Transarterial radioembolization for hepatocellular carcinoma: An update and perspectives

A comprehensive exploration of gallbladder health: from common to rare imaging findings

This comprehensive review explores a wide range of imaging findings associated with the gallbladder (GB), from anatomic variants to rare diseases. Through an in-depth review of diagnostic modalities including ultrasound, magnetic resonance cholangiopancreatography, CT, and MRI, we aim to highlight the crucial role of imaging techniques in diagnosing GB disorders, as congenital anomalies, inflammatory diseases, neoplasms, and surgical complications. Employing a detailed analysis and comparison of imaging findings across various modalities, this review seeks to improve diagnostic accuracy for GB-related pathologies, facilitating optimal patient management.

Bridge Therapy before Liver Transplant for Advanced Hepatocellular Carcinoma

Hepatocellular carcinoma is the most common primary liver tumor. Orthotopic liver transplant is one of the best treatment options, but its waiting list has to be considered. Bridge therapies have been introduced in order to limit this issue. The aim of this study is to evaluate if bridge therapies in advanced hepatocellular carcinoma can improve overall survival and reduce de-listing. We selected 185 articles. The search was limited to English articles involving only adult patients. These were deduplicated and articles with incomplete text or irrelevant conclusions were excluded. Sorafenib is the standard of care for advanced hepatocellular carcinoma and increases overall survival without any significant drug toxicity. However, its survival benefit is limited. The combination of transarterial chemoembolization + sorafenib, instead, delays tumor progression, although its survival benefit is still uncertain. A few studies have shown that patients undergoing transarterial chemoembolization + radiation therapy have similar or even better outcomes than those undergoing transarterial chemoembolization or sorafenib alone for rates of histopathologic complete response (89% had no residual in the explant). Also, the combined therapy of transarterial chemoembolization + radiotherapy + sorafenib was compared to the association of transarterial chemoembolization + radiotherapy and was associated with a better survival rate (24 vs. 17 months). Moreover, immunotherapy revealed new encouraging perspectives. Combination therapies showed the most encouraging results and could become the gold standard as a bridge to transplant for patients with advanced hepatocellular carcinoma.

The Use of Microspheres for Cancer Embolization Therapy: Recent Advancements and Prospective

Embolization therapy involving biomaterials has improved the therapeutic strategy for most liver cancer treatments. Developing biomaterials as embolic agents has significantly improved patients' survival rates. Various embolic agents are present in liquid agents, foam, particulates, and particles. Some of the most applied embolic agents are microparticles, such as microspheres (3D micrometer-sized spherical particles). Microspheres with added functionalities are currently being developed for effective therapeutic embolization. Their excellent properties of high surface area and capacity for being loaded with radionuclides and alternate active or therapeutic agents provide an additional advantage to overcome limitations from traditional cancer treatments. Microspheres (non-radioactive and radioactive) have been widely used and explored for localized cancer treatment. Non-radioactive microspheres exhibit improved clinical performance as drug delivery vehicles in chemotherapy due to their controlled and sustained drug release to the target site. They offer better flow properties and are beneficial for the ease of delivery via injection procedures. In addition, radioactive microspheres have also been exploited for use as an embolic platform in internal radiotherapy as an alternative to cancer treatment. This short review summarizes the progressive development of non-radioactive and radioactive embolic microspheres, emphasizing material characteristics. The use of embolic microspheres for various modalities of therapeutic arterial embolization and their impact on therapeutic performance are also discussed.

Therapeutic options in hepatocellular carcinoma: a comprehensive review

Hepatocellular carcinoma (HCC) is a chronic liver disease that is highly fatal if not detected and treated early. The incidence and death rate of HCC have been increasing in recent decades despite the measures taken for preventive screening and effective diagnostic and treatment strategies. The pathophysiology of HCC is multifactorial and highly complex owing to its molecular and immune heterogeneity, and thus the gap in knowledge still precludes making choices between viable therapeutic options and also the development of effective regimens. The treatment of HCC demands multidisciplinary approaches and primarily depends on tumor stage, hepatic functional reserve, and response to treatment by patients. Although curative treatments are limited but critical in the early stages of cancer, there are numerous palliative treatments available for patients with intermediate and advanced-stage HCC. In recent times, the use of combination therapy has succeeded over the use of monotherapy in the treatment of HCC by achieving effective tumor suppression, increasing survival rate, decreasing toxicity, and also aiding in overcoming drug resistance. This work focuses on reviewing the current and emerging treatment strategies for HCC.

Oncoviruses: How do they hijack their host and current treatment regimes

Viruses have the ability to modulate the cellular machinery of their host to ensure their survival. While humans encounter numerous viruses daily, only a select few can lead to disease progression. Some of these viruses can amplify cancer-related traits, particularly when coupled with factors like immunosuppression and co-carcinogens. The global burden of cancer development resulting from viral infections is approximately 12%, and it arises as an unfortunate consequence of persistent infections that cause chronic inflammation, genomic instability from viral genome integration, and dysregulation of tumor suppressor genes and host oncogenes involved in normal cell growth. This review provides an in-depth discussion of oncoviruses and their strategies for hijacking the host's cellular machinery to induce cancer. It delves into how viral oncogenes drive tumorigenesis by targeting key cell signaling pathways. Additionally, the review discusses current therapeutic approaches that have been approved or are undergoing clinical trials to combat malignancies induced by oncoviruses. Understanding the intricate interactions between viruses and host cells can lead to the development of more effective treatments for virus-induced cancers.

Impact of aortoceliac angle in implantation of subcutaneous hepatic artery port-catheter system for hepatic arterial infusion chemotherapy via femoral approach

BACKGROUND

In patients with an acute aortoceliac angle, the diagnostic catheter often fails to enter the common hepatic artery.

PURPOSE

To retrospectively evaluate the impact of aortoceliac angle on the implantation of a port-catheter system via a femoral approach for hepatic arterial infusion chemotherapy (HAIC) in patients with advanced hepatocellular carcinoma (HCC).

MATERIAL AND METHODS

A total of 399 patients with advanced HCC underwent percutaneous implantation of a port-catheter system for HAIC. Among these patients, 383 underwent successful implantation via a femoral artery approach (success group). In 16 patients, port-catheter systems were implanted via a subclavian artery approach (failure group) after failure of the initial attempt via the femoral artery due to failed catheter tip fixation to the gastroduodenal artery. We statistically analyzed aortoceliac angle, ostial celiac stenosis, sex, age, weight, height, and body mass index (BMI) between groups.

RESULTS

The average aortoceliac angle, weight, and BMI were significantly different between the two groups (P < 0.001, P = 0.02, P < 0.001, respectively). Among them, only the aortoceliac angle was a significant risk factor in logistic regression analysis. The smaller the aortoceliac angle, the more often the femoral approach failed (P < 0.001, odds ratio = 0.817, 95% confidence interval = 0.752-0.887). There were no significant differences in ostial celiac stenosis, sex, or age between the two groups (P = 0.549, 0.056, 0.173, and 0.773, respectively).

CONCLUSION

For patients with an acute aortoceliac angle, the femoral approach is likely to fail. A subclavian artery approach should be preferentially considered for percutaneous implantation of a port-catheter system in such patients.

Recent advances in oncolytic virus therapy for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a highly refractory cancer and the fourth leading cause of cancer-related mortality worldwide. Despite the development of a detailed treatment strategy for HCC, the survival rate remains unsatisfactory. Oncolytic virus has been extensively researched as a new cancer therapeutic agent in the treatment of HCC. Researchers have designed a variety of recombinant viruses based on natural oncolytic diseases, which can increase the targeting of oncolytic viruses to HCC and their survival in tumors, as well as kill tumor cells and inhibit the growth of HCC through a variety of mechanisms. The overall efficacy of oncolytic virus therapy is known to be influenced by anti-tumor immunity, toxic killing effect and inhibition of tumor angiogenesis, etc. Therefore, a comprehensive review of the multiple oncolytic mechanisms of oncolytic viruses in HCC has been conducted. So far, a large number of relevant clinical trials are under way or have been completed, and some encouraging results have been obtained. Studies have shown that oncolytic virus combined with other HCC therapies may be a feasible method, including local therapy, chemotherapy, molecular targeted therapy and immunotherapy. In addition, different delivery routes for oncolytic viruses have been studied so far. These studies make oncolytic virus a new and attractive drug for the treatment of HCC.

Management of Hepatocellular Carcinoma in Decompensated Cirrhotic Patients: A Comprehensive Overview

Primary liver cancer is the sixth most common cancer and the fourth leading cause of cancer-related death. Hepatocellular carcinoma (HCC) accounts for 75% of primary liver cancer cases, mostly on the basis of cirrhosis. However, the data and therapeutic options for the treatment of HCC in patients with decompensated cirrhosis are rather limited. This patient category is often considered to be in a terminal stage without the possibility of a specific treatment except liver transplantation, which is restricted by several criteria and liver donor shortages. Systemic treatments may provide a solution for patients with Child Pugh class B or C since they are less invasive. Although most of the existing trials have excluded patients with decompensated cirrhosis, there are increasing data from real-life settings that show acceptable tolerability and satisfying efficacy in terms of response. The data on the administration of locoregional treatments in such patients are also limited, but the overall survival seems to be potentially prolonged when patients are carefully selected, and close adverse event monitoring is applied. The aim of this review is to analyze the existing data regarding the administration of treatments in decompensated patients with HCC, evaluate the effect of therapy on overall survival and highlight the potential risks in terms of tolerability.

Bench-to-bedside development of multifunctional flexible embolic agents

Transarterial chemoembolization (TACE) has been demonstrated to provide a survival benefit for patients with unresectable hepatocellular carcinoma (HCC). However, conventional TACE still faces limitations associated with complications, side effects, unsatisfactory tumor responses, repeated treatment, and narrow indications. For further improvement of TACE, additional beneficial functions such as degradability, drug-loading and releasing properties, detectability, targetability, and multiple therapeutic modalities were introduced. The purpose here is to provide a comprehensive overview of current and emerging particulate embolization technology with respect to materials. Therefore, this review systematically identified and described typical features, various functions, and practical applications of recently emerging micro/nano materials as particulate embolic agents for TACE. Besides, new insights into the liquid metals-based multifunctional and flexible embolic agents were highlighted. The current development routes and future outlooks of these micro/nano embolic materials were also presented to promote advancement in the field.

Differential expression of hepatic cancer stemness and hypoxia markers in residual cancer after locoregional therapies for hepatocellular carcinoma

Transarterial chemoembolization (TACE) and transarterial radioembolization (TARE) treatment to hepatocellular carcinoma (HCC) are effective tools to control tumor growth, prolong survival, palliate symptoms, and improve quality of life for patients with intermediate-stage HCC. Nevertheless, there is high variability of local HCC responses to locoregional therapies; therefore, better and personalized prediction of tumor response to TACE is necessary for management of patients with HCC, especially when these modalities of treatment are used to bridge patients for liver transplant. Here, we investigated differential expression of hepatic cancer stem cell and hypoxia in residual HCC after TACE treatment in comparison with TARE. A publicly available gene data set was screened for differentially expressed genes (DEGs) in TACE_Response compared with TACE_Non-response HCC. Analysis of the GSE104580 data set displayed a total of 406 DEGs, including 196 down-regulated and 210 up-regulated DEGs. Of the 196 down-regulated DEGs, three hepatic cancer stem cell (CSC) markers and 11 hypoxia-related genes were identified. Immunohistochemical staining of hepatic CSC and hypoxia markers on explant liver tissues exhibited more intense positive staining of hepatic CSC markers (CD24, EpCAM) and hypoxia marker carbonic anhydrase 9 (CA9) in residual tumor nodule from patients with HCC treated with TACE compared with nontreated patients. Furthermore, Pearson's correlation analysis revealed the significant correlation between hepatic CSC markers and hypoxia marker, CA9. Conclusion: Hepatic CSC and hypoxia markers predict nonresponse to TACE and are differentially expressed in residual tumor after TACE compared with TARE. In the long term, TACE-induced hypoxia may select an aggressive HCC phenotype.

Relevance of artefacts in 99mTc-MAA SPECT scans on pre-therapy patient-specific 90Y TARE internal dosimetry: a GATE Monte Carlo study

Objective. The direct Monte Carlo (MC) simulation of radiation transport exploiting morphological and functional tomographic imaging as input data is considered the gold standard for internal dosimetry in nuclear medicine, and it is increasingly used in studies regarding trans-arterial radio-embolization (TARE). However, artefacts affecting the functional scans, such as reconstruction artefacts and motion blurring, decrease the accuracy in defining the radionuclide distribution in the simulations and consequently lead to errors in absorbed dose estimations. In this study, the relevance of such artefacts in patient-specific three-dimensional MC dosimetry was investigated in three cases of 90Y TARE. Approach. The pre-therapy 99mTc MacroAggregate Albumin (Tc-MAA) SPECTs and CTs of patients were used as input for simulations performed with the GEANT4-based toolkit GATE. Several pre-simulation SPECT-masking techniques were implemented, with the aim of zeroing the decay probability in air, in lungs, or in the whole volume outside the liver. Main results. Increments in absorbed dose up to about +40% with respect to the native-SPECT simulations were found in liver-related volumes of interest (VOIs), depending on the masking procedure adopted. Regarding lungs-related VOIs, decrements in absorbed doses in right lung as high as −90% were retrieved. Significance. These results highlight the relevant influence of SPECT artefacts, if not properly treated, on dosimetric outcomes for 90Y TARE cases. Well-designed SPECT-masking techniques appear to be a promising way to correct for such misestimations.

Practical utility of liver segmentation methods in clinical surgeries and interventions

Clinical imaging (e.g., magnetic resonance imaging and computed tomography) is a crucial adjunct for clinicians, aiding in the diagnosis of diseases and planning of appropriate interventions. This is especially true in malignant conditions such as hepatocellular carcinoma (HCC), where image segmentation (such as accurate delineation of liver and tumor) is the preliminary step taken by the clinicians to optimize diagnosis, staging, and treatment planning and intervention (e.g., transplantation, surgical resection, radiotherapy, PVE, embolization, etc). Thus, segmentation methods could potentially impact the diagnosis and treatment outcomes. This paper comprehensively reviews the literature (during the year 2012-2021) for relevant segmentation methods and proposes a broad categorization based on their clinical utility (i.e., surgical and radiological interventions) in HCC. The categorization is based on the parameters such as precision, accuracy, and automation.

Precision dosimetry in yttrium-90 radioembolization through CT imaging of radiopaque microspheres in a rabbit liver model

PURPOSE

To perform precision dosimetry in yttrium-90 radioembolization through CT imaging of radiopaque microspheres in a rabbit liver model and to compare extracted dose metrics to those produced from conventional PET-based dosimetry.

MATERIALS AND METHODS

A CT calibration phantom was designed containing posts with nominal microsphere concentrations of 0.5 mg/mL, 5.0 mg/mL, and 25.0 mg/mL. The mean Hounsfield unit was extracted from the post volumes to generate a calibration curve to relate Hounsfield units to microsphere concentration. A nominal bolus of 40 mg of microspheres was administered to the livers of eight rabbits, followed by PET/CT imaging. A CT-based activity distribution was calculated through the application of the calibration curve to the CT liver volume. Post-treatment dosimetry was performed through the convolution of yttrium-90 dose-voxel kernels and the PET- and CT-based cumulated activity distributions. The mean dose to the liver in PET- and CT-based dose distributions was compared through linear regression, ANOVA, and Bland-Altman analysis.

RESULTS

A linear least-squares fit to the average Hounsfield unit and microsphere concentration data from the calibration phantom confirmed a strong correlation (r2 > 0.999) with a slope of 14.13 HU/mg/mL. A poor correlation was found between the mean dose derived from CT and PET (r2 = 0.374), while the ANOVA analysis revealed statistically significant differences (p < 10-12) between the MIRD-derived mean dose and the PET- and CT-derived mean dose. Bland-Altman analysis predicted an offset of 15.0 Gy between the mean dose in CT and PET. The dose within the liver was shown to be more heterogeneous in CT than in PET with an average coefficient of variation equal to 1.99 and 1.02, respectively.

CONCLUSION

The benefits of a CT-based approach to post-treatment dosimetry in yttrium-90 radioembolization include improved visualization of the dose distribution, reduced partial volume effects, a better representation of dose heterogeneity, and the mitigation of respiratory motion effects. Post-treatment CT imaging of radiopaque microspheres in yttrium-90 radioembolization provides the means to perform precision dosimetry and extract accurate dose metrics used to refine the understanding of the dose-response relationship, which could ultimately improve future patient outcomes.

Clinical application of advances and innovation in radiation treatment of hepatocellular carcinoma

Background

Hepatocellular carcinoma (HCC) management has evolved over the past two decades, with the development of newer treatment modalities. While various options are available, unmet needs are reflected through the mixed treatment outcome for intermediate-stage HCC. As HCC is radiosensitive, radiation therapies have a significant role in management. Radiation therapies offer local control for unresectable lesions and for patients who are not surgical candidates. Radiotherapy also provides palliation in metastatic disease, and acts as a bridge to resection and transplantation in selected patients. Advancements in radiotherapy modalities offer improved dose planning and targeted delivery, allowing for better tumor response and safer dose escalations while minimizing the risks of radiation-induced liver damage. Radiotherapy modalities are broadly classified into external beam radiation therapy and selective internal radiation therapy. With emerging modalities, radiotherapy plays a complementary role in the multidisciplinary care of HCC patients.

Aim

We aim to provide an overview of the role and clinical application of radiation therapies in HCC management.

Relevance for Patients

The continuous evolution of radiotherapy techniques allows for improved therapeutic outcomes while mitigating unwanted adverse effects, making it an attractive modality in HCC management. Rigorous clinical studies, quality research and comprehensive datasets will further its application in the present era of evidence-based practice in Medicine.

CalliSpheres® microspheres drug-eluting bead transhepatic artery chemoembolization with or without sorafenib for the treatment of large liver cancer: a multi-center retrospective study

PURPOSE

To explore the clinical efficacy and safety of CalliSpheres^® microspheres drug-eluting bead transarterial chemoembolization (DEB-TACE) combined with sorafenib in the treatment of large liver cancer.

METHOD

The study retrospectively analyzed 90 patients with large liver cancer. 42 patients who received DEB-TACE and sorafenib were included in the experimental group and 48 patients who received only DEB-TACE were included in the control group. The efficacy, TTP, OS and ARs were evaluated and further analysis was conducted on factors which might affect the prognosis.

RESULTS

As of June 2020. The median OS of the experimental group was significantly longer than that of the control group (18.6 months vs. 12.7 months), and the TTP was also longer in the experimental group (8.3 months vs. 6.9 months). Three months after the intervention, the ORR and DCR of the experimental group were significantly higher than those of the control group. The main ARs of the experimental group taking sorafenib included hand-foot syndrome, skin rash, diarrhea, fatigue, hypertension, and anorexia. And they could be alleviated through treatment of the symptoms. TACE-related ARs for both groups were fever, pain, nausea, and vomiting, and there was no significant difference. Logistic regression analysis showed that the combined sorafenib treatment was a protective factor improving the prognosis of patients with large liver cancer, and risk factors were the number of tumors and vascular invasion.

CONCLUSION

DEB-TACE combined with sorafenib is safe and well tolerated in the treatment of large liver cancer. It can improve the tumor control rate and prolong the survival time.

Long-Term Outcomes of Transarterial Radioembolization for Large Single Hepatocellular Carcinoma: A Comparison to Resection

The surgical treatment for large hepatocellular carcinoma (HCC) remains controversial due to a high risk of recurrence after resection. This study aimed to compare long-term outcomes of transarterial radioembolization (TARE) with resection for patients with large HCC. Methods: This retrospective cohort study included a total of 557 patients who were initially treated with either resection (the resection group, n = 500) or TARE (the TARE group, n = 57) for large (≥5 cm) single nodular HCC at two tertiary centers in Korea. Patients with major portal vein tumor thrombosis or extrahepatic metastasis were excluded. The primary endpoint was overall survival (OS), and secondary endpoints were time to progression (TTP), time to intrahepatic progression (TTIP), and safety. Results: The resection group were younger (median, 60 years vs. 69 years) with smaller tumor size (median, 7.0 cm vs. 10.0 cm) (all P<0.05). After baseline characteristics were balanced using inverse probability of treatment weighting (IPTW), the TARE group showed comparable OS (hazard ratio [HR], 0.98; 95% confidence interval [CI], 0.40-2.43; P = 0.97), TTP (HR, 1.10; 95% CI, 0.55-2.20; P = 0.80), and TTIP (HR, 1.45; 95% CI, 0.72-2.93; P = 0.30) to the resection group. TARE was not an independent risk for OS (adjusted-HR, 1.04; 95% CI, 0.42-2.59; P = 0.93), TTP (adjusted-HR, 0.98; 95% CI, 0.50-1.95; P = 0.96), or TTIP (adjusted-HR, 1.30; 95% CI, 0.65-2.58; P = 0.46). The TARE group showed shorter hospital stay and fewer adverse events than the resection group. Conclusion: TARE showed comparable OS, TTP, and TTIP with better safety profile compared to surgical resection for large single nodular HCC.

LI-RADS Version 2018 Treatment Response Algorithm: Diagnostic Performance after Transarterial Radioembolization for Hepatocellular Carcinoma

Objective

To assess the diagnostic performance of the Liver Imaging Reporting and Data System (LI-RADS) version 2018 treatment response algorithm (TRA) for the evaluation of hepatocellular carcinoma (HCC) treated with transarterial radioembolization.

Materials and Methods

This retrospective study included patients who underwent transarterial radioembolization for HCC followed by hepatic surgery between January 2011 and December 2019. The resected lesions were determined to have either complete (100%) or incomplete (< 100%) necrosis based on histopathology. Three radiologists independently reviewed the CT or MR images of pre- and post-treatment lesions and assigned categories based on the LI-RADS version 2018 and the TRA, respectively. Diagnostic performances of LI-RADS treatment response (LR-TR) viable and nonviable categories were assessed for each reader, using histopathology from hepatic surgeries as a reference standard. Inter-reader agreements were evaluated using Fleiss κ.

Results

A total of 27 patients (mean age ± standard deviation, 55.9 ± 9.1 years; 24 male) with 34 lesions (15 with complete necrosis and 19 with incomplete necrosis on histopathology) were included. To predict complete necrosis, the LR-TR nonviable category had a sensitivity of 73.3–80.0% and a specificity of 78.9–89.5%. For predicting incomplete necrosis, the LR-TR viable category had a sensitivity of 73.7–79.0% and a specificity of 93.3–100%. Five (14.7%) of 34 treated lesions were categorized as LR-TR equivocal by consensus, with two of the five lesions demonstrating incomplete necrosis. Inter-reader agreement for the LR-TR category was 0.81 (95% confidence interval: 0.66–0.96).

Conclusion

The LI-RADS version 2018 TRA can be used to predict the histopathologic viability of HCCs treated with transarterial radioembolization.

BRAZILIAN SOCIETY OF HEPATOLOGY UPDATED RECOMMENDATIONS FOR DIAGNOSIS AND TREATMENT OF HEPATOCELLULAR CARCINOMA

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related mortality worldwide. The Brazilian Society of Hepatology (SBH) published in 2015 its first recommendations about the management of HCC. Since then, new data have emerged in the literature, prompting the governing board of SBH to sponsor a single-topic meeting in August 2018 in São Paulo. All the invited experts were asked to make a systematic review of the literature reviewing the management of HCC in subjects with cirrhosis. After the meeting, all panelists gathered together for the discussion of the topics and the elaboration of updated recommendations. The text was subsequently submitted for suggestions and approval of all members of the Brazilian Society of Hepatology through its homepage. The present manuscript is the final version of the reviewed manuscript containing the recommendations of SBH.

RECOMMENDATIONS FOR INVASIVE PROCEDURES IN PATIENTS WITH DISEASES OF THE LIVER AND BILIARY TRACT: REPORT OF A JOINT MEETING OF THE BRAZILIAN SOCIETY OF HEPATOLOGY (SBH), BRAZILIAN SOCIETY OF DIGESTIVE ENDOSCOPY (SOBED) AND BRAZILIAN SOCIETY OF INTERVENTIONAL RADIOLOGY AND ENDOVASCULAR SURGERY (SOBRICE)

Liver and biliary tract diseases are common causes of morbidity and mortality worldwide. Invasive procedures are usually performed in those patients with hepatobiliary diseases for both diagnostic and therapeutic purposes. Defining proper indications and restraints of commonly used techniques is crucial for proper patient selection, maximizing positive results and limiting complications. In 2018, the Brazilian Society of Hepato-logy (SBH) in cooperation with the Brazilian Society of Interventional Radiology and Endovascular surgery (SOBRICE) and the Brazilian Society of Digestive Endoscopy (SOBED) sponsored a joint single-topic meeting on invasive procedures in patients with hepatobiliary diseases. This paper summarizes the proceedings of the aforementioned meeting. It is intended to guide clinicians, gastroenterologists, hepatologists, radiologists, and endoscopists for the proper use of invasive procedures for management of patients with hepatobiliary diseases.

Large hepatocellular carcinoma with local remnants after transarterial chemoembolization: treatment by sorafenib combined with radiofrequency ablation or sorafenib alone

The present study aims to investigate retrospectively the efficacy and safety of sorafenib combined with radiofrequency ablation (RFA) to treat unresectable remnant large hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE). The 229 consecutive patients with unresectable remnant large HCC (diameter ≥ 5 cm) received RFA and sorafenib (RFA + Sor group, n = 102) or sorafenib (Sor group, n = 127) from January 2010 to January 2016. Complications and overall survival (OS) of the two groups were compared and subgroup analysis carried out. Survival curves were drawn using the Kaplan-Meier method. The RFA + Sor group had no additional serious adverse events. The average OS was 18.3 ± 1.6 months (95% confidence interval [CI]: 15.2-21.4) in the RFA + Sor group and 14.1 ± 1.1 months (95% CI: 11.8-16.3) in the Sor group, a difference the log-rank test indicated was significant (P = 0.03). The 1-, 2- and 3-year survival rates of the RFA + Sor group were 56.9%, 34.3%, and 11.7%, and those of the Sor group were 42.5%, 22.0%, and 5.5%, respectively. The between-group differences in 1- and 2-year survival rates were statistically significant, but not the difference in 3-year survival rates. Subgroup analysis showed that the RFA + Sor group achieved significantly more lifetime benefits than the Sor group in: patients with tumors 5-10 cm in diameter (hazard ratio [HR] 0.42, 95% CI 0.21-1.06 vs. HR 0.94, 95% CI 0.63-1.22); patients with an isolated tumor (HR 0.36, 95% CI 0.19-0.81 vs. HR 0.93, 95% CI 0.55-1.24); and patients with remnant lesion volume < 50% after TACE (HR 0.47, 95% CI 0.21-1.12 vs. HR 0.77, 95% CI 0.46-0.81). RFA with sorafenib is safe and effective for unresectable remnant large HCC, controlling tumor progression and prolonging survival better than sorafenib alone.

Targeted and Immune-Based Therapies for Hepatocellular Carcinoma

Treatment options for patients with hepatocellular carcinoma are rapidly changing based on positive results from phase 3 trials of targeted and immune-based therapies. More agents designed to target specific pathways and immune checkpoints are in clinical development. Some agents have already been shown to improve outcomes of patients with hepatocellular carcinoma, as first- and second-line therapies, and are awaiting approval by the Food and Drug Administration or have been recently approved. We summarize the targeted and immune-based agents in trials of patients with advanced hepatocellular carcinoma and discuss the future of these strategies for liver cancer.

Dual-Port versus Mono-Port Implantation for Intra-Arterial Chemoinfusion Therapy for Treatment of Hepatocellular Carcinoma in Patients with Anatomic Hepatic Artery Variation

PURPOSE

To compare the feasibility and safety of mono-port catheter system and dual-port catheter system for advanced hepatocellular carcinoma (HCC) in patients with anatomic hepatic artery variation and portal vein tumor thrombosis.

MATERIALS AND METHODS

This retrospective study consisted of 22 patients with infiltrative or multiple HCC with unilateral or bilateral portal vein thrombosis who had hepatic artery variation. A mono-port or dual-port catheter system was determined according to the degree of blood supply to the entire tumor through the common hepatic and variant hepatic arteries. Intrahepatic perfusion pattern, hepatic toxicity, and tumor response were investigated on computed tomography, medical records, and follow-up imaging study.

RESULTS

The most common hepatic arterial variation was replaced right hepatic artery arising from the superior mesenteric artery (n = 16), followed by replaced left hepatic artery (n = 5) and replaced right posterior segmental artery (n = 1). Twelve patients were treated with mono-port catheter system, and 10 patients were treated with dual-port catheter system. All 10 patients in the dual-port group showed homogeneous distribution of contrast material in the entire liver after port implantation, and 6 patients (50%, n = 6/12) in the mono-port group showed heterogeneous distribution (P = .018). The objective tumor response rates (P = .361) were 18.2% and 40%, and the disease control rates (P = .395) were 36.4% and 60% in the mono-port and dual-port groups, respectively.

CONCLUSIONS

The dual-port catheter system is a safe and effective technique that allows the even distribution of hepatic arterial infusion chemotherapy without hemodynamic modification of anatomic variation in the hepatic arteries.

Cost–effectiveness analysis of treatments involving radioembolization in intermediate-stage hepatocellular carcinoma

Aim: We evaluated two treatment sequences, transarterial radioembolization followed by transarterial chemoembolization and possibly sorafenib (=TTS) versus transarterial radioembolization followed by sorafenib alone (=TS), to identify the most cost-effective pathway to treat intermediate-stage hepatocellular carcinoma from the Italian healthcare system perspective. Materials & methods: A Markov model was developed to project costs and health outcomes for TTS and TS over a lifetime horizon. Data available at three hospitals in Italy were collected. Healthcare resource utilization was derived from standard clinical protocols. Costs were obtained from official regional tariffs. Results & Conclusion: Taking into consideration 16 patients for TTS and 22 patients for TS pathways, the TTS sequence provided a dominant strategy in comparison to TS. Further evidence is desirable to confirm these results.

Efficacy of 125I Versus Non-125I Combined with Transcatheter Arterial Chemoembolization for the Treatment of Unresectable Hepatocellular Carcinoma with Obstructive Jaundice

PURPOSE

To compare the therapeutic effects of ¹²⁵I versus non-¹²⁵I combined with transcatheter arterial chemoembolization (TACE) for the treatment of unresectable hepatocellular carcinoma (HCC) with obstructive jaundice.

METHODS

A retrospective analysis was conducted using the records of 54 consecutive patients who were initially diagnosed with HCC with obstructive jaundice between May 2009 and July 2016. Twenty-one cases (group A) were treated with percutaneous transhepatic biliary drainage (PTBD) followed by ¹²⁵I radioactive seed strip implantation through the PTBD tube. After the total serum bilirubin level was reduced to normal and the liver function recovered to Child-Pugh class A or early B, TACE was conducted. In 33 cases (group B) PTBD was performed in combination with TACE without applying the ¹²⁵I radioactive seeds. The duration of biliary patency and survival were analyzed.

RESULTS

The technical success rate in both groups was 100%. The median biliary patency time was 6.000 ± 0.315 months (95% CI 5.382-6.618 months) in group A and 4.000 ± 0.572 months (95% CI 2.879-5.121 months) in group B; the two groups were significantly different (P = 0.001). The median survival was 11.000 ± 0.864 months (95% CI 9.306-12.694 months) in group A and 9.000 ± 0.528 months (95% CI 7.965-10.035 months) in group B; the two groups were significantly different (P = 0.022).

CONCLUSIONS

The combination of 125I with TACE was more effective than TACE without the radioactive seeds for treating patients with unresectable HCC with obstructive jaundice. Future prospective trials with larger samples will be required to validate these results.

Absorbed dose kernel and self-shielding calculations for a novel radiopaque glass microsphere for transarterial radioembolization

PURPOSE

Radiopaque microspheres may provide intraprocedural and postprocedural feedback during transarterial radioembolization (TARE). Furthermore, the potential to use higher resolution x-ray imaging techniques as opposed to nuclear medicine imaging suggests that significant improvements in the accuracy and precision of radiation dosimetry calculations could be realized for this type of therapy. This study investigates the absorbed dose kernel for novel radiopaque microspheres including contributions of both short and long-lived contaminant radionuclides while concurrently quantifying the self-shielding of the glass network.

METHODS

Monte Carlo simulations using EGSnrc were performed to determine the dose kernels for all monoenergetic electron emissions and all beta spectra for radionuclides reported in a neutron activation study of the microspheres. Simulations were benchmarked against an accepted ⁹⁰ Y dose point kernel. Self-shielding was quantified for the microspheres by simulating an isotropically emitting, uniformly distributed source, in glass and in water. The ratio of the absorbed doses was scored as a function of distance from a microsphere. The absorbed dose kernel for the microspheres was calculated for (a) two bead formulations following (b) two different durations of neutron activation, at (c) various time points following activation.

RESULTS

Self-shielding varies with time postremoval from the reactor. At early time points, it is less pronounced due to the higher energies of the emissions. It is on the order of 0.4-2.8% at a radial distance of 5.43 mm with increased size from 10 to 50 μm in diameter during the time that the microspheres would be administered to a patient. At long time points, self-shielding is more pronounced and can reach values in excess of 20% near the end of the range of the emissions. Absorbed dose kernels for ⁹⁰ Y, ^90m Y, ^85m Sr, ⁸⁵ Sr, ^87m Sr, ⁸⁹ Sr, ⁷⁰ Ga, ⁷² Ga, and ³¹ Si are presented and used to determine an overall kernel for the microspheres based on weighted activities. The shapes of the absorbed dose kernels are dominated at short times postactivation by the contributions of ⁷⁰ Ga and ⁷² Ga. Following decay of the short-lived contaminants, the absorbed dose kernel is effectively that of ⁹⁰ Y. After approximately 1000 h postactivation, the contributions of ⁸⁵ Sr and ⁸⁹ Sr become increasingly dominant, though the absorbed dose-rate around the beads drops by roughly four orders of magnitude.

CONCLUSIONS

The introduction of high atomic number elements for the purpose of increasing radiopacity necessarily leads to the production of radionuclides other than ⁹⁰ Y in the microspheres. Most of the radionuclides in this study are short-lived and are likely not of any significant concern for this therapeutic agent. The presence of small quantities of longer lived radionuclides will change the shape of the absorbed dose kernel around a microsphere at long time points postadministration when activity levels are significantly reduced.

Treatment options for unresectable HCC with a focus on SIRT with Yttrium-90 resin microspheres

Hepatocellular carcinoma (HCC), the predominant form of primary liver cancer, is the second leading cause of cancer-related deaths across the globe. Only a small percentage of HCC patients (~20%-30%) are diagnosed at an early stage when first-line treatment options may be effective. The majority of HCC patients (>70%) are diagnosed with unresectable disease and given a poor overall prognosis. Current treatment guidelines recommend locoregional therapy with transarterial chemoembolisation (TACE) and systemic therapy with sorafenib as first-line treatment for patients with intermediate and advanced stage HCC. However, multiple factors including contraindications, technical considerations and treatment-related toxicities pose significant challenges in achieving favourable treatment outcomes, underscoring the need for a paradigm shift in managing these patients. In 2002, yttrium-90 (Y-90) resin microspheres was approved by the U.S. Food and Drug Administration (FDA) for the treatment of unresectable metastatic colorectal cancer to the liver with adjuvant floxuridine chemotherapy. However, thousands of patients with unresectable HCC have also been treated with resin Y-90. For over two decades, several small-scale prospective trials and retrospective studies have investigated and reported on the efficacy of locoregional selective internal radiation therapy (SIRT) with Y-90 microspheres in treating unresectable HCC. Although it is currently a treatment option for intermediate-stage HCC patients, mainstream clinical application of resin Y-90 has been largely limited because of the lack of sufficient clinical data from a randomised controlled trial. This could change with the imminent announcement of results from the phase 3 Sorafenib vs Radioembolization in Advanced Hepatocellular carcinoma (SARAH) trial. To provide the foundation and context for interpreting results from the SARAH trial, this article provides an overview of treatment modalities and current challenges in managing unresectable HCC. There is also a review of key prospective and retrospective studies evaluating the use of Y-90 SIRT, specifically Y-90 resin microspheres in unresectable HCC, which led to the development of the SARAH trial.

METHODS

To identify relevant publications, the PubMed database was queried using one or more of the following search terms alone or in combination with Boolean operators: epidemiology, hepatocellular, hepatocellular cancer, hepatocellular carcinoma, unresectable, radioembolisation, selective internal radiation therapy, SIR-Spheres, yttrium 90, TACE, and sorafenib. The results were sorted or filtered by "Author", "Publication dates" or "Article types" to identify articles relevant to each section of the review. To ensure that information on ongoing clinical trials involving Y-90 resin was included, we conducted a search on "ClinicalTrials.gov", by combining the search terms "HCC" OR "hepatocellular carcinoma" with "Y 90" OR "yttrium 90" OR "radioembo", and screened for studies that involved treatment with Y-90 resin microspheres.

Interventional Radiologic Treatment of Hepatocellular Carcinoma

The current treatment modalities for patients with hepatocellular carcinoma are discussed in this review. Hepatocellular carcinoma arises in up to 90% of cirrhotic patients, mainly due to chronic viral hepatitis and alcohol abuse. Nearly two-thirds of all patients with hepatocellular carcinoma are diagnosed at advanced stages, thus causing problems with treatment. Regardless of the stage of the disease, interventional radiology offers both curative and palliative treatment options in the management of this disease. Selecting the most appropriate treatment requires an initial staging assessment and detailed clinical and radiologic workup. Treatment allocation is based on liver function, size and number of tumors, macrovascular invasion, and extrahepatic spread of disease.

Prognostic significance of XRCC4 expression in hepatocellular carcinoma

Background

Our previous investigations have shown that the variants of X-ray repair complementing 4 (XRCC4) may be involved in hepatocellular carcinoma (hepatocarcinoma) tumorigenesis. This study aimed to investigate the possible prognostic significance of XRCC4 expression for hepatocarcinoma patients and possible value for the selection of transarterial chemoembolization (TACE) treatment.

Materials and Methods

We conducted a hospital-based retrospective analysis (including 421 hepatocarcinoma cases) to analyze the effects of XRCC4 on hepatocarcinoma prognosis and TACE. The levels of XRCC4 expression were tested using immunohistochemistry. The sensitivity of cancer cells to anti-cancer drug doxorubicin was evaluated using the half-maximal inhibitory concentration (IC50).

Results

XRCC4 expression was significantly correlated with pathological features including tumor stage, liver cirrhosis, and micro-vessel density. XRCC4 expression was an independent prognostic factor of hepatocarcinoma, and TACE treatments had no effects on prognosis of hepatocarcinoma patients with high XRCC4 expression. More intriguingly, TACE improved the prognosis of hepatocarcinoma patients with low XRCC4 expression. Functionally, XRCC4 overexpression increased while XRCC4 knockdown reduced the IC50 of cancer cells to doxorubicin.

Conclusions

These results suggest that XRCC4 may be an independent prognostic factor for hepatocarcinoma patients, and that decreasing XRCC4 expression may be beneficial for post-operative adjuvant TACE treatment in hepatocarcinoma.

Transarterial chemoembolization for the treatment of hepatocellular carcinoma: a review

According to the current European Association for the Study of Liver guidelines, transarterial chemoembolization (TACE) is the recommended first-line therapy for patients with intermediate-stage (Barcelona Clinic Liver Cancer-B class) hepatocellular carcinoma (HCC). The efficacy of this therapy is supported by robust evidence; however, there is still a lack of standardization in treatment methodology, and TACE protocols are widely variable. Moreover, TACE can be associated with a number of contraindications. Despite these limitations, research on TACE is still ongoing with the aim of optimizing the use of this methodology in the current management of HCC. In particular, TACE represents a control in comparative studies, and it is currently being investigated in combination schemes, for example, with sorafenib. In this review, we briefly describe the current scenario and the clinical innovations regarding TACE for the treatment of HCC.

Differences in Radiation Activity Between Glass and Resin 90Y Microspheres in Treating Unresectable Hepatic Cancer

The purpose of this study was to compare the difference in prescribed radiation activity between glass and resin yttrium-90 (Y) microspheres for radioembolization of unresectable hepatocellular carcinoma (HCC) or liver metastases at a tertiary care teaching institution. The authors performed a retrospective analysis on 126 patients with primary HCC and hepatic metastatic disease from extrahepatic primary cancers who underwent radioembolization with glass or resin particles between 2008 and 2013 at their institution. Radiation activity estimates for prescribed treatments, as well as for the alternate embolization particles, were calculated using commonly employed formulae for both glass and resin particles for all treatments. A total of 217 treatments were performed on 126 patients, with 136 (62.7%) using glass particles and 81 (37.3%) using resin particles. Forty-six (36.5%) patients had metastatic colorectal cancer (CRC), 51 (40.5%) had primary HCC, while 11 (8.7%) had neuroendocrine carcinoma, and 18 (14.3%) had metastases from other primary tumors. The average prescribed activity was 2.66 GBq for glass treatments and 1.06 GBq for resin treatments across all cancer types. When the alternative treatment activity was calculated, activities were projected to decrease by an average of 1.52 GBq per treatment if resin microspheres were used instead of glass microspheres (-52.5%), while activities were projected to increase by an average of 1.57 GBq per treatment if glass microspheres were used instead of resin microspheres (148.9%; p < 0.001). Similar results were seen within each malignancy type and all projected changes were statistically significant (p < 0.001). In conclusion, prescribed radiation activity for radioembolization of unresectable hepatic cancer was significantly lower for resin compared to glass microspheres.

Real-World Data for the Evaluation of Transarterial Radioembolization versus Sorafenib in Hepatocellular Carcinoma: A Cost-Effectiveness Analysis

OBJECTIVES

To perform a cost-effectiveness analysis comparing the use of transarterial radioembolization (TARE) with that of sorafenib in the treatment of patients with intermediate or advanced hepatocellular carcinoma (HCC) according to the Barcelona Clinic Liver Cancer staging system.

METHODS

Patient-level data were consecutively recorded and collected at three oncology centers in Italy. A propensity score matching was performed to compare patients with similar clinical characteristics who underwent TARE or sorafenib treatment. Clinical data from the matched cohorts were used to populate a Markov model to project, on a lifetime horizon, life years, quality-adjusted life years, and economic outcomes associated with TARE and sorafenib for both intermediate and advanced HCC stages.

RESULTS

Starting from data covering 389 and 241 patients who underwent TARE and sorafenib treatment, respectively, the propensity score matching yielded a total of 308 matched patients. For intermediate-stage patients, the model estimated for TARE versus sorafenib an incremental cost-utility ratio of €3,302/QALY (incremental cost-effectiveness ratio of €1,865 per life year gained), whereas for patients in advanced stage TARE dominated (lower costs and greater health improvements) compared with sorafenib.

CONCLUSIONS

From an Italian health care service perspective, TARE could be a cost-effective strategy in comparison with sorafenib for patients with intermediate or advanced HCC. The results from forthcoming randomized controlled trials comparing TARE with sorafenib will be able to confirm or reject the validity of this preliminary evaluation. In the meantime, decision makers can use these results to control and coordinate the diffusion of the technology.

Treating hepatocellular carcinoma with 90Y-bearing microspheres: a review

Hepatocellular carcinoma (HCC) is a disease usually diagnosed in its advanced-stage, and is frequently not amenable to curative surgical treatment. Also, HCC is resistant to chemotherapy and less vulnerable to radiation therapy compared to normal hepatic parenchyma. Both of these facts render the efficacy of adjuvant and palliative treatments problematic. Selective internal radiation therapy (SIRT) with ⁹⁰Y-bearing microspheres is characterized by preferentially delivering substantially high doses of radiation to a liver tumor dose simultaneously limiting the damage to its non-tumorous cells, providing an opportunity for effective local tumor control and even tumor regression therapy. The current article reviews the specific characters, dosimetry, possible applications, and special considerations toward the pre-existing radiation therapy of ⁹⁰Y microsphere SIRT in treating HCC.

Microfluidic chip for isolation of viable circulating tumor cells of hepatocellular carcinoma for their culture and drug sensitivity assay

Circulating tumor cells (CTCs) have been proposed to be an active source of metastasis or recurrence of hepatocellular carcinoma (HCC). The enumeration and characterization of CTCs has important clinical significance in recurrence prediction and treatment monitoring in HCC patients. We previously developed a unique method to separate HCC CTCs based on the interaction of the asialoglycoprotein receptor (ASGPR) expressed on their membranes with its ligand. The current study applied the ligand-receptor binding assay to a CTC-chip in a microfluidic device. Efficient capture of HCC CTCs originates from the small dimensions of microfluidic channels and enhanced local topographic interactions between the microfluidic channel and extracellular extensions. With the optimized conditions, a capture yield reached > 85% for artificial CTC blood samples. Clinical utility of the system was further validated. CTCs were detected in all the examined 36 patients with HCC, with an average of 14 ± 10/2 mL. On the contrary, no CTCs were detected in healthy, benign liver disease or non-HCC cancer subjects. The current study also successfully demonstrated that the captured CTCs on our CTC-chip were readily released with ethylene diamine tetraacetic acid (EDTA); released CTCs remained alive and could be expanded to form a spheroid-like structure in a 3-dimensional cell culture assay; furthermore, sensitivity of released CTCs to chemotherapeutic agents (sorafenib or oxaliplatin) could be effectively tested utilizing this culture assay. In conclusion, the methodologies presented here offer great promise for accurate enumeration and easy release of captured CTCs, and released CTCs could be cultured for further functional studies.

Consensus for Radiotherapy in Hepatocellular Carcinoma from The 5th Asia-Pacific Primary Liver Cancer Expert Meeting (APPLE 2014): Current Practice and Future Clinical Trials

A consensus meeting to develop practice guidelines and to recommend future clinical trials for radiation therapy (RT), including external beam RT (EBRT), and selective internal RT (SIRT) in hepatocellular carcinoma (HCC) was held at the 5th annual meeting of the Asia-Pacific Primary Liver Cancer Expert consortium. Although there is no randomized phase III trial evidence, the efficacy and safety of RT in HCC has been shown by prospective and retrospective studies using modern RT techniques. Based on these results, the committee came to a consensus on the utility and efficacy of RT in the management of HCC according to each disease stage as follows: in early and intermediate stage HCC, if standard treatment is not compatible, RT, including EBRT and SIRT can be considered. In locally advanced stage HCC, combined EBRT with transarterial chemoembolization or hepatic arterial infusion chemotherapy, and SIRT can be considered. In terminal stage HCC, EBRT can be considered for palliation of symptoms and reduction of morbidity caused by the primary tumor or its metastases. Despite the currently reported benefits of RT in HCC, the committee agreed that there is a compelling need for large prospective studies, including randomized phase III trial evidence evaluating the role of RT. Specifically studies evaluating the efficacy and safety of sequential combination of EBRT and SIRT are strongly recommended.

Yttrium-90 radioembolization for advanced inoperable hepatocellular carcinoma

BACKGROUND

Advanced inoperable hepatocellular carcinoma (HCC) conferring a grave prognosis may benefit from yttrium-90 ((90)Y) radioembolization.

METHODS

Thirty patients with advanced inoperable HCC including those with any lesion >8 cm in maximal diameter or multiple bi-lobar lesions (totally more than five lesions), or portal vein thrombosis treated with radioembolization were reviewed. Treatment efficacy and safety were evaluated. Univariate and multivariate analyses were performed for identifying potential prognostic factors.

RESULTS

After a median follow-up of 18.3 months, the response rate was 30.0%, and the disease control rate was 50.0%. Median overall progression-free survival (PFS) and overall survival (OS) were 3.3 months and 13.2 months, respectively. Longer median PFS was noted in those who had transarterial chemoembolization before radioembolization (7.3 months vs 3.1 months; P=0.021) and duration of alfafeto protein (AFP) response ≥6 months (11.8 months vs 3.0 months; P<0.001). Longer median OS was also revealed in those without portal vein thrombosis (17.1 months vs 4.4 months; P=0.015) and those whose duration of AFP response was ≥6 months (21.2 months vs 8.6 months; P=0.001). Seventeen patients (56.7%) developed treatment-related complications including five (16.7%) grade 3 events. Multivariate analysis revealed that treatment responders (P=0.001) and duration of AFP response ≥6 months (P=0.006) were prognostic of PFS, whereas the absence of portal vein invasion (P=0.025), treatment responders (P=0.010), and duration of AFP response ≥6 months (P=0.001) were prognostic of OS.

CONCLUSION

(90)Y radioembolization is an alternative treatment with a promising outcome for poor-risk advanced inoperable HCC.