The optimal selection of radiotherapy treatment for hepatocellular carcinoma

Functional hydrogels for hepatocellular carcinoma: therapy, imaging, and in vitro model

Hepatocellular carcinoma (HCC) is among the most common malignancies worldwide and is characterized by high rates of morbidity and mortality, posing a serious threat to human health. Interventional embolization therapy is the main treatment against middle- and late-stage liver cancer, but its efficacy is limited by the performance of embolism, hence the new embolic materials have provided hope to the inoperable patients. Especially, hydrogel materials with high embolization strength, appropriate viscosity, reliable security and multifunctionality are widely used as embolic materials, and can improve the efficacy of interventional therapy. In this review, we have described the status of research on hydrogels and challenges in the field of HCC therapy. First, various preparation methods of hydrogels through different cross-linking methods are introduced, then the functions of hydrogels related to HCC are summarized, including different HCC therapies, various imaging techniques, in vitro 3D models, and the shortcomings and prospects of the proposed applications are discussed in relation to HCC. We hope that this review is informative for readers interested in multifunctional hydrogels and will help researchers develop more novel embolic materials for interventional therapy of HCC.

Competing risks analysis of external versus internal radiation in patients with hepatocellular carcinoma after controlling for immortal time bias

PURPOSE

In cohort studies on liver cancer, there are often immortal time bias and interference of competing risk events. This study proposes to explore the role of internal and external radiotherapy for hepatocellular carcinoma using SEER data, using a competing risk model and controlling immortal time bias.

METHODS

Data of SEER from 2004 till 2015 was included. To analyze whether there was a difference in survival between HCC (hepatocellular carcinoma) patients receiving external radiation and internal radiation, we used a competing risk analysis after excluding immortal time bias, and created a nomogram to assess the risk of cancer-specific death (CSD) in hepatocellular carcinoma patients receiving radiotherapy.

RESULTS

Potential confounding factors adjusted, there was no significant difference in CSD between external and internal radiation therapy [HR and its 95% CI = 1.098 (0.874-1.380)]. The constructed nomogram performed better than the traditional AJCC model. The AUC and calibration curve results showed that this well-calibrated nomogram could be used to make clinical decisions regarding the prognosis and personalized treatment of hepatocellular carcinoma treated. There was no difference in the cumulative risk of death between patients with liver cancer treated with external radiation therapy and internal radiation therapy.

CONCLUSION

There is no difference in the cumulative risk of death between patients with liver cancer treated with external radiation therapy and internal radiation therapy. The nomogram predicts the results more accurately. These results can be used to guide the choice of treatment options for patients with HCC and to predict their survival prognosis.

A case of complete remission of advanced hepatocellular carcinoma with type III portal vein tumor thrombosis treated using transarterial chemoembolization with microspheres and radiation therapy

Portal vein tumor thrombosis (PVTT) is an extremely locally advanced form of hepatocellular carcinoma. The natural median survival time of patients with hepatocellular carcinoma with PVTT is 2.7 to 4.0 months. A 63-year-old woman visited our clinic complaining of abdominal distention and appetite loss, which she had had for 3 weeks prior to admission. A contrast-enhanced computed tomography scan showed double hepatocellular carcinomas with Type III PVTT and massive ascites caused by arterio-portal shunts within the PVTT. The ascites could not be treated by concentrated ascites reinfusion therapy or diuretics. Transarterial embolization using microspheres followed by radiation therapy against PVTT and five courses of transarterial chemoembolization using microspheres and cisplatin led to the maintaining of complete remission of both ascites and tumors for over 12 months after treatment. Fluoroglucose accumulation of PVTT showed 11.2 as a maximum standard uptake value on positron emission tomography before treatment. No fluoroglucose accumulation within PVTT was observed for over 12 months following treatment. Transarterial chemoembolization using microspheres followed by radiation therapy against Type III PVTT may result in drastic anti-cancer effects and improvement of both serum albumin and intractable ascites after treatment of arterio-portal shunts within the PVTT causing portal hypertension.

External Radiation versus Internal Radiation for Patients with Advanced Unresectable HCC -A SEER Based Study

Hepatocellular carcinoma (HCC), 2nd most lethal cancer globally, is the major type of primary liver malignancies currently resulting in about 800,000 deaths globally per annum. Surgical resection remains the only curative treatment to HCC, which does not fit for many patients diagnosed with advanced HCC. Radiation therapy has been gradually concerned as an optional treatment for patients with advanced unresectable HCC. This study aimed to compare external radiation (beam radiation) and internal radiation as a single radiation therapy to advanced HCC patients (TNA stage III and IV according to the derived AJCC Stage, 6th edition) stratified by other risk factors, based on the data collected from the Surveillance, Epidemiology and End Results (SEER) national database. In this cohort study, we mainly clarified the following three points: 1. Choices of radiation therapy for advanced HCC patients vary in demographic and clinical factors. Among these, TNM classification is the key factor. 2. Internal radiation provides a better prognosis in both OS and CSS. 3. Patients in stage IV could benefit from internal radiation preferentially, while for patients in stage III, internal radiation therapy makes no difference compared with external radiation.

Phase I/II trial of helical IMRT-based stereotactic body radiotherapy for hepatocellular carcinoma

BACKGROUND

To report the results of a phase I/II study of helical IMRT-based stereotactic body radiotherapy (SBRT) for hepatocellular carcinoma (HCC).

METHODS

Eligibility included Child-Turcotte-Pugh class A or B, ≤3 lesions, and cumulative tumor diameter ≤6 cm. Dose was escalated from 36 Gy to 60 Gy delivered in 4 fractions. Grade ≥3 gastrointestinal toxicities (CTCAE v3.0) or radiation-induced liver disease defined dose-limiting toxicity (DLT).

RESULTS

Thirty-two patients were enrolled: seven in dose levels 1-2 (36-44 Gy) and 25 in levels 3-4 (42-60 Gy). Failures included 1 local, 14 outfield intrahepatic, 2 distant, 1 concurrent local and outfield, 1 concurrent outfield and distant, and 1 concurrent local, outfield, and distant. Nine had grade 3 hematologic toxicities and 5 had grade 2 hepatic toxicities; no patient experienced DLT. Two-year local control (LFFS), outfield intrahepatic control (OutFFS), and overall survival (OS) rates were 80.9%, 46.7%, and 81.3%, respectively. Dose levels 3-4 and pre-radiotherapy multi-segment recurrence were independent prognostic factors for LFFS and OutFFS, respectively. Two-year LFFS, OutFFS, and OS were significantly higher for patients who were treated with dose-levels 3/4 for tumor(s) involving single segment compared with the rest of the patients.

CONCLUSIONS

Helical IMRT-based SBRT was safe and effective, and patients with multi-segment recurrences prior to SBRT need to be closely followed.

Comprehensive treatments for hepatocellular carcinoma with portal vein tumor thrombosis

Portal vein tumor thrombosis (PVTT) is one of the most common complications in hepatocellular carcinoma (HCC). HCC with PVTT usually indicates poor prognosis, which has a number of characteristics including a rapidly progressive disease course, worse liver function, complications connected with portal hypertension, and poorer tolerance to treatment. The exact mechanisms of PVTT remain unknown, even though some concerned signal transduction or molecular pathways have been identified. In western countries, sorafenib is the only recommended therapeutic strategy regardless of PVTT types. However, multiple treatment options including transhepatic arterial chemoembolization, hepatectomy, radiotherapy, and sorafenib available in the clinic. In this review, we enumerate and discuss therapeutics against patients with HCC having PVTT available in the clinic and put forward directions for future research.

Modulation of adenylate cyclase signaling in association with MKK3/6 stabilization under combination of SAC and berberine to reduce HepG2 cell survivability

Cancer cells often have faulty apoptotic pathways resulting in sustenance of survivability, tumour metastasis and resistance to anticancer drugs. Alternate strategies are sought to improve therapeutic efficacy and therefore HepG2 cells were treated with S-allyl-cysteine (SAC) and berberine (BER) to analyze their mechanistic impact upon necroptosis along with its interacting relationship to apoptosis. In the present study we observed that SAC and BER exposure reduced NFκβ nuclear translocation through adenylate cyclase-cAMP-protein kinaseA axis and eventually evaded c-FLIP inhibition. Effective RIP1 k63-polyubiquitination and persistent MKK3/MKK6 expression during drug treatment potentiated caspase8 activity via p53-DISC conformation. Resultant tBid associated lysosomal protease mediated AIF truncation induced DNA fragmentation and persuaded effector caspase mediated scramblase activation resulting induction of necroptosis in parallel to apoptotic events. SAC+BER effectively reduced Rb-phosphorylation resulting insignificant nuclear E2F presence led to ending of cell proliferation. Therefore necroptosis augmented the drug response and may be targeted alongside cell proliferation inhibition in formation of efficient therapeutics against liver cancer.

High dose and compartmental target volume may improve patient outcome after radiotherapy for pelvic bone metastases from hepatocellular carcinoma

PURPOSE

Pelvic bone metastases are difficult to treat because of complex pelvic bone anatomy and the proximity of normal organs. The adequacy of radiation dose and field coverage was evaluated.

PATIENTS AND METHODS

We analyzed 146 cases of pelvic bone metastases from HCC treated with radiotherapy (RT). Bone metastases were confirmed using CT/MRI. Subjective pain response was assessed using the visual analogue scale, and treatment-related toxicity with the Common Terminology Criteria for Adverse Events v3.0. Local failure free survival (LFFS) and overall survival were estimated using the Kaplan-Meier method.

RESULTS

The local control rate was 80.1% and the pain control rate was 68.5%. Compartmental target volume (CTV), encompassing the whole compartment of the involved bone, was found to be a significant factor (1-year LFFS, 78% vs. 50%; p=0.001). Sites of metastasis were categorized as either upper or lower pelvic bone; both categories showed improved local control with CTV. Metastatic lesions that received more than 50 Gy of EQD2 showed more partial response in pain after RT (58% vs. 79%; p=0.007). No patient showed toxicity higher than Grade IV.

CONCLUSION

Compartmental RT targeted to the involved bone was associated with improved local control and LFFS. High-dose radiation was associated with an improved treatment response.

A Review and Update of Treatment Options and Controversies in the Management of Hepatocellular Carcinoma

OBJECTIVE

To review the current management, outline recent advances and address controversies in the management of hepatocellular carcinoma (HCC).

SUMMARY OF BACKGROUND DATA

The treatment of HCC is multidisciplinary involving hepatologists, surgeons, medical oncologists, radiation oncologists, radiologists, interventional radiologists, and other disciplines. Each of these disciplines brings its unique perspective and differing opinions that add to controversies in the management of HCC.

METHODS

A focused literature review was performed to identify recent studies on the management of HCC and thereby summarize relevant information on the various therapeutic modalities and controversies involved in the treatment of HCC.

RESULTS

The main treatment algorithms continue to rely on hepatic resection or transplantation with controversies involving patients harboring early stage disease and borderline hepatic function. The other treatment strategies include locoregional therapies, radiation, and systemic therapy used alone or in combination with other treatment modalities. Recent advances in locoregional therapies, radiation, and systemic therapies have provided better therapeutic options with curative intent potential for some locoregional therapies. Further refinements in combination therapies such as algorithms consisting of locoregional therapies and systemic or radiation therapies are likely to add additional options and improve survival.

CONCLUSIONS

The management of HCC has witnessed significant strides with advances in existing options and introduction of several new treatment modalities of various combinations. Further refinements in these treatment options combined with enrollment in clinical trials are essential to improve the management and outcomes of patients with HCC.

2-DG-Regulated RIP and c-FLIP Effect on Liver Cancer Cell Apoptosis Induced by TRAIL

Background

Cancer cells survival depends on glucose metabolism and ATP. Inhibiting glucose metabolism is a possible anticancer treatment. The phosphorylation of 2-deoxy-D-glucose (2-DG), which is a glycogen analogue, seriously affects the normal glycometabolism phosphorylation process, leading to ATP consumption. Studies showed that 2-DG could regulate RIP and c-FLIP. This paper aimed to investigate the effect of 2-DG on RIP and c-FLIP expression in HepG2 and Hep3B cells, further illustrating the effect and mechanism of 2-DG regulating RIP and c-FLIP expression on liver cancer cell apoptosis induced by TRAIL.

Material/Methods

RIP and c-FLIP gene silencing HepG2 and Hep3B cell models were established by siRNA and detected by Western blot. Cell viability was determined by MTT and apoptosis rate was measured by flow cytometry. JC-1 fluorescent probe was used to test mitochondrial membrane potential.

Results

2-DG or TRAIL alone significantly reduced HepG2 and Hep3B cell survival rate and promoted apoptosis. Compared with the single TRAIL treatment group, the combination of 2-DG and TRAIL could reduce cell survival rate, increase apoptosis rate, and decease mitochondrial membrane potential, which is dependent on Caspases. 2-DG can inhibit RIP and c-FLIP expression, leading to increased TRAIL-induced HepG2 and Hep3B cells apoptosis.

Conclusions

2-DG can down-regulate RIP and c-FLIP expression, and change Caspases activities to increase the liver cancer cell apoptosis induced by TRAIL.

210Po microsphere radiological design for tumor vascular disruption

The feasibility of disrupting a tumor’s vascular structure using ²¹⁰Po microspheres is investigated using standard ion and photon absorbed dose methodologies. Calculated absorbed dose profiles for ²¹⁰Po alpha particles are sufficient to disrupt a tumor’s arteriole structure while minimizing the dose outside the blood vessel wall. ²¹⁰Po photons contribute minimal dose to healthy tissue. The requisite activity of ²¹⁰Po to facilitate vascular disruption is calculated.

Survival analysis of transarterial radioembolization with yttrium-90 for hepatocellular carcinoma patients with HBV infection

INTRODUCTION

For patients with resectable hepatocellular carcinoma (HCC), hepatectomy remains one of the best treatment options to provide long-term survival. However, more than 50% of the patients have unresectable disease upon diagnosis even though there are no distant metastases. Transarterial chemoembolization (TACE) is a well-established treatment option that offers a palliative survival benefit for this group of patients. A better treatment for unresectable HCC has been sought after. There is some evidence that transarterial radioembolization (TARE) with the agent yttrium-90 produces encouraging outcomes, especially in patients with portal vein tumor thrombus. This study aims to analyze the outcomes of TARE at our center.

METHODS

From August 2009 to April 2013, 16 patients underwent TARE at our center. Sixteen patients with similar tumor characteristics were selected to undergo TACE alone for comparison. A retrospective analysis of the prospectively collected data of the patients was conducted. Only patients with newly diagnosed primary tumors were included in this study.

RESULTS

The median survival for patients having TARE was 19.9 versus 14.0 months in the TACE group (P=0.615). There was no difference in terms of tumor response according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST) (P=0.632). The 1-, 2- and 3-year survival rates in the TARE group were 80.0%, 30.5% and 20.3% respectively. The 1-year survival in the TACE group was 58.3% (P=0.615). For patients who had major vascular invasion (eight in each group), the 1- and 2-year survival rates in the TARE group were 62.5% and 15.6% respectively, while the 1-year survival in the TACE group was 35.0% (P=0.664).

CONCLUSIONS

The two groups showed similar results in terms of tumor response and overall survival benefit. TARE might provide a survival benefit for patients with major vessel invasion.

Tumor vascular disruption using various radiation types

The feasibility of disrupting a tumor's vascular structure with various radiation types and radionuclides is investigated. Calculated absorbed dose profiles for photons and (4)He ions suggest that low-energy beta-gamma and alpha emitting radionuclides can deposit sufficient absorbed dose to disrupt a tumor's vascular structure while minimizing the dose outside the blood vessel. Candidate radionuclides uniformly distributed in microspheres are theoretically investigated with respect to their vascular disruption potential and to offer an alternative to (90)Y microsphere therapy. Requisite activities of candidate low-energy beta-gamma and alpha emitting radionuclides to facilitate vascular disruption are calculated.

Radiotherapeutic options for hepatocellular carcinoma with portal vein tumor thrombosis

Portal vein tumor thrombosis (PVTT) is a common paraneoplastic condition in advanced primary hepatocellular carcinoma or hepatobiliary tract malignancies. Tumors with PVTT are frequently associated with adverse and aggressive features such as intrahepatic tumor dissemination, early treatment failure, or deterioration of hepatic function. Therefore, the treatment outcomes for PVTT in historical series are often dismal and discouraging. More recently, beneficial effects and excellent outcomes of external beam radiation therapy (EBRT) for treating this disease have been reported, and the use of EBRT is becoming more common because of the non-invasive nature of RT and rapid advances in RT technology. We hope to be able to cure this devastating condition in the near future with more advanced and efficacious disease management strategies. The current status and clinical trial results for EBRT as a promising treatment option for managing PVTT will be discussed here.

Water soluble fluorescence quantum dot probe labeling liver cancer cells

Water soluble quantum dots (QDs) have been prepared by hydrothermal method and characterized by ultraviolet irradiation, XRD, TEM, UV-Vis absorption spectrometer and fluorescence spectrometer. Then the QD-antibody-AFP probes (QD-Ab-AFP) were synthesized by chemical process and specifically labeled AFP antigen in PLC/PRF/5 liver cancer cells. The results showed that the QDs were cubic structure and had excellent optical properties. Moreover, the QD-Ab-AFP with good stability could specifically label liver cancer cells. This work provides strong foundation for further studying and developing new approach to detect liver cancer at early stage.

Sorafenib enhances radiation-induced apoptosis in hepatocellular carcinoma by inhibiting STAT3

PURPOSE

Hepatocellular carcinoma (HCC) is one of the most common and lethal human malignancies. Lack of efficient therapy for advanced HCC is a pressing problem worldwide. This study aimed to determine the efficacy and mechanism of combined sorafenib and radiation therapy treatment for HCC.

METHODS AND MATERIALS

HCC cell lines (PLC5, Huh-7, Sk-Hep1, and Hep3B) were treated with sorafenib, radiation, or both, and apoptosis and signal transduction were analyzed.

RESULTS

All 4 HCC cell lines showed resistance to radiation-induced apoptosis; however, this resistance could be reversed in the presence of sorafenib. Inhibition of phospho-STAT3 was found in cells treated with sorafenib or sorafenib plus radiation and subsequently reduced the expression levels of STAT3-related proteins, Mcl-1, cyclin D1, and survivin. Silencing STAT3 by RNA interference overcame apoptotic resistance to radiation in HCC cells, and the ectopic expression of STAT3 in HCC cells abolished the radiosensitizing effect of sorafenib. Moreover, sorafenib plus radiation significantly suppressed PLC5 xenograft tumor growth.

CONCLUSIONS

These results indicate that sorafenib sensitizes resistant HCC cells to radiation-induced apoptosis via downregulating phosphorylation of STAT3 in vitro and in vivo.

Antitumor effect of SIRT1 inhibition in human HCC tumor models in vitro and in vivo

Sirtuins (SIRT1-7) are a highly conserved family of NAD(+)-dependent enzymes that control the activity of histone and nonhistone regulatory proteins. SIRT1 is purposed to promote longevity and to suppress the initiation of some cancers. Nevertheless, SIRT1 is reported to function as a tumor suppressor as well as an oncogenic protein. Our data show that compared with normal liver or surrounding tumor tissue, SIRT1 is strongly overexpressed in human hepatocellular carcinoma (HCC). In addition, human HCC cell lines (Hep3B, HepG2, HuH7, HLE, HLF, HepKK1, skHep1) were screened for the expression of the sirtuin family members and only SIRT1 was consistently overexpressed compared with normal hepatocytes. To determine its effect on HCC growth, SIRT1 activity was inhibited either with lentiviruses expressing short hairpin RNAs or with the small molecule inhibitor, cambinol. Knockdown or inhibition of SIRT1 activity had a cytostatic effect, characterized by an altered morphology, impaired proliferation, an increased expression of differentiation markers, and cellular senescence. In an orthotopic xenograft model, knockdown of SIRT1 resulted in 50% fewer animals developing tumors and cambinol treatment resulted in an overall lower tumor burden. Taken together, our data show that inhibition of SIRT1 in HCC cells impairs their proliferation in vitro and tumor formation in vivo. These data suggest that SIRT1 expression positively influences the growth of HCC and support further studies aimed to block its activity alone or in combination as a novel treatment strategy.