Lipiodol deposition in portal vein tumour thrombus predicts treatment outcome in HCC patients after transarterial chemoembolisation

Partial hepatectomy versus interventional treatment in patients with hepatitis B virus-related hepatocellular carcinoma and clinically significant portal hypertension: a randomized comparative clinical trial

BACKGROUND

The widely accepted view that portal hypertension (PHT) is a contraindication to hepatectomy for patients with hepatocellular carcinoma (HCC) is being increasingly challenged. The long-term survival outcomes and safety of partial hepatectomy versus interventional treatment using ablation with or without pre-ablation transarterial chemoembolization (TACE) in patients with HBV-related HCC within the Milan criteria and with clinically significant PHT were compared in this study.

METHODS

This open-label randomized clinical trial was conducted on consecutive patients with clinically PHT and hepatitis B virus (HBV)-related HCC with tumors which were within the Milan criteria. These patients were randomized 1:1 to receive either partial hepatectomy or interventional treatment between December 2012 and June 2018. The primary endpoint was overall survival (OS); secondary endpoints included recurrence-free survival (RFS) and therapeutic safety.

RESULTS

Each of the 2 groups had 80 patients. The 1-, 3- and 5-year OS rates in the partial hepatectomy group and the interventional treatment group were 95.0%, 86.2%, 69.5% versus 93.8%, 77.5%, 64.9%, respectively (P = 0.325). The corresponding RFS rates were 78.8%, 55.0%, 46.2% versus 71.3%, 52.5%, 45.0%, respectively (P = 0.783). The partial hepatectomy group had a higher complication rate compared to the interventional group (67.5% vs. 20%, P < 0.001). However, the differences were mainly in Clavien-Dindo Grade I complications (P < 0.001), while not significant in Grade II/III/IV/V (All P > 0.05).

CONCLUSIONS

This study shows that partial hepatectomy treatment did not meet prespecified significance for improved OS and RFS compared to interventional treatment for patients with HBV-related HCC within the Milan criteria and with clinically significant PHT. However, partial hepatectomy is still a safe procedure and should be considered as a treatment option rather than a contraindication.

Immune-Targeted Therapy with or without Transarterial Chemoembolization (TACE) for Advanced Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis (PVTT): A Multicenter Retrospective Study

PURPOSE

In the present study, we aimed to assess the effectiveness and safety of immune-targeted therapy (IT) with or without transarterial chemoembolization (TACE) for advanced hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT).

PATIENTS AND METHODS

This was a multicenter retrospective study that included 265 HCC patients with PVTT (IT + TACE: 82, IT: 183). Overall survival (OS) and progression-free survival (PFS), as well as tumor responses and adverse events, were evaluated.

RESULTS

Patients in the IT + TACE group experienced significantly longer overall survival (OS) and progression-free survival (PFS) periods, compared with those in the IT group (OS 19.0 vs. 13.0 months, p < 0.001; PFS 12.0 vs. 7.3 months, p < 0.001). Multivariable analysis confirmed IT + TACE as an independent predictor for improved OS and PFS. Subgroup analysis demonstrated the benefits of IT + TACE in patients with rich PVTT blood supply. Preoperative imaging and DSA offered predictive value.

CONCLUSIONS

TACE combined with IT provides a safe and effective treatment option for advanced-HCC patients with PVTT, particularly those with abundant PVTT blood supply.

A real-world study of tyrosine kinase inhibitors plus anti-PD-1 immunotherapy with or without chemoembolization for hepatocellular carcinoma patients with main portal vein invasion

BACKGROUND

Although systemic therapies are recommended for hepatocellular carcinoma (HCC) patients with main portal vein (MPV) invasion and preserved liver function, the outcome is limited. In the real-world, chemoembolization is a commonly used local treatment for advanced HCC.

PURPOSE

To evaluate whether the additional chemoembolization treatment yields survival benefits compared to systemic therapy for HCC patients with MPV invasion and preserved liver function (Child-Pugh score ≤ B7) in a real-world study from multiple centers.

PATIENTS AND METHODS

Between January 2020 and December 2022, 91 consecutive HCC patients with MPV invasion who received either systemic medical therapy (i.e., tyrosine kinase inhibitors (TKIs) plus anti-PD-1 immunotherapy, S group, n = 43) or in combination with chemoembolization treatment (S-T group, n = 48) from five centers were enrolled in the study. The primary outcome was overall survival (OS), and the secondary outcomes were progression-free survival (PFS) and treatment response. Adverse events (AEs) related to treatment were also recorded. Survival curves were constructed with the Kaplan-Meier method and compared using the log-rank test.

RESULTS

The baseline characteristics were comparable between the two groups. The mean number of chemoembolization sessions per patient was 2.1 (range 1-3). The median OS was 10.0 months and 8.0 months in the S-T group and S group, respectively (P = 0.254). The median PFS between the two groups was similar (4.0 months vs. 4.0 months, P = 0.404). The disease control rate between the S-T and S groups were comparable (60.4% vs. 62.8%, P = 0.816). Although no chemoembolization-related deaths occurred, 13 grade 3-4 AEs occurred in the S-T group.

CONCLUSIONS

The results of the real-world study demonstrated that additional chemoembolization treatment did not yield survival benefits compared to TKIs plus anti-PD-1 immunotherapy for the overall patients with advanced HCC and MPV invasion.

Liver resection in selective hepatocellular carcinoma with Vp3 or Vp4 portal vein tumor thrombosis improves prognosis

BACKGROUND/AIM

Hepatocellular carcinoma (HCC) tumor thrombi located in the first branch of the portal vein (Vp3) or in the main portal trunk (Vp4) are associated with poor prognosis. This study aimed to investigate the clinicopathological characteristics and risk factors for HCC recurrence and mortality following liver resection (LR) in patients with Vp3 or Vp4 HCC.

METHODS

The study included 64 patients who underwent LR for HCC with Vp3 or Vp4 portal vein tumor thrombosis (PVTT).

RESULTS

Fifty-eight patients (90.6%) had Vp3 PVTT, whereas the remaining six patients exhibited Vp4 PVTT. The median tumor size measured 8 cm, with approximately 36% of patients presented with multiple tumors. Fifty-four patients (84.4%) underwent open LR, whereas 10 patients underwent laparoscopic LR. In the Vp4 cases, combined LR and tumor thrombectomy were performed. The 3-year cumulative disease-free survival rate was 42.8% for the Vp3 group and 22.2% for the Vp4 group. The overall survival (OS) rate at 3 years was 47.9% for the Vp3 group and 60.0% for the Vp4 group. Intrahepatic metastasis has been identified as an important contributor to HCC recurrence. High hemoglobin levels are associated with high mortality.

CONCLUSION

LR is a safe and effective treatment modality for selected patients with Vp3 or Vp4 HCC PVTT. This suggests that LR is a viable option for these patients, with favorable outcomes in terms of OS.

CT-based radiomics nomogram for prediction of survival after transarterial chemoembolization with drug-eluting beads in patients with hepatocellular carcinoma and portal vein tumor thrombus

OBJECTIVES

To develop and validate a CT-based radiomics model for the prediction of the overall survival (OS) of patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT) treated with drug-eluting beads transarterial chemoembolization (DEB-TACE).

METHODS

Patients were retrospectively enrolled from two institutions for the constitution of training (n = 69) and validation (n = 31) cohorts with a median follow-up of 15 months. A total of 396 radiomics features were extracted from each baseline CT image. Features selected by variable importance and minimal depth were used for random survival forest model construction. The performance of the model was assessed using the concordance index (C-index), calibration curves, integrated discrimination index (IDI), net reclassification index (NRI), and decision curve analysis.

RESULTS

Type of PVTT and tumor number were proved to be significant clinical indicators for OS. Arterial phase images were used to extract radiomics features. Three radiomics features were selected for model construction. The C-index for the radiomics model was 0.759 in the training cohort and 0.730 in the validation cohort. To improve the predictive performance, clinical indicators were integrated into the radiomics model to form a combined model with a C-index of 0.814 in the training cohort and 0.792 in the validation cohort. The IDI was significant in both cohorts for the combined model versus the radiomics model in predicting 12-month OS.

CONCLUSIONS

Type of PVTT and tumor number affected the OS of HCC patients with PVTT treated with DEB-TACE. Moreover, the combined clinical-radiomics model had a satisfactory performance.

CLINICAL RELEVANCE STATEMENT

A CT-based radiomics nomogram, which consisted of 3 radiomics features and 2 clinical indicators, was recommended to predict 12-month overall survival of patients with hepatocellular carcinoma and portal vein tumor thrombus initially treated with drug-eluting beads transarterial chemoembolization.

KEY POINTS

• Type of portal vein tumor thrombus and tumor number were significant predictors of the OS. • Integrated discrimination index and net reclassification index provided a quantitative evaluation of the incremental impact added by new indicators for the radiomics model. • A nomogram based on a radiomics signature and clinical indicators showed satisfactory performance in predicting OS after DEB-TACE.

Mapping research trends of transarterial chemoembolization for hepatocellular carcinoma from 2012 to 2021: A bibliometric analysis

BACKGROUND

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the second leading cause of cancer-related deaths. Transcatheter arterial chemoembolization (TACE) is a therapy where drugs aimed to slow or halt tumor development are injected into the artery supplying for HCC tissues. A comprehensive analysis of all the articles on TACE for HCC can give us a general understanding of the progress in this field and provide guidance for future research.

AIM

To analyze and visualize scientific results and research trends in TACE treatment for HCC.

METHODS

The "Web of Science" database was used to identify articles regarding TACE for the treatment of HCC from 2012 to 2021. VOSviewer and CiteSpace were used to analyze the publications trends, collaboration between countries/insti-tutions/authors, and the co-occurrence of keywords, keyword bursts, and references.

RESULTS

A total of 5728 original articles on TACE for HCC were retrieved. Regarding the volume of publications, the total number of yearly publications showed a generally increasing trend. China had the highest number of articles, while the United States achieved the highest Hirsch index and highest number of citations. The Sun Yat-sen University in China was most prolific institution. The most active author was Park, J.W from South Korea. The Journal of Vascular and Interventional Radiology (234 articles) was the most productive journal. There is a growing trend toward international collaboration in TACE for HCC. Cluster networks of co-cited references suggested that practice guidelines and targeted therapies are an essential theme in this field. In addition, cluster analysis based on keyword co-occurrence identified the research topic "prediction of TACE treatment" as a hotspot, and propensity score matching can be used to help investigators conduct innovative studies in the future.

CONCLUSION

The results of our bibliometric analysis provide the latest trends and hot topics in TACE therapy for HCC.

TACE-HAIC combined with targeted therapy and immunotherapy versus TACE alone for hepatocellular carcinoma with portal vein tumour thrombus: a propensity score matching study

BACKGROUND

The long-term survival of patients with hepatocellular carcinoma (HCC) with portal vein tumour thrombus (PVTT) is poor. Systemic therapy, transcatheter arterial chemoembolization (TACE), and hepatic artery infusion chemotherapy are widely used in HCC patients with PVTT. This study aims to explore the efficacy of combining systemic therapy with transarterial-based therapy in HCC patients with PVTT.

MATERIALS AND METHODS

The authors retrospectively reviewed data of HCC patients with PVTT treated with combination therapy (TACE-hepatic artery infusion chemotherapy with tyrosine kinase inhibitors and PD-1 inhibitors) or TACE alone in SYSUCC from 2011 to 2020. The overall survival (OS), progression-free survival, and overall response rate were compared. Propensity score matching was used to minimize confounding bias.

RESULTS

A total of 743 HCC patients with PVTT received combination therapy ( n =139) or TACE alone ( n =604). After propensity score matching, the overall response rate was significantly higher in the combination group than in the TACE group [42.1% vs. 5.0%, P < 0.001 (response evaluation criteria in solid tumours); 53.7% vs. 7.8%, P < 0.001 (modified response evaluation criteria in solid tumours)]. The combination group showed significantly better OS than the TACE group (median OS not reached vs. 10.4 months, P < 0.001). The median progression-free survival of the combination and TACE groups was 14.8 and 2.3 months ( P < 0.001), respectively. Tumour downstaging followed by salvage liver resection was significantly more common for the combination therapy group than for TACE group (46.3% vs. 4.5%, P < 0.001). After salvage liver resection, 31.6% (30/95) and 1.7% (3/179) of the patients achieved a pathological complete response in the combination and TACE groups, respectively ( P < 0.001). The grade 3/4 adverse events rates were similar between the two groups (28.1% vs. 35.9%, P =0.092).

CONCLUSION

Compared with TACE alone, combination therapy was safe enough and resulted in survival benefits. This is a promising treatment option for HCC patients with PVTT.

Study on the changes of CT texture parameters before and after HCC treatment in the efficacy evaluation and survival predication of patients with HCC

Objective

To investigate texture parameters of contrast-enhanced computed tomography (CT) images before and after transarterial chemoembolization (TACE) as a tool for assessing the therapeutic response and survival predication in hepatocellular carcinoma (HCC).

Materials and methods

Data of 77 HCC patients who underwent three-phase dynamic contrast-enhanced CT examination within 4 weeks before and 4–8 weeks after TACE were collected and efficacy evaluation was performed according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST) standard. The remission group consisted of 31 patients (12 with complete remission+19 with partial remission), while the non-remission group consisted of 46 patients (27 with stable disease+19 with progressive disease). Full-volume manual delineation of the region of interest (ROI) and texture analysis of the ROI were performed on the CT images using FireVoxel software. Changes in the 48 texture parameters from three-phase CT images before and after TACE were calculated and compared between the two groups. The receiver operating characteristic (ROC) curve and the areas under the curve (AUC) were used to analyze the diagnostic performance of texture parameters. A multifactorial Cox model was used for predicting survival. The C-indices of texture parameter difference values with predictive value, texture features model, and texture features combined with mRECIST in predicting OS were compared with those of mRECIST.

Results

A total of 41 changes in texture parameters were statistically significant between the remission and non-remission groups. The receiver operating characteristic (ROC) curve showed that the AUC of changes in the 90th percentile in the arterial phase was the largest at 0.842. When the cut-off value was 70.50, the Youden index was the largest (0.621), and the sensitivity and specificity were 0.710 and 0.911, respectively. Three changes in texture parameters were independent factors associated with patient survival, with a hazard of 0.173, 2.068, and 1.940, respectively. The C-index of the OS predicted by the texture features model was not statistically different from that of the mRECIST (0.695 vs. 0.668, p=0.493). While the C-indices of skewness in the portal venous phase combined with mRECIST (0.729, p=0.015), skewness in the delayed phase combined with mRECIST (0.715, p=0.044), and skewness in both two phases combined with mRECIST (0.728, p=0.017) were statistically different.

Conclusion

Changes in the texture parameters of CT images before and after TACE treatment can be used to obtain relevant grayscale histogram parameters for evaluating the early efficacy of TACE in HCC treatment. And the texture analysis combined with mRECIST may be superior to the mRECIST alone in predicting survival in HCC after TACE treatment.

I-125 seeds insertion with TACE for advanced HCC: a meta-analysis of randomized controlled trials

PURPOSE

To assess the effectiveness of I-125 seeds (IS) insertion with transcatheter arterial chemoembolization (TACE) in treating patients with advanced hepatocellular carcinoma (HCC).

MATERIAL AND METHODS

An extensive search was conducted for relevant randomized controlled trials (RCTs) from the establishment date of each database to November 2020.

RESULTS

A total of nine RCTs were included in this study. Our analysis showed no significant changes in the pooled Δalpha-fetoprotein values (p = .06), incident rates of myelosuppression (p = .46), vomit occurrence (p = .27), and abnormal liver function (p = .42) between the two treatment groups. However, the complete response (p < .00001), total response (p < .00001), and disease control (p < .00001) rates were significantly higher in patients who underwent TACE with IS insertion, as opposed to patients who received TACE alone. Furthermore, patients who underwent TACE with IS insertion experienced markedly longer pooled overall survival (OS) time (p < .0001), with better OS rates at the six-month (p = .0002), one-year (p < .0001), and three-year (p = .0003) follow-ups than patients who received TACE alone.

CONCLUSION

TACE with IS insertion can significantly improve clinical response and prolong the survival of advanced HCC patients.

Assessment of efficacy and prognostic factors by Gelfoam for DEB-TACE in unresectable large hepatocellular carcinoma with portal vein tumor thrombus: a multi-center retrospective study

OBJECTIVE

To explore the clinical efficacy and prognostic factors of the use of Gelfoam for drug-eluting bead (DEB) transarterial chemoembolization (GMD-TACE) in patients with unresectable large hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT).

METHODS

A retrospective analysis was conducted using the mRECIST standard to evaluate tumor response after GMD-TACE. Overall survival time, median survival time, time to progression (TTP) after the first intervention, and other treatment methods were recorded.

RESULTS

The follow-up time was 2-110 months (mean 17.97 + 19.12 months), the median follow-up time was 12.5 months, and the first TTP after the first GMD-TACE was 4 months (95% CI 3.020-4.980). The median overall survival (OS) time was 14 months (95% CI 9.801-18.199). The 1-, 3-, and 5-year survival rates were 53.6%, 32.3%, and 8.9%, respectively. Multivariate analysis showed that the type of tumor thrombus was an independent factors affecting prognosis, and combination therapy was a protective factor affecting prognosis.

CONCLUSIONS

GMD-TACE can be used as the core treatment for unresectable large HCC combined with a PVTT. This can improve the quality of life and further improve the median OS, and is worthy of clinical promotion and application.

I-125 seeds brachytherapy with transcatheter arterial chemoembolization for subcapsular hepatocellular carcinoma

BACKGROUND

I-125 seeds brachytherapy (ISB) has been used to improve the clinical effectiveness of transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). We aim to appraise the safety and clinical efficacy of combined ISB and TACE for the treatment of subcapsular HCC.

MATERIALS AND METHODS

A retrospective investigative study extending from January 2017 to December 2020, involved individuals suffering from subcapsular HCC, who were subjected to TACE treatment with or without ISB in our center. The clinical effectiveness was compared between 2 groups.

RESULTS

Sixty-four patients, in total, with subcapsular HCC had to undergo TACE with (n = 32) or without (n = 32) ISB in our center. After CT-guided ISB, only 2 (6.3%) patients experienced a self-limited pneumothorax. Combined treatment resulted in a significantly higher complete response (56.3% vs. 18.8%, P = 0.002) and total response (90.7% vs. 59.4%, P = 0.004) rates than that of TACE alone. In comparison to the TACE alone group, the median progression-free survival was substantially longer in the combined treatment group (11 months vs. 5 months, P = 0.016). Further, 15 and 28 patients in combined and TACE alone groups respectively died within the follow-up. The median OS was comparable between combined and TACE alone groups (22 months vs. 18 months, P = 0.529).

CONCLUSIONS

Combined TACE and ISB therapy is a safe treatment method for individuals suffering from subcapsular HCC. When compared, combined treatment had significantly enhanced clinical efficacy as a subcapsular HCC therapy, in comparison to TACE alone.

Management of hepatocellular carcinoma patients with portal vein tumor thrombosis: A narrative review

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the main reasons for malignancy-related death. Portal vein tumor thrombosis (PVTT) is the most common form of macrovascular invasion related to HCC occurring in 10%-60% of patients. HCC with PVTT is usually characterized by worsening liver function, vulnerability to blood metastasis, higher incidence of complications associated with portal hypertension, and intolerance to treatment when compared with that without PVTT. If only treated with supportive care, the median survival of HCC with PVTT is about 2.7 months. In the past, sorafenib was the only recommended therapy by guidelines with limited effectiveness. This narrative review aimed to describe the current management options for HCC with PVTT.

DATA SOURCES

We have reviewed literature from PubMed on the treatment of HCC with PVTT and compiled evidence-based facts on effective therapies available for different types of PVTT.

RESULTS

Sorafenib monotherapy is not much effective, but combining it with other methods can improve survival. Each type of PVTT can benefit from the combination of transarterial chemoembolization and sorafenib than sorafenib monotherapy. The tumor downstaging can be realized possibly after transarterial chemoembolization, but tumor invasion into the main trunk of the portal vein greatly impairs efficacy. Although surgery is a curative approach, it is often not recommended for Vp4 PVTT. Some new methods can broaden the indication, but further explorations are needed. Radiotherapy can decrease the possibility of Vp3 progression to Vp4, but building a forecast model of best radiation dose and response is necessary. Systemic chemotherapy, hepatic arterial infusion chemotherapy, radiofrequency ablation, portal stenting, and traditional Chinese medicine are also beneficial in Vp3-4 PVTT. The accurate diagnosis of PVTT can be made by radiomics, and prognostic classification models can be used to design personalized treatments. The application of new treatment methods such as the atezolizumab plus bevacizumab scheme may increase survival.

CONCLUSIONS

HCC with PVTT is still a thorny problem, and effective therapeutics need to be explored.

Copy number profiling of circulating free DNA predicts transarterial chemoembolization response in advanced hepatocellular carcinoma

Transarterial chemoembolization (TACE) is the most commonly used treatment for advanced hepatocellular carcinoma (HCC), but still lacks accurate real-time biomarkers for monitoring its therapeutic efficacy. Here, we explored whether copy number profiling of circulating free DNA (cfDNA) could be utilized to predict responses and prognosis in HCC patients with TACE treatment. In total, 266 plasma cfDNA samples were collected from 64 HCC patients, 57 liver cirrhosis (LC) patients and 32 healthy volunteers. We performed low-depth whole-genome sequencing (LD-WGS) on cfDNA samples to conduct copy number variants (CNVs) analysis and tumor fraction (TFx) quantification. Then, the correlation between TFx/CNVs and therapeutic efficacy, treatment outcomes and lipiodol deposition were explored. The change of TFx during TACE treatment was associated with patient tumor burden and could accurately predict treatment response and prognosis, and at an earlier timepoint than modified RECIST (mRECIST) assessment, providing an alternative strategy: the chromosomal 16q/NQO1 amplification indicated worse therapeutic response; in patients who underwent multiple TACE sessions, TFx change during their first TACE treatment reflected the long-term survival; additionally, the copy number amplification of chromosome 1q, 3p, 6p, 8q, 10p, 12q, 18p or 18q affected lipiodol deposition. Overall, we have provided a new liquid biopsy approach for future TACE management of HCC patients.

Transarterial Chemoembolization Combined With Endoscopic Therapy Is Beneficial for Unresectable Hepatocellular Carcinoma With Esophagogastric Varices

Background

The efficacy of transarterial chemoembolization (TACE) combined with endoscopic therapy for unresectable hepatocellular carcinoma with esophagogastric varices remains unclear.

Methods

The study has been registered on ClinicalTrials.gov with the number NCT05017922 (https://register.clinicaltrials.gov). Eligible patients were divided into combined group (received TACE plus endoscopic therapy) and control group (only received TACE). The occurrence of death and bleeding episodes during the follow-up was recorded. Kaplan–Meier analysis was used to compare outcomes between the two groups. Cox proportional hazard model was used to determine independent predictors for the survival.

Results

Eighty-nine patients were included, 42 in the combined group, others in the control group. During the follow-up, 51 patients died, the 1-year, 2-year, and 3-year survival rates were 64.9%, 45.5%, and 34.5%. The cumulative survival was significantly higher in the combined group than in the control group (p = 0.027); the 1-year, 2-year, and 3-year survival rates were 75.5%, 55.9%, 43.8% and 55.0%, 35.9%, 26.6%, respectively. Forty-four patients experienced bleeding, the bleeding rate was significantly higher in the control group than in the combined group (77.4% vs. 56.8%, p = 0.016). Multivariate analysis showed that treatment, hemoglobin, portal vein tumor thrombosis, and aspartate aminotransferase were independent predictors for overall survival; the first three factors were also independent predictors for bleeding-free survival. Patients who received primary prophylaxis had longer overall survival (p = 0.042) and bleeding-free survival (p = 0.029) than those who received secondary prophylaxis.

Conclusions

TACE combined with endoscopic therapy significantly improved survival and reduced bleeding rates in unresectable hepatocellular carcinoma with esophagogastric varices patients. Portal vein tumor thrombosis was a strong negative prognostic factor for both overall survival and bleeding-free survival. Primary prophylaxis improved survival benefits compared with secondary prophylaxis.

Intraarterial Lidocaine Administration for Pain Control by Water-in-Oil Technique in Transarterial Chemoembolization: in vivo and Randomized Clinical Trial

Objective

To investigate the sustained release of lidocaine from a lidocaine–epirubicin–lipiodol emulsion created by water-in-oil (W/O) technique in vivo and evaluate the efficacy and safety of intraarterial lidocaine administration for intra- and postoperative pain control in transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

Methods

The in vivo concentrations of lidocaine were determined in tumor tissues after VX2 rabbit models for hepatic tumor were administered with intra-arterial lidocaine–epirubicin–lipiodol emulsion. A prospective randomized controlled clinical trial was performed, enrolling 70 consecutive patients who underwent TACE. Patients were randomized into two groups: Group A received an immediate bolus intraarterial lidocaine injection before TACE, and Group B received a lidocaine–epirubicin–lipiodol emulsion during TACE. Pain intensity was compared between the two groups using a visual analog scale (VAS) score before (T_before) and at 0 h (T₀), 4 h (T₄), 8 h (T₈), 24 h (T₂₄), 48 h (T₄₈), and 72 h (T₇₂) after the procedure. Adverse events and intake of analgesics were evaluated and compared between the two groups.

Results

The concentrations of lidocaine in tumor tissues were higher in experimental group than in control group at T_0.5 (P=0.004), T₁ (P=0.038), T₄ (P=0.036), and T₈ (P=0.029). In the clinical trial, VAS scores in Group B were significantly lower than in Group A at T₀ (P=0.006), T₄ (P=0.001), T₈ (P=0.002), and T₂₄ (P=0.005). The tramadol intake in Group B was significantly lower than in Group A (P=0.021). No significant difference was observed regarding the incidence of adverse events between the two groups.

Conclusion

This study demonstrated the effectiveness and safety of intraarterial lidocaine administration using the W/O technique in controlling intra- and post-TACE pain.

The Progress in the Treatment of Hepatocellular Carcinoma With Portal Vein Tumor Thrombus

Hepatocellular carcinoma (HCC) is one of most prevalent cancer and is a serious healthcare issue worldwide. Portal vein tumor thrombus (PVTT) is a frequent complication and remains as the blockage in the treatment of HCC with high recurrence rate and poor prognosis. There is still no global consensus or standard guideline on the management of HCC with PVTT. In western countries, Sorafenib and Lenvatinib are recommended as the first-line treatment options for HCC patients with PVTT where this condition is now regarded as BCLC Stage C regardless of PVTT types. However, there is growing evidence that supports the close relationship of the extent of PVTT to the prognosis of HCC. Besides the targeted therapy, more aggressive treatment modalities have been proposed and practiced in the clinic which may improve the prognosis of HCC patients with PVTT and prolong the patients’ survival time, such as transarterial chemoembolization, radiotherapy, hepatic resection, liver transplantation, and various combination therapies. Herein, we aim to review and summarize the advances in the treatment of HCC with PVTT.

Brachytherapy with Iodine-125 seeds for treatment of portal vein-branch tumor thrombus in patients with hepatocellular carcinoma

BACKGROUND

There is currently no widely-accepted consensus for the management of hepatocellular carcinoma with portal vein tumor thrombus. We evaluate the safety and efficacy of ultrasound-guided percutaneous brachytherapy with iodine-125 seeds for the treatment of hepatocellular carcinoma with portal vein-branch tumor thrombus (PVBTT).

METHODS

Sixty-nine hepatocellular carcinoma patients with PVBTT were enrolled; 34 received transarterial chemoembolization (TACE) combined with iodine-125 seeds implanted in the PVBTT; 35 were treated with TACE alone. Adverse events, objective response rate, disease control rate, progression-free survival, and overall survival were compared between the two groups. Tumor responses of PVBTT and intrahepatic tumor were correlated. Multivariate and subgroup analyses were conducted for overall survival.

RESULTS

No grade 3 or 4 adverse events were recorded, and there was no difference in grade 1 or 2 adverse events between the two groups. Objective response rate and disease control rate for PVBTT were 58.9 and 91.2%, respectively, in the combined treatment group, which were significantly greater than the 5.7 and 54.3% rates, respectively, in the TACE-alone group (both p's ≤ 0.001). Intrahepatic tumor response was positively correlated with the PVBTT response (γ = 0.782, p < 0.01). Survival outcomes were better in the combined treatment group than in the TACE-alone group: the median progression-free survival for PVBTT was 9 months versus 3 months (HR = 0.187 [95% CI: 0.101, 0.345], p < 0.001), and the median overall survival was 11 months versus 7 months (HR = 0.448 [95% CI: 0.265, 0.758], p = 0.003). Multivariate analysis revealed that application of brachytherapy and lower grade PVBTT (Vp1 + Vp2 vs. Vp3) were protective predictors of overall survival. In stratified analysis, the benefit of overall survival was more significant in the subgroup of PVBTT Vp1 + Vp2 rather than in Vp3.

CONCLUSIONS

The combination of iodine-125 seed brachytherapy guided by ultrasound and TACE is a convenient, safe, and effective treatment for patients with HCC and PVBTT, conferring a better survival benefit than TACE alone.

Prognostic Accuracy of the ADV Score Following Resection of Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis

BACKGROUND

We assessed the prognostic accuracy of ADV score (α-fetoprotein [AFP]-des-γ-carboxyprothrombin [DCP]-tumor volume [TV] score) following resection of hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT).

METHODS

This was a retrospective observational study. This study included 147 patients who underwent hepatic resection for HCC with PVTT. They were followed up for ≥ 66 months or until patient death.

RESULTS

The grades of PVTT were Vp1 in 121 (14.3%), Vp2 in 41 (27.9%), Vp3 in 71 (48.3%), and Vp4 in14 (9.5%) cases. Preoperative HCC treatment was performed in 48 (32.7%) patients. R0 and R1 resections were performed in 119 (81.0%) and 28 (19.0%) cases, respectively. The 5-year tumor recurrence, HCC-specific survival, and post-recurrence survival rates were 79.2%, 43.5%, and 25.4%, respectively. Neither PVTT grade nor history of preoperative HCC treatment was a significant prognostic indicator. Stratification in accordance with ADV scores of 1log- and 3log-intervals resulted in high prognostic accuracy in predicting tumor recurrence and patient survival. Following cluster analysis, the cutoff for ADV score was determined at 9log and was more prognostically significant in terms of tumor recurrence and patient survival than surgical curability or microvascular invasion. Further comparisons revealed that prognostic prediction with an ADV score cutoff at 9log was more accurate than that using the Eastern Hepatobiliary Surgery Hospital-PVTT score.

CONCLUSIONS

ADV score is an integrated surrogate biomarker for post-resection prognosis in HCC with PVTT. Our prognostic prediction model using ADV scores provides reliable post-resection prognosis for patients with various grades of these tumors.

Hepatic Artery Infusion Chemotherapy Using Fluorouracil, Leucovorin, and Oxaliplatin versus Transarterial Chemoembolization as Initial Treatment for Locally Advanced Hepatocellular Carcinoma: A Propensity Score-Matching Analysis

PURPOSE

To compare the efficacy and safety of hepatic arterial infusion chemotherapy (HAIC) with a modified fluorouracil, leucovorin, and oxaliplatin (mFOLFOX) regimen with that of transarterial chemoembolization as a locoregional treatment for patients with locally advanced hepatocellular carcinoma (HCC).

METHODS

This retrospective study included adult patients with locally advanced HCC who received first-line treatment with either HAIC-mFOLFOX or conventional transarterial chemoembolization monotherapy from January 2015 to December 2016. The outcomes, including tumor response rates, evaluated via imaging assessment using the modified response evaluation criteria in solid tumors; overall survival; progression-free survival; and safety, were compared. The propensity score-matching methodology was used to reduce the influence of confounding factors on the outcomes.

RESULTS

The study included 131 patients with locally advanced HCC who underwent transarterial chemoembolization and 101 who received HAIC-mFOLFOX as initial treatment. After propensity score matching (n = 67 in each group), patients who received HAIC-mFOLFOX had a higher objective response rate (43.3% vs 13.4%, P = .001), longer median overall survival (13.9 vs 6.0 months, P < .001), and longer median progression-free survival (6.4 vs 2.8 months, P = .001) than those who underwent transarterial chemoembolization. The survival benefit with HAIC-mFOLFOX was strengthened in patients with HCC with vascular invasion (hazard ratio: 0.379; 95% confidence interval: 0.237-0.607). HAIC-mFOLFOX was associated with lower incidences of severe adverse events (8.9% vs 22.9%) and liver toxicity than transarterial chemoembolization.

CONCLUSIONS

Compared with transarterial chemoembolization, HAIC-mFOLFOX is a potentially safer and more effective locoregional therapy for patients with locally advanced HCC.

Conversion to Resectability Using Transarterial Chemoembolization Combined With Hepatic Arterial Infusion Chemotherapy for Initially Unresectable Hepatocellular Carcinoma

Objective

To evaluate whether this conversion rate to resectability could be increased when patients are treated with transarterial chemoembolization and hepatic arterial infusion chemotherapy (TACE-HAIC) using oxaliplatin plus fluorouracil/leucovorin.

Background

Conventional TACE (c-TACE) is a common regimen for initially unresectable hepatocellular carcinoma (HCC), which converts to curative-intent resection in about 10% of those patients. It is urgent need to investigated better regimen for those patients.

Methods

The data of 83 initially unresectable HCC patients were examined, including 41 patients in the TACE-HAIC group and 42 patients in the c-TACE group. Their response rate, conversion rate to resection, survival outcome, and adverse events were compared.

Results

The conversion rate was significantly better in the TACE-HAIC group than in the c-TACE group (48.8% vs 9.5%; P < 0.001). The TACE-HAIC had marginal superiority in overall response rate as compared to c-TACE (14.6% vs 2.4%; P = 0.107 [RECIST]; 65.9% vs 16.7%; P < 0.001 [mRECIST], respectively). The median progression-free survival was not available and 9.2 months for the TACE-HAIC and cTACE groups, respectively (hazard rate [HR]: 0.38; 95% confidence interval [CI], 0.20-0.70; P = 0.003). The median overall survival was not available and 13.5 months for the TACE-HAIC and c-TACE groups, respectively (HR, 0.63; 95% CI, 0.34-1.17; P = 0.132). The 2 groups had similar rates of grade 3/4 adverse events (all P > 0.05).

Conclusions

TACE-HAIC demonstrated a higher conversion rate and progression-free survival benefit than c-TACE and could be considered as a more effective regimen for patients with initially unresectable HCC. Future prospective randomized trials are needed to confirm it.

Prospective study of Lipiodol distribution as an imaging marker for doxorubicin pharmacokinetics during conventional transarterial chemoembolization of liver malignancies

OBJECTIVES

To evaluate the prognostic potential of Lipiodol distribution for the pharmacokinetic (PK) profiles of doxorubicin (DOX) and doxorubicinol (DOXOL) after conventional transarterial chemoembolization (cTACE).

METHODS

This prospective clinical trial ( ClinicalTrials.gov : NCT02753881) included 30 consecutive participants with liver malignancies treated with cTACE (5/2016-10/2018) using 50 mg DOX/10 mg mitomycin C emulsified 1:2 with ethiodized oil (Lipiodol). Peripheral blood was sampled at 10 timepoints for standard non-compartmental analysis of peak concentrations (C_max) and area under the curve (AUC) with dose normalization (DN). Imaging markers included Lipiodol distribution on post-cTACE CT for patient stratification into 1 segment (n = 10), ≥ 2 segments (n = 10), and lobar cTACE (n = 10), and baseline enhancing tumor volume (ETV). Adverse events (AEs) and tumor response on MRI were recorded 3-4 weeks post-cTACE. Statistics included repeated measurement ANOVA (RM-ANOVA), Mann-Whitney, Kruskal-Wallis, Fisher's exact test, and Pearson correlation.

RESULTS

Hepatocellular (n = 26), cholangiocarcinoma (n = 1), and neuroendocrine metastases (n = 3) were included. Stratified according to Lipiodol distribution, DOX-C_max increased from 1 segment (DOX-C_max, 83.94 ± 75.09 ng/mL; DN-DOX-C_max, 2.67 ± 2.02 ng/mL/mg) to ≥ 2 segments (DOX-C_max, 139.66 ± 117.73 ng/mL; DN-DOX-C_max, 3.68 ± 4.20 ng/mL/mg) to lobar distribution (DOX-C_max, 334.35 ± 215.18 ng/mL; DN-DOX-C_max, 7.11 ± 4.24 ng/mL/mg; p = 0.036). While differences in DN-DOX-AUC remained insignificant, RM-ANOVA revealed significant separation of time concentration curves for DOX (p = 0.023) and DOXOL (p = 0.041) comparing 1, ≥ 2 segments, and lobar cTACE. Additional indicators of higher DN-DOX-C_max were high ETV (p = 0.047) and Child-Pugh B (p = 0.009). High ETV and tumoral Lipiodol coverage also correlated with tumor response. AE occurred less frequently after segmental cTACE.

CONCLUSIONS

This prospective clinical trial provides updated PK data revealing Lipiodol distribution as an imaging marker predictive of DOX-C_max and tumor response after cTACE in liver cancer.

KEY POINTS

• Prospective pharmacokinetic analysis after conventional TACE revealed Lipiodol distribution (1 vs. ≥ 2 segments vs. lobar) as an imaging marker predictive of doxorubicin peak concentrations (C_max). • Child-Pugh B class and tumor hypervascularization, measurable as enhancing tumor volume (ETV) at baseline, were identified as additional predictors for higher dose-normalized doxorubicin C_max after conventional TACE. • ETV at baseline and tumoral Lipiodol coverage can serve as predictors of volumetric tumor response after conventional TACE according to quantitative European Association for the Study of the Liver (qEASL) criteria.

The PPRD score stratifies patients with hepatocellular carcinoma and portal vein tumor thrombus treated with sorafenib plus transarterial chemoembolization

OBJECTIVES

To identify clinical prognostic and predictive factors in patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT) undergoing sorafenib plus transarterial chemoembolization (TACE) and establish a prognostic score for these patients.

METHODS

Between January 2012 and December 2017, 184 consecutive patients with HCC and PVTT were concurrently treated with sorafenib and TACE. Univariate and multivariate analyses were performed to explore the clinical factors independently correlated with overall survival (OS). A prognostic score was then developed to identify different prognoses in an initial cohort and validated in an external cohort (n = 72).

RESULTS

In the multivariate analysis, performance status, extension of PVTT, initial radiological response, and sorafenib-related dermatologic toxicity were identified as predictors associated with OS. These factors were used to develop a prognostic score (PPRD score, range from 0 to 11). The median survival was found to decrease as the PPRD score increased, and patients were stratified into a favorable group (0 points), intermediate group (1-4 points), and dismal group (> 4 points). The median survival of patients in the three groups was 34.0 months, 20.0 months, and 7.0 months, respectively (p < 0.001). Additionally, the time to progression (TTP) (p < 0.001) was stratified along the same prognostic groups. The external validation cohort confirmed the prognostic scores.

CONCLUSIONS

The proposed score system can accurately stratify the outcomes of patients with HCC and PVTT treated with sorafenib plus TACE to help identify which group of patients may benefit from treatment.

KEY POINTS

• The survival benefits of patients with advanced HCC treated with sorafenib plus TACE remains controversial. • The independent factors associated with survival were identified to develop a prognostic score, called the PPRD score (standing for performance status, PVTT grade, radiological response, and sorafenib-related dermatologic toxicity); the median survival decreases as the score increases. • The scoring system can accurately stratify the survival benefits of patients with HCC and PVTT treated with combination therapy and help to identify which group of patients may benefit from the treatment. Graphical abstract.

Transcatheter arterial chemoembolization alone or combined with ablation for recurrent intermediate-stage hepatocellular carcinoma: a propensity score matching study

PURPOSE

The recurrence after curative hepatectomy is common. Limited data have investigated the effect of transcatheter arterial chemoembolization (TACE) combined with ablation in treating recurrent intermediate-stage hepatocellular carcinoma (HCC) after hepatectomy. We aim to compare the efficacy of TACE combined with ablation versus TACE alone in treating recurrent intermediate-stage HCC after hepatectomy.

METHODS

A total of 183 patients with recurrent intermediate-stage HCC after hepatectomy were enrolled at Sun Yat-sen University Cancer Centre, including 111 patients who underwent TACE alone and 72 patients who underwent TACE combined with ablation (TACE-Ablation). Overall survival (OS) and progression-free survival (PFS) were compared by the log-rank test. Propensity score matching (PSM) was used to reduce the confounding bias.

RESULTS

Before PSM, the 5-year OS rates were 43.3% vs. 27.9% (P = 0.001), and the 5-year PFS rates were 21.7% vs. 13.0% (P < 0.001) for TACE-Ablation and TACE-alone groups, respectively. After PSM, TACE-Ablation still resulted in better 5-year OS (41.6% vs. 30.2%, P = 0.028) and 5-year PFS rate (21.3% vs. 15.8%, P = 0.024) than that of TACE alone. Patients in TACE-Ablation group exhibited similar major complication rates to TACE-alone group but higher minor complication rates both before and after PSM. Cox regression analysis identified TACE-alone modality as an independently unfavourable predictor for OS and PFS (both P < 0.05).

CONCLUSION

TACE combined with ablation is safe and superior to TACE alone in tumour control and prolonging overall survival in recurrent intermediate-stage HCC after hepatectomy.

The safety and efficacy of balloon-occluded transcatheter arterial chemoembolization for hepatocellular carcinoma refractory to conventional transcatheter arterial chemoembolization

OBJECTIVES

To evaluate the safety and efficacy of balloon-occluded transcatheter arterial chemoembolization (B-TACE) for the treatment of HCC refractory to conventional TACE (C-TACE).

METHODS

This single-center retrospective analysis included 60 consecutive patients who underwent B-TACE (mean age, 61.4 years; male:female ratio, 4.5:1) for the treatment of residual viable (n = 40) or recurrent HCC (n = 20) refractory to C-TACE between November 2017 and November 2018. Technical success, radiologic response rate (proportion of the patients achieving complete response [CR] or partial response [PR] on first follow-up CT according to m-RECIST), major complication rate, and time to progression (TTP) were evaluated. The TTP of B-TACE was also compared with that of the last C-TACE. Factors associated with achieving CR and TTP were explored.

RESULTS

B-TACE resulted in 100% technical success and radiologic response rate (CR in 45 and PR in 15 patients). The major complication rate was 6.7% (4/60). The median TTP after B-TACE was 5.3 months (95% confidence interval [CI], 4.0-6.9 months). The TTP of B-TACE for treating residual HCC was significantly longer than that of the last C-TACE (median [95% CI], 4.4 [3.2-6.9] vs. 2.7 [2.3-4.4] months; p = 0.013). BCLC stage C (adjusted OR, 4.448; 95% CI, 1.691-11.700; p = 0.002) and multiplicity of HCC (adjusted OR, 2.746; 95% CI, 1.206-6.251; p = 0.016) were significantly associated with tumor progression after B-TACE.

CONCLUSIONS

B-TACE is safe and effective for the treatment of HCC refractory to C-TACE. BCLC stage C and multiplicity of HCC were independent factors associated with TTP after B-TACE.

KEY POINTS

• B-TACE for the treatment of HCC refractory to C-TACE showed a 100% radiologic response at first follow-up and a significantly longer TTP than the last C-TACE when treating residual tumor. • The major complication rate after B-TACE was 6.7%. Although AST, ALT, and total bilirubin increase were more profound in B-TACE than in the last C-TACE, these were normalized at the first follow-up. • Tumor size, multiplicity of HCC, and hepatic arterial injury were independent factors associated with achieving a complete response. BCLC stage C and multiplicity of HCC were significantly associated with TTP after B-TACE.

Tracking the important role of JUNB in hepatocellular carcinoma by single-cell sequencing analysis

Hepatocellular carcinoma (HCC) is the most commonly diagnosed liver cancer, accounting for ~90% of all primary malignancy of the liver. Although various medical treatments have been used as systemic therapies, patient survival time may be extended by only a few months. Moreover, the underlying mechanisms of HCC development and progression remain poorly understood. In the present study, the single-cell transcriptome of one in vivo HCC tumor sample, two in vitro HCC cell lines and normal peripheral blood mononuclear cells were analysed in order to identify the potential mechanism underlying the development and progression of HCC. Interestingly, JunB proto-oncogene was identified to serve a role in the immune response and in development and progression of HCC, potentially contributing to the development of novel therapeutics for HCC patients.