Ablative-Transarterial Radioembolization resulting in complete histopathological response of hepatocellular carcinoma in the resected liver specimen after salvage hepatectomy.

INTRODUCTION: Hepatocellular carcinoma (HCC) is a common disease. Many patients at the time of diagnosis of HCC are in advanced stages and cannot benefit from curative treatment. Palliative treatments remain the only treatment option. Advances in palliative treatment can occasionally downstage HCC and induce enough liver hypertrophy to allow salvage hepatectomy to be performed on patients with initially unresectable HCC. We herein present a patient who underwent salvage hepatectomy after successful Ablative-Transarterial Radioembolization (A-TARE) with complete histopathologic response in the resected liver specimen. CASE REPORT: A 67-year old obese patient presented with a 9.7 cm HCC at liver segment 8, with local tumour extension to involve segments 4,5 and 7. Initial workup suggested the tumour to be unresectable. A-TARE with yttrium-90 microspheres was given. Further workup 4 months after A-TARE showed the tumour to be downstaged with adequate hypertrophy of future liver remnant. Salvage hepatectomy became possible and the patient underwent salvage trisectionectomy 5 months after A-TARE. He recovered uneventfully from the operation. Histopathological examination of the resected liver specimen showed no viable tumour cells inside a fibrous mass which corresponded to the radiologic residual tumour. DISCUSSION: Salvage hepatectomy should be offered to patients after tumour downstaging with A-TARE as viable malignant cells are likely to persist. Complete response with no viable tumour cells in the resected liver specimen, to our knowledge, has never been reported in literature. CONCLUSION: A-TARE was able to induce complete histopathological response in a patient who initially presented with a large and unresectable HCC mass.

Significant Value of 11C-Acetate and 18F-Fluorodeoxyglucose PET/Computed Tomography on 90Y Microsphere Radioembolization for Hepatocellular Carcinoma.

Pretreatment dual-tracer (18F-fluorodeoxyglucose and 11C-acetate) PET/computed tomography (CT) has potential to predict treatment response for 90Y microsphere radioembolization (RE) in patients with inoperable hepatocellular carcinoma (HCC). Patients with 11C-acetate-avid HCC have a better response to 90Y microsphere RE, and possibly better survival. Pretreatment dual-tracer PET/CT has a significant theranostic value on 90Y microsphere RE in determining target tumor dose for HCCs with different cellular differentiation, metabolic tumor volume, and functioning liver volume, and can be used to prescribe individual injected activity of 90Y microspheres.

Radioembolization with 90Y glass microspheres for hepatocellular carcinoma: significance of pretreatment 11C-acetate and 18F-FDG PET/CT and posttreatment 90Y PET/CT in individualized dose prescription.

PURPOSE: The aim of this study was to establish an algorithm for the prescription of 90Y glass microsphere radioembolization (90Y-GMRE) of HCC in individual patients based on the relationship between tumour dose (TD) and response validated by 90Y PET/CT dosimetry and dual-tracer PET/CT metabolic parameters. METHODS: The study group comprised 62 HCC patients prospectively recruited for 90Y-GMRE who underwent pretreatment dual-tracer (11C-acetate and 18F-FDG) PET/CT as surrogate markers of HCC cellular differentiation. Pretreatment tumour-to-nontumour ratio on 99mTc-MAA SPECT/CT (T/NTMAA) was correlated with posttreatment 90Y PET/CT T/NT90Y after quantification validation. The TD-response relationship for HCC of different tracer groups was assessed on follow-up PET/CT 2 months after treatment. RESULTS: 90Y PET/CT was accurate in the measurement of recovery of injected 90Y activity (81.9-99.9%, median 94.8%). Pretreatment SPECT/CT T/NTMAA was strongly correlated with posttreatment 90Y PET/CT T/NT90Y (5.6 ± 3.2 versus 5.9 ± 3.5, T/NT90Y 1.01 × T/NTMAA + 0.161, r = 0.918, P < 0.05). The response rates were 72.4% (21/29), 70.6% (12/17) and 25% (4/16) for well, moderately and poorly differentiated HCC, respectively. The cut-off TD for a good response was significantly different between poorly differentiated and well/moderately differentiated HCC (262 Gy versus 152/174 Gy) with 89.2% sensitivity and 88% specificity. At a limiting tolerated liver dose of 70 Gy, the T/NTMAA thresholds for predicting a good response in poorly differentiated and well/moderately differentiated HCC were 3.5 and 2.0/2.3. Disregarding HCC cellular differentiation, the cut-off TD became 170 Gy, with lower sensitivity (70.3%) and specificity (76%). CONCLUSION: 90Y PET/CT can provide accurate dosimetry for 90Y-GMRE. Pretreatment T/NTMAA predicts posttreatment T/NT90Y. The TD thresholds for a good response are tracer-dependent, with a strong correlation between HCC radiosensitivity and cellular differentiation and other PET-based parameters. These cytokinetic factors improve treatment efficacy while minimizing organ damage for the prescription of personalized 90Y-GMRE.

Intrasession and Intersession Repeatability of Diffusion Tensor Imaging in Healthy Human Liver.

OBJECTIVE: The aim of this study was to evaluate the effect of signal to noise ratio (SNR) and number of gradient directions (NGD) on intra- and intersession repeatability of liver diffusion tensor imaging (DTI) metrics. METHODS: At each of 3 liver DTI scan sessions, liver diffusion was assessed in 5 healthy volunteers using a 6-direction DTI scan performed 9 separate times (ie, number of signal averages [NSA]). In addition, 4 combinations of NSA and NGD were acquired (NSA/NGD = 1/30, 3/10, 3/12, and 5/6) to determine the combined effect to DTI metrics, which was based on intersubject variability and intrasession (Vintra) and intersession (Vinter) repeatability. RESULTS: Intersubject variability was less than 20%, whereas Vintra and Vinter repeatability were less than 5% and less than 10%, respectfully. Vinter was not affected by the NGD used. Decreases in Vinter(FA), Vinter(λ1), Vinter(RD), and Vinter(MD) were observed with increasing NSA, and hence SNR. CONCLUSION: Increased SNR may improve intrasession and intersession repeatability of liver DTI metrics. Scan repeatability was not influenced by NGD.

A comparison of three transarterial lipiodol-based formulations for hepatocellular carcinoma: in vivo biodistribution study in humans.

This study aimed to evaluate and compare the biodistribution properties of three transarterial Lipiodol-based therapeutic regimens in human hepatocellular carcinoma (HCC). In this prospective study with 13 patients randomly allocated to one of three study groups, each of the patients received transcatheter intra-arterial administration into a solitary HCC with one of three different Lipiodol-based formulations: Lipiodol-ethanol mixture (LEM; Group A), Lipiodol alone (Group B), and Lipiodol and gelatin pledgets (Group C). With the use of radioactive iodine-131-labeled Lipiodol, each group was assessed for (1) pattern of Lipiodol accumulation in the lungs within the first 2 weeks as evaluated by single-photon emission computed tomography and (2) decomposition of Lipiodol formulation within the first 2 weeks as evaluated by radioactivity detected in peripheral blood and urine. The degree of Lipiodol retention in the tumor within the first 4 weeks was evaluated with CT. No statistically significant difference in Lipiodol accumulation in the lungs was detected among the three groups. However, the peak accumulation in the lungs was delayed 3 days for Group A compared to Groups B and C. The degree of Lipiodol retention within the tumor in Group A was significantly greater than that in Groups B and C on day 14 (p = 0.014) and day 28 (p = 0.013). This study showed that LEM is associated with a greater embolic effect in intrahepatic HCC at 4 weeks, and a comparable degree of lung shunting and decomposition rates, compared with ethanol-free Lipiodol formulations.

Synthesis and structure evaluation of a novel cantharimide and its cytotoxicity on SK-Hep-1 hepatoma cells.

A remarkable control of the potency of cantharimide is described based on the electronic properties of functional group and it exhibits a relatively less toxic effect to the non-malignant hematological disorder bone marrow cells.

Apoptotic activity of a novel synthetic cantharidin analogue on hepatoma cell lines.

Cantharidin isolated from Mylabris caraganae and other insects is used traditionally as an anti-cancer drug. However, its toxicity on the renal system and suppression effect on bone marrow limits its clinical usage. Recently, we have synthesized two cantharidin analogues, CAN 029 (compound 2) and CAN 030 (compound 3). Although both showed an apoptotic induction ability on cancer cells, they were still relatively toxic towards non-malignant haematological disordered bone marrow. Based on the principle structure of cantharidin, we have further chemically synthesized another analogue, CAN 032. The cytotoxic activity of this analogue was screened on both Hep3B hepatocellular carcinoma and SK-Hep-1 liver adenocarcinoma cell lines by [3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium] (MTS) assay. Morphological changes of hepatoma cell lines were recorded under an inverted microscope. The possible tolerance of these analogues was further investigated using non-malignant haematological bone marrow primary culture. CAN 032 showed a significant cytotoxic response on both hepatoma cell lines in which the potencies were comparable to that of cantharidin. Further screening on the bone marrow tolerance revealed that compound CAN 032 showed a relatively less toxic effect. Phase contrast microscopy demonstrated that cell shrinkage, rounding, loss of adherent property and loss of colony-formation ability were induced. The dose-dependence of the response of CAN 032 on Hep3B was further assayed by DNA fragmentation gel electrophoresis. The G1 peak of Hep3B cells was reduced. Chemically synthesized CAN 032 may provide an improved therapeutic advantage over traditional cantharidin.

Apoptotic potential of the concentrated effective microorganism fermentation extract on human cancer cells.

The effective microorganism fermentation extract (EM-X, the first generation) was claimed to possess strong anti-oxidation property. On the other hand, we have shown that the second generation of the effective microorganism fermentation extract (EM-X2) possessed growth inhibition on human cancer cells involving MDA-MB231 breast cancer and K-562 chronic myelogenous leukaemia cells. Elevation of super oxide dismutase activity from EM-X2 treated cancer cell extract was observed. However, the possible anti-cancer activity of the first generation of the EM-X was not reported. Here we demonstrate that the concentrated form of the EM-X from its original fluid also possess antiproliferation ability together with induction of apoptosis on the human cancer cell lines including Hep3B hepatocellular carcinoma (HCC) and KG1a acute myelogenous leukaemia (AML). Similar effect could also be demonstrated on primary cultured bone marrow samples isolated from patients with AML. Morphological inspection revealed that common apoptotic feature was found on these concentrated EM-X treated cancer cells. Both the anchorage-dependent clonogenicity assay on Hep3B HCC and methyl-cellulose colony formation assay on KG1a cells and bone marrow cells from AML patients further revealed the ability of the concentrated EM-X on reducing their colony formation ability. Incubating KG1a with concentrated EM-X readily induced apoptosis as demonstrated by flow cytometric analysis. Interestingly, few growth inhibition effect of the concentrated EM-X was observed on both the SV40 transformed THLE-2 liver epithelial cells and primary cultured non-malignant haematological disordered bone marrow. Collectively, this concentrated EM-X is effective in inducing cell death and reducing the regeneration potential of both Hep3B HCC and KG1a AML cells in vitro.

Does percutaneous liver biopsy of hepatocellular carcinoma cause hematogenous dissemination? An in vivo study with quantitative assay of circulating tumor DNA using methylation-specific real-time polymerase chain reaction.

OBJECTIVE: Our purpose was to find out whether percutaneous biopsy of hepatocellular carcinoma will cause significant dissemination of tumor into the circulation by quantitative analysis of circulating tumor DNA. SUBJECTS AND METHODS: In this prospective study of 32 patients with suspected hepatocellular carcinoma who underwent sonographically guided liver biopsy, a peripheral venous blood sample was obtained before and 5 min after the procedure. Biopsy was performed using an 18-gauge biopsy gun. DNA was extracted from the plasma of the blood samples for methylation-specific polymerase chain reaction. Quantitative measures of the plasma tumor DNA were determined with real-time quantitative polymerase chain reaction, and the amount was expressed as a methylation index (%) in plasma. RESULTS: Nineteen (59.4%) of 32 patients did not have detectable p16 tumor suppressor gene marker (p16M) in plasma before biopsy, and they showed no detectable plasma p16M after biopsy. Thirteen (65%) of 20 patients had p16M identified in the plasma before liver biopsy. Quantitative analysis of the plasma tumor DNA in these 13 patients showed no statistically significant difference in the methylation index before and after biopsy (p = 0.345, Wilcoxon's signed rank test). CONCLUSION: No evidence exists that percutaneous liver biopsy results in hematogenous dissemination of hepatocellular carcinoma as shown by quantitative analysis of circulating tumor DNA (p16M) using methylation-specific real-time polymerase chain reaction.

Superoxide anion is involved in the early apoptosis mediated by Gleditsia sinensis fruit extract.

Changes in the intracellular level of reactive oxygen species (ROS) including superoxide anion, hydroxyl radical, hydrogen peroxide and finally cellular acid-base equilibrium are reported to play an important role in the early step of apoptosis. All of which would precede the loss of mitochondrial membrane potential and releasing of those apoptotic inducing factors such as cytochrome c as well as caspases activation. Any potential chemotherapeutic agent that could drive such changes in ROS would be particularly attractive. Recently we have reported the potential use of Gleditsia sinensis extract (GSE) in cancer therapy including solid tumour and leukaemia cell lines as well as primary cultured leukaemia cells in vitro. We demonstrated that apoptotic activity is involved. Here we further showed that the mechanism of GSE induced apoptosis, including an early decreasing of intracellular superoxide anion as measured by nitroblue tetrazolium (NBT) reduction assay. This phenomenon readily occurred before any shrinkage of cancer cells including MDA-MB231 breast cancer, CNE-2 nasopharyngeal carcinoma, K-562 chronic myelogenous leukaemia and KG1-a, acute myelogenous leukaemia. Cell viability was determined by morphological investigation and the [3-(4,5-dimethyl-thiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium] (MTS) assay. Furthermore, the superoxide dismutase activity from those cellular extracts after GSE treatment seemed to be increased. Taken together, we speculate that the GSE-induced apoptosis, via ROS pathway, involves an early decrease of intracellular superoxide anion.

Azacitidine induces demethylation of the Epstein-Barr virus genome in tumors.

PURPOSE: To determine whether therapy with a DNA methyltransferase inhibitor is effective in achieving demethylation and gene re-expression in tumor DNA in patients. METHODS: Biopsy specimens were obtained from patients with Epstein-Barr virus-associated tumors, enrolled on a clinical trial of 5-azacitidine, within 72 hours of the conclusion of the last infusion of the first cycle of therapy, and compared to pretreatment specimens. Methylation-specific polymerase chain reaction, bisulfite genomic sequencing, and immunohistochemistry were used to assess demethylation and gene re-expression. RESULTS: Substantial degrees of demethylation were detected in all latent and lytic Epstein-Barr virus promoters examined. Immunohistochemistry suggested activation of a previously silent viral antigen expression in one instance. CONCLUSION: Pharmacologic reversal of dense CpG methylation in tumor tissue can be achieved in patients.

Gleditsia sinensis fruit extract induced growth inhibition involves basic fibroblast growth factor and nitric oxide.

Recently we have shown the antiproliferative activity of Gleditsia sinensis fruit extract (GSE) on various solid tumour and leukaemia cell lines as well as primary cultured bone marrow cells isolated from patients with acute and chronic myelogenous leukaemia. We further studied whether the growth inhibitory effect of GSE involves basic fibroblast growth factor (bFGF) in cancer cell lines including breast cancer MDA-MB231, nasopharyngeal cancer CNE-2 and prostate cancer LNCaP. We also investigated whether GSE could alter the production of nitric oxide (NO) pattern from these cancer cell lines. Growth inhibition assay was quantitated by sulforhodamine B protein staining method. Enzyme linked immunosorbent assay (ELISA) was used to quantitate the total bFGF protein. The amount of NO secreted into culture medium in terms of nitrite ion concentration was measured by the Greiss method. ELISA showed that GSE could stimulate total bFGF protein level which was dose- dependent. NO production was also stimulated from these cancer cell lines after treating with GSE. Both of the increment in total bFGF and NO levels were correlated with the degree of growth inhibition. Changes involving cell shrinkage and detachment of cancer cells could readily be observed. Taken together, our results here suggest that growth inhibition induced by GSE in these solid tumour cell lines may involve both bFGF and NO regulations.

Gleditsia sinensis fruit extract is a potential chemotherapeutic agent in chronic and acute myelogenous leukemia.

The anti-leukemia activity of the saponin rich Gleditsia sinensis Lam. fruit extract (GSE) was investigated on cancer cell lines and bone marrow cells obtained from consented patients with chronic myelogenous leukemia (CML) and acute myelogenous leukemia (AML) during presentation. The growth inhibitory activity of the extract was determined by [3-(4,5-dimethylthiazol-2-yl)-5-(3-carboxymethoxyphenyl)-2-(4-sulfophenyl)-2H-tetrazolium] (MTS) assay. Colony formation assay was performed to investigate the regeneration potential. Cellular morphology change was studied. Apoptosis was demonstrated by DNA electrophoresis, reverse transcription polymerase chain reaction (RT-PCR) and flow cytometry. The mean concentration to inhibit the cell growth by 50% (MTS50) was 18+/-1.6 micro g/ml for K562 CML cell line and 12+/-1.3 micro g/ml for HL-60 acute promyelocytic leukemia cell line. Patient samples showed a mean MTS50 of 13-28 micro g/ml. Non-malignant hematological disorder bone marrow samples showed a mean MTS50 from 45 to 53 micro g/ml. Loss of regeneration property after treatment with GSE of these two cancer cell lines were confirmed by colony formation assay. GSE was able to induce cell shrinkage in K-562. DNA laddering was observed by incubating the leukemia cells with GSE. RT-PCR demonstrated that the pro-apoptic gene bax was induced while the anti-apoptic gene bcl-2 and cell cycle active gene PCNA were reduced. Flow cytometric analysis showed that the apoptotic effect of GSE on leukemia cell line was time- and dose-dependent. Thus GSE might be potentially used as a chemotherapeutic drug to treat patients with acute and chronic myelogenous leukemia.

Anti-angiogenic potential of Gleditsia sinensis fruit extract.

Blood supply plays a crucial role in solid tumour development and leukaemogenesis. It has been suggested that blocking of angiogenesis could be possible in cancer therapy. We have demonstrated the antiproliferative activity of Gleditsia sinensis fruit extract (GSE) on various human solid tumour cancer cell lines as well as leukaemia cell lines and primary cultured leukaemia cells obtained from leukaemia patients. However, the antiangiogenic potential of GSE has not been demonstrated. Here we demonstrated that GSE could reduce vascular endothelial growth factor (VEGF) mRNA expression in dose- and time course-dependently in MDA-MB231 breast cancer and HepG2 hepatoblastoma cell lines as measured by reverse transcriptase polymerase chain reaction. Enzyme-linked immunosorbent assay further showed that GSE could reduce the VEGF secretion from various cancer cell lines including MDA-MB231, HepG2, HL-60 (acute promyelocytic leukaemia) and eleven primary cultured leukaemia cells obtained from acute myelogenous leukaemia patients. In vivo chick chorioallantoic membrane assay illustrated that GSE could reduce the angiogenic activity of basic fibroblast growth factor. Taken together, the information suggested that GSE could be potentially used as an angiogenic inhibitor in both solid tumour and leukaemia therapy.