Percutaneous Ablation of T1b Renal Cell Carcinoma: An Overview

PURPOSE OF REVIEW

There is increasing incidence of renal cell carcinoma (RCC) with multiple treatment options currently available. The purpose of this review is to outline patient selection and technical approaches and present the current literature for percutaneous ablation of T1b (4.1-7 cm) RCC.

RECENT FINDINGS

An increasing number of retrospective studies and meta-analyses have evaluated the use of percutaneous ablation for T1b RCC. Overall, these studies tend to show that percutaneous ablation in this patient population is feasible. However, rates of major adverse events and local recurrence after percutaneous ablation for T1b RCC are both higher than when ablation is used for smaller tumors. As such, a multi-disciplinary, patient-centered approach is required. Due to the increasing literature in this area, the most recent National Comprehensive Cancer Network (NCCN) guidelines include percutaneous ablation as an option for non-surgical patients with T1b RCC.

Nationwide Trends and the Influence of Age and Gender in the In-Patient Care of Patients with Hepatocellular Carcinoma in Germany between 2010 and 2020

This study analyzes nationwide trends in HCC hospitalizations focusing on interventional liver-directed treatments and the influence of age and gender. Using data from the German Federal Statistical Office all hospitalizations for HCC between 2010 and 2020 were included. Uni- and multivariable logistic regression analyses were performed to identify variables independently associated with the use of liver-directed therapies. Due to the COVID-19 pandemic, data from 2020 were analyzed separately. A total of 134,713 hospitalizations (2010-2019) were included, increasing by 3.4% annually (12,707 to 13,143). The mean in-hospital stay (-15.0% [7.2 to 6.1 days]) and mortality (-23.2% [6.8 to 5.2%]) decreased while transarterial, surgical, and percutaneous ablative interventions increased by 38.6, 31.5, and 19.3%, respectively. In-hospital mortality was 7.7% in admissions with surgical treatment, while it was 0.6 and 0.5% for transarterial and percutaneous interventions. Mortality was higher in females (6.2 vs. 5.7%). Females (OR 0.89 [0.86,0.91], p < 0.001) and patients ≥80 years (OR 0.81 [0.79,0.84], p < 0.001) were less likely to receive liver-directed treatments. Liver-directed therapies were increasingly performed while in-hospital mortality and in-hospital stay decreased. Minimally invasive approaches showed lower mortality, shorter in-hospital stay, and lower costs compared to surgery. Proportionately, more women and older patients were hospitalized, receiving fewer liver-directed treatments while their mortality was higher.

Ablative Therapy in Non-HCC Liver Malignancy

Surgical extirpation of liver tumors remains a proven approach in the management of metastatic tumors to the liver, particularly those of colorectal origin. Ablative, non-resective therapies are an increasingly attractive primary therapy for liver tumors as they are generally better tolerated and result in far less morbidity and mortality. Ablative therapies preserve greater normal liver parenchyma allowing better post-treatment liver function and are particularly appropriate for treating subsequent liver-specific tumor recurrence. This article reviews the current status of ablative therapies for non-hepatocellular liver tumors with a discussion of many of the clinically available approaches.

Transarterial chemoembolization (TACE) plus apatinib vs. TACE alone for hepatocellular carcinoma

OBJECTIVE

Transarterial chemoembolization (TACE) is a common therapy for hepatocellular carcinoma (HCC), while TACE-induced tumor angiogenesis would increase progression and metastasis risk. Besides, apatinib possesses the capability of inhibiting tumor angiogenesis. Thus, this study aimed to explore the efficacy and safety of TACE plus apatinib compared to TACE alone in HCC patients.

METHODS

Ninety-six intermediate-advanced HCC patients were retrospectively enrolled and classified into TACE plus apatinib group (N = 45) and TACE group (N = 51) based on the treatment.

RESULTS

Objective response rate (68.9% vs. 47.1%) was increased in TACE plus apatinib group than in TACE group (P = 0.031). However, no difference was found in disease-control rate between groups (95.6% vs. 86.3%) (P = 0.167). Progression-free survival (PFS) (median PFS (95% confidence interval (CI)): 20.0 (13.2-26.8) vs. 14.0 (8.3-19.7) months) was enhanced in TACE plus apatinib group compared with TACE group (P = 0.030), while no difference was found in overall survival between groups (P = 0.060). Additionally, multivariate Cox's analysis presented that TACE plus apatinib (vs. TACE alone) independently associated with prolonged PFS (P = 0.043, hazard ratio = 0.617). Regarding safety profile, no difference in liver function indexes (albumin, total bilirubin, alanine aminotransferase and aspartate aminotransferase) was found after treatment between two groups; meanwhile, only the incidence of hand-foot skin reaction (24.4% vs. 7.8%) was higher in TACE plus apatinib group compared to TACE group (P = 0.025), while no difference was found in other adverse events between two groups (all P > 0.05).

CONCLUSION

TACE plus apatinib illustrates a superior efficacy with tolerable safety than TACE alone in intermediate-advanced HCC patients.

Comprehensive Treatment of Trans-Arterial Chemoembolization Plus Lenvatinib Followed by Camrelizumab for Advanced Hepatocellular Carcinoma Patients

Aim: This study aimed to report the efficacy and safety of trans-arterial chemoembolization (TACE) plus lenvatinib and camrelizumab in patients with advanced hepatocellular carcinoma (HCC). Methods: This retrospective study enrolled 22 patients with advanced HCC from March 2018 to December 2019. All the patients received comprehensive treatment with TACE plus lenvatinib followed by camrelizumab. Overall survival (OS) and progression-free survival (PFS) were calculated and analysed using the Kaplan-Meier method and log-rank test. Treatment response and adverse events (AEs) were also evaluated. Results: The objective response rate (ORR) and disease control rate (DCR) for the whole cohort were 68.2 and 100% at the first month and 72.7 and 95.5% at the third month, respectively. The median OS was 24 months (95% CI, 20.323-27.677 months), and the median PFS was 11.4 months (95% CI, 8.846-13.954 months). The majority of treatment-related adverse reactions were mild or moderate, except for 4 that developed to grade 3-4 (3 reactions of grade 3, 1 reaction of grade 4). No deaths or other serious adverse reactions occurred. Conclusion: Trans-arterial chemoembolization plus lenvatinib and camrelizumab shows good results incontrolling tumour progression and prolonging median OS in patients with advanced HCC.

Biliary-Caval Fistula following Y90 Radioembolization

The safety of radioembolization with yttrium-90 ( ⁹⁰ Y) is well documented and major complications are rare. Previous studies have demonstrated that biliary complications following ⁹⁰ Y, including bile duct injury and hepatic abscess formation, occur at an increased rate in patients who have had prior biliary surgery and interventions. This article reviews a case of a patient who developed recurrent cholangitis and sepsis as well as a biliary-caval fistula following radioembolization. Additionally, we review current data regarding biliary complications following radioembolization in patients with prior biliary intervention.

A Seven-Gene Signature to Predict Prognosis of Patients With Hepatocellular Carcinoma

Purpose: Hepatocellular carcinoma (HCC) is one of the most prevalent malignant diseases worldwide and has a poor prognosis. Gene-based prognostic models have been reported to predict the overall survival of patients with HCC. Unfortunately, most of the genes used in earlier prognostic models lack prospective validation and, thus, cannot be used in clinical practice.

Methods: Candidate genes were selected from GEPIA (Gene Expression Profiling Interactive Analysis), and their associations with patients’ survival were confirmed by RT-PCR using cDNA tissue microarrays established from patients with HCC after radical resection. A multivariate Cox proportion model was used to calculate the coefficient of corresponding gene. The expression of seven genes of interest (MKI67, AR, PLG, DNASE1L3, PTTG1, PPP1R1A, and TTR) with two reference genes was defined to calculate a risk score which determined groups of different risks.

Results: Our risk scoring efficiently classified patients (n = 129) with HCC into a low-, intermediate-, and high-risk group. The three groups showed meaningful distinction of 3-year overall survival rate, i.e., 88.9, 74.5, and 20.6% for the low-, intermediate-, and high-risk group, respectively. The prognostic prediction model of risk scores was subsequently verified using an independent prospective cohort (n = 77) and showed high accuracy.

Conclusion: Our seven-gene signature model performed excellent long-term prediction power and provided crucially guiding therapy for patients who are not a candidate for surgery.

Role of the radiologist at HCC multidisciplinary conference and use of the LR-TR algorithm for improving workflow

Multidisciplinary conferences (MDCs) play a major role in management and care of oncology patients. Hepatocellular carcinoma (HCC) is a complex disease benefiting from multidisciplinary discussions to determine optimal patient management. A multitude of liver-directed locoregional therapies have emerged allowing for more options for treatment of HCC. A radiologist dedicated to HCC-MDC is an important member of the team contributing to patient care in multiple ways. The radiologist plays a key role in image interpretation guiding initial therapy discussions as well as interpreting post-treatment imaging following liver-directed therapy. Standardization of image interpretation can lead to more consistent treatment received by the patient as well as accurate assessment of transplant eligibility. The radiologist can facilitate this process using structured reporting that is also supported by stakeholders involved in interdisciplinary management of liver diseases. The Liver Imaging Reporting and Data System (LI-RADS), is a living document which offers a standardized reporting algorithm for consistent communication of radiologic findings for HCC screening and characterization of liver observations in patients at risk for HCC. The LI-RADS post-treatment algorithm (LR-TR algorithm) has been developed to standardize liver observations following liver-directed locoregional therapy. This review article focuses on the role of the radiologist at HCC-MDC and implementation of the LR-TR algorithm for improving workflow.

Imaging After Locoregional Therapy for Hepatocellular Carcinoma with Emphasis on LIRADS Treatment Response Assessment Criteria

Radiologists play an essential role in assessing hepatocellular carcinoma treatment response and help guide further clinical management of patients. Interpretation of treatment response after locoregional therapy is challenging. The post-treatment imaging findings vary and depend on the type of treatment, the degree of treatment response, time interval after treatment and several other factors. Given the widespread use of local-regional therapies, understanding the appearance of treated lesions has become crucial to allow for a more accurate interpretation of post-treatment imaging. Several response criteria including the recently introduced Liver Imaging Reporting and Data System (LI-RADS) treatment response algorithm (TRA) are currently used to assess treatment response. This review article describes the imaging assessment of HCC treatment response after several locoregional therapies using various response assessment criteria, emphasizing the LI-RADS treatment algorithm.

Inhibition of vitamin D analog eldecalcitol on hepatoma in vitro and in vivo

Hepatoma is a serious liver cancer with high morbidity and mortality. Eldecalcitol (ED-71), a vitamin D analog, is extensively used as anti-cancer agent in vitro. Hepatocellular carcinoma cell, SMMC-7721 cell lines were used in this study. Transwell assay, cell apoptosis and cell cycle detection assays were investigated after treatment with ED-71 and phosphate buffered saline (PBS) as control. Sizes of tumors were measured after ED-71 treatment in a mouse model. E-cadherin and Akt gene expressions were detected by real-time PCR (RT-PCR). The results showed that cell invasion and migration were decreased markedly after ED-71 treatment compared to control group. Cell cycle detection showed that the G2 stage was 13.18% and total S-stage was 41.16% in the ED-71 group and G2 stage: 22.88%, total S-stage: 27.34% in the control group. Cell apoptosis rate was promoted in the ED-71 group. Size of the tumors reduced more after the ED-71 treatment than the PBS treatment in mice. ED-71 markedly inhibited the expression of Akt and E-cadherin, either detected by immunohistochemistry or RT-PCR. ED-71 treatment can inhibit the hepatoma agent proliferation by increasing the E-cadherin expression and decreasing Akt expression. Therefore, these findings provide novel evidence that ED-71 can be used as an anti-hepatoma agent.

Doxorubicin-loaded hollow gold nanospheres for dual photothermal ablation and chemoembolization therapy

Background

Doxorubicin-loaded hollow gold nanospheres (Dox@HAuNS) are a promising technology for simultaneous trans-arterial tumor-targeted chemotherapy delivery and thermal ablation. We evaluated the efficacy of intra-arterial delivery of Dox@HAuNS followed by photothermal ablation (PTA) in a rabbit model of liver cancer. Adult New Zealand white rabbits (N=25) were inoculated with VX2 tumors into the left lobe of the liver. The animals were then randomized to sham surgery (N=5), PTA only (N=3), Dox@HAuNS only (N=5), HAuNS + PTA (N=5), and Dox@HAuNS + PTA (N=7). Nanoparticles were delivered as an emulsion with Lipiodol (Guerbet, France) via a trans-arterial approach. Following nanoparticle delivery, PTA was performed using an 808nm fibered laser at 1.5W for 3 minutes. Thermography during PTA demonstrated a sustained elevation in tumoral temperature in both HAuNS + laser and Dox@HAuNS + laser treatment groups relative to animals that underwent laser treatment without prior nanoparticle delivery.

Results

There was a significant decrease in tumor volumes in all three treatment arms relative to control arms (P = 0.004). Concentrations of intratumoral doxorubicin were significantly greater in animals treated with laser compared to those that were not treated with laser (P< 0.01).

Conclusions

Doxorubicin-loaded HAuNS is a promising therapeutic agent for dual ablation/chemoembolization treatment of liver cancer.

Anticoagulation status post radiofrequency ablation in a patient with hepatocellular carcinoma and delayed bleeding event

Restarting anticoagulation is a tricky component of patient care. This is a case of a 65-year-old female presenting with hepatocellular carcinoma. A nonocclusive thrombus in the main portal vein was also identified. Six days postradiofrequency ablation (RFA), the patient's hemoglobin dropped to critical values and noncontrast computed tomography of the abdomen/pelvis revealed high density free fluid consistent with a bleed. The patient was medically managed and accepted for transfer to another hospital for IR-guided TIPS procedure. Patient recovered without any other complications. In conclusion, VTE prophylaxis be routinely initiated immediately following hepatectomy in hemodynamically stable patients without signs of active bleeding and should bleeding occur halt source then restart anticoagulation immediately.

Safety and Efficacy of Drug-Eluting Bead Transarterial Chemoembolization Combined with Apatinib in Patients with Advanced Hepatocellular Carcinoma

RATIONALE AND OBJECTIVE

The goal of this study was to determine the clinical efficacy and safety of drug-eluting bead (DEB) transarterial chemoembolization (TACE) in combination with apatinib administration in patients with advanced hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

From December 2015 to May 2017, a total of 32 patients with advanced HCC treated with DEB-TACE combined with apatinib were consecutively enrolled in this study. The treatment response and laboratory outcomes were assessed at the first- and third month after DEB-TACE therapy. Overall survival, progression-free survival, and adverse events were also analyzed and assessed.

RESULTS

The objective response rate and disease control rate were 62.5% and 96.9% at the first month after treatment, respectively. At the third month after the first therapy, a slightly higher objective response rate (68.8%) and lower disease control rate (90.6%) were achieved. There were no differences in the levels of aspartate aminotransferase, alanine aminotransferase, serum albumin, or total bilirubin at M1 or M3 compared to M0 (all p> 0.05) The median progression-free survival was 9.5 months (95% confidence interval, 8.1-10.9 months), and the median overall survival was 22.0 months (95% confidence interval, 20.2-23.9 months). Among the 32 patients, 2 had hypertension and 1 had grade 3 diarrhea; the rest of the patients had mild to moderate adverse reactions that were acceptable, and no serious adverse reactions occurred.

CONCLUSION

DEB-TACE combined with apatinib is a safe and promising treatment approach for patients with advanced HCC.

Assessment of efficacy and safety of the transcatheter arterial chemoembolization with or without apatinib in the treatment of large hepatocellular carcinoma

PURPOSE

The goal of this study was to assess the clinical efficacy and safety of the transcatheter arterial chemoembolization (TACE) in combination with apatinib or TACE treatment alone in patients with large hepatocellular carcinoma (HCC).

METHODS

A total of 82 patients with large HCC were consecutively enrolled between January 2016 and December 2017. Of the 82 patients, 34 underwent the combined treatment, while 48 underwent TACE alone. The treatment response was assessed at first month and third month after TACE therapy, and the survival rate at median follow-up time was also compared between the two treatment groups. Furthermore, progression-free survival (PFS), overall survival (OS) and treatment-related complications were assessed and compared.

RESULTS

Patients treated with TACE + apatinib presented with better objective response rate and disease control rate compared to those who only underwent TACE. Median OS as well as median PFS was longer in the TACE plus apatinib group compared to the TACE alone group. Multivariate Cox's regression analysis further illustrated that TACE plus apatinib compared to TACE alone was an independent protective factor for PFS and OS.

CONCLUSION

TACE combined with apatinib is a safe and promising treatment approach for patients with large HCC.

Percutaneous image-guided therapies of primary liver tumors: Techniques and outcomes

Embolization and percutaneous ablations became well-established therapeutic options for hepatocellular carcinomas (HCC). All are performed under minimally invasive conditions using imaging guidance. Selection of a technique over another follows guidelines but also patient's status and availability of the techniques. The aim of this review is to present these techniques performed in routine to treat HCC and to report the outcomes.

MRI analysis of hydrogel-loaded apatinib for local therapy of hepatocellular carcinoma model in nude mice

AIM

To investigate the effect of local treatment of gadolinium-polyethylene glycol (Gd-PEG) hydrogel containing apatinib injected into hepatocellular carcinoma model of HepG2 in nude mice, and to evaluate the MRI findings in vivo.

METHODS

HepG2 cells were treated in vitro and OD 450 value were measured. The four groups (n = 6) were Apatinib-Gd-PEG hydrogel, Gd-PEG hydrogel, Apatinib, and Saline. T1WI and DWI scans were performed before and 1d, 3d, and 14d postoperatively. The samples were examined by histomorphology and immunohistochemistry for CD34 and VEGFR2. Microvessel density (MVD) was evaluated and the average optical density (AOD) of VEGFR2 was obtained by IPP6.0 image software.

RESULTS

The OD450-time curves of Gd-PEG hydrogel and phosphate buffer saline (PBS) were similar and that of apatinib at all concentrations are located below; the higher the concentration, the lower the curve. On T1WI and DWI, the newly injected Gd-PEG hydrogel showed significant high signal and was immobilized in the tumor. Subsequently, the size and signal of Gd-PEG hydrogel gradually decreased with time. In Apatinib-Gd-PEG hydrogel group, compared with other three groups, MRI and histomorphology showed that the necrotic area of hepatocellular carcinoma model was larger, immunohistochemistry displayed minimal expression of CD34 and VEGFR2, the AOD of VEGFR2 and MVD differed markedly.

CONCLUSION

Gd-PEG hydrogel can significantly enhance and prolong the inhibitory effect of apatinib. It can be visualized by MRI, which can be used to evaluate the local therapeutic effect.

Treatment of Primary Liver Tumors and Liver Metastases, Part 2: Non-Nuclear Medicine Techniques

Image-guided procedures are used worldwide in the management of primary liver tumors and liver metastases. These locoregional therapies include local tumor ablation and transarterial therapies and can occasionally downstage an inoperable patient to an operable status. In hepatocellular carcinoma, data have suggested that for tumors smaller than 2 cm ablation may be preferable to surgery. Similar results are emerging for colorectal cancer liver metastases. Catheter-directed therapies such as bland embolization, transarterial chemoembolization, and drug-eluting beads represent potential techniques that can provide survival benefit for inoperable patients. In this review we highlight the most used techniques and the evidence supporting their current indications for the treatment of liver tumors. We briefly review upcoming developments in combination strategies with temperature-sensitive liposomes or immunotherapy for enhancing ablation efficacy.

The safety and efficacy of TACE combined with apatinib on patients with advanced hepatocellular carcinoma: a retrospective study

As a novel vascular endothelial growth factor receptor-2 tyrosine kinase inhibitor (VEGFR2-TKI), apatinib has a certain anti-tumor effect for a variety of solid tumors. The present study evaluates its efficacy and safety in advanced hepatocellular carcinoma (HCC). In this study, 47 patients with advanced HCC were included. TACE monotherapy group included 22 patients that responded to TACE, while the group that received TACE and apatinib included 25 patients that progressed on TACE and were able to receive apatinib off label. Median overall survival (OS) was significantly improved in the apatinib plus TACE group compared with the TACE group. Similarly, apatinib in combination with TACE significantly prolonged median progression-free survival (PFS) compared with TACE monotherapy. Furthermore, there was a significant difference between combination therapy and monotherapy in both Barcelona clinic liver cancer (BCLC) B and BCLC C group. The combination therapy had a dramatic effect on OS and PFS for patients at both BCLC B and BCLC C level. The most common clinically adverse events of apatinib plus TACE group were fatigue, weight loss, hypertension, hand-foot syndrome and anorexia, which were manageable and tolerable. The efficacy analysis showed that there was no significant association of survival benefit with age, gender, Eastern Cooperative Oncology Group (ECOG) performance status, hypertension and hand-foot syndrome. Patients with macrovascular invasion and extrahepatic invasion showed worse survival benefits. In conclusion, apatinib combined with TACE revealed certain survival benefits for HCC patients who experienced progression following TACE, which can provide a promising strategy for HCC treatment.

Inhibition of CUG-binding protein 1 and activation of caspases are critically involved in piperazine derivative BK10007S induced apoptosis in hepatocellular carcinoma cells

Though piperazine derivative BK10007S was known to induce apoptosis in pancreatic cancer xenograft model as a T-type CaV3.1 a1G isoform calcium channel blocker, its underlying antitumor mechanism still remains unclear so far. Thus, in the present study, the antitumor mechanism of BK10007S was elucidated in hepatocellular carcinoma cells (HCCs). Herein, BK10007S showed significant cytotoxicity by 3-[4,5-2-yl]-2,5-diphenyltetra-zolium bromide (MTT) assay and anti-proliferative effects by colony formation assay in HepG2 and SK-Hep1 cells. Also, apoptotic bodies and terminal deoxynucleotidyl transferase (TdT) dUTP Nick End Labeling (TUNEL) positive cells were observed in BK10007S treated HepG2 and SK-Hep1 cells by 4',6-diamidino-2-phenylinodole (DAPI) staining and TUNEL assay, respectively. Consistently, BK10007S increased sub G₁ population in HepG2 and SK-Hep1 cells by cell cycle analysis. Furthermore, Western blotting revealed that BK10007S activated the caspase cascades (caspase 8, 9 and 3), cleaved poly (ADP-ribose) polymerase (PARP), and downregulated the expression of cyclin D1, survivin and for CUG-binding protein 1 (CUGBP1 or CELF1) in HepG2 and SK-Hep1 cells. Conversely, overexpression of CUGBP1 reduced cleavages of PARP and caspase 3, cytotoxicity and subG₁ population in BK10007S treated HepG2 cells. Overall, these findings provide scientific evidences that BK10007S induces apoptosis via inhibition of CUGBP1 and activation of caspases in hepatocellular carcinomas as a potent anticancer candidate.