Hepatocellular carcinoma: is current therapy really altering outcome?

Traditional uses, phytochemistry, pharmacology, and pharmacokinetics of the root bark of Paeonia x suffruticosa andrews: A comprehensive review

ETHNOPHARMACOLOGICAL RELEVANCE

Moutan Cortex (MC), commonly known as "Mu dan pi", refers to the dried root bark of Paeonia x suffruticosa Andrews and is broadly used as a traditional herbal medication in China, Japan, and Korea. For thousands of years, it has been utilized to treat female genital, extravasated blood, cardiovascular, and stagnant blood disorders.

AIM OF THE REVIEW

The purpose of this review article was to summarize information on the traditional uses, phytochemistry, pharmacology and pharmacokinetics of MC, as well as to outline the further research directions for the development of new drugs and the associations between traditional uses and pharmacological effects.

MATERIALS AND METHODS

The information involved in the study was gathered from a variety of electronic resources, including PubMed, Web of Science, ScienceDirect, SciFinder, China Knowledge Resource Integrated Database, and Google Scholar. The date was from 1992 to 2022.

RESULTS

Approximately 163 chemical compounds have been extracted and identified from MC, including monoterpenes, monoterpene glycosides, triterpenes, phenolics, flavonoids, volatile oils, alkaloids, and others. In these categories, the monoterpene glycosides and phenols being the most common. A wide variety of pharmacological effects have been described for MC crude extracts and active molecules, such as antioxidant, anti-inflammatory, antibacterial and antiviral, antitumor, antidiabetic, organ protection, and neuroprotective activities, as well as treating cardiovascular diseases. Pharmacokinetics has been also used in the study of MC, including its crude extracts or chemical constituents, in order to explore the therapeutic mechanism, direct clinically appropriate application and provide new ideas for the exploitation of innovative medicines.

CONCLUSION

Modern pharmacological research has demonstrated that MC, as a significant therapeutic resource, has the ability to heal a wide range of diseases, particularly female genital and cardiovascular problems. These researches propose therapeutic ideas for the development of novel MC medicines. Furthermore, preclinical and clinical study have verified several observed pharmacological properties related with the traditional usages of MC.

Cell membrane breakage and triggering T cell infiltration are involved in human telomerase reverse transcriptase (hTERT) promoter-driven novel peptide KK-64 for liver cancer gene therapy

Liver cancer is an aggressive malignancy with exhibits both high mortality and morbidity. The current treatment options are associated with several limitations, novel specific anti-cancer drugs are urgently needed to improve liver cancer treatment. In this study, a new peptide KK-64 was designed, and it showed strong cytotoxicity against liver cancer cells. To obtain the tumor targeting property, a plasmid that contains KK-64 DNA fragment and driven by human telomerase reverse transcriptase (hTERT) promoter was constructed. pcTERT-kk-64 plasmid was found to specifically inhibit the viability of liver cancer cells HepG2, induce substantial apoptosis as well as damage to the cell membranes, but had minimal effects toward normal liver HL-7702 cells. Furthermore, pcTERT-kk-64 plasmids was also noted to significantly attenuate migration and invasion of HepG2 cells. The anti-tumor effect of pcTERT-kk-64 plasmid was also observed in H22 cell-bearing mice, and it appeared to cause significant tumor regression, trigger tumor cell apoptosis, and infiltrate cytotoxicity T cells to the tumor tissues after plasmids injection. Thus, pcTERT-kk-64 plasmids showed both strong cytotoxicity and tumor selectivity in vitro and in tumor-bearing mice in liver cancer models.

Phytochemical evaluation and anticancer activity of rambutan (Nephelium lappaceum) fruit endocarp extracts against human hepatocellular carcinoma (HepG-2) cells

The current investigation was taken to screen the phytoconstituents present in fruit endocarp various extracts of Nephelium lappaceum commonly called as Rambutan fruit and its anticancer property against human hepatocellular carcinoma (HepG-2) cells. Different analytical techniques including qualitative phytochemical analysis, cell viability assay (MTT), apoptotic nuclear staining (DAPI), DNA fragmentation assay, Attenuated total reflection (ATR) and Gas chromatography–mass spectrometry (GC–MS) spectral analysis were carried out. ATR and GC–MS study revealed the presence of functional groups and 9 compounds, respectively in methanol endocarp extract. The results obtained depicts that methanol endocarp extract profoundly controlled cell proliferation and caused shrinkage of HepG-2 cells from polygonal to spherical shape. DAPI staining revealed that methanol endocarp extract caused increased fragmentation of nucleus and DNA fragmentation, which can be taken as a sign of apoptosis. The anticancer potential of methanol fruit endocarp extract of Nephelium lappaceum than other extracts and could be used successfully in future drug delivery systems and other biomedical concerns.

USP33 regulates c-Met expression by deubiquitinating SP1 to facilitate metastasis in hepatocellular carcinoma

AIMS

Deubiquitinase ubiquitin-specific protease 33 (USP33) is abnormally expressed in various tumors and participates in tumor progression. However, the expression and biological role of USP33 in hepatocellular carcinoma (HCC) are still unclear.

MAIN METHODS

We performed immunohistochemistry, western blotting, and qRT-PCR analysis to determine the expression of USP33 in HCC. We then analyzed the effects of USP33 expression on the prognosis of HCC. The roles of USP33 in regulating HCC cell migration and invasion were further explored in vitro. Animal studies were performed to investigate the effects of USP33 on tumor metastasis. RNA sequencing and luciferase reporter and immunofluorescence assays were used to identify the activation of the specificity protein 1 (SP1)/c-Met axis.

KEY FINDINGS

Here, for the first time, we reported an abnormal increase in the expression of USP33 in HCC tissues and that USP33 may act as a prognostic biomarker for HCC patients. We found that USP33 knockdown inhibited the invasion and metastasis in HCC cells both in vitro and in vivo, which was partly dependent on c-Met. Further investigations revealed that USP33 regulated c-Met expression by enhancing the protein stability of the transcription factor SP1 in HCC cells. Mechanistically, USP33 directly bound SP1 and decreased its ubiquitination, thereby upregulating c-Met expression.

SIGNIFICANCE

Our results reveal that USP33 acts as the deubiquitinating enzyme of SP1 and contributes to HCC invasion and metastasis through activation of the SP1/c-Met axis. These data indicate a previously unknown function of USP33, which may provide potential targets for the treatment of HCC patients.

The role of MDM2-p53 axis dysfunction in the hepatocellular carcinoma transformation

Liver cancer is the second most frequent cause of cancer-related death globally. The main histological subtype is hepatocellular carcinoma (HCC), which is derived from hepatocytes. According to the epidemiologic studies, the most important risk factors of HCC are chronic viral infections (HBV, HCV, and HIV) and metabolic disease (metabolic syndrome). Interestingly, these carcinogenic factors that contributed to HCC are associated with MDM2-p53 axis dysfunction, which presented with inactivation of p53 and overactivation of MDM2 (a transcriptional target and negative regulator of p53). Mechanically, the homeostasis of MDM2-p53 feedback loop plays an important role in controlling the initiation and progression of HCC, which has been found to be dysregulated in HCC tissues. To maintain long-term survival in hepatocytes, hepatitis viruses have lots of ways to destroy the defense strategies of hepatocytes by inducing TP53 mutation and silencing, promoting MDM2 overexpression, accelerating p53 degradation, and stabilizing MDM2. As a result, genetic instability, chronic ER stress, oxidative stress, energy metabolism switch, and abnormalities in antitumor genes can be induced, all of which might promote hepatocytes' transformation into hepatoma cells. In addition, abnormal proliferative hepatocytes and precancerous cells cannot be killed, because of hepatitis viruses-mediated exhaustion of Kupffer cells and hepatic stellate cells (HSCs) and CD4+T cells by disrupting their MDM2-p53 axis. Moreover, inefficiency of hepatic immune response can be further aggravated when hepatitis viruses co-infected with HIV. Unlike with chronic viral infections, MDM2-p53 axis might play a dual role in glucolipid metabolism of hepatocytes, which presented with enhancing glucolipid catabolism, but promoting hepatocyte injury at the early and late stages of glucolipid metabolism disorder. Oxidative stress, fatty degeneration, and abnormal cell growth can be detected in hepatocytes that were suffering from glucolipid metabolism disorder, and all of which could contribute to HCC initiation. In this review, we focus on the current studies of the MDM2-p53 axis in HCC, and specifically discuss the impact of MDM2-p53 axis dysfunction by viral infection and metabolic disease in the transformation of normal hepatocytes into hepatoma cells. We also discuss the therapeutic avenues and potential targets that are being developed to normalize the MDM2-p53 axis in HCC.

Radiofrequency ablation vs. surgical resection for resectable hepatocellular carcinoma: A systematic review and meta-analysis

The treatment of hepatocellular carcinoma (HCC) is a significant challenge. Although radiofrequency ablation (RFA) has emerged as a popular therapeutic option for patients with resectable HCC, whether it can achieve comparable survival outcomes compared with surgical resection (RES) remains unclear. The aim of the present study was to conduct a meta-analysis to assess the survival outcomes of RFA vs. RES in patients with early resectable HCC tumors. A Medline, Embase, and Cochrane Library search was performed for data published between January 2000 and February 2018. A meta-analysis of the efficacy of RFA compared with RES for HCC was subsequently performed, with particular emphasis on overall survival and disease-free survival (DFS) rates. Pooled odds ratios (ORs) with 95% confidence intervals (CIs) were calculated using the random-effects model. In the present study, a total of 13,147 patients with HCC were included; of which, 6,727 were treated with RFA and 6,420 were treated with RES. The overall survival rates (OR_1-year, 0.757, 95% CI, 0.578–0.989; OR_3-year, 0.530, 95% CI, 0.401–0.700; OR_5-year, 0.566, 95% CI, 0.423–0.758) and the DRS rates (OR_1-year, 0.569, 95% CI, 0.456–0.711; OR_3-year, 0.418, 95% CI, 0.267–0.653; OR_5-year, 0.374, 95% CI, 0.231–0.606) of RES were significantly higher than those of RFA. The results indicate that RES is superior to RFA for promoting the survival of selected patients with resectable HCC. However, future randomized controlled trials are required to investigate the specific relevance of these modalities in the treatment of HCC.

18F-FDG PET with or without CT in the diagnosis of extrahepatic metastases or local residual/recurrent hepatocellular carcinoma

The aim of the present study was to meta-analyze the literature on the diagnostic value of 18-fluorodeoxyglucose (F-FDG) positron emission tomography (PET) with or without computed tomography (CT) in detecting extrahepatic metastases or local residual/recurrent hepatocellular carcinoma (HCC).Systematic review of literature in MEDLINE, Embase, and Cochrane databases was conducted in March 2017, and relevant studies analyzing the diagnostic performance of F-FDG PET with or without CT were meta-analyzed.Meta-analysis was carried out on data from 11 studies involving 572 patients. F-FDG PET, with or without CT, showed pooled sensitivity of 64% and pooled specificity of 95%. Pooled sensitivity was similar with CT (74%) or without (52%; P = .279). Similarly, pooled specificity was comparable with CT (93%) or without 95% (P = .481).F-FDG PET, with or without CT, shows relatively low sensitivity but high specificity for diagnosing extrahepatic metastases or local residual/recurrent HCC. Adding CT to F-FDG PET may improve diagnostic performance, but the available evidence suggests that the improvement is not statistically significant.

Suppression of the Wnt signaling pathway may contribute to the inhibition of proliferation of human hepatocellular carcinoma SMMC-7721 cells by esculetin

The aims of the present study were to investigate the effects of esculetin on the proliferation of human hepatocellular carcinoma SMMC-7721 cells and to determine the underlying mechanism behind this activity. An MTT assay was used to assess cell proliferation, reverse transcription-quantitative polymerase chain reaction was used to determine the relative mRNA expression levels of β-catenin, c-Myc and cyclin D1, and western blot analysis was utilized to determine the levels of the associated proteins. Compared with the dimethyl sulfoxide control, esculetin reduced the cell viability of SMMC-7721 and HL-7702 cells in a dose- and time-dependent manner. Treatment of SMMC-7721 cells with esculetin resulted in downregulation of the mRNA and protein levels of β-catenin, c-Myc and cyclin D1. Esculetin increased the phosphorylation of β-catenin at Ser33/Ser37/Thr41 and inhibited the proliferation of human hepatoma SMMC-7721 cells by suppressing the Wnt signaling pathway. The results of the present study suggest that esculetin inhibited the Wnt/β-catenin signaling pathway in SMMC-7721 cells and may have potential as an effective anti-cancer drug, acting to inhibit the Wnt/β-catenin signaling pathway.

Combination of aspartic acid and glutamic acid inhibits tumor cell proliferation

Placental extract contains several biologically active compounds, and pharmacological induction of placental extract has therapeutic effects, such as improving liver function in patients with hepatitis or cirrhosis. Here, we searched for novel molecules with an anti-tumor activity in placental extracts. Active molecules were separated by chromatographic analysis, and their antiproliferative activities were determined by a colorimetric assay. We identified aspartic acid and glutamic acid to possess the antiproliferative activity against human hepatoma cells. Furthermore, we showed that the combination of aspartic acid and glutamic acid exhibited enhanced antiproliferative activity, and inhibited Akt phosphorylation. We also examined in vivo tumor inhibition activity using the rabbit VX2 liver tumor model. The treatment mixture (emulsion of the amino acids with Lipiodol) administered by hepatic artery injection inhibited tumor cell growth of the rabbit VX2 liver. These results suggest that the combination of aspartic acid and glutamic acid may be useful for induction of tumor cell death, and has the potential for clinical use as a cancer therapeutic agent.

The Limonoids TS3 and Rubescin E Induce Apoptosis in Human Hepatoma Cell Lines and Interfere with NF-κB Signaling

Hepatocellular carcinoma (HCC) is extremely resistant towards pharmacological therapy. To date, the multi-kinase inhibitor Sorafenib is the only available therapeutic agent with the potential to prolong patient survival. Using the human hepatoma cell lines HepG2 and Huh7, we analyzed anti-cancer activities of 6 purified havanensin type limonoids isolated from the traditional African medicinal plant Trichilia rubescens Oliv. Our results show that two of the compounds, TR4 (TS3) and TR9 (Rubescin E) reduced hepatoma cell viability, but not primary hepatocyte viability, at TC50s of 5 to 10 μM. These were significantly lower than the TC50s for Sorafenib, the histone deacetylase inhibitor SAHA or 5-Fluoruracil. In comparison, TR3 (Rubescin D), a limonoid isolated in parallel and structurally highly similar to TR4 and TR9, did not interfere with hepatoma cell viability. Both, TR4 and TR9, but not TR3, induced apoptosis in hepatoma cells and interfered with NF-κB activation. TR4 as well as TR9 significantly supported anti-cancer activities of Sorafenib. In summary, the limonoids TR4 and TR9 exhibit anti-cancer activities and support Sorafenib effects in vitro, having the potential to support future HCC therapy.

Cordyceps militaris induces tumor cell death via the caspase‑dependent mitochondrial pathway in HepG2 and MCF‑7 cells

Cordyceps militaris (CM), an entomopathogenic fungus belonging to the class ascomycetes, possesses various pharmacological activities, including cytotoxic effects, on various types of human tumor cells. The present study investigated the anti-hepatocellular carcinoma (HCC) and anti-breast cancer effects of CM in in vitro and in vivo models. CM aqueous extract reduced cell viability, suppressed cell proliferation, inhibited cell migration ability, caused the over-release of lactate dehydrogenase, induced mitochondrial dysfunction and enhanced apoptotic rates in MCF-7 and HepG2 cells. The expression levels of cleaved poly (ADP ribose) polymerase and caspase-3, biomarkers of apoptosis, were increased following treatment with CM aqueous extract for 24 h. Furthermore, in the MCF-7 and HepG2 cells, enhanced levels of B cell-associated X protein and cleaved caspase-8 were observed in the CM-treated cells. Finally, the antitumor activities of CM in HCC and breast cancer were also confirmed in MCF-7- and HepG2-xengraft nude mice models. Collectively, the data obtained in the present study suggested that the cytotoxic effects of CM aqueous extract on HCC and breast cancer are associated with the caspase-dependent mitochondrial pathway.

Severity of liver cirrhosis: a key role in the selection of surgical modality for Child-Pugh A hepatocellular carcinoma

Hepatocellular carcinoma is the third leading cause of cancer-related death in the world, and cirrhosis is the main cause of hepatocellular carcinoma and adversely affects surgical outcomes. Liver resection, liver transplantation, and local ablation are potentially curative therapies for early hepatocellular carcinoma (HCC). There exists an obvious histological variability of severity within cirrhosis which has different clinical stages. For patients with Child-Pugh B cirrhosis and/or portal hypertension and HCC within Milan criteria, consensus guidelines suggest that liver transplantation is the best treatment of choice; liver resection is widely accepted as first-line treatment for patients with early-stage HCC and preserved liver function; and local ablation is the treatment of choice in patients with small tumors who are not candidates for surgery or can be used as a temporary treatment during the waiting period for transplantation. For patients with compensated cirrhosis or Child A cirrhosis, the selection of surgical modality based on subclassification of cirrhosis remains unclear. This review examines the current status of the selection of surgical modality for hepatocellular carcinoma treatment in cirrhotic patients and aims to emphasize the effects of the severity of cirrhosis on the selection of surgical modality for the treatment of hepatocellular carcinoma.

High expression of long non-coding RNA ANRIL is associated with poor prognosis in hepatocellular carcinoma

INTRODUCTION

long non-coding RNA ANRIL (lncRNA ANRIL) has been demonstrated to play a crucial role in cancer progression. However, its effects in hepatocellular carcinoma (HCC) have not been explored. The aim of this study was to investigate the clinical significance of lncRNA NRIL in human HCC.

METHODS

In this study, we determined for the first time the expression of lncRNA ANRIL in human HCC by quantitative Real-time-PCR analysis. Kaplan-Meier curves and multivariate Cox proportional models were used to study the impact on clinical outcome. Small interfering RNA (siRNA) was used to silence lncRNA ANRIL and to explore the effects of reduced lncRNA ANRIL expression on cell growth and metastasis.

RESULTS

lncRNA ANRIL expression in HCC tissues was significantly higher than in the adjacent non-tumor tissues (P<0.05). The expression of lncRNA ANRIL was remarkably associated with the histologic grade and TNM stage of HCC patients (P<0.05). In addition, HCC patients with higher lncRNA ANRIL expression had significantly poorer overall survival (P<0.05). Multivariate analysis suggested that high lncRNA ANRIL expression was an independent predictor of poor prognosis (P<0.05). Moreover, in vitro assays revealed that the decreased expression of lncRNA ANRIL could suppress the cell proliferation, migration and invasion HCC cells.

CONCLUSIONS

Our results suggest that lncRNA ANRIL may serve as an efficient clinical biomarker and a therapeutic target for HCC patients.

Cryoprotective therapy for huge hepatocellular carcinoma: a study of 14 patients with a single lesion

Percutaneous cryoablation is a potential cure for hepatocellular carcinoma (HCC). This study reviewed retrospectively clinical data from 14 patients who underwent cryoablation of huge HCC (long diameter >7 cm). The side effects of cryosurgeries and liver function reverse were recorded and compared everyday. All the patients survived cryosurgery and none died before leaving hospital 2 weeks later. Despite liver-protective treatment before cryosurgery, alanine transaminase (ALT) and aspartate transaminase (AST) levels were increased significantly, but returned to preoperative levels 2 weeks post-cryosurgery. Before cryosurgery, mean total bilirubin (T.BIL) and direct bilirubin (D.BIL) levels were normal; 8-10 days after cryosurgery, they increased more than two-fold, but returned to the preoperative level 2 weeks post-cryosurgery. Serum transaminase and bilirubin levels were compared between hepatitis B positive and negative patients. The hepatitis B negative group's AST level increased significantly 1 day post-cryosurgery (mean, 186 U/L) and decreased to the preoperative level at day 14. In the hepatitis B positive group, means transaminase and bilirubin reached peak values at different days post-cryosurgery. Overall, ALT and AST are valuable indicators of liver function impairment following cryosurgery. In patients with hepatitis B virus, close attention to the serum bilirubin level should be paid 8-10 days after cryosurgery. Liver-protective treatment may alleviate liver function impairment caused by cryosurgery of huge HCC.

Ubiquitin-like protein FAT10 promotes the invasion and metastasis of hepatocellular carcinoma by modifying β-catenin degradation

The ubiquitin-like protein FAT10 and the homeobox protein HOXB9 each promote metastatic progression in hepatocellular carcinoma (HCC). In this study, we investigated the clinicopathologic significance of FAT10 and HOXB9 in HCC and investigated a mechanistic role for FAT10 in HOXB9-mediated invasiveness and metastasis. Relative to adjacent normal tissues, FAT10 and HOXB9 were markedly overexpressed in HCC, where a positive correlation in their expression and associated malignant characteristics were found. RNAi-mediated silencing of FAT10 decreased HOXB9 expression and inhibited HCC invasion and metastasis in vitro and in vivo. The effects of FAT10 silencing were reversed by HOXB9 overexpression, whereas RNAi-mediated silencing of HOXB9 decreased HCC invasion and metastasis driven by FAT10 overexpression. Mechanistically, FAT10 regulated HOXB9 expression by modulating the β-catenin/TCF4 pathway, directly binding to β-catenin and preventing its ubiquitination and degradation. Together, our results identified a novel HCC regulatory circuit involving FAT10, β-catenin/TCF4, and HOXB9, the dysfunction of which drives invasive and metastatic character in HCC. Cancer Res; 74(18); 5287-300. ©2014 AACR.

Conventional oral systemic chemotherapy for postoperative hepatocellular carcinoma: A systematic review

The findings of randomized clinical trials (RCTs) regarding the efficacy of adjuvant conventional oral systemic chemotherapy (COSC) for patients with hepatocellular carcinoma (HCC) following curative hepatic resection (HR) are contradictory. Therefore, a systematic review of RCTs is required to evaluate the clinical efficacy of adjuvant COSC. Sources such as Medline, Embase and the Cochrane Library were systematically searched and all the RCTs comparing curative HR alone to HR plus COSC for HCC were identified. The odds ratios (ORs) and 95% confidence intervals (CIs) were calculated. No treatment-related mortality was reported by the included RCTs and the adverse effects of COSC were generally mild. However, adjuvant COSC did not achieve a statistically significant improvement in the 1-, 3- and 5-year overall survival (OR=1.43, 95% CI: 0.58-3.56, P=0.44; OR=1.39, 95% CI: 0.75-2.55, P=0.29; and OR=1.20, 95% CI: 0.46-3.16, P=0.71, respectively). In addition, adjuvant COSC did not achieve a statistically significant decrease in the incidence of 1-, 3- and 5-year tumor recurrence, with pooled ORs of 0.92 (95% CI: 0.26-1.35, P=0.66); 0.82 (95% CI: 0.66-1.01, P=0.06); and 0.84 (95% CI: 0.71-1.01, P=0.06), respectively. Narrative reviews offer no evidence supporting the use of COSC. Adjuvant COSC has provided marginal benefits for HCC patients following curative HR. Considering the efficacy of sorafenib for advanced HCC and the results of this systematic review, no further trials should be performed to assess the efficacy of adjuvant COSC.

Cryoprotective therapy for hepatocellular carcinoma: study of 51 patients with a single lesion

Percutaneous cryoablation is a potentially curative treatment for hepatocellular carcinoma (HCC). After liver cryosurgery, rapid elevations of transaminases and bilirubin are common, but are usually transient and normalize within a few days. This study retrospectively reviewed clinical data from 51 patients who underwent liver cryoablation in our hospital during the past 4.5 years. Sixty-six percutaneous cryoablations were performed in these patients and transaminase and bilirubin levels before and after the procedure were observed. Although most patients received liver-protective treatment before cryosurgery, transaminase levels were double (mean alanine transaminase (ALT) and aspartate transaminase (AST) were 71 U/L and 85 U/L, respectively) the normal ranges in our hospital. One day after cryosurgery, ALT and AST had increased 3.3-fold (peak mean was 241 U/L) and 5-fold (peak mean was 427 U/L), respectively, but were close to the preoperative level 5 days post-cryosurgery. No significant increase of serum bilirubin was observed. Serum transaminase and bilirubin levels were compared between hepatitis B positive and hepatitis B negative patients. Only in the hepatitis B positive group were total bilirubin (74 μmol/L/23 μmol/L=3.2) and direct bilirubin (45 μmol/L/12 μmol/L=3.8) more than 3 times the preoperative level 7-9 days after treatment. Overall, ALT and AST are valuable as indicators of liver function impairment following cryosurgery. In patients with hepatitis B virus, serum bilirubin was 3 times the preoperative level 7-9 days after cryosurgery. Liver-protective treatment may alleviate liver function impairment due to cryosurgery.

Comparison of pharmacokinetics, tissue distribution and pharmacodynamics of liposomal and free doxorubicin in tumour-bearing mice following intratumoral injection

OBJECTIVES

The clinical application of doxorubicin (DOX) is limited by severe systemic side effects. The aim of this study was to develop a strategy that combined the liposomal DOX (LipDOX) and intratumoral injection to reduce the toxicity and enhance the antitumor efficiency.

METHODS

The pharmacokinetics, tissue distribution and pharmacodynamics of LipDOX compared with free DOX were investigated by intratumoral injection in murine H22 hepatoma-bearing mice at a dose of 20 mg/kg body weight. A sensitive HPLC-tandem mass spectrometry method was used to determine the DOX levels in plasma and tissues. The tumour volume and body weight of mice were measured every 3 days.

KEY FINDINGS

LipDOX administration resulted in 1.3-fold longer mean residence time (MRT) and 2.4-fold higher area under concentration (AUC)-time curve compared with free DOX administration in tumour. Free DOX caused higher peak plasma concentration (Cmax ) than LipDOX in plasma and major organs, which may result in significant mortality for acute cardiac toxicity. After successive 21 days treatment, the final volume of tumour treated by normal saline, free DOX and LipDOX was 5.0-, 1.3-fold higher and 1.6-fold lower than the initial tumour volume, respectively.

CONCLUSIONS

Our results indicated that the intratumoral injection of LipDOX is a promising approach with higher therapeutic efficacy and lower systemic toxicity than free DOX.

Lens culinaris agglutinin-reactive α-fetoprotein decline after transcatheter arterial chemoembolization in patients with hepatocellular carcinoma predicts survival

BACKGROUND

Lens culinaris agglutinin-reactive α-fetoprotein (AFP-L3) is a fucosylated fraction of AFP that is highly specific for hepatocellular carcinoma (HCC). We studied the relationship between AFP-L3 response and treatment outcome in terms of radiologic response and overall survival in patients undergoing transcatheter arterial chemoembolization (TACE).

METHODS

We retrospectively analyzed 152 patients with advanced HCC undergoing TACE. Serum AFP-L3 and AFP levels were measured simultaneously with a novel lectin dual-label time-resolved immunofluorometric assay (lectin dual-label TRFIA). AFP-L3 response was defined as a ≥20% reduction in AFP-L3 level after a minimum of 2 cycles of chemotherapy.

RESULTS

A total of 47 AFP-L3 responders had improved median overall survival of 42.9 months compared with 15.4 months in nonresponders (P<0.0001), and AFP-L3 response was strongly associated with radiologic response (P<0.0001). The combination of AFP-L3 response and serum AFP response provided further prognostic information. On multivariate analysis, the prognostic value of AFP-L3 response was independent of maximum tumor diameter and BCLC stage.

CONCLUSION

A significant reduction in AFP-L3 in patients with advanced HCC is an important predictor of survival. Achieving an AFP-L3 response should be one of the therapeutic intents of TACE.

Combination treatment with comprehensive cryoablation and immunotherapy in metastatic hepatocellular cancer

AIM: To retrospectively assess the effect of comprehensive cryosurgery (ablation of intra- and extra-hepatic tumors) plus dendritic cell-cytokine-induced killer cell immunotherapy in metastatic hepatocellular cancer.

METHODS: We divided 45 patients into cryo-immunotherapy (21 patients), cryotherapy (n = 12), immunotherapy (n = 5) and untreated (n = 7) groups. Overall survival (OS) after diagnosis of metastatic hepatocellular cancer was assessed after an 8-year follow-up.

RESULTS: Median OS was higher following cryo-immunotherapy (32 mo) or cryotherapy (17.5 mo; P < 0.05) than in the untreated group (3 mo) and was higher in the cryo-immunotherapy group than in the cryotherapy group (P < 0.05). In the cryo-immunotherapy group, median OS was higher after multiple treatments (36.5 mo) than after a single treatment (21 mo; P < 0.05).

CONCLUSION: Cryotherapy and, especially, cryo-immunotherapy significantly increased OS in metastatic hepatocellular cancer patients. Multiple cryo-immunotherapy was associated with a better prognosis than single cryo-immunotherapy.

NC-6300, an epirubicin-incorporating micelle, extends the antitumor effect and reduces the cardiotoxicity of epirubicin

Epirubicin is widely used to treat various human tumors. However, it is difficult to achieve a sufficient antitumor effect because of dosage limitation to prevent cardiotoxicity. We hypothesized that epirubicin-incorporating micelle would reduce cardiotoxicity and improve the antitumor effect. NC-6300 comprises epirubicin covalently bound to PEG polyaspartate block copolymer through an acid-labile hydrazone bond. The conjugate forms a micellar structure of 40-80 nm in diameter in an aqueous milieu. NC-6300 (10, 15 mg/kg) and epirubicin (10 mg/kg) were given i.v. three times to mice bearing s.c. or liver xenograft of human hepatocellular carcinoma Hep3B cells. Cardiotoxicity was evaluated by echocardiography in C57BL/6 mice that were given NC-6300 (10 mg/kg) or epirubicin (10 mg/kg) in nine doses over 12 weeks. NC-6300 showed a significantly potent antitumor effect against Hep3B s.c. tumors compared with epirubicin. Moreover, NC-6300 also produced a significantly longer survival rate than epirubicin against the liver orthotopic tumor of Hep3B. With respect to cardiotoxicity, epirubicin-treated mice showed significant deteriorations in fractional shortening and ejection fraction. In contrast, cardiac functions of NC-6300 treated mice were no less well maintained than in control mice. This study warrants a clinical evaluation of NC-6300 in patients with hepatocellular carcinoma or other cancers.

Radiofrequency ablation compared to resection in early-stage hepatocellular carcinoma

OBJECTIVES

This study aimed to compare survival outcomes after hepatic resection (HR) and radiofrequency ablation (RFA) in early-stage hepatocellular carcinoma (HCC) at a Western hepatobiliary centre.

METHODS

Demographic details, clinicopathologic tumour characteristics and survival outcomes were compared among non-transplant candidate patients undergoing HR (n= 50) and RFA (n= 60) for early-stage HCC during 2001-2011.

RESULTS

Patients who underwent HR had larger tumours, a longer length of stay and a higher rate of postoperative complications. After a median follow-up of 29 months, there were no significant differences between the treatment groups in 1-, 3- and 5-year overall survival (OS) [RFA group: 86%, 50%, 35%, respectively; HR group: 88%, 68%, 47%, respectively (P= 0.222)] or disease-free survival (DFS) [RFA group: 68%, 42%, 28%, respectively; HR group: 66%, 42%, 34%, respectively (P= 0.823)]. The 58 patients who underwent RFA demonstrated ablation success on follow-up computed tomography at 3 months. Of these, 96.5% of patients showed sustained ablation success over the entire follow-up period. In a subgroup analysis of patients with tumours measuring 2-5 cm, no differences in OS or DFS emerged between the HR and RFA groups. Similarly, no significant differences in outcomes in patients with Child-Pugh class A cirrhosis were seen between the RFA and HR groups.

CONCLUSIONS

  Radiofrequency ablation is comparable with HR in terms of OS and DFS. It is a reasonable alternative as a first-line treatment for HCC in well-selected patients who are not candidates for transplant.

Highlights for α-fetoprotein in determining prognosis and treatment monitoring for hepatocellular carcinoma

AIM: To explore the prognostic value in the monitoring of treatment efficacy of serial α-fetoprotein (AFP) in hepatocellular carcinoma (HCC) patients.

METHODS: We searched MEDLINE, EMBASE and COCHRANE LIBRARY through April 21, 2012, to find qualifying articles. Our overall search strategy included terms for HCC, AFP, treatment response, and prognosis. Literature was limited to English-language, human studies. Studies reporting cumulative survival rates were summarized qualitatively. For the prognostic meta-analysis, we undertook a series of meta-analyses that summarised the Cox proportional hazard ratios (HRs) by assuming a random effects model. With regards to the correlation of AFP change with radiologic response, the categorical dichotomous variables were assessed using Poisson relative risks (RRs), which were incorporated into the random effects model meta-analysis of accuracy prediction. Between-study heterogeneity was estimated by use of the I² statistic. Publication bias was evaluated using the Begg funnel plot and Egger plot. Sensitivity analyses were conducted first by separating systemic treatment estimates from locoregional therapy estimates, evaluating different AFP response cut-off point effects, and exploring the impact of different study sizes.

RESULTS: Of 142 titles identified in our original search, 11 articles (12 clinical studies) met our criteria. Six studies investigated outcome in a total of 464 cases who underwent systemic treatment, and six studies investigated outcome in a total of 510 patients who received locoregional therapy. A random-effects model meta-analysis showed that AFP response was associated with an mortality HR of 0.55 (95%CI, 0.47-0.65) across HCC in overall survival (OS) and 0.50 (95%CI, 0.38-0.65) in progression-free survival. Restricting analysis to the six eligible analyses of systemic treatment, the pooled HRs were 0.64 (95%CI, 0.53-0.77) for OS. Limiting analysis to the six analyses of locoregional therapy, the pooled HRs for OS was 0.39 (95%CI, 0.29-0.53). We showed a larger pooled HR in the 50% definition studies (HR, 0.67, 95%CI, 0.55-0.83) compared with that from the 20% definition studies (HR, 0.41, 95%CI, 0.32-0.53). Restricting analysis to the four studies including over 100 patients individually, the pooled HR was 0.65 (95%CI, 0.54-0.79), with a pooled HR for OS of 0.35 (95%CI, 0.23-0.46) in the studies of less than 100 patients. As to radiological imaging, 43.1% (155/360) of the patients in the AFP response group presented with a radiological overall response, while the response rate decreased to 11.5% (36/313) in the patients from the AFP nonresponse group. The RR of having no overall response was significantly lower in the AFP response group than the AFP nonresponse group (RR, 0.67; 95%CI, 0.61-0.75). In terms of disease control rate, 86.9% (287/330) in the AFP response group and 51.0% (153/300) in the AFP nonresponse group showed successful disease control, respectively. The RR of disease control failure, similarly, was significantly lower in the AFP response group (RR, 0.37; 95%CI, 0.23-0.58). But these findings could be overestimates because of publication and reporting bias.

CONCLUSION: HCC patients presenting with an AFP response are at decreased risk of mortality. In addition, patients with an AFP response also present with a higher overall response rate and disease control rate.

Percutaneous comprehensive cryoablation for metastatic hepatocellular cancer

Percutaneous ablation is the currently preferred locoregional therapy for non-resectable hepatocellular cancer (HCC). Cryoablation is an attractive option because it forms an ice ball viewable by many imaging methods. This study assessed the therapeutic effect of comprehensive cryoablation (of intra- and extrahepatic tumors) in patients with metastatic HCC. Forty-five patients met the inclusion criteria from January, 2004 to October, 2011. Treatment was performed on 33 patients; 12 patients received no treatment. Procedural safety and overall survival (OS) were assessed according to metastatic stage. The OS of patients who received comprehensive treatment was significantly longer than that of those who received no treatment (median: 26 vs. 3.5months, P<0.001). Large (⩾5cm long diameter) hepatic tumors were treated in advance with transarterial chemoembolization, but the OS of patients in the same metastatic stage was similar (P=0.0677). In the comprehensive cryoablation group, timely treatment (within 2months after diagnosis of metastatic HCC) was associated with a longer OS than when treatment was delayed for 3-7months (median: 38.5 vs. 21months, P=0.0167). Multiple treatments improved the survival of patients who received comprehensive treatment (P=0.0489). In terms of increasing the survival time of metastatic HCC patients, the effect of comprehensive cryosurgery was significant. Timely or multiple treatments had greater therapeutic effects than delayed or single treatment.

Role of miR-224 in hepatocellular carcinoma: a tool for possible therapeutic intervention?

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide, characterized by high mortality rate and poor prognosis. Our understanding of the HCC pathology is still very much fragmented and little progress has been made to improve the clinical outcome of HCC patients. While recently discovered microRNA deregulation in HCC has added to the complexity of our understanding of HCC, it has also presented promising novel approaches to understand, diagnose and treat HCC. Here, we highlight one miRNA, miR-224, which has been more consistently reported to be upregulated in HCC than other miRNAs. We will discuss the validated and predicted functional roles of this miRNA in HCC, speculate on the possible mechanism for its upregulation in HCC and explore the potential of miR-224 as an exciting novel biomarker for the early detection of liver malignancies as well as a novel therapeutic target for HCC treatment.

A survey on herbal management of hepatocellular carcinoma

In this review we outline the different mechanisms mediating hepatocarcinogenesis. We also discuss possible targets of bioactive herbal agents at different stages of hepatocarcinogenesis and highlight their role at each individual stage. We gathered information on the most common herbal prescriptions and extracts thought to be useful in prevention or sensitization for chemotherapy in management of hepatocellular carcinoma (HCC). The value of this topic may seem questionable compared to the promise offered for HCC management by chemotherapy and radiation. However, we would recommend the use of herbal preparations not as alternatives to common chemo /and or radiotherapy, but rather for prevention among at-risk individuals, given that drug/herb interactions are still in need of extensive clarification. The bioactive constituents of various herbs seem to be promising targets for isolation, cancer activity screening and clinical evaluation. Finally, herbal preparations may offer a cost effective protective alternative to individuals known to have a high risk for HCC and possibly other cancers, through maintaining cell integrity, reversing oxidative stress and modulating different molecular pathways in preventing carcinogenesis.

Meta-analysis of the therapeutic effect of hepatectomy versus radiofrequency ablation for the treatment of hepatocellular carcinoma

Surgical resection has been considered to be the best treatment for hepatocellular carcinoma (HCC). However, in recent years, there has been growing interest in the therapy of radiofrequency ablation (RFA). This meta-analysis is to evaluate the therapeutic effect of those 2 therapeutic methods. Outcomes evaluated were death rate, complications, survival rates, recurrence-free survival rates, and recurrence. Primary authors were contacted to retrieve further information if necessary. There is no significant difference in death rates of the treatment of HCC in the groups of hepatectomy and RFA, although the recurrence of HCC may be lower in the hepatectomy group. In the group of RFA, the recurrence rate in the previous site was higher but was lower in the new area, whereas it seems equal in the extrahepatic area. RFA may have comparable results with surgical resection in patients in the therapeutic effect of ablation for the treatment of HCC, if recurrence of HCC after RFA could be timely detected and effectively treated.

Combination chemotherapy of doxorubicin and paclitaxel for hepatocellular carcinoma in vitro and in vivo

PURPOSE

Systemic combination chemotherapy is the only option for patients with unresectable hepatocellular carcinoma (HCC) not suitable for intra-arterial treatment. However, no systemic chemotherapy has been able to provide durable remission. The search for a new combination of drugs for HCC is significant. The combination of doxorubicin and paclitaxel shows promise in breast cancer therapy. This study was carried out to determine the synergistic effect of combined doxorubicin and paclitaxel in the two HCC cell lines: HepG2 and Huh7 in vitro and murine HCC H22-bearing BALB/c mice in vivo.

METHODS

The morphology of the two cell lines treated with drugs was photomicrographed. The 3-(4,5-dimethylthiazol-2-yl)-2,5 diphenyltetrazolium bromide assay was used to determine the number of surviving cells. Cell cycle was evaluated by flow cytometry. Cell viability was measured by the ability of single cells to form colonies in vitro. Anti-tumor activities against subcutaneoulsy implanted solid tumor induced by H22 cells in mice were evaluated.

RESULTS

Our data demonstrated that the cytotoxicity produced by doxorubicin and paclitaxel was additive in HCC cells, while it was mainly held in the G2/M phase of the cell cycle by paclitaxel. In vivo anti-tumor activity assay also showed that the combination of the two drugs resulted in more significant tumor regression, compared to the single one.

CONCLUSION

The study may provide a new combination of cytotoxic drugs for HCC chemotherapy.

Combination chemotherapy of doxorubicin and paclitaxel for hepatocellular carcinoma in vitro and in vivo

PURPOSE

Systemic combination chemotherapy is the only option for patients with unresectable hepatocellular carcinoma (HCC) not suitable for intra-arterial treatment. However, no systemic chemotherapy has been able to provide durable remission. The search for a new combination of drugs for HCC is significant. The combination of doxorubicin and paclitaxel shows promise in breast cancer therapy. This study was carried out to determine the synergistic effect of combined doxorubicin and paclitaxel in the two HCC cell lines: HepG2 and Huh7 in vitro and murine HCC H22-bearing BALB/c mice in vivo.

METHODS

The morphology of the two cell lines treated with drugs was photomicrographed. The 3-(4,5-dimethylthiazol-2-yl)-2,5 diphenyltetrazolium bromide assay was used to determine the number of surviving cells. Cell cycle was evaluated by flow cytometry. Cell viability was measured by the ability of single cells to form colonies in vitro. Anti-tumor activities against subcutaneoulsy implanted solid tumor induced by H22 cells in mice were evaluated.

RESULTS

Our data demonstrated that the cytotoxicity produced by doxorubicin and paclitaxel was additive in HCC cells, while it was mainly held in the G2/M phase of the cell cycle by paclitaxel. In vivo anti-tumor activity assay also showed that the combination of the two drugs resulted in more significant tumor regression, compared to the single one.

CONCLUSION

The study may provide a new combination of cytotoxic drugs for HCC chemotherapy.

Role of alpha-fetoprotein in hepatocellular carcinoma: prognostication, treatment monitoring or both?

Despite recent breakthroughs in the treatment for both early and advanced hepatocellular carcinoma, the development of markers for prognostication and treatment monitoring remains to be explored. Serum alpha-fetoprotein has been frequently measured at diagnosis and serially during treatment by clinicians for decades, with an aim for prognostication of disease and monitoring of treatment response. In this review, the evidence regarding the prognostic value of serum alpha-fetoprotein and the value of serial alpha-fetoprotein in the monitoring of treatment efficacy will be discussed, with emphasis on recent data.

Photodynamic therapy inhibits P-glycoprotein mediated multidrug resistance via JNK activation in human hepatocellular carcinoma using the photosensitizer pheophorbide a

Background

Multidrug resistance (MDR) is frequently observed after prolonged treatment in human hepatoma with conventional anti-tumor drugs, and photodynamic therapy (PDT) is a recently suggested alternative to overcome MDR. The therapeutic potential of PDT was evaluated in a multidrug resistance (MDR) human hepatoma cell line R-HepG2 with photosensitizer pheophorbide a (Pa).

Results

Our results demonstrated that intracellular accumulation of Pa was not reduced by the overexpression of P-glycoprotein. Pa-based PDT (Pa-PDT) significantly inhibited the growth of R-HepG2 cells with an IC50 value of 0.6 μM. Mechanistic study demonstrated that genomic DNA fragmentation and phosphatidylserine externalization occurred where increase of intracellular singlet oxygen level triggers the phosphorylation of c-Jun N-terminal Kinase (JNK) and leads to activation of intrinsic apoptotic caspases cascade during the Pa-PDT treatment. The cytotoxicity of Pa-PDT, accumulation of sub-G1 population, and depolarization of mitochondrial membrane could be inhibited by JNK inhibitor in the Pa-PDT treated cells. Interestingly, the Pa-PDT induced JNK activation showed inhibitory effect on MDR by the down-regulation of P-glycoprotein in R-HepG2 cells in a dose-dependent manner. In addition, significant reduction of tumor size was obtained in Pa-PDT treated R-HepG2-bearing nude mice with no significant damages in liver and heart.

Conclusion

In summary, our findings provided the first evidence that PDT could inhibit the MDR activity by down-regulating the expression of P-glycoprotein via JNK activation using pheophorbide a as the photosensitizer, and our work proved that Pa-PDT inhibited the growth of MDR hepatoma cells by mitochondrial-mediated apoptosis induction.

Cucurbitacin D isolated from Trichosanthes kirilowii induces apoptosis in human hepatocellular carcinoma cells in vitro

The aim of the present study is to examine the effects of the anti-tumor component isolated from Trichosanthes kirilowii on human hepatocellular carcinoma cells. Using Sephadex G-25 column chromatography, Sep-Pak Plus C18 cartridge and high-performance liquid chromatography (HPLC), we isolated the active component from trichosanthes extract. By fast atom bombardment mass spectrometric analysis, the molecular mass of the active fraction was determined, the active components identified, and their mechanisms of action were analyzed by cell growth assay, cell cycle analysis, TUNEL staining and Western blot analysis. We found that the anti-tumor components isolated from the extract of trichosanthes (EOT) are cucurbitacin D and dihydrocucurbitacin D, and suggest that cucurbitacin D induces apoptosis through caspase-3 and phosphorylation of JNK in hepatocellular carcinoma cells. These results suggest that cucurbitacin D isolated from Trichosanthes kirilowii could be a valuable candidate for anti-tumor drug.

New utility of an old marker: serial alpha-fetoprotein measurement in predicting radiologic response and survival of patients with hepatocellular carcinoma undergoing systemic chemotherapy

PURPOSE

There are limitations in using radiologic evaluation to assess the treatment outcome of patients with hepatocellular carcinoma (HCC). The use of serial alpha-fetoprotein (AFP) in monitoring response has not been rigorously evaluated. We aimed to study the clinical value of AFP trend in an attempt to validate AFP as a surrogate serologic end point.

PATIENTS AND METHODS

Participants from a phase III randomized trial of systemic chemotherapy in HCC were studied. Serum AFP was prospectively collected in parallel with clinical and radiologic outcome. AFP response was defined as a decrease in AFP of more than 20% after a minimum of two cycles of chemotherapy. We studied the relationship between AFP response and treatment outcome in terms of radiologic response and overall survival.

RESULTS

Of 188 patients, 117 patients with elevated serum AFP (> 20 microg/L) and documented radiologic evaluation had received at least two cycles of chemotherapy. A total of 47 AFP responders were identified. AFP responders had better survival than nonresponders (13.5 v 5.6 months, respectively; P < .0001), and AFP response was strongly associated with radiologic response (P < .0001). Multivariate analysis suggested that AFP response was significantly associated with survival (hazard ratio, 0.413; 95% CI, 0.273 to 0.626; P < .0001). AFP responses were frequently observed in patients with radiologically stable disease (SD) and tended to identify a subgroup of SD patients with better survival.

CONCLUSION

Serial AFP measurement is useful in prognostication and monitoring treatment response in HCC patients undergoing systemic chemotherapy. Incorporation of AFP response into the criteria evaluating treatment outcome should be considered in clinical practice and clinical trials of novel agents in HCC.

Down-regulation of osteopontin suppresses growth and metastasis of hepatocellular carcinoma via induction of apoptosis

BACKGROUND & AIMS

Expression of osteopontin correlates with tumor progression and metastasis. The mechanisms by which osteopontin promotes tumor cell survival remain unclear. Here we used short-hairpin RNA-mediated gene silencing to investigate the antitumor effects by osteopontin depletion in hepatocellular carcinoma (HCC).

METHODS

We applied polyethylenimine nanoparticles to deliver a short-hairpin RNA for depletion of osteopontin expression in HCC cells. Tumorigenicity and metastatic potentials of HCC cells were studied in vitro and in nude mice. Nuclear factor-kappaB (NF-kappaB) activation was analyzed by gel shift assay and luciferase analysis. The expressions of integrins were examined by real-time reverse-transcription polymerase chain reaction. Apoptosis was examined by terminal deoxynucleotidyl transferase-mediated deoxyuridine triphosphate nick-end labeling assay and mitochondrial membrane potential analysis.

RESULTS

Down-regulation of osteopontin inhibited HCC cell growth, anchorage-independent growth, adhesion with fibronectin and invasion through extracellular matrix in vitro, and suppressed tumorigenicity and lung metastasis in nude mice. Osteopontin silencing resulted in suppression of alphav, beta1, and beta3 integrin expressions, blockade of NF-kappaB activation, inhibition of Bcl-2/Bcl-xL and XIAP expressions, increase of Bax expression, and induction of a mitochondria-mediated apoptosis. Furthermore, down-regulation of osteopontin inhibited drug-induced NF-kappaB activation and sensitized HCC cells to chemotherapeutic agents in vitro, which led to complete regression of HCC xenografts in nude mice.

CONCLUSIONS

Osteopontin may facilitate tumorigenesis and metastasis through prevention of tumor cells from apoptosis. RNA interference-mediated depletion of osteopontin may be a promising strategy for the treatment of HCC by sensitizing the chemotherapeutic drugs.

Thermal ablation of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cause of cancer, and its incidence is increasing worldwide because of the dissemination of hepatitis B and C virus infection. Patients with cirrhosis are at the highest risk of developing HCC and should be monitored every 6 months to diagnose the tumour at an early, asymptomatic stage. Patients with early-stage HCC should be considered for any of the available curative therapies, including surgical resection, liver transplantation and percutaneous image-guided ablation. Liver transplantation is the only option that provides cure of both the tumour and the underlying chronic liver disease. However, the lack of sufficient liver donation greatly limits its applicability. Resection is the treatment of choice for HCC in non-cirrhotic patients, who account for about 5% of the cases in western countries. However, in patients with cirrhosis, candidates for resection have to be carefully selected to reduce the risk of postoperative liver failure. It has been shown that a normal bilirubin concentration and the absence of clinically significant portal hypertension are the best predictors of excellent outcomes after surgery. However, less than 5% of cirrhotic patients with HCC fit these criteria. Image-guided percutaneous ablation is the best therapeutic choice for non-surgical patients with early-stage HCC. While ethanol injection has been the seminal percutaneous technique, radiofrequency ablation has emerged as the most effective method for local tumour destruction and is currently used as the primary ablative modality at most institutions.

Anti-tumor effects of paeonol in a HepA-hepatoma bearing mouse model via induction of tumor cell apoptosis and stimulation of IL-2 and TNF-alpha production

Paeonol, a phenolic component from the root bark of Paeonia moutan, is traditionally used as a Chinese herbal medicine to activate the blood flow and remove blood stasis. Evidence shows that paeonol have anti-tumor, anti-inflammatory, and analgesic effects; however, the underlying mechanisms remain unknown. In this study, we investigated the molecular mechanisms by which paeonol exerts the anti-tumor effects by using a murine model of hepatoma established by in vivo injection of mouse HepA-hepatoma cells. Treatment of mice with 100, 200, or 400 mg/kg/day of paeonol significantly inhibited the growth of the HepA tumor in mice, induced HepA cell apoptosis as demonstrated by light microscopy and electron microscopy analyses, decreased the expression of Bcl-2 and increased the expression of Bax in HepA tumor tissues in a dose-related manner. Administration of paeonol in vivo also elevated serum levels of IL-2 and TNF-alpha in tumor-bearing mice. Moreover, splenocytes and macrophages isolated from paeonol-treated HepA tumor-bearing mice produced higher levels of IL-2 and TNF-alpha in response to concanavalin A and lipopolysaccharide stimulation, respectively, compared to these isolated from non-treated HepA tumor-bearing mice. In vitro treatment with paeonol was able to directly stimulate IL-2 and TNF-alpha production in splenocytes and macrophages from tumor-bearing mice, respectively. In conclusion, paeonol has the anti-tumor effect against hepatoma cells, which are likely mediated via induction of tumor cell apoptosis and stimulation of IL-2 and TNF-alpha production. Paeonol could be a promising drug to treat hepatocellular carcinoma.

The kringle 1 domain of hepatocyte growth factor has antiangiogenic and antitumor cell effects on hepatocellular carcinoma

The kringle 1 domain of human hepatocyte growth factor (HGFK1) was previously shown to inhibit bovine aortic endothelial cell proliferation, suggesting that it might be an antiangiogenic molecule. Here, we evaluated the in vivo efficacy of a recombinant adenoassociated virus carrying HGFK1 (rAAV-HGFK1) for the treatment of hepatocellular carcinoma (HCC) in a rat orthotopic HCC model and explored its molecular mechanisms in vitro in both endothelial and tumor cells. We first showed that rAAV-HGFK1 treatment significantly prolonged the survival time of rats transplanted with tumor cells. Treatment with rAAV-HGFK1 inhibited tumor growth, decreased tumor microvessel density, and completely prevented intrahepatic, lung, and peritoneal metastasis in this in vivo model. In vitro, rAAV-HGFK1 exhibited both antiangiogenic and antitumor cell effects, inhibiting the proliferation of both murine microvascular endothelial cells (MEC) and tumor cells, and inducing apoptosis and G(0)-G(1) phase arrest in these cells. To our surprise, rAAV-HGFK1 did not act through the hepatocyte growth factor/hepatocyte growth factor receptor pathway. Instead, it worked mainly through epidermal growth factor (EGF)/epidermal growth factor receptor (EGFR) signaling, with more minor contributions from vascular endothelial growth factor/vascular endothelial growth factor receptor and beta fibroblast growth factor (bFGF)/beta fibroblast growth factor receptor (bFGFR) signaling. In both MECs and tumor cells, rAAV-HGFK1 acted through two pathways downstream of EGFR, namely inhibition of extracellular signal-regulated kinase activation and stimulation of p38 mitogen-activated protein kinase/c-Jun-NH(2)-kinase activation. These results suggest for the first time that HGFK1 exerts both antiangiogenic and antitumor cell activities mainly through EGF/EGFR signaling, and may thus be considered as a novel therapeutic strategy for the treatment of HCC.

Systemic therapy for hepatocellular carcinoma: cytotoxic chemotherapy, targeted therapy and immunotherapy

Conventional cytotoxic chemotherapy has not provided clinical benefit or prolonged survival for patients with advanced HCC. This review summarizes the results of prospective clinical trials of several categories of systemic therapy, with emphasis on the more promising results from recent trials of biologically targeted therapeutic agents in HCC.

Radiation dose limits and liver toxicities resulting from multiple yttrium-90 radioembolization treatments for hepatocellular carcinoma

PURPOSE

To assess the relationship between cumulative hepatic lobar radiation dose and liver toxicities in patients with hepatocellular carcinoma (HCC) treated with multiple sessions of yttrium-90 radioembolization.

MATERIALS AND METHODS

Forty-one patients with HCC (age range, 46-82 years) underwent radioembolization with 90Y. Patients were classified according to the Okuda scoring system. All patients received single liver lobar treatments on two or more occasions according to standard clinical 90Y embolization protocol. Cumulative radiation dose to each liver lobe was measured and patients were followed to assess liver toxicities. Statistical analysis was performed with the Student t test and Kaplan-Meier analysis.

RESULTS

Patients with Okuda stage I disease received more treatments than those with Okuda stage II disease (mean, 2.65 vs 2.24; P<.05). For average cumulative radiation dose, patients with Okuda stage I disease received 247 Gy (range, 88-482 Gy) and those with Okuda stage II disease received 198 Gy (range, 51-361 Gy; P<.05). A total of 13 toxicities occurred in seven patients (16%). Patients with Okuda stage I disease were given a greater cumulative dose than patients with Okuda stage II disease before worsening of liver function: 390 Gy versus 196 Gy (P<.005). For patients with Okuda stage I disease, a higher cumulative radiation dose was associated with occurrence of one or more toxicities: 222 Gy (no toxicities) versus 390 Gy (>or=1 toxicity; P<.005). No correlation between cumulative radiation dose and liver toxicities existed in patients with Okuda stage II disease. The maximum tolerated dose was between 222 and 390 Gy. Median survival times were 660 and 431 days for patients with Okuda stage I and stage II disease, respectively.

CONCLUSIONS

Patients with HCC can tolerate high cumulative radiation doses with 90Y therapy. Compared with patients with Okuda stage II disease, patients with Okuda stage I disease tolerate a higher cumulative radiation dose without liver toxicity, but liver toxicities increase with increasing cumulative radiation doses.

Growth inhibitory effects of IFN-beta on human liver cancer cells in vitro and in vivo

We investigated the effects of interferon-beta (IFN-beta) on the growth of human liver cancer cells. The effects of IFN-beta with or without 5-fluorouracil (5-FU) on the proliferation of 13 liver cancer cell lines were investigated in vitro. Chronologic change in IFN-alpha receptor 2 (IFNAR-2) expression was monitored in hepatocellular carcinoma (HCC) cells (HAK-1B) cultured with IFN-beta. After HAK-1B cells were transplanted into nude mice, various doses of IFN-beta were administered, and the tumor volume, weight, histology, tumor blood vessel, and angiogenesis factor expression were examined. IFN-beta inhibited the growth of 11 cell lines with apoptosis in a dose-dependent and time-dependent manner. With IFN-beta, IFNAR-2 expression in HAK-1B cells was significantly downregulated from 6 to 12 h. IFN-beta induced a dose-dependent decrease in tumor volume and weight and a significant increase of apoptosis in the tumor. Both basic fibroblast growth factor (bFGF) and blood vessel number in the tumor decreased only in mice receiving the lowest dose (1000 IU) of IFN-beta. IFN-beta with 10 muM of 5-FU frequently induced synergistic antiproliferative effects. IFN-beta with or without 5-FU induces strong antitumor effects in HCC cells, and we conclude that IFN-beta is useful for the prevention and treatment of HCC.

Combined intra-arterial 5-fluorouracil and subcutaneous interferon-alpha therapy for highly advanced hepatocellular carcinoma

Because of the difficulties of low sensitivity for anticancer agents and giving sufficient dose because of poor liver function, chemotherapy may not play a central role for treatment of hepatocellular carcinoma (HCC) patients, especially those with liver cirrhosis. However, chemotherapy must be one of the important possibilities of multimodal treatment for advanced HCC, for which hepatic resection, percutaneous ablation, transcatheter arterial embolization and other general therapies would not be effective or even possible. Also, intra-arterial perfusion chemotherapy is a common therapy for HCC and it is not difficult to maintain; but the effective rate is not sufficient. Recently, the combination therapy of s.c. interferon (IFN)-alpha and intra-arterial 5-fluorouracil (5-FU) showed an outstandingly effective rate for intractable HCC (with portal vein thrombosis). In addition,recent preclinical and clinical studies have revealed that the mechanism of combination therapy may concern direct antitumor effects (through cell-cycle arrest and induction of apoptosis) and indirect actions (through immunocompetent cells and anti-angiogenic effect). For the further advance of HCC treatment and prognosis, this therapy might be a promising treatment modality and is expected to develop. In this review, we summarize recent clinical and preclinical data regarding IFN-alpha and 5-FU combination therapy and discuss the further prospects of this therapy.

Strategies for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) generally develops as a consequence of underlying liver disease, most commonly viral hepatitis. The development of HCC follows an orderly progression from cirrhosis to dysplastic nodules to early cancer development, which can be reliably cured if discovered before the development of vascular invasion (typically occurring at a tumor diameter of approximately 2 cm). The identifiable population at risk makes screening a realistic possibility, and liver imaging is recommended every 6 months for patients with cirrhosis. For patients with preserved liver function and no portal hypertension who develop HCC that is confined to one region of the liver, resection is the preferred treatment. If resection is not possible because of poor liver function, and the HCC is within the Milan criteria (1 nodule > or =5 cm, 2-3 nodules > or =3 cm), liver transplantation is the treatment of choice. To prevent tumor progression while waiting, nonsurgical treatments including percutaneous ethanol injection, radiofrequency ablation, and transarterial chemoembolization are employed, but drop-out from the waiting list remains a problem. Living donor transplantation is an alternative that can eliminate drop-out and enable liver transplantation for patients with HCC whose disease does not fall within the Milan criteria. There is a need for more effective adjuvant therapies after resection and liver transplantation; newer antiangiogenic agents offer hope for improved outcomes in the future.

Hepatitis B viral load predicts survival of HCC patients undergoing systemic chemotherapy

HCC is a common cause of morbidity and mortality. For patients who are not candidates for curative surgery, systemic chemotherapy is one of the standard treatments. In parts of China and the Far East, over 80% of HCC patients have chronic HBV infection. In this study, we aimed to assess the relationship between pre-chemotherapy HBV viral load and the survival of HCC patients. HBV infection status was determined prior to chemotherapy in 188 patients, 170 of whom had evidence of HBV chronic infection/exposure (160 hepatitis B surface antigen [HBsAg]-positive, 10 HBsAg-negative/hepatitis B core antibody-positive). Of these, 125 had pretreatment HBV DNA levels determined via real-time PCR. Virological data were analyzed using conventional clinical variables to identify factors that influenced survival. Multivariate analysis revealed that high total bilirubin (P = 0.0016; hazard ratio = 1.040 per 1 muM increase; 95% CI 1.015-1.065), HCV infection (P = 0.0095; hazard ratio = 6.955; 95% CI 1.606-30.129), and high HBV DNA level (P = 0.0217; hazard ratio = 1.650; 95% CI 1.076-2.531) affected survival significantly. Exploratory analysis revealed that high levels of pretreatment HBV DNA had a significantly higher incidence of severe hepatitis during chemotherapy.

CONCLUSION

For HCC patients with HBV chronic infection/exposure, a high viral load prior to treatment is an adverse factor for survival and may be associated with a higher incidence of severe hepatitis during chemotherapy. Future strategies to improve the prognosis of HCC patients undergoing chemotherapy should consider supportive therapy that incorporates antiviral therapies to reduce HBV viral load.