Novel treatment strategy for advanced hepatocellular carcinoma: combination of conventional transcatheter arterial chemoembolization and modified method with portal vein occlusion for cases with arterioportal shunt: a preliminary study

TIPS plus sequential systemic therapy of advanced HCC patients with tumour thrombus-related symptomatic portal hypertension

Objectives

Portal vein tumour thrombus (PVTT)–related symptomatic portal hypertension (SPH) leads to a poor prognosis in hepatocellular carcinoma (HCC) patients. A transjugular intrahepatic portosystemic shunt (TIPS) can effectively relieve SPH but its effect remains unclear in PVTT-related SPH. This study aimed to evaluate the clinical value of the TIPS procedure combined with sequential systemic therapy in advanced HCC patients with PVTT-related SPH.

Methods

After 1:1 propensity score matching (PSM), this retrospective study analysed 42 patients who underwent TIPS placement plus sequential systemic therapy (group A) and 42 patients who received only symptomatic and supportive treatment (group B). The evaluated outcomes were overall survival (OS) and SPH control rate. Cox proportional hazards regression analysis was used to compare OS in the two groups.

Results

In group A, the technical success rate of the TIPS procedure was 95.2%, and no severe complications occurred. The rebleeding rates in group A and group B were 5.0% and 73.7%, respectively (p < 0.001), and the ascites control rates were 92.0% and 28.0%, respectively (p < 0.001). The median OS of group A was significantly better than that of group B (9.6 [95% CI: 7.1, 12.0] vs. 4.9 [95% CI: 3.9, 5.8], months, p < 0.001). Multivariable analysis showed that TIPS plus sequential systemic therapy (hazard ratio [HR] = 5.799; 95% CI: 3.177, 10.585; p < 0.001) was an independent prognostic factor related to OS. Additionally, PVTT degree (I+II) (p = 0.008), AFP ≤ 400 ng/ml (p = 0.003), and Child–Pugh class A (p = 0.046) were significant predictors of OS.

Conclusion

TIPS plus sequential systemic therapy is safe and feasible for treating advanced HCC with tumour thrombus-related SPH.

Key Points

• Portal vein tumour thrombus (PVTT) is common in advanced hepatocellular carcinoma (HCC) and transforms compensated portal hypertension into symptomatic portal hypertension (SPH).

• HCC patients with PVTT-related SPH have a very poor prognosis, and there are no effective treatments recommended by the guidelines.

• Therefore, a treatment strategy that utilises a transjugular intrahepatic portosystemic shunt (TIPS) to manage SPH combined with sequential systemic therapy in advanced HCC patients is explored in this study for its feasibility and clinical value. This research can fill the gap in current research data to provide clinically meaningful treatment options.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00330-022-08705-7.

Hepatocellular carcinoma Liver Imaging Reporting and Data Systems treatment response assessment: Lessons learned and future directions

Hepatocellular carcinoma (HCC) is a leading cause of morbidity and mortality worldwide, with rising clinical and economic burden as incidence increases. There are a multitude of evolving treatment options, including locoregional therapies which can be used alone, in combination with each other, or in combination with systemic therapy. These treatment options have shown to be effective in achieving remission, controlling tumor progression, improving disease free and overall survival in patients who cannot undergo resection and providing a bridge to transplant by debulking tumor burden to downstage patients. Following locoregional therapy (LRT), it is crucial to provide treatment response assessment to guide management and liver transplant candidacy. Therefore, Liver Imaging Reporting and Data Systems (LI-RADS) Treatment Response Algorithm (TRA) was created to provide a standardized assessment of HCC following LRT. LI-RADS TRA provides a step by step approach to evaluate each lesion independently for accurate tumor assessment. In this review, we provide an overview of different locoregional therapies for HCC, describe the expected post treatment imaging appearance following treatment, and review the LI-RADS TRA with guidance for its application in clinical practice. Unique to other publications, we will also review emerging literature supporting the use of LI-RADS for assessment of HCC treatment response after LRT.

Assessment of hepatocellular carcinoma treatment response with LI-RADS: a pictorial review

Computed tomography (CT) and magnetic resonance imaging (MRI) play critical roles for assessing treatment response of hepatocellular carcinoma (HCC) after locoregional therapy. Interpretation is challenging because posttreatment imaging findings depend on the type of treatment, magnitude of treatment response, time interval after treatment, and other factors. To help radiologists interpret and report treatment response in a clear, simple, and standardized manner, the Liver Imaging Reporting and Data System (LI-RADS) has developed a Treatment Response (LR-TR) algorithm. Introduced in 2017, the system provides criteria to categorize response of HCC to locoregional treatment (e.g., chemical ablation, energy-based ablation, transcatheter therapy, and radiation therapy). LR-TR categories include Nonevaluable, Nonviable, Equivocal, and Viable. LR-TR does not apply to patients on systemic therapies. This article reviews the LR-TR algorithm; discusses locoregional therapies for HCC, treatment concepts, and expected posttreatment findings; and illustrates LI-RADS treatment response assessment with CT and MRI.

Safety and efficacy assessment of transarterial chemoembolization using drug-eluting beads in patients with hepatocellular carcinoma and arterioportal shunt: a single-center experience

Objective

To evaluate the feasibility and safety of transarterial chemoembolization with drug-eluting beads (DEB-TACE) in patients with hepatocellular carcinoma (HCC) and arterioportal shunts (APSs).

Materials and methods

Fifty-eight patients with unresectable HCC and APSs who were treated with DEB-TACE (n=26) or polyvinyl alcohol (PVA) plus TACE (PVA-TACE, n=32) were included in this retrospective study. The tumor response was evaluated by the modified Response Evaluation Criteria in Solid Tumors. Toxicity was graded by the Common Terminology Criteria for Adverse Events version 5.0 (CTCAE v5.0) and compared between the two groups. Survival curves were calculated by the Kaplan-Meier method and compared by the log-rank test between the two groups. The influence of potential prognostic factors on survival in the DEB-TACE group was analyzed via a multivariate Cox regression model.

Results

The disease control rate was better in the DEB-TACE group than in the PVA-TACE group. The median survival times were 346 and 274 days in the DEB-TACE group and PVA-TACE group, respectively. There was no significant difference in survival rates between the two groups (P=0.081). Patients treated with DEB-TACE were significantly less likely to have fever (P=0.048) or a low-grade (grade 1-2) increase in transaminases (P=0.046) than the patients treated with PVA-TACE. The potential predictive prognostic factors in the DEB-TACE group were tumor response, APS grading, and serum bilirubin.

Conclusion

DEB-TACE may be feasible and safe in HCC patients with APS. Survival in the DEB-TACE group was associated with tumor response, APS grading, and serum bilirubin levels.