- Original article
- Open Access
Transarterial chemoembolization combined with recombinant human adenovirus type 5 H101 prolongs overall survival of patients with intermediate to advanced hepatocellular carcinoma: a prognostic nomogram study
© The Author(s) 2017
- Received: 10 October 2016
- Accepted: 23 April 2017
- Published: 20 July 2017
Patients with intermediate to advanced hepatocellular carcinoma (HCC) are most commonly treated with transarterial chemoembolization (TACE). Previous studies showed that TACE combined with recombinant human adenovirus type 5 (H101) may provide a clinical survival benefit. In the present study, we aimed to determine the survival benefit of TACE with or without H101 for patients with intermediate to advanced HCC and to develop an effective nomogram for predicting individual survival outcomes of these patients.
We retrospectively collected data from 590 patients with intermediate to advanced HCC who were treated at Sun Yat-sen University Cancer Center between January 2007 and July 2015. After propensity score matching, 238 patients who received TACE with H101 (TACE with H101 group) and 238 patients who received TACE without H101 (TACE group) were analyzed. Overall survival (OS) was evaluated using the Kaplan–Meier method; the nomogram was developed based on Cox regression analysis. Discrimination and calibration were measured using the concordance index (c-index) and calibration plots.
Clinical and radiologic features were similar between the two groups. OS rates were significantly lower in the TACE group than in the TACE with H101 group (1-year OS rate, 53.8% vs. 61.3%; 2-year OS rate, 33.4% vs. 44.2%; 3-year OS rate, 22.4% vs. 40.5%; all P < 0.05). Multivariate Cox regression analysis for the entire cohort showed that alpha-fetoprotein level, alkaline phosphatase level, tumor size, metastasis, vascular invasion, and TACE with or without H101 were independent factors for OS, all of which were included in the nomogram. Calibration curves showed good agreement between nomogram-predicted survival and observed survival. The c-index of the nomogram for predicting OS was 0.716 (95% confidence interval 0.686–0.746).
TACE plus H101 extends the survival of patients with intermediate to advanced HCC. Our proposed nomogram provides individual survival prediction and stratification for patients with intermediate to advanced HCC who receive TACE with or without H101.
- Transarterial chemoembolization
- Recombinant human adenovirus type 5
- Hepatocellular carcinoma
Liver cancer is prevalent in East and Southeast Asia and in North and West Africa . In China, it accounts for 13.79% of all cancer cases and its mortality ranks the third among all cancers . Worldwide, hepatocellular carcinoma (HCC) is the major type of liver cancer, which is the fifth most common cancer and the third leading cause of cancer-related death [3, 4]. Hepatectomy, liver transplantation, and radiofrequency ablation are recommended as curative approaches for patients with early-stage HCC [5–7]. Other patients who present with portal vein tumor invasion or multiple tumors, which are categorized as Barcelona Clinic Liver Cancer stage B and C, are diagnosed with intermediate to advanced HCC. Transarterial chemoembolization (TACE), which allows chemotherapeutics to focus on the tumor while blocking tumor-feeding arteries, is most commonly used for patients with intermediate to advanced HCC [8–10]. Because of diminished liver function, enlarged tumors, and portal vein involvement, TACE becomes less effective when administered for longer than 6 months and is associated with unfavorable prognosis . Furthermore, because of liver ischemia and hypoxia which can up-regulate the expression of vascular endothelial growth factor and enhance angiogenesis, TACE can actually promote tumor growth [12, 13]. The prognosis of patients with intermediate to advanced HCC who are treated with TACE is unfavorable, with a median overall survival (OS) of only 6.7 months . This indicates that new treatment strategies for intermediate to advanced HCC are necessary.
As shown in past studies, genetic abnormalities were presented in HCC cells, including the activation of oncogenes  and the inactivation of tumor suppressor genes . Mutations of the tumor protein P53 (TP53) gene frequently happen during tumor development. The P53 protein has many functions, including arrest of the G1 phase of cell cycle via the cyclin-dependent kinase inhibitor P21Cip1 and induction of apoptosis via inducing the expression of apoptosis-related genes, such as Bcl-2-associated X protein (BAX). Consequently, P53 plays an important role in tumor apoptosis and necrosis . Mutations or deletions of wild-type TP53 exist in nearly 50% of all tumor types  and in 30%–50% of HCCs  and indicate an unfavorable prognosis for patients with HCC. The administration of recombinant adenovirus p53 (rAd-p53) can improve the prognosis of cancer patients [20–23]. Furthermore, the combination of TACE and rAd-p53 may be superior to TACE alone in delaying the progression of HCC and extending the survival of patients with HCC [24–26]. H101, recombinant human adenovirus type 5 (rAd5), is generated by deleting the entire E1B gene and partial E3 gene in the viral genome . H101 selectively replicates in cancer cells but cannot replicate in normal cells or lyse normal cells where P53 is active without E1B to inactivate P53 . The segment of E3 gene in H101, which encodes the death protein, is deleted to potentially improve the safety of this virus product . H101 infects tumors and finally kills tumor cells through viral oncolysis [27, 28]. Some studies showed that H101 replicates in many tumor cell lines regardless of the P53 status [17, 29–31]. The activated host immune system and enhanced cell-medicated immune responses induced by H101 injection may contribute to tumor regression, thereby enhancing the antitumor effect of TACE treatment .
Some studies showed that H101 is safe and efficacious via transarterial infusion when combined with TACE in patients with intermediate to advanced HCC [33, 34]. However, the heterogeneity of the study populations led to variations in OS estimation. Moreover, it is difficult to stratify the prognosis of patients according to their risk level. Therefore, it is essential to develop a predictive system that incorporates parameters associated with the prognosis of patients with intermediate to advanced HCC who received TACE with H101.
Nomograms are statistical models developed specifically for individual and highly accurate estimation of prognosis . Furthermore, nomograms can improve the prognosis-predicting abilities of staging systems from the population level to the individual level; this indicates that researchers can use nomograms to calculate the approximate survival probability of individual patients at the time of diagnosis. In the present study, we aimed to develop a prognostic nomogram for patients with intermediate to advanced HCC after initial treatment with TACE with or without H101.
Patients who were newly diagnosed with intermediate to advanced HCC and those who underwent TACE with or without H101 as initial therapy at the Department of Hepatobiliary Oncology of Sun Yat-sen University Cancer Center (Guangzhou, China) between January 2007 and July 2015 were included. Inclusion criteria were as follows: (1) three courses of TACE with or without H101 as the only treatment and (2) pre-TACE liver function of Child–Pugh A or Child–Pugh B. Exclusion criteria were as follows: (1) other treatments, including hepatic resection, radiofrequency treatment, and liver transplantation for HCC before or after TACE; (2) inadequate renal function (serum creatinine level and blood urea nitrogen level higher than the upper limits of normal); (3) severe coagulopathy (prothrombin activity <40% or platelet count <40,000/mm3); (4) Child–Pugh C liver function or evidence of hepatocellular decompensation, including refractory ascites, esophageal or gastric variceal bleeding, and hepatic encephalopathy; (5) obstructive jaundice; (6) other concurrent primary tumors; or (7) lost to follow-up. All patients were followed up for at least 1 year after treatment. This study was approved by the Institutional Review Board of Sun Yat-sen University Cancer Center. All procedures performed in the present study involving human participants were in accordance with the ethical standards of institutional and/or national research committees and the 1964 Helsinki Declaration and its later amendments or similar ethical standards.
Clinical data collection
All clinical and radiologic data for diagnosis were retrieved from medical records archived at Sun Yat-sen University Cancer Center. Hematologic and imaging examinations, including alpha-fetoprotein (AFP) test, liver ultrasonography, magnetic resonance imaging (MRI), contrast-enhanced dynamic computed tomography (CT), and hepatic arterial angiography, were used in the clinical diagnosis of HCC. Diagnoses were based on the findings of typical radiologic features in at least two imaging examinations, histological confirmation by needle biopsy, or a single positive imaging diagnosis combined with elevated serum AFP level . Vascular invasion was defined as the presence of thrombus adjacent to the tumor in the portal system or hepatic vein system with a vague boundary, confirmed by at least two imaging modalities .
The following clinical and radiologic data were collected and analyzed: age, sex, white blood cell count, platelet count, neutrophil cell count, lymphocyte count, serum levels of AFP, alanine transaminase (ALT), aspartate aminotransferase (AST), total bilirubin (TBIL), indirect bilirubin (IBIL), alkaline phosphatase (ALP), albumin (ALB), C-reactive protein (CRP), and hepatitis B surface antigen (HBsAg), neutrophil-to-lymphocyte ratio (NLR), hepatitis B virus (HBV)-DNA load, splenomegaly, tumor number, vascular invasion, antiviral therapy, and tumor size (which refers to tumor diameter of the single tumor or the largest tumor when patients presented with multiple tumors).
For each patient, a uniform treatment protocol was performed. All selected patients received three courses of TACE with or without H101. The Seldinger technique for TACE was used as previously described . Conventional chemoembolization was performed by administering 300 mg carboplatin, 50 mg epirubicin, and 6 mg mitomycin. Depending on tumor location, tumor size, and number of tumors, the dose of lipiodol delivered ranged from 5 mL to 30 mL. Chemotherapeutic agents suspended in lipiodol were injected as selectively as possible into the hepatic segmental artery where the target tumor was located.
For patients treated with TACE with H101, H101 was administered before the injection of chemotherapeutic agents via the catheter into the hepatic artery supplying the tumor(s). A total of 1.0 × 1012 virus particles in 10 mL of 0.9% sodium chloride solution were administered. Aseptically purified particles of virus H101 were produced for human clinical use by Shanghai Sunway Biotech (Shanghai, China). The titer, sterility, and general safety were tested by the National Institute for the Control of Pharmaceutical and Biological Products (Beijing, China) .
After the first course of TACE, patients were followed up at least every 2 months during the first year and every 3 months thereafter. AFP test, liver ultrasonography, CT, and MRI were selectively performed as needed. OS was defined as the duration (in months) from the date of the first course of TACE until death or the last follow-up. The last follow-up was completed on August 31, 2016.
To minimize potential selection bias, patients treated with TACE alone were selected to match those treated with TACE with H101 using the propensity score matching. Patients were matched according to age, sex, tumor size, tumor number, metastasis, vascular invasion, and splenomegaly. The optimal cutoff value for NLR was determined using time-dependent receiver operating curve (ROC) analysis, which was performed using the package “survivalROC” in R version 3.2.5. The nearest 1:1 neighbor method without replacement was applied to match patients in the TACE group to patients in the TACE with H101 group. After matching, the Chi square test was used to compare the two groups for homogeneity. Propensity score matching analysis was performed using the “MatchIt” package in R version 3.2.5 (R Foundation for Statistical Computing, Vienna, Austria).
SPSS version 22 software (SPSS Inc., Chicago, IL, USA) was used to analyze the data. Continuous variables are expressed as means with standard deviations or medians with ranges and were compared between the TACE with H101 group and the TACE group using the two-tailed unpaired t test. The chi square test and Fisher’s exact test were used to compare categorical variables, which are presented as the numbers of patients and percentages.
The patients who were alive at last follow-up, died of non-cancer related causes, or lost to follow-up were censored. OS curves were analyzed using the Kaplan–Meier method, and differences between groups were identified using the log-rank test. Analyses for survival curves were performed using MedCalc software version 220.127.116.11 (MedCalc, Ostend, Belgium). Univariate analysis was performed to assess significance of clinical and radiologic characteristics. Multivariate analysis was performed using the Cox regression model for variables found to be significant in univariate analysis, and the corresponding 95% confidence intervals (CIs) were calculated. Two-tailed P values less than 0.05 were considered statistically significant.
A nomogram was developed based on the independent risk factors identified in the multivariate analysis, using the package rms in R version 3.2.5. The final model was selected via a backward step-down selection process with the Akaike information criterion . Performance of the nomogram was determined with the concordance index (c-index), which was estimated by analyzing the area under ROC curve and by analyzing the calibration curve comparing the nomogram-predicted survival probability versus the Kaplan–Meier estimated survival probability. Bootstraps with 1000 resamples were used for the development of the nomogram and calibration curve.
Of the 590 included patients who were newly diagnosed with intermediate to advanced HCC and treated with TACE with or without H101 as initial therapy, 352 received TACE, and 238 received TACE with H101. The thresholds for the clinical or radiologic variables were used as the cutoff values. With the cutoff value of 3, NLR was associated with the optimal Youden index for OS prediction. After propensity score matching, 238 patients who received TACE and 238 patients who received TACE with H101 were sorted into the TACE group and the TACE with H101 group, respectively.
Clinical and radiologic characteristics of patients with intermediate to advanced hepatocellular carcinoma (HCC) who received transarterial chemoembolization (TACE) with or without H101
Overall [cases (%)]
TACE group [cases (%)]
TACE with H101 group [cases (%)]
Tumor size (cm)
Overall survival of two groups
Construction of the nomogram
Univariate and multivariate analyses for factors associated with overall survival of patients with intermediate to advanced HCC who received TACE with or without H101
HR (95% CI)
HR (95% CI)
PLT (vs. <100 × 109/L)
ALT (vs. <40 U/L)
AST (vs. <45 U/L)
ALB (vs. <35 g/L)
TBIL (vs. <20 mmol/L)
IBIL (vs. <15 mmol/L)
ALP (vs. <100 U/L)
CRP (vs. <8.2 mg/L)
AFP (vs. <25 ng/mL)
HBsAg (vs. negative)
HBV-DNA (vs. <100 IU/mL)
NLR (vs. <3)
Tumor size (vs. <5 cm)
Tumor number (vs. single)
Splenomegaly (vs. no)
Metastasis (vs. no)
Vascular invasion (vs. no)
Antiviral therapy (vs. no)
TACE (vs. without H101)
In the present study, we compared two regimens of TACE: a conventional regimen with commonly used protocols and a regimen combining TACE with H101. We found that, compared with TACE alone, TACE with H101 extended the OS of patients with intermediate to advanced HCC. Results from multivariate Cox regression analyses showed that TACE with or without H101 was an independent prognostic factor for these patients. We developed a nomogram as an easy-to-apply model to predict the individual survival risk of patients with intermediate to advanced HCC who received TACE with or without H101. For patients who were eligible for TACE treatment, the nomogram internally showed that the combination of TACE with H101 was superior to TACE alone in terms of extending OS. For patients who previously received TACE with or without H101 as their primary treatment, the nomogram can serve as a quantitative scoring system to estimate OS.
The following mechanisms may explain the results of extended OS in patients who were treated with TACE with H101. In Asia generally, over 80% of patients with HCC are HBV-positive [41, 42]; in the present study, 94.3% of enrolled patients were positive for HBsAg. The overexpressed HBV X protein (HBx), which is produced by HBV, can inhibit TP53 gene expression . Therefore, patients with HBV-related intermediate to advanced HCC can also benefit from H101. In addition, carboplatin, which is commonly used in our institution in the TACE regimen, is similar to lobaplatin and inhibits the proliferation of human HCC cells primarily by inducing apoptosis and cell cycle arrest through the P53 apoptosis axis . Furthermore, more tumor cell necrosis can be elicited by the intra-arterial injection of H101 combined with TACE, because tumor cells grow faster in the capsular end of the tumor, which is a vascular-rich area, than in a vascular-poor area such as the tumor center .
Our nomogram was based on routine clinical characteristics. After treating the continuous variables, including levels of AFP, ALB, and ALP, and tumor size, as dichotomous variables, significant independent risk factors were integrated to develop the nomogram for predicting the OS of the study cohort. Of all variables included in the nomogram, AFP level before TACE, tumor size, metastasis, and vascular invasion were previously recognized as prognostic factors of patients with intermediate to advanced HCC [46, 47]. The strong prognostic power of tumor size may suggest that tumor size is an irreplaceable component for worldwide guidelines of HCC [9, 36, 46, 47]. In the present study, tumor size had the highest BETA and was treated as the denominator for ratios of BETAs. Based on the ratios of BETAs, nomogram points were assigned to each parameter. Compared with published nomograms for patients with HCC who received TACE treatment [48, 49], our study included not only the conventional clinical and radiologic factors included in previous nomograms but also two additional variables: TACE with or without H101 and ALP level. The inclusion of these two additional variables may contribute to significantly greater predictive accuracy, because variables that were associated with treatment and underlying liver diseases were included in our nomogram. Our nomogram demonstrated good accuracy for OS prediction. The c-index of our study cohort was 0.716. This indicates that there was a greater than 70% probability that a patient with a high nomogram score would die earlier than a patient with a low nomogram score. Calibration plots also showed the accuracy of the OS probability that was predicted by the nomogram model. For the study cohort, calibration plot lines fell along the ideal 45-degree reference, indicating that the nomogram-predicted 1-, 2-, and 3-year survival probabilities were similar to those estimated using the Kaplan–Meier method. Combining the results of the c-index and the calibration plots, this nomogram may be considered a practical tool for risk prediction.
Our study had several limitations. First, this retrospective analysis of patients with intermediate to advanced HCC who were treated with TACE with or without H101 relied on a single-institutional dataset. Geographic and institutional heterogeneity of patients may affect these results. Second, we did not conduct an external validation for predictive accuracy of the nomogram for OS. Third, because of a high proportion of HBsAg-positive patients (94.3% of patients in the present study), this nomogram was suitable for predicting the OS of HBV-positive patients only. Finally, the combination of H101 and TACE is not widely administered in other clinical centers around the world, which limits the use of the present nomogram.
In the present study, we found that patients with intermediate to advanced HCC who were treated with TACE with H101 had longer OS than those treated with TACE alone. We developed a nomogram that could predict the probability of OS for patients with intermediate to advanced HCC who were treated with or without H101. Large prospective studies are needed to confirm the survival benefit of TACE with H101 and further validate the accuracy of this prognostic nomogram.
XJL conceived the study, participated in its design, and supervised and participated in the data analysis and interpretation and in the writing of the manuscript. CBH performed data collection and statistical analyses. XML followed-up all patients and participated in data collection. All authors read and approved the final manuscript.
The authors declare that they have no competing interests.
The authenticity of this article has been validated by uploading the key raw data onto the Research Data Deposit public platform (http://www.researchdata.org.cn), with the Approval Number as RDDA2017000160.
Open AccessThis article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made. The Creative Commons Public Domain Dedication waiver (http://creativecommons.org/publicdomain/zero/1.0/) applies to the data made available in this article, unless otherwise stated.
- Bosch FX, Ribes J, Diaz M, Cleries R. Primary liver cancer: worldwide incidence and trends. Gastroenterology. 2004;127(5 Suppl 1):S5–16.View ArticlePubMedGoogle Scholar
- Chen W, Zheng R, Zeng H, Zhang S. The updated incidences and mortalities of major cancers in China, 2011. Chin J Cancer. 2015;34(11):502–7. doi:10.1186/s40880-015-0042-6.PubMedGoogle Scholar
- Torre LA, Bray F, Siegel RL, Ferlay J, Lortet-Tieulent J, Jemal A. Global cancer statistics, 2012. CA Cancer J Clin. 2015;65(2):87–108. doi:10.3322/caac.21262.View ArticlePubMedGoogle Scholar
- Llovet JM, Burroughs A, Bruix J. Hepatocellular carcinoma. Lancet. 2003;362(9399):1907–17. doi:10.1016/s0140-6736(03)14964-1.View ArticlePubMedGoogle Scholar
- Forner A, Llovet JM, Bruix J. Hepatocellular carcinoma. Lancet. 2012;379(9822):1245–55. doi:10.1016/s0140-6736(11)61347-0.View ArticlePubMedGoogle Scholar
- Raza A, Sood GK. Hepatocellular carcinoma review: current treatment, and evidence-based medicine. World J Gastroenterol. 2014;20(15):4115–27. doi:10.3748/wjg.v20.i15.4115.View ArticlePubMedPubMed CentralGoogle Scholar
- Zhang J, Zhou ZG, Huang ZX, Yang KL, Chen JC, Chen JB, et al. Prospective, single-center cohort study analyzing the efficacy of complete laparoscopic resection on recurrent hepatocellular carcinoma. Chin J Cancer. 2016;35:25. doi:10.1186/s40880-016-0088-0.View ArticlePubMedPubMed CentralGoogle Scholar
- Llovet JM, Bruix J. Systematic review of randomized trials for unresectable hepatocellular carcinoma: chemoembolization improves survival. Hepatology. 2003;37(2):429–42. doi:10.1053/jhep.2003.50047.View ArticlePubMedGoogle Scholar
- Bruix J, Sherman M. Management of hepatocellular carcinoma: an update. Hepatology. 2011;53(3):1020–2. doi:10.1002/hep.24199.View ArticlePubMedPubMed CentralGoogle Scholar
- Li S, Zhang L, Huang ZM, Wu PH. Transcatheter arterial chemoembolization combined with CT-guided percutaneous thermal ablation versus hepatectomy in the treatment of hepatocellular carcinoma. Chin J Cancer. 2015;34(6):254–63. doi:10.1186/s40880-015-0023-9.PubMedGoogle Scholar
- Bruix J, Sala M, Llovet JM. Chemoembolization for hepatocellular carcinoma. Gastroenterology. 2004;127(5 Suppl 1):S179–88.View ArticlePubMedGoogle Scholar
- Yoshimitsu K. Transarterial chemoembolization using iodized oil for unresectable hepatocellular carcinoma: perspective from multistep hepatocarcinogenesis. Hepat Med. 2014;6:89–94. doi:10.2147/HMER.S31440.View ArticlePubMedPubMed CentralGoogle Scholar
- Fernandez M, Semela D, Bruix J, Colle I, Pinzani M, Bosch J. Angiogenesis in liver disease. J Hepatol. 2009;50(3):604–20. doi:10.1016/j.jhep.2008.12.011.View ArticlePubMedGoogle Scholar
- Zhao Y, Duran R, Chapiro J, Sohn JH, Sahu S, Fleckenstein F, et al. Transarterial chemoembolization for the treatment of advanced-stage hepatocellular carcinoma. J Gastrointest Surg. 2016;20(12):2002–9. doi:10.1007/s11605-016-3285-x.View ArticlePubMedGoogle Scholar
- Bishop JM. The molecular genetics of cancer. Science. 1987;235(4786):305–11.View ArticlePubMedGoogle Scholar
- Cowell JK. Tumour suppressor genes. Ann Oncol. 1992;3(9):693–8.View ArticlePubMedGoogle Scholar
- Goodrum FD, Ornelles DA. p53 status does not determine outcome of E1B 55-kilodalton mutant adenovirus lytic infection. J Virol. 1998;72(12):9479–90.PubMedPubMed CentralGoogle Scholar
- Honda K, Sbisa E, Tullo A, Papeo PA, Saccone C, Poole S, et al. p53 mutation is a poor prognostic indicator for survival in patients with hepatocellular carcinoma undergoing surgical tumour ablation. Br J Cancer. 1998;77(5):776–82.View ArticlePubMedPubMed CentralGoogle Scholar
- Tabor E. Tumor suppressor genes, growth factor genes, and oncogenes in hepatitis B virus-associated hepatocellular carcinoma. J Med Virol. 1994;42(4):357–65.View ArticlePubMedGoogle Scholar
- Yu W, Fang H. Clinical trials with oncolytic adenovirus in China. Curr Cancer Drug Targets. 2007;7(2):141–8.View ArticlePubMedGoogle Scholar
- van Beusechem VW, van den Doel PB, Grill J, Pinedo HM, Gerritsen WR. Conditionally replicative adenovirus expressing p53 exhibits enhanced oncolytic potency. Cancer Res. 2002;62(21):6165–71.PubMedGoogle Scholar
- Wang X, Su C, Cao H, Li K, Chen J, Jiang L, et al. A novel triple-regulated oncolytic adenovirus carrying p53 gene exerts potent antitumor efficacy on common human solid cancers. Mol Cancer Ther. 2008;7(6):1598–603. doi:10.1158/1535-7163.mct-07-2429.View ArticlePubMedGoogle Scholar
- Fujiwara T, Urata Y, Tanaka N. Telomerase-specific oncolytic virotherapy for human cancer with the hTERT promoter. Curr Cancer Drug Targets. 2007;7(2):191–201.View ArticlePubMedGoogle Scholar
- Tu K, Zheng X, Zhou Z, Li C, Zhang J, Gao J, et al. Recombinant human adenovirus-p53 injection induced apoptosis in hepatocellular carcinoma cell lines mediated by p53-Fbxw7 pathway, which controls c-Myc and cyclin E. PLoS ONE. 2013;8(7):e68574. doi:10.1371/journal.pone.0068574.View ArticlePubMedPubMed CentralGoogle Scholar
- Tian G, Liu J, Zhou JS, Chen W. Multiple hepatic arterial injections of recombinant adenovirus p53 and 5-fluorouracil after transcatheter arterial chemoembolization for unresectable hepatocellular carcinoma: a pilot phase II trial. Anticancer Drugs. 2009;20(5):389–95. doi:10.1097/CAD.0b013e32832a2df9.View ArticlePubMedGoogle Scholar
- Guan YS, Liu Y, He Q, Li X, Yang L, Hu Y, et al. p53 gene therapy in combination with transcatheter arterial chemoembolization for HCC: one-year follow-up. World J Gastroenterol. 2011;17(16):2143–9. doi:10.3748/wjg.v17.i16.2143.View ArticlePubMedPubMed CentralGoogle Scholar
- Kasuya H, Takeda S, Shimoyama S, Shikano T, Nomura N, Kanazumi N, et al. Oncolytic virus therapy-foreword. Curr Cancer Drug Targets. 2007;7(2):123–5.View ArticlePubMedGoogle Scholar
- Zhang H, Wang H, Zhang J, Qian G, Niu B, Fan X, et al. Enhanced therapeutic efficacy by simultaneously targeting two genetic defects in tumors. Mol Therapy. 2009;17(1):57–64. doi:10.1038/mt.2008.236.View ArticleGoogle Scholar
- Heise C, Sampson-Johannes A, Williams A, McCormick F, Von Hoff DD, Kirn DH. ONYX-015, an E1B gene-attenuated adenovirus, causes tumor-specific cytolysis and antitumoral efficacy that can be augmented by standard chemotherapeutic agents. Nat Med. 1997;3(6):639–45.View ArticlePubMedGoogle Scholar
- Hay JG, Shapiro N, Sauthoff H, Heitner S, Phupakdi W, Rom WN. Targeting the replication of adenoviral gene therapy vectors to lung cancer cells: the importance of the adenoviral E1b-55kD gene. Hum Gene Ther. 1999;10(4):579–90. doi:10.1089/10430349950018652.View ArticlePubMedGoogle Scholar
- Harada JN, Berk AJ. p53-Independent and -dependent requirements for E1B-55K in adenovirus type 5 replication. J Virol. 1999;73(7):5333–44.PubMedPubMed CentralGoogle Scholar
- Lu W, Zheng S, Li XF, Huang JJ, Zheng X, Li Z. Intra-tumor injection of H101, a recombinant adenovirus, in combination with chemotherapy in patients with advanced cancers: a pilot phase II clinical trial. World J Gastroenterol. 2004;10(24):3634–8.View ArticlePubMedPubMed CentralGoogle Scholar
- Reid T, Galanis E, Abbruzzese J, Sze D, Wein LM, Andrews J, et al. Hepatic arterial infusion of a replication-selective oncolytic adenovirus (dl1520): phase II viral, immunologic, and clinical endpoints. Cancer Res. 2002;62(21):6070–9.PubMedGoogle Scholar
- Shen A, Liu S, Yu W, Deng H, Li Q. p53 gene therapy-based transarterial chemoembolization for unresectable hepatocellular carcinoma: a prospective cohort study. J Gastroenterol Hepatol. 2015;30(11):1651–6. doi:10.1111/jgh.13009.View ArticlePubMedGoogle Scholar
- Fu YP, Ni XC, Yi Y, Cai XY, He HW, Wang JX, et al. A novel and validated inflammation-based score (IBS) predicts survival in patients with hepatocellular carcinoma following curative surgical resection: a STROBE-compliant article. Medicine. 2016;95(7):e2784. doi:10.1097/MD.0000000000002784.View ArticlePubMedPubMed CentralGoogle Scholar
- Bruix J, Sherman M, Llovet JM, Beaugrand M, Lencioni R, Burroughs AK, et al. Clinical management of hepatocellular carcinoma. Conclusions of the Barcelona-2000 EASL conference. European Association for the Study of the Liver. J Hepatol. 2001;35(3):421–30.View ArticlePubMedGoogle Scholar
- Lee YH, Hsu CY, Huang YH, Hsia CY, Chiou YY, Su CW, et al. Vascular invasion in hepatocellular carcinoma: prevalence, determinants and prognostic impact. J Clin Gastroenterol. 2014;48(8):734–41. doi:10.1097/MCG.0b013e3182a8a254.View ArticlePubMedGoogle Scholar
- Luo J, Guo RP, Lai EC, Zhang YJ, Lau WY, Chen MS, et al. Transarterial chemoembolization for unresectable hepatocellular carcinoma with portal vein tumor thrombosis: a prospective comparative study. Ann Surg Oncol. 2011;18(2):413–20. doi:10.1245/s10434-010-1321-8.View ArticlePubMedGoogle Scholar
- Lin XJ, Li QJ, Lao XM, Yang H, Li SP. Transarterial injection of recombinant human type-5 adenovirus H101 in combination with transarterial chemoembolization (TACE) improves overall and progressive-free survival in unresectable hepatocellular carcinoma (HCC). BMC Cancer. 2015;15:707. doi:10.1186/s12885-015-1715-x.View ArticlePubMedPubMed CentralGoogle Scholar
- Harrell FE Jr, Lee KL, Mark DB. Multivariable prognostic models: issues in developing models, evaluating assumptions and adequacy, and measuring and reducing errors. Stat Med. 1996;15(4):361–87. doi:10.1002/(SICI)1097-0258(19960229)15:4<361:AID-SIM168>3.0.CO;2-4.View ArticlePubMedGoogle Scholar
- Sherman M. Hepatocellular carcinoma: epidemiology, surveillance, and diagnosis. Semin Liver Dis. 2010;30(1):3–16. doi:10.1055/s-0030-1247128.View ArticlePubMedGoogle Scholar
- Zhou ZG, Zheng XR, Zhou Q, Shi M, Zhang YJ, Guo RP, et al. Impact of oral anti-hepatitis B therapy on the survival of patients with hepatocellular carcinoma initially treated with chemoembolization. Chin J Cancer. 2015;34(5):205–16. doi:10.1186/s40880-015-0017-7.PubMedGoogle Scholar
- Matsuda Y, Ichida T. Impact of hepatitis B virus X protein on the DNA damage response during hepatocarcinogenesis. Med Mol Morphol. 2009;42(3):138–42. doi:10.1007/s00795-009-0457-8.View ArticlePubMedGoogle Scholar
- Wang Y, Zheng WL, Ma WL. Lobaplatin inhibits the proliferation of hepatollular carcinoma through p53 apoptosis axis. Hepat Mon. 2012;12(10 HCC):e6024. doi:10.5812/hepatmon.6024.View ArticlePubMedPubMed CentralGoogle Scholar
- Lyng H, Skretting A, Rofstad EK. Blood flow in six human melanoma xenograft lines with different growth characteristics. Cancer Res. 1992;52(3):584–92.PubMedGoogle Scholar
- Omata M, Lesmana LA, Tateishi R, Chen PJ, Lin SM, Yoshida H, et al. Asian Pacific Association for the Study of the Liver consensus recommendations on hepatocellular carcinoma. Hepatol Int. 2010;4(2):439–74. doi:10.1007/s12072-010-9165-7.View ArticlePubMedPubMed CentralGoogle Scholar
- European Association For The Study Of The L, European Organisation For R, Treatment Of C. EASL-EORTC clinical practice guidelines: management of hepatocellular carcinoma. J Hepatol. 2012;56(4):908–43. doi:10.1016/j.jhep.2011.12.001.View ArticleGoogle Scholar
- Xu L, Peng ZW, Chen MS, Shi M, Zhang YJ, Guo RP, et al. Prognostic nomogram for patients with unresectable hepatocellular carcinoma after transcatheter arterial chemoembolization. J Hepatol. 2015;63(1):122–30. doi:10.1016/j.jhep.2015.02.034.View ArticlePubMedGoogle Scholar
- Hu H, Han XK, Long XR, Fan J, Yan ZP, Wang JH, et al. Prognostic nomogram for post-surgical treatment with adjuvant TACE in hepatitis B virus-related hepatocellular carcinoma. Oncotarget. 2016;7(36):58302–14. doi:10.18632/oncotarget.11078.PubMedPubMed CentralGoogle Scholar