Experiment And Clinical Application Research On TACE Combined With Anti-Angiogenesis In The Treatment Of Hepatic Cancer

Part one:Effects of Transcatheter Arterial Chemoembolization Combinated with Anti-angiogenesis in Rabbit VXⅡHepatic Tumor:An Experimental StudyObjective:1. To compare the dynamic parameters of computed tomography perfusion imaging (CTPI) of rabbit VXⅡhepatic tumor after transcatheter arterial chemoembolization (TACE) only and TACE combinated with antiangiogenesis, and to explore the underling therapeutic mechanism of these two therapeutic regimens by correlating CTPI with histopathological findings.2. To provide therapeutic baisis by comparing the therapeutic effect of TACE on hepatocellular carcinoma (HCC) with that of TACE combinated with antiangiogenesis.Materials and Methods:1. Establishment of rabbit VXⅡhepatic tumor modelSixty rabbit VXⅡhepatic tumor models were established.2. CTPI of rabbits VXⅡhepatic tumorCTPI for each rabbit was performed with a 16-section multidetector row CT scanner (LightSpeed; GE Medical Systems, Milwaukee, Wis) after two weeks of tumor embedding. Perfusion parameters of blood flow (BF), blood volume (BV) and permeability surface (PS) in tumor area were measured. The tumor sizes of pre-therapy were also measured.3. Grouping and treatmentSixty rabbit VXⅡhepatic tumor models were randomly divided into three groups: group A (n=20), TACE combined therapy group (pharmorubicin 5mg+ liquid iodized oil 2ml+Endostar lmg); group B (n=20) TACE group (pharmorubicin 5mg+liquid iodized oil 2ml); group C (n=20) as control group (0.9% sodium chloride 2 ml). Intra-arterial infusion was performed in all of the 60 rabbits.4. CTPI after intervention treatmentCTPI for each rabbit was performed after seven days of interventional treatment. BF, BV, PS and the gross tumor volume after treatment were measured. The rate of tumor growth and inhibition rate of tumor growth were calculated according to the tumor size of pre-and post-therapy for each group.①The rate of tumor growth= (the tumor volume of two weeks of post-therapy-the tumor volume of pre-therapy)/the tumor volume of pre-therapy×100%;②Inhibition rate of tumor growth= (the mean tumor volume of post-therapy of the control group-the mean tumor volume of two weeks of post-therapy)/the mean tumor volume of post-therapy of control group×100%.All rabbits were sacrificed after MSCT perfusion scans. Then, the tumor and adjacent hepatic tissue were collected and performed with immunohistochemistry studies for microvessel density (MVD) and vascular endothelial growth factor (VEGF).5. Statistical analysisData were compiled in a database by using a software package of SPSS 11.5. Repeated-measures variance analysis was firstly performed to test whether time, grouping existed interactive effect and principal effect or not. Then, one-way analysis of variance was used to compare the significant differences in CT perfusion parameters between tumor and background liver in different groups. In addition, LSD-t was used to compare the significant differences in pairwise comparison, and Tamhane was used to compare the significant differences in pairwise comparison for heterogeneity of variance. T-test was used to compare the significant differences in pre-and post-therapy. A P value of less than 0.05 was considered to indicate a significant difference.Results:1. Imaging findingsSixty rabbits VXⅡhepatic tumor model was established successfully. The tumors were round-or oval-shaped, solitary and expansive growth. Twenty-six VXⅡliver tumors demonstrated as isodensity and 34 demonstrated as low density on precontrast CT images. Low-density lesion with ring enhancement was found on arterial phase on postcontrast CT images, and lower density was found in the tumor center on venous phase CT images. All the VXⅡtumors in rabbits were hypervascular solid tumors on DSA images. Vasa vasorum were found to circumambulate the tumors and presented as "harboring globular sign" on arterial phase images. Reticulodromous and lamellar staining were found on parenchymal phase images. After interventional treatment, the tumors in control group demonstrated as low density on precontrast CT images and manifested as conspicuous enhancement on postcontrast CT images. Tumors in group A and group B were completely or partially filled with lipiodol and foliated necrosis could be detected in the tumorous centre area in some cases.2. The changes of tumor volume of pre- and post-therapyBefore treatment, no significant statistical difference (F=0.862,p=0.428) was observed in the mean tumor volume among group A (0.488±0.097 cm), group B (0.493±0.105 cm) and group C (0.456±0.088 cm). After treatment, a significant difference was observed in the mean tumor volume among the three groups (F=211.606,p=0.000). The mean tumor volume in group C was significantly lager than group A and group B (both p=0.000), and the mean tumor volume in group B was significantly lager than that of group A (p=0.000). All the post-therapy tumor volume of the three groups were significantly lager than that of pre-therapy (all p=0.000).The rate of tumor growth and the inhibition rate of tumor growth of combined therapy group was 90.57% and 51.788%, respectively. The rate of tumor growth and the inhibition rate of tumor growth of combined therapy group was 141.78% and 38.206%, respectively.3. CT perfusion parameters of pre-and post-therapyBefore treatment, there was no significant difference (all P>0.05) in CT perfusion parameters of mean BF, BV and PS among group A, B and C. After treatment, a significant difference (all P<0.01) was observed in mean BF, BV and PS among group A, B and C, and the Mean BF, BV and PS in group A was significantly higher than that of group B and C (all P<0.01). But no significant difference was observed in mean BF between group B and C. By comparing the parameters of post-therapy with that of pre-therapy, a significantly increased BF was observed in group A and C, but no difference in BF was seen in group B. Pairwise comparison after therapy, a significantly increased BV and PS was observed in group C compared with that of pretherapy, but no significant difference was observed in group B. A significantly increased PS in three groups post-therapy was observe as compared with that in pretherapy.4. The change of VEGF and MVD of pre- and post-therapyAfter treatment, a significant difference was observed in VEGF and MVD among three groups (F=482.531,620.175, both P=0.000). A significantly decreased VEGF and MVD was observed in group A (56.000±1.892/HP and 19.150±0.988/HP) as compared with that of group B (134.400±16.561/HP and 40.100±1.373/HP) and group C (101.250±8.252/HP and 32.050±2.819/HP) (both P=0.000), and they significantly increased in group B as compared with that of group C (P=0.000).Part two:A Clinical Application Study of Transcatheter Arterial Chemoembolization Combinated with Antiangiogenesis in Hepatic Cellular CarcinomaObjective:To investigate the clinical application of CTPI in evaluating the therapeutic effects of TACE and TACE combinated with antiangiogenesis on hepatocellular carcinoma (HCC), and to explore the feasibility of TACE combinated with antiangiogenesis for treatment of HCC.Materials and Methods:1. Study populationThe study cohort included 34 men and 6 women (age range,39-75 years) with a biopsy-confirmed diagnosis of HCC. The patients were divided into two groups according to the consulting order. The patients of group A was treated with routine TACE(n=20). The patients of group B was treated with TACE combinated with antiangiogenesis (Endostar) (n=20).2. CT perfusion imagingCT perfusion imaging (CTPI) was performed before one week of interventional therapy and after 2-4 weeks of interventional therapy for all patients. Perfusion parameters of blood flow (BF), blood volume (BV) and permeability surface (PS) in tumorous parenchyma were measured in all hepatic lesions.3. Immunohistochemistry study Percutaneous needle biopsy was performed for the quantitative immunohistochemistry of vascular endothelial growth factor (VEGF) and micro vessel density (MVD) before 1 week of interventional therapy.4. Interventional therapyAll the patients were performed through intubation intra-arterial infusion. The patients in group A were treated with 0.5-1.Omg of FUDR + 5～10 mg of hydroxycamptothecin + 300～600mg of oxaliplatin + lipiodol ultra fluid. And the patients in group B were treated with the above drug combination + 30mg of Endostar/YH-16.5. CTPI after interventionCTPI was performed for each patient after 2-4 weeks of interventional therapy. Perfusion parameters of BF, BV and PS in tumorous parenchyma were measured. Then, the patients underwent tumour-reductive surgery and the excised tumors were studied with quantitative immunohistochemistry for VEGF and MVD expression.6. Statistical Analysis:Data were compiled in a database by using a commercial software package of SPSS 11.5. Repeated-measures variance analysis was firstly performed to test whether subgroups and time exist interactive effect and principal effect or not. Then, independent sample t-test and paired sample t-test were used to investigate the significant difference in subgroups and in pre-and post-therapy intervention. A P value of less than 0.05 was considered to indicate a significant difference.Results:1. Study CohortWe divided our cohort into two groups according to the consulting order. Group A (n=20) (16 men,4 women; mean age,57 years; age range,41-75 years):The staging of tumor of group A was as follows:stagingⅢ,12 cases; stagingⅣ,8 cases. Forty-five tumors could be detected in the liver, with the largest tumor size of 10.4 cm. Group B (n= 20) (18 men,2 women; mean age,57 years; age range,39-74 years):The staging of tumor of group B was as follows:stagingⅢ,11 cases; stagingⅣ9 cases. Forty-one tumors could be detected in the liver, with the largest tumor size of 12.3 cm. The pathological grading was as follows:gradeⅠ,7 cases (group A,3 cases; group B,4 cases); grade II,13 cases (group A,8 cases; group B,5 cases); gradeⅢ,12 cases (group A,6 cases; group B,6 cases); gradeⅣ, 8 cases (group A,4 cases; group B,4 cases). There was no significant statistical difference in general condition between group A and B.2. The change of VEGF and MVD of pre- and post-therapyBefore therapy, no significant statistical difference (all p>0.05) was found in the expression of VEGF and MVD between group A and group B. After therapy, a significant statistical difference (p<0.001) was found in the expression of VEGF and MVD between group A and group B. A significantly increased VEGF and MVD was observed in group A (227.900±43.515/HP,108.750±21.141/HP) as compared with that of observed before therapy (131.700±15.051/HP,69.900±17.809/HP) (all p< 0.001). A significantly decreased VEGF expression was observed in group B (103.800±19.215/HP) compared with that of observed before therapy (128.800±8.432/HP) (t=5.053,p=0.000). No significant difference (p>0.05) was found in MVD expression between post-therapy and pre-therapy (t=1.386, P=0.166) for group B.3. Analysis of CTPIBefore treatment, the HCC lesions were manifested on hepatic artery perfusion map as homogeneous hyper-perfusion in 13 cases (6 cases in group A, and 7 in group B) and inhomogeneous hyper-perfusion in 27 cases (14 cases in group A, and 13 in group B). Lack of blood perfusion was observed in the central area of the inhomogeneous hyper-perfusion lesions. After treatment, the tumor was completely filled with lipiodol in 14 cases (6 cases in group A, 8 in group B) and partially filled with lipiodol in 26 (14 cases in group A,12 in group B). Lack of blood perfusion was found in lipiodol-filling areas, but in sparsely or insufficiently lipiodol-filled areas blood perfusion could still be seen.Before treatment, no significant statistical deference was found in CT perfusion parameters of BF, BV and PS between group A and group B (t=0.269～1.252, all p>0.05). After treatment, a significant statistical difference was found in BF, BV and PS between group A and group B (t=5.732～9.988, all p<0.05). The BF of both group A and group B was significantly decreased compared with that of pre-therapy (t=10.272, P=0.000 and t=3.882, P=0.020). The BV and PS in group A was significantly lower than those measured before therapy (t=9.988, P=0.000 and t=7.683, P=0.001), while the BV and PS in group B determined between post-therapy and pre-therapy was of no statistical significance (P>0.05).Conclusions:1. The blood perfusion in rabbit VX2 hepatic tumor significantly decreased after TACE, which demonstrated that TACE could effectively block the tumor blood supply. The expression of VEGF and MVD of rabbit VX2 hepatic tumor significantly increased after TACE, which reflected the activity of neovascularization. This phenomenon might be explained as tumor-self redemption mechanism activated by TACE, and also might be explained the increase rate of relapse and metastasis after TACE for management of HCC.2. The expression of VEGF and MVD of rabbit VX2 hepatic tumor significantly decreased in combined therapy group, which demonstrated that Endostar might inhibit tumor angiogenesis and therefore improved the therapeutic effects of TACE.3. The blood perfusion of combined therapy group significantly increased as compared that of TACE group although there was not significant statistical difference between pre-therapy and post-therapy. This phenomenon indicated that Endostar may directely react to vascular endothelial cell and inhibit neovascularization. Consequently, it was almost impossible for the remnant tumor to establish its potential blood perfusion and to proliferate rapidly. The decrease of the pressure of tumor mesenchymal lead to the functional blood vessels being in the condition of high perfusion in combined therapy group.4. The expression of VEGF and MVD and CT perfusion parameters of hepatocellular carcinoma was similar to those of rabbit VX2 hepatic tumor.5. The management of TACE combined with endostar could improve the curative effect for HCC. Therefore, it was of feasibility and practicability to combine TACE with antiangiogenesis for treatment of advanced HCC.