Imaging and Imaging-Guided Interventions in the Diagnosis and Management of Hepatocellular Carcinoma (HCC)-Review of Evidence

Assessment of Systemic Toxicity, Genotoxicity, and Early Phase Hepatocarcinogenicity of Iron (III)-Tannic Acid Nanoparticles in Rats

Iron-tannic acid nanoparticles (Fe-TA NPs) presented MRI contrast enhancement in both liver cancer cells and preneoplastic rat livers, while also exhibiting an anti-proliferative effect via enhanced autophagic death of liver cancer cells. Hence, a toxicity assessment of Fe-TA NPs was carried out in the present study. Acute and systemic toxicity of intraperitoneal Fe-TA NPs administration was investigated via a single dose of 55 mg/kg body weight (bw). Doses were then repeated 10 times within a range of 0.22 to 5.5 mg/kg bw every 3 days in rats. Furthermore, clastogenicity was assessed by rat liver micronucleus assay. Carcinogenicity was evaluated by medium-term carcinogenicity assay using glutathione S-transferase placental form positive foci as a preneoplastic marker, while three doses ranging from 0.55 to 17.5 mg/kg bw were administered 10 times weekly via intraperitoneum. Our study found that the LD50 value of Fe-TA NPs was greater than 55 mg/kg bw. Repeated dose administration of Fe-TA NPs over a period of 28 days and 10 weeks revealed no obvious signs of systemic toxicity, clastogenicity, and hepatocarcinogenicity. Furthermore, Fe-TA NPs did not alter liver function or serum iron status, however, increased liver iron content at certain dose in rats. Notably, antioxidant response was observed when a dose of 17.5 mg/kg bw was given to rats. Accordingly, our study found no signs of toxicity, genotoxicity, and early phase hepatocarcinogenicity of Fe-TA NPs in rats.

Low UGP2 Expression Is Associated with Tumour Progression and Predicts Poor Prognosis in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a malignant tumour associated with a high mortality rate and poor prognosis worldwide. Uridine diphosphate-glucose pyrophosphorylase 2 (UGP2), a key enzyme in glycogen biosynthesis, has been reported to be associated with the occurrence and development of various cancer types. However, its diagnostic value and prognostic value in HCC remain unclear. The present study observed that UGP2 expression was significantly downregulated at both the mRNA and protein levels in HCC tissues. Receiver operating characteristic (ROC) curve analysis revealed that UGP2 may be an indicator for the diagnosis of HCC. In addition, Kaplan-Meier and Cox regression multivariate analyses indicated that UGP2 is an independent prognostic factor of overall survival (OS) in patients with HCC. Furthermore, gene set enrichment analysis (GSEA) suggested that gene sets negatively correlated with the survival of HCC patients were enriched in the group with low UGP2 expression levels. More importantly, a significant correlation was identified between low UGP2 expression and fatty acid metabolism. In summary, the present study demonstrates that UGP2 may contribute to the progression of HCC, indicating a potential therapeutic target for HCC patients.

Feasibility of hyperspectral analysis for discrimination of rabbit liver VX2 tumor

BACKGROUND

Hepatocellular carcinoma is one of the most common malignant tumors worldwide. Currently, the most accurate diagnosis imaging modality for hepatocellular carcinoma is enhanced magnetic resonance imaging. However, it is still difficult to distinguish cirrhosis lesions, and novel diagnosis modalities are still needed.

AIM

To investigate the feasibility of hyperspectral analysis for discrimination of rabbit liver VX2 tumor.

METHODS

In this study, a rabbit liver VX2 tumor model was established. After laparotomy, under direct view, VX2 tumor tissue and normal liver tissue were subjected to hyperspectral analysis.

RESULTS

The spectral signature of the liver tumor was clearly distinguishable from that of the normal tissue, simply from the original spectral curves. Specifically, two absorption peaks at 600-900 nm wavelength in normal tissue disappeared but a new reflection peak appeared in the tumor. The average optical reflection at the whole waveband of 400-1800 nm in liver tumor was higher than that of the normal tissue.

CONCLUSION

Hyperspectral analysis can differentiate rabbit VX2 tumors. Further research will continue to perform hyperspectral imaging to obtain more information for differentiation of liver cancer from normal tissue.

From diagnosis to treatment of hepatocellular carcinoma: An epidemic problem for both developed and developing world

Hepatocellular carcinoma (HCC) is the most frequent primary liver malignancy and the third cause of cancer-related death in the Western Countries. The well-established causes of HCC are chronic liver infections such as hepatitis B virus or chronic hepatitis C virus, nonalcoholic fatty liver disease, consumption of aflatoxins and tobacco smocking. Clinical presentation varies widely; patients can be asymptomatic while symptomatology extends from right upper abdominal quadrant paint and weight loss to obstructive jaundice and lethargy. Imaging is the first key and one of the most important aspects at all stages of diagnosis, therapy and follow-up of patients with HCC. The Barcelona Clinic Liver Cancer Staging System remains the most widely classification system used for HCC management guidelines. Up until now, HCC remains a challenge to early diagnose, and treat effectively; treating management is focused on hepatic resection, orthotopic liver transplantation, ablative therapies, chemoembolization and systemic therapies with cytotocix drugs, and targeted agents. This review article describes the current evidence on epidemiology, symptomatology, diagnosis and treatment of hepatocellular carcinoma.

Preliminary results of ultrasound-guided laser ablation for unresectable metastases to retroperitoneal and hepatic portal lymph nodes

BACKGROUND

Laser ablation with a neodymium-doped yttrium aluminum garnet (Nd:YAG) laser is a minimally invasive approach which is able to achieve a precise tissue necrosis. The study was aimed to assess the feasibility and efficiency of laser ablation in the treatment of retroperitoneal and hepatic portal unresectable metastatic lymph nodes.

METHODS

Eight patients including 11 pathologically proven metastatic lymph nodes, 4 in retroperitoneal, 7 in hepatic portal region, were treated by laser ablation. Primary cancers were cholangiocarcinoma (n = 4) and hepatocellular carcinoma (n = 4). Under sonographic guidance, the laser ablation was performed percutaneously. Follow-up contrast computed tomography or magnetic resonance image was performed.

RESULTS

The treatments were completed in single process in all the patients. No severe complications occurred. Follow-up contrast computed tomography or magnetic resonance imaging at 1 and 3 months showed partial responses in 11 lymph nodes. The local response rate at the 6 month follow-up was 75.0 %. The overall response rate was 62.5 %. Abdominal pain scores decreased significantly in all patients. Tumor marker levels decreased in six patients. The Child-Pugh grade did not change.

CONCLUSIONS

The results suggest that sonographically guided laser ablation is technically feasible for the local treatment of unresectable retroperitoneal and hepatic portal lymph nodes from hepatic cancer. Although further study is needed to evaluate its long time efficacy, abdominal pain relief is prominent.

Clinical outcome of immunotherapy with dendritic cell vaccine and cytokine-induced killer cell therapy in hepatobiliary and pancreatic cancer

The aim of this study was to determine the therapeutic effects of adoptive immunotherapy following dendritic cell (DC) vaccine and cytokine-induced killer (CIK) cell therapy and evaluate its cytotoxicity, survival benefits and quality of life (QOL) changes in patients with hepatobiliary and pancreatic cancer (HPC). We performed a retrospective analysis of 407 clinical cases, including 77 patients with HPC who received immunotherapy with DC vaccine and CIK cells (I group) and 330 patients with similar characteristics who underwent baseline treatment but did not receive immunotherapy [non-immunotherapy (NI) group)] as the control group. After a follow-up period of 294±207.5 days, the median survival time (MST) of the two groups was compared using the Kaplan-Meier method. In the I group, 61% of the patients developed a positive, delayed-type hypersensitivity response and 65% of the patients exhibited an improvement in QOL. The most notable adverse events included fever (28%), insomnia (25%), anorexia (17%), skin rash (12%) and arthralgia (31%). No severe toxicities were observed in patients in the I group; in addition, the MST was significantly longer in the I group compared with that in the NI group (P=0.014). Thus, the DC vaccine and CIK cell therapy was associated with mild adverse effects, but was able to induce an immune response and effectively eliminate tumor cells, thereby improving the QOL and prolonging the MST of the patients.

Assessment of Lipiodol Deposition and Residual Cancer for Hepatocellular Carcinoma After Transcatheter Arterial Chemoembolization via Iodine-Based Material Decomposition Images with Spectral Computed Tomography Imaging: A Preliminary Study

Background:

It is critical to follow up hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE) in clinical practice. Computed tomography (CT) is used to assess lipiodol deposition, whereas it is difficult to assess hypovascular residual cancer masked by lipiodol. In contrast, magnetic resonance imaging (MRI) is superior to CT in showing residual cancer, but cannot display lipiodol deposition.

Objectives:

The aim of this study was to investigate the value of spectral CT imaging in both lipiodol deposition and residual cancer for HCC patients after TACE.

Patients and Methods:

Ten HCC patients after treated with TACE underwent Discovery CT750 HD and MRI750 3T examination. Receiver operating characteristic (ROC) curves of iodine-based material decomposition images, monochromatic images and conventional CT images were generated.

Results:

Consequently, 30 residual lesions were detected in MRI of 10 patients. They were found in iodine-based images and monochromatic images versus 29 in conventional CT images. The area under ROC curves for the lesion-to-normal parenchyma ratio (LNR) on arterial phase (AP) in iodine-based material decomposition images, monochromatic images and conventional CT images were 0.933, 0.833 and 0.817, respectively.

Conclusion:

The study data highlighted good value of iodine-based material decomposition images of spectral CT in assessment of both lipiodol deposition and residual cancer for follow-up of HCC patients previously treated with TACE.

Percutaneous microwave ablation vs radiofrequency ablation in the treatment of hepatocellular carcinoma

Hepatocellular cancer ranks fifth among cancers and is related to chronic viral hepatitis, alcohol abuse, steatohepatitis and liver autoimmunity. Surgical resection and orthotopic liver transplantation have curative potential, but fewer than 20% of patients are suitable candidates. Interventional treatments are offered to the vast majority of patients. Radiofrequency (RFA) and microwave ablation (MWA) are among the therapeutic modalities, with similar indications which include the presence of up to three lesions, smaller than 3 cm in size, and the absence of extrahepatic disease. The therapeutic effect of both methods relies on thermal injury, but MWA uses an electromagnetic field as opposed to electrical current used in RFA. Unlike MWA, the effect of RFA is partially limited by the heat-sink effect and increased impedance of the ablated tissue. Compared with RFA, MWA attains a more predictable ablation zone, permits simultaneous treatment of multiple lesions, and achieves larger coagulation volumes in a shorter procedural time. Major complications of both methods are comparable and infrequent (approximately 2%-3%), and they include haemorrhage, infection/abscess, visceral organ injury, liver failure, and pneumothorax. RFA may incur the additional complication of skin burns. Nevertheless, there is no compelling evidence for differences in clinical outcomes, including local recurrence rates and survival.

Transcatheter arterial chemoembolization therapy for patients with unresectable hepatocellular carcinoma

BACKGROUND

Although transcatheter arterial chemoembolization (TACE) has been widely used as a palliative treatment for unresectable hepatocellular carcinoma (HCC), its actual efficacy and prognostic usefulness have not been clarified in past studies.

OBJECTIVES

The aim of the study is to investigate the efficacy, complications, and prognostic factors of the TACE in unresectable HCC patients.

PATIENTS AND METHODS

Thirty-two patients with unresectable HCC were treated with TACE. The procedure was performed with a combination of Lipiodol, doxorubicin, and cytomycin followed by gelatin-sponge particles embolization. CT-scan imaging and liver function tests (AST, ALT, ALP, BIL, and PT) were performed before and after the TACE. All patients were followed-up for 6-months.

RESULTS

Of all patients, 1 and 11 patients respectively, exhibited a complete response (CR) and a partial response (PR) (response rate, CR+PR, 44%). Data have shown that tumor size, number of lesions and number of involved segments are significantly reduced after the TACE performance (P < 0.05). No significant clinical adverse effect was observed in patients after the intervention. Also, liver function tests including AST, ALT, ALP, BIL, and PT did not significantly differ before and after the intervention (P > 0.05). The 6-month cumulative survival rates of the 32 patients were 78.1 %, respectively. Univariate analysis showed that survival correlated significantly with the following factors: tumor size; ≥ 8 cm versus < 8 cm (P < 0.010), serum ALP level; < 300 versus ≥ 300 (P < 0.043), and number of liver involved segments; < 2 versus ≥ 2 (P < 0.020).

CONCLUSIONS

We showed that in treatment of patients with unresectable hepatocellular carcinoma, TACE significantly improved the disease and the overall survival rate. Also, we introduce the tumor size, serum ALP level, and number of liver involved segments as prognostic factors of the procedure. Finally, TACE can be recommended as the initial treatment for unresectable HCC patients.

Management of liver hemangioma using trans-catheter arterial embolization

BACKGROUND

Hemangioma, a congenital vascular malformation, is the most common benign liver lesion that is usually remain stable subsequently requiring not treatment; however, complications such as abdominal pain or fullness, coagulation disturbances, and inflammatory syndrome may occur, demanding a specific treatment of hemangioma.

OBJECTIVES

To assess the safety, feasibility and efficacy of trans-catheter arterial embolization (TAE) for the treatment of Liver hemangioma.

PATIENTS AND METHODS

TAE was performed on 20 patients with liver hemangioma. The embolic agent used was polyvinyl alcohol (PVA) particles (300-400 micron, Jonson and Johnson Cordis, USA). All patients were followed up for 6 months. Imaging was carried out and patients were also evaluated symptomatically through telephone interview by a physician.

RESULTS

Twenty patients aged from 21 to 63 years (mean: 46.8, SD: 10.26) were included in this study. Post embolization syndrome, including abdominal pain, fever, and leukocytosis occurred in one patient 1 week after TAE and lasted for 3 days. No serious adverse event and TAE-related death was observed. None of the patient underwent another intervention including surgery. During follow up interval, decreased episode of abdominal pain was documented in all patients who had pain. Tumor enlargement was also stopped during the follow up. The average diameter of tumors was 97.00 mm (range: 25-200 SD: 47.85) and 88.95 mm (range: 23-195 SD: 43.27) before and after embolization, respectively. Comparison of images before and after TAE revealed statistically significant decrease in the size of lesion (P value: 0.004, t: 3.31).

CONCLUSIONS

Our findings indicate that TAE is a safe and efficient procedure for the treatment of liver hemangioma. Further studies with larger sample sizes are required to support therapeutic effects of TAE.

How to start interventional radiology

Interventional techniques aim to find safer and better ways to treat vascular diseases even in many instances, the interventional radiology solutions has been considered the only treatment option for the patients. Interventional radiologists are specialists who perform minimally invasive procedures instead of surgery or other treatments. These procedures apply various imaging and catheterization procedures in order to diagnose and treat diseases. In each country, interventional radiology practice establishment of varies according to local factors, but following a standard strategy seems better to set up this facility. According to above mentioned points, we decided to establish this specialty in our hospital since 2001 as the pioneer center in Iran. In this presentation we will discuss about our experience for start interventional radiology.

Percutaneous ablation therapy versus surgical resection in the treatment for early-stage hepatocellular carcinoma: a meta-analysis of 21,494 patients

PURPOSE

To compare comprehensively the benefits of radiofrequency ablation (RFA) and percutaneous ethanol injection (PEI) with those of surgical resection (SR) in early-stage hepatocellular carcinoma (HCC).

METHODS

The potentially relevant studies comparing the efficacy and safety of RFA and/or PEI with those of SR were searched using the databases such as PubMed, MEDLINE, Embase and Chinese databases (CNKI and Wanfang data). Overall survival rate, recurrence-free survival rate and complications were compared and analyzed. Pooled odds ratios with 95 % confidence intervals (95 % CIs) were calculated using either the fixed-effects model or random-effects model. All statistic analyses were conducted using the Review Manager (version 5.1.) from the Cochrane Collaboration.

RESULTS

Our analysis showed that the overall survival rate in patients treated with SR was significantly higher than that of percutaneous ablation therapy (PAT) [SR vs. PAT: 95 % confidence interval (95 % CI)2-year 0.46-0.89, P = 0.009; 95 % CI3-year 0.57-0.83, P < 0.0001; 95 % CI5-year 0.45-0.46, P < 0.0001]. SR was associated with significantly higher recurrence-free survival rate compared with PAT (SR vs. PAT: 95 % CI1-year 0.51-0.90, P = 0.008; 95 % CI2-year 0.41-0.78, P = 0.0004; 95 % CI3-year 0.38-0.77, P = 0.0006; 95 % CI5-year 0.33-0.61, P < 0.0001). SR resulted in longer survival than PAT in HCCs no larger than 3 cm. PAT was associated with less complications compared with SR (PAT vs. SR: 95 % CI 0.14-0.76, P = 0.01).

CONCLUSIONS

Although SR was associated with more complications, SR was superior to RFA and PEI for treatment of patients with early-stage HCC.