Clinical characteristics and outcome of patients with combined hepatocellular-cholangiocarcinoma-a European multicenter cohort

BACKGROUND

There is no clear consensus on the optimal systemic treatment regimen in combined hepatocellular-cholangiocarcinoma (cHCC-CCA) patients. We describe clinical characteristics and outcome of cHCC-CCA patients, with a special focus on patients receiving palliative systemic therapy, including immune checkpoint inhibitors (ICIs).

METHODS

In this European retrospective, multicenter study, patients with histologically proven cHCC-CCA treated at four institutions between April 2003 and June 2022 were included. In patients receiving palliative systemic therapy, outcome was compared between cytotoxic chemotherapy (CHT)- and non-cytotoxic CHT (nCHT)-treated patients.

RESULTS

Of 101 patients, the majority were male (n = 70, 69%) with a mean age of 64.6 ± 10.6 years. Only type of first-line treatment was independently associated with overall survival (OS). Palliative systemic therapy was administered to 44 (44%) patients. Of those, 25 (57%) patients received CHT and 19 (43%) had nCHT (n = 16 of them sorafenib) in systemic first line. Although there was no significant difference in overall response rate (ORR; CHT versus nCHT: 8% versus 5%), disease control rate (24% versus 21%), and median progression-free survival {3.0 months [95% confidence interval (CI) 1.4-4.6 months] versus 3.2 months (95% CI 2.8-3.6 months), P = 0.725}, there was a trend towards longer median OS in the CHT group [15.5 months (95% CI 8.0-23.0 months) versus 5.3 months (95% CI 0-12.5 months), P = 0.052]. However, in multivariable analysis, type of first-line regimen (CHT versus sorafenib) was not associated with OS. ORR in patients receiving ICIs (n = 7) was 29%.

CONCLUSIONS

In patients with cHCC-CCA, OS, progression-free survival, ORR, and disease control rate were not significantly different between individuals receiving CHT and patients receiving nCHT. Immunotherapy may be effective in a subset of patients. Prospective studies are needed to identify optimal systemic treatment regimens in cHCC-CCA.

An empirical assessment of the factors influencing acceptance of COVID-19 vaccine uptake between Kenyan and Hungarian residing populations: A cross-sectional study

The development of effective, safe, and acceptable vaccines is a long process. COVID-19 vaccine hesitancy continues to elicit mixed reactions among different quarters despite numerous evidence of their effectiveness. This study aimed to determine the availability and acceptance rates of SARS-CoV-2 vaccines, among Kenyan and Hungarian residing populations and the underlying reasons contributing to the hesitancy of uptake. A non-probability, snowball sampling design was employed, and a survey questionnaire tool link was expeditiously disseminated. Data were carefully analyzed descriptively. Demographic variables, COVID-19 awareness, possible exposure, reasons associated with hesitancy in taking up a vaccine, choice of a vaccine, and availability of vaccines among other important variables were tested to explore their associations with vaccine acceptance rates between the two distinct countries. A total of 1960 participants were successfully enrolled in the research study, while 67 participants were excluded based on the inclusion criterion set. There was, however, no significant difference in COVID-19 public awareness between the Kenyan and Hungarian-residing participants, p = 0.300. Of the respondents, 62.4% were willing and ready to receive vaccines against COVID-19 disease. There was a significant difference (p = 0.014) between the Kenyan and Hungarian-residing respondents concerning vaccine uptake and acceptance rates. The vaccine acceptance rates in Hungary were higher than in Kenya, with mean = 0.27, SD = 0.446, S. E = 0.045 for the Hungarian population sample and mean = 0.40, SD = 0.492, S. E = 0.026, for the Kenyan sample respectively. Concerning gender and vaccine acceptance, there was a notable significant difference between males and females, p = 0.001, where the mean for males and females were 0.29 and 0.46 respectively. Acceptance rates among males were higher than among females. The functions of One-Way ANOVA and Chi-square were used to establish any significant differences and associations between means and variables respectively. Concerns regarding the safety, efficacy, and accuracy of information about the developed vaccines are significant factors that must be promptly addressed, to arrest crises revolving around COVID-19 vaccine hesitancy, especially in Kenya and among females in both populations, where acceptance rates were lower. Expansion of the screening program to incorporate antibody (serology) tests, is also highly recommended in the present circumstance. Equitable distribution of vaccines globally should be encouraged and promoted to adequately cover low- and middle-income countries. To enhance effective combat on vaccination hesitancy and apprehension in different countries, mitigation techniques unique to those countries must be adopted.

Cancer and hepatic steatosis

Non-alcoholic fatty liver disease (NAFLD) is a highly prevalent and increasing liver disease, which encompasses a variety of liver diseases of different severity. NAFLD can lead to liver cirrhosis with all its complications as well as hepatocellular carcinoma (HCC). Steatosis of the liver is not only related to obesity and other metabolic risk factors, but can also be caused by several drugs, including certain cytotoxic chemotherapeutic agents. In patients undergoing liver surgery, hepatic steatosis is associated with an increased risk of post-operative morbidity and mortality. This review paper summarizes implications of hepatic steatosis on the management of patients with cancer. Specifically, we discuss the epidemiological trends, pathophysiological mechanisms, and management of NAFLD, and its role as a leading cause of liver cancer. We elaborate on factors promoting immunosuppression in patients with NAFLD-related HCC and how this may affect the efficacy of immunotherapy. We also summarize the mechanisms and clinical course of chemotherapy-induced acute steatohepatitis (CASH) and its implications on cancer treatment, especially in patients undergoing liver resection.

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Non-alcoholic fatty liver disease can lead to cirrhosis with all its complications, including hepatocellular carcinoma.

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Chemotherapy-associated acute steatohepatitis is a side-effect of chemotherapeutic agents and may limit treatment options.

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In this review we summarize current clinical concepts of NAFLD and CASH that help clinicians in their clinical practice.

Non-selective β-blockers improve the correlation of liver stiffness and portal pressure in advanced cirrhosis

BACKGROUND

Liver stiffness (LS) correlates with portal pressure (hepatic venous pressure gradient, HVPG). However, the dynamic components of portal hypertension (PHT) in advanced cirrhosis may not be adequately assessed by TE. The influence of treatment with non-selective β-blockers (NSBB) on the correlation of HVPG and LS has not been investigated.

METHODS

One hundred and twenty-two patients with esophageal varices were included. LS, hemodynamic parameters, and HVPG were recorded at baseline (BL) and after 6 weeks of treatment with NSBB (FU). The correlation of LS and HVPG was compared to control patients with HVPG ≤ 12 mmHg.

RESULTS

Patients with higher Child-Pugh stages (A:88/B:25/C:9) had higher levels of liver stiffness (47.4 ± 16.5 vs. 70.3 ± 7.9 vs. 73.7 ± 2.1 kPa) and HVPG (21 ± 5 vs. 26 ± 5 vs. 26 ± 4 mmHg). The correlation of LS and HVPG was stronger in controls with HVPG ≤ 12 mmHg (R = 0.951; P < 0.0001) than in patients with HVPG > 12 mmHg (R = 0.538; P = 0.0004). The association of HVPG with LS became stronger under treatment with NSBB, which finally restored the linear correlation of HVPG and LS (R = 0.930; P < 0.0001). Forty-three percent (53/122) of patients were hemodynamic responders to NSBB. The improvement in the correlation of LS and HVPG under NSBB was mainly noted in hemodynamic responders (R = 0.864), but not in nonresponders (R = 0.535), whereas changes in LS, heart rate, and MAP were similar in responders and nonresponders.

CONCLUSIONS

Targeting the hyperdynamic circulation and the increased splanchnic blood inflow by treatment with NSBB unmasks the linear (mechanical) correlation of HVPG and LS in patients with HVPG > 12 mmHg. Measurement of LS by TE is not a feasible method to assess the dynamic components of PHT.

The effects of sorafenib on the portal hypertensive syndrome in patients with liver cirrhosis and hepatocellular carcinoma--a pilot study

BACKGROUND

Increased intrahepatic vascular resistance and hyperperfusion in the splanchnic circulation are the principal mechanisms leading to portal hypertension in cirrhosis. Several preclinical studies have demonstrated a beneficial effect of the multikinase inhibitor sorafenib on the portal hypertensive syndrome.

AIM

To investigate the effect of sorafenib on hepatic venous pressure gradient (HVPG), systemic hemodynamics and intrahepatic mRNA expression of proangiogenic, profibrogenic and proinflammatory genes.

METHODS

Patients with liver fibrosis/cirrhosis and hepatocellular carcinoma were treated with sorafenib 400 mg b.d. HVPG measurement and transjugular liver biopsy were performed at baseline and at week 2. Changes in HVPG and intrahepatic mRNA expression of vascular endothelial growth factor (VEGF), platelet-derived growth factor (PDGF), RhoA, tumour necrosis factor-alpha (TNF-α) and placental growth factor (PlGF) were evaluated.

RESULTS

Thirteen patients (m/f = 12/1; Child-Pugh class A/B = 10/3) were included. The most common aetiology of liver disease was alcohol consumption (n = 7). Eleven patients had an elevated portal pressure, including eight patients with clinically significant portal hypertension. A significant decrease of HVPG (≥ 20% from baseline) was observed in four subjects. In HVPG responders, we observed mRNA downregulation of VEGF, PDGF, PlGF, RhoA kinase and TNF-α, while no substantial mRNA decrease was found in nonresponders in any of the five genes. In two of the four HVPG responders we observed a dramatic (43-85%) mRNA decrease of all five investigated genes.

CONCLUSION

Larger controlled clinical trials are needed to demonstrate any potential beneficial effect of sorafenib on portal hypertension in patients with cirrhosis.

Prognostic factors in patients with advanced hepatocellular carcinoma treated with sorafenib

BACKGROUND

Sorafenib is the new reference standard for patients with advanced hepatocellular carcinoma (HCC).

AIM

To identify prognostic factors in sorafenib-treated HCC patients and to evaluate outcomes with respect to liver function.

METHODS

In this retrospective study, 148 HCC patients received sorafenib 400 mg b.d. across 11 Austrian institutions. Seventy-eight HCC patients who received best supportive care (BSC) in the pre-sorafenib era served as a control.

RESULTS

In sorafenib-treated patients, low baseline α-fetoprotein, low Child-Pugh (CP) score, compensated cirrhosis, and low baseline aspartate aminotransferase (AST) were associated with significantly longer overall survival (OS) on univariate analysis. CP score and baseline AST remained independent prognostic factors on multivariate analysis. In patients with Barcelona Clinic liver Cancer (BCLC) stage B or C HCC (sorafenib: n = 139; BSC: n = 39), CP-A patients had a median OS of 11.3 (sorafenib [n = 76]) vs. 6.4 (BSC [n = 17]) months (P = 0.010), and CP-B patients had a median OS of 5.5 (sorafenib [n = 55]) vs. 1.9 (BSC [n = 22]) months (P = 0.021). In the sorafenib group, median OS according to baseline AST was 11.8 (<100 U/L [n = 58]) vs. 3.9 (≥100 U/L [n = 15]) months for CP-A patients (P = 0.127), and 6.5 (<100 U/L [n = 33]) vs. 2.1 (≥100 U/L [n = 21]) months for CP-B patients (P = 0.011). There was no survival difference between sorafenib and BSC in patients with BCLC stage D HCC (1.5 vs. 1.4 months; P = 0.116).

CONCLUSIONS

Sorafenib was associated with improved survival in both CP-A and CP-B patients. In CP-B patients, baseline AST may be helpful in determining which patients are most likely to benefit from sorafenib.

Multicentre European study of thalamic stimulation for parkinsonian tremor: a 6 year follow-up

AIM

To evaluate the results of ventral intermediate (Vim) thalamic deep brain stimulation (DBS) in patients with tremor predominant Parkinson's disease (PD) at 6 years post surgery.

METHODS

This was a prolonged follow-up study of 38 patients from eight centres who participated in a multicentre study, the 1 year results of which have been published previously. Total scores as well as scores for individual items of the motor part and the disability part of the Unified Parkinson's Disease Rating Scale were used for evaluation.

RESULTS

Tremor was still effectively controlled by DBS and appendicular rigidity and akinesia remained stable compared with baseline. Axial scores (speech, gait and postural instability), however, worsened, and in parallel the initial improvement in activities of daily living scores at the 1 year follow-up had disappeared at 6 years, despite sustained improvement of tremor. Remarkably, neither daily doses of dopaminergic medication nor fluctuations and dyskinesias had changed at 6 years compared with baseline in this particular patient group.

CONCLUSION

This study confirms that patients with tremor dominant PD who do not present with fluctuations and dyskinesias may have a relatively benign progression of the disease. Vim DBS, although having no effect on akinesia and rigidity, is a relatively lenient surgical procedure and may still have a place for long term symptomatic control of PD tremor in selected patients.

Motoneuronal projection pattern of single C3-C4 propriospinal neurones

The pattern of motoneuronal projection and termination of single C3-C4 propriospinal neurones in the forelimb segments C6-T1 of the cat was investigated by intra-axonal injection of horseradish peroxidase into stem axons. Twelve well-stained axons were used for analysis. Termination was observed in the estimated location of motor nuclei innervating pure shoulder muscles in 10 cases. Among motoneurones innervating shoulder, elbow, wrist, and digit muscles, projection and termination were observed in motor nuclei controlling muscles of two or three joints in the following combinations: shoulder + elbow, shoulder + wrist, shoulder + elbow + wrist, shoulder + elbow + digit, and elbow + wrist + digit. In one case it was difficult to exclude the possibility of projection and termination in motor nuclei controlling muscles at all four joints. These patterns of motoneuronal projection from C3-C4 propriospinal neurones are compatible with their function in mediating the descending command for visually guided target reaching movements with the forelimb. In addition, it was found that the C3-C4 propriospinal neurones project and terminate in the region of ventral and ventromedial motor nuclei, which innervate axial muscles acting on the trunk. This was confirmed by intracellular recording from presumed ventromedial motoneurones in the C6-C7 segments. It is postulated that the C3-C4 propriospinal neurones, in addition to their control of forelimb movements, provide for conjoint control of axial muscles to stabilize the trunk during target reaching.

Electrophysiological responses in foetal spinal cord transplants evoked by regenerated dorsal root axons

Cut dorsal root axons regenerate into intraspinal transplants of foetal spinal cord (FSC) and establish synaptic connections there. The aim of the present study was to determine whether transplant neurons are driven synaptically in response to electrical stimulation of regenerated dorsal root axons. Adult Sprague-Dawley rats received FSC transplants (E14) into dorsal quadrant cavities at the lumbar enlargement. The cut L4 or L5 dorsal root stump was placed at the bottom of the lesion cavity and secured between the transplant and host spinal cord. Four to ten weeks later the animals were prepared for electrical stimulation and recording. We stimulated regenerated dorsal roots and recorded extracellular single unit post-synaptic activities which were evoked close to the dorsal root-transplant interface. We used intracellular recording to observe several examples of monosynaptic EPSPs in transplant neurons evoked by dorsal root stimulation. These results indicate that the regenerated dorsal root axons establish functional connections with neurons within the transplants and suggest that FSC transplants can be used to reconstruct functional connections between neurons that have been interrupted by spinal cord injury.

Long C3-C5 propriospinal neurones in the cat

Intracellular recording was made in the C3-C5 segments of cats from cells identified as long propriospinal neurones (PNs) by antidromic activation from the lower thoracic segments. The cell bodies were in laminae VII and VIII and their ventrally located axons were either uncrossed or crossed. Stimulation of higher motor centres revealed monosynaptic excitatory postsynaptic potentials (EPSPs) from cortico-, rubro-, tecto-, reticulo-, interstitio-, fastigio- and trigeminospinal fibres. Monosynaptic inhibitory postsynaptic potentials (IPSPs) were evoked from reticulospinal fibres. These PSPs were in addition to the separately described effects from the vestibular nuclei. Monosynaptic EPSPs were also evoked in some cells from neck or forelimb afferents and disynaptic EPSPs or IPSPs from forelimb afferents.

Vestibular effects in long C3-C5 propriospinal neurones

The effects of stimulation of the vestibular nerve and of regions in and around the vestibular nuclei on long C3-C5 propriospinal neurones (PNs) were investigated with intracellular recording. Disynaptic excitatory postsynaptic potentials were evoked from the contralateral (co) or ipsilateral (i) vestibular nerve in many long PNs but mainly in crossed PNs from the co and in uncrossed from the i nerve. Disynaptic inhibitory postsynaptic potentials were evoked more rarely, mainly from the i vestibular nerve. Threshold mapping revealed an excitatory relay from the co nerve in the medial vestibular nucleus (MVN) and also that the excitatory MVN neurones projecting to the long PNs send collaterals to the abducens and interstitial nucleus of Cajal. Excitation from the i vestibular nerve was relayed in the lateral vestibular nucleus (LVN) and in the MVN. Also, non-second order LVN neurones project to the long PNs. Monosynaptic IPSPs were evoked from the i MVN and i LVN.

Subpopulations and functions of long C3-C5 propriospinal neurones

Long C3-C5 propriospinal neurones (PNs) are classified in 3 types depending on their pyramidal and vestibular input. The first type of PNs received pyramidal excitation but lacked vestibular effects. The second type of PNs was excited from the medial vestibular nucleus but not from the pyramid. The third type of PNs was excited from the lateral vestibular nucleus either from second order neurones or from non-second order neurones. Monosynaptic excitatory postsynaptic potentials from neck afferents and/or oligosynaptic postsynaptic potentials from forelimb afferents were found in some of the PNs of the second and third type but not in those of the first type. Collision experiments revealed that cortico- and rubrospinal fibres to the long C3-C5 PNs terminate in the rostral spinal cord, presumably in the forelimb segments. Vestibular and reticular effects on the PNs are partly from fibres terminating in the rostral spinal cord and partly from fibres projecting to the lumbar cord. It is postulated that the different types of PNs contribute to the adjustment of hindlimb posture which is required during different movements of the forebody. It is suggested that the basic tonus is maintained mainly by the direct projection to the hindlimb segments from lateral vestibulospinal and reticulospinal neurones which excite antigravity muscles via lumbar interneurones and that the long C3-C5 PNs converge onto the same interneurones so that they act by modulation of the basic tonus.

Convergence on reticulospinal neurons mediating contralateral pyramidal disynaptic EPSPs to neck motoneurons

Convergence upon reticulospinal neurons which mediate disynaptic, contralateral pyramidal EPSPs to neck motoneurons has been examined in cats with contralateral pyramidal transection at the obex. Conditioning stimuli in the contralateral tectum and ipsilateral mesencephalic tegmentum produced monosynaptic facilitation of the disynaptic pyramidal EPSP, whereas facilitation evoked from the ipsilateral pyramid showed a disynaptic time course. These results show that contralateral pyramidal, tectal and ipsilateral tegmental fibers converge onto common reticulospinal neurons which have direct excitatory connections with neck motoneurons.

Brainstem relay of disynaptic pyramidal EPSPs to neck motoneurons in the cat

A short train of stimuli delivered to the contralateral pyramid evoked EPSPs with disynaptic latencies in neck motoneurons. After a transection of the pyramid at the obex, stimulation rostral to the lesion still evoked disynaptic EPSPs. Stimulation of the pyramid rostral to a transection at the level of the trapezoid body did not produce synaptic effects. It is suggested that the disynaptic EPSPs in neck motoneurons from the contralateral pyramid are mediated by medullary reticulospinal neurons.