Medical Treatment of Hepatocellular Carcinoma: Any Progress?

Background

Hepatocellular carcinoma (HCC) remains one of the most common neoplasms worldwide. Curative treatment options include liver transplantation or resection. Unfortunately, most patients still have unresectable or untransplantable HCC due to disease extension or comorbid factors and are therefore candidate only for palliative treatments.

Methods

In this review we have analyzed the different medical approaches employed in the treatment of HCC in an attempt to better define their roles.

Results

Palliative medical treatments including systemic chemotherapy, immunotherapy or hormonal manipulation rarely influence survival of the patients. Although a high response rate is often reported with new local therapies such as transcatheter arterial embolization, intraarterial chemotherapy or percutaneous ethanol injection, the real impact of these treatment modalities on patient survival remains to be determined.

Conclusion

One way to improve the diagnosis of HCC patients would be an appropriate approach to evaluate new drugs or treatment modalities. To answer all the open questions, further trials, possibly randomized, should be conducted on a substantial number of patients with homogeneous prognostic factors.

Treatment of Hepatocellular Carcinoma by Intraarterial Injection of Adriamycin/Mitomycin C Oil Suspension (ADMOS) Alone or Combined with CIS-Diaminodichloroplatinum (CDDP)

We evaluated the effects of intraarterial injection of Adriamycin/Mitomycin C oil (Lipiodol) suspension (ADMOS) alone and ADMOS + cis-diaminodichloroplatinum (CDDP) in 135 patients with hepatocellular carcinoma (HCC). A total of 59 patients received ADMOS alone and 76 patients received ADMOS + CDDP (ADMOS/CDDP). Tumor size was reduced by over 25% in 13 (34%) of the evaluable 38 patients in the ADMOS-alone group and in 39 (51%) of the 76 evaluable patients in the ADMOS/CDDP group. Serum alpha-fetoprotein (AFP) levels decreased by more than 50% in 10 (59%) of 17 ADMOS-alone patients and in 23 (70%) of 33 ADMOS/CDDP patients whose pretreatment AFP levels were above 0.2 mg/l. The overall one- and 2-year survival rates were 68% and 41%, respectively. No severe complications and no significant changes in laboratory values were observed, except for one patient in the ADMOS/CDDP group who developed a liver abscess. Although the tumor response was significantly better in patients treated by ADMOS/CDDP than in those treated by ADMOS-alone (p < 0.05), there was no significant difference in the survival rates between the 2 groups. The intraarterial injection of ADMOS and CDDP was concluded to be effective in treating HCC judging by tumor response.

Treatment of Liver Metastases by Arterial Injection of Adriamycin/Mitomycin C Lipiodol Suspension

Sixty-one patients with liver metastases were treated with hepatic arterial injection of Adriamycin/Mitomycin C oil suspension (ADMOS). The liver metastases originated from the gastrointestinal tract in 41 patients and from other organs in 20 patients. Sixty-nine liver tumors were analyzed in these 61 patients. Computed tomography (CT) after ADMOS injection (Lip-CT) gave more information in 19 cases (31%) than enhanced CT with a water-soluble contrast medium. With Lip-CT, Lipiodol tumor enhancement was observed in 64 of 69 lesions. The patterns of Lipiodol uptake in the tumors were classified into 4 types: Homogeneous accumulation (20%), heterogeneous accumulation (16%); accumulation with a central defect (57%); and no accumulation (7%). A tumor response was achieved in 41 of 69 lesions (59%). Anticancer effects were also shown as a decrease in serum CEA levels. The one year survival rate estimated by the Kaplan-Meier method was 43 per cent and the median survival time was 337 days. The results were better among patients who received multiple doses of ADMOS. Only minimal side effects were associated with ADMOS. The method is considered to be an excellent diagnostic and therapeutic procedure for liver metastases.

Oxygen-15 positron-emission tomography for predicting selective delivery of a chemotherapeutic agent to hepatic cancers during angiotensin II-induced hypertension

PURPOSE

Selective drug delivery is important for successful chemotherapy. In patients with hepatic cancer, we used (15)O-carbon dioxide (steady-state) and (15)O-water (dynamic) positron emission tomography (PET) to evaluate changes in blood flow induced by angiotensin (AT) II in the liver parenchyma, hepatic tumors, and spleen.

METHODS

The study group comprised 13 patients, 6 with hepatic metastasis and 7 with hepatocellular carcinoma. PET was performed before and during AT II administration to induce hypertension.

RESULTS

Steady-state PET images showed a preferential increase in blood flow to hepatic tumor compared with liver parenchyma during hypertension. In dynamic PET, tumor blood flow was maintained during induced hypertension while hepatic arterial blood flow, portal blood flow, total hepatic blood flow, and splenic blood flow decreased to 71.4% (not significant), 65% (P<0.01), 67.2% (P<0.001), and 72.3% (P<0.01) of the respective baseline values.

CONCLUSION

AT II-induced hypertension produced a relative increase in tumor blood flow. Oxygen-15 PET should be useful for predicting preferential drug delivery to hepatic cancers.

Hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the sixth most common cancer of men and eleventh most common cancer of women world-wide. However, because almost every individual who develops liver cancer dies of the disease, HCC is the third most common cause of the cancer deaths in men and seventh most common in women. The treatment of choice for hepatocellular carcinoma remains surgical resection or liver transplantation, in carefully selected cases. In patients with hepatocellular carcinoma not amenable to surgical intervention a variety of different therapeutic interventions have been investigated. These include direct ablation of the tumour using agents such as ethanol or acetic acid, transcatheter arterial chemoembolization, or systemic chemotherapy. The evaluation of their efficacy is compromised by the paucity of adequately powered randomised clinical trials. The main challenge facing the research community over the next decade is to prioritise the most promising treatments and take these forward into multicentre controlled trials. Even if these fail to improve results, they will help reduce the variation in clinical practice by eliminating anecdotal treatment.

Pharmacokinetics of regional angiotensin-II: a novel biologic response modifier

BACKGROUND

The splanchnic vasoconstrictor angiotensin-II (A-II) has been shown to redistribute blood flow to hepatoma during systemic infusions. The hepatoma tumor derives all blood flow from the hepatic artery, whereas the normal liver has a dual blood supply from both the portal vein and the hepatic artery. We hypothesized that the pharmacokinetics of regional intrahepatic arterial A-II infusion could favorably distribute blood flow to the tumor while preserving portal flow to normal liver.

METHODS

ACI rats had 10(6) cultured H4IIE cells inoculated into the liver 10-14 days before study. Both systemic and splanchnic hemodynamics were measured by the radio-labeled microsphere technique during intrahepatic arterial or intravenous infusion of angiotensin-II or normal saline. The tumor-to-normal liver hepatic artery blood flow ratio was calculated.

RESULTS

Regional A-II produced a proportionately less systemic effect than did intravenous infusion. The tumor vasoconstrictive response to A-II was minimal, and the tumor-to-normal blood flow ratio was greater with intrahepatic arterial or intravenous A-II infusion than with normal saline. Cardiac output and portal vein flow were decreased dramatically during intravenous, but not during intrahepatic, arterial A-II.

CONCLUSION

Intrahepatic arterial A-II exhibits saturation kinetics with a system effect observed only after hepatic receptor saturation. Furthermore, the pharmacokinetics of intrahepatic arterial versus intravenous A-II indicate that intrahepatic arterial A-II will preferentially redistribute arterial blood flow to the tumor while synchronously preserving portal blood flow to the normal liver.

Transarterial internal radiation therapy with I-131 Lipiodol for multifocal hepatocellular carcinoma: immediate and long-term results

Transarterial internal radiation with I-131 Lipiodol (TAIR) was performed in 21 patients with multifocal hepatic carcinoma. Eight patients were treated by TAIR alone and 13 by combination of TAIR and intraarterial infusion of cis-diamminedichloroplatinum (CDDP) and/or adriamycin mitomycin C oil suspension (ADMOS). TAIR was found effective immediately and long-term. Serum alpha-feto-protein (AFP) levels dropped to 50% or less in 7 of 14 patients. Eleven of 21 patients (52%) showed 50% or greater decrease in tumor size. The overall 1-year survival rate was 43% and 67% in patients who received 50 Gy or greater tumor dose. Lipiodol distribution pattern of the tumor indicated some difference in the prognosis between the scattered pattern and solid pattern. The solid pattern showed a statistically significant better survival rate. Patients treated with TAIR alone versus those treated with TAIR and chemotherapy showed no difference in their survival rate.

Non-surgical treatment of hepatocarcinoma

Hepatocellular carcinoma (HCC) is one of the most common tumors affecting man. It is the general feeling that only hepatectomy can give a chance for cure. However, less than 20% of patients can be resected, and other treatment modalities are required. Systemic (chemotherapy, hormonotherapy, immunotherapy) and loco-regional (intratumoral injection of alcohol, intra-arterial chemotherapy embolization, internal radiotherapy) approaches have been developed. In view of the small number of patients, tumor and patient heterogeneity, and difficulties in assessing tumor response, the real place of these treatments is difficult to evaluate. A review of the literature suggests that embolization with Gelfoam, even when given without chemotherapy, has an effect on response rate and on survival, and could be considered, at the present time, as the most attractive treatment in non-operable HCC. Chemotherapy seems effective only if combined with embolization. When administered alone by the systemic or the intra-arterial hepatic route, no clinically significant activity can be found. Unexpectedly, Lipiodol by itself seems inactive, and the co-administration of chemotherapy does not improve activity. Other approaches such as intratumoral injection of alcohol, immunotherapy, hormonotherapy, and radioimmunotherapy are still experimental, and well-designed studies are needed to identify their role.

Comparison of the anticancer effect of ADMOS alone and ADMOS with CDDP in the treatment of hepatocellular carcinoma by intra-arterial injection

A total of 135 patients with hepatocellular carcinoma (HCC) were treated by intra-arterial injection of an Adriamycin/mitomycin C oil (lipiodol) suspension (ADMOS) alone or of ADMOS plus cis-diammine-dichloroplatinum (CDDP). In all, 59 patients were treated with ADMOS alone and 76 were treated with ADMOS plus CDDP. A reduction of more than 25% in the tumor size was obtained in 13 of 38 (34%) evaluable patients in the former group and in 39 of 76 (51%) evaluable patients in the latter group. Serum alpha-fetoprotein (AFP) levels decreased by more than 50% in 10 of 17 (59%) and 23 of 33 (70%) patients in the respective groups whose pretreatment AFP level was estimated to be over 200 ng/ml. Overall, the 1-year survival value was 68% and the 2-year value was 41% as determined by the Kaplan-Meier method. No statistically significant difference in survival was observed between the two groups. The initial tumor response correlated with the survival value. No severe complication was encountered except for one case of liver abscess formation. No serious change in the laboratory data was observed following treatment with these regimens. Although the tumor response was significantly better in patients treated with ADMOS combined with CDDP injection than in those treated with ADMOS alone (P < 0.05), no significant difference in survival was found between the two groups.

Multimodality cisplatin treatment in nonresectable alpha-fetoprotein-positive hepatoma

Twenty-eight patients with alpha-fetoprotein-positive (AFP+) nonresectable hepatoma have been enrolled in a new multimodality Phase I, II program. Induction therapy consisted of 50 mg/m2 intravenous cisplatin followed by 2100 cGy irradiation to the tumor volume in seven fractions over 10 days. Hepatic arterial infusion of 50 mg/m2 cisplatin (IA-CDDP) was then administered at monthly intervals. Twenty-one patients have completed induction and at least two cycles of IA-CDDP. Twelve-month cumulative survival was 52% for all 28 patients and 69% for the 21 patients completing induction and IA-CDDP. Median survival has not yet been reached. Response rate (complete and partial) was 36% overall and 48% among the 21 patients who completed treatment. The improved survival of the present series of patients as well as the minimal hematologic toxicity suggests possible further integration of new modalities for therapy.

Polymer-coated albumin microspheres as carriers for intravascular tumour targeting of cisplatin

We used a poly-lactide-co-glycolide polymer (PLAGA 50:50) to formulate cisplatin (cDDP) into microspheres designed for intravascular administration. Two systems were developed. PLAGA-coated albumin microspheres and microspheres consisting of PLAGA only. PLAGA-coated microspheres displayed a mean diameter of 31.8 +/- 0.9 microns and a payload of 7.5% cDDP (w/w). Solid PLAGA microspheres exhibited a mean diameter of 19.4 +/- 0.6 microns and a payload of 20% cDDP. Release characteristics and in vitro effects on L1210 leukemia and B16 melanoma cell lines were investigated. Both types of microsphere overcame the initial rapid release of cDDP (burst effect), and PLAGA-coated albumin microspheres also showed a lag phase of approximately 30 min before cDDP release began. PLAGA-coated albumin microspheres released most of their payload through diffusion, and the coating eventually cracked after 7 days' incubation in saline supplemented with 0.1% Tween at 37 degrees C, enabling the release of any cDDP remaining. Effects of platinum, pre-released from PLAGA-coated albumin microspheres on the in vitro growth of L1210 cells were comparable with those of standard formulations (dissolved) of cDDP. Material released from non-drug-loaded PLAGA microspheres had no effect on L1210 cell growth, suggesting the absence of cytotoxic compounds in the matrix. The colony-forming ability of B16 cells was also equally inhibited by standard cDDP and pre-released drug. These studies show that formulation of cDDP in PLAGA-based microspheres prevents the rapid burst effect of cDDP seen in previous preparations and offers an improved system of administration for hepatic artery infusion or adjuvant therapy, enabling better clinical handling and the promise of a higher ratio of tumour tissue to normal tissue.

Increased therapeutic effect on metastatic liver tumors in rats of two-route chemotherapy using cis-diamminedichloroplatinum (II) and its antidote, sodium thiosulfate, with temporary clamping of the abdominal aorta

To improve the therapeutic effects of conventional "two-route chemotherapy" (TRC) comprising cis-diamminedichloroplatinum(II) (CDDP) given via the hepatic artery plus simultaneous i.v. sodium thiosulfate (STS) on metastatic liver tumors in rats, we combined TRC with aortic clamping at the supraceliac level. Treatments were evaluated in Wistar-King-Aptekman (WKA) rats bearing metastatic liver tumors 7 days after the inoculation of 10(6) syngenic RBT-1 (transitional-cell carcinoma) cells via the mesenteric vein. When 15 mg/kg CDDP was injected i.a. over 5 min, immediately followed by STS 1,580 mg/kg (200-fold the molar equivalent of 15 mg/kg CDDP) given i.v. over a further 5 min, the antitumor activity, evaluated by the number of tumor nodules present 12 days after treatment, was superior to that of conventional TRC (15 mg/kg i.a. CDDP plus simultaneous administration of 1,580 mg/kg i.v. STS), but the blood urea nitrogen (BUN) level was highly elevated (63.6 mg/dl). With aortic clamping for 7.5 min during CDDP administration and the first half of STS treatment, the TRC consisting of CDDP plus delayed STS (modified TRC) exhibited a further improvement in antitumor activity, with no nephrotoxicity (BUN, 17.1 mg/dl). Although the antitumor activity of 3 or 5 mg/kg i.a. CDDP was also increased by aortic clamping, in animals with normal BUN levels the survival of those treated with modified TRC was greater than that of rodents given 3 mg/kg i.a. CDDP with aortic clamping; however, the former was the same as that of animals given 5 mg/kg i.a. CDDP with aortic clamping whose BUN levels were elevated (31.2 mg/dl). Loss of body weight, the decrease in WBC counts, and changes in the serum transaminase levels in rats given modified TRC were tolerable. The improved therapeutic effect of modified TRC can be explained as follows: during aortic clamping, (a) CDDP delivery to the kidney decreased by 96% and made feasible the delay in STS administration after CDDP without nephrotoxicity, and (b) CDDP retention in the liver was increased by 366%, as aortic clamping decreased the portal blood flow, thereby inhibiting the washout of CDDP from the liver.