Clinical Management of Liver Cancer in India and Other Developing Nations: A Focus on Radiation Based Strategies

Hepatocellular carcinoma (HCC) is a global killer with preponderance in Asian and African countries. It poses a challenge for successful management in less affluent or developing nations like India, with large populations and limited infrastructures. This review aims to assess the available options and future directions for management of HCC applicable to such countries. While summarizing current and emerging clinical strategies for detection, staging and therapy of the disease, it highlights radioisotope- and radioactivity-based strategies as part of an overall program. Using the widely accepted Barcelona Clinic Liver Cancer (BCLC) staging system as a base, it evaluates the applicability of different therapeutic approaches and their synergistic combination(s) in the context of a patient-specific dynamic results-based strategy. It distills the conclusions of multiple HCC management-focused consensus recommendations to provide a picture of clinical strategies, especially radiation-related approaches. Additionally, it discusses the logistical and economic feasibility of these approaches in the context of the limitations of the burdened public health infrastructure in India (and like nations) and highlights possible strategies both at the clinical level and in terms of an administrative health policy on HCC to provide the maximum possible benefit to the widest swathe of the affected population.

Current Understanding of Ablative Radiation Therapy in Hepatocellular Carcinoma

The role of ablative stereotactic body radiotherapy (SBRT) in hepatocellular carcinoma (HCC) has been evolving over the last few decades. SBRT has mostly been used in early stages of HCC, including few (≤ 3 in number) tumors, small tumours (< 3 cm in size), as well as larger tumours which are ineligible for other ablative modalities, mostly without vascular invasion. In early stage HCC, SBRT is used as a definitive treatment with curative intent or with intent to bridge to liver transplant. Retrospective and prospective institutional series document a high rate of local control (68–95% at 3 years) following SBRT. This coupled with a low risk of toxicity makes this non-invasive ablative treatment an attractive option for patients who are ineligible for other ablative treatments. Small randomized studies of ablative radiation have also shown non-inferiority of radiation as compared to radiofrequency ablation (RFA). Currently, SBRT is widely available as a safe and effective liver directed therapy, although there is a need for more studies providing higher level evidence. This review gives a brief overview of SBRT and the evidence for its use in HCC patients with ablative intent.

Single-cell mapping of focused ultrasound-transfected brain

Gene delivery via focused ultrasound (FUS) mediated blood-brain barrier (BBB) opening is a disruptive therapeutic modality. Unlocking its full potential will require an understanding of how FUS parameters (e.g., peak-negative pressure (PNP)) affect transfected cell populations. Following plasmid (mRuby) delivery across the BBB with 1 MHz FUS, we used single-cell RNA-sequencing to ascertain that distributions of transfected cell types were highly dependent on PNP. Cells of the BBB (i.e., endothelial cells, pericytes, and astrocytes) were enriched at 0.2 MPa PNP, while transfection of cells distal to the BBB (i.e., neurons, oligodendrocytes, and microglia) was augmented at 0.4 MPa PNP. PNP-dependent differential gene expression was observed for multiple cell types. Cell stress genes were upregulated proportional to PNP, independent of cell type. Our results underscore how FUS may be tuned to bias transfection toward specific brain cell types in vivo and predict how those cells will respond to transfection.

SUNSET: Stereotactic Radiation for Ultracentral Non-Small-Cell Lung Cancer-A Safety and Efficacy Trial

BACKGROUND

Lung stereotactic body radiotherapy (SBRT) is considered a standard curative treatment for medically inoperable early stage non-small-cell lung cancer (NSCLC). Patients with ultracentral tumors (signifying tumors whose planning target volume touches or overlaps the central bronchial tree, esophagus, or pulmonary artery) may be at higher risk of serious toxicities such as bronchial stricture and collapse, esophageal strictures, tracheal-esophageal fistula, and hemorrhage. The primary objective of the study is to determine the maximum tolerated dose of radiotherapy for ultracentral NSCLC.

METHODS

This multicenter phase 1 dose-escalation study will use a time-to-event continual reassessment method (TITE-CRM). Accrual will start at level 1 (60 Gy in 8 fractions delivered daily). The model will use all available information from previously accrued patients to assign the highest dose with a predicted risk of grade 3-5 toxicity of 30% or less. All patients with newly diagnosed stage T1-3 N0M0 NSCLC (International Union Against Cancer, 8th edition) with tumor size ≤ 6 cm and meeting the criteria for ultracentral location (ie, tumors whose planning target volume touches or overlaps the central bronchial tree, esophagus, pulmonary vein, or pulmonary artery) will be eligible for this study.

DISCUSSION

It is important to identify a safe dose-fractionation regimen for treating ultracentral tumors with SBRT. In addition, the data from this study may be informative in guiding future studies on the use of SBRT in treating malignancies within the mediastinum-for example, for salvage treatment of mediastinal lymph nodes for recurrent NSCLC or mediastinal oligometastases.

A prospective study of telephonic contact and subsequent physical follow-up of radically treated lung cancer patients

BACKGROUND

We tested the hypothesis that telephonic follow-up (FU) may offer a convenient and equivalent alternative to physical FU of radically treated lung cancer patients.

DESIGN

Prospective study carried out at a tertiary referral cancer care institute, Mumbai.

MATERIALS AND METHODS

Two hundred consecutive lung cancer patients treated with curative intent were followed up regularly with telephonic interviews paired with their routine physical FU visits. Patient satisfaction with the telephonic call and the physical visit, the anxiety level of the patient after meeting the physician and the economic burden of the visit to the patient were noted in a descriptive manner. Kappa statistics was used to assess concurrence between the telephonic and physical impression of disease status.

RESULTS

With a median FU duration of 21.5 months, the median satisfaction scores for telephonic and physical FU were 8 and 9, respectively. The prevalence and bias adjusted kappa (PABAK) score of the entire cohort of patients was 0.64 (95% confidence interval [CI] =0.58-0.70). Data analyzed up to first disease progression/relapse on FU had a PABAK score of 0.71 (95% CI = 0.64-0.77) indicating substantial agreement. Patients with disease controlled at the FU had a significant PABAK score of 0.88 (95% CI = 0.80-0.94) indicating excellent concurrence. On average, each patient spent Rs. 5117.10 on travel and Rs. 3079.06 on lodging per FU visit.

CONCLUSION

Telephonic FU is substantially accurate in assessing disease status until the first relapse. In a resource-constrained country like India, it is worthwhile to further explore the benefits of such an alternative strategy.

Positioning high-dose radiation in multidisciplinary management of unresectable cholangiocarcinomas: review of current evidence

Cholangiocarcinoma is a rare malignancy of the bile ducts. The current standard of care for unresectable nonmetastatic disease is doublet systemic chemotherapy, which provides a median survival of 11.7 months. Although chemoradiation is a therapeutic option that provides almost equivalent or superior survival, the lack of level I evidence presents a major hurdle in routinely recommending it within multidisciplinary clinics. This mini review presents the current evidence on the use of chemoradiation for unresectable nonmetastatic cholangiocarcinoma and rationale for positioning it within multidisciplinary management of unresectable cholangiocarcinomas.

Effects of atrial natriuretic peptide in clinical acute renal failure

Fifty-three consenting patients meeting clinical and urine composition criteria for established intrinsic ARF were assigned to two treatment groups. Group I patients were treated with human atrial natriuretic peptide (ANP) with or without diuretics. Groups II patients were treated with or without diuretics and with no ANP. Age, sex, etiology of ARF, entry serum creatinines (SCr) (Group I, 5.3 +/- 1.8; Group II, 5.1 +/- 2.1 mg/dl) and creatinine clearances (CCr) (Group I, 9.9 +/- 2.1; Group II, 9.2 +/- 2.1 ml/min) were similar. Thirty patients received ANP [0.20 micrograms/kg/min i.v. x 24 hr (N = 20) or 0.08 micrograms/kg/min i.a. x 8 hr (N = 10)] and furosemide, 0.5 mg/kg/hr x 24 hr or mannitol, 12.5 g every six hours x 4, or no diuretic; 23 Group II patients received diuretics as above or no diuretic in a similar distribution to Group I. CCr (verified with simultaneous inulin clearances x 12, r = 0.93, P < 0.001) increased significantly by eight hours of ANP treatment to 17.1 +/- 3.2 ml/min and by 24 hours after discontinuing ANP to 21.0 +/- 4.4 ml/min (both P < 0.05). There was no corresponding increase in CCr in Group II. Dialysis was required in 23% of Group I and in 52% of Group II patients (different at P < 0.05). Mortality rates of 17% for Group I and 35% for Group II were not significantly different (P = 0.11). It is concluded that parenteral ANP increases CCr and reduces need for dialysis in patients with established intrinsic ARF.