Primary liver tumors

131Iodine-DEM TACE vs. conventional TACE in cirrhotic patients with hepatocellular carcinoma: a single center experiment

Background

To evaluate the safety and efficacy of transcatheter arterial chemoembolization (TACE) with ¹³¹iodine-doxorubicin-eluting gelatin microspheres (¹³¹I-DEM TACE) compared with conventional TACE (cTACE) with polyvinyl alcohol foam (PVA) embolization microspheres.

Methods

A total of 22 patients diagnosed with hepatocellular carcinoma were equally divided into 2 groups. The patients who underwent TACE with ¹³¹I-DEM (25.7×10⁷ Bq of 131iodine and 10 mg of doxorubicin) were compared to controls who received cTACE with PVA embolization microspheres. Therapeutic effects were evaluated by the tumor regression rates, levels of alpha-fetoprotein in serum, survival rates, and complications.

Results

The operative complications of the 2 groups were not significantly different (P=0.753). The radioactivity ratio of the tumor to the liver was approximately 4.1:1 for the ¹³¹I-DEM TACE group. In the ¹³¹I-DEM TACE group, 54.5% of patients achieved tumor regression of more than 50%, compared to 36.6% of patients in the cTACE group. AFP levels in serum declined in 100% of patients in the ¹³¹I-DEM TACE group and 50% of patients in the cTACE group. The median survival time of the patients was 12.0±3.3 months for the ¹³¹I-DEM TACE group and 10.0±3.3 months for the cTACE group. There were no significant differences in survival between the 2 groups (P=0.414).

Conclusions

¹³¹I-DEM may become a potential radiochemoembolization agent to treat patients with unresectable hepatocellular carcinoma through TACE.

Electrocoagulation for liver metastases

BACKGROUND

Primary liver tumours and liver metastases from colorectal carcinoma are two of the most common malignant tumours to affect the liver. The liver is second only to the lymph nodes as the most common site for metastatic disease. More than half of the people with metastatic liver disease will die from metastatic complications. Electrocoagulation by diathermy is a method used to destroy tumour tissue, using a high-frequency electric current generating high temperatures, applied locally with an electrode (needle, blade, or ball). The objective of this method is to destroy the tumour completely, if possible, in a single session. With the time, electrocoagulation by diathermy has been replaced by other techniques, but the evidence is unclear.

OBJECTIVES

To assess the beneficial and harmful effects of electrocoagulation by diathermy, administered alone or with another intervention, versus no intervention, other ablation methods, or systemic treatments in people with liver metastases.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, CENTRAL, MEDLINE Ovid, Embase Ovid, LILACS, Science Citation Index Expanded, Conference Proceedings Citation Index - Science, CINAHL, ClinicalTrials.gov, ICTRP, and FDA to October 2020.

SELECTION CRITERIA

We considered all randomised trials that assessed beneficial and harmful effects of electrocoagulation by diathermy, administered alone or with another intervention, versus comparators, in people with liver metastases, regardless of the location of the primary tumour.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We assessed risk of bias of the included trial using predefined risk of bias domains, and presented the review results incorporating the certainty of the evidence using GRADE.

MAIN RESULTS

We included one randomised clinical trial with 306 participants (175 males; 131 females) who had undergone resection of the sigmoid colon, and who had five or more visible and palpable hepatic metastases. The diagnosis was confirmed by histological assessment (biopsy) and by carcinoembryonic antigen (CEA) level. The trial was conducted in Iraq. The age of participants ranged between 38 and 79 years. The participants were randomised to four different study groups. The liver metastases were biopsied and treated (only once) in three of the groups: 75 received electrocoagulation by diathermy alone, 76 received electrocoagulation plus allopurinol, 78 received electrocoagulation plus dimethyl sulphoxide. In the fourth intervention group, 77 participants functioning as controls received a vehicle solution of allopurinol 5 mL 4 x a day by mouth; the metastases were left untouched. The status of the liver and lungs was followed by ultrasound investigations, without the use of a contrast agent. Participants were followed for five years. The analyses are based on per-protocol data only analysing 223 participants. We judged the trial to be at high risk of bias. After excluding 'nonevaluable patients', the groups seemed comparable for baseline characteristics. Mortality due to disease spread at five-year follow-up was 98% in the electrocoagulation group (57/58 evaluable people); 87% in the electrocoagulation plus allopurinol group (46/53 evaluable people); 86% in the electrocoagulation plus dimethyl sulphoxide group (49/57 evaluable people); and 100% in the control group (55/55 evaluable people). We observed no difference in mortality between the electrocoagulation alone group versus the control group (risk ratio (RR) 0.98, 95% confidence interval (CI) 0.94 to 1.03; 113 participants; very low-certainty evidence). We observed lower mortality in the electrocoagulation combined with allopurinol or dimethyl sulphoxide group versus the control group (RR 0.87, 95% CI 0.80 to 0.95; 165 participants; low-certainty evidence). We are very uncertain regarding post-operative deaths between the electrocoagulation alone group versus the control group (RR 1.03, 95% CI 0.07 to 16.12; 152 participants; very low-certainty evidence) and between the electrocoagulation combined with allopurinol or dimethyl sulphoxide groups versus the control group (RR 1.00, 95% CI 0.09 to 10.86; 231 participants; very low-certainty evidence). The trial authors did not report data on number of participants with other adverse events and complications, recurrence of liver metastases, time to progression of liver metastases, tumour response measures, and health-related quality of life. Data on failure to clear liver metastases were not provided for the control group. There was no information on funding or conflict of interest. We identified no ongoing trials.

AUTHORS' CONCLUSIONS

The evidence on the beneficial and harmful effects of electrocoagulation alone or in combination with allopurinol or dimethyl sulphoxide in people with liver metastases is insufficient, as it is based on one randomised clinical trial at low to very low certainty. It is very uncertain if there is a difference in all-cause mortality and post-operative mortality between electrocoagulation alone versus control. It is also uncertain if electrocoagulation in combination with allopurinol or dimethyl sulphoxide may result in a slight reduction of all-cause mortality in comparison with a vehicle solution of allopurinol (control). It is very uncertain if there is a difference in post-operative mortality between the electrocoagulation combined with allopurinol or dimethyl sulphoxide group versus control. Data on other adverse events and complications, failure to clear liver metastases or recurrence of liver metastases, time to progression of liver metastases, tumour response measures, and health-related quality of life were most lacking or insufficiently reported for analysis. Electrocoagulation by diathermy is no longer used in the described way, and this may explain the lack of further trials.

Efficacy of cytokine-induced killer cell infusion as an adjuvant immunotherapy for hepatocellular carcinoma: a systematic review and meta-analysis

This study was designed to evaluate the efficacy and safety of cytokine-induced killer (CIK) cell-based immunotherapy as an adjuvant therapy for hepatocellular carcinoma (HCC). Published studies were identified by searching Medline, Cochrane, EMBASE, and Google Scholar databases with the keywords: cytokine-induced killer cell, hepatocellular carcinoma, and immunotherapy. The outcomes of interest were overall survival, progression-free survival, and disease-free survival. Eight randomized controlled trials (RCTs), six prospective studies, and three retrospective studies were included. The overall analysis revealed that patients in the CIK cell-treatment group had a higher survival rate (pooled hazard ratio (HR) =0.594, 95% confidence interval [CI] =0.501–0.703, P<0.001). Patients treated with CIK cells in non-RCTs had a higher progression-free survival rate (pooled HR =0.613, 95% CI =0.510–0.738, P<0.001). However, CIK cell-treated patients in RCTs had progression-free survival rates similar to those of the control group (pooled HR =0.700, 95% CI =0.452–1.084, P=0.110). The comparison between pooled results of RCTs and non-RCTs regarding the progression-free survival rate did not reach statistical significance. Patients in the CIK cell-treatment group had lower rates of relapse in RCTs (pooled HR =0.635, 95% CI =0.514–0.784, P<0.001). Similar results were found when non-RCT and RCTs were pooled (pooled HR =0.623, 95% CI =0.516–0.752, P<0.001). Adjuvant CIK cell-based immunotherapy is a promising therapeutic approach that can improve overall survival and reduce recurrence in patients with HCC.

Umbilical cord-derived mesenchymal stem cells inhibit growth and promote apoptosis of HepG2 cells

Hepatocellular carcinoma is the fifth most common type of cancer worldwide and remains difficult to treat. The aim of this study was to investigate the effects of mesenchymal stem cells (MSCs) derived from the umbilical cord (UC‑MSCs) on HepG2 hepatocellular carcinoma cells. UC‑MSCs were co‑cultured with HepG2 cells and biomarkers of UC‑MSCs were analyzed by flow cytometry. mRNA and protein expression of genes were determined by reverse transcription‑polymerase chain reaction and flow cytometry, respectively. Passage three and seven UC‑MSCs expressed CD29, CD44, CD90 and CD105, whereas CD34 and CD45 were absent on these cells. Co‑culture with UC‑MSCs inhibited proliferation and promoted apoptosis of HepG2 cells in a time‑dependent manner. The initial seeding density of UC‑MSCs also influenced the proliferation and apoptosis of HepG2 cells, with an increased number of UC‑MSCs causing enhanced proliferation inhibition and cell apoptosis. Co‑culture with UC‑MSCs downregulated mRNA and protein expression of α‑fetoprotein (AFP), Bcl‑2 and Survivin in HepG2 cells. Thus, UC‑MSCs may inhibit growth and promote apoptosis of HepG2 cells through downregulation of AFP, Bcl‑2 and Survivin. US-MSCs may be used as a novel therapy for treating hepatocellular carcinoma in the future.

Integrating subpathway analysis to identify candidate agents for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the second most common cause of cancer-associated death worldwide, characterized by a high invasiveness and resistance to normal anticancer treatments. The need to develop new therapeutic agents for HCC is urgent. Here, we developed a bioinformatics method to identify potential novel drugs for HCC by integrating HCC-related and drug-affected subpathways. By using the RNA-seq data from the TCGA (The Cancer Genome Atlas) database, we first identified 1,763 differentially expressed genes between HCC and normal samples. Next, we identified 104 significant HCC-related subpathways. We also identified the subpathways associated with small molecular drugs in the CMap database. Finally, by integrating HCC-related and drug-affected subpathways, we identified 40 novel small molecular drugs capable of targeting these HCC-involved subpathways. In addition to previously reported agents (ie, calmidazolium), our method also identified potentially novel agents for targeting HCC. We experimentally verified that one of these novel agents, prenylamine, induced HCC cell apoptosis using 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide, an acridine orange/ethidium bromide stain, and electron microscopy. In addition, we found that prenylamine not only affected several classic apoptosis-related proteins, including Bax, Bcl-2, and cytochrome c, but also increased caspase-3 activity. These candidate small molecular drugs identified by us may provide insights into novel therapeutic approaches for HCC.

Spontaneous ruptured hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) is rising worldwide. Spontaneous rupture of HCC occasionally occurs, and ruptured HCC with intraperitoneal hemorrhage is potentially life-threatening. The most common symptom of ruptured HCC is acute abdominal pain. The tumor size in ruptured HCC is significantly greater than that in non-ruptured HCC, and HCC protrudes beyond the original liver margin. In the acute phase, hemostasis is the primary concern and tumor treatment is secondary. Transcatheter arterial embolization (TAE) can effectively induce hemostasis. The hemostatic success rate of TAE ranges 53-100%. A one-stage surgical operation is a treatment modality for selected patients. Conservative treatment is usually given to patients in a moribund state with inoperable tumors and thus has poor outcomes. Patients with severe ruptures of advanced HCC and poor liver function have high mortality rates. Liver failure occurs in 12-42% of patients during the acute phase. In the stable phase, tumor treatment, such as transarterial chemoembolization or hepatic resection should be concerned. The combination of acute hemorrhage and cancer in patients with ruptured HCC requires a two-step therapeutic approach. TAE followed by elective hepatectomy is considered an effective strategy for patients with ruptured HCC.

Downregulation of Kinesin spindle protein inhibits proliferation, induces apoptosis and increases chemosensitivity in hepatocellular carcinoma cells

Background: Kinesin spindle protein (KSP) plays a critical role in mitosis. Inhibition of KSP function leads to cell cycle arrest at mitosis and ultimately to cell death. The aim of this study was to suppress KSP expression by specific small-interfering RNA (siRNA) in Hep3B cells and evaluate its anti-tumor activity. Methods: Three siRNA targeting KSP (KSP-siRNA #1-3) and one mismatched-siRNA (Cont-siRNA) were transfected into cells. Subsequently, KSP mRNA and protein levels, cell proliferation, and apoptosis were examined in both Hep3B cells and THLE-3 cells. In addition, the chemosensitivity of KSP-siRNA-treated Hep3B cells with doxorubicin was also investigated using cell proliferation and clonogenic survival assays. Results: The expression of endogenous KSP at both mRNA and protein levels in Hep3B cells was higher than in THLE-3 cells. In Hep3B cells, KSP-siRNA #2 showed a further downregulation of KSP as compared to KSP-siRNA #1 or KSP-siRNA #3. It also exhibited greater suppression of cell proliferation and induction of apoptosis than KSP-siRNA #1 or KSP-siRNA #3; this could be explained by the significant downregulation of cyclin D1, Bcl-2, and survivin. In contrast, KSP-siRNAs had no or lower effects on KSP expression, cell proliferation and apoptosis in THLE-3 cells. We also noticed that KSP-siRNA transfection could increase chemosensitivity to doxorubicin in Hep3B cells, even at low doses compared to control. Conclusion: Reducing the expression level of KSP, combined with drug treatment, yields promising results for eradicating hepatocellular carcinoma (HCC) cells in vitro. This study opens a new direction for liver cancer treatment.

Microwave coagulation for liver metastases

BACKGROUND

Primary liver cancer and liver metastases from colorectal carcinoma are the two most common malignant tumours to affect the liver. The liver is second only to the lymph nodes as the most common site for metastatic disease. More than half of patients with metastatic liver disease will die from metastatic complications. Microwave coagulation involves placing an electrode into a lesion under ultrasound or computed tomography guidance. The microwave coagulator generates and transmits microwave energy to the electrode. Coagulative necrosis causes cellular death and destroys tissue in the treatment area, resulting in reduction of tumour size.

OBJECTIVES

To study the beneficial and harmful effects of microwave coagulation compared with no intervention, other ablation methods, or systemic treatments in patients with liver metastases.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, LILACS, and CINAHL up to December 2012.

SELECTION CRITERIA

We included all randomised clinical trials assessing beneficial and harmful effects of microwave coagulation and its comparators, irrespective of the location of the primary tumour.

DATA COLLECTION AND ANALYSIS

We extracted relevant information on participant characteristics, interventions, and study outcomes and data on outcome measures for our review, as well as information on design and methodology of the studies. Bias risk assessment of trials, determination of whether they fulfilled the inclusion criteria, and data extraction from retrieved for final evaluation trials were done by one review author and were checked by a second review author.

MAIN RESULTS

One randomised clinical trial fulfilled the inclusion criteria of the review. Forty participants with multiple liver metastases of colorectal cancer and no evidence of extrahepatic disease were randomly assigned. Thirty of these participants (14 females and 16 males) were included in the analysis: 14 participants received microwave coagulation and 16 underwent conventional surgery (hepatectomy or liver resection). The diagnosis of colorectal cancer (Stage IB to IIIC; tumour (T)2 node (N)0 to T3N2) and liver metastases was confirmed by histological assessment. Mean participant age was 61 years. The tumours were resectable. The risk of bias in the trial was judged to be high.Participants were followed for three years. Mortality at the last follow-up was 64% (9/14) in the microwave group and 75% (12/16) in the conventional surgery group (risk ratio (RR) 0.86; 95% confidence interval (CI) 0.53 to 1.39), that is, no significant difference was observed. In the microwave coagulation group, 71%, 57%, and 14% survived 1, 2, and 3 years, and in the conventional surgery group, the percentages were 69%, 56%, and 23%. The hazard ratio calculated using the Parmar method was 0.91 (0.39 to 2.15).Mean survival time was 27 months in the microwave group and 25 months in the conventional surgery group, and the mean disease-free interval was 11.3 months in the microwave group and 13.3 months in the hepatectomy group. Differences for both outcomes were not statistically significant. Reported frequency of adverse events was similar between the microwave coagulation and conventional surgery groups, except for the required blood transfusion, which was more common in the conventional surgery group. No intervention-related mortality was observed. After treatment, the carcinoembryonic antigen level decreased significantly in both groups.

AUTHORS' CONCLUSIONS

On the basis of one randomised clinical trial, which did not describe allocation concealment or blinding, and which excluded from analysis 25% of participants after random assignment, evidence is insufficient to show whether microwave coagulation brings any significant benefit in terms of survival or recurrence compared with conventional surgery for participants with liver metastases from colorectal cancer. The number of adverse events, except for the requirement for blood transfusion, which was more common in the liver resection group, was similar in both groups. At present, microwave therapy cannot be recommended outside randomised clinical trials.

Cryotherapy for liver metastases

BACKGROUND

Primary liver tumours and liver metastases from colorectal carcinoma are the two most common malignant tumours to affect the liver. The liver is second only to the lymph nodes as the most common site for metastatic disease. More than half of the patients with metastatic liver disease will die from metastatic complications. In cryoablation, liquid nitrogen or argon gas is delivered to the liver tumour, guided by ultrasound using a specially designed probe. Ice crystal formation during the rapid freezing process causes destruction of cellular structure and kills the tumour cells.

OBJECTIVES

To study the beneficial and harmful effects of cryotherapy compared with no intervention, other ablation methods, or systemic treatments in patients with liver metastases.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, LILACS, and CINAHL up to December 2012.

SELECTION CRITERIA

We included all randomised clinical trials assessing the beneficial and harmful effects of cryotherapy and its comparators, irrespective of the location of the primary tumour.

DATA COLLECTION AND ANALYSIS

We extracted relevant information on participant characteristics, interventions, study outcomes, and data on the outcomes for our review, as well as information on the design and methodology of the trials. Bias risk assessment of and data extraction from the trials fulfilling the inclusion criteria were done by one author and checked by a second author.

MAIN RESULTS

One randomised clinical trial fulfilled the inclusion criteria of the review. The trial was judged as a trial with high risk of bias due to the unclear report on the generation of the allocation sequence and allocation concealment, blinding, incomplete outcome data and the selective outcome reporting domain. The trial included 123 consecutive patients with solitary or multiple unilobar or bilobar liver metastases who were randomised into two groups, 63 received cryotherapy and 60 received conventional surgery. There were 36 females and 87 males. The primary sites for the metastases were colorectal (66.6%), stomach (7.3%), breast (6.5%), melanoma (4.9%), ovarian adenocarcinoma (4.1%), uterus (3.3%), kidney (3.3%), intestinal (1.6%), pancreatic (1.6%), and unknown (0.8%). The tumours were resectable and non-resectable.The patients were followed for up to 10 years (minimum five months). Mortality at the last follow-up was 81% (51/63) in the cryotherapy group and 92% (55/60) in the conventional surgery group (RR 0.88; 95% CI 0.77 to 1.02); that is, no statistically significant difference was observed. In the cryotherapy group, 60%, 44%, and 19% of the participants survived 3, 5, and 10 years respectively, while in the conventional surgery group the percentages were 51%, 36%, and 8%. The hazard ratio calculated using the Parmar method was 0.71 (95% confidence interval (CI) 0.47 to 1.09). Recurrence in the liver was observed in 86% (54/63) of the patients in the cryotherapy group and 95% (57/60) of the patients in the conventional surgery group (relative risk (RR) 0.9; 95% CI 0.8 to 1.01); that is, no statistically significant difference was observed. Frequency of reported complications was similar between the cryotherapy group and the conventional surgery group except for postoperative pain. Both insignificant and pronounced pain were reported to be more common in the cryotherapy group while intense pain was reported to be more common in the control group. However, it was not reported by the authors whether the differences were significant. No intervention-related mortality and no bile leakage were observed.

AUTHORS' CONCLUSIONS

On the basis of one randomised clinical trial with high risk of bias, there is insufficient evidence to conclude if in patients with liver metastases from various primary sites cryotherapy brings any significant benefit in terms of survival or recurrence compared with conventional surgery. In addition, there is no evidence for the effectiveness of cryotherapy when compared with no intervention. At present, cryotherapy cannot be recommended outside randomised clinical trials.

Percutaneous ethanol injection for liver metastases

BACKGROUND

Primary liver tumours and liver metastases from colorectal carcinoma are the two most common malignant tumours to affect the liver. The liver is second only to the lymph nodes as the most common site for metastatic disease. More than half of the patients with metastatic liver disease will die from metastatic complications. Percutaneous ethanol injection (PEI) causes dehydration and necrosis of tumour cells accompanied by small vessel thrombosis, leading to tumour ischaemia and destruction.

OBJECTIVES

To study the beneficial and harmful effects of percutaneous ethanol injection compared with no intervention, other ablation methods, or systemic treatments in patients with liver metastases.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, LILACS, and CINAHL up to December 2012.

SELECTION CRITERIA

We included all randomised clinical trials assessing the beneficial and harmful effects of percutaneous ethanol injection versus no intervention, other ablation methods, or systemic treatments in patients with liver metastases.

DATA COLLECTION AND ANALYSIS

We extracted the relevant information on participant characteristics, interventions, study outcome measures, and data on the outcome measures for our review, as well as information on the design and methodology of the studies. Quality assessment of the trials fulfilling the inclusion criteria and data extraction from the trials retrieved for final evaluation were done by one author and checked by a second author.

MAIN RESULTS

One randomised clinical trial was included, comparing transcatheter arterial chemoembolisation (TACE) + percutaneous intratumour ethanol injection (PEI) versus TACE alone. Forty-eight patients with liver metastases were included; 25 received the intervention with PEI and 23 received TACE alone.Mortality data were not reported. The trial reported the survival data after one, two, and three years. In the TACE + PEI group, 92%, 80%, and 64% of the patients survived after 1, 2, and 3 years respectively; in the TACE group, 78.3%, 65.2%, and 47.8% of the patients survived after 1, 2, and 3 years respectively. The hazard ratio was 0.57 (95% CI 0.19 to 1.67). The local recurrence was 16% in the TACE + PEI group and 39.1% in the TACE group, resulting in a relative risk (RR) of 0.41 (95% CI 0.15 to 1.07). Forty-five tumours (66.2%) out of 68 tumours in total shrunk by at least 25% in the TACE + PEI group versus 31 tumours (48.4%) out of 64 tumours in total in the TACE group (RR 2.08; 95% CI 1.03 to 4.2). The authors reported some adverse events, but with very few details.

AUTHORS' CONCLUSIONS

On the basis of one small randomised trial, it can be concluded that addition of PEI to TACE, as compared with TACE alone, in patients with liver metastases seems to bring no clear benefit in terms of survival and local recurrence. The size of the tumour necrosis was larger in the combined treatment group. No intervention-related mortality or major complications were reported. More trials are needed.

Electro-coagulation for liver metastases

BACKGROUND

Primary liver tumours and liver metastases from colorectal carcinoma are the two most common malignant tumours to affect the liver. The liver is second only to the lymph nodes as the most common site for metastatic disease. More than half of the patients with metastatic liver disease will die from metastatic complications. Electro-coagulation is the coagulation (clotting) of tissue using a high-frequency electrical current applied locally with a metal instrument or needle with the aim of stopping bleeding. The object of this technique is to destroy the tumour completely, if possible, in a single surgical session.

OBJECTIVES

To study the beneficial and harmful effects of electro-coagulation compared with no intervention, to other ablation methods, or systemic treatments in patients with liver metastases.

SEARCH METHODS

We searched The Cochrane Hepato-Biliary Group Controlled Trials Register, the Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, LILACS, and CINAHL up to December 2012.

SELECTION CRITERIA

We included one randomised clinical trial that assessed beneficial and harmful effects of electro-coagulation and its comparators in patients with liver metastases, irrespective of the location of the primary tumour.

DATA COLLECTION AND ANALYSIS

We extracted relevant information on participant characteristics, interventions, study outcome measures, and data on the outcome measures as well as information on the design and methodology of the trials. Risk of bias of the trials and data extraction was carried out by one author and checked by a second author.

MAIN RESULTS

We included one randomised clinical trial that compared four groups: electro-coagulation alone, electro-coagulation + dimethyl sulphoxide, electro-coagulation + allopurinol, and control (Salim 1993). The risk of bias in the trial is high. In three groups, patients had their metastases destroyed with diathermy electro-coagulation (current set at No 5) and received: 1) solution of allopurinol by mouth 5 mL 4 x a day or 2) allopurinol by mouth 5 mL (50 mg) 4 x a day or 3) dimethyl sulphoxide by mouth 5 mL (500 mg) 4 x a day. In the control group patients received a solution of allopurinol by mouth 5 mL 4 x a day. The treatment was started in the fifth postoperative day and was continued for five years. Three hundred and six patients who had undergone resection of the sigmoid colon and who had five or more hepatic metastases were included; 75 received electro-coagulation alone (58 were evaluable), 76 received electro-coagulation plus allopurinol (53 were evaluable), 78 received electro-coagulation plus dimethyl sulphoxide (57 were evaluable), and 77 were in the control group (55 evaluable).The authors reported the number of deaths due to disease spread (100% in the control, 98% in electro-coagulation, 87% in electro-coagulation + allopurinol, and 86% in the electro-coagulation + dimethyl sulphoxide groups). There was a significant benefit in favour of the electro-coagulation + allopurinol (risk ratio (RR) 0.87 (95% confidence interval (CI) 0.78 to 0.96)) and electro-coagulation + dimethyl sulphoxide (RR 0.86 (95% CI 0.77 to 0.95)) groups compared to the control group, but no such benefit in the electro-coagulation alone group (RR 0.98 (95% CI 0.95 to 1.02)) compared to the control group. There were no local recurrences, no positive tests for occult blood, and observed pulmonary metastases were always with ultrasonographic evidence of hepatic secondaries and were not significantly different for the experimental groups compared to the control group (electro-coagulation: RR 1.11 (95% CI 0.4 to 3.09)), electro-coagulation + allopurinol (RR 0.86 (95% CI 0.28 to 2.66)), electro-coagulation + dimethyl sulphoxide (RR 0.8 (95% CI 0.26 to 2.48)). None of the adverse events were significantly associated with treatment.

AUTHORS' CONCLUSIONS

On the basis of one randomised trial which did not describe its methodology in sufficient detail to assess risk of bias and quality, excluded 27% of patients after randomisation due to various reasons, and is probably not free from selective outcome reporting bias, there is insufficient evidence to conclude that in patients with colonic cancer liver metastases, electro-coagulation alone brings any significant benefit in terms of survival or recurrence compared with the control. In addition, there is insufficient evidence for the effectiveness of adding allopurinol or dimethyl sulphoxide to electro-coagulation. The probability for selective outcome reporting bias in the trial is high. More randomised trials are needed in order to sufficiently validate electro-coagulation with or without co-interventions.

Transarterial (chemo)embolisation versus no intervention or placebo intervention for liver metastases

BACKGROUND

Primary liver tumours and liver metastases from colorectal carcinoma are the two most common malignant tumours to affect the liver. The liver is second only to the lymph nodes as the most common site for metastatic disease. More than half of the patients with metastatic liver disease will die from metastatic complications. Chemoembolisation is based on the concept that the blood supply to hepatic tumours originates predominantly from the hepatic artery. Therefore, embolisation of the hepatic artery can lead to selective necrosis of the liver tumour while it may leave normal parenchyma virtually unaffected.

OBJECTIVES

To study the beneficial and harmful effects of transarterial (chemo)embolisation compared with no intervention or placebo intervention in patients with liver metastases.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, LILACS, and CINAHL up to December 2012.

SELECTION CRITERIA

We included all randomised clinical trials assessing beneficial and harmful effects of transarterial (chemo)embolisation compared with no intervention or placebo intervention in patients with liver metastases, no matter the location of the primary tumour.

DATA COLLECTION AND ANALYSIS

We extracted relevant information on participant characteristics, interventions, study outcome measures, and data on the outcome measures for our review as well as information on the design and methodology of the studies. Bias risk assessment of the trials, fulfilling the inclusion criteria, and data extraction from the retrieved final evaluation trials were done by one author and checked by a second author.

MAIN RESULTS

One randomised clinical trial fulfilled the inclusion criteria of the review. Sixty-one patients with colorectal liver metastases were randomised into three intervention groups: 22 received hepatic artery embolisation, 19 received hepatic artery infusion chemotherapy, and 20 were randomised to control, described as "no active therapeutic intervention, although symptomatic treatment was provided whenever necessary". As hepatic artery infusion chemotherapy is not in the scope of this review, we have not included the data from this intervention group. In the remaining two groups that were of interest to the review, 43 of the participants were men and 18 women. Most tumours were synchronous metastases involving up to 75% of the liver and non-resectable. The risk of bias in the trial was judged to be high.Patients were followed-up for a minimum of seven months. Mortality at last follow-up was 86% (19/22) in the hepatic artery embolisation group versus 95% (19/20) in the control group (RR 0.91; 95% CI 0.75 to 1.1), that is, no statistically significant difference was observed. Median survival after trial entry was 7.0 months (range 2 to 44) in the hepatic artery embolisation group and 7.9 months (range 1 to 26) in the control group. Nine out of 22 (41%) in the hepatic artery embolisation group and five out of 20 (25%) in the control group developed evidence of extrahepatic disease (RR 1.64; 95% CI 0.60 to 4.07). Local recurrence was reported for 10 patients in the trial without details about the trial group. Most patients in the embolisation group experienced post-embolic syndrome (82%), and one patient had local haematoma. No other adverse events were reported. The authors did not report if there were any adverse events in the control group.

AUTHORS' CONCLUSIONS

On the basis of one small randomised trial that did not describe sequence generation, allocation concealment or blinding, it can be concluded that in patients with liver metastases no significant survival benefit or benefit on extrahepatic recurrence was found in the embolisation group in comparison with the palliation group. The probability for selective outcome reporting bias in the trial is high. At present, transarterial (chemo)embolisation cannot be recommended outside randomised clinical trials.

Transarterial (chemo)embolisation versus no intervention or placebo intervention for liver metastases

BACKGROUND

Primary liver tumours and liver metastases from colorectal carcinoma are the two most common malignant tumours to affect the liver. The liver is second only to the lymph nodes as the most common site for metastatic disease. More than half of the patients with metastatic liver disease will die from metastatic complications. Chemoembolisation is based on the concept that the blood supply to hepatic tumours originates predominantly from the hepatic artery. Therefore, embolisation of the hepatic artery can lead to selective necrosis of the liver tumour while it may leave normal parenchyma virtually unaffected.

OBJECTIVES

To study the beneficial and harmful effects of transarterial (chemo)embolisation compared with no intervention or placebo intervention in patients with liver metastases.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, LILACS, and CINAHL up to November 2011.

SELECTION CRITERIA

We included all randomised clinical trials assessing beneficial and harmful effects of transarterial (chemo)embolisation compared with no intervention or placebo intervention in patients with liver metastases, no matter the location of the primary tumour.

DATA COLLECTION AND ANALYSIS

We extracted relevant information on participant characteristics, interventions, study outcome measures, and data on the outcome measures for our review as well as information on the design and methodology of the studies. Bias risk assessment of the trials, fulfilling the inclusion criteria, and data extraction from the retrieved final evaluation trials were done by one author and checked by a second author.

MAIN RESULTS

One randomised clinical trial fulfilled the inclusion criteria of the review. Sixty-one patients with colorectal liver metastases were randomised into three intervention groups: 22 received hepatic artery embolisation, 19 received hepatic artery infusion chemotherapy, and 20 were randomised to control, described as "no active therapeutic intervention, although symptomatic treatment was provided whenever necessary". As hepatic artery infusion chemotherapy is not in the scope of this review, we have not included the data from this intervention group. In the remaining two groups that were of interest to the review, 43 of the participants were men and 18 women. Most tumours were synchronous metastases involving up to 75% of the liver and non-resectable. The risk of bias in the trial was judged to be high.Patients were followed-up for a minimum of seven months. Mortality at last follow-up was 86% (19/22) in the hepatic artery embolisation group versus 95% (19/20) in the control group (RR 0.91; 95% CI 0.75 to 1.1), that is, no statistically significant difference was observed. Median survival after trial entry was 7.0 months (range 2 to 44) in the hepatic artery embolisation group and 7.9 months (range 1 to 26) in the control group. Nine out of 22 (41%) in the hepatic artery embolisation group and five out of 20 (25%) in the control group developed evidence of extrahepatic disease (RR 1.64; 95% CI 0.60 to 4.07). Local recurrence was reported for 10 patients in the trial without details about the trial group. Most patients in the embolisation group experienced post-embolic syndrome (82%), and one patient had local haematoma. No other adverse events were reported. The authors did not report if there were any adverse events in the control group.

AUTHORS' CONCLUSIONS

On the basis of one small randomised trial that did not describe sequence generation, allocation concealment or blinding, it can be concluded that in patients with liver metastases no significant survival benefit or benefit on extrahepatic recurrence was found in the embolisation group in comparison with the palliation group. The probability for selective outcome reporting bias in the trial is high. At present, transarterial (chemo)embolisation cannot be recommended outside randomised clinical trials.

Does Surgical Resection Have a Role in the Treatment of Large or Multinodular Hepatocellular Carcinoma?

Several effective treatments are available for patients with small solitary hepatocellular carcinomas (HCCs). Conversely, the management of patients with large or multinodular HCCs is controversial, and the role of surgical resection is not well defined. Between 2000 and 2006, 51 patients with large or multinodular HCC underwent liver resection. Clinicopathologic and follow-up data were prospectively collected and retrospectively reviewed. The perioperative and long-term outcomes were analyzed. Univariate and multivariate analysis of prognostic factors were conducted. Although 20 patients had multinodular HCCs, 31 had large solitary tumors. Perioperative mortality occurred in eight patients and complications in 15. In patients with large solitary tumors, 5-year disease-free and overall survival were 41.3 per cent and 56.1 per cent, respectively. Those with multinodular HCCs demonstrated 5-year disease-free and overall survival rates of 0 per cent and 33.6 per cent, respectively. Liver resection can result in long-term survival in select patients with large or multinodular HCCs, even in select patients with impaired liver function. Large solitary HCCs seem to have better prognoses than multinodular tumors, with lower recurrence and higher survival rates after surgery. Randomized controlled trials comparing resection to other treatment modalities are indicated to determine optimal patient management.

Liver transplantation for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the commonest primary malignancy of the liver. It usually occurs in the setting of chronic liver disease and has a poor prognosis if untreated. Orthotopic liver transplantation (OLT) is a suitable therapeutic option for early, unresectable HCC particularly in the setting of chronic liver disease. Following on from disappointing initial results, the seminal study by Mazzaferro et al in 1996 established OLT as a viable treatment for HCC. In this study, the “Milan criteria” were applied achieving a 4-year survival rate similar to OLT for benign disease. Since then various groups have attempted to expand these criteria whilst maintaining long term survival rates. The technique of living donor liver transplantation has evolved over the past decade, particularly in Asia, and published outcome data is comparable to that of OLT. This article will review the evidence, indications, and the future direction of liver transplantation for liver cancer.

siRNA targeting VEGF inhibits hepatocellular carcinoma growth and tumor angiogenesis in vivo

BACKGROUND/AIMS

We have investigated whether siRNA targeted against VEGF inhibits functional properties of endothelial cells in vitro and HCC tumor growth and blood vessel formation in vivo.

METHODS

The influence of siRNA-VEGF on endothelial cell proliferation, apoptosis and tube formation were analyzed in vitro. Antitumoral effects were examined in an orthotopic tumor model after ex vivo transfer or intraperitoneal treatment of siRNA, respectively. Intratumoral microvessel density was assessed by CD31 staining.

RESULTS

VEGF expression was inhibited in Hepa129 by 70% and in SVEC4-10 by 48% within two days after transfection. In vitro, endothelial cell proliferation and tube formation was reduced by 23% and 38%, respectively. Interference with VEGF signaling was demonstrated by reduced pAKT in hepatoma cells. Tumor growth was inhibited by ex vivo transfer or intraperitoneal application of siRNA-VEGF by 83% or 63% in orthotopic tumors within 14 days. VEGF protein was reduced in both models by 29% and 44%. Microvessel density dropped to 34% for tumors from ex vivo transfected cells and 39% for systemic treated tumors.

CONCLUSIONS

The results show that VEGF knockdown can be associated with reduced endothelial cell proliferation and tube formation in vitro and decreased tumor growth and microvessel density in vivo.

Results of resection and transplantation for hepatocellular carcinoma in cirrhosis and noncirrhosis

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. Both liver resection (LR) and orthotopic liver transplantation (OLT) are surgical treatment options depending on the size of the tumor and the presence of cirrhosis. Liver cirrhosis is the main reason for the high early postoperative mortality after resection. Even in the Child A stage, extensive resections are not recommended. This study presented the results of surgical treatment (LR or OLT) for HCC in cirrhotic and noncirrhotic livers. We analyzed the data of 76 patients who underwent LR or OLT for HCC from January 2001 to December 2006. In noncirrhotic livers the following resections were performed: 30 right and extended right hemihepatectomies (54.5%); 11 left hemihepatectomies (20%); and 14 mono- or bisegmentectomies (25.5%). In cirrhotic livers the following procedures were performed: in Child A stage 1 right hemihepatectomy, 1 extended right hemihepatectomy, 1 extended left hemihepatectomy, and 4 mono- or bisegmentectomies; and in Child B stage, 3 mono- or bisegmentectomies. Among 11 patients who underwent transplantation, tumors in 2 patients exceeded the Milan criteria. Five patients in the LR group were treated with transarterial chemoembolization before transplantation. LR for HCC in cirrhosis should be performed with caution; there were no long-term survivors in our data. Our study confirmed that OLT shows good long-term survival in early HCC stages. However, this may also be true for stages above the Milan criteria. For HCC in noncirrhotic livers, LR remains the treatment of choice, justifying an extensive surgical approach. Such an approach achieved favorable long term survivals.

Transcatheter arterial chemoembolization in patients with hepatocellular carcinoma on the waiting list for orthotopic liver transplantation

OBJECTIVE

The objective of this study was to perform a retrospective analysis of patients with hepatocellular carcinoma (HCC) who underwent transcatheter arterial chemoembolization (TACE) before undergoing liver transplantation at our institution.

SUBJECTS AND METHODS

From January 2000 to August 2005, 56 patients with HCC underwent TACE before orthotopic liver transplantation (OLT). Radiologic findings before and after TACE were assessed and correlated with histologic findings after OLT. The area of induced necrosis was pathologically evaluated in each HCC nodule.

RESULTS

One hundred thirty-one HCC nodules were detected at histologic study. One hundred seventeen HCC nodules (91.4%) were hyperenhancing in the arterial phase on the preoperative imaging studies. The percentage of tumor necrosis was greater than 90% in 48 nodules (38%), between 50% and 90% in 19 nodules (15%), and less than 50% in 61 nodules (48%); tumor necrosis data were not recorded for the remaining three nodules. The size of the preoperatively detected lesions ranged from 0.2 to 9 cm (mean, 2.58 cm). The mean percentage of tumor necrosis was 67.8% in this group, but it rose to 79.2% in the hypervascular lesions. The size of the nodules that were not detected preoperatively ranged from 0.1 to 1.9 cm (mean, 0.68 cm), and the mean percentage of tumor necrosis was only 1.57%.

CONCLUSION

TACE is a safe treatment in well-selected patients. Its antitumoral effect is high in hypervascular lesions (mean necrosis, 79.2%). It provides good local control in preoperatively diagnosed HCC (mean necrosis, 67.8%), but its impact is limited in lesions not detected preoperatively (mean necrosis, 1.57%).

Chemo-embolization for unresectable hepatocellular carcinoma with different sizes of embolization particles

The purpose of this study was to evaluate the size responses and vascular responses to three different sizes of Embosphere (EMBS) embolization particles used for chemo-embolization in patients with unresectable hepatocellular carcinoma (HCC). Forty-seven patients with biopsy proven HCC treated with TACE using EMBS (Biosphere Medical, Rockland, MA, USA) were included in this study. EMBS are non-resorbable tris-acryl gelatin defined-size microspheres. Sixteen patients were treated with 40-120 micron (40-microm), 13 patients with 100-300 (100-microm), and 18 patients with 300-500 (300-microm) EMBS particles. We measured the two-dimensional area and vascularity of the tumor index lesion on initial and subsequent CTs after treatment. Lesions were classified into four grades based on the degree of vascularity measured in 25% increments. Size of tumor after one treatment decreased by an average (avg) of 18% for 40-120-microm particles, 38% for 100-300-microm particles, and 17% for 300-500-microm particles. After three treatments, size decreased by an avg of 46% for 40-120-microm particles, 76% for 100-300-microm particles, and 46% for 300-500-microm particles. Vascularity decrease was also measured after the first and third treatments, and defined as a decrease of one or more grades in tumor vascularity. Results were as follows (% of patients with decrease). For 40-120-microm particles: 1 and 3 treatments, 53% and 88% of patients. For 100-300-microm particles: 1 and 3 treatments, 60% and 88% of patients. For 300-500-microm particles: 1 and 3 treatments, 50% and 57% of patients. It was concluded the 100-300-microm EMBS particles produce slightly higher responses.

Adenovirus-delivered CIAPIN1 small interfering RNA inhibits HCC growth in vitro and in vivo

Hepatocellular carcinoma (HCC) is an aggressive cancer with a poor prognosis. The specific cellular gene alterations responsible for hepatocarcinogenesis are not well known. Cytokine-induced antiapoptotic molecule (CIAPIN1), a recently reported antiapoptotic molecule which plays an essential role in mouse definitive hematopoiesis, is considered a downstream effecter of the receptor tyrosine kinase–Ras signaling pathway. However, the exact function of this gene in tumors is not clear. In this study, we reported that CIAPIN1 is highly expressed in HCC as compared with non-tumor hepatic tissue (P < 0.05). We employed adenovirus-mediated RNA interference technique to knock down CIAPIN1 expression in HCC cells and observed its effects on HCC cell growth in vitro and in vivo. Among the four HCC and one normal human liver cell lines we analyzed, CIAPIN1 was highly expressed in HCC cells. Knock down of CIAPIN1 could inhibit HCC cell proliferation by inhibiting the cell cycle S-phase entry. Soft agar colony formation assay indicated that the colony-forming ability of SMMC-7721 cells decreased by ∼70% after adenovirus AdH1-small interfering RNA (siRNA)/CIAPIN1 infection. In vivo experiments showed that adenovirus AdH1-siRNA/CIAPIN1 inhibited the tumorigenicity of SMMC-7721 cells and significantly suppressed tumor growth when injected directly into tumors. These results suggest that knock down of CIAPIN1 by adenovirus-delivered siRNA may be a potential therapeutic strategy for treatment of HCC in which CIAPIN1 is overexpressed.

Positional expression profiling indicates candidate genes in deletion hotspots of hepatocellular carcinoma

Molecular characterizations of hepatocellular carcinoma have indicated frequent allelic losses on chromosomes 4q, 8p, 16q and 17p, where the minimal deleted regions have been further defined on 4q12-q23, 4q31-q35, 8p21-p22, 16q12.1-q23.1 and 17p13. Despite these regions are now well-recognized in early liver carcinogenesis, few underlying candidate genes have been identified. In an effort to define affected genes within common deleted loci of hepatocellular carcinoma, we conducted transcriptional mapping by high-resolution cDNA microarray analysis. In 20 hepatocellular carcinoma cell lines and 20 primary tumors studied, consistent downregulations of novel transcripts were highlighted throughout the entire genome and within sites of frequent losses. The array-derived candidates including fibrinogen gamma peptide (FGG, at 4q31.3), vitamin D binding protein (at 4q13.3), fibrinogen-like 1 (FGL1, at 8p22), metallothionein 1G (MT1G, at 16q12.2) and alpha-2-plasmin inhibitor (SERPINF2, at 17p13) were confirmed by quantitative reverse transcription-polymerase chain reaction, which also indicated a more profound downregulation of FGL1, MT1G and SERPINF2 relative to reported tumor-suppressor genes, such as DLC1 (8p22), E-cadherin (16q22.1) and TP53 (17p13.1). In primary hepatocellular carcinoma examined, a significant repression of MT1G by more than 100-fold was indicated in 63% of tumors compared to the adjacent nonmalignant liver (P = 0.0001). Significant downregulations of FGG, FGL1 and SERPINF2 were also suggested in 30, 23 and 33% of cases, respectively, compared to their nonmalignant counterparts (P < 0.016). In summary, transcriptional mapping by microarray indicated a number of previously undescribed downregulated genes in hepatocellular carcinoma, and highlighted potential candidates within common deleted regions.

Gene therapy of liver tumors with human liver-specific nanoparticles

The development of safe and efficient liver-specific gene delivery approaches offers new perspectives for the treatment of liver disease, in particular, liver cancer. We evaluated the therapeutic potential of hepatotropic nanoparticles for gene therapy of liver tumor. These nanoparticles do not contain a viral genome and display the hepatitis B virus L antigen, which is essential to confer hepatic specificity. It has not been shown whether a therapeutic effect could be obtained using L nanoparticles in a human liver tumor xenograft model. Rats bearing human hepatic (NuE) and non-hepatic tumors were injected with L nanoparticles containing a green fluorescent protein (GFP) expression plasmid. GFP expression was observed only in NuE-derived tumors but not in the non-hepatic tumor. The potential for treatment of liver tumors was analyzed using L nanoparticles containing the herpes simplex virus thymidine kinase gene, in conjunction with ganciclovir pro-drug administration. The growth of NuE-derived tumors in L particle-injected rats was significantly suppressed, but not of the non-hepatic tumor control. In summary, this is the first demonstration that nanoparticles could be used for delivery of therapeutic genes with anti-tumor activity into human liver tumors. This intravenous delivery system may be one of the major advantages as compared to many other viral vector systems.

Effective antitumour mono- and combination therapy by gene delivery of angiostatin-like molecule and interleukin-12 in a murine hepatoma model

METHODS

We applied an experimental approach employing two recombinant adenoviral vectors (Ad) that express interleukin-12 (IL-12) and angiostatin-like molecule (K1-3) respectively to a subcutaneous hepatoma model in mice.

RESULTS

Injection of AdK1-3 into tumour nodules established by subcutaneous (s.c.) implantation of Hepa129 hepatoma cells in C3H mice resulted in a significant dose-dependent reduction in tumour growth by 57% in the high dosage group (5x10(9) plaque-forming units [pfu], n=8) 10 days after treatment initiation. Similar antitumoural effects were found for the intratumoural mono-therapy with IL-12 (2.5x10(9) pfu, n=8) resulting in 60% tumour inhibition at the same time point. The survival rate was significantly (p=0.009) improved in the IL-12 but not in the K1-3 treatment group. A combination therapy of AdK1-3 and AdIL-12 was also effective, but did not further improve antitumour efficacy compared with the monotherapy.

CONCLUSION

In conclusion, both mono- and combination therapy of K1-3 and IL-12 significantly inhibited tumour progression in this experimental tumour model. The co-administration of both compounds did not result in additive antitumour effects. We hypothesise that the lack of additive antitumour effects of the combination treatment might be attributed to partially counteracting antitumour effects and further studies are needed to illustrate the interference of tumour angiogenesis and tumour inflammation in this tumour model.

Liver Transplantation for Hepatocellular Carcinoma: Is there Evidence for Expanding the Selection Criteria?

A consequent application of the Milan criteria in patients undergoing liver transplantation for hepatocellular carcinoma (HCC) may lead to excellent long-term survival and a low incidence of recurrence. Expanding the selection criteria will result in more patients with hepatocellular carcinoma being potentially curative treated, but this approach is associated with at least a higher incidence of recurrence. Kaplan-Meier analysis of 110 patients, who underwent liver transplantation for HCC in our institution between 1987 and 2004, showed a significant improvement in patient survival with time. A change in criteria for patient selection may have contributed to the improved outcome. In 28 of 110 patients a recurrence of HCC was observed. In 82% of patients, who developed recurrence of carcinoma, the Milan criteria were not met. Dropout from the waiting list is common and several methods, including percutaneous ethanol injection, radiofrequency ablation, and chemoembolization, are used to prevent tumor progression and thus prevent dropout. As no randomized trials are available some uncertainty remains, whether these neoadjuvant procedures improve outcome. At present, there is no evidence that this approach enables expansion of the selection criteria. Hepatocellular carcinoma is a major indication for living related liver transplantation because the risk of dropout while waiting is negligible. Extension of the Milan criteria in the setting of living related liver transplantation may offer more patients a potentially curative treatment, without reducing the donor pool of organs for other patients on the waiting list with nonmalignant liver disease.

Inhibitory effect of recombinant adenovirus carrying melittin gene on hepatocellular carcinoma

OBJECTIVES

To search for a new clinical application of melittin (Mel): treating hepatocellular carcinoma with Mel gene.

METHODS

Recombinant adenoviruses carrying the Mel gene and alpha-fetoprotein (AFP) promoter (Ad-rAFP-Mel) were constructed through a bacterial homologous recombinant system. The efficiency of adenovirus-mediated gene transfer and the inhibitory effect of Ad-rAFP-Mel on the proliferation of hepatocarcinoma cells were determined by X-gal stain and MTT assay, respectively. The tumorigenicity of hepatocarcinoma cells transfected by Ad-rAFP-Mel and the antitumor effect of Ad-rAFP-Mel on transplanted tumor in nude mice were detected in vivo.

RESULTS

The Mel mRNA was transcribed in BEL-7402 hepatocellular carcinoma cells transducted by Ad-rAFP-Mel. The efficiency of adenovirus-mediated gene transferred to BEL-7402 cells was 100% when the multiplicity of infection of Ad-rAFP-Mel was 10 in vitro, and was also high in vivo. The inhibitive rates of Ad-rAFP-Mel and Ad-rAFP for BEL7402 cells were 66.2 +/- 2.7% and 2.9 +/- 2.3% (t=30.83, P=6.6 x 10(-6)) by MTT assay. The inhibitive rates of Ad-CMV-Mel for BEL7402, SMMC7721 and L02 cells were 58.9 +/- 9.6%, 65.9 +/- 3.8% and 31.7 +/- 1.2%, respectively, and of Ad-rAFP-Mel were 66.2 +/- 2.7%, 16.1 +/- 6.6% and 7.5 +/- 3.3%, respectively (t=1.27, P=0.27; t=11.31, P=3.5 x 10(-4); and t=12.12, P=2.7 x 10(-4) versus the Ad-CMV-Mel group in the same cells). The tumorigenicity rates of hepatocarcinoma cells transfected by Ad-rAFP-Mel were decreased. A significant antineoplastic effect was detected on transplanted tumor in nude mice by intratumoral injection of Ad-rAFP-Mel.

CONCLUSIONS

Ad-rAFP-Mel can inhibit specifically proliferation of AFP-producing human hepatocarcinoma cells in vitro and in vivo. This suggests that animal toxin gene can be used as an antitumor gene.

The significance of transarterial embolization for advanced hepatocellular carcinoma in liver transplantation

INTRODUCTION

Transarterial embolization (TAE) is the treatment of choice for advanced HCC to control or even induce tumor shrinkage. The aim of this study was to evaluate the effect of pretransplantation TAE for treatment of advanced HCC.

MATERIAL AND METHODS

From 1996 to 2002, we studied 12 cirrhotic patients with HCC, including six who met and six who exceeded the Milan criteria. All patients had sufficient hepatic function to undergo TAE. Liver transplantations were performed subsequently and they were followed prospectively for a median of 22 months (range = 12 to 53 months).

RESULTS

The explanted livers from the 12 patients who had undergone TAE were noted to have extensive tumor necrosis. The pathological specimens at LT showed downstaging of the HCC, which allowed those six patients to meet the Milan criteria. The overall 1- and 2-year survival rates were 92% and 73%, respectively. The overall 1- and 2-year disease-free survival rates were 92% and 73%, respectively. One death unrelated to liver disease at 2 years after LT was noted in the downgraded group. One patient of the initially eligible group developed lung metastasis at 6 months and died at 12 months after LT.

CONCLUSION

TAE is effective to downstage advanced HCC and reduce the dropout rate on the LT waiting list. Pre-LT TAE may be considered as a better therapeutic strategy for patients with advanced HCC.

The outcome of liver transplantation in patients with hepatocellular carcinoma in the United States between 1988 and 2001: 5-year survival has improved significantly with time

PURPOSE

We hypothesized that the outcome of liver transplantation in patients with hepatocellular carcinoma (HCC) has improved over the past decade because of the application of published criteria for patient selection. In this study, we compared the outcome of liver transplantation in patients with and without HCC at different time periods using the United Network for Organ Sharing data.

PATIENTS AND METHODS

We excluded children, patients with multiple organ transplantation or retransplantation, and those with incomplete survival data. The study period was arbitrarily divided into three time intervals: 1987 to 1991, 1992 to 1996, and 1997 to 2001.

RESULTS

During the study period, 985 patients with HCC (HCC group), and 33,339 without HCC underwent liver transplantation (control group). Kaplan-Meier patient and graft survivals were significantly lower for the HCC group compared with the control group. Cox regression analysis (after adjusting for other confounding variables) confirmed a lower patient survival in the HCC group (1-year survival, 77.0% v 86.7%; hazard ratio [HR], 1.7; 95% CI, 1.5 to 2.0; P <.0001) compared with the control group (5-year survival, 48.2% v 74.7%; HR, 2.2; 95% CI, 1.9 to 2.4; P <.0001); HCC was an independent predictor of survival. Kaplan-Meier analysis showed a significant improvement in 5-year patient survival with time in patients with HCC (1987 to 1991, 25.3%; 1992 to 1996, 46.6%; 1997 to 2001, 61.1%; P <.0001). During the same period, there was only minimal improvement in survival among the control group.

CONCLUSION

Five-year survival of patients transplanted for HCC is excellent, with a steady improvement in survival over the past decade. It is possible that the published criteria for patient selection may have contributed to the better outcome.

Role of liver transplantation in the management of hepatocellular carcinoma

The treatment options for hepatocellular carcinoma (HCC) are liver resection, liver transplantation, or local ablation (e.g., percutaneous ethanol injection, cryosurgery, radio-frequency ablation, and chemoembolization). Most patients are not eligible for curative resection because of the location of the tumor or the severity of liver disease. For many of these patients, liver transplantation remains the best curative option. Because of the shortage of donor organs, much of the recent effort has been aimed at patient selection. In this review, the authors address outcomes after liver transplantation for HCC, the role of selection criteria as a predictor of mortality and recurrence, and the emerging role of living donor liver transplantation and chemoembolization.

Hepatitis viruses and hepatocellular carcinoma in HIV-infected patients

Hepatocellular carcinoma, the most common primary cancer of the liver, results in significant morbidity and mortality. Several disease entities have been shown to predispose to hepatocellular carcinoma. In most cases, however, hepatitis B virus, hepatitis C virus, and cirrhosis are the principal etiologic factors. In HIV-positive patients, a significant increase in the incidence of certain malignancies has been noted. Although HIV and the hepatitis viruses share common modes of transmission, an increase in the incidence of hepatocellular carcinoma in the patients with HIV has not been observed. This finding may be a function of premature death in patients with HIV before the advent of effective antiretroviral therapy. The introduction of such therapy may alter the epidemiology of hepatocellular carcinoma and strain health services, because current treatment options targeting both the underlying causative viruses and liver cancer itself are unsatisfactory and are the subject of ongoing research.

Gene therapy of hepatocellular carcinoma and gastrointestinal tumors

Primary liver cancer and liver metastases from gastrointestinal tumors lack effective therapy. Gene therapy is a promising therapeutic approach and is based on the introduction of genetic material into cells to generate a curative biological effect. Adenoviral vectors can very efficiently transduce a wide variety of malignant epithelial cells both in vitro and in vivo. A variety of gene therapy-based anticancer strategies have been effective in animal tumor models, including replacement of tumor suppressor genes, selective activation of prodrugs, genetic immunotherapy, and antiangiogenic actions. Enzymes used for genetic activation include viral thymidine kinase (tk), which may activate nucleoside analogs such as ganciclovir. We and others have demonstrated the efficacy of the tk/ganciclovir system in the treatment of hepatocellular carcinoma and metastatic colorectal cancer in experimental models. Also, this strategy can be safely applied to patients with liver tumors. Interleukin-12 (IL-12) is among the most potent cytokines in stimulating antitumor immunity. In models of primary and metastatic liver cancer we showed that intratumoral administration of recombinant adenovirus encoding IL-12 activates natural killer cells, induces specific antitumor immunity, and displays a powerful antiangiogenic effect, resulting in tumor regression. There is a synergistic effect with the gene transfer of the chemokine IP-10. Also, intratumoral injection of either dendritic cells transfected ex vivo with recombinant adenovirus encoding IL-12 (Ad.IL-12) or an adenovirus coding for the CD40 ligand have shown an intense antitumor effect against experimental colorectal cancer. In summary, a variety of gene therapy strategies have been effective against animal models of gastrointestinal tumors. Clinical trials should determine whether human patients can be treated safely and effectively by such strategies.

Liver imaging. A surgeon's perspective

Advances in the diagnosis and treatment of liver lesions have improved therapy for a broad range of clinical conditions, many of which could not be effectively treated in the recent past. These advances are the result of better surgical techniques as well as diagnostic imaging. This article discusses the anatomy of the liver and the clinical evaluation of patients with liver lesions. Common benign and malignant liver lesions are presented with radiologic characteristics and treatment options.