Multidisciplinary Approach to HCC Management: How Can This Be Done?

Tanshinone IIA and hepatocellular carcinoma: A potential therapeutic drug

Because of its high prevalence and poor long-term clinical treatment effect, liver disease is regarded as a major public health problem around the world. Among them, viral hepatitis, fatty liver, cirrhosis, non-alcoholic fatty liver disease (NAFLD), and autoimmune liver disease are common causes and inducements of liver injury, and play an important role in the occurrence and development of hepatocellular carcinoma (HCC). Tanshinone IIA (TsIIA) is a fat soluble polyphenol of Salvia miltiorrhiza that is extracted from Salvia miltiorrhiza. Because of its strong biological activity (anti-inflammatory, antioxidant), it is widely used in Asia to treat cardiovascular and liver diseases. In addition, TsIIA has shown significant anti-HCC activity in previous studies. It not only has significant anti proliferation and pro apoptotic properties. It can also play an anti-cancer role by mediating a variety of signal pathways, including phosphatidylinositol-3-kinase (PI3K)/protein kinase B (Akt)/rapamycin (mTOR), mitogen-activated protein kinase (MAPK), and nuclear factor kappa-B (NF-κB). This review not only reviews the existing evidence and molecular mechanism of TsIIA's anti-HCC effect but also reviews the liver-protective effect of TsIIA and its impact on liver fibrosis, NAFLD, and other risk factors for liver cancer. In addition, we also conducted network pharmacological analysis on TsIIA and HCC to further screen and explore the possible targets of TsIIA against hepatocellular carcinoma. It is expected to provide a theoretical basis for the development of anti-HCC-related drugs based on TsIIA.

Development and Validation of an Autophagy-Related Gene Signature for Predicting the Prognosis of Hepatocellular Carcinoma

Purpose

Autophagy is a lysosomal degradation pathway that is essential for maintaining the homeostasis of the intracellular environment. Mounting evidence indicates that autophagy plays an essential role in the occurrence and development of hepatocellular cancer (HCC). This research is aimed at exploring the prognostic value of autophagy-related genes (ARGs) in HCC patients.

Methods

The Wilcoxon test was used to identify differentially expressed ARGs in The Cancer Genome Atlas (TCGA) HCC cohort. Then, the TCGA cohort was randomly divided into training and testing groups. Cox and LASSO regression models were used to screen for autophagy-related genes that affect overall survival (OS) in the TCGA training group. Based on the coefficient of risk genes, we constructed an autophagy-related gene signature for predicting the prognosis of HCC patients. Finally, we validated the prognostic significance of autophagy-related gene signature using the TCGA testing group and three external datasets.

Results

ATG10, BIRC5, GAPDH, and TMEM74 are risk genes for OS. According to the optimal cutoff value of risk score in each HCC dataset, HCC patients can divide into high- and low-risk groups. ARG risk score can significantly distinguish HCC patients with different survival outcomes. Meanwhile, the ARG risk score is independently correlated with OS in multiple HCC cohorts.

Conclusions

The autophagy-related risk score can effectively screen high-risk HCC patients and provide guidance for clinical prevention and treatment of HCC.

An Overview of Hepatocellular Carcinoma with Emphasis on Dietary Products and Herbal Remedies

The most common principal malignant tumor that accounts for ∼80% of cases of liver cancer across the world is hepatocellular carcinoma (HCC). It is a multifacetedillness that is caused by several risk factors and often progresses in the context of underlying cirrhosis. It is tremendously difficult and essential for the screening of novel therapeutic medications to establish HCC preclinical models that are equivalent to clinical diseases settings, i.e., representing the tumor microenvironment of HCC. In the progress of HCC, numerous molecular cascades have been supposed to play a part. Sorafenib is the only drug permitted by the US Food and Drug Administration for the treatment of HCC. Yet because of the increasing resistance to the drug and its toxicity, clinical treatment methods are not completely adequate. Newer treatment therapy options are essential for the management of HCC in patients. Natural compounds can be afforded by the patients with improved results with less toxicity and fewer side effects, among different methods of liver cancer treatment. The treatment and management of HCC with natural drugs and their phytoconstituents are connected to several paths that can prevent the occurrence and progress of HCC in several ways. The present review summarizes the etiology of HCC, molecular pathways, newer therapeutic approaches, natural dietary products, herbal plants and phytoconstituents for HCC treatment.

Evaluation of Hepatocellular Carcinoma Treatment Response After Locoregional Therapy

Locoregional therapy (LRT) for hepatocellular carcinoma can be used alone or with other treatment modalities to reduce rates of progression, improve survival, or act as a bridge to cure. As the use of LRT expands, so too has the need for systems to evaluate treatment response, such as the World Health Organization and modified Response Evaluation Criteria In Solid Tumors systems and more recently, the Liver Imaging Reporting and Data System (LI-RADS) treatment response algorithm (TRA). Early validation results for LI-RADS TRA have been promising, and as research accrues, the TRA is expected to evolve in the near future.

Role of the radiologist at HCC multidisciplinary conference and use of the LR-TR algorithm for improving workflow

Multidisciplinary conferences (MDCs) play a major role in management and care of oncology patients. Hepatocellular carcinoma (HCC) is a complex disease benefiting from multidisciplinary discussions to determine optimal patient management. A multitude of liver-directed locoregional therapies have emerged allowing for more options for treatment of HCC. A radiologist dedicated to HCC-MDC is an important member of the team contributing to patient care in multiple ways. The radiologist plays a key role in image interpretation guiding initial therapy discussions as well as interpreting post-treatment imaging following liver-directed therapy. Standardization of image interpretation can lead to more consistent treatment received by the patient as well as accurate assessment of transplant eligibility. The radiologist can facilitate this process using structured reporting that is also supported by stakeholders involved in interdisciplinary management of liver diseases. The Liver Imaging Reporting and Data System (LI-RADS), is a living document which offers a standardized reporting algorithm for consistent communication of radiologic findings for HCC screening and characterization of liver observations in patients at risk for HCC. The LI-RADS post-treatment algorithm (LR-TR algorithm) has been developed to standardize liver observations following liver-directed locoregional therapy. This review article focuses on the role of the radiologist at HCC-MDC and implementation of the LR-TR algorithm for improving workflow.

Travel distance and overall survival in hepatocellular cancer care

BACKGROUND

Our objective was to assess the relationship between overall survival (OS) and distance travelled to the treating facility for patients undergoing liver resection for hepatocellular carcinoma and to determine whether this relationship was dependent upon the structural factors of the treating facility.

METHODS

Using National Cancer Database, we focused on extremes of travel: Local (<12.5 miles to treating facility) and Travel (≥50 miles). We analyzed OS with Cox models; we estimated stratified models to assess interaction between distance and facility characteristics (volume, academic status).

RESULTS

We included 6860 patients. After correction for confounding, distance travelled was not associated with OS (p = 0.444). However, Travel patients treated at high-volume, academic centers had worse OS compared to Local patients (HR 1.54, 95%CI 1.07-2.21); this association was not seen for patients treated at low volume, academic centers (p = 0.708) high volume non-academic centers (p = 0.174) or low volume non-academic centers (p = 515).

CONCLUSION

For those patients treated at high-volume, academic centers, living far from the facility was associated with worse OS. The reasons for this association should be investigated further.

Efficacy and Safety of the Radiotherapy for Liver Cancer: Assessment of Local Controllability and its Role in Multidisciplinary Therapy

This study investigated the efficacy and safety of radiotherapy as part of multidisciplinary therapy for advanced hepatocellular carcinoma (HCC). Clinical data of 49 HCC patients treated with radiotherapy were assessed retrospectively. The efficacy of radiotherapy was assessed by progression-free survival, disease control rate, and overall survival. Safety was assessed by symptoms and hematological assay, and changes in hepatic reserve function were determined by Child-Pugh score and albumin-bilirubin (ALBI) score. Forty patients underwent curative radiotherapy, and nine patients with portal vein tumor thrombus (PVTT) underwent palliative radiotherapy as part of multidisciplinary therapy. Local disease control for curative therapy was 80.0% and stereotactic body radiotherapy was 86.7% which was greater than that of conventional radiotherapy (60.0%). Patients with PVTT had a median observation period of 651 days and 75% three-year survival when treated with multitherapy, including radiotherapy for palliative intent, transcatheter arterial chemoembolization, and administration of molecular targeted agents. No adverse events higher than grade 3 and no changes in the Child-Pugh score and ALBI score were seen. Radiotherapy is safe and effective for HCC treatment and can be a part of multidisciplinary therapy.

Gastrointestinal tract injuries after thermal ablative therapies for hepatocellular carcinoma: A case report and review of the literature

BACKGROUND

Radiofrequency ablation (RFA) and microwave ablation (MWA) represent the standard of care for patients with early hepatocellular carcinoma (HCC) who are unfit for surgery. The incidence of reported adverse events is low, ranging from 2.4% to 13.1% for RFA and from 2.6% to 7.5% for MWA. Gastrointestinal tract (GIT) injury is even more infrequent (0.11%), but usually requires surgery with an unfavourable prognosis. Due to its low incidence and the retrospective nature of the studies, the literature reporting this feared complication is heterogeneous and in many cases lacks information on tumour characteristics, comorbidities and treatment approaches.

CASE SUMMARY

A 77-year-old man who had undergone extended right hepatectomy for HCC was diagnosed with early disease recurrence with a small nodule compatible with HCC in the Sg4b segment of the liver with a subcapsular location. He was treated with percutaneous RFA and a few week later he was urgently admitted to the Surgery ward for abdominal pain and fever. A subcutaneous abscess was diagnosed and treated by percutaneous drainage. A fistulous tract was then documented by the passage of contrast material from the gastric antrum to the abdominal wall. The oesophagogastroduodenoscopy confirmed a circular wall defect at the lesser curvature of gastric antrum, leading directly to the purulent abdominal collection. An over-the-scope clip (OTSC) was used to successfully close the defect

CONCLUSION

This is the first reported case of RFA-related GIT injury to have been successfully treated with an OTSC, which highlights the role of this endoscopic treatment for the management of this complication.

Effects of a Matrine- and Sophoridine-Containing Herbal Compound Medicine (AH-05) on Liver Cancer

Herbal medicine can present an alternative way of treating liver cancer. Here, we explored a matrine- and sophoridine-containing herbal compound medicine (AH-05) extracted from Adenophora capillaris, Sophora flavescens, Astragalus, and other plants. H22 and HepG2 cell models, as well as an H22 xenograft model, were established. Cell proliferation and apoptosis were measured in vitro, and tumor volume and weight were observed in vivo. The activation of AKT/mTOR and nuclear factor-κB (NF-κB) pathways in tumor cells and the polarization of CD4/CD8 T cells in the spleen were tested. To assess safety, hematological toxicity and pathology of the liver, kidney, spleen, and intestine were evaluated. AH-05 inhibited cell viability in a dose- and time-dependent manner. In vivo, tumor volume and weight were reduced, and the activation of NF-κB p50, NF-κB p65, AKT, p-AKT Ser473, and mTOR was suppressed. In addition, AH-05 promoted CD4+ T cell polarization in the spleen. With regard to safety, slight intestinal mucosa edema was observed, but no severe pathological or hematological toxicity was detected. AH-05 exhibited its therapeutic effects against liver cancer by regulating the AKT/mTOR and NF-κB signaling pathways, and the immune environment, by promoting CD4+ T cell polarization in the spleen. Thus, AH-05 represents a potential supplementary herbal compound medicine for liver cancer.

Surgical and oncological outcomes after laparoscopic vs. open major hepatectomy for hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

The short- and long-term prognoses are unclear following laparoscopic major hepatectomy (LMH) for hepatocellular carcinoma (HCC). We performed a meta-analysis to compare the surgical and oncological outcomes of LMH vs. open major hepatectomy (OMH) in patients with HCC.

METHODS

All studies comparing LMH with OMH for HCC published until April 2019 were identified independently by searching PubMed, Embase, Web of Science, and the Cochrane Central Register of Controlled Trials. We analyzed data for surgical and oncological outcomes, namely, operative time, intraoperative blood loss, blood transfusion rate, postoperative morbidity, major complications, mortality, hospital stay, margin distance, negative margin rate, long-term overall survival, and corresponding disease-free survival (DFS).

RESULTS

We included 13 studies involving 1,225 patients with HCC (LMH: 534 patients; OMH: 691 patients) in the meta-analysis. Regarding short-term outcomes, the pooled data showed that LMH was associated with longer operative time [weighted mean difference (WMD): 72.14 min; 95% confidence interval (CI): 43.07-101.21; P<0.00001], less blood loss (WMD: -102.32 mL; 95% CI: -150.99 to -53.64; P<0.0001), shorter hospital stay (WMD: -3.77 d; 95% CI: -4.95 to -2.60; P<0.00001), lower morbidity [risk difference (RD): -0.01; 95% CI: -0.16 to -0.06; P<0.00001], and lower major complication rates (RD: -0.08; 95% CI: -0.11 to -0.05; P<0.00001). However, the need for blood transfusion (RD: -0.01; 95% CI: -0.06 to 0.05; P=0.78), mortality (RD: -0.01; 95% CI: -0.02 to 0.01; P=0.57), margin distance (WMD: 0.05 mm; 95% CI: -0.1 to 0.19; P=0.52), and negative margin rate (RD: 0.01; 95% CI: -0.03 to 0.05; P=0.65) were significantly comparable between the two groups. Regarding long-term outcomes, there was no difference in 3-year DFS [hazard ratio (HR): 0.99; 95% CI: 0.72-1.37; P=0.95], 3-year overall survival (HR: 1.25; 95% CI: 0.70-2.21; P=0.45), 5-year DFS (HR: 0.94; 95% CI: 0.64-1.38; P=0.76), and 5-year overall survival (HR: 0.94; 95% CI: 0.45-1.99; P=0.88).

CONCLUSIONS

LMH can be performed as safely as OMH in select patients and provides improved short-term surgical outcomes without affecting long-term survival. However, confirming our results requires more evidence from high-quality and prospective randomized controlled trials.

Alkaloids from Traditional Chinese Medicine against hepatocellular carcinoma

Hepatocellular carcinoma (HCC) has become one of the major diseases that are threatening human health in the 21st century. Currently there are many approaches to treat liver cancer, but each has its own advantages and disadvantages. Among various methods of treating liver cancer, natural medicine treatment has achieved promising results because of their superiorities of high efficiency and availability, as well as low side effects. Alkaloids, as a class of natural ingredients derived from traditional Chinese medicines, have previously been shown to exert prominent anti-hepatocarcinogenic effects, through various mechanisms including inhibition of proliferation, metastasis and angiogenesis, changing cell morphology, promoting apoptosis and autophagy, triggering cell cycle arrest, regulating various cancer-related genes as well as pathways and so on. As a consequence, alkaloids suppress the development and progression of liver cancer. In this study, the mechanisms of representative alkaloids against hepatocarcinoma in each class are described systematically according to the structure classification, which mainly divides alkaloids into piperidine alkaloids, isoquinoline alkaloids, indole alkaloids, terpenoids alkaloids, steroidal alkaloids and other alkaloids. Besides using them alone, synergistic effects created together with other chemotherapy drugs and some special preparation methods also have been demonstrated. In this review, we have summarized the potential roles of several common alkaloids in the prevention and treatment of HCC, by revising the preclinical studies, highlighting the potential applications of alkaloids when they function as a therapeutic choice for HCC treatment, and integrating them into clinical practices.