Comparison of CT findings with resected specimens after chemoembolization with iodized oil for hepatocellular carcinoma

Baseline Tumor Lipiodol Uptake after Transarterial Chemoembolization for Hepatocellular Carcinoma: Identification of a Threshold Value Predicting Tumor Recurrence

Background

The aim of the study was to evaluate the association between baseline Lipiodol uptake in hepatocellular carcinoma (HCC) after transarterial chemoembolization (TACE) with early tumor recurrence, and to identify a threshold baseline uptake value predicting tumor response.

Patients and methods

A single-institution retrospective database of HCC treated with Lipiodol-TACE was reviewed. Forty-six tumors in 30 patients treated with a Lipiodol-chemotherapy emulsion and no additional particle embolization were included. Baseline Lipiodol uptake was measured as the mean Hounsfield units (HU) on a CT within one week after TACE. Washout rate was calculated dividing the difference in HU between the baseline CT and follow-up CT by time (HU/month). Cox proportional hazard models were used to correlate baseline Lipiodol uptake and other variables with tumor response. A receiver operating characteristic (ROC) curve was used to identify the optimal threshold for baseline Lipiodol uptake predicting tumor response.

Results

During the follow-up period (mean 5.6 months), 19 (41.3%) tumors recurred (mean time to recurrence = 3.6 months). In a multivariate model, low baseline Lipiodol uptake and higher washout rate were significant predictors of early tumor recurrence (P = 0.001 and < 0.0001, respectively). On ROC analysis, a threshold Lipiodol uptake of 270.2 HU was significantly associated with tumor response (95% sensitivity, 93% specificity).

Conclusions

Baseline Lipiodol uptake and washout rate on follow-up were independent predictors of early tumor recurrence. A threshold value of baseline Lipiodol uptake > 270.2 HU was highly sensitive and specific for tumor response. These findings may prove useful for determining subsequent treatment strategies after Lipiodol TACE.

Long-term survival in a patient with unresectable liver metastases from uveal melanoma treated with transarterial chemoembolization with irinotecan eluting beads - case report and review of literature

Introduction

Treatment of unresectable liver metastases (LM) from uveal melanoma (UM) remains a major clinical challenge. Systemic chemotherapy and chemoimmunotherapy regimens extrapolated from cutaneous melanoma are considered to be ineffective in therapy of metastases from uveal melanoma. Studies suggest that the progression of hepatic metastases rather than the primary tumor or metastases in other organs determines survival.

Case report

We report a case of transarterial chemoembolization of 57-year-old man diagnosed with unresectable liver metastases from uveal melanoma with irinotecan eluting beads. Therapy resulted in long progression free survival and overall survival, 41 months and 45 months after diagnosis of metastatic disease respectively. Patient did not experience any major side effects of the therapy. Follow-up CTs indicate stable disease in mRECIST criteria and partial response in CHOI criteria.

Conclusions

Transarterial chemoembolization with drug eluting beads loaded with irinotecan may be an effective treatment of unresectable liver metastases from uveal melanoma.

Value of the portal venous phase in evaluation of treated hepatocellular carcinoma following transcatheter arterial chemoembolisation

AIM

To evaluate the utility of the portal venous phase on multiphasic computed tomography (CT) after treatment of hepatocellular carcinoma (HCC) with trans-arterial chemoembolisation (TACE).

MATERIALS AND METHODS

This was a retrospective review of patients who underwent TACE for HCC between 1 April 2012 and 21 December 2014, with appropriate multiphasic, pre- and post-procedural CT examinations. The maximum non-contrast, arterial phase, and portal venous phase attenuation values of the tumour and tumour bed were evaluated within a region of interest (ROI), with values adjusted against background hepatic parenchyma. Linear regression analyses were performed for both the arterial and venous phases, to assess the level of enhancement and to determine if the venous phase had additional value in this setting.

RESULTS

A total of 86 cases from 51 patients were reviewed. All pre-procedural CT examinations of lesions demonstrated arterial phase enhancement with portal venous and delayed phase washout compatible with HCC. The post-procedural CT examinations following TACE revealed expected decreased arterial enhancement. Sixty-five cases (76%) showed persistent non-enhancement on the portal venous phase following embolisation therapy. A total of 21 cases (24%), however, demonstrated progressive portal venous hyper enhancement. Linear regression analysis demonstrated a statistical significance between the difference in maximal arterial and portal venous enhancement in these cases.

CONCLUSION

Following TACE, the treated lesion may demonstrate portal venous phase hyper-enhancement within the tumour bed. As such, full attention should be given to these images for comprehensive evaluation of tumour response following treatment.

TACE plus percutaneous chemotherapy-lipiodol treatment of unresectable pedunculated hepatocellular carcinoma

Pedunculated hepatocellular carcinoma (P-HCC) is rare type of HCC. The study aimed to evaluate the clinical features and outcomes of unresectable P-HCC treated with transcatheter arterial chemoembolization (TACE) and percutaneous chemotherapeutic agents lipiodol emulsion (CALE) injection. The clinical features and outcomes of 25 patients with unresectable P-HCC treated with TACE plus percutaneous CALE injection were retrospectively reviewed, and factors associated with outcomes were analyzed. Comparison with nonpedunculated unresectable HCC was also performed. Patients underwent a median of 4 TACE sessions and received a median of 2 percutaneous CALE injections. The 1-, 2-, 3-, and 5-year actuarial survival rates were 78.9%, 52.6%, 42.1%, and 12.0%, respectively, for patients with P-HCC, and median survival was 27 months (95% confidence interval, 22.6-43.2 months). Patients with P-HCC had better overall survival than those with nonpedunculated HCC (NP-HCC) (P = .002). Vascular invasion and abdominal lymph node metastasis were poor prognostic factors for overall survival in patients with P-HCC. TACE plus percutaneous CALE injection is a safe and effective treatment for unresectable P-HCC. Patients with unresectable P-HCC might have better overall survival than those with NP-HCC after TACE plus percutaneous CALE injection. However, their prognosis remains poor.

Hepatic imaging following intra-arterial embolotherapy

PURPOSE

To discuss guidelines and salient imaging findings of solid tumors treated with common intra-arterial procedures used in interventional oncology.

METHODS

A meticulous literature search of PubMed-indexed articles was conducted. Key words included "imaging + embolization," "imaging + TACE," "imaging + radioembolization," "imaging + Y90," "mRECIST," and "EASL." Representative post-treatment cross-sectional images were obtained from past cases in this institution.

RESULTS

Intra-arterial therapy (IAT) in interventional oncology includes bland embolization, chemoembolization, and radioembolization. Solid tumors of the liver are the primary focus of these procedures. Cross-sectional CT and/or MR are the main modalities used to image tumors after treatment. Traditional size-based response criteria (WHO and RECIST) alone are of limited utility in determining response to IAT; tumoral necrosis and enhancement must be considered. Specifically for HCC, the EASL and mRECIST guidelines are becoming widely adopted response criteria to assess these factors. DWI, FDG-PET, and CEUS are modalities that play an adjunctive but controversial role.

CONCLUSIONS

Radiologists must be aware that the different forms of intra-arterial therapy yield characteristic findings on cross-sectional imaging. Knowledge of these findings is integral to accurate assessment of tumor response and progression.

Hepatocellular Carcinoma Post Embolotherapy: Imaging Appearances and Pitfalls on Computed Tomography and Magnetic Resonance Imaging

Embolotherapies used in the treatment of hepatocellular carcinoma (HCC) include bland embolization, conventional transarterial chemoembolization (cTACE) using ethiodol as a carrier, TACE with drug-eluting beads and super absorbent polymer microspheres (DEB-TACE), and selective internal radiation therapy (SIRT). Successfully treated HCC lesions undergo coagulation necrosis, and appear as nonenhancing hypoattenuating or hypointense lesions in the embolized region on computed tomography (CT) and magnetic resonance. Residual or recurrent tumours demonstrate arterial enhancement with portal venous phase wash-out of contrast, features characteristic of HCC, in and/or around the embolized area. Certain imaging features that result from the procedure itself may limit assessment of response. In conventional TACE, the high-attenuating retained ethiodized oil may obscure arterially-enhancing tumours and limit detection of residual tumours; thus a noncontrast CT on follow-up imaging is important post-cTACE. Hyperenhancement within or around the treated zone can be seen after cTACE, DEB-TACE, or SIRT due to physiologic inflammatory response and may mimic residual tumour. Recognition of these pitfalls is important in the evaluation embolotherapy response.

Response Evaluation Criteria in Cancer of the Liver (RECICL) (2015 Revised version)

The Response Evaluation Criteria in Solid Tumors (RECIST) is inappropriate to assess the direct effects of treatment on hepatocellular carcinoma (HCC) by locoregional therapies such as radiofrequency ablation (RFA) and transarterial chemoembolization (TACE). Therefore, establishment of response evaluation criteria solely devoted to HCC is needed urgently in clinical practice as well as in clinical trials of HCC treatment, such as molecular-targeted therapies, which cause necrosis of the tumor. The Response Evaluation Criteria in Cancer of the Liver (RECICL) was revised in 2015 by the Liver Cancer Study Group of Japan based on the 2009 version of RECICL, which was commonly used in Japan. Major revised points of the RECICL 2015 is to define the target lesions of two lesions per organ or three lesions per liver, up to a maximum of five lesions. The second revised point is that setting the timing at which the overall treatment response has been changed. The third point is that the definition of treatment effect 1 has been changed to more than 50% tumor enlargement, excluding the area of necrosis after treatment. Overall evaluation of treatment response has been amended to make it possible to evaluate the overall response including extrahepatic lesions by systemic therapy, which is similar to RECIST or modified RECIST. We hope this new treatment response criteria, RECICL, proposed by the Liver Cancer Study Group of Japan will benefit HCC treatment response evaluation in the setting of daily clinical practice and clinical trials, not only in Japan, but also internationally.

Safety and efficacy of sorafenib in Japanese patients with hepatocellular carcinoma in clinical practice: a subgroup analysis of GIDEON

BACKGROUND

GIDEON was a prospective, global, non-interventional study evaluating the safety of sorafenib in patients with unresectable hepatocellular carcinoma in real-world practice. The aim of this subgroup analysis was to assess the safety and efficacy of sorafenib as used by Japanese patients.

METHODS

In Japan, 508 patients were valid for safety analysis. Efficacy and safety were evaluated by the Child-Pugh score.

RESULTS

The number of patients with Child-Pugh A and B was 432 (85.0 %) and 58 (11.4 %), respectively. The median overall survival time and time to progression in patients with Child-Pugh A and Child-Pugh B were 17.4 and 4.9 months, 3.7 and 2.3 months, respectively. The most common drug-related adverse events (AEs) included hand-foot skin reaction (47.8 %), diarrhea (35.8 %) and hypertension (24.2 %). The incidences of all or drug-related AEs were similar between patients with Child-Pugh A and B. However, all or drug-related serious AEs, AEs resulting in permanent discontinuation of sorafenib and deaths were observed more frequently in patients with Child-Pugh B compared with Child-Pugh A. Duration of treatment tended to be shorter as the Child-Pugh score worsened.

CONCLUSIONS

Sorafenib was well tolerated by Japanese HCC patients in clinical settings. Patients with Child-Pugh B had shorter duration of treatment and higher incidence of SAEs. It is important to carefully evaluate patients' conditions and assess the benefit and risk before making a decision to treat patients with sorafenib.

Treatment of Liver Tumors with Lipiodol TACE: Technical Recommendations from Experts Opinion

Transarterial chemoembolization with Lipiodol (Lipiodol TACE), also called conventional TACE, was developed in the early 1980s and widely adopted worldwide after randomized control trials and meta-analysis demonstrated superiority of Lipiodol TACE to best supportive care. Presently, there is no level one evidence that other TACE techniques are superior to Lipiodol TACE for intermediate stage hepatocellular carcinoma (HCC), which includes patients with preserved liver function and nonsurgical large or multinodular HCC without distant metastases. In addition, TACE is part of the treatment for progressive or symptomatic liver metastases from gastroenteropancreatic neuroendocrine tumors. When injected into the hepatic artery, Lipiodol has the unique property of selective uptake and retention in hyperarterialyzed liver tumors. Lipiodol/drug emulsion followed by particle embolization has been demonstrated to improve the pharmacokinetic of the drug and tumor response. Radio opacity of Lipiodol helps to monitor treatment delivery, with retention of Lipiodol serving as an imaging biomarker for tumor response. For 30 years, Lipiodol TACE has been inconsistently referenced in many publications with various levels of details for the method of preparation and administration, with reported progressive outcomes following improvements in the technique and the devices used to deliver the treatment and better patient selection. Consequently, there is no consensus on the standard method of TACE regarding the use of anticancer agents, embolic material, technical details, and the treatment schedule. In order to develop an internationally validated technical recommendation to standardize the Lipiodol TACE procedure, a worldwide panel of experts participated in a consensus meeting held on May 10, 2014 .

Assessment of Lipiodol Deposition and Residual Cancer for Hepatocellular Carcinoma After Transcatheter Arterial Chemoembolization via Iodine-Based Material Decomposition Images with Spectral Computed Tomography Imaging: A Preliminary Study

Background:

It is critical to follow up hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE) in clinical practice. Computed tomography (CT) is used to assess lipiodol deposition, whereas it is difficult to assess hypovascular residual cancer masked by lipiodol. In contrast, magnetic resonance imaging (MRI) is superior to CT in showing residual cancer, but cannot display lipiodol deposition.

Objectives:

The aim of this study was to investigate the value of spectral CT imaging in both lipiodol deposition and residual cancer for HCC patients after TACE.

Patients and Methods:

Ten HCC patients after treated with TACE underwent Discovery CT750 HD and MRI750 3T examination. Receiver operating characteristic (ROC) curves of iodine-based material decomposition images, monochromatic images and conventional CT images were generated.

Results:

Consequently, 30 residual lesions were detected in MRI of 10 patients. They were found in iodine-based images and monochromatic images versus 29 in conventional CT images. The area under ROC curves for the lesion-to-normal parenchyma ratio (LNR) on arterial phase (AP) in iodine-based material decomposition images, monochromatic images and conventional CT images were 0.933, 0.833 and 0.817, respectively.

Conclusion:

The study data highlighted good value of iodine-based material decomposition images of spectral CT in assessment of both lipiodol deposition and residual cancer for follow-up of HCC patients previously treated with TACE.

PET/Computed Tomography in Evaluation of Transarterial Chemoembolization

Transarterial chemoembolization is a minimally invasive procedure that deprives the tumor of its blood supply, and is especially used for the treatment of unresectable hepatocellular carcinoma. Metabolic evaluation of interventional therapies such as transarterial chemoembolization in hepatocellular carcinoma is proving to be a valuable tool in choosing therapies that are better targeted to patients, especially because of its likely contribution in predicting treatment response in unresectable lesions after these therapies.

Parametric response mapping of dynamic CT for predicting intrahepatic recurrence of hepatocellular carcinoma after conventional transcatheter arterial chemoembolization

OBJECTIVES

The aim of our study was to determine the diagnostic value of a novel image analysis method called parametric response mapping (PRM) for prediction of intrahepatic recurrence of hepatocellular carcinoma (HCC) treated with conventional transcatheter arterial chemoembolization (TACE).

METHODS

This retrospective study was approved by the IRB. We recruited 55 HCC patients who achieved complete remission (CR) after TACE and received longitudinal multiphasic liver computed tomography (CT). The patients fell into two groups: the recurrent tumour group (n = 29) and the non-recurrent tumour group (n = 26). We applied the PRM analysis to see if this technique could distinguish between the two groups. The results of the PRM analysis were incorporated into a prediction algorithm. We retrospectively removed data from the last time point and attempted to predict the response to therapy of the removed data.

RESULTS

The PRM analysis was able to distinguish between the non-recurrent and recurrent groups successfully. The prediction algorithm detected response to therapy with an area under the curve (AUC) of 0.76, while the manual approach had AUC 0.64.

CONCLUSIONS

Adopting PRM analysis can potentially distinguish between recurrent and non-recurrent HCCs and allow for prediction of response to therapy after TACE.

KEY POINTS

Parametric response mapping (PRM) could help assess patients with recurrent HCCs after TACE. Parametric response mapping could direct patients to individualized therapy. Longitudinal CT images were analyzed with advanced image analysis method.

Imaging for assessment of treatment response in hepatocellular carcinoma: Current update

Morphologic methods such as the Response Evaluation Criteria in Solid Tumors (RECIST) are considered as the gold standard for response assessment in the management of cancer. However, with the increasing clinical use of antineoplastic cytostatic agents and locoregional interventional therapies in hepatocellular carcinoma (HCC), conventional morphologic methods are confronting limitations in response assessment. Thus, there is an increasing interest in new imaging methods for response assessment, which can evaluate tumor biology such as vascular physiology, fibrosis, necrosis, and metabolism. In this review, we discuss various novel imaging methods for response assessment and compare them with the conventional ones in HCC.

Optimal methods for measuring eligibility for liver transplant in hepatocellular carcinoma patients undergoing transarterial chemoembolization

BACKGROUND & AIMS

We investigated the optimal radiologic method for measuring hepatocellular carcinoma (HCC) treated by transarterial chemoembolization (TACE) in order to assess suitability for liver transplantation (LT).

METHODS

271 HCC patients undergoing TACE prior to LT were classified according to both Milan and up-to-seven criteria after TACE by using the enhancement or size method on computed tomography images. The cumulative incidence function curves with competing risks regression was used in post-LT time-to-recurrence analysis. The predictive accuracy for recurrence was compared using area under the time-dependent receiver operating characteristic curves (AUC) estimation.

RESULTS

Of the 271 patients, 246 (90.8%) and 164 (60.5%) fell within Milan and 252 (93.0%) and 210 (77.5%) fell within up-to-seven criteria, when assessed by enhancement and size methods, respectively. Competing risks regression analyses adjusting for covariates indicated that meeting the criteria by enhancement and by size methods was independently related to post-LT time-to-recurrence in the Milan or up-to-seven model. Higher AUC values were observed with the size method only in the up-to-seven model (p<0.05). Mean differences in the sum of tumor diameter and number of tumors between pathologic and radiologic findings were significantly less by the enhancement method (p<0.05). Cumulative incidence curves showed similar recurrence results between patients with and without prior TACE within the criteria based on either method, except for the within up-to-seven by the enhancement method (p=0.017).

CONCLUSIONS

The enhancement method is a reliable tool for assessing the control or downstaging of HCC within Milan after TACE, although the size method may be preferable when applying the up-to-seven criterion.

GEP-NETS update: Interventional radiology: role in the treatment of liver metastases from GEP-NETs

Neuroendocrine tumors from gastro-pancreatic origin (GEP-NET) can be responsible for liver metastases. Such metastases can be the dominant part of the disease as well due to the tumor burden itself or the symptoms related to such liver metastases. Intra-arterial therapies are commonly used in liver only or liver-dominant disease and encompass trans-arterial chemoembolization (TACE), trans-arterial embolization (TAE), and radioembolization (RE). TACE performed with drug emulsified in Lipiodol has been used for the past 20 years with reported overall survival in the range of 3-4 years, with objective response up to 75%. Response to TACE is higher when treatment is used as a first-line therapy and degree of liver involvement is lower. Benefit of TACE over TAE is unproven in randomized study, but reported in retrospective studies namely in pancreatic NETs. RE provides early interesting results that need to be further evaluated in terms of benefit and toxicity. Radiofrequency ablation allows control of small size and numbered liver metastases, with low invasiveness. Ideal metastases to target are one metastasis <5 cm, or three metastases <3 cm, or a sum of diameter of all metastases below 8 cm. Ablation therapies can be applied in the lung or in the bones when needed, and more invasive surgery should be probably saved for large-size metastases. Even if the indication of image-guided therapy in the treatment of GEP-NET liver metastases needs to be refined, such therapies allow for manageable invasive set of treatments able to address oligometastatic patients in liver, lung, and bones. These treatments applied locally will save the benefit and the toxicity of systemic therapy for more advanced stage of the disease.

Parametric response mapping of dynamic CT as an imaging biomarker to distinguish viability of hepatocellular carcinoma treated with transcatheter arterial chemoembolization

PURPOSE

Accurate assessment of viability of hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE) is important for therapy planning. The purpose of this study is to determine the diagnostic value of a novel image analysis method called parametric response mapping (PRM) in predicting viability of tumor in HCC treated with TACE for dynamic CT images.

METHODS

35 patients who had 35 iodized-oil defect areas (IODAs) in HCCs treated with TACE were included in our study. These patients were divided into two groups, one group with viable tumors (n = 22) and the other group with non-viable tumors (n = 13) in the IODA. All patients were followed up using triple-phase dynamic CT after the treatment. We compared (a) manual analysis, (b) using PRM results, and (c) using PRM results with automatic classifier to distinguish between two tumor groups based on dynamic CT images from two longitudinal exams. Two radiologists performed the manual analysis. The PRM approach was implemented using prototype software. We adopted an off-the-shelf k nearest neighbor (kNN) classifier and leave-one-out cross-validation for the third approach. The area under the curve (AUC) values were compared for three approaches.

RESULTS

Manual analysis yielded AUC of 0.74, using PRM results yielded AUC of 0.84, and using PRM results with an automatic classifier yielded AUC of 0.87.

CONCLUSIONS

We improved upon the standard manual analysis approach by adopting a novel image analysis method of PRM combined with an automatic classifier.

Tumour-related neoangiogenesis: functional dynamic perfusion computed tomography for diagnosis and treatment efficacy assessment in hepatocellular carcinoma

BACKGROUND

Aim of the study was to determine the value of perfusion computed tomography in the quantitative assessment of tumour-related neoangiogenesis for the diagnosis and treatment of hepatocellular carcinoma lesions.

METHODS

Overall, 47 consecutive patients with cirrhotic liver disease, with a high risk of hepatocellular carcinoma, and undergoing standard surveillance (six-month intervals) were eligible for inclusion in this prospective study; based on Barcelona Clinic Liver Cancer guidelines, 27 patients were enrolled. Perfusion computed tomography was performed in 29 biopsy-proven hepatocellular carcinoma lesions before and after treatment with transarterial chemoembolization or radiofrequency ablation. The dynamic study was performed with a 256-slice multidetector-computed tomography scanner; the following parameters were measured: hepatic perfusion, arterial perfusion, blood volume, hepatic perfusion index, and time-to-peak in all patients.

RESULTS

Hepatocellular carcinoma lesions had the following median perfusion values: perfusion 46.3mL/min/100g; blood volume 20.4mL/100mg; arterial perfusion 42.9mL/min; hepatic perfusion index 92.5%; time to peak 18.7s. Significantly lower perfusion values were obtained in correctly treated lesions or surrounding parenchyma than in viable hepatocellular carcinoma tissue.

CONCLUSIONS

In hepatocellular carcinoma, perfusion computed tomography could contribute to a non-invasive quantification of tumour blood supply related to the formation of new arterial structures, and enable the assessment of therapeutic response.

Volumetric assessment of tumour response using functional MR imaging in patients with hepatocellular carcinoma treated with a combination of doxorubicin-eluting beads and sorafenib

OBJECTIVE

To prospectively assess treatment response using volumetric functional magnetic resonance imaging (MRI) metrics in patients with hepatocellular carcinoma (HCC) treated with the combination of doxorubicin-eluting bead-transarterial chemoembolization (DEB TACE) and sorafenib.

METHODS

A single center study enrolled 41 patients treated with systemic sorafenib, 400 mg twice a day, combined with DEB TACE. All patients had a pre-treatment and 3-4 week post-treatment MRI. Anatomic response criteria (RECIST, mRECIST and EASL) and volumetric functional response (ADC, enhancement) were assessed. Statistical analyses included paired Student's t-test, Kaplan-Meier curves, Cohen's Kappa, and multivariate cox proportional hazard model.

RESULTS

Median tumour size by RECIST remained unchanged post-treatment (8.3 ± 4.1 cm vs. 8.1 ± 4.3 cm, p = 0.44). There was no significant survival difference for early response by RECIST (p = 0.93). EASL and mRECIST could not be analyzed in 12 patients. Volumetric ADC increased significantly (1.32 × 10(-3) mm(2)/sec to 1.60 × 10(-3) mm(2)/sec, p < 0.001), and volumetric enhancement decreased significantly in HAP (38.2% to 17.6%, p < 0.001) and PVP (76.6% to 41.2%, p < 0.005). Patients who demonstrated ≥ 65% decrease PVP enhancement had significantly improved overall survival compared to non-responders (p < 0.005).

CONCLUSION

Volumetric PVP enhancement was demonstrated to be significantly correlated with survival in the combination of DEB TACE and sorafenib for patients with HCC, enabling precise stratification of responders and non-responders.

KEY POINTS

• PVP enhancement is significantly correlated with survival in responders (p < 0.005). • There was no significant survival difference for early response using RECIST (p = 0.93). • mRECIST or EASL could not assess tumour response in 29% of patients.

Quantitative evaluation of CT-perfusion map as indicator of tumor response to transarterial chemoembolization and radiofrequency ablation in HCC patients

PURPOSE

To assess if radiofrequency ablation (RFA) and transarterial chemoembolization (TACE) may influence the evaluation of perfusion parameters obtained with CT-perfusion (CT-p) in HCC treated patients.

MATERIALS AND METHODS

Thirty-three consecutive cirrhotic patients with biopsy-proven diagnosis of HCC lesions and candidates to TACE or RFA were included. The CT-p study of hepatic parenchyma and of treated lesions was performed about 1 month after treatment on 16 multidetector CT after injection of 50mL of non ionic contrast agent (350mg I/mL) at a flow rate of 6mL/s acquiring 40 dynamic scans. A dedicated perfusion software which generated a quantitative map of arterial and portal perfusion by means of colour scale was employed.The following perfusion parameters were assessed before and after RFA or TACE treatment: hepatic perfusion (HP), arterial perfusion (AP), blood volume (BV), time to peak (TTP), hepatic perfusion index (HPI).

RESULTS

A complete treatment was obtained in 16 cases and incomplete treatment in the 17 remaining cases. The perfusion data of completely treated lesions were: HP 10.2±6.3; AP 10.4±7; BV 4.05±4.8; TTP 38.9±4.2; HPI 9.9±9.2, whereas in partially treated lesions were: HP 43.2±15.1mL/s/100g; AP 38.7±8.8mL/min; BV 20.7±9.5mL/100mg; TTP 24±3.7s; HPI 61.7±7.5%. In adjacent cirrhotic parenchyma, the parameters of all evaluated patients were: HP 13.2±4; AP 12.3±3.4; BV 11.8±2.8; TTP 43.9±2.9; and HPI 17.1±9.8. A significant difference (P<0.001) was found for all parameters between residual viable tumor tissue (P<0.001) compared to successfully treated lesion due to the presence of residual arterial vascular structure in viable portion of treated HCC.

CONCLUSION

According to our results, CT-p evaluation is not influenced by TACE or RFA treatments, thus representing a feasible technique that allows a reproducible quantitative evaluation of treatment response in HCC patients.

New approaches for precise response evaluation in hepatocellular carcinoma

With the increasing clinical use of cytostatic and novel biologic targeted agents, conventional morphologic tumor burden assessments, including World Health Organization criteria and Response Evaluation Criteria in Solid Tumors, are confronting limitations because of their difficulties in distinguishing viable tumor from necrotic or fibrotic tissue. Therefore, the investigation for reliable quantitative biomarkers of therapeutic response such as metabolic imaging or functional imaging has been desired. In this review, we will discuss the conventional and new approaches to assess tumor burden. Since targeted therapy or locoregional therapies can induce biological changes much earlier than morphological changes, these functional tumor burden analyses are very promising. However, some of them have not gone thorough all steps for standardization and validation. Nevertheless, these new techniques and criteria will play an important role in the cancer management, and provide each patient more tailored therapy.

Three-dimensional evaluation of lipiodol retention in HCC after chemoembolization: a quantitative comparison between CBCT and MDCT

RATIONALE AND OBJECTIVES

To evaluate the capability of cone-beam computed tomography (CBCT) acquired immediately after transcatheter arterial chemoembolization (TACE) in determining lipiodol retention quantitatively and volumetrically when compared to 1-day postprocedure unenhanced multidetector computed tomography (MDCT).

MATERIALS AND METHODS

From June to December 2012, 15 patients met the inclusion criteria of unresectable hepatocellular carcinoma (HCC) that was treated with conventional TACE (cTACE) and had intraprocedural CBCT and 1-day post-TACE MDCT. Four patients were excluded because the lipiodol was diffuse throughout the entire liver or lipiodol deposition was not clear on both CBCT and MDCT. Eleven patients with a total of 31 target lesions were included in the analysis. A quantitative three-dimensional software was used to assess complete, localized, and diffuse lipiodol deposition. Tumor volume, lipiodol volume in the tumor, percent lipiodol retention, and lipiodol enhancement in Hounsfield units (HU) were calculated and compared between CBCT and MDCT using two-tailed Student's t test and Bland-Altman plots.

RESULTS

The mean value of tumor volume, lipiodol-deposited regions, calculated average percent lipiodol retention, and HU value of CBCT were not significantly different from those of MDCT (tumor volume: 9.37 ± 11.35 cm(3) vs 9.34 ± 11.44 cm(3), P = .991; lipiodol volume: 7.84 ± 9.34 cm(3) vs 7.84 ± 9.60 cm(3), P = .998; lipiodol retention: 89.3% ± 14.7% vs. 90.2% ± 14.9%, P = .811; HU value: 307.7 ± 160.1 HU vs. 257.2 ± 120.0 HU, P = .139). Bland-Altman plots showed only minimal difference and high agreement when comparing CBCT to MDCT.

CONCLUSIONS

CBCT has a similar capability, intraprocedurally, to assess lipiodol deposition in three dimensions for patients with HCC treated with cTACE when compared to MDCT.

Comparison of air kerma between C-arm CT and 64-multidetector-row CT using a phantom

PURPOSE

To compare air kerma after scanning a phantom with C-arm CT and with 64-multidetector row CT (64MDCT).

MATERIALS AND METHODS

A phantom was scanned using parameters based on data of ten patients with hepatocellular carcinoma who had C-arm CT during hepatic arteriography and 64MDCT during arterial portography. Radiation monitors were used to measure air kerma ten times at each of five points: the center (A), top (B), left side (C), bottom (D), and right side (E).

RESULTS

For C-arm CT vs. 64MDCT, air kerma after scanning was 10.5 ± 0.2 vs. 6.4 ± 0.0 for A, 1.5 ± 0.0 vs. 11.6 ± 0.2 for B, 37.1 ± 0.2 vs. 11.1 ± 0.1 for C, 55.6 ± 1.0 vs. 10.6 ± 0.1 for D, and 40.5 ± 0.5 vs. 11.7 ± 0.1 for E, respectively. Air kerma for A, B, C, D, and E was 1.64, 0.13, 3.34, 5.24, and 3.46 times greater for C-arm CT than for 64MDCT, respectively.

CONCLUSION

Using the same scanning parameters as for clinical cases, air kerma values were greater with C-arm CT than with 64MDCT; at the dorsal side of the phantom, they were 5.24 times greater with C-arm CT compared with 64MDCT.

Use of Lipiodol as a drug-delivery system for transcatheter arterial chemoembolization of hepatocellular carcinoma: a review

Hepatocellular carcinoma (HCC) remains a major public health problem. Transarterial chemoembolization (TACE) is recognized as the standard of care for patients with unresectable, asymptomatic, noninvasive and multinodular HCC. This procedure is based on percutaneous administration of a cytotoxic drug emulsified with Lipiodol followed by embolization of the tumour-feeding arteries. The standard procedure involves Lipiodol, an oily contrast medium which consists of a mixture of long-chain di-iodinated ethyl esters of poppy seed fatty acids. The aim of this review is to discuss the physical properties, tumour uptake behaviour and drug delivery effects of Lipiodol, the parameters influencing tumour uptake and future prospects. Lipiodol has a unique place in TACE as it combines three specific characteristics: drug delivery, transient and plastic embolization and radiopacity properties. Substantial heterogeneity in the physicochemical characteristics of Lipiodol/cytotoxic agent emulsions might reduce the efficacy of this procedure and justifies the current interest in Lipiodol for drug delivery.

Dynamic computed tomography appearance of tumor response after stereotactic body radiation therapy for hepatocellular carcinoma: How should we evaluate treatment effects?

AIM

To evaluate the dynamic computed tomography (CT) appearance of tumor response after stereotactic body radiation therapy (SBRT) for hepatocellular carcinoma (HCC) and reconsider response evaluation criteria for SBRT that determine treatment outcomes.

METHODS

Fifty-nine patients with 67 tumors were included in the study. Of these, 56 patients with 63 tumors underwent transarterial chemoembolization using lipiodol prior to SBRT that was performed using a 3-D conformal method (median, 48 Gy/four fractions). Dynamic CT scans were performed in four phases, and tumor response was evaluated by comparing tumor appearance on CT prior SBRT and at least 6 months after SBRT. The median follow-up time was 12 months.

RESULTS

The dynamic CT appearance of tumor response was classified into the following: type 1, continuous lipiodol accumulation without early arterial enhancement (26 lesions, 38.8%); type 2, residual early arterial enhancement within 3 months after SBRT (17 lesions, 25.3%); type 3, residual early arterial enhancement more than 3 months after SBRT (19 lesions, 28.4%); and type 4, shrinking low-density area without early arterial enhancement (five lesions, 7.5%). Only two tumors with residual early arterial enhancement did not demonstrate remission more than 6 months after SBRT.

CONCLUSION

The dynamic CT appearance after SBRT for HCC was classified into four types. Residual early arterial enhancement disappeared within 6 months in most type 3 cases; therefore, early assessment within 3 months may result in a misleading response evaluation.

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.

Therapeutic response assessment of transcatheter arterial chemoembolization for hepatocellular carcinoma: ultrasonography, CT and MR imaging

Two randomized controlled trials identified that transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) shows a significant survival benefit compared with controls, after a long-term controversy. Thus, TACE is the current standard of care for patients presenting with multinodular HCC. Monitoring tumor response to TACE is part of the clinical management of HCC patients. Imaging, including ultrasonography, computed tomography and magnetic resonance imaging, has an important role in assessing therapeutic effects earlier and more objectively. Imaging assessment needs to detect not only a reduction in overall tumor load but also a reduction in viable tumor. Here, we give an overview of the current status of the imaging assessment of HCC response to TACE.

Image-based response assessment of liver metastases following stereotactic body radiotherapy with respiratory tracking

Objective

To describe post-CyberKnife® imaging characteristics of liver metastases as an aid in assessing response to treatment, and a novel set of combined criteria (CC) as an alternative to response according to change in size (RECIST).

Subjects and Methods

Imaging data and medical records of 28 patients with 40 liver metastases treated with stereotactic body radiotherapy (SBRT) were reviewed. Tumor size, CT attenuation coefficient, and contrast enhancement of lesions were evaluated up to 2 years post SBRT. Rates of local control, progression-free survival, time to progression, and overall survival according to RECIST and CC were estimated.

Results

Complete response (CR) was 3.6% (95% CI: 0.1–18%) and 18% (95% CI: 6–37%) according to RECIST and combined criteria, respectively. Two progressive diseases and two partial responses according to RECIST were classified as CR by the combined criteria and one stable response according to RECIST was classified as progressive by CC (Stuart-Maxwell test, p = 0.012). The disease control rate was 60.7% (95% CI: 41–78%) by RECIST and 64% (95% CI: 44%–81%) by CC.

Conclusion

Use of response criteria based on change in size alone in the interpretation of liver response to SBRT may be inadequate. We propose a simple algorithm with a combination of criteria to better assess tumor response. Further studies are needed to confirm their validity.

Optimal measurement modality and method for evaluation of responses to transarterial chemoembolization of hepatocellular carcinoma based on enhancement criteria

PURPOSE

To determine the usefulness of enhancement by iodized oil deposits on computed tomography (CT) following transarterial chemoembolization for hepatocellular carcinoma (HCC), and to compare the reliability of such CT imaging with that of magnetic resonance (MR) imaging.

MATERIALS AND METHODS

Fifty-one patients for whom resected or explanted livers containing chemoembolized HCC lesions of at least 1 cm were available. Imaging responses were determined based on modified Response Evaluation Criteria In Solid Tumors (mRECIST) and European Association for the Study of the Liver (EASL) criteria for 59 target tumors on CT and MR scans before surgery. CT-based evaluation was performed per mRECIST and EASL criteria, considering iodized oil retention as indicating necrosis and, alternatively, as enhancing viable tissue ("mRECIST-Lipiodol" and "EASL-Lipiodol"). Pathologic necrosis was graded as 100%, 50%-99%, or less than 50%.

RESULTS

Goodman-Kruskal γ-values for radiologic-pathologic correlation were greater than 0.95 for mRECIST and EASL criteria on CT or MR imaging. However, mRECIST-Lipiodol and EASL-Lipiodol measurements showed weaker correlation with pathologic findings, with γ-values of 0.797 and 0.846, respectively. With respect to intermethod agreement, weighted γ-values for mRECIST by CT and MR, and for EASL criteria by CT and MR, both exceeded 0.80, whereas mRECIST-Lipiodol and EASL-Lipiodol showed only moderate levels of agreement with mRECIST/EASL criteria by CT or MR imaging, with γ-values of 0.522-0.631.

CONCLUSIONS

Response estimation based on measurement of iodized oil deposits as necrosis on CT when applying enhancement criteria after chemoembolization for HCC correlated well with actual pathologic class, and agreed with MR-based evaluation.

Detection of recurrent hepatocellular carcinoma in cirrhotic liver after transcatheter arterial chemoembolization: value of quantitative color mapping of the arterial enhancement fraction of the liver

Objective

To investigate the additional diagnostic value of color mapping of the hepatic arterial enhancement fraction (AEF) for detecting recurrent or residual hepatocellular carcinoma (HCC) in patients treated with transcatheter arterial chemoembolization (TACE).

Materials and Methods

Seventy-six patients with 126 HCCs, all of whom had undergone previous TACE, and subsequently, underwent follow-up multiphasic liver CT scans, were included in this study. Quantitative color maps of the AEF of the whole liver were created, by using prototype software with non-rigid registration. The AEF was defined as the ratio of the attenuation increment during the arterial phase to the attenuation increment during the portal phase. Two radiologists independently analyzed the two image sets at a two-week interval, i.e., the multiphasic CT image set and the second image set of the AEF color maps and the CT images. The additional diagnostic value of the AEF color mapping was determined, by the use of the jackknife-alternative free-response receiver-operating-characteristic analysis. The sensitivity and positive predictive values for detecting HCCs of each image set were also evaluated and compared.

Results

The reader-averaged figures of merit were 0.699 on the initial interpretation of the MDCT image set, and 0.831 on the second interpretation of the combined image set; the difference between the two interpretations was significant (p value < 0.001). The mean sensitivity for residual or recurrent HCC detection increased from 62.7% on the initial analysis to 82.1% on the second analysis using the AEF color maps (p value < 0.001). The mean positive predictive value for HCC detection was 74.5% on the initial analysis using MDCT, and 71.6% on the second analysis using AEF color mapping.

Conclusion

Quantitative color mapping of the hepatic AEF may have the possibility to increase the diagnostic performance of MDCT for the detection of recurrent or residual HCC without the potential risk of radiation-related hazards.

A randomized phase II trial of intra-arterial chemotherapy using SM-11355 (Miriplatin) for hepatocellular carcinoma

BACKGROUND

SM-11355 is a platinum complex developed to treat hepatocellular carcinoma (HCC) via administration into the hepatic artery as a sustained-release suspension in iodized oil. We conducted a multicenter phase II trial in patients with HCC to evaluate the efficacy and safety of SM-11355, using a Zinostatin stimalamer suspension in iodized oil as a reference.

METHODS

Patients with unresectable HCC were randomized 2:1 to receive administration of the SM-11355 or Zinostatin stimalamer suspension into the hepatic artery. A second injection was given 4-12 weeks later. Efficacy was evaluated by CT 3 months after treatment and categorized as therapeutic effect (TE) V to I, where TE V was defined as disappearance or 100% necrosis of all treated tumors.

RESULTS

A total of 122 patients were evaluated for efficacy and toxicity (SM-11355, n = 83; Zinostatin stimalamer, n = 39). Baseline characteristics were similar in the two groups. The TE V rates were 26.5% (22/83) and 17.9% (7/39) in the SM-11355 and Zinostatin stimalamer groups, respectively. In the SM-11355 group,the most frequent drug-related adverse events (AEs) of ≥ grade 3 were elevated AST, elevated ALT, thrombocytopenia, and hyperbilirubinemia. The AEs with the largest difference between the two groups (SM-11355 vs. Zinostatin stimalamer) were hepatic vascular injury (0 vs. 48.4%) and eosinophilia (84.3 vs. 41.0%). The 2-year and 3-year survival rates were 75.9% vs. 70.3% and 58.4% vs. 48.7%, respectively.

CONCLUSIONS

The results suggest that SM-11355 in iodized oil has similar efficacy to Zinostatin stimalamer and that repeated dosing of SM-11355 is possible without hepatic vascular injury in cases of relapse.

Predictive value of immunogenic cell death biomarkers HMGB1, sRAGE, and DNase in liver cancer patients receiving transarterial chemoembolization therapy

Transarterial chemoembolization (TACE) therapy is an effective locoregional anticancer treatment for liver cancer patients. Serum biomarkers involved in immunogenic cell death may be valuable for early predicting therapy response and estimating prognosis. Sera of 50 prospectively and consecutively included hepatocellular carcinoma (HCC) patients, undergoing TACE therapy, were taken before and 24 h after TACE application. In these samples, soluble biomarkers involved in immunogenic cell death, and among them, high-mobility group box 1 (HMGB1), soluble receptor of advanced glycation end products (sRAGE), and DNase activity were measured. They were compared with radiological response to therapy. A total of 71 TACE therapies were evaluated, of which 32 were classified as "no progression," and 39, as "progression." While HMGB1 levels increased already 24 h after TACE, there was an early decrease of sRAGE and DNase activity. Pretherapeutic and 24-h values of sRAGE were significantly higher in the no progression group than those in the progression group. There was no difference with respect to treatment response for DNase and HMGB1. Soluble RAGE is a new parameter with predictive relevance in primary liver cancer patients undergoing TACE therapy.

Imaging of HCC

Imaging techniques play a crucial role in the management of patients with liver cirrhosis in whom a nodular hepatic lesion is detected. The most severe complication of patients with liver cirrhosis is the development of a hepatocellular carcinoma (HCC), and the prognosis of the disease depends on the tumoral stage. Surveillance programs based on ultrasonography (US) are recommended in cirrhotic patients with possibility to be treated if an HCC is detected, in order to improve the patient's survival. Nevertheless, early detection and diagnostic confirmation of HCC remains a challenge despite technological advances. The non-invasive criteria to characterize small HCCs in patients with cirrhosis are based on the evaluation of the vascular profile of the lesion. Dynamic multidetector computed tomography (MDCT) and dynamic magnetic resonance imaging (MRI) are the suitable techniques for this purpose. When diagnosis is not achieved, fine US-guided fine needle biopsy (FNB) is indicated. Cellular-MRI contrast agents may have a role in lesions with atypical vascular pattern in which FNB is not feasible. The assessment of the disease extent is another important goal for imaging techniques. Again, dynamic MDCT and dynamic MRI may be used for staging purposes. Although MRI is more accurate in the detection of additional nodules ranging 1-2 cm, both remain relatively insensitive for the detection of tiny satellite nodules below 1 cm. The therapeutic decision can be made in any particular patient on the basis of the tumoral extension, the liver function, and the general status. After curative and palliative therapeutic procedures, the monitoring of the response is mandatory to decide the next approach: to follow-up, to repeat the treatment, to modify the treatment indication, or to suspend the treatment. In this review, we discuss the most recent information on the imaging of HCC.

Value of noncontrast CT immediately after transarterial chemoembolization of hepatocellular carcinoma with drug-eluting beads

PURPOSE

To retrospectively evaluate the presence and distribution patterns of contrast agent retention in the liver on noncontrast computed tomography (CT) immediately following chemoembolization with drug-eluting beads (DEBs).

MATERIALS AND METHODS

From 2008 to 2010, 95 patients with 224 liver lesions had chemoembolization performed with DEBs and a noncontrast CT examination of the liver performed immediately after embolization. Of these, 85 patients with 193 lesions were included. The postembolization CT scan was reviewed by a diagnostic radiologist, and the presence of contrast agent retention within the lesion was assessed. Varying patterns of contrast agent retention were defined.

RESULTS

Of the 193 lesions included, 146 (76%) retained contrast medium. Aside from some contrast medium in vessels, very little if any contrast medium was seen in the surrounding liver. Various patterns of contrast agent retention were noted within lesions. In a single case, repeat imaging was obtained 6 hours later, which demonstrated washout of contrast agent in a lesion that had retained contrast agent on the postprocedure CT scan. Of significance, 13 additional foci of contrast agent retention were identified on postchemoembolization CT scans that, on retrospective review of preprocedure imaging, represented enhancing lesions not previously identified.

CONCLUSIONS

Noncontrast CT after chemoembolization with DEBs demonstrates contrast agent retention in 76% of cases, without significant contrast medium seen in the adjacent liver parenchyma. The presence or absence of contrast agent retention may prove to be useful in evaluating accurate targeting of a lesion.

Imaging predictors of the response to transarterial chemoembolization in patients with hepatocellular carcinoma: a radiological-pathological correlation

Transarterial chemoembolization (TACE) is one of the standard therapies for bridging patients with hepatocellular carcinoma (HCC) to transplantation. This study was designed to determine which features on pre- and post-TACE imaging are associated with tumor necrosis in pathological specimens. Records of 105 patients with 132 HCC lesions who underwent liver transplantation after TACE were retrospectively reviewed. In 70% of the nodules, >90% necrosis was achieved. The development of >90% lesion necrosis upon pathological analysis was associated with avid lesion enhancement (P = 0.03) and the presence of a feeding vessel larger than 0.9 mm in diameter on the pre-TACE visceral angiogram (P = 0.01). Near-complete lesion necrosis was also associated with an extensive accumulation of ethiodized oil within a lesion during TACE administration (P = 0.04). On post-TACE computed tomography imaging, a lack of residual contrast enhancement (P < 0.0001), a decrease in the lesion size (P = 0.04), a high lesion density due to an accumulation of ethiodized oil (P = 0.03), and a diffuse distribution of ethiodized oil throughout the lesion (P = 0.0001) were also correlated with near-complete lesion necrosis upon pathological analysis. In conclusion, this study found multiple pre- and post-TACE imaging characteristics of HCC that were associated with near-complete tumor necrosis upon histopathological analysis after TACE. These findings may help to guide the selection of an optimal treatment strategy for bridging patients with HCC to liver transplantation.

Effect of transcatheter arterial infusion chemotherapy using iodized oil and degradable starch microspheres for hepatocellular carcinoma

BACKGROUND

Transcatheter arterial infusion chemotherapy (TAI) using a combination of iodized oil (lipiodol) and degradable starch microspheres (DSMs) has been reported to be superior to TAI with either lipiodol or DSMs separately for the treatment of hepatocellular carcinoma (HCC), based on the results of a prospective randomized study. In the study reported here, we investigated the predictors influencing response and survival in HCC patients receiving TAI using lipiodol and DSMs.

METHODS

A total of 50 HCC patients [Child-Pugh A/B, 34/16 patients; maximum tumor size 2.9 cm (mean); tumor number <5/≥5 = 29/21 patients] were administered a mixture of cisplatin and lipiodol, followed by the injection of DSMs.

RESULTS

According to the criteria of the Liver Cancer Study Group of Japan, the response [complete response (CR) + partial response (PR)] rate and CR rate were 72 and 38%, respectively [CR, 19 patients; PR, 17; stable disease, 9; progressive disease, 5]. The 1-, 2-, 3-, and 4-year cumulative survival rates were 85, 67, 41, and 35%, respectively, and the median survival time was 32.6 months. Multivariate analysis identified tumor number <5 nodules [odds ratio 10.651, 95% confidence interval (CI) 2.168-52.317; P = 0.004] as an independent predictor of response and des-γ-carboxyprothrombin level <100 mAU/mL [hazard ratio (HR), 0.268, 95% CI 0.091-0.786, P = 0.017] and therapeutic effect CR or PR (HR 0.255, 95% CI 0.099-0.659; P = 0.005) as independent predictors of survival.

CONCLUSION

Transcatheter arterial infusion chemotherapy using lipiodol and DSMs might be considered as a potential intervention in HCC patients, especially those with tumors of <5 nodules.

Severity and timing of progression predict refractoriness to transarterial chemoembolization in hepatocellular carcinoma

BACKGROUND AND AIM

Patients with hepatocellular carcinoma (HCC) that is refractory to repeated transarterial chemoembolization (TACE) are considered for systemic therapy, but TACE refractoriness is not well defined. The aim of this study was to determine the characteristics of patients whose HCC is refractory to repetitive TACE.

METHODS

We evaluated 264 patients with intermediate-stage HCC who underwent TACE between January 2006 and September 2009. We designated the development of vascular invasion or extrahepatic spread during follow up as "stage progression" (SP), and hypothesized that SP might be the surrogate end-point for TACE refractoriness.

RESULTS

The median follow up was 18.2 months, and median number of TACE was 3.0 (range, 1-13). Median time-to-progression was 5.5 months (95% confidence interval, 4.8-6.2), and median overall survival was 25.3 months (95% confidence interval, 21.6-29.0). We classified the patients according to disease course as: no progressive disease (PD(-); n = 33); PD without SP (PD(+)SP(-); n = 113); PD followed by SP (PD→SP; n = 47); and simultaneous PD and SP (PD&SP; n = 64). PD(-) and PD(+)SP(-) groups showed no difference in overall survival, PD→SP group had worse overall survival than PD(-) and PD(+)SP(-) groups, and PD&SP group had the worst overall survival. The significant prognostic factors for SP-free survival were development of PD and need for three sessions of TACE during the first 6 months.

CONCLUSIONS

SP-free survival can be regarded as an end-point for TACE refractoriness. Development of progression or need for three sessions of TACE within the first 6 months could be predictive of TACE refractoriness.

Transarterial chemoembolization for hepatocellular carcinoma over three decades: current progress and perspective

Transcatheter arterial chemoembolization has been performed worldwide for patients with unresectable hepatocellular carcinoma for three decades. After long controversy, survival benefit was revealed by two randomized controlled trials. In Japan, chemoembolization accounted for initial treatment of 32% of patients and 58% for recurrent foci. The indications of chemoembolization are various: they are multinodular tumors in the Barcelona Clinic Liver Cancer staging system and two or three tumors >3 cm or four or more tumors in the Japanese guidelines, and both indications fulfill the Child-Pugh Class A/B or liver damage A/B and exclusion of vascular invasion or extrahepatic spread. Recently, both guidelines were identified to have almost similar content. The 4966 patients stratified to chemoembolization recommended by the Japanese guidelines showed that 3-year survival of patients with two or three tumors >3 cm or four or more tumors was 55 and 46% in Child-Pugh A, respectively, and 30 and 22% in Class B, respectively. These results would help in comparing the outcome of chemoembolization in the different backgrounds of the East and West. The modified Response Evaluation Criteria in Solid Tumor guideline is now proposed to cover the deficiency of Response Evaluation Criteria in Solid Tumor to evaluate the response to chemoembolization. Recently, chemoembolization with drug-eluting beads and radioembolization with yttrium-90 microspheres have been introduced, and each of them showed similar tumor response and median survival compared with conventional chemoembolization. Moreover, the combination of chemoembolization and molecular targeted agent is now on-going to evaluate the synergistic effect.

Transarterial chemoembolization plus sorafenib: a sequential therapeutic scheme for HCV-related intermediate-stage hepatocellular carcinoma: a randomized clinical trial

BACKGROUND

Recurrence of hepatocellular carcinoma (HCC) is a major problem after surgical or ablative treatments. The aim of this prospective, single-center, placebo-controlled, randomized, double-blind clinical study was to evaluate the effectiveness of transarterial chemoembolization (TACE) combined with sorafenib as a sequential treatment regimen in delaying time to progression (TTP) of intermediate-stage HCC in patients with chronic hepatitis C virus (HCV) infection.

MATERIAL AND METHODS

Between October, 2007 and January, 2011, 80 HCV-infected patients with Barcelona Clinic Liver Cancer stage B HCC underwent the TACE procedure. All had Child-Pugh class A disease. They were randomized 1:1 to receive sorafenib at a dose of 400 mg twice daily or placebo. Endpoints were the TTP and the rates of adverse events and toxicity.

RESULTS

Sixty-two of 80 patients (77%), 31 in the sorafenib group and 31 in the control group, completed the study. The median TTP was 9.2 months in the sorafenib group and 4.9 months in the placebo group (hazard ratio, 2.5; 95% confidence interval, 1.66-7.56; p < .001). Metachronous, multicentric HCC progression occurred less frequently in sorafenib-treated patients (p < .05). Adverse reactions to sorafenib caused withdrawal from the study of 9 (22%) patients.

CONCLUSION

A conventional TACE procedure followed by sorafenib treatment resulted in a significantly longer TTP in patients with intermediate-stage HCV-related HCC, with no unexpected side effects.