Retrospective European Multicentric Evaluation of Selective Transarterial Chemoembolisation with and without Balloon-Occlusion in Patients with Hepatocellular Carcinoma: A Propensity Score Matched Analysis

An Alternative Endovascular Technique for Treatment of Pulmonary Arteriovenous Malformation: Microballoon-occluded Transcatheter Embolization Using n-butyl-2-cyanoacrylate

PURPOSE

To investigate the safety and efficacy of microballoon-occluded transcatheter embolization using n-butyl-2-cyanoacrylate (NBCA) in patients with a single pulmonary arteriovenous malformation (PAVM).

METHODS

From November 2017 to November 2020, this retrospective study included 38 previously untreated patients with a single PAVM who underwent microballoon-occluded transcatheter embolization using NBCA. All 38 patients had follow-up that included simple chest radiography and contrast-enhanced chest computed tomography (CT).

RESULTS

A microballoon was successfully placed in a feeding artery of the PAVM to control the delivery of the NBCA cast in all 38 patients, with complete embolization of sacs and the feeding artery achieved in all cases. The mean diameters of the feeding artery, sac, and draining vein were 3.9 ± 0.9 mm, 7.5 ± 2.6 mm, and 4.6 ± 1.3 mm, respectively. A fixed 1:2 NBCA/Lipiodol ratio was used, and the mean amount of embolic mixture per patient was 1.4 mL (range 0.6-2.2 mL). There were no complications related to microballoon adhesion and non-target embolization of the systemic circulation. Follow-up CT in all 38 patients with a mean delay of 34.5 ± 8.8 months (range 20.7-56.5 months) showed no continued perfusion of the PAVM.

CONCLUSION

In our hands, microballoon-occluded n-butyl-2-cyanoacrylate embolization seemed to be safe and appeared to be clinically effective in patients with simple and complex types of single PAVM. Therefore, the present technique has the potential to become a standard treatment for a single PAVM.

Long-Term Outcomes of Balloon TACE for HCC: An European Multicentre Single-Arm Retrospective Study

PURPOSE

To report response rates (using mRECIST), overall survival (OS), progression-free survival and local tumour recurrence-free survival (LRFS) of balloon-occluded transarterial chemoembolisation (bTACE) for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Patients from five European centres treated with conventional or drug-eluting microsphere bTACE for HCC were included, and patients already lost to follow-up before 12 months were excluded. Possible factors contributing to LRFS and OS were evaluated with Cox proportional hazards models.

RESULTS

Seventy-three patients were enrolled. The mean number of nodules per patient was 2.07(± 1.68), and the average maximum diameter of the nodules was 37 ± 19.9 mm. The response of the target lesion at 6 months was complete response (CR) in 58.9%, partial response (PR) in 28.8%, stable disease (SD) in 6.8% and progressive disease (PD) in 5.5%. The median follow-up time was 31 months; at the last follow-up, target tumour response was CR in 49.3%, PR in 12.3%, SD in 5.5% and PD 32.9%. Overall response at the last follow-up was CR in 17.8%, PR in 9.6%, SD 2.7% and PD in 69.9% (for new lesions in 37% of patients). Median OS was not reached; mean overall survival was 50.0 months, while median LRFS was 31.0 months. At uni- and multivariable analysis, only tumour maximum diameter was related to LRFS (hazard ratio [HR] = 1.021; 95% CI 1.004-1.038, P = 0.015).

CONCLUSIONS

bTACE demonstrated high efficacy for HCC, with a complete response in 58.9% of patients, a median local recurrence-free survival of 31.0 months and a mean overall survival of 50.0 months.

Efficacy and features of balloon-occluded transarterial chemoembolization for hepatocellular carcinoma: a narrative review

Background and Objective

Systemic therapy for hepatocellular carcinoma (HCC) is recommended in transarterial chemoembolization (TACE)-refractory and unsuitable cases. In Japan, TACE is broadly classified into conventional TACE (C-TACE), balloon occluded TACE (B-TACE), and drug-eluting beads TACE. However, the type of TACE recommended for TACE-refractory or unsuitable cases has not been elucidated, and a targeted approach for individual cases and appropriate TACE selection is important. B-TACE is considered a valuable therapeutic option in the management of HCC. The technique involves the precise placement of a microcatheter with a balloon into the target hepatic artery, followed by selective occlusion of the hepatic artery, including tumor-feeding vessels, using the balloon. By leveraging the hemodynamic changes resulting from arterial occlusion, B-TACE enables effective accumulation of chemotherapeutic agents within the tumor. Incorporating B-TACE into the treatment strategy for HCC is of utmost importance. Therefore, this article provides an overview of the technique.

Methods

A comprehensive review of all available literature in the English language through December 1, 2023 utilizing PubMed was conducted.

Key Content and Findings

In the intermediate stage, TACE and systemic therapy play complementary roles, and it is important to select a treatment strategy that considers tumor status and hepatic reserve. However, no study has investigated the various types of TACE in the treatment of such patients. Currently, TACE in Japan is broadly classified into C-TACE, B-TACE, and drug-eluting beads TACE (DEB-TACE). This article outlines the evolution of B-TACE for HCC. We identified retrospective and prospective studies evaluating B-TACE. In this review, we evaluate data on B-TACE for HCC.

Conclusions

In the era of systemic therapy, B-TACE may play a complementary and synergy effect role.

Preoperative Balloon-Occluded Transcatheter Arterial Chemoembolization Followed by Surgical Resection: Pathological Evaluation of Necrosis

This study investigates the clinical and pathological outcomes of preoperative balloon-occluded transcatheter arterial chemoembolization (B-TACE) in patients with single hepatocellular carcinoma (HCC). The data are from 25 consecutive patients who underwent sequential treatment of subsegmental B-TACE and hepatic surgery for single HCC. Radiological and pathological evaluation of oily subsegmentectomy, defined as the iodized oil-laden necrotic area that includes the entire HCC and surrounding liver parenchyma, were performed. Subsegmental B-TACE was technically successful in all patients. The major and minor complication rates were 8% and 24%, respectively. On the first follow-up computed tomography (CT), oily subsegmentectomy was observed in 18 (72%) out of 25 patients. Apart from one patient showing a partial response, the remaining 24 (96%) patients showed a complete response. Pathological complete necrosis of the HCC was observed in 18 (72%) out of 25 patients with complete or extensive necrosis of the peritumoral liver parenchyma. The remaining seven patients without peritumoral parenchymal necrosis had extensive necrosis of the HCCs. In conclusion, preoperative B-TACE can be a safe and effective method for the treatment of single HCC and a good bridge treatment for subsequent surgical resection. In addition, oily subsegmentectomy itself on the CT can be a good predictor of pathological complete necrosis of the HCC. The findings obtained from this study would provide a potential role of B-TACE in the treatment strategy for single HCC.

Local Recurrence following Radiological Complete Response in Patients Treated with Subsegmental Balloon-Occluded Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma

The aim of this study was to determine the local recurrence (LR) rate and identify factors associated with LR in patients who achieve a radiological complete response (CR) after undergoing balloon-occluded transcatheter arterial chemoembolization (B-TACE) for hepatocellular carcinoma (HCC). From November 2017 to September 2021, 60 patients (44 men, 16 women; mean age, 63.5 years; range, 39-82 years) with 72 HCCs (mean diameter, 31 mm; range, 10-50 mm) who underwent subsegmental B-TACE were included in this retrospective study. Radiological and clinical evaluation of oily subsegmentectomy, defined as radiological CR of the HCC and peritumoral parenchymal necrosis, was performed. The CR rate was 97.2% (70 of 72 HCCs) at first follow-up (mean, 41 days; range, 14-110 days). Overall, 13 HCCs (19.7%) demonstrated LR at a mean of 29.8 months (range, 3-63 months) and cumulative LR rates were 1.5% 14.2% 21%, 21%, and 21% at 6, 12, 24, 36, and 48 months, respectively. In 28 (38.9%) of 72 HCCs, oily subsegmentectomy was achieved, tumor markers were normalized, and LR did not occur. The oily subsegmentectomy-positive group had a significantly lower LR rate than the oily subsegmentectomy-negative group (p = 0.001). Age ≥65 years (adjusted hazard ration (HR), 0.124; 95% confidence interval (CI), 0.037-0.412; p < 0.001) and peripheral location (adjusted HR, 0.112; 95% CI, 0.046-0.272; p < 0.001) were independent predictive factors of LR. Subsegmental B-TACE can be an effective method with a high initial CR rate and low LR incidence. Oily subsegmentectomy can be considered as an index of successful treatment because it did not demonstrate any LR.

Balloon-occluded transarterial chemoembolization versus conventional transarterial chemoembolization for the treatment of single hepatocellular carcinoma: a propensity score matching analysis

OBJECTIVES

To compare the safety and efficacy of balloon-occluded transarterial chemoembolization (B-TACE) and conventional TACE (C-TACE) in treating single hepatocellular carcinoma (HCC).

METHODS

This single-center retrospective study included 523 patients who underwent C-TACE and 44 who underwent B-TACE as first-line treatment for single HCCs between November 2017 and December 2019. After propensity score matching (PSM), initial tumor response rates, local tumor progression (LTP), and major complication rates were evaluated in the 32 pairs of PSM matched population.

RESULTS

In the 32 pairs of PSM cohort, B-TACE showed distinct superiority over C-TACE in treating single HCCs, with significantly higher initial complete response (CR) rates (93.8% vs. 62.5%, p = 0.005). During a median follow-up of 37 months (range, 12.7-46.5 months), 13 patients (40.6%) who underwent B-TACE and 16 (50%) who underwent C-TACE showed LTP of treated lesions. Size-based sub-group analysis showed that the median times to LTP in patients with medium- to large-sized tumors (> 3 cm) were significantly longer in the B-TACE (27 months; 95% confidence interval [CI], 19.7-34.3 months) than in the C-TACE (13 months; 95% CI, 3.9-22.1 months) group (p = 0.019). The major complication rate was similar between the two groups.

CONCLUSIONS

B-TACE had a higher initial CR rate than C-TACE in treating single HCCs. Moreover, size-based subgroup analysis showed that time to LTP was significantly longer in patients with medium- to large-sized HCCs (> 3 cm) who underwent B-TACE rather than C-TACE.

KEY POINTS

• B-TACE was superior to C-TACE in treating single HCC, with a significantly higher initial complete response rate after one session of treatment. • In size-based subgroup analysis, time to LTP was significantly longer in patients with medium- to large-sized HCCs (>3 cm) who underwent B-TACE rather than C-TACE. • B-TACE should be considered an alternative treatment option for medium- to large-sized single HCCs (>3 cm) in patients with a nonresectable condition and those who prefer nonsurgical treatment.

Interventional oncology of liver tumors: how it all started and where are we now

Liver was the very first organ for which interventional procedures were applied for the local treatment of primary and secondary malignancies. In this paper, the history of Interventional Oncology of liver, from the very beginning to the current situation, is summarized, including both percutaneous and intravascular procedures, and together with the evolution of the techniques for image guidance. The main ongoing developments, such as new techniques, combined interventional treatments and association of local interventions with new drugs are briefly described, too.

Single medium-sized hepatocellular carcinoma treated with sequential conventional transarterial chemoembolization (cTACE) and microwave ablation at 4 weeks versus cTACE alone: a propensity score

Background

Microwave ablation (MWA) is a potentially curative treatment for unresectable patients with hepatocellular carcinoma (HCC) ≤ 3 cm, while its therapeutic efficacy decreases significantly for HCC > 3cm. Previous studies have demonstrated that conventional transarterial chemoembolization (cTACE) combined with MWA (cTACE-MWA) may improve local tumor control rate and reduce the recurrence rate for HCC > 3cm. However, there have been few study designs to analyze the clinical efficacy of cTACE-MWA for medium-sized HCC (3–5cm). Therefore, this study aims to compare the clinical efficacy and safety of cTACE-MWA with cTACE alone for a single medium-sized HCC of 3–5 cm in diameter.

Methods

We retrospectively investigate the data of 90 patients with a single medium-sized HCC who were referred to our hospital and underwent cTACE-MWA or cTACE alone from December 2017 to March 2020. Then, patients were identified with propensity score-matched (1:1). The local tumor response to treatment and time to progression (TTP) were compared using mRECIST criteria between the cTACE-MWA group and the cTACE group.

Results

A total of 42 patients were included after matching (cTACE-MWA: 21; cTACE: 21). Comparing with cTACE, cTACE-MWA demonstrate significantly better local tumor control (ORR: 95.2% vs 61.9%, p = 0.02; DCR: 95.2% vs 66.7%, p = 0.045) and TTP (median 19.8 months vs 6.8 months, p < 0.001). The 1- and 2-year cumulative probabilities of OS were 100% and 95% in the cTACE-MWA group, which were significantly higher than those in the cTACE group (95% and 76%) (p = 0.032). Multivariate Cox regression analysis illustrates that cTACE-MWA was associated with better TTP (hazard ratio, 0.28; 95% CI: 0.1, 0.76; p = 0.012), but tumor size was associated with worse TTP (hazard ratio, 1.71; 95% CI: 1.01, 2.89; p = 0.045).

Conclusions

cTACE followed by MWA improved TTP and OS in patients with a single medium-sized HCC, and no major complication was observed in this study.

Percutaneous Thermal Segmentectomy: Proof of Concept

AIM

To report the multicenter retrospective experience on combination of balloon-occluded MWA(b-MWA) followed by balloon-occluded TACE(b-TACE) in patients with liver malignancies > 3 cm, focusing on appearance and volume of necrotic area, safety profile and oncological results.

MATERIALS AND METHODS

Twenty-three patients with liver primary malignancies (hepatocellular carcinoma,HCC = 18; intrahepatic cholangiocarcinoma,iCC = 2) and metastasis (colorectal cancer metastasis = 1;sarcoma metastasis = 1;breast metastasis = 1) were treated. Maximum mean diameter of lesions was 4.4 cm (± 1 cm). Treatments were performed using a single-step approach:b-MWA was performed after balloon-microcatheter inflation, followed by b-TACE (with epirubicin or irinotecan). Necrotic area shape and discrepancy with the expected volume of necrosis suggested by vendor's ablation chart were assessed at post-procedural CT. Complications were categorized according to CIRSE classification. Oncological results at 1 and 3-6 months were evaluated using m-RECIST(HCC) and RECISTv1.1(metastasis/iCC).

RESULTS

Mean volume of necrotic area was 75 cm³ (± 36). Discrepancy with vendor chart consisted in a medium percentage of volumetric incrementation of necrotic area of 103.2% (± 99.8). Non-spherical shape was observed in 22/23 patients (95.7%). No complications occurred; Post-embolization syndrome occurred in 12/23patients. Complete response and partial response were, respectively, 91, 3% (21/23) and 8.7% (2/23) at 1 month, 85.7% (18/21) and 9.5% (2/21) at 3-6 months. Progression of disease was 4.7% (1/21) at 3-6 months for extra-hepatic progression. Among partial responders, average percentage of tumor volume debulking was 78.8% (± 9.8%).

CONCLUSION

b-MWA followed by b-TACE in a single-step procedure led to larger necrotic areas than the proposed by vendors ablation chart, non-spherical in shape and corresponded to the vascular segment occluded during ablation. This permitted to safely achieve promising oncological results in patients with > 3 cm tumors.

In Vivo Comparison of Micro-Balloon Interventions (MBI) Advantage: A Retrospective Cohort Study of DEB-TACE Versus b-TACE and of SIRT Versus b-SIRT

PURPOSE

The purpose of this study was to evaluate in vivo the role of the micro-balloon by comparing trans-arterial chemoembolization (DEB-TACE) and selective internal radiotherapy (SIRT) procedures performed with and without balloon micro-catheter (b-DEB-TACE and DEB-TACE/SIRT and b-SIRT) for the treatment of hepatocellular carcinoma (HCC).

METHODS

The impact of a balloon micro-catheter on trans-arterial loco-regional treatment was analyzed using non-enhanced post-procedural cone-beam CT (Ne-CBCT) by comparing the attenuation values in the embolized area and the surrounding liver tissue before and after DEB-TACE versus b-DEB-TACE and by comparing 2D/3D dosimetry in single-photon emission computed tomography after SIRT versus b-SIRT, and by comparing the histological count of the beads following orthotopic liver transplantation in the DEB-TACE versus b-DEB-TACE subgroup.

RESULTS

We treated 84 HCC patients using trans-arterial loco-regional therapy. Fifty-three patients (26 DEB-TACE and 27 b-DEB-TACE) were analyzed in the TACE group. Contrast, signal-to-noise ratio, and contrast-to-noise ratio were all significantly higher in b-DEB-TACE subgroup than DEB-TACE (182.33 HU [CI95% 160.3-273.5] vs. 124 HU [CI95% 80.6-163.6]; 8.3 [CI95% 5.7-10.1] vs. 4.5 [CI95% 3.7-6.0]; 6.9 [CI95% 4.3-7.8] vs. 3.1 [CI95% 2.2-5.0] p < 0.05). Thirty-one patients (24 SIRT and 7 b-SIRT) were analyzed in the SIRT group. 2D dosimetry profile evaluation showed an activity intensity peak significantly higher in the b-SIRT than in the SIRT subgroup (987.5 ± 393.8 vs. 567.7 ± 302.2, p = 0.005). Regarding 3D dose analysis, the mean dose administered to the treated lesions was significantly higher in the b-SIRT than in the SIRT group (151.6 Gy ± 53.2 vs. 100.1 Gy ± 43.4, p = 0.01). In histological explanted liver analysis, there was a trend for higher intra-tumoral localization of embolic microspheres for b-DEB-TACE in comparison with DEB-TACE.

CONCLUSIONS

Due to the use of three different methods, the results of this study demonstrate in vivo, a better embolization profile of oncological intra-arterial interventions performed with balloon micro-catheter regardless of the embolic agent employed.

Balloon-assisted radioembolization via the proper hepatic artery to treat a left liver hepatocellular carcinoma and portal vein tumor thrombus with an inaccessible left hepatic artery: A case report

Although yttrium-90 (⁹⁰Y) transarterial radioembolization (TARE) is an effective treatment for hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT), inability to cannulate tumor-feeding vessels can preclude its use. In this case we demonstrate the feasibility of employing balloon occlusion within the proper hepatic artery to treat a left lobar HCC and PVTT with an inaccessible left hepatic artery. Vessel angulation prevented subselection of the left hepatic artery, and subsequent mapping studies indicated significant non-target radiotracer activity. Through occlusion of the proper hepatic artery by a balloon microcatheter, flow alterations were created that led to uptake of the ⁹⁰Y microspheres by the tumor while sparing the non-diseased liver parenchyma. Thus, this innovative approach may permit the use of TARE in patients when proximal tumor vessels are inaccessible.

CIRSE Standards of Practice on Hepatic Transarterial Chemoembolisation

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing transarterial chemoembolisation. It has been developed by an expert writing group under the guidance of the CIRSE Standards of Practice Committee. It will encompass all technical details reflecting European practice of different TACE procedures (Lp-TACE, DEM-TACE, DSM-TACE, b-TACE) as well as revising the existing literature on the various clinical indications (HCC, mCRC, ICC, NET). Finally, new frontiers of development will also be discussed.

In the Era of Systemic Therapy for Hepatocellular Carcinoma Is Transarterial Chemoembolization Still a Card to Play?

Conventional transarterial embolization (cTACE) has been proven to be effective for intermediate stage hepatocellular carcinoma (HCC), with a recent systematic review showing an overall survival (OS) of 19.4 months. Nevertheless, due to the rapid development of the systemic therapeutic landscape, the place of TACE is becoming questionable. Is there still a niche for TACE in the era of immunotherapy and combination treatments such as atezolizumab-bevacizumab, which has shown an OS of 19.2 months with excellent tolerance? The development of drug-eluting microspheres (DEMs) has led to the standardization of the technique, and along with adequate selection, it showed an OS of 48 months in a retrospective study. In order to increase treatment selectivity, new catheters have also been added to the TACE arsenal as well as the use of cone-beam CT (CBCT), which provides three-dimensional volumetric images and guidance during procedures. Moreover, the TACE indications have also widened. It may serve as a "bridging therapy" for liver transplantation candidates while they are on the waiting list, and it represents a valuable downstaging tool to transplantation criteria. The aim of this review is to explore the current data on the advancements of TACE and its future place amongst the growing panel of treatments.

Blood Flow Diversion Within Hepatocellular Carcinoma (HCC) after Selective Occlusion of Feeding Arteries (SOFA) and Feasibility of Utilizing the SOFA Technique in Transarterial Chemoembolization (SOFA-TACE)

PURPOSE

Arterial feeders supplying a hepatocellular carcinoma are known to be interconnected through the sinusoid-like tumor vasculature. It was observed angiographically that when one of the feeders is selectively catheterized for drug delivery in transarterial chemoembolization (TACE), the whole tumor vasculature will be filled up, if the arterial inflow from all the other feeders is temporarily arrested with selective occlusion of feeding arteries (SOFA) using an additional catheter (balloon catheter). The feasibility of using the SOFA technique in TACE (SOFA-TACE) is discussed.

MATERIALS AND METHODS

In this prospective, monocentric feasibility study, with informed consent obtained, 8 consecutive patients of median age 64.5 years (60-68.8) and tumor dimension 4.7 cm (3.2-6.1), having specific tumor features (solitary, hypervascularity, well-defined, ≤ 7 cm, multiple tumor feeders), received SOFA-TACE using ethiodized oil-cisplatin suspension. Tumor response was assessed with 3-monthly CT using modified RECIST.

RESULTS

A single tumor feeder was catheterized for drug delivery (8 cases). All other tumor feeders were successfully occluded with a balloon at one site (8 cases). Complete filling of the vasculature of the whole tumor was achieved in 7 of 8 cases with the SOFA technique as shown on arteriogram and CT, except in a case with an intratumoral septum. There was no complication. Surveillance CT (median 25 months, range 22-28) showed complete response in all cases.

CONCLUSION

SOFA-TACE is feasible with reasonable safety and favorable treatment outcome; it may be a valuable technical option that may facilitate the procedures of selective TACE in technically challenging cases.