Transarterial chemoembolisation is not superior to embolisation alone: The recent European Association for the Study of the Liver (EASL)–European Organisation for Research and Treatment of Cancer (EORTC) guidelines

Ten-eleven translocation-2-mediated macrophage activation promotes liver regeneration

BACKGROUND

The remarkable regenerative capacity of the liver enables recovery after radical Hepatocellular carcinoma (HCC) resection. After resection, macrophages secrete interleukin 6 and hepatocyte growth factors to promote liver regeneration. Ten-eleven translocation-2 (Tet2) DNA dioxygenase regulates pro-inflammatory factor secretion in macrophages. In this study, we explored the role of Tet2 in macrophages and its function independent of its enzymatic activity in liver regeneration.

METHODS

The model of liver regeneration after 70% partial hepatectomy (PHx) is a classic universal model for studying reparative processes in the liver. Mice were euthanized at 0, 24, and 48 h after PHx. Enzyme-linked immunosorbent assays, quantitative reverse transcription-polymerase chain reaction, western blotting, immunofluorescence analysis, and flow cytometry were performed to explore immune cell infiltration and liver regenerative capability. Molecular dynamics simulations were performed to study the interaction between Tet2 and signal transducer and activator of transcription 1 (Stat1).

RESULTS

Tet2 in macrophages negatively regulated liver regeneration in the partial hepatectomy mice model. Tet2 interacted with Stat1, inhibiting the expression of proinflammatory factors and suppressing liver regeneration. The Tet2 inhibitor attenuated the interaction between Stat1 and Tet2, enhanced Stat1 phosphorylation, and promoted hepatocyte proliferation. The proliferative function of the Tet2 inhibitor relied on macrophages and did not affect hepatocytes directly.

CONCLUSION

Our findings underscore that Tet2 in macrophages negatively regulates liver regeneration by interacting with Stat1. Targeting Tet2 in macrophages promotes liver regeneration and function after a hepatectomy, presenting a novel target to promote liver regeneration and function.

Cyclin B2 overexpression promotes tumour growth by regulating jagged 1 in hepatocellular carcinoma

Background: Our previous study showed that Cyclin B2 (CCNB2) is closely related to the occurrence and progression of hepatocellular carcinoma (HCC).

Aim of the study: This study aimed to clarify the effect of CCNB2 gene silencing on tumorigenesis in nude mice and to detect the potential mechanism.

Methods: The effect of CCNB2 on HCC was tested in vivo. The downstream target genes of CCNB2 were predicted by proteomics and confirmed by western blot assay. The regulatory functions of CCNB2 in the proliferation and migration of HCC cells were determined through functional recovery experiments. The expression of the downstream target genes of CCNB2 was detected by immunohistochemistry.

Results: Knockdown of CCNB2 decreased tumour formation rate and tumour volume and weight and inhibited tumour proliferation. A total of 130 differentially expressed proteins were detected by proteomics, and Jagged 1 (JAG1) was predicted as the potential downstream target of CCNB2. Western blot assay revealed that CCNB2 and JAG1 expression was significantly correlated in HCC cells. The results of functional recovery experiments suggested that CCNB2 knockdown weakened the proliferation and migration ability of HCC cells, while JAG1 overexpression restored this ability of HCC cells that was weakened by CCNB2 knockdown. Immunohistochemistry showed that JAG1 expression was higher in HCC tissues than in paracancerous tissues and was related to tumour size and number and tumour thrombus formation.

Conclusions: The proliferation of HCC cells in vivo was inhibited by CCNB2 knockdown. CCNB2 may accelerate the proliferation and metastasis of HCC cells by increasing JAG1 expression.

Efficacy and safety of various primary treatment strategies for very early and early hepatocellular carcinoma: a network meta-analysis

BACKGROUND

Several treatments are available for treatment of early and very early-stage Hepatocellular Carcinoma, also known as small Hepatocellular Carcinoma (SHCC). However, there is no consensus with regards to the efficacies of these methods. We aimed at identifying the most effective initial treatment strategy for SHCC through Bayesian network meta-analyses.

METHODS

Studies published between January, 2010, and February, 2021 were searched in EMBASE, Cochrane Library, PubMed and Web of science databases, and conference proceedings for trials. The included studies reported the survival outcomes of very early and early Hepatocellular Carcinoma patients subjected to radiofrequency ablation (RFA), microwave ablation (MWA), surgical resection (SR), transarterial chemoembolization (TACE), percutaneous ethanol injection (PEI), minimally invasive liver surgery (MIS), stereotactic body radiotherapy (SBRT) and cryoablation (CA). Then, data were extracted from studies that met the inclusion criteria. Patient survival data were retrieved from the published Kaplan-Meier curves and pooled. A Bayesian random-effects model was used to combine direct and indirect evidence.

RESULTS

A total of 2058 articles were retrieved and screened, from which 45 studies assessing the efficacies of 8 different treatments in 11,364 patients were selected. The included studies had high methodological quality. Recurrence free survival* (progression/recurrence/relapse/disease/tumor-free survival were combined and redefined as RFS*) and overall survival (OS) outcomes were highest in MIS-treated patients (HR 0·57, 95% confidence intervals [CI] 0·38-0·85; HR 0.48,95% CI 0.36-0.64, respectively), followed by SR-treated patients (HR 0.60, 95% CI 0.50-0.74; HR 0.62, 95% CI 0.55-0.72, respectively). TACE was highly efficacious (58.9%) at decreasing the rates of major complications. Similar findings were obtained through sensitivity analysis, and in most of the prognostic subgroups.

CONCLUSIONS

MIS and SR exhibited the highest clinical efficacies, however, they were associated with higher rates of complications. Ablation is effective in small tumors, whereas SBRT is a relatively promising treatment option for SHCC. More well-designed, large-scale randomized controlled trials should be performed to validate our findings.

The Emerging Influences of Alpha-Fetoprotein in the Tumorigenesis and Progression of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer worldwide, and its mortality rate is the third-highest, after lung cancer and colorectal cancer. Currently, systematic targeted therapies for HCC mainly include multiple kinase inhibitors and immunotherapy. However, these drugs carry a black-box warning about the potential for inducing severe toxicity, and they do not significantly prolong the survival period of patients due to the highly heterogeneous characteristics of HCC etiology. In order to improve the prediction, effective treatment and prognosis of HCC, the tools and different biomarkers in clinical practices are recommended. Alpha-fetoprotein (AFP) is the earliest and the most widely used serum marker in the detection of HCC. Interestingly, serum AFP and cytoplasmic AFP show different, even opposite, roles in the cancer progression of HCC. This review focuses on biological characteristics, regulatory mechanisms for gene expression, emerging influences of AFP in HCC and its possible implications in HCC-targeted therapy.

High-Intensity Focused Ultrasound Ablation for Unresectable Primary and Metastatic Liver Cancer: Real-World Research in a Chinese Tertiary Center With 275 Cases

This retrospective analysis was conducted to evaluate the feasibility and safety of high-intensity focused ultrasound ablation for primary liver cancer and metastatic liver cancer. Patients with liver cancer who received high-intensity focused ultrasound were included in this analysis, including a primary liver cancer cohort (n=80) and a metastatic liver cancer cohort (n=195). The primary endpoint of our research was tumor response. The secondary endpoints included survival outcomes, visual analog scale pain scores, alpha-fetoprotein relief, and complications. Objective response rate and disease control rate were observed to be 71.8% and 81.2%, respectively, in patients with primary liver cancer and were 63.7% and 83.2% in cases with metastatic liver cancer. Alpha-fetoprotein levels and visual analogue scale levels significantly decreased after treatment compared with the baseline levels in patients with primary liver cancer (p<0.05). Median overall survival was estimated to be 13.0 and 12.0 months in the primary liver cancer and metastatic liver cancer cohorts. The 1-year survival rate was 70.69% and 48.00%, respectively. Multivariate regression analysis showed that visual analogue scale ≥ 5, longest diameter ≥ 5 cm, and portal vein invasion were the independent risk factors for poor survival in primary liver cancer. For patients with metastatic liver cancer, independent risk factors were identified as visual analogue scale ≥ 5, longest diameter ≥ 5 cm, existence of extrahepatic metastases, existence of portal vein invasion, and time to high-intensity focused ultrasound treatment from diagnosis < 3 months. Severe adverse events were rarely reported. In conclusion, high-intensity focused ultrasound might be an effective and safe option for patients with liver cancer regardless of primary and metastatic lesions.

Therapeutic advances for patients with intermediate hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common malignant tumor and constitutes a major health threat globally. Intermediate HCC (Barcelona Clinic Liver Cancer Staging, stage B) encompasses a wide range of patients and is characterized by substantial heterogeneity with varying tumor burdens and liver functions. Therefore, it is paramount to evaluate the patient's overall conditions and to select the most appropriate therapy based on available evidence. Transarterial chemoembolization is the recommended first-line therapy for intermediate HCC patients. However, in clinical practice, other treatment options are also used as alternative therapies, such as hepatic resection, percutaneous thermal ablation, radiotherapy (RT), systemic treatment, immunotherapy, and so forth. In this review, we will introduce current treatment strategies for intermediate HCC, discuss their advantages and disadvantages, and propose future directions.

A systematic review comparing outcomes of surgical resection and non-surgical treatments for patients with hepatocellular carcinoma and portal vein tumor thrombus

BACKGROUND

The prognosis of patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT) is very poor. According to most HCC guidelines, sorafenib, transarterial chemoembolization (TACE) or other non-surgical treatments are recommended as the first-line therapy for these patients. However, selected patients with HCC and PVTT can undergo surgical resection (SR). The aim of this meta-analysis was to compare the outcomes of SR with Non-SR for such patients.

METHODS

The PubMed, Embase, Medline and Cochrane library were searched for studies which compared SR with Non-SR for HCC and PVTT published before December 2017.

RESULTS

4810 patients from 7 studies who were enrolled in this meta-analysis were divided into the SR group (n = 2 344, 49%) and the Non-SR group (n = 2 476, 51%). The pooled hazard ratios (HRs) for the 1-, 3- and 5-year OS rates of the SR group when compared with the Non-SR group, were 0.57 (95% CI 0.48-0.67, P <0.001), 0.66 (95% CI 0.56-0.77, P <0.001) and 0.68 (95% CI 0.57-0.81, P <0.001), respectively. On subgroup analysis, the pooled HRs for the 1-, 3- and 5-year OS rates of the SR group when compared with the TACE group, were 0.62 (95% CI 0.54-0.71, P <0.001), 0.74 (95% CI 0.66-0.83, P <0.001) and 0.78 (95% CI 0.70-0.87, P <0.001), respectively.

CONCLUSION

This meta-analysis showed SR resulted in better OS than TACE, or other Non-SR treatments, for patients with HCC and PVTT. SR should be considered in selected patients with resectable HCC and PVTT.

Microwave ablation provides better survival than liver resection for hepatocellular carcinoma in patients with borderline liver function: application of ALBI score to patient selection

BACKGROUND

Studies comparing microwave ablation (MWA) and liver resection are lacking. This study evaluates the survival of patients with hepatocellular carcinoma (HCC) treated with liver resection or MWA and the role of Albumin-Bilirubin (ALBI) score in patient selection for treatments.

METHODS

This is a retrospective analysis of patients who received curative liver resection or MWA for HCC. Propensity score matching was used at a 1:1 ratio. The value of ALBI grade for patient selection was evaluated. Overall and disease-free survival were compared between two groups.

RESULTS

Of the 442 patients underwent MWA or liver resection for HCC during the study period, 63 patients received MWA and 379 patients received liver resection. Propensity scoring matching analysis resulted in 63 matched pairs for further analysis. Subgroup analysis according to the ALBI grade was performed. Liver resection offered better overall and disease-free survivals in patients with ALBI grade 1. MWA provided a significantly better overall survival (p = 0.025) and a trend towards better disease-free survival (p = 0.39) in patients with ALBI grade 2 or 3.

CONCLUSIONS

Liver resection offered superior disease-free survival to MWA in patients with HCC. The ALBI grade could identify patients with worse liver function who might gain survival advantage from MWA.

Role of interventional radiology in managing pediatric liver tumors : Part 1: Endovascular interventions

Primary liver malignancies are rare in children. Hepatoblastoma and hepatocellular carcinoma (HCC) together represent the overwhelming majority of cases. Overall survival of hepatoblastoma approaches 80% with multimodal treatment approaches that include chemotherapy, surgery and transplantation. However, there remains a subset of children with hepatoblastoma in whom resection or transplantation is not possible. The 5-year survival for children diagnosed with HCC is less than 30% and remains a significant therapeutic challenge. The poor outcomes for children with primary liver tumors motivate investigation of new therapeutic alternatives. Interventional oncology offers a broad scope of percutaneous and transcatheter endovascular cancer therapies that might provide clinical benefits. Minimally invasive approaches are distinct from medical, surgical and radiation oncologic treatments, and in adults these approaches have been established as the fourth pillar of cancer care. Transarterial chemoembolization is a minimally invasive locoregional treatment option performed by interventional radiologists with level-I evidence as standard of care in adults with advanced liver malignancy; transarterial chemoembolization in adults has served to prolong disease-free progression, downstage and bridge patients for surgical and transplant interventions, and improve overall survival. However, while several groups have reported that transarterial chemoembolization is feasible in children, the published experience is limited primarily to small retrospective case series. The lack of prospective trial evidence has in part limited the utilization of transarterial chemoembolization in the pediatric patient population. The purpose of this article is to provide an overview of the role of interventional radiology in the diagnosis and endovascular management of hepatic malignancies in children.

Surgical resection versus transarterial chemoembolization for BCLC intermediate stage hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND & OBJECTIVE

Transarterial chemoembolization (TACE) is recommended as the first-line therapy for intermediate stage hepatocellular carcinoma (HCC) according to the Barcelona Clinic Liver Cancer (BCLC) algorithm. However, in clinical practice, many such patients undergo surgical resection. A meta-analysis with a systematic search of the medical literature was conducted to compare these two procedures for BCLC intermediate stage HCC.

METHODS

PubMed, Embase, Medline and Cochrane library were searched for studies comparing surgical resection with TACE for BCLC intermediate stage HCC that were published before December 2016. The primary outcome was overall survival, and the secondary outcomes were postoperative complications and 30-day mortality.

RESULTS

This meta-analysis included 9 studies with 2619 patients (surgical resection, n = 1204 (46%) and TACE, n = 1415 (54%)). When compared with the TACE group, the pooled hazard ratio (HR) for the 1, 3 and 5-year OS rates in patients who underwent surgical resection were 0.62 (95% CI 0.51-0.75, P = 0.39; I2 = 6%, P < 0.001), 0.58 (95% CI 0.51-0.67, P = 0.25; I2 = 22%, P < 0.001) and 0.59 (95% CI 0.54-0.64, P = 0.18; I2 = 20%, P < 0.001). No significant differences in the pooled odds ratios (OR) were found between surgical resection and TACE in postoperative complications and 30-day mortality [OR 1.23 (95% CI 0.87 to 1.74, P = 0.390; I2 = 0%, P = 0.240) and OR 1.11 (95% CI 0.60 to 2.04, P = 0.89; I2 = 0%, P = 0.740), respectively].

CONCLUSION

This meta-analysis on studies on Asian HCC patients demonstrated surgical resection had better overall survival than TACE for patients with intermediate stage HCC, without any significant increase in postoperative complication or 30-day mortality rates. Further studies are needed to validate these results on Western patients, moreover, a reappraisal of the recommended treatments for BCLC intermediate stage HCC should be considered.

Response to transarterial chemoembolization may serve as selection criteria for hepatocellular carcinoma liver transplantation

Aims

This study sought to extend the inclusion criteria for hepatocellular carcinoma (HCC) liver transplantation (LT), particularly addressing the safety and effectiveness of pre-LT transarterial chemoembolization (TACE).

Materials and Methods

Our study included 115 patients with HCC who underwent LT after TACE. The response measured after each TACE session was based on the mRECIST criteria: complete response (CR), partial response (PR), stable disease (SD) or progressive disease (PD). We defined CR and PR patients as responders (64 cases) and SD and PD patients as non-responders (51 cases).

Results

The majority of responders could be identified after the first or second TACE sessions (57 cases, 89.1%). Overall survival rates at 1, 3 and 5 years were 95.3%, 89.1% and 75.0%, respectively, in the responder group, and these rates were much higher than those in the non-responder group (86.3%, 66.7% and 54.9%, P=0.016). In addition, the tumor-free survival rate in the responder group was also higher than in the non-responder group (P=0.009). In the responder group, a statistically improved long-term outcome was observed in patients whose HCC did not satisfy the Milan criteria (P<0.05). Univariate and multivariate Cox analyses showed that achieving CR or PR was the best predictor of survival and tumor-free survival following TACE.

Conclusion

The response to TACE, particularly following the first two sessions, primarily and robustly predicted overall and tumor-free survival in HCC patients, particularly those whose HCC did not satisfy the Milan criteria.

Intermediate hepatocellular carcinoma: the role of transarterial therapy

According to Barcelona Clinic Liver Cancer, the recommended first-line treatment for patients with intermediate stage of hepatocellular carcinoma (HCC) is transarterial chemoembolization. Patients with intermediate stage of HCC represent 20% with a 2-year survival of approximately 50%. Nowadays, transarterial therapies have proved precious in the treatment of hepatic malignancies. During the last years, there were important developments in practiced transarterial therapies and their efficacy is still controversial. The purpose of this review is to discuss in further details these transarterial therapies that have been used to treat cases of HCC.

ART and science in using transarterial chemoembolization for retreating patients with hepatocellular carcinoma

Intermediate stage hepatocellular carcinoma (HCC) comprises of a highly heterogeneous patient population, both in terms of liver function and tumour burden. Transarterial chemoembolization (TACE) is the treatment of choice for this subgroup of patients, provided that liver function is relatively preserved. Not all patients respond to an initial session of TACE, and further session might impair liver function. The ART score consists of an increase of AST >25%, increase of Child-Pugh of one or two points and absence of radiological tumour response and helps identify patients that would not benefit from further TACE sessions. We critically appraise the use of this score, particularly in terms of patient selection and timing of calculation of its variables. Once sufficiently validated, it can become a safe, objective and accurate clinical tool in everyday practice.

Simvastatin induces growth inhibition and apoptosis in HepG2 and Huh7 hepatocellular carcinoma cells via upregulation of Notch1 expression

Statins, cholesterol‑lowering drugs, are one of the most commonly prescribed types of medications. Previous studies have suggested that simvastatin may inhibit the cell function and tumor growth of hepatocellular carcinoma (HCC) cells; however, the molecular mechanisms underlying simvastatin‑induced apoptosis in HCC cells remains to be elucidated. The aim of the present study was to investigate the role of simvastatin in the regulation of cell viability, proliferation and apoptosis in HepG2 and Huh7 HCC cells, and to elucidate the specific regulatory mechanisms by which simvastatin proceeds. MTT, trypan blue and flow cytometric analyses were performed in order to detect viability, proliferation and apoptosis in HepG2 and Huh7 cells. The results of the present study demonstrated that simvastatin significantly decreased cell viability and proliferation as well as increased apoptosis in HepG2 and Huh7 cells compared to that in untreated cells. In addition, reverse transcription quantitative polymerase chain reaction and western blot analysis revealed that simvastatin‑treated cells exhibited increased expression levles of Notch1, p53, and Bax, as well as decreased expression levels of B cell lymphoma 2; furthermore, Notch1 upregulation resulted in the inhibition of Akt phosphorylation. In conclusion, the results of the present study indicated that simvastatin significantly promoted apoptosis in HCC cells, the mechanism of which may have proceeded via the upregualtion of the Notch1 gene in the Akt‑dependent signaling pathway.

Transarterial chemoembolization and bland embolization for hepatocellular carcinoma

Transarterial chemoembolization (TACE) is the first line treatment for patients with intermediate stage hepatocellular carcinoma but is also increasingly being used for patients on the transplant waiting list to prevent further tumor growth. Despite its widespread use, TACE remains an unstandardized procedure, with variation in type and size of embolizing particles, type and dose of chemotherapy and interval between therapies. Existing evidence from randomized controlled trials suggest that bland transarterial embolization (TAE) has the same efficacy with TACE. In the current article, we review the use of TACE and TAE for hepatocellular carcinoma and we focus on the evidence for their use.