Local recurrence following complete radiologic response in patients treated with transarterial chemoembolization for hepatocellular carcinoma

Comparative outcomes of trans-arterial radioembolization in patients with non-alcoholic steatohepatitis/non-alcoholic fatty liver disease-induced HCC: a retrospective analysis

PURPOSE

Tumorigenesis in NAFLD/NASH-induced HCC is unique and may affect the effectiveness of trans-arterial radioembolization in this population. The purpose of this study was to retrospectively compare the effectiveness of trans-arterial radioembolization for the treatment of hepatocellular carcinoma (HCC) between patients with non-alcoholic steatohepatitis (NASH)/non-alcoholic fatty liver disease (NAFLD) and non-NASH/NAFLD liver disease.

MATERIALS AND METHODS

Consecutive patients with HCC who underwent TARE at a single academic institution were retrospectively reviewed. Outcome measures including overall survival (OS), local progression-free survival (PFS), and hepatic PFS as assessed by modified response evaluation criteria in solid tumors (mRECIST) were recorded. Kaplan-Meier and Cox proportional hazard models were utilized to compare progression-free survival and overall survival.

RESULTS

138 separate HCCs in patients treated with TARE between July 2013 and July 2022 were retrospectively identified. Etiologies of HCC included NASH/NAFLD (30/122, 22%), HCV (52/122, 43%), alcoholic liver disease (25/122, 21%), and combined ALD/HCV (14/122, 11%). NASH/NAFLD patients demonstrated a significantly higher incidence of type 2 diabetes mellitus (p < 0.0001). There was no significant difference in overall survival (p = 0.928), local progression-free survival (p = 0.339), or hepatic progression-free survival between the cohorts (p = 0.946) by log-rank analysis. When NASH/NAFLD patients were compared to all combined non-NASH/NAFLD patients, there was no significant difference in OS (HR 1.1, 95% C.I. 0.32-3.79, p = 0.886), local PFS (HR 1.2, 95% C.I. 0.58-2.44, p = 0.639), or hepatic PFS (HR 1.3, 95% C.I. 0.52-3.16, p = 0.595) by log-rank analysis.

CONCLUSION

TARE appears to be an equally effective treatment for NASH/NAFLD-induced HCC when compared to other causes of HCC. Further studies in a larger cohort with additional subgroup analyses are warranted.

Should Hypervascular Incidentalomas Detected on Per-Interventional Cone Beam Computed Tomography during Intra-Arterial Therapies for Hepatocellular Carcinoma Impact the Treatment Plan in Patients Waiting for Liver Transplantation?

BACKGROUND

Current guidelines do not indicate any comprehensive management of hepatic hypervascular incidentalomas (HVIs) discovered in hepatocellular carcinoma (HCC) patients during intra-arterial therapies (IATs). This study aims to evaluate the prognostic value of HVIs detected on per-interventional cone beam computed tomography (CBCT) during IAT for HCC in patients waiting for liver transplantation (LT).

MATERIAL AND METHODS

In this retrospective single-institutional study, all liver-transplanted HCC patients between January 2014 and December 2018 who received transarterial chemoembolization (TACE) or radioembolization (TARE) before LT were included. The number of ≥10 mm HCCs diagnosed on contrast-enhanced pre-interventional imaging (PII) was compared with that detected on per-interventional CBCT with a nonparametric Wilcoxon test. The correlation between the presence of an HVI and histopathological criteria associated with poor prognosis (HPP) on liver explants was investigated using the chi-square test. Tumor recurrence (TR) and TR-related mortality were investigated using the chi-square test. Recurrence-free survival (RFS), TR-related survival (TRRS), and overall survival (OS) were assessed according to the presence of HVI using Kaplan-Meier analysis.

RESULTS

Among 63 included patients (average age: 59 ± 7 years, H/F = 50/13), 36 presented HVIs on per-interventional CBCT. The overall nodule detection rate of per-interventional CBCT was superior to that of PII (median at 3 [Q1:2, Q3:5] vs. 2 [Q1:1, Q3:3], respectively, p < 0.001). No significant correlation was shown between the presence of HVI and HPP (p = 0.34), TR (p = 0.095), and TR-related mortality (0.22). Kaplan-Meier analysis did not show a significant impact of the presence of HVI on RFS (p = 0.07), TRRS (0.48), or OS (p = 0.14).

CONCLUSIONS

These results may indicate that the treatment plan during IAT should not be impacted or modified in response to HVI detection.

Local recurrence following a complete radiologic response in hepatocellular carcinoma patients: comparison of transarterial chemoembolisation and transarterial radioembolisation

AIM

To evaluate and compare the rates of local recurrence in hepatocellular carcinoma (HCC) patients who undergo selective transarterial radioembolisation (TARE) or transarterial chemoembolisation (TACE) and achieve a complete response (CR) radiologically.

MATERIALS AND METHODS

All patients undergoing treatment with TARE or TACE at a single academic institution were reviewed retrospectively. Those who had been treated previously, presented with multifocal disease, had non-selective TARE or TACE, or did not achieve a complete response (CR) radiologically were excluded.

RESULTS

In total 110 patients were included (TACE n=60 [54.5%]; TARE n=50 [45.5%]). TARE patients were older (66.4 ± 9.4 versus 61.2 ± 5.6 years, p<0.001) and had larger tumours (4.4 ± 2.2 versus 3 ± 1.4 cm, p=0.002). TACE patients were significantly more likely to suffer a local recurrence (31/60, 51.7% versus 9/50, 18%, p<0.001) and had a significantly shorter time to recurrence (median 8.3 {interquartile range [IQR]}: 12 versus median 17.9 [IQR: 23.5] months, p=0.001). A local time to progression (TTP) Kaplan-Meier curve demonstrated TACE patients had a significantly shorter local TTP (hazard ratio [HR]: 7.2; 95% confidence interval [CI]: 3.64-14.24; p<0.001) and treatment modality (TACE or TARE; HR: 0.05; 95% CI: 0.005-0.5; p=0.01) was found to be associated with local recurrences on multivariate Cox proportional HR analysis. When overall TTP was evaluated, again TACE patients were found to have a significantly shorter TTP (HR: 2.13 [1.28-3.53], p=0.004).

CONCLUSION

In HCC patients undergoing selective treatment who achieve a CR radiologically, those treated with TARE may be less likely to suffer recurrence, either local or general, than those treated with TACE.

Combination of intrahepatic TARE and extrahepatic TACE to treat HCC patients with extrahepatic artery supply: A case series

Purpose

The aim of this study was to report the safety and tumor response rate of combined transarterial radioembolization (TARE) through the intrahepatic arteries and transarterial chemoembolization (TACE) through the extrahepatic feeding arteries (EHFA) in patients with hepatocellular carcinoma (HCC).

Methods

Patients with HCC, who had both intrahepatic and extrahepatic arterial supply visible on preinterventional multiphase CT and were treated between 2016 and 2021 with a combination of TACE and TARE on the same nodule, were retrospectively included. Epidemiological, clinical, biological, and radiological characteristics were recorded. Safety and tumor response were assessed at 6 months.

Results

Nine patients (8 men, median age 62 years [IQR: 54-72 years]) were included. Seven patients had previous treatments on the target nodule (TARE: 5; TACE: 2). The median longest axis (LA) of the lesion was 70 mm (IQR: 60-79 mm). Three patients had portal vein invasion (VP3). The EHFA originated from the right diaphragmatic artery (n = 6), the right adrenal artery (n = 2), and the left gastric artery (n = 1). The LA of the tumor portion treated with TACE was 47 mm (range: 35-64 mm). The ratio between the LA of the entire lesion and the LA treated with TACE was 1.44 (range: 1.27-1.7). One major complication occurred: acute on chronic liver failure. Median follow-up was 23 months (range: 16-29 months). Seven patients underwent further treatment: on the same lesion (n = 2), on newly appeared nodules (n = 2), and systemic treatment (n = 3). At 6-month follow-up, seven patients showed a local objective response. Time-to-progression was 13 (3.5-19) months.

Conclusion

The combination of TARE and extrahepatic TACE for HCC with both intrahepatic and extrahepatic arterial supplies seems feasible and safe. Further studies are needed to validate the effectiveness of these preliminary results.

CT and MRI of abdominal cancers: current trends and perspectives in the era of radiomics and artificial intelligence

Abdominal cancers continue to pose daily challenges to clinicians, radiologists and researchers. These challenges are faced at each stage of abdominal cancer management, including early detection, accurate characterization, precise assessment of tumor spread, preoperative planning when surgery is anticipated, prediction of tumor aggressiveness, response to therapy, and detection of recurrence. Technical advances in medical imaging, often in combination with imaging biomarkers, show great promise in addressing such challenges. Information extracted from imaging datasets owing to the application of radiomics can be used to further improve the diagnostic capabilities of imaging. However, the analysis of the huge amount of data provided by these advances is a difficult task in daily practice. Artificial intelligence has the potential to help radiologists in all these challenges. Notably, the applications of AI in the field of abdominal cancers are expanding and now include diverse approaches for cancer detection, diagnosis and classification, genomics and detection of genetic alterations, analysis of tumor microenvironment, identification of predictive biomarkers and follow-up. However, AI currently has some limitations that need further refinement for implementation in the clinical setting. This review article sums up recent advances in imaging of abdominal cancers in the field of image/data acquisition, tumor detection, tumor characterization, prognosis, and treatment response evaluation.

Cryoablation in the liver: how accurately does the iceball predict the ablation zone?

PURPOSE

To evaluate the accuracy with which the iceball predicts the realized ablation zone in patients undergoing cryoablation of the liver.

MATERIALS AND METHODS

Continuous patients who underwent cryoablation of primary or secondary malignancies of the liver were retrospectively reviewed. Iceball and ablation zone dimensions on 1 month follow up imaging were collected in three orientations, the long axis (LA), perpendicular transverse (PTR), and perpendicular craniocaudal (PCC). Factors which may predict differences in the measurements were evaluated with regression analysis. Oncologic outcomes were also collected.

RESULTS

The mean size of the iceball was 5.5 ± 1.1 cm, 3.9 ± 1.1 cm, and 4.4 ± 1.4 cm in the LA, PTR, and PCC orientations, respectively. The mean size of the one-month ablation cavity was 4.3 ± 1.3 cm, 3 ± 1.1 cm, and 3 ± 1.3 cm in the LA, PTR, and PCC orientations, respectively. The iceball was significantly larger than the ablation zone in all orientations (p < 0.001). When comparing HCC and non-HCC patients the Kaplan-Meier analysis of TTLP, the Kaplan Meier curves deviated significantly (p = 0.015, HR 2.26 (95%CI 1.17-4.37)). When a similar analysis was performed looking at TTP again the curves diverged significantly (p = 0.002, HR 2.4 (95%CI 1.37-4.19)).

CONCLUSION

The iceball seems to overestimate the realized ablation zone by about 1 cm in all orientations during hepatic cryoablation.

Comparison Between Radial and Femoral Artery Access for Transarterial Chemoembolisation in Patients With Hepatocellular Carcinoma

PURPOSE

The purpose of this study was to compare the technical success rate, the selectivity of transarterial chemoembolisation (TACE), the complication rate, the radiation dose given to the patients and the hospitalization stay between TACE performed using femoral artery approach (FAA) and TACE performed using radial artery approach (RAA) in patients with hepatocellular carcinoma (HCC).

METHODS

Between June 2020 and April 2022, 49 patients with HCC who underwent 116 TACEs (75 using FAA and 41 using RAA) were included. Differences in technical success rate, selectivity of micro-catheterization, radiation dose given to the patients, fluoroscopy time, hospitalization stay duration, and complication rate were compared between FAA and RAA using Fisher exact or Student t tests.

RESULTS

No differences in technical success rates were found between RAA (93%; 39/41 TACEs) and FAA (100%; 75/75 TACEs) (P = .12). There were no differences between the two groups in terms of selectivity of catheterization, radiation dose, fluoroscopy time and hospitalization stay duration. Five patients had Grade 2 complications (hematoma) after FAA vs. one patient with one Grade 1 complication (radial artery occlusion) after RAA (5/75 [7%] vs. 1/41 [2%], respectively; P = .42). No major arterial access site complications occurred with FAA or RAA.

CONCLUSIONS

This study confirms that RAA is a safe approach that does not compromise the technical efficacy and the selectivity of TACE compared to FAA in patients with HCC.

Interpretations of the Role of Plasma Albumin in Prognostic Indices: A Literature Review

This review assesses how publications interpret factors that influence the serum or plasma albumin (PA) level in prognostic indices, focusing on inflammation and nutrition. On PubMed, a search for "albumin AND prognosis" yielded 23,919 results. From these records, prognostic indices were retrieved, and their names were used as search strings on PubMed. Indices found in 10 or more original research articles were included. The same search strings, restricted to "Review" or "Systematic review", retrieved yielded on the indices. The data comprised the 10 latest original research articles and up to 10 of the latest reviews. Thirty indices had 294 original research articles (6 covering two indices) and 131 reviews, most of which were from recent years. A total of 106 articles related the PA level to inflammation, and 136 related the PA level to nutrition. For the reviews, the equivalent numbers were 54 and 65. In conclusion, more publications mention the PA level as a marker of nutrition rather than inflammation. This is in contrast to several general reviews on albumin and nutritional guidelines, which state that the PA level is a marker of inflammation but not nutrition. Hypoalbuminemia should prompt clinicians to focus on the inflammatory aspects in their patients.

Improving pain control during transarterial chemoembolization for hepatocellular carcinoma performed under local anesthesia with multimodal analgesia

PURPOSE

The purpose of this study was to assess the performance of a reinforced analgesic protocol (RAP) on pain control in patients undergoing conventional trans-arterial chemoembolization (cTACE) for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Eighty-one consecutive patients (57 men, 24 women) with a mean age of 69 ± 10 (standard deviation) years (age range: 49-92 years) underwent 103 cTACEs. Standard antalgic protocol (50 mg hydroxyzine, 10 mg oxycodone, 8 mg ondansetron, and lidocaine for local anesthesia) was prospectively compared to a RAP (standard + 40 mg 2-h infusion nefopam and 50 mg tramadol). The individual pain risk was stratified based on age, the presence of cirrhosis and alcoholic liver disease, and patients were assigned to a low-risk group (standard protocol) or high-risk group (RAP). The primary endpoint was severe periprocedural abdominal pain (SAP), defined as a visual analog scale score ≥30/100. A predefined intermediate analysis was performed to monitor the benefit-risk of the RAP. Based on the intermediate analysis, all patients were treated with the RAP.

RESULTS

The intermediate analysis performed after 52 cTACE showed that 2/17 (12%) high-risk patients (i.e., those receiving the RAP) experienced SAP compared to 15/35 (43%) low-risk patients (odds ratio [OR] = 0.18; 95% confidence interval [CI]: 0.02-0.98; P = 0.03). Analysis of all procedures showed that 12/67 (18%) patients in cTACE receiving the RAP experienced SAP compared to 15/36 (42%) patients who did not receive it (OR = 3.27; 95% CI: 1.32-8.14; P = 0.01). There were no statistical differences in adverse events, particularly for nausea, between groups.

CONCLUSION

Reinforcing the analgesic protocol by combining non-opioid and opioid molecules reduces perioperative pain in patients undergoing cTACE for HCC.

Life expectancy of patients with hepatocellular carcinoma according to the upfront treatment: A nationwide analysis

PURPOSE

The purpose of this study was to update the life expectancy of patients with hepatocellular carcinoma (HCC) in an exhaustive nationwide population according to the upfront treatment performed.

MATERIALS AND METHODS

From the French Program for the Medicalization of Information System database, all patients older than 18 years diagnosed with a de novo HCC from January 2011 to December 2018 were retrospectively selected. Five-year survival rates (95% confidence intervals [CI]) were computed according to the first surgical or interventional radiology procedures performed.

RESULTS

A total of 63,996 patients (80% men) with a median age of 68 years (Q₁, Q₃: 61, 77) were selected, including 24,007 patients who underwent at least one procedure (5-year survival of 45.5%; (95% CI: 44.8-46.2), and 39,989 with none (5-year survival, 9.6%; (95% CI: 9.3-10.0). Only 20.5% (13,101/63,996) of patients could undergo an upfront curative procedure. Liver transplantation achieved the best outcome, whether performed upfront (n = 791; 5-year survival, 79.0% [95% CI: 76.1-82.1]) or during subsequent steps (n = 2217; 5-year survival 80.9% [95% CI: 79.2-82.7]). Tumor ablation (n = 5306), open resection (n = 5171), and minimally-invasive resection (n = 1833) achieved 5-year survival rates of 53.8% (95% CI: 52.3-55.4), 54.1% (95% CI: 52.6-55.6), and 66.2% (95% CI: 63.7-68.7), respectively, with more patients with cirrhosis and subsequent procedures in the tumor ablation group. Patients with upfront transarterial (chemo)embolization (n = 10,247) and selective internal radiation therapy (n = 659) had 5-year survival rates of 31.3% (95% CI: 30.3-32.4) and 18.5% (95% CI: 15.2-22.5).

CONCLUSION

While HCC remains mostly diagnosed at an advanced stage associated with a poor prognosis, all the curative options provide 5-year survival rates above 50%.

Recurrence of Hepatocellular Carcinoma After Complete Radiologic Response to Trans-Arterial Embolization: A Retrospective Study on Patterns, Treatments, and Prognoses

BACKGROUND

There is limited information about the long-term outcomes and patterns of progression in patients who have unresectable, liver-confined hepatocellular carcinoma (HCC) with complete response (CR) to transarterial embolization and do not undergo resection or transplantation (LT).

METHODS

A retrospective review analyzed participants in a randomized trial comparing hepatic artery embolization (HAE) and drug-eluting bead transarterial chemoembolization (DEB-TACE) with doxorubicin who had CR according to modified response evaluation criteria in solid tumors (mRECIST). The overall survival (OS), incidence and patterns of progression, and factors associated with progression were assessed.

RESULTS

Of the 101 patients in the trial, 37 with CR were included in this study. This cohort had 17 patients treated with HAE (46 %), and 20 patients managed with DEB-TACE (54 %). The median age was 67 years (range, 42-82 years). Most of the cohort were male (86.5 %) and Caucasian (78 %). The median pre-treatment Model for End-Stage Liver Disease (MELD) score was 10, and 70 % of the cohort had Barcelona Clinic Liver Cancer (BCLC) stage B or C. The median follow-up period was 49 months (95 % confidence interval [CI], 9-108 months), and the median OS was 25 months (95 % CI, 18.9-30.9 months). The 3- and 5-year survival rates were respectively 31 % (95 % CI, 16.7-45.9 %) and 18 % (95 % CI, 6.8-32.1 %). The 1- and 2-year cumulative incidences of progression were respectively 76 % (95 % CI, 57.7-86.8 %) and 92 % (95 % CI, 74.5-97.6 %). The most common first site of progression was the previously treated hepatic site or local site (32 %, 12/37). The 3-year cumulative incidence of progression was 65 % (95 % CI, 46.4-78.4 %) for the local site.

CONCLUSION

Patients with advanced-stage HCC and CR to embolization do not have durable responses and experience inevitable disease progression. Most patients with progression have liver-confined disease and should be evaluated for additional consolidative treatments.

Liver imaging reporting and data system (LI-RADS) v2018: Reliability and agreement for assessing hepatocellular carcinoma locoregional treatment response

PURPOSE

The purpose of this study was to determine the reliability and interobserver agreement of the liver imaging reporting and data system (LI-RADS) treatment response algorithm (LR-TR) v2018 using dynamic contrast-enhanced magnetic resonance imaging (DCE-MRI) and the added value of diffusion-weighted imaging (DWI).

MATERIALS AND METHODS

A total of 54 patients who underwent DCE-MRI and DWI after locoregional treatment of 81 hepatocellular carcinoma (HCC) lesions from September 2020 to July 2021 were included. There were 47 men and 7 women, with a mean age of 63.9 ± 9.2 (SD) years (age range: 23-77 years). Locoregional treatments included transarterial chemoembolization (TACE) (53/81; 65.4%), radiofrequency ablation (RFA) (25/81; 30.9%) and microwave ablation (MWA) (3/81; 3.7%). Two independent radiologists retrospectively evaluated DCE-MRI examinations obtained after locoregional treatment using LR-TR, and then three months later both radiologists reevaluated DCE-MRI examinations with DWI. Interobserver agreement was assessed using intraclass correlation coefficient (ICC) and Kappa test. Diagnostic performances were evaluated in term of sensitivity, specificity, and area under ROC curve (AUC) using a composite standard of reference that included results of histopathological examinations and follow-up findings.

RESULTS

Using DCE-MRI alone, observer 1 had 83.9% sensitivity (26/31; 95% confidence interval [CI]: 66-95%), 88% specificity (44/50; 95% CI: 76-95%) and 86.4% accuracy (70/81; 95%CI: 77-93%), and observer 2 had 71% sensitivity (22/31; 95% CI: 52-86%), 92% specificity (46/50; 95% CI: 81-98%) and 83.9% accuracy (68/81; 95% CI: 74-91%). For the diagnosis of viable tumors using DCE-MRI with DWI, observer 1 and observer 2 had 87.1% (27/31; 95% CI: 70-96%) and 74.2% (23/31; 95% CI: 55-88%) sensitivity, respectively. The diagnostic performance of DCE-MRI with DWI yielded an AUC (0.875; 95% CI: 0.789-0.962) not different from that of DCE-MRI without DWI (0.859; 95% CI: 0.768-0.951) (P = 0.317). Interobserver agreement for arterial phase hyperenhancement, washout, enhancement similar to pretreatment and DWI findings in all treated HCCs was almost perfect (kappa = 0.815, 0.837, 0.826 and 0.81 respectively). Agreement between observers for LR-TR category was substantial (kappa = 0.795; 95% CI: 0.665-0.924). Interobserver agreement for size of viable HCC was excellent (ICC = 0.938; 95% CI: 0.904-0.960).

CONCLUSION

LR-TR using DCE-MRI alone or DCE-MRI with DWI are both accurate for detecting viable HCC lesions after locoregional treatment, with no differences in diagnostic performance and excellent interobserver agreement.

Quantitative and qualitative evaluation of liver metastases with intraprocedural cone beam CT prior to transarterial radioembolization as a predictor of treatment response

Purpose

To investigate, by quantitative and qualitative enhancement measurements, the correlation between tumor enhancement on cone beam computed tomography (CBCT) images and treatment response at 6 months in patients undergoing transarterial radioembolization (TARE) for liver metastases.

Materials and Methods

36 patients (56% male; median age 62.5 years) with 104 metastases were retrospectively included. Quantitative and qualitative enhancement of liver metastases were evaluated on CBCT images before TARE. Quantitative analysis consisted of lesion enhancement measurements (ROI HU lesion - ROI HU relative to inferior vena cava). Qualitative analysis consisted of subjective enhancement pattern analysis (diffuse, sparse, rim-like or non-enhancing). Morphologic tumor response was evaluated according to RECIST 1.1 criteria on follow-up CT or MR imaging.

Results

At a mean follow up of 6.5 ± 3.7 months, progressive disease (PD) was found in 4 patients, partial response (PR) in 11 and stable disease (SD) in 21. Relative lesion enhancement was significantly different between these groups (-37.5±154.2 HU vs. 103.8±93.4 vs. 181±144 HU in PD vs. SD vs. PR group, respectively; p<0.01). ROC analysis of relative lesion enhancement to predict progressive disease showed an area under the curve of 0.86 (p<0.01). For qualitative lesion enhancement analysis, no difference between groups was found.

Conclusion

Quantitative enhancement measurements derived from intraprocedural contrast enhanced CBCT may identify responders to TARE in patients with liver metastases.