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Granata V, Fusco R, De Muzio F, Brunese MC, Setola SV, Ottaiano A, Cardone C, Avallone A, Patrone R, Pradella S, Miele V, Tatangelo F, Cutolo C, Maggialetti N, Caruso D, Izzo F, Petrillo A. Radiomics and machine learning analysis by computed tomography and magnetic resonance imaging in colorectal liver metastases prognostic assessment. LA RADIOLOGIA MEDICA 2023; 128:1310-1332. [PMID: 37697033 DOI: 10.1007/s11547-023-01710-w] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/18/2023] [Accepted: 08/22/2023] [Indexed: 09/13/2023]
Abstract
OBJECTIVE The aim of this study was the evaluation radiomics analysis efficacy performed using computed tomography (CT) and magnetic resonance imaging in the prediction of colorectal liver metastases patterns linked to patient prognosis: tumor growth front; grade; tumor budding; mucinous type. Moreover, the prediction of liver recurrence was also evaluated. METHODS The retrospective study included an internal and validation dataset; the first was composed by 119 liver metastases from 49 patients while the second consisted to 28 patients with single lesion. Radiomic features were extracted using PyRadiomics. Univariate and multivariate approaches including machine learning algorithms were employed. RESULTS The best predictor to identify tumor growth was the Wavelet_HLH_glcm_MaximumProbability with an accuracy of 84% and to detect recurrence the best predictor was wavelet_HLH_ngtdm_Complexity with an accuracy of 90%, both extracted by T1-weigthed arterial phase sequence. The best predictor to detect tumor budding was the wavelet_LLH_glcm_Imc1 with an accuracy of 88% and to identify mucinous type was wavelet_LLH_glcm_JointEntropy with an accuracy of 92%, both calculated on T2-weigthed sequence. An increase statistically significant of accuracy (90%) was obtained using a linear weighted combination of 15 predictors extracted by T2-weigthed images to detect tumor front growth. An increase statistically significant of accuracy at 93% was obtained using a linear weighted combination of 11 predictors by the T1-weigthed arterial phase sequence to classify tumor budding. An increase statistically significant of accuracy at 97% was obtained using a linear weighted combination of 16 predictors extracted on CT to detect recurrence. An increase statistically significant of accuracy was obtained in the tumor budding identification considering a K-nearest neighbors and the 11 significant features extracted T1-weigthed arterial phase sequence. CONCLUSIONS The results confirmed the Radiomics capacity to recognize clinical and histopathological prognostic features that should influence the choice of treatments in colorectal liver metastases patients to obtain a more personalized therapy.
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Affiliation(s)
- Vincenza Granata
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale - IRCCS di Napoli, Naples, Italy.
| | | | - Federica De Muzio
- Department of Medicine and Health Sciences V. Tiberio, University of Molise, 86100, Campobasso, Italy
| | - Maria Chiara Brunese
- Department of Medicine and Health Sciences V. Tiberio, University of Molise, 86100, Campobasso, Italy
| | - Sergio Venanzio Setola
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale - IRCCS di Napoli, Naples, Italy
| | - Alessandro Ottaiano
- Clinical Experimental Abdominal Oncology Unit, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, 80131, Naples, Italy
| | - Claudia Cardone
- Clinical Experimental Abdominal Oncology Unit, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, 80131, Naples, Italy
| | - Antonio Avallone
- Clinical Experimental Abdominal Oncology Unit, Istituto Nazionale Tumori, IRCCS Fondazione G. Pascale, 80131, Naples, Italy
| | - Renato Patrone
- Division of Hepatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131, Naples, Italy
| | - Silvia Pradella
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
- SIRM Foundation, Italian Society of Medical and Interventional Radiology (SIRM), 20122, Milan, Italy
| | - Vittorio Miele
- Department of Radiology, Careggi University Hospital, Largo Brambilla 3, 50134, Florence, Italy
- SIRM Foundation, Italian Society of Medical and Interventional Radiology (SIRM), 20122, Milan, Italy
| | - Fabiana Tatangelo
- Division of Pathological Anatomy and Cytopathology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131, Naples, Italy
| | - Carmen Cutolo
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084, Salerno, Italy
| | - Nicola Maggialetti
- Department of Medical Science, Neuroscience and Sensory Organs (DSMBNOS), University of Bari "Aldo Moro", 70124, Bari, Italy
| | - Damiano Caruso
- Department of Medical Surgical Sciences and Translational Medicine, Radiology Unit-Sant'Andrea University Hospital, Sapienza-University of Rome, 00189, Rome, Italy
| | - Francesco Izzo
- Division of Hepatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale-IRCCS di Napoli, 80131, Naples, Italy
| | - Antonella Petrillo
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale - IRCCS di Napoli, Naples, Italy
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Granata V, Fusco R, Setola SV, Simonetti I, Picone C, Simeone E, Festino L, Vanella V, Vitale MG, Montanino A, Morabito A, Izzo F, Ascierto PA, Petrillo A. Immunotherapy Assessment: A New Paradigm for Radiologists. Diagnostics (Basel) 2023; 13:diagnostics13020302. [PMID: 36673112 PMCID: PMC9857844 DOI: 10.3390/diagnostics13020302] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2022] [Revised: 12/31/2022] [Accepted: 01/08/2023] [Indexed: 01/14/2023] Open
Abstract
Immunotherapy denotes an exemplar change in an oncological setting. Despite the effective application of these treatments across a broad range of tumors, only a minority of patients have beneficial effects. The efficacy of immunotherapy is affected by several factors, including human immunity, which is strongly correlated to genetic features, such as intra-tumor heterogeneity. Classic imaging assessment, based on computed tomography (CT) or magnetic resonance imaging (MRI), which is useful for conventional treatments, has a limited role in immunotherapy. The reason is due to different patterns of response and/or progression during this kind of treatment which differs from those seen during other treatments, such as the possibility to assess the wide spectrum of immunotherapy-correlated toxic effects (ir-AEs) as soon as possible. In addition, considering the unusual response patterns, the limits of conventional response criteria and the necessity of using related immune-response criteria are clear. Radiomics analysis is a recent field of great interest in a radiological setting and recently it has grown the idea that we could identify patients who will be fit for this treatment or who will develop ir-AEs.
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Affiliation(s)
- Vincenza Granata
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
- Correspondence:
| | - Roberta Fusco
- Medical Oncology Division, Igea SpA, 80013 Naples, Italy
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy
| | - Sergio Venanzio Setola
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Igino Simonetti
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Carmine Picone
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Ester Simeone
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, 80131 Naples, Italy
| | - Lucia Festino
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, 80131 Naples, Italy
| | - Vito Vanella
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, 80131 Naples, Italy
| | - Maria Grazia Vitale
- Melanoma, Cancer Immunotherapy and Development Therapeutics Unit, Istituto Nazionale Tumori IRCCS Fondazione G. Pascale, 80131 Naples, Italy
| | - Agnese Montanino
- Thoracic Medical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Alessandro Morabito
- Thoracic Medical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Francesco Izzo
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Paolo Antonio Ascierto
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy
| | - Antonella Petrillo
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
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Cutolo C, Fusco R, Simonetti I, De Muzio F, Grassi F, Trovato P, Palumbo P, Bruno F, Maggialetti N, Borgheresi A, Bruno A, Chiti G, Bicci E, Brunese MC, Giovagnoni A, Miele V, Barile A, Izzo F, Granata V. Imaging Features of Main Hepatic Resections: The Radiologist Challenging. J Pers Med 2023; 13:jpm13010134. [PMID: 36675795 PMCID: PMC9862253 DOI: 10.3390/jpm13010134] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2022] [Revised: 12/31/2022] [Accepted: 01/06/2023] [Indexed: 01/12/2023] Open
Abstract
Liver resection is still the most effective treatment of primary liver malignancies, including hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), and of metastatic disease, such as colorectal liver metastases. The type of liver resection (anatomic versus non anatomic resection) depends on different features, mainly on the type of malignancy (primary liver neoplasm versus metastatic lesion), size of tumor, its relation with blood and biliary vessels, and the volume of future liver remnant (FLT). Imaging plays a critical role in postoperative assessment, offering the possibility to recognize normal postoperative findings and potential complications. Ultrasonography (US) is the first-line diagnostic tool to use in post-surgical phase. However, computed tomography (CT), due to its comprehensive assessment, allows for a more accurate evaluation and more normal findings than the possible postoperative complications. Magnetic resonance imaging (MRI) with cholangiopancreatography (MRCP) and/or hepatospecific contrast agents remains the best tool for bile duct injuries diagnosis and for ischemic cholangitis evaluation. Consequently, radiologists should be familiar with the surgical approaches for a better comprehension of normal postoperative findings and of postoperative complications.
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Affiliation(s)
- Carmen Cutolo
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Salerno, Italy
| | - Roberta Fusco
- Medical Oncology Division, Igea SpA, 80013 Napoli, Italy
- Correspondence:
| | - Igino Simonetti
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Federica De Muzio
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, 86100 Campobasso, Italy
| | - Francesca Grassi
- Division of Radiology, Università degli Studi della Campania Luigi Vanvitelli, 80127 Naples, Italy
| | - Piero Trovato
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Pierpaolo Palumbo
- Department of Diagnostic Imaging, Area of Cardiovascular and Interventional Imaging, Abruzzo Health Unit 1, 67100 L’Aquila, Italy
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy
| | - Federico Bruno
- Department of Diagnostic Imaging, Area of Cardiovascular and Interventional Imaging, Abruzzo Health Unit 1, 67100 L’Aquila, Italy
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy
| | - Nicola Maggialetti
- Department of Medical Science, Neuroscience and Sensory Organs (DSMBNOS), University of Bari “Aldo Moro”, 70124 Bari, Italy
| | - Alessandra Borgheresi
- Department of Radiology, University Hospital “Azienda Ospedaliera Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy
- Department of Clinical, Special and Dental Sciences, University Politecnica delle Marche, Via Conca 71, 60126 Ancona, Italy
| | - Alessandra Bruno
- Department of Radiology, University Hospital “Azienda Ospedaliera Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy
- Department of Clinical, Special and Dental Sciences, University Politecnica delle Marche, Via Conca 71, 60126 Ancona, Italy
| | - Giuditta Chiti
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Eleonora Bicci
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Maria Chiara Brunese
- Department of Medicine and Health Sciences “V. Tiberio”, University of Molise, 86100 Campobasso, Italy
| | - Andrea Giovagnoni
- Department of Radiology, University Hospital “Azienda Ospedaliera Universitaria delle Marche”, Via Conca 71, 60126 Ancona, Italy
- Department of Clinical, Special and Dental Sciences, University Politecnica delle Marche, Via Conca 71, 60126 Ancona, Italy
| | - Vittorio Miele
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, Via della Signora 2, 20122 Milan, Italy
- Department of Emergency Radiology, University Hospital Careggi, Largo Brambilla 3, 50134 Florence, Italy
| | - Antonio Barile
- Department of Applied Clinical Sciences and Biotechnology, University of L’Aquila, 67100 L’Aquila, Italy
| | - Francesco Izzo
- Division of Epatobiliary Surgical Oncology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
| | - Vincenza Granata
- Division of Radiology, Istituto Nazionale Tumori IRCCS Fondazione Pascale—IRCCS di Napoli, 80131 Naples, Italy
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Risk Assessment and Pancreatic Cancer: Diagnostic Management and Artificial Intelligence. Cancers (Basel) 2023; 15:cancers15020351. [PMID: 36672301 PMCID: PMC9857317 DOI: 10.3390/cancers15020351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 12/30/2022] [Accepted: 01/03/2023] [Indexed: 01/06/2023] Open
Abstract
Pancreatic cancer (PC) is one of the deadliest cancers, and it is responsible for a number of deaths almost equal to its incidence. The high mortality rate is correlated with several explanations; the main one is the late disease stage at which the majority of patients are diagnosed. Since surgical resection has been recognised as the only curative treatment, a PC diagnosis at the initial stage is believed the main tool to improve survival. Therefore, patient stratification according to familial and genetic risk and the creation of screening protocol by using minimally invasive diagnostic tools would be appropriate. Pancreatic cystic neoplasms (PCNs) are subsets of lesions which deserve special management to avoid overtreatment. The current PC screening programs are based on the annual employment of magnetic resonance imaging with cholangiopancreatography sequences (MR/MRCP) and/or endoscopic ultrasonography (EUS). For patients unfit for MRI, computed tomography (CT) could be proposed, although CT results in lower detection rates, compared to MRI, for small lesions. The actual major limit is the incapacity to detect and characterize the pancreatic intraepithelial neoplasia (PanIN) by EUS and MR/MRCP. The possibility of utilizing artificial intelligence models to evaluate higher-risk patients could favour the diagnosis of these entities, although more data are needed to support the real utility of these applications in the field of screening. For these motives, it would be appropriate to realize screening programs in research settings.
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De Muzio F, Grassi F, Dell’Aversana F, Fusco R, Danti G, Flammia F, Chiti G, Valeri T, Agostini A, Palumbo P, Bruno F, Cutolo C, Grassi R, Simonetti I, Giovagnoni A, Miele V, Barile A, Granata V. A Narrative Review on LI-RADS Algorithm in Liver Tumors: Prospects and Pitfalls. Diagnostics (Basel) 2022; 12:diagnostics12071655. [PMID: 35885561 PMCID: PMC9319674 DOI: 10.3390/diagnostics12071655] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2022] [Revised: 06/27/2022] [Accepted: 07/05/2022] [Indexed: 11/16/2022] Open
Abstract
Liver cancer is the sixth most detected tumor and the third leading cause of tumor death worldwide. Hepatocellular carcinoma (HCC) is the most common primary liver malignancy with specific risk factors and a targeted population. Imaging plays a major role in the management of HCC from screening to post-therapy follow-up. In order to optimize the diagnostic-therapeutic management and using a universal report, which allows more effective communication among the multidisciplinary team, several classification systems have been proposed over time, and LI-RADS is the most utilized. Currently, LI-RADS comprises four algorithms addressing screening and surveillance, diagnosis on computed tomography (CT)/magnetic resonance imaging (MRI), diagnosis on contrast-enhanced ultrasound (CEUS) and treatment response on CT/MRI. The algorithm allows guiding the radiologist through a stepwise process of assigning a category to a liver observation, recognizing both major and ancillary features. This process allows for characterizing liver lesions and assessing treatment. In this review, we highlighted both major and ancillary features that could define HCC. The distinctive dynamic vascular pattern of arterial hyperenhancement followed by washout in the portal-venous phase is the key hallmark of HCC, with a specificity value close to 100%. However, the sensitivity value of these combined criteria is inadequate. Recent evidence has proven that liver-specific contrast could be an important tool not only in increasing sensitivity but also in diagnosis as a major criterion. Although LI-RADS emerges as an essential instrument to support the management of liver tumors, still many improvements are needed to overcome the current limitations. In particular, features that may clearly distinguish HCC from cholangiocarcinoma (CCA) and combined HCC-CCA lesions and the assessment after locoregional radiation-based therapy are still fields of research.
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Affiliation(s)
- Federica De Muzio
- Department of Medicine and Health Sciences V. Tiberio, University of Molise, 86100 Campobasso, Italy;
| | - Francesca Grassi
- Division of Radiology, Università degli Studi della Campania Luigi Vanvitelli, 81100 Naples, Italy; (F.G.); (F.D.); (R.G.)
| | - Federica Dell’Aversana
- Division of Radiology, Università degli Studi della Campania Luigi Vanvitelli, 81100 Naples, Italy; (F.G.); (F.D.); (R.G.)
| | - Roberta Fusco
- Medical Oncology Division, Igea SpA, 80013 Naples, Italy
- Correspondence:
| | - Ginevra Danti
- Division of Radiology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy; (G.D.); (F.F.); (G.C.); (V.M.)
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy; (P.P.); (F.B.)
| | - Federica Flammia
- Division of Radiology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy; (G.D.); (F.F.); (G.C.); (V.M.)
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy; (P.P.); (F.B.)
| | - Giuditta Chiti
- Division of Radiology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy; (G.D.); (F.F.); (G.C.); (V.M.)
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy; (P.P.); (F.B.)
| | - Tommaso Valeri
- Department of Clinical Special and Dental Sciences, University Politecnica delle Marche, 60126 Ancona, Italy; (T.V.); (A.A.); (A.G.)
- Department of Radiological Sciences, University Hospital Ospedali Riuniti, Via Tronto 10/a, 60126 Torrette, Italy
| | - Andrea Agostini
- Department of Clinical Special and Dental Sciences, University Politecnica delle Marche, 60126 Ancona, Italy; (T.V.); (A.A.); (A.G.)
- Department of Radiological Sciences, University Hospital Ospedali Riuniti, Via Tronto 10/a, 60126 Torrette, Italy
| | - Pierpaolo Palumbo
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy; (P.P.); (F.B.)
- Area of Cardiovascular and Interventional Imaging, Department of Diagnostic Imaging, Abruzzo Health Unit 1, 67100 L’Aquila, Italy
| | - Federico Bruno
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy; (P.P.); (F.B.)
- Emergency Radiology, San Salvatore Hospital, Via Lorenzo Natali 1, 67100 L’Aquila, Italy;
| | - Carmen Cutolo
- Department of Medicine, Surgery and Dentistry, University of Salerno, 84084 Fisciano, Italy;
| | - Roberta Grassi
- Division of Radiology, Università degli Studi della Campania Luigi Vanvitelli, 81100 Naples, Italy; (F.G.); (F.D.); (R.G.)
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy; (P.P.); (F.B.)
| | - Igino Simonetti
- Radiology Division, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, Via Mariano Semmola, 80131 Naples, Italy; (I.S.); (V.G.)
| | - Andrea Giovagnoni
- Department of Clinical Special and Dental Sciences, University Politecnica delle Marche, 60126 Ancona, Italy; (T.V.); (A.A.); (A.G.)
- Department of Radiological Sciences, University Hospital Ospedali Riuniti, Via Tronto 10/a, 60126 Torrette, Italy
| | - Vittorio Miele
- Division of Radiology, Azienda Ospedaliera Universitaria Careggi, 50134 Florence, Italy; (G.D.); (F.F.); (G.C.); (V.M.)
- Italian Society of Medical and Interventional Radiology (SIRM), SIRM Foundation, 20122 Milan, Italy; (P.P.); (F.B.)
| | - Antonio Barile
- Emergency Radiology, San Salvatore Hospital, Via Lorenzo Natali 1, 67100 L’Aquila, Italy;
| | - Vincenza Granata
- Radiology Division, Istituto Nazionale Tumori-IRCCS-Fondazione G. Pascale, Via Mariano Semmola, 80131 Naples, Italy; (I.S.); (V.G.)
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Combined Hepatocellular-Cholangiocarcinoma: What the Multidisciplinary Team Should Know. Diagnostics (Basel) 2022; 12:diagnostics12040890. [PMID: 35453938 PMCID: PMC9026907 DOI: 10.3390/diagnostics12040890] [Citation(s) in RCA: 16] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2022] [Revised: 04/01/2022] [Accepted: 04/01/2022] [Indexed: 12/10/2022] Open
Abstract
Combined hepatocellular-cholangiocarcinoma (cHCC-CCA) is a rare type of primary liver malignancy. Among the risk factors, hepatitis B and hepatitis C virus infections, cirrhosis, and male gender are widely reported. The clinical appearance of cHCC-CCA is similar to that of HCC and iCCA and it is usually silent until advanced states, causing a delay of diagnosis. Diagnosis is mainly based on histology from biopsies or surgical specimens. Correct pre-surgical diagnosis during imaging studies is very problematic and is due to the heterogeneous characteristics of the lesion in imaging, with overlapping features of HCC and CCA. The predominant histological subtype within the lesion establishes the predominant imaging findings. Therefore, in this scenario, the radiological findings characteristic of HCC show an overlap with those of CCA. Since cHCC-CCAs are prevalent in patients at high risk of HCC and there is a risk that these may mimic HCC, it is currently difficult to see a non-invasive diagnosis of HCC. Surgery is the only curative treatment of HCC-CCA. The role of liver transplantation (LT) in the treatment of cHCC-CCA remains controversial, as is the role of ablative or systemic therapies in the treatment of this tumour. These lesions still remain challenging, both in diagnosis and in the treatment phase. Therefore, a pre-treatment imaging diagnosis is essential, as well as the identification of prognostic factors that could stratify the risk of recurrence and the most adequate therapy according to patient characteristics.
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Granata V, Fusco R, Belli A, Borzillo V, Palumbo P, Bruno F, Grassi R, Ottaiano A, Nasti G, Pilone V, Petrillo A, Izzo F. Conventional, functional and radiomics assessment for intrahepatic cholangiocarcinoma. Infect Agent Cancer 2022; 17:13. [PMID: 35346300 PMCID: PMC8961950 DOI: 10.1186/s13027-022-00429-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2022] [Accepted: 03/18/2022] [Indexed: 02/08/2023] Open
Abstract
Background This paper offers an assessment of diagnostic tools in the evaluation of Intrahepatic Cholangiocarcinoma (ICC). Methods Several electronic datasets were analysed to search papers on morphological and functional evaluation in ICC patients. Papers published in English language has been scheduled from January 2010 to December 2021.
Results We found that 88 clinical studies satisfied our research criteria. Several functional parameters and morphological elements allow a truthful ICC diagnosis. The contrast medium evaluation, during the different phases of contrast studies, support the recognition of several distinctive features of ICC. The imaging tool to employed and the type of contrast medium in magnetic resonance imaging, extracellular or hepatobiliary, should change considering patient, departement, and regional features. Also, Radiomics is an emerging area in the evaluation of ICCs. Post treatment studies are required to evaluate the efficacy and the safety of therapies so as the patient surveillance. Conclusions Several morphological and functional data obtained during Imaging studies allow a truthful ICC diagnosis.
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Li H, Lu JW, Huo X, Li Y, Li Z, Gong Z. Effects of sex hormones on liver tumor progression and regression in Myc/xmrk double oncogene transgenic zebrafish. Gen Comp Endocrinol 2019; 277:112-121. [PMID: 30926469 DOI: 10.1016/j.ygcen.2019.03.018] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/27/2018] [Revised: 03/21/2019] [Accepted: 03/24/2019] [Indexed: 02/07/2023]
Abstract
Hepatocellular carcinoma (HCC) shows clear sex disparity with men being more prone to developing HCC and having higher mortality than women. Previous studies have indicated that sex hormones play important roles in HCC initiation and development, but the effects of sex hormones on HCC in clinical trials remain inconsistent. Using zebrafish liver tumor model co-induced by oncogenes Myc and xmrk, we observed similar sex disparity between male and female zebrafish in liver tumor progression and regression; i.e. male Myc/xmrk transgenic zebrafish developed HCC significantly faster and regressed HCC significantly slower than female Myc/xmrk transgenic zebrtafish. To investigate the effects of sex hormones on liver tumor progression and regression, Myc/xmrk fish were treated with either androgen or estrogen, we observed that androgen promoted HCC progression and retarded HCC regression in females, while estrogen attenuated HCC progression and accelerated HCC regression in males. Furthermore, androgen promoted cell proliferation while estrogen inhibited it. Overall, the present study suggested that sex hormones affected liver tumor progression and regression in the Myc/xmrk transgenic zebrafish.
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Affiliation(s)
- Hankun Li
- Department of Biological Sciences, National University of Singapore, Singapore
| | - Jeng-Wei Lu
- Department of Biological Sciences, National University of Singapore, Singapore
| | - Xiaojing Huo
- Department of Biological Sciences, National University of Singapore, Singapore
| | - Yan Li
- Department of Biological Sciences, National University of Singapore, Singapore
| | - Zhen Li
- Department of Biological Sciences, National University of Singapore, Singapore
| | - Zhiyuan Gong
- Department of Biological Sciences, National University of Singapore, Singapore.
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Sim HW, Knox J, Dawson LA. An Update on Randomized Clinical Trials in Hepatocellular Carcinoma. Surg Oncol Clin N Am 2017; 26:647-666. [PMID: 28923223 DOI: 10.1016/j.soc.2017.05.006] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Hepatocellular carcinoma is a common malignancy that typically occurs in the setting of comorbid liver disease. Optimal management is challenging, especially given the assortment of available treatment modalities. This article reviews the randomized clinical trials that have formed the basis of contemporary hepatocellular carcinoma management.
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Affiliation(s)
- Hao-Wen Sim
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada
| | - Jennifer Knox
- Department of Medical Oncology and Hematology, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada
| | - Laura A Dawson
- Radiation Medicine Program, Princess Margaret Cancer Centre, University Health Network, 610 University Avenue, Toronto, Ontario M5G 2M9, Canada.
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Cidon EU. Systemic treatment of hepatocellular carcinoma: Past, present and future. World J Hepatol 2017; 9:797-807. [PMID: 28706578 PMCID: PMC5491402 DOI: 10.4254/wjh.v9.i18.797] [Citation(s) in RCA: 51] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2017] [Revised: 05/07/2017] [Accepted: 05/12/2017] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is a common neoplasia which represents the second leading cause of cancer related death. Most cases occur in developing countries, but its incidence is rising in Western countries due to hepatitis C. Although hepatitis therapies have evolved and the HCC screening has increased in several areas, 40% present with advanced disease which is only amenable for palliative systemic treatment. HCC continues posing a challenge, in part due to the inherent chemoresistance of this neoplasia, the pharmacologic challenges due to an ill liver, difficulty in assessing radiological responses accurately, etc. Traditional chemotherapy have shown some responses without clear survival benefit, however, sorafenib demonstrated advantages in survival in advanced HCC when liver function is kept and recently immunotherapy seems to be a promising approach for some patients. This article will briefly expose the most relevant systemic treatment modalities to offer a general view from the past to the future.
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Affiliation(s)
- Esther Una Cidon
- Esther Una Cidon, Department of Medical Oncology, Royal Bournemouth Hospital, Bournemouth BH7 7DW, United Kingdom
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11
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Chen KW, Ou TM, Hsu CW, Horng CT, Lee CC, Tsai YY, Tsai CC, Liou YS, Yang CC, Hsueh CW, Kuo WH. Current systemic treatment of hepatocellular carcinoma: A review of the literature. World J Hepatol 2015; 7:1412-20. [PMID: 26052386 PMCID: PMC4450204 DOI: 10.4254/wjh.v7.i10.1412] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/26/2014] [Revised: 11/29/2014] [Accepted: 03/30/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the fifth most common form of human cancer worldwide and the third most common cause of cancer-related deaths. The strategies of various treatments for HCC depend on the stage of tumor, the status of patient's performance and the reserved hepatic function. The Barcelona Clinic Liver Cancer (BCLC) staging system is currently used most for patients with HCC. For example, for patients with BCLC stage 0 (very early stage) and stage A (early stage) HCC, the curable treatment modalities, including resection, transplantation and radiofrequency ablation, are taken into consideration. If the patients are in BCLC stage B (intermediate stage) and stage C (advanced stage) HCC, they may need the palliative transarterial chemoembolization and even the target medication of sorafenib. In addition, symptomatic treatment is always recommended for patients with BCLC stage D (end stage) HCC. In this review, we will attempt to summarize the historical perspective and the current developments of systemic therapies in BCLC stage B and C in HCC.
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Affiliation(s)
- Kai-Wen Chen
- Kai-Wen Chen, Department of Internal Medicine, Hualien Armed Forces General Hospital, Hualien 97144, Taiwan
| | - Tzu-Ming Ou
- Kai-Wen Chen, Department of Internal Medicine, Hualien Armed Forces General Hospital, Hualien 97144, Taiwan
| | - Chin-Wen Hsu
- Kai-Wen Chen, Department of Internal Medicine, Hualien Armed Forces General Hospital, Hualien 97144, Taiwan
| | - Chi-Ting Horng
- Kai-Wen Chen, Department of Internal Medicine, Hualien Armed Forces General Hospital, Hualien 97144, Taiwan
| | - Ching-Chang Lee
- Kai-Wen Chen, Department of Internal Medicine, Hualien Armed Forces General Hospital, Hualien 97144, Taiwan
| | - Yuh-Yuan Tsai
- Kai-Wen Chen, Department of Internal Medicine, Hualien Armed Forces General Hospital, Hualien 97144, Taiwan
| | - Chi-Chang Tsai
- Kai-Wen Chen, Department of Internal Medicine, Hualien Armed Forces General Hospital, Hualien 97144, Taiwan
| | - Yi-Sheng Liou
- Kai-Wen Chen, Department of Internal Medicine, Hualien Armed Forces General Hospital, Hualien 97144, Taiwan
| | - Chen-Chieh Yang
- Kai-Wen Chen, Department of Internal Medicine, Hualien Armed Forces General Hospital, Hualien 97144, Taiwan
| | - Chao-Wen Hsueh
- Kai-Wen Chen, Department of Internal Medicine, Hualien Armed Forces General Hospital, Hualien 97144, Taiwan
| | - Wu-Hsien Kuo
- Kai-Wen Chen, Department of Internal Medicine, Hualien Armed Forces General Hospital, Hualien 97144, Taiwan
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12
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Trauner M, Halilbasic E. Nuclear receptors as new perspective for the management of liver diseases. Gastroenterology 2011; 140:1120-1125.e1-12. [PMID: 21334334 DOI: 10.1053/j.gastro.2011.02.044] [Citation(s) in RCA: 83] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Nuclear receptors (NRs) are ligand-activated transcription factors that act as sensors for a broad range of natural and synthetic ligands and regulate several key hepatic functions including bile acid homeostasis, bile secretion, lipid and glucose metabolism, as well as drug deposition. Moreover, NRs control hepatic inflammation, regeneration, fibrosis, and tumor formation. Therefore, NRs are key for understanding the pathogenesis and pathophysiology of a wide range of hepatic disorders. Finally, targeting NRs and their alterations offers exciting new perspectives for the treatment of liver diseases.
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Affiliation(s)
- Michael Trauner
- Division of Gastroenterology and Hepatology, Department of Internal Medicine III, Medical University of Vienna, Austria.
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13
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Abstract
OBJECTIVE As sex favorably modulates the natural history of chronic liver diseases and the risk for neoplastic evolution, our study aimed to ascertain whether female hepatocellular carcinoma (HCC) patients are also characterized by better prognosis. METHODS The ITA.LI.CA (Italian Liver Cancer) database was used, including 1834 HCC patients (482 females, 1352 males) that were consecutively diagnosed. The following variables were considered: age, etiology, modality of diagnosis, earlier interferon treatment, bilirubin, alpha-fetoprotein levels, constitutional syndrome, portal thrombosis, metastasis, number and size of nodules, grading, Child-Pugh class, tumor-nodes-metastases and Cancer of the Liver Italian Program staging, and treatment. RESULTS Female HCC patients were characterized by older age (P=0.0001), higher prevalence of HCV infection (P=0.0001), diagnosis more frequently by surveillance (P=0.003), higher alpha-fetoprotein levels (P=0.0055), lower prevalence of constitutional syndrome (P=0.03), portal thrombosis (P=0.04), and metastasis (P=0.0001). HCC in females was more frequently unifocal (P=0.0001), smaller (P=0.001), well differentiated (P=0.001), and of lower Cancer of the Liver Italian Program and tumor-nodes-metastases stage (P=0.0001 and 0.0001). However, females underwent curative treatments (transplantation, resection, percutaneous ablation) in the same percentage of cases as males. Finally, females had a significantly longer survival (median 29 [95% confidence interval (CI): 24-33] vs. 24 (22-25) months, P=0.0001). The difference was sharper [median 36 (CI: 31-41] vs. 17 (CI: 15-19)] when females undergoing surveillance were compared with males diagnosed incidentally or for symptoms. The Cox model also identified sex as an independent predictor of survival. When only patients undergoing surveillance were considered, no significant difference was observed. CONCLUSION HCC in females has better prognosis, but this is possibly more because of higher compliance with surveillance than to real biological differences.
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Moser C, Lang SA, Mori A, Hellerbrand C, Schlitt HJ, Geissler EK, Fogler WE, Stoeltzing O. ENMD-1198, a novel tubulin-binding agent reduces HIF-1alpha and STAT3 activity in human hepatocellular carcinoma(HCC) cells, and inhibits growth and vascularization in vivo. BMC Cancer 2008; 8:206. [PMID: 18651980 PMCID: PMC2496914 DOI: 10.1186/1471-2407-8-206] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2008] [Accepted: 07/23/2008] [Indexed: 02/06/2023] Open
Abstract
Background Hepatocellular carcinoma (HCC) represents a highly vascularized tumor entity and the process of angiogenesis is essential for the growth of HCC. Importantly, the pro-angiogenic transcription factors HIF-1α and STAT3 have been implicated in HCC progression, thus representing interesting targets for molecular targeted therapy. We hypothesized that therapeutic inhibition of HIF-1α could be achieved by using a novel tubulin-binding agent (ENMD-1198). ENMD-1198 is an analog of 2-methoxyestradiol (2ME2) with antiproliferative and antiangiogenic activity. Methods The human HCC cell lines HUH-7 and HepG2 were used for experiments. Effects of ENMD-1198 on constitutive and inducible (hypoxia, growth factors) activation of signaling cascades, including HIF-1α and STAT3, were investigated by Western blotting. Changes in VEGF expression were determined by real-time PCR. Effects of ENMD-1198 on cancer cell migration and invasion were evaluated in in vitro-assays. The growth-inhibitory effects of ENMD-1198 (200 mg/kg/day) were determined in a subcutaneous tumor model (HUH-7). Results ENMD-1198 inhibited the phosphorylation of MAPK/Erk, PI-3K/Akt and FAK. Moreover, activation of HIF-1α and STAT3 was dramatically reduced by ENMD-1198, which resulted in lower VEGF mRNA expression (P < 0.05). In addition, tumor cell migratory and invasive properties were significantly inhibited (P < 0.05, for both). In vivo, treatment with ENMD-1198 led to a significant reduction in tumor growth, tumor vascularization, and numbers of proliferating tumor cells (P < 0.05 for all). Conclusion The novel microtubule destabilizing agent ENMD-1198 is suitable for inhibiting HIF-1α and STAT3 in human HCC cells and leads to reduced tumor growth and vascularization in vivo. Hence, inhibition of HIF-1α and STAT3 could prove valuable for therapy of hepatocellular carcinoma.
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Affiliation(s)
- Christian Moser
- Department of Surgery, Regensburg Medical Center, Regensburg, Germany.
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15
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Maio MD, Daniele B, Pignata S, Gallo C, Maio ED, Morabito A, Piccirillo MC, Perrone F. Is human hepatocellular carcinoma a hormone-responsive tumor? World J Gastroenterol 2008; 14:1682-9. [PMID: 18350599 PMCID: PMC2695908 DOI: 10.3748/wjg.14.1682] [Citation(s) in RCA: 37] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Before the positive results recently obtained with multitarget tyrosine kinase inhibitor sorafenib, there was no standard systemic treatment for patients with advanced hepatocellular carcinoma (HCC). Sex hormones receptors are expressed in a significant proportion of HCC samples. Following preclinical and epidemiological studies supporting a relationship between sex hormones and HCC tumorigenesis, several randomized controlled trials (RCTs) tested the efficacy of the anti-estrogen tamoxifen as systemic treatment. Largest among these trials showed no survival advantage from the administration of tamoxifen, and the recent Cochrane systematic review produced a completely negative result. This questions the relevance of estrogen receptor-mediated pathways in HCC. However, a possible explanation for these disappointing results is the lack of proper patients selection according to sex hormones receptors expression, but unfortunately the interaction between this expression and efficacy of tamoxifen has not been studied adequately. It has been also proposed that negative results might be explained if tamoxifen acts in HCC via an estrogen receptor-independent pathway, that requires higher doses than those usually administered, but an Asian RCT conducted to assess dose-response effect was completely negative. Interesting, preliminary results have been obtained when hormonal treatment (tamoxifen or megestrol) has been selected according to the presence of wild-type or variant estrogen receptors respectively, but no large RCTs are available to support this strategy. Negative results have been obtained also with anti-androgen therapy. In conclusion, there is no robust evidence to consider HCC a hormone-responsive tumor. Hormonal treatments should not be part of the current management of HCC.
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16
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Han CJ. Recent developments in systemic chemotherapy for hepatocellular carcinoma. THE KOREAN JOURNAL OF HEPATOLOGY 2008; 14:4-11. [DOI: 10.3350/kjhep.2008.14.1.4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Affiliation(s)
- Chul Ju Han
- Department of Internal Medicine, Korea Cancer Center Hospital, Seoul, Korea
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17
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Cancer of the Liver and Bile Ducts. Oncology 2007. [DOI: 10.1007/0-387-31056-8_44] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
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18
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Farinati F, Cardin R, Bortolami M, Burra P, Russo FP, Rugge M, Guido M, Sergio A, Naccarato R. Hepatitis C virus: from oxygen free radicals to hepatocellular carcinoma. J Viral Hepat 2007; 14:821-9. [PMID: 18070284 DOI: 10.1111/j.1365-2893.2007.00878.x] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Epidemiological evidence clearly identifies chronic infection with hepatitis C virus (HCV) as a major risk factor for the development of hepatocellular carcinoma (HCC). Among the mechanisms that have been implicated in the pro-carcinogenic effect of HCV infection, an increased production of reactive oxygen species in the liver seems to have a major pathogenetic role in leading from chronic inflammation to cancer. Recent data have also demonstrated that HCV is capable of inducing this active production of free radicals per se, not just through inflammation, a feature peculiar to this virus and the specific activity of its core protein. This paper provides an overview of the inter-relationships between HCV, liver damage, free radical production and HCC, describing at least in part the complex network involving DNA oxidative damage, cytokine synthesis, proto-oncogene activation and oestrogen receptor expression, that may all be deeply involved in liver carcinogenesis.
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Affiliation(s)
- F Farinati
- Dipartimento di Scienze Chirurgiche e Gastroenterologiche, Sezione di Gastroenterologia, Policlinico Universitario, Università di Padova, Padova, Italy.
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19
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Chuah B, Lim R, Boyer M, Ong AB, Wong SW, Kong HL, Millward M, Clarke S, Goh BC. Multi-centre phase II trial of Thalidomide in the treatment of unresectable hepatocellular carcinoma. Acta Oncol 2007; 46:234-8. [PMID: 17453375 DOI: 10.1080/02841860600702076] [Citation(s) in RCA: 12] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Hepatocellular carcinoma (HCC) is a hypervascular tumour, which overexpresses vascular endothelial growth factor. Thalidomide is an antiangiogenic agent with activity in refractory multiple myeloma. The purpose of this multi-centre phase II study was to evaluate the efficacy and toxicity of thalidomide in patients with advanced HCC. From February 2000 to November 2001, 37 patients with histologically proven, bi-dimensionally measurable advanced, unresectable HCC were enrolled. The starting dose of Thalidomide was 100 mg per day and escalated weekly by 100 mg to a maximum dose of 800 mg/day according to individual patient tolerance. Radiological tumour response and treatment related toxicities were prospectively assessed. Thirty-seven patients were evaluable for toxicity and 24 patients were evaluable for response. The median Thalidomide dose was 400 mg/day. There was no complete response (CR). One patient had a radiological partial response (PR) (3%; 95% confidence interval [95% CI], 0% to 8%) and six (16%) patients had stable disease for more than 6 months. Somnolence and fatigue were the most common side effects, occurring in 84% and 73% of patients respectively. Thalidomide monotherapy is tolerable and associated with modest antitumour activity in advanced HCC.
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Affiliation(s)
- Benjamin Chuah
- Cancer Therapeutics Research Group, Department of Hematology-Oncology, National University Hospital, Singapore
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20
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Alberts SR, Gores GJ, Kim GP, Roberts LR, Kendrick ML, Rosen CB, Chari ST, Martenson JA. Treatment options for hepatobiliary and pancreatic cancer. Mayo Clin Proc 2007; 82:628-37. [PMID: 17493429 DOI: 10.4065/82.5.628] [Citation(s) in RCA: 52] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/23/2022]
Abstract
Hepatobiliary and pancreatic cancers account for 4% of all cancers in the United States. Traditionally, these cancers have had a high mortality rate and have been poorly responsive to therapy. Because of a growing number of treatment options, patients are now living longer. For hepatocellular carcinoma, a broad number of treatment options are available, including surgery, ablation, embolization, systemic therapy, and liver transplantation. Treatment options for cholangiocarcinoma include surgery, systemic therapy, and liver transplantation. For pancreatic cancer, surgery, radiation, and systemic therapy all have potential roles. This review provides an updated summary of diagnosis and assessment together with treatment options for this group of cancers.
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Affiliation(s)
- Steven R Alberts
- Division of Medical Oncology, College of Medicine, Mayo Clinic, Rochester, MN 55905, USA.
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21
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Di Maio M, De Maio E, Morabito A, D'Aniello R, De Feo G, Gallo C, Perrone F. Hormonal treatment of human hepatocellular carcinoma. Ann N Y Acad Sci 2007; 1089:252-61. [PMID: 17261772 DOI: 10.1196/annals.1386.007] [Citation(s) in RCA: 28] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Animal models of experimental liver carcinogenesis and epidemiological studies in humans suggest a relationship between sex hormones and hepatocellular carcinoma (HCC). In 1997, a systematic review of the existing, small randomized trials evaluating the antiestrogen tamoxifen yielded a positive result, but the large randomized CLIP-1 trial showed no survival advantage from the addition of tamoxifen to best supportive care. A possible explanation for the negative results is the lack of patient selection, but the expression of estrogen (ER) and progesterone (PgR) receptors in HCC does not clearly affect the survival outcome of the patients treated with tamoxifen. In the last years, it has been proposed that negative results might be due to the fact that tamoxifen in HCC could act via an ER-independent pathway, which requires much higher doses than those usually administered, but a double-blind Asian randomized trial conducted to assess possible dose-response effect showed no efficacy for tamoxifen, with an inversely negative impact with increasing dose. According to the results of large trials and of the Cochrane systematic review, neither further trials are warranted with tamoxifen in HCC, nor should any use in clinical practice be considered. Interesting results have been obtained when the type of hormonal treatment (tamoxifen or megestrol) has been chosen according to the presence of wild-type or variant ER, but these results should be confirmed in large randomized trials. Negative results have been obtained with antiandrogen therapy. In conclusion, hormonal treatment should not be a part of the current management of HCC patients.
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Affiliation(s)
- Massimo Di Maio
- Clinical Trials Unit, National Cancer Institute, via Mariano Semmola, 80131 Napoli, Italy
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22
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Gallo C, De Maio E, Di Maio M, Signoriello G, Daniele B, Pignata S, Annunziata A, Perrone F. Tamoxifen is not effective in good prognosis patients with hepatocellular carcinoma. BMC Cancer 2006; 6:196. [PMID: 16863588 PMCID: PMC1555599 DOI: 10.1186/1471-2407-6-196] [Citation(s) in RCA: 16] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2006] [Accepted: 07/24/2006] [Indexed: 12/31/2022] Open
Abstract
Background Large randomised clinical trials and systematic reviews substantiate that tamoxifen is ineffective in improving survival of patients with hepatocellular carcinoma (HCC). However, a recent report suggested that the drug might prolong survival among patients with well preserved liver function. The aim of this paper is to validate this hypothesis. Methods We used the updated database of the phase 3 randomised CLIP-1 trial that compared tamoxifen with supportive therapy. Primary endpoint was overall survival. Treatment arms were compared within strata defined according to the Okuda stage and the CLIP-score. Survival differences were tested by the Log-rank test. Results Tamoxifen was not effective in prolonging survival in Okuda I-II subgroup (p = 0.501). Median survival times were equal to 16.8 (95%CI 12.7–18.5) months for tamoxifen and 16.8 (95%CI 13.5–22.4) months for the control arms; 1-year survival probabilities were equal to 58.8% (95%CI 51.7–65.8) and 59.4 (95%CI 52.5–66.2), respectively. Similar results were observed in the better CLIP subgroup (score 0/1), without evidence of difference between the two treatment arms (p = 0.734). Median survival times were equal to 29.2 (95%CI 20.1–36.4) months with tamoxifen and 29.0 (95%CI 23.3–35.2) months without; 1-year survival probabilities were equal to 80.9% (95%CI 72.5–89.3) with tamoxifen and 77.1% (95%CI 68.6–85.7) for the control arm. Conclusion The recent suggestion that tamoxifen might be effective in the subgroup of patients with better prognosis is not supported by a reanalysis of the CLIP-1 trial. Tamoxifen should no longer be considered for the treatment of HCC patients and future trials of medical treatment should concentrate on different drugs.
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Affiliation(s)
- Ciro Gallo
- Department of Medicine and Public Health, Second University, Naples, Italy
| | | | - Massimo Di Maio
- Clinical Trials Unit, National Cancer Institute, Naples, Italy
| | | | | | - Sandro Pignata
- Medical Oncology B, National Cancer Institute, Naples, Italy
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Han J, Ding L, Yuan B, Yang X, Wang X, Li J, Lu Q, Huang C, Ye Q. Hepatitis B virus X protein and the estrogen receptor variant lacking exon 5 inhibit estrogen receptor signaling in hepatoma cells. Nucleic Acids Res 2006; 34:3095-106. [PMID: 16757575 PMCID: PMC1475750 DOI: 10.1093/nar/gkl389] [Citation(s) in RCA: 40] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Hepatitis B virus (HBV) X protein (HBx) is considered to play a role in the development of hepatocellular carcinoma (HCC) during HBV infection. HCC was shown to be more prevalent in men than in women. Estrogen, which exerts its biological function through estrogen receptor (ER), can inhibit HBV replication. ERDelta5, an ERalpha variant lacking exon 5, was found to be preferentially expressed in patients with HCC compared with patients with normal livers. Here, we report the biological role of ERDelta5 and a novel link between HBx and ERalpha signaling in hepatoma cells. ERDelta5 interacts with ERalpha in vitro and in vivo and functions as a dominant negative receptor. Both ERalpha and ERDelta5 associate with HBx. HBx decreases ERalpha-dependent transcriptional activity, and HBx and ERDelta5 have additive effect on suppression of ERalpha transactivation. The HBx deletion mutant that lacks the ERalpha-binding site abolishes the HBx repression of ERalpha. HBx, ERalpha and histone deacetylase 1 (HDAC1) form a ternary complex. Trichostatin A, a specific inhibitor of HDAC enzyme, can restore the transcriptional activity of ERalpha inhibited by HBx. Our data suggest that HBx and ERDelta5 may play a negative role in ERalpha signaling and that ERalpha agonists may be developed for HCC therapy.
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Affiliation(s)
| | | | | | | | | | | | - Qiujun Lu
- Beijing Institute of Radiation MedicineBeijing 100850, People's Republic of China
| | | | - Qinong Ye
- To whom correspondence should be addressed. Tel: +8610 6818 0809; Fax: +8610 6824 8045;
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24
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Doffoël M, Ananna A. [Palliative treatment of hepatocellular carcinoma]. GASTROENTEROLOGIE CLINIQUE ET BIOLOGIQUE 2006; 30:887-90. [PMID: 16885874 DOI: 10.1016/s0399-8320(06)73337-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/11/2023]
Affiliation(s)
- Michel Doffoël
- Hépato-Gastroentérologie, Hôpital Civil, 1 place de l'Hôpital, 67091 Strasbourg Cedex.
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25
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Brown KS. Chemotherapy and other systemic therapies for hepatocellular carcinoma and liver metastases. Semin Intervent Radiol 2006; 23:99-108. [PMID: 21326724 PMCID: PMC3036302 DOI: 10.1055/s-2006-939845] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
For hepatocellular carcinoma (HCC) that has advanced to the point that it is no longer amenable to local therapies, systemic therapy can be considered in select patients who have a good performance status. No systemic therapy has been clearly shown to improve overall survival compared with supportive care alone, although cancer-related symptoms can sometimes be palliated with therapy and some objective responses are seen. Systemic therapies for HCC include chemotherapy, both intravenous and infused via the hepatic artery, as well as hormonal therapy, immunotherapy, and targeted biologic agents. Colorectal, pancreatic, breast, and lung cancer are some of the most common tumors that metastasize to the liver. Response rates and effect on overall survival as a result of systemic therapy for liver metastases vary widely depending on primary tumor site. Targeted biologic agents are being integrated into standard treatment regimens for all of these cancer types, with variable effects on survival and other outcomes for all affected patients including those with liver metastases.
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Affiliation(s)
- Kevin S Brown
- Assistant Professor of Medicine, Denver Health Medical Center, University of Colorado Health Sciences Center, Department of Medicine, Division of Medical Oncology, Denver, Colorado
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26
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Farinati F, Marino D, De Giorgio M, Baldan A, Cantarini M, Cursaro C, Rapaccini G, Del Poggio P, Di Nolfo MA, Benvegnù L, Zoli M, Borzio F, Bernardi M, Trevisani F. Diagnostic and prognostic role of alpha-fetoprotein in hepatocellular carcinoma: both or neither? Am J Gastroenterol 2006; 101:524-32. [PMID: 16542289 DOI: 10.1111/j.1572-0241.2006.00443.x] [Citation(s) in RCA: 291] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND The clinical usefulness of alpha-fetoprotein (AFP) in hepatocellular carcinoma (HCC) management is debatable. OBJECTIVES To assess, in a large multi-centric survey, diagnostic and prognostic reliability of AFP, predictive factors, and any correlation with the tumor immunophenotype. METHODS A total of 1,158 patients with HCC were analyzed with reference to serum AFP levels at diagnosis. We evaluated: HCC grading, histotype, and size; Okuda, tumor-nodes-metastases (TNM), and Child-Pugh scores; liver function, symptoms, presence of metastases or portal thrombosis, etiology, survival, and treatment. In 66 patients with histological diagnosis, the pathologists evaluated p53 overexpression, MIB 1 labeling index, BCL-2 positive cells (index of apoptosis), and CD44 (adhesion molecule) positivity. RESULTS Patients were divided into three AFP groups: normal (<20 ng/mL) [46%], elevated (21-400 ng/mL) [36%], and diagnostic (>400 ng/mL) [18%]. Statistical correlations were significant for: weight loss (p= 0.0056), pain (p= 0.0025), Child-Pugh score (p= 0.001), tumor size, Okuda's and TNM stages, metastases, thrombosis, type of treatment (all p < 0.0001), and female sex (p < 0.004). AFP correlated with survival overall, in patients untreated, transplanted, or undergoing locoregional treatments; but not in those surgically treated. In the discriminant analysis, the related variables were size, female sex, Child-Pugh score, TNM staging (steps 1-4). When using the receiver operating characteristic curve, the prognostic reliability of AFP was limited with area under the curve of 0.59. Finally, patients with low expression of BCL2 had high AFP levels (p < 0.05). AFP positively correlated with Edmonson score (p < 0.0001). CONCLUSION The evaluation of this large series of HCC patients allowed us to: confirm the low sensitivity (54%) of AFP in the diagnosis of HCC and its prognostic value, albeit limited, being tumor size, female sex (intriguingly enough), Child-Pugh score, and TNM staging independent predictors.
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Affiliation(s)
- Fabio Farinati
- Dept. of Surgical and Gastroenterological Sciences, Universitary Policlinic, Via Giustiniani 2, 35128 Padua, Italy
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Abstract
The nearly ubiquitous association of hepatocellular cancer (HCC) with underlying liver dysfunction portends a dismal prognosis. At the time of presentation with HCC, many patients have advanced cirrhosis that precludes effective therapy. Important prognostic factors include characteristics of the tumor (size, location, involvement of major blood vessels) and the functional state of the liver (quantified by synthetic function and portal hypertension). Localized tumors in a noncirrhotic liver may be treated successfully with surgical resection. In the setting of mild to moderate cirrhosis, localized therapy such as radiofrequency ablation, percutaneous ethanol ablation, chemoembolization, or Yttrium 90 microsphere infusion may be options, depending on the liver reserve and resources available. In the setting of advanced cirrhosis, treatment of the tumor may exacerbate liver decompensation, resulting in a shortened survival. In all of these instances, regardless of the therapy pursued, the underlying field defect with malignant potential remains in place. Liver transplantation has been employed to resolve both life-threatening problems, but it is fraught with many barriers. Appropriate patient selection and the use of adjuvant therapies are being pursued to improve the outcome of transplantation for HCC. Patients may have limited therapy options if they have poor performance status, are not surgical candidates, have a tumor that extends into the main portal vein, or have metastases to distant lymph nodes or organs. Chemotherapy is of marginal efficacy. Emerging therapies exploiting molecular targets are being explored with some promise.
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Affiliation(s)
- Mary F Mulcahy
- Department of Medicine, Division of Hematology/Oncology, Feinberg School of Medicine, Northwestern University, Robert H. Lurie Comprehensive Cancer Center, Chicago, IL 60611, USA.
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Chow PK. Tamoxifen does not improve overall survival in people with advanced-stage hepatocellular carcinoma. Cancer Treat Rev 2005; 31:491-5. [PMID: 16214294 DOI: 10.1016/j.ctrv.2005.07.005] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Pierce K Chow
- Department of General Surgery, Singapore General Hospital, Singapore, Republic of Singapore
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Barbare JC, Bouché O, Bonnetain F, Raoul JL, Rougier P, Abergel A, Boige V, Denis B, Blanchi A, Pariente A, Milan C, Bedenne L. Randomized controlled trial of tamoxifen in advanced hepatocellular carcinoma. J Clin Oncol 2005; 23:4338-46. [PMID: 15994145 DOI: 10.1200/jco.2005.05.470] [Citation(s) in RCA: 85] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
PURPOSE Randomized studies on tamoxifen treatment of hepatocellular carcinoma (HCC) produced conflicting results. The aim of this study was to assess the efficacy of tamoxifen administration in improving overall survival of patients with advanced HCC. PATIENTS AND METHODS A total of 420 patients with HCC who were not suitable for surgery or local treatment were randomly assigned between April 1995 and May 2000: 210 in the control group and 210 in the tamoxifen group (20 mg/d orally). Patients with WHO performance status greater than 2, belonging to Child-Pugh class C, or with serum creatinine greater than 130 mumol/L were not eligible. RESULTS Tolerance was good and the main reported adverse effects were thrombophlebitis (three patients), nausea (two patients), and hot flushes (three patients). Outcome did not differ between the two treatment arms: estimated median survival was 4.8 and 4.0 months in the tamoxifen and in the control groups, respectively (P = .25). Univariate analysis showed significant association of survival with age, Okuda stage, WHO performance status, Child-Pugh class, intrahepatic tumor stage, alpha-fetoprotein serum concentration, and presence of extrahepatic spread, portal vein thrombosis, hepatomegaly, or hepatalgia. In a Cox proportional hazards model we found a significant beneficial effect of tamoxifen on survival in patients belonging to Okuda I or II stages. CONCLUSION In this large study, tamoxifen did not improve the survival of patients with advanced HCC, but there is a suggestion that patients without major hepatic insufficiency seem to have some survival benefit. New trials involving this specific population are warranted.
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Affiliation(s)
- Jean-Claude Barbare
- Service d'Hépato-Gastroentérologie, Centre Hospitalier, 8 avenue Henri Adnot, 60321 Compiègne, France.
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30
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Affiliation(s)
- Melanie B Thomas
- The University of Texas M.D. Anderson Cancer Center, Houston, TX, USA
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31
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Nowak AK, Stockler MR, Chow PKH, Findlay M. Use of tamoxifen in advanced-stage hepatocellular carcinoma. Cancer 2005; 103:1408-14. [PMID: 15744746 DOI: 10.1002/cncr.20963] [Citation(s) in RCA: 44] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND Hepatocellular carcinoma (HCC) is the third most common cause of cancer mortality worldwide. Survival is poor for patients with advanced-stage HCC, and small trials of tamoxifen for patients with this disease have shown conflicting results. The authors conducted a systematic review of randomized clinical trials to compare the effect of a tamoxifen-containing arm with a nontamoxifen-containing arm in advanced HCC. METHODS Eligible trials were identified from the Cochrane Hepato-Biliary Group register and other databases. Studies were selected for inclusion and their methodologic quality assessed by three independent reviewers. Hazard ratios (HR) were derived for overall survival where possible. Metaanalysis was performed using a fixed-effect model. RESULTS The authors identified 10 randomized trials with a total of 1709 patients. Use of tamoxifen had no effect on median survival (HR, 1.05; 95% confidence interval, 0.94-1.16; P = 0.4) or tumor response rate. The findings were stable in sensitivity analyses and were not affected by publication bias or inclusion of low-quality studies or studies reported in abstract form only. Few adverse events or withdrawals were noted. CONCLUSIONS There was no support for the therapeutic use of tamoxifen in advanced HCC, nor for its use as a control arm in future clinical trials.
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Affiliation(s)
- Anna K Nowak
- National Health and Medical Research Council (NHMRC) Clinical Trials Centre, University of Sydney, Camperdown, New South Wales, Australia
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32
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Abstract
Hepatocellular carcinoma, a common malignancy globally, has been increasing in incidence in the United States, mostly due to the rising incidence of Hepatitis C viral (HCV) infection. The prognosis of patients with this cancer has been poor and even tumor resection has rarely been curative. However, orthotopic liver transplantation (OLT) has been associated with long-term survival benefit and cures, provided rigorous patient-selection criteria were adhered to. Liver cirrhosis is the most common precursor for HCC, and attempts have been made to prevent the progression from liver cirrhosis to HCC. Post resection adjuvant therapies have included interferon, polyprenoic acid, and adoptive immunotherapy. Finding effective systemic treatments for non-resectable HCC has been challenging and quite frustrating. The presence of liver cirrhosis and the associated volume expansion, electrolyte imbalances, decreased liver synthetic and metabolic reserve, and portal hypertension has made the design of systemic therapy for HCC a major challenge. Additionally staging of HCC using the Tumor Node Metastases (TNM) system, but ignoring the underlying liver disease made it extremely difficult to compare results of different trials. However by and large it would seem, that the more aggressive chemotherapy agents and combinations were associated with median survival times of 3-5 months. Considering the vascular nature of HCC it may be reasonable to combine tolerable chemotherapy with newly released agents with angiogenesis inhibiting properties. Thus, systemic therapy of HCC is a work in progress that calls for additional trials of tolerable newer agents and combinations.
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Affiliation(s)
- Mike Cusnir
- University of Maryland, Greenebaum Cancer Center, Baltimore, Maryland, USA
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33
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Nowak AK, Chow PKH, Findlay M. Systemic therapy for advanced hepatocellular carcinoma: a review. Eur J Cancer 2004; 40:1474-84. [PMID: 15196530 DOI: 10.1016/j.ejca.2004.02.027] [Citation(s) in RCA: 118] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2004] [Accepted: 02/13/2004] [Indexed: 12/19/2022]
Abstract
Hepatocellular carcinoma (HCC) is a common cause of cancer mortality worldwide. Whilst local treatments are useful in selected patients, they are not suitable for many with advanced disease. Here, we review phase II and III trials for systemic therapy of advanced disease, finding no strong evidence that any chemotherapy, hormonal therapy, or immunotherapy regimen trialled to date benefits survival in this setting. Many trials were inadequately powered, single centre, and enrolled highly selected patients. From this review, we cannot recommend any therapeutic approach in these patients outside of a clinical trial setting. Including an untreated control arm in clinical trials in HCC is still justified. Every effort should be made to enroll these patients into adequately powered trials, and promising phase II results must be tested in a multicentre phase III setting, preferably against a placebo control arm. Prevention of hepatitis B and C remains vital to decrease deaths from HCC.
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Affiliation(s)
- Anna K Nowak
- NHMRC Clinical Trials Centre, University of Sydney, Locked Bag 77 Camperdown, NSW 1450, Australia.
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Spangenberg HC, Thimme R, Von Weizsäcker F, Blum HE. [Best supportive care of hepatocellular carcinoma]. Internist (Berl) 2004; 45:777-85. [PMID: 15160245 DOI: 10.1007/s00108-004-1226-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
Abstract
Hepatocellular carcinoma (HCC) is one of the most common malignant tumors in some areas of the world. The major etiologic risk factors include toxins (alcohol, aflatoxin B(1)), hepatitis B and C virus infection as well as various inherited metabolic disorders. The prognosis of HCC patients is generally very poor with a 5-year survival rate of less than 5%. The diagnosis is based on biochemical and imaging tests as well as histology. Therapeutic strategies include surgery (resection or liver transplantation) and non-surgical interventions, such as percutaneous ethanol injection or radiofrequency thermal ablation as well as transarterial embolization or chemoembolization. Radio- or chemotherapy are mostly ineffective. Therefore, the development and evaluation of novel HCC treatment strategies as well as the implementation of existing and the development of new measures to prevent HCC are of utmost importance. The better understanding of the clinical and molecular pathogenesis of HCC should lead to improved diagnostic, therapeutic and preventive strategies with the aim to reduce the incidence of HCC, one of the most devastating malignancies worldwide.
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Affiliation(s)
- H C Spangenberg
- Abteilung Innere Medizin II, Medizinische Universitätsklinik, Albert-Ludwigs-Universität Freiburg
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Hourmand-Ollivier I, Chiche L. [Treatment of hepatocellular carcinoma in the cirrhotic liver]. ACTA ACUST UNITED AC 2004; 141:71-83. [PMID: 15133430 DOI: 10.1016/s0021-7697(04)95574-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
The incidence of hepatocellular carcinoma (HCC) in cirrhotic patients is increasing. Despite advances in imaging and laboratory screening which allow earlier diagnosis, the surgeon is all too often confronted with an HCC of advanced stage or arising in the setting of severe cirrhosis; this severely limits the treatment possibilities. Treatment options are constrained not only by the characteristics of the tumor but also by hepatocellular reserve, severity of portal hypertension, and the general condition of the host. "Curative treatments" envisage the complete eradication of the malignancy; they include liver transplantation, resection, or tumor destruction by radiofrequency or alcohol ablation. They are most effective in the early stages of HCC. Total hepatectomy and transplantation, by far the most complex surgical therapy, also has the best results avoiding the all-too-frequent local recurrence of HCC in the residual liver. Other medical and interventional treatments (chemo-embolization, radiotherapy with lipiodol) can only slow the progress of the HCC. Goals for the future include more precise and directed screening of the population at risk, and better chemopreventive and chemotherapeutic treatments.
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Abstract
BACKGROUND Hepatocellular carcinoma (primary liver cancer) is the third commonest cause of cancer mortality world-wide. Survival is poor for patients with advanced disease. Trials of tamoxifen for hepatocellular carcinoma have conflicting results. OBJECTIVES To conduct a systematic review of the literature to assess the effect of tamoxifen on overall survival, quality-of-life, tumour response, and treatment toxicity in people with advanced hepatocellular carcinoma. SEARCH STRATEGY We identified trials from The Cochrane Hepato-Biliary Group Controlled Trials Register (January 2004), The Cochrane Central Register of Controlled Trials on The Cochrane Library (Issue 3, 2003), and MEDLINE database (1966 to November 2003). We searched bibliographies of review articles and identified trials, and hand-searched abstracts from relevant other meetings. SELECTION CRITERIA All randomised clinical trials of treatment with tamoxifen compared to a control treatment without tamoxifen in people with hepatocellular carcinoma, including trials of tamoxifen versus placebo, tamoxifen versus best supportive care, and tamoxifen plus other treatment versus the same other treatment alone. DATA COLLECTION AND ANALYSIS Three independent reviewers selected studies for inclusion, rated them for methodologic quality components (generation of allocation sequence; allocation concealment; blinding; and follow-up), and extracted data on the specified outcomes. Hazard ratios were derived for overall survival where possible. Meta-analysis was performed using a fixed-effect model. MAIN RESULTS Ten randomised trials randomising 1709 patients were included. Tamoxifen versus placebo/no intervention had no significant effect on overall survival (hazard ratio 1.05; 95% CI 0.94 to 1.16; P = 0.4). This comparison showed no statistical heterogeneity (P = 0.2 and I(2 ) = 25.9%). Subgroup analysis showed that tamoxifen tended to increase mortality in trials with three adequate/three methodological components (hazard ratio 1.15; 95% CI 0.99 to 1.34; P = 0.06), showed no significant effect in trials with two adequate/three methodological components (hazard ratio 1.00; 95% CI 0.84 to 1.18; P = 0.98), and tended to reduce mortality in trials with one or less adequate/three methodological components (hazard ratio 0.82; 95% CI 0.60 to 1.12; P = 0.2), although this may have been confounded by the use of higher doses of tamoxifen in the better quality trials. Tamoxifen was associated with adverse effects. One trial measured patient quality of life, but the results were not reported in detail. REVIEWERS' CONCLUSIONS These data do not support the use of tamoxifen for patients with hepatocellular carcinoma. Further research on the effects of tamoxifen in hepatocellular carcinoma does not seem warranted.
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Abstract
Hepatocellular carcinoma (HCC) is one of the most common malignancies worldwide, with increasing incidence in Western countries. Many pharmacologic treatments have been tested against HCC; most of them belong to three categories: chemotherapy, hormone therapy, and immunotherapy. Neither single agent nor combination chemotherapy have demonstrated a clear reproducible advantage in terms of overall survival; therefore, systemic or intraarterial chemotherapy should not be considered as standard strategies for patients with HCC. Tamoxifen and antiandrogen therapy were not effective in prolonging survival when tested in randomized, controlled trials. Promising results have been obtained with octreotide in a small randomized trial, but confirmation studies are needed. Although adoptive immunotherapy was effective in the adjuvant setting, interferon should be further investigated in this setting or investigated as a preventive strategy in cirrhotic patients. On the contrary, interferon does not seem to have a role in advanced disease, where it is tolerated poorly. In the future, innovative and promising therapeutic strategies will be tested in HCC, including new biologic target-based drugs, cyclooxygenase inhibitors, and gene therapy.
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Chow PKH, Tai BC, Tan CK, Machin D, Win KM, Johnson PJ, Soo KC. High-dose tamoxifen in the treatment of inoperable hepatocellular carcinoma: A multicenter randomized controlled trial. Hepatology 2002; 36:1221-6. [PMID: 12395333 DOI: 10.1053/jhep.2002.36824] [Citation(s) in RCA: 150] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
In the Asia-Pacific region and elsewhere, almost 85% of patients with hepatocellular carcinoma (HCC) are inoperable at diagnosis and have a dismal prognosis. Tamoxifen (TMX) is believed to inhibit HCC positive for estrogen receptor (ER), but most HCCs are ER negative. Results of previous phase 3 trials in inoperable HCC have been conflicting and inconclusive. At higher doses, however, TMX inhibits HCC through ER-independent mechanisms. A multicenter randomized controlled trial was performed to assess the role of high-dose TMX versus placebo (P) in the treatment of patients with inoperable HCC with respect to survival and quality of life (QoL). A total of 329 patients from 10 centers in 9 countries in the Asia-Pacific region enrolled in a double-blind randomized controlled trial of TMX 120 mg/d (TMX120) against P as a control arm with an intermediate dosage of TMX 60 mg/d (TMX60) to assess possible dose response. An independent data monitoring committee reviewed all aspects of the trial. QoL was assessed using the European Organization for Research and Treatment of Cancer QLQ-C30 questionnaire. Three-month survival rates for the P, TMX60, and TMX120 groups were 44%, 41%, and 35%, respectively, with a statistically significant trend difference in survival across the 3 treatment regimens (P =.011). There was a significantly higher risk of death in the TMX120 group compared with the P group (hazard ratio, 1.39; 95% confidence interval, 1.07-1.81). Adverse drug reactions were reported in 3% (9 patients), and 8 patients were lost to follow-up. In conclusion, TMX does not prolong survival in patients with inoperable HCC and has an increasingly negative impact with increasing dose. No appreciable advantage to QoL with TMX was observed.
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Affiliation(s)
- Pierce K h Chow
- Department of General Surgery, Singapore General Hospital, Singapore
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