Synergistic inhibitory effects on hepatocellular carcinoma with recombinant human adenovirus Aspp2 and oxaliplatin via p53-independent pathway in vitro and in vivo

The present study was designed to investigate the synergistic inhibitory effects on hepatocellular carcinoma with recombinant human adenovirus Aspp2 (Aspp2-ad) and oxaliplatin via p53-independent pathway in vitro and in vivo. After being treated with Aspp2-ad and/or oxaliplatin for 24-48 h, HepG2P53-/- and Hep3B cells showed a significant growth inhibition compared with vehicle control. Combination group showed a synergetic effect, the inhibitory rates were all above 80% at 48 h point in HepG2P53-/- and Hep3B cells. The apoptotic cell numbers of Aspp2-ad and/or oxaliplatin treatment groups were increased remarkably, especially for the combined therapy group in the liver cancer cells. The Hep3B xenograft experiment also showed similar inhibition of Aspp2-ad and/or oxaliplatin to the in vitro experiment. H&E results showed that combination group had the least mitotic indexes and the most necrosis. The immunohistochemistry results showed that PCNA, CD31 expression decreased greatly in treatment groups. These results suggested that Aspp2-ad might inhibit proliferation and vascular growth of hepatocarcinoma. Aspp2 induced apoptosis protein expression in Aspp2-ad and combination groups, the Aspp2, Bax and activation of caspase-3 expression increased greatly both in vitro and in vivo. But interestingly, the autophagy proteins showed different responses not only in HepG2P53-/- and Hep3B cells but also in vitro and in vivo. We found that Aspp2-ad downregulated the p-ERK, p-STAT3 expression, the synergistic effects were observed in combination group, while there was not response of mTOR to Aspp2-ad. In conclusion, Aspp2-ad, in P53-independent manner, regulated ERK and STAT3 signal moleculars to inhibit hepatocarcinoma in coordination with oxaliplatin by influencing the protein expression of proliferation, apoptosis, autophagy and vascular growth. Aspp2-ad has the potential to be developed in gene therapy for HCC, especially for P53 deletion or mutation in HCC.

Expression and association of VEGF-Notch pathways in infantile hemangiomas

The vascular endothelial growth factor (VEGF) and Notch signaling pathways have been identified to be involved in the neovascularization, and angiogenesis of various tumor types. However, there is little data regarding their roles and association in infantile hemangiomas (IHs). In the present study, the significance and association of the VEGF-VEGF receptor (R)2, and δ like canonical Notch ligand 4 (Dll4)-Notch1 pathways in different clinical phases of IHs were investigated. Specimens in the proliferating phase (n=15) and involuting phase (n=12) were collected. Quantitative polymerase chain reaction was used to analyze the mRNA levels of VEGF, VEGFR2, Dll4 and Notch1. A further 61 paraffin-embedded IHs (26 in the proliferating group and 35 in the involuting group) specimens were collected to investigate the protein levels of Notch1 and Dll4 using immunohistochemistry, and then analyzed for the association between these factors and microvessel density (MVD). The relative expression levels of VEGF, VEGFR2 and Dll4 mRNA in the proliferating group were significantly higher compared with that in the involuting group. In addition, the relative levels of Notch1 mRNA were similar in the proliferating and involuting phases. Expression levels of VEGFR2 and Dll4 mRNA were positively correlated with Notch1 expression in the proliferating IHs. The relative expression of VEGFR mRNA was positively correlated with Dll4 in the proliferating and involuting groups. Immunohistochemical staining demonstrated that Notch1 and Dll4 protein were upregulated in the proliferating IHs compared with the control group. In the proliferating IHs, Notch1 and Dll4 protein expression levels were positively correlated with MVD, while in the involuting phase, only Dll4 was positively correlated with MVD. The expression levels of related factors in the VEGF and Notch pathways, and the associations among them suggest that they may be involved in the regulation of IH neovascularization and angiogenesis.

Post-pancreaticoduodenectomy hemorrhage: DSA diagnosis and endovascular treatment

Objective

To explore the diagnostic value of digital subtraction angiography (DSA) and the effectiveness of endovascular treatment for a post-pancreaticoduodenectomy hemorrhage (PPH).

Results

During the DSA examination, positive results were found in 29 patients, yielding a positive rate of 69.0%. The manifestations of the DSA examination included contrast medium extravasation, pseudoaneurysm, and artery walls coarse. All 29 patients with positive results underwent endovascular treatment, including transartery embolization (TAE) in 28 patients and covered stents placement in one patient. The technical success and clinical success rates were 100% and 72.4%, respectively. Re-bleeding occurred in 8 of the 29 patients after the first treatment (27.6%). The mortality of PPH was 17.2% (5 of 29). Two of the five PPH patients died following severe infections, and three died from multiple organ failure.

Materials and Methods

A DSA examination was conducted using clinical and imaging data of 42 patients, and endovascular treatment for delayed PPH was retrospectively analyzed.

Conclusions

DSA examination is a minimally invasive and rapid method for the diagnosis of delayed PPH. For patients with positive DSA results, endovascular treatment can be performed rapidly, safely, and effectively. Therefore, the DSA examination and endovascular treatment could be considered a preferred treatment approach for delayed PPH.

Safety and efficacy of transcatheter arterial chemoembolization with embospheres in treatment of hepatocellular carcinoma

OBJECTIVE

To investigate the safety and efficacy of transcatheter arterial chemoembolization (TACE) with embospheres for the treatment of unresectable hepatocellular carcinoma (HCC).

METHODS

Patients with unresectable HCC who were treated with TACE followed by embosphere treatment (Embo-TACE) or conventional TACE (cTACE) between May 2010 and March 2014 were retrospectively included in this study. The Embo-TACE group received lipiodol and chemotherapeutic agent emulsion, followed by embospheres. The cTACE group received lipiodol and chemotherapeutic agent emulsion, followed by gelatin sponge pellets. Time to progression (TTP), overall survival (OS), overall response rate (ORR), and safety were compared between the two groups. Univariate and multivariate regression analyses of the factors affecting survival were conducted.

RESULTS

The median TTP and OS in the Embo-TACE group were significantly longer than those in the cTACE group (TPP: 7.0 months vs 5.4 months, P = 0.035; OS: 15 months vs 12 months, P = 0.032). Seven days after the first TACE treatment, alanine aminotransferase level was higher in the cTACE group than in the Embo-TACE group (P = 0.015). The ORR did not significantly differ between the two groups (P = 0.827). Additional therapy and local responses one month after the first TACE treatment were associated with OS.

CONCLUSIONS

Embo-TACE resulted in a significant improvement in TTP and OS for patients with unresectable HCC, compared with cTACE. Furthermore, Embo-TACE was better tolerated. Additional therapy and local responses one month after the first TACE were independent prognostic factors for OS.

Chinese consensus guidelines for diagnosis and management of gastrointestinal stromal tumor

In order to further promote the standardization of diagnosis and treatment of gastrointestinal stromal tumor (GIST) in China, the members of Chinese Society of Clinical Oncology (CSCO) Expert Committee on GIST thoroughly discussed the key contents of the consensus guidelines, and voted on the controversial issue. In final, the Chinese consensus guidelines for the diagnosis and management of GIST (2017 edition) was formed on the basis of 2013 edition consensus guidelines, which is hereby announced. The consensus included the pathological diagnosis, recurrence risk classification evaluation, targeted agent therapy, surgery and principles of surveillance of GIST.

Polyunsaturated Fatty Acids and Their Derivatives: Therapeutic Value for Inflammatory, Functional Gastrointestinal Disorders, and Colorectal Cancer

Polyunsaturated fatty acids (PUFAs) are bioactive lipids which modulate inflammation and immunity. They gained recognition in nutritional therapy and are recommended dietary supplements. There is a growing body of evidence suggesting the usefulness of PUFAs in active therapy of various gastrointestinal (GI) diseases. In this review we briefly cover the systematics of PUFAs and their metabolites, and elaborate on their possible use in inflammatory bowel disease (IBD), functional gastrointestinal disorders (FGIDs) with focus on irritable bowel syndrome (IBS), and colorectal cancer (CRC). Each section describes the latest findings from in vitro and in vivo studies, with reports of clinical interventions when available.

Risk Factors and Treatment for Hemorrhage after Pancreaticoduodenectomy: A Case Series of 423 Patients

The study aimed to investigate the risk factors of postpancreatectomy hemorrhage (PPH) after pancreaticoduodenectomy (PD). A retrospective analysis of 423 patients who underwent PD between January 2008 and January 2014 was conducted. The overall incidence and all-cause mortality of PPH were 9.9% (42/423) and 2.1% (9/423), respectively. Independent risk factors of early PPH were revascularization (odds ratio (OR) = 6.786; 95% confidence interval (95% CI): 1.785–25.792; P = 0.005), history of abdominal surgery (OR = 5.009; 95% CI: 1.968–12.749; P = 0.001), and preoperative albumin levels (OR = 4.863; 95% CI: 1.962–12.005; P = 0.001). Independent risk factors of late PPH included postoperative pancreatic leakage (OR = 4.696; 95% CI: 1.605–13.740; P = 0.005), postoperative biliary fistula (OR = 6.096; 95% CI: 1.575–23.598; P = 0.009), postoperative abdominal infection (OR = 4.605; 95% CI: 1.108–19.144; P = 0.036), revascularization (OR = 9.943; 95% CI: 1.900–52.042; P = 0.007), history of abdominal surgery (OR = 8.790; 95% CI: 2.779–27.806; P < 0.001), and preoperative albumin levels (OR = 5.563; 95% CI: 1.845–16.776; P = 0.002).

Docetaxel-loaded lipid microbubbles combined with ultrasound-triggered microbubble destruction for targeted tumor therapy in MHCC-H cells

BACKGROUND

Efficient and targeted delivery of cytotoxic drugs is still a challenge in the fight against cancer. Ultrasound-targeted destruction of cytotoxic drug-loaded lipid microbubbles (LMs) might be a promising method. This study aimed to explore the antitumor effects of docetaxel-loaded LM (DLLM) combined with ultrasound-targeted microbubble destruction (UTMD) on liver cancer.

MATERIALS AND METHODS

DLLMs were made by a mechanical vibration technique. The effects of docetaxel, DLLM alone, and DLLM + UTMD on cell viability and cell proliferation (Cell Counting Kit-8 assay) of MHCC-H cells and HepG2 cells were tested. The effects on cell cycle (flow cytometry) and apoptosis (flow cytometry and immunoblotting) of MHCC-H cells were tested. Solid fast-growing tumor mouse models were established and were randomized to blank LM + UTMD (controls) or DLLM + UTMD. Tumor volume was compared between the two groups.

RESULTS

DLLMs had an 18%±7% drug-loading capacity, an 80%±3% encapsulation efficiency, and a mean particle size of 2,845 nm (75% range 1,527-5,534 nm). Compared to the other groups, DLLM + UTMD decreased the proliferation and increased the apoptosis of MHCC-H cells. DLLM + UTMD resulted in the inhibition of a higher proportion of cells in the G1 phase. Compared to the control group, the tumor volume in mice receiving DLLM + UTMD was smaller.

CONCLUSION

DLLM + UTMD can increase the proportion of cells arrested in the G1 phase, decrease tumor cell proliferation, and induce MHCC-H cell apoptosis. The growth of solid tumors in mice was inhibited. These results could provide a novel targeted strategy against liver cancer.

Targeting PCDH20 gene by microRNA-122 confers 5-FU resistance in hepatic carcinoma

Drug resistance is one of the main hurdles for the successful treatment of hepatic carcinoma. However, the detailed mechanisms underlying resistance remain largely unknown and therapeutic approaches are limited. In the present study, we show that miR-122 confers resistance to 5-fluorouracil induced hepatocellular carcinoma cell apoptosis in vitro and reduces the potency of 5-fluorouracil in the inhibition of tumor growth in a mouse xenograft model in vivo. Further studies indicate that miR-122 modulates drug resistance through down-regulation of expression of PCDH20, which belongs to the protocadherin gene family and negatively regulates Akt activation. Knockdown of PCDH20 expression increases Akt phosphorylation, which leads to elevated mTOR activity and enhanced 5-fluorouracil resistance; whereas rescue of PCDH20 expression in miR-122-expressing cells decreases Akt and mTOR phosphorylation, re-sensitizing hepatocellular carcinoma cell to 5-fluorouracil induced apoptosis. Moreover, a specific and potent Akt inhibitor reverses miR-122-conferred 5-fluorouracil resistance. These findings indicate that the miR-122/PCDH20/Akt/mTOR signaling axis has an important role in mediating response to chemotherapy in human hepatocellular carcinoma. A major implication of our study is that inhibition of miR-122 or restoration of PCDH20 expression may have significant therapeutic potential to overcome drug resistance in hepatocellular carcinoma and that the combined use of an Akt inhibitor with 5-fluorouracil may increase efficacy in liver cancer treatment.

Transarterial chemoembolization combined with sorafenib for the treatment of hepatocellular carcinoma with hepatic vein tumor thrombus

Objective

To compare the treatment outcomes of sorafenib plus transarterial chemoembolization (TACE) vs TACE alone in patients with hepatocellular carcinoma (HCC) and hepatic vein tumor thrombus (HVTT).

Methods

Twenty patients who were initially diagnosed with HCC and HVTT and received TACE combined with sorafenib during February 2009 to October 2013 were included in the study. To minimize selection bias, these patients were compared with 60 case-matched controls selected from a pool of 81 patients (in a 1:3 ratio) who received TACE alone during the same period. The primary end point was overall survival (OS). The secondary end points were time to progression, disease control rate, and adverse events.

Results

After a median follow-up period of 12.5 months (range, 1.03–44.23 months), the OS of the combined group was found to be significantly higher compared with the monotherapy group (14.9 vs 6.1 months, P=0.010). The time to progression was found to be significantly longer in the combined group (4.9 vs 2.4 months, P=0.016). Univariate and multivariate analyses revealed that the treatment allocation was an independent predictor of OS.

Conclusion

Sorafenib plus TACE was well tolerated and was more effective in treating patients with advanced HCC and HVTT. Future trials with prospective larger samples are required to validate these results.

Clinical significance of vascular endothelial growth factor in hepatitis C related hepatocellular carcinoma in Egyptian patients

Background and aims

Several angiogenic factors are involved in the development and progression of hepatocellular carcinoma (HCC), a hypervascular tumor. Vascular endothelial growth factor (VEGF) is a primary driving force for angiogenesis, and its overexpression has been reported in HCC. However, the significance of plasma and tissue VEGF levels in HCC in Egyptian patients with chronic hepatitis C (CHC) infection is understudied. The aim of this study was to evaluate the role of VEGF (measured in plasma and liver tissue) in patients with hepatitis C virus-related HCC and to assess its significance in the diagnosis and prognosis of HCC.

Materials and methods

A total of 90 subjects were studied. Among 90 subjects, 60 with CHC were examined and were subdivided into two groups: 30 patients with CHC-related HCC (HCC group) and 30 patients with CHC without HCC (non-HCC group). Thirty apparently healthy subjects served as the control group. VEGF was estimated in plasma by enzyme-linked immunosorbent assay and its expression in liver tissue was evaluated by real-time polymerase chain reaction. VEGF expression level and its relationship to tumor parameters, patients’ liver function profile, and patients’ clinical parameters were also investigated.

Results

Plasma VEGF levels in the HCC group were significantly higher than those of the non-HCC group, and both groups had significantly higher plasma VEGF levels than did the control group. Liver tissue VEGF expression was significantly higher in the HCC group than in the non-HCC group and positively correlated with plasma VEGF in the HCC group. The plasma VEGF levels were positively correlated with patients’ age, aspartate aminotransferase levels, serum alpha-fetoprotein levels, the presence of portal vein thrombosis, and the number of hepatic focal lesions in the HCC group. However, plasma VEGF levels were not significantly correlated with the Child-Pugh score, alanine aminotransferase levels, the size of focal lesions, and Okuda stage. Using both the VEGF and alpha-fetoprotein levels to detect HCC maximizes the sensitivity and specificity.

Conclusion

Plasma levels of VEGF may be a useful diagnostic and prognostic marker for HCC in patients who have been diagnosed with CHC.

The Changes of HIF-1α and VEGF Expression After TACE in Patients With Hepatocellular Carcinoma

As a common malignant tumor, hepatocellular carcinoma (HCC) has a high prevalence and is a serious threat to human health. The surgical resection rate of HCC is low, and the prognosis is poor. Although transarterial chemoembolization (TACE) is the main treatment for HCC patients who are not candidates for surgical resection, it is not considered a curative procedure. For HCC, poor TACE efficacy or TACE failure may be related to tumor angiogenesis of the residual disease. Among the many regulatory factors in tumor angiogenesis, hypoxia-inducible factor-1α (HIF-1α) and vascular endothelial growth factor (VEGF) play vital roles in this process. In this paper, we conducted a review of the dynamic change and relevance of HIF-1α and VEGF levels after TACE of HCC patients.

Unusual case of digestive bleeding nine months after a cephalic pancreaticoduodenectomy (CPD)

INTRODUCTION

Post-pancreaticoduodenectomy hemorrhage is mostly due to the gastroduodenal artery stump erosion. The diagnosis of arterial bleeding is done by digestive endoscopy, selective angiography or video capsule endoscopy. On failure of etiological research, surgery is the last resort despite its technical difficulties.

CASE PRESENTATION

A 63 years-old woman was admitted in surgery, nine months after cephalic pancreaticoduodenectomy for a pain of the right hypochondria combined with a pneumoperitoneum, after a 3rd episode of hemorrhage. Exploratory laparotomy is performed after a third hemorrhagic episode and failure of etiological research. Bleeding from the gastroduodenal artery stump was discovered and successfully treated.

DISCUSSION

Post-pancreaticoduodenectomy hemorrhage can occur very late. In these cases, a secondary arterial erosion obstructed by left hemi-liver should not be excluded. In these cases, despite the technical risks, surgery is required.

CONCLUSION

The failure of the means used for diagnostic must lead to the surgery right away, despite operating risk.

Target hepatic artery regional chemotherapy and bevacizumab perfusion in liver metastatic colorectal cancer after failure of first-line or second-line systemic chemotherapy

Colorectal cancer liver metastasis (CRLM) is a refractory disease after failure of first-line or second-line chemotherapy. Bevacizumab is recommended as first-line therapy for advanced colorectal cancer, but is unproven in CRLM through the hepatic artery. We report favorable outcomes with targeted vessel regional chemotherapy (TVRC) for liver metastatic gastric cancer. TVRC with FOLFOX and bevacizumab perfusion through the hepatic artery was attempted for CRLM for efficacy and safety evaluation. In a single-institution retrospective observational study, 246 patients with CRLM after at least first-line or second-line failure of systemic chemotherapy received TVRC with FOLFOX (i.e. oxaliplatin, leucovorin, and 5-fluorouracil). Of 246 patients, 63 were enrolled into two groups: group 1 (n=30) received bevacizumab and TVRC following tumor progression during previous TVRC treatments; group 2 (n=33) received TVRC plus bevacizumab for CRLM on initiating TVRC. There were no significant differences in the median survival time (14.7 vs. 13.2 months, P=0.367), although the median time to progression was significant (3.3 vs. 5.5 months, P=0.026) between groups. No severe adverse events related to TVRC plus bevacizumab perfusion occurred. Target vessel regional chemotherapy with FOLFOX plus bevacizumab perfusion through the hepatic artery was effective and safe in CRLM. The optimal combination of TVRC and bevacizumab needs further confirmation in future phase II-III clinical trials.

Contemporary Management of Metastatic Gastrointestinal Stromal Tumors: Systemic and Locoregional Approaches

The treatment of metastatic gastrointestinal stromal tumors (GISTs) changed dramatically with the introduction of imatinib into the therapeutic lexicon in 2001. Over the past 15 years, tyrosine kinase inhibitors in the adjuvant and metastatic settings have remained the standard of care for this disease, though alternate classes of agents and new therapeutic targets are being actively explored in clinical trials. Although data are limited, the use of surgical and non-surgical locoregional techniques for the treatment of GIST metastases has increased and given reports of promising and durable responses. Herein we provide an overview of the contemporary therapeutic landscape of metastatic GIST.

Ischemic Liver Injury After Complete Occlusion of Hepatic Artery in the Treatment of Delayed Postoperative Arterial Bleeding

BACKGROUND

Delayed postoperative arterial bleeding is rare and may be life-threatening. When the bleeding source is the hepatic artery, complete ligation or embolization from the proximal to the distal area of the ruptured lesion usually results in complete occlusion of hepatic arterial flow.

METHODS

To evaluate the frequency and severity of ischemic liver injury following complete hepatic artery occlusion, a retrospective study was conducted. Patients who underwent complete hepatic artery occlusion in the treatment of delayed postoperative arterial bleeding between January 2007 and December 2014 in our institution were reviewed. Changes of hepatic function and rates of associated complications and prognosis were analyzed.

RESULTS

A total of 24 patients experienced 26 episodes of bleeding. Nineteen experienced transient liver enzyme elevation alone. There were no signs of acute liver failure after complete hepatic artery occlusion. The rates of liver infarction and liver abscess were 23.8 % (5/21) and 19 % (4/21), respectively. The 30-day mortality rate was 8.3 % (2/24).

CONCLUSION

Complete occlusion of the hepatic artery does not always result in severe hepatic ischemic injury. As a common cause of delayed postoperative bleeding, intra-abdominal infection may be fatal when it is not controlled successfully.

Comparison of Safety and Efficacy of Different Models of Target Vessel Regional Chemotherapy for Gastric Cancer with Liver Metastases

BACKGROUND/AIMS

We previously demonstrated the safety and efficacy of low-dose, short-interval target vessel regional chemotherapy (TVRC(LDSI)) delivered through the hepatic artery with transarterial embolization (TAE) in patients with advanced gastric cancer (AGC). The present study aimed to compare the efficacy of TAE + TVRC(LDSI) with that of standard TAE + TVRC in AGC patients with liver metastases who failed to respond to first- or second-line systemic chemotherapy.

METHODS

This study recruited a total of 58 GC patients with liver metastases after failure of first- or second-line systemic chemotherapy. Twenty-eight patients were assigned to the TAE + TVRC(LDSI) group and 30 patients to the TAE + TVRC group. The primary end point was overall survival (OS(TVRC)), which was defined as the time from the initiation of TVRC until the last follow-up or death.

RESULTS

OS(TVRC), time to progression (TTP) until appearance of intra- and extrahepatic metastases, and overall TTP and treatment periods in the TAE + TVRC(LDSI) group were all significantly longer than in the TAE + TVRC group (all p < 0.001).

CONCLUSION

TAE + TVRC(LDSI) had a higher efficacy and safety, which was reflected by OS rates, progression-free survival rates, longer duration of treatment and milder side effects compared to standard TAE + TVRC.

Management of a delayed post-pancreatoduodenectomy haemorrhage using endovascular techniques

BACKGROUND

A delayed post-pancreatoduodenectomy haemorrhage is associated with a significant increase in peri-operative mortality. Endovascular techniques are frequently used for a delayed haemorrhage. However, limited data exists on the short- and long-term outcomes of this approach. A retrospective review over a 10-year period at a quaternary-referral pancreatic centre was performed.

METHODS

Between 2002-2012, 1430 pancreatoduodenectomies were performed, and 32 patients had a delayed haemorrhage (occurring >24 h post-operatively) managed by endovascular techniques. The clinicopathological variables related to a haemorrhage were investigated.

RESULTS

A total of 42 endovascular procedures were performed at a median of 25 days, with the majority of delayed haemorrhages occurring after 7 days. There were four deaths (13%) with three occurring in patients with a grade C haemorrhage. Seven patients (22%) experienced rebleeding, and two patients developed hepatic abscesses.

CONCLUSION

A delayed haemorrhage post-pancreaticoduodenectomy can be managed by endovascular techniques with acceptable morbidity and mortality. Rebleeding and hepatic abscesses may occur and can be managed non-operatively in most cases. The association of a delayed haemorrhage with a pancreatic fistula makes this a challenging clinical problem.

Multidisciplinary treatment of liver metastases of gastric cancer

The liver is the main target organ of the metastasis for gastric cancer. In cases of liver metastases of gastric cancer, the clinical effects of many treatments are not ideal. The morbidity of liver metastases of gastric cancer is high, which is one of the leading causes of death in gastric cancer patients. Currently, there have been no standardized treatment strategies. In recent years, the use of multidisciplinary treatment can prolong the survival of gastric cancer patients with liver metastases. Multidisciplinary treatment, which is based on individual patient's condition and combines surgery, chemotherapy, radiofrequency ablation, transarterial chemoembolization and targeted therapy, may improve the outcomes radically.

Hepatic artery embolization for liver metastasis of gastrointestinal stromal tumor following imatinib and sunitinib therapy

PURPOSE

The purpose of the study is to determine the efficacy of hepatic artery embolization (HAE) as a therapy for gastrointestinal stromal tumor (GIST) in patients who are refractory to imatinib and sunitinib.

METHODS

After institutional review board approval, a retrospective review revealed 11 patients with GIST metastatic to the liver who underwent 15 HAEs between February 2002 and May 2013. These patients were stratified into two groups according to the previous treatment: (a) those treated with HAE as second-line treatment after failing first-line imatinib (n = 3) and (b) those treated with HAE as third-line therapy after failing first-line imatinib and second-line sunitinib (n = 8). Initial therapeutic response, overall survival (OS), progression-free survival (PFS), and safety were evaluated.

RESULTS

Initial therapeutic response rates at 3 months after HAE were 27.3 % (95 % confidence interval (CI), 6.0-61.0 %) by Response Evaluation Criteria in Solid Tumor (RECIST) version 1.0 and 45.5 % (95 % CI, 16.7-76.6 %) by modified RECIST (mRECIST). The median OS and PFS after HAE were 14.9 and 3.9 months in group A and 23.8 and 3.4 months in group B, respectively. No procedure-related mortality or major complication was observed.

CONCLUSIONS

HAE is an effective and well-tolerated therapeutic option for GIST liver metastases. Although larger studies are necessary, HAE should be considered as an alternative or adjuvant to third-line or even second-line systemic treatment.

Efficacy and Clinical Outcomes of Transcatheter Arterial Embolization for Gastrointestinal Bleeding from Gastrointestinal Stromal Tumor

PURPOSE

To evaluate the efficacy and clinical outcomes of transcatheter arterial embolization (TAE) for gastrointestinal (GI) bleeding from gastrointestinal stromal tumor (GIST).

MATERIALS AND METHODS

TAE was performed in 20 referred patients (male:female = 13:7; median age, 56.3 y) for GI bleeding from GISTs. The locations of GISTs were assessed using contrast-enhanced computed tomography (CT) and catheter angiography. The technical and clinical success of TAE and clinical outcomes including procedure-related complications, recurrent bleeding, 30-day and overall mortality, and cumulative survival were evaluated.

RESULTS

The sites of GIST-related bleeding or tumor staining were the jejunum (n = 9), stomach (n = 5), ileum (n = 3), duodenum (n = 2), and jejunum and colon (n = 1). Angiography showed bleeding from GIST in 5 patients, and tumor staining was noted in only 15 patients. TAE was performed for patients with and without contrast medium extravasation on angiography. Technical and clinical success rates of TAE were 95% (19 of 20 patients) and 90% (18 of 20 patients), respectively. Recurrent bleeding was noted in 1 patient. There were no procedure-related complications. In 15 patients, surgical resection of the tumors was performed after TAE. The 30-day and overall mortality rates were 10% (2 of 20 patients) and 30% (6 of 20 patients), respectively.

CONCLUSIONS

TAE is a safe and effective method for controlling GI bleeding from the GIST.

Relationship between ADH2 Arg47His variation and hepatocellular carcinoma susceptibility: a meta analysis

BACKGROUND

To further investigate the relationship between ADH2 Arg47His variation and hepatocellular carcinoma (HCC) susceptibility through a meta-analysis.

METHODS

The related articles were searched in PubMed, Embase and CNKI databases. And finally 518 cases and 607 controls were included in our meta-analysis Odds ratios (ORs) with 95% confidence intervals (95% CIs) were used to assess the relationship between ADH2 Arg47His variation and HCC risk. A fixed-effect model or a random-effect model was applied according to the between-study heterogeneity.

RESULTS

Quantitative synthesis demonstrated that no significant association was found between ADH2 Arg47His variation and HCC susceptibility (His/His vs. Arg/Arg: OR=0.99, 95% CI=0.79-1.25; His/His + Arg/His vs. Arg/Arg: OR=1.01, 95% CI=0.86-1.20; His/His vs. Arg/Arg + Arg/His: OR=0.90, 95% CI=0.74-1.11; His vs. Arg: OR=0.98, 95% CI=0.86-1.11; Arg/His vs. Arg/Arg: OR=1.05, 95% CI=0.82-1.34).

CONCLUSION

Our analysis showed that ADH2 Arg47His vvariation may not be associated with HCC susceptibility.

Lipopolysaccharide Effect on Vascular Endothelial Factor and Matrix Metalloproteinases in Leukemic Cell Lines In vitro

Background:

Angiogenesis, the process of new vessels generation, plays a critical role in tumor invasion and metastasis. Vascular Endothelial Growth Factor (VEGF), as a cytokine, and Matrix Metalloproteinases (MMPs), has been the important factors that involved in angiogenesis. Lipopolysaccharide (LPS) has an essential effect on angiogenesis.

Objectives:

In this study the effect of LPS on VEGF production and MMP-2/MMP-9 activity in two leukemic cell lines has been assessed in vitro.

Materials and Methods:

Human leukemic U937 and THP1 cells were cultured in complete RPMI medium. Then the cells at the exponential growth phase were incubated with different concentrations of LPS (0 - 4 μg/mL) for 48 hours. Then the level of VEGF production and MMP-2/MMP-9 activity in cell culture supernatants were evaluated with the ELISA standard kits and gelatin zymography respectively.

Results:

U937 cells have produced a large amount of VEGF without any stimulus and LPS has not shown any substantial effect on VEGF production by these cells. However THP1 cells have produced a small amount of VEGF without stimulation and LPS significantly has increased VEGF production in these cells dose-dependently. Moreover LPS significantly has augmented the MMP-2/MMP-9 activity in the both leukemic cell lines in a dose-dependent manner.

Conclusions:

Our results have shown that LPS might be a potential inducer/enhancer of VEGF production and MMP-2/MMP-9 activity (angiogenic factors) in leukemia. Moreover the LPS effect on angiogenesis might be in part, due to its stimulatory effects on VEGF and MMPs. Overall LPS-stimulated leukemic cells might be good models for study and planning the useful therapeutic approaches for angiogenesis- dependent diseases.

γ-H2AX promotes hepatocellular carcinoma angiogenesis via EGFR/HIF-1α/VEGF pathways under hypoxic condition

Hepatocellular carcinoma (HCC) is one of the most deadly cancers. Using mRNA microarray analysis, we found that H2AX decreased under hypoxic conditions. Hypoxia is an important physiological and pathological stress that induces H2AX phosphorylation (γ-H2AX), but the regulatory mechanism of γ-H2AX remains elusive in the progress of HCC. We report here that increased γ-H2AX expression in HCC is associated with tumor size, vascular invasion, TNM stage and reduced survival rate after liver transplantation (LT). γ-H2AX knockdown was able to effectively inhibit VEGF expression in vitro and tumorigenicity and angiogenesis of HCC in vivo. The mechanism of γ-H2AX on the angiogenic activity of HCC might go through EGFR/HIF-1α/VEGF pathways under hypoxic conditions. Combined γ-H2AX, HIF-1α and EGFR has better prognostic value for HCC after LT. This study suggests that γ-H2AX is associated with angiogenesis of HCC and γ-H2AX or a combination of γ-H2AX/EGFR/HIF-1α is a novel marker in the prognosis of HCC after LT and a potential therapeutic target.

Treatment and survival of gastric cancer patients with metachronous liver metastases

AIM: To investigate the treatment and survival of gastric cancer patients with metachronous liver metastases.

METHODS: Clinical data for 92 gastric cancer patients pathologically diagnosed with metachronous liver metastases treated from January 2004 to December 2009 were included. The patients received treatments including chemotherapy (n = 44), chemotherapy + hepatic artery chemoembolization (TACE) (n = 28), and chemotherapy + liver cancer resection (n = 20). The patients were followed for 6 mo to 70 mo, and the 5-year survival rate was calculated. Prognostic factors were assessed using univariate and Cox regression analysis.

RESULTS: The total effective rate was 50.00% and the 1-, 3- and 5-year survival rates were 72.73%, 22.73% and 2.27% in the patients receiving chemotherapy alone; the corresponding percentages were 57.14%, 71.43%, 28.57% and 10.71% in the chemotherapy + TACE group, and 60.00%, 75.00%, 60.00% and 40.00% in the chemotherapy + liver cancer resection group. Although the total effective rate and 1-year survival rate showed no significant difference among the three group (P > 0.05), the differences in the 3- and 5-year survival rates were statistically significant (P < 0.05). Univariate analysis showed that the diameter of primary tumor, differentiation, hepatic metastasis, liver cancer type, the number of cancer metastases, and treatment efficacy were associated with the prognosis in gastric cancer patients with metachronous liver metastases (all P < 0.05). Cox regression analysis showed that the diameter of primary tumor, the number of liver metastases and liver cancer type were independent risk factors.

CONCLUSION: Chemotherapy + liver cancer resection can effectively improve survival in gastric cancer patients with metachronous liver metastases. When selecting appropriate treatment, the type of liver cancer, tumor size and the number of liver metastases should be taken into account.

Improved antitumor activity and reduced cardiotoxicity of epirubicin using hepatocyte-targeted nanoparticles combined with tocotrienols against hepatocellular carcinoma in mice

Hepatocellular carcinoma (HCC) is the third most common cause of cancer death worldwide. Epirubicin (EPI), an anthracycline derivative, is one of the main line treatments for HCC. However, serious side effects including cardiomyopathy and congestive heart failure limit its long term administration. Our main goal is to develop a delivery strategy that ensures improved efficacy of the chemotherapeutic agent together with reduced cardiotoxicity. In this context, EPI was loaded in chitosan-PLGA nanoparticles linked with asialofetuin (EPI-NPs) selectively targeting hepatocytes. In an attempt to reduce cardiotoxicity, targeted EPI-NPs were coadministered with tocotrienols. EPI-NPs significantly enhanced the antiproliferative effect compared to free EPI as studied on Hep G2 cell line. Nanoencapsulated EPI injected in HCC mouse model revealed higher p53-mediated apoptosis and reduced angiogenesis in the tumor. Combined therapy of EPI-NPs with tocotrienols further enhanced apoptosis and reduced VEGF level in a dose dependent manner. Assessment of cardiotoxicity indicated that EPI-NPs diminished the high level of proinflammatory cytokine tumor necrosis factor-α (TNF-α) as well as oxidative stress-induced cardiotoxicity as manifested by reduced level of lipid peroxidation products (TBARS) and nitric oxide (NO). EPI-NPs additionally restored the diminished level of superoxide dismutase (SOD) and reduced glutathione (GSH) in the heart. Interestingly, tocotrienols provided both antitumor activity and higher protection against oxidative stress and inflammation induced by EPI in the heart. This hepatocyte-targeted biodegradable nanoparticle/tocotrienol combined therapy represents intriguing therapeutic strategy for EPI providing not only superior efficacy but also higher safety levels.

Challenges in combining antiangiogenic therapy with transarterial chemoembolization for hepatocellular carcinoma

BACKGROUND

The combination of systemic antiangiogenic therapy and transarterial chemoembolization (TACE) for the treatment of unresectable hepatocellular carcinoma (HCC) is the subject of several ongoing clinical trials. We present a series of patients treated with sorafenib and TACE at our institution, highlighting the technical challenges of combining these two modalities of treatment.

METHODS

We retrospectively identified patients with HCC treated with TACE and sorafenib at our institution.

RESULTS

Five patients were treated with the combination of TACE and sorafenib given off-protocol based on preliminary reports in the literature. The first four patients started sorafenib 7 days prior to TACE resulting in intratumoral vascular pruning and poor visualization of lesions on angiography. This was managed by either superselective angiography or lobar TACE. The fifth patient stopped sorafenib 7 days prior to TACE with full visualization of multiple hypervascular lesions on angiography prior to embolization.

CONCLUSIONS

Our observations suggest that the biologically preferable strategy of continuous antiangiogenic therapy should be weighed against the possibility of suboptimal TACE due to poor visualization of lesions on angiography and safety.

State of the Art in the Treatment of Gastrointestinal Stromal Tumors

BACKGROUND

Gastrointestinal stromal tumors (GISTs) are the most frequently diagnosed mesenchymal neoplasms of the gastrointestinal tract. Despite their biological and clinical heterogeneity, the majority of these tumors are positive for the receptor tyrosine kinase KIT and are driven by KIT- or platelet-derived growth factor receptor alpha (PDGFRA)-activating mutations. There are still uncertainties regarding their clinical and molecular characterization and the optimal treatment regimens, making it difficult to establish a universal treatment algorithm for these tumors.

SUMMARY

From a clinical perspective, the main difference between GISTs and other gastrointestinal neoplasms is that the benign or malignant behavior of GISTs cannot be predicted from histopathology, but instead relies on empirically established scoring systems. Clinical data suggest that malignant potential may be an inherent quality of some GISTs rather than a feature acquired by the tumor during disease progression. Thus, some patients may require prolonged anti-tumor treatment even after complete surgical removal of the tumor.

KEY MESSAGE

Although GISTs are the most frequently occurring mesenchymal neoplasms in the gastrointestinal tract, no universal treatment algorithms exist. This paper reviews the current evidence that guides the management of GISTs.

PRACTICAL IMPLICATIONS

The management of localized GISTs involves the use of surgical resection, with the inclusion of preoperative tyrosine kinase inhibitor treatment for locally advanced, primarily unresectable tumors and for resectable cases requiring extensive surgery. Imatinib is also indicated as adjuvant therapy after complete surgical removal of GISTs with a high estimated risk of recurrence unless specific mutations conferring imatinib resistance are present. The optimal duration of adjuvant treatment is still controversial. For patients with metastatic imatinib-sensitive GISTs, imatinib constitutes the first-line standard treatment. Molecular characterization of the tumor (with respect to the PDGFRA and KIT genes) is mandatory prior to imatinib therapy. Sunitinib and regorafenib are established as alternative treatments for patients demonstrating generalized disease progression on imatinib. New tyrosine kinase inhibitors such as ponatinib and crenolanib as well as drugs targeting alternative pathways are currently under investigation. Surgery and locally ablative treatments may be indicated in some metastatic patients.

Impact of vascular endothelial growth factor expression on overall survival in patients with osteosarcoma: a meta-analysis

Osteosarcoma is the most common primary malignant bone tumor of childhood. Vascular endothelial growth factor (VEGF) expression has been implicated in tumor development and progression of osteosarcoma, but previous studies investigating the impact of VEGF expression on overall survival in patients with osteosarcoma report conflicting findings. A meta-analysis of published studies was performed. The pooled hazard ratio (HR) with its 95% confidence interval (95% CI) was used to assess the impact of VEGF expression on overall survival in patients with osteosarcoma. Nine studies with a total of 432 osteosarcoma patients were included into this meta-analysis. There was no between-study heterogeneity among those nine studies (I (2) = 0.0%). Overall, high VEGF expression was obviously associated with poorer overall survival (HR = 1.68, 95% CI 1.33-2.12, P < 0.001). Sensitivity analysis performed by excluding single study in turns showed the pooled estimate was stable. Egger's test also did not suggest evidence for publication bias (P = 0.216). Therefore, this meta-analysis suggests that VEGF expression has an important impact on overall survival in patients with osteosarcoma and high VEGF expression is associated with poorer overall survival.

A comparative study between Embosphere(®) and conventional transcatheter arterial chemoembolization for treatment of unresectable liver metastasis from GIST

OBJECTIVE

Transcatheter arterial chemoembolization (TACE) is a standard treatment for hepatocellular carcinoma (HCC) and/or some unresectable liver metastasis tumors. Hypervascular liver metastatic lesions such as metastasis from gastrointestinal stromal tumor (GIST) are an indication for transcatheter arterial embolization (TAE). The purpose of this study was to evaluate the efficacy and safety of Embosphere(®)-TAE (Embo-TAE) in comparison with conventional TACE (cTACE) for the treatment of liver metastasis from GIST.

METHODS

A total of 45 patients who underwent TACE between Aug 2008 and Feb 2013 were enrolled. Patients with GIST who underwent TAE with Embosphere(®) (n=19) were compared with controls who received cTACE (n=26). The primary end points were treatment response and treatment-related adverse events. The secondary end points were progression-free survival (PFS) and overall survival (OS).

RESULTS

The treatment response of Embo-TAE group was significantly higher than that of the cTACE group (P<0.001). The PFS was significantly better in the Embosphere(®)-group than in the cTACE group (56.6 and 42.1 weeks, respectively; P=0.003). However, there was no statistically significant difference in liver toxicity between the two groups (P>0.05). The median OS in the Embo-TAE group was longer than that in the cTACE group (74.0 weeks, 95% CI: 68.2-79.8 vs. 61.7 weeks, 95% CI: 56.2-67.2 weeks) (unadjusted P=0.045). The use of Embo-TAE significantly reduced the risk of death in patients with GIST with liver metastases according to the Cox proportional hazards regression model [hazard ratio (HR): 0.149; 95% CI: 0.064-0.475].

CONCLUSIONS

TAE with Embosphere(®) showed better treatment response and delayed tumor progression compared with cTACE. There was no significant difference in treatment-related hepatic toxicities. Embo-TAE thus appears to be a feasible and promising approach in the treatment of liver metastasis from GIST.

Factors predictive for a positive invasive mesenteric angiogram following a positive CT angiogram in patients with acute lower gastrointestinal haemorrhage

INTRODUCTION

Computed tomographic mesenteric angiography (CTMA) is increasingly adopted in patients with massive lower gastrointestinal (LGI) bleeding. However, a positive computed tomography scan does not always translate to a positive invasive mesenteric angiography (MA) when performed. The aim of this study was to identify factors that could predict a positive invasive MA following a positive CTMA.

METHODS

A review of all patients with LGI haemorrhage who had a positive CTMA followed by an invasive MA was performed.

RESULTS

From July 2009 to October 2012, 33 positive CTMA scans from 30 patients were identified. Of the 33 bleeding points, 28 were in the colon, while 5 were in the small intestine. Diverticular disease accounted for 20 of the bleeding points. The median duration from the CTMA to the invasive MA was 165 (74-614) min. Of the 33 invasive MAs that were performed, only 14 demonstrated positive extravasation. Factors that were significant for a positive invasive MA included non-diverticular aetiology (odds ratio (OR), 6.75, 95 % confidence interval (CI), 1.43-31.90, p = 0.029) and haemoglobin <100 g/l (OR, 14.44, 95 % CI, 1.56-133.6, p = 0.009). When the invasive MA procedure was performed within <150 min of the positive CTMA scan, it was 2.89 (95 % CI, 0.69-12.12) times more likely to be associated with a positive invasive MA.

CONCLUSIONS

Patients with non-diverticular aetiologies and lower haemoglobin levels are associated with a positive invasive MA following a positive CTMA. It is prudent to consider performing the invasive MA within 150 min after a positive CTMA.