Role of liver transplantation in the management of hepatocellular carcinoma

GPC3-targeted CAR-M cells exhibit potent antitumor activity against hepatocellular carcinoma

Chimeric antigen receptor (CAR)-modified macrophages are a promising treatment for solid tumor. So far the potential effects of CAR-M cell therapy have rarely been investigated in hepatocellular carcinoma (HCC). Glypican-3 (GPC3) is a biomarker for a variety of malignancies, including liver cancer, which is not expressed in most adult tissues. Thus, it is an ideal target for the treatment of HCC. In this study, we engineered mouse macrophage cells with CAR targeting GPC3 and explored its therapeutic potential in HCC. First, we generated a chimeric adenoviral vector (Ad5f35) delivering an anti-GPC3 CAR, Ad5f35-anti-GPC3-CAR, which using the CAR construct containing the scFv targeting GPC3 and CD3ζ intracellular domain. Phagocytosis and killing effect indicated that macrophages transduced with Ad5f35-anti-GPC3-CAR (GPC3 CAR-Ms) exhibited antigen-specific phagocytosis and tumor cell clearance in vitro, and GPC3 CAR-Ms showed significant tumor-killing effects and promoted expression of pro-inflammatory (M1) cytokines and chemokines. In 3D NACs-origami spheroid model of HCC, CAR-Ms were further demonstrated to have a significant tumor killing effect. Together, our study provides a new strategy for the treatment of HCC through CAR-M cells targeting GPC3, which provides a basis for the research and treatment of hepatocellular carcinoma.

The improvement of irreversible electroporation therapy using saline-irrigated electrodes: a theoretical study

Irreversible electroporation (IRE) is a novel therapy used to ablate tumors with high-field electric pulses applied in short durations. It is important to reduce the generation of heat in IRE to avoid the harmful effects of thermal damage. The objective of this simulation study was to examine the effects of saline irrigation in the reduction of heat upon electrodes used in IRE treatment of hepatocellular carcinoma. We used a two dimensional Finite Element Model of a tumor in a liver with electrodes placed at the center of the tumor. We simulated a typical electroporation protocol with varying thicknesses and conductivities of the saline layer, and we observed the maximum temperature and the distribution of the electric field and temperature in the tissue. Our results showed that the maximum temperature in the tissue decreases with the use of saline, but the surface area of the tumor that could potentially be thermally damaged may increase with the thickness and conductivity of the saline. With the use of saline, one can achieve upwards of a 17% reduction of the maximum temperature at the electrodes. Also, the distribution of temperature and the electric field becomes more homogenous between the electrodes as the conductivity of the saline layer increases for all thicknesses of saline. We conclude that irrigating electrodes with saline may be an effective measure to enhance the efficacy of irreversible electroporation by reducing the maximum temperature at the electrodes and also improving the extent and distribution of the electric field in the tissue. However, the properties of the saline should be adjusted so as to limit the increase of thermal damage propagated in the tissue.

Decreasing disparity in liver transplantation among white and Asian patients with hepatocellular carcinoma : California, 1998-2005

BACKGROUND

A preliminary study using national cancer surveillance data from 1998 through 2002 suggested that there were significant differences between non-Hispanic whites ('whites') and Asian/Pacific Islanders (APIs) in the use of liver transplantation as a treatment for hepatocellular carcinoma (HCC).

METHODS

The objective of the current study was to examine whether differences in liver transplantation between whites and APIs with HCC were changing over time. By using a population-based, statewide cancer registry, data were obtained on all HCC cases diagnosed in California between 1998 and 2005, and the study was limited to white and API patients with nonmetastatic HCC who had tumors that measured < or = 5 cm in greatest dimension (n = 1728 patients).

RESULTS

From 1998 through 2003 (n = 1051 patients), the odds of undergoing liver transplantation were 2.56 times greater for white patients than for API patients (95% confidence interval [CI], 1.72-3.80 times higher), even after adjusting for age, sex, marital status, year of diagnosis, TNM stage, and tumor grade. In contrast, during 2004 and 2005 (n = 677 patients), there were no significant differences in the odds of undergoing liver transplantation. Between 2002 and 2004, changes in liver transplantation policy assigned priority points to patients with HCC (initially to stage I and II, then to stage II only). After the policy changes, API patients with HCC experienced a significant increase in stage II diagnoses, whereas white patients did not.

CONCLUSIONS

In California, there was a large and significant disparity in the rate of liver transplantation among white and API patients with HCC from 1998 through 2003 but not during 2004 and 2005. Changes in liver transplantation policy from 2002 through 2004 may have played a role in decreasing this difference.

Management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common tumors globally, with varying prevalence based on endemic risk factors. In high-risk populations, including those with hepatitis B or C or with cirrhosis, serum alpha-fetoprotein (AFP) and screening ultrasound have improved detection of resectable HCC. Treatment options, including surgical resection, for patients with HCC must be selected based on the number and size of hepatic tumors, underlying hepatic function, patient condition, and available resources. An approach, which has been summarized shows the corresponding treatment choices under given clinical circumstances. For cirrhotic patients with less than three tumor nodules of a size less than 3 cm or a solitary HCC less than 5 cm, liver transplantation offers long-term survival similar to that observed in patients transplanted for nonmalignant disease. Ablative treatment using either chemical or thermal techniques provides locally effective tumor destruction. Transcatheter arterial chemoembolization (TACE) is commonly used for palliation of unresectable tumors as well as an adjunct to surgical resection, treatment of tumors before transplant, and in conjunction with other ablative therapies in a multimodality approach. Regional approaches to chemotherapy have produced more encouraging results than systemic chemotherapy, although both remain ineffective for long-term tumor control. Several newer treatment modalities are under investigation, including gene therapy, tagged antibodies, isolated perfusion, and novel radiotherapy techniques.

Local therapeutic treatments for focal liver disease

Patients diagnosed with primary hepatic malignancies or metastases to the liver remain a difficult population to treat. A small percentage of these people can undergo surgical resection or transplantation. The remaining nonsurgical aggregate does not often benefit from conventional radiation and chemotherapy; minimally invasive means either to cure or palliate these patients are a requirement for complete cancer care. This article discusses image-guided local therapies used to treat this difficult patient population, focusing predominantly on radiofrequency ablation.

MRI in detection of hepatocellular carcinoma (HCC)

Hepatocellular carcinoma (HCC) is the commonest malignancy of the liver and is usually due to cirrhosis. Early detection of HCC and the premalignant dysplastic nodules has implications on the management options of tumor ablation, liver resection and transplantation. Magnetic resonance imaging is useful for the detection and characterization of lesions, in the identification of dysplastic nodules and their malignant transformation into HCC.

Hepatocellular carcinoma: current surgical management

Hepatocellular carcinoma (HCC) is the fifth most common malignancy in the world, responsible for 500,000 deaths globally every year. Although HCC is a slow-growing tumor, it is often rapidly fatal because it is usually not discovered until the disease is advanced. HCC occurs primarily in individuals with cirrhosis, a condition that increases the risk of performing potentially curative surgical therapy. Over the last 2 decades, however, the safety of surgical resections has greatly improved because of advances in radiologic assessment, patient selection, and perioperative care. As such, the operative mortality rate for hepatectomy has decreased from the 10%-20% level seen in the 1980s to less than 5% today. The ultimate goal of treatment of HCC is to prolong the quality of life by eradicating the malignancy while preserving hepatic function. For treatment with a curative intent, the gold standard remains surgical resection, by either partial hepatectomy or total hepatectomy followed by liver transplantation. Resectability and choice of procedure depend on many factors, including baseline liver function, absence of extrahepatic metastases, size of residual liver, availability of resources including liver graft, and expertise of the surgical team. Patients without cirrhosis can tolerate extensive resections, and partial hepatectomy should be considered first. For Child class B and C patients with a small HCC, liver transplantation offers the best results, whereas partial liver resection is indicated in patients with well-compensated cirrhosis. Living donor liver transplantation should be considered using the same criteria as that used for cadaveric transplantation.

Yttrium-90 microspheres for the treatment of hepatocellular carcinoma

Unresectable hepatocellular carcinoma is extremely difficult to treat. TheraSphere consists of yttrium-90 (a pure beta emitter) microspheres, which are injected into the hepatic arteries. This article reviews the safety and survival of patients with hepatocellular carcinoma who were treated with yttrium-90 microspheres. Eighty patients were selected from a database of 108 yttrium-90 microsphere-treated patients and were staged by using Child-Pugh, Okuda, and Cancer of the Liver Italian Program scoring systems. Patients were treated with local, regional, and whole-liver approaches. Survival from first treatment was analyzed with Kaplan-Meier and Cox regression methods. Adverse events and complications of treatment were coded by using the Southwest Oncology Group toxicity scoring system. Patients received liver doses ranging from 47 to 270 Gy. Thirty-two patients (40%) received more than 1 treatment. Survival correlated with pretreatment Cancer of the Liver Italian Program scores ( P = .002), as well as with the individual Cancer of the Liver Italian Program components, Child-Pugh class, alpha-fetoprotein levels, and percentage of tumor replacement. Patients classified as Okuda stage I (n = 54) and II (n = 26) had median survival durations and 1-year survival rates of 628 days and 63%, and 384 days and 51%, respectively ( P = .02). One patient died of liver failure judged as possibly related to treatment. Thus, in selected patients with hepatocellular carcinoma, yttrium-90 microsphere treatment is safe and well tolerated. On the basis of these results, a randomized controlled trial is warranted comparing yttrium-90 microsphere treatment with transarterial chemoembolization by using the Cancer of the Liver Italian Program system for prospective stratified randomization.