Combination of transcatheter arterial chemoembolization and portal vein embolization for patients with hepatocellular carcinoma: a review

Chitosan-based biomaterial delivery strategies for hepatocellular carcinoma

Background

Hepatocellular carcinoma accounts for 80% of primary liver cancers, is the most common primary liver malignancy. Hepatocellular carcinoma is the third leading cause of tumor-related deaths worldwide, with a 5-year survival rate of approximately 18%. Chemotherapy, although commonly used for hepatocellular carcinoma treatment, is limited by systemic toxicity and drug resistance. Improving targeted delivery of chemotherapy drugs to tumor cells without causing systemic side effects is a current research focus. Chitosan, a biopolymer derived from chitin, possesses good biocompatibility and biodegradability, making it suitable for drug delivery. Enhanced chitosan formulations retain the anti-tumor properties while improving stability. Chitosan-based biomaterials promote hepatocellular carcinoma apoptosis, exhibit antioxidant and anti-inflammatory effects, inhibit tumor angiogenesis, and improve extracellular matrix remodeling for enhanced anti-tumor therapy.

Methods

We summarized published experimental papers by querying them.

Results and Conclusions

This review discusses the physicochemical properties of chitosan, its application in hepatocellular carcinoma treatment, and the challenges faced by chitosan-based biomaterials.

Safety and Effectiveness of Portal Vein Embolization after Hepatic Arterial Infusion Therapy

Portal vein embolization (PVE) is a tool potentially useful for inducing future liver remnant (FLR) hypertrophy in patients with advanced hepatic malignancies who are at high risk of hepatic insufficiency if treated with surgical resection. However, the safety and effectiveness of PVE in the context of patients who have undergone hepatic arterial infusion (HAI) are unknown. This retrospective, single-center study identified 9 patients who underwent PVE after HAI between January 2015 and December 2022. There were no major adverse events, including biliary injury or high-grade liver failure. Analysis showed an increase in standardized FLR from 21.1% (SEM ± 2.4) to 34.8% (SEM ± 2.1) over 9.8 weeks (SEM ± 1.2), with a mean kinetic growth rate of 1.9% (interquartile range, 0.9%-2.4%). Patients who have undergone HAI therapy should not be excluded from consideration of PVE as part of their operative clearance strategy.

Efficacy and safety of transarterial chemoembolization combined with lenvatinib, programmed death-1 inhibitor, and iodine-125 seed brachytherapy for hepatocellular carcinoma with portal vein tumor thrombosis

BACKGROUND

Therapy for hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) is still controversial. This study was performed to evaluate the efficacy and safety of the combination therapy comprising transarterial chemoembolization (TACE), lenvatinib (L), programmed death-1 inhibitor (P), and iodine-125 seed (I125) brachytherapy relative to TACE in combination with lenvatinib plus programmed death-1 inhibitor therapy and TACE plus lenvatinib therapy.

METHODS

The data of HCC patients with PVTT from July 2017 to August 2022 were assessed in this single-center retrospective study. Primary study outcomes were progression-free survival (PFS) and overall survival (OS), while the secondary outcomes were disease control rate (DCR), objective response rate (ORR), and treatment-related adverse events.

RESULTS

We enrolled 150 patients totally, including 50 patients treated with TACE plus lenvatinib therapy (TACE+L group), 45 patients treated with TACE in combination with lenvatinib plus programmed death-1 inhibitor therapy (TACE+L+P group), and 55 patients treated with the combination therapy of TACE along with I125 brachytherapy, lenvatinib, and programmed death-1 inhibitor therapy (TACE+L+P+I125 group). The median OS in the TACE+L+P+I125 group (21.0; 95% confidence interval [CI]: 18.4∼23.5 months) was significantly longer than that in the TACE+L group (10; 95% CI: 7.8∼12.1months) (p = 0.006), while it was insignificantly longer than that in the TACE+L+P group (14.0; 95% CI: 10.7∼17.2months) (p = 0.058). The median PFS in the TACE+L+P+I125 group (13.0; 95% CI: 10.2∼15.7 months) was significantly longer than that in the TACE+L group (5.0; 95% CI: 4.2∼5.7 months) (p = 0.014) and the TACE+L+P group (9.0; 95% CI: 6.7∼11.2 months) (p = 0.048). Statistically significant differences between groups were found in DCR (p = 0.015). There were no significant between-group differences in treatment-related adverse events (p > 0.05).

CONCLUSIONS

A combination therapy of TACE, lenvatinib, programmed death-1 inhibitor, and I125 seed brachytherapy significantly improve OS, PFS, and DCR and show better survival prognosis for HCC patients accompanied by PVTT.

Recent therapeutics in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a malignant tumor of hepatocytes. It is a common malignant tumor of the digestive system that often has initially hidden presentation followed by rapid progression. There are no obvious symptoms in the early stage of HCC. When diagnosed, most patients have locally advanced tumor or distant metastasis; therefore, HCC is difficult to treat and only supportive and symptomatic treatment is adopted. The prognosis is poor and survival time is short. How to effectively treat HCC is important clinically. In recent years, advances in medical technology have resulted in comprehensive treatment methods based on surgery.

Comparison of efficacy and safety between transarterial chemoembolization (TACE) combined with lenvatinib versus TACE combined with sorafenib in the treatment of intermediate and advanced hepatocellular carcinoma

OBJECTIVE

To compare the clinical effect and safety of transcatheter arterial chemoembolization (TACE) combined with lenvatinib versus TACE combined with sorafenib in the treatment of intermediate-advanced hepatocellular carcinoma.

METHODS

In this retrospective study, 84 patients with intermediate-advanced hepatocellular carcinoma admitted to the First Affiliated Hospital of Anhui Medical University and the First Affiliated Hospital of USTC from June 2019 to June 2021 were enrolled. The control group was given TACE combined with sorafenib, and the experimental group was given TACE combined with lenvatinib. The clinical efficacy, tumor markers, liver function indexes, and occurrence of toxic and side effects were compared between the two groups.

RESULTS

The disease control rate (DCR) and the objective remission rate (ORR) of the experimental group was higher than that of the control group, and the difference was statistically significant (P<0.05). Before treatment, there were no significant differences in the levels of alpha fetoprotein (AFP) and des-gamma carboxyprothrombin (DCP) between the two groups (both P>0.05); after the treatment, the levels of AFP and DCP in both groups decreased, and those in the experimental group were lower than the control group (all P<0.05). Before treatment, there were no significant differences in the levels of alanine aminotransferase (ALT), aspartate aminotransferase (AST) or lactate dehydrogenase (LDH), bilirubin (BIL) between the two groups (all P>0.05); after treatment, the levels of ALT, AST and LDH, BIL in both groups decreased, with the experimental group lower than the control group (all P<0.05). The overall survival (OS) and progression-free survival (PFS) in the experimental group were significantly higher than in the control group (both P<0.05). The incidences of symptoms of diarrhea, hand-foot syndrome, hypertension and rash in the experimental group were higher than those in the control group (all P<0.05). Fatigue, digestive tract reaction, bone marrow suppression and abnormal liver function of the two groups were similar (all P>0.05).

CONCLUSION

Compared with TACE plus sorafenib, TACE plus lenvatinib can better control disease progression, reduce the levels of tumor markers, and stabilize the liver function of patients with intermediate-advanced hepatocellular carcinoma.

Comparison of the efficacy and safety of repeated hepatectomy and radiofrequency ablation in the treatment of primary recurrent liver cancer: a meta-analysis

Background

Since there is still controversy about the comparison of the efficacy and safety of RH and RFA in the treatment of recurrent liver cancer, we conducted a meta-analysis to compare the efficacy and safety, in order to provide evidence-based evidence for future research and clinical treatment.

Methods

We searched PubMed, Embase, and Cochrane Library from the establishment of the database to Feb 2021. We included studies that reported liver cancer patients underwent repeated hepatectomy (RH) or radiofrequency ablation (RFA), and we excluded duplicate publications, research without full text, incomplete information, or inability to conduct data extraction, animal experiments, reviews, and systematic reviews. The STATA 15.1 was used to analyze the data.

Results

The pooled results show that the 3-year and 5-year overall survival (OS) rate of the repeated hepatectomy group was significantly higher than the radiofrequency ablation group (odds ratio (OR) = 1.95, 95% confidence interval (CI):1.47–2.60, P ≤ 0.001; OR = 1.65, 95% CI: 1.12–2.43, P = 0.012). Similarly, the pooled results show that the 3-year and 5-year disease-free survival (DFS) rate of the repeated hepatectomy group was significantly higher than the radiofrequency ablation group (OR = 1.73, 95% CI: 1.30–2.31, P ≤ 0.001; OR = 1.84, 95% CI: 1.38–2.49, P ≤ 0.001). However, there is no significant difference in the 1-year OS and DFS rate of repeated hepatectomy group and radiofrequency ablation group. Additionally, the pooled results show that the postoperative Clavien-Dindo (CD) grade II or higher complication rate of the repeated hepatectomy group was significantly higher than the radiofrequency ablation group (OR = 2.80, 95% CI: 1.37–5.75, P = 0.005).

Conclusion

Based on the pooled results of 8 existing retrospective studies, RH has a higher OS rate and DFS rate in the treatment of recurrent liver cancer, while the postoperative complication rate of RFA is lower. When survival is the primary goal, RH should be the first choice for recurrent liver cancer.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-022-02649-4.

Intended preoperative trans-arterial embolization for large hepatocellular carcinoma: a retrospective cohort study

Background

Generally, a large tumor size of hepatocellular carcinoma (HCC) is associated with poor visibility and uncertainty in the surgical field which results in increased surgical difficulty as well as unfavorable postoperative outcomes. We performed intended preoperative trans-arterial embolization (TAE) in patients with a large HCC. In this study, we investigated the oncological significance of intended preoperative TAE for a large HCC, using a comparison between patients with and without TAE, and detailed analyses for pre- and post-TAE status.

Methods

A total of 411 patients who underwent hepatectomy for primary HCC at the University of Yamanashi Hospital between January 2007 and December 2018 were included in this study. The patients were divided into two groups: patients with larger HCCs (≥50 mm, n=51) and those with smaller HCC (<50 mm, n=360) according to the size of their HCCs. Comparison of clinicopathological features between these groups and clinical outcomes between the TAE and non-TAE groups were compared. In addition, a detailed analysis of each case in the TAE group was conducted, comparing clinicopathological factors between pre- and post-TAE status.

Results

The clinical unfavorable short- and long-term outcomes of patients with large HCCs (≥50 mm) were revealed compared to those with small HCCs (<50 mm). The prognostic analyses showed that a large tumor size and increased tumor markers, multiple tumor numbers, and others were adverse prognostic factors, and vascular invasions and residual tumors were included in the multivariate analysis.

Further detailed analyses revealed that the average rates of change in tumor size and tumor shrinkage after TAE were − 48.6±35.6 mm and − 30.7±17.0%, respectively. Pathological high necrotic changes in the tumor, after multiple-times TAE aiming to a better effect, were related to a better prognosis in patients with large HCC. Poor prognostic factors became less common in patients who underwent intended preoperative TAE, and these patients had better prognoses.

Conclusions

The large tumor size of HCC is associated with unfavorable outcomes; the intended preoperative TAE for large HCC patients performed multiple times aiming to affect the tumor as much as possible might improve their prognoses.

Efficacy and safety of endovascular brachytherapy combined with transarterial chemoembolization for the treatment of hepatocellular carcinoma patients with type III or IV portal vein tumor thrombosis

Background

The purpose of this study was to evaluate the efficacy and safety of endovascular brachytherapy (EVBT) combined with transarterial chemoembolization (TACE) for the treatment of hepatocellular carcinoma (HCC) complicated with type III OR IV portal vein tumor thrombosis (PVTT) and to further analyze the prognostic predictors for the patients with HCC and PVTT.

Methods

We retrospectively analyzed the medical records of 54 patients who were diagnosed with HCC complicated with type III or IV PVTT and received EVBT combined with modified TACE treatment from January 2017 to June 2019. Adverse events, treatment response, overall survival (OS), progression-free survival (PFS), and stent patency were analysed to evaluate the efficacy and safety of this treatment. The independent prognostic predictors of OS were also statistically analyzed by the cox regression model.

Results

No adverse events occurred in the enrolled patients receiving EVBT combined with TACE treatment. The objective response and disease control rates were 42.6% and 96.3% respectively within 4 weeks after the treatment. The median OS and PFS were 209 days and 138 days, respectively. Cumulative stent patency rate was 70.4% at the last follow-up. AFP ≥ 400 ng/ml, ECOG PS > 1, Child Pugh grade B, and non-hemihepatic HCC were independent risk predictors to evaluate the OS of HCC patient with type III or IV PVTT.

Conclusions

EVBT combined with TACE was a relatively effective and safe strategy to treat HCC patients with type III or IV PVTT.