difficult clinical problem. This review provides an overview of selected basic and applied aspects of the care of hepatoma patients. Important pathophysiologic and prognostic features are now recognized. Initially, chemotherapy programs focused on the use of those agents commonly employed for gastrointestinal neoplasms (fluoropyrimidines, anthracyclines and alkylators). When employed as a conventional intravenous bolus, only Adriamycin is a reproducibly effective agent. However, because of the unique dual vascular supply of the liver and tumor, the use of intraarterial (IA) infusion chemotherapy has become more popular. In this regard, of promise are the application of IA FUDR and Adriamycin, the use of totally implanted infusion systems, and hepatic artery embolization. Furthermore, combinations of whole liver irradiation with chemotherapy seem efficacious. New directions for the therapy of hepatoma patients will focus on superior drug-radiation combinations, exploration of isotopic immunoglobulin, and hormonal therapy. There is currently no standard therapy for hepatoma patients, but prospects for the future have never been so bright.

Induction of remission in hepatocellular carcinoma. A comparison of VP 16 with adriamycin

Following a pilot study of VP-16.213 (180 mg/m2 on 3 consecutive days at 2 weekly intervals) in the treatment of patients with hepatocellular carcinoma, the efficacy of the drug was compared with that of adriamycin in another 35 patients in a randomized crossover trial. Each drug gave a similar response rate (18 and 28%, respectively) but the duration of response was significantly longer in those receiving Adriamycin. Some patients who had not responded to treatment with Adriamycin had worthwhile remission with VP 16.

Primary carcinoma of the liver: diagnosis, prognosis, and management

Hepatoma accounts for less than 2% of all cancer death in this country, but it is responsible for 10-20% lethal malignancy in Asia and Africa. There are racial differences in its clinical manifestation, association with cirrhosis and/or hepatitis viral infection, pattern of spread, and prognosis. Mass screening program in China using alpha-fetal protein test has detected earlier cases, improved resectability and cure rate. About 10-15% of the patients in this country had surgical treatment. For patients with locally advanced and unresectable carcinoma, regional therapies such as infusion chemotherapy (IA hepatic or IV portal), ligation of hepatic artery, radiotherapy (external or internal), immunotherapy, either singularly or in various combinations have been tried. Despite the availability of Adriamycin and newer combinations of chemotherapeutic agents, patients with disseminated disease rarely respond. Other than earlier diagnosis, search for more effective drugs and multinodal approaches should be continued.

Combination chemotherapy (vincristine, adriamycin, cyclophosphamide, and 5-fluorouracil) in the treatment of children with malignant hepatoma

Members of Childrens Cancer Study Group and the Pediatric Division of the Southwest Oncology Group conducted a study of chemotherapy for children with malignant liver tumors. All patients received vincristine, cyclophosphamide, Adriamycin and 5-fluorouracil in 6 weekly cycles for one year. Surgical resection and irradiation were employed when indicated. Between January 1976 and August 1978, 62 patients were entered on study; one was rejected for a protocol error, and ten had inadequate trials of chemotherapy, dying within one month of entry. The median time on study for all patients was 12 months. Twenty-four patients had no measurable disease following surgical treatment and chemotherapy was employed as adjuvant treatment; 20/24 (83%) remain relapse-free from 8-42+ months, (median, 30 months). In 27 patients, residual measurable disease was available to determine the response to chemotherapy. The response rate was 12/27 (44%), lasting 3-45 months (median, 18 months). The median follow-up of all survivors is 30 months. Hematologic toxicity was significant, particularly during the initial courses of chemotherapy; 28/57 patients developed severe toxicity which was fatal in three. The results from the current study were compared to those from a previous one initiated in 1972, in which actinomycin D, vincristine, and cyclophosphamide were given in sequence, one during each month for one year. Although the population of the two studies was not identical, there was a difference in the response rates (P = 0.02), relapse-free interval (P = 0.008), and survival (P = 0.003). The most striking improvement was seen in the patients with Group I disease, there were 7/11 relapses in the first study and 1/16 in the current one.

Effect of doxorubicin on liver regeneration and host survival after two-thirds hepatectomy in rats

The effects of doxorubicin (Adriamycin) on regenerating liver were studied after two-thirds hepatectomy in rats. In Group I, standard two-thirds hepatectomy was performed. Doxorubicin in a dose of 2 mg/kg (Group II) and 6 mg/kg (Group III) was given intravenously immediately after the same hepatectomy. In Group IV, 6 mg/kg doxorubicin was given after sham operation. Animal survival, body weight restoration, wet weight and mitotic activity of remnant livers, and serum albumin concentrations were examined 1-14 days after operation. The survival rates were 95.5% in Group I, 76.8% in Group II, 10.3% in Group III, and 96.7% in Group IV. Although there were no differences in the residual liver weights among the hepatectomized groups, treatment with doxorubicin induced substantial, dose-dependent suppression and delay of liver cell division. Serum albumin levels dropped considerably in hepatectomized, doxorubicin-treated rats. Light microscopy showed degenerative changes with a single cell necrosis of hepatocytes in Group III. Death among rats hepatectomized and treated with doxorubicin was considered to be mainly due to the failure of residual livers since albumin synthesis was impaired and no marked changes were seen in vital organs other than the liver. For patients with hepatoma, the present results may indicate that the administration of adjuvant chemotherapy with doxorubicin, when necessary immediately after hepatectomy, should be performed with great care. In the absence of such necessity, doxorubicin should be withheld until life-sustaining liver regeneration has taken place.

Adriamycin and methyl-CCNU combination therapy in hepatocellular carcinoma: clinical and pharmacokinetic aspects

Twenty-one patients with unresectable hepatocellular carcinoma (hepatoma) were treated with adriamycin (15-45 mg/m2 q21 D) and methyl-CCNU (75-150 mg/m2 q 63 D) with dosage adjusted for hepatic dysfunction. Objective response frequency was 14% with all responses occurring in patients with normal pretreatment bilirubin levels. Median survival of all patients was 87 days. Initial bilirubin levels greater than 2 mg/dl predicted for decreased survival (median 30 days vs. 115 days, P less than 0.05). Only moderate hematologic toxicity was observed. Plasma profiles of Adriamycin and adriamycinol were determined during 11 courses of Adriamycin administration in seven of these patients. Despite moderately elevated transaminase levels (all cases) and bilirubin levels (three cases), plasma Adriamycin profiles in hepatoma patients were not elevated (terminal half-life of 30 hours) and were indistinguishable from that of non-hepatoma patients with normal liver functions. However, delayed appearance of peak levels and prolongation of terminal half-lives were routinely observed for adriamycinol, a major metabolite of Adriamycin. This resulted ina significant increase in the CXT (concentration X time) ratio of adriamycinol/Adriamycin in hepatoma patients compared with nonhepatoma patients (2.36 +/- 2.12 vs 0.76 +/- 0.31, (P less than 0.05). We conclude that the combination of relatively mild toxicity and normal Adriamycin disposition indicates unusual tolerance to Adriamycin therapy for patients with hepatoma and cirrhosis. As a result, severe dosage adjustments of Adriamycin may not be indicated for all such patients having only moderate hepatic dysfunction.

[Approaches to a selective chemotherapy of hepatocellular carcinoma (author's transl)]

1. An improvement of the chemotherapy of hepatocellular carcinoma with adriamycin or 5-fluorouracil and a reduction of side effects has been achieved by intra-arterial administration of the drugs. This treatment provides a somewhat extended survival but no cure. 2. The treatment of hepatocellular carcinoma in patients by reduction of an inactive precursor of a cytocidal alkylating agent by azoreductase of the tumor showed no therapeutic effect. 3. A selective hepatocellular uptake of drugs coupled to asialoglycoproteins has been described. An application of this concept for the chemotherapy of hepatocellular carcinoma seems doubtful since a loss of binding proteins for desialylated glycoproteins during experimental hepatocarcinogenesis has been demonstrated. 4. The increased uptake of 5-fluorouridine in hepatomas after induction of a tissue-specific depletion of uridine 5'-triphosphate and cytidine 5'-triphosphate provides an effective experimental chemotherapy with limited side effects. A clinical use of this new concept for the chemotherapy of hepatocellular carcinoma may serve as a useful approach.