Transarterial Therapies for Hepatocellular Carcinoma: a Comprehensive Review with Current Updates and Future Directions

Development of nomograms to predict recurrence after conversion hepatectomy for hepatocellular carcinoma previously treated with transarterial interventional therapy

BACKGROUND

Lack of opportunity for radical surgery and postoperative tumor recurrence are challenges for surgeons and hepatocellular carcinoma (HCC) patients. This study aimed to develop nomograms to predict recurrence risk and recurrence-free survival (RFS) probability after conversion hepatectomy for patients previously receiving transarterial interventional therapy.

METHODS

In total, 261 HCC patients who underwent conversion liver resection and previously received transarterial interventional therapy were retrospectively enrolled. Nomograms to predict recurrence risk and RFS were developed, with discriminative ability and calibration evaluated by C-statistics, calibration plots, and the Area under the Receiver Operator Characteristic (AUROC) curves.

RESULTS

Univariate/multivariable logistic regression and Cox regression analyses were used to identify predictive factors for recurrence risk and RFS, respectively. The following factors were selected as predictive of recurrence: age, tumor number, microvascular invasion (MVI) grade, preoperative alpha-fetoprotein (AFP), preoperative carbohydrate antigen 19-9 (CA19-9), and Eastern Cooperative Oncology Group performance score (ECOG PS). Similarly, age, tumor number, postoperative AFP, postoperative protein induced by vitamin K absence or antagonist-II (PIVKA-II), and ECOG PS were incorporated for the prediction of RFS. The discriminative ability and calibration of the nomograms revealed good predictive ability. Calibration plots showed good agreement between the nomogram predictions of recurrence and RFS and the actual observations.

CONCLUSIONS

A pair of reliable nomograms was developed to predict recurrence and RFS in HCC patients after conversion resection who previously received transarterial interventional therapy. These predictive models can be used as guidance for clinicians to help with treatment strategies.

Nomograms for predicting the recurrence probability and recurrence-free survival in patients with hepatocellular carcinoma after conversion hepatectomy based on hepatic arterial infusion chemotherapy: a multicenter, retrospective study

BACKGROUND

This study aimed to establish and validate nomograms to predict the probability of recurrence and recurrence-free survival (RFS) in patients with hepatocellular carcinoma (HCC) after conversion hepatectomy based on hepatic arterial infusion chemotherapy (HAIC).

METHODS

Nomograms were constructed using data from a retrospective study of 214 consecutive patients treated with HAIC-based conversion liver resection between January 2016 and July 2020. Nomograms predicting the probability of tumor recurrence and RFS were established based on predictors selected by multivariate regression analysis. Predictive accuracy and discriminative ability of the nomogram were examined. Bootstrap method was used for internal validation. External validation was performed using cohorts ( n =128) from three other centers.

RESULTS

Recurrence rates in the primary and external validation cohorts were 63.6 and 45.3%, respectively. Nomograms incorporating clinicopathological features of tumor recurrence and RFS were generated. Concordance index (C-index) scores of the nomograms for predicting recurrence probability and RFS were 0.822 (95% CI, 0.703-0.858) and 0.769 (95% CI, 0.731-0.814) in the primary cohort, and 0.802 (95% CI, 0.726-0.878) and 0.777 (95% CI, 0.719-0.835) in the external validation cohort, respectively. Calibration curves indicated good agreement between the nomograms and actual observations. Moreover, the nomograms outperformed the commonly used staging systems. Patients with low risk, stratified by the median nomogram scores had better RFS (low risk vs. high risk, 36.5 vs. 5.2 months, P <0.001). The external validation cohort supported these findings.

CONCLUSIONS

The presented nomograms showed favorable accuracy for predicting recurrence probability and RFS in HCC patients treated with HAIC-based conversion hepatectomy. Identifying risk factors and estimating tumor recurrence may help clinicians in the decision-making process regarding adjuvant therapies for patients with HCC, which eventually achieves better oncological outcomes.

Evaluation of the use of a novel bioabsorbable polymer drug-eluting microsphere for transarterial embolization of hepatocellular neoplasia in dogs

In dogs with non-resectable hepatic neoplasia, treatment options are limited. The objectives of this study were to describe the use of a novel drug-eluting embolic microsphere containing paclitaxel for use during transarterial chemoembolization (TACE), to compare results of liver-specific owner questionnaires and tumor volume pre- and post-TACE, and to measure systemic paclitaxel concentration post-TACE. Client-owned dogs with non-resectable hepatic neoplasia were prospectively enrolled. All owners completed questionnaires validated for the assessment of subjective outcomes in dogs with cancer before the TACE procedure and approximately 4 weeks after the TACE procedure. A CT scan was performed before TACE and 1 month after TACE; results were compared. Blood samples were obtained at specified time points post-TACE to determine systemic paclitaxel concentrations. Seven dogs (median weight: 8.9 kg; range, 4.3-31 kg) were enrolled. TACE was successfully performed in all dogs, and no intra-procedural complications were encountered. Questionnaire scores improved significantly post-TACE. Among the 6 dogs for which full data were available, median pre-TACE tumor volume was 390 cc (range 152-1,484; interquartile range 231-1,139) and median post-TACE tumor volume was 203 cc (range 98-889; interquartile range 151-369), which was significantly (P = .028) lower. All 6 dogs had a reduction in volume at the post-TACE measurement. Mean percent change in tumor volume was -45.6% (95%CI -58.6 to -32.6%). The mean plasma paclitaxel concentration in canine blood peaked at 4 days post-TACE procedure and was 25.7 ng/mL (range = 3.09-110 ng/mL) Median survival time was 629 days (95%CI 18 to upper limit not reached). The use of a novel paclitaxel-eluting microsphere in this cohort of dogs successfully decreased tumor volume significantly after TACE and improved clinical signs. Future investigation into the use of TACE and other similar therapies is warranted due to the promising outcomes noted in this cohort.

Rim Enhancement after Technically Successful Transarterial Chemoembolization in Hepatocellular Carcinoma: A Potential Mimic of Incomplete Embolization or Reactive Hyperemia?

Contrast enhancement at the margins/rim of embolization areas in hepatocellular-carcinoma (HCC) lesions treated with transarterial chemoembolization (TACE) might be an early prognostic indicator for HCC recurrence. The aim of this study was to evaluate the predictive value of rim perfusion for TACE recurrence as determined by perfusion CT (PCT). A total of 52 patients (65.6 ± 9.3 years) underwent PCT directly before, immediately after (within 48 h) and at follow-up (95.3 ± 12.5 days) after TACE. Arterial-liver perfusion (ALP), portal-venous perfusion (PVP) and hepatic-perfusion index (HPI) were evaluated in normal liver parenchyma, and on the embolization rim as well as the tumor bed. A total of 42 lesions were successfully treated, and PCT measurements showed no residually vascularized tumor areas. Embolization was not entirely successful in 10 patients with remaining arterialized focal nodular areas (ALP 34.7 ± 10.1 vs. 4.4 ± 5.3 mL/100 mL/min, p < 0.0001). Perfusion values at the TACE rim were lower in responders compared to normal adjacent liver parenchyma and edges of incompletely embolized tumors (ALP liver 16.3 ± 10.1 mL/100 mL/min, rim responder 8.8 ± 8.7 mL/100 mL/min, rim non-responder 23.4 ± 8.6 mL/100 mL/min, p = 0.005). At follow-up, local tumor relapse was observed in 17/42, and 15/42 showed no recurrence (ALP 39.1 ± 10.1 mL/100 mL/min vs. 10.0 ± 7.4 mL/100 mL/min, p = 0.0008); four patients had de novo disseminated disease and six patients were lost in follow-up. Rim perfusion was lower compared to adjacent recurring HCC and not different between groups. HCC lesions showed no rim perfusion after TACE, neither immediately after nor at follow-up at three months, both for mid-term responders and mid-term relapsing HCCs, indicating that rim enhancement is not a sign of reactive hyperemia and not predictive of early HCC recurrence.

Borealin Promotes Tumor Growth and Metastasis by Activating the Wnt/β-Catenin Signaling Pathway in Hepatocellular Carcinoma

Background and Aims

Hepatocellular carcinoma (HCC) is a common malignant disease with high morbidity and mortality throughout the world. While Borealin is a putative oncogene that is dysregulated in multiple tumors, its exact role in HCC remains less investigated.

Methods

Quantitative reverse transcription polymerase chain reaction (qRT-PCR) and immunohistochemistry (IHC) assays were employed to examine the relative amount of Borealin. Gene set enrichment analysis (GSEA) and other bioinformatic analyses were implemented to probe into the potential functions of Borealin. The biological roles and mechanisms of Borealin in the tumorigenesis and development of HCC were further evaluated using a battery of functional assays in vivo and in vitro.

Results

Borealin was enhanced in the HCC tissue samples and hepatoma cells when compared with the nontumor tissues and normal liver cells. Higher Borealin expression was positively linked with advanced pathological phenotypes and inferior overall survival. The overexpression of Borealin promoted the cells’ abilities on proliferation, invasion and epithelial–mesenchymal transition (EMT) in vitro, facilitated tumor growth and lung metastasis in vivo, whereas the silencing of Borealin inhibited these capabilities in vitro. Furthermore, Borealin interacted with β-catenin and further activated the Wnt/β-catenin signaling pathway, which endowed HCC cells with highly aggressive and metastatic capabilities.

Conclusion

Borealin was identified as an oncogene that could promote HCC growth and metastasis by activating the WNT/β-catenin signaling pathway. These findings extended the understanding of Borealin in HCC tumorigenesis and development and highlighted the significance of Borealin in HCC diagnosis and treatment.

Neoadjuvant treatment strategies for hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) remains high globally. Surgical treatment is the best treatment for improving the prognosis of patients with HCC. Neoadjuvant therapy plays a key role in preventing tumor progression and even downstaging HCC. The liver transplantation rate and resectability rate have increased for neoadjuvant therapy. Neoadjuvant therapy is effective in different stages of HCC. In this review, we summarized the definition, methods, effects, indications and contraindications of neoadjuvant therapy in HCC, which have significance for guiding treatment.

Conventional versus drug-eluting bead transarterial chemoembolization: A better option for treatment of unresectable hepatocellular carcinoma

Transarterial chemoembolization (TACE) is a minimally invasive procedure involving intra-arterial catheter-based chemotherapy to selectively administer high doses of cytotoxic drugs to the tumor bed along with ischemic necrosis induced by arterial embolization. Chemoembolization forms the essential core of management in patients with hepatocellular carcinoma (HCC) who are not suitable for curative therapies such as transplantation, resection, or percutaneous ablation. TACE of hepatic cancer(s) has proven to be helpful in achieving local tumor control, and has supported the ability to prevent tumor progression, prolong patient life, and manage patient symptoms. Recent data have demonstrated that, in patients with single-nodule HCC ≤3 ​cm without vascular invasion, the 5-year overall survival with TACE was found to be comparable with hepatic resection and radiofrequency ablation. Used for several years, Lipiodol continues to play a vital role as a tumor-seeking and radiopaque drug delivery vector in interventional oncology. Efforts have been made to enhance the administration of chemotherapeutic agents to tumors. Compared with conventional TACE, drug-eluting bead TACE is a fairly new drug delivery embolization technique that permits fixed dosing and has the ability to provide sustained release of anticancer agents over a period of time. The present review discusses the basic procedure of TACE and its properties, and the effectiveness of conventional and drug-eluting bead chemoembolization systems currently available or presently undergoing clinical evaluation.

Hepatocellular carcinoma locoregional therapies: Outcomes and future horizons

Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver and has an overall five-year survival rate of less than twenty percent. For patients with unresectable disease, evolving liver-directed locoregional therapies provide efficacious treatment across the spectrum of disease stages and via a variety of catheter-directed and percutaneous techniques. Goals of locoregional therapies in HCC may include curative intent in early-stage disease, bridging or downstaging to surgical resection or transplantation for early or intermediate-stage disease, and local disease control and palliation in advanced-stage disease. This review explores the outcomes of chemoembolization, bland embolization, radioembolization, and percutaneous ablative therapies. Attention is also given to prognostic factors related to each of the respective techniques, as well as future directions of locoregional therapies for HCC.

What Should Be the Rules for Downstaging for Hepatocellular Carcinoma?

INTRODUCTION

Liver transplantation remains the main curative treatment method for hepatocellular carcinoma. There are several criteria for hepatocellular carcinoma to be eligible for liver transplantation, and it depends on main transplantation centers worldwide. Locoregional treatments and downstaging protocols are used for either to achieve these criteria or to prevent drop outs on the transplant waiting lists. But who can benefit from these bridging therapies effectively for the main purpose of curative treatment? Main contraindications are known for locoregional treatments like cirrhosis or low hepatic function, total main portal vein occlusion, and extrahepatic metastasis. HCCs, which are confined to liver but have high tumor burden, remains the main controversial issue.

AIM

On this aspect, we reviewed the literature for downstaging protocols for hepatocellular carcinoma with their effect on survival and recurrence rates after liver transplantation.

CONCLUSION

Although candidates for downstaging is still controversial, with the absence of main contraindications, LRT can be applied to selected HCCs, which have a certain degree of tumor burden.

Long noncoding RNA TP53TG1 suppresses the growth and metastasis of hepatocellular carcinoma by regulating the PRDX4/β-catenin pathway

Emerging evidence has shown that aberrant expression of lncRNA-TP53TG1 plays important roles in various malignancies. However, the biological functions of lncRNA-TP53TG1 in hepatocarcinogenesis, as well as the underlying mechanisms, remain largely unknown. Here, we assessed whether lncRNA-TP53TG1 plays a key role in the progression of hepatocellular carcinoma (HCC). The expression of lncRNA-TP53TG1 was significantly decreased in HCC tissues and cells. Decreased expression of lncRNA-TP53TG1 was associated with aggressive clinical phenotypes and a poor prognosis. Ectopic expression of lncRNA-TP53TG1 inhibited hepatoma cell proliferation and migration in vitro and in vivo, whereas lncRNA-TP53TG1 knockdown exerted the opposite effects. Furthermore, lncRNA-TP53TG1 played an important role in slowing the epithelial-mesenchymal transition (EMT) process in HCC. Mechanistically, lncRNA-TP53TG1 physically interacted with PRDX4 and promoted its ubiquitin-mediated degradation, resulting in the inactivation of the WNT/β-catenin signaling pathway in hepatoma cells. Our findings demonstrate a novel mechanism by which lncRNA-TP53TG1 exerts its tumor-suppressive effects through the WNT/β-catenin signaling pathway in a PRDX4-mediated manner in HCC. Based on these results, lncRNA-TP53TG1 potentially represents a prognostic indicator and therapeutic target for patients with HCC.

Milan-out Criteria and Worse Intention-to-Treat Outcome Postliver Transplantation

Milan criteria are widely used for liver transplantation selection in hepatocellular carcinoma but have been recognized to be too restrictive. Milan-out criteria are increasingly being adopted. Our aim was to analyze if liver transplantation waitlisted Milan-out hepatocellular carcinoma patients have different outcome than Milan patients.

Down-regulation of MARCO associates with tumor progression in hepatocellular carcinoma

Hepatocellular carcinoma(HCC) is a malignant tumor with high mortality due to lack of early diagnostic methods and effective treatments, and the molecular mechanisms are intricate and remain unclear. In the present study, the role of macrophage receptor with collagenous structure (MARCO) in tumor advancement of HCC was investigated. We examined expression level of MARCO in HCC samples, corresponding adjacent nontumor tissues and six hepatoma cell lines by polymerase chain reaction and immunohistochemistry (IHC). Clinical information of HCC patients was also analyzed. The role of MARCO involved in HCC progression via multiple functional experiments in vitro and in vivo was investigated. Bioinformatics analysis was conducted to further explore biological functions of MARCO. We found MARCO was suggestively down-regulated in HCC and associated with favorable prognosis, and MARCO upregulation oppressed tumor cell migration and invasion. Besides, overexpression of MARCO not only promoted apoptosis of hepatoma cells but also suppressed proliferation in vivo and in vitro. Furthermore, gene set enrichment analysis (GSEA) analysis suggested that MARCO may be related to the P53 signaling pathway, and this prediction was confirmed in this study as well. In sum, our study indicated that MARCO was involved in HCC progression and it can be defined as a novel probable biomarker as well as treatment target for HCC.

Numerical zero-dimensional hepatic artery hemodynamics model for balloon-occluded transarterial chemoembolization

Balloon-occluded transarterial chemoembolization (B-TACE) is a valuable treatment option for patients with inoperable malignant tumors in the liver. Balloon-occluded transarterial chemoembolization consists of the transcatheter infusion of an anticancer drug mixture and embolic agents. Contrary to conventional TACE, B-TACE is performed via an artery-occluding microballoon catheter, which makes the blood flow to redistribute due to the intra- and extrahepatic arterial collateral circulation. Several recent studies have stressed the importance of the redistribution of blood flow in enhancing the treatment outcome. In the present study, the geometries of a representative hepatic artery and the communicating arcades (CAs) are modeled. An in silico zero-dimensional hemodynamic model is created by characterizing the geometry and the boundary conditions and then is validated in vitro. The role of CAs is assessed by combining 2 cancer scenarios and 2 catheter locations. The importance of the diameter of the CAs is also studied. Results show that occluding a main artery leads to collateral circulation and CAs start to play a role in blood-flow redistribution. In summary, numerical zero-dimensional simulations permit a fast and reliable approach for exploring the blood-flow redistribution caused by the occlusion of a main artery, and this approach could be used during B-TACE planning.

Post Locoregional Therapy Treatment Imaging in Hepatocellular Carcinoma Patients: A Literature-based Review

Imaging plays a crucial role in the diagnosis of hepatocellular carcinoma (HCC) as well as in determining treatment efficacy, or complications, following therapy. Unlike other cancers, HCC is most commonly treated by locoregional therapies (LRTs) such as thermal ablation, transarterial chemoembolization, and transarterial radioembolization. These treatments can lead to changes on imaging that make determination of residual/recurrent disease difficult. This literature-based review discusses the expected postimaging findings following LRT.

Hepatocellular Carcinoma: Diagnosis, Treatment Algorithms, and Imaging Appearance after Transarterial Chemoembolization

Hepatocellular carcinoma (HCC) is a common cause of cancer-related death, with incidence increasing worldwide. Unfortunately, the overall prognosis for patients with HCC is poor and many patients present with advanced stages of disease that preclude curative therapies. Diagnostic and interventional radiologists play a key role in the management of patients with HCC. Diagnostic radiologists can use contrast-enhanced computed tomography (CT), magnetic resonance imaging, and ultrasound to diagnose and stage HCC, without the need for pathologic confirmation, by following established criteria. Once staged, the interventional radiologist can treat the appropriate patients with percutaneous ablation, transarterial chemoembolization, or radioembolization. Follow-up imaging after these liver-directed therapies for HCC can be characterized according to various radiologic response criteria; although, enhancement-based criteria, such as European Association for the Study of the Liver and modified Response Evaluation Criteria in Solid Tumors, are more reflective of treatment effect in HCC. Newer imaging technologies like volumetric analysis, dual-energy CT, cone beam CT and perfusion CT may provide additional benefits for patients with HCC.

Post-operative care of interventional therapy for 40 liver cancer patients with obstructive jaundice

The care of 40 patients with primary liver cancer with obstructive jaundice treated with liver puncture bile drainage or biliary stent implantation was reported. Treated with the interventional therapy, patients were observed closely to identify symptoms of hepatic encephalopathy and pain; diet care was well performed. Bile drainage tube and skin acre were performed carefully. Liver function, bilirubin and other biochemical indicators were monitored; occurrence of bleeding, acute pancreatitis, biliary tract infection, leakage of ascites around drainage tube and other complication were observed with good discharge instruction. After this operation, three rounds of liver had poor function, and hepatic encephalopathy and death occurred during hospitalisation. Seven patients had bloody bile drainage fluid after operation; eight had increased blood amylase; nine had biliary infection and four had leakage of ascites around the drainage tube. After positive treatment and care, the situation was improved with varied degrees of jaundice increase.

Drug-eluting beads transarterial chemoembolization for hepatocellular carcinoma: Current state of the art

Transarterial chemoembolization (TACE) represents the current gold standard for hepatocellular carcinoma (HCC) patients in intermediate stage. Conventional TACE (cTACE) is performed with the injection of an emulsion of a chemotherapeutic drug with lipiodol into the artery feeding the tumoral nodules, followed by embolization of the same vessel to obtain a synergistic effect of drug cytotoxic activity and ischemia. Aim of this review is to summarize the main characteristics of drug-eluting beads (DEB)-TACE and the clinical results reported so far in the literature. A literature search was conducted using PubMed until June 2017. In order to overcome the drawbacks of cTACE, namely lack of standardization and unpredictability of outcomes, non-absorbable embolic microspheres charged with cytotoxic agents (DEBs) have been developed. DEBs are able to simultaneously exert both the therapeutic components of TACE, either drug-carrier function and embolization, unlike cTACE in which applying the embolic agent is a second moment after drug injection. This way, risk of systemic drug release is minimal due to both high-affinity carrier activity of DEBs and absence of a time interval between injection and embolization. However, despite promising results of preliminary studies, clear evidence of superiority of DEB-TACE over cTACE is still lacking. A number of novel technical devices are actually in development in the field of loco-regional treatments for HCC, but only a few of them have entered the clinical arena. In absence of well-designed randomized-controlled trials, the decision on whether use DEB-TACE or cTACE is still controversial.

Trends and outcomes of transarterial chemoembolization in hepatocellular carcinoma: a national survey

BACKGROUND

Transarterial chemoembolization (TACE) is a palliative procedure frequently used in patients with advanced hepatocellular carcinoma (HCC). We examined the national inpatient trends of TACE and related outcomes in the United States over the last decade.

METHODS

We utilized the National Inpatient Sample (2002 to 2012) and performed trend analyses of TACE for HCC in all adult patients (age >18 years). Multivariate analyses for the outcomes of in-hospital "procedure-related complications" (PRCs) and "post-procedure complications" (PPCs) were performed. We also compared early (2002 to 2006) and late (2007 to 2012) eras by multivariate analyses to identify predictors of complications, healthcare resource utilization and mortality.

RESULTS

Overall, 19058 patients underwent TACE for HCC where PRCs and PPCs were seen in 24.2% and 17.6% of patients, respectively. The overall trends in the use of TACE (P<0.001) and associated PRCs (P=0.006) were observed to be increasing. There was less mortality [adjusted Odds ratio (aOR): 0.58; 95% CI: 0.41, 0.82], reduced length of hospital stay (-1.87 days; 95% CI: -2.77, -0.97) and increased hospital charges ($19232; 95% CI: 11013, 27451) in the late era. Additionally, there was increased mortality (aOR: 4.07; 95% CI: 2.96, 5.59), PRCs (aOR: 3.21; 95% CI: 2.56, 4.02), and PPCs (aOR: 2.70; 95% CI: 2.11, 3.46) among patients with coagulopathy.

CONCLUSIONS

There is an increasing trend of TACE utilization in HCC. However, the outcomes are worse in patients with coagulopathy. Although PRCs have increased, mortality has decreased in recent years. These findings should be considered during TACE evaluation in patients with HCC.

Locoregional and systemic therapy for hepatocellular carcinoma

The management of hepatocellular carcinoma (HCC) remains challenging due to late presentation and the presence of accompanying liver dysfunction. As such, most patients are not eligible for curative resection and liver transplant. Management in this scenario depends on a number of factors including hepatic function, tumor burden, patency of hepatic vasculature and patients' functional status. Based on these, patients can be offered catheter based intra-arterial therapy for intermediate stage disease and in more advanced disease, sorafenib. Given recent data, regorafenib is now an option following failure of sorafenib. Catheter directed intra-arterial therapy takes advantage of tumor hypervascularity and the unique dual blood supply of the liver, as hepatic tumors receive arterial perfusion via the hepatic artery while the rest of the liver is supplied by the portal vein. This allows selective embolization and delivery of chemotherapeutic agents to the tumor. Compared to best supportive care, intra-arterial therapy offers a survival benefit in intermediate stage HCC and is the recommended approach for treatment. None of the catheter based approaches; including bland embolization, conventional trans-arterial chemoembolization (cTACE), drug eluting bead trans-arterial chemoembolization (DEB-TACE) or trans-arterial radioembolization (TARE) offers a clear advantage over the other, although DEB-TACE may be characterized by less systemic toxicity. All of these approaches are contraindicated in patients with portal vein thrombosis (PVT). On the other hand, intra-arterial, radio embolization, with Yttrium-90 (Y90) can be offered to patients with PVT. The place of this modality in management of HCC is still being investigated. The role of sorafenib in advanced HCC is not in doubt, as until recently, it was the only systemic therapy approved for the management in this setting. This is despite multiple trials evaluating other agents. The addition of sorafenib to catheter-based therapy in intermediate stage disease has also failed to show any benefit. The modest survival benefit with sorafenib and the failure of other targeted agents suggest that it is important to look beyond inhibition of angiogenesis in advanced HCC. Identification of key drivers and mediators of HCC remains paramount for successful drug development. In line with this, it is refreshing that the excitement that has followed developments in cancer immunotherapy is finding its way to HCC with early trials of anti-PD1 monoclonal antibodies showing sufficient activity that phase III trials are now ongoing for Pembrolizumab and Nivolumab in advanced HCC. Future drug development efforts will focus on defining the feasibility of combining different treatment approaches targeting multiple important modulators of HCC.

Microwave ablation for hepatocellular carcinoma associated with Budd-Chiari syndrome after transarterial chemoembolization: an analysis of ten cases

PURPOSE

To evaluate the feasibility, efficacy, and safety of microwave ablation (MWA) in the treatment of hepatocellular carcinoma associated with Budd-Chiari syndrome (BCS) after transarterial chemoembolization (TACE).

METHODS

A total of 10 patients (mean 50.0 ± 7.5 years) with 15 BCS-associated HCC lesions were retrospectively evaluated. All patients received MWA treatment for residual tumors after 1 to 3 sessions of TACE. The diagnosis of residual tumors was confirmed by at least two types of enhanced imaging. CEUS images were performed to confirm the residual lesions and guide the placement of antenna before MWA. Thermal monitoring and artificial pleural effusion or ascites were used to guarantee ablative accuracy and safety for patients with tumors adjacent to vital structures. Technical success, technique efficacy, local tumor progression, survival rate, and the incidence of complications were comprehensively analyzed.

RESULTS

Technical success and technique effectiveness were achieved in all patients. Thirteen lesions achieved complete ablation for the first time, and 2 lesions needed two sessions. Thermal monitoring was used in 2 patients, artificial pleural effusion was used in 1 patient, and artificial ascites in 2 patients. In a median follow-up of 34.5 months (range 21-52 months), no LTP was founded in all patients. Intrahepatic recurrence was found in 5 patients. 1-, 2-, 3-, and 4-year survival rates were 100%, 100%, 74.1%, and 37.0%, respectively. No major or minor complications were observed.

CONCLUSION

Microwave ablation is a feasible and effective way to treat residual tumors after TACE treatment in patients with BCS-associated HCC.

Upregulation of P2Y2 nucleotide receptor in human hepatocellular carcinoma cells

Objective

To examine if hypoxia inducible factor-1α (HIF-1α) can induce the upregulation of the purinergic receptor P2Y2 (P2Y2) and thereby promote the viability of human hepatocellular carcinoma (HCC) cells under hypoxic conditions.

Methods

Archival HCC tumour specimens and corresponding non-cancerous tissues were examined immunohistochemically for P2Y2 protein. A series of in vitro experiments were undertaken using HCC cell lines to determine the effect of hypoxia on HIF-1α and P2Y2 levels, the effect of HIF-1α upregulation on P2Y2 levels, and the effect of P2Y2 upregulation on cell viability under hypoxic conditions.

Results

Human HCC specimens were positive for P2Y2. Hypoxia and upregulated HIF-1α both upregulated the P2Y2 levels in HCC cell lines. P2Y2 upregulation using plasmid transfection resulted in enhanced cell viability under hypoxia. Treatment of HepG2 cells with the selective P2Y2 antagonist MRS2312 downregulated P2Y2 and reduced cell viability in five HCC cell lines. P2Y2 knockdown reduced HepG2 cell viability under hypoxia.

Conclusions

These present results suggest that HCC cells upregulate P2Y2 levels during hypoxia, which in turn promotes their growth. P2Y2 could be a potential therapeutic target for treating HCC.