Review Article Targeted Therapy Against Hepatocellular .
Int J Clin Exp Med 2019;12(1):106-116www.ijcem.com /ISSN:1940-5901/IJCEM0078753Review ArticleTargeted therapy against hepatocellular carcinomaSonglin Chen1*, Lei Yang1*, Yanhui Cen1,2*, Jingpeng Feng1, Ping Li1, Mingfen Li1, Xiaoqi Huang1, Aiping Pan1,Yinghui Lin1Department of Clinical Laboratory of First Affiliated Hospital of Guangxi University of Chinese Medicine, Nanning,Guangxi, People’s Republic of China; 2Guangxi University of Chinese Medicine, Nanning, Guangxi, People’sRepublic of China. *Equal contributors.1Received April 30, 2018; Accepted July 26, 2018; Epub January 15, 2019; Published January 30, 2019Abstract: As a frequent solid tumor of the liver, hepatocellular carcinoma (HCC), has a very poor prognosis. It hasbeen the second most common cause of death which leaded by cancer all of the world. With more and more riskfactors, such as fatty liver, hepatitis B and C viral infections, alcohol abuse, and metabolic syndrome, HCC represents an increasing incidence and mortality. It is still a challenge for HCC curative treatment. There are no effectivetherapeutic strategies to meet the clinical need. Despite increasing research about the novel drugs, most of themultimately fail in Phase III clinical trials. In this review, we provide key point summaries and present research agendaof targeting therapeutic strategies for HCC regarding biomarkers and targeting delivery vehicles. Then, the CAR-Tcell and Bite targeting strategies efficiency are discussed. Finally, this review provides a critical evaluation of thetargets and strategies discussed above for personalized treatment of HCC.Keywords: HCC, incidence, treatmentIntroductionHepatocellular carcinoma (HCC), in most cases,occurs as a result of chronic hepatitis, and thebiggest risk factor is cirrhosis [1, 2]. Currently,some clinical treatments are available for HCC,surgical approaches, chemotherapeutics, andradiation percutaneous approaches are themain therapeutic strategies. Immunotherapeutics are a promising approach for treating cancer [3]. However, only surgical approaches haveproven effective thus far [4, 5]. Surgicalapproaches are highly limited by the advancedstage HCC. Despite tumor cells and tumormicroenvironment are relatively more sensitivethan normal tissues to the exposure of chemotherapeutics, non-specific anticancer drugshold non-selective physiological activity, whichcontributes to serious systemic cytotoxicity tonormal tissues. Radiation percutaneous approaches have a similar situation [6-8]. Someexisting chemotherapeutic medicines havebeen used to treat HCC, such as doxorubicin,sorafenib, cisplatin, and mitomycin, but none ofthem have shown clinical efficacy without overttoxicity and adverse effects due to their inherent drug resistance and nonspecific bio-distribution. Sorafenib has been approved by theFood and Drug Administration (FDA) to be usedas the first-line clinic treatment for HCC [9, 10].Although some research has reported thatSorafenib can improve HCC patients’ mediansurvival from 7.9 months to 10.7 months, unordered accumulation and nonspecific distribution in the body lead to much systemic sideeffects and also deficiency dosage targetingthe tumor cells and tumor microenvironment[11]. Recent discoveries of new cancer biomakers has been providing novel therapeutictools for cancer targeting treatments, especially concerning immunotherapeutic approaches[12]. New promising therapeutic strategies, likeCAR-T-cell and bispecific antibodies (bsAbs),have paved the ways to anticancer treatments.In this review, biomarkers and the therapeutictools for HCC will be described as the guide linefor clinical treatment [13].HCC bio-markerGlypican-3 (GPC3): GPC3 is a heparan sulfateproteoglycan expressed on the HCC cell surface while not in normal hepatocytes or tissue[14, 15]. Previous research has reported thatGPC3 can be used as a reliable diagnosis biomarker of HCC. Furthermore, more and more
Targeted therapy against HCCtributed in extra-hepatic tissues [24, 25]. As one of themost studied HCC targets,ASGPR is expressed on theearly and advanced HCC patient tumor cells. Researchershave exploited galactose, lactoferrin moieties, lactose, toproduce drug delivery systemstargeting ASGPR. Their studiesreported that drug delivery systems are significant for effective recognition by ASGPR[26-28].Figure 1. Therapeutic strategy CAR-T-cells.studies indicated that GPC3 worked as a coreceptor which play a part in promoting neoplastic transformation [16, 17]. In addition, Li etal. has reported that GPC3 could upregulatec-Myc expression which is a typical target ofthe classical Wnt signaling pathway [18].Furthermore, reducing expression GPC3 couldsuppress the volume and survival of HCC cellsin vivo and in vitro. Moreover, further studiesindicated that GPC3 is treated as a potentialbiomarker for HCC diagnosis and treatment[19, 20].Some anti-GPC3 monoclonal antibodies (mAbs)has been designated according to their structure and bioactivity toward the GPC3 molecule[21]. The earliest therapeutic mAb againstGPC3, named GC33 which specifically binds tothe C-terminal of GPC3 spatial structure with ahigh affinity. GC33 showed cytotoxic activitytarget GPC3-positive hepatoma cells and exhibited potential antitumor activity in xenograftmodels [22]. Furthermore, antibodies whicharm to GPC3 for HCC treatment have beenreported, such as humanized mouse YP7 antibodies, human antibodies MDX-1414 and HN3.Further research has been toward preclinicalevaluation [23].Asialoglycoprotein receptorThe asialoglycoprotein receptor (ASGPR) islargely expressed on hepatocytes without dis107Lactobionic acid (LA) is a specific binding ligand for galactose group [29, 30]. It can beused as hepatoma-targetedbio-mark to improve the effective to target hepatocytes. Inthese models, the medicineswere released in tumor cells byreceptor-mediated endocytosis between ASGPR and galactose residues on the cells.Additionally, some studies have reported thatLA-modified target systems could improve theincept drugs as described in the murine models bearing hepatoma. The galactosylatednanoparticles incorporated with Docetaxel andconferred anti-tumor efficacy and enhancedcytotoxicity with better tolerance for treatmentin vivo [31, 32].SerpinB3Recently studies have certified the serpin-protease inhibitor SerpinB3, a novel molecule inhepatocyte malignant transformation [33, 34].It is expressed on the hepatocyte as soon as itturns to malignant transformation. Hence,SerpinB3 can be exploited for diagnostic andtherapeutic purposes targeting in the primaryliver cancer. SerpinB3 and SerpinB4 are isoform which highly expressed in hepatocellulartumor and in dysplastic nodules without detectable in normal hepatocytes [35, 36]. They aresuggesting a diagnostic in relatively early phaseof HCC. Novel cellular localization skills havebeen used to describe for SerpinB3 and its isoform SerpinB4, while cytosolic localization andsurface localization was both initially reported.Moreover, nuclear localization mediated byJNK1 (c-Jun NH2-terminal kinase-1) has beendescribed, like following exposure to ultravioletInt J Clin Exp Med 2019;12(1):106-116
Targeted therapy against HCCirradiation [37, 38]. Researchers have reportedthat SerpinB3 promotes epithelial-mesenchymal transition and inhibits apoptosis. It acts asa key process of differentiation and migrationof epithelial cells by reducing intercellular adhesion and increasing motility into motile mesenchymal cells. Recently, studies indicate thathypoxia can upregulated SerpinB3 by hypoxiainducible factor-2α (HIF-2α). Besides, the ETSfamily transcription factor PEA3 and oncogenicRas via MAPK is also induced the expression ofSerpinB3 [39-41].Therapeutic strategiesCAR-T: Adoptive cellular immunotherapy (ACI)has brought new therapeutic strategies for cancer. Since Mitchison found that lymphocyte“adoptive transfer” caused rejection of allografttumors in the mouse model, adoptive immunotherapy has shown sustainable development.Whether in vitro preparation, cell proliferationand prolong cell survival, or the efficacy of cancer patients and side effects, this therapeuticstrategy has advanced considerably [42-44]and CAR-T-cells have undergone four generations of evolution (Figure 1).The principle is that a single-chain fragmentvariable (scFv) is edited and linked to T-cells invitro to form an artificial T-cell receptor TCR,scFv regulates its targeting function againstspecific antigens. Compared with the unmodified TCR, CAR can both recognize the targetedbiomarker through the extracellular antigenrecognition domain scFv and mediate the T-cellactivation through the intracellular TCR signaltransduction domain. This optimized designallows T-cells recognition to unrestricted fromhuman leukocyte antigen (HLA) and avoid thedependence on antigen presentation [45-48].A classical CAR structure is composed of anextracellular antigen recognition domain, atransmembrane domain, and an intracellularTCR signaling domain. The extracellular antigenrecognition domain is a typical scFv structure.It usually derived from the heavy and light chainvariable regions of specific antibodies whichtarget to tumor associated antigen (TAA). In ageneral way, the TAA includes proteins whichspecifically expressed in tumor cells, glycoproteins of peptide antigens and surface markermolecules, as well as glycolipids and ganglio-108sides. The transmembrane region of CAR isusually derived from type I membrane proteinssuch as CD3, CD4, CD8, and CD28. If the transmembrane region is mutated, CAR can reducethe recognition ability of CAR. The intracellularTCR signal transduction domain of CAR isderived from CD3ζ, as well as co-stimulatorymolecules such as CD28 and tumor necrosisfactor (TNF) receptor family members. CD3ζ isinvolved in the formation of endogenous TCRcomplexes in the CAR as a key molecule inT-cell active signaling. In contrast to CD3ζ aloneCAR, CAR T-cells with co-stimulatory signaldomain have enhanced viability, proliferationability and cytokine production ability after antigen recognition. At present, the four generations of CAR have been designed and the maindifferences in the intracellular signal domain(Figure 2) [49-53].The first-generation CARThe first-generation CAR only has the basic CARstructure consisting of bound scFv epitopes,transmembrane region, and CD3ζ intracellularsignal transduction region. This structure allowsthe first-generation CAR to activate calciumchannels and thus cause transient T-cell activation and proliferation, but does not significantlystimulate T-cells [54, 55].The second- and third- generation CARCompared with the first-generation, the second-generation CARs added a costimulatorydomain to the intracellular signal domain.Hence, the second-generation CAR has dualintracellular signal domains: the first is from theCD3ζ signal chain and the second is fromcostimulatory molecules. Second-generationCARs are effective at generating repetitive antigenic stimulation, promoting T-cell proliferationand producing IL-2 [52].In order to improve the clinical efficacy of CART-cell therapeutic strategies, the third-generation of CAR was improved. OX40 and 4-BB(CD137), which are members of the TNF receptor family, can provide co-stimulation signals toactivate T-cells to proliferate and produce cytokines. The third-generation CAR utilizes triplexsignal domains, including CD3ζ, co-stimulationsignaling domains and OX40/4-1BB (CD137),which perform significantly better effectiveInt J Clin Exp Med 2019;12(1):106-116
Targeted therapy against HCCFigure 2. Four generations of CAR-T.than the second-generation. OX40 signalingnot only promotes T-cell production of IL-2 andTNF-α, while maintaining clonal expansion ofT-cells, but also induces lysis of targeT-cells.Hombach et al., reported that CD28-CD3ζOX40 signal can reduce IL-10 production, toprevent its inhibition of T-cell function, thestudy from another side to prove that multiplesignal domains on the CAR T-cell function aspromotion role. However, the third generationof CARs still lacks clinical support. Currently,the second generation of CARs are still themost widely used generation in clinical practice[56-58].The factors which influence the effect of CART-cells in various clinical stages in vivo can bedivided into the following three categories.Such as the combination strategies of infusionproducts (T-cells and their subtypes), the distribution of tumor as well as its microenvironmentand the patient’s physical situation. In secondgeneration of CAR-T-cell applications, the therapeutic effectiveness on hematologic tumorsare much better than solid tumors. One of thereasons is that the solid tumor microenvironment is disadvantageous to CAR-T-cell proliferation and tumor targeting. In view of the aboveproblems in practice, the fourth generation ofCARs, called T-cells redirected for universal109cytokine killing (TRUCKs), came into being [59,60].TRUCKsThe basic design strategy of the fourth-generation of CAR-T-cell is combining with a NFAT(nuclear factor activated T-cell) to provide cytokine. As soon as scFv identified the targetingmark and activated CAR-CD3ζ signal, the activated NFAT could release transgenes (such asIL-12). As a pro-inflammatory cytokine, IL-12can recruit NK cells, macrophages, and othernon-specific immune responses to kill CART-cell unrecognized tumor cells. Additionally, itcan continue to stimulate CAR T-cell proliferation and activation, release of IL-2, act as a synergistic cytokine of IL-12 [61-63].The value of IL-12 in TRUCKs is demonstratedin many pre-clinical model trials. The higher cellular activity, stronger recognition ability, andmore sustained release of interferon-γ (IFN-γ)in targeting assays to melanoma models andIL-12 showed by NFAT-driven T-cells are continuously produced. A large number of experiments have shown that: maintaining a certainconcentration of IL-12 in local tissues willbe more conducive to anti-tumor immuneresponse. Furthermore, IL-2 can be continuousrelease by T-cells does to maintain the thera-Int J Clin Exp Med 2019;12(1):106-116
Targeted therapy against HCCpeutic dose without persistent drug supporting[64-66].The results of the previous clinical trial showedthat IL-2 has some special advantages in thetreatment of cancer due to its pleiotropic function. IL-12 is enriched in tumor tissue and thusit can act on tumor stroma and local immunecells particularly by inducing the Fas pathway topromote tumor matrix disintegration. In addition, IL-12 recruits and activates naïve immunecells (such as NK cells, NKT-cells and macrophages), regulates related immunosuppressivecells, induces tumor vessel injury, and necrosisduring the target tissue immune response. Atthe same time, IL-12 is also capable of sustaining T-cell expansion in target tumor tissues andavoiding T-cell depletion by inhibiting BIM proapoptotic molecules which in combination withPD-I block the enhancement of T-cell functionApoptosis [67-69].tissue which has the same or similar epitopewith the tumor tissue and cause cytotoxicitywhich results in normal tissue damage. On theother hand, normal tissues repeatedly provideCAR T-cell stimulation, thereby amplifying theCAR T-cell effect and prolonging its anti-tumorresponse, known as cytokine storm. SerumC-reactive protein can be used as a reliableindicator of the cytokine storm [73-75].Bispecific antibody (BsAb)It is worth mentioning that TRUCK releases ofIL-12 can motivate and activate non-specificimmune cells, such as NK cells, tumor macrophages, and to recruit a variety of other immunecells. They have the ability to recognize antigentargeted negative tumor cells which commonCAR T-cells cannot. As soon as tumor macrophages are activated, the tumor immuneresponse is modulated by the release of TNF-α.Under such a mechanism, mixed-type cancercell tumors can be effectively removed. In theabsence of IL-12, CAR-T-cells without IL-12structure were able to clear only antigen-targeted tumor cells, and antigen-targeted negativetumor cells would relapse after a reduction ininitial T-cells [70-72].The essence of tumor immunotherapy is following the immune response mechanism of thehuman immune system to treat cancer. Tumortargeting immunotherapy is a big part of tumorimmunotherapy which depend on the activation between antibody and targeting bio-mark.Monoclonal antibodies (or other novel functionality peptide and micro-molecule) engage theinnate immune system. In the past thirty years,antibody-dependent complement-dependentcytotoxicity and cell-mediated cytotoxicity havebeen the chief mechanisms of anti-tumordrugs. Researchers have tried to exploit thepotential of the immune system. Bispecific antibody (BsAb) drugs have been treated as similarplatforms through preclinical and clinical trials.Antibodies are extraordinary molecules hasbeen used over millions of years of evolution.Each antibody molecule has the similar structure. They are two uniform antigen binding sitesat the N-terminal variable region which are regulation for antigen specificity and the affinity ofthese maker molecules, and a steady fragmentcrystallizable (Fc) region at the C-terminuswhich triggers multiple effector mechanisms[76-78].Although TRUCK’s therapeutics potential islarge, it comes with potential risks. A large number of clinical reports have confirmed that thesecond generation of CAR-T-cells that haveentered clinical practice have achieved gratifying results in the treatment of hematologicalmalignancies. However, irreversible side effectsstill deserve attention. The same problemappeared in pre-TRUCK clinical trials as well.Among them, one of the most serious sideeffects is “off-target effects” which produce tissue damage and can lead to the rapid death ofCAR T-cells after infusion therapy for severepatients. During targeted clearance of tumortissue, CAR-T-cells target to recognize normalBased on the specific antigen/antibody combine, binding alone just physically block theantigen (targeting marker) or initiate/inhibit signaling via the antigen (targeting marker) resultin apoptosis of target cells. As the majority ofcancer therapeutic, like IgG antibodies, theywork for their immune functions via recruitingnatural killer cells and myeloid cells/macrophages by the Fc region. Moreover, as soon asthe Fc region initiate the classical complementcascade, they can deposit membrane attackon the surface membrane of tumor cells.Researchers have studied and exploited theseFc dependent targeting lysis mechanisms inhuman medicine (Figure 3) [79-82].110Int J Clin Exp Med 2019;12(1):106-116
Targeted therapy against HCChave evaluated lumbar injection administration of catumaxomab in patients withmalignant ascites caused byvarious EpCAM tumors. Ina clinical phase II/III study,researchers increased thedose of heavily pre-treatedpatients with symptomaticmalignant ascites. Comparedwith both non-treated controlpatients and baseline levels,analyses of ascites indicatedthe reduced level of vascularendothelial growth factor (VEFigure 3. Bispecific antibodies recruit effector cells to the proximity targetGF), and raising levels of acticells.vated CD8 and CD4 T-cellstogether with the distortionSince 1960s, when Nisonoff predicted thelevel of CD133 /EpCAM cancer stem cellspotential value of combining one of the two uni(CSC). Particularly, compared with controlform antigen binding arms with a different antipatients, patients treated by catumaxomabgen binding specificity, the concept of bispecifichave had significantly prolonged survival. Withantibodies has captured attention. Researchersdata described above, European Medicinehave developed this concept further in theAgency (EMA) approved catumaxomab for1980s for a second specificity against T-cellpatients with EpCAM-positive carcinomas whodeterminants. Over the past three decades,cannot be treated with standard therapy.bispecific antibodies have been widely develAnother classical anti-Her2-anti-CD3 Triomaboped.
targets and strategies discussed above for personalized treatment of HCC. Keywords: HCC, incidence, treatment Introduction Hepatocellular carcinoma (HCC), in most cases, occurs as a result of chronic hepatitis, and the biggest risk factor is cirrhosis [1, 2]. Currently, some clinical treatments are available for HCC,
Amendments to the Louisiana Constitution of 1974 Article I Article II Article III Article IV Article V Article VI Article VII Article VIII Article IX Article X Article XI Article XII Article XIII Article XIV Article I: Declaration of Rights Election Ballot # Author Bill/Act # Amendment Sec. Votes for % For Votes Against %
Occupational Therapy Occupational Therapy Information 29 Occupational Therapy Programs 30 Occupational Therapy Articulation Agreements 31 Occupational Therapy Prerequisites 33 Physical Therapy Physical Therapy Information 35 Physical Therapy Programs and Prerequisites 36 Physical Therapy Articulation Agreements 37 Physical Therapy vs .
TR-THERAPY concEPT The Targeted Radiofrequency Therapy delivers a new concept, allowing for effective combination of the therapist's unique skills with physical modality. The effect of the therapy is significantly improved through this simultaneous action and the therapy brings instant and long-lasting results. tR-tHERAPY concEPT TR-THERAPY MAssAGE
in the history of family therapy. They include Bowen Natural Systems Theory, contex-tual therapy, Virginia Satir’s Growth Model, brief therapy of the Mental Research Insti-tute, strategic family therapy, Milan Systemic Family Therapy, structural family therapy, solution-focused brief therapy, and narrative therapy.
REVIEW Targeted therapy: resistance and re-sensitization Dao‑Hong Chen1* and Xiao‑Shi Zhang2 Abstract The last two decades have witnessed a paradigm shift from cytotoxic drugs to targeted therapy in medical oncol‑ ogy and pharmaceutical innovation. Inspired by breakthroughs in molecular and cellular biology, a number of novel
Natural medicine Mistletoe- thymus-, pancreas peptide therapy Oxygen therapy, oxygen multistep-therapy according to Prof. von Ardenne, Ozone therapy and colozon-therapy for the intestine Deferring methods Colon irrigations, colon-hydro-therapy Hirudin treatment Phytotherapy Vitamin therapy Traditional Chinese medicine and
2) Internal Family Systems Therapy with Richard Schwartz 3) Satir Therapy with Jean McLendon 4) Behavioral Therapy with Richard Stuart 5) Strategic Therapy with James Coyne 6) Structural Therapy with Harry Aponte 7) Feminist Therapy with Cheryl Rampage 8) Narrative Therapy with Steve Madigan 9) Culture-Se
(2008). Occupational therapy practice framework: Domain and process (2nd ed.). American Journal of Occupational Therapy, 62, 625-683. American Occupational Therapy Association. (2013). Guidelines for Documentation of Occupational Therapy. American Journal of Occupational Therapy, 67 (6), S32-S38. American Physical Therapy Association. (2009).
