Survival after locoregional treatments for hepatocellular carcinoma: a cohort study in real-world patients

PROZ May Serve as a Prognostic Biomarker for Early Hepatocellular Carcinoma

Objective

The occurrence and development of hepatocellular carcinoma (HCC) remain unclear. This study aimed to investigate potential diagnostic or prognostic markers for early HCC by applying bioinformatic analysis.

Methods

The gene expression profiles of early HCC and normal tissues from a TCGA dataset were used to identify differentially expressed genes (DEGs) and then analysed by weighted gene coexpression network analysis. The integrated genes were selected to construct the protein–protein interaction (PPI) network and determine the hub genes. The prognostic impact of the hub genes was then analysed.

Results

A total of 508 integrated genes were selected from the 615 DEGs and 8956 genes in the turquoise module. A PPI network was constructed, and the top 20 hub genes, including apolipoprotein A-IV (APOA4), fibrinogen gamma chain (FGG), vitamin K-dependent protein Z (PROZ), secreted phosphoprotein 24 (SPP2) and fetuin-B (FETUB), were identified. Only PROZ was significantly associated with the prognosis of early HCC.

Conclusion

In this study, we demonstrated that the expression of PROZ was decreased in early HCC compared with normal liver controls, and low PROZ expression might result in poor overall survival of early HCC.

Hepatocellular carcinoma Liver Imaging Reporting and Data Systems treatment response assessment: Lessons learned and future directions

Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality worldwide, with rising clinical and economic burden as incidence increases. There are a multitude of evolving treatment options, including locoregional therapies which can be used alone, in combination with each other, or in combination with systemic therapy. These treatment options have shown to be effective in achieving remission, controlling tumor progression, improving disease free and overall survival in patients who cannot undergo resection and providing a bridge to transplant by debulking tumor burden to downstage patients. Following locoregional therapy (LRT), it is crucial to provide treatment response assessment to guide management and liver transplant candidacy. Therefore, Liver Imaging Reporting and Data Systems (LI-RADS) Treatment Response Algorithm (TRA) was created to provide a standardized assessment of HCC following LRT. LI-RADS TRA provides a step by step approach to evaluate each lesion independently for accurate tumor assessment. In this review, we provide an overview of different locoregional therapies for HCC, describe the expected post treatment imaging appearance following treatment, and review the LI-RADS TRA with guidance for its application in clinical practice. Unique to other publications, we will also review emerging literature supporting the use of LI-RADS for assessment of HCC treatment response after LRT.

Novel molecular targets in hepatocellular carcinoma

Globally, hepatocellular carcinoma (HCC) is a leading cause of cancer and cancer-related deaths. The therapeutic efficacy of locoregional and systemic treatment in patients with advanced HCC remains low, which results in a poor prognosis. The development of sorafenib for the treatment of HCC has resulted in a new era of molecular targeted therapy for this disease. However, the median overall survival was reported to be barely higher in the sorafenib treatment group than in the control group. Hence, in this review we describe the importance of developing more effective targeted therapies for the management of advanced HCC. Recent investigations of molecular signaling pathways in several cancers have provided some insights into developing molecular therapies that target critical members of these signaling pathways. Proteins involved in the Hedgehog and Notch signaling pathways, Polo-like kinase 1, arginine, histone deacetylases and Glypican-3 can be potential targets in the treatment of HCC. Monotherapy has limited therapeutic efficacy due to the development of inhibitory feedback mechanisms and induction of chemoresistance. Thus, emphasis is now on the development of personalized and combination molecular targeted therapies that can serve as ideal therapeutic strategies for improved management of HCC.

Population-based matching comparison between radiofrequency ablation and percutaneous ethanol or acetic acid injection for hepatocellular carcinoma

BACKGROUND

Loco-regional therapies are evolving for hepatocellular carcinoma (HCC) treatment. Radiofrequency ablation (RFA) has changed the landscape in treating HCC; however, percutaneous ethanol or acetic acid injection (PEI/PAI) remains a widely used and easily performed technique by experienced clinicians. Nevertheless, the effectiveness of RFA compared to that of PEI/PAI remains unclear.

METHODS

Records of 73,136 patients with newly diagnosed HCC between 2007 and 2013 were drawn from the Taiwan Cancer Registry. The primary outcome measures were the overall survival and local recurrence-free survival. Propensity score matching (PSM) was performed to compare the effectiveness of RFA and PEI. Median follow-up time was 61.6 months (36-120 months).

RESULTS

After PSM, 4496 patients diagnosed with stage I-III HCC, who were initially treated with RFA (3372 patients) or PEI/PAI (1124 patients), were assessed. Compared to PEI/PAI, patients treated with RFA had better 5- and 9-year overall survival, cancer-specific survival, disease-free survival, and local recurrence-free survival. Median overall survival and recurrence-free survival of patients treated with RFA vs PEI/PAI were 61.5 vs 41.9 months and 72.1 vs 45.2 months, respectively. Multivariate Cox model analysis revealed that, except for patients with high cell grade or advanced stage, RFA resulted in better overall survival (HR: 0.74, 95% CI 0.68-0.81, P < 0.001) and local recurrence-free survival (HR: 0.69, 95% CI 0.63-0.75, P < 0.001) than PEI/PAI.

CONCLUSIONS

RFA provides advantages over conventional PEI/PAI for HCC. Considering technological advances in instruments, loco-regional therapies for HCC can be employed in carefully selected patients.

Percutaneous microwave ablation for HCV-related hepatocellular carcinoma: Efficacy, safety, and survival

BACKGROUND/AIMS

Hepatocellular carcinoma (HCC) has a poor prognosis if managed late. Percutaneous microwave ablation (MWA) emerged as one of the top therapeutic decisions for non-surgical patients. The aim of the present study aim was to evaluate the efficacy, side effects, and survival after MWA of hepatitis C virus (HCV)-related HCC tumors with spectrum sizes up to 5 cm.

MATERIALS AND METHODS

Fifty-nine patients with early HCC were treated in the Hepatology Department using percutaneous MWA. Patients were assessed for side effects and efficacy that includes the rate of complete ablation, primary or de novo recurrence, and survival.

RESULTS

Complete ablation was achieved in 57 (96.6%) patients treated by MWA, with a minor complication rate of 3.3% (n=2) including liver abscess formation and abdominal skin burn. The ablation rates in lesions <3 versus 3-5 cm were not different. Of the patients, 3 (5%) had primary recurrence in the treated HCC tumors, de novo lesions (secondary recurrence) developed in 8 (13.5%, 5 of them >3 cm), and 2 (3.3%) had malignant portal vein thrombosis. The survival rates were 95.4% and 69% at 1 and 2 years, respectively.

CONCLUSION

Percutaneous MWA had achieved a safe and effective treatment with good overall survival in patients with HCV-related HCC.

Comparative efficacy of treatment strategies for hepatocellular carcinoma: systematic review and network meta-analysis

OBJECTIVE

Hepatocellular carcinoma (HCC) is the third leading cause of cancer death worldwide. We conducted network meta-regression within a Bayesian framework to compare and rank different treatment strategies for HCC through direct and indirect evidence from international studies.

METHODS AND ANALYSES

We pooled the OR for 1-year, 3-year and 5-year overall survival, based on lesions of size ˂ 3 cm, 3-5 cm and ≤5 cm, using five therapeutic options including resection (RES), radiofrequency ablation (RFA), microwave ablation (MWA), transcatheter arterial chemoembolisation (TACE) plus RFA (TR) and percutaneous ethanol injection (PEI).

RESULTS

We identified 74 studies, including 26 944 patients. After adjustment for study design, and in the full sample of studies, the treatments were ranked in order of greatest to least benefit as follows for 5 year survival: (1) RES, (2) TR, (3) RFA, (4) MWA and (5) PEI. The ranks were similar for 1- and 3-year survival, with RES and TR being the highest ranking treatments. In both smaller (<3 cm) and larger tumours (3-5 cm), RES and TR were also the two highest ranking treatments. There was little evidence of inconsistency between direct and indirect evidence.

CONCLUSION

The comparison of different treatment strategies for HCC indicated that RES is associated with longer survival. However, many of the between-treatment comparisons were not statistically significant and, for now, selection of strategies for treatment will depend on patient and disease characteristics. Additionally, much of the evidence was provided by non-randomised studies and knowledge gaps still exist. More head-to-head comparisons between both RES and TR, or other approaches, will be necessary to confirm these findings.

Percutaneous ethanol injection therapy is comparable to radiofrequency ablation in hepatocellular carcinoma smaller than 1.5 cm: A matched case-control comparative analysis

Although percutaneous ethanol injection therapy (PEIT) is best indicated for patients with small hepatocellular carcinoma (HCC), the survival advantage of PEIT needs confirmation in real-world practice. This study was approved by the institutional review board, and the informed consent was waived. The study included 535 consecutive patients with newly diagnosed early stage (Barcelona Clinic Liver Cancer [BCLC] 0 or A) HCC who underwent initially radiofrequency ablation (RFA) (n = 288) or PEIT (n = 247) from January 2005 to December 2010. The primary outcome was overall survival (OS) and the secondary outcome was time to progression (TTP). The longest diameters of tumors of the groups differed significantly and larger for RFA group than PEIT group (P < 0.001; 1.94 ± 0.65 cm vs 1.60 ± 0.50 cm, respectively). The 5-year OS rates were 72.2% in the RFA group and 67.4% in the PEIT group (P = 0.608). Even after propensity score matching, OS rates between the 2 groups were similar (5-year OS: 72.8% with RFA [n = 175] and 68.0% with PEIT [n = 175]) (P = 0.709). Moreover, in patients with the longest diameter of tumors (≤1.5 cm), multivariate Cox regression analysis showed that the treatment modality was not a significant prognosticator for OS (hazard ratio [HR], 1.690; 95% confidence interval [CI], 0.828-3.449; P = 0.149) and time to progression (HR, 1.160; 95% CI, 0.773-1.740; P = 0.474). PEIT and RFA show equal effectiveness in treating HCCs <1.5 cm in terms of OS and time to progression.

MWA Versus RFA for Perivascular and Peribiliary CRLM: A Retrospective Patient- and Lesion-Based Analysis of Two Historical Cohorts

Purpose

To retrospectively analyse the safety and efficacy of radiofrequency ablation (RFA) versus microwave ablation (MWA) in the treatment of unresectable colorectal liver metastases (CRLM) in proximity to large vessels and/or major bile ducts.

Method and Materials

A database search was performed to include patients with unresectable histologically proven and/or ¹⁸F–FDG–PET avid CRLM who were treated with RFA or MWA between January 2001 and September 2014 in a single centre. All lesions that were considered to have a peribiliary and/or perivascular location were included. Univariate logistic regression analysis was performed to assess the distribution of patient, tumour and procedure characteristics. Multivariate logistic regression was used to correct for potential confounders.

Results

Two hundred and forty-three patients with 774 unresectable CRLM were ablated. One hundred and twenty-two patients (78 males; 44 females) had at least one perivascular or peribiliary lesion (n = 199). Primary efficacy rate of RFA was superior to MWA after 3 and 12 months of follow-up (P = 0.010 and P = 0.022); however, after multivariate analysis this difference was non-significant at 12 months (P = 0.078) and vanished after repeat ablations (P = 0.39). More CTCAE grade III complications occurred after MWA versus RFA (18.8 vs. 7.9 %; P = 0.094); biliary complications were especially common after peribiliary MWA (P = 0.002).

Conclusion

For perivascular CRLM, RFA and MWA are both safe treatment options that appear equally effective. For peribiliary CRLM, MWA has a higher complication rate than RFA, with similar efficacy. Based on these results, it is advised to use RFA for lesions in the proximity of major bile ducts.

Huaier polysaccharide induces apoptosis in hepatocellular carcinoma cells through p38 MAPK

The underlying mechanism of the antitumor activity of Huaier polysaccharide (HP) remains to be explored. The present study aimed to investigate the inhibitory effect of HP on hepatocellular carcinoma (HCC) cells, and to explore the possible mechanisms of its anticancer effect. Cell viability was measured by 3-(4,5-dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide assay, while apoptotic nuclear changes were observed using Hoechst 33258 staining. The distribution of cell cycle and apoptosis were analyzed by flow cytometry, and western blotting was used to test the apoptotic pathways. Apoptosis and mitogen-activated protein kinase (MAPK) inhibitors were used to investigate the mechanism of apoptosis. HP triggered cell cycle arrest and apoptosis in HepG2 and Huh7 cells. Both the extrinsic and intrinsic apoptotic pathways were activated after HP treatment. Furthermore, HP enhanced the three major MAPK pathways (extracellular signal-regulated kinase, c-Jun N-terminal kinase and p38 MAPK) and inhibited the AKT/mechanistic target of rapamycin signaling pathway in HCC cells. Notably, the inactivation of p38 MAPK impaired the HP-induced cell death. HP exerted its antitumor effect on HCC cells through the regulation of the expression of the apoptosis-related proteins B-cell lymphoma (Bcl)-2, Bcl-2-associated X protein and survivin. The present study provides evidence that HP induces apoptosis in HCC cells and demonstrated the role of p38 MAPK in HP-triggered cancer cell death.

Radiofrequency ablation versus percutaneous ethanol injection for hepatocellular carcinoma: a meta-analysis of randomized controlled trials

BACKGROUND

Radiofrequency ablation (RFA) and percutaneous ethanol injection (PEI) are treatment methods for patients with early-stage hepatocellular carcinoma (HCC) who are not suitable for surgery. Although some reports indicate that RFA is better than PEI, results from previous reviews and analyses are inconsistent. Therefore, this meta-analysis was performed to more thoroughly evaluate the effects of these treatments in patients with HCC.

METHODS

A literature search was conducted using the Excerpta Medica dataBASE, PubMed, the Cochrane Library, the American Society of Clinical Oncology database, the China National Knowledge Infrastructure database, the Wanfang database, the Chinese Biomedical Literature Database, and the Chongqing VIP database without language limitations. The primary outcome evaluated was overall survival, and secondary outcomes included complete response and local recurrence. Comparisons were made between Asian and European studies.

RESULTS

Total pooled and subgroup analyses of Asian studies that included selection biases revealed that RFA is superior to PEI with respect to overall survival (hazard ratio (HR), 0.54; 95% confidence interval (CI), 0.37 to 0.80; P < 0.01) and complete response (relative risk (RR), 1.10; 95% CI 1.03 to 1.18; P < 0.01). However, no significant difference was observed between RFA and PEI in the European studies. In Asian studies, RFA was associated with a lower local recurrence rate than PEI at 1 year (RR, 0.44; 95% CI 0.20 to 0.95; P < 0.05) and 3 years (RR, 0.35; 95% CI 0.22 to 0.55; P < 0.01). However, local recurrence was significantly lower after only 3 years in European studies (RR, 0.50; 95% CI 0.32 to 0.78; P < 0.05).

CONCLUSIONS

RFA was only superior to PEI in Asian studies that included selection bias. Thus, there is insufficient evidence to support the idea that RFA is superior to PEI for patients with cirrhotic HCC. Additional large-scale, multicenter, randomized controlled trials that control for selection bias are needed to fully elucidate the optimal treatment method for HCC.

Efficacy and survival analysis of percutaneous radiofrequency versus microwave ablation for hepatocellular carcinoma: an Egyptian multidisciplinary clinic experience

BACKGROUND

Hepatocellular carcinoma (HCC) is a primary tumor of the liver with poor prognosis. For early stage HCC, treatment options include surgical resection, liver transplantation, and percutaneous ablation. Percutaneous ablative techniques (radiofrequency and microwave techniques) emerged as best therapeutic options for nonsurgical patients.

AIMS

We aimed to determine the safety and efficacy of radiofrequency and microwave procedures for ablation of early stage HCC lesions and prospectively follow up our patients for survival analysis.

PATIENTS AND METHODS

One Hundred and 11 patients with early HCC are managed in our multidisciplinary clinic using either radiofrequency or microwave ablation. Patients are assessed for efficacy and safety. Complete ablation rate, local recurrence, and overall survival analysis are compared between both procedures.

RESULTS

Radiofrequency ablation group (n = 45) and microwave ablation group (n = 66) were nearly comparable as regards the tumor and patients characteristics. Complete ablation was achieved in 94.2 and 96.1% of patients managed by radiofrequency and microwave ablation techniques, respectively (p value 0.6) with a low rate of minor complications (11.1 and 3.2, respectively) including subcapsular hematoma, thigh burn, abdominal wall skin burn, and pleural effusion. Ablation rates did not differ between ablated lesions ≤ 3 and 3-5 cm. A lower incidence of local recurrence was observed in microwave group (3.9 vs. 13.5% in radiofrequency group, p value 0.04). No difference between both groups as regards de novo lesions, portal vein thrombosis, and abdominal lymphadenopathy. The overall actuarial probability of survival was 91.6% at 1 year and 86.1% at 2 years with a higher survival rates noticed in microwave group but still without significant difference (p value 0.49).

CONCLUSION

Radiofrequency and microwave ablations led to safe and equivalent ablation and survival rates (with superiority for microwave ablation as regards the incidence of local recurrence).

Treatment outcomes of transcatheter arterial chemoembolization combined with local ablative therapy versus monotherapy in hepatocellular carcinoma: a meta-analysis

PURPOSE

To evaluate the effectiveness comparing the combination of TACE with local ablative therapy and monotherapy on the treatment of HCC using meta-analytical techniques.

METHODS

Randomized controlled trials and clinical studies comparing TACE plus local ablative therapy with monotherapy for HCC were included in this meta-analysis. Response rate, 1-, 2-, 3-, and 5-year survival rate, and overall survival (OS) were analyzed and compared.

RESULTS

Eighteen studies included a total of 2,120 patients with HCC 1,071 and 1,049 patients for treatment with combination therapy and monotherapy, respectively. The combination therapy group had a significantly better survival in terms of 1-, 2-, 3-, and 5-year survival rate (RR 1.10, 95 % CI 1.03–1.18, P = 0.005; RR 1.20, 95 % CI 1.10–1.30, P < 0.0001; RR 1.43, 95 % CI 1.18–1.73, P < 0.0001; RR 1.40, 95 % CI 1.22–1.61, P < 0.0001, respectively), OS (HR 0.66, 95 % CI 0.51–0.85, P = 0.001), and response rate (RR 1.54, 95 % CI 1.09–2.18, P = 0.013) than that monotherapy group in patients with HCC.

CONCLUSIONS

The meta-analysis indicates that the combination of TACE with local ablative therapy was superior to monotherapy in the treatment for patients with HCC.

The Enhanced metastatic potential of hepatocellular carcinoma (HCC) cells with sorafenib resistance

Acquired resistance towards sorafenib treatment was found in HCC patients, which results in poor prognosis. To investigate the enhanced metastatic potential of sorafenib resistance cells, sorafenib-resistant (SorR) cell lines were established by long-term exposure of the HCC cells to the maximum tolerated dose of sorafenib. Cell proliferation assay and qPCR of ABC transporter genes (ABCC1-3) were first performed to confirm the resistance of cells. Migration and invasion assays, and immunoblotting analysis on the expression of epithelial to mesenchymal transition (EMT) regulatory proteins were performed to study the metastatic potential of SorR cells. The expression of CD44 and CD133 were studied by flow cytometry and the gene expressions of pluripotency factors were studied by qPCR to demonstrate the enrichment of cancer stem cells (CSCs) in SorR cells. Control (CTL) and SorR cells were also injected orthotopically to the livers of NOD-SCID mice to investigate the development of lung metastasis. Increased expressions of ABCC1-3 were found in SorR cells. Enhanced migratory and invasive abilities of SorR cells were observed. The changes in expression of EMT regulatory proteins demonstrated an activation of the EMT process in SorR cells. Enriched proportion of CD44⁺ and CD44⁺CD133⁺ cells were also observed in SorR cells. All (8/8) mice injected with SorR cells demonstrated lung metastasis whereas only 1/8 mouse injected with CTL cells showed lung metastasis. HCC cells with sorafenib resistance demonstrated a higher metastatic potential, which may be due to the activated EMT process. Enriched CSCs were also demonstrated in the sorafenib resistant cells. This study suggests that advanced HCC patients with acquired sorafenib resistance may have enhanced tumor growth or distant metastasis, which raises the concern of long-term sorafenib treatment in advanced HCC patients who have developed resistance of sorafenib.

Puncture injection of para-toluenesulfonamide combined with chemoembolization for advanced hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is difficult to eradicate due to its resilient nature. Portal vein is often involved in tumors of large size, which exclude the patient from surgical resection and local ablative therapy, such as percutaneous ethanol injection (PEI) and radiofrequency ablation (RFA) because they were considered neither effective nor safe. Currently, there is almost no effective treatment for HCC of such condition. As a unique antitumor agent in form of lipophilic fluid for local injection, para-toluenesulfonamide (PTS) produces mild side effects while necrotizing the tumor tissues quickly and efficiently. Being largely different from both PEI and RFA therapies, PTS can disseminate itself in tumors more easily than other caustic agents, such as alcohol. So PTS may offer additional benefit to HCCs with vascular involvement. We herein describe a 70-year-old HCC patient who was treated with the combination of PTS injection and transcatheter arterial chemoembolization, resulting in a significantly improved clinical prognosis.