Pan-Asian adapted ESMO Clinical Practice Guidelines for the management of patients with intermediate and advanced/relapsed hepatocellular carcinoma: a TOS-ESMO initiative endorsed by CSCO, ISMPO, JSMO, KSMO, MOS and SSO

The most recent version of the European Society for Medical Oncology (ESMO) Clinical Practice Guidelines for the diagnosis, treatment and follow-up of hepatocellular carcinoma (HCC) was published in 2018, and covered the diagnosis, management, treatment and follow-up of early, intermediate and advanced disease. At the ESMO Asia Meeting in November 2018 it was decided by both the ESMO and the Taiwan Oncology Society (TOS) to convene a special guidelines meeting immediately after the Taiwan Joint Cancer Conference (TJCC) in May 2019 in Taipei. The aim was to adapt the ESMO 2018 guidelines to take into account both the ethnic and the geographic differences in practice associated with the treatment of HCC in Asian patients. These guidelines represent the consensus opinions reached by experts in the treatment of patients with intermediate and advanced/relapsed HCC representing the oncology societies of Taiwan (TOS), China (CSCO), India (ISMPO) Japan (JSMO), Korea (KSMO), Malaysia (MOS) and Singapore (SSO). The voting was based on scientific evidence, and was independent of the current treatment practices, the drug availability and reimbursement situations in the individual participating Asian countries.

Phase III randomized study of second line ADI-PEG 20 plus best supportive care versus placebo plus best supportive care in patients with advanced hepatocellular carcinoma

Background

Arginine depletion is a putative target in hepatocellular carcinoma (HCC). HCC often lacks argininosuccinate synthetase, a citrulline to arginine-repleting enzyme. ADI-PEG 20 is a cloned arginine degrading enzyme-arginine deiminase-conjugated with polyethylene glycol. The goal of this study was to evaluate this agent as a potential novel therapeutic for HCC after first line systemic therapy.

Methods and patients

Patients with histologically proven advanced HCC and Child-Pugh up to B7 with prior systemic therapy, were randomized 2 : 1 to ADI-PEG 20 18 mg/m2 versus placebo intramuscular injection weekly. The primary end point was overall survival (OS), with 93% power to detect a 4-5.6 months increase in median OS (one-sided α = 0.025). Secondary end points included progression-free survival, safety, and arginine correlatives.

Results

A total of 635 patients were enrolled: median age 61, 82% male, 60% Asian, 52% hepatitis B, 26% hepatitis C, 76% stage IV, 91% Child-Pugh A, 70% progressed on sorafenib and 16% were intolerant. Median OS was 7.8 months for ADI-PEG 20 versus 7.4 for placebo (P = 0.88, HR = 1.02) and median progression-free survival 2.6 months versus 2.6 (P = 0.07, HR = 1.17). Grade 3 fatigue and decreased appetite occurred in <5% of patients. Two patients on ADI-PEG 20 had ≥grade 3 anaphylactic reaction. Death rate within 30 days of end of treatment was 15.2% on ADI-PEG 20 versus 10.4% on placebo, none related to therapy. Post hoc analyses of arginine assessment at 4, 8, 12 and 16 weeks, demonstrated a trend of improved OS for those with more prolonged arginine depletion.

Conclusion

ADI-PEG 20 monotherapy did not demonstrate an OS benefit in second line setting for HCC. It was well tolerated. Strategies to enhance prolonged arginine depletion and synergize the effect of ADI-PEG 20 are underway.

Clinical Trial number

www.clinicaltrials.gov (NCT 01287585).

[Interpretation for diagnosis of Yersiniosis]

Yersiniosis is one of the "other infectious diarrhea" of the notifiable infectious diseases and also an important food-borne disease. However, it lacked the basis or standard for diagnosis. The Chinese Preventive Medicine Association coordinated experienced researchers from National Institute for Communicable Disease Control and Prevention, China CDC and other institutes to produce the group standard entitled "Diagnosis of Yersiniosis" (T/CPMA 005-2019). Based on the principle of "legality, scientificity, advancement, and feasibility" , the standard gives a clear definition for Yerisiniosis, stipulates diagnosis basis, principles and main differential diagnosis and provides two informative appendixes for epidemiological and clinical characteristics and a normative appendix for laboratory detection. The standard provides accurate basis and methods of Yersiniosis diagnosis for hospitals and CDCs at all levels in China. It will solve the problems that Yersiniosis cannot be clearly diagnosed for clinical cases and in the outbreaks.

Wnt pathway regulates IL-34 level in lupus nephritis

OBJECTIVE

The aim of this study was to investigate the role of the Wnt pathway in regulating the IL-34 level of lupus nephritis (LN) patients, and to explore the underlying mechanism.

MATERIALS AND METHODS

Human mesangial cells (HMCs) of LN patients were selected. The expression level of IL-34 was detected by quantitative Real Time-Polymerase Chain Reaction (qRT-PCR) and Western blot, respectively. Subsequently, HMCs were treated with the Wnt pathway antagonist, DDK1. Meanwhile, the IL-34 level in DDK1 transfected HMCs was then detected. In addition, the viability of HMCs treated with DDK1 was detected by cell counting kit-8 (CCK-8) and colony formation assay, respectively.

RESULTS

Both the mRNA and protein levels of IL-34 were significantly upregulated in HMCs of LN patients. Higher expression of β-catenin was observed in HMCs of LN patients than those of controls, which was reduced after DDK1 treatment. Meanwhile, IL-34 level in HMCs of LN patients was significantly downregulated after DDK1 treatment. In addition, DDK1 treatment remarkably increased the proliferative ability and colony formation ability of HMCs in LN patients.

CONCLUSIONS

IL-34 is highly expressed in HMCs of LN patients and is negatively regulated by the Wnt pathway. Furthermore, HMCs viability is remarkably enhanced after blocking the Wnt pathway.

[Influence of Toll-like receptor 7 on CD8(+) T lymphocytes in patients with breast cancer]

Objective: To investigate the effect of Toll-like receptor 7 (TLR7) in CD8(+) T cells activity from patients with breast cancer. Methods: Thirty-three patients with breast cancer, twenty-three patients with benign breast tumor, and twenty healthy individuals were collected from The First Affiliated Hospital of Xinxiang Medical University between December 2017 and March 2018. Peripheral blood mononuclear cells (PBMCs) were isolated, and CD8(+) T cells were purified. TLR7 protein and mRNA relative expression in CD8(+) T cells was measured using flow cytometry and real-time PCR, respectively. mRNA relative expressions corresponding to perforin, granzyme B, and FasL in CD8(+) T cells were measured in response to TLR7 agonist stimulation. Direct/indirect contact co-culture system of CD8(+) T cells and breast cancer cell line MCF-7 was also used to assess cytolytic and noncytolytic function in response to TLR7 agonist CL097 stimulation. Results: The mean fluorescence intensity corresponding to TLR7 protein in CD8(+) T cells from breast cancer patients was 124.0±15.32, which was significantly down-regulated in comparison with benign breast tumor patients (255.5±54.91) and healthy individuals (261.9±68.65) (P<0.000 1). TLR7 mRNA relative level was also remarkably reduced in CD8(+) T cells from breast cancer patients (1.97±1.18) in comparison with benign breast tumor patients (4.84±1.01) and healthy individuals (4.75±1.40) (P<0.000 1). TLR7 agonist CL097 stimulation notably increased mRNA relative levels of perforin and granzyme B mRNA in CD8(+) T cells (P<0.01), but not elevated FasL mRNA (P>0.05).Furthermore, TLR7 agonist CL097 stimulation enhanced the cytolytic and noncytolytic function of CD8(+) T cells to MCF-7 cells, which presented as the elevation of target cell death and increase of interferon-γ production in direct and indirect contact co-culture system. Conclusion: TLR7 agonist promoted CD8(+) T cells function from breast cancer patients.

Efficacy and safety of Rhizoma curcumea longae with respect to improving the glucose metabolism of patients at risk for cardiovascular disease: a meta-analysis of randomised controlled trials

BACKGROUND

Clinical evidence suggests that curcuminoids, as a natural polyphenol, can provide support for cardioprotection and glucose metabolism. This meta-analysis assessed the efficacy and safety of curcumin with respect to improving glucose metabolism in patients with cardiovascular risk factors.

METHODS

Four databases (PubMed, Cochrane Library, Web of Science and Embase) were searched up to June 2018. The inclusion criteria included (i) randomised controlled trials (RCT) and (ii) subjects with risk factors for cardiovascular disease supplemented with curcumin and curcuminoids. A random-effects model and a standardised mean difference with a 95% confidence interval were used to perform quantitative data synthesis. Sensitivity and subgroup analyses were conducted to assess the effects.

RESULTS

Fourteen eligible RCT with 1277 subjects were included. In the overall analyses, curcumin led to significant decreases in fasting blood glucose (FBG), glycated haemoglobin (HbA1c) and homeostatic model assessment of insulin resistance (HOMA-IR). The subgroup analyses suggested that curcumin or combined curcuminoids were more effective at reducing FBG and HbA1c in type 2 diabetes patients than in individuals with metabolic syndrome. Supplementation with curcuminoids at doses ≥300 mg day^-1 showed significant decreases in FBG, HbA1c and HOMA-IR. The effects of supplementation on FBG, HbA1c and HOMA-IR were more significant over long periods (≥12 weeks) than short periods. Curcumin and curcuminoids were well tolerated, with no serious adverse events.

CONCLUSIONS

Curcumin or combined curcuminoids could exert cardioprotective effects in patients at risk for cardiovascular disease by improving glucose metabolism. However, further high-quality studies and larger sample sizes are required to confirm these results.

A prospective genome-wide study of prostate cancer metastases reveals association of wnt pathway activation and increased cell cycle proliferation with primary resistance to abiraterone acetate-prednisone

Background

Genomic aberrations have been identified in metastatic castration-resistant prostate cancer (mCRPC), but molecular predictors of resistance to abiraterone acetate/prednisone (AA/P) treatment are not known.

Patients and methods

In a prospective clinical trial, mCRPC patients underwent whole-exome sequencing (n = 82) and RNA sequencing (n = 75) of metastatic biopsies before initiating AA/P with the objective of identifying genomic alterations associated with resistance to AA/P. Primary resistance was determined at 12 weeks of treatment using criteria for progression that included serum prostate-specific antigen measurement, bone and computerized tomography imaging and symptom assessments. Acquired resistance was determined using the end point of time to treatment change (TTTC), defined as time from enrollment until change in treatment from progressive disease. Associations of genomic and transcriptomic alterations with primary resistance were determined using logistic regression, Fisher's exact test, single and multivariate analyses. Cox regression models were utilized for determining association of genomic and transcriptomic alterations with TTTC.

Results

At 12 weeks, 32 patients in the cohort had progressed (nonresponders). Median study follow-up was 32.1 months by which time 58 patients had switched treatments due to progression. Median TTTC was 10.1 months (interquartile range: 4.4-24.1). Genes in the Wnt/β-catenin pathway were more frequently mutated and negative regulators of Wnt/β-catenin signaling were more frequently deleted or displayed reduced mRNA expression in nonresponders. Additionally, mRNA expression of cell cycle regulatory genes was increased in nonresponders. In multivariate models, increased cell cycle proliferation scores (≥ 50) were associated with shorter TTTC (hazard ratio = 2.11, 95% confidence interval: 1.17-3.80; P = 0.01).

Conclusions

Wnt/β-catenin pathway activation and increased cell cycle progression scores can serve as molecular markers for predicting resistance to AA/P therapy.

Shenfu Formula reduces cardiomyocyte apoptosis in heart failure rats by regulating microRNAs

ETHNOPHARMACOLOGICAL RELEVANCE

Shenfu decoction consists of the water extract from the dried root or rootstalk of Panax ginseng C. A. Mey (Asian ginseng) and the lateral root of Aconitum carmichaeli Debx (Fuzi, Heishunpian in Chinese). Shenfu Formula has been used as a folk Chinese medicine for thousands of years. Recent studies have shown that Shenfu injection can enhance cardiac function and regulate arrhythmia.

AIM OF THE STUDY

Shenfu Formula plays an important role in the treatment of heart failure. However, its microRNA-mediated mechanisms are still not fully understood. Thus, we established a heart failure model in rats to investigate the microRNA mechanism of Shenfu Formula in cardiac function and apoptosis.

MATERIALS AND METHODS

The heart failure animal model was established via left-anterior descending coronary artery ligation in rats. Seven days after surgery, Shenfu Formula was given to the heart failure rats, which were selected by echocardiography with an LVEF< 45%. After Shenfu Formula was given intragastrically for 30 days, blood samples were drawn, the heart was excised after echocardiography, and echocardiographic parameters and apoptosis-related proteins were further examined. Fas/Fas-L and Bcl-2/Bax proteins were analyzed by Western blot, and microRNAs were evaluated using Affymetrix GeneChip miRNA arrays.

RESULTS

Shenfu Formula increased the left ventricular ejection fraction, improved the hemodynamic index of heart failure rats, and decreased serum brain natriuretic peptide (BNP) levels. Shenfu Formula also decreased the positive rate of myocardial cells as detected by the TUNEL method and significantly suppressed caspase 3 expression. Moreover, we found that Shenfu Formula can regulate the initiative factors Fas/Fas-L in the intrinsic pathway and Bcl-2/Bax in the extrinsic apoptosis pathway to suppress apoptosis in heart failure rats. Finally, Shenfu Formula potentially alters the balance of microRNAs involved in activating and inhibiting apoptosis, ultimately suppressing apoptosis; this leads to changes in the gene expression profiles of microRNAs targets.

CONCLUSION

Shenfu Granule can effectively improve cardiac function in heart failure rats, and the anti-apoptosis effects of Shenfu Formula are potential mechanisms for inhibiting heart failure.

The severity of NAFLD is associated with the risk of urolithiasis

BACKGROUND AND AIMS

Population-based studies suggest a strong association between the presence of nonalcoholic fatty liver disease (NAFLD) and an increased risk of urolithiasis. However, the available information on the association of the severity of NAFLD with urolithiasis is limited. We hypothesised a link between the severity of NAFLD and the risk of urolithiasis.

METHODS

We recruited 1527 adult patients with NAFLD who completed a comprehensive health checkup. The severity of NAFLD was measured with AST to platelet ratio (APRI score). Logistic regression analysis was used to detect the association of APRI score with the risk of urolithiasis among NAFLD patients. ROC analysis was used to assess the diagnostic value of APRI score for identifying urolithiasis among NAFLD patients.

RESULTS

Multivariate analysis showed three independent risk factors for urolithiasis: obesity (OR 2.06 95%CI 1.35-3.13), APRI score (OR 1.29 95%CI 1.05-1.59), and serum uric acid (OR 1.07 95%CI 1.05-1.09), suggesting an independent association between the noninvasive staging of liver fibrosis and the risk of urolithiasis in NAFLD patients. A three-variable model (obesity, APRI score, and serum uric acid) with an AUROC of 0.73 (95% CI 0.70-0.75) was significant in identifying urolithiasis.

CONCLUSIONS

The severity of NAFLD is associated with the risk of urolithiasis among NAFLD patients. Moreover, a three-variable model (obesity, APRI score, serum uric acid) could serve as a useful tool for identifying individuals at high risk for urolithiasis in these patients.