Radiofrequency Ablation Versus Stereotactic Body Radiotherapy for Localized Hepatocellular Carcinoma in Nonsurgically Managed Patients: Analysis of the National Cancer Database

Predicting Regional Recurrence and Prognosis in Stereotactic Body Radiation Therapy-Treated Clinical Stage I Non-small Cell Lung Cancer Using a Radiomics Model Constructed With Surgical Data

PURPOSE

Risk stratification of regional recurrence (RR) is clinically important in the design of adjuvant treatment and surveillance strategies in patients with clinical stage I non-small cell lung cancer (NSCLC) treated with stereotactic body radiation therapy (SBRT). This study aimed to develop a radiomics model predicting occult lymph node metastasis (OLNM) using surgical data and apply it to the prediction of RR in SBRT-treated early-stage NSCLC patients.

METHODS AND MATERIALS

Patients with clinical stage I NSCLC who underwent curative surgery with systematic lymph node dissection from January 2013 to December 2018 (the training cohort) and from January 2019 to December 2020 (the validation cohort) were included. A preoperative computed tomography-based radiomics model, a clinical feature model, and a fusion model predicting OLNM were constructed. The performance of the 3 models was quantified and compared in the training and validation cohorts. Subsequently, the radiomics model was used to predict RR in a cohort of consecutive SBRT-treated early-stage NSCLC patients from 2 academic medical centers.

RESULTS

A total of 769 patients were included. Eight computed tomography features were identified in the radiomics model, achieving areas under the curves of 0.85 (95% CI, 0.81-0.89) and 0.83 (95% CI, 0.80-0.88) in the training and validation cohorts, respectively. Nevertheless, adding clinical features did not improve the performance of the radiomics model. With a median follow-up of 40.0 (95% CI, 35.2-44.8) months, 32 of the 213 patients in the SBRT cohort developed RR and those in the high-risk group based on the radiomics model had a higher cumulative incidence of RR (P < .001) and shorter regional recurrence-free survival (P = .02), progression-free survival (P = .004) and overall survival (P = .006) than those in the low-risk group.

CONCLUSIONS

The radiomics model based on pathologically confirmed data effectively identified patients with OLNM, which may be useful in the risk stratification among SBRT-treated patients with clinical stage I NSCLC.

Exploring the molecular mechanism of Artemisia rupestris L. for the treatment of hepatocellular carcinoma via PI3K/AKT pathway

ETHNOPHARMACOLOGICAL RELEVANCE

Hepatocellular carcinoma (HCC) is a common gastrointestinal malignancy in China. Most tumors develop from chronic inflammation. Artemisia rupestris L. (ARL) has been found to have a significant effect on viral influenza and hepatitis, but the mechanism of action of ARL against liver cancer is unclear.

AIM OF THE STUDY

The study objective was to explore the mechanism of action of ARL for the treatment of hepatocellular carcinoma (HCC) by ethanol extract and in vitro experimental design.

MATERIALS AND METHODS

Interactions between ARL and cellular target proteins against HCC were analyzed through network pharmacology and network topology with the utilization of the DAVID database. The rate of HepG2 cells' growth inhibition was assessed using the MTT assay in vitro cellular assay; hoechst33342 detects apoptosis of cells; the ability of HepG2 cells to migrate and invade was assessed using the transwell assay and the cell scratch experiment; and the levels of protein expression in HepG2 cells were assessed using the western blot assay.

RESULTS

Network pharmacology prediction results demonstrated that 22 active ingredients were tested, 176 possible action targets were discovered, and the PI3K/Akt signaling pathway was found to be the most pertinent action pathway for the treatment of hepatocellular carcinoma. In vitro results showed that it can effectively restrict HepG2 cell proliferation, apoptosis, migration, and invasion as well as the regulation of protein expressions.

CONCLUSION

Conclusively, Quercetin, Linarin, and Kaempferol were found most essential active ingredients from ARL that regulate the antitumor effects against HCC through the PI3K/Akt signaling pathway. The study provides a fundamental basis for further comprehensive evaluation of ARL to treat tumor diseases in general and its therapeutic potential against hepatocellular carcinoma in particular.

Multidisciplinary treatment of hepatocellular carcinoma in 2023: Italian practice Treatment Guidelines of the Italian Association for the Study of the Liver (AISF), Italian Association of Medical Oncology (AIOM), Italian Association of Hepato-Bilio-Pancreatic Surgery (AICEP), Italian Association of Hospital Gastroenterologists (AIGO), Italian Association of Radiology and Clinical Oncology (AIRO), Italian Society of Pathological Anatomy and Diagnostic Cytology (SIAPeC-IAP), Italian Society of Surgery (SIC), Italian Society of Gastroenterology (SIGE), Italian Society of Medical and Interventional Radiology (SIRM), Italian Organ Transplant Society (SITO), and Association of Patients with Hepatitis and Liver Disease (EpaC) - Part II - Non-surgical treatments

Worldwide, hepatocellular carcinoma (HCC) is the third most common cause of cancer-related death. The remarkable improvements in treating HCC achieved in the last years have increased the complexity of its management. Following the need to have updated guidelines on the multidisciplinary treatment management of HCC, the Italian Scientific Societies involved in the management of this cancer have promoted the drafting of a new dedicated document. This document was drawn up according to the GRADE methodology needed to produce guidelines based on evidence. Here is presented the second part of guidelines, focused on the multidisciplinary tumor board of experts and non-surgical treatments of HCC.

Deep learning based automatic internal gross target volume delineation from 4D-CT of hepatocellular carcinoma patients

BACKGROUND

The location and morphology of the liver are significantly affected by respiratory motion. Therefore, delineating the gross target volume (GTV) based on 4D medical images is more accurate than regular 3D-CT with contrast. However, the 4D method is also more time-consuming and laborious. This study proposes a deep learning (DL) framework based on 4D-CT that can achieve automatic delineation of internal GTV.

METHODS

The proposed network consists of two encoding paths, one for feature extraction of adjacent slices (spatial slices) in a specific 3D-CT sequence, and one for feature extraction of slices at the same location in three adjacent phase 3D-CT sequences (temporal slices), a feature fusion module based on an attention mechanism was proposed for fusing the temporal and spatial features. Twenty-six patients' 4D-CT, each consisting of 10 respiratory phases, were used as the dataset. The Hausdorff distance (HD95), Dice similarity coefficient (DSC), and volume difference (VD) between the manual and predicted tumor contour were computed to evaluate the model's segmentation accuracy.

RESULTS

The predicted GTVs and IGTVs were compared quantitatively and visually with the ground truth. For the test dataset, the proposed method achieved a mean DSC of 0.869 ± 0.089 and an HD95 of 5.14 ± 3.34 mm for all GTVs, with under-segmented GTVs on some CT slices being compensated by GTVs on other slices, resulting in better agreement between the predicted IGTVs and the ground truth, with a mean DSC of 0.882 ± 0.085 and an HD95 of 4.88 ± 2.84 mm. The best GTV results were generally observed at the end-inspiration stage.

CONCLUSIONS

Our proposed DL framework for tumor segmentation on 4D-CT datasets shows promise for fully automated delineation in the future. The promising results of this work provide impetus for its integration into the 4DCT treatment planning workflow to improve hepatocellular carcinoma radiotherapy.

Risk prediction and treatment assessment in glioma patients using SEER database: a prospective observational study

OBJECTIVES

To use a nomogram to predict the risk of mortality and estimate the impact of current treatment on the prognosis of glioma patients.

METHODS

A total of 3798 cases were obtained from the Surveillance Epidemiology and End Results database according to the selection criteria. A nomogram was built on the independent clinical factors screened by the variance inflation factor, univariate analyses and a multivariate Cox regression model. Then, categorising the overall population into high-risk, medium-risk and low-risk groups using nomogram-derived risk scores, to study the impact of treatment on different subgroups' survival outcomes. Furthermore, based on the postmatch cohorts, the influences of treatment on survival outcomes were assessed by the log-rank test.

RESULT

Age, race, stage of disease, histological type, histological grade, surgery, radiotherapy and chemotherapy were identified as the independent prognostic factors. A nomogram with good discrimination and consistency was built. Generally, the patients who underwent surgery, radiotherapy and chemotherapy were more likely to achieve better prognosis than those who did not, except for those who received radiotherapy in the low-risk cohort and those who underwent surgery in the high-risk cohort. Furthermore, the isocitrate dehydrogenase 1/2 (IDH1/2) wild-type patients with surgery, radiotherapy or chemotherapy tended to have higher survival probabilities, while some inconsistent results were observed in the IDH mutant-type cohort.

CONCLUSION

Surgery, radiotherapy and chemotherapy improved the prognosis, while appropriate selection of topical treatment for the low-risk or high-risk patients deserves further consideration. IDH status gene might be a reliable indicator of therapeutic effectiveness.

Combination treatment of HCC with SBRT and immune checkpoint inhibition

The treatment of unresectable or metastatic HCC has been significantly advanced in recent years by developments in both radiotherapy and systemic cancer therapies. Independently, both Stereotactic Ablative Body Radiotherapy (SBRT) and Immune Checkpoint Inhibitors (ICIs) are licensed for the treatment of these tumours. Building on the successes seen in other solid tumours, there is significant interest in exploring combination treatments. In this review article we briefly present the evidence base for the use of these treatments in patients with HCC. With reference to our current understanding of the immuno-oncology and radiobiology of HCCs, we demonstrate why combining these two modalities is of interest. Finally, we discuss the clinical trials that are currently underway or planned and the direction that future research may take.

A prospective registry study of stereotactic magnetic resonance guided radiotherapy (MRgRT) for primary liver tumors

BACKGROUND AND PURPOSE

Stereotactic body radiation therapy (SBRT) has demonstrated safe and effective results for primary liver tumors. Magnetic Resonance guided Radiotherapy (MRgRT) is an innovative radiotherapy modality for abdominal tumors. The aim of this study is to report on acute and late toxicities and initial oncological results for primary liver tumors treated with MRgRT.

MATERIALS AND METHODS

We prospectively included in our cohort all patients treated by MRgRT for a primary liver tumor at the Montpellier Cancer Institute. The primary endpoint was acute and late toxicities assessed according to CTCAE v 5.0. The mean prescribed dose was 50 Gy in 5 fractions.

RESULTS

Between October 2019 and April 2022, MRgRT treated 56 patients for 72 primary liver lesions. No acute or late toxicities of CTCAE grade greater than 2 attributable to radiotherapy were noted during follow-up. No cases of radiation-induced liver disease (RILD), either classical or non-classical, occurred. After a median follow-up of 13.2 months (95% CI [8.8; 15.7]), overall survival was 85.1% (95% CI: [70.8; 92.7]) at 1 year and 74.2% at 18 months (95% CI [52.6; 87.0]). Local control was 98.1% (95% CI: [87.4; 99.7]) and 94.7% (95% CI: [79.5; 98.7]) at 12 and 18 months, respectively. Among the HCC subgroup, no local recurrences were observed.

CONCLUSION

MRgRT for primary liver tumors is safe without severe adverse events and reach excellent local control. Numerous studies are underway to better assess the value of MRI guidance and adaptive process in these indications.

Loco-regional therapies competing with radiofrequency ablation in potential indications for hepatocellular carcinoma: a network meta-analysis

BACKGROUND/AIMS

There is no clear consensus on the relative ranking of interventional and radiation techniques with indications similar to those of radiofrequency ablation (RFA) for the treatment of early hepatocellular carcinoma (HCC). We used a network meta-analysis to compare the efficacy of non-surgical treatments for early HCC.

METHODS

We searched databases for randomized trials assessing the efficacy of loco-regional treatments for HCCs ≤5 cm with no extrahepatic spread or portal invasion. The primary outcome was the pooled hazard ratio (HR) for overall survival (OS), and secondary outcomes included overall and local progression-free survival (PFS). A frequentist network meta-analysis was performed, and the relative ranking of therapies was assessed with P-scores.

RESULTS

Nineteen studies comparing 11 different strategies in 2,793 patients were included. Chemoembolization plus RFA improved OS better than RFA alone (HR 0.52, 95% confidence interval [CI] 0.33-0.82; P-score=0.951). Cryoablation, microwave ablation, laser ablation, and proton beam therapy had similar effects on OS compared with RFA. For overall PFS, but not local PFS, only chemoembolization plus RFA performed significantly better than RFA (HR 0.61, 95% CI 0.42-0.88; P-score=0.964). Injection of percutaneous ethanol or acetic acid was significantly less effective than RFA for all measured outcomes, while no differences in progression outcomes were identified for other therapies included in the network.

CONCLUSION

Our results suggest that chemoembolization combined with RFA is the best option for local treatment of early HCC. Cases with potential contraindications for RFA may benefit from a tailored approach using thermal or radiation modalities.

Therapeutic Outcome of Stereotactic Body Radiotherapy for Small Hepatocellular Carcinoma Lesions - A Systematic Review and Network Meta-analysis

Surgical resection, stereotactic body radiotherapy (SBRT) and radiofrequency ablation (RFA) have seldom been compared for small hepatocellular carcinoma (HCC). We explored the treatment outcomes of SBRT for small HCC by conducting a network meta-analysis (NMA). We compared the efficacy and safety of surgical resection, RFA and SBRT for liver-confined small HCC (three or fewer lesions with a diameter ≤5 cm). The study endpoint included the odds ratios of the 1-, 3- and 5-year progression/recurrence/disease-free survival (disease progression-free survival; DPFS) and overall survival rates, as well as severe complications. Forty-five studies included 21 468 patients. In the NMA with comparable data, SBRT had comparable 1-, 3- and 5-year DPFS but significantly worse pooled long-term overall survival (3- and 5-year overall survival) than surgical resection (odds ratio 1.39, 95% confidential interval 1.3-1.89; odds ratio 1.33, 95% confidence interval 1.06-1.69, respectively). SBRT was associated with significantly better pooled 1-year DPFS compared with RFA (odds ratio 0.39, 95% confidence interval 0.15-0.97), with the remaining outcomes being comparable. SBRT had significantly less incidence of severe complications compared with surgical resection (odds ratio 0.62, 95% confidence interval 0.42-0.88) and RFA (odds ratio 0.2, 95% confidence interval 0.03-0.94). In conclusion, for small HCCs (≤5 cm) with one to three nodules, SBRT may be favourable to reduce the risks of severe complications. In terms of DPFS, SBRT may be recommended as an alternative first-line therapy for RFA and surgical resection. The results regarding overall survival should be interpreted with caution, considering the potentially uneliminated bias. There is a clear need for well-designed randomised trials to conclusively identify real differences in efficacy between these treatments, especially SBRT and surgical resection.

Thermal ablation compared to stereotactic body radiation therapy for hepatocellular carcinoma: A multicenter retrospective comparative study

BACKGROUND AIMS

Early-stage HCC can be treated with thermal ablation or stereotactic body radiation therapy (SBRT). We retrospectively compared local progression, mortality, and toxicity among patients with HCC treated with ablation or SBRT in a multicenter, US cohort.

APPROACH RESULTS

We included adult patients with treatment-naïve HCC lesions without vascular invasion treated with thermal ablation or SBRT per individual physician or institutional preference from January 2012 to December 2018. Outcomes included local progression after a 3-month landmark period assessed at the lesion level and overall survival at the patient level. Inverse probability of treatment weighting was used to account for imbalances in treatment groups. The Cox proportional hazard modeling was used to compare progression and overall survival, and logistic regression was used for toxicity. There were 642 patients with 786 lesions (median size: 2.1 cm) treated with ablation or SBRT. In adjusted analyses, SBRT was associated with a reduced risk of local progression compared to ablation (aHR 0.30, 95% CI: 0.15-0.60). However, SBRT-treated patients had an increased risk of liver dysfunction at 3 months (absolute difference 5.5%, aOR 2.31, 95% CI: 1.13-4.73) and death (aHR 2.04, 95% CI: 1.44-2.88, p < 0.0001).

CONCLUSIONS

In this multicenter study of patients with HCC, SBRT was associated with a lower risk of local progression compared to thermal ablation but higher all-cause mortality. Survival differences may be attributable to residual confounding, patient selection, or downstream treatments. These retrospective real-world data help guide treatment decisions while demonstrating the need for a prospective clinical trial.

Breakthroughs in Hepatocellular Carcinoma Therapies

Several breakthroughs in hepatocellular carcinoma (HCC) therapy across tumor stages provide hope to improve its dismal prognosis. Although surgical and local ablative therapies have few significant changes in technique, an improved understanding of tumor biology has facilitated increase numbers of patients who are now eligible to undergo curative-intent procedures. Most notably, acceptable post-transplant outcomes can be achieved in well selected patients whose tumors are downstaged into Milan Criteria. Adjuvant therapy in patients at high risk of recurrence also significantly improves recurrence-free survival after resection or ablation. For patients with liver-localized disease who are not eligible for curative-intent procedures, transarterial chemoembolization (TACE) was historically the treatment modality of choice, regardless of tumor burden; however, there is now increased recognition of patients who are "TACE unsuitable" and may be better treated with systemic therapy. The greatest evolution in HCC treatment options has occurred with systemic therapy, where several new agents are now available in the first- and second-line setting, including immune checkpoint inhibitor combinations. Objective responses are observed in approximately 30% of patients and median survival is approaching 2 years. The availability of immune checkpoint inhibitors has renewed interest in combination therapies for earlier tumor stages, with several phase III trials ongoing. Considering increasing complexities of HCC care, requiring decisions between therapies delivered by different providers, multidisciplinary care is critical and is associated with improved clinical outcomes. In this review, we detail major breakthroughs in HCC therapy, how these breakthroughs can be applied in clinical practice, and remaining areas in need of further research.

Local Therapies for Hepatocellular Carcinoma and Role of MRI-Guided Adaptive Radiation Therapy

Hepatocellular carcinoma (HCC) is the most common liver tumor, with a continually rising incidence. The curative treatment for HCC is surgical resection or liver transplantation; however, only a small portion of patients are eligible due to local tumor burden or underlying liver dysfunction. Most HCC patients receive nonsurgical liver-directed therapies (LDTs), including thermal ablation, transarterial chemoembolization (TACE), transarterial radioembolization (TARE), and external beam radiation therapy (EBRT). Stereotactic ablative body radiation (SABR) is a specific type of EBRT that can precisely deliver a high dose of radiation to ablate tumor cells using a small number of treatments (or fractions, typically 5 or less). With onboard MRI imaging, MRI-guided SABR can improve therapeutic dose while minimizing normal tissue exposure. In the current review, we discuss different LDTs and compare them with EBRT, specifically SABR. The emerging MRI-guided adaptive radiation therapy has been reviewed, highlighting its advantages and potential role in HCC management.

Stereotactic Body Radiation Therapy versus Surgical Resection for Stage I/II Hepatocellular Carcinoma

SBRT is an emerging locoregional treatment modality for hepatocellular carcinoma (HCC). Although local tumor control rates seem encouraging, large-scale survival data comparing SBRT to surgical resection are lacking. We identified patients with stage I/II HCC from the National Cancer Database amenable for potential surgical resection. Patients undergoing hepatectomy were matched by propensity score (1:2) with patients who underwent SBRT as primary treatment. A total of 3787 (91%) and 366 (9%) patients underwent surgical resection or SBRT between 2004 and 2015, respectively. After propensity matching, the 5-year overall survival was 24% (95% CI 19-30%) in the SBRT group versus 48% (95% CI 43-53%) in the surgery group (p < 0.001). The association of surgery with overall survival was consistent in all subgroups. In patients treated with SBRT, a biologic effective dose (BED) of ≥100 Gy (31%, 95% CI 22%-40%) compared with BED < 100 Gy (13%, 95% CI 8-22%) was associated with a higher 5-year overall survival rate (hazard ratio of mortality of 0.58, 95% CI 0.43-0.77; p < 0.001). Surgical resection may be associated with prolonged overall survival compared with SBRT in patients with stage I/II HCC.

Cathepsin H Knockdown Reverses Radioresistance of Hepatocellular Carcinoma via Metabolic Switch Followed by Apoptosis

Despite the wide application of radiotherapy in HCC, radiotherapy efficacy is sometimes limited due to radioresistance. Although radioresistance is reported with high glycolysis, the underlying mechanism between radioresistance and cancer metabolism, as well as the role of cathepsin H (CTSH) within it, remain unclear. In this study, tumor-bearing models and HCC cell lines were used to observe the effect of CTSH on radioresistance. Proteome mass spectrometry, followed by enrichment analysis, were used to investigate the cascades and targets regulated by CTSH. Technologies such as immunofluorescence co-localization flow cytometry and Western blot were used for further detection and verification. Through these methods, we originally found CTSH knockdown (KD) perturbed aerobic glycolysis and enhanced aerobic respiration, and thus promoted apoptosis through up-regulation and the release of proapoptotic factors such as AIFM1, HTRA2, and DIABLO, consequently reducing radioresistance. We also found that CTSH, together with its regulatory targets (such as PFKL, HK2, LDH, and AIFM1), was correlated with tumorigenesis and poor prognosis. In summary, our study found that the cancer metabolic switch and apoptosis were regulated by CTSH signaling, leading to the occurrence of radioresistance in HCC cells and suggesting the potential value of HCC diagnosis and therapy.

Clinical consensus statement: Establishing the roles of locoregional and systemic therapies for the treatment of intermediate-stage hepatocellular carcinoma in Canada

BACKGROUND

Hepatocellular carcinoma (HCC) a leading cause of cancer mortality worldwide and approximately one-third of patients present with intermediate-stage disease. The treatment landscape of intermediate-stage HCC is rapidly evolving due to developments in local, locoregional and systemic therapies. Treatment recommendations focused on this heterogenous disease stage and that take into account the Canadian reality are lacking. To address this gap, a pan-Canadian group of experts in hepatology, transplant, surgery, radiation therapy, nuclear medicine, interventional radiology, and medical oncology came together to develop consensus recommendations on management of intermediate-stage HCC relevant to the Canadian context.

METHODS

A modified Delphi framework was used to develop consensus statements with strengths of recommendation and supporting levels of evidence graded using the AHA/ACC classification system. Tentative consensus statements were drafted based on a systematic search and expert input in a series of iterative feedback cycles and were then circulated via online survey to assess the level of agreement.

RESULTS & CONCLUSION

The pre-defined ratification threshold of 80 % agreement was reached for all statements in the areas of multidisciplinary treatment (n = 4), intra-arterial therapy (n = 14), biologics (n = 5), radiation therapy (n = 3), surgical resection and transplantation (n = 7), and percutaneous ablative therapy (n = 4). These generally reflected an expansion in treatment options due to developments in previously established or emergent techniques, introduction of new and more active therapies and increased therapeutic flexibility. These developments have allowed for greater treatment tailoring and personalization as well as a paradigm shift toward strategies with curative intent in a wider range of disease settings.

Short- and long-term outcomes of laparoscopic versus open liver resection for large hepatocellular carcinoma: a propensity score study

PURPOSE

Laparoscopic liver resection (LLR) for hepatocellular carcinoma (HCC) remains controversial, especially for tumors larger than 5 cm. We compared the short- and long-term outcomes of laparoscopic and open liver resection (OLR) for large HCC.

METHODS

Patients with large HCC after curative hepatectomy were enrolled. To compare the short-term outcomes, propensity score matching (PSM) and inverse probability treatment weighting (IPTW) were performed to reduce the effect of confounding factors, respectively. Subsequently, Cox-regression analyses were conducted to identify the independent risk factors associated with decreased recurrence-free survival (RFS) and poor overall survival (OS).

RESULT

There were 265 patients enrolled in the final analysis: 146 who underwent OLR and 119 who underwent LLR. There was no significant difference between the OLR and LLR groups according to PSM and IPTW analysis (all P > 0.05). Multivariable analysis revealed that LLR was not independently associated with poorer OS (HR 1.15, 95% CI 0.80-1.67, P = 0.448) or RFS (HR 1.22, 95% CI 0.88-1.70, P = 0.238).

CONCLUSION

There were no significant differences in perioperative complications or long-term prognosis between LLR and OLR for large HCC, which provides evidence for standard laparoscopic surgical practice with adequate surgeon experience and careful patient selection.

Radiofrequency ablation versus stereotactic body radiation therapy for hepatocellular carcinoma: a meta-regression

Aim: The aim of this meta-regression was to assess the impact of mean/median age, mean/median tumor size, percentage of males in total sample, and total sample size on the comparative effectiveness of radiofrequency ablation (RFA) and stereotactic body radiation therapy (SBRT). Methods: Ten studies reporting on the composite outcome of overall survival and local control were included. Results: A significant relationship was found between age and overall survival at 1 and 2 for both RFA and SBRT. A significant relationship was noted also between age and local control at 1 and 2 years for RFA. Conclusion: Patients treated with SBRT had a wider range of tumor sizes and larger tumor sizes; no relationship was observed between tumor size and overall survival or local control by SBRT.

Evaluation of the Clinical Efficacy of Intensity-Modulated Radiotherapy Combined with Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma with Extrahepatic Oligometastasis and Prognostic Factors for Patient Survival

Objective

To investigate the clinical efficacy of intensity-modulated radiotherapy (IMRT) combined with transcatheter arterial chemoembolization (TACE) in hepatocellular carcinoma (HCC) patients with extrahepatic oligometastasis and the prognosis of patients receiving this treatment.

Patients and Methods

Twenty-one HCC patients with extrahepatic oligometastasis were retrospectively analyzed; seven patients received IMRT only, and 14 received IMRT plus TACE. TACE treatment was administered before IMRT (50 mg epirubicin, oxaliplatin 100 mg, and mitomycin 10 mg). The short-term efficacy of this treatment and patient prognosis were evaluated.

Results

Complete response (CR) and partial response (PR) in the intrahepatic region were achieved in three and 14 patients, respectively. The objective response rate (ORR) approached 81%. CR and PR were achieved in six and 10 patients with extrahepatic metastases, respectively, for an ORR of 100%. Pain was completely relieved in all patients with bone metastases. The median overall survival (OS) and progression-free survival (PFS) were 21 months and 9.1 months, respectively. The 1-year PFS rate was 43%, and the 1-, 2-, 3-, and 4-year OS rates were 83%, 35%, 9%, and 4%, respectively. Univariate analysis showed that the prognostic factors for patient survival included Child-Pugh class, vascular thrombus, Karnofsky performance status (KPS), radiotherapy dose, ascites, combination therapy, and pattern of progression. Multivariate analysis showed that vascular thrombus, combination therapy, and pattern of failure were prognostic factors for PFS, and the KPS was the only prognostic factor for OS. No grade 3-4 adverse reactions were observed.

Conclusion

IMRT combined with TACE is safe and feasible without major toxicities for the treatment of advanced HCC patients with extrahepatic oligometastasis and results in excellent objective efficacy and a potential survival benefit. The KPS is the only predictive factor for OS. This approach is expected to be a useful palliative option for selected HCC patients with extrahepatic metastases.

SOCS2-enhanced ubiquitination of SLC7A11 promotes ferroptosis and radiosensitization in hepatocellular carcinoma

Radioresistance is a principal culprit for the failure of radiotherapy in hepatocellular carcinoma (HCC). Insights on the regulation genes of radioresistance and underlying mechanisms in HCC are awaiting for profound investigation. In this study, the suppressor of cytokine signaling 2 (SOCS2) were screened out by RNA-seq and bioinformatics analyses as a potential prognosis predictor of HCC radiotherapy and then were determined to promote radiosensitivity in HCC both in vivo or in vitro. Meanwhile, the measurements of ferroptosis negative regulatory proteins of solute carrier family 7 member 11 (SLC7A11) and glutathione peroxidase 4 (GPX4), intracellular lipid peroxidation and Fe²⁺ concentration suggested that a high level of ferroptosis contributed to the radiosensitization of HCC. Moreover, SOCS2 and SLC7A11 were expressed oppositely in HCC clinical tissues and tumour xenografts with different radiosensitivities. Mechanistically, the N-terminal domain of SLC7A11 was specifically recognized by the SH2-structural domain of SOCS2. While the L162 and C166 of SOCS2-BOX region could bind elongin B/C compound to co-form a SOCS2/elongin B/C complex to recruit ubiquitin molecules. Herein, SOCS2 served as a bridge to transfer the attached ubiquitin to SLC7A11 and promoted K48-linked polyubiquitination degradation of SLC7A11, which ultimately led to the onset of ferroptosis and radiosensitization of HCC. In conclusion, it was demonstrated for the first time that high-expressed SOCS2 was one of the biomarkers predicting radiosensitivity of HCC by advancing the ubiquitination degradation of SLC7A11 and promoting ferroptosis, which indicates that targeting SOCS2 may enhance the efficiency of HCC radiotherapy and improve the prognosis of patients.

Stereotactic body radiation therapy versus radiofrequency ablation in hepatocellular carcinoma: an up-date meta-analysis

PURPOSE

Radiofrequency ablation (RFA) and stereotactic body radiotherapy (SBRT) are available locoregional curative treatments for nonsurgical Hepatocellular carcinoma (HCC) patients. We aimed to compare the clinical efficacy and safety of SBRT versus RFA for HCC.

METHODS

A computerized bibliographic search was performed using PubMed, Embase, the Cochrane Library and Web of Science to identify comparative studies. The primary outcome was overall survival (OS), and the secondary outcomes were freedom from local progression (FFLP) and treatment-related complications.

RESULTS

In total, there were 17 trials involving 22,180 patients. Patients receiving RFA showed significantly better 1-, 2- year OS (OR 0.69, 95% CI 0.50-0.96, P = 0.141,OR 0.69, 95% CI 0.53-0.89, P = 0.082), whereas SBRT resulted in significantly better 1-, 2-, 3- year FFLP (OR 2.19, 95% CI 1.44-3.34, P = 0.303; OR 1.57, 95% CI 1.12-2.19, P = 0.268; OR 2.22, 95% CI 1.70-2.90, P = 0.470). There were no significant differences for 3-, 5- year OS in both groups (OR 0.94, 95% CI 0.65-1.38, P = 0.001; OR 0.98, 95% CI 0.68-1.34, P = 0.016). The overall treatment-related complication rate did not differ significantly between the two treatment arms, while SBRT was significantly associated with Child-Pugh worsening.

CONCLUSIONS

Though SBRT has excellent FFLP, RFA yields superior short-term survival for HCC. But the discrepancy between FFLP and OS requires further investigation.

Proton Beam Therapy and Photon-Based Magnetic Resonance Image-Guided Radiation Therapy: The Next Frontiers of Radiation Therapy for Hepatocellular Carcinoma

External beam radiation therapy (EBRT) has increasingly been utilized in the treatment of hepatocellular carcinoma (HCC) due to technological advances with positive clinical outcomes. Innovations in EBRT include improved image guidance, motion management, treatment planning, and highly conformal techniques such as intensity-modulated radiation therapy (IMRT) and stereotactic body radiation therapy (SBRT). Moreover, proton beam therapy (PBT) and magnetic resonance image-guided radiation therapy (MRgRT) have expanded the capabilities of EBRT. PBT offers the advantage of minimizing low- and moderate-dose radiation to the surrounding normal tissue, thereby preserving uninvolved liver and allowing for dose escalation. MRgRT provides the advantage of improved soft tissue delineation compared to computerized tomography (CT) guidance. Additionally, MRgRT with online adaptive therapy is particularly useful for addressing motion not otherwise managed and reducing high-dose radiation to the normal tissue such as the stomach and bowel. PBT and online adaptive MRgRT are emerging technological advancements in EBRT that may provide a significant clinical benefit for patients with HCC.

Bovine Colostrum Treatment of Specific Cancer Types: Current Evidence and Future Opportunities

Worldwide, the incidence of cancer is on the rise. Current cancer treatments include chemotherapy, radiation therapy, and surgery. Chemotherapy and radiation treatment are typically associated with severe adverse effects and a decline in patients' quality of life. Anti-cancer substances derived from plants and animals need to be evaluated therapeutically as it is cost-effective, have fewer side effects, and can improve cancer patients' quality of life. Recently, bovine colostrum (BC) has attracted the interest of numerous researchers investigating its anti-cancer potential in humans. Dressings loaded with BC are beneficial in treating chronic wounds and diabetic foot ulcers. Lactoferrin, a glycoprotein with potent anti-oxidant, anti-inflammatory, anti-cancer, and anti-microbial effects, is abundant in BC. The BC pills successfully promote the regression of low-grade cervical intraepithelial neoplasia when administered intravaginally. The biological, genetic, and molecular mechanisms driving BC remain to be determined. Oral BC supplements are generally well-tolerated, but some flatulence and nausea may happen. To evaluate the therapeutic effects, long-term safety, and appropriate dosages of BC drugs, well-designed clinical trials are necessary. The purpose of this article is to emphasize the anti-cancer potential of BC and its constituents.

Comparison of stereotactic body radiation therapy with hepatic resection and radiofrequency ablation as initial treatment in patients with early-stage hepatocellular carcinoma

BACKGROUND

Stereotactic body radiation therapy (SBRT) has emerged as a novel intervention for early-stage hepatocellular carcinoma (HCC). The outcomes of SBRT, liver resection (LR), and radiofrequency ablation (RFA) as the initial treatment for AJCC stage I HCC patients remain unclear.

METHODS

Patients with AJCC stage I HCC from the Surveillance, Epidemiology and End Results database were analyzed for survival rates using the Kaplan-Meier method and stratified according to tumor size: S subgroup (≤2 cm), M subgroup (>2-3 cm), and L subgroup (>3 cm). For factors including age, year of diagnosis, sex, race, grade, tumor size, AFP, and fibrosis score, propensity score matching was performed to eliminate the imbalance of baseline features and selection bias during groups.

RESULTS

A total of 4,002 patients were included; the difference in median overall survival (mOS) between the SBRT group and the LR or RFA group in the S subgroup was statistically insignificant (p=0.109 and p=0.744), while that of the RFA group was significantly worse than that of the LR group (p <0.001). In the M and L subgroups, the mOS of the SBRT group was worse than that of the RFA group (p=0.040 and p<0.001, respectively). The mOS of LR was the best when compared with either the SBRT or RFA group regardless of the subgroup M or L (all p<0.001).

CONCLUSION

For HCC ≤ 2 cm, SBRT can be used as an alternative treatment for RFA. For patients with HCC larger than 2 cm, RFA can provide better long-term survival than SBRT, while LR remains the best choice.

Stereotactic body radiotherapy versus radiofrequency ablation as initial treatment of small hepatocellular carcinoma

BACKGROUND/AIM

Stereotactic body radiotherapy (SBRT) may be an alternative treatment for patients with small (≤3 cm) hepatocellular carcinomas (HCCs) who were not indicated for resection or local ablation therapy. This study compared the therapeutic effects of radiofrequency ablation (RFA) and SBRT in patients with small (≤3 cm) HCCs.

METHODS

Data of HCC patients who underwent SBRT or RFA as an initial treatment at four tertiary referral hospitals between March 2011 and February 2017 were reviewed. The patient inclusion criteria were a single nodule measuring ≤3 cm in size and not suitable for resection.

RESULTS

SBRT and RFA were performed for 72 (SBRT group) and 134 (RFA group) patients, respectively. The 1-, 3-, and 5-year overall survival (OS) rates were 97.0%, 80.3%, and 80.3%, respectively, in the SBRT group compared with 98.5%, 83.9%, and 80.8%, respectively, in the RFA group, with no significant differences between the groups (P = 0.81). The estimated five-year local control (LC) rate was 68.1% in the SBRT group and 73.1% in the RFA group (P = 0.81). In the SBRT group analysis, both SBRT alone (n = 34) and SBRT combined with transarterial chemoembolization (n = 38) showed no difference with RFA in OS (P = 0.72 and P = 0.90) or LC rate (P = 0.95 and P = 0.68), respectively.

CONCLUSION

SBRT is an effective and safe treatment method for small HCCs, with survival and tumor recurrence rates similar to those of RFA.

ACR Appropriateness Criteria® Management of Liver Cancer: 2022 Update

The treatment and management of hepatic malignancies can be complex because it encompasses a variety of primary and metastatic malignancies and an assortment of local and systemic treatment options. When to use each of these treatments is critical to ensure the most appropriate care for patients. Interventional radiologists have a key role to play in the delivery of a variety of liver directed treatments including percutaneous ablation, transarterial embolization with bland embolic particles alone, transarterial chemoembolization (TACE) with injection of a chemotherapeutic emulsion, and transarterial radioembolization (TARE). Based on 9 clinical variants, the appropriateness of each treatment is described in this document. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Hepatocellular carcinoma

Hepatocellular carcinoma is one of the most common cancers worldwide and represents a major global health-care challenge. Although viral hepatitis and alcohol remain important risk factors, non-alcoholic fatty liver disease is rapidly becoming a dominant cause of hepatocellular carcinoma. A broad range of treatment options are available for patients with hepatocellular carcinoma, including liver transplantation, surgical resection, percutaneous ablation, and radiation, as well as transarterial and systemic therapies. As such, clinical decision making requires a multidisciplinary team that longitudinally adapts the individual treatment strategy according to the patient's tumour stage, liver function, and performance status. With the approval of new first-line agents and second-line agents, as well as the establishment of immune checkpoint inhibitor-based therapies as standard of care, the treatment landscape of advanced hepatocellular carcinoma is more diversified than ever. Consequently, the outlook for patients with hepatocellular carcinoma has improved. However, the optimal sequencing of drugs remains to be defined, and predictive biomarkers are urgently needed to inform treatment selection. In this Seminar, we present an update on the causes, diagnosis, molecular classification, and treatment of hepatocellular carcinoma.

Intelligent Algorithm-Based Ultrasound Images in Evaluation of Therapeutic Effects of Radiofrequency Ablation for Liver Tumor and Analysis on Risk Factors of Postoperative Infection

This research aimed to explore the therapeutic effects of radiofrequency ablation (RFA) for liver tumors and to investigate the postoperative infection factors. Specifically, 80 patients with liver tumors undergoing ultrasound-guided FRA were selected as research subjects. They were diagnosed in the hospital. An intelligent fitting (IF) algorithm was compared with a genetic algorithm (GA) and applied to the RFA of the 80 patients. It was found that the running time of the IF algorithm was about 0.2 times than that of the GA, demonstrating better global searching capabilities. The mean diameter of single liver tumors was (3.45 ± 1.24) cm, and the complete ablation rate of tumors with diameters less than 3 cm was 87.88%, that of tumors with diameters of 3-5 cm was 72.92%, and that of tumors with a diameter of more than 5 cm was 63.33%. Posttreatment, the AST level decreased significantly and the ALB level increased significantly, and the difference was notable (P < 0.05P<); the TBIL level (36.8 ± 9.7 umol/L) was lower than prior treatment (17.9 ± 8.5 umol/L) and the ALT level (45.2 ± 6.8 g/L) was lower than prior treatment (19.6 ± 5.7 g/L), showing a notable difference (P < 0.05P<). The diameter, whether there was great vessel invasion, and TNM staging were associated with infection after RFA, and the difference was notable. The ultrasound images can effectively evaluate the therapeutic effects of RFA and the degree of inactivation of liver tumors. In addition, the tumor stage was an independent risk factor for postoperative infection.

Comparison of radiofrequency ablation and ablative external radiotherapy for the treatment of intrahepatic malignancies: A hybrid meta-analysis

Background & Aims

Radiofrequency ablation (RFA) and ablative external beam radiotherapy (ablative RT) are commonly used to treat small intrahepatic malignancies. We meta-analysed oncologic outcomes and systematically reviewed the clinical consideration of tumour location and size.

Methods

PubMed, Medline, Embase, and Cochrane Library databases were searched on February 24, 2022. Studies comparing RFA and ablative RT, providing one of the endpoints (local control or survival), and encompassing ≥5 patients in each arm were included.

Results

Twenty-one studies involving 4,638 patients were included. Regarding survival, the odds ratio (OR) was 1.204 (p = 0.194, favouring RFA, not statistically significant) among all studies, 1.253 (p = 0.153) among hepatocellular carcinoma (HCC) studies, and 1.002 (p = 0.996) among colorectal cancer metastasis studies. Regarding local control, the OR was 0.458 (p <0.001, favouring ablative RT) among all studies, 0.452 (p <0.001) among HCC studies, favouring the ablative RT arm, and 0.649 (p = 0.484) among colorectal cancer metastasis studies. Pooled 1- and 2-year survival rates for HCC studies were 91.8% and 77.7% after RFA, and 89.0% and 76.0% after ablative RT, respectively; and for metastasis studies were 88.2% and 66.4% after RFA and 82.7% and 60.6% after RT, respectively. Literature analysis suggests that ablative RT can be more effective than RFA for tumours larger than 2-3 cm or for specific sublocations in the liver (e.g. subphrenic or perivascular sites), with moderate quality of evidence (reference to the grading system of the American Society for Radiation Oncology Primary Liver Cancer Clinical Guidelines). The pooled grade ≥3 complication rates were 2.9% and 2.8% in the RFA and ablative RT arms, respectively (p = 0.952).

Conclusions

Our study shows that ablative RT can yield oncologic outcomes similar to RFA, and suggests that it can be more effective for the treatment of tumours in locations where RFA is difficult to perform or for large-sized tumours.

Systematic Review Registration

This study was registered with PROSPERO (Protocol No: CRD42022332997).

Impact and implications

Radiofrequency ablation (RFA) and ablative radiotherapy (RT) are non-surgical modalities for the treatment of small intrahepatic malignancies. Ablative RT showed oncologic outcomes at least similar to those of RFA, and was more effective at specific locations (e.g. perivascular or subphrenic locations).

The Current Role of Stereotactic Body Radiation Therapy (SBRT) in Hepatocellular Carcinoma (HCC)

The role of stereotactic body radiotherapy (SBRT), which can deliver high radiation doses to focal tumors, has greatly increased in not only early-stage hepatocellular carcinoma (HCC), but also in portal vein or inferior vena cava thrombi, thus expanding this therapy to pre-transplantation and the treatment of oligometastases from HCC in combination with immune checkpoint inhibitors (ICI). In early-stage HCC, many promising prospective results of SBRT have been reported, although SBRT is not usually indicated as a first treatment potion in localized HCC according to several guidelines. In the treatment of portal vein or inferior vena cava tumor thrombi, several reports using various dose-fraction schedules have shown relatively good response rates with low toxicities and improved survival due to the rapid advancements in systemic therapy. Although SBRT is regarded as a substitute therapy when conventional bridging therapies to transplantation, such as transarterial chemoembolization (TACE) and radiofrequency ablation (RFA), are not applicable or fail in controlling tumors, SBRT may offer advantages in patients with borderline liver function who may not tolerate TACE or RFA, according to several reports. For oligometastases, the combination of SBRT with ICI could potentially induce an abscopal effect in patients with HCC, which is expected to provide the rationale for SBRT in the treatment of oligometastatic disease in the near future.

The role of stereotactic body radiotherapy in hepatocellular carcinoma: guidelines and evidences

Hepatocellular carcinoma (HCC) is a common malignancy with high mortality rates. While surgery can be curative in early-stage disease, 80% of patients cannot undergo surgical resection. Stereotactic body radiotherapy (SBRT), an emerging, non-invasive, precision treatment, has shown promising results across various stages of HCC and has thus been adopted in practice to varying degrees around the world. This article aims to review current guideline recommendations on SBRT, clinical evidence, and outcome comparisons with other local treatment modalities. Attempts are also made to compare the differences in clinical trials between Asian and Western countries.

Improving on-treatment risk stratification of cancer patients with refined response classification and integration of circulating tumor DNA kinetics

BACKGROUND

Significant intertumoral heterogeneity exists as antitumor treatment is introduced. Heterogeneous therapeutic responses are conventionally evaluated by imaging examinations based on Response Evaluation Criteria in Solid Tumors (RECIST); nevertheless, there are increasing recognitions that they do not fully capture patient clinical benefits. Currently, there is a paucity of data regarding the clinical implication of biological responses assessed by liquid biopsy of on-treatment circulating tumor DNA (ctDNA). Here, we investigated whether biological response evaluated by ctDNA kinetics added critical information to the RECIST, and whether integrating on-treatment biological response information refined risk stratification of cancer patients.

METHODS

In this population-based cohort study, we included 821 patients with Epstein-Barr virus (EBV)-associated nasopharynx of head and neck cancer (NPC) receiving sequential neoadjuvant chemotherapy (NAC) and chemoradiotherapy (CRT), who had pretreatment and on-treatment cfEBV DNA and magnetic resonance imaging (MRI) surveillance. Biological responses evaluated by cfEBV DNA were profiled and compared with conventional MRI-based RECIST evaluation. The inverse probability weighting (IPW)-adjusted survival analysis was performed for major survival endpoints. The Cox proportional hazard regression [CpH]-based model was developed to predict the on-treatment ctDNA-based individualized survival.

RESULTS

Of 821 patients, 71.4% achieved complete biological response (cBR) upon NAC completion. RECIST-based response evaluations had 25.3% discordance with ctDNA-based evaluations. IPW-adjusted survival analysis revealed that cfEBV DNA_post-NAC was a preferential prognosticator for all endpoints, especially for distant metastasis. In contrast, radiological response was more preferentially associated with locoregional recurrence. Intriguingly, cfEBV DNA_post-NAC further stratified RECIST-responsive and non-responsive patients; RECIST-based non-responsive patients with cBR still derived substantial clinical benefits. Moreover, detectable cfEBV DNA_post-NAC had 83.6% prediction sensitivity for detectable post-treatment ctDNA, which conferred early determination of treatment benefits. Finally, we established individualized risk prediction models and demonstrated that introducing on-treatment ctDNA significantly refined risk stratification.

CONCLUSIONS

Our study helps advance the implementation of ctDNA-based testing in therapeutic response evaluation for a refined risk stratification. The dynamic and refined risk profiling would tailor future liquid biopsy-based risk-adapted personalized therapy.

Does HCC Etiology Impact the Efficacy of Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma? An Asian Liver Radiation Therapy Group Study

Background/Purpose

The Asian Liver Radiation Therapy Study Group has formed a large and detailed multinational database of outcomes following stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC). Here, we explored the potential impact of HCC etiology on SBRT efficacy. Tumor control probability (TCP) models were established to estimate the likelihood of local control (LC).

Methods

Data from 415 patients who were treated with SBRT for HCC were reviewed. Cox proportional hazards models were used to identify key predictors of LC. TCP models accounting for biologic effective dose (BED) and tumor diameter were generated to quantify associations between etiology and LC.

Results

Cox models demonstrated that hepatitis C virus (HCV) infection was associated with favorable LC following SBRT (HR=0.52, 95% CI 0.04–0.96, p=0.036). The 2-year LC rate for patients with HCV etiology was 88%, compared to 78% for other patients. Small tumor and high BED were also associated with favorable LC. TCP models demonstrated a 10–20% absolute increase in predicted LC across the range of SBRT doses and tumor sizes.

Conclusion

We found a novel association between HCV status and LC after SBRT for HCC that warrants further exploration. If validated in other datasets, our findings could help clinicians tailor SBRT schedules.

Paradigm shift in the treatment options of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is prevalent worldwide with suboptimal therapeutic outcomes. The advancement of therapeutic options and the development of new systemic therapies expand the armamentarium to tackle HCC. Treatment options should be provided based on the hierarchy of efficacy in a multidisciplinary perspective, instead of the traditional stage-guided scheme. In advanced HCC, lenvatinib has a comparable efficacy as sorafenib for the first-line therapy of HCC; while regorafenib, cabozantinib, and ramucirumab have been approved as second-line therapy after the failure of sorafenib. Immune checkpoint inhibitor therapy prolongs response rate and survival and enables long-term cure. Atezolizumab plus bevacizumab is superior to sorafenib as the first-line therapy for advanced HCC. Several emerging regimens by the combination of various systemic therapies are currently under clinical trials. Systemic therapy may be used in the neoadjuvant, adjuvant or even as initial therapy for intermediate-stage HCC. The paradigm shift of HCC treatment will improve patient outcomes.

Integration of glucose and cardiolipin anabolism confers radiation resistance of HCC

BACKGROUND AND AIMS

Poor response to ionizing radiation (IR) due to resistance remains a clinical challenge. Altered metabolism represents a defining characteristic of nearly all types of cancers. However, how radioresistance is linked to metabolic reprogramming remains elusive in hepatocellular carcinoma (HCC).

APPROACH AND RESULTS

Baseline radiation responsiveness of different HCC cells were identified and cells with acquired radio-resistance were generated. By performing proteomics, metabolomics, metabolic flux, and other functional studies, we depicted a metabolic phenotype that mediates radiation resistance in HCC, whereby increased glucose flux leads to glucose addiction in radioresistant HCC cells and a corresponding increase in glycerophospholipids biosynthesis to enhance the levels of cardiolipin. Accumulation of cardiolipin dampens the effectiveness of IR by inhibiting cytochrome c release to initiate apoptosis. Mechanistically, mammalian target of rapamycin complex 1 (mTORC1) signaling-mediated translational control of hypoxia inducible factor-1α (HIF-1α) and sterol regulatory element-binding protein-1 (SREBP1) remodels such metabolic cascade. Targeting mTORC1 or glucose to cardiolipin synthesis, in combination with IR, strongly diminishes tumor burden. Finally, activation of glucose metabolism predicts poor response to radiotherapy in cancer patients.

CONCLUSIONS

We demonstrate a link between radiation resistance and metabolic integration and suggest that metabolically dismantling the radioresistant features of tumors may provide potential combination approaches for radiotherapy in HCC.

Is hepatocellular carcinoma complicated with portal vein tumor thrombosis potentially curable by radiotherapy in the form of stereotactic body radiation therapy?

PURPOSE

The prognosis of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) is dismal. Despite best treatment and care, the patients with this malignancy only showed 2.7-4 months of overall survival. It is debatable whether liver transplantation helps PVTT sufferers. The effectiveness of radiation therapy in treating HCC patients with PVTT should not be undervalued. By limiting the high dosage region to a small planning target volume, stereotactic radiation delivery has shifted toward hypofractionation, limiting the radiation exposure to healthy organs and tissues. Stereotactic body radiotherapy (SBRT) has a local control rate of 75-100%, depending on the treatment. The major limitation in SBRT for hepatocellular carcinoma with PVTT is the paucity of prospective evidence for longer periods beyond the first two years after treatment. More prospective studies/randomized clinical trials with a longer follow-up, larger sample size, and adequate statistical power are the dire need of the present situation to ascertain the curative effect of SBRT as primary therapy for advanced HCC with PVTT.

CONCLUSION

SBRT can improve survival, particularly for patients receiving multidisciplinary treatment. This review sums up our most current understanding of how radiation therapy, notably SBRT, can be used to treat hepatocellular carcinoma when combined with PVTT. Recent research has led us to believe that irradiation in the form of SBRT may cure hepatocellular carcinoma complicated by PVTT.

Engineering ROS-Responsive Bioscaffolds for Disrupting Myeloid Cell-Driven Immunosuppressive Niche to Enhance PD-L1 Blockade-Based Postablative Immunotherapy

The existence of inadequate ablation remains an important cause of treatment failure for loco-regional ablation therapies. Here, using a preclinical model, it is reported that inadequate microwave ablation (iMWA) induces immunosuppressive niche predominated by myeloid cells. The gene signature of ablated tumor presented by transcriptome analyses is highly correlated with immune checkpoint blocking (ICB) resistance. Thus, an in situ scaffold with synergistic delivery of IPI549 and anti-programmed death-ligand 1 blocking antibody (aPDL1) for postablative cancer immunotherapy is designed and engineered, in which IPI549 capable of targeting myeloid cells could disrupt the immunosuppressive niche and subsequently improve ICB-mediated antitumor immune response. Based on five mouse cancer models, it is demonstrated that this biomaterial system (aPDL1&IPI549@Gel) could mimic a "hot" tumor-immunity niche to inhibit tumor progression and metastasis, and protect cured mice against tumor rechallenge. This work enables a new standard-of-care paradigm for the immunotherapy of myeloid cells-mediated "cold" tumors after loco-regional inadequate practices.

Radiofrequency ablation vs radiation therapy vs transarterial chemoembolization vs yttrium 90 for local treatment of liver cancer - a systematic review and network meta-analysis of survival data

INTRODUCTION

The comparative effectiveness of radiofrequency ablation (RFA), radiation therapy (RT), transarterial chemoembolization (TACE) and transarterial radioembolization with Yttrium-90 (Y90) relative to one another for the treatment of hepatocellular carcinoma (HCC) is unclear. The aim of this systematic review and network meta-analysis is to compare RFA to RT to TACE to Y90 in the treatment of HCC.

METHODS

Pubmed, Embase and Cochrane CENTRAL were searched up until April 19, 2021. Observational analyses with propensity score matched (PSM) cohort analyses and randomized controlled trials (RCT) reporting on two or more treatments relative to one another with respect to overall survival (OS) and/or progression free survival (PFS) were included. Survival data were extracted from Kaplan-Meier survival curves, and meta-analyzed using a multivariate network meta-analysis.

RESULTS

After exclusions, 24 RCTs or PSM observational studies reporting on 5549 patients were included. While 1-year OS was greater for Y90 than TACE (RR 0.85, 95% CI: 0.72-0.99), all other 1-year OS comparisons across the 4 modalities yielded similar OS, and there were no differences across any modalities in 2-year and 3-year OS. TACE had a modest PFS advantage relative to RFA (RR 0.81, 95% CI: 0.68-0.95) and RT (RR 0.65, 95% CI: 0.51-0.83) at 2 years.

CONCLUSION

All modalities assessed resulted in similar OS, which explains the current heterogenous practice patterns. This conclusion may assist in decision making based on administrative and patient costs, and implementation of these modalities. Other factors such as toxicity rate specific to individual patients could not be assessed using network meta-analysis and may also play a role in selection of modality. Further studies, ideally using PSM cohort analyses or RCT study design, reporting on OS, PFS, local control, complete response and toxicity are needed prior to drawing definitive conclusions.

Radiofrequency ablation in the management of primary hepatic and biliary tumors

In the United States, 80%-90% of primary hepatic tumors are hepatocellular carcinomas and 10%-15% are cholangiocarcinomas (CCA), both with high mortality rate, particularly CCA, which portends a worse prognosis. Traditional management with surgery has good outcomes in appropriately selected patients; however, novel ablative treatment options have emerged, such as radiofrequency ablation (RFA), which can improve the prognosis of both hepatic and biliary tumors. RFA is aimed to generate an area of necrosis within the targeted tissue by applying thermal therapy via an electrode, with a goal to completely eradicate the tumor while preserving surrounding healthy tissue. Role of RFA in management of hepatic and biliary tumors forms the focus of our current mini-review article.

Clinical application of advances and innovation in radiation treatment of hepatocellular carcinoma

Background:

Hepatocellular carcinoma (HCC) management has evolved over the past two decades, with the development of newer treatment modalities. While various options are available, unmet needs are reflected through the mixed treatment outcome for intermediate-stage HCC. As HCC is radiosensitive, radiation therapies have a significant role in management. Radiation therapies offer local control for unresectable lesions and for patients who are not surgical candidates. Radiotherapy also provides palliation in metastatic disease, and acts as a bridge to resection and transplantation in selected patients. Advancements in radiotherapy modalities offer improved dose planning and targeted delivery, allowing for better tumor response and safer dose escalations while minimizing the risks of radiation-induced liver damage. Radiotherapy modalities are broadly classified into external beam radiation therapy and selective internal radiation therapy. With emerging modalities, radiotherapy plays a complementary role in the multidisciplinary care of HCC patients.

Aim:

We aim to provide an overview of the role and clinical application of radiation therapies in HCC management.

Relevance for Patients:

The continuous evolution of radiotherapy techniques allows for improved therapeutic outcomes while mitigating unwanted adverse effects, making it an attractive modality in HCC management. Rigorous clinical studies, quality research and comprehensive datasets will further its application in the present era of evidence-based practice in Medicine.

Prediction of late recurrence after radiofrequency ablation of HBV-related hepatocellular carcinoma with the age-male-albumin-bilirubin-platelets (aMAP) risk score: a multicenter study

BACKGROUND

Long-term survivals of patients with HBV-related hepatocellular carcinoma are limited by the high incidence of tumor recurrence after radiofrequency ablation (RFA), identification of the risk factors and understanding the patterns of recurrence can help to improve the comprehensive management of patients after RFA. Therefore, the purpose of the study is to explore the prognostic value of the age-male-albumin-bilirubin-platelets (aMAP) score in patients with early-stage HBV-related hepatocellular carcinoma (HCC) receiving RFA; investigate the risk factors and patterns of late recurrence (LR); and develop a nomogram to predict recurrence-free survival (RFS).

METHODS

A retrospective review of HBV-related HCC patients who underwent primary RFA from March 2012 to December 2020 was conducted. The prognostic value of the aMAP score was evaluated in a primary cohort (n=302) and then further validated in an independent validation cohort (n=143). The optimal threshold of aMAP scores was calculated by X-tile 3.6.1 software. A prognostic nomogram was constructed from multivariate analysis and validated in an external validation cohort.

RESULTS

Patients with aMAP scores ≤63.8, 63.8-67.8, and >67.8 were classified into low-, medium-, and high-recurrence risk groups, respectively. The C-index to predict LR was 0.76 (95% CI: 0.700-0.810). The high-risk group was associated with the worst RFS (HR: 5.298; 95% CI, 2.697-10.408; P<0.001) and overall survival (OS) (HR: 2.639; 95% CI, 1.097-6.344; P=0.03) compared with medium- and low-risk groups. The aMAP score, multiple tumors and preoperative HBV DNA level were independent risk factors for LR. The proposed nomogram had excellent performance in predicting LR of HBV-related HCC [C-index: 0.82 (95% CI: 0.772-0.870)].

CONCLUSIONS

This study demonstrated that the aMAP score can serve as an objective predictor of LR for HBV-related HCC patients after RFA. The nomogram based on preoperative HBV DNA level, aMAP score, and number of tumors can reliably help clinicians to stratify the recurrence risk of HCC patients after RFA.

Stereotactic body radiation therapy versus radiofrequency ablation for single small hepatocellular carcinoma: a propensity-score matching analysis of their impact on liver function and clinical outcomes

Background

Stereotactic body radiation therapy (SBRT) has high efficacy for early-stage hepatocellular carcinoma (HCC) and is an accepted alternative to radiofrequency ablation (RFA). However, SBRT for HCC may cause subacute liver injury leading to negative clinical outcomes. In this study, we compared changes of liver function and prognosis after SBRT or RFA in patients with single, small HCC by using a propensity-score matching analysis.

Methods

We reviewed medical records of 140 patients with single ≤3 cm HCC treated with SBRT or RFA at Kurashiki Central Hospital between January 2014 and February 2019. Changes of albumin-bilirubin (ALBI) score, local recurrence, and overall survival were compared between the propensity-score matched groups (31 patients treated with SBRT and 62 treated with RFA).

Results

The ALBI score increased modestly but significantly after SBRT, while it was unchanged in the RFA group; the intergroup difference was statistically significant (P=0.004). No local recurrence was identified in the SBRT group, whereas the cumulative recurrence incidence was 9.7% in the RFA group (P=0.023). Overall survival was not significantly different between the two groups (hazard ratio: 1.32, 95% confidence interval: 0.60-2.89, P=0.401).

Conclusions

SBRT had modestly negative impact on liver function but with appraisable local control of HCC. Our findings should contribute to the selection of this modality for treatment of single, small HCC.

Effectiveness of individual audio-visual coaching, respiratory modulated stereotactic body radiotherapy for localized hepatocellular carcinoma: Analysis of 29 cases from a single academic radiotherapy center

Objectives:

Recently, Stereotactic Body Radiotherapy (SBRT) has been suggested for managing hepatocellular carcinoma (HCC) curatively. Thus, we conducted this clinical study to evaluate retrospectively the effect of individualized audio-visual (AV) coaching, respiratory modulated SBRT.

Materials and Methods:

Between 2014 and 2018, 29 patients with inoperable Barcelona Clinic Liver Cancer (BCLC) stage 0-B HCC received AV coaching, respiratory-modulated SBRT. We constructed a task-oriented multidisciplinary team to establish a standard operation process of respiratory modulation procedures and developed our AV coaching devices. In the training period, a goodness-of-fit test was applied individually. SBRT was delivered with a total dose of 40–54 Gy in 5–6 fractions individually. Freedom from local progression (FFLP) and overall survival (OS) were estimated using SPSS (version 17, SPSS Inc., Chicago, IL, USA) life tables.

Results:

The patient characteristics were as follows: 32.7 ± 16 mm in maximum tumor diameter (range 11–94); BCLC stage 0: 3.4%, BCLC A: 48.3%, BCLC B: 48.3%; Child-Pugh classification A: 86.2%, Child-Pugh classification B: 13.8%, and a median of 2 prior liver-directed treatments (range 0–7). One-, 2-, and 3-year rates of FFLP of SBRT were 96.6%, 96.6%, and 96.6%, respectively. One-, 2-, and 3-year rates of OS were 81.5%, 72.4%, and 67.2%, respectively. No adverse event (AE) occurred in 41.4% of patients, 48.3% developed grade (G) 1–2 AE, 10.3% had G3 AE and none had G4-5 AE.

Conclusion:

Respiration-modulated SBRT is a promising noninvasive treatment option for patients with inoperable and localized HCC. Our data show that SBRT provides comparable tumor control to historical curative options like surgery and radiofrequency ablation of localized tumors. Thus, we are conducting a further prospective clinical trial with the intent to demarcate the clinical effectiveness of SBRT in a larger population of patients with HCC.

Stereotactic body radiation therapy versus radiofrequency ablation in patients with small hepatocellular carcinoma: a systematic review and meta-analysis

Background

This study aimed to compare the clinical outcomes and toxicity between small hepatocellular carcinoma (HCC) patients treated with stereotactic body radiation therapy (SBRT) and those treated with radiofrequency ablation (RFA).

Methods

We searched databases for relevant clinical studies. The primary outcomes of interest were overall survival (OS) at 1 and 2 years, freedom from local progression (FFLP) rate at 2 years, and complications.

Results

Five cohorts from 5 retrospective studies and 4,814 patients with HCC were included. Pooled OS at 2 years was significantly lower for SBRT than for RFA [odds ratio (OR): 0.63; 95% confidence interval (CI): 0.51-0.79; P<0.0001], but the pooled FFLP rate at 2 years was higher for SBRT than for RFA (OR: 1.66; 95% CI: 1.05-2.61; P=0.03). In addition, there was no significant difference in the local and liver toxicities of the two treatments. The contradictory conclusion between the OS and FFLP outcome may be attributed to the difference in radiological dose and location, but there were no uniform criteria to illustrate the radiological dose and location in the included studies.

Conclusions

SBRT had a higher local control ratio but poorer prognosis than RFA in patients with small HCC. The local toxicity was comparable in both treatments. Further trials should be designed with uniform standards for SBRT and RFA treatments.

Minimally Invasive versus Open Liver Resection for Stage I/II Hepatocellular Carcinoma

Minimally invasive liver resection (MILR) is increasingly used as a surgical treatment for patients with hepatocellular carcinoma (HCC). However, there is no large scale data to compare the effectiveness of MILR in comparison to open liver resection (OLR). We identified patients with stage I or II HCC from the National Cancer Database using propensity score matching techniques. Overall, 1931 (66%) and 995 (34%) patients underwent OLR or MILR between 2010 and 2015. After propensity matching, 5-year OS was similar in the MILR and OLR group (51.7% vs. 52.8%, p = 0.766). MILR was associated with lower 90-day mortality (5% vs. 7%, p = 0.041) and shorter length of stay (4 days vs. 5 days, p < 0.001), but higher rates of positive margins (6% vs. 4%, p = 0.001). An operation at an academic institution was identified as an independent preventive factor for a positive resection margin (OR 0.64: 95% CI 0.43-0.97) and 90-day mortality (OR 0.61; 95% CI 0.41-0.91). MILR for HCC is associated with similar overall survival to OLR, with the benefit of improved short term postoperative outcomes. The increased rate of positive margins after MILR requires further investigation, as do the differences in perioperative outcomes between academic and nonacademic institutions.

A Systemic Inflammation Response Index (SIRI)-Based Nomogram for Predicting the Recurrence of Early Stage Hepatocellular Carcinoma After Radiofrequency Ablation

OBJECTIVE

To explore the prognostic value of the systemic inflammation response index (SIRI) defined as neutrophil count × monocyte count/lymphocyte count in the patients with early stage hepatocellular carcinoma (HCC) within the Milan criteria after radiofrequency ablation (RFA).

MATERIALS AND METHODS

The prognostic value of SIRI was evaluated in a primary cohort (n = 403) and then further validated in an independent test cohort (n = 140). A novel preoperative prognostic nomogram was constructed from a multivariate analysis and validated in an external validation cohort.

RESULTS

The optimal cutoff value of SIRI for patient stratification into a low SIRI group and a high SIRI group was 1.36. Survival analysis showed that the median overall survival (OS) and recurrence-free survival (RFS) were significantly higher in patients with a low SIRI compared to those with a high SIRI. The alpha-fetoprotein (AFP), SIRI, tumor number and size were independent predictors of RFS based on multivariate analysis. The nomogram including the SIRI, tumor number, tumor size, AFP could more accurately determine the prognosis of HCC patients than BCLC stage (0.74 vs. 0.62, P < 0.001). In addition, the dynamic changes in post-RFA SIRI also had prognostic significance and patients with a reduction in the SIRI by > 75% had a better prognosis.

CONCLUSION

Preoperative SIRI was an independent predictor for RFS in patients with early stage HCC within the Milan criteria. The comprehensive nomogram can objectively and reliably help clinicians identify high-risk patients and develop individualized treatment plans.

Radiofrequency ablation versus stereotactic body radiotherapy for hepatocellular carcinoma: a meta-analysis

The present meta-analysis was performed to evaluate the efficacy of radiofrequency ablation (RFA) and stereotactic body radiotherapy (SBRT) in hepatocellular carcinoma (HCC) patients. A systematic literature search was conducted of online databases prior to February 21, 2021. Eleven articles involving 8429 patients were included. The pooled hazard ratio for overall survival (OS) of RFA versus SBRT was 0.79 (p < 0.001). Statistically significant differences were found in the 1-, 2-, 3-, 4- and 5-year pooled OS and freedom from local progression (FFLP) rates between the two groups, favoring the RFA arms. However, the pooled local control (LC) rates were higher in the SBRT arm. RFA provided better OS and FFLP for treating HCC, while SBRT achieved superior LC. PROSPERO registration number: CRD42020207877.