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Fu J, Lin G, Fang C, Chen B, Deng X, Chen J, Yang W, Huang Y, Qin A, Li X, Zeng C, Li X, Du L. Preparation, evaluation and application of MRI detectable sunitinib-loaded calcium alginate/poly(acrylic acid) hydrogel microspheres. Int J Biol Macromol 2024:131730. [PMID: 38688794 DOI: 10.1016/j.ijbiomac.2024.131730] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2023] [Revised: 01/29/2024] [Accepted: 04/19/2024] [Indexed: 05/02/2024]
Abstract
Transcatheter arterial chemoembolization (TACE) is an effective method for the treatment of unresectable hepatocellular carcinoma. Although many embolic agents have been developed in TACE, there are few ideal embolic agents that combine drug loading, imaging properties and vessel embolization. Here, we developed novel magnetic embolic microspheres that could simultaneously load sunitinib malate (SU), be detected by magnetic resonance imaging (MRI) and block blood vessels. Calcium alginate/poly (acrylic acid) hydrogel microspheres (CA/PAA-MDMs) with superparamagnetic iron oxide nanoparticles (SPIONs) modified by citric acid were prepared by a drip and photopolymerization method. The embolization and imaging properties of CA/PAA-MDMs were evaluated through a series of experiments such as morphology, X-ray diffraction and X-ray photoelectron spectroscopy, magnetic responsiveness analysis, elasticity, cytotoxicity, hemolysis test, in vitro MRI evaluation, rabbit ear embolization and histopathology. In addition, the ability of drug loading and drug release of CA/PAA-MDMs were investigated by using sunitinib (SU) as the model drug. In conclusion, CA/PAA-MDMs showed outstanding drug loading capability, excellent imaging property and embolization effect, which would be expected to be used as a potential biodegradable embolic agent in the clinical interventional therapy.
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Affiliation(s)
- Jijun Fu
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, The Second Affiliated Hospital and The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 511436, PR China; The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, Qingyuan, Guangdong 511436, PR China
| | - Guanli Lin
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, The Second Affiliated Hospital and The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 511436, PR China
| | - Chenchen Fang
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, The Second Affiliated Hospital and The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 511436, PR China
| | - Baiqi Chen
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, The Second Affiliated Hospital and The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 511436, PR China
| | - Xingmei Deng
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, The Second Affiliated Hospital and The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 511436, PR China
| | - Junhong Chen
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, The Second Affiliated Hospital and The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 511436, PR China
| | - Weiqi Yang
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, The Second Affiliated Hospital and The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 511436, PR China
| | - Yugang Huang
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, The Second Affiliated Hospital and The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 511436, PR China; The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, Qingyuan, Guangdong 511436, PR China
| | - Aiping Qin
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, The Second Affiliated Hospital and The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 511436, PR China
| | - Xufeng Li
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, The Second Affiliated Hospital and The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 511436, PR China
| | - Caifang Zeng
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, The Second Affiliated Hospital and The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 511436, PR China.
| | - Xin Li
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, The Second Affiliated Hospital and The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 511436, PR China; The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, Qingyuan, Guangdong 511436, PR China.
| | - Lingran Du
- Guangzhou Municipal and Guangdong Provincial Key Laboratory of Molecular Target & Clinical Pharmacology, The NMPA and State Key Laboratory of Respiratory Disease, School of Pharmaceutical Sciences, The Second Affiliated Hospital and The Fifth Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong 511436, PR China; The Sixth Affiliated Hospital of Guangzhou Medical University, Qingyuan People's Hospital, Qingyuan, Guangdong 511436, PR China.
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Chen Q, Shu L, Sun Y, Guo P, Wang D, Sha X. In Vitro Drug Loading, Releasing Profiles, and In Vivo Embolic Efficacy and Safety Evaluation of a Novel Drug-Eluting Microsphere (CalliSpheres). Cancer Biother Radiopharm 2023; 38:512-520. [PMID: 33493417 DOI: 10.1089/cbr.2020.3766] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023] Open
Abstract
Background: To investigate morphology, physical property, loadability, stability, and release profiles of a novel drug-eluting microsphere, CalliSpheres, in vitro and to explore its embolic efficacy and safety in vivo. Materials and Methods: CalliSpheres (50-150 μm, 100-300 μm, and 300-500 μm) and doxorubicin in different amounts (20, 40, 80, and 100 mg) and concentrations (5 and 10 mg/mL) were prepared for experiments. Dynamic light scattering and an Agilent 1260 high-performance liquid chromatography system were used to quantify bead diameters and the efficiency of drug loading and release, respectively. Twelve New Zealand rabbits were treated with catheter-aided hepatic embolization using CalliSpheres. Results: CalliSpheres displayed a red color after loading with doxorubicin, and the mean diameters decreased by 20.7-25.8%. Almost 100% of the drug was incorporated with CalliSpheres in different sizes immersed with doxorubicin 20 mg, while loading efficiency ranged from 75.8% to 100.0% with doxorubicin at 40, 80, and 100 mg dependent on CalliSpheres sizes (smaller sizes, higher loading efficiency). Elevated loading efficiency was observed at higher concentration of doxorubicin solutions. Regarding release profiles, doxorubicin was released from CalliSpheres quickly at the very beginning, and doxorubicin release percentage was increased in the 50-150 μm group (39.2% ± 1.2%) compared with the 100-300 μm group (31.3% ± 1.3%) and 300-500 μm group (31.7% ± 2.5%). Digital subtraction angiography, computed tomography, and histopathologic emanation results proved in vivo safety and embolic efficacy of CalliSpheres. Conclusions: CalliSpheres present with good physical characteristics and satisfactory loading and releasing profiles in vitro and are well tolerated and efficient in embolization in vivo.
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Affiliation(s)
- Qinyue Chen
- Key Laboratory of Smart Drug Delivery, Department of Pharmaceutics, School of Pharmacy, Fudan University, Shanghai, China
| | - Lan Shu
- Key Laboratory of Smart Drug Delivery, Department of Pharmaceutics, School of Pharmacy, Fudan University, Shanghai, China
| | - Yali Sun
- Key Laboratory of Smart Drug Delivery, Department of Pharmaceutics, School of Pharmacy, Fudan University, Shanghai, China
| | - Ping Guo
- Jiangsu Hengrui Medicine Co., Ltd., Shanghai, China
| | - Dong Wang
- Jiangsu Hengrui Medicine Co., Ltd., Shanghai, China
| | - Xianyi Sha
- Key Laboratory of Smart Drug Delivery, Department of Pharmaceutics, School of Pharmacy, Fudan University, Shanghai, China
- The Institutes of Integrative Medicine of Fudan University, Shanghai, China
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Safety and efficacy of drug-eluting microspheres chemoembolization under cone beam computed tomography control in patients with early and intermediate stage hepatocellular carcinoma. Radiol Oncol 2022; 56:311-318. [PMID: 35535426 PMCID: PMC9400446 DOI: 10.2478/raon-2022-0019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/19/2021] [Accepted: 03/31/2022] [Indexed: 11/21/2022] Open
Abstract
BACKGROUND Drug-eluting microsphere transarterial chemoembolization (DEM-TACE) is the standard of care in patients with intermediate-stage hepatocellular carcinoma and ensures targeted and controlled cytotoxic and ischemic effects. Proper patient selection and optimized treatment techniques are associated with longer median survival. The aim of this single-institution retrospective study was to evaluate safety and efficacy of DEM-TACE under cone beam computed tomography (CBCT) control in patients with early and intermediate stage hepatocellular carcinoma. PATIENTS AND METHODS A total of 144 patients (mean age 67.9 ± 8.0 years, 127 males and 17 females) between February 2010 and December 2018 were studied. Microparticles of different dimensions according to two manufacturers (diameter of 70-150 μm, 100-300 μm or 300-500 μm and 40-μm, 75-μm or 100-μm) were used and loaded with 50-150 mg of doxorubicin. The objective tumour response according to the modified Response Evaluation Criteria in Solid Tumours (mRECIST), the time to progression, adverse events and overall survival were (OS) evaluated. RESULTS In total, 452 procedures were performed (median, 3 per patient). Four (0.9% of all procedures) major complications were noted. Postembolization syndrome occurred after 35% of procedures. At the first imaging follow-up 2-3 months after first treatment, 91% of patients achieved an objective response. The median time to progression was 10.2 months (95% CI: 8.3-12.1 months). OS rates at 1, 2, 3, 4, and 5 years were 85%, 53%, 33%, 20% and 14%, respectively. The median survival time was 25.8 months (95% CI: 22.1-29.5 months). CONCLUSIONS DEM-TACE under CBCT control in patients with early and intermediate stage hepatocellular carcinoma is a safe and effective method of treatment with high objective tumour response and survival rates.
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Jugovec V, Benedik J, Jeruc J, Popovic P. Long-term survival of a patient with liver metastases from clear cell gastric adenocarcinoma after multimodality treatment including interventional oncology techniques: case report. BMC Gastroenterol 2022; 22:103. [PMID: 35255812 PMCID: PMC8900438 DOI: 10.1186/s12876-022-02150-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/17/2021] [Accepted: 02/11/2022] [Indexed: 11/30/2022] Open
Abstract
Background Gastric cancer (GC) is the fourth most common cancer and the third leading cancer-related cause of death worldwide since most patients are diagnosed at an advanced stage. The majority of GCs are adenocarcinomas (ACs), and the poorly characterized clear cell AC represents a unique subgroup of GCs and is an independent marker of poor prognosis. Even though the prognosis for patients with advanced GC is poor we present a report of a patient with long-term survival despite having liver metastases from clear cell gastric AC. Case presentation A 45-year-old male with clear cell gastric AC underwent subtotal gastrectomy and postoperative chemoradiation. Only a year and a half after his initial treatment the disease spread to his liver. He received two lines of chemotherapy treatment within the next two years before a right hepatectomy was suggested. Due to an initially insufficient future liver remnant (FLR), transarterial chemoembolization (TACE) and portal vein embolization (PVE) were performed, which made the surgical procedure possible. Shortly after a disease progression in the remaining liver was detected. In the following three years the patient was treated with a carefully planned combination of systemic therapy and different interventional oncology techniques including selective internal radiation therapy (SIRT) and TACE. And as illustrated, an attentive, patient-tailored, multimodality treatment approach can sometimes greatly benefit our patients as he had an overall survival of 88 months despite the poor prognosis of his disease.
Conclusion To the best of our knowledge, this report is the first to describe a patient with liver metastases from clear cell gastric AC treated with interventional oncology techniques (PVE, TACE, and SIRT) in combination with other locoregional and systemic therapies thereby presenting that these interventional oncology techniques can be successfully integrated into long-term management of non-conventional liver tumors.
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Affiliation(s)
- Vesna Jugovec
- Department of Radiology, Institute of Oncology Ljubljana, Zaloška Cesta 2, 1000, Ljubljana, Slovenia.
| | - Jernej Benedik
- Division of Medical Oncology, Institute of Oncology Ljubljana, Zaloška Cesta 2, 1000, Ljubljana, Slovenia
| | - Jera Jeruc
- Institute of Pathology, Faculty of Medicine, University of Ljubljana, Korytkova 2, 1000, Ljubljana, Slovenia
| | - Peter Popovic
- Institute of Radiology, University Medical Centre Ljubljana, Zaloška Cesta 7, 1000, Ljubljana, Slovenia.,Department of Radiology, Faculty of Medicine, University of Ljubljana, Vrazov Trg 2, 1000, Ljubljana, Slovenia
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Tovar-Felice G, García-Gámez A, Benito-Santamaría V, Balaguer-Paniagua D, Villalba-Auñón J, Sampere-Moragues J. Unresectable hepatocellular carcinoma treatment with doxorubicin-eluting polyethylene glycol microspheres: a single-center experience. Hepat Oncol 2021; 8:HEP38. [PMID: 34408848 PMCID: PMC8369521 DOI: 10.2217/hep-2020-0035] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2020] [Accepted: 04/12/2021] [Indexed: 12/19/2022] Open
Abstract
Background Transarterial chemoembolization (TACE) is indicated for unresectable hepatocellular carcinoma. Methods This was a retrospective study of 50 hepatocellular carcinoma patients treated with TACE using doxorubicin-loaded LifePearl™ to investigate the safety and efficacy of TACE. Results There was no 30-day mortality, and limited adverse events were reported. At best tumor response, complete response and disease control were 58% and 94%, respectively, with a median of 4.5 months of follow-up. Median overall survival was 33.8 months. Patients with Barcelona Clinic Liver Cancer stage 0 and stage A at best tumor response showed a higher complete response rate (83%) than patients with Barcelona Clinic Liver Cancer stage B (complete response: 50%; p = 0.0414). Conclusion Doxorubicin-loaded LifePearl™ TACE might be an effective treatment, with a good safety profile, for patients with early/intermediate-stage hepatocellular carcinoma. Further prospective data, especially with a small cohort of selected patients, are required to confirm these results.
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Affiliation(s)
- Gerardo Tovar-Felice
- Germans Trias I Pujol (Can Ruti) University Hospital, Carretera de Canyet, Badalona, 08916, Spain
| | - Andrés García-Gámez
- Germans Trias I Pujol (Can Ruti) University Hospital, Carretera de Canyet, Badalona, 08916, Spain
| | | | - David Balaguer-Paniagua
- Germans Trias I Pujol (Can Ruti) University Hospital, Carretera de Canyet, Badalona, 08916, Spain
| | - Jordi Villalba-Auñón
- Germans Trias I Pujol (Can Ruti) University Hospital, Carretera de Canyet, Badalona, 08916, Spain
| | - Jaume Sampere-Moragues
- Germans Trias I Pujol (Can Ruti) University Hospital, Carretera de Canyet, Badalona, 08916, Spain
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Complications Following Irinotecan-Loaded Microsphere Chemoembolization of Colorectal Metastatic Liver Lesions Associated with Hepatic-Artery Branch Temporary Stasis. ACTA ACUST UNITED AC 2021; 28:2296-2307. [PMID: 34203031 PMCID: PMC8293090 DOI: 10.3390/curroncol28030211] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2021] [Revised: 06/04/2021] [Accepted: 06/14/2021] [Indexed: 01/01/2023]
Abstract
Chemoembolization with irinotecan-loaded microspheres has proven effective in the treatment of unresectable liver metastases in the course of colorectal cancer (CRC). Most researchers recommend slowly administering the embolizate at the level of the lobar arteries, without obtaining visible stasis. However, there are reports of a relationship between postoperative embolizate retention in metastatic lesions and the response to treatment. To retain residual embolizate throughout the entire neoplastic lesion requires a temporary flow stop (stasis) within all supply vessels, which may cause temporary stasis in subsegmental or even segmental vessels. Objective: To assess the risk of complications and post-embolization syndrome severity following chemoembolization of CRC metastatic liver lesions with microspheres loaded with Irinotecan, with regard to hepatic-artery branch level of temporary stasis. Patients and methods: The study included 52 patients (29 female, 23 male) with liver metastases from CRC, who underwent 202 chemoembolization treatments (mean: 3.88 per patient) with microspheres loaded with 100 mg irinotecan. Postembolization syndrome (PES) severity and complication occurrence were assessed with regard to the hepatic-artery branch level of temporary stasis. Adverse events were assessed according to Cancer Therapy Evaluation Program Common Terminology Criteria for Adverse Events. Results: Median survival from the start of chemoembolization was 13 months. From 202 chemoembolization sessions, 15 (7.4%) significant complications were found. The study found a significant relationship between the branch level of temporary stasis and the presence of complications (p < 0.001), with the highest number of complications observed with temporary stasis in segmental vessels. PES was diagnosed after 103 (51%) chemoembolization treatments. A significant association was found between PES severity and the branch level of temporary stasis (p < 0.001). Conclusions: The branch level of temporary stasis affected the severity of post-embolization syndrome. A significant association was found between the branch level of temporary stasis obtained in chemoembolization procedures and the presence of complications. The apparent lack of change in numbers of complications when stasis was applied at tumor supply vessels or subsegmental arteries may indicate the safe use of temporary stasis in some cases where colorectal cancer metastases are treated. Further research is needed to determine the most effective chemoembolization technique.
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Li X, Ji X, Chen K, Yuan X, Lei Z, Ullah MW, Xiao J, Yang G. Preparation and evaluation of ion-exchange porous polyvinyl alcohol microspheres as a potential drug delivery embolization system. MATERIALS SCIENCE & ENGINEERING. C, MATERIALS FOR BIOLOGICAL APPLICATIONS 2021; 121:111889. [PMID: 33579501 DOI: 10.1016/j.msec.2021.111889] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 11/19/2020] [Revised: 01/07/2021] [Accepted: 01/10/2021] [Indexed: 01/27/2023]
Abstract
The present study aimed to develop a new drug delivery system with efficient drug loading and sustained drug release for potential application in transarterial chemoembolization (TACE). The porous polyvinyl alcohol microspheres (PPVA MS) were prepared by a combination of inverse emulsification and thermal-induced phase separation (TIPS) method, this was followed by the grafting polymerization of sodium 4-styrene sulfonate (SSS) onto the PPVA MS to obtain the grafted PPVA-g-PSSS MS. The prepared PPVA MS showed a well-defined spherical shape with 'honeycomb-like' porous structure, which could be readily tailored by adjusting the quenching temperature. In vitro biocompatibility analysis indicated the non-cytotoxic and hemocompatible nature of PPVA MS. The porous structure and presence of ionically charged groups in the PPVA-g-PSSS MS favoured the loading of cationic doxorubicin (DOX) onto the MS through ionic-interactions and demonstrated a sustained drug release pattern. Moreover, the cytotoxicity of DOX-loaded PPVA-g-PSSS (DOX@PPVA-g-PSSS) MS against HepG2 cells and the intracellular uptake of DOX demonstrated the potent in vitro antitumor activity. Furthermore, the central auricular artery embolization in rabbits showed that both the PPVA-g-PSSS and DOX@PPVA-g-PSSS MS could occlude the auricular arteries and induced superior embolization effects, such as progressive ear appearance changes, irreversible parenchymal damage and fibrosis, and ultrastructural alternations in endothelial cells. Besides, the DOX fluorescence was distributed around the embolized arteries, without decreasing its intensity when prolonged embolization up to 15 days. These findings suggest that the newly developed DOX@PPVA-g-PSSS MS could be employed as a promising drug-loaded embolic agent for the treatment of hepatocellular carcinoma.
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Affiliation(s)
- Xiaohong Li
- Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, China
| | - Xiongfa Ji
- Department of Orthopedics, Guangdong Provincial People's Hospital, Guangdong Academy of Medical Sciences, Guangzhou 510080, China
| | - Kun Chen
- Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, China
| | - Xi Yuan
- Department of Orthopaedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Zehua Lei
- Department of Orthopaedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China
| | - Muhammad Wajid Ullah
- Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, China.
| | - Jun Xiao
- Department of Orthopaedics, Tongji Hospital, Tongji Medical College, Huazhong University of Science and Technology, Wuhan 430030, China.
| | - Guang Yang
- Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, China.
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Li X, Ji X, Chen K, Ullah MW, Yuan X, Lei Z, Cao J, Xiao J, Yang G. Development of finasteride/PHBV@polyvinyl alcohol/chitosan reservoir-type microspheres as a potential embolic agent: from in vitro evaluation to animal study. Biomater Sci 2020; 8:2797-2813. [PMID: 32080688 DOI: 10.1039/c9bm01775e] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
Benign prostatic hyperplasia (BPH) is a prevalent urological disease affecting elders. Currently, the prostatic artery embolization (PAE) is considered as a minimally invasive and safe technique to treat BPH. However, various drug-loaded embolic agents have not been thoroughly investigated in BPH therapy. In this study, finasteride/poly(3-hydroxybutyrate-3-hydroxyvalerate)@polyvinyl alcohol/chitosan (FNS/PHBV@PVA/CS) reservoir-type microspheres were prepared via the solid-in-water-in-oil (S/W/O) emulsion crosslinking method with the aim to reduce the burst effect and control localized drug delivery. The structure and properties of the drug and resultant microspheres were characterized via field emission scanning electron microscopy (FESEM), Fourier-transform infrared (FTIR) spectroscopy, X-ray diffraction (XRD), and thermogravimetric analysis (TGA). The results showed that the drug-loaded hybrid microspheres were well-dispersed and spherical with a mean diameter of 238.1 ± 27.3 μm. All samples exhibited excellent thermal stability. The FNS/PHBV microspheres were successfully encapsulated inside the PVA/CS polymeric matrix, which effectively suppressed the burst effect and prolonged the drug release up to 51 days. In vitro biocompatibility assessment indicated that the microspheres possessed excellent cytocompatibility and hemocompatibility. Furthermore, in vivo studies performed in the rabbit ear embolization model showed the formation of progressive ischemic necrosis after treatment for various periods. Histopathological studies revealed that the microspheres completely occluded the blood vessels with minimal foreign body response and formed the fibrotic area at the periphery of embolized arteries. Furthermore, the auricular vascular endothelial cells showed acute ultrastructural changes, associated with the ischemic necrosis induced by the embolization procedures. All these findings suggest that the FNS/PHBV@PVA/CS hybrid microspheres could be used as a promising drug delivery system for potential applications in BPH therapy.
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Affiliation(s)
- Xiaohong Li
- Department of Biomedical Engineering, College of Life Science and Technology, Huazhong University of Science and Technology, Wuhan 430074, China.
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Chen S, Ji R, Shi X, Wang Z, Zhu D. Retrospective analysis of efficacy, safety, and prognostic factors in a cohort of Chinese hepatocellular carcinoma patients treated with drug-eluting bead transarterial chemoembolization. ACTA ACUST UNITED AC 2019; 52:e8467. [PMID: 31800729 PMCID: PMC6886383 DOI: 10.1590/1414-431x20198467] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/21/2019] [Accepted: 09/03/2019] [Indexed: 02/06/2023]
Abstract
The aim of our study was to assess the efficacy, safety, and prognostic factors of drug-eluting bead transarterial chemoembolization (DEB-TACE) in Chinese hepatocellular carcinoma (HCC) patients. Patients (n=102) diagnosed as primary HCC were consecutively enrolled in this retrospective cohort study. Treatment responses were assessed following the modified Response Evaluation Criteria in Solid Tumors. Progression-free survival (PFS) and overall survival (OS) were evaluated, and adverse events (AEs) as well as liver function-related laboratory indexes of all DEB-TACE records (N=131) were assessed. Complete response (CR) rate, objective response rate, and disease control rate were 51.0, 87.3, and 95.1%, respectively, at 1–3 months post DEB-TACE. The mean PFS and OS were 227 (95%CI: 200–255) days and 343 (95%CI: 309–377) days, respectively. Multivariate logistic regression revealed that portal vein invasion and abnormal total protein (TP) were independent predictive factors for worse CR, and multivariate Cox's regression analysis showed that multifocal disease independently correlated with shorter PFS. Most of the liver function-related laboratory indexes worsened at 1 week but recovered at 1–3 months post-treatment, only the percentage of patients with abnormal ALP increased at 1–3 months. In addition, 112 (85.5%), 84 (64.1%), 53 (40.5%), 40 (30.5%), and 16 (12.2%) patients had pain, fever, nausea, vomiting, and other AEs, respectively. DEB-TACE is efficient and safe in Chinese HCC patients, and portal vein invasion, abnormal TP level as well as multifocal disease could be used as unfavorable prognostic factors to DEB-TACE treatment.
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Affiliation(s)
- Sihan Chen
- Department of Liver Cancer, Ningbo No. 2 Hospital, Ningbo, China
| | - Rengbin Ji
- Department of Cirrhosis, Ningbo No. 2 Hospital, Ningbo, China
| | - Xiaojun Shi
- Department of Liver Cancer, Ningbo No. 2 Hospital, Ningbo, China
| | - Zhe Wang
- Department of Liver Cancer, Ningbo No. 2 Hospital, Ningbo, China
| | - Dedong Zhu
- Department of Liver Cancer, Ningbo No. 2 Hospital, Ningbo, China
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Sun J, Zhou G, Xie X, Gu W, Huang J, Zhu D, Hu W, Hou Q, Shi C, Li T, Zhang X, Ji W, Ying S, Peng Z, Zhou J, Yu Z, Ji J, Du H, Guo X, Fang J, Han J, Xu H, Sun Z, Yu W, Shao G, Wu X, Hu H, Li L, Zheng J, Luo J, Chen Y, Cao G, Hu T. Efficacy and Safety of Drug-Eluting Beads Transarterial Chemoembolization by CalliSpheres ® in 275 Hepatocellular Carcinoma Patients: Results From the Chinese CalliSpheres ® Transarterial Chemoembolization in Liver Cancer (CTILC) Study. Oncol Res 2019; 28:75-94. [PMID: 31558180 PMCID: PMC7851504 DOI: 10.3727/096504019x15662966719585] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
The purpose of this study was to investigate the efficacy and safety of drug-eluting beads transarterial chemoembolization (DEB-TACE) treatment in Chinese hepatocellular carcinoma (HCC) patients and the prognostic factors for treatment response as well as survival. A total of 275 HCC patients were included in this prospective study. Treatment response was assessed by modified Response Evaluation Criteria in Solid Tumors (mRECIST), and progression-free survival (PFS) as well as overall survival (OS) were determined. Liver function and adverse events (AEs) were assessed before and after DEB-TACE operation. Complete response (CR), partial response (PR), and objective response rate (ORR) were 22.9%, 60.7%, and 83.6%, respectively. The mean PFS was 362 (95% CI: 34.9–375) days, the 6-month PFS rate was 89.4 ± 2.1%, while the mean OS was 380 (95% CI: 370–389) days, and the 6-month OS rate was 94.4 ± 1.7%. Multivariate logistic regression revealed that portal vein invasion (p = 0.011) was an independent predictor of worse clinical response. Portal vein invasion (p = 0.040), previous cTACE treatment (p = 0.030), as well as abnormal serum creatinine level (BCr) (p = 0.017) were independent factors that predicted worse ORR. In terms of survival, higher Barcelona Clinic Liver Cancer (BCLC) stage (p = 0.029) predicted for worse PFS, and abnormal albumin (ALB) (p = 0.011) and total serum bilirubin (TBIL) (p = 0.009) predicted for worse OS. The number of patients with abnormal albumin, total protein (TP), TBIL, alanine aminotransferase (ALT), and aspartate aminotransferase (AST) were augmented at 1 week posttreatment and were similar at 1–3 months compared with baseline. The most common AEs were pain, fever, nausea, and vomiting, and no severe AEs were observed in this study. DEB-TACE was effective and tolerable in treating Chinese HCC patients, and portal vein invasion, previous cTACE treatment, abnormal BCr, ALB, and TBIL appear to be important factors that predict worse clinical outcome.
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Affiliation(s)
- Junhui Sun
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang UniversityHangzhouP.R. China
| | - Guanhui Zhou
- Hepatobiliary and Pancreatic Interventional Treatment Center, Division of Hepatobiliary and Pancreatic Surgery, The First Affiliated Hospital, College of Medicine, Zhejiang UniversityHangzhouP.R. China
| | - Xiaoxi Xie
- Interventional Center, Xinchang People's HospitalShaoxingP.R. China
| | - Wenjiang Gu
- Department of Intervention, Jiaxing Second HospitalJiaxingP.R. China
| | - Jing Huang
- Department of Hepatobiliary Surgery, Ningbo Medical Center, Lihuili Eastern HospitalNingboP.R. China
| | - Dedong Zhu
- Department of Liver Oncology, Ningbo No. 2 HospitalNingboP.R. China
| | - Wenhao Hu
- Department of Intervention, The First Affiliated Hospital of Wenzhou Medical UniversityWenzhouP.R. China
| | - Qinming Hou
- Department of Radiology, Xixi Hospital of Hangzhou, Hangzhou 6th People's HospitalHangzhouP.R. China
| | - Changsheng Shi
- Department of Intervention, The Third Affiliated Hospital of Wenzhou Medical UniversityRuianP.R. China
| | - Tiefeng Li
- Department of Radiology, Beilun District People's Hospital of NingboNingboP.R. China
| | - Xin Zhang
- Department of Radiology, The First Affiliated Hospital, College of Medicine, Zhejiang UniversityHangzhouP.R. China
| | - Wenbin Ji
- Department of Radiology, Taizhou Hospital of Zhejiang ProvinceLinhaiP.R. China
| | - Shihong Ying
- Department of Radiology, The First Affiliated Hospital, College of Medicine, Zhejiang UniversityHangzhouP.R. China
| | - Zhiyi Peng
- Department of Radiology, The First Affiliated Hospital, College of Medicine, Zhejiang UniversityHangzhouP.R. China
| | - Jian Zhou
- Department of Radiology, Hangzhou Cancer HospitalHangzhouP.R. China
| | - Zhihai Yu
- Department of Vascular and Interventional Radiology, The Affiliated Hospital of Medical College of Ningbo UniversityNingboP.R. China
| | - Jiansong Ji
- Department of Radiology, Lishui Central Hospital, Lishui Hospital of Zhejiang University, The Fifth Affiliated Hospital of Wenzhou Medical UniversityLishuiP.R. China
| | - Haijun Du
- Department of Intervention, Dong Yang People's HospitalDongyangP.R. China
| | - Xiaohua Guo
- Department of Intervention, Jinhua Central HospitalJinhuaP.R. China
| | - Jian Fang
- Department of Hepatobiliary Surgery, Quzhou People's HospitalQuzhouP.R. China
| | - Jun Han
- Department of Intervention, Jiaxing First HospitalJiaxingP.R. China
| | - Huanhai Xu
- Division of Digestive Endoscopy, YueQing City People's HospitalYueqingP.R. China
| | - Zhichao Sun
- Department of Radiology, The First Affiliated Hospital of Zhejiang Chinese Medical UniversityHangzhouP.R. China
| | - Wenqiang Yu
- Department of Intervention, Zhejiang Provincial People's HospitalHangzhouP.R. China
| | - Guoliang Shao
- Department of Intervention, Zhejiang Cancer HospitalHangzhouP.R. China
| | - Xia Wu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University College of MedicineHangzhouP.R. China
| | - Hongjie Hu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University College of MedicineHangzhouP.R. China
| | - Ling Li
- Department of Intervention, The First Affiliated Hospital of Wenzhou Medical UniversityWenzhouP.R. China
| | - Jiaping Zheng
- Department of Intervention, Zhejiang Cancer HospitalHangzhouP.R. China
| | - Jun Luo
- Department of Intervention, Zhejiang Cancer HospitalHangzhouP.R. China
| | - Yutang Chen
- Department of Intervention, Zhejiang Cancer HospitalHangzhouP.R. China
| | - Guohong Cao
- Department of Radiology, Shulan (Hangzhou) Hospital, Zhejiang University International HospitalHangzhouP.R. China
| | - Tingyang Hu
- Department of Intervention, Zhejiang Provincial People's HospitalHangzhouP.R. China
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11
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Zhu D, Yuan D, Wang Z, Chen S. Efficacy of drug-eluting bead transarterial chemoembolization (DEB-TACE) combined with radiofrequency ablation versus DEB-TACE alone in Chinese hepatocellular carcinoma patients. Medicine (Baltimore) 2019; 98:e15682. [PMID: 31261491 PMCID: PMC6617285 DOI: 10.1097/md.0000000000015682] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
To compare the efficacy of drug-eluting bead transarterial chemoembolization combined with radiofrequency ablation (DEB-TACE+RFA) versus DEB-TACE alone in Chinese hepatocellular carcinoma (HCC) patients.The 28 patients receiving DEB-TACE+RFA and 74 HCC patients receiving DEB-TACE were recruited in this study. Treatment responses, progression-free survival (PFS), and overall survival (OS) were evaluated.One to 3 months after treatments, the proportion of patients achieving complete response (CR) (78.6% vs 33.8%, P <.001) and objective response rate (ORR) (92.9% vs 78.4%, P =.010) were elevated in DEB-TACE+RFA group compared with DEB-TACE group. Multivariate logistic regression displayed that DEB-TACE+RFA was an independently predicting factor for better CR (P = .006). Subgroup analysis of CR achievement illuminated that DEB-TACE+RFA disclosed better CR achievement in patients with history of cirrhosis (P <.001), tumor located in right liver (P = .003), bilobar disease (P = .013), tumor size <3.3 cm (P = .001), no portal vein invasion (P = .001), no hepatic vein invasion (P <.001), Child-pugh stage A (P <.001), Barcelona Clinic Liver Cancer (BCLC) stage 0, A-B (P <.001), abnormal alpha-fetoprotein (AFP) (P = .001) and normal AFP (P = .016). The PFSs were similar between 2 groups (P = .112), however, the OS was more prolonged in DEB-TACE+RFA group (P = .025) compared with DEB-TACE group. And subgroup analysis displayed that PFS of patients with largest nodule size >3.3 cm (P = .025) was longer and patients with unilobar disease (P = .009), and patients with no hepatic invasion (P = .019) and Child-pugh stage A (P = .037) had more favorable OS in DEB-TACE+RFA group compared with DEB-TACE group.DEB-TACE+RFA achieved better treatment responses and OS compared with DEB-TACE alone in Chinese HCC patients.
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12
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Nouri YM, Kim JH, Yoon HK, Ko HK, Shin JH, Gwon DI. Update on Transarterial Chemoembolization with Drug-Eluting Microspheres for Hepatocellular Carcinoma. Korean J Radiol 2018; 20:34-49. [PMID: 30627020 PMCID: PMC6315076 DOI: 10.3348/kjr.2018.0088] [Citation(s) in RCA: 50] [Impact Index Per Article: 8.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2018] [Accepted: 07/24/2018] [Indexed: 01/27/2023] Open
Abstract
Conventional transcatheter arterial chemoembolization (c-TACE) is a widely used first-line palliative treatment for patients with unresectable hepatocellular carcinoma (HCC). Despite the effectiveness of c-TACE, to date, technique and procedure scheduling has not yet been standardized. Drug-eluting microspheres (DEMs) were therefore introduced to ensure more sustained and tumor-selective drug delivery for permanent embolization. These DEMs can load various drugs and release them in a sustained manner over a prolonged period. This approach ensures the delivery of high concentrations of chemotherapeutic agents to tumors, without increasing systemic concentrations, and promote tumor ischemia and necrosis. This review summarizes the recent advances in the use of DEM-TACE to treat HCC.
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Affiliation(s)
- Yasir M Nouri
- Department of Radiology and Research Institute of Radiology, Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Jin Hyoung Kim
- Department of Radiology and Research Institute of Radiology, Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Hyun-Ki Yoon
- Department of Radiology and Research Institute of Radiology, Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Heung-Kyu Ko
- Department of Radiology and Research Institute of Radiology, Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Ji Hoon Shin
- Department of Radiology and Research Institute of Radiology, Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Dong Il Gwon
- Department of Radiology and Research Institute of Radiology, Asan Liver Center, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
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13
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Liu Y, Huang W, He M, Lian H, Guo Y, Huang J, Zhou J, Zhu K. Efficacy and Safety of CalliSpheres ® Drug-Eluting Beads Transarterial Chemoembolization in Barcelona Clinic Liver Cancer Stage C Patients. Oncol Res 2018; 27:565-573. [PMID: 30005719 PMCID: PMC7848450 DOI: 10.3727/096504018x15313896322888] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
This study aimed to investigate the efficacy and safety of drug-eluting beads transarterial chemoembolization (DEB-TACE) treatment in Barcelona Clinic Liver Cancer (BCLC) stage C liver cancer patients. In 39 patients with BCLC stage C liver cancer, after the first cycle of DEB-TACE, 2 (5.1%) and 24 (61.5%) patients achieved complete response (CR) and partial response (PR) to give an overall objective response rate (ORR) of 66.7%. With respect to the second cycle of therapy, the ORR was higher in patients receiving DEB-TACE compared with those receiving cTACE (57.1% vs. 11.1%). After the first cycle of DEB-TACE treatment, the percentages of abnormal albumin (ALB), total protein (TP), total bilirubin (TBIL), and alanine aminotransferase (ALT) worsened at 1 week and recovered at 1 month. The number of patients with abnormal aspartate aminotransferase (AST) did not increase at 1 week but elevated at 1 month. After the second cycle of DEB-TACE or cTACE treatment, no difference was observed between cTACE and DEB-TACE in terms of all adverse events (AEs) at all visits, and most of the AEs did not change after the second cycle in both groups. The most common AEs after the first and second treatment cycles were pain, fever, and nausea/vomiting. These results demonstrate that DEB-TACE offers patients with BCLC stage C liver cancer a clinically active short-term treatment that is safe and relatively well tolerated.
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Affiliation(s)
- Yaohong Liu
- Department of Minimally Invasive Interventional Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P.R. China
| | - Wensou Huang
- Department of Minimally Invasive Interventional Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P.R. China
| | - Mingji He
- Department of Minimally Invasive Interventional Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P.R. China
| | - Hui Lian
- Department of Minimally Invasive Interventional Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P.R. China
| | - Yongjian Guo
- Department of Minimally Invasive Interventional Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P.R. China
| | - Jingjun Huang
- Department of Minimally Invasive Interventional Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P.R. China
| | - Jingwen Zhou
- Department of Minimally Invasive Interventional Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P.R. China
| | - Kangshun Zhu
- Department of Minimally Invasive Interventional Radiology, The Second Affiliated Hospital of Guangzhou Medical University, Guangzhou, Guangdong, P.R. China
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14
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Popovic P, Leban A, Kregar K, Garbajs M, Dezman R, Bunc M. Computed Tomographic Perfusion Imaging for the Prediction of Response and Survival to Transarterial Chemoembolization of Hepatocellular Carcinoma. Radiol Oncol 2017. [PMID: 29520201 PMCID: PMC5839077 DOI: 10.1515/raon-2017-0052] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Background The purpose of this retrospective cohort study was to evaluate the clinical value of computed tomographic perfusion imaging (CTPI) parameters in predicting the response to treatment and overall survival in patients with hepatocellular carcinoma (HCC) treated with drug-eluting beads transarterial chemoembolization (DEBTACE). Patients and methods Between December 2010 and January 2013 eighteen patients (17 men, 1 woman; mean age 69 ± 5.8 years) with intermediate stage HCC underwent CTPI of the liver prior to treatment with DEBTACE. Treatment response was evaluated on follow-up imaging according to modified Response Evaluation Criteria in Solid Tumors. Pre-treatment CTPI parameters were compared between patients with complete response and partial response with a Student t-test. We compared survival times with Kaplan-Meier method. Results CTPI parameters of patients with complete response and others did not show statistical significant difference. The mean survival time was 25.4 ± 3.2 months (95%; CI: 18.7-32.1). Survival was statistically significantly longer in patients with hepatic blood flow (BF) lower than 50.44 ml/100 ml/min (p = 0.033), hepatic blood volume (BV) lower than 13.32 ml/100 ml (p = 0.028) and time to peak (TTP) longer than 19.035 s (p = 0.015). Conclusions CTPI enables prediction of survival in patients with intermediate stage HCC, treated with DEBTACE based on the pre-treatment values of BF, BV and TTP perfusion parameters. CT perfusion imaging can’t be used to predict treatment response to DEBTACE.
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Affiliation(s)
- Peter Popovic
- Clinical Institute of Radiology, University Medical Centre, Ljubljana, Slovenia
| | - Ana Leban
- General Hospital Dr. Franca Derganca, Šempeter pri Gorici, Slovenia
| | | | - Manca Garbajs
- Clinical Institute of Radiology, University Medical Centre, Ljubljana, Slovenia
| | - Rok Dezman
- Clinical Institute of Radiology, University Medical Centre, Ljubljana, Slovenia
| | - Matjaz Bunc
- Department of Cardiology, University Medical Centre, Ljubljana, Slovenia
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15
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Gabr A, Abouchaleh N, Ali R, Vouche M, Atassi R, Memon K, Asadi AA, Baker T, Caicedo JC, Desai K, Fryer J, Hickey R, Abeccassis M, Habib A, Hohlastos E, Ganger D, Kulik L, Lewandowski RJ, Riaz A, Salem R. Comparative study of post-transplant outcomes in hepatocellular carcinoma patients treated with chemoembolization or radioembolization. Eur J Radiol 2017; 93:100-106. [DOI: 10.1016/j.ejrad.2017.05.022] [Citation(s) in RCA: 18] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Revised: 05/18/2017] [Accepted: 05/19/2017] [Indexed: 02/08/2023]
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