Poor prognosis for hepatocellular carcinoma with transarterial chemoembolization pre-transplantation: Retrospective analysis

Adjuvant and Neoadjuvant Treatments for Resectable Hepatocellular Carcinoma

PURPOSE OF REVIEW

This review provides an update on the developments of adjuvant and neoadjuvant liver-directed and systemic therapy options for patients with resectable hepatocellular carcinoma.

RECENT FINDINGS

Data on liver-directed treatment in the adjuvant and neoadjuvant settings are sparse and results are conflicting; many studies suggest that optimizing patient selection criteria is a key milestone required to improve study design and clinical benefit to patients. Systemic treatment options are primarily focused on investigation of anti-PD-1/L1 immunotherapeutic agents, either alone or in combination with other drugs. Numerous clinical trials in both adjuvant and neoadjuvant settings are in progress. Exploration of liver-directed and systemic treatment options for adjuvant and neoadjuvant treatment of patients with resectable hepatocellular carcinoma has the potential to improve clinical outcomes for this patient population.

Usefulness of PIVKA-II for monitoring after liver transplantation in patients with hepatocellular carcinoma

The high morbidity and mortality of hepatocellular carcinoma (HCC) has encouraged the search for new biomarkers to be used alongside alpha-foetoprotein (AFP) and imaging tests. The aim of this study was to evaluate the clinical contribution of protein induced by vitamin K absence or antagonist-II (PIVKA-II) for HCC monitoring after liver transplantation (LT) and compare it with AFP, a routinely used tumour marker. A total of 46 HCC patients (Milan criteria) were enrolled in this study. Serum levels of PIVKA-II and AFP were measured before and after transplantation. Clinical features were determined for all the patients that were included. Significant correlations were found between PIVKA-II expression levels and some clinicopathological features, such as tumour size and number of pre-transplant transarterial chemoembolizations (TACEs). Serum levels of PIVKA-II and AFP decreased significantly after LT and increased in patients with tumour recurrence. Serum PIVKA-II levels may play an important role in predicting disease severity. Furthermore, monitoring PIVKA-II levels in HCC transplant recipients reflects the tumor early recurrence after transplantation and could be used, complementing AFP and imaging tests, as a novel biomarker of this pathology.

Role of immunotherapy in downsizing hepatocellular carcinoma prior to liver transplantation

Hepatocellular carcinoma (HCC) is an aggressive primary liver neoplasm that, according to tumor stage, can be treated with resection, transplantation, locoregional treatment options, or systemic therapy. Although interventions only in early-stage disease can offer complete tumor regression, systemic therapy in advanced disease can significantly prolong overall survival, according to published clinical trials. The emergence of immunotherapy in the field of cancer therapy has had a positive impact on patients with HCC, resulting in atezolizumab–bevacizumab currently being the first-line option for treatment of advanced HCC. In light of this, application of immunotherapy in the preoperative process could increase the number of patients fulfilling the criteria for liver transplantation (LT). Implementation of this approach is faced with challenges regarding the safety of immunotherapy and the possibly increased risk of rejection in the perioperative period. Case reports and clinical trials assessing the safety profile and effectiveness of neoadjuvant immunotherapy, highlight important aspects regarding this newly evolving approach to HCC management. More studies need to be conducted in order to reach a consensus regarding the optimal way to administer immunotherapy prior to LT. In this review, we summarize the role, safety profile and future considerations regarding the use of neoadjuvant immunotherapy prior to LT in patients with HCC.

Neoadjuvant treatment strategies for hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) remains high globally. Surgical treatment is the best treatment for improving the prognosis of patients with HCC. Neoadjuvant therapy plays a key role in preventing tumor progression and even downstaging HCC. The liver transplantation rate and resectability rate have increased for neoadjuvant therapy. Neoadjuvant therapy is effective in different stages of HCC. In this review, we summarized the definition, methods, effects, indications and contraindications of neoadjuvant therapy in HCC, which have significance for guiding treatment.

Transcatheter arterial chemoembolization followed by surgical resection for hepatocellular carcinoma: a focus on its controversies and screening of patients most likely to benefit

Surgical resection (SR) is recommended as a radical procedure in the treatment of hepatocellular carcinoma (HCC). However, postoperative recurrence negatively affects the long-term efficacy of SR, and preoperative adjuvant therapy has therefore become a research hotspot. Some clinicians adopt transcatheter arterial chemoembolization (TACE) as a preoperative adjuvant therapy in patients undergoing SR to increase the resection rate, reduce tumor recurrence, and improve the prognosis. However, the findings of the most relevant studies remain controversial. Some studies have confirmed that preoperative TACE cannot improve the long-term survival rate of patients with HCC and might even negatively affect the resection rate. Which factors influence the efficacy of preoperative TACE combined with SR is a topic worthy of investigation. In this review, existing clinical studies were analyzed with a particular focus on several topics: screening of the subgroups of patients most likely to benefit from preoperative TACE, exploration of the optimal treatment regimen of preoperative TACE, and determination of the extent of tumor necrosis as the deciding prognostic factor.

Long-term survival and postoperative complications of pre-liver transplantation transarterial chemoembolisation in hepatocellular carcinoma: A systematic review and meta-analysis

OBJECTIVES

The aim of this meta-analysis was to conduct a contemporary systematic review of high quality non-randomised controlled trials to determine the effect of pre-liver transplantation (LT) transarterial chemoembolisation (TACE) on long-term survival and complications of hepatocellular carcinoma (HCC) patients.

BACKGROUND

TACE is used as a neoadjuvant therapy to mitigate waitlist drop-out for patients with HCC awaiting LT. Previous studies have conflicting conclusions on the effect of TACE on long-term survival and complications of HCC patients undergoing LT.

METHODS

CINAHL, Cochrane Controlled Register of Trials, Embase, PubMed, and Web of Science were systematically searched. Baseline characteristics included number of patients outside Milan criteria, tumour diameter, MELD score, and time on the waiting list. Primary outcomes included 3- and 5-year overall and disease-free survival. Secondary outcomes included tumour recurrence, 30-day postoperative mortality, and hepatic artery and biliary complications.

RESULTS

Twenty-one high-quality NRCTs representing 8242 patients were included. Tumour diameter was significantly larger in TACE patients (3.49 cm vs 3.15 cm, P = 0.02) and time on the waiting list was significantly longer in TACE patients (4.87 months vs 3.46 months, P = 0.05), while MELD score was significantly higher in non-TACE patients (10.81 vs 12.35, P = 0.005). All primary and secondary outcomes displayed non-significant differences.

CONCLUSION

Patients treated with TACE had similar survival and postoperative outcomes to non-TACE patients, however, they had worse prognostic features compared to non-TACE patients. These findings strongly support the current US and European clinical practice guidelines that neoadjuvant TACE can be used for patients with longer expected waiting list times (specifically >6 months). Randomised controlled trials would be needed to increase the quality of evidence.

Neoadjuvant Transarterial Chemoembolization Improves Survival After Liver Transplant in Patients With Hepatocellular Carcinoma

OBJECTIVES

Our aims were to determine whether transarterial chemoembolization before liver transplant for hepatocellular carcinoma improves posttransplant survival and whether patients downstaged by transarterial chemoembolization within Milan criteria have a posttransplant survival benefit.

MATERIALS AND METHODS

In this retrospective analysis of prospectively collected data, survival rates of 87 patients treated with and 68 patients not treated with transarterial chemoembolization before liver transplant were compared using 2-sample t tests and multivariate Cox regression. We also compared posttransplant survival of patients within Milan criteria versus those downstaged after transarterial chemoembolization. We controlled for disease severity by assessing, among other variables, tumor diameter before and at transplant and alpha-fetoprotein levels before transplant and transarterial chemoembolization.

RESULTS

Overall 1-, 3-, and 5-year survival rates were 84%, 71%, and 63%, respectively. These rates were 91%, 78%, and 73% for patients who received and 76%, 63%, and 54% for patients who did not receive transarterial chemoembolization. Hazard ratios were 0.56 for having versus not having transarterial chemoembolization (P = .04), 1.06 for total tumor diameter on explantation (P = .01), 1.5 for largest tumor > 3 cm (P = .15), and 2.9 for pretransplant alpha-fetoprotein > 659 ng/mL (P = .006). A higher end-stage liver disease score correlated with poorer overall survival (hazard ratio = 1.53; P < .001). Laboratory values, lipiodol uptake, imaging response, and downstaging into Milan criteria were not correlated with survival.

CONCLUSIONS

Patients with hepatocellular carcinoma who were treated with neoadjuvant transarterial chemoembolization had better survival rates posttransplant than those not treated with transarterial chemoembolization. A high pretransplant alpha-fetoprotein level was negatively correlated with survival. Patients downstaged to Milan criteria after transarterial chemoembolization fared equally well versus those who met Milan criteria initially. Pretreatment with transarterial chemoembolization was positively correlated with survival posttransplant, with patients having a 44% reduction in posttransplant mortality.

Apigenin loaded nanoparticle delayed development of hepatocellular carcinoma in rats

Hepatocellular carcinoma (HCC) is one of the major causes of cancer related death globally. Apigenin, a dietary flavonoid, possesses anti-tumor activity against HCC cells in-vitro. Development, physicochemical characterization of apigenin loaded nanoparticles (ApNp), biodistribution pattern and pharmacokinetic parameters of apigenin upon intravenous administration of ApNp, and effect of ApNp treatment in rats with HCC were investigated. Apigenin loaded nanoparticles had a sustained drug release pattern and successfully reached the hepatic cancer cells in-vitro as well as in liver of carcinogenic animals. ApNp predominantly delayed the progress of HCC in chemical induced hepatocarcinogenesis in rats. Quantification of apigenin by liquid chromatography-mass spectroscopy (LC-MS/MS) showed that apigenin availability significantly increased in blood and liver upon ApNp treatment. Apigenin loaded nanoparticle delivery substantially controlled the severity of hepatocellular carcinoma and could be a future hope for lingering the survival in hepatic cancer patients.

Therapies for patients with hepatocellular carcinoma awaiting liver transplantation: A systematic review and meta-analysis

Patients with hepatocellular carcinoma (HCC) who are listed for liver transplantation (LT) are often treated while on the waiting list with locoregional therapy (LRT), which is aimed at either preventing progression of HCC or reducing the measurable disease burden of HCC in order to receive increased allocation priority. We aimed to synthesize evidence regarding the effectiveness of LRT in the management of patients with HCC who were on the LT waitlist. We conducted a comprehensive search of multiple databases from 1996 to April 25, 2016, for studies that enrolled adults with cirrhosis awaiting LT and treated with bridging or down-staging therapies before LT. Therapies included transcatheter arterial chemoembolization, transarterial radioembolization, ablation, and radiotherapy. We included both comparative and noncomparative studies. There were no randomized controlled trials identified. For adults with T1 HCC and waiting for LT, there were only two nonrandomized comparative studies, both with a high risk of bias, which reported the outcome of interest. In one series, the rate of dropout from all causes at 6 months in T1 HCC patients who underwent LRT was 5.3%, while in the other series of T1 HCC patients who did not receive LRT, the dropout rate at median follow-up of 2.4 years and the progression rate to T2 HCC were 30% and 88%, respectively. For adults with T2 HCC awaiting LT, transplant with any bridging therapy showed a nonsignificant reduction in the risk of waitlist dropout due to progression (relative risk [RR], 0.32; 95% confidence interval [CI], 0.06-1.85; I² = 0%) and of waitlist dropout from all causes (RR, 0.38; 95% CI, 0.060-2.370; I² = 85.7%) compared to no therapy based on three comparative studies. The quality of evidence is very low due to high risk of bias, imprecision, and inconsistency. There were five comparative studies which reported on posttransplant survival rates and 10 comparative studies which reported on posttransplant recurrence, and there was no significant difference seen in either of these endpoints. For adults initially with stage T3 HCC who received LRT, there were three studies reporting on transplant with any down-staging therapy versus no downstaging, and this showed a significant increase in 1-year (two studies, RR, 1.11; 95% CI, 1.01-1.23) and 5-year (1 study, RR, 1.17; 95% CI, 1.03-1.32) post-LT survival rates for patients who received LRT. The quality of evidence is very low due to serious risk of bias and imprecision.

CONCLUSION

In patients with HCC listed for LT, the use of LRT is associated with a nonsignificant trend toward improved waitlist and posttransplant outcomes, though there is a high risk of selection bias in the available evidence. (Hepatology 2018;67:381-400).

Evaluation of the treatment of the hepatocarcinoma nodules in the patients in waiting list for liver transplant

OBJECTIVE

to compare the outcome of liver transplantation for hepatocarcinoma in submitted or not to locoregional treatment and downstaging regarding survival and risk of recurrence in transplant waiting list patients.

METHODS

retrospective study of patients with hepatocarcinoma undergoing liver transplantation in the metropolitan region of São Paulo, between January 2007 and December 2011, from a deceased donor. The sample consisted of 414 patients. Of these, 29 patients were included in the list by downstaging. The other 385 were submitted or not to locoregional treatment.

RESULTS

the analysis of 414 medical records showed a predominance of male patients (79.5%) with average age of 56 years. Treatment of the lesions was performed in 56.4% of patients on the waiting list for transplant. The most commonly used method was chemoembolization (79%). The locoregional patients undergoing treatment had a significant reduction in nodule size greater (p<0.001). There was no statistical difference between groups with and without locoregional treatment (p=0.744) and on mortality among patients enrolled in the Milan criteria or downstaging (p=0.494).

CONCLUSION

there was no difference in survival and recurrence rate associated with locoregional treatment. Patients included by downstaging process had comparable survival results to those previously classified as Milan/Brazil criteria.

Transarterial chemoembolization prior to liver transplantation for patients with hepatocellular carcinoma: A meta-analysis

BACKGROUND AND AIM

A debate exists over whether using preoperative transarterial chemoembolization for patients with hepatocellular carcinoma before liver transplantation. Numerous studies have been investigating on this, but there is still no unanimous conclusion about the effect of preoperative transarterial chemoembolization. We conducted the meta-analysis of all available studies to systematically evaluate the influence of preoperative transarterial chemoembolization on liver transplant.

METHODS

A systematic search was performed by two authors (Si TF. and Guan RY.) through PubMed, Embase, Cochrane, and Science Citation Index Expanded, combined with Manual Retrieval and Cited Reference Search. The searching cut-off date was 2016/07/31, and all the data obtained were statistically analyzed using Review Manager version 5.1 software (Copenhagen, The Nordic Cochrane Center, The Cochrane Collaboration, 2011) recommended by Cochrane Collaboration.

RESULTS

The study showed that there was no difference between the experimental group and the control group on perioperative mortality (RR = 1.10, 95% confidence interval (CI) = [0.49-2.48], P = 0.82) or biliary complications (RR = 0.96, 95%CI = [0.66-1.39], P = 0.83). Preoperative transarterial chemoembolization had no obvious effect on improving overall survival (HR = 1.05, 95%CI = [0.65-1.72], P = 0. 83) but would result in a higher rate of vascular complications (RR = 2.01, 95%CI = [1.23-3.27], P = 0.005) and a reduction of disease free survival (HR = 1.66, 95%CI = [1.02-2.70], P = 0.04). Subgroup analysis also revealed that patients from transarterial chemoembolization group in Asia had a much lower overall survival rate (HR = 2.65, 95%CI = [1.49-4.71], P = 0.0009) compared with the control group.

CONCLUSIONS

Considering the possible adverse impacts on liver transplantation and the variation in sensitivity to transarterial chemoembolization, clinicians should be more cautious when considering transarterial chemoembolization as the bridging therapy for patients in the waiting list.

Cryptotanshinone enhances the effect of Arsenic trioxide in treating liver cancer cell by inducing apoptosis through downregulating phosphorylated- STAT3 in vitro and in vivo

Background

Arsenic trioxide (ATO) is approved for treating terminal-stage liver cancer in China. Cryptotanshinone (CT), a STAT3 inhibitor, has exhibited certain anti-tumor potency; however, the use of CT enhanced ATO for treating liver cancer has not been reported. Here we try to elucidate how CT could enhance the efficacy of ATO for treating liver cancer and its correlation to STAT3 in vitro and in vivo.

Methods

Cell viability of ATO combined with CT was assessed by ¹MTT assay. Cell apoptosis induced by ATO combined with CT was detected by Annexin V/PI staining and apoptosis-related proteins were detected by western blotting. STAT3-related proteins were analysis by western blotting analysis and Immunofluorescence assays. Efficacy evaluation of ATO combined with CT on xenograft was carried in nude mice and related proteins were analysis by Immunohistochemistry assays.

Results

First we evaluated cell vitality, and our data indicated that the ATO combined with CT showed obvious growth inhibition of Bel-7404 cells compared to ATO or CT alone. Next we found that ATO combined with CT induced cell apoptosis in Bel-7404 cells and upregulated the activation of apoptosis-related proteins cleaved-caspase-3, cleaved-caspase-9, and cleaved-poly(ADP-ribose) polymerase in a time-dependent manner. Next, we found that ATO combined with CT not only inhibited the constitutive levels of phosphorylated-JAK2 and phosphorylated-STAT3^Tyr705 but did so in a time-dependent manner. We also found that ATO combined with CT reversed the upregulated expression of phosphorylated-STAT3^Tyr705 stimulated by interleukin-6 and downregulated STAT3 direct target genes and the anti-apoptotic proteins Bcl-2, XIAP, and survivin but obviously upregulated the promoting apoptosis proteins Bak,.In vivo studies showed that ATO combined with CT decreased tumor growth. Tumors from ATO combined with CT–treated mice showed decreased levels of phosphorylated-STAT3^Tyr705 and the anti-apoptotic protein Bcl-2 but an increased level of pro-apoptotic protein Bax.

Conclusions

Our study provides strong evidence that CT could enhance the efficacy of ATO in treating liver cancer both in vitro and in vivo. Downregulation of phosphorylated-STAT3 expression may play an important role in inducing apoptosis of Bel-7404 cells.

Tumor vascularity and lipiodol deposition as early radiological markers for predicting risk of disease progression in patients with unresectable hepatocellular carcinoma after transarterial chemoembolization

This study evaluated the factors impacting overall survival (OS) and time to progression (TTP) in patients with unresectable hepatocellular carcinoma (HCC) who received transarterial chemoembolization (TACE). HCC patients were grouped based on tumor vascularity and lipidiol deposition after TACE. Tumor vascularity was classified based on contrast enhancement on arterial phase baseline CT scans. Lipiodol deposition was evaluated using CT scans. The progression-free rate was significantly higher in patients with good blood supply + good lipiodol deposition compared to those with good blood supply + poor lipiodol deposition. In patients with poor lipidiol deposition, risk of death was significantly positively correlated with stage, and negatively correlated with number of TACE procedures and degree of lipidiol deposition after the first TACE. Risk of disease progression in these patients was positively correlated with tumor size, and negatively correlated with number of TACE procedures and degree of lipidiol deposition after the first TACE. Our data showed that tumor vascularity and lipiodol deposition can be used as early radiological markers to identify patients who do not respond to TACE, and who can be considered earlier for alternative combination treatment strategies. Our data also indicated that poor lipiodol retention may predict a poor TTP and OS despite the blood supply status.

Preoperative transarterial chemoembolization for resectable hepatocellular carcinoma in Asia area: a meta-analysis of random controlled trials

OBJECTIVE

We aimed to systematically evaluate the influence of preoperative transarterial chemoembolization (TACE) for resectable hepatocellular carcinoma (HCC) on long-term prognosis and perioperative safety.

MATERIALS AND METHODS

Databases including PubMed, Embase, Cochrane, Wanfang, CNKI, VIP data were searched, combined with Manual Retrieval and Cited Reference Search to collect the published randomized controlled trial (RCT) about the influence of pre-TACE for curative resection of HCC. The searching cutoff date was 2016/02/25, all the data obtained were statistically analyzed using RevMan5.2 software recommended by Cochrane Collaboration.

RESULTS

A total of 5 RCT including 430 (pre-TACE group: 212, surgery alone group: 218) patients were included. The results of meta-analysis showed that: there was no difference between the 2 groups on overall survival (OS) rate [HR 1.25, 95%CI (0.92-1.68)], disease free survival (DFS) rate [HR 0.95 (0.76-1.19)], perioperative mortality rate [OR 0.70 (0.22-2.30)], or blood loss [SMD 0.07 (-0.14-0.29)], whereas the subgroup analysis revealed that pre-TACE would result in longer operation time [SMD 0.31 (0.06-0.57)], higher postoperative morbidity rate [OR 1.90 (1.02-3.53)] and combined resection rate of perihepatic organs [OR 5.46 (2.73-11.78)] in subgroup with mean tumor diameter >5cm.

CONCLUSIONS

According to our study, pre-TACE treatment cannot improve the long-term prognosis of resectable HCC. With the growth of the tumor diameter, especially when it is over 5cm, it might add difficulties to surgery and affect the perioperative safety.

Predictive values of serum VEGF and CRP levels combined with contrast enhanced MRI in hepatocellular carcinoma patients after TACE

This study explored the predictive value of serum vascular endothelial growth factor (VEGF) and C-reactive protein (CRP) levels combined with enhanced magnetic resonance imaging (MRI) in hepatocellular carcinoma (HCC) patients after transcatheter arterial chemoembolization (TACE). One hundred and seventeen patients who received TACE from June 2010 to December 2012 in our hospital were included in this study. Serum VEGF and CRP levels before and after TACE were determined by ELISA and single immunodiffusion method for analyzing the association of serum levels with pathological features. Enhanced MRI was utilized before and after TACE to measure tumor size and ADC value in enhanced region and non-enhanced region. MRI data were combined with serum VEGF and CRP levels to analyze the predictive value in efficacy and prognosis for HCC patients after TACE. The serum VEGF and CRP levels after TACE were increased, but can return to normal levels in a certain time. VEGF and CRP levels were not statistically associated with tumor location, tumor staining or presence of membrane (all P > 0.05), but closely correlated with combined portal vein tumor thrombus, combined arteriovenous fistula and distant metastasis (all P < 0.05). Low levels of serum VEGF and CRP, small tumor size and low ADC value before treatment indicated a better prognosis. The sensitivity and specificity of serum VEGF and CRP levels, tumor size and ADC value were respectively 92.31% and 88.46%, 93.85% and 90.38%, 81.54% and 78.85% as well as 47.69% and 84.62%. Serum VEGF and CRP levels, tumor size and ADC value could predict the efficacy of TACE for HCC patients. Serum VEGF and CRP levels combined with enhanced MRI may serve as markers for efficacy and prognosis evaluation in HCC patients after TACE.

Liver transplantation for hepatocellular carcinoma - factors influencing outcome and disease-free survival

Hepatocellular carcinoma is one of the leading causes of cancer-related death worldwide. Liver transplantation can be a curative treatment in selected patients. However, there are several factors that influence disease-free survival after transplantation. This review addresses the pre-, intra- and postoperative factors that influence the risk of tumor recurrence after liver transplantation.