A prediction model for overall survival after transarterial chemoembolization for hepatocellular carcinoma invading the hepatic vein or inferior vena cava

Intermediate-stage (BCLC stage B) infiltrative hepatocellular carcinoma: safety and efficacy of chemoembolization

OBJECTIVES

To evaluate the safety and efficacy of chemoembolization in patients with intermediate-stage infiltrative Hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This retrospective study evaluated outcomes in treatment-naïve patients who received chemoembolization as first-line treatment for intermediate-stage infiltrative HCC between 2002 and 2022. Of the 2029 treatment-naïve patients who received chemoembolization as first-line treatment for intermediate-stage HCC, 244 (12%) were identified as having the infiltrative type. After excluding two patients lost to follow-up, 242 patients were evaluated.

RESULTS

Median post-chemoembolization overall survival (OS) was 16 months. Multivariable Cox analysis identified four factors predictive of OS: Child-Pugh class B (hazard ratio [HR], 1.84; p = 0.001), maximal tumor size ≥ 10 cm (HR, 1.67; p < 0.001), tumor number ≥ 4 (HR, 1.42; p = 0.037), and bilobar tumor involvement (HR, 1.64; p = 0.003). These four factors were used to create pretreatment prediction models, with risk scores of 0-1, 2-4, and 5-7 defined as low, intermediate, and high risk, respectively. Median OS times in these three groups were 34, 18, and 8 months, respectively (p < 0.001). The objective tumor response rate following chemoembolization was 53%. The major complication rate was 9% overall and was significantly higher in the high-risk group (22%) than in the low (2%) and intermediate (3%) risk groups (p < 0.001).

CONCLUSION

Chemoembolization is safe and effective in selected patients with intermediate-stage infiltrative HCC. Chemoembolization is not recommended in high-risk patients with intermediate-stage infiltrative HCC because of poor OS and high rates of major complications.

CLINICAL RELEVANCE STATEMENT

A pretreatment prediction model was developed using four risk factors associated with overall survival following chemoembolization for intermediate-stage infiltrative hepatocellular carcinoma. This model may provide valuable information for clinical decision-making.

KEY POINTS

• Four risk factors (Child-Pugh score B, maximal tumor size ≥ 10 cm, tumor number ≥ 4, and bilobar tumor involvement) were used to create pretreatment prediction models, with risk scores of 0-1, 2-4, and 5-7 defined as low, intermediate, and high risk, respectively. • Median overall survival (OS) times and major complication rate in these three groups were 34, 18, and 8 months, and 2%, 3%, and 22%, respectively (p < 0.001). Chemoembolization is not recommended in high-risk patients with intermediate-stage infiltrative Hepatocellular carcinoma (HCC) because of poor OS and high rates of major complications.

Review of outcomes of combination therapy using yttrium 90 radioembolization and sorafenib/nivolumab for HCC with hepatic vein or IVC invasion

Background

A systematic review of the outcomes of combination therapy using Yttrium 90 radioembolization (Y90) and sorafenib/nivolumab for patients with hepatocellular carcinoma (HCC), with hepatic vein (HV) or inferior vena cava (IVC) invasion. The aim of this study is to summarise the results of different studies that used the combination therapy for HCC patients with tumor thrombosis involving the HV or IVC.

Method

A literature search was performed using keywords in Medline and Google Scholar limited to publications from 2010 to 2021. There were 173 articles identified during the initial literature search. During abstract screening, 81 articles were excluded. Another 83 did not contain information on hepatic vein or IVC invasion. Therefore, 9 articles met the eligibility criteria and were included in the synthesis.

Results

In total, 37 patients with hepatic vein or IVC invasion were identified. There were 31 patients who were given sorafenib, 7 were given nivolumab and 1 was given both sorafenib and nivolumab. Among the 37 patients, 21 had hepatic vein invasion, 22 had IVC invasion and 6 had both HV and IVC invasion. The median OS was 20.55 months and median PFS was 8.18 months. For the results, 23 patients were evaluated via modified RECIST (mRECIST) criteria and 14 were evaluated via RECIST 1.1.

Conclusion

The combination of local and systemic therapies demonstrated potential results for increased response rates, OS and PFS benefits. Further studies are required to determine the long-term outcomes of the combination therapy for this group of patients.

Development and Validation of a Vascular Endothelial Growth Factor A-associated Prognostic Model for Unresectable Hepatocellular Carcinoma

Purpose

High serum vascular endothelial growth factor (VEGF) levels have been identified as an independent risk factor for hepatocellular carcinoma (HCC). We aimed to construct a VEGF-included prognostic model to accurately perform individualized predictions of survival probability for patients with unresectable HCC.

Patients and Methods

From October 2018 to March 2021, 182 consecutive newly diagnosed patients with unresectable HCC were retrospectively enrolled. Baseline serum VEGF-A and other characteristics were collected for all patients. Univariate Cox regression analysis and LASSO regression model were applied to develop the prognostic model, enhanced bootstrap method with 100 replicates was performed to validate its discrimination and calibration. We compared the final model with China Liver Cancer (CNLC) stage, American Joint Committee on Cancer (AJCC) stage, Barcelona Clinic Liver Cancer (BCLC) stage, and the model without the "VEGF". Finally, the established model was stratified by age.

Results

The VEGF-associated prognostic model we established has high accuracy with an overall C-index of 0.7892 after correction for optimistic estimates. The area under the curve (AUC) of the time-dependent receiver operating characteristic (ROC) curves at 6-month, 1-year, and 2-year after correction were 0.843, 0.860, 0.833, respectively, and the calibration of the model was 0.1153, 0.1514, and 0.1711, respectively. The final model showed significant improvement in predicting OS when compared to the other models according to Harrell's C-index, The AUC of the time-dependent ROC, area under the decision curve analysis (AUDC), integrated discrimination improvement (IDI), and continuous net reclassification index (NRI).

Conclusion

The VEGF-associated prognostic model may help to predict the survival probabilities of HCC patients with favorable performance and discrimination. However, further validation is required since we only verified this model using internal but not external data.

Performance of current ultrasound-based malignancy risk stratification systems for thyroid nodules in patients with follicular neoplasms

OBJECTIVES

To investigate the ability of the currently used ultrasound-based malignancy risk stratification systems for thyroid neoplasms (ATA, AACE/ACE/AME, K-TIRADS, EU-TIRADS, ACR-TIRADS and C-TIRADS) in distinguishing follicular thyroid carcinoma (FTC) from follicular thyroid adenoma (FTA). Additionally, we evaluated the ability of these systems in correctly determining the indication for biopsy.

METHODS

Three hundred twenty-nine follicular neoplasms with definitive postoperative histopathology were included. The nodules were categorized according to each of six stratification systems, based on ultrasound findings. We dichotomized nodules into the positive predictive group of FTC (high and intermediate risk) and negative group of FTC based on the classification results. Missed biopsy was defined as neoplasms that were diagnosed as FTCs but for which biopsy was not indicated based on lesion classification. Unnecessary biopsy was defined as neoplasms that were diagnosed as FTAs but for whom biopsy was considered indicated based on classification. The diagnostic performance and missed and unnecessary biopsy rates were evaluated for each stratification system.

RESULTS

The area under the curve of each system for distinguishing follicular neoplasms was < 0.700 (range, 0.511-0.611). The missed biopsy rates were 9.0-22.4%. The missed biopsy rates for lesions ≤ 4 cm and lesions sized 2-4 cm were 16.2-35.1% and 0-20.0%, respectively. Unnecessary biopsy rates were 65.3-93.1%. In ≤ 4 cm group, the unnecessary biopsy rates were 62.2-89.7%.

CONCLUSION

The malignancy risk stratification systems can select appropriate nodules for biopsy in follicular neoplasms, while they have limitations in distinguishing follicular neoplasms and reducing unnecessary biopsy. Specific stratification systems and recommendations should be established for follicular neoplasms.

KEY POINTS

• Current ultrasound-based malignancy risk stratification systems of thyroid nodules had low efficiency in the characterization of follicular neoplasms. • The adopted stratification systems showed acceptable performance for selecting FTC for biopsy but unsatisfactory performance for reducing unnecessary biopsy.

Tumor in vein (LR-TIV) and liver imaging reporting and data system (LI-RADS) v2018: diagnostic features, pitfalls, prognostic and management implications

Vascular invasion by hepatocellular carcinoma (HCC), also known as tumor in vein (TIV), indicates highly invasive tumor behavior and is also associated with poor outcome. Because a diagnosis of TIV precludes liver transplantation, knowledge of the imaging findings to differentiate between TIV and bland thrombus is key for proper patient management. Prior versions of liver imaging reporting and data system (LI-RADS) included presence of TIV as part of LR-5 criteria. However, even if HCC is the most common liver malignancy associated with TIV, other tumors can have vascular invasion and may occur in cirrhotic patients. For these reasons, in LI-RADS v2017 LR-TIV has been introduced as a new different diagnostic category. The aim of this article is to discuss the diagnostic criteria of LR-TIV according to LI-RADS v2018 and analyze potential pitfalls encountered on daily clinical practice. Indeterminate cases and how to manage them will also be discussed.

Sorafenib Combined with Chemoembolization for Locally Advanced Hepatocellular Carcinoma with Macroscopic Vascular Invasion: A Propensity Score Analysis

The purpose of this study was to compare the efficacy and safety of transarterial chemoembolization (TACE) plus sorafenib with those of TACE alone in patients with locally advanced hepatocellular carcinoma (HCC). Treatment-naïve patients with preserved hepatic reserve (Child–Pugh score ≤ 7) who received TACE plus sorafenib (n = 91) or TACE alone (n = 109) for locally advanced HCC with macrovascular invasion were retrospectively evaluated. Propensity score matching (PSM) was used to correct selection bias, and 63 pairs were created. In the entire study population, the median progression-free survival (PFS) and overall survival (OS) with TACE plus sorafenib were better than those with TACE alone. After PSM, the median PFS (7.0 vs. 4.3 months; p = 0.017) and OS (17.5 vs. 12.8 months; p = 0.049) were again significantly longer with TACE plus sorafenib than with TACE alone. Stratified Cox regression analysis and doubly robust estimation revealed that treatment type was significantly associated with both PFS and OS. In the subgroup analysis, TACE plus sorafenib did not show a significant survival benefit for patients with main portal vein or inferior vena cava invasion. Major complications were similar in both groups (p = 0.330). In conclusion, TACE plus sorafenib showed better survival outcomes than TACE alone in patients with locally advanced HCC.

Integrated prognostication of intrahepatic cholangiocarcinoma by contrast-enhanced computed tomography: the adjunct yield of radiomics

Purpose

To test radiomics for prognostication of intrahepatic mass-forming cholangiocarcinoma (IMCC) and to develop a comprehensive risk model.

Methods

Histologically proven IMCC (representing the full range of stages) were retrospectively analyzed by volume segmentation on baseline hepatic venous phase computed tomography (CT), by two readers with different experience (R1 and R2). Morphological CT features included: tumor size, hepatic satellite lesions, lymph node and distant metastases. Radiomic features (RF) were compared across CT protocols and readers. Univariate analysis against overall survival (OS) warranted ranking and selection of RF into radiomic signature (RSign), which was dichotomized into high and low-risk strata (RSign*). Models without and with RSign* (Model 1 and 2, respectively) were compared.

Results

Among 78 patients (median follow-up 262 days, IQR 73–957), 62/78 (79%) died during the study period, 46/78 (59%) died within 1 year. Up to 10% RF showed variability across CT protocols; 37/108 (34%) RF showed variability due to manual segmentation. RSign stratified OS (univariate: HR 1.37 for R1, HR 1.28 for R2), RSign* was different between readers (R1 0.39; R2 0.57). Model 1 showed AUC 0.71, which increased in Model 2: AUC 0.81 (p < 0.001) and AIC 89 for R1, AUC 0.81 (p = 0.001) and AIC 90.2 for R2.

Conclusion

The use of RF into a unified RSign score stratified OS in patients with IMCC. Dichotomized RSign* classified survival strata, its inclusion in risk models showed adjunct yield. The cut-off value of RSign* was different between readers, suggesting that the use of reference values is hampered by interobserver variability.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00261-021-03183-9.

LI-RADS treatment response algorithm after first-line DEB-TACE: reproducibility and prognostic value at initial post-treatment CT/MRI

PURPOSE

To evaluate the inter-reader reproducibility and prognostic accuracy of the Liver Imaging Reporting and Data System (LI-RADS) treatment response algorithm (LR-TR) at the time of initial post-treatment evaluation following drug-eluting beads transarterial chemoembolization (DEB-TACE) for hepatocellular carcinoma (HCC).

METHODS

This retrospective study included patients with HCC who underwent first-line DEB-TACE between January 2011 and December 2015. Six readers (three fellowship-trained radiologists and three radiology trainees) independently assessed lesion-level response in up to two treated lesions per LR-TR and modified Response Evaluation Criteria in Solid Tumors (mRECIST)-target criteria, as well as patient-level response per mRECIST-overall criteria, on the initial post-treatment CT/MRI. Inter-reader agreement was calculated by Fleiss' multi-reader κ. We tested whether LR-TR, mRECIST-target, and mRECIST-overall response were associated with overall survival using Kaplan-Meier and Cox proportional hazard model analyses.

RESULTS

A total of 82 patients with 113 treated target lesions were included. Inter-reader agreement was moderate for LR-TR and mRECIST-overall (κ range 0.42-0.57), and substantial for mRECIST-target (κ range 0.62-0.66), among all three reader-groups: all readers, experienced readers, and less-experienced readers. LR-TR and mRECIST-target response were not significantly associated with overall survival regardless of reader experience (P > 0.05). In contrast, mRECIST-overall response was significantly associated with overall survival when assessed by all readers (P = 0.02) and experienced readers (P = 0.03), but not by the less-experienced readers (P = 0.35).

CONCLUSION

Although LR-TR algorithm has moderate inter-reader reproducibility, it alone may not predict overall survival on the initial post-treatment CT/MRI after first-line DEB-TACE for HCC.

Hepatocellular carcinoma: metastatic pathways and extra-hepatic findings

Although a small portion of patients with hepatocellular carcinoma (HCC) have radiologically evident extrahepatic disease at the initial presentation, a larger number of them develop metastatic disease later during the course of treatment or after definitive treatment. Furthermore, early metastatic disease could be overlooked by imaging due to small size and non-specificity of findings. Extrahepatic spread of HCC occurs via different pathways and is directly fueled by tumor biology and its molecular characteristics. Early and accurate detection of extrahepatic disease in patients with HCC has significant impact on management and selection of treatment options. Additionally, precise staging of disease will allow for better prediction of survival and outcome. Different pathways of regional and systemic spread of HCC with their proposed mechanisms and relevant underlying molecular derangement will be discussed in this article. Potential roles in management of patients with HCC will be discussed and reviewed in this article.

Ground-glass opacity (GGO): a review of the differential diagnosis in the era of COVID-19

Thoracic imaging is fundamental in the diagnostic route of Coronavirus disease 2019 (COVID-19) especially in patients admitted to hospitals. In particular, chest computed tomography (CT) has a key role in identifying the typical features of the infection. Ground-glass opacities (GGO) are one of the main CT findings, but their presence is not specific for this viral pneumonia. In fact, GGO is a radiological sign of different pathologies with both acute and subacute/chronic clinical manifestations. In the evaluation of a subject with focal or diffuse GGO, the radiologist has to know the patient’s medical history to obtain a valid diagnostic hypothesis. The authors describe the various CT appearance of GGO, related to the onset of symptoms, focusing also on the ancillary signs that can help radiologist to obtain a correct and prompt diagnosis.

Combined Chemoembolization and Radiotherapy Versus Chemoembolization Alone for Hepatocellular Carcinoma Invading the Hepatic Vein or Inferior Vena Cava

PURPOSE

To evaluate the efficacy and safety of transarterial chemoembolization (TACE) plus radiotherapy compared with TACE alone for patients with hepatocellular carcinoma (HCC) invading the hepatic vein (HV) or inferior vena cava (IVC).

MATERIALS AND METHODS

Data from 79 patients who underwent TACE plus radiotherapy as a first-line treatment for non-metastatic HCC invading the HV or IVC between 2006 and 2018 were retrospectively evaluated. These findings were compared with data from a historical control group, consisting of 80 patients who received TACE alone between 2000 and 2006.

RESULTS

Baseline characteristics were similar in both groups. Median progression-free survival (PFS) (8.1 vs. 4.4 months, P = 0.003) and overall survival (OS) (18.3 vs. 9.5 months, P = 0.002) were longer in the TACE plus radiotherapy than in the TACE alone group. Multivariate analysis showed that PFS and OS were significantly associated with treatment type. Subgroup analyses found that TACE plus radiotherapy showed better OS than TACE alone in patients with Child-Pugh class A, maximal tumor size < 9 cm, tumor number < 4, serum alpha-fetoprotein level ≥ 400 ng/mL, infiltrative tumor, IVC tumor thrombus, and combined portal vein invasion. The major complication rates were similar between the TACE plus radiotherapy (16.5%) and the TACE alone (13.8%) group (P = 0.664) CONCLUSION: Both TACE plus radiotherapy and TACE alone showed similar safety in treating non-metastatic HCC invading the HV or IVC. TACE plus radiotherapy seems effective to prolong OS and PFS compared to TACE alone in this specific patient group.

Optimisation and evaluation of the random forest model in the efficacy prediction of chemoradiotherapy for advanced cervical cancer based on radiomics signature from high-resolution T2 weighted images

PURPOSE

Our objective was to establish a random forest model and to evaluate its predictive capability of the treatment effect of neoadjuvant chemotherapy-radiation therapy.

METHODS

This retrospective study included 82 patients with locally advanced cervical cancer who underwent scanning from March 2013 to May 2018. The random forest model was established and optimised based on the open source toolkit scikit-learn. Byoptimising of the number of decision trees in the random forest, the criteria for selecting the final partition index and the minimum number of samples partitioned by each node, the performance of random forest in the prediction of the treatment effect of neoadjuvant chemotherapy-radiation therapy on advanced cervical cancer (> IIb) was evaluated.

RESULTS

The number of decision trees in the random forests influenced the model performance. When the number of decision trees was set to 10, 25, 40, 55, 70, 85 and 100, the performance of random forest model exhibited an increasing trend first and then a decreasing one. The criteria for the selection of final partition index showed significant effects on the generation of decision trees. The Gini index demonstrated a better effect compared with information gain index. The area under the receiver operating curve for Gini index attained a value of 0.917.

CONCLUSION

The random forest model showed potential in predicting the treatment effect of neoadjuvant chemotherapy-radiation therapy based on high-resolution T2WIs for advanced cervical cancer (> IIb).

Use of radiomics to differentiate left atrial appendage thrombi and mixing artifacts on single-phase CT angiography

To assess if radiomics can differentiate left atrial appendage (LAA) contrast-mixing artifacts and thrombi on early-phase CT angiography without the need for late-phase images. Our study included 111 patients who underwent early- and late-phase, contrast-enhanced cardiac CT. Of these, 79 patients had LAA filling defects from thrombus (n = 46, mean age: 72  ±  12 years, M:F 26:20) or contrast-mixing artifact (n = 33, mean age: 71  ±  13 years, M:F 21:12) on early-contrast-enhanced phase. The remaining 32 patients (mean age: 66  ±  10 years, M:F 19:13) had homogeneous LAA opacification without filling defects. The entire LAA volume on early-phase CT images was manually segmented to obtain radiomic features (Frontier, Siemens). A radiologist assessed for the presence of LAA filling defects and recorded the size and mean CT attenuation (HU) of filling defects and normal LAA. The data were analyzed using multiple logistic regression with receiver operating characteristics area under the curve (AUC) as an output. The radiologist correctly identified all 32 patients without LAA filling defects, 42/46 LAA with thrombi, and 23/33 contrast mixing artifacts. Although HU of LAA thrombi and contrast mixing artifacts was significantly different, with the lowest AUC (0.66), it was inferior to both radiologist assessment and radiomics (p = 0.05). Combination of radiologist assessment and radiomics (AUC 0.92) was superior to HU (0.66), radiomics (0.85), and radiologist (0.80) alone (p < 0.008). Radiomics can differentiate between LAA filling defects from thrombi and contrast mixing artifacts on early-phase contrast-enhanced CT images without the need for late-phase CT.