Tumor multifocality and serum albumin levels can identify groups of patients with hepatocellular carcinoma and portal vein thrombosis having distinct survival outcomes

Background

Macroscopic portal vein thrombosis (PVT) is a major poor prognosis factor in patients with hepatocellular carcinoma (HCC), but constitute a heterogeneous group.

Aims

To examine blood and tumor parameters of 1667 HCC patients who had PVT to identify factors that could differentiate different survival subsets.

Methods

a large HCC database was examined for presence of patients with PVT and analyzed retrospectively for PVT-associated factors and prognosis.

Results

A logistic regression model was calculated for presence of PVT. Highest odds ratios were found for tumor multifocality and serum albumin levels, as well as serum alpha-fetoprotein (AFP) and bilirubin levels. A Kaplan-Meier and Cox model on survival also showed the highest hazard ratios for tumor multifocality and serum albumin. A model was constructed on all 4 possible combinations of tumor focality and serum albumin in PVT patients. The longest survival group had <2 tumor nodules plus serum albumin >3.5 g/dL. Conversely, the shortest survival group had >2 tumor nodules plus serum albumin <3.5 g/dL. These 2 patient groups differed in maximum tumor diameter and levels of serum AFP, AST and bilirubin.

Conclusions

Combination low tumor focality and high serum albumin identifies prognostically better PVT patient subgroups that might benefit from aggressive therapies.

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Portal vein thrombosis (PVT) is a major poor prognosis factor in HCC patients.

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We found that the highest odds ratios for PVT included number of tumor foci and serum albumin levels.

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A model was constructed with all 4 possible combinations of these 2 parameters.

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The longest survival group had <2 tumor nodules plus normal albumin. Conversely, the shortest survival group had >2 tumor nodules plus low albumin. These 2 PVT groups had a 3-fold difference in survival and had significantly different AFP and bilirubin levels.

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These findings provide simple patient selection criteria for treating in PVT patients.

Plasma lipids, tumor parameters and survival in HCC patients with HBV and HCV

INTRODUCTION AND AIMS

Hepatocellular carcinoma (HCC) is a consequence of chronic liver disease, particularly from hepatitis B or C and increasingly from obesity and metabolic syndrome. Since lipids are an important component of cell membranes and are involved in cell signaling and tumor cell growth, we wished to evaluate the relationship between HCC patient plasma lipids and maximum tumor diameter and other indices of HCC human biology.

METHODS

We examined prospectively-collected data from a multi-institutional collaborative Turkish HCC working group, from predominantly HBV-based patients, for plasma lipid profiles, consisting of triglycerides, total cholesterol, LDL-cholesterol (LDL) and HDL-cholesterol (HDL) and compared these with the associated patient maximum tumor diameter (MTD), portal vein thrombosis, alpha-fetoprotein (AFP) and also with patient survival.

RESULTS

We found that both low HDL (p=0.0002) and high LDL (p=0.003) levels were significantly associated with increased MTD, as well as in a final multiple linear regression model on MTD. The combination of low HDL combined with high HDL levels were significant in a regression model on MTD, PVT and an HCC Aggressiveness Index (Odds Ratio 12.91 compared to an Odds Ratio of 1 for the reference). Furthermore, in a Cox regression model on death, the HDL plus LDL combination had a significantly higher Hazard Ratio than the reference category.

CONCLUSIONS

Low plasma HDL, high plasma LDL and especially the combination, were significantly related to more aggressive HCC phenotype and the combination was significantly related to a higher Hazard Ratio for death.

Portal Vein Thrombosis and Markers of Inflammation in Hepatocellular Carcinoma

BACKGROUND

Macroscopic portal vein thrombosis (PVT) is a major poor prognosis factor in patients with hepatocellular carcinoma (HCC). Inflammation is increasingly recognized to be part of the hepatocarcinogenic process and its markers are also prognostically useful.

AIMS

To examine the relationship of inflammation biomarkers to the presence of PVT and to survival in PVT patients with HCC.

METHODS

A large HCC cohort was examined for the presence of PVT and analyzed retrospectively.

RESULTS

Blood levels of NLR, PLR, ESR, CRP, AFP and GGTP were significantly related to the presence of PVT, but not the Glasgow Index. For patients with low alpha-fetoprotein levels, blood ESR and GGTP levels were also significantly increased in patients with PVT compared with those in patients without PVT. In a Cox regression model, serum GGTP levels had a significantly increased hazard ratio on death (1.52, p = 0.008). Kaplan-Meier analysis showed that PVT patients with low serum GGTP levels had significantly longer survival than PVT patients with high GGTP levels (p = 0.0041).

CONCLUSIONS

Indices of inflammation, especially serum GGTP levels, related significantly to the presence of PVT and to survival in HCC patients with PVT.

Serum levels of gamma-glutamyl transpeptidase in relation to HCC human biology and prognosis

Background and aim:

Hepatocellular carcinoma (HCC) biomarkers are limited, as even the best studied, alpha-fetoprotein (AFP), is elevated in no more than 50% of HCC patients. The aim was to evaluate several serum liver function tests in relation to survival and tumor characteristics in a large cohort of Turkish HCC patients.

Methods:

We retrospectively examined the serum levels of gamma glutamyl transpeptidase (GGT) in relation to patient survival.

Results:

Kaplan-Meier analysis showed that only GGT and albumin amongst liver function tests, were significantly associated with survival. Survival worsened with increase in GGT levels semi-quantitatively. Increase in GGT levels was also found to significantly correlate with an increase in maximum tumor diameter from 4.5 to 7 cm, a 20-fold increase in serum alpha-fetoprotein level, an increase in tumor multifocality from 20 to 54% of patients, and a doubling in percent of patients with portal vein thrombosis (PVT) from 20 to 40%. Serum GGT levels also showed significant survival differences for patients with low AFP levels. A doublet combination of serum GGT with albumin levels was associated with higher hazard ratios in a Cox regression analysis, as compared with single parameter GGT. The combination parameter pair was also prognostically useful in the low-AFP patient subcohort and was associated with significant differences in patient tumor characteristics.

Conclusions:

Serum GGT levels and especially combination serum GGT plus albumin levels, were significantly associated both with HCC patient survival and tumor aggressiveness characteristics, regardless of AFP levels in a large Turkish cohort. This might be especially useful since the majority of HCC patients do not have elevated levels of AFP.

Epidermal growth factor receptor overexpression in resected pancreatic cancer

317

Background: The effect of overexpression of epidermal growth factor receptor (EGFR) in pancreatic carcinoma is uncertain. In this study, we examine the association between EGFR overexpression (membrane and cytoplasmic) and histopathologic features and clinical outcomes in patients post resection.

Methods: Seventy three patients underwent curative resection for pancreatic cancer from 4/08 to 4/10. Tumor EGFR expression was determined immunohistochemically using EGFR pharmDxTM kit. Cytoplasmic overexpression was considered positive if EGFR expression was seen in the cytoplasm in ≥10% of cells. Cell membrane staining scores were assigned: 0 (no membrane staining), 1+ (incomplete membrane staining in ≥ 10% of cells, 2+ (complete weak/moderate membrane staining in ≥ 10% of cells) and 3+ (complete heavy staining in ≥ 10% of cells). A score of 2+ and 3+ were considered as membrane overexpression. Comparisons between EGFR overexpression and clinicopathologic features were assessed by chi-square test with p-value < 0.05 as statistically significant. Proportional hazard regression was used to estimate progression free survival and overall survival.

Results: Out of 73 patients, 43 (59%) and 50 (68%) patients had membrane and cytoplasmic EGFR overexpression respectively. AJCC stages were: stage I: 8, stage II: 63, stage III: 1 and stage IV: 1 patient. There was statistically significant correlation between cell membrane EGFR overexpression and lymph node positivity (p=0.04). Membrane EGFR overexpression was not significantly associated with local invasion, margin positivity, vascular invasion, perineural invasion, histologic grade or stage. Cytoplasmic EFGR overexpression was significantly associated with margin positivity (p=0.01) only. The hazard ratios (95% CI) for PFS and OS in patients with membrane EGFR overexpression was 1.37 (0.72-2.60) and 1.27 (0.62-2.61) respectively. The corresponding values for patients with cytoplasmic overexpression were 1.65 (0.80-3.37) and 1.25 (0.58-2.71) respectively.

Conclusions: Membrane EGFR overexpression was associated with lymph node status and cytoplasmic EFGR overexpression with margin positivity. There was no association of EFGR expression and clinical outcomes.

No significant financial relationships to disclose.

A phase II study of ABT-869 in hepatocellular carcinoma (HCC): Interim analysis

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Background: ABT-869 is a novel orally active, potent and selective inhibitor of the vascular endothelial growth factor and platelet derived growth factor families of receptor tyrosine kinases. Results of an interim analysis of a phase 2 trial of ABT-869 in HCC are presented. Methods: An open-label, multicenter phase II trial (M06–879) of oral ABT-869 at 0.25 mg/kg daily in Child-Pugh A (C-PA) or QOD in Child-Pugh B (C-PB) patients (pts) until progressive disease (PD) or intolerable toxicity, is ongoing. Key eligibility criteria included unresectable or metastatic HCC; up to one prior line of systemic treatment; and at least one measurable lesion by computed tomography (CT) scan. The primary endpoint was the progression free (PF) rate at 16 weeks. Secondary endpoints included objective response rate (ORR), time to progression (TTP), progression free survival (PFS) and overall survival (OS). CT scans were assessed centrally and by the investigators; presented results are from central assessment. Results: 44 pts were enrolled from 09/07 to 08/08 at 6 centers internationally, with interim data available for 34 pts. There were 28 C-PA pts (median age, 63.5 y [range, 20- 81]) and 6 C-PB pts (median age, 64.5 y [range, 36–69]) and 73.5% received no prior systemic therapy. For the 19 evaluable C-PA pts included in the per-protocol interim analysis, 8 (42.1%) were progression free at 16 weeks [95% CI 20.3, 66.5]. The estimated ORR was 8.7% [95% CI, 1.1, 28] for the 23 C-PA pts and 0% for the 2 C-PB pts who had at least one post-baseline CT scan reviewed by central imaging. For all 34 pts, median TTP was 112 d [95% CI, 110, -], median PFS was 112 d [95% CI, 61, 168] and median OS was 295 d [95% CI, 182, 333]. The most common adverse events (AEs) for all pts were hypertension (41%), fatigue (47%), diarrhea (38%), rash (35%), proteinuria (24%), vomiting (24%), cough (24%) and oedema peripheral (24%). The most common grade 3/4 AEs for all pts were hypertension (20.6%) and fatigue (11.8%). Most AEs were mild/moderate and reversible with interruption/dose reductions/or discontinuation of ABT-869. Conclusions: ABT-869 appears to benefit HCC patients, with an estimated TTP of 112 days and an acceptable safety profile. Updated results from this ongoing study will be presented.

[Table: see text]

Health-related quality of life and pain assessment in 36 patients with resected pancreas adenocarcinoma: Preliminary analysis

e20692

Background: In order to begin to understand the effects of disease on the patient (pt) and possibly of the pt on the disease, we have begun a systematic psychological inventory of all our pts who have has a pancreatectomy for pancreas adenocarcinoma and have began to correlate this with disease extent, and later with survival. Methods: Prior to post-op discharge home, pts were invited to fill out a brief pain inventory (BPI-SF), BPI interference, emotional (EWB) and physical well-being score (Fact-Hep), as well as social/family and functional well-being (FWB) Fact-Hep. The data was entered into a database, together with pertinent lab results, tumor markers, and tumor characteristics from the pre-op CT scan and post-op pathology report. Data was analyzed by descriptive statistics, frequencies and Pearson Correlation (2-tailed sig). Results: Descriptive means (and ranges) were - tumor size 3.43 cm mean (2.0 min-5.2 max), bilirubin 1.26 (0.2–4.7), albumin 2.69 (1.5–3.6), Hb 10.3 (7.5–13.2), platelets 254K (109K-672K), CEA 4.7 (0.8–24), and Ca 19–9 was 987 (1.0–8127). Pain at presentation pre-op of moderate severity was present in 11% of pts and severe pain was present in 5.6% of pts (16.6% total). Pathologically, LNs were involved by cancer in 50% of pts, vascular invasion in 30%, neural invasion in 35% and any margin positive in 14%. 22% had metastases noted at surgery. Statistically significant correlations were found for tumor size and pain severity (p<.035), platelets and FWB (p<.022), albumin and Hb (p=.000), CA 19–9 and bilirubin (p<.030 i.e. high CA 19–9 and high bilirubin). There was a negative correlation between CEA (but not CA 19–9) and both EWB (p<.039) and FWB (p<.035). Pain severity correlated with depressed mood (p<.010), lower physical well-being (p<.01) and interference with life activities (p<.01). Conclusions: CEA, but not CA 19–9 correlated with both emotional and functional well-being. Baseline pain was present in only 16.6% of this cohort. We plan to follow up to examine how these parameters correlate with pt coping throughout therapy and survival.

No significant financial relationships to disclose.

Expressed emotion, depression, and survival in patients diagnosed with hepatobiliary carcinoma

e20597

Background: The aims of the present study were to (1) investigate the association between expressed emotion, health related quality of life, and depression, and (2) explore the association between expressed emotion and survival in patients diagnosed with hepatobiliary carcinoma. Methods: The study was prospective in design. Ninety-six patients diagnosed with hepatobiliary carcinoma were administered a battery of questionnaires that measured depression, health-related quality of life, and expressed emotion. Medical chart review was used to gather disease specific information. Mann Whitney U and Kruskal Wallis tests were performed to test differences between groups and Cox regression analyses were performed to test predictors of survival. Results: At diagnosis, 54% of the patients reported a CES-D score ≥ 16 (clinical range). Patients who reported CES-D scores in the clinical range were found to have significantly lower overall health related quality of life (Mann Whitney U= 506, p = 0.003) and in particular lower emotional (Mann Whitney U=551, = 0.009) and functional well being (Mann Whitney U=507.5, p = 0.003). Patients who reported CES-D scores in the clinical range also reported a higher frequency of cancer-related symptoms (Mann Whitney U=503.5, p= 0.002) at diagnosis using the FACT-Hepatobiliary module. Patients who reported lower levels of emotional expression were found to have higher levels of depression (Mann Whitney U-6.6, p=0.04) and lower social and family well-being (Mann Whitney U=6.4, p=0.04). Using Cox regression, sociodemographic and disease-specific characteristics, depression, and expressed emotion were entered into a model. Significant predictors of survival included greater number of lesions (p=0.04), larger size of tumor (p=0.02), and lower levels of emotional expression (p=0.03). Conclusions: Preliminary findings suggest that patients with low levels of emotional expression reported higher rates of depression, poorer quality of life, and shorter survival. Interventions should be developed to treat symptoms of depression to improve quality of life. Expression of both positive and negative emotions should be encouraged by health care professionals.

No significant financial relationships to disclose.

Cdc25A protein phosphatase: a therapeutic target for liver cancer therapies

Cdc25A, a dual specificity protein phosphatase, is well-recognized as a critical regulator for cell cycle progression. We recently found that it also regulates mitogen-activated protein kinase (MAPK) signal transduction pathway. Inhibition of Cdc25A activity by a K vitamin analog Compound 5 (Cpd 5) can induce a strong and prolonged activation of epidermal growth factor receptor (EGFR)-MAPK pathway, which leads to suppression of transcription factors CREB and c-Myc, resulting in decreased expression of Cdc25A and cyclin D1 levels. Our investigations suggest that Cdc25A plays a central role in regulating and linking cell cycle progression and MAPK signal transduction pathways. Several other recently synthesized K vitamin analogs also affect this pathway, including the non-quinone PM20 and fluoro-Cpd 5. Thus, searching for new and efficient small molecules to inhibit Cdc25A activity may provide new means to control cancers of the liver and other sites.

Treatment before liver transplantation for HCC

Liver transplantation (LT) which is currently an established therapy for sma1l, early stage hepatocellular carcinoma (HCC) in patients with cirrhosis requires in most cases long waiting period. Tumor development during the waiting period may be associated with vascular invasion which is a strong factor of postoperative recurrence. Therefore, local treatment of the tumor including trans-arterial chemoembolization (TACE), percutaneous radiofrequency (RF) or partial liver resection can be used before transplantation. In the present paper we reviewed the efficacy of these treatments prior to LT. Although, TACE induced complete tumor necrosis in some patients there is no convincing arguments showing that this treatment reduces the rate of drop out before LT, nor improves the survival after LT. Although, RF can induce complete necrosis in the majority of small tumors (<2.5 cm), there is no data demonstrating that this treatment reduce the rate of drop out before LT, nor improves the survival after LT. It has been showed that both short and long term survival after LT was not compromised by previous partial liver resection of HCC. However, there is no data demonstrating that liver resection before LT, which can be used either as a bridge treatment or as a primary treatment, improves the survival after LT. The current data suggest that there is no role for pre-transplant therapy for HCC within Milano criteria transplanted within six months. On the opposite, if the waiting time is predicted to be prolonged, the risk of tumor progression and either drop-off from the list or interval dissemination with post-transplant tumor recurrence is recognized. In this setting, bridge therapy can reduce that risk but its efficacy has to be determined.

Causes of death in patients with unresectable hepatocellular carcinoma

Most patients with hepatocellular carcinoma (HCC) also have cirrhosis, an independent cause of death. We considered an alternative definition of tumor-related death in patients with HCC and attempted to validate our definition. Two hundred thirty-seven HCC patients were diagnosed, followed, and died over a 12-year period and were evaluated every 2 months, including their last 6 months of life. We defined death by cancer if there was, in the last 6 months of life, a CT scan increase of >25% in the sum of tumor index lesions' cross-sectional areas or new onset of, or increase in, either vascular invasion or metastatic disease (Group 1). Patients with stable cancer were considered to have died from any other cause (Group 2). We found that 135 (57%) patients died from cancer progression (Group 1), whereas 102 (43%) patients did not (Group 2). There was a statistically significant difference between Group 1 and Group 2 patients in percentage with bilobar disease (P = 0.03), more than one tumor (P = 0.01), an increase in AFP (P = 0.04), vascular invasion (P = 0.001), and the presence of metastases (P = 0.01). We conclude that 57% of patients with unresectable HCC died as a direct result of cancer progression, but 43% did not. The latter died from complications of their cirrhosis, including sepsis, GI bleeds, and renal failure.

Prognostic models in hepatocellular carcinoma (HCC) and statistical methodologies behind them

Hepatocellular carcinoma (HCC) is estimated to be responsible for 250,000 deaths worldwide yearly. Aggressive surgical resection or liver transplantation still remain the only viable curative options for patients suffering the disease despite the multitude of emerging therapies for HCC. However, even with the most aggressive surgical intervention, survival varies widely within each particular stage of HCC. In order to improve utilization of available therapeutic modalities, a number of outcome prognostic models have been developed. This manuscript reviews the prognostic models most commonly utilized in clinical practice and the statistical methodologies on which these models are based. A multitude of statistical and mathematical techniques can be used for prognostic model development. The most common methodologies used for HCC prognostic model development can be generally divided into four groups: survival, artificial neural networks, analysis of variance, and cluster analysis. Survival methodologies (such as Cox proportional hazard model) are commonly employed for estimation of relative significance of risk factors for patient survival or cancer recurrence. Artificial neural networks (such as back-propagation network) can be supreme approximation tools for any continuous or binary function, and as such can be employed for prognostication of HCC recurrence (death). Analysis of variance and cluster analysis are the most common statistical tools of recently evolved microarrays technology, which, in turn, is one of the most promising tools available to the cancer researcher.

Depression, immunity, and survival in patients diagnosed with hepatobiliary carcinoma

18525

Background: Depression has been found to be associated with increased morbidity and mortality in healthy adults. The prevalence of depression in patients diagnosed with cancer, and in particular hepatobiliary carcinoma (HBC), is significantly higher than the general population. The aims of the present study were to: (1) examine the prevalence of depressive symptoms in patients with HBC, (2) test the relationship between depressive symptoms and survival, and (3) begin to explore underlying mechanisms that explain the relationship between depression and survival in patients with HBC. Methods: 101 patients diagnosed with HBC were administered a battery of questionnaires which included the Center for Epidemiological Studies-Depression (CES-D) questionnaire. Disease-specific data was gathered from medical charts and survival was measured from the date of diagnosis to death. Immune markers (NK cell, IL-4 and 5, TNF, and IFN) were collected in 24 patients. Results: At diagnosis, 39% of the sample reported a score of 16 or greater (clinical range). Using Cox Regression, demographic (age, gender, ethnicity) and disease specific variables (diagnosis, treatment, hepatitis, cirrhosis, tumor location, tumor number, tumor size, vascularity of lesion, and portal vein invasion) variables, as well as CES-D score at diagnosis were analyzed. CES-D scores >16 [Wald = 4.0, p = 0.05] and portal vein invasion (PVI) [Wald = 9.0, p = 0.003] significantly predicted survival. Using Kaplan Meier Survival analysis (Breslow test) and stratifying for PVI, a trend was found [Chi-Square = 3.1, p = 0.08] in which patients with PVI and CES-D scores >16, survived 7.4 months whereas patients with CES-D scores <16 survival 13 months. Patients without PVI and CES-D scores >16 survived 18.2 months whereas those with CES-D scores <16 survived 24.7 months. In a sample of 24 patients, those who reported CES-D scores >16 had significantly lower Natural Killer cell numbers than patients with CES-D scores <16 while covarying age, gender, stress, social support, and coping style [F(1,21) = 9.39, p = 0.003]. Conclusions: Depression may be an important prognostic factor for patients diagnosed with HBC.

No significant financial relationships to disclose.

Gemcitabine hepatic arterial chemoembolization (TACE) in the treatment of unresectable HCC

4141

Background: Hepatocellular carcinoma (HCC) generally arises in the presence of cirrhosis and is typically multifocal and bilobar and thus not often resectable. A major limitation of chemotherapy is due to the damaged underlying liver as a result of cirrhosis. A non-hepatotoxic drug such as Gemcitabine is thus potentially useful in patient management. Methods: 57 patients with biopsy-proven HCC were evaluated for response, survival and toxicity after treatment with gemcitabine via hepatic arterial chemoembolization. Patients were treated with 1250 mg/m2, given in 150 ml of normal saline over 30 min to either the right or left hepatic artery at any one treatment session. Treatments were repeated every 8 to 10 weeks. Embospheres (Embogold, Biosphere Medical) 100–300 micron size were also injected to vascular slowing but not to occlusion of the same hepatic artery during the chemotherapy infusion. A CT scan was performed at baseline and just prior to each repeat treatment, which was continued until tumor progression. CBC, liver function tests and AFP were performed at baseline and monthly. Results: There were 19 partial responses (PR) (33%), 2 minor responses (4%), 24 patients with stable tumors (42%), 9 with tumor progression (16%) and 3 unevaluable (diffuse) (5%). Survival was: median 12 mo (range 1–36 mo). 23 patients survived 24 mo. There were no hepatotoxicities greater than grade 1 and no myelotoxicities greater than grade 2 (NCI common toxicity criteria). Conclusions: Gemcitabine chemoembolization (TACE) in unresectable HCC patients with normal bilirubin and without ascites appears to be entirely safe with a minimal clinical or laboratory toxicity and is associated with encouraging responses and survival.

No significant financial relationships to disclose.

Clinically meaningful changes in health-related quality of life in patients diagnosed with hepatobiliary carcinoma

BACKGROUND

To test the reliability, sensitivity to change in biomarkers associated with disease progression and response to treatment, and clinical meaningfulness of the Functional Assessment of Cancer Therapy-Hepatobiliary (FACT-Hep) in patients with hepatobiliary carcinoma.

PATIENTS AND METHODS

One hundred and fifty-eight patients diagnosed with hepatobiliary carcinoma were prospectively studied. Health-related quality of life (HRQL) was assessed at baseline (prior to treatment), 3-month follow-up (n=55) and 6-month follow-up (n=27).

RESULTS

The internal consistency of all the scales of the FACT-Hep were adequate at all time points (>0.75). The FACT-Hep was found to be sensitive to changes in clinical indicators (alkaline phosphate, alpha-fetoprotein, hemoglobin and survival) that reflect disease progression and response to treatment. Combined results from distribution-based and cross-sectional anchor-based analyses provide the following minimally important difference (MID) estimates: FACT-General (FACT-G) subscales=2-3; FACT-G=6-7; Hepatobiliary Cancer Subscale=5-6; FACT-Hep=8-9; Trial Outcome Index=7-8; and FACT-Hepatobiliary Symptom Index=2-3 points.

CONCLUSIONS

The FACT-Hep is a reliable instrument that is responsive to clinical indicators of disease progression and response to treatment. The MID estimates can aid interpretation of HRQL data and facilitate sample size calculation in clinical trials.

The role of psychosocial factors in the progression of hepatocellular carcinoma

The number of deaths per year from hepatocellular carcinoma (HCC) exceeds 250000, placing it sixth as the cause of death from cancer worldwide. The primary etiology of most cases of HCC in the US is hepatitis B and/or C. Extensive research has demonstrated that the relationship between hepatitis B infection and the progression to HCC is mediated by the immune system. A substantial, but unrelated literature, describes the relationship between psychosocial factors (e.g., stress, psychiatric morbidity), immune system reactivity, and disease progression in patients with cancer. However, the role of these factors in the progression of HBV-HCC has not been explored. An understanding of the relationship among virology, immunology, and behavior in the development and recurrence of HCC may provide alternative methods for secondary prevention of HCC (e.g., behavioral) until a vaccine and/or pharmacological treatments are developed, feasible, and affordable.

Tumor cell growth inhibition and extracellular signal-regulated kinase (ERK) phosphorylation by novel K vitamins

2-(2-hydroxy-ethylsulfanyl)-3-methyl-1,4-naphthoquinone or CPD-5, a K vitamin analog, was previously indicated to be a potent growth inhibitor for Hep 3B hepatoma cells in vitro. Here, we show that CPD-5 and two newly synthesized analogs, 2-(2-hydroxy-ethylsulfanyl)-3-methyl-5- nitro-1,4-naphthoquinone (PD-37) and 2-(2-hydroxy-ethylsulfanyl)-3- methyl-5-acetylamino-1,4-naphthoquinone (PD-42), are potent growth inhibitors of 13 different human cancer cell lines, with IC50 values in the range of 3-54 microM. Phospho-ERK was induced by each of three K vitamin analogs in every cell line in a dose-dependent manner, at growth inhibitory doses. ERK phosphorylation and growth inhibitory effects were strongly correlated, with p=0.0080 for CPD-5, p=0.0076 for PD-37 and p=0.0251 for PD-42. The induction of phospho-ERK and growth inhibition were antagonized by thiol-containing anti-oxidants, but not by catalase, consistent with a possible arylating mechanism. The data show a novel class of growth inhibitors with a wide spectrum of action that induces ERK hyper-phosphorylation, as a possible new growth inhibitory feature.

Involvement of Cdc25A phosphatase in Hep3B hepatoma cell growth inhibition induced by novel K vitamin analogs

We previously found that K vitamin analogues caused cell growth inhibition in Hep3B hepatoma cells in vitro, which was associated with their inhibitory effects on protein tyrosine-phosphatases. In this study, we show that Cdc25A, a protein phosphatase, was inactivated by novel arylating K vitamin analogues. The inactivation of Cdc25A correlated with their effects on cell growth inhibition. Cyclin-dependent kinase (Cdk) 4, an important regulator for G(1) progression, was found to be tyrosine-phosphorylated by the arylating analogues, and this phosphorylation was correlated with the inhibitory effects of the analogues on Cdc25A activity. Furthermore, Cdk4 dephosphorylation experiments showed that Compound (Cpd) 5, a prototype arylating analogue, inhibited Cdc25A-mediated Cdk4 dephosphorylation, whereas Cpd 26, a nonarylating vitamin K analogue, had no effect on this event. We also examined Cdk4 kinase activity using retinoblastoma protein as a substrate and found that Cpd 5 inhibited retinoblastoma protein phosphorylation in a concentration-dependent manner, indicating that Cdk4 activity was inhibited by Cpd 5 treatment. Moreover, the thiol-antioxidants glutathione and N-acetyl-L-cysteine antagonized the Cpd 5-induced Cdk4 tyrosine phosphorylation, whereas the nonthiol-antioxidants catalase and superoxide dismutase did not. These results suggest that Hep3B cell growth inhibition by these K vitamin analogues may be related in part to inactivation of Cdc25A activity and support the hypothesis that Cdc25A is an attractive target for drugs designed to inhibit cancer cell growth.

Spatial analysis of key signaling proteins by high-content solid-phase cytometry in Hep3B cells treated with an inhibitor of Cdc25 dual-specificity phosphatases

Protein phosphorylation frequently results in the subcellular redistribution of key signaling molecules, and this spatial change is critical for their activity. Here we have probed the effects of a Cdc25 inhibitor, 2-(2-mercaptoethanol)-3-methyl-1,4-naphthoquinone, or Compound 5, on the spatial regulation and activation kinetics of tyrosine phosphorylation-dependent signaling events using two methods: (i) high-content, automated, fluorescence-based, solid-phase cytometry and (ii) a novel cellular assay for Cdc25A activity in intact cells. Immunofluorescence studies demonstrated that Compound 5 produced a concentration-dependent nuclear accumulation of phospho-Erk and phospho-p38, but not nuclear factor kappaB. Immunoblot analysis confirmed Erk phosphorylation and nuclear accumulation, and in vitro kinase assays showed that Compound 5-activated Erk was competent to phosphorylate its physiological substrate, the transcription factor Elk-1. Pretreatment of cells with the MEK inhibitor U-0126 prevented the induction by Compound 5 of phospho-Erk (but not phospho-p38) nuclear accumulation and protected cells from the antiproliferative effects of Compound 5. Overexpression of Cdc25A in whole cells caused dephosphorylation of Erk that was reversed by Compound 5. The data show that an inhibitor of Cdc25 increases Erk phosphorylation and nuclear accumulation and support the hypothesis that Cdc25A regulates Erk phosphorylation status.

Mechanism of novel vitamin K analog induced growth inhibition in human hepatoma cell line

BACKGROUND/AIMS

To understand the mechanisms of liver regeneration or hepatoma apoptosis, it is important to estimate the turning point of the signal transduction by growth factor receptor. Since 2-(2-hydroxyethylsulfaryl) 3-methyl-1,4-naphthoquinone or CPD 5 has been shown to mediate the phosphorylation of epidermal growth factor (EGF) receptor in Hep3B hepatoma cells, the differences between EGF and CPD 5-mediated signal transduction were studied.

METHODS

DNA content was measured by Hoechst fluorescent assay. Phosphorylated proteins were described with Western blots or two-dimensional electrophoresis.

RESULTS

CPD 5-induced EGFR phosphorylation was functional to stimulate Ras pathway. However, CPD 5-mediated extracellular signal-regulated kinase (ERK) phosphorylation was not antagonized by inhibition of upstream activation with PD153035. CPD 5 inhibited ERK dephosphorylation in cell lysate, suggesting that ERK phosphorylation by CPD 5 was depending on kinase activity and phosphatase inhibition. Two-dimensional electrophoresis showed extra phospho ERK spot, which was indicated to have close association with CPD 5-induced growth inhibition, since U0126 antagonized growth inhibition and appearance of this spot.

CONCLUSIONS

The turning point of EGFR pathway was proved to have close association with the expressed level of phosphorylated ERK. ERK phosphorylation was suggested to play a critical role in growth factor-induced signal transduction.

Continuous infusion prochlorperazine: pharmacokinetics, antiemetic efficacy, and feasibility of high-dose therapy

PURPOSE

The purpose of these sequential phase I studies was to evaluate the antiemetic efficacy and pharmacokinetics of high-dose continuous infusion prochlorperazine.

METHODS

A total of 52 patients with advanced cancer were treated in two sequential phase I studies utilizing high-dose prochlorperazine. In study 1, designed to investigate the antiemetic effects of dose-intensive prochlorperazine, various cisplatin-based multiagent chemotherapeutic regimens were administered in combination with escalating doses of prochlorperazine. In study 2, a fixed dose of cisplatin (60 mg/m2) was administered over 24 h as a continuous intravenous infusion in combination with infusional high-dose prochlorperazine. Antiemetic efficacy in the first trial was assessed in terms of the number of episodes of nausea, retching, and/or emesis during the 24 h following cisplatin administration. The pharmacokinetics of high-dose prochlorperazine were evaluated in eight patients treated in study 2 at the two dose levels below those at which dose-limiting toxicity was noted.

RESULTS

The maximally tolerated dose of prochlorperazine in combination with cisplatin (60 mg/m2 administered as a continuous infusion over 24 h) was 24 mg/h. The dose-limiting toxicity was grade 4 agitation and confusion noted in one patient treated at 26 mg/h. This patient died 3 days following cessation of chemotherapy due to the toxicity of the regimen in combination with the debilitating pulmonary effects of the disease. The mean end of infusion prochlorperazine level at the 24 mg/h dose level was 1.1 microM, a concentration previously reported to be consistent with the reversal of the multidrug resistance phenotype. Two partial responses were observed in study 2.

CONCLUSIONS

We conclude that the antiemetic efficacy of high-dose infusional prochlorperazine does not appear to be improved over more convenient bolus administration. However, prochlorperazine levels consistent with those required in vitro for drug resistance reversal are attainable within the dose range having a tolerable toxicity profile.

Expression of the Hoxa-13 gene correlates to hepatitis B and C virus associated HCC

To study the Hoxa-13 gene in the liver, we examined its expression by RT-PCR in various liver cell lines, rat livers under different conditions, and human primary hepatocellular carcinomas (HCCs). The gene was found to be expressed in cell lines originating from liver stem-like cells, but not in cell lines originating from hepatocytes and bile duct epithelia. Expression was induced in rat livers after treatment with d-galactosamine, which is known to induce oval cell proliferation, but not after a two-thirds partial hepatectomy (2/3 PH) where induction of oval cell proliferation is thought not to occur. Expression of the gene correlated with human HCC samples associated with Hepatitis B or C virus infection in this small series. These results suggest that the Hoxa-13 gene may provide a potentially useful tool for elucidation of mechanisms involved in lineage-specific differentiation and carcinogenesis of liver stem cells.

Growth inhibition and protein tyrosine phosphorylation in MCF 7 breast cancer cells by a novel K vitamin

We have now found that the most potent, Cpd 5 [2-(2-mercaptoethanol)-3-methyl-1, 4-napthoquinone], inhibits growth of doxorubicin-resistant and doxorubicin-sensitive breast cancer cells (MCF 7r and MCF 7w) in culture. Growth inhibition by Cpd 5 was antagonized by the thiol antioxidants glutathione and cysteine, but not by catalase or superoxide dismutase, suggesting that growth inhibition is probably via conjugation of cellular thiols. In support of this, we found that Cpd 5 inhibited the activity of thiol containing cellular protein tyrosine phosphatase (PTP) enzyme, with consequent induction of various tyrosine phosphoproteins, but not serine or tyrosine phosphoproteins. The tyrosine phosphorylation was also inhibited by exogenous glutathione or cysteine and could be enhanced by depletion of cellular glutathione by BSO. This effect of Cpd 5 on protein tyrosine phosphorylation was highly selective, however. Tyrosine phosphorylation of EGF-R, Erb-B2, and ERK1/2 was increased, but not that of Insulin-R or JNK. ERK1/2 tyrosine phosphorylation and growth inhibition increased with increasing concentrations of Cpd 5. Furthermore, suppression of Cpd 5-mediated ERK1/2 phosphorylation by an ERK-kinase inhibitor antagonized growth inhibition. These results suggest a strong correlation between ERK1/2 phosphorylation by Cpd 5 and growth inhibition. This novel K-vitamin analog thus inhibits MCF 7 cell growth and induces selective protein tyrosine phosphorylation.

Prognostic significance of arterial phase CT for prediction of response to transcatheter arterial chemoembolization in unresectable hepatocellular carcinoma: a retrospective analysis

OBJECTIVE

The purpose of this study was to use hepatic arterial phase helical CT to assess tumor vascularity and predict the likelihood of response to transcatheter arterial chemoembolization in patients with hepatocellular carcinoma.

MATERIALS AND METHODS

Helical CT findings for 57 patients with hepatocellular carcinoma were classified into one of three patterns of vascularity on the basis of the degree of tumor or liver enhancement during the hepatic arterial phase. Cases in which hypervascular lesions predominated were classified as a type 1 pattern. Cases in which hypovascular lesions predominated were classified as a type 2 pattern. Patients were classified as responders or nonresponders on the basis of the changes of tumor size revealed on CT after three transcatheter arterial chemoembolization treatments.

RESULTS

We classified the 57 patients as 37 responders (65%) and 20 nonresponders (35%). A statistically significant correlation between the type 1 hypervascular pattern and response to transcatheter arterial chemoembolization was seen; conversely, the type 2 hypovascular pattern correlated with nonresponse to transcatheter arterial chemoembolization (chi-square = 7.85, p = 0.02). Patients classified as responders lived significantly longer than those classified as nonresponders with 12-, 24-, and 36-month survival rates of 90%, 67%, and 36%, respectively, for responders and 70%, 17%, and 10%, respectively, for nonresponders.

CONCLUSION

We found that patients who responded to transcatheter arterial chemoembolization had prolonged survival (p < 0.01). Response correlated closely with tumor vascularity as shown on hepatic arterial phase helical CT.

Critical role of extracellular signal-regulated kinase (ERK) phosphorylation in novel vitamin K analog-induced cell death

In the present study, we show that 2-(2-hydroxyethylsulfaryl)-3-methyl-1,4-naphthoquinone, or CPD 5, is a potent growth inhibitor for pancreas cancer cell lines (ID(50): 21.4 +/- 3.8, 31.8 +/- 2.7 and 55.2 +/- 4.5 microM for MiaPaCa, Panc-1 and BxPc3, respectively). It induced protein tyrosine phosphor-ylation of hepatocyte growth factor (HGF) receptor (c-Met) or epidermal growth factor receptor (EGFR), which increased progressively to a maximum level at 30 min in Panc-1 cells. The receptor phosphorylation by CPD 5 was indicated to be functional, since these receptors were found to bind with Grb2 or SOS1 protein. CPD 5 was also suggested to induce phosphorylation of external signal-regulated kinase (ERK). EGF induced cell proliferation through ERK phosphorylation, since U0126, which is an inhibitor of ERK phosphorylation, abrogated the increase of cyclin D1 by EGF. HGF increased the amount of p27 protein, suggesting that it is associated with cell differentiation. By contrast, U0126 reduced CPD 5-induced cell death. On two-dimensional electrophoresis, we found an extra type of phospho-ERK, and this was completely and selectively abolished by U0126. These results suggest that ERK phosphorylation, especially the extra spot on two-dimensional gel, is critically associated with CPD 5-mediated cell death.

Intrahepatic chemoembolization in unresectable pediatric liver malignancies

OBJECTIVE

To determine the effectiveness of a new multidisciplinary approach using neoadjuvant intrahepatic chemoembolization (IHCE) and liver transplant (OLTx) in patients with unresectable hepatic tumors who have failed systemic chemotherapy.

MATERIALS AND METHODS

From November 1989 to April 1998, 14 children (2-15 years old) were treated with 50 courses of intra-arterial chemotherapy. Baseline and post-treatment contrast-enhanced CT and alpha-fetoprotein levels were performed. Seven had hepatoblastoma, and 7 had hepatocellular carcinoma (1 fibrolamellar variant). All patients had subselective hepatic angiography and infusion of cisplatin and/or adriamycin (36 courses were followed by gelfoam embolization). The procedure was repeated every 3-4 weeks based on hepatic function and patency of the hepatic artery.

RESULTS

Six of 14 children received orthotopic liver transplants (31 courses of IHC). Pretransplant, 3 of 6 showed a significant decrease in alpha-fetoprotein, while only 1 demonstrated a significant further reduction in tumor size). Three of 6 patients are disease free at this time. Three of 6 patients died of metastatic tumor 6, 38, and 58 months, respectively post-transplant. One of 14 is currently undergoing treatment, has demonstrated a positive response, and is awaiting OLTx. Three of 14 withdrew from the program and died. Four of 14 patients developed an increase in tumor size, developed metastatic disease, and were not transplant candidates. Two hepatic arteries thrombosed, and one child had a small sealed-off gastric ulcer as complications of intrahepatic chemoembolization.

CONCLUSION

The results of intrahepatic chemoembolization are promising and suggest that some children who do not respond to systemic therapy can be eventually cured by a combination of intrahepatic chemoembolization orthotopic liver transplant. Alpha-fetoprotein and cross-sectional imaging appear to be complementary in evaluating tumor response. IHCE does not appear to convert an anatomically unresectable lesion to a candidate for partial hepatectomy.

Involvement of hepatocyte epidermal growth factor receptor mediated activation of mitogen-activated protein kinase signaling pathways in response to growth inhibition by a novel K vitamin

Compound 5 (Cpd 5), a synthetic K vitamin analogue, or 2-(2-mercaptoethanol)-3-methyl-1,4-naphthoquinone, is a potent inhibitor of epidermal growth factor (EGF)-induced rat hepatocyte DNA synthesis and induces EGF receptor (EGFR) tyrosine phosphorylation. To understand the cellular responses to Cpd 5, its effects on the EGF signal transduction pathway were examined and compared to those of the stimulant, EGF. Cpd 5 induced a cellular response program that included the induction of EGFR tyrosine phosphorylation and the activation of the mitogen-activated protein kinase (MAPK) cascade. EGFR tyrosine phosphorylation was induced by Cpd 5 in a time- and dose-dependent manner. Coimmunoprecipitation studies demonstrated that both EGF and Cpd 5 induced tyrosine phosphorylation of EGFR was associated with increased amounts of adapter proteins Shc and Grb2, and the Ras GTP-GDP exchange protein Sos, indicating the formation of functional EGFR complexes. Although EGFR phosphorylation was induced both by the stimulant EGF and the inhibitor Cpd 5, the timing and intensity of activation by EGF and Cpd 5 were different. EGF activated EGFR transiently, whereas Cpd 5 induced an intense and sustained activation. Cpd 5-altered cells had a decreased ability to dephosphorylate tyrosine phosphorylated EGFR, providing evidence for an inhibition of tyrosine phosphatase activity. Both EGF and Cpd 5 caused an induction of phospho-extracellular response kinase (ERK), which was also more sustained with Cpd 5. Moreover, whereas Cpd 5 induced a striking translocation of phosphorylated ERK from cytosol to the nucleus, no significant nuclear translocation occurred after stimulation with EGF. The data suggest that this novel compound causes growth inhibition through antagonism of EGFR phosphatases and consequent induction of EGFR and ERK phosphorylation. This is supported by experiments with PD 153035 and PD 098059, antagonists of phosphorylation of EGFR and MAP kinase kinase (MEK), respectively, which both antagonized Cpd 5-induced phosphorylation and the inhibition of DNA synthesis. These results imply a mechanism of cell growth inhibition associated with intense and prolonged protein tyrosine phosphorylation. Protein tyrosine phosphatases may thus be a novel target for drugs designed to inhibit cell growth.

Cdc25 inhibition and cell cycle arrest by a synthetic thioalkyl vitamin K analogue

A synthetic vitamin K analogue, 2-(2-mercaptoethanol)-3-methyl-1,4-naphthoquinone or compound 5 (Cpd 5), was found previously to be a potent inhibitor of tumor cell growth. We now demonstrate that Cpd 5 arrested cell cycle progression at both G1 and G2-M. Because of the potential arylating activity of Cpd 5, it might inhibit Cdc25 phosphatases, which contain a cysteine in the catalytic site. To test this hypothesis, we examined the inhibitory activity of Cpd 5 against several cell cycle-relevant protein tyrosine phosphatases and found that Cpd 5 was a potent, selective, and partially competitive inhibitor of Cdc25 phosphatases. Furthermore, Cpd 5 caused time-dependent, irreversible enzyme inhibition, consistent with arylation of the catalytic cysteine in Cdc25. Treatment of cells with Cpd 5 blocked dephosphorylation of the Cdc25C substrate, Cdc2, and its kinase activity. Cpd 5 enhanced tyrosine phosphorylation of both potent regulators of G1 transition, ie., Cdk2 and Cdk4, and decreased the phosphorylation of Rb, an endogenous substrate for Cdk4 kinase. Furthermore, close chemical analogues that lacked in vitro Cdc25 inhibitory activity failed to block cell cycle progression and Cdc2 kinase activity. Cpd 5 did not alter the levels of p53 or the endogenous cyclin-dependent kinase inhibitors, p21 and p16. Our results support the hypothesis that the disruption in cell cycle transition caused by Cpd 5 was attributable to intracellular Cdc25 inhibition. This novel thioalkyl K vitamin analogue could be useful for cell cycle control studies and may provide a valuable pharmacophore for the design of future therapeutics.

Inhibition of hepatoma cell growth in vitro by arylating and non-arylating K vitamin analogs. Significance of protein tyrosine phosphatase inhibition

We recently found that a thioether analog of K vitamin (Cpd 5) inhibited the activity of protein-tyrosine phosphatases (PTPases) and induced protein-tyrosine phosphorylation in a human hepatoma cell line (Hep3B). We have now examined the structural requirements for induction of protein-tyrosine phosphorylation and PTPase inhibition by several K vitamin analogs. Thioether analogs with sulfhydryl arylation capacity, especially those with a hydroxy (Cpd 5) or a methoxy group at the end of the side chain, induced protein-tyrosine phosphorylation, but non-arylating analogs, such as those with an all-carbon or O-ether side chain, did not. Among the receptor-tyrosine kinases, epidermal growth factor receptors were tyrosine-phosphorylated by treatment with thioether analogs, whereas insulin and hepatocyte growth factor receptors were not. An increase in tyrosine-phosphorylated ERK2 mitogen-activated protein kinase was also observed. The activity of purified T cell PTPase was inhibited only by the thioether analogs, but not by non-arylating analogs. Furthermore, the epidermal growth factor receptor dephosphorylation activity of Hep3B cell lysates was inhibited by Cpd 5 treatment. A similar induction of protein-tyrosine phosphorylation by Cpd 5 was seen in other human hepatoma cell lines together with growth inhibition. However, one cell line (HepG2), which was relatively resistant to growth inhibition by Cpd 5, did not increase its phosphorylation levels upon Cpd 5 treatment. These results suggest that cell growth inhibition by thioether analogs is closely associated with inhibition of PTPases by sulfhydryl arylation and with tyrosine phosphorylation of selected proteins.

ERCP and stent therapy for progressive jaundice in hepatocellular carcinoma: which patients benefit, which patients don't?

Jaundice in hepatocellular carcinoma (HCC) can be due to biliary obstruction. Endoscopic retrograde cholangiopancreatography (ERCP) can be both diagnostic and therapeutic. Biliary stenting can relieve jaundice and allow further chemotherapy, but at additional expense and potential morbidity. We sought to determine whether CT scan or ultrasound (US) could identify which patients with HCC and jaundice would benefit from endoscopic stenting. We retrospectively analyzed 26 patients with HCC and jaundice who underwent ERCP after CT or US. We compared biliary dilation on CT or US with the dominant biliary stricture seen on ERCP, and with response to biliary stenting. Eleven of 26 patients had dominant biliary stricture on ERCP; 11 underwent stenting. Six of 11 (55%) stented patients had a significant decline in bilirubin; three became eligible for further chemotherapy. All six responders to stenting had biliary dilation on prior CT or US. Procedure-related complications occurred in 1/11 (9%) who underwent stent placement. In conclusion, in selected patients, stenting can safely relieve jaundice and allow subsequent chemotherapy. CT or US accurately predicted lesions that responded to stenting. ERCP and stenting provided no benefit in the absence of biliary dilation on CT or US.

Multiple genetic alterations, 4q28, a new suppressor region, and potential gender differences in human hepatocellular carcinoma

Primary hepatocellular carcinomas (HCCs) of different etiologies were studied to determine the rate of alteration of several genetic regions previously associated with the HCC phenotype. The focus of our study was to identify the frequency of genetic alterations within individual HCCs and their distribution among male and female cases. Genetic differences were evaluated between DNA isolated from tumor (T) and corresponding non-tumor (N) tissue using short tandem repeat (STR)-microsatellites and restriction fragment length polymorphism (RFLP) analyses. Twenty-eight HCC cases were studied with polymorphic markers from different parts of the genome. Three or more loci were identified with genetic alterations from 28 loci tested in 63% of HCC cases. The highest frequency of alteration occurred in the chromosome regions 1p36, 13q14, 17p13, and the 4q28 region identified in HCCs for the first time. High loss of heterozygosity (LOH) in 1p36, 4q28, 13q14, and 17p13 regions indicates important HCC suppressors within the regions. The study documents no association between cause and specific genetic change or their frequency in HCCs analyzed. The data document a significant gender distortion for genetic alteration in chromosome 13q14 and 17p13 regions and a concordant gender alteration rate in the 1p36 and 4q28 regions. An overall higher frequency of genetic alterations was identified in male cases. Future study with an extended number of HCC cases should substantiate the frequency of alteration between genders and identify tentative suppressors in the 1p36 and 4q28 regions.

Radiotherapy and multimodality management of cholangiocarcinoma

PURPOSE

To evaluate the results of radiotherapy in cholangiocarcinoma patients managed with various combinations of chemotherapy and surgical resection with selective liver transplantation.

METHODS AND MATERIALS

From January 1990 to December 1995, 61 patients with histologically confirmed biliary duct adenocarcinoma were seen in the Radiation Oncology Department of the University of Pittsburgh. Median follow-up was 22 months (1 to 91 months). The extent of surgery was complete resection in 23 patients (including 17 with orthotopic liver transplant), partial resection in 4, and biopsy in 34. All patients had radiotherapy; median dose was 49.5 Gy. Thirty patients received chemotherapy: 5-fluorouracil (5-FU)-leucovorin with interferon alpha (IFNalpha) in 27, and taxol in 3.

RESULTS

The median survival was 20 months (95% CI 15-25 months). The 5-year actuarial survival was 23.8 +/- 6.8%. The only significant variable in multivariate analysis was achieving a complete resection with negative margins through conventional surgery or liver transplantation (p = 0.001, hazard rate ratio [HRR] = 0.25, 95% CI 0.12-0.54). Patients with complete resections had a 5-year actuarial survival of 53.5 +/- 10.9%.

CONCLUSION

Combined modality therapy that includes complete surgical resection with or without transplantation can be curative in the majority of patients with biliary duct carcinoma. Further study is needed to better define the roles of chemotherapy and radiotherapy in cholangiocarcinoma.

Changes in TGF-beta receptors of rat hepatocytes during primary culture and liver regeneration: increased expression of TGF-beta receptors associated with increased sensitivity to TGF-beta-mediated growth inhibition

To clarify the role of transforming growth factor-beta (TGF-beta) and its receptors in hepatocyte growth, we studied the expression of TGF-beta1 and its receptors and the sensitivity to growth inhibition by TGF-beta1 protein in rat hepatocytes derived from resting and regenerating livers. In hepatocytes derived from resting livers, mRNAs for TGF-beta type II receptor (TbetaR-II), insulin-like growth factor-II/mannose 6-phosphate receptor (IGF-II/M-6-PR), and TGF-beta1 increased with time in primary culture. The cell surface TGF-beta receptor proteins (TbetaR-I, II, and III), examined by the receptor affinity-labeling assay using 125I-TGF-beta1, also increased, especially after 48 hr of culture. Hepatocytes were more sensitive to inhibition of DNA synthesis, when the TGF-beta1 protein was added at later times in culture, corresponding to the presence of increased TGF-beta receptors. In hepatocytes from regenerating livers after a partial hepatectomy (PH), an increase of TbetaR-I, TbetaR-II, TbetaR-III, IGF-II/M-6-PR, and TGF-beta1 mRNAs was found, compared with hepatocytes from resting livers. Similarly, using TGF-beta receptor affinity-labeling assay, hepatocytes from PH livers were found to have an increase in TbetaR-I, II, and III proteins, with a peak at 4 days post-PH, compared with hepatocytes from resting livers. When TGF-beta1 protein was added for a short period (6 or 24 hr) after cell attachment to hepatocyte cultures, it inhibited DNA synthesis more effectively in hepatocytes from regenerating compared with resting livers. Our results show that hepatocyte TGF-beta receptors and sensitivity to growth inhibition by TGF-beta1 protein change together and are modulated during liver regeneration, as well as during the conditions of primary culture.

Changes in TGF-beta receptors of rat hepatocytes during primary culture and liver regeneration: increased expression of TGF-beta receptors associated with increased sensitivity to TGF-beta-mediated growth inhibition

To clarify the role of transforming growth factor-beta (TGF-beta) and its receptors in hepatocyte growth, we studied the expression of TGF-beta1 and its receptors and the sensitivity to growth inhibition by TGF-beta1 protein in rat hepatocytes derived from resting and regenerating livers. In hepatocytes derived from resting livers, mRNAs for TGF-beta type II receptor (TbetaR-II), insulin-like growth factor-II/mannose 6-phosphate receptor (IGF-II/M-6-PR), and TGF-beta1 increased with time in primary culture. The cell surface TGF-beta receptor proteins (TbetaR-I, II, and III), examined by the receptor affinity-labeling assay using 125I-TGF-beta1, also increased, especially after 48 hr of culture. Hepatocytes were more sensitive to inhibition of DNA synthesis, when the TGF-beta1 protein was added at later times in culture, corresponding to the presence of increased TGF-beta receptors. In hepatocytes from regenerating livers after a partial hepatectomy (PH), an increase of TbetaR-I, TbetaR-II, TbetaR-III, IGF-II/M-6-PR, and TGF-beta1 mRNAs was found, compared with hepatocytes from resting livers. Similarly, using TGF-beta receptor affinity-labeling assay, hepatocytes from PH livers were found to have an increase in TbetaR-I, II, and III proteins, with a peak at 4 days post-PH, compared with hepatocytes from resting livers. When TGF-beta1 protein was added for a short period (6 or 24 hr) after cell attachment to hepatocyte cultures, it inhibited DNA synthesis more effectively in hepatocytes from regenerating compared with resting livers. Our results show that hepatocyte TGF-beta receptors and sensitivity to growth inhibition by TGF-beta1 protein change together and are modulated during liver regeneration, as well as during the conditions of primary culture.