Updated use of TACE for hepatocellular carcinoma treatment: How and when to use it based on clinical evidence

Hepatocellular carcinoma (HCC) is the most common primary liver cancer, representing the sixth leading cause of cancer and the third leading cause of cancer-related mortality. Patient stratification and treatment allocation are based on tumor stage, liver function, and performance status. According to the Barcelona Clinic Liver Cancer (BCLC) staging system, transarterial chemoembolization (TACE) is the first-line treatment for patients with intermediate stage HCC, including those with large or multinodular HCC, well-preserved liver function, and no cancer-related symptoms or evidence of vascular invasion or extrahepatic spread. Two TACE techniques have been used since 2004, conventional TACE (cTACE) and TACE with drug-eluting beads (DEB-TACE). cTACE was evidenced first to treat intermediate stage HCC patients. It combines the transcatheter delivery of chemotherapy using Lipiodol-based emulsion plus an embolizing agent to achieve strong cytotoxic and ischemic effects. Drug-eluting beads (DEBs) were developed in order to slowly release chemotherapeutic agents, and to increase ischemia intensity and duration. Recent advances allow TACE treatment of both early stage patients (i.e. those with a solitary nodule or up to 3 nodules under 3 cm) and some advanced stage patients. Here we review recent clinical evidence related to TACE treatment of patients with early, intermediate, and advanced stage HCC. Based on the 2014 TACE algorithm of Raoul et al., this international expert panel proposes an updated TACE algorithm and provides insights into TACE use for patients at any HCC stage.

Slightly acidic electrolyzed water combined with chemical and physical treatments to decontaminate bacteria on fresh fruits

Effect of sequential combination of slightly acidic electrolyzed water (SAEW) with chemical and physical treatments on bacterial decontamination on fruits was investigated in this study. Effect of treatments on microbial and sensory quality was also analyzed after subsequent storage at 4 °C and room temperature (RT, 23 ± 0.15 °C). Whole apple and tomato fruits were inoculated with cocktail strains of Escherichia coli O157:H7 and Listeria monocytogenes. Uninoculated and inoculated fruits were washed first with distilled water (DW), calcium oxide (CaO), fumaric acid (FA), and SAEW at RT for 3 min. Combinations were performed by adding treatment one at a time to SAEW as following FA + SAEW, CaO + FA + SAEW, and CaO + FA + SAEW + ultrasonication (US) or microbubbles (MB). All the sanitizer treatments resulted in significant (p < 0.05) bacterial reduction compared to DW used as control. Increasing the treatments in combination from FA + SAEW to CaO + FA + SAEW + US resulted in an increased bacterial decontamination. The cavitation induced by ultrasonication in FA + SAEW solution resulted in a higher additive effect in decontamination of Escherichia coli O157:H7 and Listeria monocytogenes compare to the agitation generated by microbubble generator in FA + SAEW solution. CaO + FA + SAEW and CaO + FA + SAEW + US were effective in improving the microbial safety and quality of apple fruits. However, additional treatment of US impacted on the quality of tomato fruits during storage at RT. Therefore, a combination of SAEW with sanitizers (CaO and FA) and mechanical force (Ultrasonication) has the potential to be used in postharvest sanitation processing in the fresh fruit industry.

Occurrence, statutory guideline values and removal of contaminants of emerging concern by Electrochemical Advanced Oxidation Processes: A review

A wide variety of chemical compounds are used in human activities; however, part of these compounds reach surface water, groundwater and even water considered for potable uses. Due to the limited efficiency of water treatment by the Water and Wastewater Treatment Plants, the presence of these compounds in natural and human consumption waters can be very harmful due to their high persistence and adverse effects; these characteristics define the contaminants of emerging concern (CECs). Water treatment by Electrochemical Advanced Oxidation Processes (EAOPs) has been evaluated as a promising process for the removal of persistent and recalcitrant organic contaminants. With this background, the present review aims to gather studies and information published between 2015 and 2020 regarding the occurrence of CECs in surface, potable and groundwater, its treatment by EAOPs, the main operating conditions and by-product generation of EAOPs, contaminant toxicity assessments and international statutory guideline values concerning CEC standards and allowable concentrations in the environment and treated drinking water. Therefore, in this review it was found that the compounds bisphenol A (BPA), diethyltoluamide (DEET), 17α-ethinyl estradiol (EE2), perfluorobutanoic acid (PFBA), carbamazepine, caffeine and atrazine were the most frequently detected in water sources, with concentrations ranging from 35.54-4800, 1.21-98, 0.005-38.5, 5-742.904, 0.0071-586, 0.89-1040, and 100-323 (ng L-1), respectively. Among the operational conditions of EAOPs, current density, pH and oxidant concentration are the main operational parameters that have an influence on these treatment technologies, besides the by-products generated, which might be removed by the integration of EAOPs with biological digestion treatments. Regarding the values of water quality standards, many CECs do not have established standard allowable concentration values, which represents a concern toward the possible toxic effects of these compounds on non-target organisms.

Effect of single or combined chemical and natural antimicrobial interventions on Escherichia coli O157:H7, total microbiota and color of packaged spinach and lettuce

Aqueous extract of Origanum vulgare (oregano), sodium hypochlorite (60 and 300 ppm of free chlorine), Citrox® (containing citric acid and phenolic compounds [bioflavonoids] as active ingredients), vinegar, lactic acid, and double combinations of Citrox, lactic acid and oregano were evaluated against Escherichia coli O157:H7 and total mesophilic microbiota on fresh-cut spinach and lettuce and for their impact on color of treated vegetables. Spinach and lettuce leaves were inoculated with E. coli O157:H7 to a level of 5-6 log CFU/g and immersed in washing solutions for 2 or 5 min at 20 °C, followed by rinsing with ice water (30s). Bacterial populations on vegetables were enumerated immediately after washing and after storage of the samples at 5 °C for 7 days under 20% CO2: 80% N2. No significant post-washing microbial reductions were achieved by chlorinated water, whereas after storage total microbiota was increased by 2.4 log CFU/g on lettuce. Vinegar wash was the most effective treatment causing E. coli O157:H7 reductions of 1.8-4.3 log CFU/g. During storage, pathogen was further decreased to below the detection limit level (<2 log CFU/g) and total microbiota exhibited the highest reductions compared to other treatments. Lactic acid reduced pathogen by 1.6-3.7 log CFU/g after washing; however levels of total microbiota increased by up to 2 log CFU/g on packaged lettuce during storage. Washing lettuce samples with oregano for 2 min resulted in 2.1 log CFU/g reduction of E. coli O157:H7. When Citrox was combined with oregano, 3.7-4.0 log CFU/g reduction was achieved on spinach and lettuce samples, with no significant effect on color parameters. Additionally, rinsing with ice water after decontamination treatments contributed to maintenance of color of the treated vegetables. In conclusion, the results indicated that vinegar, lactic acid or oregano aqueous extract alone or in combination, as alternative washing solutions to chlorine, may be effectively used to control E. coli O157:H7 and sustain acceptable appearance of fresh cut spinach and lettuce.

Treatment of Small Hepatocellular Carcinoma (≤2 cm) in the Caudate Lobe with Sequential Transcatheter Arterial Chemoembolization and Radiofrequency Ablation

PURPOSE

To evaluate technical feasibility and treatment results of sequential transcatheter arterial chemoembolization (TACE) and cone-beam computed tomography-guided percutaneous radiofrequency ablation (CBCT-RFA) for small hepatocellular carcinoma (HCC) in the caudate lobe.

MATERIALS AND METHODS

Institutional review board approved this retrospective study. Radiologic database was searched for the patients referred to perform TACE and CBCT-RFA for small caudate HCCs (≤2 cm) between February 2009 and February 2014. A total of 14 patients (12 men and 2 women, mean age; 61.3 years) were included. Percutaneous ultrasonography-guided RFA (pUS-RFA) and surgery were infeasible due to poor conspicuity, inconspicuity or no safe electrode pathway, and poor hepatic reserve. Procedural success (completion of both TACE and CBCT-RFA), technique efficacy (absence of tumor enhancement at 1 month after treatment), and complication were evaluated. Treatment results including local tumor progression (LTP), intrahepatic distant recurrence (IDR), overall survival (OS), and progression-free survival (PFS) were analyzed.

RESULTS

Procedural success and technique efficacy rates were 78.6 % (11/14) and 90.9 % (10/11), respectively. Average follow-up period was 45.3 months (range, 13.4-64.6 months). The 1-, 3-, and 5-year LTP probabilities were 0, 12.5, and 12.5 %, respectively. IDR occurred in seven patients (63.6 %, 7/11). The 1-, 3-, and 5-year PFS probabilities were 81.8, 51.9, and 26 %, respectively. The 1-, 3-, and 5-year OS probabilities were 100, 80.8, and 80.8 %, respectively.

CONCLUSION

Combination of TACE and CBCT-RFA seems feasible for small HCC in the caudate lobe not amenable to pUS-RFA and effective in local tumor control.

One case of intrahepatic cholangiocarcinoma amenable to resection after radioembolization

We report the case of a 57-year-old man who was diagnosed with a large unresectable cholangiocarcinoma associated with 2 satellite nodules and without clear margins with the right hepatic vein. Despite 4 cycles of GEMOX (stopped due to a hypertransaminasemia believed to be due to gemcitabine) and 4 cycles of FOLFIRINOX, the tumor remained stable and continued to be considered unresectable. Radioembolization (resin microspheres, SIRS-spheres^®) targeting the left liver (474 MBq) and segment IV (440 MBq) was performed. This injection was very well tolerated, and 4 more cycles of FOLFIRINOX were given while waiting for radioembolization efficacy. On computed tomography scan, a partial response was observed; the tumor was far less hypervascularized, and a margin was observed between the tumor and the right hepatic vein. A left hepatectomy enlarged to segment VIII was performed. On pathological exam, most of the tumor was acellular, with dense fibrosis around visible microspheres. Viable cells were observed only at a distance from beads. Radioembolization can be useful in the treatment of cholangiocarcinoma, allowing in some cases a secondary resection.

Vitiligo in Children: A Review of Conventional Treatments

Vitiligo is an important skin disease of childhood, which may lead to deep psychological trauma, resulting in a poor quality of life and low self-esteem. The Authors discuss a short review of the more conventional therapies available for the treatment of vitiligo in children.

[RadioTransNet, the French network for preclinical research in oncological radiotherapy]

The ambition of the RADIOTRANSNET network, launched by the INCa at the end of 2018, is to create a French research consortium dedicated to preclinical radiotherapy to foster scientific and clinical interactions at the interface of radiotherapy and radiobiology, and to identify research priorities dedicated to innovation in radiotherapy. The activities of the network are organized around four major axes that are target definition, normal tissue, combined treatments and dose modelling. Under the supervision of the Scientific Council, headed by a coordinator designated by the SFRO and a co-coordinator designated by the SFPM, three leaders coordinate each axis: a radiation-oncologist, a medical physicist and a biologist, who are responsible for organizing a scientific meeting based on the consensus conference methodology to identify priority issues. The selected themes will be the basis for the establishment of a strategic research agenda and a roadmap to help coordinate national basic and translational research efforts in oncological radiotherapy. This work will be published and will be transmitted to the funding institutions and bodies with the aim of opening dedicated calls to finance the necessary human and technical resources. Structuration of a preclinical research network will allow coordinating the efforts of all the actors in the field and thus promoting innovation in radiotherapy.

Approaching the challenges of MKK3/p38delta MAPK targeting for therapeutic purpose in colorectal cancer

MKK3 is a member of the dual specificity kinase group specific upstream activator of p38 MAPK proteins. We originally identified MKK3 as mutant p53 (mutp53) gain-of-function (GOF) upregulated target gene in different tumor models. To deeply investigate the MKK3 functions in cancer, taking advantage of a panel of authenticated colorectal cancer (CRC) lines and primary colonocytes, we found that MKK3 activates specifically p38delta MAPK protein, which signaling is further triggered by 5-fluorouracil (5-FU) treatments, a largely adopted chemotherapeutic drug in CRC clinical practice. The overall achieved results proposed the MKK3/p38delta MAPK as relevant molecular axis involved in abrogating efficacy to 5-FU treatments in CRC. This commentary will provide an overall discussion of the results that have been achieved contextualizing them in the overview of the knowledge in the p38 MAPK field in cancer disease.

Juvenile Fibromyalgia

Juvenile fibromyalgia is a common referral in pediatric rheumatology settings. Providing a clear diagnosis and explanation of altered pain processing offers reassurance that pain has a biologic basis and the symptoms are part of a recognized pain syndrome. Physicians should acknowledge the impact of chronic pain and associated symptoms on patient's lives and take time to understand contributing factors including stress, mood, inactivity, and lifestyle factors. The optimal treatment for juvenile fibromyalgia is multidisciplinary, focusing on education about juvenile fibromyalgia, along with physical therapy, cognitive behavioral therapy, sleep hygiene, healthy lifestyle habits, and medications for symptom management as appropriate.

Dual modification of starch: Synergistic effects of ozonation and pulsed electric fields on structural, rheological, and functional attributes

Study evaluated the influence of ozonization (O3) time combined with pulsed electric fields (PEF) on the modification of bean starch structure. O₃ was used at a concentration of 0.045 g/L for 60 min (Oz1) and 120 min (Oz2) both individually and in combination with 30 kV/cm (P30). Carbonyl content was higher than the carboxyl content, especially with prolonged treatment times (Oz2), indicating partial oxidation. Additionally, higher levels of amylose and degrees of polymerization (DP ≥ 37 and DP 25-36) were observed in the oxidized starches, with significant changes only when combined with PEF. The main morphological and structural modifications included the presence of agglomerates, partial gelatinization, reduced crystallinity, and lower IR1047/1022 in the granules treated with PEF + O3. Oxidized starches exhibited higher solubility, resulting in lower values for rheological parameters, with PEF + 2 h of O3 (Oz2P) standing out. It can be used as prebiotics, controlled release agents and a texturizer for gluten-free foods.

Two Unusual but Treatable Causes of Refractory Ascites After Liver Transplantation

Refractory ascites (RA) is thought to complicate the postoperative course of 5-7% (Nishida et al. in Am J Transplant. 6: 140-149, 2006; Gotthardt et al. in Ann Transplant. 18: 378-383, 2013) of liver transplant recipients. RA after liver transplantation is often a frustrating diagnostic dilemma with few good management options unless an obvious mechanical factor is identified. Supportive therapies often fail until a treatable precipitating cause is identified and removed. We describe two patients who developed RA following liver transplantation for primary sclerosing cholangitis, and hepatitis C and alcoholic liver disease, respectively. The cause for RA was hyperkinetic portal hypertension secondary to splenomegaly in the first case and a pancreatic AVM in the 2nd case. After failure of other interventions, surgical splenectomy resulted in immediate and durable resolution of the previously intractable ascites.

[Clinical research in radiation oncology]

Clinical research is summarizing scientific trials performed in human aiming to improve biological and medical knowledges. The management of such an activity has to be conducted in a secured environment in terms of expertise, competency and professionalism of involved actors. In the field of cancer, multidisciplinarity is key in the treatment of malignant disease and plays a major role sequentially or concomitantly. In the 90s, clinical research in radiation oncology obtained historical successes, which remain validated guidelines for national societies in a significant number of clinical situations. They concern not only technological improvements but also combined modality treatments with chemotherapy, hormonal therapy and potentially new targeted agents. Radiotherapy, in a palliative or in a curative setting, benefited from dramatic technological improvements aiming to address patient quality of life after radiation therapy. Actually, the emergence of artificial intelligence is willing to modify our current practice historically based on old concepts of clinical evaluation.