Great changes have taken place in the studies on liver cancer over the past 50 years. The main evolution and perspectives are reviewed as follows: ( 1) Infections with hepatitis B virus and hepatitis C virus, environmental factors, lifestyle, and metabolic, endocrine, and hereditary factors have become the high- risk factors for liver cancer, so the preventive measures should be adjusted. ( 2) The research data from the USA, Italy, and the author's institute showed that early diagnosis and early treatment are the main contributors to improved prognosis of liver cancer, and they remain the important means for improving treatment outcome. ( 3) Conservative therapy is being transformed, and molecular targeted therapy is a direction in the future; “tumor- killing + tumor- killing”combination therapy still holds promise for application, while“tumor- killing + rehabilitation”modality is worth more attention. ( 4) The concept of cancer metastasis has been updated: metastasis is a systemic problem; metastasis is not a phenomenon in the advanced stage; the microenvironment of immune inflammation is an important factor for cancer metastasis; cancer metastasis is mainly related to tumor stem cells; the metastatic potential of cancer can be increased or decreased. Therefore, we should pay attention to the systemic intervention involving the nervous, immune, endocrine, and metabolic systems, tumor stem cells' “return to the right way”, the application of anti- inflammatory agent, and traditional Chinese medicine. ( 5) Intervention of the adverse effects of tumor- killing therapy is an easy way to improve treatment outcome. “Evolution”is absolute, while“constancy”is relative. We should be far- sighted to promote the treatment of liver cancer.

The treatment modality for malignant tumor is changing from traditional single treatment to combined treatment and then to multidisciplinary comprehensive treatment. Based on the holistic medicine view, the author proposes the multidisciplinary holistic treatment ( MDHT) model to design and implement the comprehensive treatment regimen for cancer. The MDHT model involves three aspects: treatment target, treatment method, and treatment course. To take primary liver cancer as an example, the holistic treatment target can be divided into six basic targets: local lesion, regional lesions, systemic lesions, organ- based disease, homeostasis, and rehabilitation. Sequential therapy, synchronous therapy, and alternative therapy can be employed for the treatment targets of MDHT model. The implementation of holistic treatment regimen is achieved by different courses of multiple treatment methods. In the MDHT model for cancer, multidisciplinary treatment is the reflection of treatment modality, while holistic treatment is the treatment target pursued. The concept of MDHT contributes to the design and implementation of comprehensive treatment for cancer by multidisciplinary team.

In recent years, with the development of medical technology, the treatment outcome of hepatocellular carcinoma ( HCC) has improved substantially. However, the treatment of large HCC is still a difficult clinical problem. The biological characteristics of large HCC, as well as the surgical treatments ( hepatectomy and liver transplantation) and radiotherapy for large HCC, are reviewed. Under the guidance of surgical principle, radiotherapy can be considered as an alternative treatment for the inoperable patients. However, how to quantify the indices of hepatic functional reserve, how to limit the volume of normal liver and its radiation dose, and how to combine radiotherapy with other local treatments to increase tumor control rate are the urgent problems to be addressed.

As an inhibitor of fibroblast growth factor receptor ( FGFR) - 1, FGFR- 2, FGFR- 3, vascular endothelial growth factor receptor ( VEGFR) - 2, and VEGFR- 3, brivanib can inhibit tumor angiogenesis and growth. Phase Ⅰ and Ⅱ clinical trials have demonstrated the safety and efficacy of brivanib in the treatment of hepatocellular carcinoma ( HCC) . However, one phase Ⅲ, randomized, double-blind, placebo- controlled study showed that the overall survival was not significantly improved in patients receiving brivanib as a second-line therapy for advanced HCC, who had failed treatment with sorafenib, than in those receiving placebo. Another phase Ⅲ, randomized, double- blind, controlled study also showed that the overall survival was not significantly improved in patients receiving brivanib as a first-line therapy for HCC than in those receiving sorafenib. Due to the failure of the two phase Ⅲ studies, two other ongoing phase Ⅲ clinical trials had to be discontinued. Subgroup analysis and prior selection of patients with FGF who might benefit from brivanib may be necessary for further investigation of brivanib in the therapy for HCC.

Regorafenib, a novel multi- kinase inhibitor, has been approved for the treatment of metastatic colorectal cancer and gastrointestinal stromal tumors. The clinical trials of Regorafenib for the treatment of hepatocellular carcinoma ( HCC) are summarized. Phase Ⅰ and Ⅱ clinical trials have demonstrated the safety of Regorafenib in patients with HCC. A phase Ⅱ clinical trial has shown that as a second-line therapy for HCC, Regorafenib can achieve a relatively high disease control rate. In addition, an ongoing phase Ⅲ randomized, controlled trial will compare the safety and efficacy between Regorafenib and placebo as second- line therapies for advanced HCC. These results indicate that Regorafenib can effectively control the progression of HCC and may be used as a second- line therapy for advanced HCC.

With the rising incidence and mortality of HCC, accurate, simple, and non- invasive biomarkers are increasingly needed for the early diagnosis of this disease. MicroRNAs ( miRNAs) are a class of endogenous non- coding small RNAs, which have been widely found in animals, plants, and viruses and are stably expressed in both sera and tissues. The roles of miRNAs as oncogenes or tumor suppressor genes in the development and progression of HCC are described, and the aberrant expression of serum miRNAs in HCC is summarized. Analyses showed that these stably expressed miRNAs can be used as non- invasive biomarkers for early diagnosis of HCC.

Hepatocellular cancer ( HCC) is characterized by insidious onset, difficult early diagnosis, and rapid progression, and less than 30% of patients have the chance of being surgically treated when diagnosed with this disease. Therefore, non- surgical treatment is the main treatment modality for advanced HCC. The roles of vascular interventional therapy, molecular targeted therapy, chemotherapy, radiotherapy, and local ablation in the treatment of HCC are summarized. Although we have reached the agreement that comprehensive treatment is the best way for HCC, consensus has not been reached on the roles and order of these non- surgical therapies in comprehensive treatment. More clinical studies are needed to provide a better choice of treatment for patients with advanced HCC.

Pancreatic cancer ( PC) has the worst prognosis among all cancers, with a 5- year survival rate of less than 20% in patients with early local disease. The surgical treatment of PC has reached a plateau. Although novel drugs and treatment techniques have been increasingly applied, the survival of PC patients has not yet been improved significantly. The current status of treatment of localized PC is reviewed; the efficacy and role of precise radiotherapy are elucidated, and the potential of precise radiotherapy as the treatment option for localized PC is discussed. Clinical studies on multimodality therapy can be conducted to improve the survival of patients with localized PC.

Objective To investigate the value of contrast- enhanced ultrasound ( CEUS) in the hepatectomy for primary liver cancer. Methods The clinical data of 42 patients who underwent CEUS- guided hepatectomy for primary liver cancer in the department of hepatobiliary surgery of our hospital from January 2010 to December 2011 were collected. The number of lesions, lesion sizes, and relationship between lesions and intrahepatic bile ducts as determined by CEUS during hepatectomy were compared with those determined by preoperative ultrasound and computed tomography ( CT) . Results In addition to the positive lesions found by preoperative ultrasound and CT, the intraoperative CEUS could more accurately determine the number and nature of intrahepatic lesions and relationship between lesions and intrahepatic bile ducts and more clearly show the satellite nodules of primary lesion ( in 8 cases) . Portal vein tumor thrombus ( PVTT) was newly found in 6 cases; of these cases, 2 had PVTT in the main trunk of the portal vein, 1 had PVTT in the left branch of the portal vein, and 3 had PVTT in the right branch of the portal vein. Common bile duct tumor thrombus was found in 2 cases, and inferior vena cava tumor thrombus in 1 case. Small lesions ( around 0. 5 cm) distant from the primary lesion were found in 3 cases. Conclusion In the hepatectomy for primary liver cancer, CEUS can find residual lesions and avoid important anatomical structures, which is of great application value.

Objective To compare three- dimensional conformal radiotherapy ( 3DCRT) and intensity- modulated radiotherapy ( IMRT) in terms of their advantages of disadvantages in the treatment of primary hepatocellular carcinoma ( PHC) with portal vein tumor thrombus ( PVTT) . Methods Twenty patients with PHC accompanied by PVTT were enrolled in this study. Each patient underwent 3DCRT and IMRT with a prescribed dose of 40 Gy / 20 fractions. The parameters included the conformity index ( CI) , homogeneity index ( HI) , mean dose ( Dmean) , minimum dose ( Dmin) , maximum dose ( Dmax) , V95%, V100%, and V105% for planning target volume ( PTV) , the number of monitor units ( MUs) for evaluating planning efficiency, and Dmean, Dmax, and Dmin for the organs at risk ( OAR) . The percentage of the normal liver volume receiving ≥30, > 20, > 10, and > 5 Gy ( V30 Gy, V20 Gy, V10 Gy, and V5 Gy, respectively) were calculated to determine liver toxicity. The two radiotherapy regimens were compared in terms of the dosimetric parameters for PTV and OAR, as well as number of MUs. Results IMRT had significantly higher Dmin, Dmean, V95%, and V100% and significantly better HI and CI compared with 3DCRT ( P < 0. 05) . The liver V30 Gy and V20 Gy were 33. 55 ± 5. 67 and 44. 24 ± 6. 17, respectively, for 3DCRT, versus 29. 41 ± 2. 67 and 41. 28 ± 4. 59 for IMRT ( P = 0. 001; P = 0. 021) . There were no significant differences in liver V10 Gy, liver V5 Gy, stomach Dmax, small intestine Dmax, spinal cord Dmax, kidney Dmax, and kidney V20 Gy between IMRT and 3DCRT. The number of MUs was 303. 7 ± 35. 8 for 3DCRT and 377. 4 ± 33. 2 for IMRT ( P = 0. 000) . Conclusion IMRT provides higher tumor coverage, homogeneity, and conformity, as well as better normal liver tissue sparing, as compared with 3DCRT. However, IMRT is not superior to 3DCRT in terms of treatment efficiency.

Objective To measure the expression of Gremlin- 1 in the peripheral blood mononuclear cells ( PBMCs) and liver tissues of patients with primary liver cancer and liver cirrhosis. Methods PBMCs were obtained from 21 patients with primary liver cancer and 17 patients with liver cirrhosis during June to December 2012, as well as 15 healthy donors as control. The mRNA expression of Gremlin- 1 in PBMCs was measured by real- time quantitative PCR; the expression of Gremlin- 1 in the liver tissues of 10 patients with primary liver cancer was measured by immunohistochemistry. Comparison between groups was made by analysis of variance. Results Compared with that in control group, the mRNA expression of Gremlin- 1 in PBMCs was up- regulated by 3. 5 and 4. 4 times in patients with primary liver cancer and liver cirrhosis, respectively ( P = 0. 003 4; P = 0. 002 6) . Gremlin- 1 was highly expressed in the liver tissues of patients with primary liver cancer, with a positive rate of 72. 5%, while it was lowly or not expressed in the normal liver tissue, with a positive rate of 12. 1%; there was a significant difference in the positive rate between patients with primary liver cancer and the control group ( P < 0. 001) , but there was no significant difference in the positive rate between poorly differentiated carcinoma and well differentiated carcinoma ( 74. 7% vs 69. 1%, P > 0. 05) . The immunohistochemistry showed that Gremlin- 1 was expressed mainly in the cell membrane and cytoplasm of liver tumor and partly in stromal cells including vascular endothelial cells and fibroblasts. Conclusion The up- regulated expression of Gremlin- 1 may be closely associated with the development of primary liver cancer and liver cirrhosis.

Objective To investigate the expression of Caspase- 9 and Survivin in hepatocellular carcinoma ( HCC) tissues and its clinical significance. Methods The immunohistochemical SP method was used to measure the expression of Caspase- 9 and Survivin in the HCC tissues and paracancerous normal liver tissues of 92 HCC patients, and the relationship between their expression and the clinical malignant biological behavior of HCC was analyzed. Results Compared with paracancerous normal liver tissues, the HCC tissues had significantly lower expression of Caspase- 9 ( χ2= 6. 48, P < 0. 05) and significantly higher expression of Survivin ( χ2= 7. 05, P < 0. 05) . The positive rate of Survivin in HCC tissues was significantly higher in patients with TNM stage III- IV disease, with portal vein tumor thrombus ( PVTT) , and with lymph node metastasis ( LNM) than in those with TNM stage I- II disease, without PVTT, and without LNM ( χ2= 5. 07, P < 0. 05; χ2= 6. 18, P < 0. 05; χ2= 8. 29, P < 0. 05) , but no significant differences were found between other group pairs. The positive rate of Caspase- 9 in HCC tissues was significantly lower in patients with pathological stage III- IV disease than in those with pathological stage I- II disease ( χ2= 7. 63, P < 0. 05) , but no significant differences were found between other group pairs. Conclusion Low expression of Caspase- 9 and abnormally high expression of Survivin were both involved in the development of HCC. Low expression of Caspase- 9 may be closely associated with the malignant differentiation of HCC cells, and high expression of Survivin is closely associated with the malignant progression, such as invasion and distant metastasis, of HCC.

Objective To investigate the efficacy of argon- helium cryoablation combined with I125particle implantation in the treatment of hilar cholangiocarcinoma. Methods Five patients with hilar cholangiocarcinoma who were admitted to our hospital from January 2010 to June 2013 were selected. Under CT localization, the tumor location and puncture angle were determined using a puncture needle, and then the tumor was pierced with a 17 mm argon- helium knife; a temperature- sensing needle was placed at the main bile duct and confluence of the left and right hepatic ducts closest to the ice ball and near the side of argon- helium knife; the minimum distance between the argon-helium knife and bile duct wall was greater than 3 cm; for the tumor tissue surrounding the main bile duct, I125particles were placed along the longitudinal axis about 0. 8 cm from the bile duct wall at a spacing of 0. 3- 0. 5 cm, and then two cycles of cryoablation were performed. Results Of the five patients, two had complete relief of pain symptoms within one week after operation, and three had significant relief; two cases showed a significant decrease in total bilirubin within one week, and one showed a mild increase. No complications such as bleeding and pneumothorax were seen. Conclusion Argon- helium cryoablation combined with I125particle implantation can effectively relieve symptoms and improve the quality of life in patients with hilar cholangiocarcinoma within a short period after operation, but the evaluation of its long- term efficacy still needs large- sample case studies and long- term follow- up.

Objective To investigate the expression of delta drosophila homolog- like 1 ( DLK1) and matrix metalloproteinase 9 ( MMP- 9) in cholangiocarcinoma tissue and to analyse their clinical significance and the correlation between DLK1 and MMP- 9. Methods Cholangiocarcinoma tissues were collected from 96 patients who were pathologically diagnosed with cholangiocarcinoma from 2001 to 2010, and normal bile duct tissues were collected from 20 normal persons. The expression of DLK1 and MMP- 9 in cholangiocarcinoma tissues or normal bile duct tissues was measured by immunohistochemical S- P method. Chi- square test was performed using SPSS 17. 0. Correlation analysis was performed by Spearman's correlation test. Results The positive expression rates of DLK1 and MMP- 9 in cholangiocarcinoma tissues were 59. 38% and 79. 17%, respectively, significantly higher than those in normal bile duct tissues ( 0 and 15%) ( χ2= 23. 35, P < 0. 05; χ2= 31. 37, P < 0. 05) . The expression of DLK1 was correlated with the differentiation degree in cholangiocarcinoma ( χ2= 7. 46, P < 0. 05) ; the expression of MMP- 9 was correlated with the differentiation degree and lymph node metastasis in cholangiocarcinoma ( χ2= 7. 28, P < 0. 05; χ2= 9. 67, P < 0. 05) , but was not correlated with sex, age, and tumor size ( P > 0. 05) . There was a positive correlation between the expression of DLK1 and MMP- 9 ( r = 0. 41, P < 0. 05) . Conclusion DLK1 and MMP- 9 are highly expressed in cholangiocarcinoma, and they are positively correlated, suggesting that they are associated with the development, progression, invasion, and metastasis of cholangiocarcinoma. The detection of the two indicators provides a reference for the diagnosis and treatment of cholangiocarcinoma.

Objective To establish a three- dimensional ( 3D) cell culture model for gallbladder carcinoma ( GC) cells and to investigate the killing effect of a novel nano- drug delivery system on GC cells and its action mechanism. Methods Two- dimensional ( 2D) and 3D cell culture models for GC GBC- SD cells were established, and the normal cell toxicity of nano- drug delivery system ( CP24, folate receptor- mediated targeting poly ( epsilon- caprolactone) ) and the inhabitation rate of GC cells exposed to 5- fluorouracil ( 5- FU) carried by CP24 were determined by MTT assay, HE staining, flow cytometry ( FCM) , and Hoechst / PI staining. Results CP24 showed no significant cytotoxicity in liver and kidney cells, according to the result of HE staining. CP24 showed no significant killing effect on GC cells, according to the result of FCM. Given a 5- FU concentration of 100 μg / ml, the killing and inhibitory effects of both 5- FU- CP24 and 5- FU on GBC- SD cells were lower when using the 3D cell culture model than when using the 2D cell culture model; whether using a 2D or 3D cell culture model, 5- FU- CP24 had a significantly stronger killing effect on GBC- SD cells than 5- FU ( P < 0. 05) . 5- FU- CP24 mainly led to apoptosis in GBC- SD cells, while 5- FU mainly led to necrosis, as shown by Hoechst / PI staining. Conclusion 3D cell culture can reflect the intracellular microenvironment in vivo more accurately. Intercellular matrix may affect the cellular sensitivity to drugs. 5- FU can kill more GC cells when carried by a nano- drug delivery system. This degradable nano- drug delivery system has good drug delivery performance, sustained drug release, and high biosafety and holds promise for application in chemotherapy for GC.

Objective To amplify and determine the hepatitis B virus ( HBV) reverse transcriptase ( RT) sequences of 153 Chinese patients with chronic HBV infection and investigate the drug resistance mutations related to nucleos ( t) ide analogues, and to analyze if there are drug resistance mutations which might lead to tenofovir resistance. Methods A total of 153 patients with chronic HBV infection were divided into two groups: 78 HBV carriers who had never used nucleos ( t) ide analogues ( NAs) and 75 patients with chronic hepatitis B who had been treated with NAs. Their serum samples were used for HBV DNA extraction and RT gene amplification by PCR, and the RT sequences were analyzed to identify the known drug resistance mutations related to NAs and detect the drug resistance mutations related to tenofovir. The obtained data were statistically analyzed using SPSS 19. 0; the Student's t test was used for normally distributed data, and the Wilcoxon's rank sum test for non- normally distributed data. Results Drug resistance mutations related to NAs were detected in 7 cases ( 8. 97%) of the untreated group, but there was no drug resistance mutation related to tenofovir. Drug resistance mutations were detected in 16 cases ( 21. 33%) of the treated group, with rtA181T + rtN236T mutations in one case, which might be related to tenofovir resistance. Conclusion The drug resistance mutation detection rate in untreated group was 8. 97%. The drug resistance mutation detection rate was not significantly correlated with HBV genotype and patient's sex and age in either group. The rtA181T + rtN236T mutations were detected in only one case of the treated group, which indicates a very low rate of pre- existence of tenofovir- related drug resistance mutations in Chinese patients with chronic HBV infection.

Sorafenib can significantly improve the prognosis of patients with advanced hepatocellular carcinoma ( HCC) , and it acts as an antagonist of the anti- angiogenic targets of vascular endothelial growth factor receptors and platelet- derived growth factor receptors and an inhibitor of the Raf / MEK / ERK signaling pathway to suppress tumor growth. However, the improvement in patients' quality of life is compromised by frequent sorafenib- related adverse events. The pharmacological mechanism of the small- molecule targeted drug sorafenib in the treatment of HCC is reviewed, and the incidence, characteristics, prevention, and treatment of common sorafenib- related adverse events are summarized. Additionally, the relationship between sorafenib- related adverse events and the antitumor effect of sorafenib is elucidated. It is suggested that clinicians should consider the pros and cons comprehensively when using sorafenib in treating HCC.

Hepatocellular carcinoma ( HCC) is a progressive, multi- center, and multi- cause disease. Nowadays, numerous drugs have been investigated in clinical trials for treatment of HCC, but the prognosis was usually poor because HCC is highly invasive and metastatic. The structural characteristics and biological properties of clusterin ( CLU) are described; the research progress in relationship of secretory CLU ( sCLU) with the development and progression of HCC is summarized, and it is pointed out that the overexpression of CLU may promote cancer metastasis, induce epithelial- mesenchymal transition, inhibit apoptosis of HCC cells, and lead to resistance to chemotherapy drugs. In addition, the molecular structure of second- generation antisense nucleic acid drug Custirsen, which may downregulate the metastasis of HCC in vitro, is briefly presented. It is suggested that sCLU promotes the development and progression of HCC in many ways and deserves further research for its molecular mechanism of action.

A growing body of literature highlights the cross- talk between tumor cells and the surrounding peritumoral stroma as a key modulator in the development, invasion, and metastasis of hepatocellular carcinoma ( HCC) . Hepatic stellate cells ( HSC) , an important component in the microenvironment of HCC, play an important role in the development and progression of “inflammation- fibrosis / cirrhosis-tumor”. The origin and activation of HSC, as well as the effects of HSC and their cytokines on the immune response in the proliferation, metastasis, and invasion of HCC, are reviewed. It is thought that HSC are not only a“hotbed”for tumor growth, but also help resist the tumor tracing and elimination mechanism of the immune system. Therefore, it is worth developing treatments targeting the tumor microenvironment when the single anti- cancer therapy is ineffective.