Analysis of aggressiveness factors in hepatocellular carcinoma patients undergoing transarterial chemoembolization.

AIM: To investigate novel predictors of survival in hepatocellular carcinoma (HCC) patients following transarterial chemoembolization (TACE). METHODS: One hundred sixty seven patients with un-resectable HCC were retrospectively analyzed to identify factors that might contribute to their HCC biology and aggressiveness. We correlated routine laboratory results (total bilirubin, AST, ALKP, GGTP, albumin etc.) to maximum tumor diameter, number of tumor nodules, portal vein thrombosis and blood alpha-fetoprotein levels. These 4 parameters were previously combined to form an aggressiveness index (AgI). We used The Wilcoxon rank-sum (Mann-Whitney), to test the correlation between the AgI categories and liver function parameters. The Cox proportional hazards model was applied to evaluate the categories of AgI associated with overall survival. RESULTS: The AgI was strongly correlated with survival in this novel patient population. Three year survival probability for AgI > or < 4 was 42.4% vs 61.8%; P < 0.0863 respectively. Several factors independently correlated with AgI using univariate multiple logistic regression of AgI with 8 laboratory parameters. Lower albumin levels had an OR of 2.56 (95%CI: 1.120-5.863 P < 0.026), elevated Alkaline phosphatase and gamma glutamyl transpeptidase (GGTP) had ORs of 1.01 (95%CI: 1.003-1.026, P < 0.017) and 0.99 (95%CI: 0.99-1.00, P < 0.053) respectively. In a Cox proportional hazard model combining mortality for AgI score and liver function parameters, only GGTP levels and the AgI were independently associated with survival. An AgI > 4 had HR for mortality of 2.18 (95%CI: 1.108-4.310, P < 0.024). GGTP's single unit change had a HR for mortality of 1.003 (95%CI: 1.001-1.006, P < 0.016). These were considered in the final multivariate model with the total cohort. An AgI > 4 had a HR for mortality of 2.26 (95%CI: 1.184-4.327, P < 0.016). GGTP had a HR of 1.003 (95%CI: 1.001-1.004, P < 0.001). CONCLUSION: Our study validates the AgI in a new population with un-resectable HCC patients undergoing TACE. The analysis establishes a correlation between GGTP and the AgI.

Modulation of sensitivity and resistance to multikinase inhibitors by microenvironmental platelet factors in HCC.

INTRODUCTION: Response of a tumor to chemotherapy or multikinase inhibitor therapy has been traditionally thought to be a reflection of the sum of the characteristics of both the drug and of the tumor cell resistance mechanisms. More recently, there has been a growing awareness of the role of non-tumor factors-both cellular and humoral-in the tumor microenvironment that can increase or decrease the tumor cellular responses to the therapy. This article focuses on platelet factors in clinical HCC and experimental evidence that they provide growth stimulants that can antagonize the growth inhibitory effects of therapy. AREAS COVERED: Review of the mechanisms of multikinase cancer growth inhibitors and of the role of platelets in providing growth factors that can antagonize their effects. EXPERT OPINION: These new ideas and data show that the response of a tumor to multikinase inhibitors or chemotherapy may be strongly influenced by microenvironmental factors. Conversely, antagonists to these environmental factors, such as EGFR inhibitors and IGF1-R inhibitors, might be expected to augment the anti-tumor effect of both chemotherapy and multikinase inhibitors.

MEK 1/2 inhibitors in the treatment of hepatocellular carcinoma.

Sorafenib is the only approved systemic treatment for advanced hepatocellular carcinoma patients and all the recently published randomized controlled trials on new systemic drugs have been unsuccessful. This is likely due to a lack of understanding of tumor progression, molecular drivers, and liver toxicity, as well as flaws in trial design. An important signaling pathway in hepatocarcinogenesis is the MEK cascade involved in various cellular responses, including adaptation and survival. A key role in this cascade is played by MEK, of which MEK 1/2 represent the prototypes and an interesting target for new oncological drugs. This review analyzes recent developments and future perspectives on the role of MEK inhibitors in hepatocellular carcinoma treatment.

c-Met-Akt pathway-mediated enhancement of inhibitory c-Raf phosphorylation is involved in vitamin K1 and sorafenib synergy on HCC growth inhibition.

Sorafenib is an FDA-approved agent for treatment of human hepatocellular carcinoma (HCC), but tumor shrinkage is minor. We therefore developed a strategy to combine K vitamins with sorafenib to treat HCC, and found that this combination enhanced sorafenib-induced HCC cell growth inhibition. To explore the mechanisms involved, we examined the role of Raf kinase, since both vitamins K and sorafenib were reported to inhibit tumor cell growth via Raf signaling pathway. We found that whereas lower concentration of vitamin K1 (25 µM) or sorafenib (2.5 µM) alone slightly induced c-Raf phosphorylation at both Ser-43 and Ser-259, combination vitamin K1 plus sorafenib resulted in strong c-Raf phosphorylation at these two serine residues. A Raf kinase activity assay confirmed that combination vitamin K1 plus sorafenib had a synergistic inhibitory effect on it. Since c-Raf phosphorylation at Ser-43 and Ser-259 can be regulated by either PKA or Akt kinase, we examined the effects of both vitamin K1 and sorafenib on their phosphorylation. Although vitamin K1 or sorafenib alone induced PKA phosphorylation, no enhanced phosphorylation effects on PKA were found using this combination. However, vitamin K1 enhanced sorafenib-induced c-Met phosphorylation at Tyr-1349, a DEP-1 protein phosphatase acting site, and consequently induced phosphorylation of PI3K-Akt. Both PI3K inhibitor Ly294002 as well as dominate negative Akt plasmid transfection antagonized vitamin K1 plus sorafenib actions on c-Raf phosphorylation and cell growth inhibition, suggesting that c-Met-PI3K-Akt signaling pathway mediated inhibitory c-Raf phosphorylation may play a central role in vitamin K1 plus sorafenib synergy in inhibiting HCC cell growth.

Small HCCs identified by screening.

BACKGROUND: Survival in HCC depends on diagnosis at early tumor stage, best achieved through surveillance radiology. There is also a need for complementary serum tests. METHODS: We evaluated baseline liver function parameters from a cohort of 231 HCC patients who were diagnosed by surveillance. They were ordered according to their tumor mass and trends in the data were analyzed. RESULTS: Trends in serum GGTP levels increased linearly with increases in small tumor mass, but the patterns for AFP levels were more complex and elevated only with larger tumor mass. ALKP levels were elevated in association with small tumors and further increased with increasing tumor mass. The relationships of serum AFP to GGTP, of albumin to bilirubin and of ALKP to bilirubin, helped identify tumor mass phenotypes. There was an especially important relationship between serum bilirubin and AFP, suggesting that HCC growth and liver factors were interdependent. CONCLUSIONS: Small HCCs demonstrated several phenotypic sub-groups, with serum GGTP and ALKP increasing and albumin decreasing in many patients with increasing tumor mass.

Economic evaluation of sorafenib in unresectable hepatocellular carcinoma.

BACKGROUND AND AIM: A double-blind, randomized phase III trial of sorafenib in advanced hepatocellular carcinoma demonstrated that sorafenib significantly prolonged overall survival compared to placebo (median overall survival = 10.7 months vs 7.9 months, P < 0.001). Sorafenib is the first and only systemic agent demonstrating survival benefit in these patients. The aim of this study was to assess the cost-effectiveness of sorafenib versus best supportive care in the treatment of advanced hepatocellular carcinoma in the USA. METHODS: A Markov model was developed following time-to-progression and survival using phase III trial data. Health effects are expressed as life-years gained. Resource utilization included drugs, physician visits, laboratory tests, scans, and hospitalizations. Unit costs, expressed in 2007 $US, came from diagnosis-related groupings, fee schedules, and the Red Book. Costs and effects were evaluated over a patient's lifetime and discounted at 3%. RESULTS: Results are presented as incremental cost/life-year gained. Deterministic and probabilistic sensitivity analyses were conducted. Life-years gained were increased for sorafenib compared to best supportive care (mean ± standard deviation: 1.58 ± 0.17 vs 1.05 ± 0.10 life-years gained/sorafenib patient and best supportive care, respectively). Lifetime total costs were $US40,639 ± $US3052 for sorafenib and $US7, 804 ± $US1349 for best supportive care. The incremental cost-effectiveness ratio was $US62,473/life-year gained. CONCLUSIONS: The economic evaluation indicates that sorafenib is cost-effective compared to best supportive care, with a cost-effectiveness ratio within the established threshold that US society is willing to pay (i.e. $US50,000-$US100,000) and significantly lower than alternative thresholds suggested in recent years ($US183,000-$US264,000/life-year gained, or $US300,000/quality-adjusted life-year) in oncology.

Assessing spiritual growth and spiritual decline following a diagnosis of cancer: reliability and validity of the spiritual transformation scale.

This study assessed the factor structure, reliability, and validity of an instrument designed to assess spiritual transformations following a diagnosis of cancer-the Spiritual Transformation Scale (STS). The instrument was administering to 253 people diagnosed with cancer within the previous 2 years. Two underlying factors emerged (spiritual growth (SG) and spiritual decline (SD)) with adequate internal reliability (alpha = 0.98 and 0.86, respectively) and test-retest reliability (r = 0.85 and 0.73, respectively). Validity was supported by correlations between SG and the Positive and Negative Affect Scale (PANAS) Positive Affect Subscale (r = 0.23, p < 0.001), the Daily Spiritual Experiences Scale (r = 0.57, p < 0.001), and the Post-traumatic Growth Inventory (r = 0.68, p < 0.001). SD was associated with higher scores on the Center for Epidemiological Studies Depression scale (r = 0.38, p < 0.001) and PANAS-Negative Affect Subscale (r = 0.40, p < 0.001), and lower scores on the PANAS-Positive Affect Subscale (r = -0.23, p < 0.001), and the Daily Spiritual Experiences Scale (r = -0.30, p < 0.001). Hierarchical regression analyses indicated that the subscales uniquely predicted adjustment beyond related constructs (intrinsic religiousness, spiritual coping, and general post-traumatic growth). The results indicate that the STS is psychometrically sound, with SG predicting better, and SD predicting poorer, mental and spiritual well-being following a diagnosis of cancer.

Hepatocyte growth factor enhances protein phosphatase Cdc25A inhibitor compound 5-induced hepatoma cell growth inhibition via Akt-mediated MAPK pathway.

We have previously shown that Compound 5 (Cpd 5), an inhibitor of protein phosphatase Cdc25A, inhibits Hep3B human hepatoma cell growth. We now show that hepatocyte growth factor (HGF), a hepatocyte growth stimulant, can strongly enhance Cpd 5-induced growth inhibition in Hep3B cells, and this enhancement in cell growth inhibition is correlated with a much stronger ERK phosphorylation when compared to cells treated with Cpd 5 or HGF separately. We found that HGF/Cpd 5-induced ERK phosphorylation and cell growth inhibition were mediated by Akt (protein kinase B) pathway, since combination HGF/Cpd 5 treatment of Hep3B cells inhibited Akt phosphorylation at Ser-473 and its kinase activity, which led to the suppression of Raf-1 phosphorylation at Ser-259. The suppression of Raf-1 Ser-259 phosphorylation caused the induction of Raf-1 kinase activity, as well as hyper-ERK phosphorylation. Transient transfection of Hep3B cells with dominant negative Akt c-DNA further enhanced both Cpd 5- and HGF/Cpd 5-induced ERK phosphorylation, while over-expression of wild-type Akt c-DNA diminished their effects. In contrast, HGF antagonized the growth inhibitory actions of Cpd 5 on normal rat hepatocytes, thus showing a selective effect on tumor cells compared to normal cells. Our data suggest that Akt kinase negatively regulates MAPK activity at the Akt-Raf level. Suppression of Akt activity by either combination HGF/Cpd 5 treatment or by dominant negative Akt c-DNA transfection antagonizes the Akt inhibitory effect on Raf-1, resulting in an enhancement of Cpd 5-induced MAPK activation and cell growth inhibition.