Study of repeated arterial infusion chemotherapy with a subcutaneously implanted reservoir for advanced hepatocellular carcinoma

Efficacy and safety of hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma as first-line therapy

Background/Aims

Hepatic arterial infusion chemotherapy (HAIC) with 5-fluorouracil and cisplatin for intractable advanced hepatocellular carcinoma (HCC) may have survival benefits. We aimed to determine the efficacy and safety of HAIC for advanced HCC as first-line therapy.

Methods

A total of 54 patients who received only HAIC with 5-fluorouracil (750 mg/m² on days 1-4) and cisplatin (25 mg/m² on days 1-4) for advanced HCC from Jan. 2009 to Dec. 2011 were selected. According to Child-Pugh class, the overall survival (OS), progression-free survival (PFS), and adverse events after HAIC were investigated retrospectively.

Results

Median OS and PFS between the Child-Pugh A group (n=24) and the Child-Pugh B/C group (n=30) were 8.7 (95% confidence interval [CI]: 4.7-12.7) vs. 3.7 months (95% CI: 2.0-5.3), and 7.1 (95% CI: 3.8-10.4) vs. 3.6 months (95% CI: 2.0-5.2), respectively. Although median OS and PFS were not statistically significant between the two groups (P=0.079, P=0.196), the Child-Pugh class B/C tended to influence poor OS. Serious adverse events ≥ grade 3 occurred frequently in both groups (83.3 vs. 96.7%, P=0.159). Responders (22.2%, complete or partial response) significantly differed in median OS, compared to non-responders (13.1 vs. 4.4 months, P=0.019). Achievement of complete or partial response was an independent prognostic factor of OS (hazard ratio: 0.4, 95% CI: 0.2-0.8, P=0.011).

Conclusions

Achievement of response after HAIC provide a survival benefit in patients with advanced HCC, but HAIC should be administered cautiously in patients with Child-Pugh class B/C, because of a relatively low survival and high incidence of serious adverse events.

Modern prospection for hepatic arterial infusion chemotherapy in malignancies with liver metastases

Malignancy with liver metastasis plays an important role in daily oncology practice, especially for primary cancers of the gastrointestinal tract and hepatopancreatobiliary system. On account of the dual vascular supply system and the fact that most metastatic liver tumors are supplied by the hepatic artery, hepatic artery infusion chemotherapy (HAIC) is an appealing method for the treatment of liver metastases. Herein, we summarize recent study results reported in the literature regarding the use of HAIC for metastatic liver tumors, with special focus on colorectal cancer.

Green tea polyphenol epigallocatechin-3-gallate enhances 5-fluorouracil-induced cell growth inhibition of hepatocellular carcinoma cells

AIM

  5-Fluorouracil (5-FU) is one of the most commonly used chemotherapeutic drugs. Resistance to 5-FU is a major cause of chemotherapy failure in advanced-stage hepatocellular carcinoma (HCC). Green tea polyphenol Epigallocatechin-3-gallate (EGCG) plays a critical role in growth inhibition and apoptotic induction in HCC cell lines. The aim of this study is to investigate whether EGCG can enhance 5-FU-induced cell growth inhibition and to explore its potential mechanisms.

METHODS

  3-(4,5-Dimethylthiazol-2-yl)-2,5-diphenyltetrazolium bromide (MTT) assay was used to evaluate cell growth. Western blotting analysis was performed to detect the proteins expression in Hep3B cells. Small interfering RNA was used to suppress cyclooxygenase-2 (COX-2) expression. Furthermore, enzyme linked immunosorbent assay was used to test the prostaglandin E(2) (PGE(2) ) production in cell cultures.

RESULTS

  Epigallocatechin-3-gallate augmented the anti-tumor effect of 5-FU in Hep3B cells. Significant difference was observed between the treated groups and the control group (P < 0.05). EGCG (its concentrations at over 5 µmol/L) combined with 5-FU presented a synergic effect. Furthermore, the combination of EGCG and 5-FU abrogated the COX-2 overexpression and PGE(2) secretion induced by 5-FU. The upregulation of COX-2 expression decreased the phosphorylation of Akt (Thr(308) ) expression. These appeared to be followed by the AMPK hyperactivation.

CONCLUSION

  Epigallocatechin-3-gallate sensitizes HCC cells to 5-FU antitumor activity, and the combination of EGCG and 5-FU exhibits synergism in chemo-resistant cancer cells. The results suggest potential novel therapies for the treatment of advanced-stage liver cancer.

Hepatic arterial infusion of chemotherapy for advanced hepatocellular carcinoma

Treatment of advanced hepatocellular carcinoma (HCC) remains a significant problem for clinicians. Sorafenib, the only approved agent, improves survival rate, but is associated with a low tumor response rate. Alternative approaches for the treatment of advanced HCC are urgently needed. Hepatic arterial infusion of chemotherapy (HAIC) is a promising modality for the treatment of advanced HCC. Since its introduction, there have been improvements in implantable pumps, in catheter implantation and in the convenience and safety of HAIC in general. Numerous clinical studies have shown that HAIC provides moderate therapeutic efficacy with substantially favorable toxicity profiles in selected patient groups with advanced HCC. However, the lack of large randomized studies means that HAIC is not yet a well-established treatment for advanced HCC. We believe there is an urgent need for the further investigation of HAIC for the treatment of advanced HCC.

A phase II trial of transcatheter arterial infusion chemotherapy with an epirubicin-Lipiodol emulsion for advanced hepatocellular carcinoma refractory to transcatheter arterial embolization

INTRODUCTION

Transcatheter arterial embolization (TAE) has been recognized as an effective palliative treatment option for advanced hepatocellular carcinoma (HCC). However, no effective alternative treatments for TAE-refractory HCC have yet been established. The aim of this study was to evaluate the antitumor activity and toxicity of transcatheter arterial infusion chemotherapy using an epirubicin-Lipiodol emulsion in patients with TAE-refractory HCC.

METHODS

Patients with TAE-refractory HCC were enrolled. A dose of 60 mg/m(2) epirubicin emulsified in Lipiodol and contrast medium was administered from the feeding artery of the HCC. Treatment was repeated every 4 to 12 weeks if there was no evidence of tumor progression or unacceptable toxicity.

RESULTS

Twenty patients were enrolled in this trial. The median number of treatment courses was 1 (range 1-4). Among the enrolled patients, one (5%) achieved a partial response, and three (15%) showed a minor response. Five (25%) patients had no change and 11 (55%) showed progressive disease. The median survival time, 1-year survival rate and median progression-free survival time for the patients as a whole were 12.4 months, 52.6%, and 1.1 months, respectively. The main grade 3 and 4 toxicities were leukocytopenia (35%), neutropenia (65%), thrombocytopenia (30%), and elevations of the aspartate aminotransferase (45%) and alanine aminotransferase (35%) levels. These toxicities were generally brief and reversible.

CONCLUSION

Transcatheter arterial infusion chemotherapy with an epirubicin-Lipiodol emulsion appears to have only modest activity with moderate toxicity for treatment of patients with TAE-refractory HCC. These findings do not support its use in practice, and further studies with the same regimen in patients with TAE-refractory HCC are not recommended.

Epinephrine-infused CTHA for HCCs

BACKGROUND

Changes in the relative arterial flow to hepatocellular carcinomas and adjacent normal liver with hepatic arterial epinephrine infusion were studied with CT hepatic arteriography (CTHA).

METHODS

Data from 31 pathologically confirmed hepatocellular carcinomas were retrospectively analyzed in 16 patients who simultaneously underwent CT during arterial portography (CTAP) and CTHA for examination of liver tumors and then CTHA with hepatic arterial epinephrine infusion.

RESULTS

Regarding visual analysis, tumor enhancement of hepatocellular carcinomas on CTHA after hepatic arterial epinephrine injection changed as follows: more clear in 83.9% (26/31), equal in 16.1% (5/31), and less clear in 0% (0/31). As for the quantitative analysis, CT attenuation value of hepatocellular carcinomas significantly increased after injection of epinephrine (mean increase from 225.8 to 333.9 HU; P < 0.0001, paired t test). The CT attenuation value of normal liver parenchyma around a tumor significantly decreased after injection of epinephrine (mean decrease from 101.1 to 84.6 HU; P < 0.0001, paired t test). The tumor-to-liver conspicuity significantly increased after injection of epinephrine (mean increase from 124.6 to 249.2 HU; P < 0.0001, paired t test).

CONCLUSIONS

Hepatic arterial epinephrine infusion changes the relative arterial flow of hepatocellular carcinomas.

Efficacy and safety of hepatic artery infusion catheter placement without fixation in the right gastroepiploic artery

PURPOSE

To evaluate the feasibility of placing the tip of an infusion catheter in the right gastroepiploic artery via the femoral route and whether coil placement in the gastroduodenal artery and around the infusion catheter tip should be performed to avoid gastroduodenal toxicity and catheter dislocation.

MATERIALS AND METHODS

Seventy-eight patients (25 women and 53 men; age, 38-79 years; mean, 63 years) underwent implantation of a 5-F chemotherapeutic infusion catheter via the femoral artery, positioned so that the tip was in the right gastroepiploic artery and a side hole was in the common hepatic artery. Patients were randomly divided into two groups: group A included patients with coil placement in the gastroduodenal artery and around the infusion catheter tip and group B included patients without coil placement.

RESULTS

Catheter placement via the femoral route was successful in 70 of 78 patients (90%). Mean catheter indwell durations were 250 days (range, 0-962 days) in group A (n = 35) and 230 days (range, 0-834 days) in group B (n = 43; P = .9). Complications relating to long-term catheter duration in the right gastroepiploic artery did not occur in any patient. Two patients in each group had abdominal pain during infusion chemotherapy. Endoscopy revealed acute gastric mucosal lesions. Dislocation of the catheter tip during treatment occurred in one patient in each group.

CONCLUSION

Catheter placement in the right gastroepiploic artery is safe and feasible except in patients with a long and caudally oriented celiac trunk. Coil embolization of the gastroduodenal artery and around the catheter tip is unnecessary.

Catheter Redundancy in the Aortic Arch Increases the Risk of Stroke in Left Subclavian Arterial Port–Catheter Systems

PURPOSE

The stroke rate after left subclavian arterial port-catheter placement was compared in two groups: one with minimal redundancy of the catheter and one with pronounced redundancy in the aortic arch designed to minimize the likelihood of catheter dislocation.

MATERIALS AND METHODS

One hundred forty-eight patients (102 men, 46 women; age range, 26-83 years; mean age, 64.3 years) with inoperable advanced liver cancers underwent percutaneous implantation of port-catheter systems via the left subclavian artery. In 33 patients, a pronounced redundancy of the catheter was intentionally looped in the aortic arch. Redundancy was intentionally avoided in the remaining 115 patients. The rates of brain infarction complications in these two groups were retrospectively compared.

RESULTS

Among the 33 patients with pronounced redundant catheter looping, brain infarctions occurred in four cases (12.1%). In contrast, brain infarctions occurred in only three of the 115 patients with minimal redundant catheter looping (2.6%). The frequency of brain infarction complications was significantly higher in the patients with pronounced redundant catheter looping in the aortic arch than in patients with minimal pronounced redundant catheter looping (P = .044, Fisher exact test).

CONCLUSION

Catheter redundancy in the aortic arch increases the risk of stroke in patients undergoing implantation of port-catheter systems via a left subclavian arterial approach for repeated hepatic arterial infusion chemotherapy.

Prophylactic lamivudine administration prevents exacerbation of liver damage in HBe antigen positive patients with hepatocellular carcinoma undergoing transhepatic arterial infusion chemotherapy

BACKGROUND AND AIMS

Exacerbation of liver damage during transhepatic arterial infusion chemotherapy (THAIC) is a critical complication in patients with hepatitis B virus (HBV) related hepatocellular carcinoma (HCC). We previously reported that HBe antigen positivity was the associating factor for the exacerbation of liver damage. In the present study, we investigated the effect of lamivudine administration for exacerbation of liver damage in such patients.

PATIENTS AND METHODS

Seventeen patients with HBV-related hepatocellular carcinoma who received THAIC were reviewed. Eight of these patients received lamivudine administration. Nine patients did not receive lamivudine administration. All patients were HBe antigen positive. Liver function tests, liver enzymes, HBV-DNA levels, HBe antigen, HBe antibody, and mutation in the precore and core-promoter regions of HBV DNA were evaluated.

RESULTS

In the lamivudine-treated group, HBV-DNA levels were significantly reduced and did not increase throughout chemotherapy. Lamivudine did not induce any changes in precore or core-promoter regions. Although levels of alanine aminotransferase (ALT), asparate aminotransferase (AST), total bilirubin, and prothrombin time (PT) in the lamivudine-treated group did not change, levels of ALT, AST and total bilirubin increased, and PT were prolonged in the untreated group by chemotherapy. No patients receiving lamivudine administration showed exacerbation of liver damage. Exacerbation of liver damage was detected in six patients without lamivudine administration. Of these, three patients died of progressive liver failure due to reactivation of HBV.

CONCLUSION

These results indicate that prophylactic lamivudine administration reduces HBV-DNA levels and prevents exacerbation of liver damage throughout the period of chemotherapy in HBe antigen positive patients with hepatocellular carcinoma.

Hepatic Arterial Infusion Chemotherapy with Use of an Implanted Port System in Patients with Advanced Hepatocellular Carcinoma: Prognostic Factors

PURPOSE

This study was retrospectively undertaken to identify prognostic factors in patients with advanced hepatocellular carcinoma (HCC) treated by hepatic arterial infusion chemotherapy with a percutaneously implantable port system inserted.

MATERIALS AND METHODS

Eighty-eight patients underwent arterial infusion chemotherapy for portal venous invasion (n = 39), severe liver dysfunction (n = 6), or tumor regrowth after chemoembolization, percutaneous ethanol injection therapy, and surgery (n = 77). Twenty-five variables representing patients' characteristics, previous treatments, tumor characteristics, liver profiles, various staging systems, and therapeutic effect were analyzed with univariate and multivariate analyses.

RESULTS

The 1- and 3-year survival rates were 55% and 24%, respectively, with a mean survival period of 19.5 months +/- 1.9 in all patients. Cancer of the Liver Italian Program (CLIP) score, Okuda stage, therapeutic effect, tumor extension, alkaline phosphatase and aspartate aminotransferase levels, ascites, and portal venous invasion were identified as significant prognostic factors by univariate analysis. Multivariate analysis identified CLIP score, Okuda stage, and therapeutic effect as significant independent prognostic factors.

CONCLUSION

Although our results should be confirmed in future prospective studies, the prognostic factors identified in the present study should prove helpful in classifying patients with advanced HCC who are treated by arterial infusion chemotherapy and should serve as useful guidelines on arterial infusion chemotherapy in clinical practice.

Analysis and prevention of failure causes of percutaneous implantable port for tumor chemotherapy

The failure causes of percutaneous implantable port (PIP) for tumor chemotherapy were analyzed and the appropriate preventing measures were put forward. During Feb. 1995 to Feb. 1999, 10 patients with tumor undergoing failure insertion of PIP were retrospectively studied. We placed the PIP in the hepatic artery in 3 patients with liver carcinoma after operation, in the internal iliac artery in 5 patients with colonic or rectal carcinoma after operation and in the left gastric artery in 2 patients with stomach carcinoma after operation. The results showed that in the 10 patients, chemotherapeutic agent effusion around the PIP and local tissue necrosis in 5 cases, infection and abscess formation around the PIP in 3 cases, PIP body rupture in one case and the catheter sliding into the internal iliac artery occurred. It was concluded that taking measures during PIP insertion could prevent the occurrence of complications and is beneficial to the implementation of scheduled chemotherapeutic protocol for the patients.

Transradial approach for transcatheter arterial chemoembolization in patients with hepatocellular carcinoma: comparison with conventional transfemoral approach

We evaluated the clinical usefulness and safety of transradial approach for transcatheter arterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) compared with that of conventional transfemoral approach. The two groups (radial group, n = 177; femoral group, n = 150) of cases were retrospectively compared with regard to the successful rate of angiography or TACE, time required for catheterizaiton and complications. Hepatic angiography and TACE were completed in 174 (98.3%) of 177 cases in the radial group. There was no intergroup difference of time required for catheterization. Minor complications (dull pain, numbness) occurred in 8 (4.6%) patients in the radial group, and there were lower complications in the radial group compared to the femoral group. TACE by our new transradial approach was found to have therapeutic efficacy with lower complications comparable to that of the conventional transfemoral approach.

Pilot study of transcatheter arterial chemoembolization with degradable starch microspheres in patients with hepatocellular carcinoma

We prospectively evaluated the efficacy and safety of transcatheter arterial chemoembolization (TACE) with microembolization material, degradable starch microspheres (DSMs), and epirubicin, for treatment of multifocal hepatocellular carcinoma (HCC). Seventeen patients with multifocal HCC were treated. At the first treatment, DSMs were injected alone to determine the dose for embolization of the hepatic artery in each patient. After 4 weeks, TACE was performed every 4 to 6 weeks with a mixture of DSMs and epirubicin at a dose of 40 mg/m2. A necrotic area of more than 50% was produced in 6 patients by DSMs alone, and in 11 patients by TACE. The overall response rate was 52.9% (2 complete and 7 partial responses). The duration of the responses ranged from 4 to 21 months (median: 9 months). Common toxicities were transient abdominal pain, nausea/vomiting, fever, and leukopenia. In four patients, grade III or IV toxicity was observed as gamma-glutamyl transpeptidase elevation. TACE with DSMs had tumor necrosis efficacy with acceptable toxicity. The median survival time was 21.7 months, and the 2-year survival rate was 45.3%. Further investigation of the effects of DSM treatment on survival should be carried out.

Brain infarction after percutaneous implantation of port-catheter system via the left subclavian artery

The aim of this study was to evaluate the incidence of brain infarction after percutaneous implantation of a port-catheter system via the left subclavian artery for hepatic arterial infusion chemotherapy. In 90 patients with inoperable liver cancer, a port-catheter system was implanted via the left subclavian artery. In 5 patients (5.6%) brain infarction occurred after port-catheter implantation. In one patient (1.1%) thrombi formed around the catheter, as confirmed by autopsy. The risk of brain infarction should be taken into consideration when a trans-left subclavian arterial access route is used for the percutaneous implantation of a port-catheter system for hepatic arterial infusion chemotherapy.

Continuous arterial infusion strategies using implanted ports

Surgically implanted ports have been used in continuous or repetitive intra-arterial (IA) chemotherapeutic infusions for patients with multiple liver metastases from colorectal cancer. Recently, a percutaneous implantation procedure was developed, facilitating safe and less invasive IA infusions in the treatment of various disease conditions. This article focuses on the interventional techniques for percutaneous implantation of a vascular access device, consisting of an indwelling catheter and an implantable port, to perform IA infusions. Additionally, we describe details of the alteration of blood flow by coil-embolization that can be performed to obtain selective drug distribution to the target area and to avoid side effects caused by the administration of the chemotherapeutic agent into nontarget areas.

Combined intraarterial 5-fluorouracil and subcutaneous interferon-alpha therapy for advanced hepatocellular carcinoma with tumor thrombi in the major portal branches

BACKGROUND

The prognosis of hepatocellular carcinoma (HCC) invading into the major branches of the portal vein (Vp3) is extremely poor.

METHODS

Eleven consecutive patients with HCC and Vp3 were treated with 2-6 cycles of a "basic" combination therapy consisting of continuous arterial infusion of 5-fluorouracil (450-500 mg/day, for the initial 2 weeks) and subcutaneous injection of interferon-alpha (5 million international units, 3 times/week, 4 weeks). In the first 3 patients, methotrexate (90 mg/day 1 of every week), cisplatin (10 mg/day), and leucovorin (30 mg/days 2 and 3 of every week) also were administered for the initial 2 weeks ("full" regimen).

RESULTS

In 8 (73%) of 11 patients, an objective response (complete response [CR] or partial response [PR]) was observed with marked regression of tumor and decrease in tumor markers. The use of the full regimen was associated with objective response in all patients; instead, they developed thrombocytopenia or leukopenia. In the subsequent 8 patients with basic regimen, 5 patients showed CR (2 cases) or PR (3 cases; objective response rate, 63%), and leukopenia was observed only in 1 patient.

CONCLUSIONS

Simple combination therapy with subcutaneous interferon-alpha and intraarterial 5-fluorouracil therefore is a promising treatment modality for intractable HCC with Vp3.

Combined regional and systemic chemotherapy by a mini-invasive approach for the treatment of colorectal liver metastases

From February 1996 to December 1998, 95 patients affected with colorectal liver metastases underwent the positioning of an intraarterial hepatic catheter by a transcutaneous subclavian access, under local anesthesia. All patients were evaluated for catheter implantation complications. Moreover, 61 patients of 95 treated at our center were retrospectively evaluated for results of chemotherapy performed with two different schedules of hepatic artery infusion (HAI) combined with systemic chemotherapy (SC). Eleven patients (group A) were treated with combined SC (5-fluorouracil continuous infusion) and HAI (floxuridine). A subsequent 50 patients underwent HAI (floxuridine, 4 cycles) followed, if a response or stable disease were observed, by combined SC and HAI (group B). Three cases of aneurysm of subclavian artery occurred, which were treated by the positioning of a radiologic arterial stent and the reimplantation of the catheter by a femoral access. Thrombosis of the hepatic artery was registered in four cases. We observed 10.5% occurrence of dislocation of the catheter, which was always moved again in the hepatic artery. In group A, with 45% clinical objective response rate and 10% stable disease rate, median survival time and median time to extrahepatic progression were 9 and 6 months, respectively. In group B, we observed 44% clinical objective responses and 26% stable disease after HAI. Patients without disease progression and therefore submitted to sequential SC and HAI had a median survival time of 21 months and a median time to extrahepatic progression of 16 months. The development of the mini-invasive technique of implantation of an arterial port can avoid laparotomy for HAI. Percutaneous implantation of an arterial port has a low rate of technical complications. HAI followed by combined systemic and regional chemotherapy has good results in terms of survival and time to extrahepatic progression.

Complications encountered with a transfemorally placed port-catheter system for hepatic artery chemotherapy infusion

A port-catheter system was implanted via femoral artery access for hepatic artery chemotherapy infusion. Implantation was attempted in 90 patients and was successful in 88. Blood flow redistribution was performed using embolization coils. In the first ten patients a soft heparin-coated infusion catheter was used. For the following 78 patients we used a stiffer catheter coated with fluorine-acryl-styrene-urethane-silicone (FASUS) copolymer. The catheter was connected to a port implanted subcutaneously below the level of the inguinal ligament. Complications during the procedure and after placement were observed in 7 of 90 patients and 24 of 88 patients, respectively. These included catheter obstruction (11%), dislocation of the catheter tip (10%), drug toxicity (5.7%), and catheter infection (3.4%). In 6 of 10 patients with catheter obstruction, recanalization of the port system was achieved. In 7 of 9 patients with dislocation of the indwelling catheter tip, replacement of the port system was successful. Our complications appear to be comparable with those encountered with the subclavian/brachial approach when the new catheter coating is used. Notable is the avoidance of cerebral infarcts.

Des-gamma-carboxy prothrombin as a useful predisposing factor for the development of portal venous invasion in patients with hepatocellular carcinoma: a prospective analysis of 227 patients

BACKGROUND

Portal venous invasion (PVI) in patients with hepatocellular carcinoma (HCC) is an important factor affecting prognosis. The objective of this study was to elucidate predisposing factors for the development of PVI.

METHODS

Two hundred twenty-seven patients with HCC who did not show PVI and who received percutaneous ethanol injection therapy and/or microwave coagulation therapy at the time of their first hospital admission were enrolled between 1994 and 1996. After their HCC was treated, the patients were followed for a mean of 19 months. For the detection of HCC recurrence and/or development of PVI, ultrasonography was performed every 3 months, a computed tomography (CT) scan was performed every 6 months, and the biochemical parameters of the patients were measured every month. PVI was defined as protrusion of the tumor into the first and/or second branch or into the main trunk of the portal vein.

RESULTS

Of the 227 patients, 24 (11%) later developed PVI. Tabular analysis was performed on these 24 patients and indicated that tumor size, albumin, total bilirubin, prothrombin time, alpha-fetoprotein (AFP) level, and des-gamma-carboxy prothrombin (DCP) level differed significantly between the time of initial admission and the time of PVI development. A univariate analysis performed on the 227 patients indicated that an increase in the numbers of tumors, the histologic tumor grade (differentiation), the AFP level, and the DCP level at the time of initial diagnosis of HCC had a significant correlation with the later development of PVI; and a stepwise, multivariate Cox regression analysis revealed that the DCP level was the strongest predisposing factor (P < 0.0010; risk ratio = 5.65) followed by the histologic grade of tumor differentiation.

CONCLUSIONS

The results suggest that the serum DCP level is the most useful predisposing clinical parameter for the development of PVI.

Risk factors for recurring hepatocellular carcinoma differ according to infected hepatitis virus-an analysis of 236 consecutive patients with a single lesion

Patients with hepatocellular carcinoma (HCC) frequently experience intrahepatic HCC recurrence even after complete ablation of primary lesions. Because the oncogenic process may be different for hepatitis B viral (B-viral) and hepatitis C viral (C-viral) HCC, the present study was conducted to elucidate the factors contributing to HCC recurrence with respect to the infected hepatitis virus. Two hundred thirty-six patients with a single HCC lesion who underwent complete ablation of the tumor by PEIT and/or PMCT or surgical resection at Tokyo University and its affiliated hospitals from 1993 to 1997 were enrolled. The patients were classified into 3 groups: the B-viral group, C-viral group, and NBNC group. After complete removal of tumors, the patients were followed for a mean period of 39 months. The factors contributing to HCC recurrence were analyzed by univariate and multivariate analysis using the Cox proportional hazard model. The rate of intrahepatic recurrence in enrolled patients at 1, 3, and 5 years was 19%, 50%, and 64%, respectively. The intrahepatic recurrence rate in C-viral and B-viral HCC was higher than that in the NBNC-related HCC. Fibrosis staging, pathological grading of HCC, and serum AFP levels were significantly linked to intrahepatic recurrence by univariate analysis, and fibrosis staging was strongest in the multivariate analysis for C-viral HCC (P = .004). In contrast, fibrosis staging did not affect the recurrence in B-viral (P = .51) and NBNC-related (P = .77) HCC. Risk factors for HCC recurrence differed according to the infected viral state.

Percutaneous implantation of a catheter with subcutaneous reservoir for intraarterial regional chemotherapy: technique and preliminary results

PURPOSE

We present the technique and the preliminary results of percutaneous implantation of intraarterial catheters connected to a subcutaneous infusion reservoir for prolonged regional chemotherapy of hepatic and extrahepatic tumors.

METHODS

Two hundred patients with primary or secondary hepatic neoplasms, pelvic, pancreatic, renal, lingual, and breast cancer underwent the procedure. The access was the left axillary artery (188 patients) and the femoral artery (12 patients). The catheter tip was placed in the hepatic (170 patients), hypogastric (18), splenic (4), internal thoracic (2), gastroduodenal (3), renal (2) or the external carotid artery (1). The catheter was connected to a subcutaneous reservoir and filled with heparin; chemotherapeutic infusion was subsequently started.

RESULTS

One hundred percent immediate technical success was obtained. Forty-three of 200 (21.5%) patients had a complication: 29 patients had a catheter dislodgment, nine had arterial thrombosis, three had a pseudoaneurysm of the left axillary artery and two had a port pocket hematoma. Most complications (37/43, 86%) were treated percutaneously without interruption of chemotherapy. In only six cases (3% of the total population) was chemotherapy discontinued due to the complication itself. The mean duration of catheter patency was 7.2 months.

CONCLUSION

Percutaneous placement of an intraarterial catheter is feasible and causes less discomfort to the patient than the surgical approach. The technique has an acceptable complication rate (21.5%), similar to that for surgical implantation (17.8%), with the advantage that in most cases the complications can be resolved percutaneously. This technique represents an alternative to surgical implantation in the treatment of liver metastases from colorectal cancer and opens new therapeutic possibilities for the local prolonged treatment of other kinds of tumor, though its clinical efficacy must be assessed in selected trials.

Multimodality treatment for patients with hepatocellular carcinoma: a single institution retrospective series

BACKGROUND

The main therapeutic options for hepatocellular carcinoma (HCC) are hepatic resection, transcatheter arterial embolization (TAE), percutaneous ethanol injection therapy (PEIT) and regional chemotherapy (RC).

METHODS

This study retrospectively examined the results of primary treatment of 600 patients with hepatocellular carcinoma selected according to the treatment guidelines of our facility and the results of various combination therapies for recurrent cases. The selection criteria of therapeutic options included the number and size of tumours and hepatic function.

RESULTS

The selected primary treatment was hepatic resection for 53.7% of the cases, TAE for 31.5%, PEIT for 8.2% and RC for 6.6%,. The treatment for post-resection recurrence was TAE alone for 62.4% of the cases, TAE + RC for 4.0%, PEIT for 15.2%, TAE + PEIT alone for 4.8%, RC for 8.0% and hepatic resection for 5.6%. The treatment for post-TAE recurrence was TAE alone for 83% of the cases, TAE + PEIT for 9%, TAE + RC for 3%, RC alone for 3% and PEIT alone for 2%. For post-PEIT, therapy was PEIT alone for 71.4% of the cases and PEIT + TAE for 28.6%. For post-RC, RC alone was used for 92.5% and RC + PEIT for 7.5%. The cumulative 3 and 5-year survival rates were 84.4% and 70.6%, respectively for stage I; 61.5% and 48.6% for stage II; 52.7% and 20.5% for stage III; and 22.8% and 17.1% for stage IVA. The cumulative 5 and 7-year survival rates after the primary treatments were 52.% and 40.1%, respectively, for hepatic resection; 46.5% and 38.7%, for TAE; 49.6% and 33.1% for PEIT; and 16.7% and 8.3% for RC.

CONCLUSIONS

To improve the treatment results for HCC, early detection is essential and various modalities of treatments in combination should be used for recurrence after primary treatment.

In vitro antitumor activity, intracellular accumulation, and DNA adduct formation of cis-[((1R,2R)-1,2-cyclohexanediamine-N,N')bis(myristato)] platinum (II) suspended in lipiodol

SM-11355, cis-[((1R,2R)-1,2-cyclohexanediamine-N,N')bis(myristato)] platinum (II), is a lipophilic platinum complex under clinical development that targets primary hepatocellular carcinoma using Lipiodol as a carrier. SM-11355 was compared with cisplatin (CDDP) using an in vitro evaluation system capable of examining the release characteristics and the cytotoxicity of drugs suspended in Lipiodol. SM-11355 suspended in Lipiodol (SM-11355/Lipiodol) and CDDP suspended in Lipiodol (CDDP/Lipiodol) showed cytotoxic activity against rat ascites hepatoma AH-109A cells in a dose-dependent manner. Their IC50 values following 7-day exposure were 22.3 and 0.40 microg/ml, respectively. Following the subsequent 7-day exposure, from day 7 to day 14 after preparation of the suspension, SM-11355/Lipiodol showed an almost equivalent activity, but CDDP/Lipiodol did not show any activity at all. SM-11355/Lipiodol showed a sustained release into the culture medium over the course of a 14-day exposure. Following the exposure to CDDP/Lipiodol, the platinum concentration in the medium was at its maximum on the first day and remained constant thereafter. Intracellular platinum uptake and formation of platinum-DNA adducts were dependent on the release characteristics of each drug suspension. For SM-11355/Lipiodol, the drug release, intracellular drug uptake, and formation of platinum-DNA adducts over the course of the subsequent 7-day exposure were similar to those observed during the first 7 days. DPC, one of the compounds released from SM-11355/Lipiodol, was taken up by cells and showed formation of platinum-DNA adducts. Thus, this study suggests that SM-11355/Lipiodol may release active platinum compound(s) that bind to nuclear DNA and mediate the cytotoxic activity of SM-11355/Lipiodol.

Efficacy of an implanted drug delivery system for advanced hepatocellular carcinoma using 5-fluorouracil, epirubicin and mitomycin C

BACKGROUND

In order to assess the efficacy of repeated hepatic arterial infusion (HAI) therapy for advanced hepatocellular carcinoma, we administered HAI therapy using 5-fluorouracil, epirubicin and mitomycin C, with an implanted drug delivery system.

METHODS AND RESULTS

Thirty-seven patients received HAI therapy with a response rate of 21.6%. The 6-month and 1-year survival rates were 67.6 and 29.7%, respectively. Responders to HAI therapy showed significantly longer survival than non-responders, while patients with mild liver dysfunction tended to survive longer than those with severe dysfunction. Neither tumour thrombosis of the main trunk of the portal vein nor extrahepatic metastases were considered to constitute contraindications for HAI therapy. Catheter-related trouble occurred in eight patients and biloma in one patient, but other side effects were transient and tolerable. These patients received HAI therapy as outpatients for an average of 79.6% of the entire course of therapy.

CONCLUSIONS

Hepatic arterial infusion therapy proved effective for patients with advanced hepatocellular carcinoma in terms of improving survival and outpatient rates.

Complications and technical limitations of hepatic arterial infusion catheter placement for chemotherapy

PURPOSE

To determine the rate of complications associated with hepatic arterial infusion (HAI) catheter placement, as well as technical success related to liver perfusion.

MATERIALS AND METHODS

The authors reviewed 44 patients who underwent 106 HAI catheter placements, including 15 men and 29 women with an average age of 55 years (range, 32-82 years). One to nine placements were performed per patient with 61 (58%) via the left brachial artery, 40 (38%) via the right femoral artery, and five (4%) via the left femoral artery. Chemoinfusion lasted 4 days, with initial catheter placement assessed on technetium-99m macroaggregated albumin (MAA) perfusion scans, as well as daily abdominal radiographs.

RESULTS

One hundred attempted hepatic arterial catheter placements were completed. Liver perfusion was global in 66 (66%) cases, in the right lobe only in 28 (28%) cases, and in the left lobe only in six (6%) cases. Eight (8%) had gastrointestinal (GI) tract perfusion; this was eliminated in seven cases (7%) after catheter repositioning. Forty-six (43%) placement attempts required embolization of 62 GI vessels to preclude GI chemoinfusion. Complications included one cerebrovascular accident (related to removal of a left brachial catheter), eight brachial artery thromboses (four that required emergent thrombectomy), six hepatic arterial dissections, four hepatic arterial thromboses, and four catheter malfunctions.

CONCLUSIONS

HAI catheter placement via the left brachial artery has increased complications. Nearly one-half of placements required embolization of GI vessels to preclude GI perfusion. Global perfusion is possible in two-thirds of cases.