Hepatic Arterial Chemoembolization With Arsenic Trioxide Eluting CalliSpheres Microspheres Versus Lipiodol Emulsion: Pharmacokinetics And Intratumoral Concentration In A Rabbit Liver Tumor Model

Transcatheter arterial chemoembolization using CalliSpheres beads loaded with arsenic trioxide for unresectable large or huge hepatocellular carcinoma: a prospective study

OBJECTIVES

To determine the safety and efficacy of transcatheter arterial chemoembolization with CalliSpheres® beads loaded with arsenic trioxide (CBATO-TACE) in the first-line treatment of patients with large (5 cm ≤ maximum diameter < 10 cm) or huge (maximum diameter ≥ 10 cm) hepatocellular carcinoma (HCC).

METHODS

Patients were randomly allocated to the CBATO-TACE group and the conventional transcatheter arterial chemoembolization (cTACE) group. The primary endpoint was progression-free survival (PFS). The secondary endpoint was overall survival (OS), treatment response, and treatment-related adverse events (TRAEs). The extrahepatic collateral arteries, liver function, and liver fibrosis after the first TACE were also evaluated.

RESULTS

From September 2018 to September 2020, a total of 207 patients who underwent TACE were consecutively enrolled in this study. The median PFS was 9.5 months (range: 8.0 - 11.0) in the CBATO group, which was significantly longer than that in the cTACE group (6.0 months, range: 4.0-6.0) (p < 0.0001). Patients in the CBATO group had a median OS of 22 months (range: 20.0 - 27.0) compared with 16 months (range: 15.0 - 20.0) in the cTACE group (p = 0.0084). The most common TRAEs were fever (p = 0.043), and nausea and vomiting (p = 0.002), which were more observed in the cTACE group. In addition, the progressive disease time, pulmonary metastasis rate (p = 0.01), the mean number of extrahepatic collateral arteries (p = 0.01), and average number of TACE sessions (p = 0.025) were significantly decreased in the CBATO group.

CONCLUSIONS

CBATO-TACE achieved better therapeutic outcomes and similar safety profile compared to cTACE in large or huge HCC patients. Furthermore, CBATO-TACE was able to reduce extrahepatic collateral arteries production and extrahepatic lung metastasis.

CLINICAL RELEVANCE STATEMENT

Our study showed that CalliSpheres® beads loaded with arsenic trioxide (CBATO-TACE) were effective and safe for the treatment of large and giant HCC. In addition, CBATO-TACE can reduce lateral hepatic branch artery formation and extrahepatic pulmonary metastasis, which provides a new treatment approach for unresectable HCC.

KEY POINTS

• We compare long-term efficacy and safety of transcatheter arterial chemoembolization with CalliSpheres® beads loaded with arsenic trioxide (CBATO-TACE) and conventional transcatheter arterial chemoembolization (cTACE) in patients with large (5 cm ≤ maximum diameter < 10 cm) or huge HCC (maximum diameter ≥ 10 cm). • Compared with cTACE, CBATO-TACE significantly improved therapeutic outcomes, overall survival, and progression-free survival in patients with large or huge HCC. The safety assessment suggested that CBATO-TACE is a safe treatment that improves the quality of life and has good treatment adherence.

Microspheres as a Carrier System for Therapeutic Embolization Procedures: Achievements and Advances

The targeted delivery of anti-cancer drugs and isotopes is one of the most pursued goals in anti-cancer therapy. One of the prime examples of such an application is the intra-arterial injection of microspheres containing cytostatic drugs or radioisotopes during hepatic embolization procedures. Therapy based on the application of microspheres revolves around vascular occlusion, complemented with local therapy in the form of trans-arterial chemoembolization (TACE) or radioembolization (TARE). The broadest implementation of these embolization strategies currently lies within the treatment of untreatable hepatocellular cancer (HCC) and metastatic colorectal cancer. This review aims to describe the state-of-the-art TACE and TARE technologies investigated in the clinical setting for HCC and addresses current trials and new developments. In addition, chemical properties and advancements in microsphere carrier systems are evaluated, and possible improvements in embolization therapy based on the modification of and functionalization with therapeutical loads are explored.

Nrf2-siRNA Enhanced the Anti-Tumor Effects of As2O3 in 5-Fluorouracil-Resistant Hepatocellular Carcinoma by Inhibiting HIF-1α/HSP70 Signaling

Purpose

Chemoresistance is a major factor contributing to the failure of cancer treatment. The conventional chemotherapy agent 5-fluorouracil (5-FU) has been used for cancer treatment for decades. However, its use is limited in the treatment of hepatocellular carcinoma (HCC) due to acquired resistance. Nrf2 (NF-E2-related factor 2) is known to be associated with drug resistance across a wide range of cancer types. Also, since arsenic trioxide (As₂O₃) showed antitumor effects on HCC, the purpose of this study was to determine whether As₂O₃ and Nrf2-siRNA could inhibit HCC synergistically.

Methods

We generated two separate 5-FU-resistant HCC cell lines (SNU-387/5-FU and Hep3B/5-FU). Western blotting was used to determine protein levels. An efficient lentiviral delivery system was used to establish stable knockdown or overexpression of Nrf2 and HIF-1α. In vitro and in vivo analyses of the effects of Nrf2 gene knockdown and As₂O₃ on 5-FU-resistant HCC cells were conducted.

Results

The expression of Nrf2 was higher in the 5-FU-resistant HCC cell lines than in the parental cell lines. When coupled with Nrf2 knockdown, As₂O₃ treatment significantly decreased 5-FU-resistant SNU-387 and Hep3B cell viability, migration, and invasion, inactivated HIF-1α/HSP70 signaling, inhibited anti-apoptotic B-cell lymphoma (Bcl-2) activity, and increased the expression of pro-apoptotic Bcl-2-associated X protein (BAX) along with caspase-3. The synergistic effect was also confirmed using a 5-FU-resistant Hep3B mouse xenograft model in vivo.

Conclusion

Nrf2 knockdown could improve the effect of As₂O₃ on reversing drug resistance in 5-FU-resistant HCC cells.

Callispheres drug-eluting bead transhepatic artery chemoembolization with oral delivery of sorafenib for the treatment of unresectable liver cancer

Objective

Liver cancer is a significant contributor to global burden of cancer. Transcatheter arterial chemoembolization (TACE) is the standard of care for patients with unresectable liver cancer, and CalliSpheres, as novel drug-eluting bead (DEB) microspheres, have been found to be associated with a high tumor response rate. However, the outcomes after DEB-TACE treatment are not always satisfactory with tumor recurrence. Herein, we attempt to compare the clinical efficacy and safety of DEB-TACE with sorafenib and conventional TACE in treating advanced liver cancer.

Methods

The study retrospectively reviewed clinical records of 96 patients with liver cancer, among which there were 48 cases receiving DEB-TACE with sorafenib and 48 cases receiving conventional TACE. The physical properties of Callispheres were evaluated in HepG2 cells and a B6/J mouse model.

Results

DEB-TACE with Callispheres were demonstrated to effectively maintain stability and prolong the half-life of epirubicin. Compared with the patients receiving conventional TACE, those receiving DEB-TACE with sorafenib exhibited better patient outcomes with increased survival rate, reduced tumor volume, and declined levels of tumor markers. Additionally, DEB-TACE with Callispheres could effectively protect liver function, as well as reduce the toxic effects of loaded epirubicin, and its combination with sorafenib would not increase the incidence of adverse reactions.

Conclusion

DEB-TACE using CalliSpheres combined with sorafenib could prevent the progression of liver cancer and bring a better prognosis.

Effect of PINK1 and Parkin gene silencing on sodium arsenite-induced mitophagy in normal rat liver cells (BRL-3A)

NaAsO₂-induced liver damage leads to autophagy, which plays an important role in cell quality control. Mitophagy plays an important role in hepatocyte damage, and PINK1 and Parkin constitute an important pathway in mitophagy. PINK1 selectively degrades abnormal mitochondria, and Parkin can recognize damaged mitochondria. However, the mechanism underlying the involvement of PINK1/Parkin in NaAsO₂-induced mitophagy is unclear. Transfection plasmids containing dsRNA were used to interfere with the expression of Parkin in the following groups: the empty plasmid group was established by add the empty plasmid only, the PINK1-knockdown (KD) group was established by adding 5 μg of PINK1 dsRNA and then by adding 10 mM NaAsO₂, and the Parkin-KD group was established by adding 5 μg of Parkin dsRNA and then by adding 10 mM NaAsO₂. The expression of PINK1 and Parkin in autophagy was detected by western blotting and immunofluorescence staining. The ultrastructures of autophagosomes and mitochondria were observed by transmission electron microscopy. The successful KD of PINK1 and Parkin aggravated the NaAsO₂-induced damage to mitophagy. The degeneration of mitochondrial vacuoles and the appearance of autophagosomes were detected in the NaAsO₂, NaAsO₂ + PINK1-KD and NaAsO₂ + Parkin-KD groups. NaAsO₂ can induce mitophagy in rat hepatocytes, and the silencing of PINK1 and Parkin can aggravate mitochondrial damage during this process. This study explored the mechanism of NaAsO₂-induced mitophagy in BRL-3A cells after PINK1 and Parkin gene silencing.

Occurrence, Related Factors and Prognostic Value of Vascular Lake in Hepatocellular Carcinoma Patients Treated with Drug-Eluting Bead Transarterial Chemoembolization

Purpose

The present study aimed to assess the prevalence of vascular lake (VL), its associated factors and correlation with prognosis in hepatocellular carcinoma (HCC) patients treated with drug-eluting bead transarterial chemoembolization (DEB-TACE). 

Patients and Methods

 A total of 286 primary HCC patients (with 384 treated nodules) receiving DEB-TACE treatment were recruited, and their clinical characteristics were documented. The occurrence of VL was recorded, and treatment responses were assessed according to the modified response evaluation criteria in solid tumor (mRECIST).In terms of treatment response, the total response status (including CR, PR, SD and PD), objective response rate (ORR) and disease control rate (DCR) were elevated in VL patients compared to non-VL patients as well as in VL nodules compared to non-VL nodules. Liver function indexes and adverse events were assessed. Progression-free survival (PFS) and overall survival (OS) were evaluated with the last follow-up date of March 2020. 

Results

The patient-based and nodule-based VL occurrence rates were 17.1% and 16.4%, respectively. Larger tumor size, pseudocapsules and smaller bead size were independently associated with VL occurrence. PFS and OS were more prolonged in VL patients than in non-VL patients, and VL independently correlated with better PFS and OS. For liver function, the liver function indexes before and after DEB-TACE were of no difference between VL patients and non-VL patients. Additionally, the incidences of adverse events were similar between VL patients and non-VL patients.

Conclusion

 VL occurs in 17.1% of HCC patients treated with DEB-TACE, and it is correlated with larger tumor size, pseudocapsule, smaller bead size, more favorable treatment response and better survival.

Chemoembolizing hepatocellular carcinoma with microsphere cored with arsenic trioxide microcrystal

Chemoembolization for hepatocellular carcinoma (HCC) is often suboptimal due to multiple involved signaling and lack of effective drugs. Arsenic trioxide (ATO) is a potent chemotherapeutic agent, which can target multiple signaling and have substantial efficacy on HCC. However, its usage is limited due to systemic toxicity. Using ATO-eluting beads/microspheres for chemoembolization can have locoregional drug delivery and avoid systemic exposure but will require high drug load, which has not been achieved due to low solubility of ATO. Through an innovative approach, we generated the transiently formed ATO microcrystals via micronization and stabilized these microcrystals by solvent exchange. By encapsulating ATO microcrystals, but not individual molecules, with poly(lactide-co-glycolic acid) (PLGA), we developed microspheres cored with extremely high dense ATO. The molar ratio between ATO and PLGA was 157.4:1 and drug load was 40.1%, which is 4–20 fold higher than that of reported ATO nano/microparticles. These microspheres sustainably induced reactive oxygen species, apoptosis, and cytotoxicity on HCC cells and reduced tumor growth by 80% via locoregional delivery. Chemoembolization on mice model showed that ATO-microcrystal loaded microspheres, but not ATO, inhibited HCC growth by 60–75%, which indicates ATO within these microspheres gains the chemoembolizing function via our innovative approach.

Drug-eluting embolic microspheres: State-of-the-art and emerging clinical applications

INTRODUCTION

Drug-eluting embolic (DEE) microspheres, or drug-eluting beads (DEB), delivered by transarterial chemoembolization (TACE) serve as a therapeutic embolic to stop blood flow to tumors and a drug delivery vehicle. New combinations of drugs and DEE microspheres may exploit the potential synergy between mechanisms of drug activity and local tissue responses generated by TACE to enhance the efficacy of this mainstay therapy.

AREAS COVERED

This review provides an overview of key drug delivery concepts related to DEE microspheres with a focus on recent technological developments and promising emerging clinical applications as well as speculation into the future.

EXPERT OPINION

TACE has been performed for nearly four decades by injecting chemotherapy drugs into the arterial supply of tumors while simultaneously cutting off their blood supply, trying to starve and kill cancer cells, with varying degrees of success. The practice has evolved over the decades but has yet to fulfill the promise of truly personalized therapies envisioned through rational selection of drugs and real-time multi-parametric image guidance to target tumor clonality or heterogeneity. Recent technologic and pharmacologic developments have opened the door for potentially groundbreaking advances in how TACE with DEE microspheres is performed with the goal of achieving advancements that benefit patients.

Preparation and evaluation of ion-exchange porous polyvinyl alcohol microspheres as a potential drug delivery embolization system

The present study aimed to develop a new drug delivery system with efficient drug loading and sustained drug release for potential application in transarterial chemoembolization (TACE). The porous polyvinyl alcohol microspheres (PPVA MS) were prepared by a combination of inverse emulsification and thermal-induced phase separation (TIPS) method, this was followed by the grafting polymerization of sodium 4-styrene sulfonate (SSS) onto the PPVA MS to obtain the grafted PPVA-g-PSSS MS. The prepared PPVA MS showed a well-defined spherical shape with 'honeycomb-like' porous structure, which could be readily tailored by adjusting the quenching temperature. In vitro biocompatibility analysis indicated the non-cytotoxic and hemocompatible nature of PPVA MS. The porous structure and presence of ionically charged groups in the PPVA-g-PSSS MS favoured the loading of cationic doxorubicin (DOX) onto the MS through ionic-interactions and demonstrated a sustained drug release pattern. Moreover, the cytotoxicity of DOX-loaded PPVA-g-PSSS (DOX@PPVA-g-PSSS) MS against HepG2 cells and the intracellular uptake of DOX demonstrated the potent in vitro antitumor activity. Furthermore, the central auricular artery embolization in rabbits showed that both the PPVA-g-PSSS and DOX@PPVA-g-PSSS MS could occlude the auricular arteries and induced superior embolization effects, such as progressive ear appearance changes, irreversible parenchymal damage and fibrosis, and ultrastructural alternations in endothelial cells. Besides, the DOX fluorescence was distributed around the embolized arteries, without decreasing its intensity when prolonged embolization up to 15 days. These findings suggest that the newly developed DOX@PPVA-g-PSSS MS could be employed as a promising drug-loaded embolic agent for the treatment of hepatocellular carcinoma.

Antitumor properties of arsenic trioxide-loaded CalliSpheres® microspheres by transarterial chemoembolization in VX2 liver tumor rabbits: suppression of tumor growth, angiogenesis, and metastasis and elongation of survival

This study aimed to investigate the antitumor effect of arsenic trioxide (ATO)-loaded CalliSpheres^® microspheres (CSM) by transarterial chemoembolization (TACE) in rabbits with VX2 liver tumors. A total of 120 VX2 liver tumor rabbits were randomized into four groups (N = 30 for each group), which received ATO-loaded CSM by TACE (CSM-ATO group), ATO by conventional TACE (cTACE-ATO group), transcatheter arterial embolization using CSM (TAE-CSM group), and saline arterial injection (control group). Five rabbits in each group were sacrificed at 12 h, 3 d, 7 d and 14 d, and then tumor proliferation, apoptosis, and angiogenesis/epithelial-mesenchymal transition (EMT) markers were detected. Tumor volume, metastasis status and ascites were assessed at 14 d. Ten rabbits in each group were observed until death for accumulating survival calculation. Tumor volume and ascites were decreased in the CSM-ATO group compared to the cTACE-ATO and TAE-CSM groups. Pulmonary, abdominal wall and omentum metastases were reduced while accumulating survival was increased in the CSM-ATO group compared to the TAE-CSM group. However, no difference in metastasis foci or survival between the CSM-ATO and cTACE-ATO groups was discovered. Meanwhile, tumor apoptosis was promoted while proliferation was suppressed in the CSM-ATO group compared to the cTACE-ATO and TAE-CSM groups. Additionally, HIF-1α, VEGF and microvessel density were decreased in the CSM-ATO group compared to the cTACE-ATO and TAE-CSM groups. Additionally, twist, N-cadherin, vimentin and MMP-9 were reduced while E-cadherin was enhanced in the CSM-ATO group compared to the cTACE-ATO and TAE-CSM groups. In conclusion, ATO-loaded CSM by TACE suppressed tumor growth, angiogenesis, and metastasis and elongated survival in VX2 liver tumor rabbits.