Superselective Conventional Transarterial Chemoembolization for Hepatocellular Carcinoma: Rationale, Technique, and Outcome

Comparative study between Embosphere® and Marine gel® as embolic agents for chemoembolization of hepatocellular carcinoma

BACKGROUND

While gelatin sponge particles and calibrated microspheres are commonly used as embolic materials in conventional transarterial chemoembolization (cTACE), direct comparisons between these embolic agents are rare.

AIM

To compare the efficacy and safety of superselective cTACE using Embosphere® or Marine gel® in patients with early-stage hepatocellular carcinoma (HCC).

METHODS

This retrospective study included 70 patients with small (< 4 cm) HCC who underwent cTACE with Embosphere® (n = 33) or Marine gel® (n = 37) as the embolic agent at a single center between March 2021 and July 2022. The radiologic images and clinical data were retrospectively reviewed, with an emphasis on tumor response, procedure-related complications, and local tumor recurrence. The primary index tumor was assessed on a 1-mo follow-up image, and local progression-free survival was obtained using the Kaplan-Meier method and was compared by the log-rank test.

RESULTS

The median tumor size of both groups was 1.5 cm, and 69 patients achieved a complete response one month after cTACE. The cumulative local recurrence rate at 12 mo was 15.5% in the Embosphere® group and 14.4% in the Marine gel® group. The local progression-free survival was not significantly different between the two groups (P = 0.83). In the multivariate analysis, high serum alpha-fetoprotein was the only significant poor prognostic factor for local tumor progression (P = 0.01). Postembolization syndrome occurred in 36.4% of the Embosphere® group and 35.1% of the Marine gel® group, and there were no cases of biloma, biliary duct dilation, or liver abscess in either group.

CONCLUSION

Calibrated gelatin sponge particles (Marine gel®) and calibrated microspheres (Embosphere®) have similar outcomes in terms of tumor response for superselective cTACE of small HCC.

Analysis of the Efficacy and Safety of Palonosetron Hydrochloride in Preventing Nausea And Vomiting After TACE: A Retrospective Analysis

PURPOSE

To investigate the mechanism of nausea and vomiting after TACE, and analyze the efficacy and safety of palonosetron hydrochloride in the prevention of nausea and vomiting after TACE.

METHODS

The data of 221 patients who underwent TACE in the Department of Intervention Therapy from August 2018 to August 2020 were collected. The patients were divided into two groups: those who did not use palonosetron hydrochloride before TACE (TACE group, N=116); and those who used palonosetron hydrochloride before TACE (TACE+palonosetron group, N=105). Primary study endpoint: The control rate of nausea and vomiting in the two groups at 0-24 h (acute), 24-120 h (delayed), and 0-120 h. Secondary Study Endpoints: Adverse events of palonosetron hydrochloride.

RESULTS

TACE group vs TACE+palonosetron group: 0-24 h, 74 vs. 44 patients with nausea (63.8% vs. 41.9%); 24-120 h, 50 vs. 16 patients with nausea (43.1% vs. 15.2%); 0-120 h after TACE, 81 vs. 50 patients with nausea (69.8% vs. 47.6%). 0-24 h, 52 vs. 26 patients with vomiting (44.8% vs. 24.8%); 24-120 h, 24 vs. 8 patients with vomiting (20.7% vs. 7.6%); 0-120 h after TACE, 64 vs. 26 patients with vomiting (55.2% vs. 24.8%). The incidence of nausea and vomiting after TACE was significantly lower in the TACE+palonosetron group than in the TACE group (p < 0.05).

CONCLUSION

Palonosetron hydrochloride can significantly reduce the incidence of nausea and vomiting in patients after TACE, with exact effect and high safety.

Radiological Vascular Anatomy of the Caudate Lobe of the Liver Required for Transarterial Chemoembolization of Hepatocellular Carcinoma

The caudate lobe is located between the bilateral hepatic lobes and is divided into three subsegments: the Spiegel lobe, paracaval portion, and caudate process. The caudate artery arises from various sites of the bilateral hepatic arteries as an independent branch, common trunk, or arcade. Extrahepatic arteries can enter the caudate lobe mainly by the right inferior phrenic artery. The caudate artery also supplies the main bile duct and posterior aspect of segment IV. Although catheterization into the caudate artery is occasionally difficult because of its small size and sharp angulation, selective embolization of a tumor feeder is a significant prognostic factor in patients with hepatocellular carcinoma originating there. Therefore, we should recognize the peculiarity of its vascular anatomy and should be familiar with catheterization and embolization techniques.

Prediction of postembolization syndrome after transarterial chemoembolization of hepatocellular carcinoma and its impact on prognosis

BACKGROUND

Postembolization syndrome (PES) represents the most frequent complication after transarterial chemoembolization (TACE) in patients with HCC. Given the vague definition as a symptom complex comprising abdominal pain, fever, and nausea, PES is diagnosed in heterogeneous patient cohorts with symptoms ranging from mild pain to severe deterioration of their general condition. This study aimed to evaluate predictive factors and the prognostic impact of PES with regard to different severity grades.

METHODS

A total of 954 patients treated with TACE for HCC at the University Medical Centres Mainz and Freiburg were included in this study. PES disease severity was graded as mild, moderate, or severe according to a predefined combination of symptoms. Logistic regression models were used to identify independent predictors of PES. The prognostic impact of PES was evaluated by competing risk analyses considering liver transplantation as a competing risk.

RESULTS

PES occurred in 616 patients (64.5%), but only 56 patients (5.9%) had severe PES, defined as moderate to severe abdominal pain requiring opioids in combination with fever and nausea. The largest tumor diameter was the strongest independent predictor of PES (OR = 1.21, 95% CI = 1.13-1.28), and severe PES (OR = 1.23, 95% CI = 1.14-1.33, p < 0.0001). Presence of liver cirrhosis was protective against PES (OR = 0.48, 95% CI = 0.27-0.84, p = 0.01). Furthermore, PES was independently associated with an impaired disease control rate (OR = 0.33, 95% CI = 0.16-0.69, p = 0.003) and severe PES with poor overall survival (subdistribution HR = 1.53, 95% CI = 0.99-2.36, p = 0.04).

CONCLUSIONS

Tumor size and absence of liver cirrhosis are predictors of severe PES and associated with impaired prognosis in HCC patients after TACE.

Guidelines for the Diagnosis and Treatment of Primary Liver Cancer (2022 Edition)

Background

Primary liver cancer, of which around 75-85% is hepatocellular carcinoma in China, is the fourth most common malignancy and the second leading cause of tumor-related death, thereby posing a significant threat to the life and health of the Chinese people.

Summary

Since the publication of Guidelines for Diagnosis and Treatment of Primary Liver Cancer in China in June 2017, which were updated by the National Health Commission in December 2019, additional high-quality evidence has emerged from researchers worldwide regarding the diagnosis, staging, and treatment of liver cancer, that requires the guidelines to be updated again. The new edition (2022 Edition) was written by more than 100 experts in the field of liver cancer in China, which not only reflects the real-world situation in China but also may reshape the nationwide diagnosis and treatment of liver cancer.

Key Messages

The new guideline aims to encourage the implementation of evidence-based practice and improve the national average 5-year survival rate for patients with liver cancer, as proposed in the "Health China 2030 Blueprint."

Clinical consensus statement: Establishing the roles of locoregional and systemic therapies for the treatment of intermediate-stage hepatocellular carcinoma in Canada

BACKGROUND

Hepatocellular carcinoma (HCC) a leading cause of cancer mortality worldwide and approximately one-third of patients present with intermediate-stage disease. The treatment landscape of intermediate-stage HCC is rapidly evolving due to developments in local, locoregional and systemic therapies. Treatment recommendations focused on this heterogenous disease stage and that take into account the Canadian reality are lacking. To address this gap, a pan-Canadian group of experts in hepatology, transplant, surgery, radiation therapy, nuclear medicine, interventional radiology, and medical oncology came together to develop consensus recommendations on management of intermediate-stage HCC relevant to the Canadian context.

METHODS

A modified Delphi framework was used to develop consensus statements with strengths of recommendation and supporting levels of evidence graded using the AHA/ACC classification system. Tentative consensus statements were drafted based on a systematic search and expert input in a series of iterative feedback cycles and were then circulated via online survey to assess the level of agreement.

RESULTS & CONCLUSION

The pre-defined ratification threshold of 80 % agreement was reached for all statements in the areas of multidisciplinary treatment (n = 4), intra-arterial therapy (n = 14), biologics (n = 5), radiation therapy (n = 3), surgical resection and transplantation (n = 7), and percutaneous ablative therapy (n = 4). These generally reflected an expansion in treatment options due to developments in previously established or emergent techniques, introduction of new and more active therapies and increased therapeutic flexibility. These developments have allowed for greater treatment tailoring and personalization as well as a paradigm shift toward strategies with curative intent in a wider range of disease settings.

Hepatic Arterioportal Fistulas: A Retrospective Analysis of 97 Cases

BACKGROUND AND AIMS

Hepatic arterioportal fistulas (HAPFs) are abnormal shunts or aberrant functional connections between the portal venous and the hepatic arterial systems. Detection of HAPFs has increased with the advances in diagnostic techniques. Presence of HAPFs over a prolonged period can aggravate liver cirrhosis and further deteriorate liver function. However, the underlying causes of HAPFs and the treatment outcomes are now well characterized. This study aimed to summarize the clinical characteristics of patients with HAPFs, and to compare the outcomes of different treatment modalities.

METHODS

Data of 97 patients with HAPFs who were admitted to the Second Xiangya Hospital between January 2010 and January 2020 were retrospectively reviewed. Demographic information, clinical manifestations, underlying causes, treatment options, and short-term outcomes were analyzed.

RESULTS

The main cause of HAPF in our cohort was hepatocellular carcinoma (78/97, 80.41%), followed by cirrhosis (10/97, 10.31%). The main clinical manifestations were abdominal distention and abdominal pain. Treatment methods included transcatheter arterial embolization (n=63, 64.9%), surgery (n=13, 13.4%), and liver transplantation (n=2, 2.1%); nineteen (19.6%) patients received conservative treatment. Among patients who underwent transcatheter arterial embolization, polyvinyl alcohol, lipiodol combined with gelatin sponge, and spring steel ring showed comparable efficacy.

CONCLUSIONS

Hepatocellular carcinoma and cirrhosis are common causes of HAPFs. Transcatheter arterial embolization is a safe and effective method for the treatment of HAPFs, and polyvinyl alcohol, lipiodol combined with gelatin sponge, and spring steel ring showed comparable efficacy in our cohort.

Initiative on Superselective Conventional Transarterial Chemoembolization Results (INSPIRE)

Several publications show that superselective conventional TransArterial ChemoEmbolization (cTACE), meaning cTACE performed selectively with a microcatheter positioned as close as possible to the tumor, improves outcomes, maximizing the anti-tumoral effect and minimizing the collateral damages of the surrounding liver parenchyma. Recent recommendations coming from the European Association for the Study of the Liver (EASL) and European Society of Medical Oncology (ESMO) highlighted that TACE must be used in Hepatocellular Carcinoma (HCC) “selectively targetable” and “accessible to supraselective catheterization.” The goal of the manuscript is to better define such population and to standardize superselective cTACE (ss-cTACE) technique. An expert panel with extensive clinical-procedural experience in TACE, have come together in a virtual meeting to generate recommendations and express their consensus. Experts recommend that anytime cTACE is proposed, it should be ss-cTACE, preferably with a 1.5–2.0 Fr microcatheter. Ideally, ss-cTACE should be proposed to patients with less than five lesions and a maximum number of two segments involved, with largest tumor smaller than 5 cm. Angio Cone-Beam Computed Tomography (CBCT) should be used to detect enhancing tumors, tumor feeders and guide tumor targeting. Whole tumor volume should be covered to obtain the best response. Adding peritumoral margins is encouraged but not mandatory. The treatment should involve a water-in-oil emulsion, whose quality is assessable with the “drop test.” Additional particulate embolization should be systematically performed, as per definition of cTACE procedure. Non-contrast CBCT or Multi-Detector Computed Tomography (MDCT) combined with angiography has been considered the gold standard for imaging during TACE, and should be used to assess tumor coverage during the procedure. Experts convene that superselectivity decreases incidence of adverse effects and improves tolerance. Experts recommend contrast-enhanced Computed Tomography (CT) as initial imaging on first follow-up after ss-cTACE, and Magnetic Resonance Imaging (MRI) if remaining tumor viability cannot be confidently assessed on CT. If no response is obtained after two ss-cTACE sessions within six months, patient must be considered unsuitable for TACE and proposed for alternative therapy. Patients are best served by multidisciplinary decision-making, and Interventional Radiologists should take an active role in patient selection, treatment allocation, and post-procedural care.

Homogenous multifunctional microspheres induce ferroptosis to promote the anti-hepatocarcinoma effect of chemoembolization

Transcatheter arterial chemoembolization (TACE) is one of the main palliative therapies for advanced hepatocellular carcinoma (HCC), which is also regarded as a promising therapeutic strategy for cancer treatment. However, drug-loaded microspheres (DLMs), as commonly used clinical chemoembolization drugs, still have the problems of uneven particle size and unstable therapeutic efficacy. Herein, gelatin was used as the wall material of the microspheres, and homogenous gelatin microspheres co-loaded with adriamycin and Fe₃O₄ nanoparticles (ADM/Fe₃O₄-MS) were further prepared by a high-voltage electrospray technology. The introduction of Fe₃O₄ nanoparticles into DLMs not only provided excellent T2-weighted magnetic resonance imaging (MRI) properties, but also improved the anti-tumor effectiveness under microwave-induced hyperthermia. The results showed that ADM/Fe₃O₄-MS plus microwave irradiation had significantly better antitumor efficacy than the other types of microspheres at both cell and animal levels. Our study further confirmed that ferroptosis was involved in the anti-tumor process of ADM/Fe₃O₄-MS plus microwave irradiation, and ferroptosis marker GPX4 was significantly decreased and ACSL4 was significantly increased, and ferroptosis inhibitors could reverse the tumor cell killing effect caused by ADM/Fe₃O₄-MS to a certain extent. Our results confirmed that microwave mediated hyperthermia could amplify the antitumor efficacy of ADM/Fe₃O₄-MS by activating ferroptosis and the introduction of Fe₃O₄ nanoparticles can significantly improve TACE for HCC. This study confirmed that it was feasible to use uniform-sized gelatin microspheres co-loaded with Fe₃O₄ nanoparticles and adriamycin to enhance the efficacy of TACE for HCC.

Efficacy of Superselective Conventional Transarterial Chemoembolization Using Guidance Software for Hepatocellular Carcinoma within Three Lesions Smaller Than 3 cm

Simple Summary

Although transarterial chemoebolization (TACE) is indicated for small hepatocellular carcinoma (HCC) as a second choice, TACE for small HCC is frequently difficult and less effective because of less hypervascularity and the presence of tumor portions receiving a dual blood supply. The aim of this study was to evaluate the efficacy of superselective cTACE under guidance software for patients with HCC within three lesions smaller than 3 cm. By using TACE guidance software, 81.2% of HCC lesions could be completely embolized and the cumulative local tumor progression rates in 303 tumors at 1, 3, 5, and 7 years were 17.8, 27.8, 32.0, and 36.0%, respectively. The 1-, 3-, 5-, and 7-year overall and recurrence-free survival rates in 175 patients were 97.1 and 68.7, 82.8 and 34.9, 64.8 and 20.2, and 45.3 and 17.3%, respectively. Our results indicate the efficacy of superselective cTACE using guidance software for HCC within three lesions smaller than 3 cm.

Abstract

The indication of transarterial chemoembolization (TACE) has advanced to hepatocellular carcinoma (HCC) of Barcelona Clinic Liver Cancer (BCLC) stage A when surgical resection (SR), thermal ablation, and bridging to transplantation are contraindicated; however, TACE for small HCC is frequently difficult and ineffective because of less hypervascularity and the presence of tumor portions receiving a dual blood supply. Here, we report outcomes of superselective conventional TACE (cTACE) for 259 patients with HCCs within three lesions smaller than 3 cm using guidance software. Automated tumor feeder detection (AFD) functionality was applied to identify tumor feeders on cone-beam computed tomography during hepatic arteriography (CBCTHA) data. When it failed, the feeder was identified by manual feeder detection functionality and/or selective angiography and CBCTHA. Regarding the technical success in 382 tumors (mean diameter, 17.2 ± 5.9 mm), 310 (81.2%) were completely embolized with a safety margin (5 mm wide for HCC ≤25 mm and 10 mm wide for HCC >25 mm). In 61 (16.0%), the entire tumor was embolized but the safety margin was not uniformly obtained. The entire tumor was not embolized in 11 (2.9%). Regarding the tumor response at 2–3 months after cTACE in 303 tumors excluding those treated with combined radiofrequency ablation (RFA) or SR and lost to follow-up, 287 (94.7%) were classified into complete response, seven (2.3%) into partial response, and nine (3.0%) into stable disease. The mean follow-up period was 44.9 ± 27.6 months (range, 1–109) and the cumulative local tumor progression rates at 1, 3, 5, and 7 years were 17.8, 27.8, 32.0, and 36.0%, respectively. The 1-, 3-, 5-, and 7-year overall and recurrence-free survival rates in 175 patients, excluding those with Child–Pugh C class, who died of other malignancies, or who underwent combined RFA or hepatic resection, were 97.1 and 68.7, 82.8 and 34.9, 64.8 and 20.2, and 45.3 and 17.3%, respectively. Our results indicate the efficacy of superselective cTACE using guidance software for HCC within three lesions smaller than 3 cm.

Transcatheter chemoembolization plus percutaneous radiofrequency ablation versus laparoscopic radiofrequency ablation: improved outcome for inoperable hepatocellular carcinoma

AIMS

To retrospectively compare the efficacy of transcatheter chemoembolization (TACE) plus percutaneous radiofrequency ablation (PRFA) (hereafter, TACE + PRFA) and laparoscopic radiofrequency ablation (LRFA) in the treatment of inoperable hepatocellular carcinoma (HCC).

METHODS

From July 2014 to December 2017, 132 consecutive patients with inoperable HCC were treated with TACE + PRFA (n = 86) or LRFA (n = 46). Overall survival (OS) and recurrence-free survival (RFS) were analyzed using log-rank test and Cox regression analysis. Propensity score matched (PSM) analyses based on patient and tumor characteristics were also conducted. Additionally, we performed exploratory analyses to determine the effectiveness of TACE + PRFA and LRFA in clinically relevant subsets.

RESULTS

The baseline characteristics of TACE + PRFA patients displayed relatively inferior liver status and a higher rate of BCLC-B disease. For unmatched patients, median OS (55.0 vs. 42.0 months; p = .019) and RFS (20.0 vs. 11.0 months; p < .001) were significantly longer in TACE + PRFA group than that in the LRFA group. After PSM, 39 matched pairs were identified. The difference in median OS (60.0 vs. 44.0 months; p = .009) and RFS (27.0 vs. 11.0 months; p < .001) between the two groups remained significant. Multivariate analysis in matched patients showed that treatment modality and response to initial treatment were significant predictors of OS and RFS, while recurrence after resection was an independent prognostic factor of OS. The benefits of TACE + PRFA were consistent across all the subgroups examined. The different treatments had shared a similar complication rate.

CONCLUSIONS

Compared to LRFA, TACE + PRFA results in improved OS and RFS in patients not amenable to resection.

Clinical practice of transarterial chemoembolization for hepatocellular carcinoma: consensus statement from an international expert panel of International Society of Multidisciplinary Interventional Oncology (ISMIO)

Importance

Transarterial chemoembolization (TACE) has been associated with a wide range of practice variations for hepatocellular carcinoma (HCC) between the East and the West. This considerable ambiguity may lead to the heterogeneous quality in treatment and have a negative impact on the role of TACE in the overall multidisciplinary HCC treatment system.

Objective

It may be a good start to establish a guideline worldwide to have this consensus from experts who represent east and west, although it does not cover all aspects of TACE.

Evidence Review

An international expert panel on TACE is convened to cluster the expert's opinions and summary a standard consensus. This panel committee consist of leading physicians in TACE on HCC from USA, France, Japan, Singapore, Korea, China, and so on. The first-round face-to-face consensus meeting was held during in Nanjing, China in October 2019. The second-round conference for revision of the consensus was held during the Annual Meeting of Chinese College of Interventionalists in August 2020 by a hybrid format of a Webinar and roundtable meeting. After several on-line revisions, the final manuscript was approved by all members of the panel in June 2021.

Findings

The consensus statements were organized into the following categories: patients' selection, performing the procedure, TACE outcomes, repeat TACE, TACE failure/refractory, and TACE-based combination treatments.

Conclusions and Relevance for Reviews

More and more evidences have showed the better outcomes with strategy of combined TACE with other local therapies such as ablations. The most-recently developing strategy of combined TACE with PD-1/PD-L1 plus tyrosine kinase inhibitor (TKI) agents has shined a light to the HCC patients, especially to those with high risk of tumor recurrence after treatment or TACE failure/refractory.

In the Era of Systemic Therapy for Hepatocellular Carcinoma Is Transarterial Chemoembolization Still a Card to Play?

Conventional transarterial embolization (cTACE) has been proven to be effective for intermediate stage hepatocellular carcinoma (HCC), with a recent systematic review showing an overall survival (OS) of 19.4 months. Nevertheless, due to the rapid development of the systemic therapeutic landscape, the place of TACE is becoming questionable. Is there still a niche for TACE in the era of immunotherapy and combination treatments such as atezolizumab-bevacizumab, which has shown an OS of 19.2 months with excellent tolerance? The development of drug-eluting microspheres (DEMs) has led to the standardization of the technique, and along with adequate selection, it showed an OS of 48 months in a retrospective study. In order to increase treatment selectivity, new catheters have also been added to the TACE arsenal as well as the use of cone-beam CT (CBCT), which provides three-dimensional volumetric images and guidance during procedures. Moreover, the TACE indications have also widened. It may serve as a "bridging therapy" for liver transplantation candidates while they are on the waiting list, and it represents a valuable downstaging tool to transplantation criteria. The aim of this review is to explore the current data on the advancements of TACE and its future place amongst the growing panel of treatments.

Blood Flow Diversion Within Hepatocellular Carcinoma (HCC) after Selective Occlusion of Feeding Arteries (SOFA) and Feasibility of Utilizing the SOFA Technique in Transarterial Chemoembolization (SOFA-TACE)

PURPOSE

Arterial feeders supplying a hepatocellular carcinoma are known to be interconnected through the sinusoid-like tumor vasculature. It was observed angiographically that when one of the feeders is selectively catheterized for drug delivery in transarterial chemoembolization (TACE), the whole tumor vasculature will be filled up, if the arterial inflow from all the other feeders is temporarily arrested with selective occlusion of feeding arteries (SOFA) using an additional catheter (balloon catheter). The feasibility of using the SOFA technique in TACE (SOFA-TACE) is discussed.

MATERIALS AND METHODS

In this prospective, monocentric feasibility study, with informed consent obtained, 8 consecutive patients of median age 64.5 years (60-68.8) and tumor dimension 4.7 cm (3.2-6.1), having specific tumor features (solitary, hypervascularity, well-defined, ≤ 7 cm, multiple tumor feeders), received SOFA-TACE using ethiodized oil-cisplatin suspension. Tumor response was assessed with 3-monthly CT using modified RECIST.

RESULTS

A single tumor feeder was catheterized for drug delivery (8 cases). All other tumor feeders were successfully occluded with a balloon at one site (8 cases). Complete filling of the vasculature of the whole tumor was achieved in 7 of 8 cases with the SOFA technique as shown on arteriogram and CT, except in a case with an intratumoral septum. There was no complication. Surveillance CT (median 25 months, range 22-28) showed complete response in all cases.

CONCLUSION

SOFA-TACE is feasible with reasonable safety and favorable treatment outcome; it may be a valuable technical option that may facilitate the procedures of selective TACE in technically challenging cases.

Management of Hepatocellular Carcinoma in Japan: JSH Consensus Statements and Recommendations 2021 Update

The Clinical Practice Manual for Hepatocellular Carcinoma was published based on evidence confirmed by the Evidence-based Clinical Practice Guidelines for Hepatocellular Carcinoma along with consensus opinion among a Japan Society of Hepatology (JSH) expert panel on hepatocellular carcinoma (HCC). Since the JSH Clinical Practice Guidelines are based on original articles with extremely high levels of evidence, expert opinions on HCC management in clinical practice or consensus on newly developed treatments are not included. However, the practice manual incorporates the literature based on clinical data, expert opinion, and real-world clinical practice currently conducted in Japan to facilitate its use by clinicians. Alongside each revision of the JSH Guidelines, we issued an update to the manual, with the first edition of the manual published in 2007, the second edition in 2010, the third edition in 2015, and the fourth edition in 2020, which includes the 2017 edition of the JSH Guideline. This article is an excerpt from the fourth edition of the HCC Clinical Practice Manual focusing on pathology, diagnosis, and treatment of HCC. It is designed as a practical manual different from the latest version of the JSH Clinical Practice Guidelines. This practice manual was written by an expert panel from the JSH, with emphasis on the consensus statements and recommendations for the management of HCC proposed by the JSH expert panel. In this article, we included newly developed clinical practices that are relatively common among Japanese experts in this field, although all of their statements are not associated with a high level of evidence, but these practices are likely to be incorporated into guidelines in the future. To write this article, coauthors from different institutions drafted the content and then critically reviewed each other's work. The revised content was then critically reviewed by the Board of Directors and the Planning and Public Relations Committee of JSH before publication to confirm the consensus statements and recommendations. The consensus statements and recommendations presented in this report represent measures actually being conducted at the highest-level HCC treatment centers in Japan. We hope this article provides insight into the actual situation of HCC practice in Japan, thereby affecting the global practice pattern in the management of HCC.

Retrospective European Multicentric Evaluation of Selective Transarterial Chemoembolisation with and without Balloon-Occlusion in Patients with Hepatocellular Carcinoma: A Propensity Score Matched Analysis

PURPOSE

The aim of this retrospective multicentric study was to compare the tumour response rates of Balloon-occluded Transarterial Chemoembolisation (B-TACE) to non-B-TACE using propensity score matching (PSM) in patients with hepatocellular carcinoma and to investigate the clinical benefit, such as lower rates of TACE re-intervention achieved using B-TACE.

MATERIAL AND METHODS

The B-TACE procedures (n = 96 patients) were compared with a control group of non-B-TACE treatments (n = 434 pts), performed with conventional (cTACE) or drug-eluting microspheres TACE (DEM-TACE). Data were collected from six European centres from 2015 to 2019. Objective responses (OR) and complete response (CR) rates after the first session and the number of TACE re-interventions were evaluated using PSM (91 patients per arm).

RESULTS

The best target OR after PSM were similar for both B-TACE and non-B-TACE (90.1% and 86.8%, p = 0.644); however, CR at 1-6 months was significantly higher for B-TACE (59.3% vs. 41.8%, p = 0.026). Patients treated with B-TACE had a significantly lower retreatment rate during the first 6 months (9.9%% vs. 22.0%, p = 0.041). Post-embolisation syndrome (PES) rates were 8.8% in non-B-TACE and 41.8% in B-TACE (p < 0.001), with no significant differences between groups regarding major adverse events.

CONCLUSION

B-TACE is safe and effective, achieving higher CR rates than non-B-TACE. Patients undergoing B-TACE had a significantly lower retreatment rate within the first 6 months but higher PES rates.

LEVEL OF EVIDENCE III

Level 3, retrospective study.

Feasibility and Techniques of Securing 3D-Safety Margin in Superselective Transarterial Chemoembolization to Improve Local Tumor Control for Small Hepatocellular Carcinoma: An Intend-to-Treat Analysis

INTRODUCTION

The aim of this study was to investigate the technical success rate of obtaining 3D-safety margin in superselective conventional transarterial chemoembolization (cTACE) using 3D images for small hepatocellular carcinoma (HCC).

METHODS

Consecutive 48 HCC nodules (diameter, 1-3 cm) in 44 patients were intentionally treated by superselective cTACE in an attempt to achieve 3D-safety margin. Superselective CT during hepatic arteriography (CTHA) was obtained before cTACE. When negative 3D-safety margin was found, branches supplied into the margin area were detected by using a 3D workstation. The technical success rate to obtain 3D-safety margin was investigated by intend-to-treat analysis. Local tumor recurrence rate and adverse events were also evaluated.

RESULT

Nine of 48 tumors (18.8%) had 3D-safety margin in the initial superselective CTHA. After pulling back of the catheter and/or selection of another branch based on 3D images, 3D-safety margin was finally achieved in 45 (93.8%). There were 8 of 46 tumors (17.4%) with local recurrence after 5-year follow-up. Grade 3-4 of aspartate aminotransferase, alanine aminotransferase, and total bilirubin were found in 38.6, 36.4, and 2.3%, respectively. One portal vein thrombus and 3 biliary dilation or biloma were developed.

CONCLUSION

Superselective cTACE obtaining 3D-safety margin in small HCC was feasible with a high success rate by using 3D images, which could be tolerable and prevent local tumor recurrence.

Current locoregional therapies and treatment strategies in hepatocellular carcinoma

Locoregional therapies (lrts) play an important role in the treatment of hepatocellular carcinoma (hcc), with the aim of increasing overall survival while preserving liver function. Various forms of lrt are available, and choosing the best one depends on technical aspects, liver morphology, tumour biology, and the patient's symptoms. The purpose of the present review article is to provide an overview of the current evidence relating to the use of percutaneous ablation, transarterial chemoembolization, and transarterial radioembolization for the curative or palliative treatment of hcc. Special situations are also reviewed, including the combined use of systemic therapy and lrt, indications and techniques for bridging to transplant and downstaging, and the use of lrt to treat patients with hcc and macrovascular invasion.

Comparison of embolic effect between water-in-oil emulsion and microspheres in transarterial embolization for rat hepatocellular carcinoma model

AIM

To compare two different embolic materials, water-in-oil (W/O) emulsion followed by gelatin particles and microspheres in transarterial embolization (TAE), using a rat hepatocellular carcinoma model.

METHODS

Twenty rats bearing N1S1 cells were divided into the W/O emulsion group and Microsphere group. Water-in-oil emulsion was created by a glass membrane emulsification device. The tumor vascularity was measured by contrast-enhanced ultrasonography 24 h before and 10 min and 48 h after TAE. Tumor necrosis, hepatic infarction ratio surrounding the tumor, and locations of the embolic materials 48 h after TAE were assessed. The changes of serum liver enzymes were also evaluated. Statistical significance was determined by using either the Mann-Whitney U-test or Fisher's exact test.

RESULTS

The tumor vascularity 48 h after TAE was significantly higher in the Microsphere group (20.1 vs. 3.76%, P = 0.016). The overflow of Lipiodol into the portal veins surrounding the tumor was seen, whereas microspheres were seen only in the artery. The percentage of necrotic area and complete response ratio in the W/O emulsion group was significantly higher (99.9 vs. 87.6%, P = 0.029 and 87.5 vs. 28.6%, P = 0.041, respectively). Serum aspartate aminotransferase and serum alanine aminotransferase levels 48 h after TAE were significantly higher in the W/O emulsion group (P < 0.01).

CONCLUSIONS

The embolization using W/O emulsion followed by gelatin particles showed stronger antitumor effects with the occlusion of both the tumor feeding artery and the portal vein compared with microspheres, which occluded only the arteries.

Hepatocellular Carcinoma With Different Areas of Right Retroperitoneal Space Invasion: Evaluation of Transcatheter Arterial Chemoembolization Efficacy and Blood Supply Characteristics

Purpose

To evaluate the therapeutic efficacy of transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) with different areas of right retroperitoneal space (rRPS) invasion and analyze the blood supply.

Methods

This retrospective study enrolled 41 patients with HCC with different areas of rRPS invasion treated with TACE, including 22 HCCs with superior aspect of the right perirenal space (SARPS) invasion and 19 HCCs with right anterior pararenal space (RAPS) invasion. The overall response rate (ORR) and disease control rate (DCR) were analyzed. The prognostic factors for overall survival (OS) after TACE were determined. The blood supply characteristics of HCC with different areas of rRPS invasion were analyzed with arteriograms.

Results

All patients underwent 2.8 ± 1.8 TACE sessions over 25.0 ± 21.9 months. The median OS was 29.0 months for patients with SARPS invasion and 12.0 months for patients with RAPS invasion (P = 0.004). Only the invaded area of the rRPS was an independent prognostic factor for OS [hazard ratio (HR), 2.833; 95% CI, 1.297–6.188; and P = 0.009). The ORR and DCR were significantly higher in the group with SARPS invasion than in the group with RAPS invasion (ORR: 63.6% vs 31.6%, P = 0.041; DCR: 77.3% vs 47.4%, P = 0.047). Initially, HCC with SARPS invasion were supplied by the hepatic artery (HA; n = 8) and both the HA and extrahepatic collateral vessels (EHCs; n = 14); HCC with RAPS invasion were supplied by the HA (n = 10) and both the HA and EHCs (n = 9); as the TACE sessions increased, the tumor-feeding vessels shifted from the HA to both the HA and EHCs, and even EHCs could be the only blood supply. Rare EHCs appeared earlier and more frequently in the RAPS group than in the SARPS group.

Conclusion

The efficacy of TACE differed for HCC with different areas of rRPS invasion, and the median OS, ORR and DCR were significantly better in the SARPS group than in the RAPS group. Different common EHCs supplied HCCs with different areas of rRPS invasion, while other rare EHCs appeared more frequently in the RAPS group.

Predictive model for acute abdominal pain after transarterial chemoembolization for liver cancer

BACKGROUND

Transarterial chemoembolization (TACE) is the first-line treatment for patients with unresectable liver cancer; however, TACE is associated with postembolization pain.

AIM

To analyze the risk factors for acute abdominal pain after TACE and establish a predictive model for postembolization pain.

METHODS

From January 2018 to September 2018, all patients with liver cancer who underwent TACE at our hospital were included. General characteristics; clinical, imaging, and procedural data; and postembolization pain were analyzed. Postembolization pain was defined as acute moderate-to-severe abdominal pain within 24 h after TACE. Logistic regression and a classification and regression tree were used to develop a predictive model. Receiver operating characteristic curve analysis was used to examine the efficacy of the predictive model.

RESULTS

We analyzed 522 patients who underwent a total of 582 TACE procedures. Ninety-seven (16.70%) episodes of severe pain occurred. A predictive model built based on the dataset from classification and regression tree analysis identified known invasion of blood vessels as the strongest predictor of subsequent performance, followed by history of TACE, method of TACE, and history of abdominal pain after TACE. The area under the receiver operating characteristic curve was 0.736 [95% confidence interval (CI): 0.682-0.789], the sensitivity was 73.2%, the specificity was 65.6%, and the negative predictive value was 92.4%. Logistic regression produced similar results by identifying age [odds ratio (OR) = 0.971; 95%CI: 0.951-0.992; P = 0.007), history of TACE (OR = 0.378; 95%CI: 0.189-0.757; P = 0.007), history of abdominal pain after TACE (OR = 6.288; 95%CI: 2.963-13.342; P < 0.001), tumor size (OR = 1.978; 95%CI: 1.175-3.330; P = 0.01), multiple tumors (OR = 2.164; 95%CI: 1.243-3.769; P = 0.006), invasion of blood vessels (OR = 1.756; 95%CI: 1.045-2.950; P = 0.034), and TACE with drug-eluting beads (DEB-TACE) (OR = 2.05; 95%CI: 1.260-3.334; P = 0.004) as independent predictive factors for postembolization pain.

CONCLUSION

Blood vessel invasion, TACE history, TACE with drug-eluting beads, and history of abdominal pain after TACE are predictors of acute moderate-to-severe pain. The predictive model may help medical staff to manage pain.

Shaping the tip of microcatheters for superselective catheterization: steam vs. manual methods

PURPOSE

We aimed to evaluate and compare the shapeability and stability of five microcatheters commonly used in interventional radiology after steam shaping and manual shaping.

METHODS

Steam shaping was performed using three mandrels of different angles: L(S) shape (90°), U(S) shape (180°), and O(S) shape (360°). Three manual shapes-L(M), U(M), and O(M)-were made to have a similar angle to their steam-shaped counterparts. The stability of the microcatheters was evaluated by passing them through a 5 F catheter and inserting microguidewires. The tip angles of the microcatheters and the angle change rates were compared between groups.

RESULTS

The mean angle of the microcatheters after steam shaping was 42.4°-54.1° for L(S) shape, 80.2°-96.7° for U(S) shape, and 130.7°-150.8° for O(S) shape. Five microcatheters showed significantly different mean angle reductions after passing through the 5 F catheter (17.4%-30.3%) and inserting microguidewires (24.1%-61.2%). Different microguidewires also caused significantly different mean angle reductions (34.6%-50.8%). The reduced angle caused by the guidewire was almost completely recovered after withdrawing it (93.2%-101.6%). Although manual-shaped microcatheters showed a 4.2%-6.3% greater angle reduction than steam-shaped microcatheters after passing through the 5 F catheter, the final tip angle was not significantly different between the two groups and was within 10%.

CONCLUSION

The tip angle of the microcatheters after steam shaping using mandrels may differ depending on the shape of the mandrel and the type of microcatheter used, and the stability varies depending on the type of microcatheter. The manual shaping of microcatheters can be a good alternative to steam shaping.

Appraisal of a Model to Estimate Survival in Ambulatory Patients with Hepatocellular Carcinoma Classified as Barcelona Clinic Liver Cancer Stage B

Background/Aims

Patients with an intermediate stage of hepatocellular carcinoma (HCC) represent a highly heterogeneous population; therefore, many models have been proposed to predict the survival of these patients. The aim of this study was to evaluate the prognostic performance of a novel subclassification for tumors classified as Barcelona Clinic Liver Cancer (BCLC) stage B using the Model to Estimate Survival in Ambulatory HCC patients (MESIAH).

Methods

This analysis was based on 377 patients with HCC treated at Seoul National University Hospital (training cohort) and 189 patients at the Soonchunhyang University Bucheon Hospital (validation cohort). Four subclassification systems were tested: MESIAH; original BCLC B subclassification (B1, B2, B3, and B4); modified model A (B1, B2, and B3+B4); and modified model B (B1, B2+B3, and B4).

Results

Median survival progressively decreased from stage B1 through stages B2 to B3 according to the new MESIAH subclassification (p<0.001). Moreover, significantly different survival among contiguous stages was observed. In the multivariable Cox regression, the MESIAH subclassification was an independent predictor of overall survival (p<0.001). In terms of discrimination and calibration, MESIAH performed better than the original BCLC B subclassification, modified model A and modified model B.

Conclusions

The MESIAH model would be an effective tool for stratifying heterogeneous BCLC stage B cancer, and the ability of this model to predict survival is better than that of the other previously proposed models.

Determination of Risk Factors for Pain After Transarterial Chemoembolization with Drug-Eluting Beads for Hepatocellular Carcinoma

Purpose

To identify risk factors for pain after transarterial chemoembolization with drug-eluting beads (DEB-TACE) for hepatocellular carcinoma (HCC).

Patients and Methods

In this retrospective study, a total of 118 consecutive patients who underwent DEB-TACE between June 2016 and May 2019 with post-TACE pain were included. The patients were divided into three groups based on the severity of post-TACE pain according to the distribution of pain Visual Analogue Scale/Score (VAS). Potential risk factors for post-TACE pain were primarily analyzed using the chi-square test, one-way analysis of variance, or Kruskal–Wallis test (if appropriate). For multivariate analysis, an ordinal logistic regression model was utilized. Variables with P<0.10 in the univariate analysis were included in a multivariate model to identify independent risk factors for post-TACE pain. A multivariate analysis was also performed by means of a decision tree using the Classification and Regression Tree (CART) algorithm.

Results

The univariate analysis showed that elderly patients or patients with portal venous tumor thrombus (PVTT) were more likely to have severe post-TACE pain than young patients or those without PVTT (P=0.028 and <0.001, respectively). However, in the ordinal logistic regression, nonsuperselective chemoembolization and presence of PVTT were independent risk factors of severe post-TACE pain (P=0.046 and <0.001, respectively). In addition, the CART showed that nonsuperselective chemoembolization and PVTT could increase the probability of severe post-TACE pain.

Conclusion

Nonsuperselective chemoembolization and PVTT are independent risk factors for pain after DEB-TACE. Therefore, these factors should be taken into full consideration for the relief of pain.

Selective Chemoembolization of Caudate Lobe Hepatocellular Carcinoma: Anatomy and Procedural Techniques

Transarterial chemoembolization is the most common treatment for unresectable hepatocellular carcinomas (HCCs). However, when an HCC is located in the caudate lobe, many interventional radiologists are reluctant to perform chemoembolization and percutaneous ablation owing to the tumor's complex vascular supply and deep location. With the advent of C-arm CT, rendering the three-dimensional display of the hepatic artery and detecting the tumor-feeding vessels are possible and can help guide interventional radiologists to the tumor. The common origins of the caudate artery include the right hepatic artery, left hepatic artery, right anterior hepatic artery, and right posterior hepatic artery. The origins of the tumor-feeding arteries of a caudate lobe HCC can vary depending on the tumor's subsegmental location. Caudate lobe HCCs are commonly fed by multiple caudate arteries that are connected. In addition, extrahepatic collateral arteries frequently supply recurrent tumors in the caudate lobe. The caudate artery can supply portal vein thrombi or biliary tumor thrombi in patients with HCC. Several techniques such as preshaping the microcatheter or using the shepherd's hook technique are needed to catheterize the caudate artery in complex cases. Although uncommon, bile duct stricture is a serious complication following selective chemoembolization through the caudate artery. Identification and catheterization of the caudate artery have become possible in most patients by using C-arm CT and a fine microcatheter system, respectively. The authors review the anatomy of the caudate artery with C-arm CT and describe basic technical considerations in selective chemoembolization for caudate lobe HCCs. Unusual circumstances that require catheterization and techniques used for catheterizing the caudate artery are also described. Online supplemental material is available for this article. ^©RSNA, 2019.

Evaluation of transarterial chemoembolization refractoriness in patients with hepatocellular carcinoma

Background & aim

In clinical practice, transarterial chemoembolization (TACE) has been widely used for the treatment of hepatocellular carcinoma (HCC) beyond as well as within guideline recommendations. Here we aimed to verify whether two consecutive non-responses could be an optimal criterion for creating a rule to stop TACE being performed on these patients.

Methods

This study evaluated 200 patients with HCC beyond the Milan criteria, initially treated with TACE. TACE response was determined using the mRECIST criteria via dynamic CT or MRI. Median follow-up duration was 23.9 months.

Results

Within the 200 patients analyzed, 183 (91.5%) were male, with a total median age of 59.8 years. The mean size of the largest tumor was 6.8 cm, with 80 (40.0%) patients with ≥4 tumors. After the first TACE procedure, complete response, partial response, stable disease, or progressive disease were observed in 48 (24.0%), 87 (43.5%), 59 (29.5%) and 6 (3.0%) of patients, respectively. 45 (22.5%) patients showed no objective response (OR) following two consecutive TACE sessions. Of these, 28 received a subsequent TACE, with a 10.7% OR rate. Patients without OR showed poorer survival when compared to patients who achieved OR after repeated TACE. Multivariable analysis showed that size of the largest tumor >5cm and high alpha-fetoprotein of >200 ng/mL were significant factors associated with failure of OR to two consecutive TACE sessions.

Conclusion

Patients showing no OR to two consecutive TACE sessions will present a poor OR to subsequent TACE procedures. Early transition to systemic therapy may be advocated in such cases.

Catheter-Directed Computed Tomography Hepatic Angiography for Yttrium-90 Selective Internal Radiotherapy of Hepatocellular Carcinoma Reduces Prophylactic Embolization of Extrahepatic Vessels

OBJECTIVES

To determine the rate of prophylactic embolization of extrahepatic vessels in patients undergoing yttrium-90 selective internal radiotherapy (⁹⁰Y SIRT) for hepatocellular carcinoma (HCC) with the use of catheter-directed computed tomography hepatic angiography (CD-CTHA).

MATERIALS AND METHODS

This retrospective study included 186 HCC patients who received ⁹⁰Y SIRT from May 2010 to June 2015 in a single institution. All procedures were performed in a hybrid angiography-CT suite equipped with digital subtraction angiography (DSA) and CD-CTHA capabilities. CD-CTHA was performed during pre-treatment hepatic angiography. ⁹⁰Y SIRT was administered approximately 2 weeks later. Selective prophylactic embolization of extrahepatic vessels was performed if extrahepatic enhancement was seen on CD-CTHA or if an extrahepatic vessel opacified on DSA/CD-CTHA despite the final microcatheter position for ⁹⁰Y microsphere delivery being beyond the origin of this vessel.

RESULTS

Thirty-five patients (18.8%) required selective embolization of extrahepatic vessels. Technical success of ⁹⁰Y SIRT was 99.5%. Two patients (1.1%) developed radiation-induced gastrointestinal ulceration, and one (0.54%) developed radiation-induced pneumonitis. Extrahepatic uptake of ⁹⁰Y microspheres was seen in the gallbladder of one patient without significant complications.

CONCLUSION

The use of CD-CTHA in ⁹⁰Y SIRT of HCC was associated with a low rate of prophylactic embolization of extrahepatic vessels while maintaining a high technical success rate of treatment and low rate of complications.

LEVEL OF EVIDENCE

Level 4, case series.

Outcomes of Patients with Hepatocellular Carcinoma Treated with Conventional Transarterial Chemoembolization Using Guidance Software

PURPOSE

To evaluate the outcomes of conventional transarterial chemoembolization using guidance software for hepatocellular carcinoma (HCC) patients.

MATERIALS AND METHODS

One hundred two patients with treatment-naïve HCC with ≤ 7-cm and ≤ 5 lesions treated with conventional transarterial chemoembolization using guidance software were selected. Technical success was classified into 3 grades by computed tomography performed 1 week after transarterial chemoembolization: (i) A, complete embolization with a safety margin; (ii) B, entire tumor embolization without a safety margin; and (iii) C, incomplete embolization. Intrahepatic tumor recurrence was classified into 2 categories: local tumor progression (LTP) and intrahepatic distant recurrence (IDR). Overall survival (OS) and tumor recurrence rates were calculated by the Kaplan-Meier method. Additionally, the incidences of LTP between grade A and B tumors, IDR with/without LTP, and OS with/without LTP were compared by the log-rank test.

RESULTS

One hundred fifty-six (82.1%) tumors were determined to be grade A, 26 (13.7%) were determined to be grade B, and 8 (4.2%) were determined to be grade C. The 1-, 3-, and 5-year LTP and IDR rates were 31.7%, 49.4%, and 59.4% and 33.9%, 58.2%, and 73.3%, respectively. LTP developed more frequently in grade B tumors than grade A tumors (P = .0016). IDR developed more frequently in patients with LTP than without LTP (P = .0004). The 1-, 3-, and 5-year OS rates were 96.1%, 71.1%, and 60%, respectively; the 1-, 3-, and 5-year OS rates in patients with/without LTP were 95.7%, 69.8%, and 59.3% and 96.2%, 71.6%, and 59.4%, respectively (P = .9984).

CONCLUSIONS

Transarterial chemoembolization guidance software promotes the technical success of transarterial chemoembolization and excellent OS in HCC patients.

Combination of radiofrequency ablation and transcatheter arterial chemoembolization to treat hepatocellular carcinoma: measurement of distance from needle tip to nodule for assessment of local tumor progression

OBJECTIVE

This study was performed to determine the relationship between the minimum distance from the radiofrequency ablation (RFA) needle tip to the tumor and local tumor progression (LTP) of hepatocellular carcinoma (HCC) nodules and identify prognostic factors for LTP.

METHODS

We reviewed 197 patients (197 nodules) who underwent RFA after transcatheter arterial chemoembolization for HCC from January 2010 to January 2015. Three-dimensional registration of images was used to calculate the minimum distance from the tip to the tumor. We then divided the minimum distance into two groups: <2 and ≥2 mm. Contrast-enhanced computed tomography was performed after treatment. The LTP rate was calculated 1 and 3 years after RFA. We performed multivariate analysis to identify independent prognostic factors for LTP.

RESULTS

The cumulative 1-year LTP rates in the <2- and ≥2-mm groups were 82.7% and 4.3%, respectively, and the cumulative 3-year LTP rates in the two groups were 94.8% and 10.8%, respectively. The minimum distance from the needle tip to the tumor was an independent prognostic factor for LTP.

CONCLUSIONS

A minimum distance of 2 mm from the needle tip to the tumor should be completely ablated along with the tumor.

Ultraselective conventional transarterial chemoembolization: When and how?

Ultraselective conventional transarterial chemoembolization (cTACE), defined as cTACE at the most distal portion of the subsubsegmental hepatic artery, is mainly performed for hepatocellular carcinoma (HCC) ≤5 cm. Distal advancement of a microcatheter enables injection of a larger volume of iodized oil into the portal vein in the limited area under non-physiological hemodynamics. As a result, the reversed portal flow into the tumor through the drainage route of the tumor that occurs when the hepatic artery is embolized is temporarily blocked. By adding gelatin sponge slurry embolization, both the hepatic artery and portal vein are embolized and not only complete necrosis of can be achieved. Ultraselective cTACE can cure small HCCs including less hypervascular tumor portions and replace surgical resection and radiofrequency ablation in selected patients.

Metformin attenuates hypoxia-induced resistance to cisplatin in the HepG2 cell line

Hepatoblastoma is the most commonly occurring liver tumor in children. Preoperative chemotherapy and surgery have improved treatment outcomes; however, further improvements are required in the treatment of advanced cases. Recently, the efficacy of transarterial chemoembolization (TACE) has garnered attention. TACE increases the local concentration of drugs by transcatheterically administering antitumor agents, and induces necrosis in the tumor by embolizing the feeding artery. However, studies have revealed that tumors exhibit resistance to anticancer drugs in hypoxic environments. Metformin is a drug used to treat type 2 diabetes; however, recent reports have indicated that it may also exhibit antitumor effects in various cancer cell lines. These effects are hypothesized to be mediated by the activation of adenosine monophosphate-activated protein kinase and reduction of mammalian target of rapamycin signaling, but these effects occur at high concentrations that are not suitable for use in a clinical setting. The potential efficacy of metformin at increased physiological concentrations has not been evaluated. The present study investigated the therapeutic effect of low concentrations of metformin in combination with cisplatin on liver cancer HepG2 cells in hypoxic conditions. HepG2 cells were treated with cisplatin alone, metformin alone, or a combination of these two drugs and cultured in normoxia or hypoxia. Treatment with either 5 µM cisplatin or 1 mM metformin alone did not significantly affect cell proliferation or apoptosis in hypoxic conditions. However, when 5 µM cisplatin was combined with 1 mM metformin, a significant inhibition of cell proliferation and induction of apoptosis was observed in hypoxic HepG2 cells. In conclusion, a low concentration of metformin attenuates hypoxia-induced resistance to cisplatin in HepG2 cells. Selective delivery of an effective dose of metformin to a hepatoblastoma tumor may be achievable and clinically useful with TACE.

Comprehensive Analysis of Factors Affecting Clinical Response and Short-Term Survival to Drug-Eluting Bead Transarterial Chemoembolization for Treatment in Patients With Liver Cancer

This study aimed to investigate the clinical response and short-term survival and further explore the comprehensive factors for predicting clinical outcomes in patients with liver cancer treated by drug-eluting beads transarterial chemoembolization . Forty-nine patients with liver cancer who received drug-eluting beads transarterial chemoembolization treatment were consecutively enrolled in this cohort study. Demographic features, medical histories, clinicopathological properties, biochemical indexes, previous treatments, and chemoembolization reagents were recorded. Ten (20.4%) patients achieved complete response and 31 (63.3%) patients achieved partial response after drug-eluting beads transarterial chemoembolization treatment, with overall response rate of 83.7%. Logistic analysis revealed that high aspartate aminotransferase (P = .041), high carbohydrate antigen 199 (P = .030), and low hemoglobin (P = .020) could independently predict less possibility for complete response achievement. As to survival analysis, high alkaline phosphatase (P = .040), low albumin (P = .033) low hemoglobin (P = .018), portal vein invasion (P = .025), higher Eastern Cooperative Oncology Group performance status (P = .011), and higher Child-pugh stage (P = .001) were independent predictors for worse overall survival. In conclusion, the present study validated that drug-eluting beads transarterial chemoembolization was effective and well tolerated for patients with liver cancer, and high aspartate aminotransferase, high alkaline phosphatase, low albumin, low hemoglobin, portal vein invasion, higher Child-pugh stage, higher Barcelona Clinic Liver Cancer stage, higher Eastern Cooperative Oncology Group performance status were correlated with worse outcomes.

A Predictive Model for Postembolization Syndrome after Transarterial Hepatic Chemoembolization of Hepatocellular Carcinoma

Purpose To develop and validate a predictive model for postembolization syndrome (PES) following transarterial hepatic chemoembolization (TACE) for hepatocellular carcinoma. Materials and Methods In this single-center, retrospective study, 370 patients underwent 513 TACE procedures between October 2014 and September 2016. Seventy percent of the patients were randomly assigned to a training data set and the remaining 30% were assigned to a testing data set. Variables included demographic, laboratory, clinical, and procedural details. PES was defined as pain and/or nausea beyond 6 hours after TACE that required intravenous medication for symptom control. The predictive model was developed by using conditional inference trees and Lasso regression. Results Demographics, laboratory data, performance, tumor characteristics, and procedural details were statistically similar for the training and testing data sets. Overall, 83 of 370 patients (22.4%) after 107 of 513 TACE procedures (20.8%) met the predefined criteria. Factors identified at univariable analysis included large tumor burden (P = .004), drug-eluting embolic TACE (P = .03), doxorubicin dose (P = .003), history of PES (P < .001) and chronic pain (P < .001), of which history of PES, tumor burden, and drug-eluting embolic TACE were identified as the strongest predictors by the multivariable analysis and were used to develop the predictive model. When applied to the testing data set, the model demonstrated an area under the curve of 0.62, sensitivity of 79% (22 of 28), specificity of 44.2% (53 of 120), and a negative predictive value of 90% (53 of 59). Conclusion The model identified history of postembolization syndrome, tumor burden, and drug-eluting embolic chemoembolization as predictors of protracted recovery because of postembolization syndrome. © RSNA, 2018.

Feasibility of Boosted Radioembolization for Hepatocellular Carcinoma Larger than 5 cm

PURPOSE

To address the feasibility of yttrium-90 (⁹⁰Y) glass microspheres administered at a boosted dose in large hepatocellular carcinomas (HCCs).

MATERIALS AND METHODS

From July 2016 to August 2017, 20 patients who underwent ⁹⁰Y radioembolization for treatment-naïve HCC met the following inclusion criteria: (i) nodular tumor, (ii) tumor size > 5 cm, (iii) Barcelona Clinic Liver Cancer stage A/B disease, (iv) target perfused tissue dose > 150 Gy, and (v) all tumors treated in 1 session of radioembolization. Follow-up radiologic findings and clinical outcomes were retrospectively reviewed until May 2018. Tumor response was determined per modified Response Evaluation Criteria In Solid Tumors.

RESULTS

Mean total radiation activity infused was 4.96 GBq ± 1.82 (median, 4.88 GBq; range, 1.63-9.15 GBq). Mean target perfused tissue dose was 263.5 Gy ± 95.2 (median, 241.6 Gy; range, 156.2-550.6 Gy). The mean number of vials used per treatment was 4.15 ± 1.4 (median, 4; range, 2-7). Complete response rates were 25% at 1 month and 60% at 3 months. Complete response of the primary index tumor was achieved in 16 patients (80%) based on best tumor response. Local progression-free survival and progression-free survival rates were 94.1% and 85.0% at 6 mo and 94.1% and 74.7% at 1 year, respectively. Four patients (20%) had symptomatic (n = 3) or asymptomatic (n = 1) benign biliary strictures.

CONCLUSIONS

Radioembolization with a boosted dose in patients with large HCCs may show favorable tumor response, but with considerable biliary complications.

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.

Isolated Arteries Originating from the Intrahepatic Arteries: Anatomy, Function, and Importance in Intervention

Isolated hepatic arteries are defined as hepatic terminal arterioles that are not accompanied by portal venules or bile ductules and penetrate the liver parenchyma and distribute to the hepatic capsule and intrahepatic hepatic veins. Abundant communications exist between intra- and extrahepatic arteries through isolated arteries and capsular arterial plexus. They play a principal role in the development of subcapsular hemorrhage and arterial collateral formation following transcatheter arterial chemoembolization for liver cancers. The anatomy, function, and clinical importance of isolated hepatic arteries in interventional radiology, especially regarding subcapsular hemorrhage and arterial collateral formation, are highlighted in this article.

Bronchobiliary fistula after multiple transcatheter arterial chemoembolizations for hepatocellular carcinoma: A case report

Bronchobiliary fistula (BBF) is a rare condition, defined as an abnormal communication between the bronchial system and the biliary tree. Patients with this condition usually present with massive biliptysis, and the mortality rate is high. BBF has been reported to occur in patients with congenital conditions, complications of trauma, hepatic abscesses and biliary tract obstruction (surgical as well as non-surgical). However, to the best of our knowledge, BBF as a complication of transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) has not been reported to date. We herein report a case of BBF developing as a complication following TACE in a 71-year-old male patient with HCC. The patient was treated by placement of a metallic biliary stent followed by percutaneous transhepatic biliary drainage to decompress the intrahepatic biliary tree, and his symptoms were immediately relieved.

New intermediate-stage subclassification for patients with hepatocellular carcinoma treated with transarterial chemoembolization

BACKGROUND & AIM

The need for a subclassification of Barcelona Clinic Liver Cancer (BCLC) intermediate-stage (BCLC B) has arisen because of its diversity. We evaluated the prognostic capability of the BCLC B subclassification proposed by Bolondi et al. in patients treated with transarterial chemoembolization (TACE). Furthermore, we introduce a new subclassification for intermediate-stage hepatocellular carcinoma (HCC) by using a new parameter related to tumour burden (up-to-11 criteria).

METHODS

Of 3268 patients treated with TACE as first-line treatment, 821 patients with intermediate-stage HCC were included in this study.

RESULTS

According to the Bolondi subclassification, 208 (25.3%), 529 (64.5%), 43 (5.2%) and 41 (5%) patients were in B1, B2, B3 and B4 respectively. The B1, B2 and B3 subclasses in the Bolondi system showed significantly different survival between contiguous stages with median survival of 51.5, 26 and 14.8 months, respectively (both P<.001 for B1 vs B2 and B2 vs B3); however, survival was rather worse in B3 than B4 (14.8 vs 25 months, P=.025). According to the newly proposed subclassification, 410 (50%), 364 (44.3%) and 47 (5.7%) patients were in B1, B2 and B3 respectively. The median survival progressively decreased from B1 (44.8 months) to B2 (21.5 months) and B3 (11.3 months), with a significant difference between contiguous stages (both P<.001 for B1 vs B2 and B2 vs B3).

CONCLUSIONS

Our new BCLC B substaging system, with up-to-11 criteria and Child-Pugh class as main parameters, has excellent discriminatory power to subclassify TACE-treated patients into three prognostic substages.