Survival benefit of patients with inoperable hepatocellular carcinoma treated by a combination of transarterial chemoembolization and percutaneous ethanol injection--a single-center analysis including 132 patients

Applicability of scoring systems predicting outcome of transarterial chemoembolization for hepatocellular carcinoma

PURPOSE

Several scoring systems have been proposed to predict the outcome of transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC). However, the application of these scores to a bridging to transplant setting is poorly validated. Evaluation of the applicability of prognostic scores for patients undergoing TACE in palliative intention vs. bridging therapy to liver transplantation (LT) is necessary.

METHODS

Between 2008 and 2017, 148 patients with HCC received 492 completed TACE procedures (158 for bridging to transplant; 334 TACE procedures in palliative treatment intention at our center and were analyzed retrospectively. Scores (ART, CLIP, ALBI, APRI, SNACOR, HAP, STATE score, Child-Pugh, MELD, Okuda and BCLC) were calculated and evaluated for prediction of overall survival. ROC analysis was performed to assess prediction of 3-year survival and treatment discontinuation.

RESULTS

In patients receiving TACE in palliative intention most scores predicted OS in univariate analysis but only mSNACOR score (p = 0.006), State score (p < 0.001) and Child-Pugh score (p < 0.001) revealed statistical significance in the multivariate analysis. In the bridging to LT cohort only the BCLC score revealed statistical significance (p = 0.002).

CONCLUSIONS

Clinical usability of suggested scoring systems for TACE might be limited depending on the individual patient cohorts and the indication. Especially in patients receiving TACE as bridging to LT none of the scores showed sufficiently applicability. In our study Child-Pugh score, STATE score and mSNACOR score showed the best performance assessing OS in patients with TACE as palliative therapy.

Predictors of 5 year survival rate in hepatocellular carcinoma patients

Background

Hepatocellular carcinoma (HCC) is one of the most common primary hepatic malignancies and growing challenges of global health. In this study, for the first time in Iran, we investigated the 5-year survival rate and prognostic factors in patients with HCC.

Materials and Methods

In this historical cohort study, we examined the medical records of 227 HCC patients who were registered in the central tumor registry of our institution from September 2007 to September 2017. Demographic data, clinical parameters, received treatments, and survival curves from time of diagnosis were evaluated. Kaplan-Meier was used for univariate analysis, and multivariable analysis was performed by Cox regression.

Results

A total of 208 (91.63%) patients were dead. The 5-year survival rate was estimated 19 (8.37%). The average follow-up in this study was 14.3 months. Overall median survival rate was 12.1 months. Univariate analysis showed that tumor size, metastasis, number of involved lymph node, hepatitis type, and treatment were significantly related to the survival rate, and Cox regression analysis revealed that the tumor size >3 cm (hazard ratio [HR] = 3.06, 95% confidence interval [CI] = 1.68-4.97; P = 0.027), involved lymph nodes >2 (HR = 4.12, 95% CI = 2.66-6.38; P = 0.001), metastasis (HR = 3.87, 95% CI = 3.13-6.54; P = 0.011), combination therapy with surgery and chemotherapy (HR = 0.4, 95% CI = 0.15-0.79; P = 0.023), and coinfection with hepatitis B virus and hepatitis C virus (HR = 2.11, 95% CI = 1.81-4.6; P = 0.036) are the most relevant prognostic factors with 5-year survival rate in patients with HCC.

Conclusion

Results of this study will help estimate survival rates for patients with HCC according to their clinical status.

Multipronged ethanol ablation combined with TACE for intermediate hepatocellular carcinoma

PURPOSE

To retrospectively investigate the efficacy of multipronged ethanol ablation with or without transarterial chemoembolization (TACE) in the treatment of intermediate hepatocellular carcinoma (HCC) (3.1-5.0 cm in diameter) at high-risk locations .

MATERIAL AND METHODS

From March 2009 to April 2014, 25 consecutive patients with intermediate HCC who underwent multipronged ethanol ablation combined with TACE were included in the combination treatment group, while 50 patients who underwent multipronged ethanol ablation alone were included in the control group.

RESULTS

Primary technique effectiveness was achieved in 70 patients (25/25, 100% in the combination treatment group; 45/50, 90% in the control group; p = .162). The local tumor progression (LTP) rates at 1, 3, 5, and 7 years were 8.0%, 24.0%, 24.0%, and 24.0% in the combination treatment group, respectively, which were significantly lower than those in the control group (24.4%, 44.1%, 66.5% and 66.5%, respectively; p = .043). However, no significant differences of overall survival and disease-free survival were found between the two groups (p = .996 and .974, respectively).

CONCLUSION

Multipronged ethanol ablation combined with TACE could improve local tumor control for patients with intermediate HCC at high-risk locations when compared with multipronged ethanol ablation alone, although the survival outcomes were comparable.

Comparing the long-term efficacy of standard and combined minimally invasive procedures for unresectable HCC: a mixed treatment comparison

A small proportion of hepatocellular carcinoma (HCC) patients are suitable for surgical resections and various minimally invasive procedures have been introduced as alternatives to surgical resections. However, the relative efficacy of minimally invasive procedures remains to be studied in the current literature. Several popular minimally invasive procedures (monotherapy or combined therapies) were selected for comparison and their relative long-term efficacy were determined by using the statistics of hazard ratio (HR) which evaluates the survival status of HCC patients in one, two, three and four years, respectively. Evidence were obtained from the current literature and synthesized by using the approach of conventional pairwise meta-analysis and network meta-analysis (NMA). Moreover, selected minimally invasive procedures were ranked according to their surface under the cumulative ranking curve (SUCRA) which was produced by NMA in conjunction with the Markov Chain Monte Carlo (MCMC) sampling method. HCC patients treated by combined minimally invasive procedures, particularly transcatheter arterial chemoembolization (TACE) + high intensity focused ultrasound (HIFU), TACE + radiofrequency ablation (RFA), TACE + radiotherapy (RT) and TACE + Sorafenib (SOR) exhibited a significant decrease in the HR compared to those with standard TACE (HR < 1). The combined minimally invasive procedure of TACE + HIFU appears to be the most preferable therapy. PEI seems to be less favorable than other minimally invasive procedures. Combined minimally invasive procedures may be more preferable than standard minimally invasive procedures. Percutaneous ethanol injection (PEI) may not provide adequate efficacy compared to other minimally invasive procedures for unresectable HCC patients.

Multidisciplinary management of hepatocellular carcinoma with portal vein tumor thrombus - Eastern Hepatobiliary Surgical Hospital consensus statement

Hepatocellular carcinoma (HCC) complicated by portal vein tumor thrombus (PVTT) is associated with poor prognosis, early recurrence of HCC, and limited treatment options. Current guidelines do not have standardized diagnostic and treatment modalities, thus creating a need for a multidisciplinary treatment model for standardization of the treatment. Eastern Hepatobiliary Surgical Hospital (China) convened two working parties of experts from all the departments, to consolidate the current evidence, prevailing vision for the future, and experience of the practicing clinicians engaged in HCC management, so as to develop a consensus for PVTT diagnosis and treatment according to the GRADE system. Based on the quality of the existing evidence and the strength of recommendations, the consensus statements were categorized into 3 evidence levels (A/B/C) and 5 classes (I/II/IIa/IIb/III).The panel discussed and provided clarity on the management and research options in the field of HCC with PVTT. In addition, the panel also assessed the quality of the cited studies and assigned grades to the recommendation statements. Among the group of experts, there was excellent agreement with regard to effective diagnosis and treatment of HCC with PVTT. The recommendations of this consensus will provide guidance to physicians and clinical researchers on the effective management of HCC with PVTT.

Portal vein tumor thrombus is a bottleneck in the treatment of hepatocellular carcinoma

The effect of portal vein tumor thrombus (PVTT) on the prognosis of patients with hepatocellular carcinoma has become clear over the past several decades. However, identifying the mechanisms and performing the diagnosis and treatment of PVTT remain challenging. Therefore, this study aimed to summarize the progress in these areas. A computerized literature search in Medline and EMBASE was performed with the following combinations of search terms: “hepatocellular carcinoma” AND “portal vein tumor thrombus.” Although several signal transduction or molecular pathways related to PVTT have been identified, the exact mechanisms of PVTT are still largely unknown. Many biomarkers have been reported to detect microvascular invasion, but none have proved to be clinically useful because of their low accuracy rates. Sorafenib is the only recommended therapeutic strategy in Western countries. However, more treatment options are recommended in Eastern countries, including surgery, radiotherapy (RT), transhepatic arterial chemoembolization (TACE), transarterial radioembolization (TARE), and sorafenib. Therefore, we established a staging system based on the extent of portal vein invasion. Our staging system effectively predicts the long-term survival of PVTT patients. Currently, several clinical trials had shown that surgery is effective and safe in some PVTT patients. RT, TARE, and TACE can also be performed safely in patients with good liver function. However, only a few comparative clinical trials had compared the effectiveness of these treatments. Therefore, more randomized controlled trials examining the extent of PVTT should be conducted in the future.

Combining locoregional therapies in the treatment of hepatocellular carcinoma

In an effort to promote more durable local control of larger lesions, thermal ablation has been combined with chemical ablative techniques and with vaso-occlusive procedures such as chemoembolization and bland embolization in an effort to mitigate the limitations inherent in the use of any single treatment for hepatocellular carcinoma (HCC) >3 cm. The heat-sink effect is the underlying principle for combining vaso-occlusive therapies with ablative techniques. Combination therapies do present viable options for abrogating tumor progression and potentially downsizing tumors to facilitate transplant. We discuss the two most commonly used combination locoregional therapies by the interventionalist and the evidence defining the best techniques in practice.

Treatment outcomes of transcatheter arterial chemoembolization combined with local ablative therapy versus monotherapy in hepatocellular carcinoma: a meta-analysis

PURPOSE

To evaluate the effectiveness comparing the combination of TACE with local ablative therapy and monotherapy on the treatment of HCC using meta-analytical techniques.

METHODS

Randomized controlled trials and clinical studies comparing TACE plus local ablative therapy with monotherapy for HCC were included in this meta-analysis. Response rate, 1-, 2-, 3-, and 5-year survival rate, and overall survival (OS) were analyzed and compared.

RESULTS

Eighteen studies included a total of 2,120 patients with HCC 1,071 and 1,049 patients for treatment with combination therapy and monotherapy, respectively. The combination therapy group had a significantly better survival in terms of 1-, 2-, 3-, and 5-year survival rate (RR 1.10, 95 % CI 1.03–1.18, P = 0.005; RR 1.20, 95 % CI 1.10–1.30, P < 0.0001; RR 1.43, 95 % CI 1.18–1.73, P < 0.0001; RR 1.40, 95 % CI 1.22–1.61, P < 0.0001, respectively), OS (HR 0.66, 95 % CI 0.51–0.85, P = 0.001), and response rate (RR 1.54, 95 % CI 1.09–2.18, P = 0.013) than that monotherapy group in patients with HCC.

CONCLUSIONS

The meta-analysis indicates that the combination of TACE with local ablative therapy was superior to monotherapy in the treatment for patients with HCC.

Impact of sarcopenia on outcomes following intra-arterial therapy of hepatic malignancies

BACKGROUND

Assessment of patient performance status is often subjective. Sarcopenia--measurement of muscle wasting--may be a more objective means to assess performance status and therefore mortality risk following intra-arterial therapy (IAT).

METHODS

Total psoas area (TPA) was measured on cross-sectional imaging in 216 patients undergoing IAT of hepatic malignancies between 2002 and 2012. Sarcopenia was defined as TPA in the lowest sex-specific quartile. Impact of sarcopenia was assessed relative to other clinicopathological factors.

RESULTS

Indications for IAT included hepatocellular carcinoma (51 %), intrahepatic cholangiocarcinoma (13 %), colorectal liver metastasis (7 %), or other metastatic disease (30 %). Median TPA among men (568 mm(2)/m(2)) was greater than women (413 mm(2)/m(2)). IAT involved conventional chemoembolization (54 %), drug-eluting beads (40 %), or yttrium-90 (6 %). Median tumor size was 5.8 cm; most patients had multiple lesions (74 %). Ninety-day mortality was 9.3 %; 3-year survival was 39 %. Factors associated with risk of death were tumor size (HR = 1.84) and Child's score (HR = 2.15) (all P < 0.05). On multivariate analysis, sarcopenia remained independently associated with increased risk of death (lowest vs. highest TPA quartile, HR = 1.84; P = 0.04). Sarcopenic patients had a 3-year survival of 28 vs. 44 % for non-sarcopenic patients.

CONCLUSIONS

Sarcopenia was an independent predictor of mortality following IAT with sarcopenic patients having a twofold increased risk of death. Sarcopenia is an objective measure of frailty that can help clinical decision-making regarding IAT for hepatic malignancies.

Transarterial chemoembolization in combination with local therapies for hepatocellular carcinoma: a meta-analysis

Background

In previous randomized trials, transarterial chemoembolization (TACE) has shown an improvement of survival rate in hepatocellular carcinoma (HCC) when combined with radiofrequency ablation (RFA), percutaneous ethanol injection (PEI) or other therapies. The aim of this meta-analysis was to evaluate the effectiveness of combination therapy of TACE with RFA, PEI, radiotherapy (RT), three-dimensional conformal radiation therapy (3D-CRT) or High-Intensity Focused Ultrasound (HIFU).

Methods

Randomized or nonrandomized studies comparing TACE combined with RFA, PEI, RT, 3D-CRT or HIFU with TACE alone for HCC were included. Meta-analysis was performed using a fix-effects model in RCTs and a random-effects model among the observational studies.

Results

10 randomized trials and 18 observational studies matched the selection criteria, including 2497 patients (682 in RCTs, 1815 in non-RCTs). Meta-analysis of RCTs showed that the combination of TACE and PEI ((RR)_1-year=1.10, 95%CI=0.99-1.22, p=0.073; (RR)_3-year=2.32, 95%CI=1.52-3.53, p<0.001), TACE+RT ((RR)_1-year=1.37, 95%CI=1.11-1.70, p=0.004; (RR)_3-year=2.32, 95%CI=1.44-3.75, p=0.001) were associated with higher survival rates. The results of observational studies were in good consistency with that of RCTs. Furthermore, TACE plus 3D-CRT ((RR)_1-year=1.22, 95%CI=1.06-1.41, p=0.005; (RR)_3-year=2.05, 95%CI=1.48-2.84, p<0.001) and TACE plus HIFU ((RR)_1-year=1.16, 95%CI=1.01-1.33, p=0.033; (RR)_3-year=1.66, 95%CI=1.12-2.45, p=0.011) have introduced marked survival benefit when pooling results from observational studies.

Conclusions

This meta-analysis demonstrated that TACE combined with local treatments, especially PEI, HIFU or 3D-CRT could improve the overall survival status than performing TACE alone. Importantly, these results need to be validated in further high-quality clinical trials.

Transarterial chemoembolization in combination with local therapies for hepatocellular carcinoma: a meta-analysis

BACKGROUND

In previous randomized trials, transarterial chemoembolization (TACE) has shown an improvement of survival rate in hepatocellular carcinoma (HCC) when combined with radiofrequency ablation (RFA), percutaneous ethanol injection (PEI) or other therapies. The aim of this meta-analysis was to evaluate the effectiveness of combination therapy of TACE with RFA, PEI, radiotherapy (RT), three-dimensional conformal radiation therapy (3D-CRT) or High-Intensity Focused Ultrasound (HIFU).

METHODS

Randomized or nonrandomized studies comparing TACE combined with RFA, PEI, RT, 3D-CRT or HIFU with TACE alone for HCC were included. Meta-analysis was performed using a fix-effects model in RCTs and a random-effects model among the observational studies.

RESULTS

10 randomized trials and 18 observational studies matched the selection criteria, including 2497 patients (682 in RCTs, 1815 in non-RCTs). Meta-analysis of RCTs showed that the combination of TACE and PEI ((RR)(1-)year=1.10, 95%CI=0.99-1.22, p=0.073; (RR)(3-)year=2.32, 95%CI=1.52-3.53, p<0.001), TACE+RT ((RR)(1-)year=1.37, 95%CI=1.11-1.70, p=0.004; (RR)(3-)year=2.32, 95%CI=1.44-3.75, p=0.001) were associated with higher survival rates. The results of observational studies were in good consistency with that of RCTs. Furthermore, TACE plus 3D-CRT ((RR)1 -year=1.22, 95%CI=1.06-1.41, p=0.005; (RR)(3-)year=2.05, 95%CI=1.48-2.84, p<0.001) and TACE plus HIFU ((RR)(1-)year=1.16, 95%CI=1.01-1.33, p=0.033; (RR)(3-)year=1.66, 95%CI=1.12-2.45, p=0.011) have introduced marked survival benefit when pooling results from observational studies.

CONCLUSIONS

This meta-analysis demonstrated that TACE combined with local treatments, especially PEI, HIFU or 3D-CRT could improve the overall survival status than performing TACE alone. Importantly, these results need to be validated in further high-quality clinical trials.

Transarterial chemoembolization compared with conservative treatment for advanced hepatocellular carcinoma with portal vein tumor thrombus: using a new classification

We aimed to compare the survival benefit of transarterial chemoembolization (TACE) with conservative treatment for patients with advanced hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT), furthermore, to reveal which PVTT types benefit from TACE treatment. From August 2007 to January 2010, a prospective controlled study was performed on consecutive patients with advanced HCC and PVTT. Of a total of 150 patients, 115 were treated with TACE (lipiodol and anticancer agents ± gelatin sponge embolization), and 35 who refused to accept the procedure were treated with conservative treatment. We performed survival analysis of the two treatment groups and then stratified by a new classification of PVTT that was divided into four types. Overall survival was significantly better in the TACE group than in the conservative group (8.67 months vs. 1.4 months, P<0.001). The overall median survival for types I-IV PVTT were 12.0, 8.3, 5.0, and 2.43 months (P<0.01). On subgroup analysis of PVTT, the median survival in the TACE group compared with conservative group for type I, II, III, and IV PVTT was 19.0 months versus 4.0 months, 11.0 months versus 1.43 months, 7.1 months versus 1.3 months, and 4.0 months versus 1.0 months, respectively (P<0.01). The TACE group had significantly better survival than the conservative group for different extent of PVTT. TACE is an effective treatment mode compared with conservative treatment for HCC and PVTT and may provide a significantly better survival benefit for different extent of PVTT.

Development of regional chemotherapies: feasibility, safety and efficacy in clinical use and preclinical studies

Conventional oral and intravenous chemotherapies permeate throughout the body, exposing healthy tissues to similar cytotoxic drug levels as tumors. This leads to significant dose-limiting toxicities that may prevent patients from receiving sufficient treatment to overcome cancers. Therefore, a number of locoregional drug-delivery strategies have been evaluated and implemented in preclinical studies, clinical trials and in practice, in the past decades to minimize systemic toxicities from chemotherapeutic agents and to improve treatment outcomes. Localized treatment is beneficial because many cancers, such as melanoma, peritoneal cancer and breast cancer, advance locally adjacent to the site of the primary tumors prior to their circulatory invasion. In this article, we will review the feasibility, safety and efficacy of multiple localized chemotherapies in clinical use and preclinical development.

Evaluation of transarterial chemoembolization combined with percutaneous ethanol ablation for large hepatocellular carcinoma

AIM: To assess the effects of combined transcatheter arterial chemoembolization (TACE) and percutaneous ethanol ablation (PEA) in patients with large hepatocellular carcinoma (HCC).

METHODS: A total of 63 patients with unresectable large HCC were treated with TACE followed by PEA. The largest dimension of the tumors ranged from 5.3 cm to 17.8 cm. The survival rates, acute effects, toxicity and prognostic factors were analyzed.

RESULTS: The cumulative survival rates at 1, 3 and 5 years were 59.4%, 28.4% and 15.8%, respectively (a median survival of 27.7 mo). Tumor area was reduced by more than 50% in 30 (47.6%) cases. In 56 cases with increased α-fetoprotein (AFP) values, AFP level was declined by more than 75%. The combined therapy was generally well tolerated. Only two patients died from variceal bleeding associated with the therapy. The Cox proportional hazards model showed that the number of tumors, the tumor margin and the ethanol dose were independent prognostic factors.

CONCLUSION: The combined TACE and PEA therapy is a promising approach for unresectable large HCC.

Prognostic factors for survival in patients with unresectable hepatocellular carcinoma undergoing chemoembolization with doxorubicin drug-eluting beads: a preliminary study

BACKGROUND

Transarterial chemoembolization (TACE) with drug-eluting beads (DEB) is a new treatment modality. Little is known about prognostic factors affecting survival after DEB TACE for patients with hepatocellular carcinoma (HCC).

METHODS

Patients who underwent TACE with doxorubicin DEB for unresectable HCC during 2006-2008 were studied. Survival was calculated from the day of first transcatheter therapy. Survival analysis was performed using Kaplan-Meier estimations. Survival curves were compared using the log-rank test.

RESULTS

Fifty patients underwent chemoembolization with doxorubicin DEB. They included 39 women and 11 men, with a median age of 57.5 years (range 28-91 years). Eighteen patients died during the study period and 32 remained alive. Overall survival rates at 6 months, 1 year and 2 years from the first administration of doxorubicin DEB TACE were 71%, 65% and 51%, respectively. Prognostic factors found to be significant on univariate analysis were Child-Pugh class, Okuda staging, bilirubin > 2 mg/dl, albumin < 3.0 g/dl, Model for End-stage Liver Disease (MELD) score, serum alphafetoprotein (AFP), Cancer of the Liver Italian Programme (CLIP) score, tumour satisfying Milan criteria, Eastern Cooperative Oncology Group (ECOG) performance status (PS) and Barcelona Clinic Liver Cancer (BCLC) staging.

CONCLUSIONS

Child-Pugh class, Okuda staging, bilirubin > 2 mg/dl, albumin < 3 g/dl, MELD score, serum AFP, CLIP score, Milan criteria, ECOG PS and BCLC staging were found to be prognostic markers of survival after treatment with doxorubicin DEB TACE in patients with unresectable HCC.

Selecting a short-term prognostic model for hepatocellular carcinoma: comparison between the model for end-stage liver disease (MELD), MELD-sodium, and five cancer staging systems

BACKGROUND

The model for end-stage liver disease (MELD) and MELD-sodium (MELD-Na) are prognostic models for cirrhotic patients with or without hepatocellular carcinoma (HCC). This study compared the predictive accuracy between the MELD, MELD-Na, TNM (tumor, node, metastasis), Cancer of the Liver Italian Program (CLIP), Barcelona Clinic Liver Cancer (BCLC), Japan Integrated Scoring (JIS), and Tokyo score for 3-month and 6-month mortality in HCC patients.

METHODS

A total of 953 patients were prospectively enrolled. The predictive accuracy was compared between different models using the area under receiver operating characteristic curve (AUC).

RESULTS

The CLIP system had the highest AUC (0.875) for predicting 3-month mortality, followed by the Tokyo score (0.874), JIS (0.868), BCLC (0.855), MELD-Na (0.829), MELD (0.803), and finally, TNM (0.795) system. At 6 months, the top 3 models and their AUCs were the CLIP (0.882), Tokyo (0.861), and JIS (0.85). MELD-Na consistently had significantly better predictive accuracy than the MELD at 3 and 6 months. The MELD and MELD-Na were better prognostic models in predicting the mortality for surgical patients (AUC, 0.719 to 0.740), whereas the CLIP and Tokyo systems were the 2 better models in staging nonsurgical (AUC, 0.849 to 0.884) and high-risk patients (AUC, 0.790 to 0.846), defined as having at least 2 independent risk factors of mortality, at 3 and 6 months.

CONCLUSIONS

The MELD-Na may improve the prognostic ability of the MELD system for patients with HCC. Both the CLIP and Tokyo systems are better short-term prognostic models. These findings are helpful in designing future clinical trials for HCC.

Outcome of transarterial chemoembolization monotherapy, and in combination with percutaneous ethanol injection, or radiofrequency ablation therapy for hepatocellular carcinoma

AIM

Hepatocellular carcinoma (HCC) is one of the most commonly occurring malignances worldwide. Curative therapies such as resection, percutaneous ethanol injection (PEI) and radiofrequency ablation (RFA) have been applied to patients with early-stage HCC. Patients with more advanced cancers require local or systemic therapies. We present the results of our retrospective review conducted to evaluate whether transarterial chemoembolization (TACE) alone and combined TACE with percutaneous ablation for HCC exhibited superior efficacy to palliative treatment.

METHODS

The effects of TACE and of the combined therapies (TACE + PEI or TACE + RFA) on the long-term survival rates were evaluated in 268 untreated HCC patients by various statistical analyses.

RESULTS

The cumulative survival rates in the TACE alone group were significantly superior to those in the palliative treatment group. Further, the cumulative survival rates in the combined TACE + PEI/RFA group were significantly superior to those in the TACE alone group. When the comparison among the groups was restricted to patients with two or three tumors fulfilling the Milan criteria, significantly greater prolongation of survival was observed in the combined TACE + PEI/RFA group than in the PEI/RFA alone group.

CONCLUSIONS

The aforementioned treatment modalities yielded greater improvements of the survival rate and survival duration as compared to palliative treatment in HCC patients. Furthermore, in terms of the effect on the survival period, combined TACE + PEI/RFA therapy was more effective than TACE monotherapy, and also more effective than PEI or RFA monotherapy in cases with multiple tumors fulfilling the Milan criteria.

Adjuvant transcatheter arterial chemoembolization improves efficacy of hepatectomy for patients with hepatocellular carcinoma and portal vein tumor thrombus

PURPOSE

To study the value of postoperative transcatheter arterial chemoembolization (TACE) to improve the efficacy of hepatectomy and tumor thrombus removal for patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT).

EXPERIMENTAL DESIGN

From January 1996 to December 2004, 126 patients with HCC and PVTT were randomly assigned into 2 groups: a control group and a TACE group. The control group underwent liver resection combined with PVTT removal, and the TACE group underwent liver resection combined with adjuvant TACE after surgery. Survival time in the 2 groups was studied.

RESULTS

The 2 groups were comparable with regard to all clinicopathologic data. The median survival time was 13 months (95% confidence interval [CI] 6.25 to 19.75 months) for the TACE group and 9 months (95% CI 6.90 to 11.10 months) for the control group. Estimated survival rates for 1, 3 and 5 years were better in the TACE group (50.9%, 33.8%, 21.5%; respectively) than the control group (33.3%, 17.0%, 8.5%, respectively; log rank P = .0094).

CONCLUSIONS

Postoperative TACE enhances the effect of liver resection combined with PVTT removal for HCC patients with PVTT.

Transarterial chemoembolization in patients not eligible for liver transplantation: single-center results

OBJECTIVE

The purpose of this study was to evaluate the effectiveness of transarterial chemoembolization in the care of patients not eligible for liver transplantation.

CONCLUSIONS

Prognosis depends on local response, Okuda score, alpha-fetoprotein level, and tumor size and is independent of the presence of portal venous thrombosis.

[Molecular pathogenesis of hepatocellular carcinoma: new therapeutic approaches and predictive pathology]

Hepatocellular carcinoma is one of the most prevalent malignancies worldwide and its incidence is increasing. Multimodal strategies directed towards this carcinoma include primary (e.g. immunisation) and secondary (e.g. antiviral therapy) prevention, surgical approaches, novel specific systemic therapies (targeted therapy), and the treatment of comorbidity (cirrhosis). New molecular approaches are currently under development. These tackle several specific targets, with pathology being challenged in many aspects: experimental evaluation, the development of valid tumor-relevant diagnostic tests as well as morphological evaluation in the context of clinical studies, and finally in routine diagnosis.

Transarterial chemoembolization for primary hepatocellular carcinoma in patients at high risk

PURPOSE

Transarterial chemoembolization (TACE) has become a standard treatment option for patients with unresectable hepatocellular carcinoma (HCC). This retrospective study evaluated the safety and efficacy of TACE in patients at high risk with increased serum bilirubin level, low serum albumin level, poor hepatic reserve, or compromised hepatopetal flow in the portal vein (PV).

MATERIALS AND METHODS

A total of 52 patients underwent 65 high-risk procedures. Thirty patients treated with 38 procedures (57.7% of patients and 58.5% of procedures) had serum bilirubin levels of 2-3 mg/dL (ie, moderate elevation) and 22 patients treated with 27 procedures (42.3% and 41.5%) had a serum bilirubin level of at least 3 mg/dL (ie, considerable elevation). Forty patients (76.9%) had serum albumin levels less than 3.5 mg/dL. Thirteen recipients of 15 procedures (25% and 20%) had portal diversion or obstruction. Twenty-four patients (46.2%) had a Child-Pugh (CP) score of 8 or less and 28 patients (53.8%) had a CP score of at least 9 at the time of TACE. Thirty patients (57.7%) had focal tumors and 22 patients (42.3%) had multifocal or infiltrative disease. Superselective chemoembolization could be performed in 37 procedures (56.9%); lobar chemoembolization was performed in the remaining 28 (43.1%).

RESULTS

The 30-day mortality rate was 7.7% and the procedure-related morbidity rate was 10.8%. Patients with multifocal disease and lobar embolization had significantly higher mortality rates (P=.03). Individual factors such as serum bilirubin, serum albumin, and PV flow did not affect outcomes significantly. The 1- and 2-year survival rates in patients with focal disease were 67.9% and 37.7%, respectively, compared with 19.6% and 0% in patients with multifocal disease (P<.0001).

CONCLUSIONS

TACE in patients considered at high risk does not necessarily incur a higher incidence of morbidity or mortality. Patient selection should be based on extent of disease, and these tumors should be treated selectively at a segmental level if possible.

[Regional therapy of liver tumors]

Malignant liver tumors are either originating from the liver, such as the primary liver tumors hepatocellular carcinoma and the cholangiocellular carcinoma, or metastases from extrahepatic malignancies. Apart from surgical procedures (resection, liver transplantation) percutaneous local-ablative (ethanol injection, radiofrequency thermal ablation as well as radiation therapy) and transarterial interventions are non-surgical therapeutic options. While these regional therapies have been shown in randomised controlled studies to be effective for hepatocellular carcinoma, their therapeutic efficacy in cholangiocellular carcinoma and liver metastases has not been shown. In the following we will summarize the regional therapeutic options in primary and secondary liver tumors.

Treatment of hepatocarcinoma

This article reviews the current developments and significant trends in the treatment of hepatocarcinoma (HCC). Prevention programs should be based on large vaccination campaigns and the use of immunologic or biologic molecules to delay the onset of HCC in already cirrhotic patients. Surgery remains the therapy of choice in patients with a small and limited number of tumor nodules. To date, no preoperative treatment has been proven useful. Adjuvant treatments involving systemic chemotherapy, intra-arterial infusion, or chemoembolization failed to improve survival, whereas immune therapy, retinoids, radiolabeled isotopes, and antiangiogenic agents seem promising. Such local treatments as percutaneous ethanol injection, cryotherapy, and radiofrequency are proposed for patients with limited hepatic function and should be combined with other treatment modalities to optimize their efficacy and limit their toxicity. Regional therapy should take a selective, subsegmental approach at intervals depending on tumor response and possibly combined with other treatment modalities. Systemic therapy with cytotoxic agents remains disappointing. Hormonal therapy with tamoxifen or antiandrogens has shown no efficacy and might even be detrimental. Further progress may be expected from targeted therapy.

Emerging approaches in hepatocellular carcinoma

The incidence of hepatocellular carcinoma (HCC) is predicted to continue to increase over the next 30 years. Surgical intervention, including resection and orthotopic liver transplantation (OLT) is offered to a limited number of patients. Novel approaches to the treatment of patients with HCC are needed. This article aims to review emerging approaches in the care of the HCC patient including systemic treatment, selection of appropriate candidates for OLT, improved imaging to follow treatment response, and management pre-OLT and post-OLT.

A primer on transarterial, chemical, and thermal ablative therapies for hepatic tumors

BACKGROUND

Surgical resection is the only potentially curative approach for patients with primary and metastatic liver tumors. Unfortunately, most patients with hepatic malignancy are precluded from resection due to multifocal disease, anatomic limitations, inadequate functional liver reserve, extrahepatic metastases, or medical comorbidities. Consequently, several methods of tumor ablation have been developed as alternate treatment strategies for patients with unresectable hepatic tumors or as adjuncts in total cancer therapy. The purpose of this review is to inclusively define the various ablation modalities available (transarterial, chemical, and thermal ablative), and to describe the procedures, general applications, and reported outcomes.

DATA SOURCES

A MEDLINE and CINAHL search of the English-language literature was performed on transarterial, chemical, and thermal ablative therapies.

CONCLUSIONS

Presently, radiofrequency thermal ablation is the most widely applicable liver-directed modality for hepatic tumor ablation, enabling treatment of primary and metastatic tumors. However, other transarterial and thermoablative techniques are available with accumulating data for their use. Lacking at present are studies that define the role and potential benefit of the various liver-directed modalities in the treatment algorithm for hepatic tumors.

CD117 (c-kit) expression in human hepatocellular carcinoma

AIMS

Although various methods of treatment have been tried, treatment options for advanced hepatocellular carcinoma (HCC) remain limited. Expression of the platelet-derived growth factor has been shown in HCC, which may derive from hepatic stem cells that express the c-kit proto-oncogene. Because of the promising results of imatinib and the key role played by c-kit in gastrointestinal stromal tumours and other solid tumours, the aim of this study was to determine the prevalence of c-kit (CD117) overexpression in patients with HCC.

MATERIALS AND METHODS

A retrospective study of 258 archival specimens of subjects with histologically confirmed HCC was carried out. Expression of the c-kit proto-oncogene was evaluated by immunohistochemistry using rabbit anti-CD117 antibody A4502.

RESULTS

The overall percentage of positive immunohistochemical staining of HCCs was 2.3% (6/258).

CONCLUSIONS

Our results suggest that CD117 is not significantly overexpressed in HCC and there seems to be no role for the use of imatinib.

Long-acting octreotide versus placebo for treatment of advanced HCC: a randomized controlled double-blind study

Although numerous treatment modalities have been explored in patients with advanced HCC, the therapeutic options are still limited. Somatostatin has been shown to have antimitotic activity in endocrine as well as in a variety of nonendocrine tumors. Expression of somatostatin receptors is found in HCCs, but the efficacy of the somatostatin analogue octreotide remains controversial. Therefore, a randomized double-blind placebo-controlled multicenter trial was performed to assess the efficacy of long-acting octreotide for the treatment of advanced HCC. One hundred twenty untreated patients with histologically confirmed HCC were randomized to receive either long-acting octreotide (Sandostation LAR 30 mg) intramuscularly every 4 weeks or placebo. The study groups were comparable with respect to clinical characteristics. There was no difference in the cumulative survival. The median survival time was 4.7 months in the octreotide group compared with 5.3 months in the control group. Six-month survival rates were 41% for octreotide patients and 42% for control patients, respectively. The unadjusted relative risk for mortality in the octreotide group compared with patients in the control group was 1.11 (95% CI 0.76-1.63; P = 0.59). When adjusted for Okuda, CTP, and Cancer of the Liver Italian Program (CLIP) scores, the relative risk for octreotide did not change markedly and was 1.05 (95% CI 0.71-1.55; P = 0.83). The CLIP score seems to predict survival better than both Okuda and CTP score.

CONCLUSION

The randomized controlled double-blind HECTOR trial showed no survival benefit for HCC patients treated with long-acting octreotide compared with placebo.

Contrast-enhanced Ultrasound as a Predictor of Treatment Efficacy within 2 Weeks after Transarterial Chemoembolization of Hepatocellular Carcinoma

PURPOSE

To determine whether contrast-enhanced ultrasound (CEUS) can aid in assessing treatment efficacy within the first 2 weeks after transarterial chemoembolization for hepatocellular carcinoma.

MATERIALS AND METHODS

Contrast-enhanced ultrasound was performed to detect residual tumor blood flow after 42 transarterial chemoembolization procedures in 33 patients who had hepatocellular carcinomas, and the results were compared with final tumor outcome. Twenty-nine CEUS studies were performed within 2 weeks after treatment and the remainder within 1 month. Phase-inversion low-mechanical-index real-time and intermittent imaging were performed after the intravenous injection of 0.5-2 mL US contrast medium by experienced radiologists blind to all other imaging findings.

RESULTS

Nine tumors did not reach final outcome--patients were lost to follow-up or died without autopsy (n = 6) or tumors were retreated before final outcome was established (n = 3). Of the remaining 33 tumors, outcome was established by histology (n = 9), angiography (n = 14), tumor growth (n = 2), or by computed tomography and/or magnetic resonance imaging performed more than 6 months after treatment (n = 8). Twenty-three tumors were studied by CEUS within 2 weeks and 10 within 1 month after treatment. Of these 33 tumors, there were no false-negative results and one false-positive result. The only error occurred when the CEUS study was performed within 1 day after treatment.

CONCLUSIONS

Residual tumor blood flow on CEUS performed at 2 or more days after transarterial chemoembolization may be predictive of tumor outcome that currently requires 3 months to be reliably detected by computed tomography and/or magnetic resonance imaging.

Increasing EMMPRIN and matriptase expression in hepatocellular carcinoma: tissue microarray analysis of immunohistochemical scores with clinicopathological parameters

AIMS

To examine the expression of extracellular matrix metalloprotease inducer (EMMPRIN) and matriptase in hepatocellular carcinoma (HCC) and to correlate this with tumour progression.

METHODS AND RESULTS

Immunohistochemical analysis of EMMPRIN and matriptase was performed on tissue microarrays of 122 cases of HCC with various histological grades and/or clinical parameters. The expression of EMMPRIN and matriptase was undetectable in normal liver parenchyma of all eight control cases. However, among the 122 HCC cases, EMMPRIN and matriptase immunoreactivity was seen on the cell membrane and in the cytoplasm. The average immunostaining scores of EMMPRIN were 88 for grade I HCC, 195 for grade II HCC and 293 for grade III HCC. Of 85 HCC cases in 122 with detailed clinical TNM stages, the average immunostaining scores of EMMPRIN were 75 for stage T1, 177 for stage T2, 260 for stage T3 and 313 for stage T4 cases of HCC. In addition, the average immunostaining scores of matriptase were 84 for grade I HCC, 187 for grade II HCC, 302 for grade III HCC, and 72 for stage T1, 181 for stage T2, 224 for stage T3 and 284 for stage T4 cases of HCC. More advanced M and N stages of HCC were associated with higher intensity, greater percentages of tumour staining and immunostaining scores of EMMPRIN and matriptase. Higher EMMPRIN and matriptase immunostaining scores in HCCs also correlated significantly with tumour grading and TNM stages.

CONCLUSIONS

Our findings demonstrate for the first time that EMMPRIN and matriptase are overexpressed in HCC. These may be novel biomarkers for the diagnosis and treatment of HCC.

Treatment outcomes for hepatocellular carcinoma using chemoembolization in combination with other therapies

BACKGROUND

Although transarterial chemoembolization (TACE) improves survival in patients with hepatocellular carcinoma (HCC), it is not known if TACE combined with other treatments is beneficial.

AIM

To evaluate the evidence for improved outcomes in HCC with a multimodal treatment approach involving TACE.

METHOD

PubMed search for all cohort and randomized trials (n=84) evaluating TACE combined with other therapies; meta-analysis performed where appropriate.

RESULTS

A meta-analysis involving 4 RCTs showed a significant decrease in mortality favouring combination treatment (TACE plus percutaneous ablation) compared to monotherapy in patients with either small (<3cm) or large HCC nodules (>3cm) (OR, 0.534; 95% CI, 0.288-0.990; p=0.046). TACE combined with local radiotherapy improved survival in patients with tumour thrombosis of the portal vein in 7 non-randomized studies. Two RCTs and 13 non-randomized studies showed that TACE prior to hepatic resection does not improve survival nor tumour recurrence. Conversely, 2 RCTs and 5 comparative studies showed that transarterial injection of chemotherapeutic drugs mixed with lipiodol (TOCE) following hepatectomy confers survival benefit and less tumour recurrence. TACE before liver transplantation is safe and reduces drop-out rate from the waiting list, but there is no current evidence of improvement in subsequent survival or recurrence rate.

CONCLUSIONS

A combined approach involving TACE and percutaneous ablation improves survival. Adjuvant TOCE improves outcome after hepatectomy. TACE is useful to control tumours burden while on the waiting list for OLT. Multimodal treatment seems to be the best way to optimize TACE outcomes in HCC.

Large-sized hepatocellular carcinoma (HCC): a neoadjuvant treatment protocol with repetitive transarterial chemoembolization (TACE) before percutaneous MR-guided laser-induced thermotherapy (LITT)

This study aims to evaluate the efficacy and safety of a neoadjuvant treatment protocol with repeated transarterial chemoembolization (TACE) before MR-guided laser-induced thermotherapy (LITT) for large-sized hepatocellular carcinomas (HCC). Repeated TACE (mean, 3.5 treatments per patient) was performed in 48 patients with neoadjuvant intention (the largest lesion was between 50 and 80 mm in diameter, and there were no more than five lesions). For the TACE treatment, we used 10 mg/m(2) mitomycin, 10 ml/m(2) Lipiodol and microspheres. The tumor volume was measured by MRI. Lipiodol retention of the tumors was evaluated with CT. After the diameter of the tumors had decreased to less than 50 mm, the patients were treated with MR-guided LITT 4 to 6 weeks after embolization. Repeated TACE reduced the tumor size in 32 patients (66.7%), forming the basis for performing MR-guided LITT procedures. These patients received one to four laser treatments (mean, 1.9 per patient) for tumor ablation, resulting in a median survival of 36.0 months after the first treatment. For the remaining patients, no reduction in tumor size was achieved in 12 patients and disease progression in 4 patients. Neoadjuvant TACE appears to be an effective treatment of large-sized HCC, which extends the indication for MR-guided LITT.

Combination of repeated single-session percutaneous ethanol injection and transarterial chemoembolisation compared to repeated single-session percutaneous ethanol injection in patients with non-resectable hepatocellular carcinoma

AIM: To evaluate the treatment effect of percutaneous ethanol injection (PEI) for patients with advanced, non-resectable HCC compared with combination of transarterial chemoembolisation (TACE) and repeated single-session PEI, repeated single-session PEI alone, repeated TACE alone, or best supportive care.

METHODS: All patients who received PEI treatment during the study period were included and stratified to one of the following treatment modalities according to physical status and tumor extent: combination of TACE and repeated single-session PEI, repeated single-session PEI alone, repeated TACE alone, or best supportive care. Prognostic value of clinical parameters including Okuda-classification, presence of portal vein thrombosis, presence of ascites, number of tumors, maximum tumor diameter, and serum cholinesterase (CHE), as well as Child-Pugh stage, α-fetoprotein (AFP), fever, incidence of complications were assessed and compared between the groups. Survival was determined using Kaplan-Meier and multivariate regression analyses.

RESULTS: The 1- and 3-year survival of all patients was 73% and 47%. In the subgroup analyses, the combination of TACE and PEI (1) was associated with a longer survival (1-, 3-, 5-year survival: 90%, 52%, and 43%) compared to PEI treatment alone (2) (1-, 3-, 5-year survival: 65%, 50%, and 37%). Secondary PEI after initial stratification to TACE (3) yielded comparable results (1-, 3-, 5-year survival: 91%, 40%, and 30%) while PEI after stratification to best supportive care (4) was associated with decreased survival (1-, 3-, 5-year survival: 50%, 23%, 12%). Apart from the chosen treatment modalities, predictors for better survival were tumor number (n < 5), tumor size (< 5 cm), no ascites before PEI, and stable serum cholinesterase after PEI (P < 0.05). The mortality within 2 wk after PEI was 2.8% (n = 3). There were 24 (8.9%) major complications after PEI including segmental liver infarction, focal liver necrosis, and liver abscess. All complications could be managed non-surgically.

CONCLUSION: Repeated single-session PEI is effective in patients with advanced HCC at an acceptable and manageable complication rate. Patients stratified to a combination of TACE and PEI can expect longer survival than those stratified to repeated PEI alone. Furthermore, patients with large or multiple tumors in good clinical status may also profit from a combination of TACE and reconsideration for secondary PEI.

Safety and efficacy of transarterial chemoembolization in patients with unresectable hepatocellular carcinoma and portal vein thrombosis

PURPOSE

Despite the absence of conclusive data, portal vein (PV) thrombosis is considered a contraindication to transarterial chemoembolization (TACE) in patients with unresectable hepatocellular carcinoma (HCC). The purpose of our study was to establish the safety of TACE in such patients and identify key prognostic factors and survival.

MATERIALS AND METHODS

Data were prospectively collected from 32 consecutive patients with unresectable HCC and PV thrombosis who underwent treatment with TACE. History and physical examination, relevant laboratory values, and contrast material-enhanced magnetic resonance (MR) images were obtained before each TACE procedure. Repeated TACE was performed every 6 weeks unless patients developed a contraindication or MR imaging showed complete response.

RESULTS

Median overall survival was 9.5 months (range, 3-50 months). Child-Pugh numerical disease stage was the prognostic factor most strongly related to survival. The 30-day mortality rate was zero and there was no evidence of TACE-related hepatic infarction or acute liver failure. The 6-, 9-, 12-, and 18-month survival rates were 60%, 47%, 25%, and 12.5%, respectively.

CONCLUSIONS

PV thrombosis should not be considered a contraindication to TACE. Compared with historical control subjects who received traditional forms of treatment, the patients in the present study had extended survival. However, prospective randomized trials are necessary to show this conclusively and to show which subgroups benefit.

A combination therapy with transarterial chemo-lipiodolization and systemic chemo-infusion for large extensive hepatocellular carcinoma invading portal vein in comparison with conservative management

PURPOSE

Hepatocellular carcinoma (HCC) invading the portal vein is a medical challenge. We evaluated the therapeutic efficacy of a combination of transarterial and systemic chemo-infusion for large HCC with portal vein thrombosis (PVT) compared with conservative management.

PATIENTS AND METHODS

This was a case-control cohort study of 103 consecutive patients with Child-Pugh class A who had a large (>10 cm) HCC with PVT. The patients were assigned to receive either combined transarterial epirubicin (50 mg/m(2)) plus cisplatin (60 mg/m(2)) chemo-lipiodolization and systemic 5-fluorouracil (200 mg/m(2)) chemo-infusion (ECF regimen) at monthly intervals (n=80) or conservative management (n=23).

RESULTS

The objective tumor response (21.3 vs. 0%, P=0.011) and overall survival (8.7 vs. 3.5 months, P<0.001) were significantly better in the treatment group than in the conservative group. The prognostic factors for survival were tumor type (P=0.007), bilobar involvement (P=0.001), distant metastasis (P=0.009) and objective tumor response (P<0.001) for the treatment group. Survival benefits with the treatment were also maintained in each subgroup after stratification of these variables.

CONCLUSIONS

This study suggests that when the hepatic function is preserved, a therapeutic strategy could be more beneficial than conservative management for such a large extensive HCC. As a therapeutic option, a combination therapy using ECF regimen may provide a significantly better tumor response and survival benefit in patients with large HCC invading the portal vein.

Prognostic index for patients with hepatocellular carcinoma combined with tumor thrombosis in the major portal vein

BACKGROUND

This study sought to analyze prognostic factors in patients with hepatocellular carcinoma and tumor thrombosis in the first branch or trunk of the portal vein, and to provide a prognostic index.

STUDY DESIGN

We performed a retrospective cohort study of 78 consecutive patients with hepatocellular carcinoma and tumor thrombosis in the first branch or trunk of the portal vein who underwent liver resection. Multivariate analysis of survival used the Cox's proportional hazard model.

RESULTS

Median survival time and 3-year survival rate were 0.74 years and 21.7%, respectively. Six factors, ie, absence of ascites, average elimination rate constant of indocyanine green, prothrombin activity, serum albumin level, maximal tumor diameter, and blood loss at operation were univariately related to survival time. By multivariate analysis, absence of ascites (hazard ratio, 2.23; 95% confidence interval, 1.10 to 4.52; p = 0.027), prothrombin activity > or = 75% (hazard ratio, 2.37; confidence interval, 1.30 to 4.32; p = 0.005), and maximal tumor diameter < 5 cm (hazard ratio, 2.37; confidence interval, 1.14 to 4.94; p = 0.021) were independent prognostic factors with similar hazard ratios. We calculated a prognostic index from these factors as follows: (ascites: absent = 0, present = 1) + (prothrombin activity: > or = 75% = 0, < 75% = 1) + (maximal tumor diameter: < 5 cm = 0, > or = 5 cm = 1). This index provided good stratification ability (log-rank, p < 0.001). Median survival times for patients with prognostic index 0, 1, 2, and 3 were 5.6, 1.6, 0.5, and 0.1 years, respectively.

CONCLUSION

This prognostic index is a useful for making appropriate treatment strategy decisions for patients with hepatocellular carcinoma and tumor thrombosis in the major portal vein.

Combined TACE and PEI for palliative treatment of unresectable hepatocellular carcinoma

AIM: To assess whether the effectiveness of a combination of transarterial chemoembolization (TACE) and percutaneous ethanol injection (PEI) in the treatment of unresectable hepatocellular carcinoma (HCC) is superior to TACE alone a randomized controlled trial was performed.

METHODS: The effect of combination therapy on long-term survival rates and duration of hospitalization was evaluated in 52 previously untreated HCCs, randomly allocated to TACE-PEI (27 pts) or TACE alone (25 pts).

RESULTS: The cumulative survival rate of the TACE group was 75.8% at 6 mo, 62.9% at 12 mo, and 18.0% at 24 mo and of the TACE-PEI group 76.9%, 61.5%, and 38.7%, respectively. Comparison of overall survival in both groups showed no statistically significant difference. Regarding the patients with HCCs Okuda stage I (n = 26), the median survival of the TACE-PEI group was significantly longer (>24 mo, median not yet reached in the study period) compared to the TACE group (18.4 mo [range 11.6-21.7 mo]; p = 0.04). TACE-PEI reduced the relative risk for mortality to 0.4 (95%CI 0.15-0.96) compared to patients who received TACE alone. Median survival in patients with HCCs Okuda stage II or III was 5.0 mo in the TACE group (1.7 mo-not defined) compared to 10.4 mo in the TACE-PEI group.

CONCLUSION: The combination TACE-PEI improved survival time compared to TACE alone. Our study revealed a statistically significant improved survival in HCCs Okuda stage I. Side effects were minor and the combination therapy did not prolong duration of hospitalization considerably.

Survival rate in patients with hepatocellular carcinoma: a retrospective analysis of 389 patients

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide. However, treatment options are limited and often inefficient. The aim of this study was to determine current survival rates for patients diagnosed with HCC and to identify prognostic factors, which will help in choosing optimal therapies for individual patients. A retrospective analysis of medical records was performed on 389 patients who were identified through the central tumour registry at our institution from 1998 to 2003. Clinical parameters, treatments received and survival curves from time of diagnosis were analysed. Overall median survival was 11 months. Liver cirrhosis was diagnosed in 80.5% of all patients. A total of 170 patients received transarterial chemoembolisation (TACE) and/or percutaneous ethanol injections (PEI) with a median survival rate of 16 months for patients receiving TACE, 11 months for patients receiving PEI and 24 months for patients receiving TACE followed by PEI. Independent negative prognostic parameters for survival were the presence of portal vein thrombosis, advanced liver cirrhosis (Child–Pugh score B or C) and a score of >2. This study will help to estimate survival rates for patients with HCC according to their clinical status at diagnosis and the treatments received.

Increased populations of regulatory T cells in peripheral blood of patients with hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide with a poor prognosis and one for which immunotherapy remains a viable option. Experimental tumor models have shown that regulatory T cells, a functionally unique subset of T cells, can suppress effective antitumor immune responses. This suppression might explain the poor outcome of some of the immunotherapy protocols currently being used. A better understanding of the role of regulatory T cells in HCC is important for design of future immunotherapy-based clinical protocols. We have studied regulatory T cells from 84 patients with HCC and 74 controls, including healthy donors, patients with chronic hepatitis B virus and hepatitis C virus infection and nonviral liver cirrhosis. Regulatory T cells were identified by fluorescence-activated cell sorting using a panel of antibodies and by real-time PCR analysis for Foxp3 expression. Functional studies were done to analyze their inhibitory role. Finally, regulatory T cells were analyzed in tumors and ascites from patients with HCC. Patients with HCC have increased numbers of CD4+CD25+ regulatory T cells in their peripheral blood, which express high levels of HLA-DR, GITR, and low or no CD45RA. These cells were anergic toward T-cell receptor stimulation and, when cocultured with activated CD4+CD25- cells, potently suppressed their proliferation and cytokine secretion. There were also high numbers of regulatory T cells in tumor-infiltrating lymphocytes of HCC patients comparable with the increase in their peripheral blood. Our data suggest that the increase in frequency of regulatory T cells might play a role in modulation of the immune response against HCC and could be important in design of immunotherapeutic approaches.

Pharmacotherapy of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the more common causes of cancer death worldwide. It occurs on a background of chronic liver disease or viral hepatitis in the vast majority of cases, with hepatitis C being mostly responsible for its continuing rise in western countries. With the screening of at-risk groups, up to 70% of HCC lesions will be detected at a treatable stage but at best, only 20-30% will benefit from potentially curative hepatic resection or transplantation. How best to treat the remaining nonsurgical patients is an area of much debate and no ideal treatment is yet available. This review summarises some of the therapeutic modalities used for HCC, with an emphasis on pharmacological therapies.

Spontaneous tumor-specific humoral and cellular immune responses to NY-ESO-1 in hepatocellular carcinoma

PURPOSE

Hepatocellular carcinoma (HCC) is the fifth most common cancer around the world. Although several therapeutic approaches for treatment of HCC are available, survival rates for HCC patients are still very poor because of inefficient treatment options. For HCC, as well as other tumors, antigen-specific immunotherapy remains a viable approach that is dependent on the definition of tumor-associated antigens. NY-ESO-1, a member of the cancer testis antigen family, is one possible candidate for a tumor-specific antigen in HCC. The aim of this study was to show the relevance of NY-ESO-1 in hepatocellular carcinoma.

EXPERIMENTAL DESIGN

Sera samples from 189 HCC patients were analyzed for NY-ESO-1-specific antibodies. Forty-nine HCC patients were screened for NY-ESO-1 mRNA expression in HCC tissue. Selected patients were followed for up to 3 years to correlate their immune response with their clinical course of events. NY-ESO-1-specific CD4+ and CD8+ T-cell responses from NY-ESO-1 seropositive patients were analyzed and a NY-ESO-1+ specific cytotoxic T-cell line was generated.

RESULTS

Twelve of 49 analyzed tumor samples expressed NY-ESO-1 mRNA and 23 of 189 patients showed NY-ESO-1-specific antibody responses. These humoral immune responses were accompanied by NY-ESO-1-specific functional CD4+ and CD8+ T-cell responses. Finally, NY-ESO-1 humoral responses were dependent on the presence of NY-ESO-1-expressing tumors.

CONCLUSIONS

This is the first report of a spontaneous immune response in HCC patients to a known tumor-specific antigen, NY-ESO-1 protein. Our data favor the possibility of immunotherapeutic strategies for the treatment of HCC.

Large Infiltrative Hepatocellular Carcinomas: Treatment with Percutaneous Intraarterial Ethanol Injection Alone or in Combination with Conventional Percutaneous Ethanol Injection

PURPOSE

To retrospectively evaluate patients' tolerance and the effectiveness of percutaneous intraarterial ethanol injection (PIAEI), alone or combined with conventional percutaneous ethanol injection (PEI), for treatment of advanced hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Neither institutional review board approval nor informed consent was required for this retrospective study; however, all patients had given their consent to be treated with PIAEI. Fourteen men and four women with cirrhosis and HCC who were ineligible for conventional curative treatment (largest tumor diameter, 35-90 mm; mean, 52 mm +/- 16 [standard deviation]) and whose supplying arteries were visible on computed tomographic (CT) and color Doppler ultrasonographic (US) images were treated with US-guided PIAEI-either alone or combined with PEI. Twelve patients had infiltrative tumors, and six had nodular tumors. Four patients had portal venous tumor involvement. Tumor necrosis and recurrence were evaluated with CT, and 1- and 2-year survival rates were evaluated with Kaplan-Meier analysis.

RESULTS

In four patients, the main tumor was treated with PIAEI only, and in 14 patients, the main tumor was treated with combined PIAEI and PEI. One patient died of myocardial infarction before CT evaluation. Tumor necrosis was complete in 15 (88%) and incomplete in two (12%) of 17 patients. Results of subsequent surgery performed in three patients confirmed the radiologic findings: complete tumor necrosis in two patients and incomplete necrosis in one patient. Two severe PIAEI-related complications occurred: liver abscess, which resolved, and fatal acute pancreatitis. During the follow-up period (mean, 15 months +/- 6.7), six patients died owing to recurrent HCC, and 10 patients were alive with no detectable tumor after a mean follow-up period of 18 months +/- 11. One- and 2-year survival rates were 76.6% and 44.5%, respectively.

CONCLUSION

For patients with advanced HCC who are ineligible for other curative options, PIAEI could be an effective treatment, despite the associated risk of severe complications.

The role of radiotherapy in the treatment of liver metastases

Radiotherapy has historically played a minor role in the treatment of patients with unresectable liver metastases from colorectal cancer and other malignancies. This can be attributed chiefly to the low tolerance of the whole liver to radiation. High-precision radiotherapy planning techniques have allowed much higher doses of radiation to be delivered safely to focal liver metastases, while sparing most of the normal liver. When combined with hepatic arterial fluorodeoxyuridine, high-dose focal liver radiotherapy is associated with excellent response rates, local control, and survival in patients with unresectable liver metastases from colorectal cancer. Radiotherapy, with and without concurrent systemic chemotherapy, has also been used with encouraging outcomes for patients with liver metastases from colorectal cancer and other cancers. There appears to be a radiation dose response for liver metastases; tumors treated with doses of 70 Gy or greater are likelier to have durable local control. Advancements in tumor imaging, in radiotherapy techniques that will allow the safe delivery of higher doses of radiation, and in novel tumor radiation sensitizers and normal tissue radioprotectors should substantially improve the outcome of patients with unresectable liver metastases treated with radiotherapy.