Locoregional treatments for hepatocellular carcinoma

Outcomes in patients with portal hypertension undergoing gastrointestinal surgery: A propensity score matched analysis from the NSQIP dataset

BACKGROUND/AIM

We aim to study the impact of PH in patients undergoing gastrointestinal surgery (GI).

METHODS

We queried the ACS-NSQIP database from 2005 through 2010 for patients undergoing GI surgery with PH. Esophageal varices (EV) diagnosis was used as a surrogate of PH.

RESULTS

A total of 192,296 patients underwent GI surgery, of which 379 had PH. Regression analyses revealed that patients with PH had a 6-fold (95% CI 4.6-7.9) increase in 30-day mortality, a 3-fold (95% CI 2.5-3.7) increase in morbidity, a 3.2-fold (95% CI 2.6-3.9) increase in critical care complications (CCC), and a 6.5-day (95% CI 5.1-7.8) increase in hospital LOS. After PSM, the impact of PH on the outcomes remained. These differences were significant regardless of the emergent or elective status of the procedure. AUC analysis demonstrated that MELD and MELDNa + score greater than 10.5 was the most predictive of peri-operative mortality in elective PH cases.

CONCLUSIONS

PH is associated with an increased risk of poor surgical outcomes in patients undergoing elective and emergent gastrointestinal surgery.

Hepatocellular carcinoma: focus on different aspects of management

Hepatocellular carcinoma (HCC) is the fifth most common cancer and the third cause of cancer-related mortality worldwide. Its incidence is clearly arising comprised by the prevalence of major risk factors mainly hepatitis B and hepatitis C. The population at risk is composed of chronic liver patients at the stage of extensive fibrosis or cirrhosis. The monitoring programs of this population have allowed early detection of disease management to promote a radical therapy. Understanding the carcinogenic process and the mastery of the staging systems remain essential keys in diagnosis and treatment of HCC. Recent advances in diagnosis and new treatments have made important impacts on the disease by increasing survival rates and improving quality of life for HCC patients. This paper outlines the different management aspects of HCC which include epidemiology, prevention, carcinogenesis, staging systems, diagnosis, surveillance, and the treatment.

Resection for hepatocellular carcinoma: is it justifiable to restrict this to the American Association for the Study of the Liver/Barcelona Clinic for Liver Cancer criteria?

Hepatocellular carcinoma (HCC) is an important cancer worldwide. The main curative treatment modality is surgical resection although only a minority of afflicted patients are amendable because of poor liver function reserve or extensive disease at the time of diagnosis. The selection criteria for surgical resection, however, are variable and frequently appear to be center-specific. Further, they are influenced by rapidly evolving data on the outcomes of surgical resection and other emerging modalities of treatment. Recently, two major international practice guidelines on the management of HCC were published at about the same time, namely those of the American Association for the Study of the Liver (AASLD), and of the Asia-Pacific Association for the Study of the Liver (APASL). These two practice guidelines differ significantly in philosophy and practice with regards to surgical resection. In fact, they reflect the two extremes of a spectrum of existing consensus opinions. The AASLD Guidelines have evolved from the guidelines of the Barcelona Clinic for Liver Cancer (BCLC), and are significantly more conservative with regard to surgical resection compared with the APASL Guidelines. The scientific basis for these major differences in criteria with regard to surgical resection for HCC is reviewed here, particularly with regard to the situation in the Asia-Pacific region where HCC is especially common.

Radiofrequency ablation combined with percutaneous ethanol injection in patients with hepatocellular carcinoma

BACKGROUND AND STUDY AIMS

Hepatocellular carcinoma (HCC) is a major burden on health-care systems worldwide. Although radiofrequency ablation (RFA) is currently considered the best technique for coagulative necrosis, the superiority of concomitant use of RFA and percutaneous ethanol injection (PEI) needs to be determined. The study was designed to compare efficacy, safety and rate of survival of patients with HCC assigned to receive combined PEI-RFA versus RFA alone and versus PEI alone.

PATIENTS AND METHODS

This 3-year study enrolled 90 cirrhotic patients with HCC (Child's class A or B, but not class C). They were randomly assigned for either PEI-RFA (group I), RFA alone (group II) or PEI alone (group III). The primary end point was ablation of the tumour. The secondary end point was rate of survival and recurrence.

RESULTS

After the first session, complete ablation was significantly higher in the combination group (87.9%) compared with the RFA group (54.54%). After the second session, complete ablation was achieved in 97.0% of the combination group and in 84.8% of the RFA group. Regarding the PEI group, 75% had complete ablation, whereas 25% had partial ablation after multiple sessions. The survival rate, 1.5 years later, was significantly higher in group I (86.7%) compared with group III (63.3%). The overall incidence of serious adverse events was nil.

CONCLUSION

Combined treatment is superior to RFA alone and to PEI alone, in safety and efficacy in patients with HCC.

Refusal of cancer-directed surgery strongly impairs survival of patients with localized hepatocellular carcinoma

Background: This study investigated the frequency of patients with HCC who refused cancer-directed surgery and the characteristics and outcomes of these patients. Patients and Methods: A retrospective study was performed using data from the Surveillance, Epidemiology, and End Results (SEER) Program. Characteristics of patients who refused CDS were compared with those who accepted surgery using logistic regression. The effect of refusing CDS on mortality was evaluated by Cox proportional hazards analysis. Results: Among 4373 surgical candidates, 142 patients (3.2%) refused the recommended CDS. The patients who refused CDS were frequently older, African American, widowed or divorced, and had advanced-stage tumors. In a logistic regression analysis, older age, African American, and being divorced or widowed were independently associated with refusal of CDS. After adjusting for other patient and tumor characteristics, the patients who refused CDS had a 2.5-fold (95% confidence interval, 2.339–3.189) higher risk of dying from HCC in comparison with patients who had CDS. Conclusions: The high rate of refusal may contribute in part to the disparity in utilization of CDS. Of greatest concern is that the patients who declined CDS had an impaired survival. This information might be helpful for patients to make a better-informed decision.

Meta-analysis of percutaneous radiofrequency ablation versus ethanol injection in hepatocellular carcinoma

BACKGROUND

Percutaneous radiofrequency ablation (RFA) has gained popularity in the treatment of hepatocellular carcinoma (HCC). However, its role versus other conventional minimally invasive therapies is still a matter of debate. The purpose of this work is to analyse the efficacy and safety of RFA versus that of ethanol injection (PEI), the percutaneous standard approach to treat nonsurgical HCC.

METHODS

Systematic review and meta-analysis of randomised or quasi-randomised controlled trials published up to August 2008 in PubMed, ISI Web of Science and The Cochrane Library. Overall survival, local recurrence rate and adverse effects were considered as primary outcomes. Studies were critically appraised and estimates of effect were calculated according to the random-effects model. Inconsistency across studies was evaluated using the I2 statistic. Sensitivity analyses were conducted to explore statistical heterogeneity.

RESULTS

Six studies were eligible. The studies reported data on 396 patients treated by RFA and 391 treated by PEI. In general, subjects were in Child-Pugh class A (74%) and had unresectable HCC (mean size 2.5 cm). Mean follow-up was 25 +/- 11 months. The survival rate showed a significant benefit for RFA over PEI at one, two, three and four years. The advantage in survival increased with time with Relative Risk values of: 1.28 (95%CI:1.12-1.45) and 1.24 (95%CI:1.05-1.48) for RFA versus PEI at 3- and 4-years respectively. Likewise, RFA achieved significantly lower rates of local recurrence (RR: 0.37, 95%CI: 0.23-0.59). The overall rate of adverse events was higher with RFA (RR:2.55, 95%CI: 1.8-3.6) yet no significant differences were found concerning major complications (RR:1.85, 95%CI: 0.68-5.01). There was not enough evidence supporting a better cost-effectiveness ratio for RFA compared to PEI.

CONCLUSION

Available evidence from adequate quality controlled studies support the superiority of RFA versus PEI, in terms of better survival and local control of the disease, for the treatment of patients with relatively preserved liver function and early-stage non-surgical HCC. However, the higher rate of adverse events displayed is something that will have to be tested with appropriate weighting of the possible benefits in each individual case. Overall cost-effectiveness of RFA needs further evaluation.

Effectiveness of real-time virtual sonography-guided radiofrequency ablation treatment for patients with hepatocellular carcinomas

AIM

Real-time virtual sonography (RVS) can synchronize B-mode ultrasound (US) images with multiplanar reconstruction (MPR)-computed tomography (CT) images on the same screen in real time. The purpose of this study was to evaluate the effectiveness of RVS for radiofrequency ablation therapy (RFA) of hepatocellular carcinomas (HCC) in which it was difficult to identify contours or margins by B-mode US.

METHODS

Sixty-three consecutive patients with a solitary HCC of less than 3.5 cm in diameter were enrolled in this study. Thirty-nine patients with HCC clearly detectable by B-mode US underwent conventional RFA, while the remaining 24 with obscure tumor lesions underwent RVS-guided RFA. A follow-up study of RFA treatment was performed every 3 months using enhanced CT imaging of the arterial and portal phase (at least 24 months). The accuracy of needle insertion was confirmed by measuring the gap between the needle insertion line and the center of the tumor from MPR-CT images.

RESULTS

The local recurrence rate of the RVS-guided RFA group was similar to that of the conventional RFA group (8.3% vs 7.7%), despite the difficulty of detecting tumor lesions in the former group. The mean gap between the needle insertion line and the center of the tumor was 1.6 mm (0-3.2 mm) in eight patients treated with RVS-guided RFA.

CONCLUSION

RVS-guided RFA can be useful for treating HCC that are difficult to detect by B-mode US.

External beam radiotherapy to treat intra- and extra-hepatic dissemination of hepatocellular carcinoma after radiofrequency thermal ablation

BACKGROUND

Radiofrequency ablation (RFA) is an alternative to percutaneous ethanol injection therapy (PEIT) for single non-surgical hepatocellular carcinoma. However, the risk of seeding along the needle track has been reported.

METHODS

Seven patients presenting with neoplastic seeding after RFA or PEIT were treated with external beam radiotherapy using conventional fractionation. All patients underwent irradiation with a total dose in the range of 44-61 Gy (median and mode value: 50 Gy).

RESULTS

An objective response to treatment was achieved in six of seven patients (86%). A complete response was obtained in two patients (29%). The median survival time was 14.7 months and the actuarial 1- and 2-year survivals were 67% and 50%, respectively.

CONCLUSIONS

The response to treatment was relatively good without serious complications. Seeding from hepatocellular carcinoma is sensitive to external beam radiotherapy. It is useful in the treatment of these patients with 50 Gy in 25 fractions.

Fiber-modified adenoviral vector expressing the tumor necrosis factor-related apoptosis-inducing ligand gene from the human telomerase reverse transcriptase promoter induces apoptosis in human hepatocellular carcinoma cells

AIM: Because of a major resistance to chemotherapy, prognosis of hepatocellular carcinoma (HCC) is still poor. New treatments are required and gene therapy may be an option. Tumor necrosis factor-related apoptosis-inducing ligand (TRAIL) induces apoptosis in multiple malignant tumors, and using adenoviral vectors has shown a targeted tumor-specific therapy. However, repeated administration of adenoviral vectors can lead to cell resistance, which may be caused by the initial coxsackie-adenovirus receptor (CAR). One technique to overcome resistance is the use of modified adenoviral vectors containing an Arg-Gly-Asp (RGD) sequence. In this study we constructed an adenoviral vector (designated Ad/TRAIL-F/RGD) with RGD-modified fibers, expressing the TRAIL gene from the human telomerase reverse transcriptase (hTERT) promoter, and evaluated its antitumor activity in HCC cell lines.

METHODS: To investigate the effects of Ad/TRAIL-F/RGD in human HCC cell lines Hep G2 and Hep 3b, cells were infected with Ad/CMV-GFP (vector control), Ad/gTRAIL (positive control), and Ad/TRAIL-F/RGD. Phosphate-buffered saline (PBS) was used as control. Cell viability was determined by proliferation assay (XTT), and apoptosis induction by fluorescence activated cell sorting (FACS).

RESULTS: Cells treated with Ad/TRAIL-F/RGD and Ad/gTRAIL showed a significantly reduced cell viability in comparison to PBS and Ad/CMV-GFP treatment in both cell lines. Whereas, treatment with PBS and Ad/CMV-GFP had no cell-killing effect. The reduced cell viability was caused by induction of apoptosis as shown by FACS analysis. The amount of apoptotic cells was similar after incubation with Ad/gTRAIL and Ad/TRAIL-F/RGD.

CONCLUSION: The new RGD modified vector Ad/TRAIL-F/RGD could become a potent therapeutic agent for the treatment of HCC, adenovirus resistant tumors, and CAR low or negative cancer cells.

[Treatment of hepatocellular carcinoma in the cirrhotic liver]

The incidence of hepatocellular carcinoma (HCC) in cirrhotic patients is increasing. Despite advances in imaging and laboratory screening which allow earlier diagnosis, the surgeon is all too often confronted with an HCC of advanced stage or arising in the setting of severe cirrhosis; this severely limits the treatment possibilities. Treatment options are constrained not only by the characteristics of the tumor but also by hepatocellular reserve, severity of portal hypertension, and the general condition of the host. "Curative treatments" envisage the complete eradication of the malignancy; they include liver transplantation, resection, or tumor destruction by radiofrequency or alcohol ablation. They are most effective in the early stages of HCC. Total hepatectomy and transplantation, by far the most complex surgical therapy, also has the best results avoiding the all-too-frequent local recurrence of HCC in the residual liver. Other medical and interventional treatments (chemo-embolization, radiotherapy with lipiodol) can only slow the progress of the HCC. Goals for the future include more precise and directed screening of the population at risk, and better chemopreventive and chemotherapeutic treatments.

In vivo antitumour activity of PBMCs via genetic modification of single-chain immunotoxin

AIM

To investigate In vivo antitumour activity of single-chain immunotoxin (sFv-TNF-α fusion protein).

METHODS

HCC-specific killer cells were generated by transducing the recombinant retroviral virus in supernatant of the virus producing cells (C₂₂) into human peripheral blood mononuclear cells (PBMCs). SMMC-7721 xenograft nude mice were given iv either 1×10⁶ (0.2 mL) transduced or mock-transduced PBMCs once five days for three weeks and tumour growth was detected.

RESULTS

Tumour growth were (20.8±4.9) mg/d in PBMCs/PST group and (28.5±6.7)mg/d in PBMCs/ pLXSN group, with a significant difference (P<0.05).

CONCLUSION

Genetic modification of PBMCs by single-chain immunotoxin has antitumour activity In vivo.

In vitro cytotoxicity of PBMCs via genetic modification of single-chain immunotoxin

AIM: To investigate the selective cytotoxicity of single-chain immunotoxin (sFv-TNF-α fusion proteins) in cell line SMMC-7721.

METHODS: HCC-specific killer cells were generated by transducing the recombinant retroviral virus in supernatant of the virus producing cells into human peripheral blood mononuclear cells (PBMCs). PCR and RT-PCR were used to detect integration and transcription of the sFv-TNF-α gene in transduced PBMCs (PBMCs/PST). MTT method was used to detect antitumour activity of the sFv-TNF-α fusion proteins.

RESULTS: There was integrated sFv-TNF-α gene in the genome of PBMCs/PST, and PBMCs/PST were able to express the fusion sFv-TNF-α proteins. Cell killing was significant in HCC cells co-cultivated with PBMCs/PST, whereas the PBMCs/pLXSN control cells had no significant cytotoxic effects on HCC cells.

CONCLUSION: Expression of sFv-TNF-α fusion proteins in PBMCs/PST has cytotoxicity to HCC cells in vitro.

Non-surgical treatment of hepatocellular carcinoma

Primary hepatocellular cancer is a disease with a poor prognosis for which there is little consensus on treatment and a paucity of comparative trials. The coexistence of cancer with cirrhosis complicates treatment, and also confers a high risk for the development of further tumours. Surgery, either by hepatic resection or orthotopic liver transplantation, is only a feasible option in a minority of patients. This article surveys the non-surgical approaches to the treatment of hepatocellular cancers-local ablation techniques, arterial embolization with and without chemotherapy, conventional chemotherapy and hormonal modulation, and targeted and external irradiation.

Low serum retinol levels are associated with hepatocellular carcinoma in patients with chronic liver disease

BACKGROUND

Retinol and other vitamin A derivatives affect the differentiation and growth of many tissues and have anti-tumour properties.

AIM

To investigate serum retinol levels in patients with liver disease and hepatocellular carcinoma (HCC) and to assess its importance as a risk factor for the development of HCC.

METHODS

Serum retinol levels were measured in healthy volunteers and 175 patients (34 with chronic hepatitis C, 117 with cirrhosis, and 24 with HCC.

RESULTS

The serum retinol levels (mean +/- s.e.) in ng/mL, were 972.1 +/- 37.7 in the control group and 647 +/- 41.1 in patients with chronic hepatitis C. Serum retinol levels in patients with cirrhosis and HCC were lower than in patients with cirrhosis alone (365.8 +/- 43.1 vs. 438.9 +/- 22.1, P < 0.04). In particular, there was a more significant difference in serum retinol levels between Child-Pugh grade A patients with cirrhosis and Child-Pugh grade A patients with cirrhosis/HCC (serum retinol levels 532.4 +/- 26.7 vs. 366.1 +/- 86.4, P < 0.03). There was a significant difference in serum retinol levels between normal controls and all patients' groups (P < 0.001). There were significantly lower serum retinol levels in cholestatic Child-Pugh grade A patients with cirrhosis compared with noncholestatic Child-Pugh grade A patients with cirrhosis/HCC (411.5 +/- 30.3 vs. 579.7 +/- 32.7, P < 0.0004). Sixty percent of patients with Child-Pugh grade A cirrhosis/HCC had serum retinol levels below 350 ng/mL compared with only 18.4% of cirrhotics without HCC (chi 2-test, P=0.01). No correlation was found between serum retinol levels and alpha FP or any other liver function tests, apart from serum albumin, which showed a positive correlation (r=0.61 P < 0.018).

CONCLUSIONS

There was a progressive reduction in serum retinol levels from controls to patients with liver cirrhosis. Those patients with cirrhosis and HCC had significantly lower values than patients with cirrhosis alone. Serum retinol levels may be a risk factor for the development of HCC.