Transcatheter arterial chemoembolization with doxorubicin-eluting superabsorbent polymer microspheres in the treatment of hepatocellular carcinoma: midterm follow-up

Long-Term Outcome of Liver Transplantation for Hepatocellular Carcinoma After Bridging or Downstaging with Doxorubicin-Eluting Superabsorbent Polymer Microspheres

PURPOSE

To retrospectively evaluate the long-term outcomes of patients treated with liver transplantation after neoadjuvant or induction transarterial chemoembolization using doxorubicin-eluting superabsorbent polymer microspheres and to assess risk factors associated with disease recurrence and death after transplantation.

MATERIALS AND METHODS

Between January 2006 and April 2021, 286 patients underwent liver transplantation related to cirrhosis and early hepatocellular carcinoma (HCC). Demographic, angiographic imaging, and clinical follow-up data were collected from patients' electronic medical records. Kaplan-Meier method was used to estimate disease-free survival. The prognostic effect of patient and disease characteristics on HCC recurrence was analyzed using logistic regression models.

RESULTS

Fifty-three out of 286 patients (19%) underwent neoadjuvant or induction chemoembolization with doxorubicin-eluting superabsorbent polymer microspheres as bridging (n = 36) or as downstaging (n = 17) treatment. Time between diagnosis and liver transplantation was 311 days (range:225-440). Post-transplant follow-up revealed HCC recurrence in n = 1 (3%) and n = 4 (23.5%) patients in the bridging and downstaging groups, respectively, and disease-free survival at 5 years of 86% and 65% (p < 0.05) in the bridging and downstaging groups, respectively. Prognostic factors for post-transplant HCC recurrence include number of HCC lesions (p = 0.0088) and total tumor size (p = 0.0188) at diagnosis, as well as number of lesions (p = 0.0181) and largest tumor size (p = 0.0179) at explant analysis.

CONCLUSION

Neoadjuvant or induction chemoembolization with doxorubicin-eluting superabsorbent polymer microspheres is associated with a low incidence of post-transplant HCC recurrence; number and total size of HCC lesions at diagnosis and at explant analysis are risk factors for post-transplant HCC recurrence.

Efficacy of transarterial chemoembolization treatment with 30-60-μm microspheres in patients with hepatocellular carcinoma

BACKGROUND

Chemoembolization with small drug-eluting microspheres is widely used in the treatment of hepatocellular carcinoma (HCC).

OBJECTIVES

This study aimed to evaluate the efficacy and safety of transarterial chemoembolization with doxorubicin-eluting 30-60-µm microspheres (DEB-TACE) in patients with Barcelona Clinic Liver Cancer (BCLC) stage A and B HCC.

MATERIALS AND METHODS

In this single-center study, 88 patients with HCC (BCLC A/B: 15.9%/84.1%) who underwent 137 DEB-TACE sessions between January 2015 and December 2020 were retrospectively assessed. Response to treatment was assessed 4-8 weeks after each DEB-TACE procedure according to mRECIST (Modified Response Evaluation Criteria in Solid Tumors) criteria. Progression-free survival (PFS), time to progression (TTP), overall survival (OS), and adverse events were recorded.

RESULTS

In 88 patients (84.1% males; median age, 66.0 years; range, 22-83), the median follow-up was 17 months (range, 2-64). Eight patients (9.1%) had a complete response, 42 (47.8%) had partial regression, 10 (11.3%) had stable disease, and 28 (31.8%) had progressive disease. There was a statistically significant difference between serum alpha-fetoprotein (AFP) levels before and after DEB-TACE treatment (p < 0.001). The median OS was 17 months (95% confidence interval [CI], 10.3-23.7). Cox regression analyses found that preprocedural serum AFP level (400+ vs. < 400; p = 0.024), Child Pugh classification (B vs. A; p = 0.019), and number of DEB-TACE sessions (1 vs. > 1; p = 0.003) were independent risk factors affecting OS. The median PFS was 8 months (95% CI, 5.8-10.2) and TTP was 6 months (1-14 months).

CONCLUSION

Chemoembolization with 30-60-µm microspheres is an effective and safe treatment for HCC. The number of DEB-TACE sessions is also one of the factors affecting OS.

Atractylenolide III predisposes miR-195-5p/FGFR1 signaling axis to exert tumor-suppressive functions in liver cancer

BACKGROUND

Antineoplastic activity of atractylenolide III (ATL) has been reported in several malignant tumors. However, its activity has not been completely clarified in hepatocellular carcinoma (HCC). Herein, anticancer effects and underlying molecular mechanisms of ATL were investigated in HCC cells in vitro.

METHODS

Cell viability was evaluated by CCK-8 assay. Cell migration and invasion were evaluated using the transwell assay. TUNEL staining was performed to evaluate cell apoptosis. Protein expression was measured by western blotting analysis. Online database TargetScan and luciferase reporter gene analysis were performed to validate FGFR1 as a target of miR-195-5p.

RESULTS

HepG2 and SMMC7721 cell growth, migration, and invasion were inhibited by ATL treatment in a dose-dependent pattern. ATL treatment-induced apoptosis of HepG2 and SMMC7721 cells. Intriguingly, ATL treatment unexpectedly inhibited FGFR1 protein expression in HepG2 and SMMC7721 cells. Knockdown of FGFR1 inhibited proliferation, migration, and invasion, and evoked apoptosis of HepG2 and SMMC7721 cells. We also found that ATL treatment could increase the expression of miR-195-5p, which as a posttranscriptional targeted FGFR1. In HCC tissues, miR-195-5p expression is negatively correlated with FGFR1. Furthermore, the antiproliferative and proapoptotic roles of miR-195-5p were neutralized by overexpressed FGFR1 in HCC cells.

CONCLUSION

ATL effectively repressed growth and induced apoptosis of human HCC cells through the upregulation of miR-195-5p to downregulate FGFR1 expression.

PRACTICAL APPLICATIONS

Atractylenolide III as a bioactive anticancer adjuvant medication will provide chemosensitization strategy for reversing the drug resistance of HCC.

Therapy of Intermediate-Stage Hepatocellular Carcinoma: Current Evidence and Clinical Practice

Intermediate-stage Hepatocellular Carcinoma (HCC) represents a wide range of disease burden. Patients with different levels of liver function, tumor size, and number of lesions may all have intermediate-stage disease according to the Barcelona Clinic Liver Cancer (BCLC) staging system. Several minimally invasive image-guided locoregional therapies are available for the treatment of intermediate-stage HCC, including conventional transarterial chemoembolization (cTACE), drug-eluting bead TACE (DEB-TACE), yttrium-90 radioembolization (Y-90 RE), thermal ablation, bland embolization, and combination therapy. Available clinical evidence points to cTACE as the current gold standard for the locoregional treatment of intermediate-stage HCC. DEB-TACE is at best non-inferior to cTACE in terms of survival benefit. Y-90 RE is a maturing therapy, and some institutions have adopted it as first-line therapy for intermediate-stage HCC. Thermal ablation combined with TACE may be used in select patients, while bland embolization has only limited evidence for its use. The combination of locoregional therapy with VEGF inhibitors or immune checkpoint inhibitors has also been explored. This article will examine in detail the clinical evidence supporting available locoregional treatment options for intermediate-stage HCC.

Bridging therapy effectiveness in the treatment of hepatocellular carcinoma prior to orthotopic liver transplantation

Background

Orthotopic liver transplantation (OLT) is the most effective treatment for hepatocellular carcinoma (HCC) in patients with underlying cirrhosis and portal hypertension. Availability of OLT is limited by donor-organ shortages, which increase patient waiting time until OLT. A variety of bridging therapies (BT) have been used to halt tumor progression in patients on the OLT waiting list. Despite complete radiologic responses following BT, viable tumor is often present in explants.

Methods

Treatment outcomes were evaluated in 50 patients who had a total of 125 BT for treatment of 93 nodules. Success of BT was assessed by radiologic response compared to histopathological examination of explanted livers.

Results

Pre-transplant treatments included: transcatheter arterial chemoembolization (TACE), alcohol ablation (ETOH), radiofrequency ablation (RFA), microwave ablation (MWA), selective internal radiation therapy (SIRT) and stereotactic body radiation therapy (SBRT). Fifty-nine (64%) nodules had a complete radiographic response to therapy; however, only 28 nodules (30%) had complete tumor necrosis (CTN) on explant examination. Ten nodules with CTN were treated with TACE alone. Seven of the 28 nodules with CTN were treated with TACE and RFA. Three of seven nodules treated with TACE and SIRT had CTN. Patients underwent a mean of 2.5 BTs. Six of 50 patients (12%) had no residual HCC in their explants. Five of those six patients (83%) had complete response (CR) on pre-transplant imaging.

Conclusions

Although favorable radiologic responses are seen following BT, viable HCC is seen in the majority of liver explants and radiographic imaging cannot always accurately predict pathological response. This underscores the need for aggressive treatment of patients who otherwise may not be eligible for OLT.

Safety and efficacy of doxorubicin-eluting superabsorbent polymer microspheres for the treatment of liver metastases from neuroendocrine tumours: preliminary results

Background

The aim of the study was to retrospectively evaluate the symptom control, tumour response, and complication rate in patients with liver-predominant metastatic neuroendocrine tumours treated with transarterial chemoembolization using doxorubicin-eluting superabsorbent polymer (SAP) microspheres.

Patients and methods

Patients with neuroendocrine liver metastases who underwent hepatic transarterial chemoembolization using doxorubicin-eluting SAP-microspheres (50–100 μm Hepasphere/Quadrasphere Microsphere® particles, Merit Medical, South Jordan, Utah, USA) were included in this study. Pre-and post-procedure imaging studies were evaluated to assess short and intermediate-term tumour response using modified RECIST criteria. Symptom relief and procedure-related complications were evaluated.

Results

A total of 27 embolization procedures were performed on 17 patients. Twelve of 17 patients (70%) were symptomatic, including carcinoid syndrome (n = 8) and severe, uncontrollable hypoglycemia (n = 4). Eight of 12 patients (67%) had complete symptom relief, and the remaining 4 (33%) had partial relief. One patient developed ischemic cholecystitis (6%). No other hepatobiliary complications occurred. Short-term and intermediate-term imaging follow-up was available for 15/17 patients (88%) and 12/14 patients (86%) respectively. At short-term follow-up (< 3 months), 14 patients (93%) showed partial response and the remaining patient had progressive disease (7%). At intermediate-term imaging follow-up (> 3 months), partial response, stable disease and progressive disease were found respectively in 7 (58%), 3 (25%) and 2 (17%) patients.

Conclusions

Chemoembolization with doxorubicin-eluting SAP-microspheres is a safe and effective treatment option for neuroendocrine liver metastases and is associated with a low complication rate. In particular, no clinically evident liver necrosis or bile duct complications were encountered.

Effect of CyberKnife stereotactic body radiation therapy for hepatocellular carcinoma on hepatic toxicity

Objective

To evaluate the safety of CyberKnife stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC) patients and identify the treatment-related risk factors of hepatic toxicity.

Materials and methods

One hundred and four HCC patients treated with CyberKnife SBRT were included in this study between August 2009 and December 2012. The average dose of prescribed radiation was 42.81±4.78 Gy (28–55 Gy) with the average fraction size of 8–16 Gy to the planning target volume. The average fractions were 3.31±0.81 (2–6 fractions). Response rates were determined, and the Child–Pugh (CP) score and class following CyberKnife SBRT were obtained to evaluate hepatic toxicity.

Results

Seventeen patients experienced progression in CP class and 24 patients experienced CTCAE V. 4.0 grade 2–3 hepatic toxicity during the five-month follow-up period, while no patient experienced grade 4 liver toxicity. Multivariate analysis indicated that only V₂₅ was an independent factor in grade 2–3 hepatic toxicity (P=0.029, <0.05). Radiation-induced hepatic toxicity (RIHT), defined as an increase of at least two points within three months following CyberKnife SBRT, occurred in 13 of the 104 patients (13/104, 12.5%), and only the normal liver tissue was found to be associated with RIHT (P=0.008, <0.05).

Conclusion

CyberKnife SBRT is a feasible and safe treatment for HCC with regard to hepatic toxicity, while V₂₅ and normal liver volume may be an independent factor of grade 2–3 hepatic toxicity and RIHT, respectively.

Malignant tumors of the liver in children

This article aims to give an overview of pediatric liver tumors; in particular of the two most frequently occurring groups of hepatoblastomas and hepatocellular carcinomas. Focus lays on achievements gained through worldwide collaboration. We present recent advances in insight, treatment results, and future questions to be asked. Increasing international collaboration between the four major Pediatric Liver Tumor Study Groups (SIOPEL/GPOH, COG, and JPLT) may serve as a paradigm to approach rare tumors. This international effort has been catalyzed by the Children's Hepatic tumor International Collaboration (CHIC) formation of a large collaborative database. Interrogation of this database has led to a new universal risk stratification system for hepatoblastoma using PRETEXT/POSTTEXT staging as a backbone. Pathologists in this international collaboration have established a new histopathological consensus classification for pediatric liver tumors. Concomitantly there have been advances in chemotherapy options, an increased role of liver transplantation for unresectable tumors, and a web portal system developed at www.siopel.org for international education, consultation, and collaboration. These achievements will be further tested and validated in the upcoming Paediatric Hepatic International Tumour Trial (PHITT).

Management of Hepatocellular Carcinoma: Current Status and Future Directions

Hepatocellular carcinoma (HCC) is the second most common cause of cancer death worldwide. This cancer commonly arises against a background of chronic liver disease. As a result, a patient with HCC requires multidisciplinary care. Treatment options vary widely based on tumor burden and metastases. The most widely utilized staging system is the Barcelona Clinic Liver Cancer staging system, which recommends treatments based on tumor size and the underlying liver disease and functional status of the patient. Treatment options range from surgical resection or transplantation to locoregional therapies with modalities such as radiofrequency ablation and transarterial chemoembolization to systemic chemotherapies. Future care involves the development of combination therapies that afford the best tumor response, further clarification of the patients best suited for therapies and the development of new oral chemotherapeutic agents.

Stimulation of apoptotic pathways in liver cancer cells: An alternative perspective on the biocompatibility and the utility of biomedical glasses

A host of research opportunities with innumerable clinical applications are open to biomedical glasses if one considers their potential as therapeutic inorganic ion delivery systems. Generally, applications have been limited to repair and regeneration of hard tissues while compositions are largely constrained to the original bioactive glass developed in the 1960s. However, in oncology applications the therapeutic paradigm shifts from repair to targeted destruction. With this in mind, the composition–structure–property–function relationships of vanadium-containing zinc-silicate glasses (0.51SiO2–0.29Na2O–(0.20- X)ZnO– XV2O5, 0 ≤  X ≤ 0.09) were characterized in order to determine their potential as therapeutic inorganic ion delivery systems. Increased V2O5 mole fraction resulted in a linear decrease in density and glass transition temperature (Tg). 29Si MAS NMR peak maxima shifted upfield while 51V MAS NMR peak maxima were independent of V2O5 content and overlapped well with the spectra NaVO3. Increased V2O5 mole fraction caused ion release to increase. When human liver cancer cells, HepG2, were exposed to these ions they demonstrated a concentration-dependent cytotoxic response, mediated by apoptosis. This work demonstrates that the zinc-silicate system studied herein is capable of delivering therapeutic inorganic ions at concentrations that induce apoptotic cell death and provide a simple means to control therapeutic inorganic ion delivery.

Chemoembolization of hepatocellular carcinoma with HepaSphere™

This review discusses the current data on Hepasphere™ in the treatment of hepatocellular carcinoma. HepaSphere is a drug-loadable microsphere that can be bound with doxorubicin, epirubicin, cisplatin or oxaliplatin. In vitro and in vivo studies confirm lower systemic exposure to the drug and fewer systemic doxorubicin-related side effects. Studies suggest that this technique is better tolerated than conventional lipiodol-based chemoembolization (c-TACE). In intermediate and early stage hepatocellular carcinoma - nonresponsive to curative treatments - complete response and partial response rates range from 22.2 to 48% and 43.7 to 51%, respectively. Studies with survival as an end-point are needed and head-to-head comparisons with other drug-eluting beads are necessary.