Hepatic and biliary damage after transarterial chemoembolization for malignant hepatic tumors: incidence, diagnosis, treatment, outcome and mechanism

Change of indocyanine green clearance ability and liver function after transcatheter intra-arterial therapies and its impact on outcomes of resectable hepatocellular carcinoma: a retrospective cohort study

BACKGROUND

Indocyanine green (ICG) clearance test is a classical measurement of hepatic reserve, which involves surgical safety and patient recovery of hepatocellular carcinoma (HCC). The authors aim to compare effects of hepatic arterial infusion chemotherapy (HAIC) and transcatheter arterial chemoembolization (TACE) on liver function and outcomes of subsequent hepatectomy.

MATERIAL AND METHODS

HCC patients receiving HAIC/TACE in SYSUCC with repeated ICG clearance tests were retrospectively enrolled. ICG eliminating rate (ICG-K), ICG retention rate at 15 min (ICG-R15) and ordinary laboratory tests were collected. Peri-therapeutic changes of values were compared between the groups. Propensity score matching (PSM) and inverse probability of treatment weighing (IPTW) were employed to validate findings. Post-hepatectomy liver failure (PHLF), overall survival (OS) and recurrence-free survival (RFS) were analyzed in patients with subsequent curative hepatectomy.

RESULTS

Two hundred and four patients treated with HAIC ( n =130) and TACE ( n =74) were included. ΔICG-R15 was greater in the HAIC arm before matching (mean, 3.8% vs. 0.7%, P <0.001), after PSM (mean, 4.7% vs. 1.1%, P =0.014) and IPTW (mean, 2.0% vs. -3.6%, P <0.001). No difference was found for ΔALB, ΔALBI, ΔTBIL, ΔALT, ΔAST and ΔPT-INR. Multivariable analyses revealed elder age, cirrhosis, HAIC, greater ΔTBIL and ΔALBI were associated with deteriorating ICG-R15. Among those (105 for HAIC and 48 for TACE) receiving hepatectomy, occurrence of grade B/C PHLF (4.8% vs. 8.3%, P =0.616), OS (median, unreached vs. unreached, P =0.94) and RFS (median, 26.7 vs. 17.1 months, P =0.096) were comparable between the two arms. In subgroup analyses, preoperative HAIC yield superior RFS (median, 26.7 vs. 16.2 months, P =0.042) in patients with baseline ICG-R15 less than or equal to 10%.

CONCLUSION

Preoperative FOLFOX-HAIC caused apparent impairment of ICG clearance ability than TACE yet comparable impact on liver function and post-hepatectomy outcomes.

Safety and Efficacy of Selective Internal Radionuclide Therapy with 90Y Glass Microspheres in Patients with Progressive Hepatocellular Carcinoma after the Failure of Repeated Transarterial Chemoembolization

Transarterial chemoembolization (TACE) is currently the standard of care in patients with unresectable hepatocellular carcinoma (HCC), and selective internal radionuclide therapy (SIRT) with 90Y microspheres is mainly used as an alternative modality in patients considered poor candidates for TACE. Treatment with sorafenib is the recommended option for patients with progressive disease after TACE. This study aims to evaluate the safety and efficacy of SIRT with glass microspheres in patients with progressive HCC after repeated TACE who are not eligible for treatment with sorafenib. Forty-seven patients with progressive HCC after a median of three TACE sessions (range 2-14) underwent SIRT (3.5 ± 1.5 GBq; liver target dose 110-120 Gy). Toxicity was recorded 4 and 12 weeks after treatment and reported according to the Common Terminology Criteria for Adverse Events Version 5.0. Treatment response was assessed three months after SIRT using multiphase computed tomography and modified criteria in solid tumors (mRECIST). Survival analyses were performed using Kaplan-Meier curves and a Cox proportional hazards model for uni- and multivariate analyses. Significant but reversible hepatotoxicity (≥grade 3) occurred in five patients (11%). No radioembolization-induced liver disease (REILD) was observed. The number of previous TACE sessions and cumulative administered activity did not predict the incidence of post-SIRT significant hepatotoxicity. Treatment responses consisted of partial responses in 26 (55%), stable disease in 12 (26%), and progressive disease in 9 (19%) patients. The median overall survival (OS) was 11 months (95% confidence interval (CI), 9-13), and objective responses to SIRT were associated with a longer OS (p = 0.008). Significant hepatotoxicity (≥grade 3) after SIRT was a contributor to impaired survival (median OS 6 months (95% CI, 4-8) vs. 12 months (95% CI, 10-14), p < 0.001). SIRT with glass microspheres is a safe and effective salvage treatment for patients with progressive HCC refractory to TACE who are considered poor candidates for sorafenib treatment.

Risk of chronic liver disease and cirrhosis mortality among patients with digestive system cancers: a registry-based analysis

Non-cancer deaths are now becoming a great threat to the health of cancer survivors. There are no comprehensive and systematic reports on chronic liver disease and cirrhosis mortality (CLDCM) among patients with digestive system cancers (DSCs). This research aimed to quantitatively assess the risks and patterns of CLDCM among patients with DSCs. From the surveillance, epidemiology and end results (SEER) program, we extracted the data of patients diagnosed with DSCs between 2000 and 2017. Trends in incidence-based mortality rate (IBMR) were calculated using Joinpoint software. The standardized mortality ratio (SMR) was obtained based on the reference of the general United States population. The cumulative incidence function curves were constructed by all causes of death. Independent indicators were identified using the multivariate Fine and Gray competing risk model. We included 906,292 eligible patients from the SEER program, of which 3068 (0.34%) died from chronic liver disease and cirrhosis (CLDC). The IBMR of CLDC continued to increase during the study period [average annual percent change (APC): 6.7%; 95% confidence interval (CI) 5.1-8.2] and the SMR was significantly increased (SMR: 3.19; 95% CI 3.08-3.30). The cumulative mortality of CLDC was the lowest in all causes of death. Furthermore, the age at diagnosis, race, gender, marital status, year of diagnosis, SEER stage, surgery, chemotherapy and radiotherapy were identified as independent indicators. Better screening, diagnostic and management approaches need to be implemented as a preferred method to protect the liver among patients with DSCs.

Machine Learning-Based Development of Nomogram for Hepatocellular Carcinoma to Predict Acute Liver Function Deterioration After Drug-Eluting Beads Transarterial Chemoembolization

RATIONALE AND OBJECTIVES

Acute liver function deterioration (ALFD) following drug-eluting beads transarterial chemotherapy embolism (DEB-TACE) was considered a risk factor for prognosis in patients with hepatocellular carcinoma (HCC). In this study, we aimed to develop and validate a nomogram for the prediction of ALFD after DEB-TACE.

MATERIALS AND METHODS

A total of 288 patients with HCC from a single center were randomly divided into a training dataset (n = 201) and a validation dataset (n = 87). The univariate and multivariate logistic regression analyses were performed to determine risk factors for ALFD. The least absolute shrinkage and selection operator (LASSO) was applied to identify the key risk factors and fit a model. The performance, calibration, and clinical utility of the predictive nomogram were assessed using receiver operating characteristic curves, calibration curves, and decision curve analysis (DCA).

RESULTS

LASSO regression analysis determined six risk factors with fibrosis index based on four factors (FIB-4) as the independent factor for the occurrence of ALFD after DEB-TACE. Gamma-glutamyltransferase, FIB-4, tumor extent, and portal vein invasion were integrated into the nomogram. In both the training and validation cohorts, the nomogram demonstrated promising discrimination with AUC of 0.762 and 0.878, respectively. The calibration curves and DCA revealed good calibration and clinical utility of the predictive nomogram.

CONCLUSION

The nomogram-based risk of ALFD stratification may improve clinical decision-making and surveillance protocols for patients with a high risk of ALFD after DEB-TACE.

Smart nanoparticles and microbeads for interventional embolization therapy of liver cancer: state of the art

The process of transcatheter arterial chemoembolization is characterized by the ability to accurately deliver chemotherapy drugs with minimal systemic side effects and has become the standard treatment for unresectable intermediate hepatocellular carcinoma (HCC). However, this treatment option still has much room for improvement, one of which may be the introduction of nanomaterials, which exhibit unique functions and can be applied to in vivo tumor imaging and therapy. Several biodegradable and multifunctional nanomaterials and nanobeads have recently been developed and applied in the locoregional treatment of hepatocellular cancer. This review explores recent developments and findings in relation to micro-nano medicines in transarterial therapy for HCC, emerging strategies to improve the efficacy of delivering nano-based medicines, and expounding prospects for clinical applications of nanomaterials.

Number of Local Regional Therapies for Hepatocellular Carcinoma and Peri-Operative Outcomes after Liver Transplantation

The wait times for patients with hepatocellular carcinoma (HCC) listed for liver transplant are longer than ever, which has led to an increased reliance on the use of pre-operative LRTs. The impact that multiple rounds of LRTs have on peri-operative outcomes following transplant is unknown. This was a retrospective single center analysis of 298 consecutive patients with HCC who underwent liver transplant (January 2017 to May 2021). The data was obtained from two institution-specific databases and the TransQIP database. Of the 298 patients, 27 (9.1%) underwent no LRTs, 156 (52.4%) underwent 1-2 LRTs, and 115 (38.6%) underwent ≥3 LRTs prior to LT. The patients with ≥3 LRTs had a significantly higher rate of bile leak compared to patients who received 1-2 LRTs (7.0 vs. 1.3%, p = 0.014). Unadjusted and adjusted regression analyses demonstrated a significant association between the total number of LRTs administered and bile leak, but not rates of overall biliary complications. The total number of LRTs was not significantly associated with any other peri-operative or post-operative outcome measure. These findings support the aggressive use of LRTs to control HCC in patients awaiting liver transplant, with further evaluation needed to confirm the biliary leak findings.

A case report of fatal hepatic portal venous gas after transcatheter arterial chemoembolization in a patient with hepatocellular carcinoma

Hepatic portal venous gas (HPVG) refers to the imaging signs formed by the abnormal accumulation of abnormal gas in the portal veins and the branches of the inner veins of the liver due to various reasons, and is usually associated with poor prognosis. HPVG is mostly caused by abdominal diseases. Herein, we reported a patient with hepatocellular carcinoma developed HPVG following transcatheter arterial chemoembolization (TACE). This patient was identified as Barcelona Clinic Liver Cancer (BCLC) stage B, and treated by five times of TACE. Gelfoam sponge was used as embolic agent in the first and last TACE treatment. After the first TACE, pneumonia occurred in the right lung, and pneumorachis with iodine oil deposition occurred in the tumor lesion in the right lobe of the liver, which was considered as hepatic abscess. After three more TACE, enhanced MRI showed significant necrosis and reduction of the lesions. After the fifth TACE, the enhancing computed tomography (CT) showed a large amount of gas in the lesions and in the portal veins, which was considered as HPVG. Although after active treatment, the patient died soon. To our knowledge, this is the first case report of a patient with hepatocellular carcinoma developed HPVG following TACE with gelfoam sponge as embolic agent.

Hepatoprotective role of peroxisome proliferator-activated receptor-α in non-cancerous hepatic tissues following transcatheter arterial embolization

Transcatheter arterial embolization (TAE) is a widely used technique in treating hepatic carcinoma but may cause liver injury in some cases. This study investigated the hepatoprotective effect of the preprocessed peroxisome proliferator-activated receptor-α (PPAR-α) agonist-WY-14643 following TAE. A total of 60 rabbit liver cancer models were developed and divided into a combined treatment (WY-14643 and TAE), TAE, and control groups. After TAE, we examined the histopathological picture and liver functions. Further, the expression of antioxidant enzymes, tumor necrosis factor-α (TNF-α), nuclear factor of κ-light chain of enhancer-activated B cells (NF-κB), PPAR-α, and B-cell lymphoma-2 (Bcl-2) was analyzed. Liver function tests, pathology score, and apoptosis index significantly worsened in the TAE group but were normalized in the combined treatment group. In addition, ELISA results showed that antioxidant enzyme activity significantly increased, while the malondialdehyde content and level of inflammatory cytokines were significantly reduced in the combined treatment group. Furthermore, compared to the TAE group, the expressions of PPAR-α, antioxidant enzymes superoxide dismutase1 (SOD1) and SOD2, and Bcl-2 were significantly elevated, while NF-κB was significantly reduced in the combined treatment group. On the other hand, the expression of NF-κB in tumor tissues was significantly reduced by pretreatment with WY-14643. Therefore, PPAR-α can ameliorate liver injury by exerting its anti-oxidative, anti-inflammatory, and anti-apoptotic functions.

Does pre-operative embolization of a replaced right hepatic artery before pancreaticoduodenectomy for pancreatic adenocarcinoma affect postoperative morbidity and R0 resection? A bi-centric French cohort study

BACKGROUND

Sacrificing a replaced right hepatic artery (rRHA) from the superior mesenteric artery is occasionally necessary to obtain an R0 resection after pancreaticoduodenectomy (PD) for pancreatic adenocarcinoma (PA). Preoperative embolization (PEA) of the rRHA has been proposed to avoid the onset of postoperative biliary and ischemic liver complications.

METHODS

Eighteen patients with cephalic PA with an rRHA underwent PEA of the rRHA from 2013 to 2019. The monitoring after embolization and PD was systematic and included a clinical-biological evaluation and a computed tomography scan. This study aimed to determine the feasibility of PEA of the rRHA, postoperative morbidity at 90 days, and quality of oncologic resection after PD.

RESULTS

Feasibility of PEA was 100% without complications. A PD was performed in 16/18 patients. Mortality was 2/16 with one death after septic shock with hepatic ischemia without an arterial obstruction. Overall morbidity was 44% including one hepatic abscess after hepatic ischemia (6%). Two resections were R1 (<1 mm) in contact with the origin of the rRHA (2/4 R1).

CONCLUSION

PEA of the rRHA before PD was safe and reproducible. PEA of the rRHA followed by en bloc PD resection seems to limit the risk of bilio-hepatic ischemia and could facilitate oncologic resection.

Biliary-Caval Fistula following Y90 Radioembolization

The safety of radioembolization with yttrium-90 ( ⁹⁰ Y) is well documented and major complications are rare. Previous studies have demonstrated that biliary complications following ⁹⁰ Y, including bile duct injury and hepatic abscess formation, occur at an increased rate in patients who have had prior biliary surgery and interventions. This article reviews a case of a patient who developed recurrent cholangitis and sepsis as well as a biliary-caval fistula following radioembolization. Additionally, we review current data regarding biliary complications following radioembolization in patients with prior biliary intervention.

Ramucirumab for Patients with Intermediate-Stage Hepatocellular Carcinoma and Elevated Alpha-Fetoprotein: Pooled Results from Two Phase 3 Studies (REACH and REACH-2)

BACKGROUND

Intermediate-stage hepatocellular carcinoma (HCC), as defined by Barcelona Clinic Liver Cancer (BCLC) stage B, is heterogeneous in terms of liver function and tumor burden. REACH and REACH-2 investigated ramucirumab in patients with HCC after prior sorafenib, with REACH-2 enrolling only patients with baseline α-fetoprotein (AFP) ≥400 ng/mL. An exploratory analysis of outcomes by BCLC stage was performed.

METHODS

A pooled meta-analysis of independent patient data (stratified by study) from REACH (AFP ≥ 400 ng/mL) and REACH-2 was performed. All patients had Child-Pugh A, Eastern Cooperative Oncology Group performance status 0-1, prior sorafenib treatment, and either HCC BCLC stage B (refractory/not amenable to locoregional therapy) or BCLC stage C. Patients were randomized to ramucirumab 8 mg/kg or placebo every 2 weeks. Median overall survival (OS) and progression-free survival were estimated by the Kaplan-Meier method. Treatment effects in BCLC stage B and C were evaluated by Cox proportional-hazards model; prognosis of BCLC staging for OS was evaluated by multivariate Cox proportional-hazards model. Tumor responses were evaluated according to Response Evaluation in Solid Tumors v1.1. Liver function was assessed with albumin-bilirubin score.

RESULTS

Baseline characteristics were generally balanced between treatment arms in each BCLC stage. BCLC staging trended as an independent prognostic factor for OS (B vs. C; hazard ratio [HR] 0.756 [95% CI 0.546-1.046]). Consistent treatment benefit was observed for ramucirumab versus placebo across BCLC stages. Median OS for ramucirumab versus placebo was 13.7 versus 8.2 months; HR (95%): 0.43 (0.23-0.83) and 7.7 versus 4.8 months; HR (95%): 0.72 (0.59-0.89) for BCLC stage B and C, respectively. Adverse events (AEs) were consistent with observations from both studies; hypertension was the most frequent grade ≥3 AE. Liver function was preserved throughout the study and similar between treatment arms in both BCLC stages.

CONCLUSIONS

Ramucirumab provided a better survival benefit irrespective of BCLC stage and was well tolerated without compromising liver function during treatment.

Effect of Transarterial Chemoembolization on ALBI Grade in Intermediate-Stage Hepatocellular Carcinoma: Criteria for Unsuitable Cases Selection

Transarterial chemoembolization (TACE) is the standard of care for intermediate stage hepatocellular carcinoma (HCC). We aimed to identify unsuitable cases who were at risk of ALBI-grade migration by TACE. Consecutive 531 BCLC-B HCC patients undergoing TACE were reviewed, and factors associated with ALBI-grade migration were analyzed. There were 129 (24.3%) patients experienced acute ALBI-grade migration after TACE, and 85 (65.9%) out of the 129 patients had chronic ALBI-grade migration. Incidences of acute ALBI-grade migration were 13.9%, 29.0% for patients within or beyond up-to-7 criteria (p < 0.001) and 20.0%, 36.2% for patients within or beyond up-to-11 criteria (p < 0.001), respectively. HBV infection, tumor size plus tumor number criteria were risk factors associated with acute ALBI-grade migration. Bilobar tumor involvement was the risk factor of chronic ALBI-grade migration in patients with acute ALBI-grade migration. Up-to-eleven (p = 0.007) performed better than up-to-seven (p = 0.146) to differentiate risk of dynamic ALBI score changes. Moreover, ALBI-grade migration to grade 3 has adverse effect on survival. In conclusion, tumor burden beyond up-to-eleven was associated with ALBI-grade migration after TACE, indicating that up-to-eleven can select TACE-unsuitable HCC patients who are at risk of liver function deterioration.

Nomogram for predicting pathologic complete response after transarterial chemoembolization in patients with hepatocellular carcinoma

Background

The pathologic responses to transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) are heterogeneous and result in disparate outcomes. The study aimed to establish and validate an effective nomogram for predicting pathologic complete response (PCR) after TACE.

Methods

We analyzed the clinicopathologic characteristics of HCC patients undergoing hepatectomy following TACE. Variables with statistical significance in a multivariate logistic regression analysis were incorporated in the nomogram.

Results

We detected PCR in 64 (50.4%) patients in the training cohort and 18 (37.5%) patients in the validation cohort. Univariable and multivariable logistic regression revealed that hepatitis B virus (HBV) DNA load (P=0.031), α-fetoprotein (AFP, P=0.040), maximum tumor diameter (P=0.003), preoperative TACE session (P=0.026), and modified Response Evaluation Criteria in Solid Tumors (mRECIST) complete response (P=0.030) were identified as significant predictors of PCR. Incorporating these 5 factors, a nomogram was developed which attained concordance indexes of 0.80 [95% confidence interval (CI): 0.72–0.87] and 0.82 (95% CI: 0.68–0.95) for predicting PCR in the training and validation cohorts, respectively.

Conclusions

The easy-to-use nomogram achieved a good post-TACE prediction of PCR in HCC patients. Using the model, patients who would benefit most from TACE could be identified, and the subsequent appropriate procedures could be guided accordingly.

Association between prophylactic antibiotic use for transarterial chemoembolization and occurrence of liver abscess: a retrospective cohort study

OBJECTIVES

Clinical evidence on prophylactic antibiotics for transarterial chemoembolization (TACE) to prevent liver abscess is limited because liver abscess is a rare event. This study aimed to analyse the association between prophylactic antibiotic use for TACE and the occurrence of liver abscess after TACE.

METHODS

Using the nationwide Diagnosis Procedure Combination database in Japan, we retrospectively identified patients who underwent TACE for hepatic cancer between July 2010 and March 2017. The primary outcome was liver abscess requiring procedural intervention within 30 days of TACE. Secondary outcomes included 30-day in-hospital mortality and length of stay. Propensity score matching was performed to adjust for potential confounding factors and compare outcomes between patients with and without prophylactic antibiotics.

RESULTS

Among 167 544 eligible patients, 134 712 received antibiotics and 32 832 did not. In the matched cohort of 29 211 pairs, the proportion of patients with liver abscess requiring procedural intervention was significantly lower in the antibiotics group than in the no-antibiotics group (0.08% vs. 0.22%, p 0.001; relative risk (95% confidence interval), 0.35 (0.22-0.57); absolute risk reduction, 0.0014 (0.0008-0.0021); and number needed to treat, 696 (476-1223)). There was no significant difference in 30-day in-hospital mortality between the groups. The length of stay was longer in the antibiotics group than in the no-antibiotics group (median, 10 vs. 9 days, p < 0.001).

CONCLUSIONS

Prophylactic antibiotic use in patients undergoing TACE was associated with a reduced occurrence of liver abscess requiring procedural intervention.

Role of residual liver volumetry and function in prediction of liver tolerability after transarterial chemoembolization for hepatocellular carcinoma in cirrhotic patients: deriving a clinical decision support score

Background

Transarterial chemoembolization (TACE) is the recommended treatment modality for non-resectable intermediate-stage hepatocellular carcinoma; however, this stage has wide variable levels of liver functions and tumor burden making a challenge as regards the tolerability of the functioning residual liver to this type of therapy. Further stratification of this intermediate stage may help the clinical decision for the suitability of TACE, so we tried to derive a clinical decision support tool to predict the tolerability of the functioning residual liver to TACE using pre-intervention liver reserve function and liver residual volume as well as tumor burden.

Results

Two hundred and fifty-two patients with non-resectable intermediate-stage hepatocellular carcinoma (HCC) were consecutively included in this cohort study; all patients were blindly followed up for 6 weeks after TACE for manifestation of liver decompensation. For univariate logistic regression analysis, the significant predictors were age, s.albumin, s.bilirubin, prothrombin concentration (PC), tumor volume (TV), residual liver volume (RLV), and residual to liver volumetric ratio (RLVR) (sig, 0.007, 0.000, 0.000, 0.000, 0.000, 0.002, and 0.000, respectively). Multivariate logistic regression analysis illustrated that s.albumin, s.bilirubin, PC, and RLVR were the most independent significant predictors (sig, 0.000 for all with adjusted OR 0.002, 22.692, 0.827, and 0.000, respectively). The discriminatory performance of our proposed decision support score (liver tolerability score) was evaluated using the receiver operating characteristics that identified two cutoff points (≤ 0.30 and ≥ 0.83) to rule out or rule in the possibility of liver decompensation after TACE, respectively (AUC, 0.942 and sig. 0.000). Liver tolerability score stratified the intermediate stage of HCC to 3 risk grades (low, medium, and high) with significant difference as regards hazard distribution.

Conclusion

Computed tomography image-based assessment of RLVR may have a possible role in predicting future tolerability of the functioning residual tissue to TACE of HCC. Liver tolerability score (LTS) could stratify the intermediate stage HCC to 3 risk grades, so LTS may have a role in clinical decision for the suitability of TACE for intermediate stage HCC.

Cured giant hepatocellular carcinoma after transarterial embolization complicated with liver abscess formation

Many patients with hepatocellular carcinoma cannot be treated surgically because of the advanced stage of the tumor and/or coexisting cirrhosis. Transcatheter arterial embolization (TAE) represents an alternative therapeutic approach for some of these patients. However, it is not a curative measure, and an additional therapy is required to eradicate the residual disease. In this communication, we report a case of 55-year-old man with giant hepatocellular carcinoma located in the right lobe of the liver that was successfully treated with TAE. TAE completely devascularized the tumor in one session. Despite of postembolization antibiotic therapy, complete tumor necrosis led to abscess formation. After 57 days of abscess drainage, necrotic tumor tissue was completely evacuated from the drained cavity; no viable tumor tissue was identified by computed tomography/magnetic resonance imaging scan on a 5 year follow-up. TAE procedure can be suggested as a modulator of antitumor immune response, by exposing tumor antigens after necrosis leading to inflammation. In addition to necrosis caused by TAE, an antimicrobial acute inflammatory reaction in the treated area led to the complete destruction of the giant tumor.

Prognostic role of alpha-fetoprotein in patients with hepatocellular carcinoma treated with repeat transarterial chemoembolisation

BACKGROUND

Repeat transarterial chemoembolisation (rTACE) is often required for hepatocellular carcinoma (HCC) to achieve disease control, however, current practice guidelines regarding treatment allocation vary significantly. This study aims to identify key factors associated with patient survival following rTACE to facilitate treatment allocation and prognostic discussion.

METHOD

Patients with HCC undergoing rTACE at six Australian tertiary centers from 2009 to 2014 were included. Variables encompassing clinical, tumour, treatment type and response factors were analysed against the primary outcome of overall survival. Univariate analysis and multivariate Cox regression modelling were used to identify factors pre- and post-TACE therapy significantly associated with survival.

RESULTS

Total of 292 consecutive patients underwent rTACE with mainly Child Pugh A cirrhosis (61%) and BCLC stage A (57%) disease. Median overall survival (OS) was 30 months (IQR 15.2-50.2) from initial TACE. On multivariate analysis greater tumour number (p = 0.02), higher serum bilirubin (p = 0.007) post initial TACE, and hepatic decompensation (p = 0.001) post second TACE were associated with reduced survival. Patients with serum AFP ≥ 200 ng/ml following initial TACE had lower survival (p = 0.001), compared to patients with serum AFP level that remained < 200 ng/ml post-initial TACE, with an overall survival of 19.4 months versus 34.7 months (p = 0.0001) respectively.

CONCLUSION

Serum AFP level following initial treatment in patients undergoing repeat TACE for HCC is a simple and useful clinical prognostic marker. Moreover, it has the potential to facilitate appropriate patient selection for rTACE particularly when used in conjunction with baseline tumour burden and severity of hepatic dysfunction post-initial TACE.

Diffuse biliary peritonitis secondary to rupture of metastatic liver adenocarcinomas after drug-eluting bead transcatheter arterial chemoembolization: a case report

Transcatheter arterial chemoembolization (TACE) has become one of the first-line standard treatments for intermediate-advanced hepatocellular carcinoma, as well as an effective treatment for metastatic hepatic carcinoma. The majority of TACE-related complications are mild and acceptable to patients. Compared with conventional (C)-TACE, drug-eluting bead (DEB)-TACE allows permanent embolization of blood vessels, a slow continuous release of anti-tumour drugs in a locally targeted manner, and reduction of the systemic release of anti-tumour drugs, so that their adverse effects are significantly reduced. The general consensus is that DEB-TACE is safer and better tolerated by patients than C-TACE because serious complications after DEB-TACE are rarely reported. This current case report describes a rare case of diffuse biliary peritonitis secondary to rupture of a hepatic tumour after DEB-TACE. After the procedure, the patient presented with progressively worsening upper abdominal pain. As conventional management methods for the suspected tumour rupture failed, an emergency laparotomy was performed to remove the metastatic mass of differentiated hepatic adenocarcinoma. The patient remains under surveillance with no further complications. In our opinion, although DEB-TACE is safe and rarely has serious complications, caution should be exercised when this method is used to treat tumours that are located close to the liver surface.

Short- and long-term effects of transarterial chemoembolization on portal hypertension in patients with hepatocellular carcinoma

Background

Transarterial chemoembolization (TACE) affects hepatic perfusion, and might have an impact on portal pressure in patients with hepatocellular carcinoma (HCC).

Objective

The objective of this article is to report the secondary outcome “hepatic hemodynamics” from the AVATACE trial, a prospective randomized, placebo-controlled trial on the efficacy of conventional TACE in combination with bevacizumab or placebo.

Methods

Hepatic venous pressure gradient (HVPG) was measured at baseline (prior to first TACE), within nine days (“acute effects”), two months (“intermediate effects”) and six months (“long-term effects”) after the first TACE.

Results

Of 28 patients with early-intermediate stage HCC, n = 20 (71%) had clinically significant portal hypertension (CSPH, HVPG ≥ 10 mmHg) at baseline (median, 12 (interquartile range (IQR): 9–19) mmHg). TACE had neither “acute effects” nor “intermediate effects” on HVPG. However, in 13 patients with available HVPG measurement at month 6, there was a significant increase in HVPG (median, 16 (IQR: 11–19) mmHg) compared with baseline (median, 10 (IQR: 5–12) mmHg; p = 0.007). Portal hypertension-related complications occurred exclusively in patients with CSPH (8 (40%) vs 0).

Conclusions

Repeated TACE was associated with a significant long-term increase in HVPG. This should be considered when deciding whether to continue with TACE or switch to systemic treatment, since CSPH drives the development of complications.

Liver abscesses after transcatheter arterial embolization

Objective

This study aimed to evaluate the clinical features, radiological findings, risk factors, and management of liver abscesses following transcatheter arterial chemoembolization (TACE) therapy in patients with primary and metastatic liver cancer.

Methods

The medical records of 163 patients who were treated with TACE in our hospital for a total of 313 times between January 2012 and January 2018 were reviewed. The incidence rate of patients who developed liver abscesses after undergoing treatment, the computed tomography findings of the abscesses, predisposing risk factors, and the method of treatment were evaluated.

Results

Formation of liver abscesses was observed after treatment in four of the 163 (2.4%) patients and in four (1.3%) of the 313 chemoembolization procedures. Additionally, bilioenteric anastomosis was found in two patients and diabetes mellitus in two patients.

Conclusion

Formation of liver abscesses after TACE is a rare, but serious, complication. Physicians should be aware of the predisposing risk factors of TACE because of the possibility of death.

Impact of immigration in presentation and outcomes of hepatocellular carcinoma in the USA

BACKGROUND AND AIMS

Hepatocellular carcinoma's (HCC) epidemiology and prognosis differs among regions across the globe, largely because of environmental factors and underlying liver disease. Little is known about the changes led by immigration and the effect on HCC outcome. We aimed to understand the effect of immigration on HCC.

PATIENTS AND METHODS

A retrospective cohort study of patients diagnosed with HCC was carried out in a tertiary center in the USA between 2005 and 2016. We characterized individuals as US born or having immigrated there after being born elsewhere. Variables related to clinical presentation, surveillance, therapy, and survival were evaluated.

RESULTS

A total of 232 HCC cases were included, 169 US born (73%) and 63 immigrants (27%). Both groups were diagnosed with HCC at similar ages (60 vs. 62 years, P=0.13). Hepatitis C was the most common underlying liver disease in the US-born population compared with the immigrant population (83 vs. 52%, P<0.001), whereas hepatitis B was more common in the latter (4 vs. 29%, P<0.001). Interestingly, hepatitis B virus-related HCC was diagnosed at similar ages in US-born and immigrant individuals (59 and 57 years). At the time of diagnosis, both populations had similar tumor sizes, rates of metastasis, and diagnosis during surveillance. One-year survival was similar in both groups (65 vs. 63%).

CONCLUSION

Immigrants that develop HCC have different underlying liver disease than those born in the USA, but similar HCC characteristics and outcomes, even when including hepatitis B virus-related HCCs. Our study, albeit small, suggests that changes in the environment by immigration leads to clinical adaptation of HCC.

Adjuvant celecoxib and lanreotide following transarterial chemoembolisation for unresectable hepatocellular carcinoma: a randomized pilot study

Recurrence of hepatocellular carcinoma (HCC) after transarterial chemoembolisation (TACE) is common due to neoangiogenesis. Cyclooxygenase-2 inhibitors and somatostatin analogues were reported to inhibit tumour angiogenesis. The pilot randomized controlled trial was aimed to prospectively evaluate the protocol of TACE combined with celecoxib and lanreotide (TACE+C+L) in patients with unresectable and advanced HCC. A total of 71 patients with HCC were enrolled and randomly assigned to either TACE (n=35) or TACE+C+L (n=36) group. Overall survival, disease control rate (DCR), and adverse events were assessed during a 3-year follow-up period. The median overall survival of the TACE+C+L group (15.0 months) was doubled compared to that of TACE group (7.5 months), p = 0.012. DCR of the TACE+C+L group was significantly higher than that of the TACE group either at 6 months (72.2% vs 42.9%, p = 0.012) or at 12 months (61.1% vs 28.6%, p = 0.006). The median overall survivals (13 months vs 4.5 months, p = 0.013) and DCR at 12 months (50% vs 13.6%, p = 0.008) of patients with advanced HCC in TACE+C+L groups were significantly higher than those in TACE group. No significant difference of adverse events was observed between the two groups. The occurrence of post-embolisation syndrome in TACE+C+L group was significantly lower than that in TACE group (16.7% vs 60.0%, p = 0.001). In conclusion, the regimen of TACE+C+L prolonged overall survival, enhanced tumour response, reduced post-embolisation syndrome and was well-tolerable in the patients with unresectable HCC. It may be more beneficial for advanced HCC.

Intrahepatic biloma following transcatheter arterial chemoembolization for hepatocellular carcinoma: Incidence, imaging features and management

Repeat transcatheter arterial chemoembolization (TACE) becomes more challenging for patients with intrahepatic biloma following TACE for hepatocellular carcinoma (HCC). The purpose of this study was to investigate the clinical course, incidence, imaging features and outcome and to explore the reasonable therapy scheme for intrahepatic biloma following TACE for HCC.A total of 4,695 TACE procedures were performed for 1,923 patients with HCC. Twenty patients with intrahepatic biloma following TACE were studied retrospectively. The incidence of intrahepatic biloma was 1.04% in this study. The 20 patients underwent 55 TACE procedures (mean, 2.75). Portal vein invasion was found in half of the patients. Eleven patients developed round solitary or multiple cystic biloma, 6 patients had branched biloma and 3 patients developed both cystic and branched biloma. Percutaneous drainage was applied for 4 patients. One patient underwent partial hepatectomy and one mortality occurred due to progressive biloma and multiple organ failure. Although severe intrahepatic biloma following TACE is rare, the procedure should be performed with caution. Timely and appropriate management, including percutaneous drainage, partial hepatectomy and antibiotic administration should be performed in the case of any signs of infection.

Infections in Cancer Patients with Solid Tumors: A Review

Solid tumors are much more common than hematologic malignancies. Although severe and prolonged neutropenia is uncommon, several factors increase the risk of infection in patients with solid tumors, and the presence of multiple risk factors in the same patient is not uncommon. These include obstruction (most often caused by progression of the tumor), disruption of natural anatomic barriers such as the skin and mucosal surfaces, and treatment-related factors such as chemotherapy, radiation, diagnostic and/or therapeutic surgical procedures, and the increasing use of medical devices such as various catheters, stents, and prostheses. Common sites of infection include the skin and skin structures (including surgical site infections), the bloodstream (including infections associated with central venous catheters), the lungs, the hepato-biliary and intestinal tracts, and the urinary tract, and include distinct clinical syndromes such as post-obstructive pneumonia, obstructive uropathy, and neutropenic enterocolitis. The epidemiology of most of these infections is changing with resistant organisms [MRSA, Pseudomonas aeruginosa, extended spectrum beta-lactamase (ESBL)-producing organisms] being isolated more often than in the past. Polymicrobial infections now predominate when deep tissue sites are involved. Conservative management of most of these infections (antibiotics, fluid and electrolyte replacement, bowel rest when needed) is generally effective, with surgical intervention being reserved for the drainage of deep abscesses, or to deal with complications such as intestinal obstruction or hemorrhage. Infected prostheses often need to be removed. Reactivation of certain viral infections (HBV, HCV, and occasionally CMV) has become an important issue, and screening, prevention and treatment strategies are being developed. Infection prevention, infection control, and antimicrobial stewardship are important strategies in the overall management of infections in patients with solid tumors. Occasionally, infections mimic solid tumors and cause diagnostic and therapeutic challenges.

The Evolving Nature of Hepatic Abscess: A Review

Hepatic abscess (HA) remains a serious and often difficult to diagnose problem. HAs can be divided into three main categories based on the underlying conditions: infectious, malignant, and iatrogenic. Infectious abscesses include those secondary to direct extension from local infection, systemic bacteremia, and intra-abdominal infections that seed the portal system. However, over the years, the etiologies and risks factors for HA have continued to evolve. Prompt recognition is important for instituting effective management and obtaining good outcomes.

Liver Abscess Formation Following Transarterial Chemoembolization: Clinical Features, Risk Factors, Bacteria Spectrum, and Percutaneous Catheter Drainage

To investigate the clinical features, risk factors, and bacterial spectrum of liver abscess following transarterial chemoembolization (TACE) and evaluate the therapeutic effect of percutaneous catheter drainage (PCD) on the abscesses.A retrospective review of patient charts was performed in 3613 patients who suffered from liver malignancies (2832 patients with hepatocellular carcinoma and 781 with metastatic hepatic tumor) and had undergone 11,054 TACE procedures from January 2005 to October 2013. Liver abscesses were found in 21 patients. PCD was performed in all abscess patients. The clinical features, risk factors, and bacterial spectrum of liver abscess following TACE were investigated and the therapeutic effect of PCD was evaluated.The incidence of liver abscess was 0.58% per patient and 0.19% per procedure. Approximately 57.1% of the patients had a medical history of bilioenteric anastomosis or biliary stent implantation. On computed tomography scans, the abscesses appeared as low-attenuation lesions and high-density iodinate oil scattered in the abscesses. The ultrasound showed the well defined, heterogeneously hypoechoic lesions. Positive microbiological isolates were obtained in all pus cultures and in 47.6% of blood cultures. The most common bacterium was Escherichia coli (52.4%). Twenty patients (95.2%) were cured from abscesses by using PCD, and 1 died of sepsis.Patients with predisposing factors are prone to an increased risk of liver abscess following TACE. Bacterial culture and antibiotic sensitivity tests on pus and blood help on the antibiotics selection. PCD combined with aggressive antibiotics can be recommended as the first-line therapeutic regimen.

Cancer and liver cirrhosis: implications on prognosis and management

Liver cirrhosis, the end-stage of every chronic liver disease, is not only the major risk factor for the development of hepatocellular carcinoma but also a limiting factor for anticancer therapy of liver and non-hepatic malignancies. Liver cirrhosis may limit surgical and interventional approaches to cancer treatment, influence pharmacokinetics of anticancer drugs, increase side effects of chemotherapy, render patients susceptible for hepatotoxicity, and ultimately result in a competitive risk for morbidity and mortality. In this review, we provide a concise overview about the impact of liver cirrhosis on the management and prognosis of patients with primary liver cancer or non-hepatic malignancies.

Hollow organ abdominal ischemia, part II: clinical features, etiology, imaging findings and management

Acute hollow organ ischemia commonly presents with acute pain prompting radiologic evaluation and almost always requires urgent treatment. Despite different risk factors and anatomic differences, ischemia is commonly due to low flow states but can also be due to arterial and venous occlusion. Radiologic diagnosis is critical as many present with nonspecific symptoms. Contrast-enhanced computed tomography (CT) is the modality of choice. Magnetic resonance imaging (MRI) is preferred in suspected appendicitis in pregnant patients and is superior in biliary necrosis. This article provides a pictorial review of the CT/MRI features of hollow abdominal organ ischemia while highlighting key clinical features, pathogenesis, and management.

Repeated transcatheter arterial chemoembolization is safe for hepatocellular carcinoma in cirrhotic patients with transjugular intrahepatic portosystemic shunt

PURPOSE

We aimed to investigate the safety and long-term outcomes of repeated transcatheter arterial chemoembolization (TACE) in cirrhotic patients with transjugular intrahepatic portosystemic shunt (TIPS).

METHODS

Data of patients with hepatocellular carcinoma, who had previous TIPS implantation and received TACE between January 2010 and December 2012, were reviewed retrospectively. The primary outcome measure was liver function, which was represented by model for end-stage liver disease score, Child-Pugh-Turcotte score, serum total bilirubin, alanine aminotransferase, and aspartate aminotransferase. Changes in liver function before and after the initial TACE procedure and hepatobiliary severe adverse events (SAEs) were compared. Liver function following the initial TACE session was compared with that obtained in later TACE sessions. The secondary outcome measures were tumor response to multiple TACE sessions and survival.

RESULTS

Seventeen patients underwent at least two TACE sessions, while nine patients underwent at least three sessions during the follow-up period. There was no statistically significant difference between the liver function tests performed before and one-month after the TACE procedure. Grade 3 or 4 SAEs occurred in six (31.6 %) patients within one month. The one, two-, and three-year survival rates were 88%, 53%, and 32%, respectively. Tumor response of multiple TACE sessions was the only predictive risk factor of mortality (OR=4.40; P = 0.030; 95% CI, 1.15-16.85).

CONCLUSION

Our results suggest that repeated TACE is safe in selected patients with TIPS.

Predictors of hepatic decompensation after TACE for hepatocellular carcinoma

Aim

To study predictive factors for hepatic decompensation after transarterial chemoembolisation (TACE) for hepatocellular carcinoma (HCC).

Methods

Between November 2009 and August 2010, of 254 patients with HCC who presented to our multidisciplinary HCC clinic for evaluation, 102 (40%) were amenable for TACE. In this prospective study, there were 102 patients with compensated cirrhosis with HCC and Child-Pugh Class A cirrhosis who underwent TACE at the National Liver Institute, Menoufiya University, Egypt. We excluded all patients with prior locoregional therapy, systemic therapy and/or surgical intervention. At baseline and at 1 month postprocedure, laboratory criteria, tumour criteria (size, number) and Child-Pugh score were recorded. Patients were classified into group 1 (no Child-Pugh point increase after TACE) and group 2 (one or more added Child-Pugh points after TACE, defining hepatic decompensation). Univariate and multivariate analyses were performed to identify factors predictive of hepatic decompensation.

Results

Patients were mostly males (82.4%) of mean age 58.4±8.1 years. The only significant changes in laboratory findings at 1 month after TACE were increased international normalised ratio, serum total bilirubin, alanine transaminase and aspartate transaminase and decreased serum albumin and α-fetoprotein (AFP). The statistically significant predictive factors for hepatic decompensation using univariate analysis were found to be baseline lower serum albumin, higher serum α-fetoprotein, more advanced Barcelona Clinic Liver Cancer (BCLC) stage, larger tumour size and a greater number of tumour nodules; with logistic regression, multivariate analysis found that at baseline larger tumour size (p=0.004 at 95% CI), higher serum AFP (p=0.046 at 95% CI) and lower serum albumin (p=0.033 at 95% CI) predicted decompensation; BCLC stage, number of tumour nodules and pre-TACE bilirubin did not predict changes in liver function.

Conclusions

Lower serum albumin and increased tumour burden (larger tumour size/more nodules and higher α-fetoprotein) at baseline may help predict post-TACE decompensation.

Hepatic artery and biliary complications in liver transplant recipients undergoing pretransplant transarterial chemoembolization

Liver transplantation (LT) is the treatment of choice for patients with cirrhosis and hepatocellular carcinoma (HCC) not amenable to resection. Locoregional therapies for HCC are often used to reduce tumor burden, bridge patients to LT, and down-stage HCC so that patients are eligible for LT. We hypothesized that prior endovascular antitumor therapy may increase the risk of hepatic artery (HA) and biliary complications after LT. The aim of this study was to compare HA and biliary complications in LT recipients with HCC who received transarterial chemoembolization (TACE) before LT with complications in LT recipients with HCC who did not receive TACE before LT. This was a retrospective cohort study of HCC patients at two transplant centers. The prevalence of HA complications (HA thrombosis, stenosis, or pseudoaneurysm) and biliary complications (nonanastomotic stricture, bile leak, and diffuse injury) were compared between patients treated with or without TACE. There were 456 HCC patients with a median age of 61 years (77% were male, and 63% had hepatitis C virus), and 328 (72%) received TACE before LT. The overall prevalence of HA complications was 4.7% in the no-TACE group and 7.9% in the TACE group (P = 0.22). All HA stenosis complications (n = 14) occurred in the TACE group (P = 0.018 versus the no-TACE group). An older donor age and a lower albumin level significantly increased the odds of HA complications. There was a nonstatistically significant increased odds of HA complications in the TACE group versus the no-TACE group according to an adjusted analysis (odds ratio = 2.02, 95% confidence interval = 0.79-5.16, P = 0.14). The overall prevalence of biliary complications was 16.4% in the no-TACE group and 19.8% in the TACE group (P = 0.40). In conclusion, a lower pre-LT albumin level and an older donor age were significantly associated with higher odds of HA complications after LT. TACE was not associated with higher odds of overall HA complications but was associated with a higher prevalence of HA stenosis. Further studies are warranted to confirm the HA stenosis findings and elucidate the pathogenesis.

Chemoembolization outcomes for hepatocellular carcinoma in cirrhotic patients with compromised liver function

BACKGROUND

Transarterial chemoembolization (TACE) is recommended as a treatment for unresectable hepatocellular carcinoma (HCC) in patients with normal underlying liver function. The efficacy of TACE in cirrhotic patients with compromised liver function is unknown.

METHODS

All ‘first’ TACE interventions for HCC performed at a single institution from 2008 to 2012 were retrospectively reviewed (n = 190). Liver function was quantified via the Child's score. Tumour necrosis after TACE was quantified via the mRECIST criteria.

RESULTS

The 'first' TACE procedures of 100 Child's A and 90 Child's B/C cirrhotic patients were evaluated. As expected, the lab-model for end-stage liver disease (MELD) score was significantly higher in the Child's B/C group. Although the number of tumours were similar between the groups, both the size of the largest tumour and the total tumour diameter were greater in the Child's A group. There were no significant differences in post-TACE tumour necrosis between groups. The median survival after TACE was significantly longer in the Child's A compared with Child's B/C patients (21.9 versus 13.7 months, P = 0.03).

CONCLUSIONS

TACE appears to be equally efficacious in cirrhotic patients regardless of their Child's classification based upon equivalent mRECIST measures of tumour necrosis. However, inferior survival after TACE was observed in the Child's B/C group.

Efficacy and nontarget effects of transarterial chemoembolization in bridging of hepatocellular carcinoma patients to liver transplantation: a histopathologic study

PURPOSE

To histologically evaluate the efficacy and nontarget effects induced by transarterial chemoembolization as a "bridge" treatment of hepatocellular carcinoma (HCC) before liver transplantation (LT) and its relation to patient survival.

MATERIALS AND METHODS

Between October 2003 and January 2011, 51 patients with HCC underwent LT after chemoembolization with iodized oil, small spherical particles, and carboplatin. The decision for LT was made according to national guidelines. The efficacy and nontarget effects of chemoembolization were determined histologically in explanted livers, and their impact on patients' survival after LT was analyzed.

RESULTS

A total of 126 chemoembolization procedures were performed in 51 patients; the median number of procedures per patient was three (range, one to six). The extent of HCC necrosis was less than or equal to 50% in 32% of treated HCCs, more than 50% and less than or equal to 90% in 17%, and more than 90%-99% in 14%; 38% showed complete necrosis of the lesion. The most common nontarget effects were focal necrosis of the liver parenchyma adjacent to the embolized HCC nodule (28%), intralesional (micro)abscess (26%), intralesional hemorrhage (22%), and peritumoral bile duct necrosis (12%). Based on histopathologic examination, 35% of patients had HCC that did not meet Milan criteria. None of these findings was significantly associated with patient survival after LT.

CONCLUSIONS

Transarterial chemoembolization induces histopathologically confirmed HCC necrosis with a high degree of efficacy, but histologically proven complete HCC necrosis was not predictive of survival in this cohort of patients. Although histopathologic examination revealed (clinically relevant) nontarget effects in a subset of patients, they did not impair survival.

Clinical problem solving: utility of sonography in oncologic patients

This review demonstrates the unique advantages of sonography in the oncologic setting. Although computed tomography, magnetic resonance imaging, and positron emission tomography-computed tomography are primary imaging modalities for evaluation of the oncologic patient, sonography is useful for evaluation of various conditions and clinical scenarios associated with cancer. The following article will illustrate the utility of sonography at a tertiary cancer center for diagnosis and problem solving.

Review of the impact of antineoplastic therapies on the risk for cholelithiasis and acute cholecystitis

BACKGROUND

Development of cholecystitis in patients with malignancies can potentially disrupt their treatment and alter prognosis. This review aims to identify antineoplastic interventions associated with increased risk of cholecystitis in cancer patients.

METHODS

A comprehensive search strategy was developed to identify articles pertaining to risk factors and complications of cholecystitis in cancer patients. FDA-issued labels of novel antineoplastic drugs released after 2010 were hand-searched to identify more therapies associated with cholecystitis in nonpublished studies.

RESULTS

Of an initial 2,932 articles, 124 were reviewed in the study. Postgastrectomy patients have a high (5-30 %) incidence of gallstone disease, and 1-7 % develop symptomatic disease. One randomized trial addressing the role of cholecystectomy concurrent with gastrectomy is currently underway. Among other risk groups, patients with neuroendocrine tumors treated with somatostatin analogs have a 15 % risk of cholelithiasis, and most are symptomatic. Hepatic artery based therapies carry a risk of cholecystitis (0.02-24 %), although the risk is reduced with selective catheterization. Myelosuppression related to chemotherapeutic agents (0.4 %), bone marrow transplantation, and treatment with novel multikinase inhibitors are associated with high risk of cholecystitis.

CONCLUSIONS

There are several risk factors for gallbladder-related surgical emergencies in patients with advanced malignancies. Incidental cholecystectomy at index operation should be considered in patients planned for gastrectomy, and candidates for regional therapies to the liver or somatostatin analogs. While prophylactic cholecystectomy is currently recommended for patients with cholelithiasis receiving myeloablative therapy, this strategy may have value in patients treated with multikinase inhibitors, immunotherapy, and oncolytic viral therapy based on evolving evidence.

Liver abscess after transarterial chemoembolization in patients with bilioenteric anastomosis: frequency and risk factors

OBJECTIVE

The purpose of this study was to clarify the frequency of and risk factors for liver abscess formation after transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma or metastatic hepatic tumors after undergoing bilioenteric anastomosis.

MATERIALS AND METHODS

From January 1996 to June 2012, 25 patients (21 men, four women; age range, 34-74 years) with hepatocellular carcinoma (n = 12) or metastatic hepatic tumors (n = 13) with an underlying bilioenteric anastomosis underwent 65 TACE procedures. The incidence of liver abscess, predisposing factors (diabetes, Child-Pugh class, leukopenia, tumor number, tumor size, tumor burden, tumor type, portal vein thrombus, lipiodol dose, particulate embolization, embolization selectivity, oily portogram, antibiotic prophylaxis, and occurrence of liver abscess at initial TACE), and clinical outcome were evaluated. Statistical analysis for relations between liver abscess and predisposing factors was performed by Fisher exact test and linear-by-linear association.

RESULTS

Liver abscess developed after 17 of 65 (26.2%) TACE procedures performed on 12 of 25 (48%) patients. Two patients died of progression of liver abscess into sepsis. Univariate and multivariate analyses showed that leukopenia (p = 0.029), occurrence of liver abscess at initial TACE (p = 0.082), and particulate embolization or oily portogram (grade 2) (p = 0.001) were associated with a higher incidence of liver abscess.

CONCLUSION

The incidence of liver abscess was high among patients with bilioenteric anastomoses who underwent TACE. Leukopenia, occurrence of liver abscess at initial session of TACE, and particulate embolization or oily portogram (grade 2) were associated with the development of liver abscess.

Lobar hepatocellular carcinoma with ipsilateral portal vein tumor thrombosis treated with yttrium-90 glass microsphere radioembolization: preliminary results

Portal vein tumor thrombosis (PVTT) is a common complication of hepatocellular carcinoma (HCC) and has a negative impact on prognosis. This characteristic feature led to the rationale of the present trial designed to assess the efficacy and the safety of yttrium-90 glass-microsphere treatment for advanced-stage lobar HCC with ipsilateral PVTT. 18 patients with unresectable lobar HCC and ipsilateral PVTT were treated in our institution with (90)Y-microS radioembolization. Patients were evaluated every 3 to 6 months for response, survival, and toxicity. Mean follow-up was 13.0 months (2.2-50.6). Outcomes were: complete response (n = 2), partial response (n = 13), stable disease (n = 1), and progressive disease (n = 2) giving a disease control rate of 88.9%. Four patients were downstaged. Treating lobar hepatocellular carcinoma with ipsilateral portal vein thrombosis with yttrium-90 glass-microsphere radioembolization is safe and efficacious. Further clinical trials are warranted to confirm these results and to compare (90)Y-microS with sorafenib, taking into account not only survival but also the possibility of secondary surgery for putative curative intention after downstaging.

Antitumoural hydroxyapatite nanoparticles-mediated hepatoma-targeted trans-arterial embolization gene therapy: in vitro and in vivo studies

BACKGROUND/AIMS

Absence of curative treatment creates urgent need for new strategies for unresectable hepatoma. Based on former discoveries of good liver cell compatibility, safety and tumour-specific inhibition of hydroxyapatite nanoparticles (nHAP), this work tries to make nHAP serve as gene vector in the hepatoma-targeted trans-arterial embolization (TAE) gene therapy to elevate and synergize the therapeutic efficacy of TAE and target gene therapy.

METHOD

Following dosage and ratio optimization, polypolex formed by surface modified nHAP and p53 expressing plasmid was applied in vitro for human hepatoma HePG2 cell, and then in vivo for rabbit hepatic VX2 tumour by injection of polypolex/lipodoil emulsion to the hepatic artery in a tumour-target manner.

RESULTS

In vitro, the polypolex transfected only about 5% HepG2 cells, but can elevate the inhibition of its growth and apoptosis in a much more degree while keeping safe to the normal hepatocyte line, L02. In vivo, the emulsion, with better dispersion than the polypolex and more specific tumour-target than lipiodol, mediated specific 4% p53 expression and antitumoural nanoparticle retention in the target tumour site, also significantly reduced tumour growth and prolonged the animal survival times more than the lipiodol (P < 0.05).

CONCLUSIONS

In all, this new treatment based on nHAP can enhance therapeutic effect of HCC safely both in vitro and in vivo.

Management of hepatocellular carcinoma with transarterial chemoembolization in the era of systemic targeted therapy

The clinical management of hepatocellular carcinoma (HCC) is often complicated by poor liver function. Treatment options for intermediate- and advanced-stage disease are limited. Transcatheter arterial chemoembolization (TACE) is an effective first-line therapy for intermediate-stage HCC. By interrupting blood flow to the tumor and administering concentrated chemotherapy locoregionally, TACE induces necrosis at the tumor site, but may create conditions that permit or encourage angiogenesis and recurrence of the tumor. Combination of TACE with new targeted agents may be an effective way to treat intermediate-stage HCC, particularly in higher risk patients. Because of the efficacy and safety of sorafenib-the first systemic therapy to show significant clinical benefit in advanced HCC-there is great interest in its potential use in combination with existing treatment modalities. The synergistic combination of TACE plus sorafenib represents a promising opportunity for tumor control.