Hepatic arterial infusion chemotherapy (HAI) using an implanted port system is the standard regimen for primary and metastatic liver cancers (MLCs). However, there have been few studies concerning HAI-induced oxidative stress and damage to the liver or other organs. The aim of the present study was to investigate the ability of green tea polyphenols (GTPs) to reduce the oxidative stress or increase the biological antioxidative potential in HAI-treated patients. A total of 19 patients with inoperable hepatocellular carcinoma (HCC) or MLC from colorectal malignancy were eligible for HAI with cisplatin (CDDP) and 5-fluorouracil (5FU). The study subjects were randomly assigned to either a 3 or a 6 oral GTP tablets per day group. Each tablet had a GTP content equivalent to 79 mg of epigallocatechin-3-gallate. The oxidative stress was assessed by measuring the levels of derivatives of reactive oxygen metabolites (d-ROMs) and the biological antioxidative potential (BAP) values in patient plasma using the Free Radical Analytical System 4 (FRAS4), and correlating the results with clinical laboratory data for the patients. The levels of d-ROMs were significantly reduced by the oral intake of 6 GTP tablets for 6–9 months (P=0.0463) but were not significantly reduced by the oral intake of 3 GTP tablets daily. BAP values remained constant in the 3 and 6 tablet groups for 6–9 months during the follow-up study. The total serum bilirubin (T-bil) levels increased significantly at 3 (P=0.028) and 9 (P=0.0151) months and the red blood cell (RBC) count decreased at 6 months (P=0.0458) after intake for the 6 GTP tablet group. Alkaline phosphatase (ALP) levels increased significantly at 9 months (P=0.0298). Cholinesterase (ChE) decreased significantly at 9 (P= 0.0127) and 12 (P= 0.0207) months after intake for the 3 GTP tablet group. The results indicate that the daily intake of 6 GTP tablets containing 474 mg polyphenols significantly reduces HAI-induced oxidative stress in HCC or MLC patients while the antioxidative potentials of the patients remain constant.
It is well known that green tea polyphenols (GTPs) have antioxidant activity (
From October 2009 to October 2010, a total of 19 patients with hepatocellular carcinoma (HCC) or metastatic liver cancer (MLC) from colorectal cancer were enrolled in this study. In 17 of the patients the cancer was causatively associated with chronic liver damage related to hepatitis B, hepatitis C or non-B non-C hepatitis infection and the remaining 2 patients had metastatic colon cancer (
HAI was performed using an implantable reservoir system. The method of implantation of the reservoir port system was as previously reported (
GTP tablets were prepared from spray-dried green tea extract powder that had been processed to remove >70% of the caffeine but retain >90% of the polyphenol compounds. The extract powder was combined with 18% dextran and 2% sucrose ester and shaped into tablets. Each tablet was 9 mm in diameter, 400 mg in weight and had a GTP content equivalent to 79 mg of epigallocatechin-3-gallate (EGCg), as previously described (
After obtaining the approval of the Institutional Review Board and the patients’ informed consent, the study subjects were randomly assigned into one of two oral GTP tablet groups; a 3 tablets per day group (n=10) and a 6 tablets per day group (n=9). Measurements of the levels of d-ROMs, as an indicator of oxidative stress, and BAP, as an indicator of the levels of antioxidant compounds in the patients, were carried out using blood samples obtained prior to and following GTP intake and clinical laboratory data were evaluated in parallel. The patients were followed up for 12 months.
Heparinized peripheral blood, freshly drawn from the patients, was spun in a low speed centrifuge to separate the plasma. Measurements of the d-ROMs and BAP in the plasma were carried out within 2 h using the Free Radical Analytical System 4 (FRAS4) designed by SEAC s.r.l. (Florence, Italy). For the measurement of d-ROMs, 10
Statistical analysis was carried out using the Student’s t-test for continuous variables and a χ2 test for categorical variables. The commercially available software package MedCalc Version 9.5.1.0 (MedCalc Software, Mariakerke, Belgium) was used. A two-tailed P-value <0.05 was considered to indicate a statistically significant result.
All 19 patients were followed up for 6 months, and 6 and 8 patients were lost at 9 and 12 months, respectively. The characteristics of the study subjects are presented in
There are increasing numbers of studies concerning the effective synergism of GTPs with anticancer drugs to reduce drug resistance and side effects (
Epidemiological studies have revealed that a daily intake of green tea of more than 10 cups per day lowered the incidence of cancers in the stomach, lung and other sites (
There are 3 limitations to this study. Firstly, this is not a randomized control study, secondly, the number of patients studied is small and thirdly, there is no direct evidence of increased antioxidant stress during the cancer treatment process. In order to address these limitations, we have initiated a fully randomized control trial studying two new patient groups, one taking GTP tablets and the other taking placebo tablets, which are followed up by the same protocol as is used in the current study.
This is the first study concerning the quantitative evaluation of HAI-induced oxidative stress in patients with liver cancer. This harmful oxidative stress may be prevented by supplementation with oral GTP tablets.
Profile of the hepatocellular carcinoma and metastatic liver cancer patients supplemented with oral GTP tablets.
Characteristics | 3 GTP tablet group (n=10) | 6 GTP tablet group (n=9) |
---|---|---|
Age (years), median (range) | 75.5 (61–82) | 68 (49–76) |
Gender (male/female) | 6/4 | 7/2 |
Hepatitis virus | ||
None | 0 | 2 |
B | 2 | 0 |
C | 6 | 5 |
Non-B non-C | 2 | 2 |
Child-Pugh score (median) | 6 | 6 |
Child-Pugh class A | 10 | 9 |
Treatments prior to supplementation | ||
None | 2 | 4 |
Surgery | 2 | 1 |
TACE | 3 | 2 |
AI | 0 | 1 |
Surgery + TACE | 1 | 1 |
Surgery + TACE + RFA | 1 | 0 |
RFA + TACE | 1 | 0 |
TACE, transcatheter arterial chemoembolization; AI, arterial infusion; RFA, radiofrequency ablation; GTP, green tea polyphenol.
Reduction in d-ROMs in the plasma of the patients following the intake of oral GTP tablets.
Dose | Follow-up
|
P-value | ||||
---|---|---|---|---|---|---|
Before | 3 months | 6 months | 9 months | 12 months | ||
6 tablet group | n=9 | n=9 | n=9 | n=6 | n=5 | |
430.5 (74.6) | 401.5 (64.4) | 376.7 (60.0) |
348.8 (59.2) |
365.4 (57.7) |
0.0463 | |
3 tablet group | n=10 | n=10 | n=10 | n=7 | n=6 | |
391.8 (87.4) | 397.9 (130.2) | 410.5 (151.1) | 373.8 (90.9) | 377.3 (100.3) | NS |
All numbers are the average d-ROM readings and the standard deviation (SD). NS, not statistically significant.
Significant difference in d-ROM readings taken before and 6 months after the intake of 6 GTP tablets.
Significant difference in d-ROM readings taken before and 9 months after the intake of 6 GTP tablets.
Not yet analyzed due to the small number of subjects (n=5). d-ROMs, derivatives of reactive oxygen metabolites; GTP, green tea polyphenol. The units for d-ROM are Carratelli units (Carr units).
Change in BAP in the plasma of the patients following the intake of oral GTP tablets.
Dose | Follow-up
|
P-value | ||||
---|---|---|---|---|---|---|
Before | 3 months | 6 months | 9 months | 12 months | ||
6 tablet group | n=9 | n=9 | n=9 | n=6 | n=5 | |
2653.1 (368.8) | 2540.1 (175.2) | 2482.3 (211.6) | 2483.0 (148.7) | 2627.6 (297.2) |
NS | |
3 tablet group | n=10 | n=10 | n=10 | n=7 | n=6 | |
2694.8 (230.0) | 2526 (160.5) | 2639.6 (165.9) | 2652.8 (263.1) | 2590.6 (158.9) |
0.0078 |
All numbers are the average BAP readings and the standard deviation (SD).
Not yet analyzed due to the small number of patients (n=5).
Significant difference in BAP readings taken before and 12 months after the intake of 3 GTP tablets. NS, not statistically significant; BAP, biological antioxidative potential; GTP, green tea polyphenol. The units for BAP are micromole/l.
Clinical laboratory data of the 6 GTP tablet group.
Follow up
|
P-value | |||||
---|---|---|---|---|---|---|
Before | 3 months | 6 months | 9 months | 12 months | ||
PIVKA II (mAU/ml) | 2,664.40 (5,796.7) | 1,285.50 (2,540.0) | 3,473.50 (8,318.9) | 172.00 (268.9) | 3,403.00 (6,686.8) | NS |
WBC (/ |
3,932.20 (1,476.5) | 3,872.20 (1,691.5) | 3,902.20 (1,249.8) | 4,476.00 (2,218.9) | 3,685.00 (1,432.6) | NS |
RBC (×104/ |
399.30 (60.8) | 394.40 (55.6) | 374.10 (66.4) |
382.50 (77.9) | 394.60 (89.0) | 0.0458 |
Hb (g/dl) | 12.60 (1.9) | 12.90 (1.5) | 12.40 (1.8) | 12.90 (2.0) | 13.10 (2.2) | NS |
Plt (×104/ |
13.10 (5.1) | 11.70 (4.8) | 10.90 (4.1) | 10.20 (3.8) | 11.30 (2.9) | NS |
AST (IU/l) | 52.60 (29.7) | 62.70 (57.2) | 69.70 (45.4) | 57.30 (39.0) | 64.20 (54.3) | NS |
ALT (IU/l) | 51.20 (37.1) | 55.90 (55.1) | 52.90 (32.3) | 46.80 (28.3) | 52.20 (45.9) | NS |
LDH (IU/l) | 226.00 (74.2) | 273.60 (144.6) | 247.60 (58.8) | 220.20 (84.8) | 228.40 (40.5) | NS |
ALP (IU/l) | 353.90 (79.4) | 411.90 (204.4) | 398.90 (152.9) | 438.30 (260.3) | 403.40 (169.3) | NS |
ChE (IU/l) | 210.40 (83.2) | 211.60 (86.2) | 200.00 (109.5) | 234.50 (138.8) | 202.20 (118.1) | NS |
T-bil (mg/dl) | 0.62 (0.22) | 0.84 (0.15) |
0.74 (0.30) | 0.88 (0.26) |
0.94 (0.29) | 0.028 |
BUN (mg/dl) | 12.00 (2.4) | 14.40 (6.1) | 14.20 (5.4) | 13.70 (3.2) | 12.60 (5.3) | NS |
Cr (mg/dl) | 0.70 (0.1) | 0.70 (0.1) | 0.70 (0.2) | 0.70 (0.2) | 0.70 (0.3) | NS |
CRP (mg/dl) | 0.70 (1.1) | 0.80 (1.8) | 0.30 (0.3) | 0.50 (0.6) | 1.00 (1.9) | NS |
AFP (ng/ml) | 9,193.90 (2,2651.0) | 9,709.00 (22,515.3) | 9,427.40 (22,577.3) | 1,845.90 (4,083.2) | 1,330.80 (2,650.8) | NS |
Collagen IV (ng/ml) | 234.40 (91.0) | 261.20 (89.6) | 304.60 (102.7) | 269.50 (68.1) | 252.00 (83.5) | NS |
All numbers are listed as average and standard deviation (SD). NS, not statistically significant difference.
Not yet analyzed due to small number of patients (n=5).
Significant difference compared with before treatment. GTP, green tea polyphenol; PIVKA-II, protein induced by vitamin K absence II or antagonist II; WBC, white blood cell; RBC, red blood cell; Hb, hemoglobin; Plt, platelets; AST, aspartate transaminase; ALT, alanine transaminase; LDH, lactate dehydrogenase; ALP, alkaline phosphatase; ChE, cholinesterase; T-bil, total serum bilirubin; BUN, blood urea nitrogen; Cr, creatinine; CRP, C-reactive protein; AFP, α-fetoprotein.
Clinical laboratory data of the 3 GTP tablet group.
Follow up
|
P-value | |||||
---|---|---|---|---|---|---|
Before | 3 months | 6 months | 9 months | 12 months | ||
PIVKA II (mAU/ml) | 1,136.70 (1,876.0) | 1,260.00 (1,955.9) | 5,918.90 (15,296.1) | 3,367.00 (4,446.7) | 3,630.80 (5,251.8) | NS |
WBC (/ |
4,137.00 (3,129.2) | 2,979.00 (764.6) | 3,147.00 (1,331.8) | 2,785.70 (990.0) | 2,895.00 (1,139.2) | NS |
RBC (×104/ |
380.70 (48.2) | 379.20 (46.9) | 378.30 (33.1) | 367.00 (36.1) | 368.30 (46.4) | NS |
Hb (g/dl) | 13.00 (1.0) | 13.00 (1.2) | 13.00 (0.9) | 12.50 (1.2) | 12.50 (1.1) | NS |
Plt (×104/ |
9.60 (1.8) | 9.10 (2.3) | 9.20 (3.4) | 9.60 (4.1) | 11.30 (7.2) | NS |
AST (IU/l) | 47.10 (16.6) | 55.50 (21.5) | 53.70 (27.5) | 55.70 (19.4) | 56.80 (29.5) | NS |
ALT (IU/l) | 35.90 (11.8) | 40.90 (22.9) | 41.60 (17.9) | 42.10 (17.9) | 41.70 (24.2) | NS |
LDH (IU/l) | 244.40 (65.4) | 296.90 (119.7) | 300.80 (141.1) | 241.90 (60.4) | 227.80 (44.6) | NS |
ALP (IU/l) | 366.00 (156.9) | 392.00 (171.2) | 527.70 (450.1) | 414.70 (120.5) |
427.80 (121.3) | 0.0298 |
ChE (IU/l) | 182.30 (40.6) | 185.30 (47.3) | 167.90 (56.7) | 143.30 (45.6) |
143.70 (54.3) |
0.0127 |
T-bil (mg/dl) | 0.81 (0.24) | 0.75 (0.24) | 0.88 (0.20) | 0.87 (0.26) | 1.02 (0.60) | NS |
BUN (mg/dl) | 15.10 (4.1) | 15.40 (5.7) | 22.70 (21.4) | 15.40 (6.2) | 15.20 (4.8) | NS |
Cr (mg/dl) | 0.80 (0.2) | 0.74 (0.17) | 0.90 (0.5) | 0.80 (0.2) | 0.80 (0.2) | NS |
CRP (mg/dl) | 0.50 (0.5) | 0.50 (0.7) | 0.40 (0.5) | 1.00 (1.0) | 0.60 (0.4) | NS |
AFP (ng/ml) | 783.40 (1,940.6) | 760.90 (1,946.0) | 3,439.90 (7,990.5) | 8,728.60 (22,829.5) | 581.70 (751.1) | NS |
Collagen IV (ng/ml) | 311.20 (57.4) | 319.40 (55.9) | 349.40 (132.1) | 336.40 (64.9) | 326.80 (68.0) | NS |
All numbers are listed as average and standard deviation (SD). NS, no statistically significant difference.
Significant difference compared with before treatment. GTP, green tea polyphenol; PIVKA-II, protein induced by vitamin K absence II or antagonist II; WBC, white blood cell; RBC, red blood cell; Hb, hemoglobin; Plt, platelets; AST, aspartate transaminase; ALT, alanine transaminase; LDH, lactate dehydrogenase; ALP, alkaline phosphatase; ChE, cholinesterase; T-bil, total serum bilirubin; BUN, blood urea nitrogen; Cr, creatinine; CRP, C-reactive protein; AFP, α-fetoprotein.