High-dose tamoxifen in the treatment of inoperable hepatocellular carcinoma: A multicenter randomized controlled trial

Simple clinical prognostic model for hepatocellular carcinoma in developing countries and its validation

PURPOSE

More than 80% of hepatocellular carcinomas (HCCs) worldwide occur in developing countries, especially in Asia. It often presents at an advanced stage beyond treatment. In this circumstance, a simple prognostic model is useful. Previous prognostic models require radiologic and laboratory investigations that are not readily available in developing countries. Our aim is to formulate and then validate a simple clinical prognostic model for HCC in an Asian population using only clinical parameters and with serum alpha-fetoprotein (AFP) as the sole laboratory test.

PATIENTS AND METHODS

Cox regression modeling was performed on several clinical parameters and serum AFP level in 397 patients with HCC who received only supportive care in Singapore. A later group of 324 HCC patients from an Asia-Pacific-wide randomized trial was then used to validate the model.

RESULTS

Ascites, physical performance status, and serum AFP were independently predictive of survival. Cox analysis yielded a simple score based on these three variables that categorizes patients into low-, medium-, and high-risk groups with 6-month survivals of 43%, 21%, and 5%, respectively. The prospective validation data provided corresponding estimates of 33%, 15%, and 3% and give confirmation of the utility of the simple model.

CONCLUSION

We have formulated and prospectively validated a simple prognostic score for untreated HCC that only requires a clinical evaluation for ascites and physical performance status and measurement of serum AFP. This simple model is particularly apt for developing country circumstances and can also be used to select patients for treatment trials.

Tamoxifen induction of aryl sulfotransferase and hydroxysteroid sulfotransferase in male and female rat liver and intestine

The antiestrogenic drug tamoxifen (TAM) is widely used in the treatment of breast cancer. Species-specific mutagenic and carcinogenic potentialities have been reported and have raised concerns. Sulfotransferases (STs) are important phase II drug-metabolizing enzymes. STs are involved in the sulfation processes of some TAM metabolites (i.e., alpha-hydroxy tamoxifen and 4-hydroxy tamoxifen). Regulation of drug-metabolizing enzymes is important for the understanding of drug metabolism and detoxification. Studies on ST induction are limited. In the present investigation, protein and mRNA expression of aryl sulfotransferase (AST-IV) and hydroxysteroid sulfotransferase (STa) have been studied in liver and intestine of male and female Sprague-Dawley rats after TAM treatment with either 6.8 or 68 mg/kg/day for 1 or 2 weeks. Enzyme assay and Western blot methods were used for protein level determination; reverse transcription-polymerase chain reaction method was used for mRNA level determination. Here, for the first time, we have demonstrated that AST-IV and STa could be induced in intestine by tamoxifen. Furthermore, intestinal inductions were found to be much greater than the inductions found in the liver, suggesting a distinct potentiality of intestinal cells in TAM metabolism. The impact of induction and regulation of intestinal STs on TAM metabolism with respect to its toxicity has yet to be studied. The role of STs induction and relevant TAM metabolism is discussed in the context of organ- and species-specific variable carcinogenic manifestations.

Systematic review of randomized trials for unresectable hepatocellular carcinoma: Chemoembolization improves survival

There is no standard treatment for patients with unresectable hepatocellular carcinoma (HCC). Survival benefits derived from medical interventions are controversial. The aim of this systematic review was to assess the evidence of the impact of medical treatments on survival. Randomized controlled trials (RCTs) that were published as full papers assessing survival for primary treatments of HCC were included. MEDLINE, the Cochrane Library, CANCERLIT, and a manual search from 1978 to May 2002 were used. The primary end point was survival, and the secondary end point was response to treatment. Estimates of effect were calculated according to the random effects model. Sensitivity analysis included methodological quality. We identified 61 randomized trials, but only 14 met the criteria to perform a meta-analysis assessing arterial embolization (7 trials, 545 patients) or tamoxifen (7 trials, 898 patients). Arterial embolization improved 2-year survival compared with control (odds ratio [OR], 0.53; 95% confidence interval [CI], 0.32-0.89; P =.017). Sensitivity analysis showed a significant benefit of chemoembolization with cisplatin or doxorubicin (OR, 0.42; 95% CI, 0.20-0.88) but none with embolization alone (OR, 0.59; 95% CI, 0.29-1.20). Overall, treatment induced objective responses in 35% of patients (range, 16%-61%). Tamoxifen showed no antitumoral effect and no survival benefits (OR, 0.64; 95% CI, 0.36-1.13; P =.13), and only low-quality scale trials suggested 1-year improvement in survival. In conclusion, chemoembolization improves survival of patients with unresectable HCC and may become the standard treatment. Treatment with tamoxifen does not modify the survival of patients with advanced disease.