Clinical outcomes of patients with a single hepatocellular carcinoma less than 5 cm treated with transarterial chemoembolization

A randomised controlled trial of Standard Of Care versus RadioAblaTion in Early Stage HepatoCellular Carcinoma (SOCRATES HCC)

BACKGROUND

Therapeutic options for early-stage hepatocellular carcinoma (HCC) in individual patients can be limited by tumor and location, liver dysfunction and comorbidities. Many patients with early-stage HCC do not receive curative-intent therapies. Stereotactic ablative body radiotherapy (SABR) has emerged as an effective, non-invasive HCC treatment option, however, randomized evidence for SABR in the first line setting is lacking.

METHODS

Trans-Tasman Radiation Oncology Group (TROG) 21.07 SOCRATES-HCC is a phase II, prospective, randomised trial comparing SABR to other current standard of care therapies for patients with a solitary HCC ≤ 8 cm, ineligible for surgical resection or transplantation. The study is divided into 2 cohorts. Cohort 1 will compromise 118 patients with tumors ≤ 3 cm eligible for thermal ablation randomly assigned (1:1 ratio) to thermal ablation or SABR. Cohort 2 will comprise 100 patients with tumors > 3 cm up to 8 cm in size, or tumors ≤ 3 cm ineligible for thermal ablation, randomly assigned (1:1 ratio) to SABR or best other standard of care therapy including transarterial therapies. The primary objective is to determine whether SABR results in superior freedom from local progression (FFLP) at 2 years compared to thermal ablation in cohort 1 and compared to best standard of care therapy in cohort 2. Secondary endpoints include progression free survival, overall survival, adverse events, patient reported outcomes and health economic analyses.

DISCUSSION

The SOCRATES-HCC study will provide the first randomized, multicentre evaluation of the efficacy, safety and cost effectiveness of SABR versus other standard of care therapies in the first line treatment of unresectable, early-stage HCC. It is a broad, multicentre collaboration between hepatology, interventional radiology and radiation oncology groups around Australia, coordinated by TROG Cancer Research.

TRIAL REGISTRATION

anzctr.org.au, ACTRN12621001444875, registered 21 October 2021.

Clinical outcomes of transarterial chemoembolization in Child-Turcotte Pugh class A patients with a single small (≤3 cm) hepatocellular carcinoma

BACKGROUND AND AIM

Transarterial chemoembolization (TACE) is one of the standard modalities used to treat unresectable hepatocellular carcinoma (HCC), but the effectiveness of TACE for treating patients with a solitary small (≤3 cm) HCC and well-preserved liver function has not been definitively established. This study aimed to determine the therapeutic impact of TACE in patients with these characteristics.

METHODS

This multicenter (four university hospitals) retrospective cohort study analyzed the medical records of 250 patients with a solitary small (≤3 cm) HCC and Child-Turcotte-Pugh (CTP) class A liver function diagnosed over 10 years. Posttreatment outcomes, including overall survival (OS), recurrence-free survival (RFS), and adverse events, were assessed following TACE therapy.

RESULTS

One hundred and thirty-eight of the 250 patients (55.2%) treated with TACE achieved complete remission (CR). Overall median OS was 77.7 months, and median OS was significantly longer in the CR group than in the non-CR group (89.1 vs. 58.8 months, P = 0.001). Median RFS was 19.1 months in the CR group. Subgroup analysis identified hypertension, an elevated serum albumin level, and achieving CR as significant positive predictors of OS, whereas diabetes, hepatitis c virus infection, and tumor size (>2 cm) were poor prognostic factors of OS.

CONCLUSIONS

The study demonstrates the effectiveness of TACE as a viable alternative for treating solitary small (≤3 cm) HCC in CTP class A patients.

Real world for management of hepatocellular carcinoma: a large population-based study

OBJECTIVES

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related death. This study investigated the risk factors, treatment responses and survival outcomes in real-world patients with HCC.

MATERIALS AND METHODS

This was a large, retrospective cohort study of patients newly diagnosed with HCC at tertiary referral centers in Thailand between 2011 and 2020. Survival time was defined as the time from the date of HCC diagnosis to the date of death or last follow-up.

RESULTS

A total of 1145 patients with a mean age of 61.4 ± 11.7 years were included. Next, 568 (48.7%), 401 (34.4%) and 167 (15.1%) patients were classified as Child-Pugh score A, B and C, respectively. Over half of the patients (59.0%) were diagnosed with noncurative-stage HCC (BCLC B-D). Patients with Child-Pugh A scores were more likely to be diagnosed with curative-stage HCC (BCLC 0-A) than noncurative stage (67.4% vs. 37.2%, p < .001). Patients with curative-stage HCC and Child-Pugh A cirrhosis underwent more liver resections than radiofrequency ablation (RFA) (91.8% vs. 69.7%, p < .001). For BCLC 0-A patients with portal hypertension, RFA was selected more frequently than liver resection (52.1% vs. 28.6%, p < .001). Patients who received RFA monotherapy tended to experience increased median survival times compared to those who underwent resection (55 vs. 36 months; p = .058).

CONCLUSIONS

Surveillance programs should be encouraged to detect early-stage HCC, which is suitable for curative treatment improving survival outcomes. RFA may be an appropriate first-line treatment for curative-stage HCC. Sequential multi-modality treatment in the curative stage can achieve favorable 5-year survival.

Metformin administration is associated with enhanced response to transarterial chemoembolization for hepatocellular carcinoma in type 2 diabetes patients

Transarterial chemoembolization (TACE) is often used as a locoregional therapy for early hepatocellular carcinoma (HCC) when local ablation or resection are not feasible, but incomplete response and recurrence are commonly observed. In this study, we sought to determine the association between metformin administration and TACE outcomes for single nodular HCC in patients with type 2 diabetes mellitus (T2DM). The retrospective cohort analysis included 164 T2DM patients with single nodular HCC who underwent TACE as an initial treatment, and 91 were exposed to metformin before and after TACE. Propensity score (PS) matching was used to balance covariates. Logistic regression analysis was used to determine the predictors of tumor response after TACE, and Cox regression analysis assessed independent predictors of local tumor recurrence (LTR) in patients with complete response after TACE. Metformin use was associated with significantly higher objective response rate (ORR) in the overall and PS-matched cohort (79.1% vs. 60.3 and 78.7% vs. 57.5%; p = 0.008 and p = 0.029, respectively). Logistic regression analysis showed that metformin use was an independent predictor of ORR in all and PS-matched patients (odds ratio = 2.65 and 3.06; p = 0.016 and 0.034, respectively). Cox regression analysis showed metformin administration was an independent predictor for lower LTR in all and PS-matched patients (hazard ratio = 0.28 and 0.27; p = 0.001 and 0.007, respectively). Metformin administration is associated with better initial response and lower local recurrence after TACE for single nodular HCC in T2DM.

Local recurrence following complete radiologic response in patients treated with transarterial chemoembolization for hepatocellular carcinoma

PURPOSE

The purpose of this study was to determine the local progression rate and identify factors that may predict local progression, in patients who achieve a complete response (CR) radiologically after undergoing transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

One-hundred-forty-seven patients, who achieved CR of 224 HCCs after TACE, were retrospectively reviewed. There were 109 men and 38 women with a mean age of 61.6 ± 6.8 (SD) years (range: 45.4-86.9 years). Logistic mixed-effects and Cox regression models were used to evaluate associations between clinical factors and local progression.

RESULTS

A total of 75 patients (75/147; 51%) and 99 (99/224,44.2%) lesions showed local progression at a median of 289.5 days (Q1: 125, Q3: 452; range: 51-2245 days). Pre-treatment, international normalization ratio (INR) (1.17 ± 0.15 [SD] vs. 1.25 ± 0.16 [SD]; P <0.001), model for end-stage liver disease (9.4 ± 2.6 [SD] vs. 10.6 ± 3.2 [SD]; P = 0.010) and Child-Pugh score (6 ± 1 [SD] vs. 6.4 ± 1.3 [SD]; P = 0.012) were significantly lower while albumin serum level (3.4 ± 0.62 [SD] vs. 3.22 ± 0.52 [SD]; P = 0.033) was significantly greater in those who showed local progression as compared to those who did not. In terms of local-recurrence free survival, the number of TACE treatments (hazard ratio [HR]: 2.05 [95% CI: 1.57-2.67]; P<0.001), INR (HR: 0.13 [95% CI: 0.03-0.61]; P = 0.010) and type of TACE (P = 0.003) were significant. Patients with local progression on any tumor did not differ from those who did in terms of overall survival (P = 0.072), however, were less likely to be transplanted (20/75, 26.7%) than those who did not (33/72; 36.1%) (P = 0.016).

CONCLUSION

A significant number of patients who achieve CR of HCC after TACE have local progression. This emphasizes the importance of long-term follow up.

Validation of Pre-/Post-TACE-Predict Models among Patients with Hepatocellular Carcinoma Receiving Transarterial Chemoembolization

This study attempted to validate the prognostic performance of the proposed Pre- and Post-TACE (transarterial chemoembolization)-Predict models, in comparison with other models for prognostication. One-hundred-and-eighty-seven patients with HCC who underwent TACE were recruited. Regarding overall survival (OS), the predictive performance of the Pre-TACE-Predict model (one-year integrated area under the curve (iAUC) 0.685 (95% confidence interval (CI) 0.593–0.772)) was better than that of the Post-TACE-Predict model (iAUC 0.659 (95% CI 0.580–0.742)). However, there was no significant statistical difference between two models at any time point. For comparison between models using pre-treatment factors, the modified hepatoma arterial embolization prognostic (mHAP)-II model demonstrated significantly better predictive performance at one year (iAUC 0.767 (95% CI 0.683–0.847)) compared with Pre-TACE-Predict. For comparison between models using first TACE response, the SNACOR model was significantly more predictive at one year (iAUC 0.778 (95% CI 0.687–0.866) vs. 0.659 (95% CI 0.580–0.742), respectively) and three years (iAUC 0.707 (95% CI 0.646–0.770) vs. 0.624 (95% CI 0.564–0.688), respectively) than the Post-TACE-Predict model. mHAP-II and SNACOR may be preferred over the Pre- and Post-TACE-Predict models, respectively, considering their similar or better performance and the ease of application.

Utility of Real-time CT/MRI-US Automatic Fusion System Based on Vascular Matching in Percutaneous Radiofrequency Ablation for Hepatocellular Carcinomas: A Prospective Study

PURPOSE

To prospectively evaluate the technical success rate of real-time computed tomography/magnetic resonance imaging and ultrasound (CT/MRI-US) automatic fusion system and the long-term therapeutic efficacy of radiofrequency ablation (RFA) guided by automatic fusion in hepatocellular carcinoma (HCC) patients.

MATERIALS AND METHODS

139 patients with 151 HCCs were prospectively enrolled for RFA guided by an automatic CT/MRI-US fusion system (PercuNav system, Philips, the Netherlands). Automatic fusion imaging, based on vascular segmentation and registration, was performed by sonographic sweeping at the intercostal plane. The fusion quality, tumor localization confidence and technical feasibility were recorded before and after fusion using a scoring system. Technical success rate of the RFA procedure and local tumor progression (LTP) were assessed during follow-up. Analysis of technical success and LTP was performed using generalized estimating equations and Cox proportional hazard regression analysis.

RESULTS

The success rate of the fusion system was 82.7% (115/139) per patient. The mean sonographic scan time for fusion was 154.4 ± 108.4 s. In patients with successful fusion, the score indicating tumor localization confidence (2.2 ± 0.8 vs. 2.7 ± 0.9) and technical feasibility (2.6 ± 0.8 vs. 3.4 ± 0.7) increased after fusion (p < 0.001). The technical success rate of the RFA procedure was 96.8% (120/124) per tumor in patients with successful fusion, including poorly localized tumors. LTP rates were 8.6%, 12.2% and 15.2% at 1, 2 and 3 years.

CONCLUSION

The CT/MRI-US automatic fusion system showed a high success rate for image registration and facilitated better feasibility and a high technical success rate of RFA in HCCs, even with poor localization on US.

LEVEL OF EVIDENCE

Level 3b, Nonrandomized prospective study.

The correlation with tumor radiological characteristics and prognosis of patients with early-stage hepatocellular carcinoma receiving transcatheter arterial chemoembolization

Transcatheter arterial chemoembolization (TACE) is a standard treatment modality for intermediate stage hepatocellular carcinoma (HCC). The aim of this study was to determine the tumor radiological characteristics associated with prognosis of patients with early-staged HCC receiving TACE.Patients with BCLC stage A HCC were enrolled at Taichung Veterans General Hospital from January 2005 to December 2009. According to mRECIST criteria, patients with or without complete response (CR) were assigned to either the CR group or the non-CR group. Clinical and radiological characteristics were compared between the two groups.In 40 enrolled patients, 24 (60%) were in the CR group, and 16 (40%) in the non-CR group. Clinical parameters were similar between the 2 groups. Radiological characteristics including complete lipidol retention and the absence of residual tumor blush were significantly correlated with achievement of CR in the patients with small-sized HCC. Patients with CR after TACE had a significantly longer overall survival than those without (31.29 vs 22.63 months, P = .021).Complete lipidol retention and the absence of residual tumor blush were correlated with the radiological complete tumor response of these patients with small-sized early-stage HCC receiving TACE.

Early dynamic changes in circulating tumor cells and prognostic relevance following interventional radiological treatments in patients with hepatocellular carcinoma

The aim of this study was to investigate the dynamic changes of circulating tumor cells (CTCs) in patients with hepatocellular carcinoma (HCC) before and immediately after conducting a microwave ablation (MWA) and conventional transarterial chemoembolization (C-TACE). Additionally, the CTCs short-term dynamics were compared with the clinical course of the HCC-patients. Blood samples from 17 patients with HCC who underwent MWA (n = 10) or C-TACE (n = 7) were analyzed. Venous blood was taken before and immediately after the radiological interventions to isolate and quantify CTCs using flow cytometry. CTCs were identified as CD45- and positive for the markers ASGPR, CD146 and CD274 (PD-L1). Patients were followed of up to 2.2 years after the radiological intervention. CTCs were detected in 13 HCC patients (76%) prior to the radiological interventions. The rate of CTCs was significantly decreased after the intervention in patients treated with MWA (0.4 CTCs/mL of blood, p = 0.031). However, no significant differences were observed in patients who received C-TACE (0.3 CTCs/mL of blood, p = 0.300). Overall, no correlation was found between the CTCs rate before and after the radiological intervention and recurrence rate of HCC. This preliminary data could confirm the tumoricidal effects of MWA in patients with HCC by significantly decreasing CTCs rate. In our study, we were able to detect CTCs in HCC patients using 3 different tumor markers. This preliminary data shows significant lower CTCs detected in response to MWA. However, large-scale randomized clinical trials are needed to determine the future role and the prognostic relevance of CTCs following this treatment.

Recent Updates of Transarterial Chemoembolilzation in Hepatocellular Carcinoma

Transarterial chemoembolization (TACE) is a standard treatment for intermediate-stage hepatocellular carcinoma (HCC). In this review, we summarize recent updates on the use of TACE for HCC. TACE can be performed using two techniques; conventional TACE (cTACE) and drug-eluting beads using TACE (DEB-TACE). The anti-tumor effect of the two has been reported to be similar; however, DEB-TACE carries a higher risk of hepatic artery and biliary injuries and a relatively lower risk of post-procedural pain than cTACE. TACE can be used for early stage HCC if other curative treatments are not feasible or as a neoadjuvant treatment before liver transplantation. TACE can also be considered for selected patients with limited portal vein thrombosis and preserved liver function. When deciding to repeat TACE, the ART (Assessment for Retreatment with TACE) score and ABCR (AFP, BCLC, Child-Pugh, and Response) score can guide the decision process, and TACE refractoriness needs to be considered. Studies on the combination therapy of TACE with other treatment modalities, such as local ablation, radiation therapy, or systemic therapy, have been actively conducted and are still ongoing. Recently, new prognostic models, including analysis of the neutrophil-lymphocyte ratio, radiomics, and deep learning, have been developed to help predict survival after TACE.