Transarterial chemoembolization of unresectable hepatocellular carcinoma with drug eluting beads: results of an open-label study of 62 patients. Cardiovasc Intervent Radiol. 2008;31:269-280. [PMID: 17999110 DOI: 10.1007/s00270-007-9226-z]

Prospective randomized study of doxorubicin-eluting-bead embolization in the treatment of hepatocellular carcinoma: results of the PRECISION V study

Transcatheter arterial chemoembolization (TACE) offers a survival benefit to patients with intermediate hepatocellular carcinoma (HCC). A widely accepted TACE regimen includes administration of doxorubicin-oil emulsion followed by gelatine sponge-conventional TACE. Recently, a drug-eluting bead (DC Bead) has been developed to enhance tumor drug delivery and reduce systemic availability. This randomized trial compares conventional TACE (cTACE) with TACE with DC Bead for the treatment of cirrhotic patients with HCC. Two hundred twelve patients with Child-Pugh A/B cirrhosis and large and/or multinodular, unresectable, N0, M0 HCCs were randomized to receive TACE with DC Bead loaded with doxorubicin or cTACE with doxorubicin. Randomization was stratified according to Child-Pugh status (A/B), performance status (ECOG 0/1), bilobar disease (yes/no), and prior curative treatment (yes/no). The primary endpoint was tumor response (EASL) at 6 months following independent, blinded review of MRI studies. The drug-eluting bead group showed higher rates of complete response, objective response, and disease control compared with the cTACE group (27% vs. 22%, 52% vs. 44%, and 63% vs. 52%, respectively). The hypothesis of superiority was not met (one-sided P = 0.11). However, patients with Child-Pugh B, ECOG 1, bilobar disease, and recurrent disease showed a significant increase in objective response (P = 0.038) compared to cTACE. DC Bead was associated with improved tolerability, with a significant reduction in serious liver toxicity (P < 0.001) and a significantly lower rate of doxorubicin-related side effects (P = 0.0001). TACE with DC Bead and doxorubicin is safe and effective in the treatment of HCC and offers a benefit to patients with more advanced disease.

Prospective randomized study of doxorubicin-eluting-bead embolization in the treatment of hepatocellular carcinoma: results of the PRECISION V study

Transcatheter arterial chemoembolization (TACE) offers a survival benefit to patients with intermediate hepatocellular carcinoma (HCC). A widely accepted TACE regimen includes administration of doxorubicin-oil emulsion followed by gelatine sponge-conventional TACE. Recently, a drug-eluting bead (DC Bead) has been developed to enhance tumor drug delivery and reduce systemic availability. This randomized trial compares conventional TACE (cTACE) with TACE with DC Bead for the treatment of cirrhotic patients with HCC. Two hundred twelve patients with Child-Pugh A/B cirrhosis and large and/or multinodular, unresectable, N0, M0 HCCs were randomized to receive TACE with DC Bead loaded with doxorubicin or cTACE with doxorubicin. Randomization was stratified according to Child-Pugh status (A/B), performance status (ECOG 0/1), bilobar disease (yes/no), and prior curative treatment (yes/no). The primary endpoint was tumor response (EASL) at 6 months following independent, blinded review of MRI studies. The drug-eluting bead group showed higher rates of complete response, objective response, and disease control compared with the cTACE group (27% vs. 22%, 52% vs. 44%, and 63% vs. 52%, respectively). The hypothesis of superiority was not met (one-sided P = 0.11). However, patients with Child-Pugh B, ECOG 1, bilobar disease, and recurrent disease showed a significant increase in objective response (P = 0.038) compared to cTACE. DC Bead was associated with improved tolerability, with a significant reduction in serious liver toxicity (P < 0.001) and a significantly lower rate of doxorubicin-related side effects (P = 0.0001). TACE with DC Bead and doxorubicin is safe and effective in the treatment of HCC and offers a benefit to patients with more advanced disease.

Transcatheter arterial chemoembolization for hepatocellular carcinoma after attempted portal vein embolization in 25 patients

OBJECTIVE

Portal vein embolization (PVE) has been widely used to facilitate major liver resection; however, curative surgery even after PVE may not be possible mainly because of inadequate hypertrophy of remnant liver or disease progression. For these patients, transcatheter arterial chemoembolization (TACE) is the next therapeutic option. We evaluated the safety and efficacy of TACE after PVE in 25 patients with hepatocellular carcinoma (HCC).

CONCLUSION

TACE using a single chemotherapeutic agent can be performed safely and effectively in HCC patients who previously underwent PVE. TACE after PVE allowed two of the patients to be downstaged so they could undergo surgical resection.

DC Bead: a major development in the toolbox for the interventional oncologist

The DC Bead is fast becoming the product of choice for use in the treatment of intermediate-stage hepatocellular carcinoma. It is a drug-eluting embolization system that is delivered intra-arterially and combines the effects of physical occlusion of the blood supply to a tumor with the local controlled delivery of a chemotherapeutic agent. While not suitable for use with all drugs, the components of this device enable rapid loading and sustained elution of therapeutic amounts of a range of clinically relevant anticancer compounds. Extensive preclinical testing has demonstrated the reproducibility and reliability of the device, together with reduced systemic drug exposure and sustained local drug delivery. Moreover, these attributes are translating into the clinic as significant benefits to patients with many types of liver tumors.

Arterial chemoembolization/embolization and early complications after hepatocellular carcinoma treatment: a safe standardized protocol in selected patients with Child class A and B cirrhosis

PURPOSE

To assess the safety of transarterial treatments of hepatocellular carcinoma (HCC), and the statistical correlation of various patient factors with the frequency of complications, in selected patients with cirrhosis when adhering to well-standardized protocols.

MATERIALS AND METHODS

Three hundred twenty consecutive patients with unresectable HCC were treated with transarterial chemoembolization, oil chemoembolization, and embolization. A total of 712 treatments were performed, with an average of 2.3 treatments for each patient. The epirubicin dose was adjusted according to defined laboratory criteria. An early complication was defined as one that occurred within 4 weeks of treatment. Complications were classified as minor and major and assessed by using clinical and laboratory data.

RESULTS

Of the 712 procedures, 21 complications (2.9%) occurred in 17 of the 320 patients (5.3%). Major complications included acute liver failure (n = 1, 0.1%), variceal bleeding (n = 2, 0.3%), moderate-to-severe ascites (n = 4, 0.6%), sepsis (n = 3, 0.4%), cholecystitis (n = 1, 0.1%), and diverticulitis (n = 1, 0.1%). Minor complications were hepatic artery damage, including spontaneously resolved dissection (n = 3, 0.4%), mild encephalopathy (n = 1, 0.1%), and aspartate aminotransferase/alanine aminotransferase levels greater than 500 U/L (n = 5, 0.7%). The 30-day mortality rate was 0.003% (n = 1). Constitutional syndrome (P = .0001), Child-Pugh score (P = .0001), ascites (P = .037), and the Model for End-Stage Liver Disease score (P = .02) were found to have a statistically significant correlation with complications after univariate analysis. Child-Pugh score (P = .012) and constitutional syndrome (P = .003) were found to have a statistically significant correlation with complications after logistic regression analysis.

CONCLUSIONS

Transarterial treatments can be considered safe in patients with Child class A and B cirrhosis when an adjusted dose of epirubicin is used according to body surface, severity of liver disease, and white blood cell count. Accurate patient selection and procedure-related factors may reduce the frequency of complications and help preserve liver function.

Analysis of nontarget embolization mechanisms during embolization and chemoembolization procedures

Complications of embolization and chemoembolization remain a problem even with the development of low-profile catheter material and the introduction of new embolization agents. In recent years many new embolization materials have become available for clinical use, so the possibilities and limitations of these new materials must be understood to allow safe and effective embolization. Although up to now some scientific work has been published reporting the basic risk of embolization procedures, the underlying pathomechanism remains the object of speculation. Besides complications like drug toxicity, allergic reactions, and bleeding of the puncture site, the characteristics of embolization materials must be known to understand the potential complications of nontarget embolization and reflux of embolization material. This article gives an overview of established and new embolization materials, their potential risks, and the underlying pathophysiology.

Drug-eluting particles in the treatment of HCC: chemoembolization with doxorubicin-loaded DC Bead

The advantage of chemoembolization of the liver as an antineoplastic treatment for hepatocellular carcinoma is that it achieves high intratumoral concentrations of the chemotherapeutic agent locally that cannot be reached with systemic chemotherapy in nontoxic doses. However, chemotherapeutic release and local concentrations cannot be standardized by this technique. Drug-eluting beads have predictable pharmacokinetics and can achieve higher doses of the chemotherapeutic and prolonged contact time with cancer cells. The DC Bead is a drug-eluting bead that has proven favorable kinetics and clinical characteristics. This review describes the features of the DC Bead loaded with doxorubicin for the treatment of hepatocellular carcinoma.

TACE versus TAE as therapy for hepatocellular carcinoma

Transarterial chemoembolization (TACE) improves survival in cirrhotic patients with hepatocellular carcinoma (HCC). The optimal schedule, best anticancer agent and best technique are still unclear. TACE may not be better than transarterial embolization (TAE). HCC is very chemoresistant, thus embolization may be more important than chemotherapy. Lipiodol cannot be considered as an embolic agent and there are no data to show that it can release chemotherapeutic agents slowly. It can mask residual vascularity on CT imaging and its use is not recommended. Both TACE and TAE result in hypoxia, which stimulates angiogenesis, promoting tumor growth; thus combination of TACE with antiangiogenic agents may improve current results. To date, there is no evidence that TACE pre-liver transplantation or resection helps to expand current selection criteria for patients with HCC, nor results in less recurrence after surgery. Combination with other techniques, such as radiofrequency ablation and drugs, may enhance the effect of TACE. New trials are being conducted to clarify these issues.

[The future of transcatheter antitumor therapy]

Transcatheter antitumor therapy very quickly accepted during the last decade and their importance in the treatment of oncology patients will be increasing. By improvement of new targeted agents, which can be given intraarterial or systemic, efficiency of transcatheteric therapeutic approaches can be drastically increased. Numerous clinical trials (study phase I / II / III) relating to the synergy of two antitumor therapeutic approaches are already in progress. Preliminary results of these trials are already very encouraging. Further improvement in the development of specific therapeutics antitumor drugs and systemic applications will be a big step in the quest for medication against malignant tumors.

Evidence-based diagnosis and locoregional therapy for hepatocellular carcinoma

Early identification of hepatocellular carcinoma (HCC) is crucial to improving the results of therapy and for patients to be eligible for liver transplantation. Recent advances in noninvasive imaging technology include various techniques of harmonic ultrasound, new ultrasound contrast agents, multislice helical computed tomography and rapid high-quality magnetic resonance. The imaging diagnosis relies on the hallmark of arterial hypervascularity with portal venous washout. Since the use of better radiological techniques has improved the accuracy of noninvasive diagnosis, the role of liver biopsy in the diagnosis of HCC has declined. With recent advances in genomics and proteomics, a great number of potential markers have been identified and developed as new candidate markers for HCC. Locoregional therapies currently constitute the best options for early nonsurgical treatment of HCC. Percutaneous ethanol injection shows similar results to resection surgery for single tumors less than 3 cm in diameter. Radiofrequency ablation is superior to percutaneous ethanol injection in terms of local recurrence. Transarterial chemoembolization is currently the most common approach for the management of HCC without curative options since it improves patient survival, but the optimal embolizing agent, length of interval between sessions and whether the chemotherapeutic agent has any effect have not yet been determined. Combining transarterial chemoembolization with antiangiogenic agents, as well as with other techniques, such as radiofrequency ablation, may improve the results. Injection of radioisotopes such as yttrium-90, via the hepatic artery, may be particularly useful in patients with portal vein thrombosis. Comparisons with other transarterial techniques are needed.

Optimal strategies for combining transcatheter arterial chemoembolization and radiofrequency ablation in rabbit VX2 hepatic tumors

PURPOSE

To determine the optimum combination strategy of transcatheter arterial chemoembolization and radiofrequency (RF) ablation in an experimentally induced hepatic tumor model.

MATERIALS AND METHODS

Twenty-five New Zealand White rabbits with VX2 carcinoma-induced hepatic tumors were randomly divided into five treatment groups, which received (i) chemoembolization followed 15 minutes later by RF ablation; (ii) RF ablation followed by chemoembolization; (iii) chemoembolization alone; (iv) RF ablation alone; and (v) bland embolization followed by RF ablation. Animals were euthanized at 48 hours to determine tumor infarction and coagulation, which were compared with analysis of variance. Representative histopathologic slides were compared.

RESULTS

Significantly larger areas of coagulation were produced by chemoembolization followed by RF ablation (22.0 cm(3) +/- 7.7) compared with RF ablation followed by chemoembolization (13.1 cm(3) +/- 3.2) and RF ablation alone (10.0 cm(3) +/- 4.5; P < .05). RF ablation followed by chemoembolization showed larger treatment areas than chemoembolization alone (25.0 cm(3) +/- 9.6 vs 12.1 cm(3) +/- 4.6; P < .001), with chemotherapeutic agent preferentially depositing around the coagulation zone. Histopathologic analysis revealed greater vascular thrombosis and necrosis and reduced islands of viable tumor cells in the chemoembolization/RF ablation group versus the groups treated with chemoembolization alone or bland embolization/RF ablation.

CONCLUSIONS

Larger treatment volumes were produced when chemoembolization was performed before RF ablation than when RF ablation preceded chemoembolization or when RF ablation or chemoembolization were performed alone. Larger treatment volumes were also produced when chemoembolization rather than bland embolization was performed before RF ablation, indicating the importance and synergy of the chemotherapeutic regimen. These results suggest that the reduction of tumor blood flow combined with the effect of hyperthermia and local chemotherapy creates the largest dimensions of treatment.

Unusual severe complication following transarterial chemoembolization for metastatic malignant melanoma: giant intrahepatic cyst and fatal hepatic failure

We describe a 45-year-old male patient with malignant melanoma who underwent hepatic arterial chemoembolization due to liver metastases. Four months after the procedure, the patient developed a giant cystic cavity in the liver. Cytologic examination of the cystic fluid retention revealed necrotic tumor material. The fluid was drained by percutaneous catheter, but the patient developed hepatic failure. This case represents another rare complication of transarterial chemoembolization and shows that transarterial chemoembolization may have rare fatal complications.

Transarterial chemoembolization for hepatocellular carcinoma with drug-eluting microspheres: preliminary results from an Italian multicentre study

The purpose of this article is to present the early results of a multicentre trial using HepaSphere microspheres loaded with chemotherapeutic agents for transarterial chemoembolization (TACE) in patients with unresectable hepatocellular carcinoma. From December 2005 to March 2007, 50 patients (36 male and 14 female, mean age 68.4 years) were treated by selective TACE using HepaSphere microspheres loaded with doxorubicin or epirubicin. The diameter of the treated lesions ranged from 20 to 100 mm (mean 42.5; maximum of 4 tumor nodules). Tumor response was evaluated by computed axial tomography according to the World Health Organization criteria as modified by the European Association for the Study of Liver Diseases. All of the procedures were technically successful, and there were no major complications. At 1-month follow-up, complete tumor response was observed in 24 of 50 (48%), partial response in 18 of 50 (36%), and stable disease in 8 of 50 (16%) patients, and there were no cases of disease progression. At 6-month follow-up (31 of 50 patients), complete tumor response was obtained in 16 of 31 (51.6%), partial response in 8 of 31 (25.8%), and progressive disease in 7 of 31 (22.6%) patients. Within the initial 9-month follow-up, TACE with HepaSphere was successfully repeated twice in 3 patients, whereas 3 patients underwent the procedure 3 times. Our initial multicentre experience demonstrates that TACE using HepaSphere is feasible, is well tolerated, has a low complication rate, and is associated with promising tumor response. When complete tumor response in not achieved, additional treatments can be performed without difficulties. Longer follow-up on larger series is mandatory to confirm these preliminary results.

[Patient information and informed consent in interventional radiology]

Patient information and informed consent consultation before any invasive examination or treatment is meant to obtain the binding consent of the patient. It makes an important contribution to the physician-patient relationship and helps the orientation of the patient as well as the physician before the intervention. The aim of this article is to briefly explain the basic practical and legal principles of the patient information. Furthermore general risks of examinations and treatments in interventional radiology and specific risks of frequent interventional procedures are explained in more detail.