Clinical practice guidelines for molecular tumor marker, 2nd edition review part 2

In recent years, rapid advancement in gene/protein analysis technology has resulted in target molecule identification that may be useful in cancer treatment. Therefore, "Clinical Practice Guidelines for Molecular Tumor Marker, Second Edition" was published in Japan in September 2021. These guidelines were established to align the clinical usefulness of external diagnostic products with the evaluation criteria of the Pharmaceuticals and Medical Devices Agency. The guidelines were scoped for each tumor, and a clinical questionnaire was developed based on a serious clinical problem. This guideline was based on a careful review of the evidence obtained through a literature search, and recommendations were identified following the recommended grades of the Medical Information Network Distribution Services (Minds). Therefore, this guideline can be a tool for cancer treatment in clinical practice. We have already reported the review portion of "Clinical Practice Guidelines for Molecular Tumor Marker, Second Edition" as Part 1. Here, we present the English version of each part of the Clinical Practice Guidelines for Molecular Tumor Marker, Second Edition.

Risk factors for liver-related mortality of patients with hepatitis C virus after sustained virologic response to direct-acting antiviral agents

BACKGROUND AND AIM

The aim of this study was to identify the factors associated with liver-related and non-liver-related mortality of patients with hepatitis C virus (HCV) after sustained virologic response (SVR) to direct-acting antiviral agents (DAAs).

METHODS

We conducted a retrospective, single-center cohort study of HCV patients cured by DAAs.

RESULTS

A total of 330 patients with SVR to DAAs were eligible. The median follow-up period was 3.38 years (inter-quartile range: 2.03-4.58). The cumulative liver-related or non-liver-related mortality rates at 1, 3, and 5 years were 0.00 or 1.29%, 2.87 or 3.60%, and 5.10 or 9.46, respectively. Among the liver-related deaths, 9 of the 10 were from liver cancer. Among the non-liver-related deaths, the most common cause was malignancy. Through multivariate analysis using the Cox proportional hazard model, diabetes mellitus (DM, hazard ratio 13.1, 95% confidence interval 2.81-61.3) and a history of hepatocellular carcinoma (HCC, 12.8, 2.76-59.2), independently predicted liver-related death. No variables were associated with non-liver-related death.

CONCLUSION

Our findings suggest that DM and a history of HCC are risk factors for liver-related mortality of HCV patients cured by DAAs. These results indicate that early management of HCV and HCC surveillance of diabetic patients after SVR are important to increase the chance of survival. Further studies are needed to confirm the association of DM and HCC history with survival.

Effects of endoscopic injection sclerotherapy for esophagogastric varices on portal hemodynamics and liver function

OBJECTIVES

To identify patients suitable for endoscopic injection sclerotherapy (EIS) by evaluating their portal hemodynamics and liver function.

METHODS

We selected 58 patients with esophagogastric varices (EGV) and liver cirrhosis (LC) related to either hepatitis C virus (C) (n = 19), hepatitis B virus (n = 2), alcohol (AL) (n = 20), C + AL (n = 6), non-alcoholic steatohepatitis (n = 6), others (n = 3), or non-LC (n = 2). All patients underwent EIS. We measured their portal venous tissue blood flow (PVTBF) and hepatic arterial tissue blood flow (HATBF) using xenon computed tomography before and after EIS. We classified them into increased group and decreased group according to the PVTBF to identify the predictors that contribute to PVTBF increase post-EIS.

RESULTS

Low value of indocyanine green retention at 15 min (ICG-R₁₅), the absence of paraesophageal veins, and low baseline PVTBF/HATBF (P/A) ratio predicted increased PVTBF in the multivariate logistic analysis (odds ratio (OR) 10.46, p = 0.0391; OR 12.45, p = 0.0088; OR 13.57, p = 0.0073). The protein synthetic ability improved 1 year post-EIS in increased group. Cox proportional hazards regression identified alcohol drinking (hazard ratio; 3.67, p = 0.0261) as an independent predictor of EGV recurrence.

CONCLUSIONS

Patients with low ICG-R₁₅, low P/A ratio, and the absence of paraesophageal veins were probable predictors of PVTBF improvement post-EIS. In addition, the improvement of hepatic hemodynamics likely enhanced liver function following EIS.

Prediction of esophagogastric varices associated with oxaliplatin administration

Background

Oxaliplatin is a key drug for the chemotherapy of colorectal cancer; however, it is also known to cause non‐cirrhotic portal hypertension. We aimed to identify the characteristics of patients who developed esophagogastric varices (EGVs) after treatment with oxaliplatin.

Methods

This study retrospectively analyzed patients with colorectal cancer who were treated with chemotherapy including oxaliplatin between 2010 and 2016. All patients were evaluated by contrast‐enhanced computed tomography (CE‐CT) every 3 months both during and after treatment; and endoscopy was performed when appearance of portal hypertension was suspected.

Results

A total of 106 patients were divided into two groups: EGV formation (n = 6) and EGV non‐formation (n = 100). In the EGV group, platelet counts decreased and the size of the spleen calculated by CT (CT spleen index; CT‐SI) increased markedly. The highest area under the receiver operating characteristic curve (AUC) for the change in platelet counts was 0.81 (80% sensitivity and 83% specificity) at 3 months post treatment, and the maximum AUC for CT‐SI was 0.89 (79% sensitivity and 83% specificity) at 6 months post treatment.

Conclusions

EGV formation could be predicted by the assessment of platelet counts and spleen size. If progressive splenomegaly and thrombocytopenia are observed not only during but also after completion of the oxaliplatin‐containing chemotherapy, EGVs should be confirmed by endoscopy for avoiding subsequent rupture.

Characteristics and Prognosis of De Novo Hepatocellular Carcinoma After Sustained Virologic Response

Hepatocellular carcinoma (HCC) can de novo develop in patients with chronic hepatitis C even after the achievement of sustained virologic response (SVR). We characterized de novo HCC after SVR, comparing it with HCC that developed in patients during persistent hepatitis C virus (HCV) infection. Characteristics, survival rates, and recurrence rates after curative treatment in 178 patients who developed initial HCC after SVR diagnosed between 2014 and 2020 were compared with those of 127 patients with initial HCC that developed during persistent HCV infection diagnosed between 2011 and 2015; HCC was detected under surveillance in both groups. HCC was less advanced and liver function worsened less in patients with SVR than in patients with persistent HCV. The survival rate after diagnosis was significantly higher for patients with SVR than for patients with persistent HCV (1-, 3-, and 5-year survival rates, 98.2%, 92.5%, and 86.8% versus 89.5%, 74.7%, and 60.8%, respectively; P < 0.001). By contrast, the recurrence rate after curative treatment was similar between groups (1-, 3-, and 5-year recurrence rates, 11.6%, 54.6%, and 60.4% versus 24.0%, 46.7%, and 50.4%, respectively; P = 0.7484). Liver function improved between initial HCC diagnosis and recurrence in patients with SVR (P = 0.0191), whereas it worsened in the control group (P < 0.001). In addition, patients with SVR could receive curative treatment for recurrence more frequently than patients with persistent HCV (80.4% versus 47.8%, respectively; P = 0.0008). Conclusion: Survival of patients with de novo HCC after SVR was significantly higher than that of patients in whom HCC developed during persistent HCV infection, despite similar rates of recurrence after curative treatment. A higher prevalence of curative treatment for recurrent HCC and improved liver function contributed to this result.

Microvascular response to locally injected collagenase. An experimental investigation in hamsters and rabbits

Collagenase was injected into the ears of rabbits and the cheek-pouches of hamsters. The acute and long-term microvascular effects were studied by vital microscopy and microangiography. The enzyme was injected at three different concentrations: 120 units/ml, 600 units/ml and 3,000 units/ml. The medium (600 units/ml) and high (3,000 units/ml) concentrations induced effects on the microcirculation such as blood flow impairment and microbleedings. The magnitude of these effects was related to the concentration of the enzyme. Generally, these microvascular effects were of low magnitude as compared with other substances tested using the same experimental models.

The effect of antihistamines and indomethacin on microvascular permeability changes due to repeated pressure-induced local ischemia

Indomethacin can reduce the microvascular permeability induced by repeated ischemia. In this investigation the influence of histamine H1 and H2 receptor blockers was studied for comparison with indomethacin. Application of 60 mmHg pressure to the hamster cheek pouch for 5 min was repeated eight times, with 10-min restitution intervals. Altered permeability was evaluated with use of FITC-dextran and intravital microscopy. Progressive efflux of FITC-dextran was observed in the control group. When either diphenhydramine or indomethacin was used alone, a few spots of extravasated dye were seen. Combination of diphenhydramine with either indomethacin or cimetidine reduced the extravasation. Furthermore, the spots appeared significantly later than in the controls, and some faded. Increase in the efflux of macromolecules due to repeated ischemia seems to be mediated via H1 and H2 receptors in conjunction with other receptors and/or amines e.g. prostaglandins.

Mechanical effects of compression of peripheral nerves

Effects of graded compression on nerve function were analyzed in order to evaluate the relative importance of pressure level and duration of compression for functional deterioration. The pressure was applied by means of a small inflatable cuff. The effects of two pressure levels, i.e., 80 mm Hg applied for 2 hr or 400 mm Hg applied for 15 min, were studied in rabbit tibial nerves. The lower pressure tested, which is known to induce ischemia of the compressed nerve segment, also causes some degree of mechanical deformation of the nerve trunk, which leads to incomplete recovery following pressure release. The duration of compression is of importance for the degree of nerve injury even at the higher pressure level tested.

Effects of collagenase on nerve tissue. An experimental study on acute and long-term effects in rabbits

Intradiscal injection of proteolytic enzymes implies a potential risk for exposure of nervous tissue to the enzyme solution. In the present study, the effects on peripheral nerve tissue of application of a solution containing a clinically recommended concentration of collagenase have been evaluated. Acute experiments showed that the enzyme induces transient swelling at the site of application and edema in the epineurium. There were, however, no detectable effects on the permeability of the perineurium or the endoneurial microvascular bed. Four and 8 weeks later, there was a slight fibrosis in the epineurium, but neurophysiologic tests did not reveal any impairment of the nerve function. The results are discussed in terms of the clinical use of collagenase for dissolution of herniated intervertebral discs.

Microvascular changes due to repeated local pressure-induced ischemia: intravital microscopic study on hamster cheek pouch

Pressure ulcer and tracheal injury occurring after endotracheal intubation are clinical examples of pressure-induced tissue damage where magnitude and duration of the applied pressure are of major importance. The objective of this study was to investigate the efflux of macromolecules caused by repeated short-time ischemia induced by a pressure of 60mmHg, which causes circulatory standstill. Pressure was applied to the hamster cheek pouch and the efflux of the macromolecules of the microvasculature was evaluated by using the fluorescein isothiocyanate (FITC) dextran dye and intravital microscopy. The pressure was applied for either 1 or 5 min and repeated 8 times with a 10min restitution period in between. The repeated 1min pressure caused almost no change in microvascular efflux of FITC-dextran while 5min repeated pressure did. The gross mechanical impact on the tissue seems to be equal in the 1 and 5min exposure and thus cannot explain the difference in the developed permeability. Ischemia of such short time as 1 and 5min does not alter the energy state of the tissue significantly. The reactive hyperemia and the mediating vasoactive amines can differ markedly after 1 and 5min ischemia and can thus contribute to the permeability alteration. However, the role of vasoactive amines is unclear and further experiments are needed to determine their role.