Activation of c-Yes in hepatocellular carcinoma： A preliminary study

TO THE EDITOR Hepatocellular carcinoma (HCC) is thought to develop through a multistep process[1]. A long history of viral hepatitis or prolonged exposure to environmental toxins predisposes liver cells to mutations of the genes critical in the control of hepatocyte growth. In fact, both activation of cellular oncogenes and inactivation of tumorsuppressor genes are involved in the development of HCC. Activation of oncogenes by hepatitis virus integration has been shown in the woodchuck animal model[2],although the significance of this finding in human hepatocarcinogenesis is still under investigation.     

Superantigen-SEA gene modified tumor vaccine for hepatocellular carcinoma： An in vitro study

AIM: To construct an eukaryotic superantigen gene expression vector containing the recombinant gene of SEA and CD80 molecule transmembrane region (CD80TM), and to express staphylococcus enterotoxin A (SEA) on the membrane of hepatocellular carcinoma (HCC) cell to form a superantigen gene modified tumor vaccine for HCC. METHODS: SEA and linker-CD80TM gene were amplified through PCR from plasmid containing cDNA of SEA and CD80. Gene fragments were then subcloned into the multiple cloning sites of retroviral vector pLXSN. Recombinant plasmid was transferred into HepG2 cells mediated with lipofectamine, positive clones were selected in culture medium containing G418. RT-PCR and indirect immunofluorescence studies confirmed that SEA was expressed specifically on HCC cell membrane. INFgamma-ELISPOT study demonstrated that SEA protein was expressed on the membrane of HCC cells. Cytotoxicity of HepG2-SEA primed CTLs (SEA-T) was analyzed by (51)Cr release assay. T cells cultured with rhIL-2 (IL-2-T) were used as control. RESULTS: Restriction digestion and sequence analyses confirmed the correctness of length, position and orientation of inserted fusion genes. SEA was expressed on the surface of HepG2 cells, HepG2-SEA had strong stimulating effect on production of HepG2 specific CTL (P<0.001). SEA-T had enhanced cytotoxicity to HepG2 cells (P<0.05). CONCLUSION: Tumor cell membrane expressed superantigen can be used to reinforce the immune effect of tumor cell vaccine for HCC, which provides a new method of the enhanced active immunotherapy for HCC.     

Radioembolization for the treatment of unresectable hepatocellular carcinoma： A clinical review

Hepatocellular carcinoma （HCC） is the sixth most common cancer in the world. The majority of patients with HCC present with unresectable disease. These patients have historically had limited treatment options secondary to HCC demonstrating chemoresistance to the currently available systemic therapies. Additionally, normal liver parenchyma has shown intolerance to tumoricidal radiation doses, limiting the use of external beam radiation. Because of these limitations, novel percutaneous liver-directed therapies have emerged. The targeted infusion of radioactive microspheres （radioembolization） represents one such therapy. Radioembolization is a minimally invasive transcatheter therapy through which radioactive microspheres are infused into the hepatic arteries that supply tumor. Once infused, these microspheres traverse the hepatic vascular plexus and selectively implant within the tumor arterioles. Embedded within the arterioles, the ^90y.impregnated microspheres emit high energy and low penetrating radiation doses selectively to the tumor. Radioembolization has recently shown promise for the treatment of patients with unresectable HCC. The objective of this review article is to highlight two currently available radioembolic devices ^90Y, ^188Rh） and provide the reader with a recent review of the literature.     

Intraperitoneal metastasis of hepatocellular carcinoma after spontaneous rupture： A case report

Rupture of hepatocellular carcinoma （HCC） is a lifethreatening complication. Peritoneal metastasis of HCC after spontaneous rupture was seldom noted. We report a case of intraperitoneal metastasis of HCC after spontaneous rupture. A previously asymptomatic 72-yearold man was admitted due to dull abdominal pain with abdominal fullness. He had a history of HCC rupture 10 mo ago and transarterial embolization was performed at that time. Abdominal computer tomograghy （CT） scan showed a huge peritoneal mass over the right upper quadrant area. Surgical resection was arranged and subsequent microscopic examination confirmed a diagnosis of moderately-differentiated HCC.     

Thrombocytosis： A paraneoplastic syndrome in patients with hepatocellular carcinoma

AIM: Hepatocellular carcinoma (HCC) patients manifest a variety of paraneoplastic syndromes. Thrombocytosis was reported in children with hepatoblastoma. The aims of this study were to evaluate the prevalence and dinical significance of thrombocytosis in HCC patients and its relationships with serum thrombopoietin (TPO).METHODS: We retrospectively reviewed clinical, biochemical and image data of 1 154 HCC patients. In addition, we measured platelet count and serum TPO in HCC patients with and without thrombocytosis, in patients with cirrhosis,chronic hepatitis and healthy subjects in a Eoss-sedJonal study.RESULTS: Thirty-one (2.7%) of 1 154 HCC patients had thrombocytosis (platelet count ≥400 K/mm^3). HCC patients with thrombocytosis were significantly younger, had a higher serum α-fetoprotein, higher rate of main portal vein thrombosis, larger tumor volume, shorter survival, and were less likely to receive therapy than HCC patients without thrombocytosis. Multivariate logistic regression analyses showed that tumor volumes ≥30% and serum α-fetoprotein≥ 140 000 ng/mL could significantly predict thrombocytosis.HCC patients with thrombocytosis had a significantly higher mean serum TPO than those without, as well as patients with cirrhosis, chronic hepatitis and healthy subjects.Platelet count and serum TPO dropped significantly after tumor resection in HCC patients with thrombocytosis and re-elevated after tumor recurred. Furthermore, the expression of TPO mRNA was found to be more in tumor tissues than in non-tumor tissues of liver in an HCC patient with thrombocytosis.CONCLUSION: Thrombocytosis is a paraneoplastic syndrome of HCC patients due to the overproduction of TPO by HCC.It is frequently associated with a large tumor volume and high serum α-fetoprotein.     

Association between hepatocellular carcinoma and type 2 diabetes mellitus in Italy： Potential role of insulin

AIM： To investigate the relationships between Type 2 diabetes mellitus （DM2） and the risk of hepatocellular carcinoma （HCC）.
METHODS： We studied the association between DM2 and HCC in a large case-control study that enrolled 465 consecutive Caucasian patients with HCC （78.3% males, mean age 68.5 ± 8.9 years） compared with an age and sex matched control group of 490 subjects. RESULTS： Prevalence of DM2 was significantly higher in HCC patients （31.2% vs 12.7%; OR = 3.12, 95% CI： 2.22-4.43） and in HCC cases with alcohol abuse. DM2 has been diagnosed before the appearance of HCC in 84.1% of diabetic HCC subjects with mean duration of 141.5 mo, higher in cases treated with insulin than in those with oral antidiabetic agents （171.5 vs 118.7 mo）. Compared to controls, males DM2 with HCC were more frequently treated with insulin （38.1% vs 17.6%, P = 0.009） and with sulfonylurea with or without metformin than with diet with or without metformin （84% vs 68.3%, P = 0.049）. CONCLUSION： DM2 in our patients is associated with a 3-fold increase risk of HCC. In most of our cases DM2 pre-existed to HCC. Patients with DM2 and chronic liver disease, particularly insulin treated males, should be considered for HCC close surveillance programs.     

Anatomic and technical skill factor of gastroduodenal complication in post-transarterial embolization for hepatocellular carcinoma：A retrospective study of 280 cases

AIM: To reduce the possibility of gastroduodenal complications. The purpose of this retrospective study was to survey the literature and compare and discuss the incidence of post-transarterial embolization (TAE) gastroduodenal complications. METHODS: We found reports describing 280 cases of hepatocellular carcinoma with TAE procedures done during the past 4 years and selected all of them for our study. Amongst these cases, 86 were suspected of suffering gastroduodenal complications within one month of post-TAE treatment. Fifteen of these cases were proved by pan-endoscopy to have gastroduodenal erosions or ulcerations. We reviewed the angiographic pictures in patient records to evaluate the possibility that anatomic and technical skill factors could explain the complications. RESULTS: Amongst the 15 cases, 9 were primary lesions of the antrum and prepylorus; 4 had duodenal ulcer or erosions; 2 had mid-body lesions; none showed a lesion at the fundus or cardia region. Three cases had not received TAEs using our ideal method, and may be associated with possible regurgitation of gel-foam pieces into the right or left gastric arteries. Two cases involved sub-selective embolization at a distal point on the hepatic artery; one case was found by angiography to have complete occlusion of the celiac trunk. CONCLUSION: Comparing our results with past cases of post-TAE gastroduodenal complications, we surmise that our relatively low incidence (5.3%) of gastric complications might be explained by our concerted efforts to improve our technical skills in multi-sequential, selective and super-selective approaches to the embolization of tumor vessels.     

Surgical treatment of hepatocellular carcinoma： Evidencebased outcomes

Surgeons may be severely criticized from the perspective of evidence-based medicine because the majority of surgical publications appear not to be convincing. In the top nine surgical journals in 1996, half of the 175 publications refer to pilot studies lacking a control group, 18% to animal experiments, and only 5% to randomized controlled trials （RCT）. There are five levels of clinical evidence： level 1 （randomized controlled trial）, level 2 （prospective concurrent cohort study）, level 3 （retrospective historical cohort study）, level 4 （pre-post study）, and level 5 （case report）. Recently, a Japanese evidence-based guideline for the surgical treatment of hepatocellular carcinoma （HCC） was made by a committee （Chairman, Professor Makuuchi and five members）. We searched the literature using the Medline Dialog System with four keywords： HCC, surgery, English papers, in the last 20 years. A total of 915 publications were identified systematically reviewed. At the first selection （in which surgery-dominant papers were selected）, 478 papers survived. In the second selection （clearly concluded papers）, 181 papers survived. In the final selection （clinically significant papers）, 100 papers survived. The evidence level of the 100 surviving papers is shown here： level-1 papers （13%）, level-2 papers （11%）, level-3 papers （52%）, and level-4 papers （24%）; therefore, there were 24% prospective papers and 76% retrospective papers. Here, we present a part of the guideline on the five main surgical issues： indication to operation, operative procedure, peri-operative care, prognostic factor, and post-operative adjuvant therapy.     

Direct invasion to the colon by hepatocellular carcinoma： Report of two cases

Although hepatocellular carcinoma （HCC） is a common tumor, direct invasion of the gastrointestinal tract by HCC is uncommon. Recently, we encountered two cases of HCC with direct invasion to the colon. The first patient was a 79-year-old man who underwent transarterial chemo-embolization （TACE） for HCC 1.5 years prior to admission to our hospital. Computed tomography （CT） showed a 7.5-cm liver tumor directly invading the transverse colon. Partial resection of the liver and transverse colon was performed. The patient survived 6 mo after surgery, but died of recurrent HCC. The second patient was a 69-year-old man who underwent TACE and ablation for HCC 2 years and 7 months prior to being admitted to our hospital for melena and abdominal distension. CT revealed a 6-cm liver tumor with direct invasion to the colon. The patient underwent partial resection of the liver and right hemicolectomy. The patient recovered from the surgery. But, unfortunately, he died of liver failure due to liver cirrhosis one month later. Although the prognosis of HCC that has invaded the colon is generally poor due to the advanced stage of the disease, surgical resection may be a favorable treatment option in patients with a good general condition.     

Angiogenesis of hepatocellular carcinoma: An immunohistochemistry study

BACKGROUND Although hepatocellular carcinoma(HCC) is one of the most vascular solid tumors, antiangiogenic therapy has not induced the expected results.AIM To uncover immunohistochemical(IHC) aspects of angiogenesis in HCC.METHODS A retrospective cohort study was performed and 50 cases of HCC were randomly selected. The angiogenesis particularities were evaluated based on the IHC markers Cyclooxygenase-2(COX-2), vascular endothelial growth factor(VEGF) A and the endothelial area(EA) was counted using the antibodies CD31 and CD105.RESULTS The angiogenic phenotype evaluated with VEGF-A was more expressed in small tumors without vascular invasion(pT1), whereas COX-2 was rather expressed in dedifferentiated tumors developed in non-cirrhotic liver. The CD31-related EA value decreased in parallel with increasing COX-2 intensity but was higher in HCC cases developed in patients with cirrhosis. The CD105-related EA was higher in tumors developed in patients without associated hepatitis.CONCLUSION In patients with HCC developed in cirrhosis, the newly formed vessels are rather immature and their genesis is mediated via VEGF. In patients with non-cirrhotic liver, COX-2 intensity and number of mature neoformed vessels increases in parallel with HCC dedifferentiation.     

RNAi及其在肝癌治疗中的作用

RNA干扰(RNAi)是指生物体内利用双链RNA诱导同源靶基因的mRNA特异性降解,导致转录后基因沉默的现象.近年来,RNA干扰技术在医学研究中的广泛应用取得显著的基因沉默效果,RNAi以其高特异性、高效性等显著优势将成为研究基因功能的新手段.此文综述该技术的发现、定义、机制、特征等及其在肝癌治疗中的应用.     

原发性肝癌基因治疗的研究进展

针对原发性肝癌的传统治疗方法疗效欠佳、预后较差，基因治疗成为新的研究方向和热点。新的基因治疗策略不断涌现，载体系统不断更新，导人方法不断优化，动物模型不断改进，本文就以上方面进行综述。     

Capecitabine in advanced hepatocellular carcinoma: A multicenter experience

BackgroundRecent data suggest a potential activity and a good tolerability of capecitabine in advanced hepatocellular carcinoma (HCC).AimsTo evaluate capecitabine activity and safety in a wide cohort of advanced HCC patients.MethodsRetrospective analysis of 143 capecitabine-treated patients (January 2010 to December 2017) in three centers of the Veneto Oncology Network.ResultsCapecitabine was administered in second and third line, but also in first line instead of sorafenib in Child-Pugh B patients (70%), compromised clinical conditions (14%) or contraindications to antiangiogenetics (16%). Median overall survival (OS) and time to progression (TTP) were 6.9 and 2.8 months, respectively. There were no differences in OS and TTP between the 32 patients treated with non-metronomic scheme (2000 mg/day for 14 days) and the 111 patients treated with metronomic scheme (1000 mg/day) after correction for prognostic factors at baseline with a propensity score analysis. Capecitabine was more active in patients intolerant to sorafenib than in those progressing during treatment (p = 0.024). At least one adverse event (mainly hematological) was experienced by 73% of patients but discontinuation was necessary only in 11 (8%).ConclusionsCapecitabine can be considered an active and safe option in advanced HCC, especially for patients unfit for other treatments.     

多模式介入治疗伴失代偿性肝硬化肝癌

目的探讨伴失代偿性肝硬化肝细胞癌（HCC）多模式介入治疗的临床价值。方法在内科治疗稳定后,147例伴肝硬化失代偿HCC患者接受不同介入模式的治疗,其中36例采用肝动脉化学栓塞（TACE,A组）,54例采用肝动脉节段性化学栓塞治疗（S-TACE,B组）,57例采用S-TACE后序贯射频消融（RFA）或（加）无水乙醇局部注射（PEI）的多模式介入治疗（C组）。结果随访6～72月,A组、B组和C组患者中位生存期分别为4．1月、9．4月（P〈0．05）和13．7月（P〈0．01和P〈0．05）;累计生存率6个月分别为22．2％、51．8％（P〈0．05）和75．44％（P〈0．01）,12个月分别为5．6％、31．5％（P〈0．05）和40．35％（P〈0．05）,24个月分别为0、9．3％和19．30％（P〈0．05）;AFP复常率分别为23．3％、60．5％（P〈0．05）和71．1％（P〈0．01）;瘤体缩小（〉50％）分别占8．3％、31．5％（P〈0．05）和50．9％（P〈0．01）。单变量分析显示包括HBVDNA在内的14项因素与预后显著相关,多因素Cox模型分析显示肝功能Child—Pugh分级、吲哚氰绿15min储留率（ICGR,s）、门静脉癌栓、介入模式及甲胎蛋白术前升高者介入后变化与预后显著相关。结论多模式介入治疗是伴肝功能失代偿HCC的有效治疗方法,对HBVDNA阳性患者应该考虑抗病毒治疗。     

Optimal combination of antiangiogenic therapy for hepatocellular carcinoma

The success of sorafenib in prolonging survival of patients with hepatocellular carcinoma (HCC) makes therapeutic inhibition of angiogenesis a component of treatment for HCC. To enhance therapeutic efficacy, overcome drug resistance and reduce toxicity, combination of antiangiogenic agents with chemotherapy, radiotherapy or other targeted agents were evaluated. Nevertheless, the use of antiangiogenic therapy remains suboptimal regarding dosage, schedule and duration of therapy. The issue is further complicated by combination antiangiogenesis to other cytotoxic or biologic agents. There is no way to determine which patients are most likely respond to a given form of antiangiogenic therapy. Activation of alternative pathways associated with disease progression in patients undergoing antiangiogenic therapy has also been recognized. There is increasing importance in identifying, validating and standardizing potential response biomarkers for antiangiogenesis therapy for HCC patients. In this review, biomarkers for antiangiogenesis therapy including systemic, circulating, tissue and imaging ones are summarized. The strength and deficit of circulating and imaging biomarkers were further demonstrated by a series of studies in HCC patients receiving radiotherapy with or without thalidomide.     

Non-surgical treatment of hepatocellular carcinoma

A wide variety of non-surgical therapies can result in clinical responses in patients with hepatocellular carcinoma. Two recent studies have suggested that transarterial chemoembolisation can, in highly selected patients with good liver function, result in an improvement in survival. No other approaches have, to date, demonstrated convincing evidence of survival advantage.     

Selective tropism of liver stem cells to hepatocellular carcinoma in vivo

AIM： To investigate the selective tropism of liver stem cells to hepatocellular carcinoma （HCC） in an animal model and its feasibility as a vector to deliver therapeutic genes for targeted therapy of HCC.
METHODS： WB-F344, a kind of rat liver stem cell, was infected with recombinant virus to establish a cell line with stable, high-level expressing enhanced green fluorescent protein （EGFP）. An animal model of HCC in Wistar rats was established by implanting HCC cells （CBRH7919） combined with an immunosuppressive drug. EGFP labeled liver stern cells were injected into caudal veins of the animals and distribution was observed at different time points after injection. SDF-1 and c-kit expression in non-tumor liver and tumor tissue were analysed by immunohistochemistry for the relationshiop between the expression and migration of liver stem cells. Furthermore, hepatic stern cells were injected via the portal vein, hepatic artery, caudal vein, or directly into the pericancerous liver tissue, respectively, and effects on migration, localization, and proliferation of the hepatic stern cells within the tumor tissue were observed and analyzed.
RESULTS： Recombinant adenovirus could deliver the EGFP gene to hepatic stem cells. A new stem cell line, named WB-EGFP, was established that stably expressed EGFP. WB-EGFP cells still showed selective tropism towards HCC and EGFP expression was stable in vivo. According to immunohistochemistry results, SDF-1 may not be related to the mechanisms of tropism of hepatic stem cells. Different application sites affected the distribution of liver stem cells. Injection via the portal vein was superior with regard to selective migration, localization, and proliferation of the hepatic stem cells within the tumor tissue.
CONCLUSION： Liver stem cells have the biological behavior of selective migration to HCC in vivo and they could localize and proliferate within HCC tissue stably expressing the target gene. Liver stem cells are a potential tool for a targeted gene therapy o     

Adjuvant heparanase inhibitor PI-88 therapy for hepatocellular carcinoma recurrence

AIM: To demonstrate that administering heparanase inhibitor PI-88 at 160 mg/d is safe and promising in reducing hepatocellular carcinoma (HCC) recurrence for up to 3 year following curative resection.METHODS: A total of 143 patients (83.1% of the 172 participants in the phase II study) participated in the follow-up study. Of these patients, 50 had received no treatment, 48 had received 160 mg/d PI-88, and 45 had received 250 mg/d PI-88 during the phase II trial. Safety parameters and the following efficacy endpoints were investigated: (1) time to recurrence; (2) disease-free survival; and (3) overall survival.RESULTS: PI-88 at 160 mg/d delayed the onset and frequency of HCC recurrence, and provided a clinically significant survival advantage for up to 3 years after treatment compared with those of the control group: (1) the recurrence-free rate increased from 50% to 63%, and (2) time to recurrence at the 36^th percentile was postponed by 78%. The efficacy of administering PI-88 at 250 mg/d was confounded by a high dropout rate (11 out of 54 patients). Additionally, subgroup analyses of patients with (1) multiple tumors or a single tumor ≥ 2 cm; and (2) hepatitis B or C revealed that administering PI-88 at 160 mg/d conferred the most significant survival advantage (56.8% improvement in disease-free survival, P = 0.045) for patients with both risk factors for recurrence.CONCLUSION: Administering PI-88 at 160 mg/d is a safe and well-tolerated dosage that may confer significant clinical benefits for patients with HCC.     

A meta-analysis of adjuvant therapy after potentially curative treatment for hepatocellular carcinoma

BACKGROUND:

The high recurrence rate of hepatocellular carcinoma (HCC) after potentially curative treatment determines the long-term prognosis.

OBJECTIVE:

To evaluate the efficacy and safety of adjuvant therapies in patients with HCC who have undergone hepatic resection, transplantation or locoregional ablation therapy.

METHODS:

Several databases were searched to identify randomized controlled trials (RCTs) fulfilling the predefined selection criteria. Meta-analyses were performed to estimate the effects of adjuvant therapies of any modality on recurrence-free survival (RFS) and overall survival (OS).

RESULTS:

Eight adjuvant modalities were identified from 27 eligible RCTs conducted predominantly in Asian populations comparing adjuvant with no adjuvant therapy. Adjuvant chemotherapy, internal radiation and heparanase inhibitor PI-88 therapy failed to improve RFS or OS, while interferon (IFN) therapy yielded significant survival results. The findings of adjuvant vitamin analogue therapy required further examination. Adjuvant adoptive immunotherapy conferred significant benefit for RFS but not for OS. Although cancer vaccine therapy and radioimmunotherapy may improve survival after radical surgery, the results were from single, small-scale trials. Severe side effects were observed in the studies of adjuvant chemotherapy and of IFN therapy.

CONCLUSIONS:

Adjuvant IFN therapy can improve both RFS and OS; however, the benefits of using this agent should be weighed against its side effects. Combination of systemic and transhepatic arterial chemotherapy is not recommended for HCC after potentially curative treatment. Other adjuvant therapies produce limited success for survival. Additional RCTs with proper design are required to establish the role of adjuvant therapies for HCC.