A randomized placebo-controlled trial of prophylactic dexamethasone for transcatheter arterial chemoembolization

Efficacy of olanzapine as an antiemetic drug for transcatheter arterial chemoembolization for hepatocellular carcinoma

Although the addition of olanzapine to conventional antiemetic therapy has been reported to be useful for systemic chemotherapy with highly emetogenic agents such as cisplatin, no studies have evaluated its efficacy in transcatheter arterial chemoembolization (TACE) for patients with hepatocellular carcinoma (HCC). We evaluated the antiemetic efficacy of olanzapine in patients with HCC undergoing cisplatin-based TACE. This prospective study included 68 patients with HCC scheduled for cisplatin-based TACE between 2021 and 2022. Patients were divided into two groups: an olanzapine group receiving olanzapine 5 mg plus the conventional triple antiemetic combination and a control group receiving only the conventional triple combination therapy. The incidence of digestive symptoms and adverse events (AEs) in both groups were compared. For TACE-induced nausea and vomiting, the olanzapine group had similar antiemetic complete response (aCR) and complete control (CC) rates at 12 h post-TACE as the control group but significantly higher aCR and CC rates during the delayed-phase after 24 h and better patient satisfaction scores. No significant differences were noted in the occurrence of severe AEs in the two groups. The use of olanzapine, in addition to conventional antiemetics, may be a new standard for patients undergoing cisplatin-based TACE.

Dexamethasone-Based Prophylactic Therapy for Prevention of Post-Embolization Syndrome: A Systematic Review and Meta-Analysis Assessing Its Efficacy and Influence of Dosage and Timing in Patients Undergoing Arterial Embolization

BACKGROUND

Postembolization syndrome (PES), characterized by pain, fever, nausea, and vomiting, is a common but nonserious adverse event following arterial embolization, negatively impacting patient satisfaction with the procedure. This study aimed to evaluate the efficacy of dexamethasone-based prophylactic therapy in preventing PES, as well as to assess the effects of its dosage and timing of administration.

METHODS

A systematic search was conducted across 3 databases, 2 trial registries, and citation searches to identify relevant studies. Data related to postoperative pain, fever, nausea, and vomiting were extracted and meta-analyzed using a random-effects model and the Mantel-Haenszel method. Meta-regression was performed to examine the role of dexamethasone dose and timing of administration as mediators.

RESULTS

Dexamethasone-based prophylactic therapy significantly reduced the risk of postoperative pain (risk ratio (RR) = 0.58, 95% confidence interval (CI): 0.48-0.69; P < 0.00001), fever (RR = 0.36, 95% CI: 0.22-0.61; P < 0.00001), nausea (RR = 0.52, 95% CI: 0.41-0.67; P < 0.00001), and vomiting (RR = 0.54, 95% CI: 0.36-0.82; P = 0.004) compared to placebo or no treatment. A higher dose of dexamethasone was associated with a significantly lower incidence of postoperative pain (P = 0.038). Regarding timing, postoperative and continuous (extending throughout the perioperative period) administration, was more effective than preoperative administration (P = 0.024; P = 0.007). A dosage of 6-12 mg was particularly effective in reducing the risk for all 4 symptoms.

CONCLUSION

Dexamethasone effectively prevents PES in patients undergoing arterial embolization. An optimal protocol may involve a divided dose regimen within the range of 6-12 mg, extending throughout the recovery period for maximum benefit.

Dexamethasone improves clinical and biological tolerance of transcatheter arterial chemoembolization for hepatocellular carcinoma

BACKGROUND

Transarterial chemoembolization (TACE) is widely used for hepatocellular carcinoma treatment but side effects hamper tolerance. Dexamethasone reduces TACE side effects in patients with viral hepatitis, but data regarding alcohol and metabolic liver diseases are lacking. We aimed to evaluate the efficacy of dexamethasone in preventing TACE-associated adverse events in European populations with predominantly alcoholic and metabolic cirrhosis.

METHODS

All cirrhotic patients undergoing TACE in our center between 2017 and 2021 were included. Dexamethasone was added to our protocol from 2019. Using a quasi-experimental study design, patients before and after introduction of dexamethasone in our procedure were compared. Factors associated with TACE adverse events were assessed by univariate and multivariate analysis. A sensitivity analysis was performed using propensity scores for covariate adjustment.

RESULTS

234 patients undergoing 398 TACE procedure were included. Cirrhosis was predominantly of alcohol or metabolic etiology (86.7 %). Dexamethasone was administered in 99 procedures (24.9 %). Incidence of fever and encephalopathy at day 2 after TACE was lower in the Dexamethasone group (p < 0.001; p = 0.02 respectively). In multivariate analysis, dexamethasone was associated with lower occurrence of fever (OR=0.03; p < 0.001), lower analgesics use (OR=0.11; p = 0.002), milder liver and kidney function impairment (OR=0.98; p = 0.001 and OR=0.94; p < 0.001 for bilirubin and creatinine variation respectively). Propensity score-adjusted analyses yielded similar results.

CONCLUSION

Dexamethasone improves TACE tolerance in a population of predominantly metabolic and alcohol cirrhosis.

Embolic and Ablative Therapy for Hepatocellular Carcinoma

Embolic and ablative locoregional therapies (LRTs) for hepatocellular carcinoma are widely used to cure, bridge, or downstage patients for more definitive therapies. Common ablative therapies include microwave ablation and radiofrequency ablation, while embolic options include transarterial chemoembolization and 90Y transarterial radioembolization. While these therapies can be highly effective for the appropriate stage of disease, LRTs can suffer from a high rate of posttreatment recurrences. Considerations for administration of specific therapies include disease burden and underlying liver function. Recent data on concomitant or adjuvant systemic therapy, with LRT, have the potential to improve disease control and improve outcomes in this high-risk patient population.

Efficacy and safety of palliative treatment in patients with autoimmune liver disease-associated hepatocellular carcinoma

INTRODUCTION AND OBJECTIVES

Autoimmune liver diseases (AILD) are rare causes hepatocellular carcinoma (HCC), and data on the efficacy and tolerability of anti-tumor therapies are scarce. This pan-European study aimed to assess outcomes in AILD-HCC patients treated with tyrosine kinase inhibitors (TKIs) or transarterial chemoembolization (TACE) compared with patients with more common HCC etiologies, including viral, alcoholic or non-alcoholic fatty liver disease.

MATERIALS AND METHODS

107 patients with HCC-AILD (AIH:55; PBC:52) treated at 13 European centres between 1996 and 2020 were included. 65 received TACE and 28 received TKI therapy. 43 (66 %) were female (median age 73 years) with HCC tumor stage BCLC A (34 %), B (46 %), C (9 %) or D (11 %). For each treatment type, propensity score matching was used to match AILD to non-AILD-HCC on a 1:1 basis, yielding in a final cohort of 130 TACE and 56 TKI patients for comparative analyses of median overall survival (mOS) and treatment tolerability.

RESULTS

HCC-AILD patients showed comparable mOS to controls for both TACE (19.5 vs. 22.1 months, p = 0.9) and TKI (15.4 vs. 15.1 months, p = 0.5). Adverse events were less frequent in AILD-HCC patients than controls (33 % % vs. 62 %, p = 0.003). For TKIs, there were no significant differences in adverse events (73% vs. 86%, p = 0.2) or interruption rates (44% vs. 36 %, p = 0.7).

CONCLUSIONS

In summary, this study demonstrates comparable mOS for AILD-HCC patients undergoing local and systemic treatments, with better tolerability than HCC of other causes. TKIs remain important therapeutic options for AILD-HCC patients, particularly given their exclusion from recent immunotherapy trials.

Dexamethasone and N-acetylcysteine before transarterial chemoembolization in hepatocellular carcinoma: A Western perspective

Post-embolization syndrome (PES) is the most common complication in patients with hepatocellular carcinoma treated with transarterial chemoembolization. Many strategies have been evaluated to reduce the incidence of PES, but no standard prevention guidelines currently exist. In a single-center, placebo-controlled trial, Simasingha et al evaluated the prophylactic administration of a combination of dexamethasone and N-acetylcysteine and documented a significant reduction in the incidence of PES (from 80% to 6%), of post-procedural liver decompensation (from 14% to 0%), and a shorter hospital stay (4 days vs 6 days), alongside an acceptable safety profile. The results of this study raise several controversial points regarding their applicability in the Western world. In the West, there is a greater and increasing prevalence of metabolic and alcoholic etiologies of liver cirrhosis, so a not negligible number of patients with type II diabetes or hypertension would be excluded from high-dosage dexamethasone prophylaxis. Furthermore, in the West, there is a preferred use of drug-eluting beads loaded with doxorubicin, which are associated with a lower incidence of PES. A study on prophylaxis with dexamethasone and/or N-acetylcysteine in a Western population is hopefully awaited.

Efficacy of High-Dose Dexamethasone in Reducing the Symptoms of Postembolization Syndrome Following Prostatic Artery Embolization: Results of a Double-Blind Randomized Controlled Trial

PURPOSE

To evaluate the efficacy of a single perioperative dose of dexamethasone in reducing postembolization syndrome following prostatic artery embolization.

MATERIALS AND METHODS

We conducted a single-center double-blind randomized controlled trial from March 2021 to May 2022 (NCT04588857). Participants were randomized to receive either i.v. 24 mg dexamethasone or saline. The primary outcome measures were temperature, pain, and quality of life in the first 5 days following prostatic artery embolization. Sample size of 60 patients was needed for the assessment of primary outcomes. Participants were followed for 6 months and assessed for a variety of secondary outcome measures including inflammatory markers and lower urinary tract symptoms severity.

RESULTS

Due to lack of clinical effect and mild symptoms in the control group, the trial was terminated early. 31 participants (16 dexamethasone vs. 15 control) were enrolled and analyzed. A difference in mean temperature was observed on day 1 (37.23 ± 0.64 °C control vs 36.74 ± 0.41 °C dexamethasone, p = 0.02, 95% CI 0.09-0.89). Difference in pain (score out of 10) was seen only on day 5 (1.48 ± 1.2 control vs. 2.9 ± 2.24 dexamethasone, p = 0.04, 95% CI - 2.78-- 0.04). A difference in C-reactive protein values was observed on day 2 (108 [54-161] mg/l control vs 10 [5-33] mg/l dexamethasone, p < 0.01). No significant differences in other outcomes were observed. No side effects were recorded.

CONCLUSIONS

Twenty-four milligrams of dexamethasone bolus is safe but does not reduce postembolization syndrome following prostatic artery embolization.

Summary of the evidence of best practices for the prevention and treatment of embolism syndrome after TACE in primary liver cancer

Objective

This study aims to retrieve, evaluate, and summarize domestic and foreign evidence on the prevention and treatment of embolism syndrome following transcatheter arterial chemoembolization (TACE) for primary liver cancer and to provide an evidence-based foundation for clinical practice.

Methods

Utilizing the "6S" model, we conducted a systematic search of UpToDate, BMJ Best Practice, domestic and foreign guidelines, and related databases on the prevention and treatment of embolism syndrome following TACE for primary liver cancer. This search included clinical decision-making, guidelines, systematic reviews, evidence summaries, randomized controlled trials, and expert consensus. The search time frame extended from January 1, 2013 to May 1, 2023. Evidence was synthesized after an independent review of the included studies by two investigators.

Results

A total of 11 articles were included in the analysis, comprising one clinical decision-making article, three clinical guidelines, six expert consensus articles, and one randomized controlled trial. We summarized 31 pieces of evidence across three categories: preoperative preparation, intraoperative interventions, and postoperative symptom management.

Conclusion

This study presents a comprehensive summary of the best available evidence on the prevention and treatment of embolism syndrome following TACE for primary liver cancer. These findings can serve as a valuable reference for clinical practitioners, enabling nurses to deliver individualized care based on the symptoms and specific needs of liver cancer patients.

Systematic review registration

http://ebn.nursing.fudan.edu.cn, identifier ES20232398.

Hepatic Hilar Block as an Adjunct to Transarterial Embolization of Neuroendocrine Tumors: A Retrospective Review of Safety and Efficacy

PURPOSE

This study investigates whether hepatic hilar nerve blocks (HHNB) provide safe, effective analgesia in patients with neuroendocrine tumors (NET) treated with transarterial embolization (TAE).

METHODS

The retrospective study included all NETs treated with TAE or TAE + HHNB from 1/2020 to 8/2022. Eighty-five patients (45 men), mean age 62 years, were treated in 165 sessions (TAE, n = 153; TAE + HHNB, n = 12). For HHNBs, ≤10 mL bupivacaine HCl 0.25% ± 2 mg methylprednisolone were injected under ultrasound guidance. The aims were to assess safety of HHNB and reduction in pain. Groups were compared with Pearson's chi-squared and Wilcoxon rank sum tests. Logistic regression assessed independent risk factors for pain.

RESULTS

No immediate complications from HHNBs were reported. No difference in incidence of major complications between TAE and TAE + HHNB one month post-embolization was observed (7.19% vs. 8.33%, p = 0.895). No differences in mean length of hospital stay after treatment were observed (TAE 2.2 days [95%CI: 1.74-2.56] vs. TAE + HHNB 2.8 days [95%CI: 1.43-4.26]; p = 0.174). Post-procedure pain was reported in 88.2% of TAE and 75.0% of TAE + HHNB patients (p = 0.185). HHNB recipients were more likely to use analgesic patches (25.0% vs. 5.88%; p = 0.014). No other differences in analgesic use were observed.

CONCLUSIONS

HHNBs can safely be performed in patients with NETs. No difference in hospital stays or analgesic drug use was observed. Managing pain after TAE is an important goal; further study is warranted.

Efficacy and safety analysis of dexamethasone + palonosetron in prevention of post-embolization syndrome after D-TACE: A retrospective study

To investigate the efficacy and safety of dexamethasone + palonosetron in the prevention of post-embolization syndrome after drug-eluting beads transcatheter arterial chemoembolization (D-TACE). The data of 278 patients who received D-TACE from January 2018 to December 2021 were collected and divided into 2 groups: D-TACE group (N = 145) and D-TACE + dexamethasone + palonosetron group (N = 133). The incidence of post-embolization syndrome and infection after D-TACE was assessed in both groups. Incidence of abdominal pain: D-TACE group versus D-TACE + dexamethasone + palonosetron group, 56.6% versus 40.6%, P = .008; incidence of fever: D-TACE group versus D-TACE + dexamethasone + palonosetron group, 40.0% versus 14.3%, P = .000; incidence of nausea: D-TACE group versus D-TACE + dexamethasone + palonosetron group, 61.4% versus 39.8%, P = .001; incidence of vomiting: D-TACE group versus D-TACE + dexamethasone + palonosetron group, 48.3% versus 21.1%, P = .000; incidence of infection: D-TACE group versus D-TACE + dexamethasone + palonosetron group, 1.4% versus 1.5%, P = .931. The combined use of dexamethasone and palonosetron before D-TACE can effectively reduce the incidence of post-embolization syndrome and reduce the degree of side effects, but it will not increase the risk of infection.

Transarterial chemoembolization for hepatocellular carcinoma: 2023 expert consensus-based practical recommendations of the Korean Liver Cancer Association

Transarterial chemoembolization (TACE) was introduced in 1977 with the administration of chemotherapeutic agent to gelatin sponge particles through the hepatic artery in patients with hepatocellular carcinoma (HCC) and was established as conventional TACE using Lipiodol in the 1980s. In the 2000s, drug-eluting beads were developed and applied clinically. Currently, TACE is a commonly used non-surgical treatment modality for patients with HCC who are unsuitable for curative treatment. Considering the vital role of TACE in the management of HCC, it is crucial to organize current knowledge and expert opinions regarding patient preparation, procedural techniques, and post-treatment care in TACE, which can enhance therapeutic efficacy and safety. A group of 12 experts in the fields of interventional radiology and hepatology, convened by the Research Committee of the Korean Liver Cancer Association (KLCA), has developed expert consensus-based practical recommendations in TACE. These recommendations have been endorsed by the Korean Society of Interventional Radiology and provide useful information and direction in performing TACE procedure as well as pre- and post- procedural patient care.

Transarterial chemoembolization for hepatocellular carcinoma: 2023 Expert consensus-based practical recommendations of the Korean Liver Cancer Association

Transarterial chemoembolization (TACE) was introduced in 1977 with the administration of chemotherapeutic agent to gelatin sponge particles through the hepatic artery in patients with hepatocellular carcinoma (HCC) and was established as conventional TACE using Lipiodol in the 1980s. In the 2000s, drug-eluting beads were developed and applied clinically. Currently, TACE is a commonly used non-surgical treatment modality for patients with HCC who are unsuitable for curative treatment. Considering the vital role of TACE in the management of HCC, it is crucial to organize current knowledge and expert opinions regarding patient preparation, procedural techniques, and post-treatment care in TACE, which can enhance therapeutic efficacy and safety. A group of 12 experts in the fields of interventional radiology and hepatology, convened by the Research Committee of the Korean Liver Cancer Association (KLCA), has developed expert consensus-based practical recommendations in TACE. These recommendations have been endorsed by the Korean Society of Interventional Radiology and provide useful information and direction in performing TACE procedure as well as pre- and post- procedural patient care.

Transarterial Chemoembolization for Hepatocellular Carcinoma: 2023 Expert Consensus-Based Practical Recommendations of the Korean Liver Cancer Association

Transarterial chemoembolization (TACE) was introduced in 1977 with the administration of chemotherapeutic agent to gelatin sponge particles through the hepatic artery in patients with hepatocellular carcinoma (HCC) and was established as conventional TACE using Lipiodol in the 1980s. In the 2000s, drug-eluting beads were developed and applied clinically. Currently, TACE is a commonly used non-surgical treatment modality for patients with HCC who are unsuitable for curative treatment. Considering the vital role of TACE in the management of HCC, it is crucial to organize current knowledge and expert opinions regarding patient preparation, procedural techniques, and post-treatment care in TACE, which can enhance therapeutic efficacy and safety. A group of 12 experts in the fields of interventional radiology and hepatology, convened by the Research Committee of the Korean Liver Cancer Association (KLCA), has developed expert consensus-based practical recommendations in TACE. These recommendations have been endorsed by the Korean Society of Interventional Radiology and provide useful information and direction in performing TACE procedure as well as pre- and post-procedural patient care.

The reproducibility of interventional radiology randomized controlled trials and external validation of a classification system

PURPOSE

The fragility index (FI) measures the robustness of randomized controlled trials (RCTs). It complements the P value by taking into account the number of outcome events. In this study, the authors measured the FI for major interventional radiology RCTs.

METHODS

Interventional radiology RCTs published between January 2010 and December 2022 relating to trans-jugular intrahepatic portosystemic shunt, trans-arterial chemoembolization, needle biopsy, angiography, angioplasty, thrombolysis, and nephrostomy tube insertion were analyzed to measure the FI and robustness of the studies.

RESULTS

A total of 34 RCTs were included. The median FI of those studies was 4.5 (range 1-68). Seven trials (20.6%) had a number of patients lost to follow-up that was higher than their FI, and 15 (44.1%) had a FI of 1-3.

CONCLUSION

The median FI, and hence the reproducibility of interventional radiology RCTs, is low compared to other medical fields, with some having a FI of 1, which should be interrupted cautiously.

Optimal interventional treatment for liver cancer: HAIC, TACE or iTACE?

Primary liver cancer is a common and lethal malignancy in China. Transcatheter arterial chemoembolization (TACE) is globally recognized as the preferred treatment modality for the non-surgical resection of hepatocellular carcinoma (HCC), while transcatheter arterial infusion (TAI) is another effective interventional treatment for HCC. In recent years, hepatic arterial infusion chemotherapy (HAIC) has gained increasing attention as an application-regulated modality for TAI. Owing to the current debate in the medical community regarding the use of HAIC and TACE for the treatment of HCC, the application of both approaches should be considered at a higher level, with a broader perspective and a more normative aspect. Accordingly, we aimed to define the rational combination of liver cancer TAI/HAIC with TACE as infusion transcatheter chemoembolization (iTACE), which suggests that the two interventions are not superior but lead to a mutually beneficial situation. In this review, we sought to discuss the development, specification, application, challenge and innovation, debate, and union of TAI/HAIC and TACE, and the clinical application and latest research on iTACE. We aimed to introduce new concepts of iTACE and expect new breakthroughs in the treatment of liver cancer owing to the combined use of the two major interventional tools.

Improving pain control during transarterial chemoembolization for hepatocellular carcinoma performed under local anesthesia with multimodal analgesia

PURPOSE

The purpose of this study was to assess the performance of a reinforced analgesic protocol (RAP) on pain control in patients undergoing conventional trans-arterial chemoembolization (cTACE) for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Eighty-one consecutive patients (57 men, 24 women) with a mean age of 69 ± 10 (standard deviation) years (age range: 49-92 years) underwent 103 cTACEs. Standard antalgic protocol (50 mg hydroxyzine, 10 mg oxycodone, 8 mg ondansetron, and lidocaine for local anesthesia) was prospectively compared to a RAP (standard + 40 mg 2-h infusion nefopam and 50 mg tramadol). The individual pain risk was stratified based on age, the presence of cirrhosis and alcoholic liver disease, and patients were assigned to a low-risk group (standard protocol) or high-risk group (RAP). The primary endpoint was severe periprocedural abdominal pain (SAP), defined as a visual analog scale score ≥30/100. A predefined intermediate analysis was performed to monitor the benefit-risk of the RAP. Based on the intermediate analysis, all patients were treated with the RAP.

RESULTS

The intermediate analysis performed after 52 cTACE showed that 2/17 (12%) high-risk patients (i.e., those receiving the RAP) experienced SAP compared to 15/35 (43%) low-risk patients (odds ratio [OR] = 0.18; 95% confidence interval [CI]: 0.02-0.98; P = 0.03). Analysis of all procedures showed that 12/67 (18%) patients in cTACE receiving the RAP experienced SAP compared to 15/36 (42%) patients who did not receive it (OR = 3.27; 95% CI: 1.32-8.14; P = 0.01). There were no statistical differences in adverse events, particularly for nausea, between groups.

CONCLUSION

Reinforcing the analgesic protocol by combining non-opioid and opioid molecules reduces perioperative pain in patients undergoing cTACE for HCC.

Prophylactic Steroids for Preventing Postembolization Syndrome after Transcatheter Arterial Embolization of Renal Angiomyolipoma: A Comparative Study

Purpose

Postembolization syndrome (PES) after renal arterial embolization (RAE) can reduce the patient's tolerance of the procedure and extend the length of hospital stay. We aimed to assess the efficacy of steroid administration in preventing PES in patients undergoing RAE for angiomyolipoma (AML).

Material and Methods

Between May 2004 and March 2020, 29 RAE procedures in 26 patients with AML were performed. Patient information, including age, sex, tumor size, tuberous sclerosis complex-associated/sporadic AML, hemorrhagic/nonhemorrhagic AML, embolic material, steroid use, medication type, some blood laboratory parameters, hospital stay, and PES occurrence were retrospectively obtained. The prophylactic steroid protocol used in the study was as follows: 250 mg of intravenous methylprednisolone (Solu-Medrol) 2 h before the RAE procedure, followed by 2 days of intravenous prednisolone (Predonine; 2 mg/kg/day), which was tapered by halving the dose every 2 days within the course of 2 weeks. After the discharge, intravenous prednisolone was changed to oral prednisolone (Predonine). PES was defined as the presence of fever, pain, nausea, or vomiting. Data were compared between the steroid and non-steroid groups and between PES and non-PES groups.

Results

The PES incidence rate was 76%, and a comparison between the steroid and non-steroid groups revealed that steroid use significantly decreased the incidence of PES (P < 0.001), including fever (P < 0.001), pain (P = 0.005), and nausea (P = 0.028). The use of anti-inflammatory drugs during the hospital stay was significantly lower in the steroid group (P = 0.019). Moreover, in the steroid group, C-reactive protein level was significantly lower (P = 0.006), whereas white blood cell count was significantly higher (P = 0.004). Conversely, the median length of hospital stay was not significantly shorter in the steroid group (P = 0.292).

Conclusions

The prophylactic use of steroids before and after embolization of renal AML may be effective in preventing PES in this small retrospective study.

Korean Liver Cancer Association (KLCA) and National Cancer Center (NCC) Korea. 2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

Complications Related to Transarterial Treatment of Hepatocellular Carcinoma: A Comprehensive Review

Currently, various types of transarterial treatments are performed for hepatocellular carcinoma from the early to advanced stages. Its indications and efficacy have been widely investigated. However, procedure-related complications have not been updated in the literature, although new types of transarterial treatments, such as drug-eluting bead transarterial chemoembolization and transarterial radioembolization, are common in daily practice. Herein, a comprehensive literature review was carried out, and complications were organized according to the organs affected and treatment modalities.

Efficacy of dexamethasone and N-acetylcysteine combination in preventing post-embolization syndrome after transarterial chemoembolization in hepatocellular carcinoma

BACKGROUND

Conventional transarterial chemoembolization (cTACE) is the current standard treatment for intermediate-stage hepatocellular carcinoma (HCC). Post-embolization syndrome (PES) is complex clinical syndrome that presents as fever, abdominal pain, nausea, and vomiting. Either dexamethasone (DEXA) or N-acetylcysteine (NAC) is used to prevent PES; however, the synergistic effect of their combined therapy for preventing PES and liver decompensation has not been determined.

AIM

To evaluate the efficacy of DEXA and NAC combination in preventing PES and liver decompensation after cTACE.

METHODS

Patients with Barcelona Clinic Liver Cancer stage A or B HCC who were scheduled for TACE were prospectively enrolled. All patients were randomly stratified to receive NAC and DEXA or placebo. The dual therapy (NAC + DEXA) group received intravenous administration of 10 mg DEXA every 12 h, NAC 24 h prior to cTACE (150 mg/kg/h for 1 h followed by 12.5 mg/kg/h for 4 h), and a continuous infusion of 6.25 mg/h NAC plus 4 mg DEXA every 12 h for 48 h after cTACE. The placebo group received an infusion of 5% glucose solution until 48 h after procedure. PES was defined by South West Oncology Group toxicity code grading of more than 2 that was calculated using incidence of fever, nausea, vomiting, and pain.

RESULTS

One-hundred patients were enrolled with 50 patients in each group. Incidence of PES was significantly lower in the NAC + DEXA group compared with in the placebo group (6% vs 80%; P < 0.001). Multivariate analysis showed that the dual treatment is a protective strategic therapy against PES development [odds ratio (OR) = 0.04; 95% confidence interval (CI): 0.01-0.20; P < 0.001). Seven (14%) patients in the placebo group, but none in the NAC + DEXA group, developed post-TACE liver decompensation. A dynamic change in Albumin-Bilirubin score of more than 0.5 point was found to be a risk factor for post-TACE liver decompensation (OR = 42.77; 95%CI: 1.01-1810; P = 0.049).

CONCLUSION

Intravenous NAC + DEXA administration ameliorated the occurrence of PES event after cTACE in patients with intermediate-stage HCC.

Transradial versus transfemoral approach for TACE: a retrospective study

OBJECTIVE

Transcatheter arterial chemoembolization (TACE) has been widely applied in the treatment of hepatocellular carcinoma (HCC). Our study aimed to investigate the feasibility and efficacy of transradial access as an alternative to transfemoral access for TACE.

METHODS

Patients undergoing TACE were divided into the radial artery (RA) route group or the femoral artery (FA) route group according to the operation approach, namely, transradial or transfemoral access. We retrospectively analysed the clinical characteristics, technical outcomes, clinical efficacy and incidence of adverse events to compare the two technologies for intervention for HCC.

RESULTS

Transradial access was found to achieve superior technical outcomes and clinical efficacy, as the patients in the RA group had a lower rate of hepatic arterial spasm, a higher partial response rate and a lower progression rate than the patients in the FA group according to the mRECIST evaluations. In contrast, the liver function indices and VAS (visual analogue scale) pain scores were consistent across the two groups. Moreover, patients in the RA group had a shorter length of stay than those in the FA group, despite similar hospitalization expenses. The total adverse events were significantly reduced by transradial access for TACE (72.5% vs. 84.1%, P = 0.027).

CONCLUSION

Our study suggested that transradial access is an effective and feasible alternative to transfemoral access for TACE. Large-scale prospective randomized controlled studies are expected.

2022 KLCA-NCC Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

Liver biopsy technique in the era of genomic cancer therapies: a single-center retrospective analysis

BACKGROUND

With the evolution of personalized medicine in the field of oncology, which includes optimal treatment selection using next-generation sequencing-based companion diagnostic systems and tumor-agnostic treatments according to common biomarkers, a liver tumor biopsy technique that can obtain a sufficient specimen volume must be established. The current study aimed to evaluate the safety and availability of a liver tumor biopsy technique with multiple puncture sites made using a coaxial introducer needle and embolization with gelatin sponge particles.

METHODS

Patients with primary or metastatic liver cancer who underwent liver tumor biopsies with puncture tract embolization using gelatin sponge (Spongel®) from October 2019 to September 2020 were included in the study. The complication and diagnostic rates were evaluated, and whether the specimen volume was sufficient for Foundation® CDx was investigated.

RESULTS

In total, 96 patients were enrolled in this analysis. The median total number of puncture times per patient was 3 (range 1-8). The pathological diagnostic rate was 79.2%. Using the FoundationOne® CDx, specimens with a sufficient volume required for genomic medicine were collected in 84.9% of patients. The incidence rate of bleeding was 4.2% (n = 4), and only one patient presented with major bleeding requiring transfusion.

CONCLUSIONS

Liver biopsy with puncture tract embolization using a gelatin sponge may be safe and effective for collecting specimens with a volume sufficient for modern cancer treatments.

Transarterial Chemoembolization and Unresectable Hepatocellular Carcinoma: A Narrative Review

Hepatocellular carcinoma (HCC) is an aggressive tumor, and even with the breakthrough in preventive strategies, and new diagnostic and treatment modalities, incidence and fatality rates continue to climb. Patients with HCC are most commonly diagnosed in the later stage, where the disease has already advanced, making it impossible to undertake potentially curative surgery. Transarterial chemoembolization (TACE) is a locoregional therapy regarded as a first-line treatment in patients with intermediate-stage HCC (Barcelona clinical liver cancer {BCLC}-B). TACE is a minimally invasive and non-surgical procedure that combines local chemotherapeutic drug administration with embolization to treat HCC. It helps limit tumor growth, preserve liver function, and increase overall and progression-free survival in patients with intermediate-stage HCC. This article has reviewed the efficacy, survival, limitations, and overall benefit of TACE in patients with unresectable HCC. This article has also discussed the effectiveness of TACE for neoadjuvant chemoembolization and the use of TACE with combination therapies.

The Impact of COVID-19 on Interventional Radiology Practice Worldwide: Results from a Global Survey

Background

The COVID-19 pandemic had an unprecedented impact on clinical practice and healthcare professionals. We aimed to assess how interventional radiology services (IR services) were impacted by the pandemic and describe adaptations to services and working patterns across the first two waves.

Methods

An anonymous six-part survey created using an online service was distributed as a single-use web link to 7125 members of the Cardiovascular and Interventional Radiological Society of Europe via email. Out of 450 respondents, 327 who completed the survey at least partially including 278 who completed the full survey were included into the analysis.

Results

Interventional radiologists (IRs) reported that the overall workload decreased a lot (18%) or mildly (36%) or remained stable (29%), and research activities were often delayed (30% in most/all projects, 33% in some projects). Extreme concerns about the health of families, patients and general public were reported by 43%, 34% and 40%, respectively, and 29% reported having experienced significant stress (25% quite a bit; 23% somewhat). Compared to the first wave, significant differences were seen regarding changes to working patterns, effect on emergency work, outpatient and day-case services in the second wave. A total of 59% of respondents felt that their organisation was better prepared for a third wave. A total of 19% and 39% reported that the changes implemented would be continued or potentially continued on a long-term basis.

Conclusion

While the COVID-19 pandemic has negatively affected IR services in terms of workload, research activity and emotional burden, IRs seem to have improved the own perception of adaptation and preparation for further waves of the pandemic.

Supplementary Information

The online version contains supplementary material available at 10.1007/s00270-022-03090-6.

Transarterial Chemoembolization for Hepatocellular Carcinoma: Why, When, How?

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy. It is principally associated with liver cirrhosis and chronic liver disease. The major risk factors for the development of HCC include viral infections (HBV, HCV), alcoholic liver disease (ALD,) and non-alcoholic fatty liver disease (NAFLD). The optimal treatment choice is dictated by multiple variables such as tumor burden, liver function, and patient's health status. Surgical resection, transplantation, ablation, transarterial chemoembolization (TACE), and systemic therapy are potentially useful treatment strategies. TACE is considered the first-line treatment for patients with intermediate stage HCC. The purpose of this review was to assess the indications, the optimal treatment schedule, the technical factors associated with TACE, and the overall application of TACE as a personalized treatment for HCC.

Efficacy of dexamethasone in reducing the postembolisation syndrome in men undergoing prostatic artery embolisation for benign prostatic hyperplasia: protocol for a single-centre, randomised, double-blind, placebo-controlled trial-the 'DEXAPAE' study

INTRODUCTION

Postembolisation syndrome (PES) is the most common side effect of vascular embolisation of solid organs. Although prophylactic corticosteroids are known to reduce the incidence and severity of PES, no trials investigating their efficacy have been conducted in men undergoing prostatic artery embolisation (PAE). We postulate that steroids can have a similar effect in reducing PES after PAE. This paper describes the rationale and detailed protocol for a randomised controlled trial evaluating the efficacy of dexamethasone (DEXA) in reducing PES after PAE.

METHODS AND ANALYSIS

In this single-centre, randomised, double-blind, placebo-controlled trial, we will enrol 60 individuals undergoing PAE for benign prostatic hyperplasia. Participants will be randomised to receive IV DEXA (24 mg) or placebo (saline). The primary outcomes will be postprocedural fever, pain and quality of life. The secondary outcomes will include postprocedural nausea, postprocedural medicine usage, laboratory parameters (C reactive protein, prostate-specific antigen) and early PAE results.

ETHICS AND DISSEMINATION

Ethics approval was obtained from the Danish Committee on Health Research Ethics in the Capital Region (H-20025910). The results from this trial will be disseminated through publication in peer-reviewed journals and national and international presentations.

TRIAL REGISTRATION NUMBER

Clinicaltrials.gov identifier: NCT04588857; EudraCT number: 2020-000915-53.

Effect and Safety of Prophylactic Parecoxib for Pain Control of Transarterial Chemoembolization in Liver Cancer: A Single-Center, Parallel-Group, Randomized Trial

OBJECTIVE

Pain is one of the most common side effects of transarterial chemoembolization (TACE) in patients with unresectable hepatocellular carcinoma. The goal of this study is to compare the analgesic effect among celecoxib, parecoxib, and oxycodone in patients undergoing TACE.

METHODS

This prospective study was a randomized, paralleled trial in which 213 patients were enrolled. Patients were assigned at the ratio of 1:1:1 to receive celecoxib, parecoxib, or controlled-release oxycodone 1 hour before TACE (T0) and once every 12 hours for 2 days after TACE. Pain scores, pain intensity, and adverse events in each time interval were evaluated and compared among the 3 groups.

RESULTS

The mean pain score 12 hours after T0 in the parecoxib group (2.8) was lower than that in the celecoxib (4.4; P = .001) and oxycodone groups (4.2; P = .005). The number of patients suffering severe pain was 10 (14.7%) in the parecoxib, 25 (36.8%) in the celecoxib, and 23 (32.9%) in the oxycodone groups (P = .009). Twelve hours after T0, the incidence of grade 3 vomiting in the parecoxib group (2.9%) was significantly lower than that in the oxycodone group (17.1%; P = .006). In the multivariate analysis, nonparecoxib prophylactic analgesia (odds ratio [OR], 4.620; 95% confidence interval [CI], 1.877-11.370; P = .001) as well as embolization of the gallbladder (OR, 8.666; 95% CI, 2.402-31.262; P = .001) and normal liver parenchyma (OR, 3.278; 95% CI, 1.409-7.627; P = .006) were the independent factors of severe pain intensity 12 hours after T0.

CONCLUSION

Parecoxib is superior to oxycodone and celecoxib for pain control with fewer adverse events. Therefore, we recommend parecoxib as a priority strategy for TACE-related pain control.

Single dose dexamethasone prophylaxis of postembolisation syndrome after chemoembolisation in hepatocellular carcinoma patient: A randomised, double-blind, placebo-controlled study

BACKGROUND

Even in the immuno-oncology era, transcatheter arterial chemoembolisation (TACE) is the most effective way to treat intermediate stage hepatocellular carcinoma (HCC). Postembolisation syndrome (PES) is the most common side effect from TACE and there is still no standard prevention guideline.

AIM

To evaluate the efficacy of single dose intravenous dexamethasone regimen to prevent PES after TACE among patients with HCC.

METHODS

This study enrolled patients with HCC who had eligible indication for TACE without macrovascular invasion/extrahepatic metastasis. Patients were randomly assigned to either an intravenous single dose of dexamethasone 8 mg or placebo one hour before TACE. The primary outcome was a negative result of PES at 48 h after TACE, which was defined as score < 2 of Southwest Oncology Group toxicity coding criteria using fever, nausea, vomiting and pain to calculated. And the secondary end point was duration of admission between two groups.

RESULTS

One hundred patients were randomly assigned 1:1. Under intention-to-treat analysis, 49 patients were randomly assigned to the dexamethasone and 51 to the placebo groups. Both groups were similar for baseline characteristics. The negative PES rate was significantly higher in the dexamethasone group than in the placebo group (63.3% vs 29.4%; P = 0.005). Mean Southwest Oncology Group toxicity coding PES was 2.14 (95%CI: 1.41-2.8) vs 3.71 (95%CI: 2.97-4.45) between the dexamethasone and placebo groups, respectively. Cumulative incidence of fever was significantly lower in dexamethasone group with P < 0.001, pain, nausea and vomiting were also lower in the dexamethasone group compared with the placebo group (P = 0.16, P = 0.11, and P = 0.49). The dexamethasone regimen was generally well tolerated by patients with HCC patients including those with hepatitis B virus infection and well-controlled diabetes mellitus.

CONCLUSION

Single dose dexamethasone was effective at preventing PES among patients with HCC treated with TACE. The study showed no adverse events of special interest related to dexamethasone.

CIRSE Standards of Practice on Hepatic Transarterial Chemoembolisation

This CIRSE Standards of Practice document is aimed at interventional radiologists and provides best practices for performing transarterial chemoembolisation. It has been developed by an expert writing group under the guidance of the CIRSE Standards of Practice Committee. It will encompass all technical details reflecting European practice of different TACE procedures (Lp-TACE, DEM-TACE, DSM-TACE, b-TACE) as well as revising the existing literature on the various clinical indications (HCC, mCRC, ICC, NET). Finally, new frontiers of development will also be discussed.

Intraarterial Lidocaine Administration for Pain Control by Water-in-Oil Technique in Transarterial Chemoembolization: in vivo and Randomized Clinical Trial

Objective

To investigate the sustained release of lidocaine from a lidocaine–epirubicin–lipiodol emulsion created by water-in-oil (W/O) technique in vivo and evaluate the efficacy and safety of intraarterial lidocaine administration for intra- and postoperative pain control in transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

Methods

The in vivo concentrations of lidocaine were determined in tumor tissues after VX2 rabbit models for hepatic tumor were administered with intra-arterial lidocaine–epirubicin–lipiodol emulsion. A prospective randomized controlled clinical trial was performed, enrolling 70 consecutive patients who underwent TACE. Patients were randomized into two groups: Group A received an immediate bolus intraarterial lidocaine injection before TACE, and Group B received a lidocaine–epirubicin–lipiodol emulsion during TACE. Pain intensity was compared between the two groups using a visual analog scale (VAS) score before (T_before) and at 0 h (T₀), 4 h (T₄), 8 h (T₈), 24 h (T₂₄), 48 h (T₄₈), and 72 h (T₇₂) after the procedure. Adverse events and intake of analgesics were evaluated and compared between the two groups.

Results

The concentrations of lidocaine in tumor tissues were higher in experimental group than in control group at T_0.5 (P=0.004), T₁ (P=0.038), T₄ (P=0.036), and T₈ (P=0.029). In the clinical trial, VAS scores in Group B were significantly lower than in Group A at T₀ (P=0.006), T₄ (P=0.001), T₈ (P=0.002), and T₂₄ (P=0.005). The tramadol intake in Group B was significantly lower than in Group A (P=0.021). No significant difference was observed regarding the incidence of adverse events between the two groups.

Conclusion

This study demonstrated the effectiveness and safety of intraarterial lidocaine administration using the W/O technique in controlling intra- and post-TACE pain.

Efficacy and safety analysis of dexamethasone-lipiodol emulsion in prevention of post-embolization syndrome after TACE: a retrospective analysis

Background

To investigate the efficacy and safety of dexamethasone-lipiodol emulsion in the prevention of post-embolization syndrome after TACE.

Method

The data of 255 patients who underwent TACE in the interventional department from June 2017 to June 2020 were collected. This is a retrospective assessment of patients who were non-randomly treated with dexamethasone in TACE. The patients were divided into two groups: TACE using lipiodol + chemotherapeutic emulsion group (TACE group, N = 133); TACE using lipiodol + dexamethasone + chemotherapeutic emulsion group (TACE + dexamethasone group, N = 122). Primary study endpoint: incidence of abdominal pain, fever, nausea and vomiting 0–72 h after TACE in both groups. Secondary study endpoints: incidence of infection after TACE in both groups.

Results

Incidence of post-embolization syndrome after TACE (TACE group vs TACE + dexamethasone group): abdominal pain, 55.6% versus 36.1% (P value 0.002); fever, 37.6% versus 13.1% (P value 0.000); nausea, 60.9% versus 41.0% (P value 0.001); vomiting, 48.1% versus 21.3% (P value 0.000). Incidence of infection after TACE (TACE group vs TACE + dexamethasone group): 1.5% versus 2.5% (P value 0.583).

Conclusion

The lipiodol + dexamethasone emulsion can significantly reduce the incidence rate of post-embolization syndrome after TACE, with exact effect and high safety.

Risk factors of infection after transarterial chemoembolization for hepatocellular carcinoma: A protocol for systematic review and meta-analysis

BACKGROUND

Transarterial chemoembolization (TACE) has the characteristics of minimally invasive, strong repeatability, and good curative effect, so it is commonly used in the nonoperative treatment of hepatocellular carcinoma (HCC). However, infection will occur after TACE, which not only increases the hospitalization time and medical expenses, but also affects the efficacy of TACE treatment. At present, there is a lack of analysis of the risk factors of infection after TACE of patients with HCC. In this study, meta-analysis was used to further explore the risk factors of postoperative infection in patients with HCC after TACE, and to provide strategies for infection prevention and intervention.

METHODS

To search the literatures about the influencing factors of post-TACE infection in patients with HCC published from the establishment of PubMed, Embase, The Cochrane Library, Web of Science, China Biology Medicine Database, China National Knowledge Infrastructure, China Science and Technology Journal Database, and WANFANG to April 2021. Screening was carried out according to inclusion criteria and exclusion criteria. A meta-analysis was performed using RevMan 5.3 software.

RESULTS

We disseminated the findings of this systematic review and meta-analysis via publications in peer-reviewed journals.

CONCLUSION

This study systematically reviewed the existing evidence and determined the incidence and predictors of infection after TACE of patients with HCC.

ETHICS AND DISSEMINATION

The private information from individuals will not be published. This systematic review also should not damage participants' rights. Approval from an ethics committee is not required for this study. The results may be published in a peer-reviewed journal or disseminated in relevant conferences.

OSF REGISTRATION NUMBER

DOI 10.17605/OSF.IO/26P5X.

Early diagnosis and therapeutic strategies for hepatocellular carcinoma: From bench to bedside

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related deaths worldwide. The prognosis of patients with HCC remains poor largely due to the late diagnosis and lack of effective treatments. Despite being widely used, alpha-fetoprotein serology and ultrasonography have limited diagnostic performance for early-stage HCC. The emergence of omics strategies has contributed to significant advances in the development of non-invasive biomarkers for the early diagnosis of HCC including proteins, metabolites, circulating tumor deoxyribonucleic acid, and circulating non-coding ribonucleic acid. Early diagnosis is beneficial to patients as it increases the proportion who can be treated with curative treatment, thus prolonging survival outcomes. Currently, multiple clinical trials involving locoregional, systemic therapies, and combinations of these modalities are changing therapeutic strategies for different stage HCC. Success in several preclinical trials that involve immunotherapeutic innovations has created the potential to complement and enforce other treatment strategies in the future. This review summarizes the most recent advances in non-invasive early molecular detection, current therapy strategies, and potential immunotherapeutic innovations of HCC.

Identifying predictors and evaluating the role of steroids in the prevention of post-embolization syndrome after transarterial chemoembolization and bland embolization

Background

Transarterial chemoembolization (TACE) and bland embolization (TAE), performed for hepatocellular carcinoma (HCC), are often complicated by post-embolization syndrome (PES). There are limited data regarding the incidence of PES after TAE and the role of steroids in PES. We report the incidence of PES post TACE and TAE, identify predictors, and evaluate the role of steroids in PES.

Methods

Demographic and clinical variables of patients who underwent embolization were collected and PES was identified. Risk factors for PES, TACE and TAE were derived by logistic regression. We compared patients who received dexamethasone to those who did not, regarding baseline characteristics, occurrence of PES, and hospital stay.

Results

A total of 171 patients, average age 60.5 years, underwent the procedure, 77.8% were male, and 87.7% had cirrhosis. Of these 171, 107 underwent TACE and 64 TAE. Dexamethasone was given to 106 (61.9%) patients, of whom 85 had TACE and 21 TAE. One hundred twenty-four patients (72.5%) developed PES. PES occurred in more patients who underwent TACE, 80 (74.7%) vs. 44 (68.7%), and resulted in a longer hospital stay (1.47 vs. 1.12 days, P=0.034). Predictive factors for PES included female sex (odds ratio [OR] 2.76, 95% confidence interval [CI] 1.04-7.34; P=0.041), and alcohol-related HCC (OR 3.14, 95%CI 1.42-6.95; P=0.005). Dexamethasone did not affect the length of hospital stay (1.43 vs. 1.29 days, P=0.422) or the rate of prolonged hospitalization (18.8% vs. 15.4%, P=0.561).

Conclusion

There was no difference in the incidence of PES following TACE or TAE and the use of dexamethasone did not reduce the incidence of PES or the duration of hospital stay.

Palliative care in hepatocellular carcinoma

Hepatocellular carcinoma is a common cancer with a poor prognosis, associated with high economic costs and a significant burden of disease. While it is often asymptomatic in the early stages, patients may experience great discomfort from advanced disease, treatment adverse effects, or decompensation of underlying cirrhosis. Palliative care has the potential to markedly improve quality of life, physical, and psychological symptoms in patients with end-stage liver disease, and has been shown to prolong survival in some nonhepatocellular carcinoma malignancies. However, this service is underutilized in hepatocellular carcinoma, and referrals are frequently late due to factors such as stigmatization, inadequate resources, lack of education for nonpalliative care physicians and inadequate modeling for integration of palliative and supportive care within liver disease services. In the future, education workshops, population-based awareness campaigns, increased funding and improved models of care, may improve the uptake of palliative care and subsequently optimize patient care, particularly towards the end of life.

Changing trends in hepatocellular carcinoma management: Results from a nationwide database in the last decade

OBJECTIVE

The therapeutic strategies for hepatocellular carcinoma (HCC) have greatly expanded in recent years. However, the actual usage of each of these treatments in clinical routine remains unknown. Here, we analysed the distribution and changes of the main surgical and radiological therapeutic procedures nationwide during the last decade.

METHODS

Retrospectively, analysis of the data on all >18-year-old patients with a diagnosis of HCC identified in the French Program for the Medicalization of Information Systems database that contains all discharge summaries from all French hospitals. The number and percentage of the therapeutic procedures performed from January 2010 to December 2019 were extracted.

RESULTS

A total of 68,416 therapeutic procedures were performed in 34,000 HCC patients. Whereas HCC incidence remained stable, the annual number of procedures frankly increased over the decade (from 4267 to 8042). Trans-arterial chemoembolization was the most frequently performed technical procedure, with a double-digit annual growth from 2010 (n = 1932) to 2015 (n = 4085), before stabilization from 2016. Selective internal radiation therapy displayed the highest increase in the decade (+475%). Among curative treatments, the annual number of percutaneous tumour ablations more than doubled in 10 years, till representing 64% of curative treatments in cirrhotic patients in 2019. Surgical tumour resections showed a 1.5-fold increase in 10 years, due to the great increase in minimally invasive approaches, whereas the proportion of open resection progressively decreased.

CONCLUSION

Minimally invasive procedures have gained major importance in HCC management during the last decade. Percutaneous thermal ablation has emerged as the first curative treatment performed for patients with HCC.

Dexamethasone prevents TACE-induced adverse events: A meta-analysis

BACKGROUND

While dexamethasone has been applied following transcatheter arterial chemoembolization (TACE) for years, its clinical effects have not been determined. In the current study, we aimed to evaluate the efficacy of dexamethasone in preventing adverse events induced by TACE.

METHODS

Literature retrieval was conducted using globally recognized online databases, namely MEDLINE, EMBASE, and Cochrane Central, to identify randomized controlled trials (RCTs) of dexamethasone application in patients undergoing TACE. The relative odds ratios (ORs) of incidence rates of three adverse events, namely, fever, abdominal pain and nausea/vomiting, were calculated. The value of I was applied to evaluate the heterogeneity of the trials, and the overall publication bias was assessed with Egger test.

RESULTS

Four RCTs containing 350 subjects were included for the pooled estimation. Dexamethasone significantly reduced the incidence rate of TACE-induced adverse events (OR = 1.237, 95% CI: 1.170-1.308, P < .001) with moderate heterogeneity (I = 46.0%). The result of Egger test revealed a publication bias for the included studies.

CONCLUSION

The current meta-analysis confirmed the efficacy of dexamethasone in preventing TACE-induced adverse events. To confirm the practicality of dexamethasone use with TACE, further studies with large sample sizes are warranted to update the evidence-based analyses.

Postembolization Syndrome after Prostatic Artery Embolization: A Systematic Review

Postembolization syndrome (PES) is the most common side effect of vascular embolization of solid organs. The aim of this review was to determine the incidence of PES and its individual components after prostatic artery embolization (PAE). A systematic review with a pre-specified search strategy for PubMed, Embase, Web of Science and Cochrane Library was performed according to PRISMA guidelines. Studies in English regarding PAE in humans with 10 or more participants were eligible for inclusion. No restrictions on participant demographics or PAE technique were imposed. The search returned 378 references, of which 32 studies with a total of 2116 patients met the inclusion criteria. The results for overall PES frequency and individual PES components were presented as median (interquartile range, (IQR)). Overall median PES frequency was 25.5% (12.5–45.8). The two most frequent individual PES components were dysuria/urethral burning and local pain, with a median frequency of 21.7% (13.8–33.3) and 20% (5.4–29.4), respectively. Most outcome measures were characterized by a marked lack of uniformity and inconsistency in reporting across studies. Development of a uniform reporting system would help the clinicians recognize and treat PES accordingly.

Dexamethasone inhibits stemness maintenance and enhances chemosensitivity of hepatocellular carcinoma stem cells by inducing deSUMOylation of HIF‑1α and Oct4

It has been controversial whether patients with hepatocellular carcinoma (HCC) should receive glucocorticoid therapy during chemotherapy. Recent studies have demonstrated that glucocorticoids increase the therapeutic sensitivity of tumors to some chemotherapeutic drugs, but the specific mechanism remains unclear. In the present study, dexamethasone (Dex) was used to treat HCC stem cells. The results demonstrated that Dex reduced stemness maintenance and self-renewal of HCC stem cells, promoted epithelial-to-mesenchymal transition, inhibited migration and angiogenesis and, more importantly, increased cell sensitivity to the herpes simplex virus thymidine kinase/ganciclovir drug system in vitro and in vivo. Further mechanistic analyses demonstrated that Dex inhibited small ubiquitin-like modifier (SUMO) modification of several proteins in HCC stem cells, including hypoxia-inducible factor (HIF)-1α, an important hypoxia tolerance protein, and octamer-binding transcription factor 4 (Oct4), a crucial stemness maintenance protein. Inducing deSUMOylation of HIF-1α and Oct4 reduced their accumulation in the nucleus, thereby inhibiting tumor angiogenesis and stemness maintenance. These findings provide a new perspective to the study of the mechanism underlying the anti-hepatocarcinogenesis effects of Dex. Due to the few side effects of glucocorticoids at low doses and their anti-inflammatory effects, the appropriate combination of glucocorticoids and chemotherapeutic drugs is expected to improve the survival of HCC patients and their prognosis.

Risk Factors for Postembolization Syndrome After Transcatheter Arterial Chemoembolization

BACKGROUND

Transarterial Chemoembolization (TACE) is a minimally invasive treatment in managing unresectable liver primary neoplasms or liver metastases. Postembolization Syndrome (PES) is the most common adverse effect after TACE procedures.

OBJECTIVE

We investigate the risk factors for the development of PES after TACE therapy in patients with primary or metastatic liver tumors.

METHODS

In a retrospective analysis of 163 patients who underwent TACE between 01/01/2012 and 31/01/2018, patients that were given medication due to pain, fever, nausea or vomiting were evaluated and noted with PES. Analyses were made to evaluate factors such as age, gender, chemotherapy agent and dose, tumor size, tumor type, a particle used for embolization, multiple tumor treatments and selective application of the procedure, which may lead to PES after TACE.

RESULTS

In a total of 316 patients, PES was observed at a rate of 55 percent after TACE. Tumor size, number of tumors treated and adopting super selective fashion in the procedure were found to be related to the development of PES. No relationship was found between age, gender, presence of ascites, tumor type, size of embolic agent and drug type and the development of PES.

CONCLUSION

A treated tumor measuring >5 cm, treating more than one tumor, and the failure to perform the procedure in a super selective fashion increase the risk of PES development after TACE.

Interventional oncology at the time of COVID-19 pandemic: Problems and solutions

•

COVID-19 pandemic modifies in-depth interventional oncology practice.

•

Identification of aerosol-generating procedures is crucial for safety.

•

Curative treatment of cancers should not be delayed during the COVID-19 pandemic.

•

Solutions to overcome shortage in anesthesiology resources are described.

The COVID-19 pandemic has deeply impacted the activity of interventional oncology in hospitals and cancer centers. In this review based on official recommendations of different international societies, but also on local solutions found in different expert large-volume centers, we discuss the changes that need to be done for the organization, safety, and patient management in interventional oncology. A literature review of potential solutions in a context of scarce anesthesiologic resources, limited staff and limited access to hospital beds are proposed and discussed based on the literature data.

Determination of Risk Factors for Pain After Transarterial Chemoembolization with Drug-Eluting Beads for Hepatocellular Carcinoma

Purpose

To identify risk factors for pain after transarterial chemoembolization with drug-eluting beads (DEB-TACE) for hepatocellular carcinoma (HCC).

Patients and Methods

In this retrospective study, a total of 118 consecutive patients who underwent DEB-TACE between June 2016 and May 2019 with post-TACE pain were included. The patients were divided into three groups based on the severity of post-TACE pain according to the distribution of pain Visual Analogue Scale/Score (VAS). Potential risk factors for post-TACE pain were primarily analyzed using the chi-square test, one-way analysis of variance, or Kruskal–Wallis test (if appropriate). For multivariate analysis, an ordinal logistic regression model was utilized. Variables with P<0.10 in the univariate analysis were included in a multivariate model to identify independent risk factors for post-TACE pain. A multivariate analysis was also performed by means of a decision tree using the Classification and Regression Tree (CART) algorithm.

Results

The univariate analysis showed that elderly patients or patients with portal venous tumor thrombus (PVTT) were more likely to have severe post-TACE pain than young patients or those without PVTT (P=0.028 and <0.001, respectively). However, in the ordinal logistic regression, nonsuperselective chemoembolization and presence of PVTT were independent risk factors of severe post-TACE pain (P=0.046 and <0.001, respectively). In addition, the CART showed that nonsuperselective chemoembolization and PVTT could increase the probability of severe post-TACE pain.

Conclusion

Nonsuperselective chemoembolization and PVTT are independent risk factors for pain after DEB-TACE. Therefore, these factors should be taken into full consideration for the relief of pain.

Switching to systemic therapy after locoregional treatment failure: Definition and best timing

In patients with unresectable hepatocellular carcinoma (HCC) without both macrovascular invasion and extrahepatic metastasis, the initial treatment choice recommended is transarterial chemoembolization (TACE). Before sorafenib came into wide use, TACE had been pointlessly carried out repeatedly. It was in the early 2010s that the concept of TACE refractory was advocated. Two retrospective studies from Japan indicated that conversion from TACE to sorafenib the day after patients were deemed as TACE refractory improved overall survival compared with continued TACE, according to the definition by the Japan Society of Hepatology. Nowadays, phase 3 trials have shown clinical benefits of several novel molecular target agents. Compared with the era of sorafenib, sequential treatments with these molecular target agents have gradually prolonged patients' survival and have become major strategies in patients with HCC. Taking these together, conversion from TACE to systemic therapies at the time of TACE refractory, compared with before, may have a greater impact on survival and may be considered deeper in the decisions-making process in patients with unresectable HCC who are candidate for TACE. Up-to-date information on the concept of TACE refractory is summarized in this review. We believe that the survival of patients with unresectable HCC without both macrovascular invasion and extrahepatic metastasis may be dramatically improved by optimal timing of TACE refractory and switching to systemic therapies.

Systematic Review and Meta-Analysis of the Benefit and Safety of Preoperative Administration of Steroid in Patients Undergoing Liver Resection

Objective: To evaluate the benefit and safety of preoperative administration of steroid in patients undergoing liver resection.

Methods: Randomized controlled trials (RCTs) which comparing preoperative administration of steroid in patients undergoing liver resection with control group were identified through a systematic literature search in PubMed, Embase, and Cochrane Library Central databases. This meta-analysis was carried out to assess the liver function, inflammatory response, and postoperative complications after liver surgery.

Results: Six RCTs including 411 patients were reviewed. The pooled result showed that there was no significant difference in the incidence of overall complications between the steroid group and the control group (OR, 0.57; 95% CI, 0.27–1.17; P = 0.13). With respect to specific complications, no significant difference was detected between the two groups in infection complications (OR, 0.95; 95% CI, 0.13–6.95; P = 0.96), wound complications (OR, 0.65; 95% CI, 0.32–1.33; P = 0.24), liver failure (OR, 0.41; 95% CI, 0.10–1.64; P = 0.21), bile leakage (OR, 0.57; 95% CI, 0.17–1.89; P = 0.36), and pleural effusion (OR, 1.24; 95% CI, 0.55–2.78; P = 0.60). For liver function, the level of serum total bilirubin (TB) on postoperative day 1 (POD 1) was significantly decreased associated with the intervention of steroid (MD, −0.54; 95% CI, −0.94 to −0.15; P = 0.007). However, no significant difference was found in the level of alanine aminotransferase (ALT) (MD, −69.39; 95% CI, −226.52 to 87.75; P = 0.39) and aspartate aminotransferase (AST) (MD, −93.44; 95% CI, −275.68 to 88.80; P = 0.31) on POD 1 between the two groups. Serum IL-6 level on POD 1 (MD, −57.98; 95% CI, −73.04 to −42.91; P < 0.00001) and CRP level on POD 3 (MD, −4.83; 95% CI, −6.07 to −3.59; P < 0.00001) were significantly reduced in the steroid group comparing to the control group. Compared with the control group, the level of early postoperative IL-10 was significant higher in the steroid group (MD, 17.89; 95% CI, 3.89 to 31.89; P = 0.01).

Conclusion: Preoperative administration of steroid in liver resection can promote the recovery of liver function and inhibit the inflammatory response without increasing postoperative complications. Further studies should focus on determining which patients would benefit most from the steroid.