Prognostic factors of hepatocellular carcinoma patients with portal vein tumor thrombosis treated with transcatheter arterial chemoembolization

Development of a Prognostic Nomogram in Hepatocellular Carcinoma with Portal Vein Tumor Thrombus Following Trans-Arterial Chemoembolization with Drug-Eluting Beads

Objective

To develop and validate a prognostic nomogram in eastern patients with hepatitis B virus (HBV)-associated hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT) receiving trans-arterial chemoembolization with drug-eluting beads (DEB-TACE).

Methods

This retrospective study included 200 patients with training cohort (n = 118) from institution 1 and test cohort (n = 82) from institution 2. All these patients received first-line DEB-TACE between October 2016 and October 2018. Multivariate Cox proportional hazard regression analysis was performed on the training cohort to reveal the independent prognostic factors, and then prognostic nomograms were developed. In order to evaluate the performance of the nomogram comprehensively in both the training and test cohorts, C-index, Kaplan–Meier curve with Log rank test, receiver operating characteristic curve (ROC), calibration plot, and decision curve analysis (DCA) were performed.

Results

Tumor number, serum γ-glutamyl transferase (GGT) level, and level of PVTT were independent risk factors of prognosis. A nomogram was constructed to predict 6-, 12- and 18-month overall survival (OS) based on these identified prognostic factors. C-indexes of the nomogram were 0.88 (95% confidence interval [CI], 0.79–0.97) in the training cohort and 0.87 (95% CI, 0.75–0.99) in the test cohort. The Kaplan–Meier curve analysis showed that the nomogram was able to separate patients into low- and high-risk subgroups. ROC curves for the nomogram at 6-, 12- and 18-month showed satisfied discrimination, with an AUC of 0.765, 0.803 and 0.809 in the training cohort, respectively, and 0.772, 0.724 and 0.746 in the test cohort, respectively. The calibration curve demonstrated good agreement between predicted and actual survival rates in the training and test cohorts. The decision curve showed good performance of the nomogram in terms of clinical application.

Conclusion

We developed and validated a nomogram that was accurate and clinically useful in eastern patients with HBV-associated HCC with PVTT who underwent DEB-TACE.

Efficacy and Safety of Transarterial Chemoembolization in Elderly Patients of Advanced Hepatocellular Carcinoma With Portal Vein Tumor Thrombus: A Retrospective Study

Objective

The aim of the current study was to evaluate the safety and efficacy of transcatheter arterial chemoembolization (TACE) in elderly patients diagnosed as advanced hepatocellular carcinoma (HCC) accompanied with different types of portal vein tumor thrombosis (PVTT).

Methods

Elderly HCC patients aged 70-year-old and above from January 2015 to December 2019 were included in this retrospective study. Efficacy data including OS, PFS, DCR, and ORR and safety data were collected in the indicated groups. Outcomes of HCC patients in the TACE group were compared with those patients in the best supportive care (BSC) group. Subgroup analyses were also conducted in the patients with different types of PVTT.

Results

Among 245 elderly HCC patients, 124 were enrolled in this study. Out of these, 50.0% (n=62) underwent BSC treatment while 50.0% (n=62) underwent TACE. There were no major differences in the baseline characteristics of the two treatment groups. TACE treatment was associated with better median OS compared with BSC alone (11.30 m vs. 7.80 m; P<0.001). Subgroup analyses showed that patients with type I and type II PVTT could benefit from TACE compared with BSC, based on that OS was 14.30 m vs. 7.80 m (P=0.007) and 13.00 m vs. 8.00 m (P=0.002), respectively. The DCR in the TACE group was 62.90%, and 17.74% in the BSC group (p<0.001). The proportion of ORR in TACE group was 35.48%, while 0.00% in the BSC group (p<0.001). Multivariable analyses showed that patients undergoing TACE treatment had 52% lower odds of mortality compared with patients undergoing BSC treatment (HR: 0.48; 95%CI: 0.32-0.72). Similarly, the media PFS was improved following TACE treatment (7.50 m vs. 4.00 m; P<0.001). TACE could significantly prolong the PFS in both type I and type II PVTT subgroups, without greatly significant improvement in type III PVTT patients (4.50 m vs. 2.70 m; P=0.103). Type III PVTT patients in the TACE group had more AEs than type I and type II PVTT patients. According to multivariable analyses, PVTT types (type III vs. type I-II) (HR: 2.18; 95%CI: 1.29-3.70; P=0.004), tumor diameter (>5 cm vs. ≤5 cm) (HR: 1.94; 95%CI: 1.28-2.93; P=0.002), and treatment (TACE vs. BSC) (HR: 0.48; 95%CI: 0.32-0.72; P<0.001) were independent indicators of overall survival.

Conclusions

In elderly advanced HCC patients with PVTT, palliative TACE treatment can be an accessible effective measure to improve the OS and PFS for both type I and type II PVTT patients.

Nomogram for Individualized Prediction of Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis on Conservative Treatment

Background

Portal vein tumor thrombosis (PVTT) is one of the major predictive factors for patients with hepatocellular carcinoma (HCC). The objective of this study was to establish a prognostic nomogram for identifying individual survival outcomes in patients with HCC and PVTT on conservative treatment based on specific factors.

Methods

Two hundred and ten patients with HCC and PVTT on conservative treatment in Beijing Ditan Hospital between June 2008 and May 2017 were studied retrospectively as a derivation cohort. We built a nomogram based on independent risk factors for survival prediction. The concordance index (c-index) and a calibration curve were used to evaluate the predictive accuracy. During the study, 102 patients were included at the Putuo Hospital and Third People's Hospital of Changzhou as a validation cohort.

Results

In the derivation cohort, the independent factors for overall survival were identified by multivariate analysis, namely, aspartate aminotransferase ≥119 IU/L, gamma-glutamyl transferase ≥115 IU/L, Child–Pugh class C liver function, creatinine ≥91 μmoI/L, α-fetoprotein ≥400 ng/ml, and largest tumor diameter ≥5 cm. The nomogram had a c-index of 0.737 (95% confidence interval, 0.692–0.782) and the calibration curves fitted well. The median survival time was 4.2 months in the derivation cohort, with an MST of 5 months for BCLC C stage and 1.8 months for BCLC D stage patients. Kaplan–Meier analysis showed significant statistical differences in the 6-month overall survival rates of the primary and validation cohorts after the total scores were divided into three quartiles (low risk: 0–85; intermediate risk: 86–210; high risk: ≥211; p < 0.0001 in both cohorts).

Conclusions

The nomogram can be a more accurate and individualized prediction for 6-month overall survival of patients with HCC and PVTT on conservative treatment, and it is possible to consider further active interventions for patients in the low-risk group (0–85 scores) to achieve the aim of prolonging survival.

Hepatic Arterial Infusion Chemotherapy Using Oxaliplatin Plus 5-Fluorouracil Versus Transarterial Chemoembolization/Embolization for the Treatment of Advanced Hepatocellular Carcinoma with Major Portal Vein Tumor Thrombosis

PURPOSE

To compare the efficacy and safety of hepatic arterial infusion chemotherapy (HAIC) to transarterial chemoembolization/embolization (TACE/TAE) for the treatment of advanced hepatocellular carcinoma (HCC) with major portal vein tumor thrombosis (PVTT).

MATERIALS AND METHODS

Forty-six patients with advanced HCC with major PVTT who underwent HAIC or TACE/TAE between April 2013 and April 2017 were included. In the HAIC group (n = 22), oxaliplatin (35-40 mg/m² for 2 h) and 5-fluorouracil (600-800 mg/m² for 22 h) on days 1-3 every 4 weeks were administered for a maximum of six serial courses. In the TACE/TAE group (n = 24), an emulsion of epirubicin (40-60 mg) and lipiodol was administered followed by particles (cTACE), or particles alone embolization (TAE). Overall survival (OS), tumor response according to mRECIST, progression-free survival (PFS), and adverse events were investigated.

RESULTS

Median OS was 20.8 months in the HAIC group versus 4.0 months in the TACE/TAE group (P < 0.001; hazard ratio [HR], 0.17). The HAIC group showed higher tumor response rates than the TACE/TAE group (59.1% [13/22] vs. 22.7% [5/22]; P = 0.014) and a longer median PFS (9.6 vs. 1.5 months; P < 0.001; HR, 0.09). The Child-Pugh class (P = 0.007) and treatment method (P = 0.002) were independent risk factors of survival. The most frequent grade 3 or worse treatment-related adverse events were liver dysfunction (2 [9.1%] vs. 5 [20.8%]), hematological abnormalities (1 [4.5%] vs. 2 [8.3%]), and fever (1 [4.5%] vs. 4 [16.7%]). One treatment-related death due to acute liver failure occurred 3 days after TACE treatment.

CONCLUSION

HAIC may significantly improve OS and provide better tumor control with mild side effects and preserved liver function in patients with advanced HCC with major PVTT compared to TACE/TAE treatment.

Prognostic Value of Prealbumin in Liver Cancer: A Systematic Review and Meta-Analysis

Accumulated studies have reported the prognostic significance of prealbumin in liver cancer, but the results were not conclusive. The aim of this study was to evaluate the association between pretreatment serum prealbumin and clinical outcome of liver cancer patients through a meta-analysis. We comprehensively searched EMBASE, PubMed, Web of Science and the Cochrane library to identify eligible studies. The pooled hazard ratios (HRs) and their 95% confidence intervals (CIs) were utilized to evaluate the prognostic value of pretreatment serum prealbumin in overall survival (OS) and recurrence-free survival (RFS) of liver cancer patients. A total of 3470 patients from 10 eligible studies were finally included for analysis. The combined effects of prealbumin on liver cancer patients' OS and RFS were HR = 1.83, 95% CI: 1.46-2.30, P < 0.001 and HR = 1.47, 95% CI: 1.01-2.14, P = 0.045, respectively. Sensitivity and subgroup analysis showed that the pooled HR of prealbumin on liver cancer patients' OS was stable. Since potential publication bias was identified in the OS studies, the trim-and-fill method therefore was performed to explore publication bias, and the results showed reliability. This meta-analysis shows that low pretreatment serum prealbumin is significantly associated with poor prognosis of liver cancer patients.