Chemoembolization and radioembolization

Development of a predictive nomogram for postembolization syndrome after transcatheter arterial chemoembolization of hepatocellular carcinoma

Post-embolization syndrome (PES) is a frequent complication after receiving transcatheter arterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC), but only a few studies have focused on the factors influencing PES in those patients. In this study, the impact factors of PES were explored and a nomogram was constructed to predict the occurrence of PES in HCC patients with TACE. This was a retrospective cohort study of HCC patients who underwent TACE obtained from the third affiliated Hospital of Kunming Medical University between January 1, 2020, and September 1, 2022. T‑test and Chi‑square test were used to search for factors influencing PES occurrence, and then the nomogram was further established based on multivariable logistic regression analysis. Validation of the predictive nomogram was also evaluated by calibration curve, concordance index (C-index), and receiver operating characteristic (ROC) curves. The enrolled patients (n = 258) were randomly assigned to the primary cohort (n = 180) and validation cohort (n = 78) in a 7:3 ratio. Among 180 patients in the primary cohort, 106 (58.89%) experienced PES. TACE types (P = 0.015), embolization degree (P = 0.008), and tumor number (P = 0.026) were identified as predictors by the logistic regression analysis and were used to develop the predictive nomogram. The internally validated and externally validated C-indexes were 0.713 and 0.703, respectively. The calibration curves presented good consistency between actual and predictive survival. Types of embolic agents, embolization degree, and tumor number were found to be the predictors of PES after TACE. The nomogram could reliably predict PES in HCC patients with TACE. This predictive model might be considered for clinical practice.

Tumor Size and Watershed Area Correlate with Incomplete Treatment and Tumor Progression after Selective Radioembolization for Hepatocellular Carcinoma

PURPOSE

To identify factors of incomplete treatment after segmental transarterial radioembolization (TARE) for treatment-naive and solitary hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

A total of 75 consecutive patients (age, 68.5 years [SD ± 8.0]; 25/75 [33.3%] women) with treatment-naive, solitary HCC underwent segmental or subsegmental TARE with glass microspheres (tumor size, 3.8 cm [SD ± 2.2]; administered dose, 222.6 Gy [SD ± 123.9]) at a single institution from November 2015 to June 2022. Radiologic response and progression-free survival (PFS) were assessed as per modified Response Evaluation Criteria in Solid Tumors.

RESULTS

Complete treatment was achieved in 48 of 75 (64.0%) patients (mean follow-up, 33.2 months [SD ± 27.4]). Patients with incomplete treatment (27/75, 36%) presented with larger tumor size (5.0 [SD ± 2.5] vs 3.1 [SD ± 1.6] cm; P = .0001), with more tumors located in the watershed zone (81.5% vs 41.7%; P = .001). These patients were less likely to be bridged to transplant or resection (22.2% vs 52.1%; P = .015). Watershed tumors demonstrated worse target tumor PFS (median PFS, 19 months vs not reached; P = .0104) and overall PFS (9.1 months vs not reached; P = .0077). Watershed location was associated with worse PFS among tumors >3 cm in size (8.4 months vs not reached; P = .035) but not in tumors ≤3 cm in size (52.2 months vs not reached; P = .915).

CONCLUSIONS

Tumor size and watershed location were associated with incomplete treatment after segmental TARE for HCC. Watershed tumors were associated with worse PFS, particularly tumors larger than 3 cm. These tumors may require careful treatment planning and repeated treatments to ensure a durable response.

Neoadjuvant transarterial chemoembolization (TACE) plus PD-1 inhibitor bridging to tumor resection in intermediate-stage hepatocellular carcinoma patients

BACKGROUND

Programmed cell death protein 1 (PD-1) inhibitor is widely utilized in advanced-stage carcinomas including hepatocellular carcinoma (HCC), while its neoadjuvant application plus transarterial chemoembolization (TACE) in HCC remains unexplored. Thereby, the current study aimed to investigate the efficacy and safety of TACE plus PD-1 inhibitor as neoadjuvant therapy bridging to surgical resection in intermediate-stage HCC patients.

METHODS

Twenty intermediate-stage HCC (China Liver Cancer (CNLC) stage II) patients treated with neoadjuvant TACE plus PD-1 inhibitor (camrelizumab or sintilimab) bridging to surgery were consecutively enrolled.

RESULTS

The objective response rate (ORR) and disease control rate (DCR) to neoadjuvant therapy were 75.0% and 100.0%, respectively; meanwhile, alpha-fetoprotein (AFP) was decreased after the neoadjuvant therapy (P < 0.001). Moreover, 14 (70.0%) patients had successful downstaging (patients converted to CNLC stage I). Neither median disease-free survival (DFS) nor median overall survival (OS) was reached; additionally, the 1-year accumulating DFS rate was 86.6%; meanwhile, the 1-year and 2-year accumulating OS rates were 100.0% and 76.4%, separately. Moreover, patients with successful downstaging had a prolonged DFS (P = 0.014) compared to patients with failed downstaging; meanwhile, this trend was also observed in assessing accumulating OS (P = 0.067) (without statistical significance). Main adverse events included pain (50.0%), fever (25.0%), neutropenia (25.0%), nausea and vomiting (25.0%), fatigue (25.0%), peripheral neuropathy (20.0%), anemia (15.0%), thrombopenia (15.0%), diarrhea (15.0%), anorexia (15.0%), and rash (15.0%).

CONCLUSION

Neoadjuvant TACE plus PD-1 inhibitor realizes a satisfying downstaging rate, acceptable survival profile, and tolerance in intermediate-stage HCC patients.

Post-Embolization Syndrome Complicated by Hypertensive Emergency and Severely Elevated Transaminases

Transarterial chemoembolization (TACE) is a procedure reserved for the treatment of hepatocellular cancer that is unresectable through surgery. It combines both embolization and chemotherapy by injecting chemotherapy via a catheter directed at the tumor and then blocking the artery to prevent blood flow to the tumor. We present the case of a 69-year-old man who experienced post-embolization syndrome (PES) with a hypertensive emergency and elevated liver transaminases following his TACE procedure. Imaging combined with clinical assessment was necessary to determine whether the patient was experiencing a ruptured hepatic abscess or PES, as both are potential complications of TACE. The patient was ultimately managed with supportive care and discharged after several days.

Assessment of hepatocellular carcinoma treatment response with LI-RADS: a pictorial review

Computed tomography (CT) and magnetic resonance imaging (MRI) play critical roles for assessing treatment response of hepatocellular carcinoma (HCC) after locoregional therapy. Interpretation is challenging because posttreatment imaging findings depend on the type of treatment, magnitude of treatment response, time interval after treatment, and other factors. To help radiologists interpret and report treatment response in a clear, simple, and standardized manner, the Liver Imaging Reporting and Data System (LI-RADS) has developed a Treatment Response (LR-TR) algorithm. Introduced in 2017, the system provides criteria to categorize response of HCC to locoregional treatment (e.g., chemical ablation, energy-based ablation, transcatheter therapy, and radiation therapy). LR-TR categories include Nonevaluable, Nonviable, Equivocal, and Viable. LR-TR does not apply to patients on systemic therapies. This article reviews the LR-TR algorithm; discusses locoregional therapies for HCC, treatment concepts, and expected posttreatment findings; and illustrates LI-RADS treatment response assessment with CT and MRI.

Health education helps to relieve postembolization pain during hepatic arterial chemoembolization therapy

Aim

Psychological intervention has been proved a complementary approach to drug analgesia. Another study suggested that health knowledge is associated with psychological symptoms in patients with liver cancer. This study is conducted to assess whether improving the health education (HE) alleviates the postembolization pain during transarterial chemoembolization (TACE).

Materials and methods

One hundred and fifteen patients, who required TACE for hepatocellular carcinoma (HCC) and suffered postembolization pain, were randomized into control group (n=63) and HE group (n=52). The health knowledge was scaled with the health knowledge questionnaire (HKQ). The postembolization pain was scored using a 0–10 numeric rating scale (NRS-10) after arterial embolization in both groups.

Results

There were no statistical differences between male and female in all HKQ scores (P>0.05). The HKQ scores of young people (≤45 years old) were significantly higher than those of elders (>45 years old; P<0.05). After teaching HE, the HKQ scores were significantly increased in patients of the HE group (P<0.01). The postembolization pain score in the HE group was significantly lower than that in the control group (P<0.05). The HKQ scores of question 1, 3, and total were negatively correlated with the pain score in this sample (P<0.05).

Conclusion

Improving the HE among HCC patients before TACE is beneficial for the pain relief during interventional procedure.

Safety and Efficacy of Transarterial Radioembolization Combined with Chemoembolization for Bilobar Hepatocellular Carcinoma: A Single-Center Retrospective Study

BACKGROUND

Radioembolization induced liver disease (REILD) is a possible sequela of transarterial radioembolization (TARE), particularly in cases of whole-liver treatment. To mitigate this problem, the safety and efficacy of combined transarterial chemoembolization (TACE) and TARE were evaluated for patients with bilobar hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Nineteen patients (mean age 60 years; range 27-82 years) treated for HCC between June 2012 and September 2014 were included in the analysis. Each patient was treated with combined TARE and TACE for bilobar HCC, with or without portal vein thrombosis. The hepatic lobe with large HCC was treated with TARE, and the other lobe with small HCC(s) was treated with TACE. Laboratory and clinical data were investigated to determine REILD occurrence. Survival data were analyzed to compare the treatment efficacy of alternative treatment modalities, including TACE and sequential TARE.

RESULTS

All patients underwent TARE for a dominant tumor in one lobe and TACE for small nodule(s) in the other lobe of the liver. The mean yttrium-90 microspheres used in TARE were 2.8 GBq (range; 1.0-3.5 GBq), and the mean doses of doxorubicin and iodized oil were 24.5 mg and 5.2 mL, respectively, for TACE. No statistical differences were noted between laboratory data measured before and after treatment, and no procedure-related major clinical complications occurred. The median time-to-progression of patients was 10.0 months, and the median overall survival was 27.3 months.

CONCLUSION

Combined radioembolization and chemoembolization appears to be a safe and effective treatment modality for bilobar HCC.

Interventional oncology for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer and is increasing in incidence. The overall prognosis of patients with liver cancer is poor. The Barcelona Clinic Liver Cancer (BCLC) classification in 5 stages is endorsed by European Association for the Study of the Liver (EASL) and American Association for the Study of Liver Disease (AASLD). This classification is recommended for treatment allocation. Because a small proportion of patients are suitable for curative surgical treatment, various locoregional therapies are widely used to manage patients with HCC. The image-guided therapies, also called interventional radiology or interventional oncology (IO) techniques consisted in percutaneous or endovascular approach. This article reviews the different IO treatments available in HCC patients and the strength of the data.

A comparison of survival in patients with hepatocellular carcinoma and portal vein invasion treated by radioembolization or sorafenib

BACKGROUND & AIMS

Sorafenib (SOR) is the standard of care for patients with hepatocellular carcinoma (HCC) and portal vein invasion (PVI), based on the results of phase 3 trials. However, radioembolization (RE) using yttrium-90 microspheres has been shown to achieve higher response rates and better survival in large cohorts and phase 2 trials. This study aimed to compare survival of HCC patients with PVI treated by RE or SOR.

METHODS

Survival among patients with HCC and PVI treated with RE or SOR in four Spanish hospitals between 2005 and 2013 was analysed retrospectively. Kaplan-Meier survival curves were plotted and baseline variables tested for prognostic value using the log-rank test. A multivariate prognostic model including variables identified in the univariate analysis and adjusted by a propensity score based on factors that may determine the probability of exposure to RE was generated using Cox regression analyses.

RESULTS

After a median follow-up of 6 months, 60 deaths had occurred: 38 and 22 in SOR and RE groups respectively. Median survival was 6.7 months (95%CI 5.2-8.1 months) for the entire cohort, and 8.8 months (95%CI 1.8-15.8) in the RE group and 5.4 months (95%CI 2.7-8.1) in the SOR group (P = 0.047). The difference in survival was still statistically significant when 13 patients in the RE group who started SOR after a median time of 8 months were censored from the analysis.

CONCLUSIONS

In a cohort of patients with HCC and PVI treatment with RE was associated with a more prolonged survival compared with SOR.

Post-embolization syndrome as an early predictor of overall survival after transarterial chemoembolization for hepatocellular carcinoma

BACKGROUND

Transarterial chemoembolization (TACE) is the most common treatment for patients with unresectable hepatocellular carcinoma (HCC). Post-embolization syndrome (PES) is a common post-TACE complication. The goal of this study was to evaluate PES as an early predictor of the long-term outcome.

METHODS

A retrospective cohort study of HCC patients treated with TACE at a tertiary referral centre was performed (2008-2014). Patients were categorized on the basis of PES, defined as fever with or without abdominal pain within 14 days of TACE. The primary outcome was overall survival (OS). Multivariate Cox regression was done to examine the association between PES and OS.

RESULTS

Among 144 patients, 52 (36.1%) experienced PES. The median follow-up for the cohort was 11.4 months. The median and 3-year OS rates were 16 months and 18% in the PES group versus 25 months and 41% in the non-PES group (log rank, P = 0.027). After multivariate analysis, patients with PES had a significantly increased risk of death [hazard ratio 2.0 (95%CI 1.2-3.3), P = 0.011].

CONCLUSIONS

PES is a common complication after TACE and is associated with a two-fold increased risk of death. Future studies should incorporate PES as a relevant early predictor of OS and examine the biological basis of this association.

Liver transplantation for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is an increasing problem in the USA and worldwide. Current treatments for HCC include chemoembolization, radioembolization, liver resection, and liver transplantation in the setting of selected cirrhotic patients. Liver transplantation for HCC was controversial initially, but is now widely accepted as a curative approach. Cirrhotic patients who meet standards for transplantation and have a tumor burden within Milan criteria are eligible for transplantation and receive Model for End-Stage Liver Disease (MELD) exception points once listed. Given the decline in availability of donor organs, rewarding MELD exception points and performing liver transplants in these patients remain controversial. Despite this, various guidelines propose expanding eligibility criteria for cirrhotics with HCC, due to post-transplant outcomes comparable to patients transplanted without HCC. Following the transplant, issues include optimizing the type and amount of immunosuppression and screening for and treating recurrence of HCC.

Transcatheter embolization therapy in liver cancer: an update of clinical evidences

Transarterial chemoembolization (TACE) is a form of intra-arterial catheter-based chemotherapy that selectively delivers high doses of cytotoxic drug to the tumor bed combining with the effect of ischemic necrosis induced by arterial embolization. Chemoembolization and radioembolization are at the core of the treatment of liver hepatocellular carcinoma (HCC) patients who cannot receive potentially curative therapies such as transplantation, resection or percutaneous ablation. TACE for liver cancer has been proven to be useful in local tumor control, to prevent tumor progression, prolong patients' life and control patient symptoms. Recent evidence showed in patients with single-nodule HCC of 3 cm or smaller without vascular invasion, the 5-year overall survival (OS) with TACE was similar to that with hepatic resection and radiofrequency ablation. Although being used for decades, Lipiodol(®) (Lipiodol(®) Ultra Fluid(®), Guerbet, France) remains important as a tumor-seeking and radio-opaque drug delivery vector in interventional oncology. There have been efforts to improve the delivery of chemotherapeutic agents to tumors. Drug-eluting bead (DEB) is a relatively novel drug delivery embolization system which allows for fixed dosing and the ability to release the anticancer agents in a sustained manner. Three DEBs are available, i.e., Tandem(®) (CeloNova Biosciences Inc., USA), DC-Beads(®) (BTG, UK) and HepaSphere(®) (BioSphere Medical, Inc., USA). Transarterial radioembolization (TARE) technique has been developed, and proven to be efficient and safe in advanced liver cancers and those with vascular complications. Two types of radioembolization microspheres are available i.e., SIR-Spheres(®) (Sirtex Medical Limited, Australia) and TheraSphere(®) (BTG, UK). This review describes the basic procedure of TACE, properties and efficacy of some chemoembolization systems and radioembolization agents which are commercially available and/or currently under clinical evaluation. The key clinical trials of transcatheter arterial therapy for liver cancer are summarized.

Chemoembolization of hepatocellular carcinoma with HepaSphere™

This review discusses the current data on Hepasphere™ in the treatment of hepatocellular carcinoma. HepaSphere is a drug-loadable microsphere that can be bound with doxorubicin, epirubicin, cisplatin or oxaliplatin. In vitro and in vivo studies confirm lower systemic exposure to the drug and fewer systemic doxorubicin-related side effects. Studies suggest that this technique is better tolerated than conventional lipiodol-based chemoembolization (c-TACE). In intermediate and early stage hepatocellular carcinoma - nonresponsive to curative treatments - complete response and partial response rates range from 22.2 to 48% and 43.7 to 51%, respectively. Studies with survival as an end-point are needed and head-to-head comparisons with other drug-eluting beads are necessary.

Systematic review comparing the safety and efficacy of conventional and drug-eluting bead transarterial chemoembolization for inoperable hepatocellular carcinoma

AIM

Conventional transarterial chemoembolization (cTACE) is widely used for treating patients with inoperable hepatocellular carcinoma (HCC). A variation on the technique based on drug-eluting beads (DEB-TACE) has recently entered the clinic, but trials of its safety and efficacy have given conflicting results. This systematic review aimed to gain a current, comprehensive picture of how DEB-TACE compares with cTACE.

METHODS

MEDLINE, EMBASE, the Cochrane Library, the Chinese National Knowledge Infrastructure database and clinical trial registries were searched through June 2014. Risk ratios (RR), hazard ratios (HR) and 95% confidence intervals (CI) were calculated.

RESULTS

The analysis included four randomized controlled trials, one uncontrolled prospective study and one prospective case-control study, altogether involving 652 patients. Overall survival benefit was similar between cTACE and DEB-TACE patients (HR = 1.07, 95% CI = 0.82-1.40, P = 0.875). However, DEB-TACE was associated with a significantly higher objective tumor response rate (RR = 1.14, 95% CI = 1.01-1.29, P = 0.03) and a slightly lower incidence of adverse events.

CONCLUSION

Though the available evidence suggests that although DEB-TACE is associated with better tumor response and potentially fewer adverse events, it does not provide greater survival benefit than cTACE. These results need to be validated in high-quality trials with large sample size.