| BackgroundHepatocellular carcinoma(HCC)is the fifth most common cancer worldwide and the third leading cause of cancer-related death.In China,the incidence and mortality of HCC are ranked 4th and 2nd respectively.HCC has brought heavy economic and mental burden to patients,but the prognosis of HCC in clinical is still poor.On the one hand,although there has been great progress in surgical resection,liver transplantation,and local treatment(radiofrequency ablation,RFA;microwave ablation,MWA)for HCC,there is a lack of accuracy and specificity in the application of these treatments.HCC is strongly invasive and often complicated with liver cirrhosis.Even in patients who undergone the radical treatment,the 5-year recurrence rate of was as high as 70%and the 5-year overall survival rate was less than 20%.On the other hand,because of the non-specificity clinical symptoms of early HCC,most patients with HCC are diagnosed at middle and advanced stages and lost the chance of radical treatment.These patients could only receive palliative treatment such as transarterial chemoembolization(TACE)and molecular targeted therapy,and the prognosis is poor.Thus,how to select appropriate treatment methods,application strategies and found more accurate and effective targets for HCC patients,remains to be further studied.Surgical resection is the first-choice treatment for HCC.However,only about 20%of patients meet the indications for surgical resection.Most patients accompany with cirrhosis and poor hepatic reserve function.The incidence of postoperative complication and recurrence rate of these patients are high.RFA is the most commonly used local treatment for HCC now.The 2018 NCCN diagnosis and treatment guidelines for HCC pointed out that RFA can be used as an alternative treatment to surgical resection for patients with single HCC nodule which is less than 3 cm.Some studies found that the complete ablation rate of RFA for HCC nodules less than 2 cm was higher than 90%.However,with the increase of tumor volume,the complete ablation rate decreased rapidly.It will lead to an increase in the recurrence rate of HCC after RFA.The main reason is the "heat-sink effect" during the procedure of RFA.In the RFA procedure,the rapid flow of blood in the vessels in the tumor area removes the heat generated by RFA,leading to a decrease in the degree of coagulation and necrosis,which reduces the efficacy of RFA.To address this limitation of RFA,TACE combined with RFA therapy is often used in the treatment of HCC.The advantages of this combination therapy are as follows:On the one hand,TACE can block the hepatic artery in the tumor area,thereby reducing the "heat-sink effect" and increasing the ablation temperature and range of RFA.On the other hand,the heat generated during RFA treatment can enhance the anti-cancer effect of the drugs of TACE.The time interval between TACE treatment and RFA treatment is the key of this combination treatment.If the interval time is too long,recanalization and neovascularization occurenced.Recanalization and neovascularization make the heat sink effect promoted and reduce the efficacy of the followed RFA.Recanalization and angiogenesis also promote tumor metastasis and affect the prognosis of HCC patients.If the interval time is too short,RFA may causes a secondary damage to the liver function and increases the risk of postoperative complications.Therefore,the choice of the time interval is the key to the efficacy of the combined treatment,and a reasonable time interval should be selected to achieve a balance between preventing eecanalization and angiogenesis and fully retaining the liver function.However,there is very little research on this key issue,and further research is urgently needed.MWA is a local ablation treatment that has developed rapidly in recent years.MWA relies on polar molecules(mainly water molecules)in the tissues and blood vessels to generate heat due to high-speed friction under the action of microwave electric fields and make tumor necrosis.Compared with RFA,MWA provides higher ablation temperature and larger ablation range in less time,and the treatment effect of MWA is not affected by the vessels near the tumor theoretically.Therefore,MWA may have potential theoretical advantages for the treatment of perivascular HCC,which accounts for about one-third of hepatocellular carcinoma.Perivascular HCC refers to an index tumour was characterized by any contact with first-or second-degree branches of a portal or hepatic vein that were 3 mm or greater in diameter.These adjacent vessels lead to the high risk of complications and less effective of surgical resection and RFA.However,safety concerns regarding ischaemic complication risk have been raised due to the more rapid formation of a large ablation zone during MWA treatment.Thus,the efficacy and safety of MWA in the treatment of perivascular HCC remains to be studied.One of the main reasons for the poor prognosis of HCC patients is the postoperative recurrence.It has been reported that the cumulative recurrence rate of HCC after 5 years exceeds 70%,but there is no guideline for the treatment of recurrent HCC Repeated resection and RFA are commonly used in the treatment of recurrent HCC in clinc.Because the postoperative follow-up is generally more regular.Compared with the primary HCC,the diameter of the tumor is smaller when the recurrent HCC is diagnosed.For single-center recurrence HCC,the number of tumors is often multiple.Due to the previous resection,the liver reserve function of patients with recurrent HCC was limited.For recurrent HCC,repeated resection may lead to further reduction of residual liver volume and a high risk of postoperative complications.Compared with repeated resection,RFA has less liver parenchymal loss and less impact on liver reserve function,but the risk of recurrence of HCC after RFA is relatively high.For now,the management of recurrent HCC remains unclear.Therefore,research on the choice of treatment strategies for recurrent hepatocellular carcinoma has a great clinical significance.For patients with advanced HCC,the targeted drugs have provided a new option for their treatment.Angiogenesis plays an important role in the occurrence and development of tumor.At present,many tumor angiogenesis pathways have been discovered in tumor,and a variety of targeted drugs for angiogenesis have been developed.But the curative effect of these targeted drugs are limited.The main reason is that most targeted drugs are not highly selective and there is no individual difference in the application.And more accurate targets,and the screening and enriching the dominant population for the target treatments are the hot researches at present.Phospholysine phosphohistidine inorganic pyrophosphate phosphatase(LHPP)is a histidine phosphatase which plays a vital role in most cellular signal transduction pathways and can regulate the signal pathway of PI3K/AKT by dephosphorylating phosphohistidine-containing proteins and affects angiogenesis in tumor tissues.LHPP may play an important role in inhibiting the progression of HCC.Recent studies have reported that the expression of LHPP in tumor tissues of HCC patients and model mice is significantly lower than that of adjacent tissues.The exogenous LHPP can significantly inhibit tumor growth in HCC model mice.However,the effect of LHPP on the human HCC tissues has not been investigatedThis study is divided into four parts.In the first part,we first analyzed the efficacy and safety of TACE combined with RFA in the treatment of HCC at different time intervals.In the second part,we further compared the efficacy and safety of MWA technology and RFA in the treatment of HCC around the blood vessels.In the third part,in view of the high postoperative recurrence rate of HCC,and the relevant treatment guidelines are not clear,the efficacy and safety of RFA and surgical resection for recurrent HCC were compared.In the fourth part,we explore the effect of LHPP on the growth of human HCC tissues using the human tissue in vitro culture technology,and prove that LHPP can inhibit the progression of HCC.This study provides clinical evidence for the application of treatment strategies for different types of HCC,and provides new ideas for accurate non-invasive treatment of HCC.Part 1 Efficacy and safety of combination therapy of chemoembolization and radiofrequency ablation with different time intervals for hepatocellular carcinoma patientsAimCombination of transcatheter arterial chemoembolization(TACE)and radiofrequency ablation(RFA)has become an effective alternative therapy for hepatocellular carcinoma(HCC).In clinical practice,the choice of time interval between TACE and RFA is a key point for curative effect,but optimal time interval is uncertain in guidelines.We aim to explore the optimal time interval for HCC patients of Child-Pugh classification A or B.Methods1.Two hundred and thirty-three HCC patients of Child A or B who had undergone TACE and RFA were enrolled and divided into seven groups according to different time intervals(1-7weeks).2.Baseline information such as age and gender of the patients,liver function grade before and after treatment,tumor ablation response,complications and overall survival time after treatment were collected.3.Analyze the tumor ablation response of patients after treatment at different time intervals,and explore the relationship between time interval and ablation response.4.Analyze the changes of liver function and postoperative complications of patients before and after treatment at different time intervals,and explore the relationship between time interval and liver function and complications.5.Overall survival(OS)of patients after treatment at different time intervals was analyzed to explore the relationship between time interval and overall survival time.Results1.Complete response rate and total effective rate decreased in groups with the prolonged time interval(p<0.05).2.Average Child-Pugh score of patients in first three groups significantly increased one month after combination treatment(p<0.01).There was no significant change in Child-Pugh score in the other groups before and after combined treatment3.Complications occurred in 16.7%patients,similarly occurred in groups(p>0.1).4.Median survival time in groups four and five were 42 months,longer than other groups(p<0.01).ConclusionA period of 4-5weeks is the optimal time interval between TACE and RFA for HCC patients of Child-Pugh classification A or B.Part 2 Microwave ablation versus radiofrequency ablation for perivascularhepatocellular carcinomaAimPerivascular HCC accounts for approximately one-third of HCC cases,and adjacent intrahepatic vessels can affect treatment outcomes.Management of perivascular HCC has not been well established.We aim to compare the efficacy and safety of microwave ablation(MWA)and RFA for perivascular HCC.Methods1.This multi-center retrospectively study enrolled 170 patients with perivascular HCC treated by MWA and RFA,and divided into different groups according to the treatment method:63 cases in MWA group and 107 cases in RFA group2.Collect baseline information such as age,gender,tumor characteristics,and liver function of patients and conduct propensity score-matched(PSM).Patients were followed up for tumor ablation response,postoperative complications,OS,and progression-free survival(PFS).3.Compare the baseline characteristics,tumor ablation response,postoperative complications,OS and PFS of the MWA and RFA groups in the overall cohort and PSM cohort,respectively.4.Subgroup analysis was performed according to the type of tumor adjacent blood vessels(portal vein/hepatic vein)and the number of tumor nodules adjacent to blood vessels(single/2-3).Results1.The disease control rates for MWA and RFA were similar in the total(93.7%vs.90.7%,p=0.492)and PSM(92.7%vs.92.7%,p=1.00)cohorts.2.The PFS rates at 1,3,and 5 years were 70.5%,55.3%and 52.2%in MWA group and 61.3%,33.2%and 28.1%in RFA group(p=0.017)3.The OS rates were comparable between the MWA and RFA groups in total(p=0.249)and PSM cohorts(p=0.345)4.Major complications were more frequent in the MWA group than in RFA group(27.0%vs.6.5%,p<0.001),all patients with major complications were cured.5.In the subgroup analyses,the PFS of patients with HCC adjacent to portal vessel(44.9 vs.35.8 months,p=0.048)or a single HCC nodule(50.9 vs.42.1 months,p=0.014)were significantly better in the MWA group than in RFA group.ConclusionCompared with RFA,MWA provides better control of tumour progression without improving OS.MWA may be preferred for periportal HCC and/or single-nodule perivascular HCC.Part 3 Radiofrequency ablation versus repeat resection for recurrenthepatocellular carcinoma(?5cm)after initial curative resectionAimRecurrence rate is up to 70%at 5 years for HCC after initial resection,but the management of recurrent HCC remains unclear.To compare the efficacy and safety of RFA and repeat resection as the first-line treatment in recurrent HCC.Methods1.This multicenter retrospective study analyzed 290 patients who underwent RFA(n=199)or repeat resection(n=91)between January 2006 and December 2016 for locally recurrent HCC(?5cm)following primary resection.2.Baseline information was collected on patient age,gender,etiology,antiviral therapy,and features of primary and recurrent HCC tumors,liver function,and PSM.Patients were followed up for postoperative complications,OS,and PFS.3.Baseline characteristics,postoperative complications,OS,and PFS of the RFA group and the resection group were compared between the overall cohort and the PSM cohort,respectively.4.Subgroup analysis was performed according to the largest tumor length(?3cm/3-5cm),the number of tumor nodules(single/2-3),and liver function grade(Child A/B)at recurrent HCC.Results1.The 1,3,and 5-year OS(90.7%,69.04%,55.6%versus 87.7%,62.9%,38.1%,p=0.11)and PFS(56.5%,27.9%,14.6%versus 50.2%,21.9%,19.2%,p=0.80)were similar in the RFA group and the repeat resection group in the total cohort2.In the PSM cohort,there was no statistical difference in the OS and PFS of the RPA group and the re-excision group at 1 year,3 years and 5 years.3.In the RFA group,the incidence of serious complications(0.5%vs.9.1%,p=0.001),the incidence of minor complications(39.3%vs.94.9%,p<0.001),and the length of hospital stay(5 days vs.14 days,p<0.001)were better than the re-excision group.4.The OS of the RFA group was significantly better than repeat resection group among those with 2 or 3 recurrent tumor nodules in both the total cohort(p=0.009)and the PSM cohort(p=0.038)ConclusionRFA has the same efficacy as repeat resection in recurrent HCC patients,but with fewer complications.RFA is more efficient and safer than repeat resection in patients with 2 or 3 recurrent tumor nodules.Part 4 The inhibitory effect of LHPP in hepatocellular carcinomaAimTo investigate the expression of phospholysine phosphohistidine inorganic pyrophosphate phosphatase(LHPP)in HCC tissues,and the correlation between LHPP with the clinical indicators and the postoperative recurrence of HCC patients.And further to explore the effect of LHPP on the growth of HCC.Methods1.HCC tissues and para-HCC tissues were collected from 60 patients of HCC who were treated by surgical resection.The clinical data and the follow-up data were also collected.2.Immunohistochemistry(IHC),quantitative real-time polymerase chain reaction(qRT-PCR)and Western Blot analyses were used to detect the expression levels and differences of LHPP in HCC and para-HCC tissues.3.To analyze the correlation between LHPP with the clinical indicators and the postoperative recurrence of HCC patients4.The Huh7 cell and HepG2 cell were used for in vitro study.The HCC tissues and para-HCC tissues were cultured in vitro.Cells and tissues were treated with different concentrations of LHPP.After culture,CCK-8 experiment was used to detect the tissue survival rate and explore the therapeutic effect of LHPP on HCC.Results1.In the IHC analysis of the 60 pairs of HCC and para-HCC tissues in this study,the low expression rate of LHPP in the HCC tissues was 63.3%.The expression of LHPP in the HCC tissues was significantly lower than that in the para-HCC tissues(0.064±0.016 vs.0.078±0.0222,p<0.01).Western Blot and qRT-PCR analyses also showed that the expression of LHPP in HCC tissues was significantly lower than that in para-HCC tissues(p<0.01).2.The correlation between LHPP expression and clinical data:the low expression of LHPP in the HCC tissues was associated with cirrhosis(p=0.003)and portal thromboembolus(PVTT)(p=0.036).Its expression was not correlated with gender,age,preoperative AFP level,child-pugh grade,tumor differentiation degree,size and number of HCC nodules(all p>0.05).3.The recurrence-free survival(RFS)of patients with high LHPP expression in the HCC tissues was significantly better than that of patients with low LHPP expression(p=0.046).Especially for the short-term(?2 years)HCC recurrence after surgery,15 patients(39.5%)with short-term HCC recurrence were found in the LHPP low-expression group,and 3 patients(13.6%)with short-term HCC recurrence were found in the LHPP high-expression group.The short-term recurrence rate of HCC in the LHPP low-expression group was significantly higher than that in the LHPP high-expression group(p=0.035).4.The effect of LHPP on HCC lines:with the increase of LHPP concentration(0,1,10,100?g/ml)and the extension of time,the inhibition rate of LHPP on Huh7 cells and HepG2 cells gradually increased,and the effect of inhibition was obviously dose-effect relationship(p<0.05).5.HCC tissues and para-HCC tissues were treated with different concentrations(0,1,10,100?g/ml)of LHPP.After 1 week of culture,inhibition rates of HCC and para-HCC tissues were analysised by the CCK-8 assay.The results of the CCK-8 assay showed that,compared with the blank control group,the survival rate of liver cancer tissues treated with LHPP decreased with the increase of LHPP concentration(p<0.01),while the survival rate of para-HCC tissues treated was not decreased significantly with different concentrations(p>0.05).ConclusionThe expression of LHPP decreased in the HCC tissues of cirrhosis related HCC patients,and it was associated with the portal thrombolysis and postoperative recurrence of HCC(especially the short-term recurrence).Exogenous LHPP significantly inhibited the proliferation and growth of HCC cells and tissues.This study provides a new way to understand the pathogenesis of HCC based on liver cirrhosis from the perspective of angiogenesis,to predict the postoperative recurrence of HCC.Tis study also provides a novel target for the target therapy of HCC. |
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