Osseous metastases from hepatocellular carcinoma: embolization for pain control

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

2022 KLCA-NCC Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

Hepatocellular cancer pain: impact and management challenges

Hepatocellular carcinoma (HCC) remains the most common primary liver malignancy. Pain comprises one of the most pervasive and troubling symptoms of HCC and may have severely negative effects on patient’s quality of life. Furthermore, because HCC frequently arises in the setting of cirrhosis, treating pain related to this malignancy poses a clinical challenge. This article summarizes manifestations of hepatocellular cancer pain, common obstacles to treatment, and practical HCC pain management.

Skull Metastasis from Hepatocellular Carcinoma

CT, MR and angiographic findings of 6 patients with 9 skull metastases from hepatocellular carcinoma (HCC) were reviewed. In 3 of 6 patients, local pain or neurologic deficit was the initial main manifestation of the disease, although all had been treated for chronic liver disease. In the remaining 3 patients, skull metastases were detected following treatment of HCC. The metastatic lesions appeared as expansile osteolytic masses on CT and as hypervascular masses on angiography. All lesions were demonstrated on MR imaging. Compared with the brain parenchyma, the lesions were iso- or hypointense on T1-weighted and T2-weighted MR images. The lesions were moderately to markedly enhanced by Gd-DTPA. Flow voids were shown in the tumors in 5 lesions. HCC should be included in the differential diagnosis of an osteolytic hypervascular lesion of the skull, especially in Oriental patients. The relatively hypointense tumor on T2-weighted MR images associated with flow void, different from primary skull tumors or directly invasive tumors, may support the diagnosis of HCC metastasis.

Preoperative embolization for bone metastasis from hepatocellular carcinoma

Preoperative transcatheter arterial embolization for hypervascular bone tumors is now widely accepted as a safe and effective procedure for reducing intraoperative blood loss and surgical morbidity. However, few studies have reported the use of preoperative transcatheter arterial embolization for nonspine bone metastases from hepatocellular carcinoma. The goal of this study was to assess the effect of preoperative embolization on blood loss and clinical outcomes in surgery for nonspine bone metastasis from hepatocellular carcinoma. Seventy-five patients with metastases from hepatocellular carcinoma to the pelvis and extremities were reviewed retrospectively. The study population consisted of 62 men and 13 women, with a mean age of 64.6 years (range, 40.0-80.1). The average follow-up period was 8.2 months (range, 0.3-66.1). Twenty-two patients underwent transcatheter arterial embolization for preoperative devascularization (group A), and 53 patients underwent operative treatment only (group B). The proportion of pelvis metastases was significantly higher (P<.001) and operative time was longer (P=.006) in group A than in group B. However, a significantly smaller decrease in hemoglobin level before and after surgery was seen in group A (P=.017). No significant differences were seen in intraoperative estimated blood loss, perioperative hemoglobin level, number of allogeneic transfusions, or length of hospitalization between the 2 groups. Preoperative transcatheter arterial embolization is an effective means to reduce bleeding during surgery for nonspine metastases from hepatocellular carcinoma. In general, surgical procedures that included transcatheter arterial embolization took longer and were more extensive.

Solitary painful osseous metastases: correlation of imaging features with pain palliation after radiofrequency ablation--a multicenter american college of radiology imaging network study

PURPOSE

To identify the correlation of pre- and postablation imaging features with pain relief, pain intensity, and patient mood after radiofrequency (RF) ablation of solitary painful osseous metastases.

MATERIALS AND METHODS

This prospective, multicenter group trial was approved by each institutional review board. Participants were enrolled between November 1, 2001, and April 6, 2006. Written informed consent was obtained from all subjects, and patient confidentiality protocols were followed in compliance with HIPAA. Computed tomography (CT)-guided RF ablation and contrast material-enhanced 1-month follow-up CT and/or magnetic resonance imaging were performed in 49 subjects (24 men, 25 women; age range, 34-83 years) with a confirmed malignant solitary bone lesion of maximum dimension of 8 cm or smaller that was causing intractable pain. Pain intensity and patient mood were measured before and after RF ablation. Tumor imaging features were recorded. Unadjusted and adjusted linear mixed-effects models, with a random intercept for each subject, were used to model patient mood, pain relief, and pain intensity scores at three times after ablation as a function of each tumor characteristic.

RESULTS

Decreased postablation tumor pain correlated with preablation tumor volume (P = .02) and pathologic fracture (P = .01), while pain relief correlated with pathologic fracture (P = .03) and percentage of bone-tumor interface (BTI) ablated (P = .02). Conversely, presence of an irregular rim after ablation (P = .02) and rim thickness (P = .01) correlated with increased pain. There was no evidence in this study that RF ablation of larger tumor percentage or larger volume leads to better pain relief or decreased pain (P > .05).

CONCLUSION

Existing pathologic fracture and smaller tumor size appear to be predictive parameters of success when selecting patients for palliative RF ablation of painful solitary osseous metastases. Successful palliation also appears to be related to the percentage of BTI ablated.

Transcatheter arterial embolization for the palliation of painful bone lesions

Pain related to bone tumors, whether benign or malignant, can be significantly debilitating to patients. Unfortunately, there is no single optimal treatment solution for tumor-related bone pain. Many treatment options exist for the palliation of bone pain, each with their own advantages and disadvantages. This article discusses the use of bland arterial embolization for the purpose of pain control in patients with both primary and metastatic bone tumors. Considerations for patient selection and preparation, procedural steps, overcoming technical challenges, potential complications, and follow-up care will be reviewed using case examples.

Embolization of musculoskeletal bone tumors

Bone tumors may present as incidental findings, with pain or loss of function, or as fractures. There is a broad range of indications for transarterial embolization (TAE) in primary or metastatic bone tumors: to reduce operative hemorrhagic risks, to simplify or allow more definitive surgery, or in the context of pain palliation, fever, bleeding, or hypercalcemic and other rheological factors. Embolization may also increase tumor sensitivity to chemotherapy or radiation therapy. The procedure itself is often complex with significant risk to adjacent structures and is usually part of a wider treatment strategy. There are many options of embolic agent, techniques, and end points but all aim to devascularize the tumor. Catheter angiography at the time of TAE is used to determine the correct embolic agent and technique with care taken to isolate at risk structures. Many factors determine the best choice of embolic material, probably the most important of which is operator experience. In life-threatening situations or in preoperative embolizations of metastatic tumors, many operators opt for a combination of particulate emboli and stainless steel or platinum coils. Agents discussed include polyvinyl alcohol particles, trisacryl microspheres, gelatin sponge, liquid embolic agents, and embolization coils. Tumor types treated include vascular metastatic lesions, commonly renal cell or thyroid, particularly in locations prone to fracture; giant cell tumors; aneurysmal bone cysts; vertebral hemangiomas, osteosarcomas; arteriovenous malformations; and osteoblastomas. TAE should be considered in the treatment algorithm of primary or secondary bone tumors. Specific benefit is present where there is a high risk of bleeding at surgery, where there is spinal involvement and neural encroachment, where active bleeding is present or in awkward surgical locations where prolonged surgery is anticipated.

Palliative interventions for pain in cancer patients

Pain is a debilitating problem that is common to most patients with cancer at some time during the course of their disease. Conventional therapies such as opiate analgesics and radiation therapy provide suboptimal and limited relief. Novel image-guided interventions have made a significant impact in the management of this difficult problem. This article reviews some of the most promising image-guided techniques for relieving bone and visceral pain in patients suffering from cancer.

Transcatheter arterial embolization for tumor seeding in the chest wall after radiofrequency ablation for hepatocellular carcinoma

Tumor seeding in the chest wall was depicted at follow-up CT obtained 9 months after radiofrequency ablation for hepatocellular carcinoma. Transcatheter arterial embolization was successfully performed, injecting emulsion of 10 mg of epirubicin and 1 ml of iodized oil followed by gelatin sponge particles via the microcatheter placed in the right eleventh intercostal artery. The patient died of tumor growth in the liver one year after the embolization, but no progression of the tumor seeding was noted during the follow-up period. We conclude that transcatheter arterial embolization was effective for the control of tumor seeding after radiofrequency ablation for hepatocellular carcinoma.

Radiotherapy for painful bone metastases from hepatocellular carcinoma

BACKGROUND

Painful bone metastases are one of the distressing clinical situations in patients with hepatocellular carcinoma (HCC). The purpose of the study was to evaluate the palliative effect of radiotherapy for painful bone metastases from HCC.

PATIENTS AND METHODS

A retrospective analysis was performed upon 51 patients, who were treated with radiotherapy for painful bone metastases from HCC at 77 sites, from January 1991 to June 2000. Twenty patients (39%) presented synchronous metastases, and the remaining 31 patients (61%) showed metachronous metastases. In addition to bone pain, neurologic symptoms and a palpable mass were presented in 13 (25%) and seven (13%) patients, respectively. Twenty-one patients (41%) had a solitary metastasis and the most frequent site was the vertebra. The total dose of radiotherapy ranged from 12.5 to 50 Gy (median 30 Gy).

RESULTS

On the Wisconsin Brief Pain Questionnaire, relief of pain was achieved at 56 sites (73%). The overall survival rate at 2 years was 4% and the median survival time was 5 months. Univariate analysis showed that tumor stage within the liver and the presence of metastases to organs, other than bones, were significant prognostic factors for survival (P < 0.05).

CONCLUSION

In conclusion, radiotherapy provides effective palliation for patients with painful bone metastases from HCC during the substantial median survival time.

Embolization of metastatic spinal tumors

Embolization is a safe and valuable primary and adjunctive treatment option for metastatic spinal tumors. Close consultation between the neurosurgeon, the oncologist, the radiation oncologist, and the interventionalist should lead to more applications of embolization techniques,thereby enhancing the treatment of metastatic spinal lesions. The development of newer embolic agents with chemotherapeutic properties should add to the efficacy of embolization for metastatic spinal disease.

Transcatheter arterial embolization for malignant osseous and soft tissue sarcomas. II. Clinical results

PURPOSE

To evaluate the clinical effects of transcatheter arterial embolization (TAE) on malignant bone and soft tissue tumors.

METHODS

TAE was performed in 10 patients with primary bone and soft tissue sarcomas and in 31 patients with metastatic bone tumors. The embolized arteries were the internal iliac artery in 30 cases, the intercostal artery in six cases, the lumbar artery in five cases, the suprascapular artery in three cases, and the iliolumbar artery, the internal pudendal artery, and the lateral sacral artery in one case each. The embolized material was gelatin sponge particles. The chemotherapeutic drugs were usually 20-40 mg of doxorubicin for primary and metastatic tumors and 50-100 mg of cisplatin only for primary tumors. In addition, 50-60 Gy of 10-MV radiotherapy with or without radiofrequency (RF)-capacitive hyperthermia in four sessions was administered before TAE for primary tumors only.

RESULTS

Even though the pain score increased immediately after TAE, 30 of 38 (79%) patients with pain (8 of 9 with primary tumors, and 22 of 29 with metastases) achieved pain control after TAE. A necrotic low-density area shown by computed tomography (CT) after TAE was found in 31 of 41 (76%) tumors [8 of 10 (80%) with primary tumors, and 23 of 31 (74%) with metastatic tumors]. The tumor size decreased in 14 of 25 (56%) primary and metastatic tumors after 3 months. Osteosclerotic changes appeared in two cases of metastatic tumors after 6 months. In five tumors resected after TAE, large areas of necrosis within the tumor were confirmed histologically. Transient local pain and numbness appeared after TAE, but were relieved by drug treatment within 1 week. No severe complications except a case of gluteal muscle necrosis were encountered after TAE. The 1-year survival rate of the patients with primary tumors was 38.1%, and the median survival was 18 months. The longest survival was 84 months. The 1-year survival rate of the patients with metastatic bone tumors was 38.9%; the median survival was 12 months. The longest survival was 24 months.

CONCLUSION

TAE could be an effective treatment for pain control and local control of malignant bone and soft-tissue tumors.

Transcatheter arterial embolization for malignant osseous and soft-tissue sarcomas. I. A rabbit experimental model

PURPOSE

To evaluate the effect of transcatheter arterial embolization (TAE) on metastatic bone tumors in an experimental study.

METHODS

Fifteen Japanese white rabbits were transplanted with VX2 sarcoma cells into the iliac crest. In 10 rabbits, the arterial supply to the iliac bone tumors, internal iliac artery and iliolumbar artery were then embolized with particles of gelatin sponge. The therapeutic effect was evaluated by comparison with the natural course of control tumors in the other five rabbits.

RESULTS

After TAE, extensive necrosis, fibrosis, and vacuolization within the tumors were confirmed histologically. In the control rabbits, 19% +/- 7% of the entire tumor was found to be spontaneous tumor necrosis; in contrast, the tumors of the TAE group showed necrosis as 62% +/- 22% of the entire tumor. In one TAE group rabbit, no active tumor cell could be detected in the residual tumor.

CONCLUSION

TAE was found to be an effective treatment for bone tumors in an experimental model.

Short communication: the value of embolization therapy in painful osseous metastases from hepatocellular carcinomas; comparative study with radiation therapy

We evaluated the therapeutic effect of transcatheter arterial embolization therapy (TAE) for painful osseous metastases from hepatocellular carcinoma (HCC) in comparison with radiation therapy (RT). TAE using gelatin sponge particles was performed for seven lesions in seven patients. Selective catheterization and embolization were successfully performed in all lesions. Within 10 days after TAE, complete pain relief (CR), partial relief (PR) and no relief (NR) were attained in 57%, 29% and 14%, respectively. RT was used to treat 34 lesions in 22 patients. The dose fractionation schedules were in the range 28.0-50.4 Gy, with 1.8-4.0 Gy per fraction. CR, PR and NR were attained in 47%, 47% and 6%, respectively. There were no serious complications related to these treatments. Both TAE and RT are effective and the treatment of choice should be selected on an individual basis.

Bone metastases of hepatocellular carcinoma after liver resection

Between January 1985 and July 1990, 323 cases of hepatocellular carcinoma underwent liver resection in our department. Bone metastases were found in 12 of these cases (3.7%). Bone metastases were mainly found in vertebral bone (58.3%) and pelvic bone (41.7%). The time interval to the development of bone metastasis after liver resection was closely related to the presence of intrahepatic metastasis and the stage at operation. In all cases, the initial clinical symptom was pain and/or motor disturbance. Radiotherapy was performed in 10 cases and transcatheter arterial embolization or surgery was performed in 4 cases. The pain or neurological symptoms improved with these therapies in all cases. Cumulative survival was 1 year in 74%, 2 years in 34%, and 3 years in 17%, respectively.