Changes in IL-6, IL-8, C-reactive protein and pancreatic secretory trypsin inhibitor after transcatheter arterial chemo-embolization therapy for hepato-cellular carcinoma

Efficacy and Safety of Percutaneous Argon-Helium Cryoablation for Hepatocellular Carcinoma Abutting the Diaphragm

PURPOSE

To evaluate the efficacy and safety of percutaneous argon-helium cryoablation (CA) for hepatocellular carcinoma (HCC) abutting the diaphragm (<5 mm).

MATERIALS AND METHODS

A total of 61 consecutive patients (50 men, 11 women; mean age, 56.3 ± 12.1 years old; range, 32-83 years) with 74 HCC tumors (mean size, 3.3 ± 1.7 cm; range, 0.8-7 cm) who were treated with percutaneous argon-helium CA were enrolled in this retrospective study. Adverse events were evaluated according to Common Terminology Criteria for Adverse Events, version 5.0. Local tumor progression (LTP) and overall survival (OS) were analyzed using the Kaplan-Meier method and the log-rank test. The risk factors associated with OS and LTP were evaluated using univariate and multivariate Cox regression analysis.

RESULTS

No periprocedural (30-day) deaths occurred. A total of 29 intrathoracic adverse events occurred in 24 of the 61 patients. Major adverse events were reported in 5 patients (pleural effusion requiring catheter drainage in 4 patients and pneumothorax requiring catheter placement in 1 patient). Median follow-up was 18.7 months (range, 2.3-60.0 months). Median time to LTP after CA was 20.9 months (interquartile range [IQR], 14.1-30.6 months). Median times of OS after CA and diagnosis were 27.3 months (IQR, 15.1-45.1 months) and 40.9 months (interquartile range, 24.8-68.6 months), respectively. Independent prognostic factors for OS included tumor location (left lobe vs right lobe; hazard ratio [HR], 2.031; 95% confidence interval [CI], 1.062-3.885; P = .032) and number of intrahepatic tumors (solitary vs multifocal; HR, 2.684; 95% CI, 1.322-5.447; P = .006). Independent prognostic factors for LTP included age (HR, 0.931; 95% CI, 0.900-0.963; P  < .001), guidance modality (ultrasound vs computed tomography and US; HR, 6.156 95% CI, 1.862-20.348; P  =   .003) and origin of liver disease.

CONCLUSIONS

Percutaneous argon-helium CA is safe for the treatment of HCC abutting the diaphragm, with acceptable LTP and OS.

Immune checkpoint blockade in advanced hepatocellular carcinoma: an update and critical review of ongoing clinical trials

Systemic treatments for advanced hepatocellular carcinoma (HCC) are evolving rapidly and several multi-targeted tyrosine kinase inhibitors have demonstrated a survival advantage over best supportive care. Despite these treatment advances, the majority of HCC patients will progress on tyrosine kinase inhibitor therapy. Preclinical data indicate that interference with immune checkpoint molecules results in HCC growth suppression. Several clinical trials applying monoclonal antibodies to immune checkpoint molecules have demonstrated durable antitumor activity in advanced HCC patients. As such, pivotal clinical trials are now in progress to assess if these agents will alter the natural history of the disease and further extend the overall survival of advanced HCC patients. This manuscript will review the current status of immune checkpoint blockade in patients with advanced HCC.

Immunomodulation in hepatocellular cancer

Hepatocellular carcinoma (HCC) is the fastest growing malignancy in the United States in relation to mortality. HCC relies on a complex immunosuppressive network to modify the host immune system and evade destruction. Intrinsic to the liver's function and anatomy, native hepatic and immune cells produce many inhibitory cytokines that promote tolerogenicity and limit immune response. Since the introduction of sorafenib in 2008, no treatment has been able to demonstrate improved survival in patients with advanced HCC post disease progression treated with sorafenib. More recent studies have shown that sorafenib has an immunomodulatory function in addition to inhibition of multiple tyrosine kinases. Clinical trials have aimed to further enhance this immunomodulatory function with other treatments, most promisingly immune checkpoint inhibitors. Additionally, ongoing studies are using combinatorial approaches with immunomodulatory treatment and liver directed therapies such as transarterial chemoembolization (TACE), radiofrequency ablation (RFA), microwave ablation (MWA), and cryoablation. This article will review recent data describing the immunosuppressive network in HCC, recent results of immunotherapies, and combinatorial approaches to treat advanced HCC.

Incidence of Post-ablation Syndrome Following Image-Guided Percutaneous Cryoablation of Renal Cell Carcinoma: A Prospective Study

PURPOSE

To prospectively evaluate the incidence of post-ablation syndrome (fever and flu-like symptoms) and impact on the quality of life in the first 10 days following percutaneous image-guided cryoablation for renal cell carcinoma (RCC).

MATERIALS AND METHODS

A prospective study of all cryoablation procedures with biopsy proven RCC was conducted with institutional review board approval between 08/2012 and 04/2016. Sixty-four patients (43 males and 21 females) underwent cryoablation. Mean age was 68 (range 24-86). A telephone questionnaire survey was conducted on days 1, 3, 5, 7 and 10 following cryoablation, and complications were recorded. Data collected included temperature, degree of flu-like symptoms, severity of pain, percentage of pain relief with analgesics, interference with general activity and with work (graded on a 0-10 Numeric Intensity Scale).

RESULTS

Following cryoablation, six patients (9%) out of 64 developed post-ablation syndrome. Thirty-three patients (52%) developed flu-like symptoms only, which completely resolved by day 10 in 25 patients (39%). One patient had pyrexia only, which was self- limiting by day 10. Twenty-four patients (38%) were asymptomatic. Pain (mean score = 2.1) and interference on general activities (mean score = 1.8) and work (mean score = 2) following cryoablation peaked on day 3 and improved subsequently. Forty-six patients (72%) had 90-100% pain relief by day 10. No major complications were observed.

CONCLUSION

The full spectrum of post-ablation syndrome following cryoablation occurs in approximately 9% of patients; however, 61% of patients experience flu-like symptoms in the first 10 days, which are self-limiting.

Advanced Hepatocellular Cancer: the Current State of Future Research

OPINION STATEMENT

Hepatocellular carcinoma is a common malignancy worldwide, rapidly rising in incidence. While there have been some developments in advancing therapeutic options in this disease, these have admittedly been modest to date, and as a result, this is a patient population with an inherently poor prognosis. Currently, sorafenib remains the only established systemic therapy proven to increase the overall survival of patients with advanced disease. The approval of sorafenib in 2007 ushered in the era of targeted therapies. Several phase 2 and 3 clinical trials have failed however to improve on sorafenib in the first-line setting, and no single agent has been demonstrated to impact outcomes after sorafenib failure. Having reached somewhat of an impasse in terms of drug development in hepatocellular carcinoma, enthusiasm in the field has moved toward innovative approaches such as molecular characterization and immunotherapy in an attempt to impact survival. This review highlights the current endeavors in terms of experimental research for patients with advanced hepatocellular carcinoma.

Review article: delivering precision oncology in intermediate-stage liver cancer

BACKGROUND

Intermediate-stage hepatocellular carcinoma (HCC), for which trans-arterial chemoembolization (TACE) constitutes the standard of care, is a patient subgroup with significant heterogeneity in clinical outcome. Sources of variation relate to differences in tumour burden, hepatic reserve, ethnicity and treatment modalities. Increasing research efforts have been dedicated to minimise the clinical diversity of this patient population and enhance optimal provision of treatment.

AIM

To comprehensively review the diverse prognostic models that have been proposed to refine the prognostic prediction of patients with HCC undergoing TACE.

RESULTS

A number of prognostic algorithms (HAP, ART, ABCR score and many others) have shown potential to address the clinical heterogeneity characterising patients with intermediate-stage HCC and facilitate early identification of patients with poor prognostic features in whom alternative treatments or best supportive care might be more appropriate than TACE.

CONCLUSIONS

While an improved characterisation of intermediate-stage HCC is a highly important clinical aim, current evidence suggests that novel prognostic algorithms in this patient population may offer potential benefits but non-negligible challenges in the provision of TACE. This review summarises the currently available evidence to facilitate the development of precision oncology in intermediate-stage HCC.

Peripheral Blood Regulatory T-Cell and Type 1 Helper T-Cell Population Decrease after Hepatic Artery Embolization

PURPOSE

To evaluate changes in T-cell populations in peripheral blood after bland hepatic artery embolization (HAE).

MATERIALS AND METHODS

Bland HAE was performed in 12 patients to treat primary (n = 5) or metastatic (n = 7) liver tumors, using microspheres and polyvinyl alcohol (n = 8) or microspheres alone (n = 4). Patient peripheral blood samples were collected within 1 month before HAE, within 1 week after HAE (early period after HAE), and 2-8 weeks after HAE (follow-up period). Peripheral blood populations of cytotoxic T lymphocytes, CD4(+) T cells, type 1 helper T cells (Th1) and type 2 helper T cells (Th2), and regulatory T cells (Treg) were evaluated using flow cytometry. Changes in T-cell populations before and after bland HAE were compared using paired t tests.

RESULTS

Peripheral blood CD4(+) T-cell populations decreased significantly in the early period after HAE (44.0% ± 2.2 to 34.4% ± 3.6, P < .01) and in the follow-up period (44.0% ± 2.2 to 36.3% ± 3.0, P < .01). Among the individual CD4(+) T-cell subtypes, Treg (2.5% ± 0.3 to 1.7% ± 0.2, P < .02) and Th1 (8.1% ± 1.8 to 5.6% ± 1.6, P < .02) decreased significantly in the early period after HAE only. The presence of extrahepatic disease was associated with decreasing Treg (P < .04).

CONCLUSIONS

After HAE, the peripheral blood T-cell environment is changed with decreases in Treg and Th1.

Immunotherapy in hepatocellular carcinoma: Primed to make a difference?

Advanced hepatocellular carcinoma (HCC) carries a dismal prognosis and the current treatment is limited to sorafenib, an agent with modest benefit. Preclinical data have indicated that several immunologic mechanisms are at play to promote HCC development and growth while impairing effective antitumor immune surveillance. Several novel approaches geared toward manipulating the immune response to HCC have suggested a therapeutic benefit in early-stage clinical trials, indicating a real potential to augment tumor-specific immunity and improve outcomes in patients with this disease. In the current study, the authors reviewed the barriers to an effective immune response against HCC and contemporary clinical investigations that may be "primed" to alter the natural history of HCC.

Percutaneous microwave ablation of hepatic tumors: prospective evaluation of postablation syndrome and postprocedural pain

PURPOSE

To prospectively investigate the frequency and severity of postablation syndrome (PAS) and postprocedural pain in a cohort of patients undergoing hepatic microwave ablation.

MATERIALS AND METHODS

From March 2009 to November 2011, 54 consecutive patients undergoing microwave ablation for liver tumors were enrolled. A questionnaire was administered to investigate PAS and pain at 1, 7, and 40 days after ablation. Four patients did not complete all three questionnaires and were excluded from the analysis. Additionally, laboratory tests with results known to significantly increase or decrease after ablation were performed, and ablation parameters were recorded. Potential predictors of PAS and pain at 1 and 7 days were evaluated by a logistic regression model.

RESULTS

Fifty patients underwent a single microwave ablation session, 33 for hepatocellular carcinoma (HCC) and 17 for liver metastasis. Median ablation volumes on computed tomography were 31 cm(3) for HCC and 42 cm(3) for metastasis. Sixty percent of patients experienced PAS in the first week. Aspartate aminotransferase (AST) levels after ablation were significantly associated with PAS during postprocedure days 1-7. Median visual analog scale scores for pain at the puncture site were 1 and 0.24 at 1 and 7 days, respectively. The risk of having at least moderate pain in the first week was significantly related to ablation volume and time and postablation increase in AST level.

CONCLUSIONS

The incidence and severity of PAS with hepatic microwave ablation is similar to that reported for radiofrequency ablation, with the best predictive factor being postablation AST level elevation. Postablation pain was best predicted by total ablation volume and AST level.

Cytokines are associated with postembolization fever and survival in hepatocellular carcinoma patients receiving transcatheter arterial chemoembolization

OBJECTIVE

Cytokines play important roles in angiogenesis, inflammation, and cell growth. The present study aimed to investigate the correlation between cytokine changes and clinical characteristics in hepatocellular carcinoma (HCC) patients receiving transcatheter arterial chemoembolization (TACE).

METHODS

Forty-one TACE-näive HCC patients receiving 73 sessions of TACE and 30 healthy controls were studied. Serum levels of tumor necrosis factor-α (TNF-α), interleukin-6 (IL-6), interleukin-8 (IL-8), vascular endothelial growth factor (VEGF), basic fibroblast growth factor (bFGF), angiogenin, epidermal growth factor (EGF), epidermal growth factor receptor, and transforming growth factor β1 (TGF-β1) before and at 1, 3, 5, 7, and 14 days after TACE as well as clinical parameters were analyzed.

RESULTS

Baseline serum levels of VEGF, bFGF, IL-6, IL-8, and TNF-α in HCC patients were significantly elevated, whereas EGF and TGF-β1 levels were lower compared to those in healthy controls (p < 0.05 for all). Serum IL-6 increased rapidly and peaked on day 1 after TACE administration, whereas VEGF increased more slowly and peaked on day 14 after TACE administration. Patients with post-TACE fever had higher serum IL-6 levels on days 1, 3, and 5 (p < 0.005 for all). Patients with pre-TACE serum VEGF < 200 pg/ml had a longer survival than those with pre-TACE serum VEGF levels ≥ 200 pg/ml (22.2 months vs. 11.6 months, p = 0.014). Cox multivariate analysis showed that baseline serum VEGF significantly predicted survival for HCC patients receiving TACE.

CONCLUSIONS

TACE is associated with the modulation of serum angiogenic, inflammatory, and cell growth cytokines in HCC patients. Serum IL-6 correlates with post-TACE fever, and baseline serum VEGF independently predicts patient survival.

Cell-mediated immune responses to alpha-fetoprotein and other antigens in hepatocellular carcinoma

Cell-mediated immune responses play an important role in the control of tumour growth. CD4 and CD8 T cells recognise tumour antigens presented via major histocompatibility complex molecules of antigen presenting cells and develop into effector cells with the ability to identify and kill tumour cells. Here, we re-examine the adaptive immune response to tumour antigens expressed by hepatocellular carcinoma (HCC) and discuss approaches that could be applied in future T-cell-based immunotherapy schedules to induce a potent and effective antitumour immunity. Moreover, we discuss cytotoxic T lymphocyte and Th1 responses to tumour antigens in patients with HCC and evaluate the effects of conventional treatments on antitumour T-cell responses.

Specificity of systemic inflammatory response syndrome during the peri-operative period in patients with GH-secreting adenoma

OBJECTIVE

To analyze the differences in systemic inflammatory responses (SIRS) during the peri-operative period following pituitary surgery, patients with pituitary adenomas were studied.

METHODS

There were three patient groups: group A consisted of 30 patients with GH-secreting adenoma, group B consisted of 20 age-matched patients with Cushing's disease, and group C consisted of 30 patients with other kinds of pituitary adenoma. Levels of white blood cells, C-reactive protein (CRP) and IL-6 in peripheral blood, as well as vital signs, were measured before and after operation.

RESULTS

Leucocytosis in peri-operative period was significantly milder in group A patients compared with either group B or C patients. The CRP level was significantly higher in both group B and group C patients than in group A patients. SIRS was observed in 17% of the cases in group A; by contrast, it was found in 55%, and 33% of the cases in group B, and in group C, respectively.

CONCLUSION

The inflammatory reaction to surgical trauma is milder in patients with GH-secreting adenomas than in patients with other kinds of pituitary adenoma.

Post-radiofrequency ablation syndrome after percutaneous radiofrequency of abdominal tumours: one centre experience and review of published works

The aim of this study was to evaluate prospectively post-radiofrequency ablation (RFA) syndrome and to determine its effect on the quality of life in the 15 days after percutaneous RFA treatment. We carried out an internal review board-approved prospective study of the delayed symptoms that occurred after 71 consecutive RFA sessions in 53 patients (12 women and 41 men; age range 45-83 years; mean age 71.6 years) with 45 primary liver tumours, 34 liver metastases, 3 renal cell carcinoma (RCC), 2 residual lesions from RCC after nephrectomy and 1 pancreatic metastases from RCC. Postablation symptoms occurred in 17 of 53 (32%) patients. Six of 17 patients developed low-grade fever (from 37.5 to 38.5 degrees C). Other symptoms included delayed pain (9/17), nausea (7/17), vomiting (3/17), malaise (3/17) and myalgia (1). Postablation syndrome is a common phenomenon after RFA of solid abdominal tumours. Not only in our study but also in the previous ones the occurrence is observed in approximately one-third patients. Patients should be informed that these symptoms are self-limiting after RFA and most patients should be able to resume near-complete preprocedural levels of activity within 10 days after the procedure.

Image-guided percutaneous radiofrequency ablation and incidence of post-radiofrequency ablation syndrome: prospective survey

PURPOSE

To evaluate prospectively the incidence of post-radiofrequency (RF) ablation syndrome and determine its impact on the quality of life in the 10 days after percutaneous RF ablation.

MATERIALS AND METHODS

This study was approved by the institutional review board and was HIPAA compliant. Informed consent was obtained for this survey in all patients by the interventional nurse coordinators. Thirty-six patients (20 men, 16 women; mean age, 69.3 years; range, 40-88 years) underwent RF ablation for 26 liver tumors and 17 renal tumors. Twenty control patients (11 men, nine women; mean age, 60.8 years; range, 35-76 years) underwent biopsy of focal liver lesions or renal lesions. With a standardized questionnaire, a telephone survey was conducted on days 1, 3, 5, and 10 after RF ablation or biopsy. The symptoms and interference with lifestyle were documented prospectively with a numeric intensity scale by using grades 0-10. Statistical analysis with Fisher exact test and analysis of variance was performed.

RESULTS

After RF ablation, 15 (42%) patients developed low-grade fever (P < .001), 29 (81%) had flulike symptoms (P < .001), and four were asymptomatic. Symptoms peaked on day 3 and mainly resolved by day 10. Twelve (33%) patients had complete post-RF ablation syndrome: fever and flulike symptoms (P = .005). Flulike symptoms were more prolonged when they were accompanied with fever, peaked on day 5, and resolved more quickly for patients with renal lesions than they did for patients with liver lesions. Four patients had persistent fever caused by pneumonia (n = 2), pleural effusion and atelectasis (n = 1), or liver abscess (n = 1). No control patients developed both fever and flulike symptoms. Post-RF ablation patients with symptoms experienced significantly greater pain and interference with general and work activities, which peaked on day 1, than did control patients (P = .01 [pain], P < .001 [general and work activities]).

CONCLUSION

Complete post-RF ablation syndrome occurs in approximately one-third of patients but is self-limiting within 10 days after the procedure. Persistent or late-onset fever may indicate concurrent infection elsewhere or possible abscess formation.

SUPPLEMENTAL MATERIAL

radiology.rsnajnls.org/cgi/content/full/237/3/1097/DC1

Preoperative administration of rebamipide significantly lowers body temperature and circulating interleukin-6 in gastric cancer patients after gastrectomy

BACKGROUND/AIMS

It has recently been reported that rebamipide (OPC-12759) inhibits inflammatory cytokines and activation of neutrophils. The aim of the present study was to investigate the effects of preoperative administration of rebamipide on parameters of systemic inflammatory response syndrome (SIRS) and serum levels of inflammatory cytokines in gastric cancer patients after gastrectomy.

PATIENTS AND METHODS

We measured the parameters of SIRS, circulating cytokines and acute phase reactants in patients after (i). distal gastrectomy with D2 lymph node dissection (group 1, n = 10); (ii). distal gastrectomy with D2 lymph node dissection following administration of rebamipide (group 2, n = 10), and (iii). laparoscopy-assisted distal gastrectomy (LADG) with D1 lymph node dissection (group 3, n = 10). Group 2 was administered 100 mg of rebamipide 3 times/day after meals for 7 days before surgery.

RESULTS

Among the parameters of SIRS, a difference was observed in body temperature on day 3. The mean body temperature of group 2 was significantly lower than group 1 (p = 0.006), and was similar to group 3. In proinflammatory cytokines, a significant difference was observed in the serum levels of interleukin (IL)-6. On day 1 the IL-6 levels of group 2 were significantly lower than those of group 1 (p < 0.001). The changes in the IL-6 level of group 2 were similar to group 3, except in the very early postoperative phase. However, other proinflammatory cytokines, such as IL-8 and IL-10, were not detected, and there was no difference in C-reactive protein between the 3 groups.

CONCLUSION

Preoperative administration of rebamipide significantly decreased postoperative body temperatures and circulating IL-6 in gastric cancer patients after gastrectomy to levels similar to those of patients with LADG.

Hepatic damage induced by transcatheter arterial chemoembolization elevates serum concentrations of macrophage-colony stimulating factor

AIMS/BACKGROUND

This study was undertaken in order to characterize the liver injury induced by transcatheter arterial chemoembolization therapy (TACE) for hepatocellular carcinoma (HCC) and to elucidate-mechanisms involved in the growth of mononuclear phagocytes in injured human liver in vivo.

PATIENTS AND METHODS

The serum levels of macrophage-colony stimulating factor (M-CSF) along with clinical parameters were examined in 43 patients with HCC who underwent TACE. Ten patients who underwent angiography alone served as controls.

RESULTS

Serum M-CSF increased and peaked on the third day after TACE showing significant correlations (p < 0.001, respectively) with the increases in serum alanine aminotransferase (ALT) and type IV collagen-7S (IVcol-7S). The lipopolysaccharide-stimulated production of interleukin (IL)-1 beta, IL-6, and tumor necrosis factor (TNF)-alpha in peripheral whole blood increased and peaked on the first or on the third day after TACE. In effective cases of TACE, significantly (p < 0.05) greater increases in serum M-CSF were noted as compared with those in ineffective cases.

DISCUSSION

The serum levels of M-CSF increased after TACE in correlation with hepatic inflammation and necrosis and increased production of IL-1 beta, TNF-alpha and IL-6 in peripheral whole blood. These results suggest a mechanism by which hepatic injury enhances the production of M-CSF via a cytokine cascade, which results in the proliferation of liver macrophages in vivo.

Peritoneal interleukin-6, interleukin-8 and granulocyte elastase activity after elective abdominal surgery

In this study we investigated the interleukin-8 concentration (IL-8) and granulocyte elastase activity (GE) after elective abdominal surgery. Postoperative interleukin-6 (IL-6), IL-8 concentrations and GE in the peritoneal fluid were examined in 27 patients who underwent various types of elective abdominal surgery. We compared these results with clinical parameters of surgical stress, operating time (OT) and blood loss during the operation (BL). P-IL-6 and P-IL-8 were significantly correlated with OT (P-IL-6; r = 0.67, P < 0.001: P-IL-8; r = 0.59, P < 0.001) and BL (P-IL-6; r = 0.61, P < 0.001: P-IL-8: r = 0.48, P < 0.01). P-IL-8 was significantly correlated with P-IL-6 (r = 0.68, P < 0.001) and there was a positive correlation between GE and P-IL-8 (r = 0.37, P < 0.05). These findings indicate that IL-8 might activate granulocytes in the peritoneal cavity after elective abdominal surgery and that assaying P-IL-6 and P-IL-8 is useful in assessing the host's response to surgical stress.

Elevation of circulating interleukin 6 after surgery: factors influencing the serum level

To investigate the effect of surgical trauma and other factors on the postoperative elevation of serum interleukin 6 (IL-6), we examined changes in IL-6 concentration after major thoracoabdominal surgery. Serum IL-6 levels reached the maximum concentration on the first postoperative day in all 38 patients, with peak ranging from 1400.8 +/- 383.4 pg/ml (mean +/- SEM) to 29.8 +/- 3.8 among six groups who underwent surgery at different sites. The IL-6 peak was significantly correlated with surgical trauma as defined by the operation length and the volume of blood loss during surgery (r = 0.554, P < 0.01 and r = 0.427, P < 0.01, respectively). The peak concentration of serum IL-6 in patients undergoing esophagectomy was significantly higher than in those undergoing pancreaticoduodenectomy (P < 0.05), despite a similar degree of surgical trauma defined by the operation length and volume of blood loss during surgery. Peak IL-6 concentration observed in a patient who underwent esophagectomy was about 100-fold greater in fluid drained from the thorax than in the peripheral blood. IL-6 mRNA was demonstrated in leukocytes from thoracic and abdominal exudate at 6, 24 and 48 h after surgery. In contrast, IL-6 mRNA could not be detected in leukocytes from the peripheral blood. Similar findings were also observed for interleukin 8 (IL-8). However, interleukin 1 beta (IL-1 beta) and tumour necrosis factor-alpha (TNF-alpha) were detected only once after surgery in the drainage fluid.(ABSTRACT TRUNCATED AT 250 WORDS)