Management of hepatocellular carcinoma.

PURPOSE: Hepatocellular carcinoma (HCC), a common cause for cancer-related death, is increasing worldwide. Over the past decade, survival and quality of life of HCC patients have significantly improved due to better prevention strategies, early diagnosis, and improved treatment options. We performed this narrative review to synthesize current status on the HCC management. METHODS: Literature search for publications especially over the last decade, which has changed the paradigm on the management of HCC. RESULTS: Hepatitis B vaccination and treatment of chronic hepatitis B and C are important measures for HCC prevention. Screening and surveillance for HCC using ultrasonogram and alpha-fetoprotein estimation are directed toward cirrhotics and hepatitis B patients at high risk of HCC. If detected at an early stage, curative treatments for HCC can be used such as tumor resection, ablation and liver transplantation. HCC patients without curative options are managed by loco-regional therapies and systemic chemotherapy. Loco-regional treatments include trans-arterial chemoembolization, radioembolization and combinations of loco-regional plus systemic therapies. Currently, sorafenib is the only FDA-approved systemic therapy and newer better chemotherapeutic agents are being investigated. Palliative care for terminally ill patients with metastatic disease and/or poor functional status focusses on comfort care and symptom control. CONCLUSIONS: In spite of significant advancement in HCC management, its incidence continues to rise. There remains an urgent need to continue refining understanding of HCC and develop strategies to increase utilization of the available preventive measures and curative treatment modalities for HCC.

Nutritional status of patients with alcoholic cirrhosis undergoing liver transplantation: time trends and impact on survival.

Alcoholic cirrhotics evaluated for liver transplantation are frequently malnourished or obese. We analyzed alcoholic cirrhotics undergoing transplantation to examine time trends of nutrition/weight, transplant outcome, and effects of concomitant hepatitis C virus (HCV) and/or hepatocellular carcinoma (HCC). Nutrition and transplant outcomes were reviewed for alcoholic cirrhosis with/without HCV/HCC. Malnutrition was defined by subjective global assessment. Body mass index (BMI) classified obesity. A total of 261 patients receiving transplants were separated (1988-2000, 2001-2006, and 2007-2011) to generate similar size cohorts. Mean BMI for the whole cohort was 28 ± 6 with 68% classified as overweight/obese. Mean BMI did not vary among cohorts and was not affected by HCV/HCC. While prevalence of malnutrition did not vary among cohorts, it was lower in patients with HCV/HCC (P < 0.01). One-year graft/patient survival was 90% and not impacted by time period, HCV/HCC, or malnutrition after adjusting for demographics and model end-stage liver disease (MELD). Alcoholic cirrhotics undergoing transplantation are malnourished yet frequently overweight/obese. Among patients selected for transplantation, 1-year post-transplant graft/patient survival is excellent, have not changed over time, and do not vary by nutrition/BMI. Our findings support feasibility of liver transplantation for alcoholic cirrhotics with obesity and malnutrition.

Expression of N-acetylglucosaminyltransferase V mRNA in mammalian tissues and cell lines.

The expression of N-acetylglucosaminyltransferase V (Glc-NAc-T V) is increased in many oncogenically transformed cells and in cell lines which are induced to proliferate. In order to characterize the regulation of GlcNAc-T V at the molecular level, we have examined the expression of Glc-NAc-T V mRNAs in a number of mouse tissues and in several human and rodent cell lines. The GlcNAc-T V mRNA is expressed in different amounts in the various mouse tissues, with the greatest amount observed in brain, followed by thymus, kidney, lung, intestine, heart and stomach, and no transcripts detected in liver or skeletal muscle. Measurements of GlcNAc-T V enzymatic activity, by contrast, show brain to have lower levels of activity than several of the other tissues, suggesting possible post-translational regulation. We find that there are two GlcNAc-T V transcripts in most of the RNAs analysed. The rodent cell lines all express both a 7.5 and a 9.5 kb mRNA, with the smaller transcript being more abundant. The human cells have mRNAs of 4.5 and 9.5 kb. Both mRNAs are expressed in HepG2 and MCF-7 cells, while A431 cells express only the 4.5 kb mRNA and HL60 cells express only the 9.5 kb transcript. Furthermore, only the 9.5 kb mRNA appears to be increased, along with activity, when HepG2 cells are stimulated to proliferate, suggesting that the two mRNAs may be under different regulatory controls. Also, a GlcNAc-T V-deficient, mutant lymphoma cell line, PHAR2.1, was found to express mRNAs which are larger than the normal mRNAs, possible due to an insertion or aberrant splicing, resulting in a defective mRNA.

Isolation, characterization, and expression of a cDNA encoding N-acetylglucosaminyltransferase V.

A cDNA clone for the complete coding sequence for alpha-1,3(6)-mannosylglycoprotein beta-1,6-N-acetylglucosaminyltransferase V (GlcNAc-T V, EC 2.4.1.155) was isolated and expressed in COS-7 cells. Degenerate oligonucleotide primers for polymerase chain reaction were synthesized based on the amino acid sequence of three tryptic peptides isolated from affinity-purified GlcNAc-T V. Polymerase chain reaction amplimers were isolated from rat and mouse mRNA. A cDNA-encoding full-length enzyme was isolated from a rat 1 cell (EJ-ras-transformed) library and sequenced. Transient expression of this clone in COS-7 cells, followed by enzymatic activity assays, demonstrated that this cDNA sequence encodes GlcNAc-T V. Northern analysis of rat kidney mRNA revealed a single band corresponding to a length of about 7 kilobases. Sequence analysis of the cDNA clone demonstrated an open reading frame that encoded a type II membrane protein of 740 amino acids.

Purification and characterization of rat kidney UDP-N-acetylglucosamine: alpha-6-D-mannoside beta-1,6-N-acetylglucosaminyltransferase.

In order to investigate the molecular mechanism of the specific increase of UDP-N-acetylglucosamine:alpha-6-D-mannoside beta-1,6-N-acetylglucosaminyltransferase (GlcNAcT-V, EC 2.4.1.155) activity after viral or oncogenic transformation, we have purified the enzyme from a Triton X-100 extract of rat kidney acetone powder. GlcNAcT-V was purified by sequential affinity chromatography using first UDP-hexanolamine-agarose and then a synthetic oligosaccharide inhibitor-agarose column. Sodium dodecyl sulfate-polyacrylamide gel electrophoresis of the purified enzyme revealed two major bands at apparent molecular masses of 69 and 75 kDa. The enzyme was recovered in a 26% final yield with a 450,000-fold increase in specific activity to a Vmax of 18.8 mumols/(mg.min). Enzyme activity was stabilized and enhanced by the addition of 20% glycerol, 0.5 mg/ml IgG, and 0.2 M NaCl. The optimal ranges of pH and Triton X-100 concentrations for enzyme activity were 6.5-7.0 and 1.0-1.5%, respectively. The divalent cations, Mn2+, Ca2+, and Mg2+, were each found to have a negligible (less than 10%) effect on activity; moreover, the enzyme was fully active in the presence of 20 mM EDTA. The Km value of the purified enzyme toward a synthetic trisaccharide acceptor was 90 microM, and the Ki value toward a synthetic active site inhibitor was 140 microM.

Regulation of N-acetylglucosaminyltransferase V activity. Kinetic comparisons of parental, Rous sarcoma virus-transformed BHK, and L-phytohemagglutinin-resistant BHK cells using synthetic substrates and an inhibitory substrate analog.

Baby hamster kidney (BHK) cells transformed with Rous sarcoma virus, RS-BHK cells, demonstrate a 2.5-fold increase in the activity of N-acetylglucosaminyltransferase V (GlcNAc-T V, EC 2.4.1.155), and this increase in activity appears to be specific for this enzyme. By contrast, a lectin-resistant BHK cell line selected for its ability to grow in high levels of L-phytohemagglutinin, LP3.3, is characterized by a specific decrease in its GlcNAc-T V activity. To test if these alterations in the apparent Vmax of GlcNAc-T V are due to changes in the efficiency of populations of enzymes in RS-BHK and LP3.3 cells compared to the parental BHK cells, we have compared the kinetic properties of the enzymes from these three sources. The Km constants observed for both the sugar nucleotide donor (UDP-GlcNAc) and two synthetic trisaccharide acceptors were indistinguishable. The Vmax values toward three synthetic acceptors were also determined first for the BHK GlcNAc-T V, and they varied by over 5-fold. When these values were measured for the variant and transformed cell enzymes, however, similar 5-fold differences were still observed, although the absolute values for these acceptors were all higher or lower for the RS-BHK and LP3.3 enzymes, respectively. In addition, we have synthesized a deoxygenated analog of the specific GlcNAc-T V acceptor, beta GlcNAc(1,2) alpha Man(1,6) beta ManOR, where the reactive 6'-OH group has been removed, and the resulting trisaccharide was found to be a competitive inhibitor of the enzyme. The Ki for this inhibitor was near 70 microM for the GlcNAc-T V from all three sources. These kinetic comparisons demonstrate that the enzymes from the three cell types have kinetically indistinguishable active sites. These results suggest that the differences in the apparent Vmax values among the cell types are most likely due to alterations in the number of active molecules rather than in the modulation of either their catalytic activities or specificities.

Recognition of oligosaccharide substrates by N-acetyl-glucosaminyltransferase-V.

Six analogs of the trisaccharide 8-methoxycarbonyloctyl 6-O-[2-O-(2-acetamido-2-deoxy-beta-D-glucopyranosyl)-alpha-D-mannopyrano syl] -beta-D-mannopyranoside (3), a previously reported acceptor for N-acetylglucosaminyltransferase-V (GnT-V) have been chemically synthesized and evaluated as GnT-V acceptors. Replacement of the beta-D-man rho-O(CH2)8COOMe "reducing end" of 3 by beta-D-Glc rho-O(CH2)7 CH3 gave octyl 6-O-[2-O-(2-acetamido-2-deoxy-beta-D-glucopyranosyl]-alpha-D- mannopyranosyl)-beta-D-glucopyranoside (5) whose activity was indistinguishable from that of 3. Removal of the 4-OH group of the beta-D-Glc residue in 5 had little effect on the activity, while the corresponding 4-O-methyl derivative was twice as active. Replacement of the C-6 pro-R hydrogen of the same residue by a methyl group gave the L-glycero-D-gluco derivative 8, whereas replacement of the corresponding pro-S hydrogen gave the D-glycero-D-gluco compound 9. Trisaccharide 8, whose rotameric distribution about the C-5-C-6 bond is sterically biased towards the gg conformation was less than half as active as 5 as a GnT-V acceptor, whereas 9, which is biased towards the gt conformation, was more than twice as active. These results provide evidence for the conformational control of oligosaccharide biosynthesis.