Transarterial chemoembolisation for advanced hepatocellular carcinoma: results from a North American cancer centre

Transarterial chemoembolization in hepatocellular carcinoma: exploring its role in vascular invasion and extrahepatic metastasis: A systematic review

BACKGROUND AND AIMS

Transarterial chemoembolization (TACE) is a significant intervention in hepatocellular carcinoma (HCC) management, but controversies persist regarding its application in advanced cases with vascular invasion or extrahepatic metastasis. This systematic review aims to explore TACE's efficacy and safety in these cases.

METHODS

A literature search was conducted on TACE in HCC patients with vascular invasion or extrahepatic metastasis. The study compared TACE with surgical resection/chemotherapeutic drugs or with no group as well. Safety was assessed for adverse outcomes and efficacy, including overall survival, mean survival, and progression-free survival (PFS). Data extraction included study characteristics, patient demographics, intervention details, outcomes, and adverse events.

RESULTS

A study of 28 studies involving 3740 patients found that TACE showed diverse safety and efficacy outcomes. Safety evaluations focused on liver function tests, while patient-reported symptoms included fever, pain, vomiting, and gastrointestinal issues. Overall survival was under 10 months in 9 studies, with PFS lower in the TACE group compared to conservative treatments. Survival rates ranged from 93.4% at 3 months to 13% at 24 months across studies. The study identified potential subsets where TACE exhibited efficacy, especially in cases with favorable liver function or specific tumor classifications.

CONCLUSION

Our findings suggest a potential role for TACE in certain subsets of advanced HCC patients. Tailored treatment algorithms, informed by rigorous clinical trials and considering various prognostic factors, hold the potential to enhance the management and outcomes for this complex patient population.

Gastrointestinal side effects in hepatocellular carcinoma patients receiving transarterial chemoembolization: a meta-analysis of 81 studies and 9495 patients

Background

Transarterial chemoembolization (TACE) is a widely used treatment for hepatocellular carcinoma (HCC), combining targeted chemotherapy and embolization. While effective, TACE can be associated with significant gastrointestinal (GI) side effects, impacting a patient's quality of life.

Objectives

Quantify the prevalence of key GI complications (diarrhea, nausea, GI toxicity, abdominal pain) following TACE.

Design

Systematic review was performed following Preferred Reporting Items for Systematic reviews and Meta-Analyses (PRISMA) guidelines, focusing on studies that reported side effects of TACE. Studies not involving cTACE or drug-eluting bead TACE (DEB-TACE), non-HCC studies, meta-analyses or systematic reviews, and inaccessible publications were excluded.

Data sources and methods

A PubMed search for clinical and randomized trials was conducted. Extracted data included study identifiers, demographics, TACE details, and GI side effect prevalences. The Mixed Methods Appraisal Tool assessed study quality and bias.

Results

The analysis included data from 81 studies with 121 individual study arms and 9495 patients. Diarrhea was reported in 38 studies, with a mean prevalence of 23.46% (2.5; 95% confidence interval (CI): 18.39-28.544) and a weighted prevalence of 23.5%. Nausea was most frequently reported, mentioned in 67 studies, with a mean prevalence of 34.66% (2.4; 95% CI: 29.89-39.44) and a weighted prevalence of 32.5%. Abdominal pain was reported in 59 studies, with the highest mean prevalence of 48.07% (2.9; 95% CI: 42.20-53.93) and a weighted prevalence of 46.1%. GI toxicity was reported in 32 studies, with a mean prevalence of 8.85% (1.4; 95% CI: 5.99-11.70) and a weighted prevalence of 9.9%. DEB-TACE generally led to slightly higher rates of nausea, diarrhea, abdominal pain, and GI toxicity compared to conventional TACE. The type of chemotherapy agent influenced prevalence of GI-side effects, with high prevalences observed for agents such as zinostatin and cisplatin.

Conclusion

This meta-analysis synthesizes current evidence on managing GI side effects in TACE. Standardizing reporting and developing effective management strategies are crucial to improving patient outcomes.

Redefining Intermediate-Stage HCC Treatment in the Era of Immune Therapies

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related mortality worldwide. At diagnosis, most patients are ineligible for curative surgery, and approximately 20% of patients are diagnosed with advanced-stage disease. A significant proportion of patients fall under an unresectable or intermediate-stage disease who have liver-limited disease but are not surgical candidates because of large tumor size, number of lesions, or technically inoperable disease. In this unique intermediate-stage patient population, locoregional therapies have been the de facto mainstay of treatment because of high local response rates and favorable safety profile, especially in the context of minimally effective systemic therapies. However, not all patients who receive locoregional therapy for incurable disease have improved survival, and importantly, some of these patients never receive systemic therapy because of disease progression or further decline in hepatic function. Meanwhile, with the remarkable progress that has been made with systemic therapy in the past few years, revisiting the treatment of intermediate-stage HCC seems prudent. In this review, we will highlight current and emerging strategies for treating patients with unresectable, liver-limited HCC.

A review on radiofrequency, microwave and high-intensity focused ultrasound ablations for hepatocellular carcinoma with cirrhosis

Importance

Hepatocellular carcinoma (HCC) is usually accompanied by liver cirrhosis, which makes treatment of this disease challenging. Liver transplantation theoretically provides an ultimate solution to the disease, but the maximal surgical stress and the scarcity of liver graft make this treatment option impossible for some patients. In an ideal situation, a treatment that is safe and effective should provide a better outcome for patients with the dilemma.

Objective

This article aims to give a comprehensive review of various types of loco-ablative treatment for HCC.

Evidence Review

Loco-ablative treatment bridges the gap between surgical resection and transarterial chemotherapy. Various types of ablative therapy have their unique ability, and evidence-based outcome analysis is the most important key to assisting clinicians to choose the most suitable treatment modality for their patients.

Findings

Radiofrequency ablation (RFA) has a relatively longer history and more evidence to support its effectiveness. Microwave ablation (MWA) is gaining momentum because of its shorter ablation time and consistent ablation zone. High-intensity focused ultrasound (HIFU) ablation is a relatively new technology that provides non-invasive treatment for patients with HCC. It has been carried out at centers of excellence and it is a safe and effective treatment option for selected patients with HCC and liver cirrhosis.

Conclusion and Relevance

Selective use of different loco-ablative therapies will enhance clinicians' treatment options for treatment of HCC.

Intra-arterial neuroprotective therapy as an adjunct to endovascular intervention in acute ischemic stroke: A review of the literature and future directions

Mechanical thrombectomy for acute ischemic stroke due to large vessel occlusion has been shown to significantly improve outcomes. However, despite efficient rates of recanalization (60-90%), the rates of functional independence remain suboptimal (14-58%), most likely due to pathways of cell death in the brain that have already committed despite successful reperfusion. Pharmacologic neuroprotection provides a potential means of preventing this inevitable damage through targeting excitotoxicity, reactive oxygen species, cellular apoptosis, and inflammation. Numerous clinical trials using various neuroprotective agents have failed, but the majority of these trials did not include endovascular reperfusion, and thus the drugs were not reaching the therapeutic target. Intra-arterial delivery of neuroprotective agents via the guide catheter already in place for mechanical thrombectomy could provide a way to deliver high doses directly to the affected territory while limiting systemic exposure. Agents that have shown promise via the intra-arterial route in preclinical as well as some clinical models include magnesium sulfate, verapamil, cold saline, stem cells, and various combined approaches. Targeted hypothermia, achieved with intra-carotid infusion of cold saline, may provide an effective means of achieving hypothermia of the ischemic tissue while avoiding the systemic effects that have limited its use previously. Combination therapy of targeted hypothermia and a cocktail of drugs that provide anti-excitotoxic, anti-oxidant, anti-apopototic, and anti-inflammatory effects may provide an ideal approach that deserves further study in clinical trials.

Dual Modality Radiation With External Beam Radiation Therapy and Transarterial Radioembolization for Hepatocellular Carcinoma With Gross Vascular Invasion

OBJECTIVES

Patients with hepatocellular carcinoma (HCC) and gross vascular invasion (GVI) have poor outcomes with systemic therapy such as sorafenib. Both external beam radiation therapy (EBRT) and transarterial radioembolization (TARE) have been utilized for this patient population. We sought to compare outcomes using dual modality radiation (EBRT+TARE) versus EBRT alone in patients with HCC and GVI.

MATERIALS AND METHODS

Between 2011 and 2017, 45 patients with HCC and GVI were treated with EBRT±TARE at our institution. Progression-free survival (PFS) and overall survival (OS) were assessed and compared using Kaplan-Meier method and log-rank test. Univariable and multivariable Cox proportional hazards regression was used to assess the impact of the variables stage, etiology of cirrhosis, Child-Pugh (CP) score, and Karnofsky Performance Score (KPS) on PFS and OS.

RESULTS

Patient characteristics were well-balanced except for KPS (80 vs. 90) and CP score. Median OS for patients receiving EBRT+TARE was 263 days (95% confidence interval [CI]: 167, -) versus 193 days (95% CI: 51, 262) for EBRT alone (P=0.049). However, this did not hold up on MVA. When EBRT and TARE were delivered within 2 months as planned (n=12), median PFS was 218 days (95% CI: 44, -) for dual modality radiation versus 63 days (95% CI: 38, 137) for EBRT alone (P=0.048). When EBRT and TARE were delivered within 6 months, the difference in PFS was no longer seen (P=NS), because some patients received TARE as a salvage therapy.

CONCLUSIONS

Dual modality radiation with EBRT and TARE may be associated with improved OS in patients with HCC and GVI. Dual modality radiation may be associated with improved PFS in patients with HCC and GVI compared with EBRT alone when EBRT and TARE are delivered within 2 months of each other as part of a planned dual modality treatment strategy. However, since this is a retrospective study with inherent selection bias, these findings need further validation in a prospective clinical trial for patients with HCC and GVI.

NCCN Guidelines Insights: Hepatobiliary Cancers, Version 1.2017

The NCCN Guidelines for Hepatobiliary Cancers provide treatment recommendations for cancers of the liver, gallbladder, and bile ducts. The NCCN Hepatobiliary Cancers Panel meets at least annually to review comments from reviewers within their institutions, examine relevant new data from publications and abstracts, and reevaluate and update their recommendations. These NCCN Guidelines Insights summarize the panel's discussion and most recent recommendations regarding locoregional therapy for treatment of patients with hepatocellular carcinoma.

Paralytic Ileus due to Superior Mesenteric Venous Thrombosis after Transarterial Injection for Hepatocellular Carcinoma

A 69-year-old man was admitted to hospital with abdominal pain. In the four years prior to his presentation, he had undergone repeated transarterial chemoembolizations and injections for hepatocellular carcinoma. He underwent his 8th transcatheter arterial therapy one month prior to admission. Abdominal X-rays and contrast-enhanced computed tomography showed large amounts of small intestinal gas and venous thrombosis from the portal vein to the superior mesenteric vein, respectively. The thrombosis was reduced after anticoagulation therapy (heparin, antithrombin III, danaparoid sodium and warfarin). This is the first case report of paralytic ileus due to superior mesenteric venous thrombosis after transcatheter arterial therapy for hepatocellular carcinoma with an arterioportal shunt.

Spinal intraarterial chemotherapy: interim results of a Phase I clinical trial

OBJECT Despite advances in therapies using radiation oncology and spinal oncological surgery, there is a subgroup of patients with spinal metastases who suffer from progressive or recurrent epidural disease and remain at risk for neurological compromise. In this paper the authors describe their initial experience with a novel therapeutic approach that consists of intraarterial (IA) infusion of chemotherapy to treat progressive spinal metastatic disease. METHODS The main inclusion criterion was the presence of progressive, metastatic epidural disease to the spine causing spinal canal compromise in patients who were not candidates for the standard treatments of radiation therapy and/or surgery. All tumor histological types were eligible for this trial. Using the transfemoral arterial approach and standard neurointerventional techniques, all patients were treated with IA infusion of melphalan in the arteries supplying the epidural tumor. The protocol allowed for up to 3 procedures repeated at 3- to 6-week intervals. Outcome measures included physiological measures: 1) periprocedural complications according to the National Cancer Institute's Common Terminology Criteria for Adverse Events; and 2) MRI to assess for tumor response. RESULTS Nine patients with progressive spinal metastatic disease and cord compression were enrolled in a Phase I clinical trial of selective IA chemotherapy. All patients had metastatic disease from solid organs and were not candidates for further radiation therapy or surgery. A total of 19 spinal intraarterial chemotherapy (SIAC) procedures were performed, and the follow-up period ranged from 1 to 7 months (median 3 months). There was 1 serious adverse event (febrile neutropenia). Local tumor control was seen in 8 of 9 patients, whereas tumor progression at the treated level was seen in 1 patient. CONCLUSIONS These preliminary results support the hypothesis that SIAC is feasible and safe.

A comparison between three-dimensional conformal radiotherapy combined with interventional treatment and interventional treatment alone for hepatocellular carcinoma with portal vein tumour thrombosis

INTRODUCTION

We investigated the therapeutic effects of three-dimensional conformal radiotherapy combined with transcatheter arterial chemoembolisation (TACE) for hepatocellular carcinoma (HCC) with portal vein tumour thrombosis (PVTT).

METHODS

Sixty-three HCC patients with PVTT were divided into two groups. Group A (30 patients) was treated with three-dimensional conformal radiotherapy followed by 2-3 series of TACE, while group B (33 patients) was only treated with TACE.

RESULTS

The 1- and 2-year survival rates of group A were 62.40% and 20.81%, respectively, with a mean survival time of 13.0 months. The 1- and 2-year survival rates of group B were 56.49% and 18.83%, respectively, with a mean survival time of 9.0 months. There were significant differences between the two groups (log-rank chi-square value = 3.950, P = 0.047).

CONCLUSION

Three-dimensional conformal radiotherapy combined with TACE can significantly improve clinical outcomes in patients with HCC and PVTT compared with TACE alone.

Quality of life and hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a common and rapidly fatal cancer ranking third among the leading causes of cancer-related deaths. Potentially curative therapies like surgery, transplant and ablation are not an option for most patients as they are often diagnosed when the disease is advanced. Liver directed therapy and oral targeted therapies are used in these patients to prolong life and palliate symptoms of the cancer and associated liver failure. Overall survival remains poor and hence health-related quality of life (HRQoL) is of paramount importance in these patients. As novel therapies are developed to improve outcomes, a comprehensive knowledge of available tools to assess impact on QoL is needed. Hence we reviewed all the studies in HCC patients published within the last 13 years from 2001-2013 which assessed HRQoL as a primary or secondary endpoint. A total of 45 studies and 4 meta-analysis were identified. Commonly used tools were European Organization for Research and Treatment of Cancer Quality of Life Questionnaire-Core 30 (EORTC QLQ-C30) (15 studies) and the Functional Assessment of Cancer Therapy-Hepatobiliary Questionnaire (FACT-Hep) (14 studies). Of the 45 publications which incorporated HRQoL as end-point only 24 were clinical trials, 17/24 (71%) assessed systemic therapies while 7/24 (29%) assessed liver-directed therapies. Majority of the publications (trials + retrospective reviews) that had HRQoL as an endpoint in HCC patients were studies evaluating liver-directed therapies (23/45 or >50%). We discuss the measures included in the tools, their interpretation, and summarize existing QoL data that will help design future HCC trials.

Outcomes after hepatic resection and subsequent multimodal treatment of recurrence for multifocal hepatocellular carcinoma

BACKGROUND

The role of liver resection in patients with multifocal hepatocellular carcinoma (HCC) with well preserved liver function is controversial. This study was conducted to evaluate the outcomes of such patients.

METHODS

This was a retrospective analysis of patients who underwent liver resection for multifocal HCC between 1992 and 2011. Postoperative outcomes, survival and predictors of outcomes were analysed.

RESULTS

Of 46 patients who underwent hepatic resection for multifocal HCC, 38 had Barcelona Clinic Liver Cancer stage B disease. Major hepatectomy was performed in 27 patients, and major complications occurred in nine (20 per cent). The 90-day postoperative mortality rate was 7 per cent. Overall 1-, 2-, 3- and 5-year survival rates were 78, 64, 59 and 53 per cent respectively (median 70 months), whereas corresponding recurrence-free survival rates were 53, 32, 30 and 27 per cent (median 14 months). Recurrence developed in 28 (61 per cent) of the 46 patients, affecting the liver only in 22. Three-quarters of patients with recurrence underwent further therapy. Major hepatectomy (hazard ratio (HR) 0.37, 95 per cent confidence interval 0.14 to 0·95; P = 0·038), microvascular (HR 3·44, 1·35 to 8·74; P = 0·009) and macrovascular (HR 2·68, 1·11 to 6·43; P = 0·028) invasion, and cirrhosis (HR 3·15, 1·12 to 8·86; P = 0·029) were associated with overall survival. Microvascular invasion (HR 2·81, 1·06 to 7·40; P = 0·037), cirrhosis (HR 3·12, 1·41 to 6·88; P < 0·001) and bilobar disease (HR 2·93, 1·09 to 7·88; P = 0·033) were associated with recurrence-free survival.

CONCLUSION

In selected patients with multifocal HCC and well preserved liver function, long-term survival is possible after liver resection and subsequent aggressive treatment of recurrence.

Consensus recommendations and review by an International Expert Panel on Interventions in Hepatocellular Carcinoma (EPOIHCC)

Hepatocellular carcinoma (HCC) presents with a high burden of disease in East Asian countries. Intermediate-stage HCC as defined by the Barcelona Clinic Liver Cancer (BCLC) staging system poses a clinical challenge as it includes a heterogeneous population of patients that can vary widely in terms of tumour burden, liver function and disease aetiology. Intermediate HCC patients often have unsatisfactory clinical outcomes with repeated transarterial chemoembolization (TACE, due to non-response of the target tumour or the development of further metastasis indicating progressive disease. In September 2011, an Expert Panel Opinion on Interventions in Hepatocellular Carcinoma (EPOIHCC) was convened in HK in an attempt to provide a consensus on the practice of TACE. To that end, current clinical practice throughout Asia was reviewed in detail including safety and efficacy data on TACE alone as well as in combination with targeted systemic therapies. This review summarises the evidence discussed at the meeting and provides expert recommendation regarding the available therapeutic options for unresectable intermediate stage HCC. A key consensus of the Expert Panel was that in order to improve patient outcomes and long-term survival, the possibility of using TACE in combination with targeted agents given systemically should be explored. While the currently available clinical data is promising, the expected completion of several pivotal phase II and III RCTs will provide further evidence in support of the rationale for combination therapy regimens.

Established and novel imaging biomarkers for assessing response to therapy in hepatocellular carcinoma

The management of hepatocellular carcinoma (HCC) is evolving because of recently introduced novel therapeutic approaches. There is growing recognition that optimal outcome requires choosing treatment tailored to suit each individual patient, necessitating an early and accurate assessment of tumor response to therapy. The established and adapted image biomarkers based on size for tumor burden measurement continues to be applied to HCC as size measurement can easily be used in any clinical practice. However, in the setting of novel targeted therapies and liver directed treatments, simple tumor anatomical changes can be less informative and usually appear later than biological changes. Therefore the importance of image biomarkers such as tumor viability measurement, functional perfusion and diffusion imaging for response assessment is increasingly being recognized. Although promising, these imaging biomarkers have not gone through all the required steps of standardization and validation. In this review, we discuss various established, evolving and emerging imaging biomarkers and the criteria of response evaluation and their challenges in HCC.

Hepatocellular carcinoma: natural history, current management, and emerging tools

Hepatocellular carcinoma (HCC) is the most common primary liver tumor and represents the third-leading cause of cancer-related death in the world. The incidence of HCC continues to increase worldwide, with a unique geographic, age, and sex distribution. The most important risk factor associated with HCC is liver cirrhosis, with the majority of cases caused by chronic infection with hepatitis B (HBV) and C (HCV) viruses and alcohol abuse, although nonalcoholic fatty liver disease is emerging as an increasingly important cause. Primary prevention in the form of HBV vaccination has led to a significant decrease in HBV-related HCC, and initiation of antiviral therapy appears to reduce the incidence of HCC in patients with chronic HBV or HCV infection. Additionally, the use of ultrasonography enables the early detection of small liver tumors and forms the backbone of recommended surveillance programs for patients at high risk for the development of HCC. Cross-sectional imaging studies, including computed tomography and magnetic resonance imaging, represent further noninvasive techniques that are increasingly employed to diagnose HCC in patients with cirrhosis. The mainstay of potentially curative therapy includes surgery – either resection or liver transplantation. However, most patients are ineligible for surgery, because of either advanced disease or underlying liver dysfunction, and are managed with locoregional and/or systemic therapies. Randomized controlled trials have demonstrated a survival benefit with both local therapies, either ablation or embolization, and systemic therapy in the form of the multikinase inhibitor sorafenib. Despite this, median survival remains poor and recurrence rates significant. Further advances in our understanding of the molecular pathogenesis of HCC hold promise in improving the diagnosis and treatment of this highly lethal cancer.

Quality of life and survival analysis of patients undergoing transarterial chemoembolization for primary hepatic malignancies: a prospective cohort study

INTRODUCTION

Transarterial chemoembolization (TACE) is indicated for primary hepatic tumours when resection or local ablation are not feasible. Patients undergoing TACE have a better survival than best supportive therapy. However, there is paucity of prospective studies on the quality of life (QOL) after TACE for primary hepatic malignancies, especially in the Western world.

PURPOSE

The primary aim of the present study was to determine if TACE impacts on the QOL of patients affected by primary hepatic tumours, and to assess treatment efficacy in a prospective cohort of patients treated at a tertiary Canadian university medical centre.

METHODS

From September 2005 to December 2010, 48 candidates for TACE underwent at least one TACE session. Data on their QOL, tumour response, serum alpha fetoprotein (AFP) and survival were prospectively collected every 3-4 months.

RESULTS

The overall QOL of patients undergoing TACE did not decline during the first 12 months after treatment. A decline was observed in the physical health domain after the third TACE that coincided with the increasing size of the largest tumour and a rise in the serum AFP levels. Psychological, social and environmental domains remained stable throughout the treatment period. Multivariate analysis revealed that tumour focality, AFP levels and model of end-stage liver disease (MELD) scores were associated with long-term survival (P= 0.001, P= 0.01, P= 0.02, respectively). The overall survival at 12, 36 and 48 months were 72%, 28% and 12%, respectively.

CONCLUSION

TACE is an effective palliative intervention for unresectable and non-ablatable primary liver tumours without affecting the QOL of patients even when repeated interventions are performed.

Analysis of survival predictors in a prospective cohort of patients undergoing transarterial chemoembolization for hepatocellular carcinoma in a single Canadian centre

BACKGROUND

Despite advances in the treatment of hepatocellular carcinoma (HCC), a great proportion of patients are eligible only for palliative therapy for reasons of advanced-stage disease or poor hepatic reserve. The use of transarterial chemoembolization (TACE) in the palliation of non-resectable HCC has shown a survival benefit in European and Asian populations. The aim of this study was to assess the efficacy of TACE by analysing overall 5-year survival, interval changes of tumour size and serum alpha-fetoprotein (AFP) levels in a prospective North American cohort.

METHODS

From September 2005 to December 2010, 46 candidates for TACE were enrolled in the study. Collectively, they underwent 102 TACE treatments. Data on tumour response, serum AFP and survival were prospectively collected.

RESULTS

In compensated cirrhotic patients, serial treatment with TACE had a stabilizing effect on tumour size and reduced serum AFP levels during the first 12 months. Overall survival rates at 1, 2 and 3 years were 69%, 58% and 20%, respectively. Younger individuals and patients with a lower body mass index, affected by early-stage HCC with involvement of a single lobe, had better survival in univariate analysis. After adjustment for risk factors, early tumour stage (T1 and T2 vs. T3 and T4) at diagnosis was the only statistically significant predictor for survival.

CONCLUSIONS

In compensated cirrhotic patients, TACE is an effective palliative intervention and HCC stage at diagnosis seems to be the most important predictor of longterm outcomes.

A comparative study of high-dose hepatic arterial infusion chemotherapy and transarterial chemoembolization using doxorubicin for intractable, advanced hepatocellular carcinoma

Background/Aims

Transarterial chemoembolization (TACE) has long been used as a palliative therapy for unresectable hepatocellular carcinoma (HCC). High-dose hepatic arterial infusion chemotherapy (HAIC) has showed favorable outcomes in patients with intractable, advanced HCC. The aim of this study was to compare the effectiveness and safety of high-dose HAIC and conventional TACE using doxorubicin for advanced HCC.

Methods

The high-dose HAIC group comprised 36 patients who were enrolled prospectively from six institutions. The enrollment criteria were good liver function, main portal vein invasion (including vascular shunt), infiltrative type, bilobar involvement, and/or refractory to prior conventional treatment (TACE, radiofrequency ablation, or percutaneous ethanol injection), and documented progressive disease. Patients received 5-fluorouracil (500 mg/m² on days 1~3) and cisplatin (60 mg/m² on day 2 every 4 weeks) via an implantable port system. In the TACE group, 31 patients with characteristics similar to those in the high-dose HAIC group were recruited retrospectively from a single center. Patients underwent a transarterial infusion of doxorubicin every 4~8 weeks.

Results

Overall, 6 patients (8.9%) achieved a partial response and 20 patients (29.8%) had stable disease. The objective response rate (complete response+partial response) was significantly better in the high-dose HAIC group than in the TACE group (16.7% vs. 0%, P=0.030). Overall survival was longer in the high-dose HAIC group than in the TACE group (median survival, 193 vs. 119 days; P=0.026). There were no serious adverse effects in the high-dose HAIC group, while hepatic complications occurred more often in the TACE group.

Conclusions

High-dose HAIC appears to improve the tumor response and survival outcome compared to conventional TACE using doxorubicin in patients with intractable, advanced HCC.

Portal vein thrombosis and arterioportal shunts: effects on tumor response after chemoembolization of hepatocellular carcinoma

AIM

To evaluate the effect of portal vein thrombosis and arterioportal shunts on local tumor response in advanced cases of unresectable hepatocellular carcinoma treated by transarterial chemoembolization.

METHODS

A retrospective study included 39 patients (mean age: 66.4 years, range: 45-79 years, SD: 7) with unresectable hepatocellular carcinoma (HCC) who were treated with repetitive transarterial chemoembolization (TACE) in the period between March 2006 and October 2009. The effect of portal vein thrombosis (PVT) (in 19 out of 39 patients), the presence of arterioportal shunt (APS) (in 7 out of 39), the underlying liver pathology, Child-Pugh score, initial tumor volume, number of tumors and tumor margin definition on imaging were correlated with the local tumor response after TACE. The initial and end therapy local tumor responses were evaluated according to the response evaluation criteria in solid tumors (RECIST) and magnetic resonance imaging volumetric measurements.

RESULTS

The treatment protocols were well tolerated by all patients with no major complications. Local tumor response for all patients according to RECIST criteria were partial response in one patient (2.6%), stable disease in 34 patients (87.1%), and progressive disease in 4 patients (10.2%). The MR volumetric measurements showed that the PVT, APS, underlying liver pathology and tumor margin definition were statistically significant prognostic factors for the local tumor response (P = 0.018, P = 0.008, P = 0.034 and P = 0.001, respectively). The overall 6-, 12- and 18-mo survival rates from the initial TACE were 79.5%, 37.5% and 21%, respectively.

CONCLUSION

TACE may be exploited safely for palliative tumor control in patients with advanced unresectable HCC; however, tumor response is significantly affected by the presence or absence of PVT and APS.

Chronic hepatitis B and hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer in the world and the third leading cause of cancer-related deaths. More than 80% of HCC cases are from the Asian and African continents, and more than 50% of cases are from mainland China. Approximately 350 million to 400 million persons are chronically infected with hepatitis B virus (HBV), and this virus is the most common cause of HCC worldwide. It is estimated that more than 50% of liver cancers worldwide are attributable to HBV and up to 89% of HBV-related HCC are from developing countries. Recently, increasing trends in HCC incidence have been reported from several Western countries, including France, Australia, and the United States.

Transcatheter arterial embolization therapy of recurrent hepatocellular carcinoma after hepatectomy with kelp micro gelation: an analysis of 40 cases

AIM: To evaluate the safety and efficacy of transcatheter arterial embolization (TAE) therapy of recurrent hepatocellular carcinoma (HCC) after hepatectomy with kelp micro gelation (KMG).

METHODS: The clinical data for 40 patients who had recurrent HCC after hepatectomy and were treated by TAE with KMG between June 2007 and December 2007 were reviewed retrospectively. The postoperative complications, the incidence of side effects, 1-month tumor necrosis rate, 1- and 2- year overall survival rates, and prognostic factors in these patients were analyzed.

RESULTS: These patients, including 32 men and 8 women, had a median age of 42 years. All patients were treated on an inpatient basis. Treatment times ranged from 2 to 7. A total of 76 tumor nodules (diameter range, 2-14 cm; average diameter, 4.2 cm) underwent 196 embolization procedures during the 2-year follow-up period. The dose of KMG used in each embolization procedure ranged between 0.2 and 1.2 g. The common adverse reactions after embolization were liver pain (39.8%), fever (35.2%), and nausea and vomiting (34.2%). No severe complications and treatment-related deaths occurred. According to modified RECIST criteria, the response rate at one year was 60% (complete response, 13% complete response; partial response, 47%). The 1- and 2-year survival rates were 85% and 47.5%, respectively.

CONCLUSION: Hepatic artery embolization with KMG is safe and effective in the therapy of postoperative recurrent HCC and can be used as a new option for recurrent HCC.

Transarterial chemoembolization as initial treatment for unresectable hepatocellular carcinoma in southern China

AIM: To identify prognostic factors from pretreatment variables of the initial transarterial chemoembolization (TACE) procedure in unresectable hepatocellular carcinoma (HCC).

METHODS: One thousand and five hundred and sixty-nine patients with unresectable HCC underwent TACE as initial treatment were retrospectively studied. Pretreatment variables of the initial TACE procedure with a P value less than 0.05 by univariate analysis were subjected to Cox proportional hazards model.

RESULTS: The median overall survival time and 1-, 5-, 10-year survival rates were 10.37 mo, 47%, 10%, and 7%, respectively. A Cox proportional hazard model showed that 8 pretreatment factors of regional lymph nodes metastasis, Child-Pugh class, macrovascular invasion, greatest dimension, α-fetoprotein (AFP), Hepatitis virus B, tumor capsule, and nodules were independent prognostic factors. Patients with multimodality therapy have better survival than those with TACE treatment only.

CONCLUSION: Tumor status, hepatic function reserve, AFP, and hepatitis virus B status were independent prognostic factors for unresectable HCC. Distant metastasis might not be a contraindication to TACE. Multimodality therapy might improve survival.

Liver transplantation, liver resection, and transarterial chemoembolization for hepatocellular carcinoma in cirrhosis: which is the best oncological approach?

The aim of the study was to evaluate our institutional experience with monotherapies for hepatocellular carcinoma (HCC) in the setting of cirrhosis. A retrospective cohort study was carried out at the tertiary care academic referral center and involved 185 consecutive HCC patients with cirrhosis and no previous treatment who underwent resection (n = 61), transarterial chemoembolization (TACE) (n = 64), or liver transplantation (LT) (n = 60). Long-term survival and survival according to the Milan criteria were the main outcomes measured. Median survival after resection, TACE, and LT was 11, 14, and 23 months, respectively. Five-year cumulative survival after resection, TACE, and LT was 23, 10, and 59%, respectively (P = 0.001). Five-year cumulative disease-free survival after resection and LT was 15% and 77%, respectively (P = 0.002). The presence of complications in the resection group (P = 0.004), MELD score (P = 0.0003), and maximum tumor diameter (P = 0.05) in the TACE group, and tumor grade (P = 0.01) and complications (P = 0.004) in the LT group were found to be independent predictors of survival. Five-year survival for patients within the Milan criteria after resection, TACE, and LT was 26, 37, and 66%, respectively. Five-year survival for patients outside the Milan criteria for patients undergoing LT was 53%. The results suggest that LT represents the best oncological treatment option for patients with HCC in the setting of cirrhosis, even for those beyond the Milan criteria. Considering the scarcity of available organs, liver resection remains the best alternative option. TACE remains a potential therapy in patients within the Milan criteria, where it may be more beneficial than resection.

Current management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC), one of the most common cancers worldwide, continues to increase in incidence in several regions around the world and is associated with poor overall survival. Patients with cirrhosis are at the highest risk and are candidates for surveillance. Wide implementation of surveillance programs and improvement in noninvasive radiologic techniques has led to tumor diagnosis at earlier stages. Surgical options that include resection and liver transplantation offer the best chance of successful outcomes. Locoregional therapies, such as radiofrequency ablation and chemoembolization, provide effective local control in those with acceptable hepatic function. A multikinase inhibitor, sorafenib, is the first molecular targeted oral therapy that has recently been shown to provide a survival benefit in HCC in select patients.

Progress in non-surgical treatment of primary hepatic carcinoma

At present, surgery-based comprehensive therapy plays a dominant role in the treatment of primary hepatic carcinoma. But the majority of patients had lost their opportunities of surgical treatment when diagnosis was confirmed. Moreover, only 15% patients may benefit from surgical excision. Therefore, non-surgical approaches still hold an important position in primary hepatic carcinoma treatment. The purpose of this article is to review the progress in non-surgical treatments of primary hepatic carcinoma such as micro-invasive therapy, radiotherapy, chemotherapy and biotherapy.

Clinical impact of selective transarterial chemoembolization on hepatocellular carcinoma: A cohort study

AIM: To prospectively evaluate the short and long term clinical impact of selective transarterial chemoembolization (TACE) on liver function in patients with hepatocellular carcinoma (HCC). To assess side effects in relation to treatments. To analyze the overall survival and HCC progression free survival probability.

METHODS: One hundred and seventeen cirrhotic patients with HCC were enrolled. Baseline liver function included Child-Pugh score and serum levels of alanine-aminotransferase (ALT), prothrombin time (PT) and bilirubin. According to Cancer Liver Italian Program (CLIP) and Barcelona Clinic Liver Cancer (BCLC) staging systems, 71 patients were eligible for TACE; 32 had previously received treatment for HCC. No significant differences in liver function were observed between previously treated and not treated patients. TACE was performed by selective catheterization of the arteries nourishing the lesions. While hospitalized, patients underwent clinical, hematologic and ultrasonographic assessments. One month after TACE a CT scan was performed to assess tumor response. A second TACE was performed “on demand”. Liver function tests were checked in all patients every four months.

RESULTS: After first TACE, the mean Child-Pugh score increased from a mean baseline 5.62 ± 1.12 to 6.11 ± 1.57 at discharge time (P < 0.0001), decreasing after four months to 5.81 ± 0.73 (not significant). ALT, PT and bilirubin significantly (P < 0.0001) increased 24 h after TACE and progressively decreased until discharge. After the second TACE, variations in Child-Pugh score, ALT, PT and bilirubin were comparable to that described after the first TACE. No major complications were observed. The mean follow-up was 14.7 ± 6.3 mo (median: 16 mo). Only one patient died. No other patient experienced important long term worsening of clinical status. The overall survival probability at twenty-four months was 98.18% with a correspondent HCC progression free survival probability of 69%.

CONCLUSION: Selective TACE may produce significant, but transitory increases in ALT values, with no major impact on liver function and Child-Pugh score. Preservation of liver function is achievable also in patients previously treated with other therapeutic modalities and in patients undergoing multiple TACE cycles. Liver function can remain stable in the long-term, with optimal medium term survival. This result can be achieved through rigorous patient selection on the basis of tumour characteristics and clinical conditions.

A prospective study of hypofractionated proton beam therapy for patients with hepatocellular carcinoma

PURPOSE

To evaluate the efficacy and safety of hypofractionated proton beam therapy for patients with hepatocellular carcinoma (HCC).

METHODS AND MATERIALS

Between September 2001 and August 2004, 51 patients with HCC greater than 2 cm away from the porta hepatis or gastrointestinal tract were treated with proton beam therapy to 66 Gy-equivalents (GyE) in 10 fractions.

RESULTS

Overall survival rates were 49.2 and 38.7% at 3 and 5 years after treatment. Local control rates were 94.5 and 87.8% at 3 and 5 years after treatment. Posttreatment serum alpha-fetoprotein values were significantly reduced when compared with pretreatment values (p < 0.0001). Patients experienced only minor acute reactions of Grade 1 or less, and 3 patients experienced late sequelae of Grade 2 or higher. However, there were no treatment-related deaths.

CONCLUSIONS

Hypofractionated proton beam therapy is safe and well-tolerated by patients with HCC located greater than 2 cm away from the porta hepatis or gastrointestinal tract and may be effective alternative to other modalities.

TACE versus TAE as therapy for hepatocellular carcinoma

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

The prognostic relevance of preoperative transcatheter arterial chemoembolization (TACE) and PCNA/VEGF expression in patients with Wilms' tumour

BACKGROUND

Wilms' tumour is the most frequent renal tumour in children. Based on the SIOP strategy, children with Wilms' tumour may benefit from preoperative chemotherapy, but few publications address the effect of preoperative transcatheter arterial chemoembolization (TACE) on patients with Wilms' tumours. The aims of this study were to investigate the prognostic relevance of preoperative TACE followed by tumour resection, proliferating cell nuclear antigen (PCNA) and vascular endothelial growth factor (VEGF) expression in patients with Wilms' tumours.

MATERIALS AND METHODS

Two therapeutic strategies including tumour resection only and TACE, followed by tumour resection were conducted in a cohort of 44 patients with Wilms' tumours. Clinical and follow-up data was analysed. Immunohistochemistry staining was used to explore PCNA and VEGF expression in the Wilms' tumour.

RESULTS

Two years tumour-free survival of the patients in the TACE group was significantly higher than that of the patients in the control group (P < 0.001) and recurrence and cases of death within one year in the TACE group was markedly lower than that in the control group (P < 0.001). Fifty-five percent of patients in the control group were PCNA-positive vs. 4.17% of patients in the TACE group (P < 0.001). Fifty percent of patients in the control group were VEGF-positive vs. 29.17% of patients in the TACE group (P > 0.05).

CONCLUSIONS

Patients with Wilms' tumours benefited from preoperative TACE treatment. PCNA expression was significantly lower in patients in the TACE group than those in the control group. There was no significant difference on VEGF expression between the patients in TACE and control groups.

Model for End-stage Liver Disease score fails to predict perioperative outcome after hepatic resection for hepatocellular carcinoma in patients without cirrhosis

BACKGROUND

The Model for End-stage Liver Disease (MELD) score was developed to reflect the hepatocellular reserve in patients with cirrhosis. We hypothesized that the MELD score would not be predictive of perioperative outcome after hepatic resection in patients without cirrhosis.

METHODS

We performed a case-control study of all consecutive patients from 1995 through 2005 undergoing hepatic resection for HCC.

RESULTS

Group A (21 patients without cirrhosis) had a mean age of 57 years, which was similar to control group B (25 patients with cirrhosis), with a mean age of 60 years. The mean tumor size in group A was 9.8 cm compared with that of group B, which was 4.8 cm (P = .03). The American Joint Committee on Cancer stage in group A was I in 14%, II in 5%, and III in 81% versus I in 48%, II in 16%, and 111 in 36% in group B (P = .002). Eighty-six percent of group A patients had a major hepatic resection (>2 segments) compared with 40% in group B (P = .001). The perioperative morbidity and mortality were 24% and 4.8%, respectively, in group A compared with 64% (P = .006) and 20% (P = .12) in group B. The mean preoperative, postoperative, and delta MELD scores were 7.0, 13.0, and 5.0, respectively, in group A compared with 9.6, 16.8, and 7.2 in group B (P = NS). In group A, none of the MELD score parameters accurately predicted perioperative outcomes despite a higher number of patients who had major hepatic resection. In group B, a preoperative MELD score of 9 or greater was associated with a higher overall perioperative morbidity (84% vs 41%, P = .03). Perioperative mortality (n = 6; 13%) was significantly higher in patients with a postoperative MELD score of 15 or higher (P = .02) and a delta MELD score of 10 or higher (P = .03).

CONCLUSIONS

Perioperative MELD score fails to predict perioperative outcomes after hepatic resection for hepatocellular carcinoma in patients without cirrhosis. Other predictive parameters need to be developed for this group of patients.