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

Efficacy and Safety of Hepatic Arterial Infusion Therapy with Cinobufacini in Advanced Hepatocellular Carcinoma with Macrovascular Invasion: A Retrospective Cohort Study

Background

The presence of macrovascular invasion (MVI) is associated with poor prognosis in advanced hepatocellular carcinoma (HCC). This study aims to evaluate the efficacy and safety of Cinobufacini therapy via hepatic arterial infusion (HAI) in advanced HCC patients with MVI.

Methods

The clinical records of 130 consecutive patients with unresectable advanced HCC and MVI who had received Cinobufacini or cisplatin plus 5-fluorouracil (CF) treatment via HAI were retrospectively analyzed. The therapeutic efficacy, overall survival (OS), progression-free survival (PFS), and adverse events were compared between the two treatment groups.

Results

The Cinobufacini group demonstrated significant curative effects on treatment via HAI compared with the CF group, including the objective response rate (44.9% vs 27.9%, P=0.048), the median OS (14.8 months vs 11.1 months, P=0.010), and the median PFS (10.3 months vs 6.0 months, P=0.006). Result in subgroup analysis of portal vein invasion grade supported the efficacy in Cinobufacini treatment, especially in the median OS of Vp1-2 (18.3 months vs 14.3 months, P=0.043) and Vp3 (15.0 months vs 11.4 months, P=0.046), as well as the median PFS of Vp1-2 (14.8 months vs 10.2 months, P=0.028) and Vp3 (10.8 months vs 6.6 months, P=0.033) compared with CF treatment. Cox proportional hazards model and forest plot analysis of factors confirmed the survival benefit from HAI with Cinobufacini over CF (hazard ratio [HR], 0.61; 95% CI: 0.40-0.91; P=0.010). Multivariable analysis identified portal vein invasion grade (Vp4; HR, 1.78; 95% CI: 1.03-2.16; P=0.032) and AFP (>1000; HR, 1.61; 95% CI: 1.08-1.91; P=0.039) as the independent factors for prognosis. Moreover, the total incidence of adverse events in the Cinobufacini group was significantly lower than in the CF group (60.9% vs 82.0%, P=0.009).

Conclusion

Cinobufacini therapy via HAI is a viable strategy for curing advanced HCC with MVI, due to prolonged survival and a superior safety profile.

Advanced hepatocellular carcinoma with major portal vein invasion: Therapeutic outcomes of hepatic arterial infusion chemotherapy vs concurrent radiotherapy

BACKGROUND

Hepatocellular carcinoma (HCC) with major portal vein invasion (MPVI) presents very poor outcomes. Hepatic artery infusion chemotherapy (HAIC) and radiation therapy (RT) have both been found to be effective for advanced HCC. In this retrospective study, we compared the therapeutic outcomes of our "new" HAIC regimen with and without concurrent RT, before and after propensity score matching (PSM) in treating HCC patients with MPVI.

METHODS

One hundred forty patients with MPVI received HAIC alone and 35 patients underwent concurrent HAIC and RT during a 16-year period. The left subclavian artery was adopted as the entry site for a temporary catheter placement for a 5-day chemoinfusion. The Modified Response Evaluation Criteria in Solid Tumors (mRECIST) was adopted to assess the objective response rate (ORR). The Kaplan-Meier curve was used to calculate progression-free survival (PFS) and overall survival (OS) between the two groups. Univariate and multivariate analyses by Cox regression model were used to assess hazard ratios.

RESULTS

Of the 140 patients with Child-Pugh A liver function, the median OS was 17.0 months. In the initial cohort, higher ORR and PFS were found in the concurrent RT group than in the HAIC alone group (80% vs 66.4% and 9 vs 8 months, respectively) but shorter OS (10.5 vs 14.5 months, p = 0.039) was observed. After PSM, the OS was 10 and 15 months ( p = 0.012), respectively. Multivariable Cox regression analysis revealed that the significant factors for adjusting hazard ratios for OS were Child-Pugh classification, alpha fetal protein (AFP) level, and hepatic vein invasion.

CONCLUSION

HAIC is an effective treatment for advanced HCC patients with MPVI. Concurrent HAIC and full-dose RT were associated with worse clinical outcomes.

Cisplatin in Liver Cancer Therapy

Hepatocellular carcinoma (HCC) is the most common primary liver tumor and is often diagnosed at an unresectable advanced stage. Systemic chemotherapy as well as transarterial chemoembolization (TACE) and hepatic arterial infusion chemotherapy (HAIC) are used to treat advanced HCC. TACE and HAIC have long been the standard of care for patients with unresectable HCC but are limited to the treatment of intrahepatic lesions. Systemic chemotherapy with doxorubicin or chemohormonal therapy with tamoxifen have also been considered, but neither has demonstrated survival benefits. In the treatment of unresectable advanced HCC, cisplatin is administered transhepatic arterially for local treatment. Subsequently, for cisplatin-refractory cases due to drug resistance, a shift to systemic therapy with a different mechanism of action is expected to produce new antitumor effects. Cisplatin is also used for the treatment of liver tumors other than HCC. This review summarizes the action and resistance mechanism of cisplatin and describes the treatment of the major hepatobiliary cancers for which cisplatin is used as an anticancer agent, with a focus on HCC.

Hepatic arterial infusion chemotherapy versus sorafenib for advanced hepatocellular carcinoma with portal vein tumor thrombus: An updated meta-analysis and systematic review

Background

Sorafenib was the first drug approved for advanced hepatocellular carcinoma (HCC). However, it is limited by poor efficacy for HCC with portal vein tumor thrombus (PVTT). Some studies suggested that hepatic artery infusion chemotherapy (HAIC) could provide survival benefits to patients with advanced HCC with PVTT.

Aim

The study aimed to compare the efficacy of HAIC versus sorafenib in patients with HCC accompanied by PVTT.

Methods

The PubMed, Embase, and Cochrane Library databases were searched for studies published until September 2022. Statistical analyses were performed using Stata SE 15 software.

Results

Eight studies with 672 patients, 403 in the HAIC group and 269 in the sorafenib group, were included in the meta-analysis. The rates of complete response (RR=3.88, 95%CI:1.35-11.16, P=0.01), partial response (RR=3.46, 95%CI:1.94-6.18, P<0.0001), objective response rate (RR=4.21, 95%CI:2.44-7.28, P<0.00001) and disease control rate (RR=1.73, 95%CI:1.28-2.35, P=0.0004) were significantly higher in the HAIC group compared to the sorafenib group, whereas the progressive disease rate (RR=0.57, 95%CI:0.40-0.80, P=0.02) was significantly lower in the former. In contrast, the stable disease rate (RR=1.10, 95%CI (0.69-1.76), P=0.68) was similar in both groups. The overall survival (HR=0.50, 95%CI:0.40-0.63, P<0.05) and progression-free survival (HR=0.49, 95%CI:0.35-0.67, P<0.05) rates were significantly higher in the HAIC group compared to the sorafenib group.

Conclusion

HAIC has better efficacy against HCC with PVTT than sorafenib and may be considered an alternative to the latter. However, more high-quality randomized control trials and longer follow-ups are needed to verify our findings.

New Regimen of Combining Hepatic Arterial Infusion Chemotherapy and Lipiodol Embolization in Treating Hepatocellular Carcinoma with Main Portal Vein Invasion

BACKGROUND

The prognosis of HCC patients with main portal vein invasion (Vp4) is poor. We retrospectively reviewed the therapeutic outcomes with our new HAIC regimen in treating Vp4 HCC patients.

PATIENTS AND METHODS

Seventy-one patients received the new regimen of combining HAIC (daily infusion of cisplatin (10 mg/m²), mitomycin-C (2 mg/m²) and Leucovorin (15 mg/m²) plus 100 mg/m² of 5-fluorouracil (5-FU) using an infusion pump for 5 consecutive days) with Lipiodol embolization between 2002 and 2018. Twenty-two patients (31.0%) also received sorafenib. The Kaplan-Meier curve was used to calculate progression-free survival (PFS) and overall survival (OS). The OS of patients with or without additional sorafenib use or extrahepatic spread (EHS) was also compared.

RESULTS

Fifty-six patients (78.9%) had Child-Pugh A liver function. The mean maximal tumor size was 10.3 cm. Twenty patients (28.2%) had EHS at their initial diagnosis. The objective response rate according to the Modified Response Evaluation Criteria in Solid Tumors (mRECIST) and median OS were 64.8% and 13 months. The 1-, 2- and 3-year survival rates were 53.1%, 21.5% and 18.7%, respectively. In the subgroup analysis, there were no significant survival difference between patients with HAIC only vs. HAIC plus sorafenib (14 vs. 13 months) and between patients with vs. without EHS (12 vs. 13 months).

CONCLUSIONS

Our new HAIC regimen is effective in treating Vp4 HCC patients. Additional sorafenib use with our new HAIC regimen provided no survival benefit.

A Phase I Study of Locoregional High-Dose Autologous Natural Killer Cell Therapy With Hepatic Arterial Infusion Chemotherapy in Patients With Locally Advanced Hepatocellular Carcinoma

Background

To explore the feasibility and safety of natural killer (NK) cell therapy in HCC, we performed a prospective, open-label, phase I trial to evaluate the synergistic effect of locoregional high-dose autologous NK cell therapy in combination with hepatic arterial infusion chemotherapy (HAIC).

Methods

Patients with locally advanced HCC who were refractory to the standard treatment were eligible for this study. Patients received expanded and activated NK cells for 5 consecutive days in a dose-escalating manner (dose 2.5×10⁸, 5×10⁸, 10×10⁸ NK cells/injection) through hepatic arterial infusion following 4 cycles of HAIC with 5-fluorouracil (750 mg/m²) and cisplatin (25 mg/m²). The primary endpoint was the safety of NK cell-based immunotherapy, and the secondary endpoints were objective response rate (ORR), progression-free survival (PFS), overall survival (OS), and immunologic responses.

Results

Of the 11 patients enrolled, the confirmed ORR was 63.6% (complete response [CR]: 36.4%, confirmed partial response [PR]: 27.3%). Stable disease (SD) and progressive disease (PD) were observed in two patients (18.2%) each, resulting in a disease control rate (DCR) of 81.8%. The median PFS and OS were 10.3 and 41.6 months, respectively. There were no incidences of decompensation or severe adverse events during HAIC, and no adverse events related to NK cell infusion were noted.

Conclusion

The combination of HAIC and locoregional high-dose NK cell therapy is a safe and effective treatment for locally advanced HCC patients who were refractory to the standard treatment. This result warrants further development of this novel treatment to establish its efficacy in HCC.

Clinical Trial Registration

cris.nih.go.kr, identifier KCT0003973.

The Effect of Encapsulated Apigenin Nanoparticles on HePG-2 Cells through Regulation of P53

Apigenin (Ap) is one of the most important natural flavonoids that has potent anticancer activity. This study was designed, for the first time, to load Ap into chitosan to improve its hydrophobicity and then it was coated with albumin-folic acid to increase its stability and bioavailability and to target cancer cells. The newly developed encapsulated Ap (Ap-CH-BSA-FANPs) was characterized and tested in vitro. The zeta potential of −17.0 mV was within the recommended range (−30 mV to +30 mV), indicating that encapsulated apigenin would not quickly settle and would be suspended. The in vitro results proved the great anticancer activity of the encapsulated apigenin on HePG-2 cells compared to pure Ap. The treated HePG-2 cells with Ap-CH-BSA-FANPs demonstrated the induction of apoptosis by increasing p53 gene expression, arresting the cell cycle, increasing caspase-9 levels, and decreasing both the MMP9 gene and Bcl-2 protein expression levels. Moreover, the higher antioxidant activity of the encapsulated apigenin treatment was evident through increasing SOD levels and decreasing the CAT concentration. In conclusion, the Ap-CH-BSA-FANPs were easy to produce with low coast, continued drug release, good loading capacity, high solubility in physiological pH, and were more stable than the formerly Ap-loaded liposomes or PLGA. Moreover, Ap-CH-BSA-FANPs may be a promising chemotherapeutic agent in the treatment of HCC.

Hepatic Arterial Infusion Chemotherapy Is a Feasible Treatment Option for Hepatocellular Carcinoma: A New Update

Background

Hepatic arterial infusion chemotherapy (HAIC) is one option for treating massive tumors and unresectable hepatocellular carcinoma (HCC). However, there is a lack of remedial treatment after these treatments are ineffective or failed.

Summary

Some studies have discovered that HAIC has greater survival in patients with advanced HCC. A previous study has shown that HAIC is effective in the treatment of advanced HCC, and the data on randomized clinical trials are limited and unclear.

Key Message

More clinical trials and research are needed in order to make HAIC a standard and recommended therapy for advanced HCC. Our review focuses on the clinical applications of hepatic artery infusion treatment.

Clinical Importance of Regimens in Hepatic Arterial Infusion Chemotherapy for Advanced Hepatocellular Carcinoma with Macrovascular Invasion

Simple Summary

Although various molecular targeted agents have been approved, the therapeutic outcomes in hepatocellular carcinoma (HCC) with macrovascular invasion (MVI) are still unsatisfactory. Locoregional treatment using hepatic arterial infusion chemotherapy is a promising treatment for MVI-HCC. In the study, we aimed to compare the therapeutic effects of low-dose cisplatin plus 5-fluorouracil (LFP), a conventional HAIC regimen, and New FP (a fine-powder cisplatin suspended with lipiodol plus 5-fluorouracil) for MVI-HCC with preserved liver function. New FP was significantly superior to LFP in all therapeutic outcomes. New FP is a recommended HAIC regimen for the treatment of patients with MVI-HCC.

Abstract

Macroscopic vascular invasion (MVI) is a poor prognostic factor in hepatocellular carcinoma (HCC). Hepatic arterial infusion chemotherapy (HAIC) is a promising treatment in MVI-HCC. However, it is not clear which regimens are suitable for HAIC. In this study, we aimed to compare the therapeutic effects between New FP (a fine-powder cisplatin suspended with lipiodol plus 5-fluorouracil) and low dose FP (LFP/cisplatin plus 5-fluorouracil) in the treatment of MVI-HCC patients with Child–Pugh class A. New FP is a regimen that consists of a fine-powder cisplatin suspended with lipiodol and 5-fluorouracil. Fifty-one patients were treated with LFP, and 99 patients were New FP. We compared the therapeutic effects of LFP and New FP and assessed factors that associated with the therapeutic effects. The median survival and progression-free survival times of LFP and New FP were 16.1/24.7 and 5.4/8.8 months, respectively (p < 0.05, p < 0.05). The complete response (29%) and objective response rate (76%) of New FP were significantly higher than those of LFP (p < 0.001, p < 0.01). Factors associated with better therapeutic response were better ALBI-grade and New FP treatment choice. New FP is a more powerful regimen than LFP in HAIC for MVI-HCC. New FP represents a recommended HAIC regimen for the treatment of patients with MVI-HCC.

Hepatic Arterial Infusion Chemotherapy for Advanced Hepatocellular Carcinoma: Radiologic and Clinical Factors Predictive of Survival

OBJECTIVE. The goal of this study was to evaluate radiologic and clinical factors associated with overall survival of advanced hepatocellular carcinoma treated with hepatic arterial infusion chemotherapy (HAIC). MATERIALS AND METHODS. This single-center retrospective study included 180 patients with advanced hepatocellular carcinoma who underwent HAIC with a 5-fluorouracil (250-500 mg/m² for 5 hours) plus cisplatin (10-20 mg/m² for 1-2 hours) regimen via an implantable port system. Survival curves were generated by the Kaplan-Meier method and compared by log-rank tests. Factors associated with overall survival were evaluated with Cox proportional hazard models. RESULTS. The median overall survival time was 7.6 months (95% CI, 6.1-9.1), and the objective response rate was 15%. In multivariate analysis, infiltrative tumor growth (hazard ratio [HR], 1.002; p = .03) and rimlike arterial enhancement (HR, 3.040; p < .001) were pretreatment radiologic factors associated with reduced overall survival. No early response to treatment (HR, 2.064-6.491) and higher Child-Pugh class (HR, 2.010-2.815) were strong prognostic factors of poor outcome. Treatment with three or more HAIC cycles (HR, 0.371; p = .001) and high-dose HAIC (HR, 0.447; p < .001) were favorable for increased overall survival. CONCLUSION. Infiltrative tumor growth and rimlike arterial enhancement in pre-treatment imaging studies were associated with poor prognosis, and better early radiologic response and preserved liver function reserve were strong indicators of prolonged survival. Recognizing these radiologic and clinical predictors may help optimize care of patients with hepatocellular carcinoma.

Comparison of Sorafenib versus Hepatic Arterial Infusion Chemotherapy-Based Treatment for Advanced Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis

Background/Aims

Sorafenib is the first approved systemic treatment for advanced hepatocellular carcinoma (HCC). However, its clinical utility is limited, especially in Asian countries. Several reports have suggested the survival benefits of hepatic arterial infusion chemotherapy (HAIC) for advanced HCC with main portal vein tumor thrombosis (PVTT). This study aimed to compare the efficacy of sorafenib-based therapy with that of HAIC-based therapy for advanced HCC with main PVTT.

Methods

Advanced HCC patients with main PVTT treated with sorafenib or HAIC between 2008 and 2016 at Korea University Medical Center were included. We evaluated overall survival (OS), time-to-progression (TTP), and the disease control rate (DCR).

Results

Seventy-three patients were treated with sorafenib (n=35) or HAIC (n=38). Baseline characteristics were not significantly different between groups, except the presence of solid organ metastasis (46% vs 5.3%, p<0.001). The median OS time was not significantly different between the groups (6.4 months vs 10.0 months, p=0.139). TTP was longer in the HAIC group than in the sorafenib group (2.1 months vs 6.2 months, p=0.006). The DCR was also better in the HAIC group than in the sorafenib group (37% vs 76%, p=0.001). Subgroup analysis, which excluded patients with extrahepatic solid organ metastasis, showed the same trends for the median OS time (8.8 months vs 11.1 months, p=0.097), TTP (1.9 months vs 6.0 months, p<0.001), and DCR (53% vs 81%, p=0.030).

Conclusions

HAIC-based therapy may be an alternative to sorafenib for advanced HCC with main PVTT by providing longer TTP and a better DCR. (Gut Liver 2021;15-294)

Cost-Effectiveness Analysis of Hepatic Arterial Infusion of FOLFOX Combined Sorafenib for Advanced Hepatocellular Carcinoma With Portal Vein Invasion

Background

Hepatic arterial infusion (HAI) of oxaliplatin, leucovorin, and fluorouracil (FOLFOX) plus sorafenib has a more desirable effect versus sorafenib for hepatocellular carcinoma (HCC) patients with portal vein invasion. However, considering the high cost of hepatic arterial infusion of chemotherapy (HAIC), this study evaluated the cost-effectiveness of HAIC plus sorafenib (SoraHAIC) versus standard care for HCC patients from the Chinese health system perspective.

Methods

A Markov multi-state model was constructed to simulate the disease course and source consumption of SoraHAIC. Costs of primary therapeutic drugs were calculated based on the national bid price, and hepatic artery catheterization fee was collected from the Fujian Provincial Price Bureau. Clinical data, other costs, and utility values were extracted from references. Primary outcomes included life-years (LYs), quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER). The robustness of model was verified by uncertainty sensitivity analyses.

Results

SoraHAIC gained 1.18 QALYs (1.68 LYs) at a cost of $65,254, while the effectiveness and cost of sorafenib were 0.52 QALYs (0.79 LYs) and $14,280, respectively. The ICER of SoraHAIC vs sorafenib was $77,132/QALY ($57,153/LY). Parameter that most influenced the ICER was utility of PFS state. The probabilistic sensitivity analysis (PSA) showed that SoraHAIC was not cost-effective in the WTP threshold of 3*Gross Domestic Product (GDP) per capita of China ($30,492/QALY). But about 38.8% of the simulations were favorable to SoraHAIC at the WTP threshold of 3*GDP per capita of Beijing ($72,000/QALY). When 3*GDP per capita of Fujian ($47,285/QALY) and Gansu Province ($14,595/QALY) were used as WTP threshold, the acceptability of SoraHAIC was 0.3% and 0%, respectively.

Conclusions

The study results indicated that SoraHAIC was not cost-effective in medium-, and low-income regions of China. In developed areas of China (Beijing), there was a 38.8% probability that the SoraHAIC regimen would be cost-effective.

Treatment strategies for advanced hepatocellular carcinoma: Sorafenib vs hepatic arterial infusion chemotherapy

Sorafenib is used worldwide as a first-line standard systemic agent for advanced hepatocellular carcinoma (HCC) on the basis of the results of two large-scale Phase III trials. Conversely, hepatic arterial infusion chemotherapy (HAIC) is one of the most recommended treatments in Japan. Although there have been no randomized controlled trials comparing sorafenib with HAIC, several retrospective analyses have shown no significant differences in survival between the two therapies. Outcomes are favorable for HCC patients exhibiting macroscopic vascular invasion when treated with HAIC rather than sorafenib, whereas in HCC patients exhibiting extrahepatic spread or resistance to transcatheter arterial chemoembolization, good outcomes are achieved by treatment with sorafenib rather than HAIC. Additionally, sorafenib is generally used to treat patients with Child-Pugh A, while HAIC is indicated for those with either Child-Pugh A or B. Based on these findings, we reviewed treatment strategies for advanced HCC. We propose that sorafenib might be used as a first-line treatment for advanced HCC patients without macroscopic vascular invasion or Child-Pugh A, while HAIC is recommended for those with macroscopic vascular invasion or Child-Pugh A or B. Additional research is required to determine the best second-line treatment for HAIC non-responders with Child-Pugh B through future clinical trials.

Simultaneous inhibition of growth and metastasis of hepatocellular carcinoma by co-delivery of ursolic acid and sorafenib using lactobionic acid modified and pH-sensitive chitosan-conjugated mesoporous silica nanocomplex

Co-delivery multiple drugs using nanocarriers has been recognized as a promising strategy for cancer treatment to enhance therapeutic efficacy. In this study, a pH sensitive mesoporous silica nanoparticles (MSN) based controlled release nanoparticles for co-delivery of sorafenib (SO), a multi-tyrosine kinase inhibitor, and ursolic acid (UA), a sensitive agent for SO, was developed, which was decorated with pH sensitive chitosan (CS) and lactobionic acid (LA) targeting to asialoglycoprotein receptor (ASGPR) over-expressing hepatocellar carcinoma cells (denoted as USMNs-CL). The nanocomplex enhanced bioavailability of hydrophobic drugs, efficient tumor cell targeting and exhibited pH-responsive function and sustained release profile. USMNs-CL showed synergistic cytotoxicity and could attenuate the adhesion, migration of ASGPR over-expressing liver cancer SMMC-7721 cells at non-toxic concentrations. Moreover, the complex nanoparticles significantly increased the cellular apoptosis and down-regulated the expression of EGFR and VEGFR2 proteins related with cell proliferation and tumor angiogenesis. In vivo, compared with UA or SO alone, the nanocomplex significantly reduced the tumor burden in hepatocellular carcinoma (HCC) H22 tumor-bearing mice model and inhibited the lung metastasis in the H22 lung metastasis models. Overall, co-delivery of UA and SO by MSN-CS-LA nanocarriers could provide a promising strategy for HCC combinational therapy, especially for the HCC metastasis chemoprevention.

Conditional survival estimate in patients with Barcelona Clinic Liver Cancer stage B/C hepatocellular carcinoma treated with hepatic arterial infusion chemotherapy with/without concurrent radiotherapy

Conditional survival (CS) provides a prognosis of patients who have already survived several years after treatment. We investigated CS in Barcelona Clinic Liver Cancer (BCLC) stage B/C hepatocellular carcinoma (HCC) patients treated with hepatic arterial infusion chemotherapy (HAIC) with or without concurrent radiotherapy (CRT). A total of 181 patients diagnosed with HCC who were treated with HAIC with or without CRT between 2011 and 2015 were retrospectively reviewed. Overall survival (OS) and CS were calculated and a subgroup analysis was performed. The 1- and 5-year survival rates of all patients were 57.0% and 24.3%. OS was significantly higher in patients with BCLC stage B than BCLC stage C patients. Patients who achieved disease control after treatment also showed longer OS than who did not respond to treatment. Provided that the patient had already survived for 0, 1, 2, and 3 years, the CS estimates of surviving an additional 2 years were 35.6%, 55.1%, 82.0%, and 77.4%, respectively. A subgroup analysis was performed to compare BCLC stage B and C patients and revealed that CS has a tendency to increase and the difference in CS between two groups decreased over time. CS reflects the change of prognosis over time and may provide a more accurate prognosis and hopeful message to patients who have already survived with treatment.

Neutrophil/lymphocyte ratio as a prognostic indicator of hepatic arterial infusion chemotherapy with arterial cisplatin plus continuous 5-fluorouracil

AIM

Hepatic arterial infusion (HAIC) therapy may be a therapeutic option for advanced hepatocellular carcinoma (HCC) in addition to administration of sorafenib, which is the only currently established standard regimen for this disease. Survival benefit of HAIC has been reported in patients positive for antitumor response. Therefore, the prediction of antitumor response is important in decision-making for HAIC treatment.

METHODS

Twenty-six consecutive patients with advanced HCC treated by HAIC using arterial cisplatin plus continuous 5-fluorouracil were retrospectively analyzed in this study. Neutrophil/lymphocyte ratio (NLR) was assessed to determine its effectiveness as a prognostic indicator of HAIC.

RESULTS

The median time to progression and overall survival time (OS) were 5.0 and 17.0 months, respectively. The overall response rate (RR) among the 26 patients was 42.3%, and RR was independent of liver function. Interestingly, RR was significantly lower in patients with NLR of 4 or more (odds ratio, 0.49; P = 0.04). When we investigated factors that influenced OS, treatment effect and NLR of less than 4 were associated with prolonged OS. No serious adverse events were found in treatment with HAIC.

CONCLUSION

HAIC is a candidate for treatment of advanced HCC, and NLR may be a useful prognostic indicator for suitability of HAIC.

A new therapeutic assessment score for advanced hepatocellular carcinoma patients receiving hepatic arterial infusion chemotherapy

Background & Aims

Hepatic arterial infusion chemotherapy (HAIC) is an option for treating advanced hepatocellular carcinoma (HCC). Because of the poor prognosis in HAIC non-responders, it is important to identify patients who may benefit from continuous HAIC treatment; however, there are currently no therapeutic assessment scores for this identification. Therefore, we aimed to establish a new therapeutic assessment score for such patients.

Methods

We retrospectively analyzed 90 advanced HCC patients with elevated baseline alpha-fetoprotein (AFP) and/or des-gamma-carboxy prothrombin (DCP) levels and analyzed various parameters for their possible use as predictors of response and survival. AFP and DCP responses were assessed after half a course of HAIC (2 weeks); a positive-response was defined as a reduction of ≥ 20% from baseline.

Results

Multivariate analysis identified DCP response (odds ratio 16.03, p < 0.001) as an independent predictor of treatment response. In multivariate analysis, Child-Pugh class A (hazard ratio [HR] 1.99, p = 0.018), AFP response (HR 2.17, p = 0.007), and DCP response (HR 1.90, p = 0.030) were independent prognostic predictors. We developed an Assessment for Continuous Treatment with HAIC (ACTH) score, including the above 3 factors, which ranged from 0 to 3. Patients stratified into two groups according to this score showed significantly different prognoses (≤1 vs. ≥2 points: median survival time, 15.1 vs. 8.7 months; p = 0.003).

Conclusions

The ACTH score may be useful in the therapeutic assessment of HCC patients receiving HAIC.

Hepatic artery infusion chemotherapy for advanced hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. Surgery, percutaneous ablation and liver transplantation are the only curative treatment modalities for HCC. However, the majority of patients have unresectable disease at diagnosis. Therefore, effective treatment options for patients with advanced HCC are required. In advanced HCC, according to current international guidelines, sorafenib, a molecular targeted agent, is the standard treatment. However, alternative treatment modalities are required because of the low response rates and unsuitability of molecular agents in real practice. In various treatment modalities, mostly in Asia, hepatic arterial infusion chemotherapy (HAIC) has been applied to advanced HCC with a view to increasing the therapeutic efficacy. HAIC provides direct drug delivery into the tumor feeding vessels and also minimizes systemic toxicities through a greater first-pass effect in the liver. However, the sample sizes of studies on HAIC have been small and large randomized trials are still lacking. In this article, we describe the treatment efficacy of HAIC for advanced stage HCC and discuss future therapeutic possibilities.

Hepatic arterial infusion in hepatocellular carcinoma: a single center experience

AIM

The aim of the present study was to evaluate a single center experience with hepatic arterial infusion (HAI) in patients with hepatocellular carcinoma.

METHODS

A retrospective analysis of 20 patients treated for hepatocellular carcinoma between 1994 and 2007.

RESULTS

Most patients were treated with an HAI of doxorubicin and cisplatin combined with 5-fluorouracil and folinic acid. The response was not evaluable in the majority of patients, predominantly because of associated surgical procedure or because only one cycle of HAI was administered. The median progression-free survival was 7.7 months. The median survival of all patients was 12.2 months (5-year survival 5%). Serious adverse events were observed in 5 patients, and one patient died of liver failure in association with the administration of HAI.

CONCLUSION

The data show the limited efficacy of HAI in patients with hepatocellular carcinoma.

Hepatic arterial infusion chemotherapy with fine-powder cisplatin and iodized-oil suspension in patients with intermediate-stage and advanced-stage (Barcelona Clinic Liver Cancer stage-B or stage-C) hepatocellular carcinoma: multicenter phase-II clinical study

PURPOSE

This single-arm, multicenter, phase-II trial evaluated the efficacy and safety of hepatic arterial infusion chemotherapy (HAIC) using fine-powder cisplatin and iodized-oil suspension in patients with intermediate- and advanced-stage [Barcelona Clinic Liver Cancer (BCLC) stage-B and stage-C] hepatocellular carcinomas (HCCs).

METHODS

The Institutional Review Board approved this study and patients provided written informed consent. Thirty-five patients (24 men and 11 women, mean 74 ± 6 years [range 60-87 years]) with BCLC stage-B (57 %, 20/35) or stage-C (43 %, 15/35) HCCs who were not candidates for other locoregional treatments were enrolled. HAIC was performed using a suspension of fine-powder cisplatin with a maximum dose of 65 mg/m(2) and iodized oil on demand. The primary endpoint was the response rate evaluated based on Response Evaluation Criteria in Solid Tumor (RECIST) and modified RECIST (mRECIST). Secondary endpoints were overall survival, progression-free survival, and safety.

RESULTS

The initial and best overall response rates at 4 weeks and 3 months, respectively, were 14 and 17 % based on RECIST, and 57 and 23 % based on mRECIST. The median overall and progression-free survival times were 18 and 4 months, respectively. The most frequent grade-3 or grade-4 adverse events were elevation of serum alanine (23 %) and aspartate aminotransferase (20 %), and thrombocytopenia (17 %).

CONCLUSION

This HAIC provides promising therapeutic effects with acceptable safety to patients with intermediate-stage and advanced-stage HCCs.

Prognostic values of vascular endothelial growth factor and matrix metalloproteinase-2 in hepatocellular carcinoma after radiotherapy

OBJECTIVES

Hepatocellular carcinoma (HCC) is a highly vascularized tumor. In this study, we investigated the prognostic and predictive values of proangiogenic factors in HCC patients receiving radiotherapy.

METHODS

Between September 2008 and December 2009, a total of 50 patients treated with radiotherapy were prospectively enrolled in this study. Serum and urine samples were collected <1 week before and after radiotherapy.

RESULTS

After completion of radiotherapy, serum vascular endothelial growth factor (VEGF)/platelet (Plt) levels were significantly increased (p < 0.01). Patients who experienced hepatic tumor recurrence outside the radiation field showed higher VEGF-A/Plt levels before and after radiotherapy than patients who did not (p = 0.04), whereas patients who had hepatic tumor recurrence inside the radiation field showed significantly higher matrix metalloproteinase (MMP)-2 levels after radiotherapy (p = 0.04). On multivariate analyses, a high level of either VEGF/Plt or MMP-2 (≥median) before radiotherapy was a significant independent prognostic factor for a worse progression-free survival (p = 0.04).

CONCLUSIONS

In HCC patients receiving radiotherapy, levels of VEGF/Plt and MMP-2 before radiotherapy can be useful to predict treatment outcome. This study also suggests the necessity of anti-angiogenic therapy, such as sorafenib, since radiotherapy increases VEGF/Plt levels, and higher levels of VEGF/Plt are associated with a poor outcome.

Serum transferrin as a predictor of prognosis for hepatic arterial infusion chemotherapy in advanced hepatocellular carcinoma

AIM

We recently reported that the iron chelator deferoxamine (DFO) is efficacious in advanced hepatocellular carcinoma (HCC) patients. Iron regulation may thus have an important impact in HCC therapy. Because transferrin is a native chelator that regulates iron homeostasis, it may act as an anticancer agent in a similar manner as DFO. The objective of this study was to evaluate serum transferrin as a prognostic predictor in advanced HCC patients undergoing hepatic arterial infusion chemotherapy (HAIC).

METHODS

We retrospectively studied 44 patients receiving HAIC and analyzed various parameters for their possible use as prognostic predictors.

RESULTS

The 1-, 2- and 3-year cumulative survival rates were 36.4%, 18.2% and 8.5%, respectively, and the median survival time (MST) was 7.0 months. The survival rates of patients who had serum transferrin of 190 mg/dL or more (MST, 12.0 months) were significantly better than those of patients who had serum transferrin of less than 190 mg/dL (MST, 4.9 months). Multivariate analysis identified serum transferrin of 190 mg/dL or more (hazard ratio [HR], 0.282; 95% confidence interval [CI], 0.132-0.603; P = 0.001) and Child-Pugh score B (HR, 1.956; 95% CI, 1.034-3.700; P = 0.039) as independent prognostic predictors. There was a significant correlation between serum transferrin level and therapeutic effect (P < 0.001).

CONCLUSION

Serum transferrin could be useful as a prognostic predictor in advanced HCC patients before HAIC treatment.

Chemotherapy for advanced hepatocellular carcinoma in the sorafenib age

The kinase inhibitor sorafenib is the only systemic therapy proven to have a positive effect on survival of patients with advanced hepatocellular carcinoma (HCC). After development of sorafenib and its introduction as a therapeutic agent used in the clinic, several critical questions have been raised. Clinical parameters and biomarkers predicting sorafenib efficacy are the most important issues that need to be elucidated. Although it is difficult to know the responders in advance using conventional characteristics of patients, there are specific serum cytokines and/or gene amplification in tumor tissues that have been reported to predict efficacy of sorafenib. Risk and benefits of continuation of sorafenib beyond radiological progression is another issue to consider because no other standard therapy for advanced HCC as yet exists. In addition, effectiveness of the expanded application of sorafenib is still controversial, although a few studies have shed some light on combinational treatment with sorafenib for intermediate-stage HCC. Recently, over 50 relevant drugs have been developed and are currently under investigation. The efficacy of some of these drugs has been extensively examined, but none have demonstrated any superiority over sorafenib, so far. However, there are several drugs that have shown efficacy for treatment after sorafenib failure, and these are proceeding to further studies. To address these issues and questions, we have done extensive literature review and summarize the most current status of therapeutic application of sorafenib.

Newer treatments for advanced hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. The only curative treatment modalities for HCC are surgery, percutaneous ablation, and liver transplantation. Unfortunately, the majority of patients have unresectable disease at diagnosis. Therefore, effective treatment options are needed for patients with advanced HCC. The current standard treatment for patients with advanced HCC, according to the Barcelona Clinic Liver Cancer staging system, is the multikinase inhibitor sorafenib. Other alternative therapies are required, due to the limited treatment response to, and tolerance of, this molecular target agent. Clinical trials of hepatic artery infusion chemotherapy, radioembolization, and multimodal treatments have shown favorable results in advanced HCC patients. This article introduces new treatment modalities for advanced HCC and discusses future therapeutic possibilities.

Efficacy of iron chelator deferoxamine for hepatic arterial infusion chemotherapy in advanced hepatocellular carcinoma patients refractory to current treatments

The prognosis of advanced hepatocellular carcinoma (HCC) remains poor. For patients with advanced HCC, the multikinase inhibitor sorafenib is recommended as the current standard of care. In contrast, hepatic arterial infusion chemotherapy (HAIC) is one of the recommended treatments in Japan. However, in Japan, the use of sorafenib versus hepatic arterial infusion chemotherapy for first-line treatment remains unclear, because there have been no randomized controlled trials comparing HAIC with sorafenib. HAIC can substantially prolong survival in patients with complete and partial response, while non-responders may be suitable candidates for sorafenib therapy. Nonetheless, HAIC non-responders with deteriorated liver function currently have no treatment options. We have shown the efficacy of an alternative therapy, the iron chelator deferoxamine, for advanced HCC patients with deteriorated liver function. Iron chelators may have future therapeutic possibilities in this patient population.

Efficacy of sorafenib monotherapy versus sorafenib-based loco-regional treatments in advanced hepatocellular carcinoma

BACKGROUND

Although sorafenib is accepted as the standard of care in advanced hepatocellular carcinoma (HCC), its therapeutic benefit is marginal. Here, we aimed to compare the efficacy and safety of sorafenib monotherapy (S-M) and sorafenib-based loco-regional treatments (S-LRTs) in advanced HCC.

METHODS

From 2007 to 2012, 290 patients with advanced HCC (Barcelona Clinic Liver Cancer stage C) with S-M (n = 226) or S-LRTs (n = 64) were reviewed retrospectively. Survival outcomes and treatment-related toxicities between two groups were analyzed.

RESULTS

Variables related to tumor burden and liver function were similar between the groups (all P > 0.05). Within the entire population, the S-LRTs group had both longer median overall survival (OS) (8.5 vs 5.5 months, P = 0.001) and progression-free survival (PFS) (5.3 vs 3.0 months, P = 0.002) than the S-M group. Furthermore, the S-LRTs group had longer Os than the S-M group in a subgroup with neither extrahepatic spread (EHS) nor regional nodal involvement (RNI) (18.0 vs 7.8 months, P = 0.019) and in a subgroup with EHS and/or RNI (8.3 vs 4.8 months, P = 0.028). In addition, the S-LRTs group had longer PFS than the S-M group in the subgroup with neither EHS nor RNI (9.6 vs 3.2 months, P = 0.027).

TREATMENT

Related toxicity was similar between two groups.

CONCLUSION

Combined use of sorafenib and LRTs may provide better treatment outcomes without significantly increasing treatment-related toxicities, even in patients with EHS and/or RNI. Therefore, addition of active LRTs might be considered, if feasible.

Effect of hepatic arterial infusion chemotherapy of 5-fluorouracil and cisplatin for advanced hepatocellular carcinoma in the Nationwide Survey of Primary Liver Cancer in Japan

BACKGROUND

The efficacy of hepatic arterial infusion chemotherapy for the treatment of advanced hepatocellular carcinoma (HCC) remains unclear.

METHODS

The outcome of 476 patients with HCC who underwent hepatic arterial infusion chemotherapy with 5-fluorouracil and cisplatin (HAIC) were compared with 1466 patients who did not receive active therapy.

RESULTS

A survival benefit of the therapy after adjusting for known risk factors was observed (hazard ratio, 0.48; 95% CI, 0.41-0.56; P<0.0001). In propensity score-matched analysis (n=682), median survival time was longer for patients who underwent chemotherapy (14.0 months) than for patients who did not receive active treatment (5.2 months, P<0.0001).

CONCLUSION

For advanced HCC, HAIC is considered to be an effective treatment.

Current status of hepatocellular carcinoma treatment in Japan: hepatic arterial infusion chemotherapy

Hepatic arterial infusion chemotherapy (HAIC) allows the long-term administration of cytotoxic drugs to the liver. In Japan, HAIC has traditionally been used to treat patients with advanced hepatocellular carcinoma (HCC) with vascular invasion or multiple intrahepatic lesions, or both. The most common chemotherapy drugs used for HAIC in Japan are 5-fluorouracil and cisplatin. Although HAIC is associated with a high rate of response in some studies, it is not associated with a survival benefit. Furthermore, HAIC is associated with complications that are not observed with systemic chemotherapy, including peptic ulcer, arterial occlusion and port infection. A molecular targeted agent, sorafenib, recently became the standard therapy for advanced HCC on the basis of data from two randomized controlled trials. For this reason, the position of HAIC in the treatment of advanced HCC in Japan is under discussion. Clinical trials must be undertaken to establish standardized protocols and regimens for HAIC, and to determine the efficacy of HAIC in comparison with other therapies for HCC. Without evidence from such trials, HAIC may not find an established role in the treatment of HCC, and may even fall out of use. Recent evidence suggests that HAIC may be useful in combination with molecular targeted therapy; this is currently being investigated in a number of clinical trials.

Dual-phase CT angiography through the port-catheter system for hepatic arterial infusion chemotherapy using multislice CT: assessment of system dysfunction and impact on predicting clinical problems

BACKGROUND

Hepatic arterial infusion (HAI) chemotherapy is being explored for treatment of malignant liver tumors. Maintenance of HAI systems is important for effective treatment.

PURPOSE

To prospectively evaluate the efficacy of dual-phase CT angiography through the port-catheter system for HAI chemotherapy.

MATERIAL AND METHODS

This study enrolled 47 patients receiving HAI chemotherapy for malignant liver tumors who underwent dual-phase CT angiography through the port-catheter system using multislice CT. Using maximum intensity projection images reconstructed from vascular-phase CT imaging, hepatic arterial patency and catheter location were assessed. Using a combination of vascular- and perfusion-phase CT imaging, system dysfunction and clinical problems were evaluated.

RESULTS

Dual-phase CT angiography was conducted 156 times. Stenosis and obstruction of the hepatic artery and catheter dislodgment were observed seven times in four patients and four times in three patients, respectively. Diagnostic accuracy using vascular-phase CT imaging was 100%. In addition, development of collateral blood supply to the liver and extrahepatic perfusion to the stomach were observed three times in three patients and twice in two patients, respectively. Overall, system dysfunction occurred 16 times in 12 patients, and system correction and treatment modification were required 11 times in 10 patients. In assessing system dysfunction and predicting clinical problems, the accuracy of dual-phase CT imaging was 100%.

CONCLUSION

Dual-phase CT angiography through the port-catheter system is helpful for assessing catheter system dysfunction and predicting clinical problems in HAI chemotherapy.

Applicability of BCLC stage for prognostic stratification in comparison with other staging systems: single centre experience from long-term clinical outcomes of 1717 treatment-naïve patients with hepatocellular carcinoma

BACKGROUND

The most informative staging system regarding survival outcomes for treatment-naïve hepatocellular carcinoma (HCC) remains debated. We evaluated prognostic values of Barcelona Clinic Liver Cancer (BCLC) stage compared with other staging systems, and identified discrepancies between treatment options chosen in Korean clinical practice and BCLC guidelines.

METHODS

Between 2003 and 2008, 1717 prospectively enrolled patients with treatment-naïve HCC were analysed. Prognostic ability of each staging system was assessed using time-dependent receiver-operating characteristic (ROC) curves.

RESULTS

The most common aetiology was hepatitis B virus (1238, 72.1%); 167 (9.8%) patients were classified as BCLC stage 0, 526 (30.6%) as A, 333 (19.4%) as B, 608 (35.4%) as C and 83 (4.8%) as D. Median overall survival was 22.5 months, and 1-, 2-, 3-, 4-, and 5-year survival rates were 62.6, 48.3, 39.9, 34.7, and 29.3% respectively. Of six staging systems, BCLC had the highest area under ROC (AUROC; 0.821) for overall survival, followed by JIS (0.809), Tokyo score (0.771), CLIP (0.746), CUPI (0.701) and GRETCH (0.685) system. In both subgroups stratified according to treatment strategy (curative vs. palliative), BCLC also showed the best AUROCs (curative, 0.708/palliative, 0.807) for overall survival. Regarding discrepancies between treatment options chosen in our cohort and BCLC guidelines, more than half with very early/early-stage HCC underwent transarterial chemoembolization, rather than resection or local ablative therapy; most of those with advanced-stage HCC received intra-arterial chemotherapy-based treatments rather than sorafenib.

CONCLUSION

BCLC was the best long-term prognostic model for treatment-naïve HCC in a large-scale Korean cohort. However, treatment modalities did not exactly match BCLC paradigm.

Preferential inhibition of hepatocellular carcinoma by the flavonoid Baicalein through blocking MEK-ERK signaling

Baicalein is a purified flavonoid extracted from the roots of Scutellaria baicalensis or Scutellaria radix. Although previous studies have suggested that Baicalein possesses an in vitro anti-hepatocellular carcinoma activity, its in vivo effects and mechanisms of action are still not completely understood. In this study, Baicalein at concentrations of 40-120 µM exhibited significant cytotoxicity to three hepatocellular carcinoma (HCC) cell lines but marginal cytotoxicity to a normal liver cell line in vitro. Compared to a standard chemotherapy drug, 5-fluorouracil (5-FU), Baicalein had greater effect on HCC cells but less toxicity on normal liver cells. Treatment with Baicalein dramatically reduced mitochondrial transmembrane potential, and activated caspase-9 and caspase-3. Blockade of Baicalein-induced apoptosis with a pan-caspase inhibitor partially attenuated Baicalein-induced growth inhibition in HCC. Baicalein treatment significantly inhibited tumor growth of HCC xenografts in mice. Induction of apoptosis was demonstrated in Baicalein-treated xenograft tumors by the terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) assay. Furthermore, Baicalein treatment dramatically decreased the levels of phosphorylation of MEK1, ERK1/2 and Bad in vitro and in vivo. Overexpression of human MEK1 partially blocked Baicalein-induced growth inhibition. Consequently, these findings suggest that Baicalein preferentially inhibits HCC tumor growth through inhibition of MEK-ERK signaling and by inducing intrinsic apoptosis.

Hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma and future treatments for the poor responders

Hepatocellular carcinoma (HCC) is one of the most common cancers worldwide. The most common problem associated with HCC is a high risk of intrahepatic recurrence despite radical treatment, and in many patients, this recurrence has fatal consequences. For patients with advanced-stage HCC according to the Barcelona Clinic Liver Cancer staging system, the multikinase inhibitor sorafenib is the current standard of care. In contrast, hepatic arterial infusion chemotherapy (HAIC) is the recommended treatment in Japan for patients with intermediate-stage or advanced-stage HCC. In this review, we describe the use of HAIC for advanced HCC. Furthermore, we demonstrate an alternative therapy for HCC, the iron chelator deferoxamine, and discuss future therapeutic possibilities.

Hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma in Japan

Transcatheter methods such as transcatheter arterial chemoembolization (TACE) and hepatic arterial infusion chemotherapy (HAIC) have an important role in the treatment for advanced hepatocellular carcinoma (HCC). Recently, sorafenib, an inhibitor of tyrosine kinases, has been found to obtain survival benefits in patients with HCC, leading to major advances in the treatment of advanced HCC. However, it is associated with a low tumor response rate, minimal survival advantage, and high rates of adverse events. On the other hand, high rates of objective treatment response with HAIC for advanced HCC have been reported, although convincing evidence of it contributing to overall survival in HAIC has been lacking. In Japan, HAIC still tends to be the preferred method for the treatment of advanced HCC, even in patients with poor liver function. However, the choice of chemotherapeutic agents in TACE/HAIC for HCC varies between institutions. In this review, based on studies reported to date in the literature, we refer to current knowledge regarding the chemotherapeutic agents used for TACE/HAIC for HCC in Japan and consider the future perspectives for HAIC for this cancer.

Utilization and outcomes of palliative therapy for hepatocellular carcinoma: a population-based study in the United States

GOALS

To evaluate the utilization and determinants of receiving palliative treatment for hepatocellular carcinoma (HCC), and its effect on survival.

BACKGROUND

Palliative treatment for HCC, including transarterial chemoembolization (TACE) and systemic chemotherapy, is available for patients who do not receive potentially curative therapy. The utilization and outcomes of these therapies in clinical practice are unknown.

STUDY

We conducted a population-based cohort study using the Surveillance, Epidemiology, and End-Results Registry data linked to Medicare claims of HCC patients aged above 65 years diagnosed during 2000 to 2005 who did not receive liver transplant, resection, or ablation. The proportions of patients who received TACE or systemic chemotherapy were calculated by tumor stage, liver disease status, and non-HCC comorbidity. Determinants of receiving palliative therapy were examined in logistic regression models and propensity scores were calculated. Cox proportional hazards models were used to evaluate mortality risk.

RESULTS

We identified 3163 HCC patients (median age, 75 y; 67% men) who did not receive potentially curative treatment. Approximately 12.5% of patients received TACE and 11.0% received chemotherapy. In patients with early or intermediate stage HCC, no liver decompensation, and little or no comorbidity, only 22.8% received TACE and 13.8% received chemotherapy. Median survival was significantly higher among patients who received TACE (14.0 mo) compared with who received chemotherapy (5.0 mo) or no therapy (2.0 mo). A significant reduction in overall mortality was observed for TACE (54%) and chemotherapy (33%).

CONCLUSIONS

Utilization of palliative treatment for HCC is low, which could not be explained by clinical features. However, misclassification could have occurred due to the data source. Receipt of TACE or systemic chemotherapy was associated with a reduction in mortality.

Adjuvant hepatic arterial infusional chemotherapy with 5-fluorouracil and cisplatin after curative resection of hepatocellular carcinoma

OBJECTIVES

We investigated whether adjuvant hepatic arterial infusional chemotherapy (HAIC) with 5-fluorouracil (5-FU) and cisplatin reduces the recurrence of hepatocellular carcinoma (HCC) after curative resection.

METHODS

Between January 2006 and December 2008, 31 HCC patients received four cycles of adjuvant HAIC with 5-FU and cisplatin via port system after curative resection. During the same period, 62 patients, who did not take any adjuvant therapy, were selected as controls.

RESULTS

Tumor characteristics, such as distribution of TNM stage, pathologic differentiation, portal vein invasion, or microscopic invasion did not differ between control and adjuvant groups. During follow-up, recurrence developed in 11 adjuvant (35.5%) and 24 control patients (38.7%; p = 0.823). Tumor progression after recurrence was the cause of death in 2 adjuvant (28.6%) and 7 control patients (38.8%; p = 0.912). The 2-year recurrence rate was 9.1% in the adjuvant group and 4.2% in the control group, with the median recurrence-free survival time being 10.5 and 7.5 months, respectively (p = 0.324). The 3-year cumulative survival rate was 73.3% in the adjuvant group and 68.3% in the control group (p = 0.355).

CONCLUSION

Adjuvant HAIC with 5-FU and cisplatin did not offer any beneficial effect on the recurrence after curative resection of HCC.

Prognostic value of the 7th edition of the AJCC staging system as a clinical staging system in patients with hepatocellular carcinoma

BACKGROUND/AIMS

In 2009, the American Joint Committee on Cancer (AJCC) published the 7th edition of the hepatocellular carcinoma (HCC) staging system. We investigated the prognostic value of the 7th AJCC staging system as a clinical staging system in patients with HCC.

METHODS

We retrospectively applied the 6th and 7th AJCC systems to 877 patients who were diagnosed with HCC between January 2004 and December 2006 using radiological findings and compared the performance of the AJCC systems to that of the Barcelona Clinic Liver Cancer (BCLC) system. The prognostic power was quantified using a linear trend χ(2) test and -2 log likelihood.

RESULTS

The median age was 57years and males predominated (n=701, 79.9%). There was no significant difference in survival between adjoining advanced stages of the 6th and 7th AJCC systems (⩾stage IIIA in the 6th and ⩾stage IIIB in the 7th; all p>0.05), although a significant difference between adjoining early stages was identified. The 7th AJCC system had greater prognostic power than the 6th (linear trend χ(2) test, 168.195 versus 160.293; -2 log likelihood, 7366.347 versus 7396.380), but not greater than that of the BCLC system (linear trend χ(2) test=207.013, -2 log likelihood=7320.726).

CONCLUSIONS

The 7th AJCC staging system provided better prognostic power than the 6th for patients with HCC, but not better than that of the BCLC system. Thus, the 7th AJCC staging system should be applied cautiously in patients with advanced HCC because of its low prognostic power in advanced stages.

Sorafenib and hepatic arterial infusion chemotherapy for unresectable advanced hepatocellular carcinoma: A comparative study

Sorafenib is a kinase-targeted drug that has high efficacy for advanced hepatocellular carcinoma (HCC). The aim of the present study was to determine whether sorafenib is more effective than hepatic arterial infusion chemotherapy (HAIC) for HCC. Twenty patients treated with sorafenib (sorafenib group) initiated at 800 mg/day and 45 patients treated with HAIC (HAIC group) for unresectable Child-Pugh A advanced HCC were investigated retrospectively. The treatment effect was assessed using the Response Evaluation Criteria in Solid Tumors (RECIST). As a result, the overall response rate was significantly lower in the sorafenib group than in the HAIC group (P=0.03), while the disease control and survival rates did not differ between the two groups. In the sorafenib group, treatment was discontinued in 19 patients, including 12 due to side effects. In subgroups of patients treated with sorafenib, the survival rate was significantly lower in patients (n=11) administered sorafenib for <60 days compared to those (n=9) treated for ≥60 days. A shorter treatment period (<60 days) was an independent risk factor for unfavorable survival [hazard ratio (HR), 3.34; 95% confidence interval (CI), 1.45-7.66 vs. HAIC], while survival in patients treated with sorafenib for ≥60 days did not differ from those treated with HAIC (HR, 0.79; 95% CI, 0.27-2.34). In conclusion, the disease control and survival rates of patients treated with sorafenib for advanced HCC were comparable to such rates in patients treated with HAIC. However, the prognosis was poor when long-term sorafenib treatment was not possible due to side effects, demonstrating the importance of patient selection for sorafenib treatment.