Medical Treatment of Hepatocellular Carcinoma: Any Progress?

Activity and Tolerability of Courses of Intra-Arterial Chemotherapy Followed by Chemoembolization in Unresectable Hepatocellular Carcinoma

AIMS AND BACKGROUND

We previously reported encouraging response rates and survival with combined intra-arterial (i.a.) chemotherapy and chemoembolization in unresectable hepatocellular carcinoma. We therefore evaluated a new program combining three courses of i.a. chemotherapy with chemoembolization administered every 28 days.

PATIENTS AND METHODS

The treatment regimen consisted of L-leucovorin (100 mg/m2 i.v.), fluorouracil (800 mg/m2 i.a.), and carboplatin (250 mg/m2 i.a.). Chemoembolization with mitoxantrone (10 mg/m2) plus ethiodized oil and gelatin sponge was performed immediately after. The same treatment was given every 28 days for 3 times.

RESULTS

Twenty-eight patients entered the study and were assessable for response and side effects. There were 24 males and 4 females (median age, 68 yrs; range, 42-75). TNM stage was II-III in 20 and IVA in 8; 17 were Child's A and 11 Child's B. Baseline alpha-fetoprotein was elevated in 15, and there was cirrhosis in 23. Twelve patients had a partial response (43%; 95% confidence interval, 24-63%), 13 had stabilization, and 3 progressive disease. Median survival was 16.6 months (range, 2-24). Sixteen patients had grade I-II pain and 14 grade I-II fever.

CONCLUSIONS

Our results indicate that the regimen is safe and well tolerated. Despite 43% objective remissions, our results do not seem better than those obtained with less intensive regimens.

A combination therapy of ethanol injection and radiofrequency ablation under general anesthesia for the treatment of hepatocellular carcinoma

AIM: To summarize the effects of laparoscopic ethanol injection and radiofrequency ablation (L-EI-RFA), thoracoscopic (T-EI-RFA) and open-surgery assisted EI-RFA (O-EI-RFA) under general anesthesia for the treatment of hepatocellular carcinoma (HCC).

METHODS: Time-lag performance of RFA after ethanol injection (Time-lag PEI-RFA) was performed in all cases. The volume of coagulated necrosis and the applied energy for total and per unit volume coagulated necrosis were examined in the groups treated under general (group G) or local anesthesia (group L).

RESULTS: The results showed that the total applied energy and the applied energy per unit volume of whole and marginal, coagulated necrosis were significantly larger in group G than those in the group L, resulting in a larger volume of coagulated necrosis in the group G. The rate of local tumor recurrence within one year was extremely low in group G.

CONCLUSION: These results suggest that EI-RFA, under general anesthesia, may be effective for the treatment of HCC because a larger quantity of ethanol and energy could be applied during treatment under pain-free condition for the patients.

Effects of cisplatin on telomerase activity and telomere length in BEL-7404 human hepatoma cells

Telomerase activity was inhibited in a dose and time-dependent manner with the treatment of cisplatin for 24, 48, or 72 h in a concentration ranged from 0.8 to 50 microM in BEL-7404 human hepatoma cells. There were no changes in expression pattern of three telomerase subunits, its catalytic reverse transcriptase subunit (hTERT), its RNA component (hTR) or the associated protein subunit (TP1), after cisplatin treated for 72 h with indicated concentrations. Mean telomere lengths were decreased by the cisplatin treatment. Cell growth inhibition and cell cycle accumulation in G2/M phase were found to be correlated with telomerase inhibition in the present study, but percentages of cell apoptosis did not change markedly during the process.

Antihepatoma effect of alpha-fetoprotein antisense phosphorothioate oligodeoxyribonucleotides in vitro and in mice

AIM: To evaluate antihepatoma effect of antisense phosphorothioate oligodeoxyribonucleotides (S-ODNs) targeted to alpha-fetoprotein (AFP) genes in vitro and in nude mice.

METHODS: AFP gene expression was examined by immunocytochemical method or enzyme-linked immunosorbent assay. Effect of S-ODNs on SMMC-7721 human hepatoma cell growth in vitro was determined using microculture tetrazolium assay. In vivo antitumor activities of S-ODNs were monitored by measuring tumor weight differences in treated and control mice bearing SMMC-7721 xenografts. Induction of cell apoptosis was evaluated by fluorescence-activated cell sorter (FACS) analysis.

RESULTS: Antisense S-ODN treatment led to reduced AFP gene expression. Specific antisense S-ODNs, but not control S-ODNs, inhibited the growth of heaptoma cells in vitro. In vivo, only antisense S-ODNs exhibited obvious antitumor activities. FACS analysis revealed that the growth inhibition by antisense S-ODNs was associated with their cell apoptosis induction.

CONCLUSION: Antisense S-ODNs targeted to AFP genes inhibit the growth of human hepatoma cells and solid hepatoma, which is related to their cell apoptosis induction.

Complete cure of established murine hepatocellular carcinoma is achievable by repeated injections of retroviruses carrying the herpes simplex virus thymidine kinase gene

Although xenotransplantation of retrovirus-producing cells into a tumor has been shown to be effective for the treatment of cancer, injections of recombinant retroviruses are much more feasible for clinical applications. We established a clone producing retroviruses carrying the herpes simplex virus thymidine kinase (HSVtk) gene with titers of up to 4 x 10(7) colony-forming units/ml, and examined the effectiveness of in vivo gene therapy against cancer. Syngeneic mice were inoculated subcutaneously with murine hepatocellular carcinoma (HCC) cells, BNL1ME A.7R.1, and the treatment was initiated after tumors were established. When mice were given an intratumoral injection of HSVtk-carrying retroviruses or their producing cells followed by ganciclovir (GCV) treatment, significantly prolonged survival periods were observed. When mice were treated with repeated intratumoral injections of HSVtk-carrying retrovirus-producing cells, significant antitumor responses and some cures were induced by GCV treatment. Furthermore, repeated intratumoral injections of HSVtk-carrying retroviruses and GCV treatment resulted in complete regression of established HCC tumors in all animals used in the experiment. Mice that completely eradicated tumors exhibited protective immunity against wild-type HCC tumors. These results suggest that repeated injections of HSVtk-carrying retroviruses followed by GCV treatment is a potent modality for the treatment of solid tumors.

Arterial hepatic embolization of unresectable hepatocellular carcinoma using a cyanoacrylate/lipiodol mixture

PURPOSE

A survival analysis in 16 patients with unresectable hepatocellular carcinoma (HCC) undergoing transcatheter arterial embolization (TAE) using a combination of lipiodol and N-butyl-2-cyanoacrylate (5:1) was performed in a retrospective study.

METHODS

A combination of lipiodol and N-butyl-2-cyanoacrylate (5:1) was used for TAE. All patients had disease compatible with Okuda stages I and II.

RESULTS

Twenty-four embolizations were done; five patients had more than one embolization. Median alpha-fetoprotein levels declined from 116 to 48.6 ng/ml. A median of 0.3 ml cyanoacrylate was administered per patient. Median survival was 8.5 months (range 2-49 months). After a median follow-up of 4 years, 12 patients have died (75%). Okuda stage I and II patients had a median survival time of 34.4 and 5.5 months respectively. Few side effects (19%) were seen.

CONCLUSION

We conclude that the TAE procedure used [lipiodol and N-butyl-2-cyanoacrylate (5:1)] is safe and produced only few side effects, thus constituting a valuable therapeutic option for patients with Okuda stage I and II HCC.

Intra-arterial chemotherapy followed by chemo-embolisation in unresectable hepatocellular carcinoma

Unresectable hepatocellular carcinoma is related to a poor prognosis. Encouraging response rates and survival have been reported with intra-arterial (i.a.) chemotherapy and chemo-embolisation, but limited data are available on the association of the two treatment modalities. We therefore started a new programme combining i.a. chemotherapy with chemo-embolisation. The treatment regimen consisted of L-leucovorin (100 mg/m2 i.v.), 5-fluorouracil (800 mg/m2 i.a.), and carboplatin (250 mg/m2 i.a.). Chemo-embolisation with mitoxantrone (10 mg/m2) plus ethiodized oil followed immediately. The same treatment plus gelatin sponge was given after 28 days. 26 patients entered the study and were evaluable for response and side-effects. Main patient characteristics were: males 21, females 5: median age 68 years (range 42-76 years); stage TNM II-III 17, IVA 9; Child's A 12, Child's B 14; elevated baseline alpha-fetoprotein 17; cirrhosis 25. 14 patients had a partial response (54%; 95% confidence interval 33-73%), 3 had stabilisation and 9 had progressive disease. Median survival was 11 months (range 2-20+). 16 patients had grade I-II pain and 15 grade I-II fever. Our results indicate that the regimen is safe, well tolerated and capable of inducing objective remissions in a high percentage of patients with hepatocellular carcinoma.