Safety and Feasibility of Helical I-125 Seed Implants Combined with Transcatheter Arterial Chemoembolization in Hepatocellular Carcinomas with Main Portal Vein Tumor Thrombus

Efficacy and factors related to prognosis of combination chemotherapy with different radiotherapy methods in patients with unresectable hepatocellular carcinoma

Apart from beam radiation (BR), treatment with radioactive implants (RI) was another important modality of cancer therapy. The main purpose was to explore which radiotherapy combined with chemotherapy was more beneficial and identify factor related to prognosis for patients with unresectable hepatocellular carcinoma (HCC). Patients were collected from the surveillance, epidemiology, and end results (SEER) database and were divided into RI group and BR group. Overall survival (OS) and HCC-specific survival were compared between two groups. Propensity score matched (PSM) was used to reduce baseline differences between the two groups. Univariate and multivariate Cox analysis were used to determine the factors affecting the prognosis, and a nomogram model was constructed based on independent risk factors. A total of 1481 HCC patients from 2000 to 2019 were enrolled, including 502 in RI group and 979 in BR group. After PSM, 376 pairs of matched cases were selected. In the matched cohort, there was no significant difference in the median OS (RI vs. BR, 15 vs. 17 months, P = 0.616) and HCC-specific survival (RI vs. BR, 18 vs. 21 months, P = 0.154) between the two groups. Subgroup analysis of different stages also showed no significant difference. Multivariate Cox analysis also did not indicate a significant prognostic difference between the two groups. Based on the independent risk factors of OS such as AFP, grade, TNM staging, and M1, a nomogram model was constructed and verified. When combined with chemotherapy in the treatment of unresectable HCC, RI demonstrated comparable prognostic outcomes to BR, suggesting its potential as an alternative treatment option. In addition, the constructed nomogram model might be able to intuitively and accurately predict the prognosis of unresectable HCC patients receiving chemotherapy combined with radiotherapy.

Clinical Therapy: HAIC Combined with Tyrosine Kinase Inhibitors and Programmed Cell Death Protein-1 Inhibitors versus HAIC Alone for Unresectable Hepatocellular Carcinoma

Purpose

The majority of new diagnoses of hepatocellular carcinoma (HCC) still pertain to unresectable cases. Currently, the combination therapy of tyrosine kinase inhibitors (TKIs) and programmed cell death protein-1 (PD-1) inhibitors has become the mainstream treatment. According to multiple clinical guidelines, it is strongly advised to consider local therapy as the primary treatment choice for uHCC. This research was conducted to examine the safety and effectiveness of combining hepatic arterial infusion chemotherapy (HAIC) with TKIs and PD-1 inhibitors for the treatment of uHCC.

Methods

Between 2015 and 2020, 208 HCC patients received HAIC alone or HAIC in combination with TKIs and PD-1 inhibitors. The overall survival(OS), and progression-free survival(PFS) and the best treatment response were compared between the two treatment groups. Propensity score matching (PSM)was used to minimize confounding bias.

Results

Among the enrolled patients, 116 patients (55.8%) received combination therapy, while 92 patients (44.2%) received HAIC alone. The baseline characteristics were similar between the two groups. After PSM, 82 pairs of well-matched liver cancer patients were selected; the overall response rate in the combination group trended better than that in the HAIC alone group. The hazard ratios (HRs) for OS and PFS of the combination approach compared to the HAIC-alone approach were 0.47 (95% CI, 0.322-0.687; p<0.001) and 0.58 (95% CI, 0.397-0.848; p=0.005), respectively.

Conclusion

For uHCC patients, combination therapy can provide better OS and PFS compared to HAIC alone.

Safety and efficacy of biliary stenting combined with iodine-125 seed strand followed by hepatic artery infusion chemotherapy plus lenvatinib with PD-1 inhibitor for the treatment of extrahepatic cholangiocarcinoma with malignant obstructive jaundice

Objectives

To evaluate the efficacy and safety of biliary stenting implantation with iodine-125 seed strand (SI) followed by hepatic artery infusion chemotherapy (HAIC) plus lenvatinib (Len) with programmed death-1 (PD-1) inhibitor for patients diagnosed with extrahepatic cholangiocarcinoma (ECC) and malignant obstructive jaundice (MOJ).

Methods

In this single-center retrospective study, the data of ECC patients with MOJ from March 2015 to January 2023 was assessed. Using probability score matching (PSM), the selection bias of patients was reduced. Primary study outcomes included overall survival (OS) and progression-free survival (PFS). The OS and PFS were performed using the Kaplan-Meier method and evaluated with the log-rank test.

Results

A total of 104 patients were enrolled finally, including 52 patients treated with interventional therapy (SI+HAIC) plus Len with PD-1 inhibitor (SI+HAIC+Len+P group) and 52 patients treated with interventional therapy (SI+HAIC) plus lenvatinib (SI+HAIC+Len group). 26 pairs of patients were matched after PSM analysis. After PSM analysis, the median OS and PFS in the SI+HAIC+Len+P group were significantly longer compared to those in the SI+HAIC+Len group (OS:16.6 vs. 12.3 months, P = 0.001; PFS:12.6 vs 8.5 months, P = 0.004). The DCR was significantly different between groups (P = 0.039), while ORR not (P = 0.548). The addition of PD-1 inhibitor was generally well tolerated without treatment-associated mortality.

Conclusion

Interventional therapy (SI+HAIC) plus Len with PD-1 inhibitor was effective for ECC patients accompanied by MOJ with a manageable safety profile.

Efficacy and safety of transarterial chemoembolization combined with lenvatinib, programmed death-1 inhibitor, and iodine-125 seed brachytherapy for hepatocellular carcinoma with portal vein tumor thrombosis

BACKGROUND

Therapy for hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT) is still controversial. This study was performed to evaluate the efficacy and safety of the combination therapy comprising transarterial chemoembolization (TACE), lenvatinib (L), programmed death-1 inhibitor (P), and iodine-125 seed (I125) brachytherapy relative to TACE in combination with lenvatinib plus programmed death-1 inhibitor therapy and TACE plus lenvatinib therapy.

METHODS

The data of HCC patients with PVTT from July 2017 to August 2022 were assessed in this single-center retrospective study. Primary study outcomes were progression-free survival (PFS) and overall survival (OS), while the secondary outcomes were disease control rate (DCR), objective response rate (ORR), and treatment-related adverse events.

RESULTS

We enrolled 150 patients totally, including 50 patients treated with TACE plus lenvatinib therapy (TACE+L group), 45 patients treated with TACE in combination with lenvatinib plus programmed death-1 inhibitor therapy (TACE+L+P group), and 55 patients treated with the combination therapy of TACE along with I125 brachytherapy, lenvatinib, and programmed death-1 inhibitor therapy (TACE+L+P+I125 group). The median OS in the TACE+L+P+I125 group (21.0; 95% confidence interval [CI]: 18.4∼23.5 months) was significantly longer than that in the TACE+L group (10; 95% CI: 7.8∼12.1months) (p = 0.006), while it was insignificantly longer than that in the TACE+L+P group (14.0; 95% CI: 10.7∼17.2months) (p = 0.058). The median PFS in the TACE+L+P+I125 group (13.0; 95% CI: 10.2∼15.7 months) was significantly longer than that in the TACE+L group (5.0; 95% CI: 4.2∼5.7 months) (p = 0.014) and the TACE+L+P group (9.0; 95% CI: 6.7∼11.2 months) (p = 0.048). Statistically significant differences between groups were found in DCR (p = 0.015). There were no significant between-group differences in treatment-related adverse events (p > 0.05).

CONCLUSIONS

A combination therapy of TACE, lenvatinib, programmed death-1 inhibitor, and I125 seed brachytherapy significantly improve OS, PFS, and DCR and show better survival prognosis for HCC patients accompanied by PVTT.

Assessment of efficacy and prognostic factors by Gelfoam for DEB-TACE in unresectable large hepatocellular carcinoma with portal vein tumor thrombus: a multi-center retrospective study

OBJECTIVE

To explore the clinical efficacy and prognostic factors of the use of Gelfoam for drug-eluting bead (DEB) transarterial chemoembolization (GMD-TACE) in patients with unresectable large hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT).

METHODS

A retrospective analysis was conducted using the mRECIST standard to evaluate tumor response after GMD-TACE. Overall survival time, median survival time, time to progression (TTP) after the first intervention, and other treatment methods were recorded.

RESULTS

The follow-up time was 2-110 months (mean 17.97 + 19.12 months), the median follow-up time was 12.5 months, and the first TTP after the first GMD-TACE was 4 months (95% CI 3.020-4.980). The median overall survival (OS) time was 14 months (95% CI 9.801-18.199). The 1-, 3-, and 5-year survival rates were 53.6%, 32.3%, and 8.9%, respectively. Multivariate analysis showed that the type of tumor thrombus was an independent factors affecting prognosis, and combination therapy was a protective factor affecting prognosis.

CONCLUSIONS

GMD-TACE can be used as the core treatment for unresectable large HCC combined with a PVTT. This can improve the quality of life and further improve the median OS, and is worthy of clinical promotion and application.

Transarterial chemoembolization failure/refractoriness: A scientific concept or pseudo-proposition

Multi-session transarterial chemoembolization (TACE) is usually needed for the treatment of intermediate-stage hepatocellular carcinoma (HCC), but it may not always have a positive influence on prognosis due to high heterogeneity of HCC. To avoid ineffective repeated TACE, the concept of TACE failure/refractoriness has been proposed by several organizations and is being addressed using tyrosine kinase inhibitors. The concept of TACE failure/refractoriness is controversial due to ambiguous definitions and low evidence-based data. To date, only a few studies have examined the rationality concerning the definition of TACE failure/refractoriness, although the concept has been introduced and applied in many TACE-related clinical trials. This review focuses on some of the issues related to different versions of TACE failure/refractoriness, the rationality of related definitions, and the feasibility of continuing TACE after so-called failure/refractoriness based on published evidence. A suggestion to re-define TAEC failure/refractoriness is also put forward.

Predicting Outcome in Combination Treatment of TACE and Camrelizumab for Advanced Hepatocellular carcinoma: Tumor Hypervascularity and Reactive Cutaneous Capillary Endothelial Proliferation

Objective

To validate the robust predictive values of tumor vascularity and reactive cutaneous capillary endothelial proliferation (RCCEP) in combination treatment of transarterial chemoembolization (TACE) and camrelizumab for patients with advanced hepatocellular carcinoma (HCC) and then select the potential candidates who would survive best from such treatment.

Methods

The clinical data of 113 patients with advanced HCC treated with TACE and camrelizumab from January 2019 to December 2021 were analyzed retrospectively. Mann Whitney U-test was used to evaluate the correlation between vascular distribution and RCCEP and tumor response; Kaplan Meier technique was used to evaluate time to progress (TTP) and overall survival (OS), and log rank test was used for comparison; multivariate Cox regression analysis was used to evaluate the related influencing factors.

Results

The TTP and OS of TACE combined with carrelizumab in patients with advanced HCC were 7.1 and 14.3 months. Hypervascularity and development of RCCEP were good predictors of TTP (HR 2.561, P < 0.001; HR 1.486, P = 0.032) and OS (HR 2.854, P < 0.001; HR 1.634, P = 0.011). The median TTP and OS of patients with hypervascularity and RCCEP were 10.6 and 19.3 months, which were better than those with only hypervascularity (6.8 months, P = 0.016; 11.6 months, P = 0.003) and only RCCEP (6.2 months, P = 0.039; 13.5 months, P = 0.042), as well as those with neither (3.8 months, P < 0.001; 7.4 months, P < 0.001).

Conclusion

Tumor hypervascularity and development of RCCEP were favorable predictive factors for the combination treatment of TACE and carrelizumab, with both of which the patients survived longest and might be the potential candidates.

To explore the curative effect of CT-guided Iodine-125 radioactive seed implantation in the treatment of stage Ⅳprimary hepatocellular carcinoma

Objectives

To explore the clinical efficacy and survival of CT-guided Iodine-125 radioactive seed implantation in the treatment of stage Ⅳ primary hepatocellular carcinoma.

Methods

A retrospective study of 62 patients with primary hepatocellular carcinoma in our hospital from January 2017 to December 2018 [60 males, 2 females, age (52.76 ​± ​10.82) years old], All patients were implanted with Iodine-125 radioactive seeds under CT guidance, followed up regularly after operation to observe the clinical efficacy, including comparison of changes in cancer size before and after treatment, tumor marker AFP, and improvement in complications such as abdominal pain and ascites. Follow-up 3–36 months to assess patient survival.

Results

Among the 62 patients, 3 months after Iodine-125 radioactive seed implantation, 5 cases (8.1%) had complete remission of cancer, 33 cases (53.2%) had partial remission, 12 cases (19.4%) had stable lesions, and 12 cases (19.4%) had disease progression. The effective rate was 61.3%. The tumor volume (31.44 ​± ​14.51cm3) was significantly smaller than before (50.96 ​± ​30.13cm3) (t ​= ​5.303, p ​< ​0.05). The tumor marker AFP (69.28 ​± ​50.99) ug/L of 3 months after implantation was significantly lower than that before treatment (90.63 ​± ​68.58) ug/L (t ​= ​3.702, P ​< ​0.05). The average survival time of Iodine-125 seed implantation for stageⅣhepatocellular carcinoma is 11.47 ​± ​0.85 months, and the median survival time is 9 months. The survival time of the group with better pathological differentiation (gradeⅠ+Ⅱ) was significantly better than that of the group with poor differentiation (grade Ⅲ+Ⅳ) (x2 ​= ​6.869 p ​< ​0.05). Among the 38 patients with different degrees of abdominal pain, 22 patients improved better than before; 15 of 28 patients with different degrees of ascites were better than before. All patients had no serious complications related to treatment.

Conclusions

Iodine-125 radioactive seed implantation therapy can safely and effectively treat hepatocellular carcinoma, and relieve the clinical symptoms of abdominal pain and ascites.

Portal Vein Irradiation Stent Plus Chemoembolization versus External Radiotherapy Plus Chemoembolization in Hepatocellular Carcinoma with Portal Vein Tumour Thrombus: A Retrospective Study

PURPOSE

To compare the clinical outcomes of portal vein irradiation stent implantation (PVIS) plus transcatheter arterial chemoembolization (TACE) and radiotherapy (RT) plus TACE in hepatocellular carcinoma (HCC) with portal vein tumour thrombus (PVTT).

METHODS

Data from 79 patients with HCC complicated by PVTT treated with PVIS implantation plus TACE (n = 53) or treated with RT plus TACE (n = 26) were retrospectively analysed. The primary outcome measure was overall survival, and the secondary outcome was the stent patency period. HCC response and complications were evaluated.

RESULTS

At a median follow-up of 14.3 (range, 1.2 ~ 60) months, the median OS was 13.1 (95% CI: 9.8 ~ 16.4) months in the PVIS plus TACE group compared to 8.0 (95% CI: 6.1 ~ 9.9) months in the RT plus TACE group (p = 0.021). Stent occlusion was observed in 11 patients with a median patency time of 8.5 (range, 2 ~ 22) months. Multivariate Cox regression analysis demonstrated that Vp4 PVTT (HR: 5.22; 95% CI: 1.74-15.74) and poor response to therapy (HR: 4.89; 95% CI: 2.66-8.99) were independent risk factors for OS, whereas PVIS plus TACE treatment (HR: 0.32; 95% CI: 0.18-0.56) was related to better prognosis. None of the patients in the two groups had grade 3-4 complications.

CONCLUSION

In conclusion, this retrospective study shows that PVIS plus TACE provides a significantly better survival outcome than RT plus TACE for HCC patients with PVTT.

Integrated I-125 Seed Implantation Combined with Transarterial Chemoembolization for Treatment of Hepatocellular Carcinoma with Main Portal Vein Tumor Thrombus

PURPOSE

To compare the safety and efficacy of integrated iodine-125 (I-125) seed implantation (sequential implantation of helical I-125 seed implant into the main portal vein and of I-125 seeds into the branch tumor thrombus directly forming main portal vein tumor thrombus (MPVTT)) combined with transarterial chemoembolization (TACE) versus TACE alone for hepatocellular carcinoma (HCC) with MPVTT.

MATERIALS AND METHODS

From December 2016 to January 2020, 46 HCC patients with MPVTT were analyzed. In the combination group, 21 patients received helical I-125 seed implantation in the main portal vein through a patent small portal vein branch and TACE in a single session. After 7-10 days, I-125 seeds were implanted percutaneously into the branch tumor thrombus directly forming MPVTT. In the TACE group, 25 patients received TACE alone. Thereafter, TACE was repeated as needed in both groups. Adverse events, tumor response, and overall survival (OS) of the two groups were compared.

RESULTS

No adverse events grade ≥ 3 were observed in either group. The optimal objective response rate and disease control rate for MPVTT in the combination group and TACE group were 52.4% versus 4.0% (P < 0.001) and 85.7% versus 32.0% (P < 0.001), respectively. Median OS in the combination group (9.8 months) was longer than in the TACE group (5.2 months) (P = 0.024). Multivariate analysis revealed that, compared with the TACE group, the mortality risk in the combination group significantly decreased (hazard ratio: 0.444; P = 0.020).

CONCLUSION

Integrated I-125 seed implantation combined with TACE is a safe and effective treatment for HCC with MPVTT.

LEVEL OF EVIDENCE

Level 3, Non-randomized controlled cohort/follow-up study.