Liver/biliary injuries following chemoembolisation of endocrine tumours and hepatocellular carcinoma: lipiodol vs. drug-eluting beads

Transarterial Chemoembolization for Hepatocellular Carcinoma: Current Role and Techniques

In the current systemic therapy era, such as immunotherapy and molecular targeted therapy, treatment strategy of hepatocellular carcinoma is changing. Transarterial chemoembolization is more expected as a curative treatment option than before. Therefore, it is important to learn key techniques of transarterial chemoembolization procedures to achieve complete response. This article delineates the current indications for transarterial chemoembolization and several techniques used for its implementation.

EASL Clinical Practice Guidelines on the management of hepatocellular carcinoma

Liver cancer is the third leading cause of cancer-related deaths worldwide, with hepatocellular carcinoma (HCC) accounting for approximately 90% of primary liver cancers. Advances in diagnostic and therapeutic tools, along with improved understanding of their application, are transforming patient treatment. Integrating these innovations into clinical practice presents challenges and necessitates guidance. These clinical practice guidelines offer updated advice for managing patients with HCC and provide a comprehensive review of pertinent data. Key updates from the 2018 EASL guidelines include personalised surveillance based on individual risk assessment and the use of new tools, standardisation of liver imaging procedures and diagnostic criteria, use of minimally invasive surgery in complex cases together with updates on the integrated role of liver transplantation, transitions between surgical, locoregional, and systemic therapies, the role of radiation therapies, and the use of combination immunotherapies at various stages of disease. Above all, there is an absolute need for a multiparametric assessment of individual risks and benefits, considering the patient's perspective, by a multidisciplinary team encompassing various specialties.

Long‑term survival after comprehensive treatment in a patient with advanced neuroendocrine neoplasm of the pancreas: A case report

Neuroendocrine neoplasms of the pancreas (pNENs) are rare. In February 2021, a 54-year-old woman was diagnosed with pNEN and multiple metastases within the liver. The patient, diagnosed with grade G2 neuroendocrine neoplasm (T4N0M1), underwent an ultrasonography-guided liver biopsy and radiofrequency ablation. After receiving Sandostatin LAR in April 2021, side effects led to its discontinuation after seven cycles. Following two sessions of radiofrequency ablation, the patient's condition was stable. However, disease progression was noted in September 2023, resulting in hemodialysis and closed peritoneal drainage. Surufatinib was administered, stabilizing the tumor by November 2023. The patient underwent transarterial chemoembolization due to a large tumor burden, with subsequent MRCP showing stability from diagnosis in February 2021 to June 2024. The present case report highlights the role of tailored treatment strategies considering patient comorbidities and tumor biology, and the significance of secondary puncture biopsy, which, despite not being pursued by the patient in the present study due to the associated risks, may provide survival benefits for patients with advanced or metastatic pNEN.

Idarubicin-loaded drug-eluting microspheres transarterial chemoembolization for intermediate stage hepatocellular carcinoma: safety, efficacy, and pharmacokinetics

BACKGROUND

Transarterial chemoembolization (TACE) is the treatment of choice for the intermediate stage hepatocellular carcinoma (HCC). Doxorubicin remains the most used chemotherapeutic agent in TACE, although in vitro screening has demonstrated that idarubicin exhibits greater cytotoxicity against HCC. This study aimed to evaluate safety, efficacy, and pharmacokinetics of idarubicin-loaded drug-eluting microspheres TACE (DEMIDA-TACE) in intermediate stage HCC patients.

PATIENTS AND METHODS

Between September 2019 and December 2021, 31 consecutive intermediate stage HCC patients (96.8% cirrhotic) were included to this study. 2 mL of LifePearl™ microspheres (100 μm) loaded with 10 mg of 1 mg/mL idarubicin were used for treatment. The adverse events, objective response rate (ORR), progression free survival (PFS), time to TACE untreatable progression (TTUP), median overall survival (mOS), and pharmacokinetics were evaluated.

RESULTS

There were 68 TACE procedures performed. Adverse events grade ≥ 3 were noted after 29.4% procedures. The ORR was 83.9%, median PFS and TTUP were 10.5 months (95% CI: 6.8-14.3 months) and 24.6 months (95% CI: 11.6-37.6 months), respectively. Median OS was 36.0 months (95% CI: 21.1-50.9 months). Significant differences between patients achieving objective response (OR) and those with progressive disease were observed regarding idarubicinol and combined idarubicin-idarubicinol plasma concentrations at 72 hours post-procedure, higher plasma concentrations were observed in patients achieving OR (p = 0.014 and 0.014; cut-off values 1.2 and 1.29 ng/mL, respectively).

CONCLUSIONS

DEMIDA-TACE emerges as a safe and effective method of treatment for the intermediate stage HCC with low rates of adverse events alongside high tumor response, favourable disease control and overall survival. Idarubicinol and combined idarubicin-idarubicinol plasma concentrations at 72 hours post-procedure may serve as prognostic factors for achieving OR.

Predictors and risk factors of bile duct injury after transcatheter arterial chemoembolization for hepatocellular carcinoma

PURPOSE

Bile duct injury is a serious complication after transcatheter arterial chemoembolization (TACE). If it is not detected early and treated actively, it will not only affect the subsequent tumor-related treatment of hepatocellular carcinoma (HCC) patients, but also may lead to serious consequences such as infection, liver failure and even death. To analyze the risk factors of bile duct injury after TACE in patients with HCC and explore the predictive indicators of bile duct injury after TACE, which is helpful for doctors to detect and intervene early and avoid the occurrence of serious complications.

METHOD

We retrospectively analyzed the clinical data of 847 patients with primary hepatocellular carcinoma who underwent TACE for the first time in our interventional department. Patients were divided into two groups according to whether bile duct injury occurred after TACE: (1) bile duct injury group, N = 55; (2) no bile duct injury group, N = 792. The basic data, intraoperative conditions and the outcome of bile duct injury were analyzed. The chi-square test was used for comparison of enumeration data. The Mann-Whitney U test was used for comparison of measurement data. Risk factor analysis was performed using binary logistic regression analysis.

RESULTS

Basic data and intraoperative conditions were compared between the bile duct injury group and the group without bile duct injury: preoperative alkaline phosphatase (ALP) (103.24 ± 32.77U/L vs. 89.17 ± 37.35U/L, P = 0.003); history of hepatobiliary surgery (36.4% vs. 20.8%, P = 0.011); intraoperative lipiodol volume (P = 0.007); combined use of gelatin sponge particles (65.5% vs. 35.0%, P < 0.001); hypovascularity (58.2% vs. 24.5%, P < 0.001); and embolization site (P < 0.001). Comparison of postoperative liver function between bile duct injury group and non-bile duct injury group: postoperative total bilirubin (43.34 ± 25.18umol/L vs. 21.94 ± 9.82umol/L, P < 0.001); postoperative γ-glutamyltransferase(GGT) (188.09 ± 55.62U/L vs. 84.04 ± 36.47U/L, P < 0.001); postoperative ALP(251.51 ± 61.51U/L vs. 99.92 ± 45.98U/L, P < 0.001).

CONCLUSION

The dosage of lipiodol in TACE, supplementation of gelatin sponge particles, embolization site, and hypovascularity of the tumor are risk factors for biliary duct injury after TACE. After TACE, GGT and ALP increased ≥ 2 times compared with preoperative indicators as predictors of bile duct injury. Bile duct injury occurring after TACE can achieve good outcomes with aggressive management.

Comparison of drug-eluting bead with conventional transcatheter arterial chemoembolization for hepatocellular carcinoma with portal vein tumor thrombus: a randomized clinical trial

BACKGROUND

Drug-eluting bead transarterial chemoembolization (DEB-TACE) has shown efficacy for treating hepatocellular carcinoma (HCC) with portal vein tumor thrombus (PVTT). However, whether DEB-TACE is superior to conventional TACE (cTACE) remains unclear.

OBJECTIVE

This randomized controlled trial aimed to compare the efficacy and safety of DEB-TACE versus cTACE in treating HCC with PVTT.

METHODS

The study was conducted at a tertiary care center in Southeast China. HCC patients with PVTT were randomized at a 1:1 ratio into the DEB-TACE or cTACE groups. The primary endpoint was progression-free survival (PFS), and the secondary endpoints were overall survival (OS) and the incidence of adverse events (AEs). An independent review committee assessed the radiologic response according to the modified Response Evaluation Criteria in Solid Tumors (mRECIST). AEs were assessed by the Common Terminology Criteria for Adverse Events (CTCAE) version 4.0. Systemic therapies were not restricted.

RESULTS

Between September 2018 and July 2020, 163 patients were randomized to undergo DEB-TACE ( n =82) or cTACE ( n =81). Nine patients were excluded, and 154 patients were included in the final analysis; the median age was 55 years (range, 24-78 years), and 140 (90.9%) were male. The median PFS in the DEB-TACE group was 6.0 months (95% CI, 5.0-10.0) versus 4.0 months (95% CI, 3.0-5.0) in the cTACE group (hazard ratio, 0.63; 95% CI, 0.42-0.95; P =0.027). The DEB-TACE group showed a higher response rate [51 (66.2%) vs. 36 (46.8%); P =0.0015] and a longer median OS [12.0 months (95% CI, 9.0-16.0) vs. 8.0 months (95% CI, 7.0-11.0), P =0.039] than the cTACE group. Multivariate analysis showed that the treatment group, ALBI score, distant metastasis and additional TKIs were the four independent prognostic factors correlated with PFS. In addition, the treatment group, PVTT group and combination with surgery were independently associated with OS. AEs were similar in the two groups, and postembolization syndrome was the most frequent AE.

CONCLUSION

DEB-TACE is superior to cTACE in treating HCC patients with PVTT, demonstrating improved PFS and OS with an acceptable safety profile, and may thus emerge as a promising treatment strategy for HCC patients with PVTT.

TRIAL REGISTRATION

Chinese Clinical Trial Registry ChiCTR1800018035.

Paraneoplastic Diarrhea From Medullary Thyroid Carcinoma Resolved With Yttrium-90 Radioembolization of Liver Metastases

Medullary thyroid carcinoma (MTC) can often have an indolent course despite distant metastatic disease. Additionally, given that metastatic MTC is incurable and systemic therapies have non-negligeable toxicities, localized treatments are often favored in presence of oligo-progressive disease. Transarterial radioembolization (TARE) with yttrium-90 (Y90) has emerged as a safe and efficacious treatment for nonresectable primary and metastatic liver tumors, yet data supporting its use in metastatic MTC are limited. We present the case of a patient with hereditary MTC and large bilobar liver metastases who demonstrated tumor response and resolution of their paraneoplastic diarrhea following TARE with Y90 microspheres.

Evaluation of a new beads reflux control microcatheter in drug-eluting bead transarterial chemoembolization

Rationale and objectives

A new microcatheter was recently developed claiming to reduce beads reflux in drug-eluting bead transarterial chemoembolization (DEB-TACE). The aim of this study was to compare the reflux control microcatheter ability versus a standard microcatheter for TACE treatment in patients with hepatocellular carcinoma.

Material and methods

Patients were prospectively included between November 2017 and February 2022. They received a DEB-TACE treatment with charged radiopaque beads using standard microcatheters or the SeQure reflux control microcatheter (Guerbet, France) and were assigned respectively to a control and a test group. Beads distribution mismatch was evaluated between the targeted territory on treatment planning CBCT and beads' spontaneous opacities on the post-intervention CBCT and the 1-month CT scanner.

Results

Twenty-three patients (21 men, median age 64 years [12.5 years]) with 37 hepatocellular carcinoma nodules were treated. The control group consisted of 13 patients - 19 nodules, while the test group included ten patients - 18 nodules. Non target embolization (NTE) was found in 20 % (2/10) of patients in the test group and 85 % (11/13) in the control group. NTE involved only an adjacent segment in the test group while it affected the adjacent biliary sector or even the contralateral liver lobe in the control group. No complication linked to NTE was found in the test group, while it led to one case of ischemic cholangitis and another case of biloma in the control group.

Conclusion

The reflux control microcatheter may be efficient in reducing NTE and thus eventual adverse events in comparison to standard of care end-hole microcatheters.

Risk factors of liver abscess and biloma formation after drug-eluting bead transarterial chemoembolization for unresectable intrahepatic cholangiocarcinoma

BACKGROUND AND STUDY AIMS

Drug-eluting bead transarterial chemoembolization (DEB-TACE) causes serious complications, including liver abscess and biloma formation. This study aimed to investigate the frequency and risk factors of liver abscess and biloma formation after dug-eluting bead transarterial chemoembolization for unresectable intrahepatic cholangiocarcinoma (ICC).

PATIENTS AND METHODS

152 unresectable ICC patients received 241 DEB-TACE procedures from February 2018 to November 2022 were studied retrospectively. Patients were evaluated for the presence of liver abscess and biloma formation after DEB-TACE. The medical records, including baseline demographic data, preoperative imaging data, DEB-TACE details, and postoperative management, were reviewed to search for risk factors of liver abscess and biloma formation.

RESULTS

Liver abscesses developed in 11 cases, with an incidence rate of 7.2 % (11/152) per patient and 4.6 % (11/241) per procedure. In the 11 patients with abscesses, the incidence of biloma formation was 36.4 % (n = 4). The binary logistic regression analysis showed that diabetes mellitus (OR 7.967, 95 % CI 1.491-42.571, p = 0.015), bilioenterostomy or biliary stent implantation (OR 18.716, 95 % CI 1.006-348.049, p = 0.049) and grade 1 arterial occlusion (OR 9.712, 95 % CI 1.054-89.484, p = 0.045) were independent risk factors for liver abscess and biloma formation.

CONCLUSION

Liver abscesses and biloma formation induced by DEB-TACE are associated with various factors. Diabetes mellitus, bilioenterostomy or biliary stent implantation, and grade 1 artery occlusion were all associated with liver abscess and biloma formation after DEB-TACE for unresectable ICC. In patients with these risk factors, the DEB-TACE procedure should be finely designed and manipulated with more caution.

Liver abscess after drug-eluting bead transarterial chemoembolization for hepatic malignant tumors: Clinical features, pathogenesis, and management

AIM

The study aimed to investigate the clinical features, incidence, pathogenesis, and management of liver abscess after drug-eluting bead transarterial chemoembolization (DEB-TACE) for primary and metastatic hepatic malignant tumors.

METHODS

From June 2019 to June 2021, patients with liver abscess after DEB-TACE for primary and metastatic hepatic malignant tumors were reviewed and evaluated at our hospital. Demographic and clinical data, radiological findings, management approaches, and prognosis were retrospectively analyzed.

RESULTS

In total, 419 DEB-TACE procedures were carried out in 314 patients with primary and metastatic liver tumors at our medical center. Twelve patients were confirmed to have liver abscesses after DEB-TACE through clinical manifestations, laboratory investigations, and imaging. In this study, the incidence of liver abscess was 3.82% per patient and 2.86% per DEB-TACE procedure. After percutaneous drainage and anti-inflammatory treatments, 10 patients recovered, and the remaining 2 patients died due to direct complications of liver abscess, such as sepsis and multiple organ failure. The mortality rate of liver abscesses after DEB-TACE was 16.7% (2/12).

CONCLUSION

The incidence of liver abscess after DEB-TACE is relatively high and can have serious consequences, including death. Potential risk factors could include large tumor size, history of bile duct or tumor resection, history of diabetes, small DEB size (100-300 μm). Sensitive antibiotics therapy and percutaneous abscess aspiration/drainage are effective treatments for liver abscess after DEB-TACE.

Chemoembolization Beyond Hepatocellular Carcinoma: What Tumors Can We Treat and When?

Liver metastases are the most common malignancy found in the liver and are 20 to 40 times more common than primary hepatic tumors, including hepatocellular carcinoma. Patients with liver metastases often present with advanced disease and are not eligible for curative-intent surgery or ablative techniques. The unique hepatic arterial blood supply of liver metastases allows interventional radiologists to target these tumors with transarterial therapies. Transarterial chemoembolization (TACE) has been studied in the treatment of liver metastases originating from a variety of primary malignancies and has demonstrated benefits in terms of hepatic progression-free survival, overall survival, and symptomatic relief, among other benefits. Depending on the primary tumor from which they originate, liver metastases may have different indications for TACE, may utilize different TACE regimens and techniques, and may result in different post-procedural outcomes. This review offers an overview of TACE techniques and specific considerations in the treatment of liver metastases, provides an in-depth review of TACE in the treatment of liver metastases originating from colorectal cancer, neuroendocrine tumor, and uveal melanoma, which represent some of the many tumors beyond hepatocellular carcinoma that can be treated by TACE, and summarizes data regarding when one should consider TACE in their treatment algorithms.

Comparative study between Embosphere® and Marine gel® as embolic agents for chemoembolization of hepatocellular carcinoma

BACKGROUND

While gelatin sponge particles and calibrated microspheres are commonly used as embolic materials in conventional transarterial chemoembolization (cTACE), direct comparisons between these embolic agents are rare.

AIM

To compare the efficacy and safety of superselective cTACE using Embosphere® or Marine gel® in patients with early-stage hepatocellular carcinoma (HCC).

METHODS

This retrospective study included 70 patients with small (< 4 cm) HCC who underwent cTACE with Embosphere® (n = 33) or Marine gel® (n = 37) as the embolic agent at a single center between March 2021 and July 2022. The radiologic images and clinical data were retrospectively reviewed, with an emphasis on tumor response, procedure-related complications, and local tumor recurrence. The primary index tumor was assessed on a 1-mo follow-up image, and local progression-free survival was obtained using the Kaplan-Meier method and was compared by the log-rank test.

RESULTS

The median tumor size of both groups was 1.5 cm, and 69 patients achieved a complete response one month after cTACE. The cumulative local recurrence rate at 12 mo was 15.5% in the Embosphere® group and 14.4% in the Marine gel® group. The local progression-free survival was not significantly different between the two groups (P = 0.83). In the multivariate analysis, high serum alpha-fetoprotein was the only significant poor prognostic factor for local tumor progression (P = 0.01). Postembolization syndrome occurred in 36.4% of the Embosphere® group and 35.1% of the Marine gel® group, and there were no cases of biloma, biliary duct dilation, or liver abscess in either group.

CONCLUSION

Calibrated gelatin sponge particles (Marine gel®) and calibrated microspheres (Embosphere®) have similar outcomes in terms of tumor response for superselective cTACE of small HCC.

Locoregional Therapies for Primary and Secondary Hepatic Malignancies

Management of hepatic malignancies is a multidisciplinary task with the involvement of hepatologists, medical/surgical/radiation oncologists, transplant surgeons, and interventional radiologists. Patients should be selected for a specific targeted therapy after multidisciplinary consensus. Interventional oncology, with image-guided locoregional cancer therapies, can decrease systemic toxicity without compromising tumoricidal effect.

Transarterial chemoembolization for liver metastases of a pancreatic neuroendocrine neoplasm: a single-center experience

Transarterial chemoembolization (TACE) is performed for pancreatic neuroendocrine tumor (PanNEN) liver metastases; however, the safety and efficacy of TACE procedures, especially for patients who have undergone previous pancreatic surgery, have not been established. We reviewed 48 TACE procedures (1-6 procedures/patient) performed on 11 patients with PanNEN liver metastases, including 16 TACE procedures (4-6 procedures/patient) for 3 patients with a history of biliary-enteric anastomosis. The overall tumor objective response rate was 94%. The incidence of Clavien‒Dindo grade ≥ 2 complications was 1/16 (6%) and 1/32 (3%), and the median time to untreatable progression was 31 (14-41) and 27 (2-60) months among patients with and without a history of biliary-enteric anastomosis, respectively. Although validation is needed in future studies, our experiences have shown that TACE treatment is a viable treatment option for PanNEN liver metastases, even after biliary-enteric anastomosis with experienced teams and careful patient follow-up.

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

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

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

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

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

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

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

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

Multifunctional nanoplatforms application in the transcatheter chemoembolization against hepatocellular carcinoma

Hepatocellular carcinoma (HCC) has the sixth-highest new incidence and fourth-highest mortality worldwide. Transarterial chemoembolization (TACE) is one of the primary treatment strategies for unresectable HCC. However, the therapeutic effect is still unsatisfactory due to the insufficient distribution of antineoplastic drugs in tumor tissues and the worsened post-embolization tumor microenvironment (TME, e.g., hypoxia and reduced pH). Recently, using nanomaterials as a drug delivery platform for TACE therapy of HCC has been a research hotspot. With the development of nanotechnology, multifunctional nanoplatforms have been developed to embolize the tumor vasculature, creating conditions for improving the distribution and bioavailability of drugs in tumor tissues. Currently, the researchers are focusing on functionalizing nanomaterials to achieve high drug loading efficacy, thorough vascular embolization, tumor targeting, controlled sustained release of drugs, and real-time imaging in the TACE process to facilitate precise embolization and enable therapeutic procedures follow-up imaging of tumor lesions. Herein, we summarized the recent advances and applications of functionalized nanomaterials based on TACE against HCC, believing that developing these functionalized nanoplatforms may be a promising approach for improving the TACE therapeutic effect of HCC.

Transarterial Chemoembolization with Anthracyclines-Loaded Polyethylene Glycol Drug Eluting Microspheres for the Treatment of Hepatocellular Carcinoma: A Pooled Multicentric Analysis of Survival in 580 Patients

PURPOSE

To evaluate survival, efficacy and safety of transarterial chemoembolization (TACE) in the treatment of patients with hepatocellular carcinoma (HCC), through a pooled analysis of patients with BCLC 0, A and B HCC stages, treated with polyethylene glycol drug eluting microspheres (PEG-DEM) TACE.

MATERIALS AND METHODS

Patients from 3 retrospective and 2 prospective registries were included. Overall survival (OS), progression-free survival (PFS), tumour response and safety were evaluated. Multivariate Cox regression analysis was performed to evaluate predictors of OS.

RESULTS

A total of 580 patients (72.1% males, mean age 66.9 ± 10.3 years) were included. 43.5% had BCLC A, and 41.0% BCLC B disease stage, and 85.8% were Child-Pugh class A. Complete and partial response (mRECIST or RECIST1.1) were achieved in 60.14% and 27.11% of patients, with overall response and disease control rates of 87.30% and 94.60%, respectively. Median OS was 50.8 months for the total population, and 61.2 and 38.1 months for BCLC 0 + A and BCLC B patients, respectively. Median PFS for the total population, BCLC 0 + A and BCLC B groups was 15.6, 21.6 and 12.7 months, respectively.

CONCLUSIONS

This multicentric pooled analysis confirmed efficacy and safety of PEG-DEM TACE, with a median OS of 50.8 months.

Prediction of bile duct injury after transarterial chemoembolization for hepatocellular carcinoma: Model establishment and verification

Objective

This study aimed to establish and validate a predictive model for bile duct injury in patients with hepatocellular carcinoma (HCC) after drug-eluting bead transarterial chemoembolization (DEB-TACE).

Methods

We retrospectively analyzed 284 patients with HCC treated with DEB-TACE at our hospital between January 2017 and December 2021, of whom 63 patients experienced postoperative bile duct injuries. Univariate and logistic multivariate regression analyses were performed to identify the risk factors for bile duct injury, as well as establish and internally validate the nomogram model. The area under the curve (AUC) of the receiver operating characteristic (ROC) curve, calibration curve, Hosmer-Lemeshow goodness of fit test, decision curve analysis (DCA), and clinical impact curve (CIC) were used to assess the predictive power, clinical value, and practicability of the nomogram model.

Results

The incidence of bile duct injuries after DEB-TACE was 22.18% (63/284), with one injury occurring in every 2.86 sessions of DEB-TACE treatment. Univariate and logistic multivariate regression analyses indicated that a history of hepatectomy (odds ratio [OR]=2.285; 95% confidence interval [CI]=1.066-4.898; P<0.05), subjective angiographic chemoembolization endpoint level (OR=1.832; 95% CI=1.258-2.667; P<0.05), alkaline phosphatase (OR=1.005; 95% CI=1.001-1.010; P<0.05), and platelet count (OR=1.005; 95% CI=1.001-1.009; P<0.05) were independent risk factors for bile duct injury after DEB-TACE among patients with HCC. The risk nomogram model based on the above four variables was validated using the bootstrap method, showing consistency between the predicted and experimental values. Furthermore, the model performed well in the Hosmer-Lemeshow goodness-of-fit test (²=3.648; P=0.887). The AUC of this model was 0.749 (95% CI=0.682-0.817), with an overall accuracy of 69.01%, a positive predictive value of 73.02%, a negative predictive value of 67.87%, a sensitivity of 73.0%, and a specificity of 67.90%, suggesting that the nomogram model had good accuracy and discrimination. In addition, DCA and CIC revealed a high clinical value and practicability of the model.

Conclusion

Bile duct injury in patients with HCC treated with DEB-TACE is caused by multiple factors rather than a single factor. The nomogram prediction model used in this study had a good fitting degree and prediction efficacy, with high clinical value and practicability.

ACR Appropriateness Criteria® Management of Liver Cancer: 2022 Update

The treatment and management of hepatic malignancies can be complex because it encompasses a variety of primary and metastatic malignancies and an assortment of local and systemic treatment options. When to use each of these treatments is critical to ensure the most appropriate care for patients. Interventional radiologists have a key role to play in the delivery of a variety of liver directed treatments including percutaneous ablation, transarterial embolization with bland embolic particles alone, transarterial chemoembolization (TACE) with injection of a chemotherapeutic emulsion, and transarterial radioembolization (TARE). Based on 9 clinical variants, the appropriateness of each treatment is described in this document. The ACR Appropriateness Criteria are evidence-based guidelines for specific clinical conditions that are reviewed annually by a multidisciplinary expert panel. The guideline development and revision process support the systematic analysis of the medical literature from peer reviewed journals. Established methodology principles such as Grading of Recommendations Assessment, Development, and Evaluation or GRADE are adapted to evaluate the evidence. The RAND/UCLA Appropriateness Method User Manual provides the methodology to determine the appropriateness of imaging and treatment procedures for specific clinical scenarios. In those instances in which peer reviewed literature is lacking or equivocal, experts may be the primary evidentiary source available to formulate a recommendation.

Treatment response, survival and safety profile of transarterial chemoembolization using different sizes of drug-eluting beads in hepatocellular carcinoma patients with portal vein tumor thrombus

BACKGROUND

Different sized microspheres may affect the efficacy and safety of drug-eluting beads transarterial chemoembolization (DEB-TACE) in hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT), but related data are lacking. Therefore, the current study aimed to investigate the treatment response, survival and safety of DEB-TACE using different sized microspheres in HCC patients with or without PVTT.

METHODS

Totally 90 HCC patients underwent DEB-TACE treatment were retrospectively enrolled (30 cases with PVTT and 60 cases without PVTT). According to the sizes of microspheres, patients were divided into 100-300 μm, 300-500 μm and 500-700 μm groups, respectively.

RESULTS

Disease control rate (DCR) was highest in 300-500 μm group (81.3%), followed by 500-700 μm group (50.0%), then the lowest in 100-300 μm group (12.5%) (P = 0.004); while objective response rate (ORR) was similar among three groups (P = 0.177) in patients with PVTT. Furthermore, overall survival (OS) (P = 0.513) and adverse events (all P>0.05) were similar among three groups in patients with PVTT. Besides, in patients without PVTT: ORR (P = 0.694), DCR (P = 0.591), OS (P = 0.816) were of no difference among three groups; but the fever incidence was highest in 300-500 μm group (65.0%), second high in 500-700 μm group (50.0%), then lowest in 100-300 μm group (25.0%) (P = 0.008), except for this, no difference of other adverse events among three groups was found (all P>0.05).

CONCLUSION

DEB-TACE using 300-500 μm microspheres (versus 100-300 μm or 500-700 μm microspheres) exhibits best treatment response without additional adverse events, indicating it might be the optimal choice for HCC patients with PVTT.

POLYETHYLENE-GLYCOL DRUG-ELUTING EMBOLIC MICROSPHERES LOADED WITH DOXORUBICIN FOR THE TREATMENT OF HEPATOCELLULAR CARCINOMA: FEASIBILITY, SAFETY AND PHARMACOKINETIC STUDY

PURPOSE

Polyethylene-glycol drug-eluting microspheres (PEG-DEM) can be loaded to elute doxorubicin. This study evaluated the pharmacokinetic profile and safety of PEG-DEMs in the treatment of patients with hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This prospective, multicentre, dose escalation study enrolled 25 patients (68% men) with early or intermediate stage HCC and performance status of 0. Patients in cohort I were assigned to receive target doxorubicin doses of 75, 100, or 150 mg. Analyses were performed based on the specific dose of doxorubicin that patients received, since some patients received less than the assigned dose. Patients in cohort II received the maximum safe tested dose. Adverse events (AEs) were classified according to Common Terminology Criteria for Adverse Events v.4.03. Tumor response was evaluated every 3 months according to European Association for the Study of the Liver criteria and modified Response Evaluation Criteria in Solid Tumors.

RESULTS

The maximum tested safe dose of doxorubicin was 150 mg. For the groups that received ≤75, 75-100, and 101-150 mg, the C_max were 286.7±220.1, 157.1±94.6 and 245.4±142.8 ng/mL, respectively; AUC_0-24h were 421.7±221.2, 288.1±100.9 and 608.3±319.3 (ng x hours)/mL respectively, with almost complete clearance at 24 hours. There were no deaths within 30 days. The best objective response rate was 81% and the disease control rate was 91%. Median overall survival was 27.2 (95% CI, 17.5-n.e) months; median progression free survival was 9.8 (95% CI, 5.5-n.e.) months.

CONCLUSION

PEG-DEMs demonstrated a favorable safety profile with low systemic concentration of doxorubicin, and promising efficacy.

Liver abscess after drug-eluting bead chemoembolization in patients with metastatic hepatic tumors

OBJECTIVE

To investigate the incidence and risk factors for liver abscess formation after treatment with drug-eluting bead chemoembolization (DEB-TACE) in patients with metastatic hepatic tumors (MHT).

METHODS

The current study is a retrospective analysis of the clinical data of 137 patients with metastatic hepatic tumors who received DEB-TACE treatment in our institute (Union Hospital, Tongji Medical College, Huazhong University of Science and Technology) between June 2015 and September 2020. Patients were evaluated for the presence or absence of post-DEB-TACE liver abscess. Univariate and multivariate analyses were used to identify risk factors for liver abscess formation.

RESULTS

The incidence of liver abscess formation after the DEB-TACE procedure was 8.76% per patient and 5.53% per procedure. Univariate analysis showed that larger maximum tumor diameter (p = 0.004), Grade 1 artery occlusion (p < 0.001) and systemic chemotherapy within 3 months before the DEB-TACE procedure (p < 0.001) were all associated with liver abscess formation. However, only systemic chemotherapy within 3 months before the DEB-TACE procedure (OR 5.49; 95% CI 0.34-13.54; p < 0.001) was identified by multivariate analysis to be an independent risk factor.

CONCLUSIONS

Tumor size, Grade 1 artery occlusion and recent systemic chemotherapy may all be associated with increased risk of liver abscess formation following DEB-TACE treatment in patients with metastatic hepatic tumors.

ADVANCES IN KNOWLEDGE

Identification of risk factors for liver abscess formation following DEB-TACE in patients with MHT. These findings suggest the need for caution and consideration of the aforementioned risk factors on the part of interventional radiologists when designing DEB-TACE strategies and performing post-procedure patient management.

Limitations and Possibilities of Transarterial Chemotherapeutic Treatment of Hepatocellular Carcinoma

Because diagnostic tools for discriminating between hepatocellular carcinoma (HCC) and advanced cirrhosis are poor, HCC is often detected in a stage where transarterial chemoembolization (TACE) is the best treatment option, even though it provides a poor survival gain. Despite having been used worldwide for several decades, TACE still has many limitations. First, there is a vast heterogeneity in the cellular composition and metabolism of HCCs as well as in the patient population, which renders it difficult to identify patients who would benefit from TACE. Often the delivered drug does not penetrate sufficiently selectively and deeply into the tumour and the drug delivery system is not releasing the drug at an optimal clinical rate. In addition, therapeutic effectiveness is limited by the crosstalk between the tumour cells and components of the cirrhotic tumour microenvironment. To improve this widely used treatment of one of our most common and deadly cancers, we need to better understand the complex interactions between drug delivery, local pharmacology, tumour targeting mechanisms, liver pathophysiology, patient and tumour heterogeneity, and resistance mechanisms. This review provides a novel and important overview of clinical data and discusses the role of the tumour microenvironment and lymphatic system in the cirrhotic liver, its potential response to TACE, and current and possible novel DDSs for locoregional treatment.

Image-Guided Local Treatment for Unresectable Intrahepatic Cholangiocarcinoma-Role of Interventional Radiology

Intrahepatic cholangiocarcinoma is a highly aggressive malignancy with an increasing incidence in recent years. Prognosis is poor and most patients are not eligible for resection at the time of initial diagnosis due to the anatomic location, inadequate hepatic reserve, limiting comorbidities or metastatic disease. Several locoregional therapies from the field of interventional radiology exist for patients who are not amenable for surgery, or in case of local recurrence as a single treatment modality or combined with systemic treatment. To date, evidence is limited, with most conclusions drawn from single-center studies with small patient cohorts, often treated in the salvage situation or for local recurrence after initial resection. Nevertheless, the results are promising and suggest a survival benefit in selected patients. This narrative review focuses on the use of different locoregional treatment options for intrahepatic cholangiocarcinoma.

Portal Vein Damage after DEB-TACE and Lipiodol-TACE: Based on Evaluation by Computed Tomography during Arterial Portography

Purpose:

To reveal the effect of drug-eluting beads transarterial chemoembolization and Lipiodol transarterial chemoembolization on portal perfusion, and to identify factors predisposing portal vein damage after transarterial chemoembolization, based on evaluation by computed tomography during arterial portography.

Material and Methods:

This retrospective cohort analysis included 49 patients with hepatocellular carcinoma who underwent transarterial chemoembolization and preprocedural/follow-up computed tomography during arterial portography between October 2013 and April 2015. The preprocedural and follow-up computed tomography during arterial portography were compared to identify the following new changes suggestive of portal vein damage in the follow-up computed tomography during arterial portography: small perfusion defects, large perfusion defects, and narrowing/disappearance or portal vein obstruction. The frequency of portal vein damage after drug-eluting beads transarterial chemoembolization and Lipiodol transarterial chemoembolization was calculated, and relationships between portal vein damage and clinical variables were analyzed. Finally, a multivariate logistic regression analysis with adjustments for potentially confounding factors was performed to identify factors predisposing portal vein damage.

Results:

The analysis included 24 patients who underwent drug-eluting beads transarterial chemoembolization and 25 who underwent Lipiodol transarterial chemoembolization. Emergence of small perfusion defects and narrowing/disappearance or obstruction of portal vein were observed at a significantly higher frequency following drug-eluting beads transarterial chemoembolization than following Lipiodol transarterial chemoembolization (70.8% [17/24] vs. 20% [5/25]; p < 0.001; 41.7% [10/24] vs. 12% [3/25]; p = 0.019). Drug-eluting beads transarterial chemoembolization and selectivity of transarterial chemoembolization (selective [<subsegmental], segmental or lobar) were significantly associated with portal vein damage (p < 0.001 and p = 0.016, respectively). However, multivariate logistic regression analysis identified drug-eluting beads transarterial chemoembolization as a significant independent predictor of portal vein damage (odds ratio: 34.95; 95% confidence interval: 1.137-1073.99; p = 0.042).

Conclusions:

Portal vein damage occurred at a significantly higher frequency following drug-eluting beads transarterial chemoembolization than following Lipiodol transarterial chemoembolization, and drug-eluting beads transarterial chemoembolization was an independent predictor of portal vein damage after transarterial chemoembolization.

Long Term Efficacy and Assessment of Tumor Response of Transarterial Chemoembolization in Neuroendocrine Liver Metastases: A 15-Year Monocentric Experience

Simple Summary

Neuroendocrine tumors (NET) are rare tumors, with long-term survival even for patients with liver metastases. Transarterial chemoembolization (TACE) is one of the most widely used treatments in this setting. The aim of the study was to assess the long-term efficacy of TACE in a large cohort of patients with NET liver metastases and to correlate imaging findings with survival. In our study including 202 patients with NET liver metastases and a mean follow-up of 8.2 years, TACE was effective to provide disease control for 26 months and a 5.3-year median overall survival (OS). Imaging responses using RECIST and mRECIST criteria were significantly correlated to OS: the median-OS was twice as long among mRECIST responders versus non-responders, with 80.5 months and 39.6 months respectively. These findings are of major importance for everyday practice as they confirm TACE’s effectiveness and usefulness of imaging evaluation to better tailor patient treatment and repeat TACE sessions whenever necessary.

Abstract

Background: transarterial chemoembolization (TACE) is an established treatment for neuroendocrine tumor (NET) liver metastases. The aim was to evaluate the long-term treatment efficacy of TACE for NET liver metastases, and correlate imaging response with survival. Methods: this IRB-approved, single-center, retrospective study evaluated all TACE procedures performed for NET liver metastases from 2003–2017 for imaging tumor response (RECIST and mRECIST), time to liver progression (TT_LP), time to untreatable progression with TACE (TTUP), and overall survival (OS). Patient, tumor, and treatment characteristics were analyzed as prognostic factors. Survival curves according to the Kaplan–Meier method were compared by Log-rank test. Tumor responses according to RECIST and mRECIST were correlated with OS. Results: 555 TACE procedures were performed in 202 NET patients (38% grade 1, 60% grade 2) with primary tumors originating from pancreas, small bowel, and lung (39, 26, and 22% respectively). Median follow-up was 8.2 years (90–139 months). Median TT_LP and TTUP were 19.3 months (95%CI 16.3–22.3) and 26.2 months (95%CI 22.3–33.1), respectively. Median OS was 5.3 years (95%CI 4.2–6.7), and was higher among mRECIST responders (80.5 months; 95%CI 64.6–89.8) than in non-responders (39.6 months; 95%CI = 32.8–60.2; p < 0.001). In multivariable analysis, age, tumor grade and liver involvement predicted worse OS, whereas administration of somatostatin analogs correlated with improved OS. Conclusion: TACE for NET liver metastases provides objective response and sustained local disease control rates. RECIST and mRECIST responses correlate with OS.

In the Era of Systemic Therapy for Hepatocellular Carcinoma Is Transarterial Chemoembolization Still a Card to Play?

Conventional transarterial embolization (cTACE) has been proven to be effective for intermediate stage hepatocellular carcinoma (HCC), with a recent systematic review showing an overall survival (OS) of 19.4 months. Nevertheless, due to the rapid development of the systemic therapeutic landscape, the place of TACE is becoming questionable. Is there still a niche for TACE in the era of immunotherapy and combination treatments such as atezolizumab-bevacizumab, which has shown an OS of 19.2 months with excellent tolerance? The development of drug-eluting microspheres (DEMs) has led to the standardization of the technique, and along with adequate selection, it showed an OS of 48 months in a retrospective study. In order to increase treatment selectivity, new catheters have also been added to the TACE arsenal as well as the use of cone-beam CT (CBCT), which provides three-dimensional volumetric images and guidance during procedures. Moreover, the TACE indications have also widened. It may serve as a "bridging therapy" for liver transplantation candidates while they are on the waiting list, and it represents a valuable downstaging tool to transplantation criteria. The aim of this review is to explore the current data on the advancements of TACE and its future place amongst the growing panel of treatments.

Efficacy of Combined Therapy with Drug-Eluting Beads-Transcatheter Arterial Chemoembolization Followed by Conventional Transcatheter Arterial Chemoembolization for Unresectable Hepatocellular Carcinoma: A Multi-Center Study

Simple Summary

Drug-eluting beads-transcatheter chemoembolization (DEB-TACE) has recently been performed. However, local recurrence of HCC at the tumor margins is often observed. Conventional transcatheter chemoembolization (cTACE) comprises accumulating lipiodol-containing anticancer drugs into the drainage area, which is the first invasive site of hepatocellular carcinoma (HCC). We evaluate the therapeutic effect of DEB-TACE followed by cTACE in patients with intermediate stage HCC. HCC patients were divided into two groups: one group received DEB-TACE followed by cTACE (cTACE group) and the other group received only DEB-TACE (non-cTACE group). The complete response (CR) rate was significantly higher in the cTACE group than in the non-TACE group. The only factor that increased the complete response rate in the cTACE group was the number of tumors. The overall survival (OS) rate of CR patients was higher than that of non-CR patients in the cTACE group. cTACE group adverse events included severe thrombocytopenia but only in one patient. The combined therapy with DEB-TACE followed by cTACE may be useful for HCC patients.

Abstract

EB-TACE has recently been performed because of its lower hepatotoxicity compared to cTACE in less advanced HCC. However, local recurrence at the tumor margins is often observed after DEB-TACE. cTACE involves filling the intratumoral sinusoids with lipiodol-containing anticancer drugs and accumulating in the drainage area, which is the first site of HCC recurrence. The aim of this study is to evaluate the therapeutic effect of DEB-TACE followed by cTACE in HCC patients. Between 2014 and 2020, 65 patients with Barcelona clinic liver cancer (BCLC) stage B (intermediate stage) of HCC were enrolled and divided into two groups: one group received DEB-TACE followed by cTACE (cTACE group) and the other group received only DEB-TACE (non-cTACE group). Sixty-five patients were medically followed. The median observation time was 14 ± 13.1 months after the first DEB-TACE and outcomes were analyzed for multiple factors. Results: The complete response rate was significantly higher in the cTACE group than in the non-TACE group. The analysis showed that the only factor that increased the CR rate in the cTACE group was the total tumor number (less than four). The OS rate of CR patients was higher than that of non-CR patients in the cTACE group. Adverse events in the cTACE group included severe thrombocytopenia but only in one of twenty-seven patients. Conclusions: The combined therapy with DEB-TACE followed by cTACE may be a new effective therapeutic strategy for the intermediate stage of HCC patients.

Ramucirumab for Patients with Intermediate-Stage Hepatocellular Carcinoma and Elevated Alpha-Fetoprotein: Pooled Results from Two Phase 3 Studies (REACH and REACH-2)

BACKGROUND

Intermediate-stage hepatocellular carcinoma (HCC), as defined by Barcelona Clinic Liver Cancer (BCLC) stage B, is heterogeneous in terms of liver function and tumor burden. REACH and REACH-2 investigated ramucirumab in patients with HCC after prior sorafenib, with REACH-2 enrolling only patients with baseline α-fetoprotein (AFP) ≥400 ng/mL. An exploratory analysis of outcomes by BCLC stage was performed.

METHODS

A pooled meta-analysis of independent patient data (stratified by study) from REACH (AFP ≥ 400 ng/mL) and REACH-2 was performed. All patients had Child-Pugh A, Eastern Cooperative Oncology Group performance status 0-1, prior sorafenib treatment, and either HCC BCLC stage B (refractory/not amenable to locoregional therapy) or BCLC stage C. Patients were randomized to ramucirumab 8 mg/kg or placebo every 2 weeks. Median overall survival (OS) and progression-free survival were estimated by the Kaplan-Meier method. Treatment effects in BCLC stage B and C were evaluated by Cox proportional-hazards model; prognosis of BCLC staging for OS was evaluated by multivariate Cox proportional-hazards model. Tumor responses were evaluated according to Response Evaluation in Solid Tumors v1.1. Liver function was assessed with albumin-bilirubin score.

RESULTS

Baseline characteristics were generally balanced between treatment arms in each BCLC stage. BCLC staging trended as an independent prognostic factor for OS (B vs. C; hazard ratio [HR] 0.756 [95% CI 0.546-1.046]). Consistent treatment benefit was observed for ramucirumab versus placebo across BCLC stages. Median OS for ramucirumab versus placebo was 13.7 versus 8.2 months; HR (95%): 0.43 (0.23-0.83) and 7.7 versus 4.8 months; HR (95%): 0.72 (0.59-0.89) for BCLC stage B and C, respectively. Adverse events (AEs) were consistent with observations from both studies; hypertension was the most frequent grade ≥3 AE. Liver function was preserved throughout the study and similar between treatment arms in both BCLC stages.

CONCLUSIONS

Ramucirumab provided a better survival benefit irrespective of BCLC stage and was well tolerated without compromising liver function during treatment.

Unresectable hepatocellular carcinoma treatment with doxorubicin-eluting polyethylene glycol microspheres: a single-center experience

Background

Transarterial chemoembolization (TACE) is indicated for unresectable hepatocellular carcinoma.

Methods

This was a retrospective study of 50 hepatocellular carcinoma patients treated with TACE using doxorubicin-loaded LifePearl™ to investigate the safety and efficacy of TACE.

Results

There was no 30-day mortality, and limited adverse events were reported. At best tumor response, complete response and disease control were 58% and 94%, respectively, with a median of 4.5 months of follow-up. Median overall survival was 33.8 months. Patients with Barcelona Clinic Liver Cancer stage 0 and stage A at best tumor response showed a higher complete response rate (83%) than patients with Barcelona Clinic Liver Cancer stage B (complete response: 50%; p = 0.0414).

Conclusion

Doxorubicin-loaded LifePearl™ TACE might be an effective treatment, with a good safety profile, for patients with early/intermediate-stage hepatocellular carcinoma. Further prospective data, especially with a small cohort of selected patients, are required to confirm these results.

Treatment of Malignant Bile Duct Obstruction: What the Interventional Radiologist Needs to Know

Management of malignant bile duct obstruction is both a clinically important and technically challenging aspect of caring for patients with advanced malignancy. Bile duct obstruction can be caused by extrinsic compression, intrinsic tumor/stone/debris, or by biliary ischemia, inflammation, and sclerosis. Common indications for biliary intervention include lowering the serum bilirubin level for chemotherapy, ameliorating pruritus, treating cholangitis or bile leak, and providing access for bile duct biopsy or other adjuvant therapies. In some institutions, biliary drainage may also be considered prior to hepatic or pancreatic resection. Prior to undertaking biliary intervention, it is essential to have high-quality cross-sectional imaging to determine the level of obstruction, the presence of filling defects or atrophy, and status of the portal vein. High bile duct obstruction, which we consider to be obstruction above, at, or just below the confluence (Bismuth classifications IV, III, II, and some I), is optimally managed percutaneously rather than endoscopically because interventional radiologists can target specific ducts for drainage and can typically avoid introducing enteric contents into isolated undrained bile ducts. Options for biliary drainage include external or internal/external catheters and stents. In the setting of high obstruction, placement of a catheter or stent above the ampulla, preserving the function of the sphincter of Oddi, may lower the risk of future cholangitis by preventing enteric contamination of the biliary tree. Placement of a primary suprapapillary stent without a catheter, when possible, is the procedure most likely to keep the biliary tree sterile.

Liver Injury and Use of Contrast-Enhanced Ultrasound for Evaluating Intrahepatic Recurrence in a Case of TACE-Refractory Hepatocellular Carcinoma Receiving Atezolizumab-Bevacizumab Combination Therapy: A Case Report

A 67-year-old male with type 2 diabetes (T2DM) was diagnosed with postoperative intrahepatic recurrence for hepatocellular carcinoma (HCC). Nine sessions of transarterial chemoembolization (TACE) proved ineffective, and the patient was diagnosed as having TACE-refractory disease and received seven cycles of atezolizumab-bevacizumab combination therapy. After that, the patient developed hyperglycemia with the HbA1c elevation and the marked fasting serum C-peptide reduction and was diagnosed with developed immune-mediated diabetes (IMD) (T2DM exacerbation with insulin-dependent diabetes development). Subsequently, the hepatobiliary enzyme levels, which were high before the systemic therapy, worsened. Thus, we clinically diagnosed an exacerbation of liver injury due to TACE-induced liver injury complicated by drug-induced liver injury such as immune-mediated hepatotoxicity (IMH). Meanwhile, after contrast-enhanced computed tomography revealed complete response, contrast-enhanced ultrasound was performed to assess intrahepatic recurrence. We found that the latter modality allowed earlier and more definitive diagnosis of intrahepatic recurrence of HCC. Subsequently, despite systemic therapy discontinuation and steroids administration, the liver injury worsened, and the patient died. The autopsy revealed intrahepatic recurrence of HCC and extensive arterial obstruction by the beads used for TACE within the liver, which indicated that disturbed circulation was the primary cause of the liver injury and histopathologically confirmed IMD, but not IMH.

The Risk Assessment and Clinical Research of Bile Duct Injury After Transcatheter Arterial Chemoembolization for Hepatocellular Carcinoma

Purpose

To retrospectively evaluate the risk factors and the clinical outcomes of bile duct injury after transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) and to evaluate factors that aid clinical detection and subsequent treatment of the injured bile duct.

Materials and Methods

All patients undergoing TACE for HCC were retrospectively reviewed for identification of bile duct injury. The clinical spectrum of all the patients analyzed including patients’ demographics, laboratory data, radiologic imaging and mode of treatment.

Results

From January 2015 to December 2017, a total of 21 patients (4.3%) out of 483 patients with 693 TACE procedures were identified to have bile duct injury at our single institution. There were 17 males and 4 females, with a mean age of 59.8±11.6 years (range 34–84). About 14.3% (3/21) patients show the high-density shadow around the bile duct wall in one week non-enhanced CT, and 76.2% (16/21) cases ALP>200 U/L, all these patients showed bile duct injury on the subsequent follow-up CT. Post-TACE follow-up blood biochemistry showed that alanine aminotransferase (ALT), aspartate aminotransferase (AST), alkaline phosphatase (ALP) and gamma glutamyl transpeptidase (GGT) increased significantly compared with pre-TACE level. The incidence of various types of bile duct injuries on CT was intrahepatic bile duct dilatation (57.1%), biloma (25.7%) and hepatic hilar biliary strictures (17.1%), respectively. Patients with prior hepatectomy as well as proximal arterial chemoembolization carried a higher risk of post-TACE bile duct injury in terms of microvascular damage to the peribiliary capillary plexus.

Conclusion

Bile duct injury complicating TACE is not caused by a single factor, but by a variety of factors, and is closely related to the microvascular compromise of the bile ducts and subsequent chronic biliary infection. Lipiodol deposited along the bile duct wall and the sharp rise of ALP>200 U/L in one week after TACE can predict bile duct injury and early intervention may prevent the occurrence of serious complications. The probability of bile duct injury in patients with prior hepatectomy and proximal arterial chemoembolization increases significantly.

Hepatocellular carcinoma: French Intergroup Clinical Practice Guidelines for diagnosis, treatment and follow-up (SNFGE, FFCD, GERCOR, UNICANCER, SFCD, SFED, SFRO, AFEF, SIAD, SFR/FRI)

INTRODUCTION

This document is a summary of the French Intergroup guidelines regarding the management of hepatocellular carcinoma (HCC) published in March 2019.

METHOD

It is a collaborative work under the auspices of most of the French medical societies involved in the management of HCC. It is based on the previous guidelines published in 2017. Recommendations are graded in 3 categories according to the level of evidence of data found in the literature.

RESULTS

The diagnosis and staging of HCC is essentially based on clinical, biological and imaging features. A pathological analysis obtained by a biopsy of tumoral and non-tumoral liver is recommended. HCCs can be divided into 2 groups, taking into account not only the tumor stage, but also liver function. HCCs accessible to curative treatments are tumors that are in Milan criteria or with an AFP score ≤ 2, mainly treated by surgical resection, local ablation or liver transplantation. Intermediate and advanced HCCs with no liver insufficiency, accessible only to palliative treatments, benefit from TACE, SIRT or systemic therapy according to the presence or absence of macrovascular invasion or extrahepatic spread.

CONCLUSION

Such recommendations are in permanent optimization and each individual case must be discussed in a multidisciplinary expert board.

Local Efficacy and Safety of Transarterial Chemoembolization for Hepatocellular Carcinoma: Epirubicin-Loaded DC Beads vs. Epirubicin-Lipiodol Emulsion with Gelatin Sponge (cTACE)

Purpose:

To compare the efficacy and safety between epirubicin-loaded DC Beads (DCB-TACE) and conventional TACE (cTACE) used in transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

Materials and Methods:

This retrospective study enrolled 64 patients (mean age, 73.3 years; 44 men, 20 women) who underwent initial DCB-TACE between 2014 and 2015, and 66 patients (mean age, 71.3 years; 38 men, 28 women) who underwent initial cTACE between 2011 and 2013 as historical controls. Treatment effects on the target lesions at 3 months after TACE, the period until re-treatment of the target lesion, and adverse events after TACE were compared between the groups. Univariate and multivariate analyses were also performed to estimate the factors influencing the treatment effects.

Results:

Based on the Response Evaluation Criteria in Cancer of the Liver version 2015, treatment response of the target lesions equivalent to a complete response and termed as TE4, was 51.0% (53/104) in the DCB-TACE group and 74.4% (64/86) in the cTACE group (p<0.001). Multivariate analysis revealed that the TACE procedure, Child-Pugh score, serum aspartate aminotransferase (AST) level, alpha fetoprotein level, and tumor size were independent significant predictors of TE4. The frequencies of elevated serum AST and alanine transaminase levels after TACE were significantly lower in patients in the DCB-TACE group (p<0.001 each). No significant difference in biliary/liver damage was evident between the groups.

Conclusion:

The local efficacy of cTACE was higher than that of DCB-TACE. Adverse events were milder after DCB-TACE than after cTACE.

Liver Embolisation for Patients with Neuroendocrine Neoplasms: Systematic Review

BACKGROUND

Liver embolisation is one of the treatment options available for patients diagnosed with neuro-endocrine neoplasms (NEN). It is still uncertain whether the benefits of the various types of embolisation treatments truly outweigh the complications in NENs. This systematic review assesses the available data relating to liver embolisation in patients with NENs.

METHODS

Eligible studies (identified using MEDLINE-PubMed) were those reporting data on NEN patients who had undergone any type of liver embolisation. The primary end points were best radiological response and symptomatic response; secondary end-points included progression-free survival (PFS), overall survival (OS) and toxicity.

RESULTS

Of 598 studies screened, 101 were eligible: 16 were prospective (15.8%). The eligible studies included a total of 5,545 NEN patients, with a median of 39 patients per study (range 5-214). Pooled rate of partial response was 36.6% (38.9% achieved stable disease) and 55.2% of patients had a symptomatic response to therapy when pooled data were analysed. The median PFS and OS were 18.4 months (95% CI 15.5-21.2) and 40.7 months (95% CI 35.2-46.2) respectively. The most common toxicities were found to be abdominal pain (48.8%) and nausea (48.1%). Outcome did not significantly vary depending on the type of embolisation performed.

CONCLUSION

Liver embolisation provides adequate symptom relief for patients with carcinoid syndrome and is also able to reach partial response in a significant proportion of patients and a reasonable PFS. Quality of studies was limited, highlighting the need of further prospective studies to confirm the most suitable form of liver embolisation in NENs.

HMGB1, the Next Predictor of Transcatheter Arterial Chemoembolization for Liver Metastasis of Colorectal Cancer?

HMGB1 is an important mediator of inflammation during ischemia-reperfusion injury on organs. The serum expression of HMGB1 was increased significantly on the 1st day after TACE and decreased significantly which was lower on the 30th day after TACE. Tumor markers of post-DEB-TACE decreased significantly. The correlational analysis showed that patients with low HMGB1 expression had lower risks of fever and liver injury compared those with the higher expression, while the ORR is relatively worse. Patients with lower expression of HMGB1 had longer PFS, better efficacy, and higher quality of life. With the high post-expression, the low expression had lower incidence of fever and liver injury too. There was no statistical difference in the one-year survival among the different groups. The quality of life of all patients was improved significantly. The over-expression of HMGB1 in LMCRC is an adverse prognostic feature and a positive predictor of response to TACE.

Therapy of Intermediate-Stage Hepatocellular Carcinoma: Current Evidence and Clinical Practice

Intermediate-stage Hepatocellular Carcinoma (HCC) represents a wide range of disease burden. Patients with different levels of liver function, tumor size, and number of lesions may all have intermediate-stage disease according to the Barcelona Clinic Liver Cancer (BCLC) staging system. Several minimally invasive image-guided locoregional therapies are available for the treatment of intermediate-stage HCC, including conventional transarterial chemoembolization (cTACE), drug-eluting bead TACE (DEB-TACE), yttrium-90 radioembolization (Y-90 RE), thermal ablation, bland embolization, and combination therapy. Available clinical evidence points to cTACE as the current gold standard for the locoregional treatment of intermediate-stage HCC. DEB-TACE is at best non-inferior to cTACE in terms of survival benefit. Y-90 RE is a maturing therapy, and some institutions have adopted it as first-line therapy for intermediate-stage HCC. Thermal ablation combined with TACE may be used in select patients, while bland embolization has only limited evidence for its use. The combination of locoregional therapy with VEGF inhibitors or immune checkpoint inhibitors has also been explored. This article will examine in detail the clinical evidence supporting available locoregional treatment options for intermediate-stage HCC.

Imaging Changes and Clinical Complications After Drug-Eluting Bead Versus Conventional Transarterial Chemoembolization for Unresectable Hepatocellular Carcinoma: Multicenter Study

BACKGROUND. Drug-eluting bead transarterial chemoembolization (DEB-TACE) has emerged as an alternative to conventional TACE (cTACE) for treatment of hepatocellular carcinoma (HCC), although selection between the approaches remains controversial. OBJECTIVE. The purpose of this study was to compare DEB-TACE and cTACE in the treatment of patients with unresectable HCC in terms of hepatobiliary changes on imaging and clinical complications. METHODS. This retrospective study included 1002 patients (871 men, 131 women; mean age, 59 ± 12 years) from three centers who had previously untreated unresectable HCC and underwent DEB-TACE with epirubicin (780 procedures in 394 patients) or cTACE with ethiodized oil mixed with doxorubicin and oxaliplatin (1187 procedures in 608 patients) between May 2016 and November 2018. Among these patients 83.4% had hepatitis B-related liver disease, 57.6% had Barcelona Clinic Liver Cancer (BCLC) stage A or B HCC, and 42.4% had three or more nodules. Mean tumor size was 6.3 ± 4.2 cm. Hepatobiliary changes and tumor response were evaluated with CT or MRI 1 month after TACE. Clinical records were reviewed for adverse events. RESULTS. Bile duct dilatation (p < .001) and portal vein narrowing (p = .006) on imaging and liver failure (p = .03) and grade 3 abdominal pain (p < .001) in clinical follow-up occurred at higher frequency in the DEB-TACE group (15.5%, 4.6%, 2.3%, and 6.1%) than in the cTACE (7.4%, 1.6%, 0.7%, and 2.1%) group. Higher frequency of bile duct dilation in patients who underwent DEB-TACE was observed in subgroup analyses that included patients with BCLC stage A or B HCC (p = .001), with cirrhosis (p < .001), without cirrhosis (p = .04), and without main portal vein tumor thrombus (p = .002). Total bilirubin level 1 month after treatment was 1.5 ± 2.4 mg/dL (95% CI, 1.2-1.8 mg/dL) for DEB-TACE versus 1.3 ± 2.0 mg/dL (95% CI, 1.1-1.5 mg/dL) for cTACE (p = .02). The cTACE and DEB-TACE groups did not differ in other manifestations of postembolization syndrome or systemic toxicity (p > .05). Local tumor disease control rates did not differ between the cTACE and DEB-TACE groups (1 month, 96.7% vs 98.5%, p = .06; 3 months, 81.8% vs 82.4%, p = .87), but overall DCR was significantly higher in the cTACE than in the DEB-TACE group (1 month, 87.5% vs 80.0%, p = .001; 3 months, 78.5% vs 72.1%, p = .02). CONCLUSION. Compared with cTACE, DEB-TACE was associated with greater frequency of hepatobiliary injury and severe abdominal pain. CLINICAL IMPACT. Greater caution and closer follow-up are warranted for patients who undergo DEB-TACE for unresectable HCC than for those who undergo cTACE.

Real Life Prospective Evaluation of New Drug-Eluting Platform for Chemoembolization of Patients with Hepatocellular Carcinoma: PARIS Registry

Simple Summary

Hepatocellular carcinoma treatment options depend on stage of disease. In intermediate stage transarterial chemoembolization with drug-eluting microspheres (DEM-TACE) is recommended. DEM-TACE is simultaneous embolization of tumour feeding arteries and local delivery of anticancer drugs. We assessed real-life practice, safety, toxicity and efficacy of this therapy using new embolization microspheres in 97 patients. Toxicity of the treatment in our study was within or below rates reported so far, and the healthy liver parenchyma, the bile ducts and the portal vein were well preserved when compared with previous study using other type of DEM. Tumour response rate was high, achieving disease control in almost all patients. Hepatocellular carcinoma was controlled during 16.7 months with DEM-TCE as the only treatment. At one year 81% and at two years 66% of patients were alive. Our study showed that DEM-TACE in patients from every-day clinical practice is safe and efficient treatment modality.

Abstract

Background and aim: Transarterial chemoembolization with drug-eluting microspheres (DEM-TACE) is recommended for patients with BCLC stage B hepatocellular carcinoma (HCC) and stage 0-A unsuitable for curative treatments. We assessed efficacy and safety along with hepatobiliary toxicities (HBT) of DEM-TACE using a novel microsphere, LifePearl^TM, loaded with anthracyclines. Materials and methods: 97 patients diagnosed with HCC were prospectively enrolled and treated using LifePearl^TM loaded with doxorubicin (77%) or idarubicin (23%). Safety and tolerability were assessed using CTCAE, HBT by CT/MRI scans, and tumor response by applying modified Response Evaluation Criteria in Solid Tumors (mRECIST). Follow-up was after 2 years. Results: Adverse events (AE) were reported in 73.2% of patients, majority being Grade 1–2. Grade ≥ 3 AE reported in 13.4% of patients were mainly related to postembolization syndrome. HBT were observed after 15.5% (29/187) of the DEM-TACEs. Objective response and disease control rates were 81% and 99%, respectively, as the best responses. Survival rates at one and two years were 81% and 66%, respectively, while the median overall survival (OS) was not reached. Median progression free survival was 13.7 months (95% CI: 11.3; 15.6) and median time to TACE untreatable progression was 16.7 months (95% CI: 12.7; not estimable (n.e.)). Conclusions: DEM-TACE using LifePearl^TM provides a high tumor response rate in HCC patients. HBT rates within or below previously reported results for cTACE and DEM-TACE indicate a good safety profile for LifePearl^TM. The trial was registered in National Library of Medicine (ID: NCT03053596).

Multi-modal and sequential treatment of liver cancer and its impact on the gastrointestinal tract

Hepatic tumors include hepatocellular cancer (HCC) and cholangiocarcinoma (CC), a small subgroup of tumors (approx. 1%) are classified as combined hepatocellularcholangiocellular carcinomas. Different stage-dependent therapeutic approaches comprise resection, local ablative techniques, locoregional therapies, systemic treatment, liver transplantation in selected cases and possible combination of these treatment modalities. This review summarizes current knowledge on multi-modal treatment strategies for liver cancer focusing on gastrointestinal side effects.

Current locoregional therapies and treatment strategies in hepatocellular carcinoma

Locoregional therapies (lrts) play an important role in the treatment of hepatocellular carcinoma (hcc), with the aim of increasing overall survival while preserving liver function. Various forms of lrt are available, and choosing the best one depends on technical aspects, liver morphology, tumour biology, and the patient's symptoms. The purpose of the present review article is to provide an overview of the current evidence relating to the use of percutaneous ablation, transarterial chemoembolization, and transarterial radioembolization for the curative or palliative treatment of hcc. Special situations are also reviewed, including the combined use of systemic therapy and lrt, indications and techniques for bridging to transplant and downstaging, and the use of lrt to treat patients with hcc and macrovascular invasion.

Recent Updates of Transarterial Chemoembolilzation in Hepatocellular Carcinoma

Transarterial chemoembolization (TACE) is a standard treatment for intermediate-stage hepatocellular carcinoma (HCC). In this review, we summarize recent updates on the use of TACE for HCC. TACE can be performed using two techniques; conventional TACE (cTACE) and drug-eluting beads using TACE (DEB-TACE). The anti-tumor effect of the two has been reported to be similar; however, DEB-TACE carries a higher risk of hepatic artery and biliary injuries and a relatively lower risk of post-procedural pain than cTACE. TACE can be used for early stage HCC if other curative treatments are not feasible or as a neoadjuvant treatment before liver transplantation. TACE can also be considered for selected patients with limited portal vein thrombosis and preserved liver function. When deciding to repeat TACE, the ART (Assessment for Retreatment with TACE) score and ABCR (AFP, BCLC, Child-Pugh, and Response) score can guide the decision process, and TACE refractoriness needs to be considered. Studies on the combination therapy of TACE with other treatment modalities, such as local ablation, radiation therapy, or systemic therapy, have been actively conducted and are still ongoing. Recently, new prognostic models, including analysis of the neutrophil-lymphocyte ratio, radiomics, and deep learning, have been developed to help predict survival after TACE.