Transarterial chemoembolization and yittrium-90 for liver cancer and other lesions

Transarterial chemoembolization (TACE) is the recommended treatment of intermediate stage hepatocellular carcinoma (HCC). Radioembolization with yttrium 90 has overcome the shortcomings of external beam radiation in the treatment of liver cancer. TACE and radioembolization have led to encouraging response, survival, and quality of life outcomes, with reduced toxicity profiles. This result has led to the use of these therapies in patients with hepatic metastases, most commonly from colorectal cancer. This article reviews the current state of the practice of TACE and radioembolization and presents recent scientific data that support their role in the treatment of HCC and hepatic metastatic disease.

Changes in arterioportal shunts in hepatocellular carcinoma patients with portal vein thrombosis who were treated with chemoembolization followed by radiotherapy

Purpose

In this study, we retrospectively investigated the prevalence of arterioportal (AP) shunts in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) and evaluated the changes in AP shunts after chemoembolization followed by external beam radiation therapy (EBRT).

Materials and Methods

We analyzed 54 HCC patients with PVTT who were treated with chemoembolization followed by EBRT. EBRT was uniformly delivered at a total dose of 30 to 45 Gy (median, 35 Gy), with a daily dose of 2 to 4.5 Gy. Angiographic images of chemoembolization before and after radiation therapy (RT) were reviewed to investigate the AP shunt.

Results

During the initial session of chemoembolization, 33 of 54 patients (61%) had an AP shunt. After EBRT, 32 out of 33 patients had an additional session of chemoembolization and were evaluated for a change in the AP shunt. The AP shunt decreased in 20 of 32 patients (63%) after chemoembolization followed by EBRT. The 1-year calculated overall survival (OS) rate for all patients was 52.6% and the 2-year OS was 36.4%. The median OS in all patients was 13 months. Patients with AP shunt showed poorer median OS than those without AP shunt, but there was no statistically significant difference (median, 12 months vs. 17 months).

Conclusion

The AP shunt frequently occurs in HCC patients with PVTT. This study suggests that a poor prognosis is associated with an AP shunt. Chemoembolization followed by RT may produce a decrease in AP shunts.

Transarterial therapies for primary liver tumors. Surg Oncol Clin N Am. 2014;23:323-351. [PMID: 24560113 DOI: 10.1016/j.soc.2013.11.002]

Over the last decade, transarterial therapies have gained worldwide acceptance as standard of care for inoperable primary liver cancer. Survival times after transarterial chemoembolization (TACE) continue to improve as the technique and selection criteria are refined. Transarterial treatments, frequently provided in an outpatient setting, are now safely and effectively being applied to patients with even advanced malignancy or partially decompensated cirrhosis. In the coming years, newer transarterial therapies such as radiation segmentectomy, boosted-transarterial radioembolzation, combined TACE-ablation, TACE-portal vein embolization, and transarterial infusion of cancer-specific metabolic inhibitors promise to continue improving survival and quality of life.

Revisiting the role of pathological analysis in transarterial chemoembolization-treated hepatocellular carcinoma after transplantation

AIM: To define the histopathological features predictive of post-transplant hepatocellular carcinoma (HCC) recurrence after transarterial chemoembolization, applicable for recipient risk stratification.

METHODS: We retrospectively reviewed the specimens of all suspicious nodules (total 275) from 101 consecutive liver transplant recipients which came to our Pathology Unit over a 6-year period. All nodules were sampled and analyzed, and follow-up data were collected. We finally considered 11 histological variables for each patient: total number of nodules, number of viable nodules, size of the major nodule, size of the major viable nodule, occurrence of microscopic vascular invasion, maximum Edmondson's grade, clear cell/sarcomatous changes, and the residual neoplastic volume. Survival data were computed by means of the Kaplan-Meier procedure and analyzed by means of the Cox proportional hazards model. The multivariate linear regression and a k-means cluster analysis were also used in order to compute the standardized histological score.

RESULTS: The total number of nodules, the residual neoplastic volume (the total volume of all evaluated nodules minus the necrotic portion) and the microvascular invasion entered the Cox multivariate hazard model with HCC recurrence as dependent variable. The histological score was therefore computed and a cluster analysis sorted recipients into 3 risk groups, with 3.3%, 18.5% and 53.8% respectively of tumor recurrence rates and 1.6%, 11.1% and 38.5% of tumor-related mortality respectively at the end of follow-up.

CONCLUSION: The histological score allows a reliable stratification of HCC recurrence risk, especially in those recipients found out to be beyond the Milan criteria after orthotopic liver transplantation (OLT).

Injectable chitosan thermogels for sustained and localized delivery of pingyangmycin in vascular malformations

Pingyangmycin (PYM) is an effective drug to treat vascular malformations (VM), but can easily diffuse from the injection site, which will reduce its therapeutic effect and increase side effect. Our study was to evaluate PYM-loaded chitosan thermogels for sustained and localized embolization therapy. It was shown that in vitro release of PYM thermogels could be delayed up to 12 days. The results measured by MTT assay showed that PYM thermogels could inhibit proliferation and induce apoptosis of EA.hy926 cells in a concentration and time dependent manner. In vivo pharmacokinetics study demonstrated that compared with PYM injections, PYM thermogels had a better sustained delivery of PYM. Macroscopic observation and histological examination of rabbit ear veins displayed that after administration with PYM thermogels for 18 days, obvious venous embolization and inflammatory response could be found. These results indicate that PYM thermogels is likely to achieve excellent prospects for VM treatment.

[18F]Fluorodeoxyglucose PET for Interventional Oncology in Liver Malignancy

[(18)F]Fluorodeoxyglucose (FDG) PET is a functional imaging tool that provides metabolic information, which has the potential to detect a lesion before it becomes anatomically apparent. This ability constitutes a strong argument for using FDG-PET/computed tomography (CT) in the management of oncology patients. Many studies have investigated the accuracy of FDG-PET or FDG-PET/CT for these purposes, but with small sample sizes based on retrospective cohorts. This article provides an overview of the role of FDG-PET or FDG-PET/CT in patients with liver malignancies treated by means of surgical resection, ablative therapy, chemoembolization, radioembolization, and brachytherapy, all being liver-directed oncologic interventions.

Hepatocellular carcinoma treated by conventional transarterial chemoembolization in field-practice: Serum sodium predicts survival

AIM: To assess the prognostic role of baseline clinical, biochemical and radiological characteristics of patients with hepatocellular carcinoma (HCC) treated with the first transarterial chemoembolization (TACE) procedure.

METHODS: Patients with HCC treated with conventional TACE in a tertiary care setting from 1997 to 2008 were retrospectively reviewed. Predictors of survival were identified using the Cox proportional regression model.

RESULTS: Two hundred and seventy patients were included. Median age was 66 years, 81% were male, 58% were HCV-positive, 18% hepatitis B surface antigen-positive, 64% had a Child A status, 40% patients had a largest nodule diameter ≥ 5 cm and 32% had more than 3 tumor nodules. Median overall survival of the whole cohort was 25 mo (95%CI: 21.8-28.2) and the 1-, 2- and 3-year probability of survival was 80%, 50% and 31%, respectively. Non-tumor segmental portal vein thrombosis (HR = 1.76, 95%CI: 1.22-2.54), serum sodium (HR = 1.65, 95%CI: 1.25-2.18), diameter of largest nodule (HR = 1.59, 95%CI: 1.22-2.091), number of nodules (HR = 1.41, 95%CI: 1.06-1.88), alpha-fetoprotein (HR = 1.35, 95%CI: 1.03-1.76) and alkaline phosphatase (HR = 1.33, 95%CI: 1.01-1.74) were independent prognostic factors for overall survival on multivariate analysis.

CONCLUSION: The inclusion of serum sodium alongside the already known prognostic factors may allow a better prognostic definition of patients with HCC as candidates for conventional TACE.

Risk factors and therapeutic results of early local recurrence after transcatheter arterial chemoembolization

AIM: To identify factors affecting early local recurrence after transcatheter arterial chemoembolization (TACE) and investigate treatments and outcomes for local recurrence.

METHODS: Early local recurrence and no early local recurrence groups drawn from 134 patients who were initially diagnosed with hepatocellular carcinoma (HCC) and showed a complete response (CR) to TACE treatment between January 1, 2006, and January 31, 2012, were analyzed by univariate and multivariate analyses. Additionally, the subsequent treatment for patients with recurrence was analyzed, and in cases in which TACE had been performed, the cumulative recurrence rates were calculated using the Kaplan-Meier method and compared with those of the primary lesion.

RESULTS: The 1-, 2-, and 3-year survival rates were 92.3%, 60.2%, and 39.8%, respectively, in the early local recurrence group, which were significantly lower than those in both the late local and no local recurrence groups (P < 0.001). On multivariate analyses, non-compact lipiodol uptake, large tumor size, and an alpha-fetoprotein > 20 ng/mL after achieving a CR were significant predictors. When TACE was performed for early and late locally recurrent lesions, a CR was observed in 15 patients (41.7%) and 11 patients (78.6%), and the cumulative recurrence rates at 6, 12, and 24 mo were 17.9%, 43.3%, and 71.2%, respectively, which did not differ significantly from those after the first CR of 20.5%, 44.0%, and 58.6%, respectively (P = 0.639).

CONCLUSION: Closer monitoring and active treatments must be provided to patients with risk factors for early local recurrence of HCC.

Recurrence of hepatocellular carcinoma: importance of mRECIST response to chemoembolization and tumor size

Determining risk for recurrence of hepatocellular carcinoma (HCC) following liver transplantation (LT) is an important clinical need. We assessed consecutive patients who underwent LT for HCC following sequential transarterial chemoembolization (TACE). Treatment response was assessed using modified response evaluation criteria in solid tumors (mRECIST) categories: complete response (CR), partial response (PR), stable disease (SD) and progressive disease (PD). Cox proportional hazard models were used to predict HCC recurrence. One hundred seventy-three patients underwent TACE and imaging to assess response prior to LT. TACE responses were: CR = 23.7%, PR = 24.3%, SD = 27.7% and PD = 24.3%. Five-year HCC recurrence rate was 5.3% in patients responding to TACE (CR/PR), versus 17.6%, among patients who did not respond (SD/PD, p = 0.014). In multivariate analysis, independent pre-LT predictors of recurrence were response to TACE and largest radiologic size of tumor (>3 cm vs. ≤3 cm). HCC recurrence rate for patients with tumor size >3 cm and no response to TACE was 35.8%, compared with 1.9% for patients with tumor size ≤3 cm and response to TACE (p = 0.0007). We conclude that mRECIST criteria and tumor size differentiate patients with high or low likelihood of HCC recurrence after LT. These findings raise the possibility of incorporating response to TACE and largest tumor size to identify patients at highest risk for HCC recurrence.

Clinical significance of Ki-67 and p130 expression in liver needle biopsy from patients with hepatocellular carcinoma treated by transcatheter arterial chemoembolization

AIM: To investigate the clinical significance of Ki-67 and p130 expression in liver needle biopsy from patients with hepatocellular carcinoma (HCC) treated by transcatheter arterial chemoembolization (TACE).

METHODS: Medical records for 41 HCC patients treated by TACE between January 2005 and August 2010 were reviewed and the major clinical features, treatment modalities and outcomes were analyzed. The protein expression of Ki-67 and p130 was detected by S-P immunohistochemical method in 41 liver needle biopsies from patients with HCC.

RESULTS: The total positive rates of Ki-67 and p130 expression in HCC were 63.41% (26/41) and 51.52% (21/41), respectively. The expression of Ki-67 and p130 proteins was related to histological grade and prognosis (P < 0.05 for both), but not to sex, age, tumor size, TNM stage or serum level of AFP (P > 0.05 for all). There was a significant negative correlation between Ki-67 and p130 protein expression (r = -0.371, P < 0.05). The prognosis of the 41 patients with HCC treated by TACE was related to TNM stage and expression of Ki-67 and p130 (P < 0.05 for all), but not to sex, age, tumor size, histological grade or serum level of AFP (P > 0.05 for all).

CONCLUSION: Ki-67 and p130 play important roles in occurrence and development of HCC.Ki-67 and p130 can be used as predictive markers for HCC patients treated with TACE.

Transarterial chemoembolization in Barcelona Clinic Liver Cancer Stage 0/A hepatocellular carcinoma

AIM: To evaluate the clinical characteristics of patients with Barcelona Clinic Liver Cancer (BCLC) stage 0 and A hepatocellular carcinoma (HCC) after transarterial chemoembolization (TACE).

METHODS: Between January 2001 and September 2011, 129 patients with BCLC stage 0 and stage A HCC who underwent TACE were retrospectively enrolled. Patient characteristics, routine computed tomography and TACE findings, survival time and 1-, 5-, and 10-year survival rates, risk factors for mortality, and survival rates according to the number of risk factors were assessed.

RESULTS: The mean size of HCC tumors was 2.4 ± 1.1 cm, and the mean number of TACE procedures performed was 2.5 ± 2.1. The mean overall survival time and 1-, 5-, and 10-year survival rates were 80.6 ± 4.9 mo and 91%, 63% and 49%, respectively. In the Cox regression analysis, a Child-Pugh score > 5 (P = 0.005, OR = 3.86), presence of arterio-venous shunt (P = 0.032, OR = 4.41), amount of lipiodol used (> 7 mL; P = 0.013, OR = 3.51), and female gender (P = 0.008, OR = 3.47) were risk factors for mortality. The 1-, 5-, and 10-year survival rates according to the number of risk factors present were 96%, 87% and 87% (no risk factors), 89%, 65%, and 35% (1 risk factor), 96%, 48% and unavailable (2 risk factors), and 63%, 17%, and 0% (3 risk factors), respectively (P < 0.001).

CONCLUSION: TACE may be used as curative-intent therapy in patients with BCLC stage 0 and stage A HCC. The Child-Pugh score, arterio-venous shunt, amount of lipiodol used, and gender were related to mortality after TACE.

Palliation: treating patients with inoperable biliary tract and primary liver tumors

This article summarizes the current literature in treatment of unresectable biliary tract and primary liver tumors. Locoregional therapies including radiofrequency ablation, percutaneous ethanol injection, cryoablation, microwave ablation, transarterial chemoembolization, hepatic artery infusion, radioembolization ((90)Y), and bland embolization are discussed and clinical trials compared. Palliative strategies including surgical, percutaneous, and endoscopic techniques to decompress the biliary system and improve symptoms are also summarized. Systemic chemotherapy and sorafenib used in conjunction with locoregional therapies or as sole therapeutic options are discussed.

Endovascular treatment of hepatocellular carcinoma with drug eluting microparticles (DC-Beads): CT evaluation of response to the treatment

BACKGROUND AND STUDY AIMS

Our aim was to assess the efficacy and tolerability of drug-eluting beads-transarterial chemoembolization (DEB-TACE) in the treatment of hepatocellular carcinoma (HCC), evaluating the response to the treatment after 1, 6, 12, and 24 months with multidetector computed tomography (MDCT) comparing European Association for the study of the Liver (EASL) and modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria.

MATERIALS AND METHODS

We enrolled 154 patients with uni- or multifocal HCC who underwent a DEB-TACE. A total of 278 HCC nodules were treated. CT follow-up was performed at 1, 6, 12, and 24 months after the procedure according to the EASL and RECIST criteria evaluating overall target and target nodule response. We also analyzed the shrinking of nodules in relation to response to treatment.

RESULTS

A total of 278 nodules of HCC underwent TACE by using DC-Beads: At 24, months complete response was similar for EASL and RECIST criteria (112 vs. 121 nodules) with optimal accordance between methods and readers with k = 0.9. Partial Response resulted significantly different among the two methods within the first month, otherwise was similar after 24-month follow-up. Similar results in both methods were found for nodules classified as Stable Disease (P > 0.05). Progressive Disease results were similar in both the groups according to both the classification criteria without any significant difference (P > 0.05).

CONCLUSION

Our study confirmed that EASL and mRECIST criteria are both effective methods for patient follow-up, however with some technical differences.

Hepatocellular carcinoma vascularization: from the most common to the lesser known arteries

Hepatocellular carcinoma is the sixth most common cancer throughout the world. It is almost exclusively arterially vascularized, unlike the vascularization of the liver, which has a dual supply with a portal component of 75 to 80% and an arterial component of 20 to 25%. The reference treatment for intermediary stages of the Barcelona (B) classification is hepatic artery chemoembolization. The aim of chemoembolization is to inject the tumor chemotherapy into the artery and then to embolize the artery (or arteries), which supply the tumor. For this, knowledge of the anatomy of the hepatic artery is essential. Approximately 55% of the patients belong to the modal distribution, although numerous anatomical variants exist and must be recognized. In addition, primarily non-hepatic arteries may contribute to the vascularization of some hepatocellular carcinomas. Furthermore, new arterial supplies can be recruited by tumors after surgical or chemoembolization treatments. The aim of this article is to describe the different arteries, which may vascularize hepatocellular carcinomas. These arteries must be looked for, recognized, and reported by the radiologist on cross-section examinations in the pre-treatment assessment.

Rapid intra-hepatic dissemination of hepatocellular carcinoma with pulmonary metastases following combined loco-regional therapy

This manuscript describes an unusual case of rapid intra-hepatic dissemination of hepatocellular carcinoma with pulmonary metastases occurring 1 month after combined chemoembolization and radiofrequency ablation. Inferior vena cava and portal vein invasion tumor thrombus was also detected, possibly accounting for the mechanism of disease dissemination route of disease.

Intra-arterial interleukin-12 gene delivery combined with chemoembolization: anti-tumor effect in a rabbit hepatocellular carcinoma (HCC) model

BACKGROUND

Interleukin-12 (IL-12), a cytokine naturally secreted by activated dendritic cells and monocytes/macrophages, is known as a key anti-tumor agent in many tumor models, including hepatocellular carcinoma (HCC) models.

PURPOSE

To evaluate the anti-tumor effect of intra-arterial IL-12 gene delivery alone and in combination with transcatheter arterial chemoembolization (TACE) in rabbit VX2 liver cancer model.

MATERIAL AND METHODS

Rabbits with VX2 liver tumors were randomized into four groups, eight in each group. After laparotomy and insertion of a 30-gauge needle into the proper hepatic artery, the following interventional procedure protocols were applied: 0.9% saline solution (group A, control), TACE (group B, TACE alone, lipiodol + mitomycin), intra-arterial interleukin-12 gene infusion (group C, IL-12 alone), and intra-arterial interleukin-12 gene infusion in combination with TACE (group D, IL-12 plus TACE). Growth ratio was estimated by computed tomography. To analyze apoptotic index, tumor tissues were explanted for terminal deoxynucleotidyl transferase mediated dUTP nick end labeling (TUNEL) staining, 14 days after therapy.

RESULTS

Significant differences of the relative tumor growth ratio were observed in TACE alone group and IL-12 plus TACE group in comparison with control (P < 0.05, ANOVA, Tukey's HSD correction) but not between IL-12 alone and control, or IL-12 plus TACE group and TACE alone group (P > 0.05). Significant changes of the apoptotic index were observed in group D in comparison with remaining three groups (P < 0.05). The difference between group C and group A was not significant statistically (P > 0.05).

CONCLUSION

Intra-arterial interleukin-12 gene therapy combined with TACE has a potent anti-tumor effect in rabbit VX2 liver cancer in comparison with TACE alone.

Unresectable hepatocellular carcinoma treated with transarterial chemoembolization: clinical data from a single teaching hospital

The aim of this study is to evaluate the survival rates of patients with unresectable hepatocellular carcinoma (HCC) following transarterial chemoembolization (TACE) performed in a single teaching hospital. This study retrospectively assessed the electronic medical records of 217 patients in whom HCC was newly diagnosed from January 2009 to February 2013 at a single medical center. Hepatic artery infusion chemotherapy was performed using one drug or combinations of oxaliplatin, fluorouracil and doxorubicin. The primary endpoint of the study was overall survival (OS). Survival rates were calculated using Kaplan-Meier method. A total of 217 HCC patients (173 men and 44 women; mean age, 56.3 years; age range, 36.1-84.3 years) were treated with TACE in a single center. The overall survival rates at 1 and 2 years were 64% and 40%, respectively. The overall median survival time from the start of TACE treatment was 13 months. Our results indicated that TACE is an effective minimally invasive therapy option for palliative treatment of HCC patients.

Trans-arterial chemo-embolization is safe and effective for very elderly patients with hepatocellular carcinoma

AIM: To assess the safety and efficacy of trans-arterial chemo-embolization (TACE) in very elderly patients.

METHODS: A prospective cohort study, from 2001 to 2010, compared clinical outcomes following TACE between patients ≥ 75 years old and younger patients (aged between 65 and 75 years and younger than 65 years) with hepatocellular carcinoma (HCC), diagnosed according to the European Association for the Study of the Liver and the American Association for the Study of Liver Diseases criteria. The decision that patients were not candidates for curative therapy was made by a multidisciplinary HCC team. Data collected included demographics, co-morbidities, liver disease etiology, liver disease severity and the number of procedures. The primary outcome was mortality; secondary outcomes included post-embolization syndrome (nausea, fever, abdominal right upper quadrant pain, increase in liver enzymes with no evidence of sepsis and with a clinical course limited to 3-4 d post procedure) and 30-d complications. Additionally, changes in liver enzyme measurements were assessed [alanine and aspartate aminotransferase (ALT and AST), gamma-glutamyl transpeptidase and alkaline phosphatase] in the week following TACE. Analysis employed both univariate and multivariate methods (Cox regression models).

RESULTS: Of 102 patients who underwent TACE as sole treatment, 10 patients (9.8%) were > 80 years old at diagnosis; 13 (12.7%) were between 75 and 80 years, 45 (44.1%) were between 65 and 75 years and 34 (33.3%) were younger than 65 years. Survival analysis demonstrated similar survival patterns between the elderly patients and younger patients. Age was also not associated with the adverse event rate. Survival rates at 1, 2 and 3 years from diagnosis were 74%, 37% and 31% among patients < 65 years; 83%, 66% and 48% among patients aged 65 to 75 years; and 86%, 41% and 23% among patients ≥ 75 years. There were no differences between the age groups in the pre-procedural care, including preventive treatment for contrast nephropathy and prophylactic antibiotics. Multivariate survival analysis, controlling for disease stage at diagnosis with the Barcelona Clinic Liver Cancer score, number of TACE procedures, sex and alpha-fetoprotein level at the time of diagnosis, found no significant difference in the mortality hazard for elderly vs younger patients, and there were no differences in post-procedural complications. Serum creatinine levels did not change after 55% of the procedures, in all age groups. In 42% of all procedures, serum creatinine levels increased by no more than 25% above the baseline levels prior to TACE. Overall, there were 69 post-embolization events (23%). Hepatocellular enzymes often increased following TACE, with no association with prognosis. In 40% of the procedures, ALT and AST levels rose by at least 100%. The increases in hepatocellular enzymes occurred similarly in all age groups.

CONCLUSION: TACE is safe and effective in very elderly patients with HCC, and is not associated with decreased survival or increased complication rates.

Impact of serum C-reactive protein level on the prognosis of patients with hepatocellular carcinoma undergoing TACE

BACKGROUND/AIMS

The aim of this study was to determine the relationship between serum CRP levels and the prognosis of hepatocellular carcinoma (HCC) patients.

METHODS

HCC patients who underwent the first session of transcatheter arterial chemoembolization (TACE) between January 2005 and December 2009 (n=211) were analyzed retrospectively. The patients were divided into two groups: high C-reactive protein (CRP; ≥1 mg/dL, n=51) and low CRP (<1 mg/dL, n=160). They were followed for a mean of 22.44 months and their clinicoradiological variables and overall survival were compared.

RESULTS

There were significant differences between the two groups in regard to tumor type, tumor-progression-free survival, 10-month mortality, white blood cell (WBC) count, tumor size, and TNM stage. Multivariate analysis revealed that a high serum CRP level was independently associated with tumor size and tumor type. Subgroup analysis of CRP groups according to tumor size demonstrated that a high serum level of CRP was significantly associated with poorly defined (diffuse) tumor type in the tumor size <5 cm group [hazard ratio (HR)=4.81, P=0.018]. A Lipiodol dose exceeding 7 mL (HR=5.55, P=0.046) and the 10-month mortality (HR=7.693, P=0.004) were significantly associated with high serum CRP level in the group of patients with a tumor size of ≥5 cm. In addition, subgroup analysis of matched CRP according to TNM stage revealed that elevated serum CRP was independently associated with tumor type, WBC count, and tumorprogression-free survival.

CONCLUSIONS

A high serum CRP level is associated with large tumors and a poorly defined tumor type, and is significantly associated with 10-month mortality in patients with large HCC (size ≥5 cm) who undergo TACE.

Hepatocellular carcinoma with blood supply from parasitized omental artery: angiographic appearance and chemoembolization

OBJECTIVE

To analyze angiographic appearance of hepatocellular carcinoma (HCC) with blood supply from parasitized omental artery (POA), and evaluate the technical feasibility, safety and therapeutic efficacy of chemo-embolization via the POAs.

METHODS

A total of 1,221 HCC patients who had undergone chemoembolization procedures were evaluated retrospectively. The evaluated indexes included the incidence rate of POAs, success rate of superselective catheterization, post-reaction after chemoembolization, and the cumulative survival rates.

RESULTS

Totally 1,221 HCC patients had undergone 3,639 chemoembolization procedures, and 32 patients with POAs were enrolled, with 97 POAs found in 76 angiography procedures, giving an incidence rate of 2.09%. POA was observed mostly at the right lobe and left medial lobe except the segment II, and 62 POAs underwent superselective catheterization with microcatheter, giving a success rate of 63.9%. The angiographic appearance was: (1) hypertrophic POAs participating in tumor staining (n=28); (2) stiff and distorted POA (n=11), displaced due to tumor's oppression (n=8); and (3) defective tumor staining close to either gastrocolic omentum distribution or liver capsule (n=7). In 19 patients, chemoembolization via POAs was performed successfully (A group), while the remaining 13 patients failed (B group). Except 1 acute edema pancreatitis case, no serious complication was recorded. The cumulative survival rates of 6-, 12-, 18- and 24-month were 78.9%, 47.4%, 31.6% and 21.1% respectively for A group; correspondingly, 61.5%, 30.8%, 15.4% and 7.7%% for B group, in which 2 patients died of ruptured HCC.

CONCLUSION

Chemoembolization with microcatheter via POAs is a relatively safe, feasible and valuable method.

Role of surgical resection for multiple hepatocellular carcinomas

AIM: To clarify the role of surgical resection for multiple hepatocellular carcinomas (HCCs) compared to transarterial chemoembolization (TACE) and liver transplantation (LT).

METHODS: Among the HCC patients who were managed at Yonsei University Health System between January 2003 and December 2008, 160 patients who met the following criteria were retrospectively enrolled: (1) two or three radiologically diagnosed HCCs; (2) no radiologic vascular invasion; (3) Child-Pugh class A; (4) main tumor smaller than 5 cm in diameter; and (5) platelet count greater than 50 000/mm³. Long-term outcomes were compared among the following three treatment modalities: surgical resection or combined radiofrequency ablation (RFA) (n = 36), TACE (n = 107), and LT (n = 17). The survival curves were computed using the Kaplan-Meier method and compared with a log-rank test. To identify the patients who gained a survival benefit from surgical resection, we also investigated prognostic factors for survival following surgical resection. Multivariate analyses of the prognostic factors for survival were performed using the Cox proportional hazard model.

RESULTS: The overall survival (OS) rate was significantly higher in the surgical resection group than in the TACE group (48.1% vs 28.9% at 5 years, P < 0.005). LT had the best OS rate, which was better than that of the surgical resection group, although the difference was not statistically significant (80.2% vs 48.1% at 5 years, P = 0.447). The disease-free survival rates were also significantly higher in the LT group than in the surgical resection group (88.2% vs 11.2% at 5 years, P < 0.001). Liver cirrhosis was the only significant prognostic factor for poor OS after surgical resection. Clinical liver cirrhosis rates were 55.6% (20/36) in the resection group and 93.5% (100/107) in the TACE group. There were 19 major and 17 minor resections. En bloc resection was performed in 23 patients, multi-site resection was performed in 5 patients, and combined resection with RFA was performed in 8 patients. In the TACE group, only 34 patients (31.8%) were recorded as having complete remission after primary TACE. Seventy-two patients (67.3%) were retreated with repeated TACE combined with other therapies. In patients who underwent surgical resection, the 16 patients who did not have cirrhosis had higher 5-year OS and disease-free survival rates than the 20 patients who had cirrhosis (80.8% vs 25.5% 5-year OS rate, P = 0.006; 22.2% vs 0% 5-year disease-free survival rate, P = 0.048). Surgical resection in the 20 patients who had cirrhosis did not provide any survival benefit when compared with TACE (25.5% vs 24.7% 5-year OS rate, P = 0.225). Twenty-nine of the 36 patients who underwent surgical resection experienced recurrence. Of the patients with cirrhosis, 80% (16/20) were within the Milan criteria at the time of recurrence after resection.

CONCLUSION: Among patients with two or three HCCs, no radiologic vascular invasion, and tumor diameters ≤ 5 cm, surgical resection is recommended only in those without cirrhosis.

Clinical significance and risk factors of postembolization fever in patients with hepatocellular carcinoma

AIM: To investigate tumor response and survival in patients with postembolization fever (PEF) and to determine the risk factors for PEF.

METHODS: Four hundred forty-three hepatocellular carcinoma (HCC) patients who underwent the first session of transcatheter arterial chemoembolization (TACE) between January 2005 and December 2009 were analyzed retrospectively. PEF was defined as a body temperature greater than 38.0  °C that developed within 3 d of TACE without evidence of infection. The tumor progression-free interval was defined as the interval from the first TACE to the second TACE based on mRECIST criteria. Clinical staging was based on the American Joint Committee on Cancer tumor, node, metastases (TNM) classification of malignant tumors. All patients were admitted before their 1^st TACE treatment, and blood samples were obtained from all patients before and after treatment. Clinicoradiological variables and host-related variables were compared between two groups: patients with PEF vs patients without PEF. Additionally, variables related to 20-mo mortality and tumor progression-free survival were analyzed.

RESULTS: The study population comprised 370 (85.4%) men and 73 (14.6%) women with a mean age of 62.29 ± 10.35 years. A total of 1836 TACE sessions were conducted in 443 patients, and each patient received between 1 and 27 (mean: 4.14 ± 3.57) TACE sessions. The mean follow-up duration was 22.23 ± 19.6 mo (range: 0-81 mo). PEF developed in 117 patients (26.41%) at the time of the first TACE session. PEF was not associated with 20-mo survival (P = 0.524) or computed tomography (CT) response (P = 0.413) in a univariate analysis. A univariate analysis further indicated that diffuse-type HCC (P = 0.021), large tumor size (≥ 5 cm) (P = 0.046), lipiodol dose (≥ 7 mL, P = 0.001), poor blood glucose control (P = 0.034), alanine aminotransferase (ALT) value after TACE (P = 0.004) and C-reactive protein (CRP) value after TACE (P = 0.036) served as possible risk factors correlated with PEF. The ALT value after TACE (P = 0.021) and lipiodol dose over 7 mL (P = 0.011) were independent risk factors for PEF in the multivariate analysis. For the 20-mo survival, poor blood sugar control (P < 0.001), portal vein thrombosis (P = 0.001), favorable CT response after TACE (P < 0.001), initial aspartate aminotransferase (P = 0.02), initial CRP (P = 0.042), tumor size (P < 0.001), TNM stage (P < 0.001) and lipiodol dose (P < 0.001) were possible risk factors in the univariate analysis. Tumor size (P = 0.03), poor blood sugar control (P = 0.043), and portal vein thrombosis (P = 0.031) were significant predictors of survival in the multivariate analysis. Furthermore, the tumor progression-free interval was closely associated with CRP > 1 mg/dL (P = 0.003), tumor size > 5 cm (P < 0.001), tumor type (poorly defined) (P < 0.001), and lipiodol dose (> 7 mL, P < 0.001).

CONCLUSION: PEF has no impact on survival at 20 mo or radiologic response. However, the ALT level after TACE and the lipiodol dose represent significant risk factors for PEF.

DC Bead Transarterial Chemoembolization Is Effective in Hepatocellular Carcinoma Refractory to Conventional Transarteral Chemoembolization: A Pilot Study

Background/Aims

To determine if hepatocellular carcinoma refractory to conventional transarterial chemoembolization (TACE) responds to TACE with DC beads.

Methods

Between July 2008 to June 2010, 435 patients underwent TACE. Of these, 10 patients who had tumors refractory to conventional TACE and who thus were treated with TACE with DC beads were enrolled in this study. The treatment response after TACE with DC beads was evaluated according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST) and the Response Evaluation Criteria in Cancer of the Liver (RECICL).

Results

Ten tumors were treated in 10 patients. Using the mRECIST and the RECICL, a complete response was observed in four (40%) of the tumors, and six tumors (60%) showed a partial response. Eight (80%) out of 10 HCCs showed delayed enhancement patterns upon angiography, and better responses were observed in these cases following DC bead treatment. The adverse effects of treatment with DC beads became tolerable.

Conclusions

TACE with DC beads was effective for HCCs refractory to conventional TACE, and this treatment elicited a better response, especially when the tumors were small and showed a delayed enhancement pattern upon angiography.

Embolization of liver tumors: Past, present and future

Curative therapies for hepatocellular carcinoma (HCC), such as resection and liver transplantation, can only be applied in selected patients with early tumors. More advanced stages require local or systemic therapies. Resection of HCC offers the only hope for cure. Even in patients undergoing resection, recurrences are common. Chemoembolization, a technique combining intra-arterial chemotherapy with selective tumor ischemia, has been shown by randomized controlled trials to be efficacious in the palliative setting. There is now renewed interest in transarterial embolization/transarterial chemoembolization (TACE) with regards to its use as a palliative tool in a combined modality approach, as a neoadjuvant therapy, in bridging therapy before transplantation, for symptomatic indications, and even as an alternative to resection. There have also been rapid advances in the agents being embolized trans-arterially (genes, biological response modifiers, etc.). The current review provides an evidence-based overview of the past, present and future trends of TACE in patients with HCC.

Hepatic artery chemoembolization for hepatocellular carcinoma recurrence confined to the transplanted liver

Background

Careful hepatocellular carcinoma (HCC) case selection permits orthotopic liver transplantation with the expectation of around 70% plus 5-year survival. However, many patients have tumor recurrences and there is little literature guidance in the management of these patients.

Aims

A retrospective examination of patients transplanted with HCC who subsequently developed liver recurrence.

Methods

A case cohort series of patients was prospectively followed who had liver-only multifocal tumor recurrence of HCC after liver transplant and were then treated with chemoembolization.

Results

All 6 patients had recurrent HCC. 2 had no response, 1 had stable disease, 2 had partial response (PR) and 1 had complete disappearance (CR) of disease. Their survival (in months) was: 13 (no response), 18 (no response), 12 (stable disease), 19 (PR), 30 (PR) and 50 (CR). There were no liver toxicities.

Conclusions

Chemoembolization for tumor recurrence in the transplanted liver is as safe as or safer than in the pre-transplant liver, due to the absence of cirrhosis. In this series, there were 3 of 6 responses with some long survivors.

Nontarget embolization complicating transarterial chemoembolization in a patient with hepatocellular carcinoma

Nontarget embolization during transarterial chemoembolization, although infrequent, can be a serious complication. The authors describe a case of nontarget gastric embolization to the stomach after transarterial chemoembolization and describe the published incidence of nontarget embolization to various organs, its diagnosis, treatment, and possible outcomes.

Transarterial chemoembolization complicated by deteriorating hepatic function

Worsening hepatic function is a well-known potential complication of chemoembolization and occurs in up to 58% of patients undergoing chemoembolization. Although liver function returns to baseline levels within 3-4 weeks in the majority of patients, fulminant liver failure and death occur with a reported frequency of ~2-10%. Poor performance status, portal vein obstruction, biliary obstruction, extensive tumor burden, and Child-Pugh status B or C are among factors predisposing to an increased risk of transient or fulminant hepatic failure, with Child-Pugh status being the most accurate. Unless the patient is a candidate for liver transplantation, treatment for hepatic failure is limited to supportive measures.

Cerebral lipiodol embolism after transarterial chemoembolization for hepatic carcinoma: A case report

We report a case of cerebral lipiodol embolism (CLE) after transarterial chemoembolization (TACE) for unresectable hepatic carcinoma (HCC). A 54-year-old man with unresectable HCC underwent TACE via the right hepatic artery and right inferior phrenic artery using a mixture of 40 mg pirarubicin and 30 mL lipiodol. His level of consciousness deteriorated after TACE, and non-contrast computed tomography revealed a CLE. The cerebral conditions improved after supportive therapy. The complication might have been due to hepatic arterio-pulmonary vein shunt caused by direct invasion of the tumor. Even though CLE is an uncommon complication of TACE, we should be aware of these rare complications in patients with high risk factors.

Chemoembolization in patients with hepatocellular carcinoma

Transcatheter arterial chemoembolization (TACE) is the standard of care for nonsurgical patients with preserved liver function with large or multinodular noninvasive hepatocellular carcinoma (HCC) confined to the liver. The administration of an anticancer-in-oil emulsion followed by embolic agents is the most popular TACE technique; however, the introduction of embolic, drug-eluting beads (DEB) has provided an alternative to conventional regimens. Experimental studies have shown that DEB-TACE results in a safe pharmacokinetic profile and effective tumor killing in animal models. Clinical experiences have confirmed that DEB-TACE provides a combined ischemic and cytotoxic effect locally, with significantly reduced drug-related toxicity and liver toxicity compared with conventional TACE. The addition of molecular targeted drugs to the therapeutic armamentarium for HCC has prompted the design of clinical trials aimed at investigating the synergies between TACE and systemic treatments. Combining TACE with antiangiogenic agents represents a promising strategy because TACE is thought to cause local hypoxia, resulting in a temporary increase in levels of vascular endothelial growth factor. Recently, a large phase 2, randomized, double-blind, placebo-controlled trial (the SPACE study) indicated that the concurrent administration of DEB-TACE and sorafenib has a manageable safety profile and suggested that the time to progression (TTP) and time to vascular invasion or extrahepatic spread may be improved compared with DEB-TACE alone. These data support the further evaluation of molecular targeted, systemically active agents in combination with DEB-TACE in a phase 3 setting.

Liver Transplantation for HCC: A Review

Hepatocellular carcinoma (HCC) often occurs in patients with chronic liver disease or cirrhosis. Liver transplantation for hepatocellular carcinoma has the potential to eliminate both the tumor as well as the underlying cirrhosis and is the ideal treatment for HCC in cirrhotic liver as well as massive HCC in noncirrhotic liver. Limitations in organ availability, necessitate stringent selection of patients who would likely to derive most benefit. Selection criteria have considered tumor size, number, volume as well as biological features. The Milan criteria set the benchmark for tumors that would benefit from liver transplantation but were found to be excessively restrictive. Modest expansion in criteria has also been shown to be associated with equivalent survival. Microvascular invasion is the single most important adverse prognostic factor for survival. Living donor liver transplantation has expanded donor options and has the advantage of lower waiting period and not impacting the non-HCC waiting list. Acceptable outcomes have been obtained with living donor liver transplantation for larger and more numerous tumors in the absence of microvascular invasion. Downstaging of tumors to prevent progression while waiting for an organ or for reduction in size to allow enrolment for transplantation has met with variable success.

A retrospective review on feasibility and safety of a new pneumatic compression device for femoral arteriotomy hemostasis

OBJECTIVE

To report our initial experience on the technical feasibility and safety for hemostasis of a new pneumatic compression device in patients undergoing femoral arteriotomy.

MATERIALS AND METHODS

This study included 40 consecutive patients in whom hemostasis after transfemoral catheterization was readered by using a pneumatic compression device consisting of an inflatable bulb-containing main body and four pieces of supplementary tape. Medical records were retrospectively reviewed for outcomes and complications of hemostasis. Technical success was defined as achieving immediate hemostasis 10 minutes after applying the device over the arteriotomy sites, and clinical success was defined as the ability to ambulate after 4 hours of bed rest without any complications.

RESULTS

Technical and clinical success was achieved in 38 (95%) and 37 (93%) patients, respectively. In two patients, hemostasis was achieved after conversion to manual compression. One patient required sand bag placement after removal of the device to control minimal oozing of blood. No patients had late complications.

CONCLUSION

The new pneumatic compression device provides effective and safe hemostasis after transfemoral catheterization in selected patient populations.

Hepatocellular carcinomas smaller than 4 cm supplied by the intercostal artery: can we predict which intercostal artery supplies the tumor?

OBJECTIVE

To predict which intercostal artery supplies a tumor by examining the spatial relationship between hepatocellular carcinoma (HCC) and the intercostal artery feeding the tumor on transverse computed tomography (CT) images.

MATERIALS AND METHODS

Between January 2000 and September 2009, 46 intercostal arteries supplying HCCs smaller than 4 cm were noted in 44 patients, and CT scans and angiograms of these patients were retrospectively reviewed. The intercostal artery feeding the tumor was marked on the CT scan showing the center of the tumor. In addition, its spatial relationship with the tumor center was examined. The angle of the tumor location was measured on the transverse CT scan in the clockwise direction from the sagittal line on the virtual circle centered in the right hemithorax. Correlations between the angle of the tumor location and the level of the tumor-feeding intercostal artery were assessed with the Spearman rank coefficient.

RESULTS

Of 46 intercostal arteries feeding HCC, 39 (85%) were the first ones observed from the tumor center in a counterclockwise direction on the transverse CT image containing the tumor center. The level of the tumor-feeding intercostal artery was significantly correlated with the angle of the tumor, as the posteriorly located tumor tends to be supplied by lower intercostal arteries, while the laterally located tumor by upper intercostal arteries (Spearman coefficient = -0.537; p < 0.001).

CONCLUSION

We can predict the tumor feeder with an accuracy of 85% as the first intercostal artery encountered from the tumor center in a counterclockwise direction on a transverse CT image.

Evaluation of transarterial chemoembolization combined with percutaneous ethanol ablation for large hepatocellular carcinoma

AIM: To assess the effects of combined transcatheter arterial chemoembolization (TACE) and percutaneous ethanol ablation (PEA) in patients with large hepatocellular carcinoma (HCC).

METHODS: A total of 63 patients with unresectable large HCC were treated with TACE followed by PEA. The largest dimension of the tumors ranged from 5.3 cm to 17.8 cm. The survival rates, acute effects, toxicity and prognostic factors were analyzed.

RESULTS: The cumulative survival rates at 1, 3 and 5 years were 59.4%, 28.4% and 15.8%, respectively (a median survival of 27.7 mo). Tumor area was reduced by more than 50% in 30 (47.6%) cases. In 56 cases with increased α-fetoprotein (AFP) values, AFP level was declined by more than 75%. The combined therapy was generally well tolerated. Only two patients died from variceal bleeding associated with the therapy. The Cox proportional hazards model showed that the number of tumors, the tumor margin and the ethanol dose were independent prognostic factors.

CONCLUSION: The combined TACE and PEA therapy is a promising approach for unresectable large HCC.

Transarterial chemoembolization with miriplatin-lipiodol emulsion for neuroendocrine metastases of the liver

Miriplatin, a cisplatin derivative with a high affinity for iodized oil, is a novel chemotherapeutic agent designed for use in the transarterial treatment of hepatocellular carcinoma. This case report describes our experience with transarterial chemoembolization (TACE) using miriplatin in 2 patients with neuroendocrine liver metastases. A 38-year-old man with multiple neuroendocrine liver metastases was treated by whole liver chemoembolization, and a 35-year-old woman with a single hepatic lesion was treated by superselective chemoembolization. No serious adverse events were noted during the interventional procedures, or during the observation period of 3 mo in either patient. Sufficient iodized oil uptake was observed in the hypervascular lesions on the unenhanced computed tomography (CT) at 7 d after the procedure. Contrast-enhanced CT obtained at 3 mo after chemoembolization revealed that all hepatic lesions were substantially reduced in size irrespective of tumor vascularity or degree of cystic degeneration, although iodized oil accumulation was only marginal for lesions with cystic degeneration. Thus, TACE with miriplatin can be a safe and effective therapeutic option for the treatment of neuroendocrine metastases of the liver.

Clinical value of inhibition of vascular endothelial growth factor in primary hepatocellular carcinoma after transcatheter arterial chemoembolization

Vascular endothelial growth factor (VEGF) is a well-known potent angiogenic factor that correlates with tumor invasion and metastasis. Primary hepatocellular carcinoma (PHC) is a common highly malignant vascular tumor with a very high mortality. Angiogenesis is considered to be important for PHC progression. Transarterial chemoembolization (TACE) has been proved to be effective for unresectable PHC. This paper aims to make a literature review of the recent advances in understanding the clinical value of inhibition of VEGF in PHC after interventional therapy.

CT volume measurement for prognostic evaluation of unresectable hepatocellular carcinoma after TACE

AIM: To analyze the value of computed tomography (CT) volume measurements for evaluation of the survival rate of unresectable hepatocellular carcinoma (HCC) patients after transcatheter arterial chemoembolization (TACE).

METHODS: One hundred and sixty-six unresectable HCC patients after TACE were involved in this retrospective study. Hepatic CT scan was performed for all patients before and 4 wk to 2 mo after TACE to define the morphologic features of HCC including its largest diameter, volume, product of the greatest axial dimension, tumor to liver volume ratio (TTLVR), and tumor shrinkage ratio. Clinical variables used in the study included gender, age, pattern of tumor growth, number of lesions, Child-Pugh classification of liver function, repeated TACE times, pre- or post-treatment α-fetoprotein (AFP) level, portal vein cancerous thrombus, tumor metastasis, degree of lipiodol retention within the tumor, and percutaneous ethanol injection. The correlation between survival time and clinical variables of patients or lesions was analyzed by combining morphologic features with the corresponding clinical and general data as input. A Cox proportional hazard model was used to analyze prognostic factors. The Kaplan-Meier method was used to calculate the cumulative survival time. Influence of the parameters on prognosis was analyzed by the log-rank test.

RESULTS: The overall 6, 12, 24, 36 and 60 mo cumulative survival rates were 78.92%, 49.85%, 23.82%, 15.60% and 8.92%, respectively. The median survival time was 12 mo. Univariate and multivariate analysis showed that only 4 parameters were the independent prognostic factors including TTLVR (χ² = 14.328, P < 0.001), portal vein cancerous thrombus (χ² = 5.643, P = 0.018), repeated TACE times (χ² = 8.746, P = 0.003), and post-treatment serum AFP level (χ² = 5.416, P = 0.020). When the TTLVR value was less than 70%, the survival time was inversely correlated with the TTLVR value.

CONCLUSION: CT volume measurement technique can predict the prognosis of unresectable HCC patients after TACE.

CT findings of completely regressed hepatocellular carcinoma with main portal vein tumor thrombosis after transcatheter arterial chemoembolization

Objective

The objective of this study was to determine the sequential CT findings of controlled hepatocellular carcinoma (HCC) with main portal vein (MPV) thrombosis with the use of transcatheter arterial chemoembolization and additional intra-arterial cisplatin infusion.

Materials and Methods

From January 2004 to September 2006, 138 patients with HCC invading MPV were referred to the angiography unit of our institution for chemoembolization and additional intra-arterial cisplatin infusion. Until August 2008, seven (5%) of 138 patients were followed-up and found not to have tumor recurrence. CT scans were retrospectively reviewed by two radiologists, focusing on the following parameters: the extent of portal vein thrombosis, the diameter of the affected portal vein, and enhancement of portal vein thrombosis.

Results

The extent of portal vein thrombosis at the initial presentation was variable: left portal vein (LPV) and MPV (n = 1), right portal vein (RPV) and MPV (n = 3), as well as RPV, LPV and MPV (n = 3). The extent and diameter of the affected portal vein decreased during follow-up examinations. In addition, the degree of enhancement for tumor thrombi and serum alpha-feto-protein levels decreased after the transcatheter arterial chemoembolization. Portal vein thrombosis was found to be completely resolved in one patient, whereas residual thrombus without viability was persistent in six patients.

Conclusion

If chemoembolization is effective in patients with HCC that invades the portal vein, the extent and enhancement of portal vein thrombosis is reduced, but residual thrombosis frequently persists for months or years, without evidence of a viable tumor.

Iodized oil uptake assessment with cone-beam CT in chemoembolization of small hepatocellular carcinomas

AIM: To evaluate the utility of assessing iodized oil uptake with cone-beam computed tomography (CT) in transarterial chemoembolization (TACE) for small hepatocellular carcinoma (HCC).

METHODS: Cone-beam CT provided by a biplane flat-panel detector angiography suite was performed on eighteen patients (sixteen men and two women; 41-76 years; mean age, 58.9 years) directly after TACE for small HCC (26 nodules under 30 mm; mean diameter, 11.9 mm; range, 5-28 mm). The pre-procedural locations of the tumors were evaluated using triphasic multi-detector row helical computed tomography (MDCT). The tumor locations on MDCT and the iodized oil uptake by the tumors were analyzed on cone-beam CT and on spot image directly after the procedures.

RESULTS: All lesions on preprocedural MDCT were detected using iodized oil uptake in the lesions on cone-beam CT (sensitivity 100%, 26/26). Spot image depicted iodized oil uptake in 22 of the lesions (sensitivity 85%). The degree of iodized oil uptake was overestimated (9%, 2/22) or underestimated (14%, 3/22) on spot image in five nodules compared with that of cone-beam CT.

CONCLUSION: Cone-beam CT is a useful and convenient tool for assessing the iodized oil uptake of small hepatic tumors (< 3 cm) directly after TACE.

Effect of Huaier extract combined with chemoembolization on the expression of VEGF, MVD and hepatic function of rabbit VX2 hepatocarcinoma

AIM: To investigate the therapeutic effect of Huaier extract combined with transcatheterized arterial chemoembolization on the expression of VEGF and MVD and hepatic function of rabbit VX2 hepatocarcinoma.

METHODS: Thirty six rabbits with experimental liver cancer diagnosed by MRI were randomly divided into 3 groups. The rabbits in group A (control group) were infused with 0.2 mL/kg physiological saline via the hepatic artery, group B (TACE group) were infused with lipiodol 0.2 mL/kg+MMC 0.5 mg/kg via the hepatic artery while group C(TACE + administration with huaier extract )were given by oral administration with 500 mg/(kg•d) Huaier extract after TACE. The levels of AST and ALT in serum were respectively tested 1 day before operation, 3 days, 7 days and 14 days after operation. Two weeks after operation, the rabbits were sacrificed and the tumors were taken out. Immunohistochemical staining was performed to detect the expression and localization of factor Ⅷ and VEGF. The MVD was calculated by counting the factor Ⅷ positive endothelial cells.

RESULTS: There was no significant difference of rabbits' serum AST and ALT among 3 groups 1 day before operation. However, 3 and 7 days after operation, there was significant difference of rabbits' serum AST and ALT among 3 groups (F = 28.411, 55.537, both P < 0.05; F = 8.565, 6.401, both P < 0.05), and there was significant difference between group B and group C (P < 0.05). The MVD and the positive express of VEGF were the lowest in group C, the highest in group B. There was significant difference among 3 groups (F = 5.22, P < 0.05; χ² =7.247, P < 0.05), and there was significant difference between group B and group C (P < 0.05).

CONCLUSION: The Huaier extract can improve the hepatic function of rabbit VX2 hepatocarcinoma after TACE, which works on hepatocarcinoma through diminishing the expression of VEGF and inhibiting the angiogenesis of tumor.

Cholangiocarcinoma: A compact review of the literature

Cholangiocarcinoma (CC) is a devastating cancer arising from biliary epithelia. Unfortunately, the incidence of this disease is increasing in Western countries. These tumors progress insidiously, and liver failure, biliary sepsis, malnutrition and cancer cachexia are general modes of death associated with this disease. To date, no established therapy for advanced disease has been established or validated. However, our knowledge in tumor biology is increasing dramatically and new drugs are under investigation for treatment of this notorious tumor. In clinical practice, there are better diagnostic tools in use to facilitate an earlier diagnosis of CC, at least in those patients with known risk factors. CC is resectable for cure in only a small percentage of patients. Preoperative staging for vascular and biliary extension of CC is very important in this tumor. Laparoscopy and recently endosonography seem to protect against unnecessary laparotomies in these patients. During the last 15 years, aggressive surgical approaches, including combined liver resections and vascular reconstructive surgical expertise, have improved survival in patients with CC. Surgery is contraindicated in CC cases having primary sclerosing cholangitis (PSC). Although CC was previously considered a contraindication to liver transplantation, new cautious protocols, including neo-adjuvant chemoradiation therapies and staging procedures before the transplantation, have made it possible to achieve long-term survival after liver transplantation in this disease. New ablative therapies with photodynamic therapy, intraductal high-intensity ultrasonography and chemotherapy-impregnated plastic biliary endoprosthesis are important steps in the palliative management of extra-hepatic CCs. Radiofrequency and chemo-embolization methods are also applicable for intra-hepatic CCs as palliative modes of treatment. We need more prospective randomized controlled trials to evaluate the role of the new emerging therapies for CC patients.

Rare pulmonary and cerebral complications after transarterial chemoembolization for hepatocellular carcinoma: A case report

We report a rare case of acute pulmonary and cerebral complication after transarterial chemoembolization (TACE) for inoperable hepatocellular carcinoma. The case involved a large tumor and hepatic vein invasion. Nonspecific pulmonary and cerebral symptoms such as acute dyspnoea and transient consciousness loss developed in the patient, a 49-year-old woman, following the TACE due to pulmonary and cerebral oil embolism. The chest and brain conditions of this patient improved after some supportive therapies and nursing interventions. She also subsequently completed the other three procedures of TACE.

Gene expression and MR diffusion-weighted imaging after chemoembolization in rabbit liver VX-2 tumor model

AIM: To investigate the dynamic characteristics and the correlation between PCNA, Bax, nm23, E-cadherin expression and apparent diffusion coefficient (ADC) on MR diffusion-weighted imaging (DWI) after chemoembolization in rabbit liver VX-2 tumor model.

METHODS: Forty New Zealand rabbit liver VX-2 tumor models were included in the study. DWI was carried out periodically after chemoembolization. All VX-2 tumor samples in each group were examined by histopathology and Strept Avidin-Biotin Complex (SABC) immunohistochemical staining.

RESULTS: The PCNA expression index in VX-2 tumors was higher than in the normal parenchyma around the tumor (P < 0.001). Nm23, Bax or E-caderin expression index in VX-2 tumors were lower than in the normal parenchyma around the tumor (all P < 0.001). PCNA and nm23 expression in the VX-2 tumor periphery first increased and then decreased (P < 0.001 and P = 0.03, respectively), while the expression of Bax and E-cadherin before and after chemoembolization was insignificant. When b-value was 100 s/mm², there was a linear correlation between PCNA expression and ADC in the area of VX-2 tumor periphery (P < 0.001), and PCNA expression in VX-2 tumor periphery influenced the ADC.

CONCLUSION: The potential of VX-2 tumor infiltrating and metastasizing decreases, while its ability to proliferate increases for a short time after chemoembolization. To some degree, the ADC value indirectly reflects the proliferation of VX-2 tumor cells.

Characteristics and pathological mechanism on magnetic resonance diffusion-weighted imaging after chemoembolization in rabbit liver VX-2 tumor model

AIM: To investigate dynamic characteristics and pathological mechanism of signal in rabbit VX-2 tumor model on diffusion-weighted imaging (DWI) after chemoembolization.

METHODS: Forty New Zealand rabbits were included in the study and forty-seven rabbit VX-2 tumor models were raised by implanting directly and intrahepatically after abdominal cavity opened. Forty VX-2 tumor models from them were divided into four groups. DWI was performed periodically and respectively for each group after chemoembolization. All VX-2 tumor samples of each group were studied by pathology. The distinction of VX-2 tumors on DWI was assessed by their apparent diffusion coefficient (ADC) values. The statistical significance between different time groups, different area groups or different b-value groups was calculated by using SPSS12.0 software.

RESULTS: Under b-value of 100 s/mm², ADC values were lowest at 16 h after chemoembolization in area of VX-2 tumor periphery, central, and normal liver parenchyma around tumor, but turned to increase with further elongation of chemoembolization treatment. The distinction of ADC between different time groups was significant respectively (F = 7.325, P < 0.001; F = 2.496, P < 0.048; F = 6.856, P < 0.001). Cellular edema in the area of VX-2 tumor periphery or normal liver parenchyma around tumor, increased quickly in sixteen h after chemoembolization but, from the 16th h to the 48th h, cellular edema in the area of normal liver parenchyma around tumor decreased gradually and that in the area of VX-2 tumor periphery decreased lightly at, and then increased continually. After chemoembolization, Cellular necrosis in the area of VX-2 tumor periphery was more significantly high than that before chemoembolization. The areas of dead cells in VX-2 tumors manifested low signal and high ADC value, while the areas of viable cells manifested high signal and low ADC value.

CONCLUSION: DWI is able to detect and differentiate tumor necrotic areas from viable cellular areas before and after chemoembolization. ADC of normal liver parenchyma and VX-2 tumor are influenced by intracellular edema, tissue cellular death and microcirculation disturbance after chemoembolization.

Combined TACE and PEI for palliative treatment of unresectable hepatocellular carcinoma

AIM: To assess whether the effectiveness of a combination of transarterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) in the treatment of unresectable hepatocellular carcinoma (HCC) is superior to TACE alone a randomized controlled trial was performed.

METHODS: The effect of combination therapy on long-term survival rates and duration of hospitalization was evaluated in 52 previously untreated HCCs, randomly allocated to TACE-PEI (27 pts) or TACE alone (25 pts).

RESULTS: The cumulative survival rate of the TACE group was 75.8% at 6 mo, 62.9% at 12 mo, and 18.0% at 24 mo and of the TACE-PEI group 76.9%, 61.5%, and 38.7%, respectively. Comparison of overall survival in both groups showed no statistically significant difference. Regarding the patients with HCCs Okuda stage I (n = 26), the median survival of the TACE-PEI group was significantly longer (>24 mo, median not yet reached in the study period) compared to the TACE group (18.4 mo [range 11.6-21.7 mo]; p = 0.04). TACE-PEI reduced the relative risk for mortality to 0.4 (95%CI 0.15-0.96) compared to patients who received TACE alone. Median survival in patients with HCCs Okuda stage II or III was 5.0 mo in the TACE group (1.7 mo-not defined) compared to 10.4 mo in the TACE-PEI group.

CONCLUSION: The combination TACE-PEI improved survival time compared to TACE alone. Our study revealed a statistically significant improved survival in HCCs Okuda stage I. Side effects were minor and the combination therapy did not prolong duration of hospitalization considerably.

Treatment of Zollinger-Ellison Syndrome

In this article, we have reviewed the main therapeutic measures for the treatment of Zollinger-Ellison syndrome (ZES). Review of the literature was based on computer searches (Pub-Med, Index Medicus) and personal experiences. We have evaluated all the measures now available for treating patients with sporadic gastrinomas or gastrinomas associated with Multiple Endocrine Neoplasia Type 1, (MEN 1) including medical therapy such as antisecretory drugs and somatostatin analogs (SST), chemotherapy and chemoembolization, and surgical procedures. In ZES patients, the best therapeutic procedure is surgery which, if radical, can be curative. Medical treatment can be the best palliative therapy and should be used, when possible, in association with surgery, in a multimodal therapeutic approach.

Efficacy of different treatment strategies for hepatocellular carcinoma with portal vein tumor thrombosis

AIM: To evaluate the efficacy of different treatment strategies for hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) and investigate factors influencing prognosis.

METHODS: One hundred and seventy-nine HCC patients with macroscopic PVTT were enrolled in this study. They were divided into four groups and underwent different treatments: conservative treatment group (n = 18), chemotherapy group (n = 53), surgical resection group (n = 24) and surgical resection with postoperative chemotherapy group (n = 84). Survival rates of the patients were analyzed by the Kaplan-Meier method. A log-rank analysis was performed to identify group differences. Cox’s proportional hazards model was used to analyze variables associated with survival.

RESULTS: The mean survival periods of the patients in four groups were 3.6, 7.3, 10.1, and 15.1 mo respectively. There were significant differences in the survival rates among the groups. The survival rates at 0.5-, 1-, 2-, and 3-year in surgical resection with postoperative chemotherapy group were 55.8%, 39.3%, 30.4%, and 15.6% respectively, which were significantly higher than those of other groups (P<0.001). Multivariate analysis revealed that the strategy of treatment (P<0.001) and the number of chemotherapy cycles (P = 0.012) were independent survival predictors for patients with HCC and PVTT.

CONCLUSION: Surgical resection of HCC and PVTT combined with postoperative chemotherapy or chemoembolization is the most effective therapeutic strategy for the patients who can tolerate operation. Multiple chemotherapeutic courses should be given postoperatively to the patients with good hepatic function reserve.

Hepatic arterial infusion chemotherapy and embolization in the treatment of primary hepatic carcinoma

AIM: To study the effects of hepatic arterial infusion chemotherapy (HAI) or embolization (HAE) in the treatment of primary hepatic carcinoma (PHC) and the factors influencing these effects.

METHODS: A retrospective analysis of 188 patients (166 males and 22 females) with PHC treated with HAI (n = 82) or HAE (n = 106) was conducted.

RESULTS: In the group as a whole, the percentage of patients experiencing therapeutic outcomes was as follows: Symptomatic relief (59.6%); Tumor shrinkage (55%); A decrease in blood alpha fetoprotein (AFP) (37.8%) and overall survival rates at 0.5, 1.0, 2.0, and 3.0 years of 75.4%, 46%, 23.5% and 14.7%, respectively. The mean survival time in the entire group was 12.2 mo, and the longest survival period was 50 mo. In the HAI group the survival rates at 0.5, 1.0. 2.0 and 3.0 years of follow-up were 61.0%, 25.4%, 4.5% and 0%, respectively, with a mean survival time of 7.7 mo. In the HAE group the corresponding survival rates were 86.8%, 61.7%, 37.8% and 26.1%, respectively, with a mean survival time of 15.7 mo. Eighteen patients received secondary surgery. Factors that had a favorable effect on therapeutic outcomes were presence of no or only mild liver cirrhosis, presence of stage I or Stage II disease, presence of only a single tumor, a tumor size less than 10 cm in diameter, an absence cancerous thrombus within the portal vein or hepatic arterio venous fistula, and HAE treatment.

CONCLUSION: This study helped identify the effects of HAI and HAE in patients with PHC, and identified some important factors which influence such treatment.