Role of Stereotactic Body Radiation Therapy in Portal Vein Tumor Thrombosis in Hepatocellular Carcinoma: A Prospective Single Institute Experience

PURPOSE/OBJECTIVE(S)

Patients diagnosed with Hepatocellular carcinoma (HCC) complicated with portal vein tumor thrombosis (PVTT) have a limited number of treatment options available and are associated with an overall poor prognosis. With the recent developments in the field of radiation therapy, the role of radiotherapy particularly Stereotactic Body radiotherapy (SBRT) has increased as a loco-regional therapy for HCC. This study was planned to evaluate the role of SBRT in Locally advanced HCC complicated with PVTT and its role as loco-regional therapy.

MATERIALS/METHODS

We conducted a prospective study that included patients diagnosed with HCC complicated with PVTT Child-Turcotte Pugh (CTP) Class A/B with a maximum score of 7, diagnosed on triple phase Contrast-Enhanced - MRI unsuitable for other ablative procedures. Patients with Bilirubin levels > 4 mg/dl, active Hepatitis, CTP score >7, normal liver volume <700cc or history of prior radiotherapy were excluded from the study. Patients underwent a contrast enhanced 4D-CT simulation with abdominal compression and were planned for SBRT using VMAT technique. Patients were followed-up as per Institute protocol. CECT or MRI for a radiological response was done for response assessment using mRECIST criteria version 1.1. A baseline MRI was done at one-month post-SBRT to understand any RT changes in the liver and to differentiate from tumor progression during the response assessment at three months.

RESULTS

A total of 22 patients with HCC were recruited and received SBRT to PVTT, with a dosage between 30-42 Gy over 6 fractions treated on alternate days. Patients were assessed post-treatment with triphasic CE-MRI every 3 months as per institute protocol. Five patients had achieved Complete response in form of Portal vein recanalization. Three patients had Partial response to the treatment. Seven patients maintained stable disease status whereas six patients had disease progression during the entire course of treatment. The response rate (CR+PR) to treatment was 36.3% at the time of analysis. The Overall Response rate (CR+PR+SD) was 69%. No grade 3 or 4 toxicities were observed and treatment was tolerated well by patients. Kaplan-Meier method was applied to calculate the survival probability at various follow-up intervals. The median time for overall survival was 25 months ((95% CI: 15-35). Out of the 22 subjects included in the study, 6 patients died. There was a 78% survival probability at 12 months and a 68% survival probability at 18 months of follow-up.

CONCLUSION

This prospective single-arm study demonstrated the vital role of SBRT in the treatment of Hepatocellular carcinoma with Portal vein tumor thrombosis and its efficacy in terms of achieving excellent local control with relatively lesser toxicities compared with existing treatment modalities. Patients have shown benefit post-treatment in terms of thrombus reduction and restoration of Portal vein flow making them suitable for further treatment like Resection or TACE.

Biological Response Assessment in Hepatocellular Carcinoma Post Stereotactic Body Radiotherapy

PURPOSE/OBJECTIVE(S)

Biological Response in Hepatocellular carcinoma (HCC) is measured in terms of serum alpha-fetoprotein (AFP) which is elevated in nearly 60% HCC patients at baseline and is directly related to the severity of the disease. This biological response is defined as the reduction of more than 50% from the baseline levels and is associated with an increased percentage of tumor necrosis and is directly related to increased loco-regional control. Patients diagnosed with HCC have very limited treatment modalities. With the recent advances in the field of radiation therapy and the development of Stereotactic Body radiotherapy (SBRT), the role of radiotherapy has increased as a loco-regional modality for HCC. In this single-arm prospective study, we evaluated the biological response post-SBRT in patients diagnosed with HCC.

MATERIALS/METHODS

We conducted a prospective study that included patients diagnosed with HCC with baseline elevation of serum AFP, Child-Turcotte Pugh (CTP) Class A/B with a maximum score of 7. Patient's serum AFP levels were recorded at baseline, pre-treatment, and post-treatment. The biological response was measured at 3 months post-treatment and compared with the baseline serum AFP levels using Wilcoxon signed rank test.

RESULTS

A total of 14 patients with HCC were recruited and received SBRT to the target lesion, with a dose between 30-42 Gy over 6 fractions treated on alternate days. Patients were assessed post-treatment at one month with triphasic CEMRI and serum AFP levels. 12 out of 14 patients (85.71%) had a biological response at 3 months follow-up and levels showed further decline unless a progression was found. The median (IQR) serum AFP level was 1131 ng/ml (359-5668 ng/ml) at baseline. Post-treatment serum AFP levels had a median (IQR) value of 156 ng/ml (15-372 ng/ml) showing a near reduction of 86% from baseline, which was significant. 2/14 pts (14.28%) showed no reduction or even increase in serum AFP levels post-treatment.

CONCLUSION

This prospective single-arm study demonstrated the vital role of SBRT in the treatment of HCC and its importance in achieving a better disease control. The response was achieved in 86% of patients with marked reduction of nearly 90% in serum AFP levels as compared to the baseline and increased median OS and PFS as compared to patients not receiving radiotherapy. Further prospective studies are warranted to confirm our findings.

A Reinvestigation of the Role of the Sorbic Acid Tail on the Antibacterial and Anti-Tuberculosis Properties of Moiramide B

Due to worldwide increasing resistances, there is a considerable need for antibacterial compounds with modes of action not yet realized in commercial antibiotics. One such promising structure is the acetyl-CoA carboxylase (ACC) inhibi-tor moiramide B which shows strong antibacterial activity against gram-positive bacteria such as Bacillus subtilis and weaker activities against gram-negative bacteria. However, the narrow structure-activity relationship of the pseudopeptide unit of moiramide B represents a formidable challenge for any opti-mization strategy. ​In contrast, the lipophilic fatty acid tail is considered an unspe-cific vehicle responsible only for the transport of moiramide into the bac-terial cell. Here we show that the sorbic acid unit, in fact, is highly relevant for ACC inhibition. A hitherto undescribed sub-pocket at the end of the sorbic acid channel binds strongly aromatic rings and allows the development of moiramide derivatives with altered antibacterial profiles including anti-tubercular activity.

Vented Individual Patient (VIP) Hoods for the Control of Infectious Airborne Diseases in Healthcare Facilities

By providing a means of separating the airborne emissions of patients from the air breathed by healthcare workers (HCWs), vented individual patient (VIP) hoods, a form of local exhaust ventilation (LEV), offer a new approach to reduce hospital-acquired infection (HAI). Results from recent studies have demonstrated that, for typical patient-emitted aerosols, VIP hoods provide protection at least equivalent to that of an N95 mask. Unlike a mask, hood performance can be easily monitored and HCWs can be alerted to failure by alarms. The appropriate use of these relatively simple devices could both reduce the reliance on personal protective equipment (PPE) for infection control and provide a low-cost and energy-efficient form of protection for hospitals and clinics. Although the development and deployment of VIP hoods has been accelerated by the coronavirus disease 2019 (COVID-19) pandemic, these devices are currently an immature technology. In this review, we describe the state of the art of VIP hoods and identify aspects in need of further development, both in terms of device design and the protocols associated with their use. The broader concept of individual patient hoods has the potential to be expanded beyond ventilation to the provision of clean conditions for individual patients and personalized control over other environmental factors such as temperature and humidity.

Does Silver in Different Forms Affect Bacterial Susceptibility and Resistance? A Mechanistic Perspective

The exceptional increase in antibiotic resistance in past decades motivated the scientific community to use silver as a potential antibacterial agent. However, due to its unknown antibacterial mechanism and the pattern of bacterial resistance to silver species, it has not been revolutionized in the health sector. This study deciphers mechanistic aspects of silver species, i.e., ions and lysozyme-coated silver nanoparticles (L-Ag NPs), against E. coli K12 through RNA sequencing analysis. The obtained results support the reservoir nature of nanoparticles for the controlled release of silver ions into bacteria. This study differentiates between the antibacterial mechanism of silver species by discussing the pathway of their entry in bacteria, sequence of events inside cells, and response of bacteria to overcome silver stress. Controlled release of ions from L-Ag NPs not only reduces bacterial growth but also reduces the likelihood of resistance development. Conversely, direct exposure of silver ions, leads to rapid activation of the bacterial defense system leading to development of resistance against silver ions, like the well-known antibiotic resistance problem. These findings provide valuable insight on the mechanism of silver resistance and antibacterial strategies deployed by E. coli K12, which could be a potential target for the generation of aim-based and effective nanoantibiotics.

Pre-coating of protein modulate patterns of corona formation, physiological stability and cytotoxicity of silver nanoparticles

Surface functionalization on silver nanoparticles greatly affects the dynamics of protein corona formation. In the present study, the implications of protein pre-coating on corona formation and nanoparticle's physiological stability, cellular uptake and toxicity were studied on similar sized alkaline protease coated nanoparticles of biological and chemical origin along with the uncoated nanoparticle as compared to the albumin coated nanoparticles. All four nanoparticle types invited serum protein adsorption on their surface. However, the presence of protein pre-coating on nanoparticle surface significantly reduced the extent of further protein binding. Moreover, corona formation on pristine nanoparticles significantly improved their stability in the biological medium. The effect was found to be diluted in protein pre-coated nanoparticles with due exception. Results obtained in the cell-based experiment suggested that the nanoparticles binding to the cell, its uptake, and toxicity in different cell lines can be directly linked to their physiological stability owing to corona formation.

Silver Nanoparticles Induce a Triclosan-Like Antibacterial Action Mechanism in Multi-Drug Resistant Klebsiella pneumoniae

Infections associated with antimicrobial-resistant bacteria now represent a significant threat to human health using conventional therapy, necessitating the development of alternate and more effective antibacterial compounds. Silver nanoparticles (Ag NPs) have been proposed as potential antimicrobial agents to combat infections. A complete understanding of their antimicrobial activity is required before these molecules can be used in therapy. Lysozyme coated Ag NPs were synthesized and characterized by TEM-EDS, XRD, UV-vis, FTIR spectroscopy, zeta potential, and oxidative potential assay. Biochemical assays and deep level transcriptional analysis using RNA sequencing were used to decipher how Ag NPs exert their antibacterial action against multi-drug resistant Klebsiella pneumoniae MGH78578. RNAseq data revealed that Ag NPs induced a triclosan-like bactericidal mechanism responsible for the inhibition of the type II fatty acid biosynthesis. Additionally, released Ag+ generated oxidative stress both extra- and intracellularly in K. pneumoniae. The data showed that triclosan-like activity and oxidative stress cumulatively underpinned the antibacterial activity of Ag NPs. This result was confirmed by the analysis of the bactericidal effect of Ag NPs against the isogenic K. pneumoniae MGH78578 ΔsoxS mutant, which exhibits a compromised oxidative stress response compared to the wild type. Silver nanoparticles induce a triclosan-like antibacterial action mechanism in multi-drug resistant K. pneumoniae. This study extends our understanding of anti-Klebsiella mechanisms associated with exposure to Ag NPs. This allowed us to model how bacteria might develop resistance against silver nanoparticles, should the latter be used in therapy.

A brief review of recent discoveries in human anatomy

In the last few years, a cluster of anatomical discoveries has been reported which overturned the long existing dogmas about the structure and function of human body. First to come was the discovery that established the existence of a lymphatic system pertaining to the central nervous system (CNS). CNS was believed to be anatomically immune privileged owing to the absence of any lymphatics and presence of the blood-brain barrier around it, but latest research has established beyond any reasonable doubt that true lymphatic channels carry immune cells in meninges thus challenging the existing theory. Studies also supported the presence of a 'Glymphatic system' (created by the perivascular spaces lined with the leptomeninges and a sheath of glial cells) in the CNS draining interstitial metabolic waste from CNS. The second discovery unraveled the previously unknown parts of the human mesentery in adult and established that it is a continuous entity all along the intra-abdominal gut tube against the previous notion that it is fragmented in the adult humans. A very recently reported third discovery demonstrated a previously unknown tissue component-'interstitium'-a networked collagen bound fluid-filled space existent in a number of human organs. All these structures bear considerable applied importance towards the pathogenesis, prognostic and diagnostic investigations and management of human diseases. This article attempts to present a brief review of all three remarkable discoveries and emphasizes their applied importance within the realm of medical sciences.

Formation and Characterization of Protein Corona Around Nanoparticles: A Review

Recent years have witnessed unprecedented increase in the use of nanoparticles in various sectors viz. electronics, catalysis, agriculture, textile, cosmetics, bio-medicine, packaging, house-holds and food-associated consumer products. This has led to the inevitable release of nanoparticles into the environment, which can have negative impact on living beings. Humans can also be exposed to these nanoparticles either intentionally or accidently. Nanoparticles can enter in the human body through food chain, inhalation, open wounds, drugs and intravenous injections etc. In majority of these cases, the nanoparticles may pass through the various cell layers, cell sap and finally enter into the blood. Upon interaction with biological fluid, nanoparticles come in close proximity particularly to the proteins present in the fluid. The assembly of proteins surrounding the nanoparticle's surface is called as protein corona and their complex is known as protein-nanoparticle complex. Formation of protein corona is a vibrant and driving process, which plays a pivotal role in the functioning of nanoparticles in biological systems. Moreover, due to interaction of proteins with nanoparticles, conformational changes may occur in the native structure of protein, which may lead to change in the functioning of proteins towards its cellular interaction. The present review provides in-depth knowledge about the formation of protein corona around nanoparticles and the factors regulating this process. Further, it discusses various techniques that can be used for the protein corona analysis and obtaining information about molecular consequences upon nanoparticle's exposure. Finally, the functional aspects of protein-nanoparticle complex have been discussed in detail. In-depth understanding of protein-nanoparticles complex can be instrumental to generate well-suited nanoparticles with desired surface characteristics in the way to biological application.

Superior Bactericidal Efficacy of Fucose-Functionalized Silver Nanoparticles against Pseudomonas aeruginosa PAO1 and Prevention of Its Colonization on Urinary Catheters

Pseudomonas aeruginosa, a Gram-negative rod-shaped bacterium is a notorious pathogen causing chronic infections. Its ability to form antibiotic-resistant biofilm has raised the need for the development of alternative treatment approaches. An ideal alternate can be silver nanoparticles known for their strong yet tunable bactericidal activity. However, their use in commercial in vivo medicine could not see the light of the day because of the unwanted toxicity of silver in the host cells at higher concentrations. Thus, strategies which can modulate the bacterial cell-silver nanoparticle interactions thereby reducing the amount of nanoparticles required to kill a typical number of bacterial cells are utmost welcomed. The current work showcases one such strategy by functionalizing the silver nanoparticles with l-fucose to increase their interactions with the LecB lectins present on P. aeruginosa PAO1. The advantage of this approach lies in the higher bactericidal and antibiofilm activity of fucose-functionalized silver nanoparticles (FNPs) as compared to the citrate-capped silver nanoparticles (CNPs) of similar size and concentrations. The superior bactericidal potential of FNPs as demonstrated by fluorescence-assisted cell sorting, confocal laser scanning microscopy, and transmission electron microscopy analyses may be attributed to the higher reactive oxygen species generation and oxidative membrane damage. Additionally, FNPs prevented the formation of biofilms by downregulating the expression of various virulence genes at lower concentrations as compared to CNPs. The practical applicability of the approach was demonstrated by preventing bacterial colonization on artificial silicone rubber surfaces. These results can be extrapolated in the treatment of catheter-associated urinary tract infections caused by P. aeruginosa. In conclusion, the present work strongly advocates the use of antivirulence targets and their corresponding binding residues for the augmentation of the bactericidal effect of silver nanoparticles.

Do physico-chemical properties of silver nanoparticles decide their interaction with biological media and bactericidal action? A review

The unprecedented increase in antibiotic resistance in this era has resuscitated the attention of scientific community to exploit silver and its various species as antimicrobial agents. Plenty of studies have been done to measure the antimicrobial potential of silver species (cationic silver, metallic Ag⁰ or silver nanoparticles, silver oxide particulates etc.) and indicated that membrane damage, oxidative stress, protein dysfunction and DNA damage to be the possible cause of injury to the microbial cell. However, the precise molecular mechanism of their mode of action has remained unclear, which makes an obstacle towards the generation of potential antibacterial agent against various pathogenic and multidrug resistant (MDR) bacteria. In order to endeavor this issue, one should first have the complete understanding about the resistance mechanisms present in bacteria that can be a therapeutic target for the silver-based drug formulations. Apart from this, in-depth understanding of the interactions of various silver species (with the biological media) is a probable deciding factor for the synthesis of silver-based drug formulations because the particular form and physico-chemical properties of silver can ultimately decide their antimicrobial action. In context to above mentioned serious concerns, the present article aims to discuss the mechanisms behind the confrontation of bacteria against various drugs and the effect of physico-chemical properties of silver species on their bactericidal action as well as critically evaluates the available reports on bacterial transcriptomic and proteomic profiles upon the exposure of various silver species. Further, this review state the mechanism of action that needs to be followed for the complete understanding of toxic potential of silver nanoparticles, which will open a possibility to synthesize new silver nanoparticle based antimicrobial systems with desired properties to ensure their safe use, exposure over extended period and fate in human body and environment.