Quality improvement guidelines for transhepatic arterial chemoembolization, embolization, and chemotherapeutic infusion for hepatic malignancy

Impact of cone-beam computed tomography with automated feeder detection software on the survival outcome of patients with hepatocellular carcinoma during treatment with conventional transarterial chemoembolization

Background

Inoperable hepatocellular carcinoma (HCC) is treated by conventional transarterial chemoembolization (cTACE) using cone-beam computed tomography (CBCT) or digital subtraction angiography (DSA). We compared patient survival outcomes between CBCT-cTACE with automated tumor-feeder detection (AFD) software and DSA-cTACE alone in inoperable HCC patients.

Methods

We reviewed the data of 337 HCC patients treated by CBCT-cTACE or DSA-cTACE between January 2015 and December 2019. Treatment response, progression-free survival (PFS), overall survival (OS), and complications between the CBCT-cTACE and DSA-cTACE groups were compared. Univariate and multivariate logistic regression analyses examined the potential prognostic factors affecting survival after chemoembolization.

Results

Tumor response rates in complete response, partial response, and stable disease at 1 month were 67%, 28%, and 4% in the CBCT-cTACE group and 22%, 48%, and 9% in the DSA-cTACE group, respectively. OS rates of patients in the CBCT-cTACE versus DSA-cTACE groups were 87% versus 54%, 44% versus 15%, and 34% versus 7% at 1, 3, and 5 years, respectively. The CBCT-cTACE group had significantly improved PFS (p < 0.001) and OS (p < 0.001). Multivariate analysis showed that CBCT with AFD software was an independent factor associated with longer OS (hazard ratio, 0.38; p < 0.001).

Conclusions

Compared with conventional DSA, combining selective cTACE with CBCT and AFD software leads to better tumor response and prolongs OS in patients with inoperable HCC.

Polymicrobial bacteremia after treatment of transcatheter arterial chemoembolization: A case report

RATIONALE

Bacteremia caused by polymicrobial infections are rare but dangerous. We report a case of hepatic abscess combined with polymicrobial bacteremia in a 49-year-old male patient after surgery and transcatheter arterial chemoembolization (TACE).

PATIENT CONCERNS

The patient was admitted to hospital with metastatic liver cancer for periodic chemotherapy and developed a high fever and tenderness to the liver following surgery and TACE.

DIAGNOSIS

Hepatic abscess combined with polymicrobial bacteremia.

INTERVENTIONS

The clinician formulated a therapy in accordance with the drug susceptibility test and the empirical drug use for anaerobic bacteria. A comprehensive treatment plan was adopted, on the basis of the combination of nitrazole and imipenem as anti-infection drugs as well as continuous abscess drainage.

OUTCOMES

After comprehensive therapy, the patient was ultimately discharged without any residual symptoms.

LESSONS

Bloodstream infection caused by multiple bacteria increases the difficulty of anti-infection treatments, leading to poor treatment outcome and high mortality. Therefore, a fast and accurate diagnosis of polymicrobial bacteremia is key for initiation of an effective antimicrobial treatment. Additionally, pre-operative prophylactic antibiotics are advisable when patients have a history of abdominal surgery and are immune-compromised.

Locoregional treatments for hepatocellular carcinoma: Current evidence and future directions

Liver cancers are the second most frequent cause of global cancer-related mortality of which 90% are attributable to hepatocellular carcinoma (HCC). Despite the advent of screening programmes for patients with known risk factors, a substantial number of patients are ineligible for curative surgery at presentation with limited outcomes achievable with systemic chemotherapy/external radiotherapy. This has led to the advent of numerous minimally invasive options including but not limited to trans-arterial chemoembolization, radiofrequency/microwave ablation and more recently selective internal radiation therapy many of which are often the first-line treatment for select stages of HCC or serve as a conduit to liver transplant. The authors aim to provide a comprehensive overview of these various image guided minimally invasive therapies with a brief focus on the technical aspects accompanied by a critical analysis of the literature to assess the most up-to-date evidence from comparative systematic reviews and meta-analyses finishing with an assessment of novel combination regimens and future directions of travel.

Safety margin of embolized area can reduce local recurrence of hepatocellular carcinoma after superselective transarterial chemoembolization

BACKGROUND/AIMS

We aimed to determine the relationship between the safety margin of an embolized area and local tumor recurrence (LTR) of patients with hepatocellular carcinoma (HCC) who underwent superselective transarterial chemoembolization (TACE).

METHODS

The medical records of 77 HCC patients with 109 HCC nodules who underwent superselective TACE were retrospectively analyzed for LTR. Univariate and multivariate analyses were performed for 16 potential factors using Cox proportional hazard regression. Iodized oil deposition on cone-beam computed tomography (CBCT) imaging was divided into three grades: A=complete tumor staining and complete circumferential safety margin, B=complete tumor staining but incomplete safety margin, C=incomplete tumor staining. The effect of a safety margin on LTR was evaluated by comparison between grade A and B group.

RESULTS

Univariate and multivariate analyses revealed that grade A iodized oil deposition and portal vein visualization were the only two independent significant factors of LTR (P<0.001 and P=0.029, respectively). The 12- and 24-month LTR rates of tumors for grade A (n=62), grade B (n=30), and grade C (n=17) were 16% vs. 41% vs. 100% and 16% vs. 61% vs. 100%, respectively (P<0.001). The tumors in the grade A group had a 75% risk reduction in LTR (odds ratio, 0.25; 95% confidence interval, 0.10 to 0.64; P=0.004) compared to the grade B group.

CONCLUSION

LTR was significantly lower when a greater degree of iodized oil deposition occurred with a complete circumferential safety margin. In superselective TACE, the safety margin of the embolized areas using intraprocedural CBCT affected LTR in HCC patients.

Chemoembolization related to good survival for selected patients with hepatocellular carcinoma invading segmental portal vein

BACKGROUND & AIMS

We evaluated survival outcomes and prognostic factors associated with survival after TACE in a large cohort of 331 patients with HCC with segmental PVTT.

METHODS

From 1997 to 2015, a total of 331 patients were included in this study from among 507 patients who underwent TACE as a first-line treatment for HCC with segmental PVTT.

RESULTS

After TACE, the median survival of the whole cohort was 10.7 months, and the 1-year, 3-year and 5-year survival rates were 44.9%, 16% and 12% respectively. Objective tumour response after TACE was achieved in 53.8% of patients. Multivariable Cox regression analyses confirmed that up-to-11 criteria, extrahepatic metastasis, Child-Pugh class, and tumour response to TACE were independent prognostic factors for patient survival. The expected median survival times among patients with 0, 1 and 2-4 risk factors were 29.1, 15.1 and 5.3 months respectively. The 30-day mortality and major complications rates after TACE were 0.9% and 5.4% respectively.

CONCLUSIONS

TACE was well-tolerated and effective in selected patients with HCC with segmental PVTT. We found that four risk factors were associated with decreased length of patient survival after TACE: a major tumour burden (up-to-11 criteria out), extrahepatic spread, Child-Pugh class B liver function and nonregression to TACE. TACE may not be recommended for HCC patients with segmental PVTT with 2-4 risk factors because of poor survival outcome.

Superselective Transarterial Chemoembolization as an Alternative to Surgery in Symptomatic/Enlarging Liver Hemangiomas

BACKGROUND

Transarterial embolization of liver hemangiomas has not been considered to be consistently effective.

METHODS

The charts of 25 patients who underwent superselective transarterial chemoembolization with the bleomycin-lipiodol emulsion were evaluated retrospectively.

RESULTS

Twenty-two patients had abdominal pain; asymptomatic/vaguely symptomatic enlargement was the treatment indication in three patients. A single session was conducted in 17 patients, two sessions in 7 and three sessions in one. After the first session, lesion volume decreased by median (range) 51% (10-92%) from median (range) 634 (226-8435) to 372(28-4710) cm³ (p < 0.01), after a median period of 4 months (range 2-8). A second session was performed in eight patients (median (range) initial volume 1276 (441-8435) cm³) with persistent complaints and/or large lesions receiving feeders from both right and left hepatic arteries (staged treatment). Median (range) lesion size decreased further from 806 (245-4710) to 464 (159-2150) cm³ (p < 0.01). Three patients experienced a postembolization syndrome that persisted after the first week. Seventeen of the 22 symptomatic patients (77%) reported resolution or marked amelioration of complaints. Regrowth after initial regression was not observed during median (range) 14 (8-39) months of follow-up (n:18).

CONCLUSION

Transarterial chemoembolization with the bleomycin-lipiodol emulsion is a potential alternative to surgery for symptomatic/enlarging liver hemangiomas. Volume reduction is universal, and symptom control is satisfactory. Centrally located and very large (>1000 cm³) lesions may require two sessions.

Transarterial chemoembolization (TACE) in the management of hepatocellular carcinoma: Results of a French national survey on current practices

PURPOSE

To report current practices of transarterial chemoembolization (TACE) by interventional radiologists (IR) for hepatocellular carcinoma (HCC) through a French national survey.

MATERIALS AND METHODS

An electronic survey was sent by e-mail to 232 IRs performing TACE in 32 private or public centers. The survey included 66 items including indications for TACE, technical aspects of TACE, other locally available treatments for HCC, follow-up imaging and general aspects of interventional radiology practices.

RESULTS

A total of 64 IRs (64/232; 27%) answered the survey. Each IR performed a mean of 49±45 (SD) TACE procedures per year. Marked variations in indications for TACE in HCC were observed. Six percent of IRs (4/64) treated only patients with Barcelona Clinic Liver Cancer (BCLC) stage B HCC. Antibioprophylaxis was not used by 43/64 of IRs (67%). The number of HCC nodules was considered to select conventional TACE versus drug-eluting beadsTACE (DEB-TACE) by 17/49 IRs (35%) followed by patient performance status and Child-Pugh score by 6/49 IRs (12%). Seventy-three percent of IRs (45/62) treated nodules selectively in patients with unilobar disease with cTACE. Thirty-three percent of IRs (21/64) planned systematically a second TACE session. Doxorubicin was the most frequently used drug (52/64; 81%) and 15/64 IRs (23%) used gelatine sponge as the only embolic agent. For DEB-TACE, 100-300μm beads were used by 26/49 IRs (53%) and no additional embolization was performed by 19/48 IRs (39%). Monopolar radiofrequency technique was widely available (59/63; 94%) compared to selective internal radiation therapy (37/64; 58%). Magnetic resonance imaging was used for follow-up by 13/63 IRs (20%).

CONCLUSION

Current practices of TACE for HCC varied widely among IRs suggesting a need for more standardized practices.

Evaluation of Texture Analysis Parameter for Response Prediction in Patients with Hepatocellular Carcinoma Undergoing Drug-eluting Bead Transarterial Chemoembolization (DEB-TACE) Using Biphasic Contrast-enhanced CT Image Data: Correlation with Liver Perfusion CT

RATIONALE AND OBJECTIVES

This study aimed to evaluate the potential role of computed tomography texture analysis (CTTA) of arterial and portal-venous enhancement phase image data for prediction and accurate assessment of response of hepatocellular carcinoma undergoing drug-eluting bead transarterial chemoembolization (TACE) by comparison to liver perfusion CT (PCT).

MATERIALS AND METHODS

Twenty-eight patients (27 male; mean age 67.2 ± 10.4) with 56 hepatocellular carcinoma-typical liver lesions were included. Arterial and portal-venous phase CT data obtained before and after TACE with a mean time of 39.93 ± 62.21 days between examinations were analyzed. TACE was performed within 48 hours after first contrast-enhanced CT. CTTA software was a prototype. CTTA analysis was performed blinded (for results) by two observers separately. Combined results of modified Response Evaluation Criteria In Solid Tumors (mRECIST) and PCT of the liver were used as the standard of reference. Time to progression was additionally assessed for all patients. CTTA parameters included heterogeneity, intensity, average, deviation, skewness, and entropy of co-occurrence. Each parameter was compared to those of PCT (blood flow [BF], blood volume, arterial liver perfusion [ALP], portal-venous perfusion, and hepatic perfusion index) measured before and after TACE.

RESULTS

mRECIST + PCT yielded 28.6% complete response (CR), 42.8% partial response, and 28.6% stable disease. Significant correlations were registered in the arterial phase in CR between changes in mean heterogeneity and BF (P = .004, r = -0.815), blood volume (P = .002, r = -0.851), and ALP (P = .002, r = -0.851), respectively. In the partial response group, changes in mean heterogeneity correlated with changes in ALP (P = .003) and to a lesser degree with hepatic perfusion index (P = .027) in the arterial phase. In the stable disease group, BF correlated with entropy of nonuniformity (P = .010). In the portal-venous phase, no statistically significant correlations were registered in all groups. Receiver operating characteristic analysis of CTTA parameters yielded predictive cutoff values for CR in the arterial contrast-enhanced CT phase for uniformity of skewness (sensitivity: 90.0%; specificity: 45.8%), and in the portal-venous phase for uniformity of heterogeneity (sensitivity: 92.3%; specificity: 81.8%).

CONCLUSIONS

Significant correlations exist between CTTA parameters and those derived from PCT both in the pre- and the post-TACE settings, and some of them have predictive value for TACE midterm outcome.

Treatment of hepatocellular carcinoma using transarterial chemoembolization: a real-life, single-centre study from Southern Brazil

OBJECTIVE

The main aim of this study was to evaluate the real-life survival rates of patients with intermediate-stage hepatocellular carcinoma treated with transarterial chemoembolization.

METHODS

A retrospective cohort study involving 95 patients was conducted and the studied variables were analysed according to survival. Treatment response was determined using the Modified Response Evaluation Criteria in Solid Tumors assessment. The Kaplan-Meier method and Cox regression were used to analyse survival.

RESULTS

Most (72.6%) patients were male, with a mean age of 64.8±9.7 years and mean Model for End-Stage Liver Disease score of 10.4±3.0. The median α-fetoprotein (AFP) level was 29.3 ng/ml. Complications were observed in 31.6% of the patients. A target response assessment revealed that 35.8% of patients exhibited complete response, 22.1% a partial response, 27.4% stable disease and 14.7% progressive disease. According to overall response rates, 63.2% exhibited progressive disease. Mean survival time was 32 months. The 1-, 2-, 3- and 5-year survival rates were 80, 59, 44 and 29%, respectively. In the multivariate model adjusted for overall response rates, only AFP level more than or equal to 100 ng/ml (hazard ratio=2.35, 95% confidence interval: 1.06-5.18, P=0.035) was associated with death.

CONCLUSION

Transarterial chemoembolization is an effective therapy; however, AFP levels more than or equal to 100 ng/ml are associated with poorer prognosis.

Post-procedural Care in Interventional Radiology: What Every Interventional Radiologist Should Know-Part I: Standard Post-procedural Instructions and Follow-Up Care

Interventional radiology (IR) has evolved into a full-fledged clinical specialty with attendant patient care responsibilities. Success in IR now requires development of a full clinical practice, including consultations, inpatient admitting privileges, and an outpatient clinic. In addition to technical excellence and innovation, maintaining a comprehensive practice is imperative for interventional radiologists to compete successfully for patients and referral bases. A structured approach to periprocedural care, including routine follow-up and early identification and management of complications, facilitates efficient and thorough management with an emphasis on quality and patient safety.

Hepatic imaging following intra-arterial embolotherapy

PURPOSE

To discuss guidelines and salient imaging findings of solid tumors treated with common intra-arterial procedures used in interventional oncology.

METHODS

A meticulous literature search of PubMed-indexed articles was conducted. Key words included "imaging + embolization," "imaging + TACE," "imaging + radioembolization," "imaging + Y90," "mRECIST," and "EASL." Representative post-treatment cross-sectional images were obtained from past cases in this institution.

RESULTS

Intra-arterial therapy (IAT) in interventional oncology includes bland embolization, chemoembolization, and radioembolization. Solid tumors of the liver are the primary focus of these procedures. Cross-sectional CT and/or MR are the main modalities used to image tumors after treatment. Traditional size-based response criteria (WHO and RECIST) alone are of limited utility in determining response to IAT; tumoral necrosis and enhancement must be considered. Specifically for HCC, the EASL and mRECIST guidelines are becoming widely adopted response criteria to assess these factors. DWI, FDG-PET, and CEUS are modalities that play an adjunctive but controversial role.

CONCLUSIONS

Radiologists must be aware that the different forms of intra-arterial therapy yield characteristic findings on cross-sectional imaging. Knowledge of these findings is integral to accurate assessment of tumor response and progression.

Response to transarterial chemoembolization as a selection criterion for resection of hepatocellular carcinomas

BACKGROUND

Liver resection for intermediate (Barcelona Clinic Liver Cancer (BCLC) stage B) hepatocellular carcinoma (HCC) remains controversial. This study attempted to demonstrate the effectiveness of preresection transarterial chemoembolization (TACE) as a selection criterion for BCLC-B HCC.

METHODS

The study included patients with BCLC-B HCC who underwent liver resection after TACE. The tumour response to TACE was evaluated according to the modified Response Evaluation Criteria in Solid Tumours (mRECIST). Patients with a complete or partial response comprised the responder group, whereas those with stable or progressive disease were classified as non-responders.

RESULTS

A total of 242 patients were included. After between one and eight sessions of TACE, 141 patients were included in the responder group: 37 patients (15·3 per cent) who achieved a complete response and 104 who had a partial response. The cumulative 1-, 3- and 5-year overall survival rates were 97·2, 88·7 and 75·2 per cent respectively in the responder group, compared with 90·1, 67·3 and 53·5 per cent among 101 non-responders (P < 0·001). Tumour-free survival rates were also better among responders than non-responders (P < 0·001). In multivariable analysis, independent predictors of overall and tumour-free survival were response to TACE and microvascular invasion (all P < 0·001).

CONCLUSION

mRECIST may represent selection criterion for intermediate HCC for surgical treatment.

Hepatic artery embolization for liver metastasis of gastrointestinal stromal tumor following imatinib and sunitinib therapy

PURPOSE

The purpose of the study is to determine the efficacy of hepatic artery embolization (HAE) as a therapy for gastrointestinal stromal tumor (GIST) in patients who are refractory to imatinib and sunitinib.

METHODS

After institutional review board approval, a retrospective review revealed 11 patients with GIST metastatic to the liver who underwent 15 HAEs between February 2002 and May 2013. These patients were stratified into two groups according to the previous treatment: (a) those treated with HAE as second-line treatment after failing first-line imatinib (n = 3) and (b) those treated with HAE as third-line therapy after failing first-line imatinib and second-line sunitinib (n = 8). Initial therapeutic response, overall survival (OS), progression-free survival (PFS), and safety were evaluated.

RESULTS

Initial therapeutic response rates at 3 months after HAE were 27.3 % (95 % confidence interval (CI), 6.0-61.0 %) by Response Evaluation Criteria in Solid Tumor (RECIST) version 1.0 and 45.5 % (95 % CI, 16.7-76.6 %) by modified RECIST (mRECIST). The median OS and PFS after HAE were 14.9 and 3.9 months in group A and 23.8 and 3.4 months in group B, respectively. No procedure-related mortality or major complication was observed.

CONCLUSIONS

HAE is an effective and well-tolerated therapeutic option for GIST liver metastases. Although larger studies are necessary, HAE should be considered as an alternative or adjuvant to third-line or even second-line systemic treatment.

Combined Cisplatin-Based Chemoembolization and Radiation Therapy for Hepatocellular Carcinoma Invading the Main Portal Vein

PURPOSE

To evaluate the safety and survival outcome of chemoembolization plus radiation therapy (RT) in patients with hepatocellular carcinoma (HCC) with main portal vein (PV) tumor thrombosis.

MATERIALS AND METHODS

This retrospective study evaluated 151 patients with HCC and main PV involvement (101 with Child-Pugh class A liver function and 50 with Child-Pugh class B liver function) treated with combined cisplatin-based chemoembolization and RT. Medical records, imaging, and laboratory studies were reviewed, and complications, survival, and mortality rates were determined.

RESULTS

After chemoembolization, major complications occurred in 19.9% of patients, with the rate of major complications significantly higher in Child-Pugh class B cases than in Child-Pugh class A cases (32% vs 13.9%; P = .016). The 30-day mortality rate was 0.7%. One hundred forty-seven patients received adjuvant RT an average of 17.4 days after chemoembolization for main PV tumor thrombosis. Adjuvant RT could not be performed in four patients because of intolerance of the initial chemoembolization. There were no major complications after RT. The objective tumor response at 6 months was 25.2%, with a median survival of 12 months (14 mo in Child-Pugh class A cases and 8 mo in Child-Pugh class B cases). Patients with Child-Pugh class B liver function with extrahepatic metastases, no tumor response, and absence of second-line sorafenib treatment had poor survival.

CONCLUSIONS

Chemoembolization combined with RT improves survival, with a median survival of 12 months in patients with HCC with main PV involvement.

Transarterial chemoembolization (TACE) for colorectal liver metastases--current status and critical review

BACKGROUND

Transarterial liver-directed therapies are currently not recommended as a standard treatment for colorectal liver metastases. Transarterial chemoembolization (TACE), however, is increasingly used for patients with liver-dominant colorectal metastases after failure of surgery or systemic chemotherapy. The limited available data potentially reveals TACE as a valuable option for pre- and post-operative downsizing, minimizing time-to-surgery, and prolongation of overall survival after surgery in patients with colorectal liver only metastases.

PURPOSE

In this overview, the current status of TACE for the treatment of liver-dominant colorectal liver metastases is presented. Critical comments on its rationale, technical success, complications, toxicity, and side effects as well as oncologic outcomes are discussed. The role of TACE as a valuable adjunct to surgery is addressed regarding pre- and post-operative downsizing, conversion to resectability as well as improvement of the recurrence rate after potentially curative liver resection. Additionally, the concept of TACE for liver-dominant metastatic disease with a focus on new embolization technologies is outlined.

CONCLUSIONS

There is encouraging data with regard to technical success, safety, and oncologic efficacy of TACE for colorectal liver metastases. The majority of studies are non-randomized single-center series mostly after failure of systemic therapies in the 2nd line and beyond. Emerging techniques including embolization with calibrated microspheres, with or without additional cytotoxic drugs, degradable starch microspheres, and technical innovations, e.g., cone-beam computed tomography (CT) allow a new highly standardized TACE procedure. The real efficacy of TACE for colorectal liver metastases in a neoadjuvant, adjuvant, and palliative setting has now to be evaluated in prospective randomized controlled trials.

Transarterial therapies for primary liver tumors

Over the last decade, transarterial therapies have gained worldwide acceptance as standard of care for inoperable primary liver cancer. Survival times after transarterial chemoembolization (TACE) continue to improve as the technique and selection criteria are refined. Transarterial treatments, frequently provided in an outpatient setting, are now safely and effectively being applied to patients with even advanced malignancy or partially decompensated cirrhosis. In the coming years, newer transarterial therapies such as radiation segmentectomy, boosted-transarterial radioembolzation, combined TACE-ablation, TACE-portal vein embolization, and transarterial infusion of cancer-specific metabolic inhibitors promise to continue improving survival and quality of life.

Chemotherapy for transarterial chemoembolization in patients with unresectable hepatocellular carcinoma

AIM: To compare the efficacy of different chemotherapeutic agents during conventional transarterial chemoembolization (cTACE) in the treatment of unresectable hepatocellular carcinoma (HCC).

METHODS: A retrospective review was undertaken of patients with unresectable HCC undergoing cTACE from May 2003 to November 2011. A total of 107 patients were treated with at least one cTACE session. Irinotecan (CPT-11) was used as a chemotherapeutic agent in 24 patients, gemcitabine (GEM) in 24 and doxorubicin in 59.

RESULTS: The time to progression and overall survival rates were significantly superior in patients treated with CPT-11 compared with the GEM or doxorubicin treated groups (11.4, 8.2, 9.5 mo, P = 0.02 and 21.7, 12.7, 14.5 mo, P = 0.004, respectively). Subgroup analysis showed that for intermediate-stage HCC, CPT-11 resulted in a significantly longer time to progression and overall survival compared with the GEM or doxorubicin treated groups (P = 0.022; P = 0.003, respectively). There were no significant differences in adverse events among the three groups (P > 0.05).

CONCLUSION: For patients treated with cTACE, the chemotherapeutic agent CPT-11 was significantly associated with improved overall survival and delayed tumor progression compared with GEM or doxorubicin. There were no significant differences in clinical adverse events between the three agents. CPT-11 thus appears to be a promising agent when combined with cTACE for the treatment of HCC.

The role of interventional radiology in the management of hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (hcc) is one of the most common causes of cancer-related death worldwide. Overall, liver transplantation and resection are the only available treatments with potential for cure. Various locoregional therapies are widely used to manage patients with advanced hcc or as a bridging therapy for patients with early and intermediate disease. This article reviews and evaluates the role of interventional radiology in the management of such cases by assessing various aspects of each method, such as effect on rates of survival, recurrence, tumour response, and complications.

METHODS

A systemic search of PubMed, medline, Ovid Medline In-Process, and the Cochrane Database of Systematic Reviews retrieved all related scientific papers for review.

RESULTS

Needle core biopsy is a highly sensitive, specific, and accurate method for hcc grading. Portal-vein embolization provides adequate expansion of the future liver remnant, making more patients eligible for resection. In focal or multifocal unresectable early-stage disease, radiofrequency ablation tops all other thermoablative methods. However, microwave ablation is preferred in large tumours and in patients with Child-Pugh B disease. Cryoablation is preferred in recurrent disease and in patients who are poor candidates for anesthesia. Of the various transarterial modalities-transarterial chemoembolization (tace), drug-eluting beads, and transarterial radio-embolization (tare)-tace is the method of choice in Child-Pugh A disease, and tare is the method of choice in hcc cases with portal vein thrombosis.

CONCLUSIONS

The existing data support the importance of a multidisciplinary approach in hcc management. Large randomized controlled studies are needed to provide clear indication guidelines for each method.

Yttrium-90 radioembolization of liver tumors: what do the images tell us?

Transarterial radioembolization (TARE) with yttrium 90 microspheres is an increasingly popular therapy for both primary and secondary liver malignancies. TARE entails delivery of β-particle brachytherapy and embolization of the tumor vasculature. The consequent biological sequelae are distinct from those of other transarterial therapies for liver tumors, as reflected in the often baffling post-treatment imaging features. As the clinical use of TARE is increasing, more diverse post-treatment radiological findings are encountered with variable overlap among treatment response, residual disease, reactionary changes and complications. Thus, post-TARE image interpretation is challenging. This review provides a comprehensive description of the different findings seen in post-treatment scans, with the aim of facilitating appropriate radiological interpretation of post-TARE pathologic changes, notwithstanding their existing limitations.

Survival outcomes and prognostic factors of transcatheter arterial chemoembolization for hepatic neuroendocrine metastases

PURPOSE

To report survival outcomes in patients with neuroendocrine tumor (NET) with hepatic metastasis who were treated by transcatheter arterial chemoembolization and determine prognostic factors that affect clinical outcome.

MATERIALS AND METHODS

Patients with NET with hepatic metastasis who underwent chemoembolization between April 2002 and July 2011 were included in this single-center, retrospective study. Progression-free survival (PFS) and overall survival (OS) were calculated by Kaplan-Meier method. The influence of possible prognostic factors on survival was analyzed by log-rank method and multivariate Cox proportional-hazards method.

RESULTS

Forty-six patients with hepatic metastasis from nonpancreatic NETs (npNETs; n = 24) or pancreatic NETs (pNETs; n = 22) were included. The median PFS and OS times for the entire group were 16.2 and 38.6 months, respectively, and response rate was 58.1%. Patients with npNET had a similar PFS (17.4 mo vs 15.3 mo) and longer OS (55.0 mo vs 27.6 mo) compared with those with pNET, but there were no significant differences in PFS and OS between groups (P = .398 and P = .375, respectively). By univariate analysis, enterobiliary communication, hepatic tumor burden, and extrahepatic metastasis before the first chemoembolization were significant prognostic factors for poor OS (P = .001, P = .010, and P<.0001, respectively). By multivariate analysis, the same prognostic factors were significant and had relative risks of 4.63, 2.71, and 5.09, respectively.

CONCLUSIONS

Transcatheter arterial chemoembolization is an effective treatment modality for hepatic metastasis from NETs, with a median OS of 38.6 months and response rate of 58%. Enterobiliary communication, large hepatic tumor burden, and extrahepatic metastasis were significant risk factors for poor survival outcome.

Interventional oncologic approaches to liver metastases

Metastatic liver disease is the most common cause of death in cancer patients. Complete surgical resection is currently considered the only curative treatment, with only about 25% of patients being amenable to surgery. Therefore, a variety of interventional oncologic techniques have been developed for treating secondary liver malignancies. The aim of these therapies is either to allow patients with unresectable tumors to become surgical candidates, provide curative treatment options in nonsurgical candidates, or improve survival in a palliative or even curative approach. Among these interventional therapies are transcatheter therapies such as portal vein embolization, hepatic artery infusion chemotherapy, transarterial chemoembolization, and radioembolization, as well as interstitial techniques, particularly radiofrequency ablation as the most commonly applied technique. The rationale, application and clinical results of each of these techniques are reviewed on the basis of the current literature. Future prospects such as gene therapy and immunotherapy are introduced.

Hepatic artery dissection in a patient on bevacizumab resulting in pseudoaneurysm formation

Interventional radiologists are frequently encountering patients with colorectal cancer that are being treated with bevacizumab. This therapeutic agent is associated with a potentially increased risk of adverse events when invasive procedures are performed while patients are on therapy. The current case report reviews a complication related to planning angiography for radioembolization with Yttrium-90 microspheres in an individual on bevacizumab and subsequent management of the patient.

Predictive factors of downstaging of hepatocellular carcinoma beyond the Milan criteria treated with intra-arterial therapies

PURPOSE

This study was designed to analyze the clinical results in patients suitable for liver transplantation with hepatocellular carcinoma (HCC) who exceeded Milan criteria, which underwent intra-arterial therapies (IAT), to determine predictive factors of successful downstaging.

METHODS

A total of 277 consecutive patients with cirrhosis and HCC were treated by IAT (transarterial oily chemoembolization, transarterial chemoembolization, transarterial embolization) in a single center. Eighty patients exceed the Milan criteria. Patients with infiltrative HCC, hypovascular HCC, and portal vein thrombosis were excluded, with a final study population of 48 patients. Tumor response to IAT was evaluated with CT and/or MRI according to modified RECIST criteria. Successful downstaging was defined as a reduction in the number and size of viable tumors to within the Milan criteria, and serum alpha-fetoprotein (AFP) <100 ng/mL, for at least 6 months.

RESULTS

Nineteen patients (39 %) had their tumors successfully downstaged; 29 patients (61 %) did not. Multivariate analysis showed that AFP level <100 ng/mL and 3-year calculated survival probability using the Metroticket calculator were the only independent predictors of successful downstaging (p < 0.023 and p < 0.049 respectively).

CONCLUSIONS

Biological characteristics of HCC as AFP levels <100 ng/mL and high 3-year calculated survival probability may predict a good response to downstage after IAT.

Interventional radiological treatment of hepatocellular carcinoma: an update

Hepatocellular carcinoma is the commonest primary liver tumor and its incidence is on an increase.Transplantation and surgical resection are the gold standard curative treatment options but less than 20%patients are surgical candidates because of advanced liver disease and/or co-morbidities.Various interventional radiological procedures have been developed and intensively investigated for treatment of inoperable HCC.This review summarizes the various interventional radiological treatments in HCC including patient selection, procedural considerations and response evaluation. Transarterial chemoembolization, radioembolization and radiofrequency ablation are mainly discussed.

A systematic review of treatment guidelines for metastatic colorectal cancer

AIM

A systematic review of treatment guidelines for metastatic colorectal cancer (mCRC) was performed to assess recommendations for monoclonal antibody therapy in these guidelines.

METHOD

Relevant papers were identified through electronic searches of MEDLINE, MEDLINE In Process, EMBASE and the Cochrane Library; through manual searches of reference lists; and by searching the Internet.

RESULTS

A total of 57 relevant guidelines were identified, 32 through electronic database searches and 25 through the website searches. The majority of guidelines were published between 2004 and 2010. The country publishing the most guidelines was the USA (12), followed by the UK (10), Canada (eight), France (eight), Germany (three), Australia (two), Spain (two) and Italy (one). In addition, eight European and three international guidelines were identified. As monoclonal antibody therapy for mCRC was not introduced until 2004, no firm recommendations for monoclonal antibody therapy were made in guidelines published between 2004 and 2006. Recommendations for monoclonal antibody therapy first appeared in 2007 and evolved as more data became available. The most recent international, European and US guidelines recommend combination chemotherapy with the addition of a monoclonal antibody for the first-line treatment of mCRC. Second-line treatment depends on the first-line regimen used. For chemoresistant mCRC, cetuximab or panitumumab are recommended as monotherapy in patients with wild-type KRAS tumours.

CONCLUSION

The study indicates that recent treatment guidelines have recognized the role of monoclonal antibodies in the management of mCRC, and that treatment guidelines should be updated in a timely manner to reflect the most recently available data.

Critical appraisal of clinical practice guidelines for diagnosis and treatment of hepatocellular carcinoma

BACKGROUND AND AIM

Hepatocellular carcinoma (HCC) is the third most common reason for cancer-related death worldwide. Many countries either lack appropriate clinical practice guidelines for the diagnosis and treatment of HCC or the quality of their guidelines has never been evaluated. The main objective of our work was to identify published HCC guidelines and assess their quality with the Appraisal of Guidelines for Research and Evaluation instrument (AGREE) and their suitability regarding adaptation for future guidelines.

METHODS

We performed a systematic literature search on HCC clinical practice guidelines of MEDLINE, National Guidelines Clearinghouse and the Guidelines International Network. Methodological quality of selected guidelines was assessed by the AGREE instrument, Version 2001.

RESULTS

A total of 286 citations were screened and 32 relevant guidelines were identified. Overall, the guidelines performed well in the clarity and presentation domain with a mean score of 67%, followed by scope and purpose (55%) and rigor of development (50%). In contrast, poor scores were given for the remaining domains: stakeholder involvement (23%), applicability (28%) and editorial independence (31%). According to the AGREE instrument, four guidelines can be strongly recommended, 18 with provisos and alterations while the remaining cannot be recommended for adaptation due to poor methodological quality.

CONCLUSION

Although existing HCC guidelines may accurately reflect agreed clinical practice, many guidelines lack proper methodological quality. Future guidelines should place more emphasis on these methodological shortcomings.

Interventional radiology and the care of the oncology patient

Interventional Radiology (IR) is occupying an increasingly prominent role in the care of patients with cancer, with involvement from initial diagnosis, right through to minimally invasive treatment of the malignancy and its complications. Adequate diagnostic samples can be obtained under image guidance by percutaneous biopsy and needle aspiration in an accurate and minimally invasive manner. IR techniques may be used to place central venous access devices with well-established safety and efficacy. Therapeutic applications of IR in the oncology patient include local tumour treatments such as transarterial chemo-embolisation and radiofrequency ablation, as well as management of complications of malignancy such as pain, organ obstruction, and venous thrombosis.

Moxifloxacin prophylaxis for chemoembolization or embolization in patients with previous biliary interventions: a pilot study

OBJECTIVE

Abscess formation is a common serious adverse event after intraarterial therapy for hepatic malignancy in patients with colonized bile ducts. The combination of antibiotic prophylaxis and bowel preparation has been used to prevent hepatic abscess. We describe our outcomes with moxifloxacin prophylaxis alone without bowel preparation.

CONCLUSION

Ten patients underwent 25 procedures and were followed for a median of 250 days. No abscesses developed. Our results suggest moxifloxacin alone may suffice for prophylaxis.

Switching the loaded agent from epirubicin to cisplatin: salvage transcatheter arterial chemoembolization with drug-eluting microspheres for unresectable hepatocellular carcinoma

PURPOSE

There is no consensus on switching anticancer agents loaded onto drug carriers in transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC). This study aimed to evaluate the safety and clinical outcomes of TACE with cisplatin-loaded microspheres (CLM-TACE) in HCC patients refractory to TACE with epirubicin-loaded microspheres (ELM-TACE).

METHODS

Between February 2008 and June 2010, 85 patients with unresectable HCC refractory to ELM-TACE were enrolled to undergo CLM-TACE. The number of ELM-TACE sessions until judgment of resistance ranged from 1 to 4 (median, 2.1). CLM-TACE was performed using 50-100-μm superabsorbent polymer microspheres loaded with 1 mg cisplatin/1 mg microspheres together with hepatic arterial infusion of 25 mg cisplatin and 500 mg 5-fluorouracil per patient. Tumor responses were evaluated by computed tomography according to the European Association for the Study of the Liver criteria.

RESULTS

The median number of CLM-TACE treatment sessions was 1.8 (range, 1-5), and the mean total dose of cisplatin per session was 42.8 mg (range, 30.0-59.0). After 6 months, 3 (3.5%) patients achieved complete response, 31 (36.5%) had partial response, 15 (17.6%) had stable disease, and 36 (42.4%) had progressive disease. The median overall survival and time to treatment failure after initial CLM-TACE were 13.3 and 7.2 months, respectively. Overall, 9.4% of patients experienced grade 3/4 adverse events.

CONCLUSION

Switching the loaded agent from epirubicin to cisplatin is a safe, well-tolerated, and efficacious treatment strategy for salvage TACE with drug-eluting microspheres in HCC patients refractory to ELM-TACE.

Locoregional therapy for hepatocellular carcinoma

Locoregional therapies for hepatocellular carcinoma have progressed greatly in the last 30 years, beginning with the introduction of chemoembolization. Embolization techniques have evolved with the use of drug-eluting beads and radioembolization with yttrium-90. In the last 10 years, several new ablation techniques were developed including radiofrequency ablation, microwave ablation, cryoablation, laser ablation, and irreversible electroporation. Isolated or in combination, these techniques have already shown that they can improve patient survival and/or provide acceptable palliation.

Transarterial chemoembolization can be safely performed in patients with hepatocellular carcinoma invading the main portal vein and may improve the overall survival

PURPOSE

To determine the efficacy and safety of transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) and main portal vein (MPV) invasion.

MATERIALS AND METHODS

This study was approved by the institutional review board, and the requirement to obtain informed consent was waived. The authors retrospectively assessed the electronic medical records of patients in whom HCC with MPV invasion was newly diagnosed from January 2004 to December 2007 at a single tertiary medical center. Patients with decompensated hepatic function were excluded. Outcomes of patients treated with TACE were compared with those of patients given supportive care according to Child-Pugh class.

RESULTS

One hundred twenty-five patients (104 men and 21 women; mean age, 55.7 years; age range, 33.4-83.0 years) were included. The median overall survival was 3.7 months (range, 0.2-33.3 months). Eighty-three of the 125 patients (66.4%) were treated with TACE and 42 (33.6%) received supportive care. Repeated TACE showed significant survival benefits compared with supportive care in patients with Child-Pugh class A (median survival, 7.4 months vs 2.6 months, respectively; P < .001) and class B (median survival, 2.8 months vs 1.9 months, respectively; P = .002) disease. Results of multivariate analysis showed that treatment with TACE (hazard ratio, 0.263; 95% confidence interval [CI]: 0.164, 0.424; P < .001) and Child-Pugh class A status (hazard ratio, 0.550; 95% CI: 0.368, 0.822; P = .004) were independent predictive factors of a favorable outcome. There were no procedure-related deaths within 4 weeks after TACE, and patient morbidity was 28.9% (24 of 83 patients).

CONCLUSION

TACE can be performed safely and may improve the overall survival of patients with HCC and MPV invasion.

[Radiological treatment of hepatocellular carcinoma in 2010]

Several radiological techniques have been used for treating hepatocellular carcinoma. These include transcatheter arterial chemoembolization (TACE) and percutaneous therapy, such as radiofrequency (RF). The treatment efficacy of radiofrequency for hepatocellular carcinoma has been confirmed by several randomized and non randomized studies, with a benefit in terms of morbidity comparatively to surgery when cirrhosis is present. Radiofrequency ablation treatment is based on tumour size, shape and location, with a defined strategy and a proper patient selection. We will also review indications and technical aspects of transcatheter arterial chemoembolization (TACE). It is an accepted worldwide and effective treatment for patients with unresectable large or multinodular hepatocellular carcinoma. It improves significantly survival for adequate selected patients with preservation of liver function.

Transarterial chemoembolization with cisplatin as second-line treatment for hepatocellular carcinoma unresponsive to chemoembolization with epirubicin-Lipiodol emulsion

PURPOSE

The purpose of this retrospective study was to investigate the efficacy of transarterial chemoembolization (TACE) using cisplatin as a second-line treatment for advanced hepatocellular carcinoma (HCC) unresponsive to TACE using epirubicin-Lipiodol emulsion at our institution.

MATERIALS AND METHODS

Between January 2006 and March 2009, 51 patients with unresectable HCC underwent TACE using cisplatin. All patients had shown persistent viable tumor or tumor progression after at least 2 sessions of TACE using epirubicin-Lipiodol emulsion. TACE procedures consisted of arterial injection of a mixture of Lipiodol and cisplatin (30-100 mg [mean 57 ± 21]) (n = 29) or arterial infusion of cisplatin (30-100 mg [mean 87 ± 19]) solution (n = 22) followed by injection of 1-mm porous gelatin particles. Early tumor response was assessed by contrast-enhanced computed tomography (CT) according to Response Evaluation Criteria in Solid Tumors (RECIST) and European Association for the Study of the Liver (EASL) criteria. Overall survival and progression-free survival was calculated using the Kaplan-Meier method. Toxicity was assessed according to NCI-CTCAE version 3 criteria.

RESULTS

Response rates were 11.8 and 27.5% by RECIST and EASL criteria, respectively. Overall survival rates were 61.9, 48.2, and 28.9% at 1, 2, and 3 years, respectively, and the median survival time was 15.4 months. Progression-free survival rate was 35.2% at 1 year, and median progression-free survival time was 3.1 months. No major complications were observed, and the occurrence of postembolization syndrome was minimal. Grade 3 to 4 toxicities included thrombocytopenia (5.8%), increased aspartate aminotransferase (AST) level (35.3%), and increased alanine aminotransferase (ALT) level (23.5%).

CONCLUSION

Switching the TACE anticancer drug from epirubicin to cisplatin might be the feasible option for advanced HCC, even when considered resistant to the initial form of TACE.

Transcatheter arterial chemoembolization with epirubicin-loaded superabsorbent polymer microspheres for 135 hepatocellular carcinoma patients: single-center experience

PURPOSE

To evaluate the safety, clinical outcomes, and hepatic artery damage after transcatheter arterial chemoembolization (TACE) with epirubicin-loaded superabsorbent polymer microspheres (ELM-TACE) in patients with hepatocellular carcinoma (HCC) in a single center in Japan.

MATERIALS AND METHODS

This embolic agent is the original form of microspheres, which has the same composition and nature as HepaSpheres. Between May 2007 and June 2009, 135 patients with unresectable HCC who underwent ELM-TACE were enrolled. Embolization through extrahepatic collaterals was performed in 27 (20.0%) patients. Tumor response was evaluated using European Association for the Study of the Liver criteria at 1 and 6 months after initial ELM-TACE.

RESULTS

All procedures were successfully performed. The median number of TACE per patient was 1.7 sessions (range 1-5), and the mean epirubicin dose per session was 19.7 mg (range 2.0-60.0). Local pooling within target tumors was observed during TACE in 34 (25.2%) patients, and in 14 (10.4%) of the patients, gelatin sponge particles were added after the microspheres until each pooling disappeared. No serious adverse events associated with TACE occurred, and the incidence of postembolization syndrome was ≤17.8%. The 1- and 6-month tumor response rates were 56.3 and 52.6%, respectively. The overall 1- and 2-year survival rates were 73.7 and 59.0%, respectively. Among 99 evaluated patients, 90 (90.9%) were found to have no hepatic artery damage after initial ELM-TACE.

CONCLUSION

ELM-TACE is safe and effective treatment for unresectable HCC and is associated with low frequency of postembolization syndrome and minimal damage to the hepatic artery.

Interventional radiological treatment of hepatocellular carcinoma

BACKGROUND

Locoregional treatments of hepatocellular carcinoma (HCC) have evolved over the past 20 years. Interventional radiologists have developed an important role in the palliative and curative treatment of the disease. This review summarizes commonly used interventional radiological treatment protocols to assist practitioners in understanding the techniques used to treat HCC.

METHODS

Various searches were performed to evaluate recent publications regarding systemic treatments of HCC as well as transplant/surgery, chemoembolization, yttrium-90 radioembolization, percutaneous radiofrequency ablation (RFA), cryoablation, and percutaneous ethanol injection (PEI).

RESULTS

No standard for chemoembolization was found. Two studies evaluating survival with chemoembolization vs medical therapy found benefits with the former. PEI offers favorable outcomes in small HCC but has increased recurrence and decreased long-term survival compared with RFA. Local recurrence, response rates, and mortality from RFA rival surgical resection in HCC less than 3 cm. Cryoablation appears to be effective, and yttrium-90 radioembolization is an additional tool.

CONCLUSIONS

Chemoembolization improves survival and offers improved tumor response compared to systemic treatment. More studies are needed to standardize chemoembolization preparations and techniques. RFA provides better results than PEI but has not been compared with cryoablation. Radioembolization appears to be as effective as chemoembolization, but the preprocedure evaluation and costs may limit its use.

Hepatocellular carcinoma: CT for tumor response after transarterial chemoembolization in patients exceeding Milan criteria--selection parameter for liver transplantation

PURPOSE

To retrospectively evaluate the clinical outcome of patients with hepatocellular carcinoma (HCC) who exceeded the Milan criteria, who underwent transarterial chemoembolization (TACE) before orthotopic liver transplantation (OLT), to determine the value of computed tomography (CT)-based tumor response to TACE as a preoperative selection criterion for OLT.

MATERIALS AND METHODS

The study included 33 patients with HCC who exceeded the Milan criteria and underwent OLT after TACE. Informed written consent was obtained before TACE and OLT. Institutional review board approval was not required. Tumor response to TACE was evaluated at 1 month with CT according to amended Response Evaluation Criteria in Solid Tumours (RECIST) guidelines. In the explanted liver, degree of tumor necrosis (> or = 90%, 50%-89%, or < 50%), residual tumor stage and grade, and presence of microvascular invasion were assessed. Follow-up after OLT ranged from 1 to 143 months.

RESULTS

After TACE, CT showed complete tumor response (CR) in 18 (55%) patients. On the explanted liver, tumor necrosis was rated 90% or greater in 20 (61%) patients, with a good correlation with CT. Microvascular invasion was observed in nine (27%) of 33 patients; none of them were reported to have a CR at CT. The 5-year cumulative survival rate after OLT was 72.5%; it was significantly (P = .003) higher in patients with a CR (94.4%) compared with patients with a partial response (PR) (45.4%) and stable disease (50%). The 5-year cumulative recurrence-free rate after OLT was 74.4%; it was not affected by the tumor nodule size and number, whereas it was significantly (P = .008) higher in patients with a CR (94.4%) compared with patients with a PR (46.7%) and stable disease (50%).

CONCLUSION

In patients with HCC who exceeded the Milan criteria, a CR after TACE, on the basis of amended RECIST guidelines, is associated with excellent posttransplantation outcomes. Therefore, 1-month response to TACE assessed at CT may represent a valid selection criterion for OLT.