Transcatheter arterial chemoembolization as primary treatment for hepatocellular carcinoma

Clinical conditions and treatment requirements for long-term survival among hepatitis B-related hepatocellular carcinoma initially treated with chemoembolization

OBJECTIVE

Transarterial chemoembolization (TACE) is recommended to treat intermediate/advanced stage of hepatocellular carcinoma (HCC). However, the overall survival among initially TACE-treated patients varies significantly. The clinical characterization of long-term survival following TACE remains uncertain. We sought to identify clinical parameters and treatment requirements for long-term survival among patients with hepatitis B-related HCC who were initially treated with TACE.

MATERIALS AND METHODS

The included patients with HCC were admitted to our cancer center between December 2009 and May 2015. Patients who survived for >3 years were compared with those who died within 3 years. The clinical and laboratory findings that were associated with the survival were also analyzed.

RESULTS

One in six (17.9%) patients with HCC in this cohort survived for > 3 years after TACE. Body mass index (BMI) ≥ 23kg/m² , aspartate aminotransferase levels ≤ 40 U/L, an activated partial thromboplastin time ≤ 34 seconds, α-fetoprotein (AFP) levels ≤ 25 ng/mL, antiviral therapy, tumor size ≤ 8 cm, solitary nodule, and the absence of vascular invasion were independently favorably associated with a 3-year survival. An absence of vascular invasion was the only independent factor associated with 3-year survival in patients who received resection and/or ablation after TACE.

CONCLUSION

In this cohort, a 3-year survival was associated with BMI, antivirus treatment, tumor status, hepatic function, and AFP level. Distant metastasis did not negatively impact the long-term survival among patients with hepatitis B-related HCC initially treated with TACE. Vascular invasion was the single impediment to long-term survival in patients who received add-on resection and/or ablation after TACE.

Neoadjuvant Locoregional Therapy and Recurrent Hepatocellular Carcinoma after Liver Transplantation

BACKGROUND

Neoadjuvant locoregional therapies (LRTs) have been widely used to reduce tumor burden or to downstage hepatocellular carcinoma (HCC) before orthotopic liver transplantation (OLT). We examined the impact of LRT response on HCC recurrence after OLT.

STUDY DESIGN

We performed a retrospective study of 384 patients with HCC treated by OLT. Tumor necrosis was determined by pathologic evaluation. The vascular and lymphatic vessels were localized by immunofluorescence staining in formalin-fixed, paraffin-embedded tissue; expressions of vascular endothelial growth factor receptor (VEGFR)-2 and VEGFR-3 were analyzed by Western blot. Plasma vascular endothelial growth factor (VEGF)-A and VEGF-C levels of a consecutive cohort of 171 HCC patients were detected by ELISA.

RESULTS

Of the 384 patients with HCC, 268 had undergone pretransplantation neoadjuvant LRTs. Patients with no tumor necrosis (n = 58; 5.2% recurrence) or complete tumor necrosis (n = 70; 6.1% recurrence) had significantly lower 5-year recurrence rates than those with partial tumor necrosis (n = 140; 22.6% recurrence; p < 0.001). Lymphatic metastases were significantly more numerous in patients with partial tumor necrosis than in those without tumor necrosis after OLT (p < 0.001). With immunofluorescence staining of peritumor zone, lymphatics were visualized around partially necrotic tumors, but not around tumors without necrosis. Plasma levels of VEGF-A and VEGF-C were elevated significantly in patients with evidence of tumor necrosis (n = 102) compared with those without necrosis (n = 69; p < 0.001). By Western blot, VEGFR-2 and VEGFR-3 expression in the peritumoral tissue associated with partially necrotic tumors was significantly higher than in peritumoral tissue of non-necrosis tumors (n = 3/group, p < 0.020 and p < 0.006, respectively).

CONCLUSIONS

Locoregional therapy-induced or spontaneous partially necrotic HCC was associated with increased risk of lymphatic metastases compared with tumors with no or complete tumor necrosis. Anti-lymphangiogenic agents with neoadjuvant LRTs can decrease the pattern of lymphatic metastasis after OLT.

Predictors of hepatic decompensation after TACE for hepatocellular carcinoma

AIM

To study predictive factors for hepatic decompensation after transarterial chemoembolisation (TACE) for hepatocellular carcinoma (HCC).

METHODS

Between November 2009 and August 2010, of 254 patients with HCC who presented to our multidisciplinary HCC clinic for evaluation, 102 (40%) were amenable for TACE. In this prospective study, there were 102 patients with compensated cirrhosis with HCC and Child-Pugh Class A cirrhosis who underwent TACE at the National Liver Institute, Menoufiya University, Egypt. We excluded all patients with prior locoregional therapy, systemic therapy and/or surgical intervention. At baseline and at 1 month postprocedure, laboratory criteria, tumour criteria (size, number) and Child-Pugh score were recorded. Patients were classified into group 1 (no Child-Pugh point increase after TACE) and group 2 (one or more added Child-Pugh points after TACE, defining hepatic decompensation). Univariate and multivariate analyses were performed to identify factors predictive of hepatic decompensation.

RESULTS

Patients were mostly males (82.4%) of mean age 58.4±8.1 years. The only significant changes in laboratory findings at 1 month after TACE were increased international normalised ratio, serum total bilirubin, alanine transaminase and aspartate transaminase and decreased serum albumin and α-fetoprotein (AFP). The statistically significant predictive factors for hepatic decompensation using univariate analysis were found to be baseline lower serum albumin, higher serum α-fetoprotein, more advanced Barcelona Clinic Liver Cancer (BCLC) stage, larger tumour size and a greater number of tumour nodules; with logistic regression, multivariate analysis found that at baseline larger tumour size (p=0.004 at 95% CI), higher serum AFP (p=0.046 at 95% CI) and lower serum albumin (p=0.033 at 95% CI) predicted decompensation; BCLC stage, number of tumour nodules and pre-TACE bilirubin did not predict changes in liver function.

CONCLUSIONS

Lower serum albumin and increased tumour burden (larger tumour size/more nodules and higher α-fetoprotein) at baseline may help predict post-TACE decompensation.

Ruptured hepatic carcinoma after transcatheter arterial chemoembolization

Background

Transcatheter arterial chemoembolization (TACE) is recommended as the first-line therapy for unresectable hepatic carcinoma (HCC). Serious complications such as hepatic abscess and hepatic decompensation are well known, but rupture of HCC after TACE is a rare complication.

Objective

The aim of this study was to identify the associated risk factors and the outcomes resulting from ruptured HCC after TACE.

Methods

A retrospective analysis was performed in 6 patients who experienced ruptured HCC after TACE.

Results

All patients underwent chemoembolization after superselective catheterization of the appropriate hepatic artery. The interval between the treatment of TACE and ruptured HCC was 6 to 17 days (mean [SD] 10.33 [4.08] days). Common features in ruptured HCC were large tumor size, location of the tumor adjacent to liver capsular membrane, and complete occlusion of the tumor feeding artery, especially in those with a large amount of iodized oil plus polyvinyl alcohol particles. Two patients underwent emergency embolization, and 4 patients received conservative treatment. Except for 2 patients treated conservatively who died 45 and 68 days after ruptured HCC with hepatic decompensation, the other 4 patients survived to the 6-month follow-up.

Conclusions

Ruptured HCC after TACE is a rare but serious complication. Large tumor size, location of the tumor adjacent to the liver capsule, and complete occlusion of the feeding artery may be predisposing factors. More research is needed to examine which patients presenting with ruptured HCC after TACE would benefit from conservative or emergency arterial embolization procedures.

Rupture and intra-peritoneal bleeding of a hepatocellular carcinoma after a transarterial chemoembolization procedure: a case report

BACKGROUND

Transarterial chemoembolization (TACE) is a well accepted treatment for inoperable hepatocellular carcinoma (HCC). While minor complications involve 10% of all patients, severe complications are rare.

CASE PRESENTATION

We describe a case of a 90-year-old male with a large, superficial HCC who underwent TACE. He had a significant intraperitoneal bleed secondary to tumor rupture immediately following the procedure.

CONCLUSION

Tumor size and superficial location must be considered risk factors for tumor rupture and related complications.

Fever after transcatheter arterial chemoembolization for hepatocellular carcinoma: incidence and risk factor analysis

OBJECTIVE

Post-treatment fever frequently occurs in hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE), but its incidence and clinical significance are unclear. The aim of this study was to identify the incidence and risk factors for fever after TACE in HCC patients.

MATERIAL AND METHODS

Forty-one consecutive HCC patients undergoing 73 sessions of TACE were included in the study. The incidence and possible risk factors associated with post-TACE fever were analyzed.

RESULTS

Forty-nine (67%) episodes of fever developed in 30 (73%) HCC patients after TACE, but none of the patients developed bacterial infection after TACE. Patients who developed fever were of younger age, had larger tumors, a higher dose of chemoembolization agents and a higher embolized volume compared with those without fever. Multivariate logistic regression disclosed that a dosage of doxorubicin plus iodized oil > 23 during chemoembolization and tumor size > 3 cm were significant predictors associated with the development ofpost-TACE fever (odds ratio: 3.749, 95% CI: 1.188-11.830, p = 0.024 and odds ratio: 3.599, 95% CI: 1.107-11.706, p = 0.033, respectively).

CONCLUSIONS

Fever after TACE is common, but infectious complications are rare. Chemoembolization dosage and tumor size are predictive of fever after transcatheter arterial chemoembolization and may be of help in the prevention and care of this distressing complication.

Fatal ischemic acute pancreatitis complicating trans-catheter arterial embolization of small hepatocellular carcinoma: do the risks outweigh the benefits?

Hepatocellular carcinoma (HCC) is an accepted indication for liver transplantation (LT). Pre-LT adjuvant ablation treatments to prevent tumour progression and drop out from the waiting list have been increasingly adopted at most transplant centers. Trans-catheter arterial chemo-embolization (TACE) is frequently used, but the procedure can be difficult and severe complications may arise. Among them, acute ischemic pancreatitis occasionally occurs and may clinically mimic a post-embolization syndrome. Fatal outcomes of this complication have been reported exceptionally but never in patients awaiting LT. The present case raises concern about the widespread application of TACE and highlights the need for a critical evaluation of the risks and benefits to patients with monofocal small HCC who are scheduled for LT. Superselective embolization of the tumour-feeding artery and systematic monitoring of serum pancreatic enzymes after this radiological procedure are recommended.

Proton beam therapy for hepatocellular carcinoma adjacent to the porta hepatis

PURPOSE

To evaluate the efficacy and safety of proton beam therapy (PBT) for patients with hepatocellular carcinoma (HCC) located adjacent to the porta hepatis.

METHODS AND MATERIALS

Subjects of the study were 53 patients with HCC located within 2 cm of the main portal vein. All patients had tumor confined to the radiation field with no evidence of metastatic disease. All patients had hepatic function levels of a Child-Pugh score of 10 or less, Eastern Cooperative Oncology Group performance status of 2 or less, and no uncontrolled ascites. Patients underwent PBT of 72.6 GyE in 22 fractions from Sept 2001 to Dec 2004.

RESULTS

After 3 years, the actuarial survival rate was 45.1% and local control rate was 86.0%. Prognostic factors for survival included Child-Pugh score, number of tumors, and alpha-fetoprotein levels. No late treatment-related toxicity of Grade 2 or higher was observed.

CONCLUSIONS

The PBT delivering 72.6 GyE in 22 fractions appears to be effective and safe for HCC adjacent to the porta hepatis.

Effect of preoperative transcatheter arterial chemoembolization on proliferation of hepatocellular carcinoma cells

AIM: To evaluate the effect of preoperative transcatheter arterial chemoembolization (TACE) on proliferation of hepatocellular carcinoma (HCC) cells.

METHODS: A total of 136 patients with HCC underwent liver resection. Of 136 patients, 79 patients received 1 to 5 courses of TACE prior to liver resection (TACE group), who were further subdivided into four groups: Group A (n = 11) who received 1 to 4 courses of chemotherapy alone; Group B (n = 33) who received 1 to 5 courses of chemotherapy combined with iodized oil; Group C (n = 23) who received 1 to 3 courses of chemotherapy combined with iodized oil and gelatin sponge; and Group D (n = 12) who received 1 to 3 courses of chemotherapy combined with iodized oil, ethanol and gelatin sponge. The other 57 patients only received liver resection (non-TACE group). The expressions of Ki-67 and proliferating cell nuclear antigen (PCNA) protein were detected in the liver cancer tissues by immunohistochemical method.

RESULTS: The Ki-67 protein expression was significantly lower in Groups C and D as compared with non-TACE group (31.35% ± 10.85% vs 44.43% ± 20.70%, 30.93% ± 18.10% vs 44.43% ± 20.70%, respectively, P < 0.05). The PCNA protein expression was significantly lower in Groups C and D as compared with non-TACE group (49.61% ± 15.11% vs 62.92% ± 17.21%, 41.16% ± 11.83% vs 62.92% ± 17.21%, respectively, P < 0.05). The Ki-67 protein expression was significantly higher in Group A as compared with non-TACE group (55.44% ± 13.72% vs 44.43% ± 20.70%, P < 0.05). The PCNA protein expression was significantly higher in Groups A and B as compared with non-TACE group (72.22% ± 8.71% vs 62.92% ± 17.21%, 69.91% ± 13.38% vs 62.92% ± 17.21%, respectively, P < 0.05).

CONCLUSION: Preoperative multi-material TACE suppresses the proliferation of HCC cells, while a single material embolization and chemotherapy alone enhance the proliferation of HCC cells.

Usefulness of laparoscopic hepatectomy

BACKGROUND

The aim of this study was to investigate the advantages of laparoscopic hepatectomy over open surgery for liver tumors.

PATIENTS AND METHOD

A retrospective study was performed of 10 patients with liver tumors (9 with hepatocellular carcinoma and 1 with focal nodular hyperplasia) at our hospital. Five patients who had received laparoscopic hepatectomy (Lap-Hx group) were compared with 5 patients who had undergone open hepatectomy (O-Hx group) in the same period. The operative procedure was partial hepatectomy and cholecystectomy in both groups. For liver excision, a microwave coagulation device and an ultrasonically activated scalpel were used.

RESULTS

Mean patient age was 55.6 +/- 13.9 years in the Lap-Hx group and 51.8 +/- 14.1 years in the O-Hx group. Four patients in the Lap-Hx group had hepatocellular carcinoma with liver cirrhosis and 1 patient had focal nodular hyperplasia. All patients in the O-Hx group had hepatocellular carcinoma and 4 patients had associated liver cirrhosis. The mean tumor size was 2.6 +/- 1.5 cm in the Lap-Hx group and 3.0 +/- 1.8 cm in the O-Hx group. The two groups did not thus differ significantly in the preoperative background factors. Blood loss and duration of the postoperative hospital stay were significantly less in the Lap-Hx than in the O-Hx groups(213 +/- 82 vs 247 +/- 97 min; 154 +/- 128 vs 648 +/- 468 ml, p=0.05: and 10.4 +/- 2.3 vs 18.0 +/- 5.1 days, p=0.017), but operating time did not differ significantly.

CONCLUSIONS

Laparoscopic hepatectomy has the advantages of reducing the amount of operative blood loss because of the magnified view afforded by the laparoscope and shortening the hospital stay. The procedure is therefore recommended for patients with appropriate liver tumors, in particular, hepatocellular carcinoma in the cirrhotic liver.

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

AIMS

In Asian countries, transarterial chemoembolisation (TACE) has long been used for palliation of unresectable hepatocellular carcinoma (HCC) without strong evidence of improved survival or quality of life. In 2002, a survival benefi of TACE was shown in two randomised controlled trials in Europe and Hong Kong. The effectiveness of interventions fo HCC is influenced by geographical factors related to diverse patient characteristics and protocols. Therefore, the validation of TACE as palliative modality for unresectable HCC requires confirmation in diverse patient populations. The aim of the present study was to assess the effectiveness of TACE for HCC in a North American population.

MATERIALS AND METHODS

This was a single centre prospective cohort study. Child-Pugh A cirrhosis or better patients wit unresectable HCC and without radiological evidence of metastatic disease or segmental portal vein thrombosis wer assessed between November 2001 and May 2004. Of 54 patients who satisfied the inclusion criteria, 47 underwent 80 TACE sessions. Chemoembolisation was carried out using selective hepatic artery injection of 75 mg/m(2) doxorubicin and lipiodol followed by an injection of embolic particles when necessary. Repeat treatments were carried out at 2-3 month intervals for recurrent disease. The primary outcome was overall survival; secondary outcomes were morbidity and tumour response.

RESULTS

The survival probabilities at 1, 2 and 3 years were 76.6, 55.5 and 50%, respectively. At 6 months after the first intervention, 31% of patients had a partial response and 60% had stable disease by RECIST criteria. Minor adverse events occurred after 39% of TACEs and major adverse events after 20% of sessions, including two treatment-related deaths (4% of patients). One patient had complete cancer remission after undergoing three TACE treatments. Further progression of tumour growth was prevented in 91% of tumours at the 6 month point after the first TACE. At 3 months, serum levels of the tumour marker alpha-feto protein were significantly reduced in patients with elevated levels before TACE.

CONCLUSIONS

The survival probabilities at 1 and 2 years after TACE were comparable with results in randomised studies from Europe and Asia. Most patients tolerated TACE well, but clinicians need to be aware that moderately severe sideeffects require close monitoring and prompt intervention.

Laparoscopic hepatectomy: indications and outcomes

We outline the indications, evaluate the degree of invasiveness, and analyze the outcomes of laparoscopic hepatectomy, mainly in the treatment of hepatocellular carcinoma (HCC). The important considerations in determining indications for laparoscopic hepatectomy include tumor size, type, and location. Nodular tumors smaller than 4 cm or pedunculated tumors smaller than 6 cm are suitable candidates. Concerning location, tumors in the lower segment or the left lateral segment are suitable. Regarding operative method, laparoscopic hepatectomy involving either partial hepatectomy or left lateral segmentectomy is a feasible, less invasive procedure. Operative time in our recent laparoscopic hepatectomy patients has decreased, with less bleeding. Furthermore, laparoscopic hepatectomy is less invasive than conventional hepatectomy on evaluation by the Estimation of Physiolic Ability and Surgical Stress (E-PASS) scoring system. Patients recovered more quickly after laparoscopic hepatectomy, which allowed shorter hospitalization. Both the 5-year survival rate for HCC and the survival rate without recurrence were nearly identical to those of open conventional hepatectomy, although further analysis will be necessary to reach definitive conclusions. In conclusion, laparoscopic hepatectomy avoids the disadvantages of standard hepatectomy in properly selected patients and is beneficial for patient quality of life, because it is a minimally invasive procedure when indications are strictly followed.

Management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common tumors globally, with varying prevalence based on endemic risk factors. In high-risk populations, including those with hepatitis B or C or with cirrhosis, serum alpha-fetoprotein (AFP) and screening ultrasound have improved detection of resectable HCC. Treatment options, including surgical resection, for patients with HCC must be selected based on the number and size of hepatic tumors, underlying hepatic function, patient condition, and available resources. An approach, which has been summarized shows the corresponding treatment choices under given clinical circumstances. For cirrhotic patients with less than three tumor nodules of a size less than 3 cm or a solitary HCC less than 5 cm, liver transplantation offers long-term survival similar to that observed in patients transplanted for nonmalignant disease. Ablative treatment using either chemical or thermal techniques provides locally effective tumor destruction. Transcatheter arterial chemoembolization (TACE) is commonly used for palliation of unresectable tumors as well as an adjunct to surgical resection, treatment of tumors before transplant, and in conjunction with other ablative therapies in a multimodality approach. Regional approaches to chemotherapy have produced more encouraging results than systemic chemotherapy, although both remain ineffective for long-term tumor control. Several newer treatment modalities are under investigation, including gene therapy, tagged antibodies, isolated perfusion, and novel radiotherapy techniques.

Successful treatment of MYCN amplified, progressive stage 4S neuroblastoma in a neonate with hepatic artery embolization in addition to multimodality treatment

Stage 4S metastatic neuroblastoma (NB) has a favorable prognosis due to a high rate of spontaneous regression. Young infants risk lethal complications arising from hepatomegaly, which can develop rapidly despite treatment. MYCN oncogene amplification confers a significantly worse prognosis. We describe a 4-week-old neonate with MYCN-amplified stage 4S NB complicated by gross hepatomegaly causing rapidly progressive respiratory, hepatic, and renal failure. The child remains in remission 3 years after hepatic artery embolization, radiotherapy, standard, and high-dose chemotherapy. Embolization of the hepatic artery, with classical treatment, is feasible and safe at this age and may contribute substantially to the management of high-risk patients.

Laparoscopic liver resection of hepatocellular carcinoma

BACKGROUND

We have continued to develop laparoscopic hepatectomy as a means of surgical therapy for hepatocellular carcinoma (HCC).

METHODS

We evaluated the degree of invasiveness and analyzed the outcomes of laparoscopic hepatectomy compared with open hepatectomy for HCC.

RESULTS

There were notable differences with respect to blood loss and operating time compared with open hepatectomy cases. Patients started walking and eating significantly earlier in the laparoscopic hepatectomy group, and these more rapid recoveries allowed shorter hospitalizations. On the Estimation of Physiologic Ability and Surgical Stress (E-PASS) scoring system, there was no difference in preoperative risk. However, a significant difference was seen in the surgical stress and comprehensive risk scores between the open hepatectomy and laparoscopic hepatectomy groups. Concerning the survival rate and disease-free survival rate, there were no significant differences between procedures.

CONCLUSIONS

Laparoscopic hepatectomy avoids some of the disadvantages of open hepatectomy and is beneficial for patient quality of life (QOL) as a minimally invasive procedure if the operative indications are appropriately based on preoperative liver function and the location and size of HCC.

Postoperative adjuvant arterial chemoembolization improves survival of hepatocellular carcinoma patients with risk factors for residual tumor: A retrospective control study

AIM: To evaluate the effect of postoperative adjuvant transcatheter arterial chemoembolization (TACE) on the prognosis of hepatocellular carcinoma (HCC) patients with or without risk factors for the residual tumor.

METHODS: From January 1995 to December 1998, 549 consecutive HCC patients undergoing surgical resection were included in this research. There were 185 patients who underwent surgical resection with adjuvant TACE and 364 patients who underwent surgical resection only. Tumors with a diameter more than 5 cm, multiple nodules, and vascular invasion were defined as risk factors for residual tumor and used for patient stratification. Kaplan-Meier method was used to analyze survival curve and Cox proportional hazard model was used to evaluate the prognostic significance of adjuvant TACE.

RESULTS: In the patients without any risk factors for the residual tumor, the 1-, 3-, 5-year survival rates were 93.48%, 75.85%, 62.39% in the control group and 97.39%, 70.37%, 50.85% in the adjuvant TACE group, respectively. There was no significant difference in the survival between two groups (P = 0.3956). However, in the patients with risk factors for residual tumor, postoperative adjuvant TACE significantly prolonged the patients’ survival. There was a statistically significant difference in survival between two groups (P = 0.0216). The 1-, 3-, 5-year survival rates were 69.95%, 49.86%, 37.40% in the control group and 89.67%, 61.28%, 44.36% in the adjuvant TACE group, respectively. Cox proportional hazard model showed that tumor diameter and cirrhosis, but not the adjuvant TACE, were the significantly independent prognostic factors in the patients without risk factors for residual tumor. However, in the patients with risk factors for residual tumor adjuvant TACE, and also tumor diameter, AFP level, vascular invasion, were the significantly independent factors associated with the decreasing risk for patients’ death from HCC.

CONCLUSION: Postoperative adjuvant TACE can prolong the survival of patients with risk factors for residual tumor, but can not prolong the survival of patients without risk factors for residual tumor.

Vascular endothelial growth factor antisense oligodeoxynucleotides with lipiodol in arterial embolization of liver cancer in rats

AIM: Transcatheter arterial embolization (TAE) of the hepatic artery has been accepted as an effective treatment for unresectable hepatocellular carcinoma (HCC). However, embolized vessel recanalization and collateral circulation formation are the main factors of HCC growth and recurrence and metastasis after TAE. Vascular endothelial growth factor (VEGF) plays an important role in tumor angiogenesis. This study was to explore the inhibitory effect of VEGF antisense oligodeoxynucleotides (ODNs) on VEGF expression in cultured Walker-256 cells and to observe the anti-tumor effect of intra-arterial infusion of antisense ODNs mixed with lipiodol on rat liver cancer.

METHODS: VEGF antisense ODNs and sense ODNs were added to the media of non-serum cultured Walker-256 cells. Forty-eight hours later, VEGF concentrations of supernatants were detected by ELISA. Endothelial cell line ECV-304 cells were cultured in the supernatants. Seventy-two hours later, growth of ECV-304 cells was analyzed by MTT method. Thirty Walker-256 cell implanted rat liver tumor models were divided into 3 groups. 0.2 mL lipiodol (LP group, n = 10), 3OD antisense ODNs mixed with 0.2 mL lipiodol (LP+ODNs group, n = 10) and 0.2 mL normal saline (control group, n = 10) were infused into the hepatic artery. Volumes of tumors were measured by MRI before and 7 d after the treatment. VEGF mRNA in cancerous and peri-cancerous tissues was detected by RT-PCR. Microvessel density (MVD) and VEGF expression were observed by immunohistochemistry.

RESULTS: Antisense ODNs inhibited Walker-256 cells’ VEGF expression. The tumor growth rate was significantly lower in LP+ODNs group than that in LP and control groups (140.1 ± 33. 8%, 177. 9 ± 64. 9% and 403.9 ± 69.4% respectively, F = 60.019, P < 0.01). VEGF mRNAs in cancerous and peri-cancerous tissues were expressed highest in LP group and lowest in LP+ODNs group. The VEGF positive rates showed no significant difference among LP, control and LP+ODNs groups (90%, 70% and 50%, H = 3.731, P>0.05). The MVD in LP+ODNs group (53.1 ± 18.4) was significantly less than that in control group (73.2 ± 20.4) and LP group (80.3 ± 18.5) (F = 5.44, P < 0.05)

CONCLUSION: VEGF antisense ODNs can inhibit VEGF expression of Walker-256 cells. It maybe an antiangiogenesis therapy agent for malignant tumors. VEGF antisense ODNs mixed with lipiodol embolizing liver cancer is better in inhibiting liver cancer growth, VEGF expression and microvessel density than lipiodol alone.

Comparison of transcatheter arterial chemoembolization, laparoscopic radiofrequency ablation, and conservative treatment for decompensated cirrhotic patients with hepatocellular carcinoma

AIM: To compare the therapeutic effect of transcatheter arterial chemoembolization (TACE), laparoscopic radiofrequency ablation (LRFA), and conservative treatment for the therapy of decompensated liver cirrhosis patients with hepatocellular carcinomas (HCC).

METHODS: Between October 2000 and July 2003, one hundred patients with histologically proven primary HCC and clinical decompensated liver cirrhosis (Child classification B or C) were included in this study. Forty patients received LRFA (LRFA group), twenty received TACE (TACE group), and forty received conservative treatment (control group). We compared the survival, recurrence, and complication rates in these three groups, making adjustment using the tumor metastastic node staging system.

RESULTS: The major complication rate in the TACE group (9/20) was significantly higher than that in the LRFA group (7/40). For patients with TMN stage II HCC, the survival rate of the LRFA group was better than that of the TACE and control groups (P = 0.003) but the recurrence rates befween the LRFA and TACE groups did not differ.

CONCLUSION: The LRFA group of patients had better clinical outcomes in terms of survival and complication rates in comparison with the TACE group or conservative treatment in patients with decompensated liver cirrhosis, especially in TMN patients with stage II HCC. LRFA is thus an appropriate alternative treatment for poor liver function among patients with HCC.

Effects of p53 on apoptosis and proliferation of hepatocellular carcinoma cells treated with transcatheter arterial chemoembolization

AIM: To evaluate the effects of p53 on apoptosis and proliferation of hepatocellular carcinoma (HCC) cells treated with transcatheter arterial chemoembolization (TACE).

METHODS: A total of 136 patients with HCC received TACE and other management before surgery were divided into TACE group and non-TACE group. TACE group included 79 patients who had 1-5 courses of TACE before surgery, of them, 11 patients had 1-4 courses of chemotherapy (group A), 33 patients had 1-5 courses of chemotherapy combined with iodized oil (group B), 23 patients had 1-3 courses of chemotherapy, iodized oil and gelatin sponge (group C), 12 patients had 1-3 courses of chemotherapy combined with iodized oil, ethanol and gelatin sponge (group D). Non-TACE group included the remaining 57 patients who had surgery only. The extent of apoptosis was analyzed by transferase mediated dUTP nick end labeling (TUNEL) staining. The expressions of p53, Bcl-2, Bax, Ki-67 and PCNA protein were detected by immunohistochemical method.

RESULTS: p53 protein expressions in trabecular and clear cells in HCC specimens were significantly lower than that in pseudoglandar, solid, poorly differentiated or undifferentiated and sclerosis HCC (P < 0.05). Expression of p53 protein in HCC cells increased with the increase of pathological grades (P < 0.05), and correlated positively with expressions of Ki-67 and PCNA protein, and negatively with Bcl-2 to Bax protein expression rate and AI (P < 0.05). Expression of p53 protein was significantly higher in group A than in groups B, C, D and the non-TACE group, and was higher in group B than in groups C and D, and lower in group D than in the non-TACE group (P < 0.05).

CONCLUSION: Expression of p53 protein can enhance proliferation of HCC cells and suppress apoptosis of HCC cells after TACE.

Carbon Dioxide–Enhanced Sonographically Guided Percutaneous Ethanol Injection:Treatment of Patients with Viable and Recurrent Hepatocellular Carcinoma

OBJECTIVE

Viable portions of tumors can persist and recurrent tumors sometimes appear in patients with hepatocellular carcinoma who have undergone transcatheter arterial chemoembolization, percutaneous ethanol injection, or a combination of the two. Some of these tumors are difficult to treat or do not respond to additional treatment using the same protocol. In this article, we examine the use of carbon dioxide (CO(2))-enhanced sonographically guided percutaneous ethanol injection to treat patients with such tumors. SUBJECTS AND METHODS. Our study population was 44 patients with 53 viable portions of tumors or recurrent hepatocellular carcinomas that had developed after the initial treatment of the primary tumor. The tumors were treated with CO(2)-enhanced sonographically guided percutaneous ethanol injection via the catheter that had been placed in the hepatic artery for angiography. Thirty-seven (84.1%) of the 44 patients had cirrhosis. Of these 37 patients, 23 had Child-Pugh class A cirrhosis, and 14 had Child-Pugh class B.

RESULTS

Overall, thirty-four (64.2%) of the 53 tumors showed complete necrosis after treatment, eight (15.1%) of the 53 showed partial necrosis, and 11 (20.8%) of the 53 showed no response. The cumulative survival rates of patients who underwent CO(2)-enhanced sonographically guided percutaneous ethanol injection were 81%, 71%, and 44% for 1, 2, and 3 years, respectively. The small tumors were more responsive to the treatment. The tumor recurrence rate was 56.8%. In 9.1% of these cases, carcinoma had metastasized to other organs.

CONCLUSION

CO(2)-enhanced sonographically guided percutaneous ethanol injection is effective for patients with viable portions of a treated tumor or new tumors who have undergone transcatheter arterial chemoembolization, percutaneous ethanol injection, or a combination of the two treatments. This finding is especially true of patients who are not good candidates for repeated treatments.

Influence of transarterial chemoembolization on angiogenesis and expression of vascular endothelial growth factor and basic fibroblast growth factor in rat with Walker-256 transplanted hepatoma: An experimental study

AIM: After transarterial chemoembolization (TACE), the residual cancer cells are under extensive hypoxic or even anoxic environment. Hypoxia can lead to adaptive responses. For example, angiogenesis will help these cells survive. In this study, we examined the effect of TACE on angiogenesis and expression of vascular endothelial growth factor (VEGF) and basic fibroblast growth factor (b-FGF) and to assess their relevance to Walker-256 transplanted hepatoma.

METHODS: Male Wistar rats were inoculated with Walker-256 tumor in the left lobe of liver. Angiography and transarterial chemoembolization were performed at d14 after transplantation. Sixty rats bearing walker-256 transplanted hepatoma were randomly divided into control group, arterial infusion group and TACE group. Each group consisted of twenty rats. Normal saline, 5-FU, 5-FU and lipiodol were infused through hepatic artery respectively. Two weeks after the infusion, staining of factor VIII, VEGF and b-FGF was performed by immunohistochemistry method in routine paraffin-embeded sections. Microvessel density (MVD) was counted in endothelial cells with positive factor VIII. Their expression levels were analyzed in conjunction with the pathologic features.

RESULTS: While a smaller tumor volume was found in TACE group (F = 37.818, P < 0.001), no statistical differences between MVD and expression of VEGF and b-FGF were found among the 3 groups. MVD of the control group, chemotherapy group and chemoemoblization group was 80.84 ± 24.24, 83.05 ± 20.29 and 85.20 ± 23.91 (F = 0.193, P = 0.873), respectively. The positive expression of VEGF and b-FGF was 75%, 75%, 85% (χ² = 0.449, P = 0.799) and 30%, 25%, 30% (χ² = 0.141, P = 0.922), respectively. Statistical analysis revealed a positive correlation between the expression of VEGF and MVD (r = 0.552, P < 0.001).

CONCLUSION: There has been little influence of lipiodol chemoembolization on the formation of tumor angiogenesis, but the development of neovascularization and expression of VEGF play important roles in establishment of collateral circulation and reconstruction of blood supply of residual cancer tissue.

Therapeutic efficacy of 5-FU bletilla striata microspheres infused through hepatic artery against rabbit VX2 transplanted hepatoma

AIM

To observe the therapeutic efficacy of 5-FU bletilla striata microspheres inFUsed through hepatic artery against rabbit VX2 transplanted hepatoma.

METHODS

Fifty rabbits bearing VX2 transplanted hepatoma were randomly divided into five groups (n =10). Normal saline 1 mL, 5-Fu solutions 1 mL, ultr-liquor-lipiodol 0.3-0.4 mL and 5-Fu solutions 1 mL, 100 g/L Bletillaolloid 0.4 mL and 5-Fu solutions 1 mL, 5 FU-bletilla striate microspheres 10 mg/kg were infused though hepatic artery respectively. The tumor growth rates, necrosis rates and hepatic function were compared among the 5 groups.

RESULTS

5-FU bletilla striata microspheres had a very good vessel embolization function. In 5FU-bletilla striata microspheres group, the tumor was significantly inhibited, tumor growth rate was lower than tant in the control group (P <0.01) and the lipiodol group (P <0.05). Tumor necrosis grades were also more higher compared with to the other 4 groups. Complete necrosis was found in 2 of 10 rabbits in 5FU-bletilla striata microspheres group, which was more severe than that in the lipiodol group and bletillaolloid group. But the damage of normal liver tissues was also more serious.

CONCLUSION

5-FU bletilla striata microsphere is a safe and effective peripheral embolization agent.

Hepatocellular carcinoma screening in patients waiting for liver transplantation: a decision analytic model

De novo hepatocellular carcinoma (HCC) may have a large impact on patients waiting for liver transplantation. The presence of HCC can lead to a status upgrade or removal from the waitlist. Our aim is to compare costs and outcomes of different liver cancer surveillance strategies. A Markov-based decision analytic model is created to simulate costs and health outcomes for a hypothetical cohort awaiting liver transplantation undergoing HCC screening. Three strategies of HCC screening are compared with the referent strategy of using alphafetaprotein (AFP) level alone: (1) ultrasound (U/S), (2) AFP plus U/S, and (3) computed tomography (CT). Screening is performed for all strategies at 6-month intervals. Selected tumors are treated locally. Costs and clinical outcomes are discounted. Using baseline assumptions, incremental cost-effectiveness ratios (ICERs) for U/S, U/S plus AFP, and CT are $60,300/life-year saved (LY), $74,000/LY, and $101,100/LY, respectively. The most cost-effective strategy was dependent on the relative costs of each screening modality. U/S screening becomes the dominant strategy when the cost of an AFP test is decreased. Our results show that screening with CT is associated the greatest gain in life expectancy and greatest costs. U/S screening strategy is the preferred screening strategy based on the lowest ICER. Ultimately, costs of the screening modalities determine the most cost-effective strategy.

Hepatocellular carcinoma: strategy for optimizing surgical resection, transplantation and palliation

In December 1997, a prospective study with informed consent was initiated to test a neoadjuvant treatment of transcatheter hepatic arterial chemo-embolization (TACE) and thermal or chemical ablation followed by transcatheter hepatic arterial chemo-infusion (TACI) in patients with hepatocellular carcinoma (HCC) referred for transplantation (OLT) and for resection. Patients were staged with American Liver Tumor Study Group-modified tumour-node-metastasis (TNM) staging classification using serial 3-6 month physical exam, alphafetoprotein (AFP), abdominal enhanced MRI, chest CT and bone scan. Sixty-five patients with HCC, out of 508 patients referred for OLT, were divided into five clinical groups and an incidental HCC patient group (n = 8), diagnosed on post-transplant explant pathology. The key focus of study was safety, site of HCC recurrence and tumour free survival. One hundred and thirty three ablation, infusion procedures were performed with an overall 24.8% morbidity, including two septic deaths. There were 13 (21.6%) HCC recurrences in 60 patients having one or more ablative treatments with only 23% hepatic HCC recurrences at 43 months of study. Eighteen HCC patients were listed for OLT (Group 3), with 12 patients transplanted after 29-424 d waiting. Two patients were removed from the OLT list due to HCC metastases, waiting a mean of 145 d. Two patients, post-OLT, had their TNM score upgraded from T2, T3 to T4. No Group 3 post-OLT patient has died or had HCC recurrence at mean follow-up of 27 +/- 15 months. No incidental HCC group post-OLT patient has died or had HCC recurrence at mean follow-up of 24 +/- 14 months. This neoadjuvant protocol is safe and effective in reducing HCC recurrence prior to and after OLT and resection.

Application of poly-lactide-co-glycolide-microspheres in the transarterial chemoembolization in an animal model of hepatocellular carcinoma

AIM: To introduce an animal model of hepatocellular carcinoma (HCC) in ACI-rats, and to evaluate the therapeutic effects of Poly-lactide-co-glycolide(Plcg)-microspheres in the transarterial chemoembolization (TACE) in this model, as well the value of this model in the experiments of interventional therapy.

METHODS: Subcapsular implantation of a solid Morris Hepatoma 3924A (1 mm³) in the livers was carried out in 11 male ACI-rats. The tumor volume (V1) was measured by magnetic resonance imaging (MRI) (13 days after implantation). After laparotomy and retrograde placement of catheter into the gastroduodenal artery (14 days after implantation), the following protocols of interventional treatment were performed: (A) mitomycin C+Poly-lactide-co-glycolide(Plcg)-microspheres (n = 4); (B) 0.9% NaCl (control group, n = 7). 13 days after these therapies the change of the tumor volume (V2) was determined by MRI again.

RESULTS: The success rate of tumor implantation reached to 100%. The mean tumor volume before TACE (V1) were 0.082 cm³ in group A and 0.096 cm³ in group B respectively. The mean tumor volume after TACE (V2) were 0.230 cm³ in group A and 1.347 cm³ in group B respectively. The mean V2/V1 were 2.860 in group A and 27.120 in group B respectively. Compared to the control group (group B), groups A showed a significant reduction of tumor growth (P = 0.004) in the period of observation.

CONCLUSION: The growth of liver tumor could be obviously prevented by utilizing Plcg-mitomycin-microspheres in TACE in animal model. This rat model of HCC is suitable for the experimental studies of interventional therapy.

Transcatheter Arterial Chemoembolization with or without Radiofrequency Ablation in the Management of Patients with Advanced Hepatic Malignancy

Transcatheter arterial chemoembolization (TACE) is efficacious against hepatic malignancies by rendering tumors ischemic while delivering high-dose chemotherapy. The added benefit of radiofrequency ablation (RFA) has not been determined. We sought to review our experience with TACE with or without RFA in the treatment of hepatocellular carcinoma and colorectal liver metastases in patients not amenable to resection. TACE and RFA were undertaken in 13 patients with hepatocellular carcinoma (n = 7) or colorectal liver metastases (n = 6). Concurrently 24 patients underwent TACE alone for hepatocellular carcinoma (n = 15) or colorectal liver metastases (n = 9). Patients undergoing TACE with or without RFA were similar in age, gender, and diagnosis. Overall follow-up was 9.1 months ± 7.1. One-year survival was greater in patients undergoing TACE with RFA than with TACE alone (100% vs 67%, P = 0.04). Mean survival was longer after TACE with RFA compared with TACE alone (25.3 months ± 15.9 vs 11.4 months ± 7.3, P < 0.05). No patients suffered significant complications. The addition of RFA to TACE improves survival in patients with unresectable primary or metastatic hepatic malignancies. RFA with TACE should be in the armamentarium of surgeons caring for patients with malignant liver lesions.

Hepatocellular carcinoma in children and adolescents: results from the Pediatric Oncology Group and the Children's Cancer Group intergroup study

PURPOSE

To determine surgical resectability, event-free survival (EFS), and toxicity in children with hepatocellular carcinoma (HCC) randomized to treatment with either cisplatin (CDDP), vincristine, and fluorouracil (regimen A) or CDDP and continuous-infusion doxorubicin (regimen B).

PATIENTS AND METHODS

Forty-six patients were enrolled onto Pediatric Intergroup Hepatoma Protocol INT-0098 (Pediatric Oncology Group (POG) 8945/Children's Cancer Group (CCG) 8881). After initial surgery or biopsy, children with stage I (n = 8), stage III (n = 25), and stage IV (n = 13) HCC were randomly assigned to receive regimen A (n = 20) or regimen B (n = 26).

RESULTS

For the entire cohort, the 5-year EFS estimate was 19% (SD = 6%). Patients with stage I, III, and IV had 5-year EFS estimates of 88% (SD = 12%), 8% (SD = 5%), and 0%, respectively. Five-year EFS estimates were 20% (SD = 9%) and 19% (SD = 8%) for patients on regimens A and B, respectively (P =.78), with a relative risk of 1.2 (95% confidence interval, 0.60 to 2.3) for regimen B when compared with regimen A. Outcome was similar for either regimen within disease stages. Events occurred before postinduction surgery I in 18 (47%) of 38 patients with stage III or IV disease, and tumor resection was possible in two (10%) of the remaining 20 children with advanced-stage disease after chemotherapy.

CONCLUSION

Children with initially resectable HCC have a good prognosis and may benefit from the use of adjuvant chemotherapy. Outcome was uniformly poor for children with advanced-stage disease treated with either regimen. New therapeutic strategies are needed for the treatment of advanced-stage pediatric HCC.

Risk of hepatic failure after transcatheter arterial chemoembolization for hepatocellular carcinoma: predictive value of the monoethylglycinexylidide test

OBJECTIVES

Transcatheter arterial chemoembolization (TACE) is the major treatment modality for patients with unresectable hepatocellular carcinoma (HCC). Hepatic failure after TACE is relatively common in patients with preexisting liver dysfunction. The purpose of this study was to evaluate whether the monoethylglycinexylidide test and other parameters might predict hepatic failure after TACE in HCC patients.

METHODS

One hundred forty-two HCC patients undergoing TACE were enrolled into this study. Before TACE, their venous blood was collected 15 min after a bolus injection of lidocaine (1 mg/kg body weight). A fluorescence polarization immunoassay was used to measure monoethylglycinexylidide oncentrations in their sera. Univariate and multivariate analyses were performed on the monoethylglycinexylidide test and other parameters between patients with and without hepatic failure after TACE.

RESULTS

Nineteen patients (13.4%) suffered hepatic failure after TACE. Univariate analysis revealed that the monoethylglycinexylidide concentration (17.7+/-5.8 vs 43.9+/-13.2 ng/ml), Child-Pugh score (6.9+/-0.6 vs 6.0+/-0.7), indocyanine green retention ratio at 15 min (32.4+/-6.5% vs 15.7+/-5.8%), prolonged PT, and serum total bilirubin and albumin showed significant differences between patients with and without hepatic failure after TACE. After a multiple logistic regression, only the monoethylglycinexylidide test was an independent predictor of hepatic failure (OR = 1.68, 95% CI = 1.07-2.65, p = 0.026). Among the 19 hepatic failure patients, three (15.8%) died of hepatic failure associated with TACE within 1 month after this procedure.

CONCLUSIONS

As a predictor of hepatic failure after TACE, the monoethylglycinexylidide test is better than conventional liver function tests and clinical parameters. The monoethylglycinexylidide test may be used to select patients with relatively good liver reserves for safe TACE treatment.

Non-surgical treatment of hepatocellular carcinoma

Primary hepatocellular cancer is a disease with a poor prognosis for which there is little consensus on treatment and a paucity of comparative trials. The coexistence of cancer with cirrhosis complicates treatment, and also confers a high risk for the development of further tumours. Surgery, either by hepatic resection or orthotopic liver transplantation, is only a feasible option in a minority of patients. This article surveys the non-surgical approaches to the treatment of hepatocellular cancers-local ablation techniques, arterial embolization with and without chemotherapy, conventional chemotherapy and hormonal modulation, and targeted and external irradiation.

The role of macroscopic classification in nodular-type hepatocellular carcinoma

BACKGROUND

Little has been reported on the role of macroscopic classification of hepatocellular carcinoma (HCC). We hypothesized that macroscopic classification of HCC might have a strong correlation with long-term prognosis after hepatectomy.

METHODS

Four hundred and four patients with a macroscopically nodular type of HCC who underwent a hepatectomy were studied. The patients were divided into three groups: single nodular (SN) group (n = 312); single nodular with extranodular growth (SNEG) group (n = 52); and confluent multinodular (CMN) group (n = 40). Clinicopathological variables were compared among the three groups. The patient survival rate was also compared among the three groups. Finally, a multivariate analysis was performed to clarify the independent significant variables of the long-term prognosis. To confirm the consistency of the results in small-size HCC, the same analyses were made using patients whose tumor size was equal to or less than 3 cm in diameter.

RESULTS

The alpha-fetoprotein value, tumor size, and rate of absolute noncurative operation in the SNEG group were higher than in other groups. The positive rate of both portal vein invasion of cancer cells and intrahepatic metastasis in the SN group was lower than those in other groups. The rate of poorly differentiated histology in the SN group was lower than in the other groups. Patient survival in the SNEG group was worst among the three groups. However, patient survival showed no significant difference between the SN and CMN groups. The multivariate analysis showed that the presence of intrahepatic metastasis, the macroscopic classification of SNEG type, and absolute noncurative operation were independent poor prognostic indicators. The results for patients with small HCCs measuring equal to or less than 3 cm in diameter were quite similar to the results for the other patients.

CONCLUSIONS

Among the three subtypes of macroscopically nodular type of HCCs, the SNEG type showed higher rates of portal vein invasion of cancer cells, intrahepatic metastasis, and poorly differentiated histology. The patient survival rate in the SNEG type was worst, and the SNEG type was an independent poor prognostic indicator. The macroscopic classification of HCC, especially the SNEG type, helps predict the long-term outcome after hepatectomy.

Feasibility and toxicity of chemoembolization for children with liver tumors

PURPOSE

To determine the feasibility, toxicity, and efficacy of hepatic arterial chemoembolization (HACE) in pediatric patients with refractory primary malignancies of the liver.

PATIENTS AND METHODS

Six patients with hepatoblastoma (HB), three with hepatocellular carcinoma (HCC), and two with undifferentiated sarcoma of the liver were treated with HACE every 2 to 4 weeks until their tumors became surgically resectable or they showed signs of disease progression. All but one newly diagnosed patient with HCC had previously received systemic chemotherapy.

RESULTS

All patients with HB and HCC responded to HACE, as measured by imaging studies and alpha-fetoprotein levels. Surgical resection (complete or microscopic residual disease) was feasible in five of 11 patients, and three patients remain alive with no evidence of disease. Elevated liver transaminase and bilirubin levels were seen after each one of the 46 courses of HACE. Other toxicities included fever, pain, nausea, vomiting, and transient coagulopathy.

CONCLUSION

HACE is feasible, well tolerated, and effective in inducing surgical resectability of primary hepatic tumors in children.