Efficacy of dexamethasone and N-acetylcysteine combination in preventing post-embolization syndrome after transarterial chemoembolization in hepatocellular carcinoma

BACKGROUND

Conventional transarterial chemoembolization (cTACE) is the current standard treatment for intermediate-stage hepatocellular carcinoma (HCC). Post-embolization syndrome (PES) is complex clinical syndrome that presents as fever, abdominal pain, nausea, and vomiting. Either dexamethasone (DEXA) or N-acetylcysteine (NAC) is used to prevent PES; however, the synergistic effect of their combined therapy for preventing PES and liver decompensation has not been determined.

AIM

To evaluate the efficacy of DEXA and NAC combination in preventing PES and liver decompensation after cTACE.

METHODS

Patients with Barcelona Clinic Liver Cancer stage A or B HCC who were scheduled for TACE were prospectively enrolled. All patients were randomly stratified to receive NAC and DEXA or placebo. The dual therapy (NAC + DEXA) group received intravenous administration of 10 mg DEXA every 12 h, NAC 24 h prior to cTACE (150 mg/kg/h for 1 h followed by 12.5 mg/kg/h for 4 h), and a continuous infusion of 6.25 mg/h NAC plus 4 mg DEXA every 12 h for 48 h after cTACE. The placebo group received an infusion of 5% glucose solution until 48 h after procedure. PES was defined by South West Oncology Group toxicity code grading of more than 2 that was calculated using incidence of fever, nausea, vomiting, and pain.

RESULTS

One-hundred patients were enrolled with 50 patients in each group. Incidence of PES was significantly lower in the NAC + DEXA group compared with in the placebo group (6% vs 80%; P < 0.001). Multivariate analysis showed that the dual treatment is a protective strategic therapy against PES development [odds ratio (OR) = 0.04; 95% confidence interval (CI): 0.01-0.20; P < 0.001). Seven (14%) patients in the placebo group, but none in the NAC + DEXA group, developed post-TACE liver decompensation. A dynamic change in Albumin-Bilirubin score of more than 0.5 point was found to be a risk factor for post-TACE liver decompensation (OR = 42.77; 95%CI: 1.01-1810; P = 0.049).

CONCLUSION

Intravenous NAC + DEXA administration ameliorated the occurrence of PES event after cTACE in patients with intermediate-stage HCC.

Impact of Transarterial Chemoembolization or Hepatic Artery Infusion Chemotherapy on Liver Function after Hepatocellular Carcinoma Resection: An Observational Study

INTRODUCTION

Liver surgery leads to a high degree of heterogeneity in the prognosis of hepatocellular carcinoma (HCC) patients. However, most previous studies focused on the postoperative therapeutic effects of other treatments, with relatively few studies on the impacts on liver function. This study investigated the impact of transarterial chemoembolization (TACE) and hepatic artery infusion chemotherapy (HAIC) on liver function after HCC resection from various angles.

METHODS

138 HCC patients were enrolled, including 27 patients who received TACE and 80 patients who received HAIC. Besides routine treatment such as liver protection and antiviral therapy, 31 patients received no other treatment. The different groups were compared with various biological parameters with four types of scoring methods.

RESULTS

In the short term after TACE, the mean (±SD) alanine transaminase and aspartate transaminase values increased by 79.22 ± 117.43 U/L and 66.33 ± 94.54 U/L, respectively (p < 0.01). The mean (±SD) total bilirubin (TBIL) values increased by 4.02 ± 6.08 μmol/L (p < 0.01). The mean (±SD) albumin (ALB) values decreased by 3.54 ± 2.93 g/L (p < 0.001). The mean (±SD) albumin bilirubin (ALBI) scores increased by 0.39 ± 0.22 (p < 0.001). In the short term after HAIC, the mean (±SD) TBIL values increased by 2.11 ± 5.57 μmol/L (p < 0.01). The mean (±SD) ALB values decreased by 2.52 ± 3.26 g/L (p < 0.001), and the mean (±SD) ALBI scores increased by 0.21 ± 0.42 (p < 0.001). In both treatment groups, the long-term liver function was not significantly different from that before treatment and also from that of the untreated group (p > 0.05).

CONCLUSION

TACE after HCC resection has a significant impact on short-term liver function, whereas HAIC has a relatively small impact, but neither has a major impact on long-term liver function.

Smart nanoparticles and microbeads for interventional embolization therapy of liver cancer: state of the art

The process of transcatheter arterial chemoembolization is characterized by the ability to accurately deliver chemotherapy drugs with minimal systemic side effects and has become the standard treatment for unresectable intermediate hepatocellular carcinoma (HCC). However, this treatment option still has much room for improvement, one of which may be the introduction of nanomaterials, which exhibit unique functions and can be applied to in vivo tumor imaging and therapy. Several biodegradable and multifunctional nanomaterials and nanobeads have recently been developed and applied in the locoregional treatment of hepatocellular cancer. This review explores recent developments and findings in relation to micro-nano medicines in transarterial therapy for HCC, emerging strategies to improve the efficacy of delivering nano-based medicines, and expounding prospects for clinical applications of nanomaterials.

Predictors of liver failure after transarterial chemoembolization in patients with spontaneously ruptured hepatocellular carcinoma: A retrospective study

Background

Spontaneously ruptured hepatocellular carcinoma (rHCC) is a life-threatening condition. Transarterial chemoembolization (TACE) is a widely accepted treatment; however, it can lead to serious complications, especially liver failure. We sought to identify preoperative predictors of liver failure in patients with rHCC undergoing TACE.

Methods

Patients with rHCC who received TACE as the initial therapy were retrospectively studied at our institution between January 2016 and December 2021. Based on the occurrence of liver failure after TACE, the patients were divided into liver failure and no-liver failure groups. Predictors of liver failure after TACE were analyzed using univariate and multivariate regression analyses. The predictive performance was assessed using the area under the curve (AUC). Delong's test was used to compare predictive efficiency.

Results

Sixty patients (19 and 41 in the liver failure and non-liver failure groups, respectively) were included. Multivariate analysis showed that preoperative prothrombin activity (PTA) level (odds ratio [OR], 0.956; 95% confidence interval [CI], 0.920-0.994; P ​= ​0.024) and Child-Pugh grade B (OR, 6.419; 95% CI, 1.123-36.677; P ​= ​0.037) were independent predictors of liver failure after TACE in patients with rHCC. The AUCs of the preoperative PTA levels and Child-Pugh grade B for predicting liver failure after TACE in patients with rHCC were 0.783 and 0.764, respectively.

Conclusion

Preoperative PTA level and Child-Pugh grade B were significant independent risk factors for liver failure after TACE in patients with rHCC. These can be used to predict liver failure after TACE in patients with rHCC for individual decision-making regarding treatment planning.

Short-term efficacy assessment of transarterial chemoembolization combined with radioactive iodine therapy in primary hepatocellular carcinoma

BACKGROUND

Transarterial chemoembolization (TACE) is an effective treatment for primary hepatocellular carcinoma (PHC). Radioactive iodine therapy has been used in the treatment of advanced PHC, especially in patients with portal vein tumor thrombosis. However, data on the therapeutic effect of TACE combined with radioactive iodine therapy in PHC are scarce.

AIM

To investigate the clinical efficacy of TACE combined with radioactive iodine implantation therapy in advanced PHC via perfusion computed tomography (CT).

METHODS

For this study, 98 advanced PHC patients were recruited and divided randomly into the study and control groups. Patients in the study group were treated with TACE combined radioactive iodine implantation therapy. Patients in the control group were treated with only TACE. The tumor lesion length, clinical effect, serum alpha-fetoprotein (AFP) and CT perfusion parameters were compared before and after therapy, and statistical analysis was performed.

RESULTS

There was no significant difference in tumor length and serum AFP between the study and control groups (P > 0.05) before treatment. However, the tumor length and serum AFP in the study group were lower than those in the control group 1 mo and 3 mo after therapy. After 3 mo of treatment, the complete and partial remission rate of the study group was 93.88%, which was significantly higher than the control group (77.55%) (P < 0.05). Before treatment, there were no significant differences between the two groups on the perfusion CT variables, including the lesion blood volume, permeability surface, blood flow, hepatic artery flow and mean transit time (P > 0.05). After 3 mo of treatment, all perfusion CT variables were lower in the study group compared to the control group (P < 0.05). The survival time of patients in the study group was 22 mo compared to 18 mo in the control group, which was significantly different [log rank (Mantel-Cox) = 4.318, P = 0.038].

CONCLUSION

TACE combined with radioactive iodine implantation in the treatment of advanced PHC can inhibit the formation of blood vessels in tumor tissue and reduce the perfusion level of tumor lesions, thereby improving the clinical efficacy and prolonging the survival time of patients.

Salvage locoregional therapies for recurrent hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the second most common cause of cancer-related death worldwide. Despite the advent of screening efforts and algorithms to stratify patients into appropriate treatment strategies, recurrence rates remain high. In contrast to first-line treatment for HCC, which relies on several factors, including clinical staging, tumor burden, and liver function, there is no consensus or general treatment recommendations for recurrent HCC (R-HCC). Locoregional therapies include a spectrum of minimally invasive liver-directed treatments which can be used as either curative or neoadjuvant therapy for HCC. Herein, we provide a comprehensive review of recent evidence using salvage loco-regional therapies for R-HCC after failed curative-intent.

Low bone mineral density is a prognostic factor for elderly patients with HCC undergoing TACE: results from a multicenter study

OBJECTIVES

Low bone mineral density (BMD) was recently identified as a novel risk factor for patients with hepatocellular carcinoma (HCC). In this multicenter study, we aimed to validate the role of BMD as a prognostic factor for patients with HCC undergoing transarterial chemoembolization (TACE).

METHODS

This retrospective multicenter trial included 908 treatment-naïve patients with HCC who were undergoing TACE as a first-line treatment, at six tertiary care centers, between 2010 and 2020. BMD was assessed by measuring the mean Hounsfield units (HUs) in the midvertebral core of the 11^th thoracic vertebra, on contrast-enhanced computer tomography performed before treatment. We assessed the influence of BMD on median overall survival (OS) and performed multivariate analysis including established estimates for survival.

RESULTS

The median BMD was 145 HU (IQR, 115-175 HU). Patients with a high BMD (≥ 114 HU) had a median OS of 22.2 months, while patients with a low BMD (< 114 HU) had a lower median OS of only 16.2 months (p < .001). Besides albumin, bilirubin, tumor number, and tumor diameter, BMD remained an independent prognostic factor in multivariate analysis.

CONCLUSIONS

BMD is an independent predictive factor for survival in elderly patients with HCC undergoing TACE. The integration of BMD into novel scoring systems could potentially improve survival prediction and clinical decision-making.

KEY POINTS

• Bone mineral density can be easily assessed in routinely acquired pre-interventional computed tomography scans. • Bone mineral density is an independent predictive factor for survival in elderly patients with HCC undergoing TACE. • Thus, bone mineral density is a novel imaging biomarker for prognosis prediction in elderly patients with HCC undergoing TACE.

Efficacy and Safety of Lobaplatin-TACE in the Treatment of Primary Hepatocellular Carcinoma: A Retrospective Study

PURPOSE

To investigate the safety and efficacy of lobaplatin-TACE in treating primary hepatocellular carcinoma.

METHODS

The data of 536 patients who underwent TACE in the interventional department from January 2016 to January 2020 were collected. Patients were divided into two groups according to the chemotherapeutic drugs used in TACE.: the epirubicin-TACE group (N = 260) and the lobaplatin-TACE group (N = 276). Primary study endpoint: (1) The tumor response after TACE; (2) The survival rates; Secondary study endpoints:(1) Changes in liver function and blood routine before and after TACE; (2) Occurrence of the post-embolization syndrome and infection after TACE.

RESULTS

The ORR was 35.0% in the epirubicin-TACE group and 51.1% in the lobaplatin-TACE group (p=0.001). The DCR was 73.1% in the epirubicin-TACE group and 82.2% in the lobaplatin-TACE group (p=0.011). The 6-month, 9- month, 12-month, and 15-month survival rates were higher in the lobaplatin-TACE group than in the epirubicin-TACE group (p=0.029, p=0.001, p=0.005, p=0.002). mOS: Epirubicin-TACE group,14.8 months; Lobaplatin-TACE group,18.6 months (p=0.007). mPFS: Epirubicin-TACE group,9.5 months; Lobaplatin-TACE group,12.8 months (P =0.000). There was no statistical difference in ALT, AST, total bilirubin and Leucocyte after TACE between the two groups (p=0.343, p=0.368, p=0.288, p=0.359). The platelet decrease after TACE was more significant in the lobaplatin- TACE group than in the epirubicin-TACE group (p=0.046). There was no statistical difference in the incidence rate of abdominal pain, fever and infection after TACE between the two groups (p=0.502, p=0.602, p=0.726). The incidence of vomiting after TACE in the lobaplatin-TACE group was higher than that in the epirubicin-TACE group (p=0.003).

CONCLUSION

Lobaplatin-TACE has a higher tumor response rate and survival rate. Lobaplatin-TACE is a safe and effective treatment strategy; it is worthy of clinical application.

Role of Interventional Radiology in Pediatric Cancer Patients

PURPOSE OF REVIEW

Pediatric interventional radiology (IR) is a growing subspecialty. Here, we review the current role of IR in children with cancer, which uses imaging such as ultrasound, fluoroscopy, and computed tomography to perform minimally invasive procedures. These include biopsy, needle localization, central venous access, thermal ablation, transarterial chemoembolization, transarterial radioembolization with yttrium-90, non-tunneled/tunneled drainage catheter placement, and lymphatic interventions.

RECENT FINDINGS

Although locoregional therapies for the treatment of cancer in adults are common, they are less common in children, perhaps due to the relative rarity of cancer in children, their typically better performance status, and paucity of comorbidities. Preliminary results from small-scale studies for ablation, transarterial chemoembolization, and transarterial radioembolization with yttrium-90 used in the front-line armamentarium of curative therapy are encouraging. Pediatric IR offers an array of minimally invasive procedures intended to diagnose and treat pediatric cancer patients. However, more research is required to determine the efficacy of locoregional therapy in children and to define the clinical scenarios where benefit is likely to be optimized.

DEM-TACE as the initial treatment could improve the clinical efficacy of the hepatocellular carcinoma with portal vein tumor thrombus: a retrospective controlled study

BACKGROUND

Conventional-transarterial chemoembolization (C-TACE) was proven to improve overall survival (OS) in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT), drug-eluting microsphere-TACE (DEM-TACE) was supposed to provide more benefit than C-TACE in this respect.

PURPOSE

To compare the safety and efficacy between DEM-TACE and C-TACE as the initial treatment in HCC patients with PVTT and to identify prognostic factors of OS.

METHODS

The medical records of advanced HCC patients with PVTT who underwent DEM-TACE or C-TACE as the initial thearpy from September 2015 with mean follow-up time 14.9 ± 1.2 (95% CI 12.6-17.2) months were retrospectively evaluated. A total of 97 patients were included, 49 patients in the DEM-TACE group and 48 in the C-TACE group. Adverse events (AEs) related to TACE were compared. Tumor and PVTT radiologic response, time to tumor progression (TTP) and OS were calculated and compared in both groups.

RESULTS

Patients in DEM-TACE group had a better radiologic response (Tumr response: 89.8% vs. 75.0%; PVTT response: 85.7% vs. 70.8%; overall response: 79.6% vs. 58.3%, P = 0.024) and longer TTP (7.0 months vs. 4.0 months, P = 0.040) than patients in C-TACE group. A lower incidence of abdominal pain was found in the DEM-TACE group than in C-TACE group (21 vs. 31, P = 0.032), but there were no significant differences between DEM-TACE and C-TACE patients in any other AEs reported. When compared to C-TACE, DEM-TACE also showed significant OS benefits (12.0 months vs. 9.0 months, P = 0.027). DEM-TACE treatment, the absence of arterioportal shunt (APS), lower AFP value and better PVTT radiologic response were the independent prognostic factors for OS in univariate/multivariate analyses, which provided us with a guide for better patient selection.

CONCLUSIONS

Based on our retrospective study, DEM-TACE can be performed safely and might be superior to C-TACE as the initial treatment for HCC patients with PVTT.

TRIAL REGISTRATION

Retrospectively registered.

Transarterial chemoembolization combined with radiofrequency ablation in the treatment of large hepatocellular carcinoma with stage C

BACKGROUND

The combination therapy of transarterial chemoembolization and radiofrequency ablation (TACE-RFA) shows promising efficacy in large hepatocellular carcinoma (HCC). Data on the clinical efficacy and safety of TACE-RFA for large HCC with barcelona clinic liver cancer (BCLC) stage C are lacking in China.

AIM

To determine the safety and efficacy of TACE-RFA for large, advanced HCC.

METHODS

Patients of HCC with BCLC stage C who were treated with TACE-RFA or TACE alone at our institute from August 2008 to January 2017 were retrospectively reviewed. The complications were observed. The associations between overall survival (OS) and treatment method were analysed.

RESULTS

Data were collected from 102 HCC patients. Among them, 64 underwent TACE-RFA and 38 underwent TACE. The combination of TACE and RFA was safe. All complications were controllable. The median OS in the TACE-RFA group was significantly longer than that in the TACE group (8.0 mo vs 4.0 mo, P = 0.000). The 6-, 12- and 24-mo survival rates of the combination group were 68.8%, 34.4%, and 10.9%, respectively, while those of the TACE group were 36.8%, 7.9%, and 0% (P < 0.05).

CONCLUSION

TACE-RFA has an advantage over TACE alone in improving OS in large HCC patients with BCLC stage C.

Transarterial chemoembolization (TACE) plus apatinib vs. TACE alone for hepatocellular carcinoma

OBJECTIVE

Transarterial chemoembolization (TACE) is a common therapy for hepatocellular carcinoma (HCC), while TACE-induced tumor angiogenesis would increase progression and metastasis risk. Besides, apatinib possesses the capability of inhibiting tumor angiogenesis. Thus, this study aimed to explore the efficacy and safety of TACE plus apatinib compared to TACE alone in HCC patients.

METHODS

Ninety-six intermediate-advanced HCC patients were retrospectively enrolled and classified into TACE plus apatinib group (N = 45) and TACE group (N = 51) based on the treatment.

RESULTS

Objective response rate (68.9% vs. 47.1%) was increased in TACE plus apatinib group than in TACE group (P = 0.031). However, no difference was found in disease-control rate between groups (95.6% vs. 86.3%) (P = 0.167). Progression-free survival (PFS) (median PFS (95% confidence interval (CI)): 20.0 (13.2-26.8) vs. 14.0 (8.3-19.7) months) was enhanced in TACE plus apatinib group compared with TACE group (P = 0.030), while no difference was found in overall survival between groups (P = 0.060). Additionally, multivariate Cox's analysis presented that TACE plus apatinib (vs. TACE alone) independently associated with prolonged PFS (P = 0.043, hazard ratio = 0.617). Regarding safety profile, no difference in liver function indexes (albumin, total bilirubin, alanine aminotransferase and aspartate aminotransferase) was found after treatment between two groups; meanwhile, only the incidence of hand-foot skin reaction (24.4% vs. 7.8%) was higher in TACE plus apatinib group compared to TACE group (P = 0.025), while no difference was found in other adverse events between two groups (all P > 0.05).

CONCLUSION

TACE plus apatinib illustrates a superior efficacy with tolerable safety than TACE alone in intermediate-advanced HCC patients.

Transarterial chemoembolization as the primary treatment for a super-giant hepatic hemangioma

Hepatic hemangiomas are common benign liver tumors. While the majority are small and require no treatment, giant hemangiomas are characterized as measuring greater than 4-6 cm in size and may require intervention. Surgical resection and enucleation have been described historically as the treatment for giant hemangiomas requiring intervention. Additionally, limited data exists about the treatment of hemangiomas measuring greater than 20 cm, particularly in regards to transarterial chemoembolization. We present a case of a super-giant hemangioma measuring greater than 20 cm treated with transarterial chemoembolization alone.

Impact of sarcopenia on tumor response and survival outcomes in patients with hepatocellular carcinoma treated by trans-arterial (chemo)-embolization

BACKGROUND

At the diagnosis of hepatocellular carcinoma (HCC), more than 90% of HCC patients present cirrhosis, a clinical condition often associated to malnutrition. Sarcopenia is an indirect marker of malnutrition assessable on computed tomography (CT).

AIM

To evaluate the prognostic value of sarcopenia in patients with HCC treated by trans-arterial (chemo)-embolization.

METHODS

Patients with HCC treated by a first session of trans-arterial (chemo)embolization and an available CT scan before treatment were included. Sarcopenia was assessed using skeletal muscle index at baseline and at the first radiological assessment. Radiological response was recorded after the first session of treatment using mRECIST.

RESULTS

Of 225 patients treated by trans-arterial bland embolization (n = 71) or trans-arterial chemoembolization (n = 154) for HCC between 2007 and 2013, Barcelona Clinic of Liver Cancer stage was A, B, and C in 27.5%, 55%, and 16.8% of cases, respectively. Sarcopenia was present in 57.7% of the patients. Patients with sarcopenia presented a higher rate of progressive disease (19% vs 8%, P = 0.0236), a shorter progression-free survival (8.3 vs 13.2 mo, P = 0.0035), and a shorter median overall survival (19.4 mo vs 35.5 mo, P = 0.0149) compared with non-sarcopenic patients. Finally, patients whose sarcopenia appeared after first transarterial treatment had the worst prognosis (P = 0.0004).

CONCLUSION

Sarcopenia is associated with tumor progression and poor survival outcomes after trans-arterial (chemo)-embolization for HCC.

Response assessment methods for patients with hepatic metastasis from rare tumor primaries undergoing transarterial chemoembolization

PURPOSE

This study assessed the response to conventional transarterial chemoembolization (cTACE) in patients with liver metastases from rare tumor primaries using one-dimensional (1D) and three-dimensional (3D) quantitative response assessment methods, and investigate the relationship of lipiodol deposition in predicting response.

MATERIALS AND METHODS

This retrospective bicentric study included 16 patients with hepatic metastases from rare tumors treated with cTACE between 2002 and 2017. Multi-phasic MR imaging obtained before and after cTACE was used for assessment of response. Response evaluation criteria in solid tumors (RECIST) and modified-RECIST (mRECIST) were utilized for 1D response assessment, and volumetric RECIST (vRECIST) and enhancement-based quantitative European Association for Study of the Liver EASL (qEASL) were used for 3D response assessment. The same day post-cTACE CT scan was analyzed to quantify intratumoral lipiodol deposition (%).

RESULTS

The mean and standard deviation (SD) of diameter of treated lesions per targeted area was 7.5 ± 5.4 cm, and the mean and SD of number of metastases in each targeted area was 4.2 ± 4.6. cTACE was technically successful in all patients, without major complications. While RECIST and vRECIST methods did not allocate patients with partial response, mRECIST and qEASL identified patients with partial response. Intratumoral lipiodol deposition significantly predicted treatment response according qEASL (R² = 0.470, p < 0.01), while no association was shown between lipiodol deposition within treated tumor area and RECIST or mRECIST (p > 0.212).

CONCLUSION

3D quantitative volumetric response analysis can be used for stratification of response to cTACE in patients with hepatic metastases originating from rare primary tumors. Lipiodol deposition could potentially be used as an early surrogate to predict response to cTACE.

Identification of predictive factors for post-transarterial chemoembolization liver failure in hepatocellular carcinoma patients: A retrospective study

BACKGROUND

Post-transarterial chemoembolization (TACE) liver failure occurs frequently in hepatocellular carcinoma (HCC) patients. The identification of predictors for post-TACE liver failure is of great importance for clinical decision-making in this population.

AIM

To investigate the occurrence rate and predictive factors of post-TACE liver failure in this retrospective study to provide clues for decision-making regarding TACE procedures in HCC patients.

METHODS

The clinical records of HCC patients treated with TACE therapy were reviewed. Baseline clinical characteristics and laboratory parameters of these patients were extracted. Logistic models were used to identify candidates to predict post-TACE liver failure.

RESULTS

A total of 199 HCC patients were enrolled in this study, and 70 patients (35.2%) developed post-TACE liver failure. Univariate and multivariate logistic models indicated that microspheres plus gelatin embolization and main tumor size > 5 cm were risk predictors for post-TACE liver failure [odds ratio (OR): 4.4, 95% confidence interval (CI): 1.2-16.3, P = 0.027; OR: 2.3, 95%CI: 1.05-5.3, P = 0.039, respectively]. Conversely, HCC patients who underwent tumor resection surgery before the TACE procedure had a lower risk for post-TACE liver failure (OR: 0.4, 95%CI: 0.2-0.95, P = 0.039).

CONCLUSION

Microspheres plus gelatin embolization and main tumor size might be risk factors for post-TACE liver failure in HCC patients, while prior tumor resection could be a favorable factor reducing the risk of post-TACE liver failure.

Neoadjuvant transarterial chemoembolization (TACE) plus PD-1 inhibitor bridging to tumor resection in intermediate-stage hepatocellular carcinoma patients

BACKGROUND

Programmed cell death protein 1 (PD-1) inhibitor is widely utilized in advanced-stage carcinomas including hepatocellular carcinoma (HCC), while its neoadjuvant application plus transarterial chemoembolization (TACE) in HCC remains unexplored. Thereby, the current study aimed to investigate the efficacy and safety of TACE plus PD-1 inhibitor as neoadjuvant therapy bridging to surgical resection in intermediate-stage HCC patients.

METHODS

Twenty intermediate-stage HCC (China Liver Cancer (CNLC) stage II) patients treated with neoadjuvant TACE plus PD-1 inhibitor (camrelizumab or sintilimab) bridging to surgery were consecutively enrolled.

RESULTS

The objective response rate (ORR) and disease control rate (DCR) to neoadjuvant therapy were 75.0% and 100.0%, respectively; meanwhile, alpha-fetoprotein (AFP) was decreased after the neoadjuvant therapy (P < 0.001). Moreover, 14 (70.0%) patients had successful downstaging (patients converted to CNLC stage I). Neither median disease-free survival (DFS) nor median overall survival (OS) was reached; additionally, the 1-year accumulating DFS rate was 86.6%; meanwhile, the 1-year and 2-year accumulating OS rates were 100.0% and 76.4%, separately. Moreover, patients with successful downstaging had a prolonged DFS (P = 0.014) compared to patients with failed downstaging; meanwhile, this trend was also observed in assessing accumulating OS (P = 0.067) (without statistical significance). Main adverse events included pain (50.0%), fever (25.0%), neutropenia (25.0%), nausea and vomiting (25.0%), fatigue (25.0%), peripheral neuropathy (20.0%), anemia (15.0%), thrombopenia (15.0%), diarrhea (15.0%), anorexia (15.0%), and rash (15.0%).

CONCLUSION

Neoadjuvant TACE plus PD-1 inhibitor realizes a satisfying downstaging rate, acceptable survival profile, and tolerance in intermediate-stage HCC patients.

Polymersome-stabilized doxorubicin-lipiodol emulsions for high-efficacy chemoembolization therapy

Transarterial chemoembolization (TACE) with free doxorubicin-lipiodol emulsions (free DOX/L) is a favored clinical treatment for advanced hepatocellular carcinoma (HCC) patients ineligible for radical therapies; however, its inferior colloidal stability not only greatly reduces its tumor retention but also hastens drug release into blood circulation, leading to suboptimal clinical outcomes. Here, we find that disulfide-crosslinked polymersomes carrying doxorubicin (Ps-DOX) form super-stable and homogenous water-in-oil microemulsions with lipiodol (Ps-DOX/L). Ps-DOX/L microemulsions had tunable sizes ranging from 14 to 44 μm depending on the amount of Ps-DOX, were stable over 2 months storage as well as centrifugation, and exhibited nearly zero-order DOX release within 15 days. Of note, Ps-DOX induced 2.3-13.4 fold better inhibitory activity in all tested rat, murine and human liver tumor cells than free DOX likely due to its efficient redox-triggered intracellular drug release. Interestingly, transarterial administration of Ps-DOX/L microemulsions in orthotopic rat N1S1 syngeneic HCC model showed minimal systemic DOX exposure, high and long hepatic DOX retention, complete tumor elimination, effective inhibition of angiogenesis, and depleted adverse effects, significantly outperforming clinically used free DOX/L emulsions. This smart polymersome stabilization of doxorubicin-lipiodol microemulsions provides a novel TACE strategy for advanced tumors.

Heat-shock protein 90α is a potential prognostic and predictive biomarker in hepatocellular carcinoma: a large-scale and multicenter study

Background

Although the diagnostic value of plasma heat-shock protein 90α (HSP90α) in hepatocellular carcinoma (HCC) has been previously reported, the causal effect of the plasma HSP90α levels on HCC prognosis remains largely unclear. To this extent, we sought to assess whether the plasma HSP90α acts as a prognostic factor for HCC patients.

Methods

A total of 2150 HCC patients were included in this retrospective study between August 2016 and July 2021. Plasma HSP90α levels were tested within a week before treatment and their association with prognosis was assessed.

Results

An optimal cutoff value of 143.5 for the HSP90α based on the overall survival (OS) was determined using the X-tile software. HCC patients with HSP90α < 143.5 ng/mL (low HSP90α) before and after propensity score matching (PSM) indicated longer median OS (mOS) relative to those with HSP90α ≥ 143.5 ng/mL (high HSP90α) (37.0 vs. 9.0 months, p < 0.001; 19.2 vs. 9.6 months, p < 0.001; respectively). In addition, the high HSP90α plasma level is an independent poor prognostic factor for OS in HCC patients. In our subgroup analysis, including the supportive care group, surgery group, transarterial chemoembolization (TACE) group, adjuvant TACE group, an immune checkpoint inhibitor (ICI) plus targeted therapy group, and TACE plus ICI group, the high HSP90α group demonstrated better OS compared to the low HSP90α group. Moreover, in the supportive care, TACE, ICI plus targeted therapy, TACE plus ICI groups, and high HSP90α levels were also an independent poor prognostic factors for OS.

Conclusions

Our study confirmed that the plasma HSP90α level can be used as a prognostic biomarker for HCC.

Supplementary Information

The online version contains supplementary material available at 10.1007/s12072-022-10391-y.

Effectuality study of a 3D motion correction algorithm in C-arm CTs of severely impaired image quality during transarterial chemoembolization

Background

To evaluate effectivity of a 3D-motion correction algorithm in C-Arm CTs (CACT) with limited image quality (IQ) during transarterial chemoembolization (TACE).

Methods

From 1/2015–5/2021, 644 CACTs were performed in patients during TACE. Of these, 27 CACTs in 26 patients (18 m, 8f; 69.7 years ± 10.7 SD) of limited IQ were included. Post-processing of the original raw-data sets (CACT_Org) included application of a 3D-motion correction algorithm and bone segmentation (CACT_{MC_no_bone}). Four radiologists (R1-4) compared the images by choosing their preferred dataset and recommending repeat acquisition in case of severe IQ-impairment. R1,2 performed additional grading of intrahepatic vessel visualization, presence/extent of movement artifacts, and overall IQ.

Results

R1,2 demonstrated excellent interobserver agreement for overall IQ (ICC 0.79,p < 0.01) and the five-point vessel visualization scale before and after post-processing of the datasets (ICC 0.78,p < 0.01). Post-processing caused significant improvement, with overall IQ improving from 2.63 (CACT_Org) to 1.39 (CACT_{MC_no_bone};p < 0.01) and a decrease in the mean distance of identifiable, subcapsular vessels to the liver capsule by 4 mm (p < 0.01). This proved especially true for datasets with low parenchymal and high hepatic artery contrast. A good interobserver agreement (ICC = 0.73) was recorded concerning the presence of motion artifacts, with significantly less discernible motion after post-processing (CACT_Org:1.31 ± 1.67, CACT_{MC_no_bone}:1.00 ± 1.34, p < 0.01). Of the 27 datasets, ≥ 23 CACT_{MC_no_bone} were preferred, with identical datasets chosen by the readers to show benefit from the algorithm.

Conclusion

Application of a 3D-motion correction algorithm significantly improved IQ in diagnostically limited CACTs during TACE, with the potential to decrease repeat acquisitions.

Arterial enhancement fraction in evaluating the therapeutic effect and survival for hepatocellular carcinoma patients treated with DEB-TACE

BACKGROUND

Arterial enhancement fraction (AEF), derived from triphasic CT scans, is considered to indirectly reflect the ratio of hepatic arterial perfusion to total perfusion. The purpose of this study was to retrospectively investigate the relationship between AEF and treatment response and survival in hepatocellular carcinoma (HCC) patients treated with drug-eluting bead (DEB) TACE.

METHODS

AEF of primary lesion (AEF_pre) and residual tumor (AEF_post) in 158 HCC patients were obtained from triphasic liver CT examinations pre- and post-treatment. Wilcoxon-signed rank test was used to compare the AEF_pre and AEF_post for different response groups. Survival curves for overall survival (OS) in patients with different AEF were created by using Kaplan-Meier method. Cox regression analyses were used to determine the association between AEF and OS.

RESULTS

There was no correlation between AEF_pre and treatment response. After DEB-TACE, AEF_post was significantly lower than AEF_pre either in the partial response group (38.9% vs. 52.7%, p <  0.001) or in the stable disease group (49.3% vs. 52.1%, p = 0.029). In the progression disease group, AEF_post was numerically higher than AEF_pre (55.5% vs. 53.0%, p = 0.604). Cox regression analyses showed that risk of death increased in patients with AEF_pre > 57.95% (HR = 1.66, p = 0.019) or AEF_post > 54.85% (HR = 2.47, p <  0.001), and the risk reduced in patients with any reduction in tumor AEF (decrease ratio ≥ 0) and with increased AEF but not exceeding the ratio of 0.102 (increase ratio <  0.102) (HR = 0.32, p <  0.001).

CONCLUSIONS

The change in AEF of viable tumor is correlated with response of HCC to DEB-TACE. In addition, the AEF could be a helpful predictor in future studies on the embolization treatment for HCC.

Preoperative CECT-based Radiomic Signature for Predicting the Response of Transarterial Chemoembolization (TACE) Therapy in Hepatocellular Carcinoma

PURPOSE

To evaluate the efficiency of radiomics signatures in predicting the response of transarterial chemoembolization (TACE) therapy based on preoperative contrast-enhanced computed tomography (CECT).

MATERIALS

This study consisted of 111 patients with intermediate-stage hepatocellular carcinoma who underwent CECT at both the arterial phase (AP) and venous phase (VP) before and after TACE. According to mRECIST 1.1, patients were divided into an objective-response group (n = 38) and a non-response group (n = 73). Among them, 79 patients were assigned as the training dataset, and the remaining 32 cases were assigned as the test dataset.

METHODS

Radiomics features were extracted from CECT images. Two feature ranking methods and three classifiers were used to find the best single-phase radiomics signatures for both AP and VP on the training set. Meanwhile, multi-phase radiomics signatures were built upon integration of images from two CECT phases by decision-level fusion and feature-level fusion. Finally, multivariable logistic regression was used to develop a nomogram by combining radiomics signatures and clinic-radiologic characteristics. The prediction performance was evaluated by AUC on the test dataset.

RESULTS

The multi-phase radiomics signature (AUC = 0.883) performed better in predicting TACE therapy response compared to the best single-phase radiomics signature (AUC = 0.861). The nomogram (AUC = 0.913) showed better performance than any radiomics signatures.

CONCLUSION

The radiomics signatures and nomogram were developed and validated for predicting responses to TACE therapy, and the radiomics model may play a positive role in identifying patients who may benefit from TACE therapy in clinical practice.

Benefits of step-by-step debulking microwave ablation for huge unresectable hepatocellular carcinoma patients after transcatheter arterial chemoembolization refractoriness

OBJECTIVES

To compare the safety and efficacy of step-by-step debulking Microwave Ablation (MWA) with Transarterial Chemoembolization (TACE) monotherapy for huge (≥10 cm in diameter) unresectable hepatocellular carcinoma (HCC) after TACE refractoriness.

METHODS

This is a multi-center retrospective study carried out on 599 patients with huge unresectable HCC who received TACE as first-line therapy at five hospitals from January 2009 to December 2018. A total of 103 patients with TACE refractoriness were divided into two cohorts: monthly step-by-step debulking MWA (n = 52) or continued TACE (n = 51). Overall survival (OS) and progression-free survival (PFS) after refractory TACE were evaluated. Residual liver and tumor volume were recorded for the MWA group.

RESULTS

Median follow-up period was 24.3 months and median OS and PFS were significantly longer in the MWA group than in the TACE group (OS 21.0 vs. 11.7 months, PFS 6.1 vs. 3.0 months, both p < 0.001). The one-, two-, and three-year OS rates in the MWA and TACE groups were 73.1%, 46.6%, and 37.2% versus 43.1%, 15.5%, and 2.9%, respectively. Furthermore, the 0.5-, 1-, and 2-year PFS rates in the MWA and TACE groups were 51.9%, 36.5%, and 25.0% versus 27.5%, 11.8%, and 0, respectively. Multivariate analyses confirmed that switching to debulking MWA treatment was an independent favorable prognostic factor for PFS and OS. In the MWA group, the average additions of residual liver volume/total liver volume were 7.7% ± 6.7%, 7.2% ± 10.2%, and 10.1% ± 8.8% after the first, second, and third MWA procedure.

CONCLUSION

Step-by-step debulking MWA can significantly improve long-term OS and PFS in patients with huge unresectable HCCs compared with repeated TACE after TACE refractoriness. Key PointThe debulking MWA therapy provides significantly longer OS and PFS than continued TACE for patients with huge unresectable HCCs after TACE-refractory, especially with complete tumor ablation.The most common complications were fever (48.1%) and pain (46.2%) in the MWA group. Two major complications (abdominal infection) were recorded in the MWA group, which recovered after symptomatic treatment.During the course of repeated MWAs, liver hyperplasia appeared mainly after the second MWA procedure and the average maximum increased RLV/TLV rate was 16.3%±12.7%.

The C-Reactive Protein to Albumin Ratio Is an Independent Prognostic Factor in Patients with Hepatocellular Carcinoma Undergoing Transarterial Chemoembolization: A Large Cohort Study

BACKGROUND

This study aimed to investigate the prognostic value of C-reactive protein to albumin ratio (CAR) in hepatocellular carcinoma (HCC) patients after transcatheter chemoembolization (TACE).

METHODS

Totally, 958 HCC patients with Barcelona Clinic Liver Cancer (BCLC) stage B were incorporated into the secondary analysis. X-Tile software was applied to determine the optimal cutoff point for CAR, and the total patients were divided into two groups. Cox proportional hazard regression models and Kaplan-Meier analyses were used to estimate the relationship between CAR and overall survival (OS). Stratified analyses were performed to evaluate the prognostic role of CAR in subgroups of major confounding factors, such as alpha-fetoprotein (AFP), diameter of the main tumor, Glasgow prognostic score (GPS) and modified GPS (mGPS).

RESULTS

The optimal cutoff level for the CAR was 0.06. There was a direct correlation between an elevated CAR (≥ 0.06) and shorter OS after adjustment (HR:1.580; 95%CI:1.193-2.092). Kaplan-Meier analysis and log-rank test showed a significant difference in OS curves between the two groups (P < 0.001). CAR showed the distinct value of prognostic stratification in most subgroups, especially in the subgroup of GPS-0 (HR:1.966; 95%CI:1.453-2.660), mGPS-0 (HR:1.984; 95%CI:1.509-2.608) and AFP ≤ 400 ng/ml (HR:1.925; 95%CI:1.393-2.659).

CONCLUSION

The CAR was one of the prognostic factors for HCC patients undergoing TACE treatment. CAR could also provide further prognostic stratification for HCC patients who appear to have a good prognosis, such as patients with AFP-negative, GPS-0 or mGPS-0 to identify patients at a higher risk of death for closer follow-up or more aggressive treatment.

LEVEL OF EVIDENCE

Level 3, Cohort Study.