Systematic Review of Single Large and/or Multinodular Hepatocellular Carcinoma: Surgical Resection Improves Survival

Portal vein embolization and subsequent major hepatectomy for hepatocellular carcinoma with insufficient residual liver volume: experience of a tertiary center

Portal vein embolization (PVE) allows for liver regeneration to enhance reduced residual liver volume before resection in hepatocellular carcinoma (HCC) patients with systemic liver disease. A retrospective review of medical records was conducted, including patients who underwent PVE and subsequent major hepatectomy to treat resectable non-metastatic HCC at the University Medical Center in Ho Chi Minh City between 01/2016 and 6/2023. Patient demographics, timing of procedures, surgical interventions, intra- and postoperative complications, pattern of recurrence, and survival were analyzed. A total of 58 patients with HCC were included, and the median length of stay after surgery was 8 days (range 5-24). Post-hepatectomy liver failure (PHLF) occurred with an overall incidence of 31% (18/58 cases). Severe PHLF occurred in 6 cases: grade B in 5 cases (8.6%) and grade C in 1 case (1.7%), resulting in patient death. Postoperative bleeding and bile leak each occurred in 1 case (1.7%). Univariable and multivariable analyses identified portal vein pressure (PVP) after PVE as the only significant preoperative parameter associated with outcomes, correlating with PHLF occurrence (OR 1.27, p = 0.009) at a cut-off of 15 mmHg (p = 0.018). The overall survival at 3, 6, and 12 months was 96%, 94%, and 94%, respectively, with disease-free survival rates of 94%, 90%, and 87%, respectively. Major hepatectomy can be performed safely and effectively in HCC patients who have PVE-induced liver hypertrophy (sFLR ≥ 40%) and preserved liver function (Child-Pugh A) maintaining low morbidity. Multivariate analysis revealed that a post-PVE PVP cutoff of 15 mmHg significantly correlated with perioperative parameters, including operating time, blood loss, and PHLF occurrence.

EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma

Liver cancer is the third leading cause of cancer-related deaths worldwide, with hepatocellular carcinoma (HCC) accounting for approximately 90% of primary liver cancers. Advances in diagnostic and therapeutic tools, along with improved understanding of their application, are transforming patient treatment. Integrating these innovations into clinical practice presents challenges and necessitates guidance. These clinical practice guidelines offer updated advice for managing patients with HCC and provide a comprehensive review of pertinent data. Key updates from the 2018 EASL guidelines include personalised surveillance based on individual risk assessment and the use of new tools, standardisation of liver imaging procedures and diagnostic criteria, use of minimally invasive surgery in complex cases together with updates on the integrated role of liver transplantation, transitions between surgical, locoregional, and systemic therapies, the role of radiation therapies, and the use of combination immunotherapies at various stages of disease. Above all, there is an absolute need for a multiparametric assessment of individual risks and benefits, considering the patient's perspective, by a multidisciplinary team encompassing various specialties.

Single large hepatocellular carcinoma > 5 cm with surgical indication: is it mandatory a major hepatectomy? a propensity-score weighted analysis

PURPOSE

Single large hepatocellular carcinoma >5cm (SLHCC) traditionally requires a major liver resection. Minor resections are often performed with the goal to reduce morbidity and mortality. Aim of the study was to establish if a major resection should be considered the best treatment for SLHCC or a more limited resection should be preferred.

METHODS

A multicenter retrospective analysis of the HE.RC.O.LE.S. Group register was performed. All collected patients with surgically treated SLHCC were divided in 5 groups of treatment (major hepatectomy, sectorectomy, left lateral sectionectomy, segmentectomy, non-anatomical resection) and compared for baseline characteristics, short and long-term results. A propensity-score weighted analysis was performed.

RESULTS

535 patients were enrolled in the study. Major resection was associated with significantly increased major complications compared to left lateral sectionanectomy, segmentectomy and non-anatomical resection (all p<0.05) and borderline significant increased major complications compared to sectorectomy (p=0.08). Left lateral sectionectomy showed better overall survival compared to major resection (p=0.02), while other groups of treatment resulted similar to major hepatectomy group for the same item. Absence of oncological benefit after major resection and similar outcomes among the 5 groups of treatment was confirmed even in the sub-population excluding patients with macrovascular invasion.

CONCLUSION

Major resection was associated to increased major post-operative morbidity without long-term survival benefit; when technically feasible and oncologically adequate, minor resections should be preferred for the surgical treatment of SLHCC.

Liver resection versus transarterial chemoembolisation for the treatment of intermediate hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

Transarterial chemoembolisation (TACE) is the primary treatment for intermediate-stage hepatocellular carcinoma (HCC), according to the updated Barcelona Clinic Liver Cancer (BCLC) staging system. Although growing evidence favours liver resection (LR) over TACE for intermediate-stage HCC, the best treatment option remains controversial. This meta-analysis aimed to compare the overall survival (OS) after LR versus TACE for intermediate-stage HCC.

METHODS

A comprehensive literature review of PubMed, Embase, Cochrane Library, and Web of Science was performed. Studies that compared the efficacy of LR and TACE in patients with intermediate (BCLC stage B) HCC were selected. According to the recent updated BCLC classification, intermediate stage of HCC was defined as follows: (a) four or more HCC nodules of any size, or (b) two or three nodules, but if at least one tumour is larger than 3 cm. The main outcome was OS, expressed as the hazard ratio.

RESULTS

Nine eligible studies of 3355 patients were included in the review. The OS of patients who underwent LR was significantly longer than that of patients who underwent TACE (hazard ratio=0.52; 95% CI: 0.39-0.69; I2=79%). Prolonged survival following LR was confirmed after sensitivity analysis of five studies using propensity score matching (HR=0.45; 95% CI: 0.34-0.59; I2=55%).

CONCLUSION

Patients with intermediate-stage HCC who underwent LR had a longer OS that those who underwent TACE. The role of LR in patients with BCLC stage B should be clarified in future randomised controlled trials.

Clinical prognosis of surgical resection versus transarterial chemoembolization for single large hepatocellular carcinoma (≥5 cm): A propensity score matching analysis

Favorable prognostic factors and therapeutic strategies are important for patients with single large hepatocellular carcinoma (HCC). This retrospective study aimed to investigate the prognostic factors in patients with single large (≥5 cm) HCC with Child-Pugh (CP) class A patients and to recommend therapeutic strategies. Overall, 298 HCC patients with single and large (≥5 cm) tumors with CP class A, but without distant metastasis and macrovascular invasion were included, and their clinicopathological data, overall survival (OS), and progression-free survival (PFS) were recorded. OS and PFS was analyzed by the Kaplan-Meier method and Cox regression analysis. Propensity score matching (PSM) analysis was performed. The 298 HCC patients were 79.2% male and median age of 64 years. For the initial treatment, surgical resection (SR) and transarterial chemoembolization (TACE) was 50.8% and 49.2%, respectively. The OS and PFS were significantly higher in patients receiving SR than those receiving TACE before and after PSM. Furthermore, in multivariate analysis, cirrhosis (Hazard ratio [HR]: 2.04; 95% confidence interval [CI]: 1.35-3.03, p < 0.001, CP class A5/6 [HR: 4.01; 95% CI: 2.43-6.66, p < 0.001], and initial treatment [SR vs. TACE HR = 3.23; 95% CI: 2.13-5.01, p < 0.001]) remained significantly associated with mortality. Moreover, in multivariate analysis, CP class A5/6 (HR: 3.23; 95% CI: 1.89-5.88, p < 0.001), and initial treatment (Resection vs. TACE; HR = 4.17; 95% CI: 1.64-8.33, p = 0.039) remained significantly associated with recurrence. In conclusion, SR was associated with significantly higher OS and PFS rates than TACE before and after PSM for single large HCC patients.

Combination Transarterial Chemoembolization and Stereotactic Body Radiation Therapy for Unresectable Single Large Hepatocellular Carcinoma: Results From a Prospective Phase 2 Trial

PURPOSE

Patients with hepatocellular carcinoma (HCC) at Barcelona Clinic Liver Cancer (BCLC) early-stage A (BCLC A) not suitable for surgery are first considered for ablation. Nonetheless, objective responses and long-term results for ablation in tumors larger than 3 to 4 cm are suboptimal, creating an unmet clinical need. This phase 2 trial studied combination of transarterial chemoembolization (TACE) and stereotactic body radiation therapy (SBRT) for BCLC A patients with a solitary HCC from 4 to 7 cm.

METHODS AND MATERIALS

Eligible patients were BCLC A, Child-Pugh score ≤7, Eastern Cooperative Oncology Group performance status 0 presenting with a single HCC from 4 to 7 cm not suitable for resection or liver transplantation. Treatment consisted of 2 sessions of drug-eluting bead-TACE within 1 month followed by immediate SBRT. SBRT delivered 35 to 50 Gy in 5 fractions. The primary endpoint was best objective response rate (ORR) by modified Response Evaluation Criteria in Solid Tumours (mRECIST). Secondary endpoints were overall survival (OS), progression-free survival (PFS), and toxic effects.

RESULTS

From 2014 to 2020, 32 were enrolled in a single institution with median follow-up of 37 months. Thirty patients had at least 1 posttreatment scan to assess response. ORR in the target lesion was 91%: 63% complete response (CR; n = 20), 28% partial response (n = 9), and 3% progression of disease (n = 1). Median time to CR was 10.1 months. Median OS was not yet reached and median PFS was 35 months. Patients achieving CR had a trend toward improved PFS (P = .09). Toxic effects were low.

CONCLUSIONS

This phase 2 trial showed very promising ORR when combining TACE + SBRT in large, unresectable HCC, which translates into excellent OS and PFS. These results provide the rationale for exploring this combination in larger phase 2 and 3 clinical trials and a space where SBRT might offer unique clinical advantage.

Patient stratification in hepatocellular carcinoma: impact on choice of therapy

INTRODUCTION

HCC comprises around 60 to 80% of all primary liver cancers and exhibits wide geographical variability. Appropriate treatment allocation needs to include both patient and tumor characteristics.

AREAS COVERED

Current HCC classification systems to guide therapy are either liver function-centric and evaluate physiologic liver function to guide therapy or prognostic stratification classification systems broadly based on tumor morphologic parameters, patient performance status, and liver reserve assessment. This review focuses on different classification systems for HCC, their strengths, and weaknesses as well as the use of artificial intelligence in improving prognostication in HCC.

EXPERT OPINION

Future HCC classification systems will need to incorporate clinic-pathologic data from a multitude of sources and emerging therapies to develop patient-specific treatment plans targeting a patient's unique tumor profile.

Multiple hepatocellular carcinoma: Long-term outcomes following resection beyond actual guidelines. An Italian multicentric retrospective study

BACKGROUND

Hepatocellular carcinoma (HCC) is frequently diagnosed as multinodular. This study aims to assess prognostic factors for survival and identify patients with multiple HCC who may benefit from surgery beyond the Barcelona Clinic Liver Cancer classification indications.

METHODS

This retrospective study included all the consecutive patients from 4 Italian tertiary centers receiving liver resection for naive multiple HCC between 1990 and 2012 to have a potential follow-up of 5 years.

RESULTS

Included patients were 144. Ninety-day morbidity and mortality rates were 38.3% and 8.3%, respectively. The 5-year overall and disease-free survival rates were 33.3% and 19.1%, respectively. Tumor size <3 cm, bilirubin, Child-Pugh A, BCLC-A stage, being within "up-to-7" criteria, and minor resections resulted in prognostic factors. The Child-Pugh score resulted in an independent prognostic factor.

CONCLUSIONS

Surgery may be related to good outcomes in selected patients with multiple HCC.

Galectin-3 not Galectin-9 as a candidate prognosis marker for hepatocellular carcinoma

BACKGROUND

Galectins (Gal) are a family of protein that bind to the β-galactoside of glycoproteins. It modulates a variety of biological functions, such as tumor growth, angiogenesis and tumor metastasis. A series of experimental and clinical evidences have been reported to support a correlation between galectin expressions and neoplastic transformation, progression and prognosis. The objective of this study was to estimate the expression of Gal-3 and Gal-9 in order to evaluate their relation to hepatocellular carcinoma (HCC) -related clinical features and their prognostic values.

METHODS

We evaluated Gal-3 and Gal-9 expression in 247 HCC patients by a tissue microarray immunohistochemistry method, then analyzed the relationship between expression levels of Gal-3 and Gal-9 protein and tumor parameters or clinical outcomes.

RESULTS

The Gal-3 expression was significantly higher in tumor tissues compared with adjacent non-tumor tissues (P < 0.001), while no significant differences of Gal-9 was detected (P = 0.222). A higher Gal-3 expression was significantly associated with lymph-vascular invasion (P = 0.049), poor histological differentiation (P = 0.016), and no cirrhosis (P = 0.040). In contrast, a lower Gal-9 expression was related to lymph-vascular invasion (P = 0.012) and poor histological differentiation (P = 0.002). Survival analysis showed that patients with higher Gal-3 expression had worse overall survival (P = 0.012) , however no correlation was found between Gal-9 expression and survival (P = 0.185). Multivariate analysis showed that multiple tumor (HR = 1.94, 95% CI [1.36-2.78]), tumor size ≥ 5 cm (HR = 1.51, 95% CI [1.07-2.12]), Lymph-vascular invasion (HR = 1.45, 95% CI [1.00-2.10]) and Gal-3 expression (HR = 1.57, 95% CI [1.06-2.33]) were independent influencing factors of prognosis in patients with hepatocellular carcinoma.

CONCLUSION

Gal-3 was expected to serve as a novel prognostic marker of hepatocellular carcinoma, while Gal-9 expression was only related to tumor progression.

Treatment of hepatocellular carcinoma beyond the Milan criteria. A weighted comparative study of surgical resection versus chemoembolization

BACKGROUND

Optimal treatment of hepatocellular carcinoma (HCC) beyond the Milan criteria (MC) is debated. The aim of the study was to assess overall-survival (OS) and disease-free-survival (DFS) for HCC beyond MC when treated by trans-arterial-chemoembolization (TACE) or surgical resection (SR).

METHOD

between 2005 and 2015, all patients with a first diagnosis of HCC beyond MC(1 nodule>5 cm, or 3 nodules>3 cm without macrovascular invasion) were evaluated. Analyses were carried out through Kaplan-Meier, Cox models and the inverse probability weighting (IPW) method to reduce allocation bias. Sub-analyses have been performed for multinodular and single large tumors compared with a MC-IN cohort.

RESULTS

226 consecutive patients were evaluated: 118 in SR group and 108 in TACE group. After IPW, the two pseudo-populations were comparable for tumor burden and liver function. In the SR group, 1-5 years OS rates were 72.3% and 35% respectively and 92.7% and 39.3% for TACE (p = 0.500). The median DFS was 8 months (95%CI:8-9) for TACE, and 11 months (95%CI:9-12) for SR (p < 0.001). TACE was an independent predictor for recurrence (HR 1.5; 95%CI: 1.1-2.1; p = 0.015). Solitary tumors > 5 cm and multinodular disease had comparable OS and DFS as Milan-IN group (p > 0.05).

CONCLUSION

Surgery allowed a better control than TACE in patient bearing HCC beyond MC. This translated into a significant benefit in terms of DFS but not OS.

Hepatocellular carcinoma surgical and oncological trends in a national multicentric population: the HERCOLES experience

Liver surgery is the first line treatment for hepatocarcinoma. Hepatocarcinoma Recurrence on the Liver Study (HERCOLES) Group was established in 2018 with the goal to create a network of Italian centres sharing data and promoting scientific research on hepatocellular carcinoma (HCC) in the surgical field. This is the first national report that analyses the trends in surgical and oncological outcomes. Register data were collected by 22 Italian centres between 2008 and 2018. One hundred sixty-four variables were collected, regarding liver functional status, tumour burden, radiological, intraoperative and perioperative data, histological features and oncological follow-up. 2381 Patients were enrolled. Median age was 70 (IQR 63-75) years old. Cirrhosis was present in 1491 patients (62.6%), and Child-A were 89.9% of cases. HCC was staged as BCLC0-A in almost 50% of cases, while BCLC B and C were 20.7% and 17.9% respectively. Major liver resections were 481 (20.2%), and laparoscopy was employed in 753 (31.6%) cases. Severe complications occurred only in 5%. Postoperative ascites was recorded in 10.5% of patients, while posthepatectomy liver failure was observed in 4.9%. Ninety-day mortality was 2.5%. At 5 years, overall survival was 66.1% and disease-free survival was 40.9%. Recurrence was intrahepatic in 74.6% of cases. Redo-surgery and thermoablation for recurrence were performed up to 32% of cases. This is the most updated Italian report of the national experience in surgical treatment for HCC. This dataset is consistently allowing the participating centres in creating multicentric analysis which are already running with a very large sample size and strong power.

A novel oncolytic adenovirus inhibits hepatocellular carcinoma growth

OBJECTIVE

To evaluate the inhibitory role of a novel oncolytic adenovirus (OA), GP73-SphK1sR-Ad5, on the growth of hepatocellular carcinoma (HCC).

METHODS

GP73-SphK1sR-Ad5 was constructed by integrating Golgi protein 73 (GP73) promoter and sphingosine kinase 1 (SphK1)-short hairpin RNA (shRNA) into adenovirus serotype 5 (Ad5), and transfecting into HCC Huh7 cells and normal human liver HL-7702 cells. The expression of SphK1 and adenovirus early region 1 (E1A) was detected by quantitative real-time PCR (qRT-PCR) and western blot, respectively. Cell viability was detected by methylthiazolyldiphenyl-tetrazolium bromide (MTT) assay, and apoptotic rate was determined by flow cytometry. An Huh7 xenograft model was established in mice injected intratumorally with GP73-SphK1sR-Ad5. Twenty days after injection, the tumor volume and weight, and the survival time of the mice were recorded. The histopathological changes in tumor tissues were observed by hematoxylin-eosin (HE) staining and transmission electron microscopy (TEM).

RESULTS

Transfection of GP73-SphK1sR-Ad5 significantly upregulated E1A and downregulated SphK1 in Huh7 cells, but not in HL7702 cells. GP73-SphK1sR-Ad5 transfection significantly decreased the viability and increased the apoptotic rate of Huh7 cells, but had no effect on HL7702 cells. Intratumoral injection of GP73-SphK1sR-Ad5 into the Huh7 xenograft mouse model significantly decreased tumor volume and weight, and prolonged survival time. It also significantly decreased the tumor infiltration area and blood vessel density, and increased the percentages of cells with nucleus deformation and cells with condensed chromatin in tumor tissues.

CONCLUSIONS

GP73-SphK1sR-Ad5 serves as a novel OA and can inhibit HCC progression with high specificity and efficacy.

Repeated postoperative adjuvant TACE after curative hepatectomy improves outcomes of patients with HCC

BACKGROUND AND AIMS

To gain a clear picture of the influence of postoperative adjuvant transcatheter arterial chemoembolization (TACE) on recurrence after curative resection for HCC.

MATERIAL AND METHODS

According to the inclusion criteria and the exclusion criteria, the clinical data of 118 patients with HCC at Qilu Hospital, Shan Dong University between January 2011 and August 2013, who were treated by curative hepatectomy and postoperative TACE (two groups of patients received TACE once or twice, respectively) or by curative hepatectomy alone were retrospectively studied.

RESULTS

The three-year survival (RFS) rate was 51.7% for the whole study population. The three-year relapse-free RFS rates were 73.0% and 55.0% for the patients who received two and one postoperative adjuvant TACE treatments, groups respectively, and 29.3% for the hepatectomy alone group. The three-year RFS of the patients who received postoperative adjuvant TACE once was significantly higher than that of the patients who received hepatectomy alone (p = .024). And the outcome of patients with two adjuvant TACE treatments was better than that of patients who received one treatment (p = .033).

CONCLUSIONS

Repeated postoperative adjuvant TACE seems to be a promising treatment for HCC that might delay tumor recurrence and improve the RFS rates of patients after curative hepatectomy.

Selective devascularization treatment for large hepatocellular carcinoma: Stage 2A IDEAL prospective case series

BACKGROUND

Rapid growth and invasiveness of hepatocellular carcinoma (HCC) largely depends on its vascularity and active angiogenic capacity. That feature was used to control the tumor in the past with some limitations. These deficiencies were addressed in our new procedure by hepatic artery ligation and extrahepatic collaterals division (HALED) of the liver lobe containing large HCC. This study tried to assess the feasibility, safety and the short term effects of HALED.

MATERIALS AND METHODS

This is a prospective stage 2a development IDEAL (Idea, Development, Exploration, Assessment and Long-term monitoring) case series. It included adult patients with large-sized HCC (diameter > 5 cm) subjected to HALED carried out in our center during five years' trial evaluating one-month postoperative outcomes. Patients will be reported prospectively in a sequential order with explanation of reasons for rejected cases and description of changes to technique or indication as the procedure evolved. This study registry number is NCT03129685 at the ClinicalTrials.gov.

RESULTS

The first HALED operation was carried out safely on 2013, followed by nineteen patients by 2018. Patients' mean age (±standard deviation) was 62·45 (±9·27), range 38-76 years. Eleven (55%) patients had tumors diameter > 10 cm 13 (65%) patients were advanced BCLC stage. Seven modifications were made on the technique and indications of the procedure towards stability. According to the modified response evaluation criteria in solid tumors, 13 patients (65%) attained complete response. Operative mortality was 5% (one patient) and major morbidity was 10% (two patients). Liver infarction and abscess formation were not noticed in this study.

CONCLUSION

Our forerunner study showed that HALED for large HCC is safe and induces tumor necrosis. Further long-term studies are suggested before starting the 2b stage.

Angio-CT-Guided Transarterial Chemoembolization Immediately in Combination with Radiofrequency Ablation for Large Hepatocellular Carcinoma

RATIONALE AND OBJECTIVES

To evaluate the method and effectiveness of Angio-CT-guided transcatheter arterial chemoembolization (TACE) immediately in combination with radiofrequency ablation (RFA) in the treatment of large hepatocellular carcinomas (HCCs; maximum enhancing diameter >5 cm).

MATERIALS AND METHODS

A retrospective analysis was conducted on 48 patients with solitary large HCCs who were admitted from October 2012 to June 2016 and treated by immediate combination therapy, and 48 patients with solitary large HCCs who were treated by a sequential combination (RFA at 2-4 weeks after TACE) therapy in the same period were randomly selected as controls. After treatment, the success rates of the immediately combined technique, the short-term outcomes of the immediately combined treatment (using the modified response evaluation criteria in solid tumor standard), and the survival rates were evaluated.

RESULTS

The success rate of the immediately combined technique was 100%. The complete remission rates 1, 3, and 6 months after treatment in the study group were 58.3%༌56.2%, and 47.9%, respectively, while the corresponding complete remission rates of control group were 37.5%, 33.3%, and 27.1%, respectively. The 1-, 2-, and 3-year survival rates of the study group were 95.8%, 85.4%, and 58.3%, respectively, while the corresponding survival rates of the control group were 83.3%, 68.7%, and 43.8%, respectively. None of the patients had any serious complications.

CONCLUSION

Angio-CT-guided TACE immediately in combination with RFA is a feasible, safe method for the treatment of large HCCs with excellent short-term outcomes and improved long-term prognoses.

Overexpression of p53 in extra large (more than 10 cm) hepatocellular carcinoma

Background: Extra large hepatocellular carcinoma (HCC) of >10 cm managed in our center shows a specific characteristic in tropical regions. This type of HCC exhibits distinct p53 expression. This study aimed to determine the association between p53 expression and tumor size and behavior. Method: Subjects with HCC who underwent surgical resection in our hospital during 2012–2015 were enrolled in thisstudy. Subject’s characteristics, tumor size, histopathology findings, and tumor behavior were variables observed. Animmunohistochemical study on p53 expression was conducted to determine its association with those variables.Results: This study involved 38 subjects with tumor size ranging from 3 cm to 25 cm in diameter and 20 subjects (52.8%) with tumor size ranging from 10 cm to 25 cm in diameter. Only 13 samples were evaluated for p53 expression. Five subjects with >10 cm (extra large) tumor showed highly/overexpressed p53 (intensity>50%), two subjects with strong p53 expression (intensity>5%–50%), and two subjects with weak expression. Three subjects with <10 cm (large) tumor showed strong expression of p53 (5%–9%) and a subject with 3 cm tumor showed weak p53 expression (<5%). Highly expressed p53 was found in patients with microvascular invasion, inflammatory response, mitosis, and necrosis.Conclusion: Overexpression of p53 was associated with extra large and poorly differentiated HCC.

Association between AKT rs2494752 single nucleotide polymorphism and the risk of metastasis in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common types of human tumors, which is characterized by high morbidity and mortality rates. AKT1 transcriptional activity is implicated in HCC initiation and development. In the present study, the effects of rs2494752 single nucleotide polymorphism (SNP) on AKT1 transcriptional activity in the progression of HCC cells were investigated. A case-control study was analyzed in 1,056 HCC patients and 1,080 healthy individuals using the PCR assay method. Results indicated AKT1 expression levels were up-regulated in HCC tissue compared to adjacent normal tissues. Furthermore, a higher frequency of AKT rs2494752 AG and AA genotypes were observed in HCC cases (P=0.0046). Gene polymorphism identified C and T alleles were frequency in HCC patients compared to healthy individuals. Individuals harboring AKT rs2494752 AG/AA genotype had a vital increased susceptibility to HCC in the dominant model (P=0.0028). In addition, AKT1 rs2494752 GG genotype showed an increasing of AKT1 promoter activity determined by the luciferase assay. Furthermore, it was demonstrated that AKT1 rs2494752 GG and C polymorphism was more aggressive than other AKT1 rs2494752 cancer cells. Moreover, AKT1 rs2494752 GG markedly increased rates of response to NCT chemotherapy. Additionally, results revealed that AKT1 rs2494752 GG and C increased the risk factors of HCC. In conclusion, these results indicate that AKT1 rs2494752 polymorphisms may be regarded as a candidate gene in assessing the susceptibility, metastasis and responses to chemotherapy in the progression of hepatocellular carcinoma.

The effect of radiotherapy in liver-confined but non-resectable Barcelona Clinic Liver Cancer stage C large hepatocellular carcinoma

Background and aims

Clinical trials to determine the efficacy of radiotherapy (RT) in liver-confined but non-resectable Barcelona Clinic Liver Cancer (BCLC) stage C hepatocellular carcinoma (HCC) are scarce. We aimed to determine the benefit of RT in such tumors and investigated large HCC tumors.

Methods

HCC data from the Korea Central Cancer Registry recorded from 2008 to 2010 were used. A total of 593 patients met our inclusion criteria; 67 were treated with RT while the remainder made up the non-RT group. Fifty-two RT recipients underwent combination treatments within 4 weeks after the first RT treatment, and were defined as the combination RT group. We performed propensity score matching (PSM) to compare the RT or combination RT groups with the non-RT group. The endpoint was overall survival (OS).

Results

Median follow-up time for surviving patients was 48 months. After PSM, there was no difference in OS between the RT and non-RT groups or between the combination RT and non-RT groups. However, the combination RT group had a longer median survival time (MST) (10.7 vs. 6.9 months, respectively). Next, we conducted PSM between the combination RT and non-RT groups in patients with tumor sizes ≥10 cm; MST was significantly longer in the former group (10.1 vs. 5.4 months, respectively; bootstrap 95% confidence interval of the difference in MST: 0.2-11.8).

Conclusions

As a combined modality, RT is a plausible therapeutic option for liver-confined but non-resectable BCLC stage C large HCC patients.

Anti-microRNA-21/221 and microRNA-199a transfected by ultrasound microbubbles induces the apoptosis of human hepatoma HepG2 cells

Gene therapy, particularly microRNA (miRNA), is a promising candidate in the treatment of cancer; however, it is challenging to develop gene delivery systems. Ultrasound microbubbles have been used for gene delivery with excellent results. The present study aimed to investigate the transfection efficiency of HepG2 cells using ultrasound microbubbles. The effects of three miRNAs (miR-21, miR-221 and miR-199a) on HepG2 cells were also determined by performing ultrasound microbubble-mediated gene transfection. Three recombinant plasmids containing anti-miR-21, anti-miR-221 and miR-199a were fused with enhanced green fluorescent protein. For the transfection of genes, the type of contrast agent, the concentration of microbubble contrast agent and the exposure intensity of ultrasound were optimized. The expression of miRNAs was detected using reverse transcription-polymerase chain reaction. To determine the effect of anti-miR-21, anti-miR-221 and miR-199a on HepG2 cells, MTT, cell cycle analysis and Annexin V-PE/7-ADD apoptosis assays were performed. The optimal condition was 10% sulfur hexafluoride microbubbles at an ultrasound frequency of 2.0 MHz and mechanical index of 0.28. When cells were transfected with three recombinant plasmids using ultrasound microbubbles, there was significant downregulation of miR-21 and miR-221 and upregulation of miR-199a (P<0.05). All three treatments inhibited cell proliferation and promoted the apoptosis of cells. The present data indicated that the delivery of anti-miR-21, anti-miR-221 and miR-199a may be mediated by ultrasound microbubble contrast agents. With this approach, cell proliferation may be effectively inhibited and cell apoptosis may be induced. These are novel cancer therapy targets.

Controversies and evidence of hepatic resection for hepatocellular carcinoma

Symptoms of early hepatocellular carcinoma (HCC) often go unnoticed, so more than half of patients with primary HCC are diagnosed after their disease has already reached an intermediate or advanced stage, or after portal hypertension has appeared. While hepatic resection is widely recognized as a first-line therapy to treat very early or early HCC, its use in treating intermediate or advanced HCC or HCC involving portal hypertension remains controversial. Here we review PubMed-indexed literature covering the use of hepatic resection for such patients. The available evidence strongly suggests that, as a result of improvements in surgical techniques and perioperative care, hepatic resection can benefit many patients with intermediate or advanced HCC or with HCC associated with portal hypertension.