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Coffman-D’Annibale K, Xie C, Hrones DM, Ghabra S, Greten TF, Monge C. The current landscape of therapies for hepatocellular carcinoma. Carcinogenesis 2023; 44:537-548. [PMID: 37428789 PMCID: PMC10588973 DOI: 10.1093/carcin/bgad052] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Revised: 06/22/2023] [Accepted: 07/07/2023] [Indexed: 07/12/2023] Open
Abstract
Globally, primary liver cancer is the third leading cause of cancer-related deaths, with approximately 830 000 deaths worldwide in 2020, accounting for 8.3% of total deaths from all cancer types (1). This disease disproportionately affects those in countries with low or medium Human Development Index scores in Eastern Asia, South-Eastern Asia, and Northern and Western Africa (2). Hepatocellular carcinoma (HCC), the most common type of primary liver cancer, often develops in the background of chronic liver disease, caused by hepatitis B or C virus, non-alcoholic steatohepatitis (NASH), or other diseases that cause cirrhosis. Prognosis can vary dramatically based on number, size, and location of tumors. Hepatic synthetic dysfunction and performance status (PS) also impact survival. The Barcelona Clinic Liver Cancer (BCLC) staging system best accounts for these variations, providing a reliable prognostic stratification. Therapeutic considerations of this complex disease necessitate a multidisciplinary approach and can range from curative-intent surgical resection, liver transplantation or image-guided ablation to more complex liver-directed therapies like transarterial chemoembolization (TACE) and systemic therapy. Recent advances in the understanding of the tumor biology and microenvironment have brought new advances and approvals for systemic therapeutic agents, often utilizing immunotherapy or VEGF-targeted agents to modulate the immune response. This review will discuss the current landscape in the treatments available for early, intermediate, and advanced stage HCC.
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Affiliation(s)
- Kelley Coffman-D’Annibale
- National Cancer Institute, Gastrointestinal Malignancies Section, Thoracic and Gastrointestinal Oncology Branch, Center for Cancer Research, Bethesda, MD, USA
| | - Changqing Xie
- National Cancer Institute, Gastrointestinal Malignancies Section, Thoracic and Gastrointestinal Oncology Branch, Center for Cancer Research, Bethesda, MD, USA
| | - Donna M Hrones
- National Cancer Institute, Gastrointestinal Malignancies Section, Thoracic and Gastrointestinal Oncology Branch, Center for Cancer Research, Bethesda, MD, USA
| | - Shadin Ghabra
- National Cancer Institute, Gastrointestinal Malignancies Section, Thoracic and Gastrointestinal Oncology Branch, Center for Cancer Research, Bethesda, MD, USA
| | - Tim F Greten
- National Cancer Institute, Gastrointestinal Malignancies Section, Thoracic and Gastrointestinal Oncology Branch, Center for Cancer Research, Bethesda, MD, USA
- National Cancer Institute, NCI CCR Liver Cancer Program, National Institutes of Health, Bethesda, MD, USA
| | - Cecilia Monge
- National Cancer Institute, Gastrointestinal Malignancies Section, Thoracic and Gastrointestinal Oncology Branch, Center for Cancer Research, Bethesda, MD, USA
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2
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Prince DS, Schlaphoff G, Davison SA, Huo YR, Xiang H, Chan MV, Lee AU, Thailakanathan C, Jebeili H, Rogan C, Al-Omary A, Gupta S, Lockart I, Tiwari N, Clark-Dickson M, Hillhouse JW, Laube R, Chang J, Nguyen V, Danta M, Cheng R, Strasser SI, Zekry A, Levy MT, Chan C, Liu K. Selective internal radiation therapy for hepatocellular carcinoma: A 15-year multicenter Australian cohort study. J Gastroenterol Hepatol 2022; 37:2173-2181. [PMID: 36031345 DOI: 10.1111/jgh.15986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 07/27/2022] [Accepted: 08/17/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND AND AIM The exact place for selective internal radiation therapy (SIRT) in the therapeutic algorithm for hepatocellular carcinoma (HCC) is debated. There are limited data on its indications, efficacy, and safety in Australia. METHODS We performed a multicenter retrospective cohort study of patients undergoing SIRT for HCC in all Sydney hospitals between 2005 and 2019. The primary outcome was overall survival. Secondary outcomes were progression-free survival and adverse events. RESULTS During the study period, 156 patients underwent SIRT across 10 institutions (mean age 67 years, 81% male). SIRT use progressively increased from 2005 (n = 2), peaking in 2017 (n = 42) before declining (2019: n = 21). Barcelona Clinic Liver Cancer stages at treatment were A (13%), B (33%), C (52%), and D (2%). Forty-four (28%) patients had tumor thrombus. After a median follow-up of 13.9 months, there were 117 deaths. Median overall survival was 15 months (95% confidence interval 11-19). Independent predictors of mortality on multivariable analysis were extent of liver involvement, Barcelona Clinic Liver Cancer stage, baseline ascites, alpha fetoprotein, and model for end-stage liver disease score. Median progression-free survival was 6.0 months (95% confidence interval 5.1-6.9 months). Following SIRT, 11% of patients were downstaged to curative therapy. SIRT-related complications occurred in 17%: radioembolization-induced liver disease (11%), pneumonitis (3%), gastrointestinal ulceration, and cholecystitis (1% each). Baseline ascites predicted for radioembolization-induced liver disease. CONCLUSION We present the largest Australian SIRT cohort for HCC. We have identified several factors associated with a poor outcome following SIRT. Patients with early-stage disease had the best survival with some being downstaged to curative therapy.
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Affiliation(s)
- David Stephen Prince
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Department of Gastroenterology and Liver, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Glen Schlaphoff
- Department of Gastroenterology and Liver, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Scott Anthony Davison
- Department of Gastroenterology and Liver, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Ya Ruth Huo
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Hao Xiang
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Michael Vinchill Chan
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia.,Sydney Adventist Hospital, Sydney, New South Wales, Australia
| | - Alice Unah Lee
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Cynthuja Thailakanathan
- Department of Gastroenterology and Hepatology, St George Hospital, Sydney, New South Wales, Australia
| | - Hazem Jebeili
- Department of Gastroenterology and Hepatology, St George Hospital, Sydney, New South Wales, Australia
| | - Christopher Rogan
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia.,Sydney Adventist Hospital, Sydney, New South Wales, Australia
| | - Ahmed Al-Omary
- Gastroenterology Department, Westmead Hospital, Sydney, New South Wales, Australia
| | - Sidhartha Gupta
- Gastroenterology Department, Westmead Hospital, Sydney, New South Wales, Australia
| | - Ian Lockart
- Gastroenterology Department, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Neha Tiwari
- Department of Gastroenterology and Hepatology, Nepean Hospital, Sydney, New South Wales, Australia
| | | | | | - Robyn Laube
- Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Jeff Chang
- Department of Gastroenterology and Hepatology, Nepean Hospital, Sydney, New South Wales, Australia.,Macquarie University Hospital, Sydney, New South Wales, Australia
| | - Vi Nguyen
- Royal North Shore Hospital, Sydney, New South Wales, Australia
| | - Mark Danta
- Gastroenterology Department, St Vincent's Hospital, Sydney, New South Wales, Australia
| | - Robert Cheng
- Gastroenterology Department, Westmead Hospital, Sydney, New South Wales, Australia
| | - Simone Irene Strasser
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
| | - Amany Zekry
- Department of Gastroenterology and Hepatology, St George Hospital, Sydney, New South Wales, Australia
| | - Miriam Tania Levy
- Department of Gastroenterology and Liver, Liverpool Hospital, Sydney, New South Wales, Australia
| | - Christine Chan
- Concord Repatriation General Hospital, Sydney, New South Wales, Australia
| | - Ken Liu
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, New South Wales, Australia
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3
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Schöler D, Castoldi M, Jördens MS, Schulze-Hagen M, Kuhl C, Keitel V, Luedde T, Roderburg C, Loosen SH. Enlarged extracellular vesicles are a negative prognostic factor in patients undergoing TACE for primary or secondary liver cancer-a case series. PLoS One 2021; 16:e0255983. [PMID: 34407090 PMCID: PMC8372935 DOI: 10.1371/journal.pone.0255983] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/05/2021] [Accepted: 07/27/2021] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Transarterial chemoembolization (TACE) has evolved as a standard treatment option in patients with intermediate stage, unresectable HCC [Barcelona Clinic Liver Cancer (BCLC) stage B] as well as in patients with liver metastases, when surgery or systemic therapy is considered not appropriate. Concentration and sizes of extracellular vesicles (EVs) recently emerged as novel diagnostic and prognostic biomarkers in patients with liver cancer, but no data on its prognostic relevance in the context of TACE exists. Here, we evaluate pre-interventional EVs as a potential biomarker in patients undergoing TACE for primary and secondary hepatic malignancies. METHODS Vesicle size distribution and concentration were measured by nanoparticle tracking analysis (NTA) in patient sera before and after TACE in 38 patients. RESULTS Extracellular vesicle size distribution measured before TACE is of prognostic significance with respect to overall survival in patients after TACE. Overall survival is significantly reduced when initial vesicle size (X50) is in the upper quartile (>145.65nm). Median overall survival in patients in the upper quartile was only 314 days, compared to 799 days in patients with vesicle size in the first to third quartile (<145.65nm; p = 0.007). Vesicle size was also shown to be a significant prognostic marker for overall survival in Cox regression analysis [HR 1.089, 95% CI: 1.021-1.162, p = 0.010]. In addition, a significant correlation was observed between initial EVs concentration/BMI (rS = 0.358, p = 0.029), X50/IL-8-concentration (rS = 0.409, p = 0.011) and X50/CRP-concentration (rS = 0.404, p = 0.016). In contrast, with regard to immediate tumor response after TACE, EVs concentration and size did not differ. SUMMARY Sizes (but not concentrations) of EVs represent a novel prognostic marker in patients receiving TACE for primary and secondary hepatic malignancies since patients with enlarged EVs display a significantly impaired prognosis after TACE.
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Affiliation(s)
- David Schöler
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Mirco Castoldi
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Markus S. Jördens
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Max Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Christiane Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Verena Keitel
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Tom Luedde
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Christoph Roderburg
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Sven H. Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
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ACR-ABS-ACNM-ASTRO-SIR-SNMMI practice parameter for selective internal radiation therapy or radioembolization for treatment of liver malignancies. Brachytherapy 2021; 20:497-511. [PMID: 33824051 DOI: 10.1016/j.brachy.2021.01.006] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/09/2020] [Accepted: 01/22/2021] [Indexed: 01/07/2023]
Abstract
PURPOSE The American College of Radiology (ACR), American Brachytherapy Society (ABS), American College of Nuclear Medicine (ACNM), American Society for Radiation Oncology (ASTRO), Society of Interventional Radiology (SIR), and Society of Nuclear Medicine and Molecular Imaging (SNMMI) have jointly developed a practice parameter on selective internal radiation therapy (SIRT) or radioembolization for treatment of liver malignancies. Radioembolization is the embolization of the hepatic arterial supply of hepatic primary tumors or metastases with a microsphere yttrium-90 brachytherapy device. MATERIALS AND METHODS The ACR -ABS -ACNM -ASTRO -SIR -SNMMI practice parameter for SIRT or radioembolization for treatment of liver malignancies was revised in accordance with the process described on the ACR website (https://www.acr.org/ClinicalResources/Practice-Parameters-and-Technical-Standards) by the Committee on Practice Parameters-Interventional and Cardiovascular Radiology of the ACR Commission on Interventional and Cardiovascular, Committee on Practice Parameters and Technical Standards-Nuclear Medicine and Molecular Imaging of the ACR Commission on Nuclear Medicine and Molecular Imaging and the Committee on Practice Parameters-Radiation Oncology of the ACR Commission on Radiation Oncology in collaboration with ABS, ACNM, ASTRO, SIR, and SNMMI. RESULTS This practice parameter is developed to serve as a tool in the appropriate application of radioembolization in the care of patients with conditions where indicated. It addresses clinical implementation of radioembolization including personnel qualifications, quality assurance standards, indications, and suggested documentation. CONCLUSIONS This practice parameter is a tool to guide clinical use of radioembolization. It focuses on the best practices and principles to consider when using radioemboliozation effectively. The clinical benefit and medical necessity of the treatment should be tailored to each individual patient.
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5
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Wirtz TH, Loosen SH, Schulze-Hagen M, Gorgulho J, Kandler J, Joerdens M, Demir M, Mohr R, Bruners P, Kuhl C, Trautwein C, Berres ML, Tacke F, Luedde T, Roderburg C. Macrophage migration inhibitory factor predicts an unfavorable outcome after transarterial chemoembolization for hepatic malignancies. Clin Transl Sci 2021; 14:1853-1863. [PMID: 33787014 PMCID: PMC8504849 DOI: 10.1111/cts.13033] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2020] [Revised: 02/16/2021] [Accepted: 02/17/2021] [Indexed: 12/13/2022] Open
Abstract
Transarterial chemoembolization (TACE) is a therapeutic option for patients with intermediate-stage hepatocellular carcinoma (HCC) or metastatic liver cancers. Identifying those patients who particularly benefit from TACE remains challenging. Macrophage migration inhibitory factor (MIF) represents is an inflammatory protein described in patients with liver cancer, but no data on its prognostic relevance in patients undergoing TACE exist. Here, we evaluate MIF serum concentrations as a potential biomarker in patients undergoing TACE for primary and secondary hepatic malignancies. MIF serum concentrations were measured by multiplex immunoassay in 50 patients (HCC: n = 39, liver metastases: n = 11) before and 1 day after TACE as well as in 51 healthy controls. Serum concentrations of MIF did not differ between patients and healthy controls. Interestingly, in the subgroup of patients with larger tumor size, significantly more patients had increased MIF concentrations. Patients with an objective tumor response to TACE therapy showed comparable concentrations of serum MIF compared to patients who did not respond. MIF concentrations at day 1 after TACE were significantly higher compared to baseline concentrations. Importantly, baseline MIF concentrations above the optimal cutoff value (0.625 ng/ml) turned out as a significant and independent prognostic marker for a reduced overall survival (OS) following TACE: patients with elevated MIF concentrations showed a significantly reduced median OS of only 719 days compared to patients below the cutoff value (median OS: 1430 days, p = 0.021). Baseline MIF serum concentrations are associated with tumor size of intrahepatic malignancies and predict outcome of patients with liver cancer receiving TACE.
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Affiliation(s)
- Theresa H Wirtz
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Sven H Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Max Schulze-Hagen
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Joao Gorgulho
- Department of Oncology, Hematology and Bone Marrow Transplantation with Section of Pneumology, University Medical Centre Hamburg-Eppendorf, Hamburg, Germany
| | - Jennis Kandler
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Markus Joerdens
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Münevver Demir
- Department of Hepatology and Gastroenterology, Charité University Medicine Berlin, Berlin, Germany
| | - Raphael Mohr
- Department of Hepatology and Gastroenterology, Charité University Medicine Berlin, Berlin, Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Christiane Kuhl
- Department of Diagnostic and Interventional Radiology, University Hospital RWTH Aachen, Aachen, Germany
| | - Christian Trautwein
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Marie-Luise Berres
- Department of Medicine III, University Hospital RWTH Aachen, Aachen, Germany
| | - Frank Tacke
- Department of Hepatology and Gastroenterology, Charité University Medicine Berlin, Berlin, Germany
| | - Tom Luedde
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany
| | - Christoph Roderburg
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf, Medical Faculty of Heinrich Heine University Düsseldorf, Düsseldorf, Germany.,Department of Hepatology and Gastroenterology, Charité University Medicine Berlin, Berlin, Germany
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6
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Loosen SH, Schulze-Hagen M, Vucur M, Gorgulho J, Paffenholz P, Benz F, Mohr R, Demir M, Wree A, Kuhl C, Trautwein C, Tacke F, Bruners P, Luedde T, Roderburg C. Elevated soluble urokinase plasminogen activator receptor serum levels indicate poor survival following transarterial chemoembolization therapy for hepatic malignancies: An exploratory analysis. JGH OPEN 2021; 5:356-363. [PMID: 33732882 PMCID: PMC7936623 DOI: 10.1002/jgh3.12501] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/01/2020] [Revised: 10/31/2020] [Accepted: 01/16/2021] [Indexed: 11/23/2022]
Abstract
Background and Aim Transarterial chemoembolization (TACE) represents a standard of care for patients with intermediate‐stage hepatocellular carcinoma (HCC) or liver metastases. However, identification of the ideal candidates for TACE therapy remains challenging. The soluble urokinase plasminogen activator receptor (suPAR) has recently evolved as a prognostic marker in patients with cancer; however no data on suPAR in the context of TACE exists. Methods Serum levels of suPAR were measured by an enzyme‐linked immunosorbent assay in n = 48 TACE patients (HCC: n = 38, liver metastases: n = 10) before intervention and 1 day after TACE, as well as in 20 healthy controls. Results Serum levels of suPAR were significantly elevated in patients with liver cancer compared to healthy controls. Patients with or without an objective tumor response to TACE therapy had comparable levels of circulating suPAR. Importantly, baseline suPARs above the ideal prognostic cut‐off value (5.39 ng/mL) were a significant prognostic marker for reduced overall survival (OS) following TACE. As such, patients with initial suPAR levels >5.39 ng/mL showed a significantly reduced median OS of only 256 days compared to patients with suPAR serum levels below the cut‐off value (median OS: 611 days). In line with previous data, suPAR serum concentrations correlated with those of creatinine but were independent of tumor entity, leukocyte count, and C‐reactive protein in multivariate analysis. Conclusion Baseline suPAR serum levels provide important information on the postinterventional outcome of liver cancer patients receiving TACE.
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Affiliation(s)
- Sven H Loosen
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf Medical Faculty of Heinrich Heine University Düsseldorf Düsseldorf Germany.,Department of Medicine III University Hospital RWTH Aachen Aachen Germany
| | - Max Schulze-Hagen
- Department of Diagnostic and Interventional Radiology University Hospital RWTH Aachen Aachen Germany
| | - Mihael Vucur
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf Medical Faculty of Heinrich Heine University Düsseldorf Düsseldorf Germany
| | - Joao Gorgulho
- Department of Medicine III University Hospital RWTH Aachen Aachen Germany
| | - Pia Paffenholz
- Department of Urology University Hospital Cologne Cologne Germany
| | - Fabian Benz
- Department of Hepatology and Gastroenterology Charité University Medicine Berlin Berlin Germany
| | - Raphael Mohr
- Department of Hepatology and Gastroenterology Charité University Medicine Berlin Berlin Germany
| | - Münevver Demir
- Department of Hepatology and Gastroenterology Charité University Medicine Berlin Berlin Germany
| | - Alexander Wree
- Department of Hepatology and Gastroenterology Charité University Medicine Berlin Berlin Germany
| | - Christiane Kuhl
- Department of Diagnostic and Interventional Radiology University Hospital RWTH Aachen Aachen Germany
| | | | - Frank Tacke
- Department of Hepatology and Gastroenterology Charité University Medicine Berlin Berlin Germany
| | - Philipp Bruners
- Department of Diagnostic and Interventional Radiology University Hospital RWTH Aachen Aachen Germany
| | - Tom Luedde
- Clinic for Gastroenterology, Hepatology and Infectious Diseases, University Hospital Düsseldorf Medical Faculty of Heinrich Heine University Düsseldorf Düsseldorf Germany
| | - Christoph Roderburg
- Department of Hepatology and Gastroenterology Charité University Medicine Berlin Berlin Germany
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7
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Prince D, Liu K, Xu W, Chen M, Sun JY, Lu XJ, Ji J. Management of patients with intermediate stage hepatocellular carcinoma. Ther Adv Med Oncol 2020; 12:1758835920970840. [PMID: 33224278 PMCID: PMC7649909 DOI: 10.1177/1758835920970840] [Citation(s) in RCA: 24] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2020] [Accepted: 10/08/2020] [Indexed: 12/12/2022] Open
Abstract
Hepatocellular carcinoma (HCC) causes a significant health burden globally and its impact is expected to increase in the coming years. Intermediate stage HCC, as defined by the Barcelona Clinic Liver Cancer (BCLC) system stage B, represents up to 30% of patients at diagnosis and encompasses a broad spectrum of tumor burden. Several attempts have been made to further subclassify this heterogenous group. The current standard of care recommended by BCLC for intermediate stage HCC patients is transarterial chemoembolization (TACE), with modest outcomes reported. While refinements have been made to TACE technique and patient selection, it remains non-curative. In the real-world setting, only 60% of patients with intermediate stage HCC receive TACE, with the remainder deviating to a range of other therapies that have shown promise in select patient subgroups. These include curative treatments (resection, ablation, and liver transplantation), radiotherapy (stereotactic and radioembolization), systemic therapies, and their combination. In this review, we summarize the classifications and current management for patients with intermediate stage HCC as well as highlight recent key developments in this space.
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Affiliation(s)
- David Prince
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
| | - Ken Liu
- AW Morrow Gastroenterology and Liver Centre, Royal Prince Alfred Hospital, Sydney, NSW, Australia
- Sydney Medical School, The University of Sydney, Sydney, NSW, Australia
- Liver Injury and Cancer Program, The Centenary Institute, Sydney, NSW, Australia
| | - Weiqi Xu
- Department of Hepatic Surgery, Fudan University Shanghai Cancer Center, Shanghai Medical College, Fudan University, Shanghai, China
- Department of Oncology, Shanghai Medical College, Fudan University, Shanghai, China
| | - Minjiang Chen
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University/Affiliated Lishui Hospital of Zhejiang University/The Central Hospital of Zhejiang Lishui, Lishui, China
- Department of Radiology, the Fifth Affiliated Hospital of Wenzhou Medical University/Affiliated Lishui Hospital of Zhejiang University/The Central Hospital of Zhejiang Lishui, Lishui, China
| | - Jin-Yu Sun
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
- Sparkfire Scientific Research Group, Nanjing Medical University, Nanjing, China
| | - Xiao-Jie Lu
- Department of General Surgery, The First Affiliated Hospital of Nanjing Medical University, Nanjing, China
| | - Jiansong Ji
- Key Laboratory of Imaging Diagnosis and Minimally Invasive Intervention Research, The Fifth Affiliated Hospital of Wenzhou Medical University/Affiliated Lishui Hospital of Zhejiang University/The Central Hospital of Zhejiang Lishui, Lishui 323000, China
- Department of Radiology, the Fifth Affiliated Hospital of Wenzhou Medical University/Affiliated Lishui Hospital of Zhejiang University/The Central Hospital of Zhejiang Lishui, Lishui, 323000, China
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8
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Li L, Li B, Zhang M. Postoperative adjuvant transarterial chemoembolization improves the prognosis of hepatocellular carcinoma patients with microvascular invasion: a systematic review and meta-analysis. Acta Radiol 2020; 61:723-731. [PMID: 31594382 DOI: 10.1177/0284185119878357] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
BACKGROUND Microvascular invasion has been widely accepted as a major risk factor of hepatocellular carcinoma prognoses after surgery. It is still controversial whether postoperative adjuvant transarterial chemoembolization could improve the survival of hepatocellular carcinoma patients with microvascular invasion. PURPOSE To evaluate the effect of postoperative adjuvant transarterial chemoembolization for postoperative hepatocellular carcinoma patients with microvascular invasion. MATERIAL AND METHODS PubMed, Web of Science, and Embase databases were searched for eligible studies, and the one-, three-, and five-year recurrence rates and overall survival rates were extracted for meta-analysis. RESULTS A total of eight studies were included in this study. The results showed that the one-, three-, and five-year recurrence rate of the postoperative adjuvant transarterial chemoembolization group were better than those of the hepatectomy alone group, with a pooled risk ratio (RR) of 0.66 (95% confidence interval [CI] 0.58-0.75, P < 0.00001), 0.82 (95% CI 0.76-0.88, P < 0.00001), and 0.89 (95% CI 0.82-0.97, P = 0.007), respectively. The overall survival rates with one-, three-, and five-year pooled RR were 0.34 (95% CI 0.25-0.47, P < 0.00001), 0.69 (95% CI 0.60-0.79, P < 0.00001), and 0.78 (95% CI 0.69-0.89, P = 0.0001), respectively. No serious side effects have been reported, indicating that postoperative intervention is safe. CONCLUSION For hepatocellular carcinoma patients with microvascular invasion confirmed by postoperative pathology, postoperative adjuvant transarterial chemoembolization is a safe treatment, which could reduce the tumor recurrence rate and improve the patient's overall survival.
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Affiliation(s)
- Lian Li
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Bo Li
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
| | - Ming Zhang
- Department of Liver Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
- Department of General Surgery, West China Hospital, Sichuan University, Chengdu, Sichuan Province, China
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9
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Utility of 'dual phase' cone beam computed tomography during radioembolisation in patients with hepatocellular carcinoma: what is really changing in flow dynamics before and after 90Y delivery? Pol J Radiol 2020; 85:e21-e28. [PMID: 32180850 PMCID: PMC7064008 DOI: 10.5114/pjr.2020.92915] [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: 08/25/2019] [Accepted: 12/17/2019] [Indexed: 12/24/2022] Open
Abstract
Purpose The aims of the study were: 1) to compare two phases of dual-phase cone beam computed tomography (DP-CBCT) achieved before and after Yttrium-90 (90Y) administration and to evaluate additional benefits during radioembolisation (RE) procedures; and 2) to compare DP-CBCT with pre-procedure contrast enhanced cross-sectional images in terms of tumour detection. Material and methods Twenty-three hepatocellular carcinoma patients undergoing RE treatment were scanned with DP-CBCT consisting of early arterial (EA) and late arterial (LA) phases before and after 90Y administration. The CT-like datasets were compared according to embolisation effect, enhancement patterns, lesion detectability, image quality, and artifacts by two interventional radiologists blinded to each other. The compatibility of the two radiologists was evaluated with kappa statistical analysis, and the difference between EA and LA phases was evaluated with marginal homogeneity test. Also, DP-CBCT images were compared with preprocedural cross-sectional images (CT/MRI). Results For 23 patients 92 data were acquired. Thirteen patients showed a decrease on post-embolisation images both visually and on Hounsfield unit (HU) measurements. No statistical difference was found for tumour detection between EA and LA phases (p = 1.0). Tumour enhancement was visually superior at LA phases whereas EA phases were better for arterial mapping for selective catheterisation. DP-CBCT images were not inferior to preprocedural cross-sectional imaging findings. Conclusions DP-CBCT is a promising tool for predicting tumour response to therapy and is not inferior to preprocedural cross-sectional imaging in terms of tumour detection. It allows better assessment during RE procedures because early phases provide good mapping for superselective catheterisation whereas late phases are better for visualisation of tumour enhancement.
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Zhang X, Zhou J, Zhu DD, Huang J, Sun JH, Li TF, Shi CS, Sun ZC, Hou QM, Peng ZY, Yu WQ, Ji JS, Gu WJ, Zhou GH, Xie XX, Guo XH, Cao GH, Yu ZH, Xu HH, Fang J, Ying SH, Hu WH, Ji WB, Han J, Wu X, Zheng JP, Luo J, Chen YT, Hu TY, Li L, Hu HJ, Du HJ, Shao GL. CalliSpheres® drug-eluting beads (DEB) transarterial chemoembolization (TACE) is equally efficient and safe in liver cancer patients with different times of previous conventional TACE treatments: a result from CTILC study. Clin Transl Oncol 2018; 21:167-177. [PMID: 30003530 DOI: 10.1007/s12094-018-1902-8] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2017] [Accepted: 05/24/2018] [Indexed: 01/27/2023]
Abstract
PURPOSE To assess the efficacy and safety of drug-eluting beads transarterial chemoembolization (DEB-TACE) in liver cancer patients with different times of previous conventional transarterial chemoembolization (cTACE) treatments. METHODS 367 liver cancer patients about to receive DEB-TACE treatment were enrolled in this prospective cohort study. All patients were divided into no previous cTACE group (NPC group), 1-2 times previous cTACE group (PC group) and triple or above previous cTACE group (TPC group) according to the times of previous cTACE treatments. RESULTS There was no difference in complete response (CR) (P = 0.671) and objective response rate (ORR) (P = 0.062) among three groups. Additionally, no difference in overall survival (OS) among groups (P = 0.899) was found. As to liver function, most liver function indexes were deteriorative at 1 week after DEB-TACE operation, but returned to baseline at 1-3 months after DEB-TACE operation in all three groups, while percentage of abnormal total bile acid (TBA) patients was higher in TPC group than NPC and PC groups at 1-3 month post-DEB-TACE (P = 0.018). As for safety profiles, the incidence of pain during DEB-TACE operation was lower in TPC group compared to NPC and PC groups (P = 0.005), while no difference of other adverse events was found during and 1 month post-DEB-TACE treatment among three groups. CONCLUSION DEB-TACE treatment was equally efficient and tolerated in liver cancer patients with different times of previous cTACE treatments.
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Affiliation(s)
- X Zhang
- Interventional Radiology Department, The First Affiliated Hospital, Zhejiang University, No. 79 Qingchun Road, Hangzhou, 310006, China
| | - J Zhou
- Department of Radiology, Hangzhou Cancer Hospital, No. 34 Yan Guan lane, Hangzhou, China
| | - D-D Zhu
- Department of Liver Oncology, Ningbo No. 2 Hospital, No. 41 Xibei Road, Ningbo, 315010, China
| | - J Huang
- Department of Hepatobiliary Surgery, Ningbo Medical Center Lihuili Easter Hospital, No. 1111 Jiangnan Road, Ningbo, 315000, China
| | - J-H Sun
- Division of Hepatobiliary and Pancreatic Surgery, Hepatobiliary and Pancreatic Interventional Treatment Center, The First Affiliated Hospital, Zhejiang University, No. 79 Qingchun Road, Hangzhou, 310006, China
| | - T-F Li
- Department of Radiology, Beilun District People's Hospital of Ningbo, No. 1288 Lushang East Road, Ningbo, 315826, China
| | - C-S Shi
- Department of Intervention, Ruian People's Hospital, The Third Affiliated Hospital of Wenzhou Medical University, No. 108 Wansong Road, Ruian, 325200, China
| | - Z-C Sun
- Department of Radiology, The First Affiliated Hospital of Zhejiang Chinese Medical University, Zhejiang Hospital of TCM, No. 54 Youdian Road, Hangzhou, 310006, China
| | - Q-M Hou
- Department of Radiology, Xixi Hospital of Hangzhou, Hangzhou 6th People's Hospital, Hengbu Street 2, Hangzhou, 310023, China
| | - Z-Y Peng
- Interventional Radiology Department, The First Affiliated Hospital, Zhejiang University, No. 79 Qingchun Road, Hangzhou, 310006, China
| | - W-Q Yu
- Department of Intervention, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, No. 158 Shangtang Road, Hangzhou, 310000, China
| | - J-S Ji
- Department of Radiology, Lishui Central Hospital, Lishui Hospital of Zhejiang University, The Fifth Affiliated Hospital of Wenzhou Medical University, No. 289 Kuocang Road, Lishui, 323000, China
| | - W-J Gu
- Department of Intervention, Jiaxing Second Hospital, No. 1518 Huangcheng North Road, Jiaxing, 314000, China
| | - G-H Zhou
- Division of Hepatobiliary and Pancreatic Surgery, Hepatobiliary and Pancreatic Interventional Treatment Center, The First Affiliated Hospital, Zhejiang University, No. 79 Qingchun Road, Hangzhou, 310006, China
| | - X-X Xie
- Interventional Center, Xinchang People's Hospital, No. 117 Gushan Road, Xinchang, 312500, China
| | - X-H Guo
- Department of Intervention, Jinhua Municipal Central Hospital, Jinhua Hospital of Zhejiang University, No. 365 Renmin East Road, Jinhua, 321000, China
| | - G-H Cao
- Department of Radiology, Shulan (Hangzhou) Hospital, No. 848 Dongxin Road, Hangzhou, 310026, China
| | - Z-H Yu
- Department of Vascular and Interventional Radiology, The Affiliated Hospital of Medical School of Ningbo University, No. 247 Renmin Road, Ningbo, 315020, China
| | - H-H Xu
- Division of Digestive Endoscopy, Yueqing City People's Hospital, No. 338 Qingyuan Road, Yueqing, 325600, China
| | - J Fang
- Department of Hepatobiliary Surgery, Quzhou People's Hospital, No. 2 Zhongloudi, Quzhou, 324000, China
| | - S-H Ying
- Interventional Radiology Department, The First Affiliated Hospital, Zhejiang University, No. 79 Qingchun Road, Hangzhou, 310006, China
| | - W-H Hu
- Department of Intervention, The First Provincial Wenzhou Hospital of Zhejiang, The First Affiliated Hospital of Wenzhou Medical University, No. 2 Fuxue Lane, Wenzhou, 325099, China
| | - W-B Ji
- Department of Radiology, Taizhou Hospital of Zhejiang Province, No. 150 Ximen Street, Linhai, 317000, China
| | - J Han
- Department of Intervention, Jiaxing First Hospital, No. 1882 Zhonghuan South Road, Jiaxing, 314001, China
| | - X Wu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Road, Hangzhou, 310016, China
| | - J-P Zheng
- Department of Intervention, Zhejiang Cancer Hospital, No. 1 Banshan East Road, Hangzhou, 310022, China
| | - J Luo
- Department of Intervention, Zhejiang Cancer Hospital, No. 1 Banshan East Road, Hangzhou, 310022, China
| | - Y-T Chen
- Department of Intervention, Zhejiang Cancer Hospital, No. 1 Banshan East Road, Hangzhou, 310022, China
| | - T-Y Hu
- Department of Intervention, Zhejiang Provincial People's Hospital, People's Hospital of Hangzhou Medical College, No. 158 Shangtang Road, Hangzhou, 310000, China
| | - L Li
- Department of Liver Oncology, Ningbo No. 2 Hospital, No. 41 Xibei Road, Ningbo, 315010, China
| | - H-J Hu
- Department of Radiology, Sir Run Run Shaw Hospital, Zhejiang University School of Medicine, No. 3 Qingchun East Road, Hangzhou, 310016, China
| | - H-J Du
- Department of Intervention, Dongyang People's Hospital, No. 60 Wuning West Road, Dongyang, 322100, China.
| | - G-L Shao
- Department of Intervention, Zhejiang Cancer Hospital, No. 1 Banshan East Road, Hangzhou, 310022, China.
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Llovet JM, Mazzaferro V, Piscaglia F, Raoul JL, Schirmacher P, Vilgrain V. EASL Clinical Practice Guidelines: Management of hepatocellular carcinoma. J Hepatol 2018; 69:182-236. [PMID: 29628281 DOI: 10.1016/j.jhep.2018.03.019] [Citation(s) in RCA: 5107] [Impact Index Per Article: 851.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2018] [Accepted: 03/20/2018] [Indexed: 02/06/2023]
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Phase 1-2 pilot clinical trial in patients with decompensated liver cirrhosis treated with bone marrow-derived endothelial progenitor cells. Transl Res 2017; 188:80-91.e2. [PMID: 26972567 DOI: 10.1016/j.trsl.2016.02.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/13/2015] [Revised: 02/12/2016] [Accepted: 02/17/2016] [Indexed: 01/13/2023]
Abstract
The aim of this nonrandomized, open label, phase 1 clinical trial was to evaluate the safety and the feasibility of the treatment with autologous bone marrow-derived endothelial progenitor cells (EPC) in decompensated liver cirrhosis. In addition, the changes in liver function and hepatic venous pressure gradient (HVPG) and their relation with the characteristics of the cellular product were analyzed. Twelve patients with Child-Pugh ≥8 liver cirrhosis underwent bone marrow harvest for ex vivo differentiation of EPC. The final product was administered through the hepatic artery in a single administration. Patients underwent clinical and radiologic follow-up for 12 months. The phenotype and the ability to produce cytokines and growth factors of the final cellular suspension were analyzed. Eleven patients were treated (feasibility 91%). No treatment-related severe adverse events were observed as consequence of any study procedure or treatment. Model for end-stage liver disease score improved significantly (P 0.042) in the first 90 days after cells administration and 5 of the 9 patients alive at 90 days showed a decreased of HVPG. There was a direct correlation between the expression of acetylated-low density lipoprotein and von Willebrand factor in the cellular product and the improvement in liver function and HVPG. The treatment with EPCs in patients with decompensated liver cirrhosis is safe and feasible and might have therapeutic potential. Patients receiving a higher amount of functionally active EPC showed an improvement of liver function and portal hypertension suggesting that the potential usefulness of these cells for the treatment of liver cirrhosis deserves further evaluation.
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Behnam B, Rezazadehkermani M, Ahmadzadeh S, Mokhtarzadeh A, Nematollahi-Mahani SN, Pardakhty A. Microniosomes for concurrent doxorubicin and iron oxide nanoparticles loading; preparation, characterization and cytotoxicity studies. ARTIFICIAL CELLS NANOMEDICINE AND BIOTECHNOLOGY 2017; 46:118-125. [PMID: 28375753 DOI: 10.1080/21691401.2017.1296850] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
Abstract
The current work deals with developing a suitable drug delivery system of doxorubicin (DOX) for intraperitoneal chemotherapy using niosomes through formulating non-ionic surfactants consisting of Brij™ 52, span™ 60 and Solulan™ C24. Entrapping the magnetite nanoparticles in the hydrophilic parts of niosomes was accompanied with high-efficient DOX loading by the current novel remote-loading method. Cytotoxicity of the prepared formulations was evaluated in vitro against A549 and PC-12 cell lines using the colorimetric WST-1 assay test. The obtained results revealed that, the cytotoxicity of DOX increased up to 22% especially on A549 cells by the current delivery system.
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Affiliation(s)
- Behzad Behnam
- a Pharmaceutics Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences , Kerman , Iran
| | - Mohammad Rezazadehkermani
- b Department of General Surgery, School of Medicine , Kerman University of Medical Sciences , Kerman , Iran
| | - Saeid Ahmadzadeh
- a Pharmaceutics Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences , Kerman , Iran
| | - Ahad Mokhtarzadeh
- c Research Center for Pharmaceutical Nanotechnology, Tabriz University of Medical Sciences , Tabriz , Iran.,d Department of Biotechnology , Higher Education Institute of Rab-Rashid , Tabriz , Iran
| | | | - Abbas Pardakhty
- a Pharmaceutics Research Center, Institute of Neuropharmacology, Kerman University of Medical Sciences , Kerman , Iran
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Sulfamethazine-based pH-sensitive hydrogels with potential application for transcatheter arterial chemoembolization therapy. Acta Biomater 2016; 41:253-63. [PMID: 27184404 DOI: 10.1016/j.actbio.2016.05.018] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2015] [Revised: 05/10/2016] [Accepted: 05/11/2016] [Indexed: 02/07/2023]
Abstract
UNLABELLED Transcatheter arterial chemoembolization (TACE) is the most common palliative therapy for unresectable hepatocellular carcinoma (HCC). The conventional TACE technique, which employs the Lipiodol® emulsion, has been widely used for human cancer treatments. However, this delivery system seems to be inconsistent and unstable in maintaining a high concentration of drugs at tumor sites. An alternative approach for TACE is loading drugs into a liquid embolic solution that exists as an injectable solution and can exhibit a sol-to-gel phase transition to form a solidified state once delivered to the tumor site. Here, we develop a novel sulfamethazine-based anionic pH-sensitive block copolymer with potential application as a radiopaque embolic material. The copolymer, named PCL-PEG-SM, and comprised of poly(ε-caprolactone), sulfamethazine, and poly(ethylene glycol), was fabricated by free radical polymerization. An aqueous solution of the developed copolymer underwent a sol-to-gel phase transition upon lowering the environmental pH to create a gel region that covered the physiological condition (pH 7.4, 37°C) and the low pH conditions at tumor sites (pH 6.5-7.0, 37°C). The release of doxorubicin (DOX) from DOX-loaded copolymer hydrogels could be sustained for more than 4weeks in vitro, and the released DOX retained its fully bioactivity via inhibition the proliferation of hepatic cancer cells. The radiopaque embolic formulations that were prepared by mixing copolymer solutions at pH 8.0 with Lipiodol®, a long-lasting X-ray contrast agent, could exhibit the gelation inside the tumor after intratumoral injection or intraarterial administration using a VX2 carcinoma hepatic tumor rabbit model. These results suggest that a novel anionic pH-sensitive copolymer has been developed with a potential application as a liquid radiopaque embolic solution for TACE of HCC. STATE OF SIGNIFICANCE Transcatheter arterial chemoembolization (TACE) has been widely used as a palliative treatment therapy for unresectable hepatocellular carcinoma (HCC). Conventional TACE technique, which usually employs emulsion of DOX-in-Lipiodol®, followed by an embolic agent, has significant limitation of inconsistency and lack of controlled release ability. To address these limitations of conventional TACE material system, we introduced a novel liquid radiopaque embolic material from our pH-sensitive hydrogel. The material has low viscosity that can be injected via a microcatheter, rather biocompatibility, and drug controlled release ability. Importantly, it can form gel in the tumor as well as tumoral vasculature in response to the lowered pH at the tumor site, which proved the potential for the use to treat HCC by TACE therapy.
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Abstract
Primary liver cancer, mostly hepatocellular carcinoma, remains a difficult-to-treat cancer. Incidence of liver cancer varies geographically and parallels with the geographic prevalence of viral hepatitis. A number of staging systems have been developed, reflecting the heterogeneity of primary liver cancer, regional preferences, and regional variations in resectability or transplant eligibility. Multimodality treatments are available for this heterogeneous malignancy, and there are variations in the management recommendations for liver cancers across specialties and geographic regions. Novel treatment strategies have merged with the advance of new treatment modalities. This work focuses on reviewing the incidence, staging, and treatment of liver cancer.
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Affiliation(s)
- Chun-Yu Liu
- Department of Medicine, Division of Hematology and Oncology, Taipei Veterans General Hospital, Taipei 112, Taiwan School of Medicine, National Yang-Ming University, Taipei 112, Taiwan Institute of Biopharmaceutical Sciences, National Yang-Ming University, Taipei 112, Taiwan
| | - Kuen-Feng Chen
- Department of Medical Research, National Taiwan University College of Medicine, Taipei 112, Taiwan National Center of Excellence for Clinical Trial and Research, National Taiwan University College of Medicine, Taipei 112, Taiwan
| | - Pei-Jer Chen
- Department of Medical Research, National Taiwan University College of Medicine, Taipei 112, Taiwan National Center of Excellence for Clinical Trial and Research, National Taiwan University College of Medicine, Taipei 112, Taiwan Graduate Institute of Molecular Medicine, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei 112, Taiwan
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Kim KM. Nonsurgical multidisciplinary approach for recurrent hepatocellular carcinoma after surgical resection. Hepat Oncol 2015; 2:29-38. [PMID: 30190985 DOI: 10.2217/hep.14.31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
Abstract
Hepatocellular carcinoma (HCC) is characterized by frequent recurrence, even after curative resection and local ablation, and this represents a major challenge for HCC treatment. Although several treatment guidelines have been reported, they detail initial treatment choices and there are no established guidelines for recurrent HCC. The current treatment options for recurrent HCC do not differ from the primary treatments, but the unique characteristics of HCC recurrence should be considered when choosing treatments and each treatment should be individualized to different clinical situations. Furthermore, combinations of various treatments have been recently attempted. This review summarizes the current evidence for nonsurgical treatments of recurrent HCC after resection and suggests a multidisciplinary approach to improving the prognosis of recurrent HCC.
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Cappelli A, Pettinato C, Golfieri R. Transarterial radioembolization using yttrium-90 microspheres in the treatment of hepatocellular carcinoma: a review on clinical utility and developments. J Hepatocell Carcinoma 2014; 1:163-82. [PMID: 27508185 PMCID: PMC4918277 DOI: 10.2147/jhc.s50472] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022] Open
Abstract
A selective intra-arterial liver injection using yttrium-90-loaded microspheres as sources for internal radiation therapy is a form of transarterial radioembolization (TARE). Current data from the literature suggest that TARE is effective in hepatocellular carcinoma (HCC) and is associated with a low rate of adverse events; however, they are all based on retrospective series or non-controlled prospective studies, since randomized controlled trials comparing the other liver-directed therapies for intermediate and locally advanced stages HCC are still ongoing. The available data show that TARE provides similar or even better survival rates. TARE is very well tolerated and has a low rate of complications; these complications do not result from the embolic effects but mainly from the unintended irradiation to non-target tissue, including the liver parenchyma. The complications can be further reduced by accurate patient selection and a strict pre-treatment evaluation, including dosimetry and assessment of the vascular anatomy. First-line TARE is best indicated for intermediate-stage patients (according to the Barcelona Clinic Liver Cancer [BCLC] staging classification) who are poor candidates for transarterial chemoembolization or patients having locally advanced disease with segmental or lobar branch portal vein thrombosis. Moreover, data are emerging regarding the use of TARE in patients classified slightly above the criteria for liver transplantation with the purpose of downstaging them. TARE can also be applied as a second-line treatment in patients progressing to transarterial chemoembolization or sorafenib; a large number of Phase II/III trials are in progress in order to evaluate the best association with systemic therapies. Given the complexity of a correct treatment algorithm for potential TARE candidates and the need for clinical guidance, a comprehensive review was carried out analyzing both the best selection criteria of patients who really benefit from TARE and the new advances of this therapy which add significant value to the therapeutic weaponry against HCC.
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Affiliation(s)
| | - Cinzia Pettinato
- Medical Physics Unit, Department of Medical and Surgical Sciences, Alma Mater Studiorum - University of Bologna, S Orsola-Malpighi Hospital, Bologna, Italy
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Terzi E, Terenzi L, Venerandi L, Croci L, Renzulli M, Mosconi C, Allegretti G, Granito A, Golfieri R, Bolondi L, Piscaglia F. The ART score is not effective to select patients for transarterial chemoembolization retreatment in an Italian series. Dig Dis 2014; 32:711-6. [PMID: 25376288 DOI: 10.1159/000368007] [Citation(s) in RCA: 43] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
BACKGROUND The ART score (a point score for the assessment of retreatment with transarterial chemoembolization, TACE) has been recently developed in Austria to differentiate patients who may benefit from multiple sessions of TACE for hepatocellular carcinoma (HCC) treatment. The primary aim of the study was to test the validity of the ART score in an Italian study cohort. The secondary aims were to evaluate overall survival (OS) and clinical determinants of improved survival in patients treated with multiple TACE sessions. METHODS The ART score and the clinical outcome of 51 consecutive patients with HCC submitted to multiple TACE sessions from April 2002 to December 2009 were retrospectively analyzed. RESULTS Median OS was 26.0 months (95% confidence interval 18.4-33.6) with 1-, 3- and 5-year survival rates of 75, 33 and 11%, respectively). Thirty-three patients had an ART score of 0-1.5 and in 18 it was ≥2.5, but in our patient series, the ART score was not found to be a predictor of survival (p = 0.173). At univariate analysis, tumor extent (uni- vs. bilobar: 34.0 vs. 9.0 months; p < 0.001), Child-Pugh score before the second TACE (A vs. B7 vs. B8-9: 26.0 vs. 16.0 vs. 5.0 months; p = 0.005) and Child-Pugh score increase between the first and second TACE (absent vs. + 1 point vs. + ≥2 points: 27.0 vs. 4.0 vs. 5.0 months; p < 0.001) were statistically related with survival. At multivariate analysis, only Child-Pugh score increase remained a significant predictor of worse survival (p = 0.001, hazard rate = 11.6). CONCLUSIONS The ART score was not found to work as an objective tool to guide TACE retreatment in our Italian patient series, only the Child-Pugh score increase was an independent predictor of a shorter survival.
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Affiliation(s)
- Eleonora Terzi
- Division of Internal Medicine, Department of Digestive Diseases and Internal Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Abstract
Over the last decade, transarterial therapies have gained worldwide acceptance as standard of care for inoperable primary liver cancer. Survival times after transarterial chemoembolization (TACE) continue to improve as the technique and selection criteria are refined. Transarterial treatments, frequently provided in an outpatient setting, are now safely and effectively being applied to patients with even advanced malignancy or partially decompensated cirrhosis. In the coming years, newer transarterial therapies such as radiation segmentectomy, boosted-transarterial radioembolzation, combined TACE-ablation, TACE-portal vein embolization, and transarterial infusion of cancer-specific metabolic inhibitors promise to continue improving survival and quality of life.
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Terzi E, Piscaglia F, Forlani L, Mosconi C, Renzulli M, Bolondi L, Golfieri R. TACE performed in patients with a single nodule of hepatocellular carcinoma. BMC Cancer 2014; 14:601. [PMID: 25139639 PMCID: PMC4155116 DOI: 10.1186/1471-2407-14-601] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2013] [Accepted: 08/06/2014] [Indexed: 02/07/2023] Open
Abstract
Background Patients with single hepatocellular carcinoma (HCC) usually undergo transarterial chemoembolization (TACE) if they are not candidates for curative surgical or ablative therapy. The primary aim of the study was to assess the overall survival and clinical determinants of survival in patients with single HCC who underwent TACE. The secondary aims were tumor response, local and distant recurrence rates, time to recurrence and the impact of TACE on liver function. Methods The outcomes of 148 consecutive patients with single HCC who underwent TACE from January 2004 to December 2009 were retrospectively analyzed. Results Complete response (CR) was observed in 95/148 (64%) patients and a partial response (PR) in 39 (26%) patients. The recurrence rate was 27%, 42% and 65% at 6, 12 and 24 months, respectively. The day after TACE, 56 (38%) patients had a Child-Pugh increase ≥1 and 93 (63%) had a MELD increase ≥1. Median survival was 36.0 months with 1-, 3- and 5-year survival rates of 85%, 50% and 26%, respectively. Bland portal thrombosis was not seen to have any impact at univariate survival analysis; however, a slight impairment of PS (PS-1) in small tumors had some, although minor, impact on prognosis. Factors associated with shorter survival at multivariate analysis were tumor >5 cm, absence of CR, ascites, alpha-fetoprotein (AFP) ≥14.5 ng/mL and a MELD increase ≥1. Conclusions Transarterial chemoembolization is a valid treatment option in patients with single HCC not suitable for curative treatment. Bland PVT has no major impact on survival and a slight impairment of PS attributable to cirrhosis in patients within the Milan criteria should not preclude the use of TACE.
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Affiliation(s)
| | - Fabio Piscaglia
- Division of Internal Medicine, Department of Digestive Disease and Internal Medicine, Sant'Orsola-Malpighi Hospital, University of Bologna, Via Albertoni 15, 40138 Bologna, Italy.
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Lodh S, Maher R, Guminski A. Intra-arterial infusion and chemo-embolization for melanoma liver metastases. J Surg Oncol 2014; 109:376-82. [PMID: 24500702 DOI: 10.1002/jso.23551] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2013] [Accepted: 11/16/2013] [Indexed: 12/31/2022]
Abstract
This article will review the rationale for hepatic arterial administration of agents to treat melanoma liver metastases, the techniques and practical considerations pertinent to hepatic arterial therapy, the variety of agents that have been used and the reported outcomes. Recent and emerging developments will be highlighted and the potential role of liver-directed therapies in the context of molecular advances and improved systemic therapy will be discussed.
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Affiliation(s)
- Suhrid Lodh
- Department of Radiology, Royal North Shore Hospital, St Leonards, Australia
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Mazioti A, Gatselis NK, Rountas C, Zachou K, Filippiadis DK, Tepetes K, Koukoulis GK, Fezoulidis I, Dalekos GN. Safety and efficacy of transcatheter arterial chemoemboliazation in the real-life management of unresectable hepatocellular carcinoma. HEPATITIS MONTHLY 2013; 13:e7070. [PMID: 24198841 PMCID: PMC3818929 DOI: 10.5812/hepatmon.7070] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/03/2012] [Revised: 09/19/2012] [Accepted: 11/18/2012] [Indexed: 02/06/2023]
Abstract
BACKGROUND Trans-arterial chemoembolization (TACE) is associated with better survival in BCLC-stage B patients with hepatocellular carcinoma (HCC) and Child-Pugh A whereas in Child-Pugh B there is no definite evidence of benefit. OBJECTIVES To assess the safety and efficacy of TACE during routine clinical practice in a consecutive Greek cohort of patients with unrespectable HCC. PATIENTS AND METHODS Seventy one patients enrolled for this study (mean follow-up:24.6 months). 100 mg cisplatin, 50 mg doxorubicin and 10 ml lipiodol as well as embolic materials were used. CT-scans and blood tests were obtained prior and post-TACE. Kaplan-Meier method and Cox proportional hazard model were used to evaluate survival and factors affecting survival. RESULTS Survival at 1-year, 2-years, 3-years and 5-years was 73.2%, 45.4%, 33.2% and 14.9% respectively. Procedure-related mortality was 1.4%. Multivariate analysis showed lesion diameter, Child-Pugh classification, alcohol abuse, tumor response and AFP prior TACE as independent prognostic factors of survival. Patients diagnosed during surveillance had significantly better survival rates compared to those diagnosed after development of symptoms (HR = 0.58, 95%CI: 0.33-1.01, P < 0.05). CONCLUSIONS TACE is safe and efficient for unrespectable HCC. Alcohol abuse, tumor burden, response criteria, Child-Pugh and AFP prior to the session were identified as independent predictors of survival whereas, adherence to surveillance programs resulted in significantly better survival in these patients.
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Affiliation(s)
- Argyro Mazioti
- Department of Radiology, Medical School, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Nikolaos K. Gatselis
- Department of Medicine and Research Laboratory of Internal Medicine, Medical School, University of Thessaly, Larissa, Greece
| | - Christos Rountas
- Department of Radiology, Medical School, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Kalliopi Zachou
- Department of Medicine and Research Laboratory of Internal Medicine, Medical School, University of Thessaly, Larissa, Greece
| | - Dimitrios K. Filippiadis
- Department of Radiology, Medical School, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - Kostantinos Tepetes
- Department of Surgery, Medical School, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - George K. Koukoulis
- Department of Pathology, Medical School, University of Thessaly, Larissa, Greece
| | - Ioannis Fezoulidis
- Department of Radiology, Medical School, University Hospital of Larissa, University of Thessaly, Larissa, Greece
| | - George N. Dalekos
- Department of Medicine and Research Laboratory of Internal Medicine, Medical School, University of Thessaly, Larissa, Greece
- Corresponding author: George N. Dalekos, Department of Medicine and Research Laboratory of Internal Medicine, School of Medicine, University of Thessaly, Biopolis, 41110 Larissa, Greece. Tel: +30-2413502285, Fax: +30-2413501557, E-mail:
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Hetta OM, Hetta WM, Shebrya NH, El Ghazaly HA. Radioembolization with Yttrium-90 resin microspheres in treatment of HCC with or without PVT: Initial Egyptian experience. THE EGYPTIAN JOURNAL OF RADIOLOGY AND NUCLEAR MEDICINE 2013. [DOI: 10.1016/j.ejrnm.2013.01.001] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
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Hernandez-Alcoceba R, Sangro B, Berraondo P, Gonzalez-Aseguinolaza G, Prieto J. Cytokines for the treatment of gastrointestinal cancers: clinical experience and new perspectives. Expert Opin Investig Drugs 2013; 22:827-41. [PMID: 23594171 DOI: 10.1517/13543784.2013.793307] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
INTRODUCTION Cytokines are key mediators of the immune system and have been proposed as therapeutic agents against cancer, either as recombinant proteins, or as transgenes in gene therapy approaches. Stimulation of immune responses against cancer cells is an appealing method to treat tumors with high risk of relapse and systemic dissemination. AREAS COVERED We provide a critical overview of clinical trials involving the use of cytokines for the treatment of liver, colon and pancreatic cancers. Special attention has been paid to advances in the field of gene therapy and oncolytic viruses. The potential of new developments still in a pre-clinical stage is also discussed. We have revised public sources of information (PubMed, US National Institutes of Health clinical trials database) up to January 2013. EXPERT OPINION The complexity of the immune system and the unfavorable pharmacokinetic properties of cytokines limit the efficacy of these molecules as single agents for the treatment of cancer. Expression from gene therapy vectors, together with new methods of targeting and stabilization, may overcome these hurdles. We believe cytokines will play a crucial role as part of combined approaches, enhancing the action of adoptive cell immunotherapy, oncolytic viruses or biological therapies.
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Affiliation(s)
- Ruben Hernandez-Alcoceba
- CIMA, University of Navarra, Division of Hepatology and Gene Therapy, Foundation for Applied Medical Research, Pamplona, Spain
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Terzi E, Golfieri R, Piscaglia F, Galassi M, Dazzi A, Leoni S, Giampalma E, Renzulli M, Bolondi L. Response rate and clinical outcome of HCC after first and repeated cTACE performed "on demand". J Hepatol 2012; 57:1258-67. [PMID: 22871502 DOI: 10.1016/j.jhep.2012.07.025] [Citation(s) in RCA: 111] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/26/2011] [Revised: 06/26/2012] [Accepted: 07/18/2012] [Indexed: 12/13/2022]
Abstract
BACKGROUND & AIMS Aim of the study was to assess the clinical impact of conventional transarterial chemoembolization (cTACE) repeated "on demand" on HCC outcome. Outcome measures were: response rate to first and repeated cTACE, recurrence rates and overall survival. METHODS The outcome of 151 consecutive HCC patients submitted to a first cTACE from January 2004 to December 2005 was retrospectively analyzed. RESULTS Complete radiological response (CR) was observed in 72/151 (48%), 34/60 (52%) and 12/22 (55%) patients after first, second and third cTACE, respectively. Recurrence rates at 6 and 12months were 37% and 61% after the first cTACE, and 40% and 59% after the second cTACE, respectively. Patients not achieving CR or with a recurrence after CR not treated with curative therapies were 94 and 84 after first and second cTACE, respectively. Of these, 60/94 (64%) and 22/84 (26%) were submitted to a second and third cTACE, respectively. Median overall survival was 32.0months but 25.0months excluding transplanted patients. Factors at the time of first cTACE associated with overall shorter survival at multivariate analysis were higher bilirubin, higher AFP and not achieving CR. CONCLUSIONS CR and recurrence rates after first and second cTACE were similar. About 64% of patients were submitted to second cTACE, while only few patients (26%) were submitted to third cTACE using an "on demand" policy. These figures may be also useful for planning trials for the evaluation of the efficacy of repeated TACE vs. TACE combined with adjuvant treatments or vs. systemic treatments.
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Affiliation(s)
- E Terzi
- BLOG-Bologna Liver Oncology Group, Sant'Orsola-Malpighi Hospital, University of Bologna, Bologna, Italy
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Theysohn JM, Müller S, Schlaak JF, Ertle J, Schlosser TW, Bockisch A, Lauenstein TC. Selective internal radiotherapy (SIRT) of hepatic tumors: how to deal with the cystic artery. Cardiovasc Intervent Radiol 2012; 36:1015-22. [PMID: 22983697 DOI: 10.1007/s00270-012-0474-1] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/17/2012] [Accepted: 07/29/2012] [Indexed: 01/01/2023]
Abstract
PURPOSE Selective internal radiotherapy (SIRT) with the beta emitter yttrium-90 (Y90) is a rapidly developing therapy option for unresectable liver malignancies. Nontarget irradiation of the gallbladder is a complication of SIRT. Thus, we aimed to assess different strategies to avoid infusion of Y90 into the cystic artery (CA). METHODS After hepatic digital subtraction angiography and administration of technetium-99m-labeled human serum albumin ((99)mTc-HSA), 295 patients with primary or secondary liver tumors underwent single-photon emission computed tomography/computed tomography (SPECT/CT). Different measures were taken before repeated Y90 mapping and SIRT to avoid unintended influx into the CA where necessary. Clinical symptoms, including pain, fever, or a positive Murphy sign, were assessed during patient follow-up. RESULTS A significant (99)mTc-HSA accumulation in the gallbladder wall (higher (99)mTc-HSA uptake than in normal liver tissue) was seen in 20 patients. The following measures were taken to avoid unintended influx into the CA: temporary/permanent occlusion of the CA with gelfoam (n = 5)/microcoil (n = 1), induction of vasospasm with a microwire (n = 4), or altering catheter position (n = 10). Clinical signs of cholecystitis were observed in only one patient after temporary CA occlusion with gelfoam and were successfully treated by antibiotics. Cholecystectomy was not required for any patient. CONCLUSION It is important to identify possible nontarget irradiation of the gallbladder. The risk for radiation-induced cholecystitis can be easily minimized by temporary or permanent CA embolization, vasospasm induction, or altering the catheter position.
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Affiliation(s)
- Jens M Theysohn
- Department of Diagnostic and Interventional Radiology and Neuroradiology, University Hospital Essen, Hufelandstrasse 55, 45122, Essen, Germany.
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Radioembolization for hepatocellular carcinoma. J Hepatol 2012; 56:464-73. [PMID: 21816126 DOI: 10.1016/j.jhep.2011.07.012] [Citation(s) in RCA: 219] [Impact Index Per Article: 18.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/09/2011] [Revised: 07/26/2011] [Accepted: 07/27/2011] [Indexed: 12/04/2022]
Abstract
Radioembolization is a form of brachytherapy in which intra-arterially injected (90)Y-loaded microspheres serve as sources for internal radiation purposes. It produces average disease control rates above 80% and is usually very well tolerated. Main complications do not result from the microembolic effect, even in patients with portal vein occlusion, but rather from an excessive irradiation of non-target tissues including the liver. All the evidence that support the use of radioembolization in HCC is based on retrospective series or non-controlled prospective studies. However, reliable data can be obtained from the literature, particularly since the recent publication of large series accounting for nearly 700 patients. When compared to the standard of care for the intermediate and advanced stages (transarterial embolization and sorafenib), radioembolization consistently provides similar survival rates. Two indications seem particularly appealing in the boundaries of these stages for first-line radioembolization. First, the treatment of patients straddling between the intermediate and advanced stages (intermediate patients with bulky or bilobar disease that are considered poor candidates for TACE, and advanced patients with solitary tumors invading a segmental or lobar branch of the portal vein). Second, the treatment of patients that are slightly above the criteria for resection, ablation or transplantation, for which downstaging could open the door for a radical approach. Radioembolization can also be used to treat patients progressing to TACE or sorafenib. With a number of clinical trials underway, the available evidence shows that it adds a significant value to the therapeutic weaponry against HCC of tertiary care centers dealing with this major cancer problem.
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Shouval D. Embolization of hepatocellular carcinoma with drug-eluting beads: new insight into the biologic effects of tumor ablation. J Hepatol 2011; 55:1169-70. [PMID: 21806947 DOI: 10.1016/j.jhep.2011.07.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/25/2011] [Accepted: 07/25/2011] [Indexed: 12/04/2022]
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Sangro B, Carpanese L, Cianni R, Golfieri R, Gasparini D, Ezziddin S, Paprottka PM, Fiore F, Van Buskirk M, Bilbao JI, Ettorre GM, Salvatori R, Giampalma E, Geatti O, Wilhelm K, Hoffmann RT, Izzo F, Iñarrairaegui M, Maini CL, Urigo C, Cappelli A, Vit A, Ahmadzadehfar H, Jakobs TF, Lastoria S. Survival after yttrium-90 resin microsphere radioembolization of hepatocellular carcinoma across Barcelona clinic liver cancer stages: a European evaluation. Hepatology 2011; 54:868-78. [PMID: 21618574 DOI: 10.1002/hep.24451] [Citation(s) in RCA: 480] [Impact Index Per Article: 36.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2011] [Accepted: 05/12/2011] [Indexed: 12/07/2022]
Abstract
UNLABELLED A multicenter analysis was conducted to evaluate the main prognostic factors driving survival after radioembolization using yttrium-90-labeled resin microspheres in patients with hepatocellular carcinoma at eight European centers. In total, 325 patients received a median activity of 1.6 GBq between September 2003 and December 2009, predominantly as whole-liver (45.2%) or right-lobe (38.5%) infusions. Typically, patients were Child-Pugh class A (82.5%), had underlying cirrhosis (78.5%), and had good Eastern Cooperative Oncology Group (ECOG) performance status (ECOG 0-1; 87.7%), but many had multinodular disease (75.9%) invading both lobes (53.1%) and/or portal vein occlusion (13.5% branch; 9.8% main). Over half had advanced Barcelona Clinic Liver Cancer (BCLC) staging (BCLC C, 56.3%) and one-quarter had intermediate staging (BCLC B, 26.8%). The median overall survival was 12.8 months (95% confidence interval, 10.9-15.7), which varied significantly by disease stage (BCLC A, 24.4 months [95% CI, 18.6-38.1 months]; BCLC B, 16.9 months [95% CI, 12.8-22.8 months]; BCLC C, 10.0 months [95% CI, 7.7-10.9 months]). Consistent with this finding , survival varied significantly by ECOG status, hepatic function (Child-Pugh class, ascites, and baseline total bilirubin), tumor burden (number of nodules, alpha-fetoprotein), and presence of extrahepatic disease. When considered within the framework of BCLC staging, variables reflecting tumor burden and liver function provided additional prognostic information. The most significant independent prognostic factors for survival upon multivariate analysis were ECOG status, tumor burden (nodules >5), international normalized ratio >1.2, and extrahepatic disease. Common adverse events were: fatigue, nausea/vomiting, and abdominal pain. Grade 3 or higher increases in bilirubin were reported in 5.8% of patients. All-cause mortality was 0.6% and 6.8% at 30 and 90 days, respectively. CONCLUSION This analysis provides robust evidence of the survival achieved with radioembolization, including those with advanced disease and few treatment options.
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Affiliation(s)
- Bruno Sangro
- Liver Unit, Clinica Universidad de Navarra and Centro de Investigacion Biomedica en Red de Enfermedades Hepaticas y Digestivas (CIBEREHD), Pamplona, Spain.
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