Phase II study of megestrol acetate in the treatment of hepatocellular carcinoma

Addressing cancer anorexia-cachexia in older patients: Potential therapeutic strategies and molecular pathways

Cancer cachexia (CC) syndrome, a feature of cancer-associated muscle wasting, is particularly pronounced in older patients, and is characterised by decreased energy intake and upregulated skeletal muscle catabolic pathways. To address CC, appetite stimulants, anabolic drugs, cytokine mediators, essential amino acid supplementation, nutritional counselling, cognitive behavioural therapy, and enteral nutrition have been utilised. However, pharmacological treatments that have also shown promising results, such as megestrol acetate, anamorelin, thalidomide, and delta-9-tetrahydrocannabinol, have been associated with gastrointestinal and cardiovascular complications. Emerging evidence on the efficacy of probiotics in modulating gut microbiota also presents a promising adjunct to traditional therapies, potentially enhancing nutritional absorption and systemic inflammation control. Additionally, low-dose olanzapine has demonstrated improved appetite and weight management in older patients undergoing chemotherapy, offering a potential refinement to current therapeutic approaches. This review aims to elucidate the molecular mechanisms underpinning CC, with a particular focus on the role of anorexia in exacerbating muscle wasting, and to propose pharmacological and non-pharmacological strategies to mitigate this syndrome, particularly emphasising the needs of an older demographic. Future research targeting CC should focus on refining appetite-stimulating drugs with fewer side-effects, specifically catering to the needs of older patients, and investigating nutritional factors that can either enhance appetite or minimise suppression of appetite in individuals with CC, especially within this vulnerable group.

A Systematic Review and Meta-Analysis of the Clinical Use of Megestrol Acetate for Cancer-Related Anorexia/Cachexia

Cancer-related anorexia/cachexia is known to be associated with worsened quality of life and survival; however, limited treatment options exist. Although megestrol acetate (MA) is often used off-label to stimulate appetite and improve anorexia/cachexia in patients with advanced cancers, the benefits are controversial. The present meta-analysis aimed to better elucidate the clinical benefits of MA in patients with cancer-related anorexia/cachexia. A systematic search of PubMed, EMBASE, OVID Medline, Clinicaltrials.gov, and Google Scholar databases found 23 clinical trials examining the use of MA in cancer-related anorexia. The available randomized, controlled trials were appraised using Version 2 of the Cochrane risk-of-bias tool (RoB 2) and they had moderate-to-high risk of bias. A total of eight studies provided sufficient data on weight change for meta-analysis. The studies were divided into high-dose treatment (>320 mg/day) and low-dose treatment (≤320 mg/day). The overall pooled mean change in weight among cancer patients treated with MA, regardless of dosage was 0.75 kg (95% CI = −1.64 to 3.15, τ2 = 9.35, I2 = 96%). Patients who received high-dose MA tended to have weight loss rather than weight gain. There were insufficient studies to perform a meta-analysis for the change in tricep skinfold, midarm circumference, or quality of life measures. MA was generally well-tolerated, except for a clear thromboembolic risk, especially with higher doses. On balance, MA did not appear to be effective in providing the symptomatic improvement of anorexia/cachexia in patients with advanced cancer.

Systemic Management for Advanced Hepatocellular Carcinoma: A Review of the Molecular Pathways of Carcinogenesis, Current and Emerging Therapies, and Novel Treatment Strategies

Hepatocellular carcinoma (HCC) arises from a number of cirrhosis-related and non-cirrhosis-related exposures and is one of the leading causes of cancer-related deaths worldwide. Achieving a durable cure currently relies on either resection or transplantation, but since most patients will be diagnosed with inoperable disease, there is great interest in achieving more effective systemic therapies. At a molecular level, HCC is heterogeneous, but initial treatment strategies, including the use of multi-targeted tyrosine kinase inhibitors and checkpoint inhibitors, have been fairly homogenous, depending on general host factors and overall tumor burden rather than specific molecular signatures. Over the past 2 decades, however, there has been significant success in identifying key molecular targets, including driver mutations involving the telomerase reverse transcriptase, p53, and beta-catenin genes, and significant work is now being devoted to translating these discoveries into the development of robust and well-tolerated targeted therapies. Furthermore, multi-modal therapies have also begun to emerge, harnessing possible synergism amongst a variety of different treatment classes. As the findings of these landmark trials become available over the next several years, the landscape of the systemic management of advanced HCC will change significantly.

Efficacy and safety of megestrol in the management of hepatocellular carcinoma: a systematic review of the literature

Introduction

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death worldwide. There is as yet no standard therapy for inoperable HCC. We aimed to systematically review all health-related evidence regarding the effectiveness and safety of megestrol in HCC patients.

Material and methods

We conducted a systematic computerised search in PubMed, Scopus, Web of Science, Embase, and Cochrane CENTRAL. All original human studies reporting the efficacy of megestrol in HCC patients were included in our review.

Results

Six studies including 357 patients were finally eligible. The overall mean survival time of 87 megestrol-treated patients, was 9.187 (95% CI 1.134–17.239) months. Eight patients had tumour size enlargement, and eight patients had tumour size reduction. From three studies including 76 patients, 42 patients reported having improvement of appetite and food intake after receiving megestrol. Diverse adverse events were noticed between studies; however, they were tolerable in most of the studies.

Conclusions

To summarise, no conclusive evidence should be declared regarding the effectiveness of megestrol in patients with inoperable HCC. However, previous studies have shown promising results at the level of prolonging the survival rate, tumour size reduction, and improving the quality of life. Therefore, we recommend that future research studies must examine the role of megestrol in large-population, randomised studies.

Enhanced antitumor activity of combined megestrol acetate and arsenic trioxide treatment in liver cancer cells

Liver cancer is an aggressive malignancy with a very high fatality rate. Although megestrol acetate (MA) and arsenic trioxide (ATO) have shown an antitumor effect in liver cancer cells, the therapeutic benefits of MA or ATO alone in patients with liver cancer were limited. The aim of the present study was to elucidate whether the co-treatment of MA/ATO could enhance antitumor efficacy in liver cancer cell lines (Hep G2 and BEL 7402) and explore the underlying anti-cancer mechanisms. The cell viability, apoptotic response and expression levels of associated proteins were detected by Cell Counting Kit-8 assay, flow cytometry and western blotting, respectively. An xenograft model in nude mice bearing a Hep G2 tumor was used to estimate tumor growth in vivo. Co-treatment with MA/ATO markedly improved the inhibition of cell viability, enhanced apoptosis, and increased the phosphorylation of p38, c-Jun N-terminal kinase 1/2 and extracellular signal-regulated kinase 1/2 on liver cancer cell lines. Furthermore, the tumor growth in the murine Hep G2 cancer xenograft model was significantly inhibited by combined treatment with MA/ATO. The results indicated that MA/ATO combined treatment enhanced antitumor efficacy and possessed potential application for treating liver cancer.

Progesterone and related compounds in hepatocellular carcinoma: basic and clinical aspects

Primary liver cancer is the fifth most common cancer worldwide and the third most common cause of cancer mortality. Hepatocellular carcinoma (HCC) accounts for 85% to 90% of primary liver cancers. Major risk factors for HCC include infection with HBV or HCV, alcoholic liver disease, and most probably nonalcoholic fatty liver disease. In general, men are two to four times more often associated with HCC than women. It can be suggested that sex hormones including progesterone may play some roles in HCC. Rather, very limited information discusses its potential involvement in HCC. This paper thus collects some recent studies of the potential involvement of progesterone and related compounds in HCC from basic and clinical aspects. In addition, two synthetic progestins, megestrol acetate (MA) and medroxyprogesterone acetate (MPA), will be discussed thoroughly. It is noted that progesterone can also serve as the precursor for androgens and estrogens produced by the gonadal and adrenal cortical tissues, while men have a higher incidence of HCC than women might be due to the stimulatory effects of androgen and the protective effects of estrogen. Eventually, this paper suggests a new insight on the associations of progesterone and related compounds with HCC development and treatment.

Randomised double-blind trial of megestrol acetate vs placebo in treatment-naive advanced hepatocellular carcinoma

Background:

Hepatocellular carcinoma (HCC) is the third leading cause of cancer deaths worldwide. We tested megestrol acetate (MA) against placebo in the treatment of advanced HCC.

Methods:

From 2002 through 2007, this randomised double-blind trial enrolled 204 patients with treatment-naive advanced HCC (Eastern Cooperative Oncology Group (ECOG) performance rating of 0-3) from specialist care centres in six Asia-Pacific nations. Patients received placebo or MA (320 mg day⁻¹). End points were overall survival (OS) and quality of life.

Results:

An adverse but not statistically significant difference in OS was found for MA vs placebo: median values 1.88 and 2.14 months, respectively (hazard ratio (HR)=1.25, 95% CI=0.92–1.71, P=0.16). However, OS was similar among patients of good functional status (Child-Pugh A and ECOG 0, 1 or 2) (44.3%) in both treatment groups, with the adverse effect of MA confined to those of poor status. Megestrol acetate patients had a worse global health status (not statistically significant) but reduced levels of appetite loss and nausea/vomiting.

Conclusion:

Megestrol acetate has no role in prolonging OS in advanced treatment-naive HCC. Overall survival with placebo differed markedly from that in similar trials conducted elsewhere, suggesting therapeutic outcomes may be strongly dependent on ECOG status and Child-Pugh score.

A retrospective study of the association between megestrol acetate administration and mortality among nursing home residents with clinically significant weight loss

BACKGROUND

Megestrol acetate (MA) is a progestin widely used to treat weight loss and cachexia in patients suffering from AIDS or cancer. Although MA is also frequently prescribed for similarly malnourished elderly individuals, the efficacy and morbidity of MA treatment in this patient population remain unclear.

OBJECTIVE

The goal of this study was to examine the effects of MA therapy on weight and overall mortality in elderly nursing home residents.

METHODS

This was a case-control cohort study of 17,328 nursing home residents admitted to Beverly Healthcare nursing home between January 1, 2000, and December 31, 2003, who had lost either 5% of total body weight within 3 months or 10% of total body weight within 6 months. Residents within this weight loss group who received MA therapy--within 30 days of their weight loss documentation--were matched (1:2) with non-MA-treated residents with respect to age, sex, race, weight, and first notation of weight loss. Residents were further matched by propensity score for activities of daily living, cognitive functioning, number of medications taken during the 7 days before data entry, clinical condition (unstable, acute episode of a recurrent problem, end-stage disease), cancer diagnosis, and human immunodeficiency virus diagnosis.

RESULTS

A total of 709 patients (mean [SD]age, 84.1 [9.7]years; 70.9% female) who received MA therapy were matched with 1418 non-MA-treated patients (mean [SD] age, 84.2 [9.0] years; 70.9% female). Of the 709 MA patients, 281 (39.6%) were alive and in the nursing home at last follow-up, 149 (21.0%) were alive and discharged to another facility or to home, and 279 (39.4%) died in the nursing home. For the controls, 651 (45.9%) were alive and in the nursing home, 308 (21.7%) were discharged to another facility or to home, and 459 (32.4%) died in the nursing home. The median survival of MA-treated residents (23.9 months; 95% CI, 20.2-27.5) was significantly less than untreated residents (31.2 months; 95% CI, 27.8-35.9) (P < 0.001). Median weight and median of weight differences were unchanged after 6 months of treatment with MA compared with matched controls.

CONCLUSIONS

MA treatment of elderly nursing home residents with significant weight loss was associated with a significant increase in all-cause mortality without a significant increase in weight. Randomized, prospective studies of the use of MA in elderly nursing home residents are necessary to more fully evaluate morbidity and mortality associated with this therapy.

Potential role of leptin expression in hepatocellular carcinoma

BACKGROUND

Obesity is associated with hepatocellular carcinoma (HCC). The association may result from the aberrant expression of adipokines.

AIM

To explore the potential biological effect and prognostic value of leptin, one of the adipokines, in HCC.

METHODS

Immunohistochemistry was used to evaluate the expression of leptin in 68 patients with HCC. The expression of Ki-67 and microvessel density (MVD) of tumorous lesions in HCC were also analysed. The result of leptin expression was further correlated with Ki-67 expression, intratumour MVD, clinicopathological characteristics, overall survival and the postoperative use of medroxyprogesterone acetate (MPA).

RESULTS

High leptin expression was seen in 60.3% of patients with HCC and was significantly correlated with intratumour MVD (high v low; 59.2 (standard deviation 3.2) v 44.2 (19.5), p = 0.004), but not with Ki-67 expression. No marked correlation was seen between leptin expression and clinicopathological characteristics. However, using a multivariate Cox's proportional hazards model, leptin expression was a predictor for improved overall survival of patients with HCC (odds ratio 0.16; 95% confidence interval 0.03 to 0.87; p = 0.033). In addition, the Kaplan-Meier survival curve showed that high leptin expression was associated with a better survival in patients with HCC, treated postoperatively with MPA (p = 0.008, log rank test).

CONCLUSION

High leptin expression was associated with an increased intratumour MVD and thus may be associated with HCC development. In addition, high leptin expression was a predictor for improved survival of patients with HCC, treated postoperatively with MPA.

The effect of megestrol acetate on growth of HepG2 cells in vitro and in vivo

PURPOSE

Hepatocellular carcinoma (HCC) is generally considered as a sex hormone-dependent tumor, and hormonal therapy has been proposed as a strategy for the treatment of HCC. The aim of the study is to investigate the effect of megestrol acetate, a synthetic progesteronal agent, on growth of HepG2 cells in vitro and in vivo.

EXPERIMENTAL DESIGN

Cell growth in vitro was assessed by a colormetric method, and cell growth in vivo was assessed by tumor volumetrics.

RESULTS

Megestrol acetate was shown to inhibit the growth of HepG2 cells in vitro in dose- and time-dependent manners with an IC (50) of 260 microm (24-h incubation). The growth of HepG2 cell-transplanted tumors in nude mice was also inhibited by i.p. injection of megestrol acetate (10 mg/kg/day). The tumor volumes of the megestrol acetate-treated group regressed to 59% of controls by week 6 and to 41% of controls by week 13. Apoptosis following G(1) arrest was observed in megestrol acetate-treated cells and may be a mechanism through which megestrol acetate inhibits HepG2 cells. Megestrol acetate was also demonstrated to have a beneficial effect on the weight gain of tumor-bearing nude mice, and the mean weight of the megestrol acetate-treated animals was higher than that of controls from week 4 of the treatment period, and the differences were statistically significant in week 5 and 6 (P < 0.05, compared with controls). No significant survival advantage was, however, demonstrated in the treatment group.

CONCLUSIONS

This study showed that megestrol acetate inhibited the growth of HepG2 cells grown in vitro and in vivo. These data provide useful information for clinical study of megestrol acetate for the treatment of HCC.

Systemic therapy for advanced hepatocellular carcinoma: a review

Hepatocellular carcinoma (HCC) is a common cause of cancer mortality worldwide. Whilst local treatments are useful in selected patients, they are not suitable for many with advanced disease. Here, we review phase II and III trials for systemic therapy of advanced disease, finding no strong evidence that any chemotherapy, hormonal therapy, or immunotherapy regimen trialled to date benefits survival in this setting. Many trials were inadequately powered, single centre, and enrolled highly selected patients. From this review, we cannot recommend any therapeutic approach in these patients outside of a clinical trial setting. Including an untreated control arm in clinical trials in HCC is still justified. Every effort should be made to enroll these patients into adequately powered trials, and promising phase II results must be tested in a multicentre phase III setting, preferably against a placebo control arm. Prevention of hepatitis B and C remains vital to decrease deaths from HCC.

Biologic therapy of liver tumors

Nonresectable primary and metastatic liver tumors are common malignancies that lack therapies allowing substantial prolongation of survival. Recent progress in molecular and cell biology has opened the way to novel therapies based on biological modifiers, gene transfer, and autologous stem cells. It is now possible to transfer therapeutic genes to the tumor or pericancerous tissue, and to control their expression for long periods of time. It is also feasible to generate autologous endothelial progenitor cells that can be recruited by tumoral vessels acting as vehicles to convey therapeutic genes to the interior of the tumor mass. Combination of biological modifiers, gene therapy, and cell therapy will hopefully provide efficient means to combat inoperable neoplasms in a not-very-distant future.

Treatment of locally advanced hepatocellular carcinoma by hepatic intra-artery chemotherapy: a pilot study

BACKGROUND

Hepatocarcinoma is one of the most common malignant tumours world-wide with poor prognosis. Treatment of locally advanced hepatocarcinoma is still controversial. Transcatheter arterial (chemo-)embolisation of hepatocarcinoma are widely used methods but some aspects regarding their use and usefulness have not yet been clarified. Systemic remedies have not yet been proven to affect patient survival.

AIMS

To determine if intra-arterial chemotherapy with 5-flurouracil and folinic acid in locally advanced hepatocarcinoma is a viable alternative to existing therapies.

PATIENTS

Twenty-four inoperable consecutive patients with locally advanced hepatocarcinoma were enrolled. They all underwent intra-arterial chemotherapy via a surgically implanted port-a-cath, and folinic acid (100 mg/m2) and 5-flurouracil (up to 550 mg/m2) were administered with a 1-week or a 2-week schedule.

RESULTS

Nineteen patients completed the study: 2 showed a complete positive response, 11 a partial response, 6 stable disease, while 4 showed a disease progression. Median survival time was 19 (range 4-85) months. Child A patients showed a significant longer survival.

CONCLUSIONS

Intra-arterial chemotherapy using folinic acid and 5-flurouracil may be useful in the treatment of locally advanced hepatocarcinoma in cirrhotic patients even in the presence of thrombosis. This treatment could be also useful in comparing transarterial chemoembolisation to a curative treatment.

Hormonal therapy with megestrol in inoperable hepatocellular carcinoma characterized by variant oestrogen receptors

Variant liver oestrogen receptor transcripts in hepatocellular carcinoma are associated with aggressive clinical course and unresponsiveness to tamoxifen. To evaluate the impact on survival and on tumour growth of megestrol (progestin drug acting at post-receptorial level) we enrolled 45 patients with HCC characterized by variant liver oestrogen receptors in a prospective, randomized study with megestrol vs. placebo. Presence of variant oestrogen receptors was determined by RT/PCR. 24 patients were randomized to no treatment and 21 to therapy with megestrol 160 mg day(-1). Results were analysed by Kaplan-Meier and Cox methods. Survival of hepatocellular carcinoma characterized by variant oestrogen receptors was extremely poor (median survival 7 months); megestrol significantly improved survival (18 months) (P = 0.0090). Tumour growth at one year was significantly slowed down in megestrol-treated patients (P = 0.0212). Bilirubin levels, presence of portal thrombosis, HBV aetiology and treatment were identified at univariate analysis as factors significantly associated with survival; at multivariate analysis, only megestrol therapy (P = 0.0003), presence of HBV infection (P = 0.0009) and presence of portal vein thrombosis (P = 0.0051) were factors independently related with survival. (1) Megestrol slows down the aggressive tumour growth of patients with hepatocellular carcinoma characterized by variant estrogen receptors and (2) is also able to favourably influence the course of disease, more than doubling median survival.

Male predominance in hepatocellular carcinoma: new insight and a possible therapeutic alternative

Hepatocellular carcinoma is one of the most common cancers in the world. The male to female ratio is 3-6 to 1 in patients with hepatocellular carcinoma. Although steroid hormones and receptors have been examined extensively for their role in the growth regulation of hepatocellular carcinoma, the direct stimulation of hepatocellular carcinoma by steroid hormones still awaits elucidation. On the other hand, clinical trials using antagonists for steroid hormones to treat hepatocellular carcinoma were found to be mostly ineffective. Recently it has been found that 2-methoxyestradiol - an estrogen metabolite - is effective in growth inhibition of various tumor cells as well as in angiogenesis inhibition. Since estrogen is metabolized in the liver, it is conceivable that females with menstruation cycles have more estrogen metabolized in their liver, consequently more 2-methoxyestradiol produced which could inhibit tumor growth in situ. We propose that the low incidence and mortality of hepatocellular carcinoma found in females may have resulted from the high levels of 2-methoxyestradiol produced in the liver during their reproductive years. Consequently, the growth of hepatocellular carcinoma in females is delayed significantly as compared to males. The potential of using 2-methoxyestradiol for treatment of patients with hepatocellular carcinoma after resection of tumor should be explored.