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Predictors of Successful Yttrium-90 Radioembolization Bridging or Downstaging in Patients with Hepatocellular Carcinoma. Can J Gastroenterol Hepatol 2021; 2021:9926704. [PMID: 34336728 PMCID: PMC8324378 DOI: 10.1155/2021/9926704] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/05/2021] [Revised: 04/28/2021] [Accepted: 07/01/2021] [Indexed: 02/08/2023] Open
Abstract
PURPOSE This study aims to identify clinical and imaging prognosticators associated with the successful bridging or downstaging to liver transplantation (LT) in patients undergoing Yttrium-90 radioembolization (Y90-RE) for hepatocellular carcinoma (HCC). METHODS Retrospectively, patients with Y90-RE naïve HCC who were candidates or potential candidates for LT and underwent Y90-RE were included. Patients were then divided into favorable (maintained or achieved Milan criteria (MC) eligibility) or unfavorable (lost eligibility or unchanged MC ineligibility) cohorts based on changes to their MC eligibility after Y90-RE. Penalized logistic regression analysis was performed to identify the significant baseline prognosticators. RESULTS Between 2013 and 2018, 135 patients underwent Y90-RE treatment. Among the 59 (42%) patients within MC, LT eligibility was maintained in 49 (83%) and lost in 10 (17%) patients. Within the 76 (56%) patients outside MC, eligibility was achieved in 32 (42%) and unchanged in 44 (58%). Among the 81 (60%) patients with a favorable response, 16 (20%) went on to receive LT. Analysis of the baseline characteristics revealed that lower Albumin-Bilirubin score, lower Child-Pugh class, lower Barcelona Clinic Liver Cancer stage, HCC diagnosis using dynamic contrast-enhanced imaging on CT or MRI, normal/higher albumin levels, decreased severity of tumor burden, left lobe HCC disease, and absence of HBV-associated cirrhosis, baseline abdominal pain, or fatigue were all associated with a higher likelihood of bridging or downstaging to LT eligibility (p's < 0.05). CONCLUSION Certain baseline clinical and tumor characteristics are associated with the successful bridging or downstaging of potential LT candidates with HCC undergoing Y90-RE.
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Jiang Y, He J, Li Y, Guo Y, Tao H. The Diagnostic Value of MicroRNAs as a Biomarker for Hepatocellular Carcinoma: A Meta-Analysis. BIOMED RESEARCH INTERNATIONAL 2019; 2019:5179048. [PMID: 31871941 PMCID: PMC6907051 DOI: 10.1155/2019/5179048] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 08/10/2019] [Revised: 10/15/2019] [Accepted: 11/05/2019] [Indexed: 12/24/2022]
Abstract
BACKGROUND Recently, the role of microRNAs (miRNAs) in diagnosing cancer has been attracted increasing attention. However, few miRNAs have been applied in clinical practice. The purpose of this study was to evaluate the diagnostic efficacy of miRNAs for hepatocellular carcinoma (HCC) at early stages clinically. METHODS A literature search was carried out using PubMed, Web of Science, and EMBASE databases. We explored the diagnostic value of miRNAs in distinguishing HCC from healthy individuals. The quality assessment was performed in Review Manager 5.3 software. The overall sensitivity and specificity and 95% confidence intervals (CIs) were obtained with random-effects models through Stata 14.0 software. And heterogeneity was assessed using Q test and I 2 statistics. Meta-regression and subgroup analyses were conducted based on the sample, nation, quality of studies, and miRNA profiling. The publication bias was evaluated through Deeks' funnel plot. RESULTS A total of 34 studies, involving in 2747 HCC patients and 2053 healthy individuals, met the inclusion criteria in the 33 included literature studies. In the summary receiver operating characteristic (sROC) curve, AUC was 0.92 (95% CI, 0.90-0.94), with 0.84 (95% CI, 0.79-0.88) sensitivity and 0.87 (95% CI, 0.83-0.90) specificity. There was no publication bias (P=0.48). CONCLUSION miRNAs in vivo can be acted as a potential diagnostic biomarker for HCC, which can facilitate the early diagnosis of HCC in clinical practice.
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Affiliation(s)
- Yao Jiang
- Department of Clinical Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Jimin He
- Department of Neurosurgery, Suining Central Hospital, Suining, China
| | - Yiqin Li
- Department of Clinical Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, China
| | - Yongcan Guo
- Clinical Laboratory of Traditional Chinese Medicine Hospital, Southwest Medical University, Luzhou, China
| | - Hualin Tao
- Department of Clinical Laboratory Medicine, The Affiliated Hospital of Southwest Medical University, Luzhou, China
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Shin J, Yu JH, Jin YJ, Chae MH, Yoon CH, Lee JW. Comparison of survival outcomes of alcohol-related hepatocellular carcinoma with or without liver cirrhosis; a ten-year experience. Medicine (Baltimore) 2019; 98:e18020. [PMID: 31764818 PMCID: PMC6882638 DOI: 10.1097/md.0000000000018020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/06/2018] [Revised: 06/11/2019] [Accepted: 10/16/2019] [Indexed: 02/06/2023] Open
Abstract
We evaluated overall survivals (OSs) of alcohol-related hepatocellular carcinoma (HCC) patients without LC compared to those with LC.Between 2005 and 2015, 1343 patients were initially diagnosed as having HCC in our hospital. Of these, 186 alcohol-related HCC patients were enrolled in this study, and their medical records were retrospectively analyzed. Significant alcohol intake was defined as more than 210 grams/week for men and more than 140 grams/week for women.Non-cirrhotic HCC was observed in 37.1% of the 186 patients. Cumulative OS rates were significantly higher in non-cirrhotic patients (P = .006). For the 117 cirrhotic patients, cumulative OS rate was significantly higher in the CTP class A patients than in the CTP class B (P < .001) or CTP class C (P < .001) patients, respectively. In the 69 non-cirrhotic patients, cumulative OS rate was significantly higher in the CTP class A patients than in the CTP class C patients (P < .001), but, not than in the CTP class B patients (P = .157). Multivariate analyses revealed that CTP class B (P < .001), CTP class C (P < .001), and tumor size (P = .006) were significant predictors for OS in cirrhotic patients, and that CTP class C (P = .002) and tumor size (P = .023) were significant predictors for OS in non-cirrhotic patients.OS was found to be better for non-cirrhotic than cirrhotic patients with alcohol-related HCC. Survivals of alcohol-related HCC patients without cirrhosis were comparable between patients with CTP class A and B.
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Al Mahtab M, Rahim MA, Noor-E-Alam SM, Alam MA, Khondaker FA, Moben AL, Ghosh J, Khan MSI. Treatment by Transarterial Chemoembolization and Sorafenib for Hepatocellular Carcinoma vs Advanced Hepatocellular Carcinoma in Bangladesh: A Real-life Situation. Euroasian J Hepatogastroenterol 2019; 9:63-66. [PMID: 32117692 PMCID: PMC7047312 DOI: 10.5005/jp-journals-10018-1300] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/14/2023] Open
Abstract
Background Although there are thousands of patients with hepatocellular carcinoma (HCC) in Bangladesh, almost there is no nationwide recommendations for therapeutic maneuver for HCC patients. As most of the HCC patients of Bangladesh are diagnosed late, patients with advanced HCC with large and multiple HCC nodules represent the usual presentation of HCC. The study is presented here to assess the effects of a combined therapy of transarterial chemoembolization (TACE) and sorafenib in advanced HCC patients. Materials and methods A total of 77 patients with advanced HCC were enrolled in this study. All of them had advanced HCC with variable etiologies and clinical conditions. All patients were treated by TACE and also given systemic sorafenib at the same time. The patients were checked 1 and 3 months after therapy commencement. Results Out of 77 patients, 18 patients died within 1 month and additional 15 patients died within 3 months after therapy commencement. Thus, there remains 44 surviving patients after 3 months. When different parameters of dead patients and survived patients were compared, no specific parameters dictated the factors about overall survival of more than 3 months. Discussion This is the first approach to initiate an invasive and a systemic therapy for treatment of advanced HCC in Bangladesh. Further follow-up of patients and their long-term overall survival may cast some lights about the role of these therapies in Bangladeshi HCC patients. How to cite this article Al Mahtab, M, Rahim MA, Noor-E-Alam SM, et al. Treatment by Transarterial Chemoembolization and Sorafenib for Hepatocellular Carcinoma vs Advanced Hepatocellular Carcinoma in Bangladesh: A Real-life Situation. Euroasian J Hepato-Gastroenterol 2019;9(2):63–66.
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Affiliation(s)
- Mamun Al Mahtab
- Department of Hepatology, Bangabandhu Sheikh Mujib Medical University, Dhaka, Bangladesh
| | - Md Abdur Rahim
- Department of Hepatology, Abdul Malek Ukil Medical College, Noakhali, Bangladesh
| | | | | | | | | | - Jhumur Ghosh
- Department of Medicine, MH Samorita Hospital and Medical College, Dhaka, Bangladesh
| | - Md Sakirul Islam Khan
- Department of Anatomy and Embryology, Graduate School of Medicine, Ehime University, Toon, Ehime, Japan
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Li YF, Yuan YY, Zhang YM, Zhao N, Zhang Q, Meng FX, Gao RP, Yu BF, Zhang YH, Guo R, Wang HL, Xie J, Xu J, Qin Q, Dong XS. HSVtk/GCV system on hepatoma carcinoma cells: Construction of the plasmid pcDNA3.1‑pAFP-TK and targeted killing effect. Mol Med Rep 2017; 16:764-772. [PMID: 28560395 PMCID: PMC5482189 DOI: 10.3892/mmr.2017.6657] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/05/2016] [Accepted: 03/17/2017] [Indexed: 12/17/2022] Open
Abstract
Previous studies demonstrated that herpes simplex virus thymidine kinase (HSVtk) could phosphorylate non-toxic gancyclovir (GCV) efficiently to produce phosphorylated products that result in cell apoptosis, to kill tumor cells. The present study aimed to construct a plasmid vector, pcDNA3.1-pAFP-TK, carrying the suicide gene driven by the alpha-fetoprotein (AFP) promoter, to investigate the cytotoxicity of HSVtk/GCV suicide gene system on hepatoma carcinoma cells. Reverse transcription-polymerase chain reaction and western blotting results demonstrated that the HSVtk gene was effectively expressed in HepG2 hepatoma carcinoma cells transfected with pcDNA3.1-pAFP-TK plasmid, whereas HSVtk gene expression was not detected in normal HL-7702 liver cells. In addition, MTT assays indicated that cell viability of HepG2 cells with the plasmid pcDNA3.1-pAFP-TK decreased in a dose-dependent manner following treatment with GCV for 48 h. Flow cytometry also revealed that the cell apoptosis rate and mitochondrial membrane potential reduction rate in the HepG2 cells treated with HSVtk/GCV suicide gene system were significantly higher than in the control group. Apoptosis rates in the control group and the pcDNA3.1-pAFP-TK group were (1.00±0.62%) and (38.70±6.03%), respectively. Mitochondrial membrane potential reduction rates in the control group and the pcDNA3.1-pAFP-TK group were (0.57±0.11%) and (22.84±5.79%), respectively. Caspase-3 staining demonstrated that activated caspase-3 increased significantly in the HepG2 cells treated with HSVtk/GCV suicide gene system, whereas in the control group activated caspase-3 increase was not observed. The results of the present study, therefore, indicated that HSVtk suicide gene was obviously expressed in the HepG2 cells and that the HSVtk/GCV system was effective at killing HepG2 hepatoma carcinoma cells.
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Affiliation(s)
- Yong-Fang Li
- Department of Biochemistry and Molecular Biology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Yang-Yang Yuan
- Department of Biochemistry and Molecular Biology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Ying-Min Zhang
- Department of Biochemistry and Molecular Biology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Na Zhao
- Department of Biochemistry and Molecular Biology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Qi Zhang
- Department of Biochemistry and Molecular Biology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Fan-Xiu Meng
- Department of Biochemistry and Molecular Biology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Ran-Peng Gao
- Department of Biochemistry and Molecular Biology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Bao-Feng Yu
- Department of Biochemistry and Molecular Biology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Yue-Hong Zhang
- Department of Biochemistry and Molecular Biology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Rui Guo
- Department of Biochemistry and Molecular Biology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Hai-Long Wang
- Department of Biochemistry and Molecular Biology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Jun Xie
- Department of Biochemistry and Molecular Biology, Shanxi Medical University, Taiyuan, Shanxi 030001, P.R. China
| | - Jun Xu
- Department of General Surgery, Affiliated Tumor Hospital of Shanxi Medical University, Taiyuan, Shanxi 030013, P.R. China
| | - Qin Qin
- Central Laboratory, Shanxi Provincial People's Hospital, Shanxi Medical University, Taiyuan, Shanxi 030012, P.R. China
| | - Xiu-Shan Dong
- Department of General Surgery, Shanxi Dayi Hospital, Taiyuan, Shanxi 030032, P.R. China
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Chang CH, Chen SJ, Liu CY. Risk of Developing Depressive Disorders following Hepatocellular Carcinoma: A Nationwide Population-Based Study. PLoS One 2015; 10:e0135417. [PMID: 26295711 PMCID: PMC4546687 DOI: 10.1371/journal.pone.0135417] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2015] [Accepted: 07/21/2015] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND & AIMS To evaluate the risk of depressive disorders among patients with Hepatocellular Carcinoma (HCC) using the National Health Insurance Research Database (NHIRD) in Taiwan. METHODS We conducted a retrospective study of a newly diagnosed HCC cohort of 55,973 participants who were selected from the NHIRD. Patients were observed for a maximum of 6 years to determine the rates of newly onset depressive disorders, and Cox regression was used to identify the risk factors associated with depressive disorders in HCC patients. RESULTS Of the total 55,973 HCC patients, 1,041 patients (1.86%) were diagnosed with depressive disorders during a mean (SD) follow-up period of 1.1 (1.2) years. The Cox multivariate proportional hazards analysis showed that age of 40-59 (HR 1.376, 95% CI 1.049-1.805, p = 0.021), age of 60-79 (HR 1.341, 95% CI 1.025-1.753, p = 0.032), women (HR 1.474 95% CI 1.301-1.669, p < 0.001), metastasis (HR 1.916, 95% CI 1.243-2.953, p = 0.003), and HCV (HR 1.445, 95% CI 1.231-1.697, p < 0.001) were independent risk factors for developing depressive disorders. CONCLUSIONS Our study indicated a subsequent risk of depressive disorders in patients with HCC, and the risk increased for those with female gender, aged 40 to 59, aged 60 to 79, with metastasis, or with HCV. Psychological evaluation and support are two critical issues in these HCC patients with the risk factors.
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Affiliation(s)
- Chun-Hung Chang
- Department of Psychiatry, China Medical University Hospital, Taichung, Taiwan
- Institute of Clinical Medicine, China Medical University, Taichung, Taiwan
| | - Shaw-Ji Chen
- Department of Psychiatry, Mackay Memorial Hospital Taitung Branch, Taitung, Taiwan
- Mackay Junior College of Medicine, Nursing, and Management, Taipei, Taiwan
- Institute of Medical Sciences, Tzu Chi University, Hualien, Taiwan
| | - Chieh-Yu Liu
- Institute of Nursing-Midwifery, National Taipei University of Nursing and Health Sciences, Taipei, Taiwan
- * E-mail:
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Li C, Wu X, Zhang H, Yang G, Hao M, Sheng S, Sun Y, Long J, Hu C, Sun X, Li L, Zheng J. A Huaier polysaccharide restrains hepatocellular carcinoma growth and metastasis by suppression angiogenesis. Int J Biol Macromol 2015; 75:115-20. [PMID: 25597429 DOI: 10.1016/j.ijbiomac.2015.01.016] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2014] [Revised: 11/26/2014] [Accepted: 01/08/2015] [Indexed: 01/16/2023]
Abstract
Hepatocellular carcinoma (HCC) is a highly metastatic cancer. Huaier polysaccharide (TP-1) is a naturally occurring bioactive macromolecule, found in Huaier fungus and has been shown to exert in vitro antitumor and antimetastasis for HCC, but no study has addressed in vivo efficacy and mechanisms of action. Presently, we found that TP-1 at doses of 0.5, 1 and 2mg/kg significantly inhibited tumor growth and metastasis to the lung in mice bearing HCC SMMC-7721 tumors without toxicity. The analysis of tumors by immunohistochemistry demonstrated that TP-1 inhibited PCNA expression, increased the number of TUNEL-positive cells and reduced microvessel density (MVD) to achieve this effect. Furthermore, TP-1 administration reduced the protein expression of hypoxia-inducible factor (HIF)-1alpha, vascular endothelial growth factor (VEGF), AUF-1 and AEG-1, in tumor tissues. Taken together, our data suggested that the antitumor and anti-metastatic activities of TP-1 might be at least partially through down-regulation of HIF-1alpha/VEGF and AUF-1/AEG-1 signaling pathways.
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Affiliation(s)
- Cong Li
- Intervention Therapy Center of Liver Diseases, Beijing You An Hospital, Capital Medical University, Beijing 100069, China
| | - Xia Wu
- Department of Infectious Disease, the Second Affiliated Hospital of Harbin Medical University, Huanghe Road, Harbin 150081, China.
| | - Honghai Zhang
- Intervention Therapy Center of Liver Diseases, Beijing You An Hospital, Capital Medical University, Beijing 100069, China
| | - Gengxia Yang
- Intervention Therapy Center of Liver Diseases, Beijing You An Hospital, Capital Medical University, Beijing 100069, China
| | - Meijun Hao
- Intervention Therapy Center of Liver Diseases, Beijing You An Hospital, Capital Medical University, Beijing 100069, China
| | - Shoupeng Sheng
- Intervention Therapy Center of Liver Diseases, Beijing You An Hospital, Capital Medical University, Beijing 100069, China
| | - Yu Sun
- Intervention Therapy Center of Liver Diseases, Beijing You An Hospital, Capital Medical University, Beijing 100069, China
| | - Jiang Long
- Intervention Therapy Center of Liver Diseases, Beijing You An Hospital, Capital Medical University, Beijing 100069, China
| | - Caixia Hu
- Intervention Therapy Center of Liver Diseases, Beijing You An Hospital, Capital Medical University, Beijing 100069, China
| | - Xicai Sun
- School of Medicine, Tsinghua Center for Life Sciences, Tsinghua University, Beijing 100084, China
| | - Li Li
- Institute of Liver Diseases, Beijing You An Hospital, Capital Medical University, Beijing 100069, China
| | - Jiasheng Zheng
- Intervention Therapy Center of Liver Diseases, Beijing You An Hospital, Capital Medical University, Beijing 100069, China.
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Liu Y, Wang Y, Zhang C, Zhou P, Liu Y, An T, Sun D, Zhang N, Wang Y. Core-shell nanoparticles based on pullulan and poly(β-amino) ester for hepatoma-targeted codelivery of gene and chemotherapy agent. ACS APPLIED MATERIALS & INTERFACES 2014; 6:18712-18720. [PMID: 25289563 DOI: 10.1021/am504203x] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/03/2023]
Abstract
This study designs a novel nanoparticle system with core-shell structure based on pullulan and poly(β-amino) ester (PBAE) for the hepatoma-targeted codelivery of gene and chemotherapy agent. Plasmid DNA expressing green fluorescent protein (pEGFP), as a model gene, was fully condensed with cationic PBAE to form the inner core of PBAE/pEGFP polycomplex. Methotrexate (MTX), as a model chemotherapy agent, was conjugated to pullulan by ester bond to synthesize polymeric prodrug of MTX-PL. MTX-PL was then adsorbed on the surface of PBAE/pEGFP polycomplex to form MTX-PL/PBAE/pEGFP nanoparticles with a classic core-shell structure. MTX-PL was also used as a hepatoma targeting moiety, because of its specific binding affinity for asialoglycoprotein receptor (ASGPR) overexpressed by human hepatoma HepG2 cells. MTX-PL/PBAE/pEGFP nanoparticles realized the efficient transfection of pEGFP in HepG2 cells and exhibited significant inhibitory effect on the cell proliferation. In HepG2 tumor-bearing nude mice, MTX-PL/PBAE/pEGFP nanoparticles were mainly distributed in the tumor after 24 h postintravenous injection. Altogether, this novel codelivery system with a strong hepatoma-targeting property achieved simultaneous delivery of gene and chemotherapy agent into tumor at both cellular and animal levels.
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Affiliation(s)
- Yuanyuan Liu
- Tianjin Cancer Institute and Hospital, Laboratory of Breast Cancer Prevention and Therapy, Ministry of Education, Research Center of Basic Medical Science & School of Pharmacy, Tianjin Key Laboratory on Technologies Enabling Development of Clinical Therapeutics and Diagnostics (Theranostics), Tianjin Medical University , No. 22 Qixiangtai Road, Heping District, Tianjin 300070, People's Republic of China
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Gandhi S, Khubchandani S, Iyer R. Quality of life and hepatocellular carcinoma. J Gastrointest Oncol 2014; 5:296-317. [PMID: 25083303 DOI: 10.3978/j.issn.2078-6891.2014.046] [Citation(s) in RCA: 27] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2014] [Accepted: 06/25/2014] [Indexed: 12/29/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is a common and rapidly fatal cancer ranking third among the leading causes of cancer-related deaths. Potentially curative therapies like surgery, transplant and ablation are not an option for most patients as they are often diagnosed when the disease is advanced. Liver directed therapy and oral targeted therapies are used in these patients to prolong life and palliate symptoms of the cancer and associated liver failure. Overall survival remains poor and hence health-related quality of life (HRQoL) is of paramount importance in these patients. As novel therapies are developed to improve outcomes, a comprehensive knowledge of available tools to assess impact on QoL is needed. Hence we reviewed all the studies in HCC patients published within the last 13 years from 2001-2013 which assessed HRQoL as a primary or secondary endpoint. A total of 45 studies and 4 meta-analysis were identified. Commonly used tools were European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) (15 studies) and the Functional Assessment of Cancer Therapy-Hepatobiliary Questionnaire (FACT-Hep) (14 studies). Of the 45 publications which incorporated HRQoL as end-point only 24 were clinical trials, 17/24 (71%) assessed systemic therapies while 7/24 (29%) assessed liver-directed therapies. Majority of the publications (trials + retrospective reviews) that had HRQoL as an endpoint in HCC patients were studies evaluating liver-directed therapies (23/45 or >50%). We discuss the measures included in the tools, their interpretation, and summarize existing QoL data that will help design future HCC trials.
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Affiliation(s)
- Shipra Gandhi
- 1 Department of Internal Medicine, University at Buffalo, NY, USA ; 2 Department of Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Sapna Khubchandani
- 1 Department of Internal Medicine, University at Buffalo, NY, USA ; 2 Department of Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA
| | - Renuka Iyer
- 1 Department of Internal Medicine, University at Buffalo, NY, USA ; 2 Department of Oncology, Roswell Park Cancer Institute, Buffalo, NY, USA
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Mitochondria-targeted antioxidant and glycolysis inhibition: synergistic therapy in hepatocellular carcinoma. Anticancer Drugs 2014; 24:881-8. [PMID: 23872912 DOI: 10.1097/cad.0b013e32836442c6] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
Abstract
Hepatocellular carcinoma (HCC) is the third leading cause of cancer-related deaths worldwide. Mito-carboxy proxyl (Mito-CP), a lipophilic cationic nitroxide, accumulates in the mitochondria because of the large negative transmembrane potential. Studies have shown that these agents act by disrupting the energy-producing mechanism, inducing mitochondrial-mediated apoptosis, and also enhancing the action of other chemotherapeutic agents in cancer cells. We hypothesized that the combination of Mito-CP and glycolysis inhibitor, 2-deoxyglucose (2-DG), would synergistically inhibit HCC in vitro. HepG2 cells and primary hepatocytes were treated with various combinations of Mito-CP and 2-DG. Cell cytotoxicity was measured using the methylthiazolyldiphenyl-tetrazolium bromide assay and ATP bioluminescence assay. In addition, caspase 3/7 enzymatic activity was examined after treatment. Mito-CP and 2-DG induced synergistic cytotoxicity in HepG2 cells in a dose-dependent and time-dependent manner, whereas primary cells remained viable and unaffected after treatment. The intracellular ATP levels of HepG2 cells were suppressed within 6 h of combination treatment, whereas primary cells maintained higher levels of ATP. Dose-dependent increases in caspase 3/7 activity occurred in HepG2 cells in a time-dependent manner, showing the initiation of cell death through the apoptotic pathway. These findings indicate that a combination of Mito-CP and 2-DG effectively inhibits HCC growth in vitro. The increase in caspase 3/7 activity supports the occurrence of 2-DG-induced and Mito-CP-induced apoptotic death in HCC. The inability of the compounds to induce cytotoxicity or suppress the production of ATP in primary hepatocytes provides a selective and synergistic approach for the treatment of HCC.
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Shaker MK, Abdella HM, Khalifa MO, El Dorry AK. Epidemiological characteristics of hepatocellular carcinoma in Egypt: a retrospective analysis of 1313 cases. Liver Int 2013; 33:1601-6. [PMID: 23714212 DOI: 10.1111/liv.12209] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2013] [Accepted: 04/29/2013] [Indexed: 12/19/2022]
Abstract
BACKGROUND & AIMS Hepatocellular carcinoma (HCC) is one of the most common malignant tumours worldwide. Egypt has the highest prevalence of HCV in the world and the prevalence of HCC is increasing in the last years. The aim was to study epidemiological characteristics of HCC in Egypt. METHODS Retrospective chart review of 1456 Egyptian patients with HCC was done. Records of 1313 patients (1035 males, 278 females; median age 56 years) fulfilling diagnostic criteria for HCC were analysed for clinical, aetiological, radiological and tumour characteristics. RESULTS The majority of cases (75%) were from rural areas. The most frequent age category affected by HCC was between 51 and 60 years (45.7%); 50% of the patients reported accidental discovery of their hepatic focal lesions. The major presenting symptom was newly developed right hypochondrial pain (66.3%). HCV Ab was detected in 91.32% of the studied patients while HVB infection was reported in 2.51%. 59.3% of patients had AFP levels below 200 ng/ml (the diagnostic level). On studying tumour characteristics, the right lobe of the liver was more frequently occupied by the focal lesions (75.4%) than the left lobe (15.7%) and 12.5% of patients had bilobar affection. Five hundred and six patients (38.6%) had more than one hepatic focal lesion and 228 patients (17.4%) had tumours occupying >50% of the liver. CONCLUSION HCC is a major health problem in Egypt and its incidence is increasing. The high prevalence of HCV infection makes screening programmes and surveillance of those patients a very important tool to early detect cases of small HCCs.
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Affiliation(s)
- Mohamed K Shaker
- Tropical Medicine Department, Ain Shams University, Cairo, Egypt
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Wang HY, Jeng LB, Lin MC, Chao CH, Lin WY, Kao CH. 18F-FDG PET/CT in detection of gynecomastia in patients with hepatocellular carcinoma. Clin Imaging 2013; 37:942-6. [PMID: 23809917 DOI: 10.1016/j.clinimag.2013.01.004] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2012] [Revised: 11/05/2012] [Accepted: 01/16/2013] [Indexed: 10/26/2022]
Abstract
OBJECTIVE We retrospectively investigate the prevalence of gynecomastia as false-positive 2-[18F]fluoro-2-deoxy-d-glucose (18F-FDG) positron emission tomography (PET)/computed tomography (CT) imaging in patients with hepatocellular carcinoma (HCC). METHODS Among the 127 male HCC patients who underwent 18F-FDG PET/CT scan, the 18FDG uptakes at the bilateral breasts in 9 patients with gynecomastia were recorded as standard uptake value (SUVmax) and the visual interpretation in both early and delayed images. RESULTS The mean early SUVmax was 1.58/1.57 (right/left breast) in nine gynecomastia patients. The three patients with early visual score of 3 had higher early SUVmaxs. CONCLUSION Gynecomastia is a possible cause of false-positive uptake on 18F-FDG PET/CT images.
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Affiliation(s)
- Hsin-Yi Wang
- Department of Nuclear Medicine, Taichung Veterans General Hospital, Taichung 40705, Taiwan; Department of Life Sciences, National Chung Hsing University, Taichung 40227, Taiwan
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Gentile NM, McKenzie KM, Hurt RT. Two rare forms of hepatocellular carcinoma metastases. BMJ Case Rep 2013; 2013:bcr-2013-008886. [PMID: 23761493 DOI: 10.1136/bcr-2013-008886] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
An 80-year-old man with known metastatic hepatocellular carcinoma, not on current treatment, was presented with bleeding gingival and penile masses. Bleeding from both sites was able to be controlled with local treatment and subsequent discontinuation of his clopidogrel. The gingival mass was biopsied and was found consistent with metastatic hepatocellular carcinoma. Owing to the concern of recurrent bleeding, the penile mass was not biopsied. Given the significant progression of his disease, the patient was discharged to hospice care.
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Qiao CX, Zhai XF, Ling CQ, Lang QB, Dong HJ, Liu Q, Li MD. Health-related quality of life evaluated by tumor node metastasis staging system in patients with hepatocellular carcinoma. World J Gastroenterol 2012; 18:2689-94. [PMID: 22690079 PMCID: PMC3370007 DOI: 10.3748/wjg.v18.i21.2689] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2011] [Revised: 02/06/2012] [Accepted: 02/16/2012] [Indexed: 02/06/2023] Open
Abstract
AIM: To investigate and evaluate the change in health-related quality of life (HRQoL) by tumor node metastasis (TNM) staging system in patients with hepatocellular carcinoma (HCC).
METHODS: A total of 140 patients diagnosed with HCC between June 2008 and April 2009 in our department were enrolled to this study. One hundred and thirty-five (96.5%) patients had liver cirrhosis secondary to hepatitis B virus (HBV) infection, 73 (54.07%) of them being HBV DNA positive; the other etiologies of liver cirrhosis were alcoholic liver disease (1.4%), hepatitis C (1.4%) or cryptogenic (0.7%). All subjects were fully aware of their diagnosis and provided informed consent. HRQoL was assessed before treatment using the functional assessment of cancer therapy-hepatobiliary (FACT-Hep) questionnaire. Descriptive statistics were used to evaluate demographics and disease-specific characteristics of the patients. One-way analysis of variance and independent samples t tests were used to compare the overall FACT-Hep scores and clinically distinct TNM stages. Scores for all FACT-Hep items were analyzed by frequency analyses. The mean scores obtained from the FACT-Hep in different Child-Pugh classes were also evaluated.
RESULTS: The mean FACT-Hep scores were reduced significantly from TNM Stage I to Stage II, Stage IIIA, Stage IIIB group (687 ± 39.69 vs 547 ± 42.57 vs 387 ± 51.24 vs 177 ± 71.44, P = 0.001). Regarding the physical and emotional well-being subscales, scores decreased gradually from Stage I to Stage IIIB (P = 0.002 vs Stage I; P = 0.032 vs Stage II; P = 0.033 vs Stage IIIA). Mean FACT-Hep scores varied by Child-Pugh class, especially in the subscales of physical well-being, functional well-being and the hepatobiliary cancer (P = 0.001 vs Stage I; P = 0.036 vs Stage II; P = 0.032 vs Stage IIIA). For the social and family well-being subscale, only Stage IIIB scores were significantly lower as compared with Stage I scores (P = 0.035). For the subscales of functional well-being and hepatobiliary cancer, there were significant differences for Stages IIΙ, IIIA and IIIB (P = 0.002 vs Stage I).
CONCLUSION: HRQoL of patients with HCC worsens gradually with progression of TNM stages. The most impaired subscales of HRQoL, as measured by FACT-Hep, were physical and emotional well-being.
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Kim BR, Jeon YK, Nam MJ. A mechanism of apigenin-induced apoptosis is potentially related to anti-angiogenesis and anti-migration in human hepatocellular carcinoma cells. Food Chem Toxicol 2011; 49:1626-32. [PMID: 21515330 DOI: 10.1016/j.fct.2011.04.015] [Citation(s) in RCA: 34] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2011] [Revised: 04/08/2011] [Accepted: 04/11/2011] [Indexed: 10/18/2022]
Abstract
Apigenin (APG) has been shown to have a strong anti-cancer effect on various cancer models via a programmed cell death, apoptosis. However, the fundamental mechanisms of these effects are still unclear. In the present study, we examined the question of whether or not APG can inhibit proliferation of hepatocellular carcinoma (HCC), huh-7 cells, resulting in apoptosis. In APG-treated cells, we observed typical features of apoptosis. To identify the proteins related to APG-induced apoptosis, we performed two-dimensional electrophoresis analysis and identified differentially expressed proteins. Among these proteins, we focused on vimentin, which plays a physiological role, such as cell migration and adhesion. We validated expression of vimentin in both mRNA and protein levels, verifying its decrease. In addition, we observed that APG down-regulated the expression levels of type I collagen, which collaborated with vimentin in cell migration and decreased the releasing amounts of VEGF and MMP-8, which are closely relevant to angiogenic activity. Finally, we confirmed the decreased capacity of cell migration due to down-regulation of vimentin, type I collagen, VEGF, and MMP-8 induced by APG. Based on the overall results, we suggested that vimentin was potentially associated with APG-induced apoptosis, as a key regulator in angiogenesis and migration.
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Affiliation(s)
- Bo Ra Kim
- Department of Biological Science, Gachon University of Medicine and Science, 534-2 Yeonsu-dong, Yeonsu-go, Incheon 406-799, Republic of Korea
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Zhu M, Wang N, Tsao SW, Yuen MF, Feng Y, Wan TSK, Man K, Feng Y. Up-regulation of microRNAs, miR21 and miR23a in human liver cancer cells treated with Coptidis rhizoma aqueous extract. Exp Ther Med 2010; 2:27-32. [PMID: 22977465 DOI: 10.3892/etm.2010.164] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2010] [Accepted: 11/01/2010] [Indexed: 12/18/2022] Open
Abstract
Coptidis rhizoma (CR; Huanglian in Chinese) has been used for the treatment of cancer in Chinese medicine, and recent studies have supported its use in cancer therapy. MicroRNAs (miRNAs) play an important role in the pathophysiology of human cancers. We examined alterations in the miRNA profile of hepatocellular carcinoma (HCC) cells after treatment with Coptidis rhizoma aqueous extract (CRAE). An on-chip microarray method was used to detect alterations in the expression profile of miRNAs in human HCC MHCC97-L cells after exposure to 175 μg/ml CRAE. Altered expression of several miRNAs was detected in the MHCC97-L cells after treatment with 175 μg/ml CRAE. The microarray results were validated by quantitative real-time PCR (qRT-PCR). Consistent results were obtained; qRT-PCR confirmed that both miR-21 and miR-23a were significantly up-regulated. TargetScan and PicTar microRNA databases were used to predict the possible target genes of the altered miRNAs. The results showed that the altered miRNAs after CRAE treatment may serve as markers for the therapy of liver cancer. To the best of our knowledge, this is the first report on the up-regulation of miRNAs, miR21 and miR23a in human liver cancer cells treated with CRAE. Our results suggest that CRAE targets miR-21 and miR-23a in liver cancer cells supporting the potential application of CRAE in the treatment of HCC.
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Health-related quality of life in patients with hepatocellular carcinoma: a systematic review. Clin Gastroenterol Hepatol 2010; 8:559-64.e1-10. [PMID: 20304101 DOI: 10.1016/j.cgh.2010.03.008] [Citation(s) in RCA: 87] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/19/2010] [Revised: 03/09/2010] [Accepted: 03/10/2010] [Indexed: 02/07/2023]
Abstract
BACKGROUND & AIMS This systematic review was conducted to identify the following: (1) generic and disease-specific measures used to assess health-related quality of life (HRQOL) in patients with hepatocellular carcinoma (HCC); (2) HRQOL in patients with HCC compared with those with chronic liver disease and the general population; (3) effects of treatment (liver surgery, hepatic artery transcatheter treatment, and radiotherapy) on HRQOL; (4) relationships between physical variables, symptoms, and HRQOL; (5) relationships between demographic characteristics, psychological variables, and HRQOL; and (6) effects of psychological interventions on HRQOL. METHODS Computerized databases including British Nursing Index, Cumulative Index to Nursing and Allied Health Literature, Cochrane library, PsychoINFO, and Pubmed were searched. RESULTS Thirty-six articles were identified. The results suggested the following. Four original articles described the development of standardized measures to assess liver cancer-specific HRQOL. Patients with HCC reported worse physical, emotional, and functional HRQOL, but better social/family HRQOL compared with the general population. HRQOL improved after liver surgery, hepatic artery transcatheter treatment, and radiotherapy. Better liver function, early stage of disease, and no recurrence were correlated positively with better HRQOL; and pain, fatigue, nausea, and performance status were associated with worse HRQOL. HRQOL was correlated negatively with depression, uncertainty, chance health locus of control, and positively with satisfaction with medical services. Psychosocial interventions may reduce negative feelings and enhance HRQOL. CONCLUSIONS Future work should explore the effects of psychological variables on HRQOL and the interaction between physical and psychological variables in relation to HRQOL.
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Sauerland C, Engelking C, Wickham R, Pearlstone DB. Cancers of the Pancreas and Hepatobiliary System. Semin Oncol Nurs 2009; 25:76-92. [DOI: 10.1016/j.soncn.2008.10.006] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
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Abstract
Hepatocellular carcinoma (HCC) annually causes about one million deaths. Because of advanced stage at diagnosis, HCC carries a five-year survival rate of less than 5% in patients diagnosed with unresectable disease. Incidence for HCC is higher in men and individuals of Asian descent, where viral hepatitis, a leading cause of HCC, is endemic. This article will provide an overview of the complex symptom management of patients with HCC. The occurrence of multiple symptoms, including pain, fatigue, weight loss, and obstructive syndromes (e.g., ascites, jaundice) in patients with HCC is common. Because of limitations in the efficacy of current treatment options, aggressive symptom management is key to preserving physical functioning and quality of life in patients with HCC. A multidisciplinary team approach to symptom management of patients with HCC is critical, with oncology nurses playing an integral role.
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Affiliation(s)
- Virginia Chih-Yi Sun
- Department of Nursing Research and Education in Division of Population Sciences, City of Hope National Medical Center, Duarte, CA, USA.
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Yin XY, Jiang JM, Liu JY, Zhu JR. Effects of endogenous nitric oxide induced by 5-fluorouracil and L-Arg on liver carcinoma in nude mice. World J Gastroenterol 2007; 13:6249-53. [PMID: 18069768 PMCID: PMC4171238 DOI: 10.3748/wjg.v13.i46.6249] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM: To study the effects of endogeous nitric oxide induced by 5-fluorouracil (5-FU) and L-arginine (L-Arg) on the human liver carcinoma model in nude mice.
METHODS: The human liver carcinoma model in nude mice was established with BEL-7402 cells and normal saline (NS), 5-FU and 5-FU + L-Arg injected intraperitoneally. The tumor size was measured. The necrotic degree and range were observed under microscope. The apoptosis of cancer cell was detected by turmina deoxynucleotidyl transferanse mediated dUTP nick end labeling (TUNEL) method. Immunohistochemical method was performed to determine the expression of iNOS, P16, BAX. The chemical colorimetry was used to test the activity and nitrate reductase method was adopted to test the concentration of nitric oxide (NO) in the tumor tissue. The BI2000 pathological image analyzer was used to analyze the result of immunohistochemistry.
RESULTS: 5-FU combined with L-Arg could inhibit the tumor growth apparently. In NS, 5-FU and 5-FU+L-Arg groups, the changes of tumor volumes were 257.978 ± 59.0, 172.232 ± 66.0 and 91.523 ± 26.7 mm3, respectively (P < 0.05 5-FU vs 5-FU + L-Arg group; P < 0.05 NS vs 5-FU + L-Arg group; P < 0.05, NS vs 5-FU group). The necrotic range and apoptosis index were significantly increased after the drug injection. The necrotic range was biggest in 5-FU + L-Arg group (χ2 = 15.963, P < 0.05).
The apoptosis indexes were as follows: NS, 17.4% ± 6.19%; 5-FU, 31.3% ± 12.3%; and 5-FU + L-Arg, 46% ± 15.24% (P < 0.05, 5-FU vs 5-FU + L-Arg; P < 0.05, NS vs 5-FU + L-Arg; P < 0.05, NS vs 5-FU). The expression and activity of iNOS were increased in the tumor tissue. The concentration of NO was also increased. F of optical density of iNOS, iNOS activity and NO concentration are 31.693, 21.949, and 33.909, respectively, P < 0.05. The concentration of NO was related to the expression of P16 and BAX. The correlation coefficient was 0.764 and 0.554.
CONCLUSION: 5-FU combined with L-Arg can inhibit the growth of tumor in nude mice. The effect may be related to inducing the synthesis and increasing the activity of iNOS. The production of NO is increased, and it can enhance the expression of apoptosis-related gene and antioncogene.
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Maki A, Kono H, Gupta M, Asakawa M, Suzuki T, Matsuda M, Fujii H, Rusyn I. Predictive power of biomarkers of oxidative stress and inflammation in patients with hepatitis C virus-associated hepatocellular carcinoma. Ann Surg Oncol 2007; 14:1182-90. [PMID: 17195915 DOI: 10.1245/s10434-006-9049-1] [Citation(s) in RCA: 105] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND This study evaluated the relationship between inflammation, intra-hepatic oxidative stress, oxidative DNA damage and the progression of liver carcinogenesis in hepatitis C virus (HCV)-infected humans. METHODS Non-cancerous liver tissues were collected from 30 patients with an HCV-associated solitary hepatocellular carcinoma (HCC) who received curative tumor removal. After surgery, the patients were followed at monthly intervals at the outpatient clinic. Distribution of the inflammatory cells (CD68+), the number of 8-hydroxydeoxyguanosine (8-OHdG) DNA adducts and 4-hydroxynonenal (HNE) protein adducts and the expression of apurinic/apyrimidinic endonuclease (APE) were determined by immunohistochemical analysis in serial liver sections from tumor-free parenchyma at the surgical margin around the tumor. RESULTS Significant positive correlations were observed between the number of CD68+ cells, the amount of HNE protein adducts, and the number of 8-OHdG adducts in liver tissue of patients with HCC and HCV. The cumulative disease-free survival was significantly shorter in patients with the highest percentage of 8-OHdG-positive hepatocytes. Using a Cox proportional hazard model, 8-OHdG, HNE and CD68 were determined to be good biomarkers for predicting disease-free survival in patients with HCC and HCV. CONCLUSIONS These results support the hypothesis that HCV-induced inflammation causes oxidative DNA damage and promotes hepatocarcinogenesis which directly affects the clinical outcome. Since patients with greater intra-hepatic oxidative stress had a higher incidence of HCC recurrence, we suggest that oxidative stress biomarkers could potentially be used as a useful clinical diagnostic tool to predict the duration of disease-free survival in patients with HCV-associated HCC.
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Affiliation(s)
- Akira Maki
- Department of Environmental Sciences and Engineering, School of Public Health, University of North Carolina at Chapel Hill, CB #7431, Chapel Hill, North Carolina 27599, USA
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Abstract
Hepatocellular carcinoma (HCC) is the fifth most common cause of all malignancies and causes approximately one million deaths each year. Surgical liver resection is the only cure for HCC; however, few patients are eligible to undergo this procedure. Hepatic artery chemoembolization (HACE) is a technique that delivers high concentrations of chemotherapeutic agents and blocks the blood supply to the liver for prolonged periods of time. HACE has demonstrated an overall increase in survival. The HACE procedure, pre- and postprocedure complications, and the care required by patients with HCC are critical for oncology nurses to understand.
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Affiliation(s)
- Bridget A Cahill
- Department of Medicine, Northwestern Medical Faculty Foundation, Chicago, IL, USA.
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