Transcatheter arterial embolization for bone metastases from hepatocellular carcinoma

Effects of Clinical and Tumor Characteristics on Survival in Patients with Hepatocellular Carcinoma with Bone Metastasis

Background

Advanced hepatocellular carcinoma (HCC) generally has a dismal prognosis. Bone metastases from HCC are infrequent, with a poorer prognosis. However, the survival influencing factors are not yet well understood.

Aim

The aim of the present study was to assess the clinical features and tumor characteristics of HCC patients with bone metastasis.

Methods

A cohort of 170,576 adult patients with HCC was studied using the National Cancer Database (NCDB) spanning from 2010 to 2019, and within this group, 5285 patients (3.1%) were diagnosed with bone metastasis. We performed the Kaplan-Meier method to calculate the median overall survival (OS). We included demographics (age at diagnosis, gender, race, insurance status), comorbidity score, and treatment characteristics.

Results

Of a total of 5285 HCC patients with bone metastasis, 86.2% were male and 61.2% were non-Hispanic white. Most patients (55.1%) were below 65, and 89% had a total Charlson-Deyo comorbidity score of under 3. Among patients with known tumor grade, 24.8% had well-differentiated tumors, and 36.1% had poorly differentiated tumors. Chemotherapy was administrated to 39.5% of patients. In univariate analysis, patients with well-differentiated tumors had better OS compared to poorly differentiated tumors (5.4 months vs 3.0 months, p = 0.001). Patients who received single or multiagent chemotherapy were significantly associated with improved OS compared to patients who did not receive chemotherapy (7.0 and 8.5 months vs 1.94 months, respectively). We also found mortality difference between age, comorbidity scores, facility types and race groups.

Conclusion

In this cohort analysis of NCDB data, we found better OS in treatment receipt, lower tumor grade, younger age, non-Hispanic Black and Hispanic race, treatment at academic facility and lower comorbidity score in HCC patients with bone metastasis. The study results may have a consequential impact on the treatment decisions for HCC patients with bone metastasis.

Multimodal locoregional procedures for cancer pain management: a literature review

Pain is the most common and fearsome symptom in cancer patients, particularly in the advanced stage of disease. In cancer pain management, the first option is represented by analgesic drugs, whereas surgery is rarely used. Prior to considering surgical intervention, less invasive locoregional procedures are available from the wide pain management arsenal. In this review article, comprehensive information about the most commonly used locoregional options available for treating cancer pain focusing on interventional radiology (neurolysis, augmentation techniques, and embolization) and interventional radiotherapy were provided, also highlighting the potential ways to increase the effectiveness of treatments.

Electrochemotherapy Is Effective in the Treatment of Bone Metastases

Bone metastases induce pain, risk of fracture, and neural compression, and reduced mobility and quality of life. Electrochemotherapy (ECT) is a minimally invasive local treatment based on a high-voltage electric pulse combined with an anticancer drug. Preclinical and clinical studies have supported the use of ECT in patients with metastatic bone disease, demonstrating that it does not damage the mineral structure of the bone and its regenerative capacity, and that is feasible and efficient for the treatment of bone metastases. Since 2009, 88 patients with bone metastasis have received ECT at the Rizzoli Institute. 2014 saw the start of a registry of patients with bone metastases treated with ECT, whose data are recorded in a shared database. We share the Rizzoli Institute experience of 38 patients treated with ECT for a bone metastasis, excluding patients not included in the registry (before 2014) and those treated with bone fixation. Mean follow-up was 2 months (1–52). Response to treatment using RECIST criteria was 29% objective responses, 59% stable disease, and 16% progressive disease. Using PERCIST, the response was 36% OR, 14% SD, and 50% PD with no significant differences between the two criteria. A significant decrease in pain and better quality of life was observed at FU.

The role of percutaneous transarterial embolization in the management of spinal bone tumors: a literature review

PURPOSE

Spinal bone tumors include a heterogeneous broad of primary or metastatic lesions that may present as incidental findings or manifest with painful symptoms and pathological fractures. Optimal management of spine bone lesions is often difficult and treatment algorithms are usually solidly based on surgery. We aimed to evaluate the contribution of trans-arterial embolization in this field, with particular attention to the procedure efficacy, technical difficulties and complications.

METHODS

We present a literature review on the role of trans-arterial embolization in the management of spinal bone tumors, both primary and metastatic, evaluating its contribution as preoperative treatment, palliative procedure and standalone curative strategy.

RESULTS

Trans-arterial embolization provides an important contribution to reducing surgery hemorrhagic risks, offering a better visualization of the operating field, and possibly increasing tumor susceptibility to chemotherapy or radiation therapy. Nonetheless, it plays an important part in pain palliation, with the unquestionable advantage of being easily repeatable in case of necessity. Its curative role as a standalone therapy is still subject of debate, and at the present time, satisfactory results have been recorded only in the treatment of aneurysmal bone cysts.

CONCLUSION

Percutaneous trans-arterial embolization has established as a highly useful minimally invasive procedure in the management of spinal bone lesions, particularly as adjuvant preoperative therapy and palliative treatment.

Chemoembolization for Symptomatic Metastatic Epidural Spinal Cord Compression Refractory to Re-radiotherapy

PURPOSE

To evaluate the efficacy of chemoembolization for inoperable metastatic epidural spinal cord compression (MESCC) refractory to re-radiotherapy.

METHODS

Nineteen consecutive patients with recurrent MESCC after re-radiotherapy who had undergone chemoembolization were retrospectively analyzed. Outcome measures were pain relief rate, neurological improvement rate, objective response rate, and adverse events. MESCC degree classification was assessed using Bilsky grades. Pain assessment was performed using Numerical Rating Scale, and neurological function was evaluated using the Frankel classification.

RESULTS

The median follow-up period was 7 (range 2-44) months. All participants had MESCC grade 2 or higher and had severe pain. Fifteen patients (79%) had neurological deficits, and ten had Frankel classification C and five had D. Symptoms were relieved in almost all patients the day following chemoembolization. Pain relief was achieved in 18 of 19 (95%) patients; the median decrease in Numerical Rating Scale score was 8 (range 0-10; p < 0.001). Neurological improvement was achieved in 11 of 15 patients (73%); the median increase in Frankel classification was 1 (range 0-2; p = 0.006). Ten of 19 (53%) patients showed a reduction in MESCC; the median decrease in Bilsky grade was 1 (range 0-2; p = 0.005). There was no correlation between the change in Bilsky grade and pain relief (p = 0.421). However, the decrease in Bilsky grade significantly improved neurological symptoms (p = 0.01). No serious adverse events occurred.

CONCLUSION

Chemoembolization may be a useful palliative treatment modality for MESCC refractory to re-radiotherapy.

LEVEL OF EVIDENCE

Level 3b, Follow up Study.

Transarterial Chemoembolization for the Palliation of Painful Bone Metastases Refractory to First-Line Radiotherapy

PURPOSE

To compare the efficacy and safety of transarterial chemoembolization for the palliation of radiotherapy (RT)-failure bone metastases (BMs) with those of re-radiotherapy (Re-RT) in achieving pain relief.

MATERIALS AND METHODS

Fifty consecutive patients with RT-failure BMs who had undergone Re-RT (23 patients) and transarterial chemoembolization (27 patients) were retrospectively analyzed. The primary endpoint was clinical response, and the secondary endpoints were objective response and adverse events. Pain assessment was performed using the numerical rating scale, and tumor response was evaluated using the modified Response Evaluation Criteria in Solid Tumors. Pain relief was defined as lack of pain with no analgesic usage (complete pain response) or a decrease in pain score by ≥3 points with analgesic usage (partial pain response).

RESULTS

The pain relief rates in the Re-RT and transarterial chemoembolization groups were 57% and 92%, respectively (P = .006). The median pain relief duration was 2 and 3 months in the Re-RT and transarterial chemoembolization groups, respectively (P = .002). The 6-month pain-free survival rates were 30% and 51% in the Re-RT and transarterial chemoembolization groups, respectively (P = .08). The median tumor reduction rates were -4% and 9% in the Re-RT and transarterial chemoembolization groups, respectively (P < .001). The objective response rates were 0% and 11% in the Re-RT and transarterial chemoembolization groups, respectively (P = .29). No serious adverse events or complications were observed.

CONCLUSIONS

Transarterial chemoembolization achieved a superior response rate and longer duration of palliation in symptomatic RT-failure BMs.

Update on Preoperative Embolization of Bone Metastases

Management of patients with bone metastasis is complex and should include different specialties. Goals of therapy should be identified for each individual patient prior to the start of treatment. Preoperative embolization has generally been considered a safe and effective means of reducing intraoperative blood loss with recent studies and advances in technique reported. Update on indications, contraindications, technique, and efficacy, as well as prognostic factors and complications of preoperative embolization of bone metastases will be reviewed. New trends such as transradial arterial access and usage of liquid embolic agents will be discussed. Large tumor size, increased preprocedural tumor vascularity, longer embolization-to-surgery interval, and radical surgical procedures are associated with greater intraoperative blood loss and prolonged operative time. An accurate, noninvasive method to evaluate tumor vascularity prior to angiography is needed to identify patients who are most likely to benefit from preoperative embolization. Particular attention will be paid to skeletal metastases and spinal metastases as each has its own set of complexity.

Ipsilateral transradial access in transarterial embolization of upper extremity bony metastases

Transarterial embolization of bone tumors is effective in both decreasing intraoperative hemorrhage and alleviating symptoms. Transradial access has been associated with a lower risk of access site complications when compared to transfemoral access. Three cases of transarterial embolization of bony metastases in the upper extremity and shoulder girdle were performed with an ipsilateral transradial access. In each case, significant decrease in tumor blush was noted after embolization, and no auxiliary access site was needed. Positive outcomes were observed in all three patients, including successful subsequent surgery without significant hemorrhage and notable post-procedural pain reduction.

Developments in the management of bone metastases with interventional radiology

Interventional radiology has known an exponential growth in the last years. Technological advances of the last decades, have made it possible to use new treatments on a larger scale, with safe and effective results. They could be considered as palliative treatments for painful lesions but also curative procedures, as single treatment or specially in combination with other techniques (surgery, radiation and oncology therapies, etc.). The main diffuse techniques are those of thermal ablation that destroy the target lesion through the heat; however there are also endovascular therapies that destroy the target tissue thanks to devascularization. Finally the is also the possibility to stabilize pathological fractures or impending fractures. In this paper all the most diffuse and effective techniques are reviewed and also a discussion of the main indications is done, with an analisys of the success and complications rates. (www.actabiomedica.it)

Modern Palliative Treatments for Metastatic Bone Disease: Awareness of Advantages, Disadvantages, and Guidance

BACKGROUND

Metastatic disease is the most common malignancy of the bone. Prostate, breast, lung, kidney, and thyroid cancer account for 80% of skeletal metastases. Bone metastases are associated with significant skeletal morbidity including severe bone pain, pathologic fractures, spinal cord or nerve roots compression, and malignant hypercalcemia. These events compromise greatly the quality of life of the patients. The treatment of cancer patients with bone metastases is mostly aimed at palliation.

OBJECTIVE

This article aims to present these palliative treatments for the patients with bone metastases, summarize the clinical applications, and review the techniques and results.

METHODS

It gives an extensive overview of the possibilities of palliation in patients with metastatic cancer to the bone.

RESULTS AND DISCUSSION

Currently, modern treatments are available for the palliative management of patients with metastatic bone disease. These include modern radiation therapy, chemotherapy, embolization, electrochemotherapy, radiofrequency ablation, and high-intensity focused ultrasound. As such it is of interest for all physicians with no experience with these developments to make palliative procedures safer and more reliable.

Preoperative embolization for bone metastasis from hepatocellular carcinoma

Preoperative transcatheter arterial embolization for hypervascular bone tumors is now widely accepted as a safe and effective procedure for reducing intraoperative blood loss and surgical morbidity. However, few studies have reported the use of preoperative transcatheter arterial embolization for nonspine bone metastases from hepatocellular carcinoma. The goal of this study was to assess the effect of preoperative embolization on blood loss and clinical outcomes in surgery for nonspine bone metastasis from hepatocellular carcinoma. Seventy-five patients with metastases from hepatocellular carcinoma to the pelvis and extremities were reviewed retrospectively. The study population consisted of 62 men and 13 women, with a mean age of 64.6 years (range, 40.0-80.1). The average follow-up period was 8.2 months (range, 0.3-66.1). Twenty-two patients underwent transcatheter arterial embolization for preoperative devascularization (group A), and 53 patients underwent operative treatment only (group B). The proportion of pelvis metastases was significantly higher (P<.001) and operative time was longer (P=.006) in group A than in group B. However, a significantly smaller decrease in hemoglobin level before and after surgery was seen in group A (P=.017). No significant differences were seen in intraoperative estimated blood loss, perioperative hemoglobin level, number of allogeneic transfusions, or length of hospitalization between the 2 groups. Preoperative transcatheter arterial embolization is an effective means to reduce bleeding during surgery for nonspine metastases from hepatocellular carcinoma. In general, surgical procedures that included transcatheter arterial embolization took longer and were more extensive.

Preoperative transarterial Embolisation in bone tumors

Bone tumors include a variety of lesions, both primary and metastatic. The treatment modalities for bone tumors vary with the individual lesion, but in general surgical excision is the treatment of choice with other adjunctive therapies. However, surgery for many bone tumors is complex due to several factors including tumor bulk, vascularity, vicinity to vital structures and potentially inaccessible location of the lesion. Transarterial Embolisation (TAE) is one of the important adjuvant treatment modalities and in some cases it may be the primary and curative treatment. Preoperative TAE has proved to be effective in both primary and metastatic bone tumors. It reduces tumor vascularity and intraoperative blood loss, the need for blood transfusion and associated complications, allows better definition of tissue planes at surgery affording more complete excision, and hence reduced recurrence. Preoperative chemoEmbolisation has also been shown to increase the sensitivity of some tumors to subsequent chemotherapy and radiotherapy. There are several techniques and embolic agents available for this purpose, but the ultimate aim is to achieve tumor devascularization. In this review, we discuss the techniques including the choice of embolic agent, application to individual lesions and potential complications.

Embolization of musculoskeletal bone tumors

Bone tumors may present as incidental findings, with pain or loss of function, or as fractures. There is a broad range of indications for transarterial embolization (TAE) in primary or metastatic bone tumors: to reduce operative hemorrhagic risks, to simplify or allow more definitive surgery, or in the context of pain palliation, fever, bleeding, or hypercalcemic and other rheological factors. Embolization may also increase tumor sensitivity to chemotherapy or radiation therapy. The procedure itself is often complex with significant risk to adjacent structures and is usually part of a wider treatment strategy. There are many options of embolic agent, techniques, and end points but all aim to devascularize the tumor. Catheter angiography at the time of TAE is used to determine the correct embolic agent and technique with care taken to isolate at risk structures. Many factors determine the best choice of embolic material, probably the most important of which is operator experience. In life-threatening situations or in preoperative embolizations of metastatic tumors, many operators opt for a combination of particulate emboli and stainless steel or platinum coils. Agents discussed include polyvinyl alcohol particles, trisacryl microspheres, gelatin sponge, liquid embolic agents, and embolization coils. Tumor types treated include vascular metastatic lesions, commonly renal cell or thyroid, particularly in locations prone to fracture; giant cell tumors; aneurysmal bone cysts; vertebral hemangiomas, osteosarcomas; arteriovenous malformations; and osteoblastomas. TAE should be considered in the treatment algorithm of primary or secondary bone tumors. Specific benefit is present where there is a high risk of bleeding at surgery, where there is spinal involvement and neural encroachment, where active bleeding is present or in awkward surgical locations where prolonged surgery is anticipated.

Palliative interventions for pain in cancer patients

Pain is a debilitating problem that is common to most patients with cancer at some time during the course of their disease. Conventional therapies such as opiate analgesics and radiation therapy provide suboptimal and limited relief. Novel image-guided interventions have made a significant impact in the management of this difficult problem. This article reviews some of the most promising image-guided techniques for relieving bone and visceral pain in patients suffering from cancer.

Selective embolization with N-butyl cyanoacrylate for metastatic bone disease

PURPOSE

To evaluate the clinical and imaging effect of selective embolization using N-butyl cyanoacrylate (NBCA) as palliation for bone metastases.

MATERIALS AND METHODS

The procedures and effect of 309 embolizations performed in 243 patients were retrospectively analyzed; 56 patients had repeat embolization at the same location at 1-3 months; 197 patients had embolization for progressive bone metastases after radiation therapy. The mean tumor diameter before embolization was 7.8 cm (range 5-30 cm). In all patients, embolizations were performed under local anesthesia through transfemoral catheterization using NBCA in 33% ethiodized oil. The technical success of embolization was evaluated by angiography after completion of the procedure. The clinical and imaging effect was evaluated at follow-up examinations with a pain score scale and use of analgesics, hypoattenuating areas, tumor size, and ossification.

RESULTS

In all 309 embolizations, postprocedural angiography showed complete occlusion of metastatic blood supply and greater than 80% devascularization of the lesions. Greater than 50% reduction of pain score and analgesic doses was achieved in 97% of procedures. The mean duration of pain relief was 8.1 months (range 1-12 months). The mean maximal tumor diameter after embolization was 5.5 cm (range 2-20 cm). Variable ossification appeared in 65 patients. Postembolization syndrome, ischemic pain at the site of embolization, paresthesias, skin breakdown, and subcutaneous necrosis were observed in 87 patients.

CONCLUSIONS

Selective embolization with NBCA is a safe and effective palliative treatment for metastatic bone lesions of various primary cancers; pain relief is temporary.

Transcatheter arterial chemoembolization (TACE) or embolization (TAE) for symptomatic bone metastases as a palliative treatment

PURPOSE

This study was designed to evaluate the effect of transcatheter arterial chemoembolization (TACE)/embolization (TAE) for symptomatic bone metastases especially in palliation.

METHODS

Between April 2006 and December 2009, 24 bone metastatic lesions of 18 patients (8 women and 10 men; mean age, 64 years) underwent palliative TACE or TAE. A total of 40 sessions were performed, with 1-4 sessions per lesion. The primary lesions included hepatocellular carcinoma, colorectal cancer, renal cell cancer, ovarian cancer, thyroid cancer, uterine cervical cancer, and esophageal cancer. Symptomatic lesions involved thoracic spine, lumbar spine, pelvis, rib, and femur. The procedures were performed with a coaxial catheter technique to catheterize selectively target arteries. If not possible due to small branches, blood flow alteration by coil was achieved. Gelatin sponge was the initial embolic materials. As anti-cancer agents, epirubicin, fluorouracil, and mitomycin were mainly used in consideration for primary lesion and past treatment.

RESULTS

Sufficient devascularization of targeted lesions was obtained in 18 of 24 (75%) lesions without any serious complication. Pain relief was obtained in 20 lesions (83%), with significantly decrease in the visual analogue scale score (P < 0.001). A relationship was found between the devascularization grade and pain relief (r = 0.49, P < 0.05). Follow-up CT images at 1 month of nine lesions (50%) revealed necrotic change in the tumors.

CONCLUSIONS

Palliative TACE/TAE for symptomatic bone metastases could be a suitable treatment method because it is minimally invasive, repeatable, effective, and rapid-acting.

Percutaneous sacroplasty for sacral metastatic tumors under fluoroscopic guidance only

Percutaneous sacroplasty is a safe and effective procedure for sacral insufficient fractures under CT or fluoroscopic guidance; although, few reports exist about sacral metastatic tumors. We designed a pilot study to treat intractable pain caused by a sacral metastatic tumor with sacroplasty. A 62-year-old man and a 38-year-old woman with medically intractable pain due to metastatic tumors of S1 from lymphoma and lung cancer, respectively, underwent percutaneous sacroplasty. Over the course of the follow-up period, the two patients experienced substantial and immediate pain relief that persisted over a 3-month and beyond. The woman had deposition of PMMA (polymethyl methacrylate) in the needle track, but did not experience significant symptoms. No other peri-procedural complications were observed for either patient.

Interventional management of hypervascular osseous metastasis: role of embolotherapy before orthopedic tumor resection and bone stabilization

OBJECTIVE

The purpose of this study was to evaluate, in relation to intraoperative estimated blood loss (EBL), the effectiveness of preoperative transcatheter arterial embolization of hypervascular osseous metastatic lesions before orthopedic resection and stabilization.

MATERIALS AND METHODS

Between June 1987 and November 2007, 22 patients underwent transcatheter arterial embolization of tumors of the long bone, hip, or vertebrae before resection and stabilization. Osseous metastatic lesions from renal cell carcinoma, malignant melanoma, leiomyosarcoma, and prostate cancer were embolized. All patients were treated with a coaxial catheter technique with polyvinyl alcohol (PVA) particles alone or a combination of PVA particles and coils. After embolization, each tumor was angiographically graded according to devascularization (grades 1-3) based on tumor blush after contrast injection into the main tumor-feeding arteries.

RESULTS

In patients with complete devascularization (grade 1), mean EBL was calculated to be 1,119 mL, whereas in patients with partial embolization (grades 2 and 3) EBL was 1,788 mL and 2,500 mL. With respect to intraoperative EBL, no significant difference between devascularization grades was found (p > 0.05). Moderate correlation (r = 0.51, p = 0.019) was observed between intraoperative EBL and tumor size before embolization. Only low correlation (r = 0.44, p = 0.046) was found between intraoperative EBL and operating time. Major complications included transient palsy of the sciatic nerve and gluteal abscess in one patient.

CONCLUSION

The results of this study support the concept that there is no statistically significant difference among amounts of intraoperative EBL with varying degrees of embolization.

Selective palliative transcatheter embolization of bony metastases from renal cell carcinoma

To examine whether transcatheter embolization of bone metastases is an effective palliative option for patients with renal cell carcinoma (RCCa). A retrospective review of 21 patients presenting for palliative embolization of painful RCCa skeletal metastases was performed. Details regarding anatomic sites, procedural details, and embolization materials were collected. The clinical response of the patient was assessed from clinic visits and analgesic use. Thirty separate embolization procedures were used to treat 39 metastatic lesions (18 pelvic, 8 lower extremity, 3 upper extremity, 5 rib/chest well, and 5 vertebral lesions). Five patients underwent more than one embolization. Polyvinyl alcohol was used in all 30 embolization procedures. Additional embolic materials were used in 16 of 30 procedures. A clinical response was achieved at 36 treated sites; the mean duration fo the response was 5.5 months. Selective embolization of bony renal cell carcinoma metastases can provide effective palliation in a patient population which has limited therapeutic options.

Image-guided ablation of painful metastatic bone tumors: a new and effective approach to a difficult problem

Painful skeletal metastases are a common problem in cancer patients. Although external beam radiation therapy is the current standard of care for cancer patients who present with localized bone pain, 20-30% of patients treated with this modality do not experience pain relief, and few further options exist for these patients. For many patients with painful metastatic skeletal disease, analgesics remain the only alternative treatment option. Recently, image-guided percutaneous methods of tumor destruction have proven effective for treatment of this difficult problem. This review describes the application, limitations, and effectiveness of percutaneous ablative methods including ethanol, methyl methacrylate, laser-induced interstitial thermotherapy (LITT), cryoablation, and percutaneous radiofrequency ablation (RFA) for palliation of painful skeletal metastases.