Preventive effect of regional radiotherapy with phosphorus-32 glass microspheres in hepatocellular carcinoma recurrence after hepatectomy

3D Hollow Porous Radio‐Granular Hydrogels for SPECT Imaging‐Guided Cancer Intravascular Brachytherapy

Radioactive microspheres have shown excellent therapeutic effects in the treatment of advanced hepatocellular carcinoma (HCC) due to indiscriminate embolization and killing of tumor cells. However, limitations such as unstable loading, in vivo reflux, and untrackable radioactive microspheres restrict their clinical applicability. Herein, a novel injectable lutetium‐177‐labeled 3D hollow porous radio‐granular hydrogels with a double‐cross‐linked network (177Lu‐3D‐HPGH) are synthesized via microfluidics combined with ultraviolet photo‐cross‐linking technology is reported. The radiolabeling efficiency of 177Lu‐3D‐HPGH can reach 97.85%. The 3D hollow porous radio‐granular hydrogels exhibited uniform, controllable size, radio‐theranostics, and excellent underwater adhesion properties, avoiding unwanted radiation damage to non‐target organs. Particularly, the extended X‐ray absorption fine structure combined with the density functional theory calculation revealed the mechanism of 3D‐HPGH loading with 177Lu through Lu‐N/O coordination. Furthermore, rabbit orthotopic kidney and liver tumor models are used to verify the excellent embolization performance, radionuclide loading stability, anti‐reflux characteristics, anti‐tumor effect, and biosafety of 177Lu‐3D‐HPGH. Briefly, this facile, green, and safe synthesis strategy provides a superior choice for intravascular brachytherapy of HCC and has great application value and transformative potential in clinical diagnosis and treatment.

Liver Cancer: New Insights into Surgical and Nonsurgical Treatments

Introduction:

Hepatocellular carcinoma (HCC) is the most common type of liver cancer that has increased in recent years worldwide. Primary liver cancer or HCC is considered the 5th and 7th most common cancer among men and women, respectively. It is also the second leading cause of cancer death worldwide. Unfortunately, HCC is frequently diagnosed at an advanced stage when the majority of the patients do not have access to remedial therapies. Furthermore, current systemic chemotherapy shows low efficacy and minimum survival benefits. Liver cancer therapy is a multidisciplinary, multiple-choice treatment based on the complex interaction of the tumour stage, the degree of liver disease, and the patient's general state of health.

Methods:

In this paper, we reviewed new insights into nonsurgical and surgical treatment of liver cancer in five English databases, including Scopus, PubMed, Web of Science, EMBASE, and Google Scholar up to December 2019.

Results:

The results demonstrated, in addition to current therapies such as chemotherapy and surgical resection, new approaches, including immunotherapy, viral therapy, gene therapy, new ablation therapies, and adjuvant therapy, are widely used for the treatment of HCC. In recent years, biomaterials such as nanoparticles, liposomes, microspheres, and nanofibers are also regarded as reliable and innovative patents for the treatment and study of liver cancers.

Conclusion:

Multidisciplinary and multi-choice treatments and therapies are available for this liver cancer, while there are differences in liver cancer management recommendations among specialties and geographic areas. Current results have shown that treatment strategies have been combined with the advancement of novel treatment modalities. In addition, the use of new approaches with greater efficacy, such as combination therapy, biomaterials, ablation therapy, etc. can be considered the preferred treatment for patients.

Radiopharmaceutical therapy in cancer: clinical advances and challenges

Radiopharmaceutical therapy (RPT) is emerging as a safe and effective targeted approach to treating many types of cancer. In RPT, radiation is systemically or locally delivered using pharmaceuticals that either bind preferentially to cancer cells or accumulate by physiological mechanisms. Almost all radionuclides used in RPT emit photons that can be imaged, enabling non-invasive visualization of the biodistribution of the therapeutic agent. Compared with almost all other systemic cancer treatment options, RPT has shown efficacy with minimal toxicity. With the recent FDA approval of several RPT agents, the remarkable potential of this treatment is now being recognized. This Review covers the fundamental properties, clinical development and associated challenges of RPT.

Liver Cancer: Current and Future Trends Using Biomaterials

Hepatocellular carcinoma (HCC) is the fifth most common type of cancer diagnosed and the second leading cause of death worldwide. Despite advancement in current treatments for HCC, the prognosis for this cancer is still unfavorable. This comprehensive review article focuses on all the current technology that applies biomaterials to treat and study liver cancer, thus showing the versatility of biomaterials to be used as smart tools in this complex pathologic scenario. Specifically, after introducing the liver anatomy and pathology by focusing on the available treatments for HCC, this review summarizes the current biomaterial-based approaches for systemic delivery and implantable tools for locally administrating bioactive factors and provides a comprehensive discussion of the specific therapies and targeting agents to efficiently deliver those factors. This review also highlights the novel application of biomaterials to study HCC, which includes hydrogels and scaffolds to tissue engineer 3D in vitro models representative of the tumor environment. Such models will serve to better understand the tumor biology and investigate new therapies for HCC. Special focus is given to innovative approaches, e.g., combined delivery therapies, and to alternative approaches-e.g., cell capture-as promising future trends in the application of biomaterials to treat HCC.

Iodine-125-labeled DNA-Triplex-forming oligonucleotides reveal increased cyto- and genotoxic effectiveness compared to Phosphorus-32

PURPOSE

The efficacy of DNA-targeting radionuclide therapies might be strongly enhanced by employing short range particle-emitters. However, the gain of effectiveness is not yet well substantiated. We compared the Auger electron emitter I-125 to the ß^--emitter P-32 in terms of biological effectiveness per decay and radiation dose when located in the close proximity to DNA using DNA Triplex-forming oligonucleotides (TFO). The clonogenicity and the induction of DNA double-strand breaks (DSB) were investigated in SCL-II cells after exposure to P-32- or I-125-labeled TFO targeting the glyceraldehyde 3-phosphate dehydrogenase (GAPDH) gene and after external homogeneous exposure to gamma-rays as reference radiation.

MATERIALS AND METHODS

TFO were labeled with P-32 or I-125 using the primer extension method. Cell survival was analyzed by colony-forming assay and DNA damage was assessed by microscopic quantification of protein 53 binding protein 1 (53BP1) foci in SCL-II cells.

RESULTS

I-125-TFO induced a pronounced decrease of cell survival (D₃₇ at ∼360 accumulated decays per cell, equivalent to 1.22 Gy cell nucleus dose) and a significant increase of 53BP1 foci with increasing decays. The P-32-labeled TFO induced neither a strong decrease of cell survival nor an increase of 53BP1 foci up to ∼4000 accumulated decays per cell, equivalent to ∼1 Gy cell nucleus dose. The RBE for I-125-TFO was in the range of 3-4 for both biological endpoints.

CONCLUSIONS

I-125-TFO proved to be much more radiotoxic than P-32-TFO per decay and per unit dose although targeting the same sequence in the GAPDH gene. This might be well explained by the high number of low energy Auger electrons emitted by I-125 per decay, leading to a high ionization density in the immediate vicinity of the decay site, probably producing highly complex DNA lesions overcharging DNA repair mechanisms.

Bi2S3-embedded mesoporous silica nanoparticles for efficient drug delivery and interstitial radiotherapy sensitization

A novel design of Bi2S3 nanoparticles with a coating of mesoporous silica (BMSN) is obtained by a surfactant induced condensation method. It was found that BMSNs exhibited a high doxorubicin (DOX) loading efficiency of 45 wt% and pH-responsive controlled drug release owing to the electrostatic interaction between silanol surface and DOX molecules. The cell viability results demonstrated the encapsulation of DOX into BMSNs could lead to significantly enhanced therapeutic effect against multidrug-resistance cancer cells compared to that of free DOX drug. Furthermore, the comparable study of tumor growth by different treatments demonstrated that the introduction of BMSNs in the X-ray therapy could lead to higher therapeutic effect, with just 2.10-fold increase in tumor volume through 24 days, in comparison to 4.40-fold increase for X-ray beams treatment alone. Meanwhile, the in vitro interstitial radiotherapy experiments demonstrated that the cell inhibiting effect of P-32 interstitial radiotherapy combined with BMSNs (50 μg/mL) was 1.55-fold higher than that of P-32 alone. Significantly, it is notable that the simultaneous chemo- and interstitial radiotherapy based on BMSNs could tremendously increase the therapeutic effect compared to those treatment alone. More importantly, the in vivo P-32 radiotherapy in conjunction with BMSNs was proved to present a significantly eradication of the tumor volumes by an average of 21% reduction to its initial values, in comparison to 2.01-fold increase in case of P-32 treatment alone. Thus, it is expected that the BMSNs could be applied as a highly efficient multifunctional nanosystem to realize the enhanced chemo- and radiotherapy in the further clinical applications.

Short-term effectiveness of radiochemoembolization for selected hepatic metastases with a combination protocol

AIM: To introduce the combination method of radiochemoembolization for the treatment of selected hepatic metastases.

METHODS: Twenty patients with biopsy proven hepatic metastases were selected from those who underwent transarterial radiochemoembolization, a novel combination protocol, between January 2009 and July 2010. Patients had different sources of liver metastasis. The treatment included transarterial administration of three chemotherapeutic drugs (mitomycin, doxorubicin and cisplatin), followed by embolization with large (50-150 μm) radioisotope particles of chromic 32P. Multiphasic computer tomography or computer tomography studies, with and without contrast medium injections, were performed for all patients for a short-term period before and after the treatment sessions. The short-term effectiveness of this procedure was evaluated by modified response evaluation criteria in solid tumors (mRECIST), which also takes necrosis into account. The subjective percentage of necrosis was also assessed. The response evaluation methods were based on the changes in size, number, and the enhancement patterns of the lesions between the pre- and post-treatment imaging studies.

RESULTS: Patients had liver metastasis from colorectal carcinomas, breast cancer, lung cancer and carcinoid tumors. The response rate based on the mRECIST criteria was 5% for complete response, 60% for partial response, 10% for stable disease, and 25% for progressive disease. Regarding the subjective necrosis percentage, 5% of patients had complete response, 50% had partial response, 25% had stable disease, and 20% had progressive disease. Based on traditional RECIST criteria, 3 patients (15%) had partial response, 13 patients (65%) had stable disease, and 4 patients (20%) had disease progression. In most patients, colorectal carcinoma was the source of metastasis (13 patients). Based on the mRECIST criteria, 8 out of these 13 patients had partial responses, while one remained stable, and 5 showed progressive disease. We also had 5 cases of breast cancer metastasis which mostly remained stable (4 cases), with only one partial response after the procedure. Six patients had bilobar involvement; three of them received two courses of radiochemoembolization. The follow up imaging study of these patients was performed after the second session. In the studied patients there was no evidence of extrahepatic occurrence, including pulmonary radioactive deposition, which was proven by Bremsstrahlung scintigraphy performed after the treatment sessions. For the short-term follow-ups for the 2 mo after the therapy, no treatment related death was reported. The mostly common side effect was post-embolization syndrome, presented as vomiting, abdominal pain, and fever. Nineteen (95%) patients experienced this syndrome in different severities. Two patient had ascites (with pleural effusion in one patient) not related to hepatic failure. Moreover, no cases of acute liver failure, hepatic infarction, hepatic abscess, biliary necrosis, tumor rupture, surgical cholecystitis, or non-targeted gut embolization were reported. Systemic toxicities such as alopecia, marrow suppression, renal toxicity, or cardiac failure did not occur in our study group.

CONCLUSION: Radiochemoembolization is safe and effective for selected hepatic metastases in a short-term follow-up. Further studies are required to show the long-term effects and possible complications of this approach.

Dose delivery estimated by bremsstrahlung imaging and partition model correlated with response following intra-arterial radioembolization with 32P-glass microspheres for the treatment of hepatocellular carcinoma

RATIONALE

The objective of this study was to retrospectively evaluate the efficacy of a combination of (32)P-glass microsphere-mediated intra-arterial internal radiation and chemoembolization for the treatment of hepatocellular carcinoma.

METHODS

Twenty-five consecutive patients with primary hepatocellular carcinoma referred for radiation therapy were treated with intra-arterial infusion of (32)P-glass microspheres followed by chemoembolization. beta-bremsstrahlung imaging was performed to monitor microsphere distribution. A partition model and a radiation dose equation were used for determination of radiation exposure in various tissues. Clinical response was evaluated using computed axial tomography scans.

RESULTS

The mean estimated absorption dose in tumor tissue was 137.42 +/- 56.69 Gy. A receiver operating characteristic curve was used to establish 90.65 Gy as the cutoff absorption dose with the best sensitivity and specificity for predicting response. The overall tumor response rate was 92%, while response in patients with radiation doses >90.65 Gy was 100%. Overall median patient survival was 15 months.

CONCLUSION

beta-bremsstrahlung imaging following intra-arterial infusion of (32)P-glass microspheres and chemoembolization incorporates effective treatment with convenient dosimetry monitoring and manageable adverse events using a single surgical procedure. This approach is a safe and effective method for ameliorating hepatocellular carcinoma.

Therapeutic equivalence in survival for hepatic arterial chemoembolization and yttrium 90 microsphere treatments in unresectable hepatocellular carcinoma: a two-cohort study

BACKGROUND

Intrahepatic arterial yttrium 90 ((90)Y) microspheres have been proposed as a less toxic, less invasive therapeutic option to transhepatic arterial chemoembolization (TACE) for patients with surgically unresectable hepatocellular carcinoma (HCC). TACE has demonstrated the ability to prolong survival. However, long-term survival remains uncertain.

METHODS

In a 2-cohort experience in the treatment of North American patients who had advanced, unresectable, biopsy-proven HCC, 691 patients received repetitive, cisplatin-based chemoembolization; and a separate cohort of 99 patients who had similar treatment criteria received a planned, single dose of (90)Y. Over the study period, an additional 142 patients were followed without treatment (total, 932 patients).

RESULTS

Overall survival was slightly better in the (90)Y group compared with the TACE group (median survival, 11.5 months vs 8.5 months). However, the selection criteria indicated a small but significant bias toward milder disease in the (90)Y group. By using stratification into a 3-tier model with patients dichotomized according to bilirubin levels <1.5 mg/dL, the absence of portal vein thrombosis (PVT), and low alpha-fetoprotein plasma levels (<25 U/dL), an analysis of survival in clinical subgroups indicated that the 2 treatments resulted in similar survival. In addition, patients who had PVT or high alpha-fetoprotein levels also had similar survival in both treatment groups.

CONCLUSIONS

Given the current evidence of therapeutic equivalence in survival, (90)Y and TACE appeared to be equivalent regional therapies for patients with unresectable, nonmetastatic HCC.

Approach to radiation therapy in hepatocellular carcinoma

Hepatocellular carcinoma (HCC), the 5th most common cancer and the third most common cause of cancer-related death in the world with an estimated incidence of approximately 1 million new cases annually, has becoming a major global health problem in the world. A variety of treatment modalities, including resection, liver transplantation, transarterial chemoembolization (TACE), local ablative therapy and radiation therapy (RT) have been reported. Although partial hepatectomy and liver transplantation may offer the best chance of cure, only 15% of the patients have the chance to be treated by surgery when diagnosed. The effectiveness of systemic chemotherapy for HCC has been minimal, and local ablative therapy may offer comparable survival in patients with small HCC and preserve liver function. Recently, with developments in radiotherapy techniques, radiotherapy has been shown to play potential roles in a wide spectrum of HCC and to become more important so that it is necessary to evaluate the effect of radiotherapy in treatment of HCC. This paper is aiming mainly at the current radiation therapy strategies and their current advances, the optimal radiation therapy strategies will complement the current treatments and improve the treatment efficiency.

Evidence-based diagnosis and locoregional therapy for hepatocellular carcinoma

Early identification of hepatocellular carcinoma (HCC) is crucial to improving the results of therapy and for patients to be eligible for liver transplantation. Recent advances in noninvasive imaging technology include various techniques of harmonic ultrasound, new ultrasound contrast agents, multislice helical computed tomography and rapid high-quality magnetic resonance. The imaging diagnosis relies on the hallmark of arterial hypervascularity with portal venous washout. Since the use of better radiological techniques has improved the accuracy of noninvasive diagnosis, the role of liver biopsy in the diagnosis of HCC has declined. With recent advances in genomics and proteomics, a great number of potential markers have been identified and developed as new candidate markers for HCC. Locoregional therapies currently constitute the best options for early nonsurgical treatment of HCC. Percutaneous ethanol injection shows similar results to resection surgery for single tumors less than 3 cm in diameter. Radiofrequency ablation is superior to percutaneous ethanol injection in terms of local recurrence. Transarterial chemoembolization is currently the most common approach for the management of HCC without curative options since it improves patient survival, but the optimal embolizing agent, length of interval between sessions and whether the chemotherapeutic agent has any effect have not yet been determined. Combining transarterial chemoembolization with antiangiogenic agents, as well as with other techniques, such as radiofrequency ablation, may improve the results. Injection of radioisotopes such as yttrium-90, via the hepatic artery, may be particularly useful in patients with portal vein thrombosis. Comparisons with other transarterial techniques are needed.