Clinical impact of selective transarterial chemoembolization on hepatocellular carcinoma: A cohort study

Can DKI-MRI predict recurrence and invasion of peritumoral zone of hepatocellular carcinoma after transcatheter arterial chemoembolization?

BACKGROUND

Hepatocellular carcinoma (HCC) is a major cause of cancer-related mortality worldwide. Transcatheter arterial chemoembolization (TACE) has been performed as a palliative treatment for patients with HCC. However, HCC is easy to recur after TACE. Magnetic resonance imaging (MRI) has clinical potential in evaluating the TACE treatment effect for patients with liver cancer. However, traditional MRI has some limitations.

AIM

To explore the clinical potential of diffusion kurtosis imaging (DKI) in predicting recurrence and cellular invasion of the peritumoral liver zone of HCC after TACE.

METHODS

Seventy-six patients with 82 HCC nodules were recruited in this study and underwent DKI after TACE. According to pathological examinations or the overall modified response evaluation criteria in solid tumors (mRECIST) criterion, 48 and 34 nodules were divided into true progression and pseudo-progression groups, respectively. The TACE-treated area, peritumoral liver zone, and far-tumoral zone were evaluated on DKI-derived metric maps. Non-parametric U test and receiver operating characteristic curve (ROC) analysis were used to evaluate the prediction performance of each DKI metric between the two groups. The independent t-test was used to compare each DKI metric between the peritumoral and far-tumoral zones of the true progression group.

RESULTS

DKI metrics, including mean diffusivity (MD), axial diffusivity (DA), radial diffusivity (DR), axial kurtosis (KA), and anisotropy fraction of kurtosis (Fak), showed statistically different values between the true progression and pseudo-progression groups (P < 0.05). Among these, MD, DA, and DR values were higher in pseudo-progression lesions than in true progression lesions, whereas KA and FAk values were higher in true progression lesions than in pseudo-progression lesions. Moreover, for the true progression group, the peritumoral zone showed significantly different DA, DR, KA, and FAk values from the far-tumoral zone. Furthermore, MD values of the liver parenchyma (peritumoral and far-tumoral zones) were significantly lower in the true progression group than in the pseudo-progression group (P < 0.05).

CONCLUSION

DKI has been demonstrated with robust performance in predicting the therapeutic response of HCC to TACE. Moreover, DKI might reveal cellular invasion of the peritumoral zone by molecular diffusion-restricted change.

Effects of Interventional Therapy on Liver Metastases-Measurement of Liver Volume by Abdominal Computed Tomography

Purpose: To evaluate the effects of transhepatic arterial infusion (TAI) with transcatheter arterial embolization (TAE) on liver volume of patients with liver metastases, by liver volumetry using 256-slice CT (iCT 256, Philips Healthcare). Methods: A retrospective analysis of 19 patients with liver metastases, who received combination treatment of TAI with TAE, were conducted. Residual liver volumes (LV) were measured before (LV0), after the first (LV1) and the second treatment (LV2) with iCT 256. Bland-Altman method was used to evaluate the agreements of residual liver volume between two reviewers. Residual liver volume changes were compared by One-Way ANOVA. Results: For the first reviewer, LV0, LV1, LV2 were: 872.67±139.31, 960.63±143.91, 842.13±141.45 cc. LV1 > LV0, but the difference was not significant (P = 0.061). LV2 < LV0, the difference was statistically significant (P = 0.013). LV2 < LV0, and the difference was not statistically significant (P = 0.509). For the second reviewer, LV0, LV1, LV2 were: 909.99±135.46, 996.36±180.10, 845.70±131.632 cc. LV1 > LV0, the difference was not statistically significant (P = 0.083). LV2 < LV1, the difference was statistically significant (P = 0.003). LV2 < LV0, the difference was not statistically significant (P = 0.194). Conclusion: Combination treatment of TAI with TAE did not induce significant liver damage in patients with metastatic liver cancer, and iCT256 volumetry provided a precise measurement of liver volume and may play a critical role in the development of interventional surgery.

Locoregional Therapies in the Treatment of 3- to 5-cm Hepatocellular Carcinoma: Critical Review of the Literature

OBJECTIVE. Treatment options for hepatocellular carcinoma (HCC) continue to expand. However, given the complexity of the patients including factors such as codominant cirrhosis or portal hypertension and transplant status, it can be difficult to know which treatment is most advantageous. The choice of HCC treatment is perhaps most complex in the setting of HCCs that are 3-5 cm. This article reviews the evidence for locoregional therapies in treating 3- to 5-cm HCCs. CONCLUSION. Combination therapy with transarterial chemoembolization (TACE) and ablation has the most robust and highest level of evidence to support its efficacy and therefore should be considered first-line therapy for nonresectable HCCs that measure 3-5 cm. The studies support that TACE followed by ablation is superior to either TACE alone or ablation alone. Data for transarterial radioembolization (TARE) to treat HCCs in this specific size range are very limited. Additional data are needed about the comparative effectiveness of TACE-ablation combination and TARE and how the TACE-ablation combination compares with surgical resection.

Diffusion Kurtosis Imaging for Assessing the Therapeutic Response of Transcatheter Arterial Chemoembolization in Hepatocellular Carcinoma

Objective: This study aimed to evaluate the therapeutic response of hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE) with diffusion kurtosis imaging (DKI).

Methods: Forty-three patients with fifty-nine hepatic cancer nodules were recruited for this study. All patients were treated by TACE. Magnetic resonance imaging (MRI) and DKI (b=0, 800, 1,500, 2,000mm²/s) were performed before and one month after initiating TACE. Patients were classified as either progressing groups or non-progressing groups. Mean kurtosis (MK), mean diffusion (MD), and apparent diffusion coefficient (ADC) values of the tumor tissue were analyzed.

Results: Twenty-three HCCs were classified as progressing groups, and thirty-six HCCs were non-progressing groups. After TACE, the values of MD and ADC in non-progressing groups (1.92±0.36×10^-3mm²/s, 1.36±0.23×10^-3mm²/s) were greater than progressing groups (1.44±0.32× 10^-3mm²/s, 1.10±0.23×10^-3mm²/s), however, the MK values in non-progressing groups (0.47±0.12) were lower than progressing groups (0.72±0.14). The MK values of tumor among non-progressing patients decreased one month after TACE (0.47±0.12) relative to the preoperative values (0.71±0.12) (P<0.05). In the non-progressing groups, the MD and ADC values of tumor after TACE (1.92±0.36×10^-3mm²/s, 1.36±0.23×10^-3mm²/s) became higher than their preoperative values (1.44±0.35×10^-3mm²/s, 1.09±0.22×10^-3mm²/s) (P<0.05). In the progressing groups, the MK, MD, and ADC values of tumor after TACE remained similar before TACE (P>0.05). The sensitivity, specificity, and AUC of the ROC curve for the assessment of HCC progress after TACE by MK (85.2%, 97.5%, and 0.95, respectively) were greater than by ADC (78.6%, 66.5%, and 0.75, respectively) and MD (76.2%, 64.3%, and 0.71, respectively).

Conclusions: DKI for assessing the therapeutic response of TACE in HCC shows great promise. MK is more advantageous in the assessment of HCC progress after TACE.

Balloon-Occluded Trans-Arterial Chemo-Embolization Technique with Repeated Alternate Infusion of Cisplatin Solution and Sparse Gelatin Slurry (RAIB-TACE) for Large Hepatocellular Carcinoma Nodules More than 7 cm in Diameter

Objective

It is sometimes difficult to obtain complete/partial response of large hepatocellular carcinoma (HCC) nodules by trans-arterial chemoembolization/embolization (TACE/TAE). The aim is retrospective investigation of tumor response of large HCC nodules (>7 cm) treated by the new TACE technique, repeated alternate infusion of cisplatin solution, and sparse gelatin slurry under balloon occlusion (RAIB-TACE). Materials and Methods. A microballoon catheter was placed at a proximal portion of the hepatic artery (subsegmental to the lobar level hepatic artery), and alternate infusion of cisplatin solution and sparse gelatin slurry were repeated under balloon occlusion until stasis of gelatin slurry beyond the catheter was seen. RAIB-TACE of multiple proximal hepatic and extrahepatic collateral arteries were performed to treat hemi-lobe or more of the liver while avoiding infusion into gastric and cystic arteries for 19 large nodules (>7 cm) in 19 patients without portal venous invasion. All patients underwent dynamic CT/MRI 1-3 months after RAIB-TACE, and tumor response of each large nodule was evaluated based on modified RECIST criteria.

Results

CR, PR, SD, and PD were achieved in 11, 8, 0, and 0 nodules, respectively. CR and PR were considered as success, and the ratio of success was 100%. Major complications were abscess formation in the necrotic nodule (n = 1) which was treated by drainage tube placement, and subsegmental level liver infarction (n = 1) which was treated by drainage tube placement, and subsegmental level liver infarction (.

Conclusion

New TACE technique, RAIB-TACE, was useful to achieve successful response of large HCC nodules.

Spectral CT in evaluating the therapeutic effect of transarterial chemoembolization for hepatocellular carcinoma: A retrospective study

This study aimed to investigate the value of computed tomographic (CT) spectral imaging in evaluating the effect of transarterial chemoembolization (TACE).The records of 67 patients with hepatocellular carcinoma (HCC) who had undergone dynamic spectral CT before treatment were selected for the study. Iodine concentrations pretreatment in liver parenchyma, the HCC lesion(s), portal vein, and aorta were measured from the decomposition images. The normalized iodine concentrations (NIC) were calculated. All of them underwent plain scan or contrast-enhanced CT post-treatment (approximately 4-6 weeks after TACE).The values of arterial phase normalized iodine concentrations (AP NIC) before TACE correlated with the grades of lipiodol deposition in tumors (r = 0.76, P < .001). However, there was no relationship between normalized iodine concentrations in the portal venous phase (PVP NIC) before TACE and the grade of lipiodol deposition (r = 0.17, P = .17). Values of AP NIC in residual tumors pre-TACE were significantly lower than those in partial lesions with deposition of iodized oil. The threshold AP NIC of 0.18 yielded an AUC of 0.895, 83.33% sensitivity, 81.03% specificity, 83.33% positive predictive value (PPV), and 82.76% negative predictive value, respectively. The survival probability in patients with AP NIC values pre-TACE ≥ 0.18 was higher than those whose AP NIC values pre-TACE were < 0.18 (P = .028).Spectral CT with quantitative analysis of AP NIC may help to evaluate the utility and predict the therapeutic effect of TACE. Values of AP NIC had high sensitivity and specificity for differentiating partial tumors with lipiodol deposition from those without lipiodol deposition.

Therapeutic efficacy of novel microwave-sensitized mPEG-PLGA@ZrO2@(DOX + ILS) drug-loaded microspheres in rabbit VX2 liver tumours

The use of nanomaterials as drug delivery systems shows good effects in treating tumors. However, the effective dose of drugs targeted to tumor tissues is very low because of the effect of the reticuloendothelial system (RES) in removing such foreign substances. In order to eliminate the RES effect, we developed mPEG-PLGA@ZrO₂@(DOX + ILS) (mPEG-PLGA@ZrO₂@[DOX + ILS]) drug-loaded microspheres. These microwave (MW)-sensitized microspheres directly embolized the blood-supply vessels of tumors to induce tumor ischemia and hypoxia, as well as to aggregate drugs within tumor tissues in a long-lasting manner. Additionally, combination with MW ablation can triple the effects for the inhibition of tumor growth. The MW sensitive ionic liquid (ILS) in microspheres can rapidly produce a high temperature in a MW field on the basis of MW sensitization, thus accelerating the degradation of microspheres to release DOX-loaded ZrO₂ into the lesions to kill tumors. Microspheres can also prolong the pharmacological time and effect of drugs through the enhanced permeability and retention (EPR) effect of nanocarriers, as well as the sustained release of nanomaterials. Studies performed in vivo revealed that mPEG-PLGA@ZrO₂@(DOX + ILS) showed good biosafety. We undertook sensitized microsphere embolism therapy using novel mPEG-PLGA@ZrO₂@(DOX + ILS) microspheres in a rabbit VX₂ liver tumor model. Three, 6 and 9 d after treatment, computed tomography indicated no significant change in tumor size, and diffusion weighted imaging showed a marked decrease of residual tumor tissues. With the multiple functions of inducing embolisms, sensitization, and the sustained release of chemotherapeutics, novel mPEG-PLGA@ZrO₂@(DOX + ILS) microspheres can achieve good therapeutic efficacy, in combination with MW ablation and chemotherapy, while embolizing the blood vessels of arterial tumors.

Role of low-molecular-weight heparins in prevention of thromboembolic complication after transarterial chemoembolization in hepatocellular carcinoma

BACKGROUND AND AIM

Portal vein thrombosis (PVT) is a common complication after transarterial chemoembolization (TACE) in hepatocellular carcinoma (HCC). This is the first clinical study to evaluate the role of low-molecular-weight heparins (LMWHs) with TACE in HCC for the prevention of thromboembolism complications (PVT).

PATIENTS AND METHODS

This study was carried out on 40 patients with HCC requiring TACE who presented to the Tropical Medicine Department, Tanta University and Interventional Radiology Department of Ain-Shams University Hospitals starting from April 2015. Patients were divided in two groups: group I included 20 patients with HCC treated by TACE only. Group II included 20 patients with HCC treated by TACE and an adjuvant dose of LMWH. Radiological assessment of efficacy of procedure and detection of PVT as a complication was performed using ultrasound abdomen and pelvis and triphasic spiral computed tomography with contrast.

RESULTS

This study was carried out on 40 patients with HCC requiring TACE who presented to the Tropical Medicine Department of Tanta University and Interventional Radiology Department of Ain-Shams University Hospitals. The incidence of PVT after TACE was higher in group I than group II, with seven cases in group I and only one case in group II.

CONCLUSION

LMWH with TACE in HCC is strongly recommended for prevention of thromboembolism complications (PVT). However, larger randomized-controlled studies are needed to confirm these obvious findings.

Volume perfusion computed tomography (VPCT)-based evaluation of response to TACE using two different sized drug eluting beads in patients with nonresectable hepatocellular carcinoma: Impact on tumor and liver parenchymal vascularisation

OBJECTIVE

Response monitoring of transarterial chemoembolization (TACE) with the help of volume perfusion computed tomography (VPCT) at day one post-TACE and analysis of TACE-impact on tumor and uninvolved liver parenchymal perfusion by using different particles sizes and epirubicin dose.

MATERIALS AND METHODS

Institutional review board approved this prospective study. VPCT was performed in the baseline, post-interventional (FU1; 24 h post-TACE) and at follow-up (FU2; median, 81 days) in 45 consecutive patients. 100-300 μm (n=17) and 300-500 μm (n=28) drug eluting beads (DEB) using an epirubicin dose of (<=25 vs. >25) were administered. VPCT was performed for 40-s using 80 kV, 100/120 mAs, 64×0.6 mm collimation, 26 consecutive measurements, IV injection (50 ml iodinated contrast), flow rate (5 ml/s). Blood flow (BF), blood volume (BV) and k-trans were registered as average and max values in the tumor. Arterial liver perfusion (ALP), portal-venous perfusion (PVP) and the hepatic perfusion index (HPI) were registered both in tumor and non-involved liver parenchyma. Response to TACE was classified by VPCT as complete (CR), partial (PR) or no response (NR).

RESULTS

A significant reduction of viable tumor tissue was found in all patients between baseline and FU1 (p<0.001) being independent on particle size and epirubicin dose (p>0.05). PPV/NPV/sensitivity/specificity of post-interventional VPCT (FU1) results for prediction of the mid-term tumor course (FU2) were 100%/70%/76%/100%. There was generally a significant increase of the ALP between baseline and FU1 in the liver parenchyma coupled by a significant subsequent decrease (normalization) of ALP and HPI between FU1 and FU2.

CONCLUSION

VPCT accurately measures impact of TACE on liver tumor and hepatic parenchymal perfusion. The former proved not to be significantly dependent on particle size and epirubicin dose. There was no persistent perfusion deficit in the liver after TACE.

Predictors of hepatic decompensation after TACE for hepatocellular carcinoma

Aim

To study predictive factors for hepatic decompensation after transarterial chemoembolisation (TACE) for hepatocellular carcinoma (HCC).

Methods

Between November 2009 and August 2010, of 254 patients with HCC who presented to our multidisciplinary HCC clinic for evaluation, 102 (40%) were amenable for TACE. In this prospective study, there were 102 patients with compensated cirrhosis with HCC and Child-Pugh Class A cirrhosis who underwent TACE at the National Liver Institute, Menoufiya University, Egypt. We excluded all patients with prior locoregional therapy, systemic therapy and/or surgical intervention. At baseline and at 1 month postprocedure, laboratory criteria, tumour criteria (size, number) and Child-Pugh score were recorded. Patients were classified into group 1 (no Child-Pugh point increase after TACE) and group 2 (one or more added Child-Pugh points after TACE, defining hepatic decompensation). Univariate and multivariate analyses were performed to identify factors predictive of hepatic decompensation.

Results

Patients were mostly males (82.4%) of mean age 58.4±8.1 years. The only significant changes in laboratory findings at 1 month after TACE were increased international normalised ratio, serum total bilirubin, alanine transaminase and aspartate transaminase and decreased serum albumin and α-fetoprotein (AFP). The statistically significant predictive factors for hepatic decompensation using univariate analysis were found to be baseline lower serum albumin, higher serum α-fetoprotein, more advanced Barcelona Clinic Liver Cancer (BCLC) stage, larger tumour size and a greater number of tumour nodules; with logistic regression, multivariate analysis found that at baseline larger tumour size (p=0.004 at 95% CI), higher serum AFP (p=0.046 at 95% CI) and lower serum albumin (p=0.033 at 95% CI) predicted decompensation; BCLC stage, number of tumour nodules and pre-TACE bilirubin did not predict changes in liver function.

Conclusions

Lower serum albumin and increased tumour burden (larger tumour size/more nodules and higher α-fetoprotein) at baseline may help predict post-TACE decompensation.

Untreated hepatocellular carcinoma in Egypt: outcome and prognostic factors

Background

Hepatocellular carcinoma (HCC) is a common cancer worldwide as well as in Egypt with hepatitis C and B, alcohol and aflatoxins being the commonest risk factors.

Aim

The objective of this study was to assess the prognostic factors affecting overall survival (OS) of untreated HCC in Egypt.

Methods

This retrospective study was conducted at Tanta Cancer Center, Egypt where 288 HCC cases who received no specific therapy and were followed-up until death were identified. The impact of possible prognostic factors on OS was assessed using the log-rank test (univariate analyses) and Cox regression method (multivariate analysis).

Results

The median OS of untreated HCC was 2.3 months (95% confidence interval: 1.9–2.6). The 1, 3, 6, 12, 24 months OS rates were 84%, 42%, 21%, 9%, and 3%, respectively. All cases had died by 46 months. Male sex, advanced Child-Pugh class, the clinical presentation of ascites, cough, fatigue, and the presence of metastases were associated with poor survival (P<0.05 for all). In multivariate analysis; cough, presence of ascites, and Child-Pugh class were independent predictors of poor survival.

Conclusion

OS in untreated HCC in Egypt is very short. Many factors interact to produce this dismal survival.

Preoperative ultrasound features as prognostic factors for patients with hepatocellular carcinoma

PURPOSE

Ultrasound is the most common imaging tool used to scan the tumours of hepatic carcinoma patients. However, very few studies have been performed to evaluate ultrasound imaging features for predicting tumour prognosis. Therefore, the goal of the current study was to evaluate preoperative ultrasound characteristics as prognostic factors that could affect survival rate after liver resection for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

A total of 104 HCC patients who underwent resection were retrospectively reviewed with regard to their clinical data, preoperative ultrasound characteristics, and survival rate. Preoperative ultrasound parameters included cirrhosis, tumour site, size, echo pattern, portal vein thrombosis, intra-tumour blood flow signal, peak systolic velocity (V max), and resistance index (RI). The Kaplan-Meier method was used to calculate survival. Pre-resection prognostic factors were assessed using univariate log-rank test and a multivariate Cox proportional hazards model.

RESULTS

The median survival was 37 months. The 1-, 3-, and 5-year disease-free survival (DFS) rates were 78.85, 53.85, and 26.92 %, respectively, and the overall survival (OS) rates at 1, 3, and 5 years were 85.58, 69.23, and 46.15 %, respectively. On univariate analysis, shorter survival was associated with mixed echo pattern, larger tumour size, portal vein thrombus, affluent flow signal, and higher V max. Application of the Cox multivariate proportional hazards model indicated that tumour size and blood flow signal in the tumours were independent prognostic factors.

CONCLUSIONS

The overall survival for HCC patients undergoing hepatic resection can be stratified on a sonographic basis of tumour size and intra-nodular vasculature. These prognostic factors may be useful to determine appropriate treatment for HCC patients.

Predictors of repeat transarterial chemoembolization in the treatment of hepatocellular carcinoma

OBJECTIVES

Repeat transarterial chemoembolization (TACE) is a common intervention performed for hepatocellular carcinoma (HCC). The aim of this study was to identify predictors of the need for repeat TACE.

METHODS

Between 2008 and 2012, data on patient and tumour variables were collected for 262 patients treated with a first TACE procedure for HCC. The decision to perform repeat TACE procedures was made at the completion of the first TACE or after follow-up imaging demonstrated the subtotal treatment of HCC tumours.

RESULTS

Repeat TACE was performed in 67 of 262 (25.6%) patients. Necrosis of HCC, measured after the first TACE, was lower in patients who subsequently received repeat TACE (P = 0.042). On multivariable analysis, total tumour diameter of >5 cm [odds ratio (OR) 2.76, 95% confidence interval (CI) 1.45-5.25; P = 0.002] and increasing age (OR 1.04/year, 95% CI 1.00-1.07; P = 0.030) were predictive of the need for repeat TACE. Measures of liver function and TACE approach (selective versus non-selective) were not predictive of repeat TACE. Median survival did not differ significantly between patients who did (median survival: 21.1 months) and did not (median survival: 26.1 months) receive a repeat TACE procedure (P = 0.574).

CONCLUSIONS

The requirement for repeat TACE is associated with older age, increased HCC tumour burden and subtotal TACE-induced HCC necrosis. Importantly, repeat TACE was not associated with reduced survival.

Chemoembolization outcomes for hepatocellular carcinoma in cirrhotic patients with compromised liver function

BACKGROUND

Transarterial chemoembolization (TACE) is recommended as a treatment for unresectable hepatocellular carcinoma (HCC) in patients with normal underlying liver function. The efficacy of TACE in cirrhotic patients with compromised liver function is unknown.

METHODS

All ‘first’ TACE interventions for HCC performed at a single institution from 2008 to 2012 were retrospectively reviewed (n = 190). Liver function was quantified via the Child's score. Tumour necrosis after TACE was quantified via the mRECIST criteria.

RESULTS

The 'first' TACE procedures of 100 Child's A and 90 Child's B/C cirrhotic patients were evaluated. As expected, the lab-model for end-stage liver disease (MELD) score was significantly higher in the Child's B/C group. Although the number of tumours were similar between the groups, both the size of the largest tumour and the total tumour diameter were greater in the Child's A group. There were no significant differences in post-TACE tumour necrosis between groups. The median survival after TACE was significantly longer in the Child's A compared with Child's B/C patients (21.9 versus 13.7 months, P = 0.03).

CONCLUSIONS

TACE appears to be equally efficacious in cirrhotic patients regardless of their Child's classification based upon equivalent mRECIST measures of tumour necrosis. However, inferior survival after TACE was observed in the Child's B/C group.

Transarterial chemoembolization and sorafenib in hepatocellular carcinoma

Transarterial chemoembolization (TACE) is considered as the standard therapy for patients with intermediate-stage hepatocellular carcinoma. However, given the high heterogeneity of this population, no common strategy or protocol standardization has been defined yet. In the last few years TACE treatment has been combined with sorafenib systemic therapy, reporting overall positive results both in terms of safety and efficacy. This systematic review presents and critically discusses the evidence available on the use of TACE in combination (concomitant or sequential) with sorafenib, focusing also on clinical trials currently ongoing to better define an optimal therapeutic strategy for this group of patients.

Re-evaluating transarterial chemoembolization for the treatment of hepatocellular carcinoma: Consensus recommendations and review by an International Expert Panel

Patients with unresectable hepatocellular carcinoma (HCC) usually receive transarterial chemoembolization (TACE) or systemic therapies with intermediate and advanced-stage disease. However, intermediate-stage HCC patients often have unsatisfactory clinical outcomes with repeated TACE and there is considerable uncertainty surrounding the criteria for repeating or stopping TACE treatment. In July 2012, an Expert Panel Opinion on Interventions in Hepatocellular Carcinoma (EPOIHCC) was re-convened in Shanghai in an attempt to provide a consensus on the practice of TACE, particularly in regard to evaluating TACE 'failure'. To that end, current clinical practice throughout Asia was reviewed in detail including safety and efficacy data on TACE alone as well as in combination with targeted systemic therapies for intermediate HCC. This review summarizes the evidence discussed at the meeting and provides expert recommendations regarding the use of TACE for unresectable intermediate-stage HCC. A key consensus of the Expert Panel was that the current definitions of TACE failure are not useful in differentiating between situations where TACE is no longer effective in controlling disease locally vs. systemically. By redefining these concepts, it may be possible to provide a clearer indication of when TACE should be repeated and more importantly, when TACE should be discontinued.

Transarterial chemoembolization for the treatment of hepatocellular carcinoma: a single center experience including 221 patients

BACKGROUND

Hepatocelluar carcinoma (HCC) is a major health problem in Egypt as well as in many countries. Transarterial chemoemoblization (TACE) is a treatment modality applicable to locally advanced HCC beyond surgery or ablative therapies and is associated with survival improvements. The aim of this study was to assess the outcomes of TACE in our center over the past four years.

METHODS

This is a retrospective cohort study that included 221 patients with locally advanced HCC treated with TACE in a single center between the years 2007 and 2010. The median age was 57 years with male predominance. Liver cirrhosis, viral hepatitis and Bilharziasis were encountered in 64%, 31% and 8% of patients, respectively. Abdominal pain was the most common presenting symptom (67%). Most cases were diagnosed based on radiology (57%) with a TNM stage I or II (73%) and a median AFP value of 150 ng/mL.

RESULTS

221 patients received 440 cycles of TACE with a median of 2 cycles per patient. Cisplatin and doxorubicin (50mg per cycle, each) were the most commonly used drugs. Impaired liver function was the most common toxicity. Liver cell failure occurred in 17% of patients. An objective tumor response was achieved in 44% of cases. The median overall survival (OS) was 16 months (95% CI, 13-19 months) and the median progression free survival (PFS) was 6 months (95% CI, 4.3-7.8 months). Responding patients, Child-Pugh class A and patients receiving standard doses of chemotherapy had a significantly better OS than their counterparts. Only Child-Pugh class A was associated with significantly longer PFS (p < 0.001).

CONCLUSION

TACE produces reasonable responses and fair survival rates in locally advanced HCC but with noticeable toxicities. Proper patients' selection and prompt liver support are mandates for improving TACE outcomes.

Hepatocellular carcinoma responding to superselective transarterial chemoembolization: an issue of nodule dimension?

PURPOSE

To evaluate the per-nodule efficacy of superselective transarterial chemoembolization of hepatocellular carcinomas (HCCs).

MATERIALS AND METHODS

From 2006-2009, 271 cirrhotic patients with 635 nodules underwent a first superselective transarterial chemoembolization, repeated "on demand" after local recurrences (LR) or partial responses (PR). Complete response (CR), time to nodule progression (TTnP), and local recurrence rate (LRR), according to three size classes (≤ 2 cm, 2.1-5 cm, and>5 cm) were evaluated.

RESULTS

After the first superselective transarterial chemoembolization, the CR was 64%, sustained over time in 77%, higher in small (68%) and intermediate-size (64%) nodules than in large nodules (25%; P<.001). The LRR was 23%:20% in small, 27% in intermediate, and 67% in large HCCs (P<.05). The median TTnP of large HCCs was 4 months versus 7-9 months for small and intermediate HCCs. The second superselective transarterial chemoembolization achieved a higher CR (63% in LR, 52% in PR) than the third superselective transarterial chemoembolization (32%). Median TTnP after the second superselective transarterial chemoembolization for LR and PR (8 months and 6 months) was longer than after the third superselective transarterial chemoembolization (3.5 months). Nodules ≤ 5 cm had a CR after the first superselective transarterial chemoembolization (66%) and the second superselective transarterial chemoembolization for LR (64%) or PR (55%) higher than after the third superselective transarterial chemoembolization (40%); nodules>5 cm had a CR of 25% after the first superselective transarterial chemoembolization, LR of 50% and PR of 25%, and after the second and third superselective transarterial chemoembolizations, PR of 0%.

CONCLUSIONS

Effectiveness of superselective transarterial chemoembolization has a clear cutoff above and below 5-cm nodules, with better results in smaller nodules. In HCCs ≤ 5 cm, the efficacy of the first and second superselective transarterial chemoembolizations performed for LR was higher than the second superselective transarterial chemoembolization for PR and the third superselective transarterial chemoembolization. For HCCs>5 cm, retreatment of PR is of little value, and the third cycle is ineffective.

Ectopic blood supply of hepatocellular carcinoma as depicted by angiography with computed tomography: associations with morphological features and therapeutic history

OBJECTIVE

To investigate the associations of ectopic blood supply of hepatocellular carcinoma (HCC) with its morphological features and therapeutic history.

METHODS

Three hundred and six patients with 373 HCC lesions were enrolled in this study, and underwent biphasic contrast-enhanced scans on a 64-section MDCT. The anatomy of ectopic blood supply, morphological characteristics of HCC including the size, location and pseudocapsule, and history of transcatheter arterial chemoembolization (TACE) therapy were quantitively assessed and statistically analyzed.

RESULTS

Ectopic blood supply was found in 30.8% (115/373) lesions. The ectopic arteries were predominantly composed of inferior phrenic artery (86/115) followed by left and right gastric artery (25/115). Tumor size, location, status of pseudocapsule, and history of TACE therapy could impact the origination of ectopic arteries (all p<0.05).

CONCLUSION

The ectopic feeding arteries of HCC predominantly composed of the perihepatic arteries are associated with the morphological features of the tumor and therapeutic history.

Hepatocellular carcinoma: initial tumour response after short-term and long-interval chemoembolization with drug-eluting beads using modified RECIST

OBJECTIVE

The aim of this study was to evaluate the initial tumour response after one, respectively, two transarterial chemoembolizations (TACE) with drug-eluting (DC) beads in patients with hepatocellular carcinoma (HCC).

METHODS

A total of 26 patients with clinically approved HCC underwent one or two TACE with DC Beads within 6 weeks and were evaluated after 12 weeks by MRI or computed tomography on the basis of the modified Response Evaluation Criteria in the Solid Tumours guidelines for HCC. For improved comparability of both groups, 16 patients were matched in terms of Child-Pugh classification, Barcelona classification of liver cancer, age and sex.

RESULTS

The overall tumour response showed progressive disease in 11% and an objective response in 89% for the double TACE group compared with progressive disease in 29.5%, objective response in 34.5% and stable disease in 35% for the single TACE group. In the matched population, absolute tumour shrinkage was 61.1 ± 28.3% for the double TACE group and 14.1 ± 38.5% for the single TACE group (P<0.05).

CONCLUSION

This retrospective study shows significantly higher tumour shrinkage in patients who underwent two TACE within 6 weeks compared with patients who underwent a single intervention in terms of the initial response rate after 12 weeks. It emphasizes the use of matched populations for the evaluation of tumour response in HCC after TACE.

Hepatic arterial embolization for unresectable hepatocellular carcinomas: do technical factors affect prognosis?

PURPOSE

To evaluate retrospectively whether technical factors of hepatic arterial embolization affect the prognosis of patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Inclusion criteria of this study were the following: (1) patients received embolization as the initial treatment during 2003-2004, (2) Child A or B liver profile, (3) five or fewer HCCs with maximum diameter of 7 cm or smaller, and (4) no extrahepatic metastasis. Patient data were gathered from 43 centers. Prognostic factors were evaluated using univariate and multivariate analyses.

RESULTS

Eight hundred fifteen patients were enrolled. The 1-, 3-, 5-, and 7-year overall survival rates were 92.0 % (95 % CI 90.1-93.9), 62.9 % (95 % CI 59.3-66.6), 39.0 % (95 % CI 35.1-43.0), and 26.7 % (95 % CI 22.6-30.8) in all patients. Univariate analysis showed a Child-Pugh class-A, alpha-fetoprotein level lower than 100 ng/ml, tumor size of 3 cm or smaller, tumor number of 3 or fewer, one-lobe tumor distribution, nodular tumor type, within the Milan criteria, stage I or II, no portal venous invasion, use of iodized oil, and selective embolization were significantly better prognostic factors. In the multivariate Cox model, the benefit to survival of selective embolization remained significant (hazard ratio 0.68; 95 % CI 0.48-0.97; p = 0.033).

CONCLUSION

Selective embolization contributes to survival in patients with HCCs.

Liver, gastrointestinal, and cardiac toxicity in intermediate hepatocellular carcinoma treated with PRECISION TACE with drug-eluting beads: results from the PRECISION V randomized trial

OBJECTIVE

The purpose of our study was to evaluate hepatic, gastrointestinal, and cardiac toxicity after PRECISION transarterial chemoembolization (TACE) with drug-eluting beads (DEB) versus conventional TACE with doxorubicin in the treatment of intermediate-stage hepatocellular carcinoma (HCC).

SUBJECTS AND METHODS

Two hundred twelve patients (185 men and 27 women; mean age, 67 years) were randomized to TACE with DEB or conventional TACE. The majority of patients (67% in both groups) presented in a more advanced stage. Safety was measured by rate of adverse events (Southwest Oncology Group criteria) and changes in laboratory parameters. Cardiotoxicity was assessed with left ventricular ejection fraction (LVEF) mainly on MRI or echocardiography.

RESULTS

The mean maximum postchemoembolization alanine transaminase increase in the DEB group was 50% less than in the conventional TACE group (p < 0.001) and 41% less in respect to aspartate transaminase (p < 0.001). End-of-study values returned to approximately baseline levels but with greater variability in conventional TACE patients. Treatment-emergent adverse events in the hepatobiliary system organ class occurred in 16.1% of DEB group patients compared with 25% of conventional TACE patients. There were fewer liver toxicity events in the DEB group. There was a small but statistically significant difference in mean change from baseline in LVEF between the two groups of 4 percentage points for the conventional TACE group (95% CI, 0.71-7.3; p = 0.018).

CONCLUSION

PRECISION TACE with DEB loaded with doxorubicin offers a safe therapy option for intermediate-stage HCC, even in patients with more advanced liver disease.

Simultaneous injection of autologous mononuclear cells with TACE in HCC patients; preliminary study

BACKGROUND

The discovery of the pluripotent stem cells made the prospect of cell therapy and tissue regeneration a clinical reality, especially with the evidence of contribution of the stem cells of bone marrow origin in hepatic regeneration. Infusion of bone marrow stem cells before trans-arterial chemoembolization may help to increase liver volume and consequently increase hepatic reserve in patients with HCC, and this may improve the outcome of this procedure.

MATERIALS AND METHODS

Four Child B class patients with unresectable hepatocellular carcinoma treated by transarterial chemoembolization were injected with autologous bone marrow mononuclear layer containing stem cell in the hepatic artery feeding the contralateral lobe of the liver in the same session, follow-up of the patients was done by doing liver profile and CT liver volumetry before the surgery and 3 months later.

RESULTS

We observed that patients receiving stem cell therapy simultaneously with TACE had shown a significant improvement in biological and volumetric parameters of liver function compared to those historically reported of patients receiving TACE only who usually shows deterioration of liver parameters.

CONCLUSION

BMC infusion into the hepatic artery synchronized with TACE for patients with chronic liver disease complicated with HCC is safe, feasible, and demonstrated an improvement in both biological and radiological volumetric parameters.

Transarterial chemoembolization in very early and early-stage hepatocellular carcinoma patients excluded from curative treatment: a prospective cohort study

AIM

To assess clinical outcome of transarterial chemoembolization (TACE) in a series of patients with early-stage hepatocellular carcinoma (HCC), within Milan criteria, but clinically unfit for liver transplantation (OLT).

METHODS

From January 2006 to May 2009, 67 patients (43 males, mean age 70 ± 7.6 years) with very early or early-stage unresectable HCC, within Milan selection criteria but clinically unfit for OLT, underwent TACE. The primary endpoint of the study was overall survival. Secondary endpoints were: safety, liver toxicity, 1-month tumour response according to the amended RECIST criteria, time to local and distant intrahepatic tumour recurrence and time to radiological progression.

RESULTS

Two major periprocedural complications occurred (3%), consisting of liver failure. Periprocedural mortality rate was 1.5% (1 patient). A significant increase in ALT and bilirubin levels 24h after treatment was reported, with progressive decrease at discharge. At 1-month follow-up, complete and partial tumour response rates were 67.2% and 29.8%, respectively, with two cases of progressive disease. Mean follow-up was 37.3 ± 15 months. The 1-, 2-, and 3-year overall survival rates were 90.9%, 86.1%, and 80.5%, respectively. Median expected time to local tumour recurrence and intrahepatic tumour recurrence were 7.9 and 13.8 months, respectively. Radiological disease progression was observed in 12 patients (17.9%) with a mean expected time of 26.5 months.

CONCLUSION

In patients with early-stage HCC, clinically excluded from OLT and unfit for surgery or percutaneous ablation, TACE is a safe and effective option, with favourable long-term survival.

Effect of necrosis modulator necrox-7 on hepatic ischemia-reperfusion injury in beagle dogs

OBJECTIVE

The liver is susceptible to ischemia-reperfusion (IR) injury during inflow occlusion for hepatectomy. There is no effective pharmacologic agent available to prevent the release of high-mobility-group box 1 (HMGB1) or to ameliorate IR injury. This pilot study sought to develop a model in beagle dogs for the purpose of testing the efficacy of a necrosis modulator, necrox-7, to prevent hepatic IR injury in beagle dogs.

METHODS

Six male beagle dogs were randomly assigned to the control group (group A; n = 3) or the treatment group (group B; n = 3). Under general anesthesia, group B received intravenous infusion of necrox-7 (13 mg/kg over 20 minutes) followed by 60 minutes of left hepatic inflow occlusion and 60 minutes of reperfusion. Both groups were tested for serum biochemicals, hematology values, liver biopsies, and plasma HMGB1 levels over a 48-hour period.

RESULTS

The maximum alanine transferase (ALT), aspartate transferase (AST), and lactate dehydrogenase (LDH) levels among group A versus group B were: ALT 868.3 ± 337.4 IU/L vs 274.3 ± 72.6 IU/L (P = .041); AST 1,024.7 ± 246.5 IU/L vs 505.3 ± 66.7 IU/L (P = .024); and LDH 962.7 ± 226.2 IU/L vs 552.7 ± 62.4 IU/L (P = .039). Liver biopsy demonstrated marked necrosis and inflammatory infiltrates in group A, whereas group B showed little evidence of IR injury. The plasma HMGB1 concentration was significantly lower among group B versus A.

CONCLUSION

This pilot study developed a hepatic IR injury model, demonstrating that necrox-7 reduced hepatic necrosis secondary to IR injury in a large animal setting.

Transcatheter arterial chemoembolisation for hepatocellular carcinoma in cirrhosis: survival rate and prognostic factors

BACKGROUND

The role of prognostic variables in the treatment of hepatocellular carcinoma (HCC) by transarterial chemoembolisation (TACE) is controversial.

AIMS

To evaluate the survival of patients with HCC on cirrhosis treated with TACE and to analyse the prognostic factors affecting survival.

METHODS

From 1996 to 2006, 580 consecutive patients with HCC in cirrhosis were observed. Of these 194 patients underwent TACE. The primary end-point was survival. Independent predictors of survival were identified using the Cox model.

RESULTS

The cumulative 1-year, 3-year, and 5-year survival rates were 96%, 60%, and 41%, respectively. The multivariate analysis showed significant reduction of survival among patients with serum bilirubin values >2mg/dl compared to patients with values <2mg/dl (Hazard ratio 3.84; CI 95% 1.70-8.66; p-value=0.001). Multivariate analysis performed in the group of patients treated with TACE alone showed that elevated serum bilirubin (Hazard ratio 2.96; CI 95% 1.20-7.3; p-value 0.02) and incomplete tumour response (Hazard ratio 2.88; CI 95% 1.18-7.05; p-value 0.02) are correlated with a worse outcome.

CONCLUSIONS

TACE was well tolerated and overall survival rate was 41% after 5 years. Complete tumour response and serum bilirubin <2mg/dl were identified as predictors of survival.

[Comparison of radiofrequency ablation and transarterial chemoembolization for the treatment of a single hepatocellular carcinoma smaller than 4 cm]

BACKGROUND/AIMS

Radiofrequency ablation (RFA) is an established curative therapeutic modality for unresectable hepatocellular carcinoma (HCC), and transarterial chemoembolization (TACE) has been used as a palliative treatment for inoperable HCC. It is still unknown whether RFA and TACE are equally effective for improving the survival of patients with unresectable HCC that is amenable to either treatment. The aim of this retrospective study was to compare the clinical impacts of two treatments, and analyze the prognostic factors for recurrence and survival.

METHODS

Ninety-three patients with a single HCC smaller than 4 cm who showed complete responses (complete ablation or complete lipiodol tagging) after treatment with RFA (n=43) or TACE (n=50) between January 2002 and February 2009 were investigated. Univariate and multivariate analyses were performed for 13 potential prognostic factors using the Cox proportional-hazards model.

RESULTS

The time-to-recurrence rates at 1, 2, and 3 years after treatment were 32.9%, 44.3%, and 55.4%, respectively, for the RFA group, and 42%, 68.3%, 71.7% for the TACE group. The probability of survival at 1, 2, and 3 years was 97.7%, 77.4%, and 63.1%, respectively, for the RFA group, and 95.9%, 76.1%, and 60.2% for the TACE group. The time-to-recurrence and overall survival rates did not differ significantly between the two treatment groups. A multivariate Cox proportional-hazards model revealed that a tumor size larger than 3 cm and lower serum albumin levels were independent risk factors for recurrence, and that being male, being seropositive for hepatitis B surface antigen, and having a higher serum albumin level were independent favorable prognostic factors for survival.

CONCLUSIONS

TACE and RFA exhibited similar therapeutic effects in terms of recurrence and survival for patients with a single HCC smaller than 4 cm, if they could exhibited complete responses.