Chinese expert consensus on technical recommendations for the standard operation of drug-eluting beads for transvascular embolization

Therapeutic analysis of 632 cases treated by transcatheter arterial chemoembolization combined with ablation in hepatocellular carcinoma: A retrospective study

OBJECTIVES

This study aims to analyze the efficacy of transcatheter arterial chemoembolization (TACE) combined with radiofrequency ablation (RFA), microwave ablation (MWA), and cryoablation (CA) in hepatocellular carcinoma (HCC).

METHODS

A retrospective analysis was conducted on 632 patients with HCC at Barcelona Clinic Liver Cancer Staging (BCLC) System stages 0, A, and B from Beijing You'an Hospital affiliated with Capital Medical University. The primary outcomes analyzed were overall survival (OS) and progression-free survival (PFS), while the secondary outcomes included one-, three-, and five-year OS rates among different groups.

RESULTS

The median follow-up period for 632 cases identified with HCC was 52.1 months (range: 3-162 months), while 127 patients died during follow-up. The one-, three-, and five-year OS rates were 97.1 %, 89.5 %, and 80.4 %, respectively. Moreover, the one-, three-, and five-year PFS rates were 58.1 %, 29.3 %, and 19.8 %, respectively. Multivariate analysis revealed that the BCLC stages and complete ablation were independent predictors of OS and PFS (all p < 0.05). Subgroup analysis showed no difference in OS rate among TACE-RFA, TACE-MWA, and TACE-CA groups, but TACE-CA showed better efficacy in improving the PFS rate (all p < 0.05).

CONCLUSIONS

The combination of TACE and ablation is effective in early-stage HCC and BCLC stage B. Complete ablation and BCLC stages are significant prognostic factors for PFS and OS. Further research, including randomized controlled trials, is needed to validate these findings.

Comparison of drug-eluting bead with conventional transcatheter arterial chemoembolization for hepatocellular carcinoma with portal vein tumor thrombus: a randomized clinical trial

BACKGROUND

Drug-eluting bead transarterial chemoembolization (DEB-TACE) has shown efficacy for treating hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). However, whether DEB-TACE is superior to conventional TACE (cTACE) remains unclear.

OBJECTIVE

This randomized controlled trial aimed to compare the efficacy and safety of DEB-TACE versus cTACE in treating HCC with PVTT.

METHODS

The study was conducted at a tertiary care center in Southeast China. HCC patients with PVTT were randomized at a 1:1 ratio into the DEB-TACE or cTACE groups. The primary endpoint was progression-free survival (PFS), and the secondary endpoints were overall survival (OS) and the incidence of adverse events (AEs). An independent review committee assessed the radiologic response according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST). AEs were assessed by the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. Systemic therapies were not restricted.

RESULTS

Between September 2018 and July 2020, 163 patients were randomized to undergo DEB-TACE ( n =82) or cTACE ( n =81). Nine patients were excluded, and 154 patients were included in the final analysis; the median age was 55 years (range, 24-78 years), and 140 (90.9%) were male. The median PFS in the DEB-TACE group was 6.0 months (95% CI, 5.0-10.0) versus 4.0 months (95% CI, 3.0-5.0) in the cTACE group (hazard ratio, 0.63; 95% CI, 0.42-0.95; P =0.027). The DEB-TACE group showed a higher response rate [51 (66.2%) vs. 36 (46.8%); P =0.0015] and a longer median OS [12.0 months (95% CI, 9.0-16.0) vs. 8.0 months (95% CI, 7.0-11.0), P =0.039] than the cTACE group. Multivariate analysis showed that the treatment group, ALBI score, distant metastasis and additional TKIs were the four independent prognostic factors correlated with PFS. In addition, the treatment group, PVTT group and combination with surgery were independently associated with OS. AEs were similar in the two groups, and postembolization syndrome was the most frequent AE.

CONCLUSION

DEB-TACE is superior to cTACE in treating HCC patients with PVTT, demonstrating improved PFS and OS with an acceptable safety profile, and may thus emerge as a promising treatment strategy for HCC patients with PVTT.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1800018035.

Efficacy of CalliSpheres® microspheres versus conventional transarterial chemoembolization in the treatment of refractory colorectal cancer liver metastasis

OBJECTIVE

CalliSpheres® is a microsphere that is already widely used for primary liver cancer treatment; however, its application in colorectal cancer liver metastasis (CRLM) is limited. The current study aimed to investigate the efficacy of CalliSpheres® drug-eluting bead (DEB) transarterial chemoembolization (TACE) therapy versus (vs.) conventional cTACE therapy in treating refractory CRLM (RCRLM) patients.

METHODS

Twenty-two RCRLM patients who underwent CalliSpheres® DEB-TACE therapy (n = 11) or cTACE therapy (n = 11) were retrospectively analyzed. Data on clinical response, progression-free survival (PFS) and overall survival (OS) were retrieved.

RESULTS

The objective response rate (36.4% vs. 18.2%, P = 0.338) and disease control rate (81.8% vs. 54.4%, P = 0.170) were both numerically (but not statistically) higher in the DEB-TACE group than in the cTACE group. Meanwhile, PFS was prolonged in the DEB-TACE group compared with the cTACE group [median: 12.0 (95% CI: 5.6-18.4) vs. 4.0 (95% CI: 0.9-7.1) months, P = 0.018]; OS was also longer in the DEB-TACE group compared with the cTACE group [median: 24.0 (95% CI: 18.3-29.7) vs. 14.0 (95% CI: 7.1-20.9) months, P = 0.040]. In addition, after adjustment by multivariate Cox analyses, DEB-TACE was superior to cTACE independently regarding PFS (HR: 0.110, 95% CI: 0.026-0.463, P = 0.003) and OS (HR: 0.126, 95% CI: 0.028-0.559, P = 0.006).

CONCLUSION

CalliSpheres® DEB-TACE therapy may prolong survival profile than cTACE therapy in RCRLM patients, while further validation is still needed.

Drug-eluting Microspheres Compared to Conventional Transarterial Chemoembolization as First Line Treatment for Unresectable Hepatocellular Carcinoma: A Single-center Retrospective Cost-utility Analysis

PURPOSE

To assess the cost-utility of initial treatment with drug-eluting microspheres (DEM) transarterial chemoembolization (TACE) versus conventional (C)-TACE in patients with hepatocellular carcinoma considering the perspective of a Local Healthcare Authority in Italy.

MATERIALS AND METHODS

The economic evaluation is based on a retrospective single-center study and individual patients' data whose details have been previously reported. The impact of initial treatment with DEM-TACE or C-TACE on disease progression, mortality, and direct health costs over a lifetime horizon were simulated and compared in terms of incremental cost-utility ratio expressed as costs per quality adjusted life years (QALY). Costs included direct health costs related to the first chemoembolization procedure and all subsequent follow-up costs associated with health care resources used for disease management. Probabilistic (PSA) sensitivity analysis was used to assess the robustness of the results.

RESULTS

A total of 101 patients in each treatment group were considered. All over the time-horizon median costs were €3,145.14 and €2,158.32 in the DEM-TACE and C-TACE group, respectively (p < 0.001); while mean costs were € 24,619 and € 17,001, respectively (p < 0.001). The ICUR was 6,461.86 €/QALY when using median costs derived from the study population as input for the health-economic evaluation and 49,932.15 €/QALY when the mean costs were considered. Results from PSA highlighted that using median costs DEM-TACE was always cost-effective, while using mean costs, it was preferable only 24.7% of times.

CONCLUSIONS

The higher prices of DEMs are counterbalanced by the positive impact on QALY.

Drug-eluting bead transarterial chemoembolization could improve the hepatic hemodynamics of patients with unresectable hepatocellular carcinoma: a retrospective cohort study

Background

Transarterial chemoembolization (TACE) is widely used for patients with unresectable hepatocellular carcinoma (HCC); however, previous studies have demonstrated that conventional TACE (cTACE) might affect hepatic hemodynamics, which both associate with liver cirrhosis and survival. Drug-eluting bead TACE (DEB-TACE) improves treatment efficacy and safety, but its effects on the hepatic hemodynamics of HCC patients with cirrhosis remain unknown.

Methods

This retrospective cohort study included unresectable HCC patients treated with DEB-TACE from April 2018 to September 2020, who had limited tumor burden and liver function. The hepatic hemodynamics was measured by hepatic venous pressure gradient (HVPG) using occlusion balloon catheter before and after treatment. Baseline characteristics of demography, laboratory (tumoral and liver-function) and hepatic hemodynamics were compared between patients with and without clinically significant portal hypertension (CSPH). Laboratory examination and imaging assessments were performed 4-6 weeks; overall survival (OS) was defined as the time from DEB-TACE initiation until death or last follow-up.

Results

Twenty-four eligible consecutive HCC patients were included, with a median age of 58.0 years and 54.2% in Child-Pugh A class. During a median follow-up of 9.8 months, median OS for the whole cohort of patients reached 10.0 months. Kaplan-Meier survival curves and Cox regression analyses demonstrated that age >60 years, ascites, Eastern Cooperative Oncology Group (ECOG) score of 1, Child-Pugh B class, Model for End-Stage Liver Disease (MELD) score >10, and albumin (ALB) <35 g/L were prognostic factors for decreased OS (P<0.05). Importantly, hepatic hemodynamics were significantly improved in patients after treatment with DEB-TACE (7.5 vs. 5.3 mmHg of HVPG, P<0.001), especially for those with CSPH (13.6 vs. 10.2 mmHg of HVPG, P=0.014).

Conclusions

DEB-TACE can improve hepatic hemodynamics in HCC patients, especially those with CSPH. Combing these findings with its effects on tumor, DEB-TACE might be more suitable for HCC patients with cirrhosis.

Efficacy and Safety of Drug-Eluting Bead TACE in the Treatment of Primary or Secondary Liver Cancer

Background

The drug-eluting beads transarterial chemoembolization (DEB-TACE) has already been used in hepatic malignancies. We aim to evaluate the efficacy and safety of DEB-TACE in treating primary or secondary liver cancer.

Methods

We retrospectively evaluated 59 patients with hepatic malignancies, including 41 patients with primary liver cancer and 18 patients with secondary liver cancer, between September 2016 and February 2019. All patients were treated with DEB-TACE. Objective response rate (ORR) and disease control rate (DCR) were evaluated by mRECIST. The pain was assessed using a numerical rating scale (NRS) where 0 represented no pain, and a score of ten was unbearable. Adverse reactions were assessed according to Common Terminology Criteria for Adverse Events 4.0 (CTCAE4.0).

Results

In the subgroup of primary liver cancer, 3 patients (7.32%) got complete response, 13 patients (31.71%) got partial response, 21 patients (51.22%) experienced stable disease, and 4 patients (9.76%) suffered progressive disease; ORR was 39.02% and DCR was 90.24%. In the subgroup of secondary liver cancer, 0 patients (0%) got complete response, 6 patients (33.33%) got partial response, 11 patients (61.11%) experienced stable disease, and 1 patient (5.56%) suffered progressive disease; ORR was 33.33% and DCR was 94.44%. We did not find any difference when comparing the efficacy between primary and secondary liver cancer (P=0.612). The one-year survival rate was 70.73% for primary liver cancer and 61.11% for secondary liver cancer. There was no significant difference between the two groups (P=0.52). For the patients with CR or PR, no factor could predict the efficacy of DEB-TACE. The most common treatment-related adverse reactions were short-term liver function disorders. The symptoms included fever (20.34%), abdomen pain (16.95%), and vomiting (5.08%), all patients with adverse reactions got remission after treatment.

Conclusions

DEB-TACE has a promising effect in the treatment of primary or secondary liver cancer. The treatment-related adverse reactions are tolerable.

Durable complete response is achieved by balloon-occluded transcatheter arterial chemoembolization for hepatocellular carcinoma

In 2013 and 2014, the development of microcatheters with balloons for the 4-Fr system and new embolization materials provided various options for transarterial chemoembolization (TACE), expanding the range of treatment strategies. At our hospital, balloon-occluded TACE (B-TACE), conventional TACE (C-TACE), and drug-eluting bead TACE (DEB-TACE) have been actively performed for hepatocellular carcinoma (HCC). This study compared the local recurrence-free (LRF) periods of nodules with complete necrosis (TE4) obtained using each treatment method by extracting the nodules evaluated as complete response by the modified Response Evaluation Criteria in Solid Tumors. We performed 580 TACE procedures between June 2013 and April 2019. Among them, 58 HCC nodules in 43 patients, 33 nodules in 30 patients, and 45 nodules in 25 patients were evaluated as having complete necrosis after C-TACE, DEB-TACE, and B-TACE, respectively. The time to local recurrence for each nodule was defined as the LRF period, and the quality of TE4 for each TACE was examined. Factors related to overall survival and the LRF period were determined by univariate and multivariate analyses, and overall survival and the LRF period were analyzed using the Kaplan-Meier method. Multivariate analysis of the LRF period showed that B-TACE was an independent factor. The median LRF periods were 39.3, 13, and 9.1 months for B-TACE, C-TACE, and DEB-TACE, respectively. Moreover, B-TACE had a significantly longer LRF period than C-TACE and DEB-TACE. Conclusion: There was no significant difference between C-TACE and DEB-TACE. The LRF period of nodules with TE4 was the longest with B-TACE, suggesting that B-TACE should be used to achieve a radical cure in patients with HCC.

Single medium-sized hepatocellular carcinoma treated with sequential conventional transarterial chemoembolization (cTACE) and microwave ablation at 4 weeks versus cTACE alone: a propensity score

Background

Microwave ablation (MWA) is a potentially curative treatment for unresectable patients with hepatocellular carcinoma (HCC) ≤ 3 cm, while its therapeutic efficacy decreases significantly for HCC > 3cm. Previous studies have demonstrated that conventional transarterial chemoembolization (cTACE) combined with MWA (cTACE-MWA) may improve local tumor control rate and reduce the recurrence rate for HCC > 3cm. However, there have been few study designs to analyze the clinical efficacy of cTACE-MWA for medium-sized HCC (3–5cm). Therefore, this study aims to compare the clinical efficacy and safety of cTACE-MWA with cTACE alone for a single medium-sized HCC of 3–5 cm in diameter.

Methods

We retrospectively investigate the data of 90 patients with a single medium-sized HCC who were referred to our hospital and underwent cTACE-MWA or cTACE alone from December 2017 to March 2020. Then, patients were identified with propensity score-matched (1:1). The local tumor response to treatment and time to progression (TTP) were compared using mRECIST criteria between the cTACE-MWA group and the cTACE group.

Results

A total of 42 patients were included after matching (cTACE-MWA: 21; cTACE: 21). Comparing with cTACE, cTACE-MWA demonstrate significantly better local tumor control (ORR: 95.2% vs 61.9%, p = 0.02; DCR: 95.2% vs 66.7%, p = 0.045) and TTP (median 19.8 months vs 6.8 months, p < 0.001). The 1- and 2-year cumulative probabilities of OS were 100% and 95% in the cTACE-MWA group, which were significantly higher than those in the cTACE group (95% and 76%) (p = 0.032). Multivariate Cox regression analysis illustrates that cTACE-MWA was associated with better TTP (hazard ratio, 0.28; 95% CI: 0.1, 0.76; p = 0.012), but tumor size was associated with worse TTP (hazard ratio, 1.71; 95% CI: 1.01, 2.89; p = 0.045).

Conclusions

cTACE followed by MWA improved TTP and OS in patients with a single medium-sized HCC, and no major complication was observed in this study.

Efficacy of Lipid Nanoparticle-Loaded Sorafenib Combined with Hepatic Artery Chemoembolization in the Treatment of Primary Hepatocellular Carcinoma Complicated with Microvascular Invasion

This work was to evaluate the therapeutic effect of lipid nanoparticle-loaded sorafenib combined with transcatheter artery chemoembolization (TACE) in patients with primary hepatocellular carcinoma (HC) complicated with microvascular invasion (MVI). In this work, 102 patients with primary HC combined with MVI after radical resection were divided into 4 groups according to different treatment methods. Experimental group 1 was treated with lipid nanoparticle-loaded sorafenib combined with TACE treatment group; experimental group 2 was treated with lipid nanoparticle-loaded sorafenib treatment group; experimental group 3 was TACE treatment group; control group was postoperative routine nursing group. Sorafenib lipid nanoparticles were prepared. The basic information, operation, MVI degree, tumor recurrence, and survival time of patients in each group were recorded and compared to evaluate the therapeutic effect of combined way. No great difference was found in MVI grade, average age, sex ratio, preoperative tumor markers, tumor size, number of patients with liver cirrhosis, operation time, and intraoperative bleeding among the four groups (P > 0.05). In addition, the tumor free survival time (TFST), overall survival time (OST), and postoperative 1-year and 2-year survival rates of patients in test group 1 were greatly higher than those in single mode treatment group and control group (P < 0.05). In summary, sorafenib nanoparticles combined with TACE can improve the survival status of patients after resection and delay the time of postoperative tumor recurrence.

Clinical Efficacy of Interventional Chemotherapy Embolization Combined with Monopolar Radiofrequency Ablation on Patients with Liver Cancer

Due to the greater prevalence of chronic hepatitis B infection, liver tumor is especially popular in China. In China, it is the 4th most prevalent tumor and the 3rd main reason for cancer fatalities. Hepatocellular carcinomas (HCCs) account for more than 91% of every liver tumor case, and chemotherapy and immunotherapy are the better therapy choices. It is a serious threat to the lives and health of Chinese citizens. Patients diagnosed with liver tumors have a bad prognosis. Surgical resection, liver transplantation, chemotherapeutic embolization, and radiofrequency ablation (RFA) are all choices for patients who are detected early. More effective therapies can result in a better prognosis. This paper analyzes the clinical efficiency of interventional transarterial chemoembolization (TACE) integrated with monopolar radiofrequency ablation (RFA) on patients with a liver tumor. Initially, the dataset is collected and the patients are treated with combined TACE and RFA. The computed tomography (CT) images are obtained using three-phase CT imaging. The images are segmented using adaptive U-Net-based segmentation. The clinical efficiency of the patients is evaluated using Robust Residual Convolutional Neural Network (RR-CNN) which is optimized using Firefly Particle Swarm Optimization (FPSO) algorithm. The performance of the system is analyzed using the MATLAB simulation tool. In performance analysis, the proposed method of RR-CNN is high when compared to the existing method of CNN, logistic regression using genetic algorithm and KNN in overall parameters are accuracy, sensitivity, F1-score, and specificity. These integrated treatments have a suggested greater response frequency, indicating a synergistic impact by combination treatment in the initial stages.

The role of neoadjuvant conventional transarterial chemoembolization with radiofrequency ablation in the treatment of recurrent hepatocellular carcinoma after initial hepatectomy with microvascular invasion

OBJECTIVES

Recurrent hepatocellular carcinoma (HCC) patients with microvascular invasion (MVI)-positive primary tumor is at high risk of re-recurrence while treated with radiofrequency ablation (RFA). We aimed to investigate whether neoadjuvant conventional transarterial chemoembolization (cTACE) was effective in reducing re-recurrence after RFA for recurrent HCC patients with MVI-positive primary tumors.

METHODS

In this retrospective multicenter study, 468 patients with solitary small recurrent HCC (≤3.0cm) underwent RFA alone (n = 322) or with neoadjuvant cTACE (n = 146) between June 2007 and December 2017 were included. Overall survival (OS) and recurrence-free survival (RFS) were compared.

RESULTS

The 1-, 5-year OS rates were 74.8%, 42.5% for RFA with neoadjuvant cTACE group, and 53.5%, 28.7% for RFA group (P < 0.001). The corresponding RFS rates were 51.7%, 24.4% for RFA with neoadjuvant cTACE group, and 36.1%, 9.3% for RFA group (P < 0.001). In subgroup analyses, the OS and RFS for neoadjuvant cTACE group were longer than those for RFA group no matter tumor size > 2cm (HR = 0.52, 95% CI: 0.36-0.77; HR = 0.49, 95% CI: 0.36-0.67) or not (HR = 0.53, 95% CI: 0.32-0.88; HR = 0.65, 95% CI: 0.42-0.98), or the time interval of recurrence from initial treatment ≤ 1 year (HR = 0.53, 95% CI: 0.36-0.77; HR = 0.70, 95% CI: 0.52-0.94) or not (HR = 0.56, 95% CI: 0.34-0.95; HR = 0.39, 95% CI: 0.25-0.62). Multivariable analyses showed that RFA alone (HR = 1.329, P = 0.031; HR = 1.764, P = 0.004) and interval of recurrence from initial treatment > 1 year(HR = 0.642, P = 0.001; HR = 0.298, P = 0.037) were independent prognostic factors of OS and RFS.

CONCLUSIONS

Neoadjuvant cTACE could effectively reduce re-recurrence after RFA, and improve the long-term survivals for patients with solitary small recurrent HCC whose primary tumor was MVI-positive. Key pointsFor recurrent hepatocellular carcinoma (HCC) patients whose primary tumor was positive for microvascular invasion, neoadjuvant conventional transarterial chemoembolization (cTACE) with radiofrequency ablation (RFA) achieved better efficacy.Multivariable analyses showed that the interval of recurrence from initial treatment > 1 year and RFA alone were independent prognostic factors of overall survival and recurrence-free survival, respectively.