Evaluation of the therapeutic effect of transcatheter arterial embolization for hepatocellular carcinoma

Contrast-Enhanced Ultrasonography Versus Contrast-Enhanced Computed Tomography for Assessment of Residual Tumor From Hepatocellular Carcinoma Treated With Transarterial Chemoembolization: A Meta-analysis

OBJECTIVES

This study reviewed the literature to directly evaluate the diagnostic performance of contrast-enhanced ultrasonography (CEUS) versus contrast-enhanced computed tomography (CECT) for assessing residual tumors of hepatocellular carcinoma treated with transarterial chemoembolization.

METHODS

PubMed, Embase, the Cochrane Library, and the China National Knowledge Infrastructure were searched through April 30, 2017. The pooled sensitivity, specificity, positive predictive value, negative predictive value, positive likelihood ratio, negative likelihood ratio, diagnostic odds ratio, and summary receiver operating characteristic curve were calculated and compared to examine the diagnostic performance of CEUS versus CECT.

RESULTS

A total of 11 studies, including 421 patients and 491 nodules were analyzed. The pooled diagnostic performances of CEUS versus CECT were as follows: (1) sensitivity (95% confidence interval), 0.97 (0.95-0.99) versus 0.72 (0.67-0.76); (2) specificity, 0.86 (0.74-0.94) versus 0.99 (0.95-1.00); (3) positive predictive value, 0.97 (0.95-0.99) versus 1.00 (0.98-1.00); (4) negative predictive value, 0.90 (0.83-0.95) versus 0.51 (0.44-0.58); (5) positive likelihood ratio, 7.79 (4.73-12.82) versus 12.50 (5.74-27.20); (6) negative likelihood ratio, 0.05 (0.03-0.09) versus 0.35 (0.26-0.48); (7) diagnostic odds ratio, 150.56 (57.03-397.49) versus 35.54 (14.89-84.83); and (8) area under the summary receiver operating characteristic curve, 0.9875 versus 0.9239. The sensitivity and negative predictive value of CEUS were significantly higher than those of CECT (both P < .001). The specificity and positive predictive value of CECT were significantly higher than those of CEUS (both P < .05).

CONCLUSIONS

Contrast-enhanced US, with better sensitivity and negative predictive value versus CECT, was an effective method for exclusion of residual tumors after transarterial chemoembolization. Contrast-enhanced CT, with higher specificity than CEUS, is a valid approach for identifying residual tumors.

Transarterial injection of recombinant human type-5 adenovirus H101 in combination with transarterial chemoembolization (TACE) improves overall and progressive-free survival in unresectable hepatocellular carcinoma (HCC)

Background

The aim of this study was to determine the clinical benefit of transhepatic arterial chemoembolization (TACE) with or without recombinant human adenovirus type 5 (H101) administration for the treatment of patients with hepatocellular carcinoma (HCC).

Methods

Tumor response, progression-free survival (PFS), and overall survival(OS) were retrospectively evaluated in consecutive patients with unresectable HCC who received TACE with or without H101 between April 2012 and April 2013.

Results

Patients with unresectable HCC were treated with transarterial injection of H101 with TACE (H101 group, n = 87) or TACE alone (control group, n = 88). Clinicopathological features were similar between the groups. Treatment response was significantly different between the groups (P = 0.01). In the H101 group, 25 patients demonstrated a complete response (CR, 28.7 %); 28 patients, a partial response (PR, 32.2 %); 23 patients, stable disease (SD, 26.4 %); and 11 patients, progressive disease (PD, 12.6 %). In the control group, 13 patients demonstrated CR (14.8 %); 19, PR (21.6 %); 34, SD (38.6 %); and 22, PD (25 %). OS and PFS was also significantly different between the groups. In the H101 group, median OS and PFS were 12.8 and 10.49 months, whereas in the control group they were 11.6 and 9.72 months, respectively (OS: P = 0.046; PFS: P = 0.044).

Conclusion

In patients with unresectable HCC, H101 combined with TACE improves OS, PFS and treatment response compared with TACE alone.

Electronic supplementary material

The online version of this article (doi:10.1186/s12885-015-1715-x) contains supplementary material, which is available to authorized users.

Transarterial chemoembolization for huge hepatocellular carcinoma with diameter over ten centimeters: a large cohort study

Patients with huge hepatocellular carcinoma >10 cm in diameter represent a special subgroup for treatment. To date, there are few data and little consensus on treatment strategies for huge hepatocellular carcinoma. In this study, we summarized the effects and safety of transarterial chemoembolization for huge hepatocellular carcinoma. A retrospective study was performed based on a large cohort of patients (n = 511) with huge hepatocellular carcinoma who underwent serial transarterial chemoembolization between January 2008 to December 2011 and were followed up until March 2013. We found median survival time was 6.5 months. On multivariate analysis, Child-Pugh class (A versus B) (p < 0.0001), alpha-fetoprotein (≤400 µg/L) (p = 0.002), Barcelona Clinic Liver Cancer stage (B versus C) (p = 0.013), and other treatments after transarterial chemoembolization such as surgical resection (p = 0.008), radiation (p = 0.018), and local radiofrequency ablation (p = 0.002) were factors significantly associated with better overall patient survival after chemoembolization. Twenty-nine percent of these patients showed a tumor response after serial transarterial chemoembolization. Severe complications were few (4.9%), including oncolytic syndrome (n = 3), tumor rupture (n = 3), gastrointestinal bleeding (n = 4), deep venous thrombosis (n = 3), acute cholecystitis (n = 4), femoral artery pseudoaneurysm (n = 1), acute pancreatitis (n = 1), and acute hepatic failure (n = 6). In conclusion, transarterial chemoembolization is a safe and effective treatment for selected patients with huge hepatocellular carcinoma and is recommended as a component of combination therapy. In addition, patients with good liver function and low alpha-fetoprotein levels may acquire greater survival benefits from transarterial chemoembolization.

Comparison of the antitumor efficacy of transcatheter arterial chemoembolization with a miriplatin-iodized oil suspension and a cisplatin-iodized oil suspension for hepatocellular carcinoma

AIM

To retrospectively compare the short-term antitumor efficacy and safety of transcatheter arterial chemoembolization (TACE) with a cisplatin-iodized oil suspension (C-IS) and a miriplatin-iodized oil suspension (M-IS) for hepatocellular carcinoma (HCC).

METHODS

Of patients who underwent TACE for unresectable HCC between January 2010 and August 2011, 25 and 21 patients received C-IS and M-IS, respectively. The short-term therapeutic efficacy of both groups was evaluated by the treatment effect seen on dynamic enhanced computed tomography or magnetic resonance imaging of tumor nodules 3 months after treatment. Adverse events were evaluated to compare C-IS and M-IS.

RESULTS

After TACE using C-IS and M-IS, 100% necrosis or tumor size reduction was achieved in 30 and 18 tumor nodules, respectively (81% vs 53%; P = 0.006). Objective responses were achieved in 30 nodules exposed to TACE using C-IS and 17 exposed to TACE using M-IS (81% vs 50%; P = 0.011). Disease control was achieved in 36 nodules exposed to C-IS and 27 exposed to M-IS (97% vs 79%; P = 0.017). The percentage of patients attaining a complete response, an objective response and disease control was significantly greater in the C-IS group than in the M-IS group. No significant differences were found in the aspartate aminotransferase, alanine aminotransferase, total bilirubin and creatinine levels between the two groups either before treatment or 1 month after treatment.

CONCLUSION

The short-term antitumor effects of TACE with C-IS may be superior to those with M-IS in terms of the complete response, objective response and disease control rates.

Use of contrast-enhanced ultrasonography with a perflubutane-based contrast agent performed one day after transarterial chemoembolization for the early assessment of residual viable hepatocellular carcinoma

OBJECTIVE

We evaluated the efficacy of contrast-enhanced ultrasonography (US), compared with contrast-enhanced computed tomography (CT), for early assessments after transarterial chemoembolization (TACE) for the treatment of hypervascular hepatocellular carcinoma (HCC) lesions.

SUBJECTS AND METHODS

Thirty-two patients with 59 HCC lesions who were scheduled to receive TACE were enrolled in this prospective study. TACE was performed by injecting a mixture of iodized oil and miriplatin hydrate, followed by a gelatin sponge. Digital subtraction angiography (DSA) and/or contrast-enhanced CT were performed 2-6 months after TACE and were used as the reference standard for residual HCC; the detection rates for residual viable HCC using contrast-enhanced US with a perflubutane-based contrast agent and a high mechanical index (MI) mode performed one day after TACE were also compared with those obtained using contrast-enhanced CT performed one month after TACE. The comparisons were made using the McNemar test.

RESULTS

Forty-seven (79.7%) of the 59 HCC lesions were diagnosed as having residual viability based on DSA and contrast-enhanced CT findings obtained 2-6 months after TACE. Eight (17.0%) of the 47 HCC lesions that were diagnosed as having residual viability using one-day contrast-enhanced US were not detected using one-month contrast-enhanced CT because of artifacts produced by the high attenuation of the iodized oil. The detection rate for residual HCC lesions using one-day contrast-enhanced US (95.7%, 45/47) was significantly higher than that using one-month contrast-enhanced CT (78.7%, 37/47) (P<0.05).

CONCLUSION

Contrast-enhanced US performed one day after TACE is more sensitive than contrast-enhanced CT performed one month after TACE for detecting residual viable HCC.

Therapeutic response assessment of transcatheter arterial chemoembolization for hepatocellular carcinoma: ultrasonography, CT and MR imaging

Two randomized controlled trials identified that transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) shows a significant survival benefit compared with controls, after a long-term controversy. Thus, TACE is the current standard of care for patients presenting with multinodular HCC. Monitoring tumor response to TACE is part of the clinical management of HCC patients. Imaging, including ultrasonography, computed tomography and magnetic resonance imaging, has an important role in assessing therapeutic effects earlier and more objectively. Imaging assessment needs to detect not only a reduction in overall tumor load but also a reduction in viable tumor. Here, we give an overview of the current status of the imaging assessment of HCC response to TACE.

A randomized phase II trial of intra-arterial chemotherapy using SM-11355 (Miriplatin) for hepatocellular carcinoma

BACKGROUND

SM-11355 is a platinum complex developed to treat hepatocellular carcinoma (HCC) via administration into the hepatic artery as a sustained-release suspension in iodized oil. We conducted a multicenter phase II trial in patients with HCC to evaluate the efficacy and safety of SM-11355, using a Zinostatin stimalamer suspension in iodized oil as a reference.

METHODS

Patients with unresectable HCC were randomized 2:1 to receive administration of the SM-11355 or Zinostatin stimalamer suspension into the hepatic artery. A second injection was given 4-12 weeks later. Efficacy was evaluated by CT 3 months after treatment and categorized as therapeutic effect (TE) V to I, where TE V was defined as disappearance or 100% necrosis of all treated tumors.

RESULTS

A total of 122 patients were evaluated for efficacy and toxicity (SM-11355, n = 83; Zinostatin stimalamer, n = 39). Baseline characteristics were similar in the two groups. The TE V rates were 26.5% (22/83) and 17.9% (7/39) in the SM-11355 and Zinostatin stimalamer groups, respectively. In the SM-11355 group,the most frequent drug-related adverse events (AEs) of ≥ grade 3 were elevated AST, elevated ALT, thrombocytopenia, and hyperbilirubinemia. The AEs with the largest difference between the two groups (SM-11355 vs. Zinostatin stimalamer) were hepatic vascular injury (0 vs. 48.4%) and eosinophilia (84.3 vs. 41.0%). The 2-year and 3-year survival rates were 75.9% vs. 70.3% and 58.4% vs. 48.7%, respectively.

CONCLUSIONS

The results suggest that SM-11355 in iodized oil has similar efficacy to Zinostatin stimalamer and that repeated dosing of SM-11355 is possible without hepatic vascular injury in cases of relapse.

Embolization of liver tumors: Past, present and future

Curative therapies for hepatocellular carcinoma (HCC), such as resection and liver transplantation, can only be applied in selected patients with early tumors. More advanced stages require local or systemic therapies. Resection of HCC offers the only hope for cure. Even in patients undergoing resection, recurrences are common. Chemoembolization, a technique combining intra-arterial chemotherapy with selective tumor ischemia, has been shown by randomized controlled trials to be efficacious in the palliative setting. There is now renewed interest in transarterial embolization/transarterial chemoembolization (TACE) with regards to its use as a palliative tool in a combined modality approach, as a neoadjuvant therapy, in bridging therapy before transplantation, for symptomatic indications, and even as an alternative to resection. There have also been rapid advances in the agents being embolized trans-arterially (genes, biological response modifiers, etc.). The current review provides an evidence-based overview of the past, present and future trends of TACE in patients with HCC.

Effect of transcatheter arterial infusion chemotherapy using iodized oil and degradable starch microspheres for hepatocellular carcinoma

BACKGROUND

Transcatheter arterial infusion chemotherapy (TAI) using a combination of iodized oil (lipiodol) and degradable starch microspheres (DSMs) has been reported to be superior to TAI with either lipiodol or DSMs separately for the treatment of hepatocellular carcinoma (HCC), based on the results of a prospective randomized study. In the study reported here, we investigated the predictors influencing response and survival in HCC patients receiving TAI using lipiodol and DSMs.

METHODS

A total of 50 HCC patients [Child-Pugh A/B, 34/16 patients; maximum tumor size 2.9 cm (mean); tumor number <5/≥5 = 29/21 patients] were administered a mixture of cisplatin and lipiodol, followed by the injection of DSMs.

RESULTS

According to the criteria of the Liver Cancer Study Group of Japan, the response [complete response (CR) + partial response (PR)] rate and CR rate were 72 and 38%, respectively [CR, 19 patients; PR, 17; stable disease, 9; progressive disease, 5]. The 1-, 2-, 3-, and 4-year cumulative survival rates were 85, 67, 41, and 35%, respectively, and the median survival time was 32.6 months. Multivariate analysis identified tumor number <5 nodules [odds ratio 10.651, 95% confidence interval (CI) 2.168-52.317; P = 0.004] as an independent predictor of response and des-γ-carboxyprothrombin level <100 mAU/mL [hazard ratio (HR), 0.268, 95% CI 0.091-0.786, P = 0.017] and therapeutic effect CR or PR (HR 0.255, 95% CI 0.099-0.659; P = 0.005) as independent predictors of survival.

CONCLUSION

Transcatheter arterial infusion chemotherapy using lipiodol and DSMs might be considered as a potential intervention in HCC patients, especially those with tumors of <5 nodules.

Is serum alpha-fetoprotein useful for predicting recurrence and mortality specific to hepatocellular carcinoma after hepatectomy? A test based on propensity scores and competing risks analysis

BACKGROUND

Serum alpha-fetoprotein (AFP) is frequently used to predict posthepatectomy outcomes in patients with hepatocellular carcinoma (HCC), but its predictive value is still not established. Therefore, we assessed the prognostic significance of AFP status.

METHODS

Of 525 patients undergoing curative hepatectomy for HCC, 290 had preoperative AFP levels of ≥20 ng/mL (AFP-positive group) and 235 had AFP levels of <20 ng/mL (AFP-negative group). We compared the 2 groups with respect to time-to-recurrence, using the inverse probability of treatment weighted (IPTW) for the entire cohort and propensity score matching, and the cumulative incidence of HCC-specific mortality using competing risks regression.

RESULTS

During follow-up (median duration 64 months, range 2-137 months), HCC recurred in 54.9 % of the AFP-negative group and 52.4 % of the AFP-positive group; there was no death without recurrence. After IPTW adjustment, time-to-recurrence did not differ in the 2 groups (hazard ratio [HR] 0.86, 95 % confidence interval [95 % CI] 0.66-1.12; P = 0.28). In a propensity-score matched cohort (152 pairs), time-to-recurrence data were similar to those obtained by IPTW adjustment (HR 0.91, 95 % CI 0.65-1.25; P = 0.55). There was no difference in recurrence pattern (site and stage) or treatment between the 2 groups even after propensity-score matching. The adjusted HR evaluating the impact of AFP positivity on the risk of HCC-specific mortality was 0.77 (95 % CI 0.54-1.08; P = 0.13) A multivariable competing risks analysis also failed to reveal a significant correlation between baseline AFP level and HCC-specific mortality in the AFP-positive group.

CONCLUSIONS

Preoperative AFP levels are not useful for predicting recurrence or survival endpoints following curative hepatectomy for HCC.

Comparative study of cisplatin-iodized oil suspension and emulsion for transcatheter arterial chemoembolization of rabbit VX2 liver tumors

AIM

  To evaluate the antitumor effects and hepatotoxicity of transcatheter arterial chemoembolization (TACE) with cisplatin-iodized oil suspension and emulsion in a rabbit tumor model.

METHODS

  Transcatheter arterial chemoembolization was performed on 12 rabbits with hepatic VX2 tumors using a cisplatin suspension (1 mg/kg cisplatin and 0.1 mL/kg iodized oil, n = 6) or emulsion (1 mg/kg cisplatin, 0.1 mL/kg of iodized oil, and 0.1 mL/kg saline solution, n = 6). Time series changes in plasma platinum concentration were compared over 24 h. All rabbits were killed at 7 days after TACE, and the growth ratio and residual viable proportion of tumors were calculated on the basis of ultrasonographic and histopathological findings. Hepatotoxicity was also evaluated. Differences between the two groups were statistically assessed with the Mann-Whitney U-test. The animal care committee of our institute approved this study.

RESULTS

  Plasma platinum concentrations were significantly higher in the suspension group than in the emulsion group at 0.5-24 h after TACE (P < 0.05). Growth ratios (-24.6 ± 9.98% vs. 21.4 ± 8.87%, respectively; P = 0.004) and residual viable proportions of tumors (25.8 ± 5.02% vs. 51.1 ± 11.4%, respectively; P = 0.009) were significantly lower in the suspension group than in the emulsion group. Hepatotoxicity was transient in all rabbits.

CONCLUSION

  Cisplatin-iodized oil suspensions facilitated the slow release of cisplatin at the tumor border. A suspension is preferable to an emulsion for drug delivery and the antitumor effect during the treatment of VX2 liver tumors with TACE.

A novel transcatheter arterial infusion chemotherapy using iodized oil and degradable starch microspheres for hepatocellular carcinoma: a prospective randomized trial

BACKGROUND

We designed a novel transcatheter arterial infusion chemotherapy (TAI) using iodized oil (lipiodol) and degradable starch microspheres (DSM) for hepatocellular carcinoma (HCC) patients. In this study, we investigated the efficacy of TAI using lipiodol and DSM in a prospective randomized trial.

METHODS

We randomly divided 45 patients with HCC into 3 groups: TAI using lipiodol (lipiodol group, n = 15), TAI using DSM (DSM group, n = 15), and TAI using lipiodol and DSM (lipiodol + DSM group, n = 15). In the lipiodol group, a mixture of cisplatin and lipiodol was administered. In the DSM group, a mixture of cisplatin and DSM was administered. In the lipiodol + DSM group, a mixture of cisplatin and lipiodol was administered, followed by DSM.

RESULTS

The response rates were 40% in the lipiodol group, 53.4% in the DSM group, and 80% in the lipiodol + DSM group, respectively. The response rate tended to improve in the lipiodol + DSM group (lipiodol group vs. lipiodol + DSM group, P = 0.07). The median progression-free survival time was 177 days in the lipiodol group, 287 days in the DSM group, and 377 days in the lipiodol + DSM group. The progression-free survival in the lipiodol + DSM group was significantly better than those in the DSM group (P = 0.020) and the lipiodol group (P = 0.035). There were no serious adverse effects among the 3 groups.

CONCLUSIONS

TAI using lipiodol and DSM was superior to TAI using lipiodol only and TAI using DSM only because of improvements in therapeutic effects and progression-free survival.

Transcatheter arterial chemoembolization with a fine-powder formulation of cisplatin for hepatocellular carcinoma

AIM: To evaluate the efficacy of transcatheter arterial chemoembolization (TACE) using a suspension of a fine-powder formulation of cisplatin (DDPH) for hepatocellular carcinoma (HCC).

METHODS: The study population was comprised of 164 patients who were treated by TACE alone. Of these patients, 76 underwent TACE using a suspension of DDPH in lipiodol (LPD) (DDPH group), and the remaining 88 underwent TACE with an emulsion of doxorubicin (ADM) with LPD (ADM group). We compared the DDPH group with the ADM group in terms of the objective early response rate, progression free survival (PFS) and overall survival (OS).

RESULTS: The objective early response rate in the DDPH group was significantly higher than that in the ADM group (54% vs 24%, P < 0.001). The PFS rate in the DDPH group was also significantly higher than that in the ADM group (P < 0.001). Moreover, the OS in the DDPH group was significantly longer than that in the ADM group (P = 0.002). Although the incidence rate of nausea or vomiting in the DDPH group was higher than that in the ADM group, the ADM group showed a higher incidence rate of the adverse events of hepatic arterial damage and leucopenia. No other serious complications were observed in either group.

CONCLUSION: We conclude that TACE using a suspension of DDPH in LPD could be a useful treatment for HCC.

A case of advanced hepatocellular carcinoma with portal vein tumor thrombus refractory to epirubicin that showed marked decrease in tumor markers after transcatheter arterial infusion with miriplatin

Miriplatin, a cisplatin derivative with a high affinity for iodized ethyl esters of fatty acids from poppy seed oil, is a novel chemotherapeutic agent designed for use in the transarterial treatment of hepatocellular carcinoma (HCC). Here, we describe transcatheter arterial infusion (TAI) using miriplatin to treat a case of advanced HCC with portal vein tumor thrombus (PVTT) refractory to TAI with epirubicin. A 66-year-old man with advanced hepatitis C virus-related HCC with PVTT in the right lobe of the liver was treated with TAI with epirubicin suspended in iodized oil; however, tumor marker levels (alpha-fetoprotein and des-gamma-carboxy protein) did not decrease. Next, he was treated twice with TAI with miriplatin suspended in iodized oil. The tumor marker levels markedly decreased to a nearly normal range and the size of the main tumor was markedly reduced according to dynamic computed tomography. No serious adverse events occurred during the course of treatment with TAI and miriplatin. Therefore, we suggest that TAI with miriplatin is a safe and effective treatment option for advanced HCCs refractory to TAI with epirubicin.

Transcatheter arterial infusion chemotherapy with cisplatin-lipiodol suspension in patients with hepatocellular carcinoma

PURPOSE

The aim of this study was to investigate the antitumor efficacy of treatment, identify prognostic factors, and construct a prognostic index in patients with hepatocellular carcinoma treated by transcatheter arterial infusion chemotherapy (TAI) using cisplatin suspended in lipiodol.

METHODS

We analyzed the outcomes in a total of 94 consecutive patients with previously untreated hepatocellular carcinoma who were treated by TAI using cisplatin suspended in lipiodol.

RESULTS

Twenty-seven patients (29%) showed complete response and 21 patients (22%) showed partial response, with an overall response rate of 51% (95% confidence interval, 41-61%). The median survival time was 2.5 years and the proportions of survivors at 1, 2, and 5 years were 81.6, 65.2, and 18.3%, respectively. The results of multivariate analysis indicated a significant association of serum albumin > or =3.0 g/dL, maximum tumor size < or =3.0 cm, absence of ascites, and unilateral distribution of the tumors with a favorable survival. For clinical application, we also propose a prognostic index based on a combination of these prognostic factors. Based on this index, the patients were classified into three groups: those with good, intermediate, and poor prognosis. The median survival times in these three groups were 4.3, 2.7, and 1.1 years, respectively (p < 0.01).

CONCLUSIONS

TAI with cisplatin suspended in lipiodol exhibited favorable tumor efficacy and survival in patients with hepatocellular carcinoma. The prognostic factors identified and the index proposed based on these factors may be useful for predicting life expectancy, determining treatment strategies, and designing future clinical trials.

Transarterial chemotherapy alone versus transarterial chemoembolization for hepatocellular carcinoma: a randomized phase III trial

BACKGROUND/AIMS

Transcatheter arterial chemoembolization (TACE) is a combination of transarterial infusion chemotherapy (TAI) and embolization, and has been widely used to treat patients with hepatocellular carcinoma (HCC). However, since the impact of adding embolization on the survival of patients treated with TAI had never been evaluated in a phase III study, we conducted a multi-center, open-label trial comparing TACE and TAI to assess the effect of adding embolization on survival.

METHODS

Patients with newly diagnosed unresectable HCC were randomly assigned to either a TACE group or a TAI group. Zinostatin stimalamer was injected into the hepatic artery, together with gelatin sponge in the TACE group and without gelatin sponge in the TAI group. Treatment was repeated when follow-up computed tomography showed the appearance of new lesions in the liver or re-growth of previously treated tumors.

RESULTS

Seventy-nine patients were assigned to the TACE group, and 82 were assigned to the TAI group. The two groups were comparable with respect to their baseline characteristics. At the time of the analysis, 51 patients in the TACE group and 58 in the TAI group had died. The median overall survival time was 646 days in the TACE group and 679days in the TAI group (p=0.383).

CONCLUSIONS

The results of this study suggest that treatment intensification by adding embolization did not increase survival over TAI with zinostatin stimalamer alone in patients with HCC.

Effect of b value on monitoring therapeutic response by diffusion-weighted imaging

AIM: To explore the diffusion gradient b-factor that optimizes both apparent diffusion coefficient (ADC) measurement and contrast-to-noise (CNR) for assessing tumor response to transarterial chemoembolization (TACE) in a rabbit model.

METHODS: Twelve New Zealand white rabbits bearing VX2 tumors in the liver were treated with TACE. Diffusion-weighted imaging (DWI) with various b values was performed using the same protocol before and 3 d after treatment with TACE. ADC values and CNR of each tumor pre- and post-treatment with different b factors were analyzed. Correlation between ADC values and extent of necrosis in histological specimens was analyzed by a Pearson’s correlation test.

RESULTS: The quality of diffusion-weighted images diminished as the b value increased. A substantial decrease in the mean lesion-to-liver CNR was observed on both pre- and post-treatment DW images, the largest difference in CNR pre- and post-treatment was manifested at a b value of 1000 s/mm² (P = 0.036 ). The effect of therapy on diffusion early after treatment was shown by a significant increase in ADCs (P = 0.007), especially with large b factors (≥ 600 s/mm²). The mean percentage of necrotic cells present within the tumor was 76.3%-97.5%. A significant positive correlation was found between ADC values and the extent of necrosis with all b values except for b200, a higher relative coefficient between ADC values and percentage of necrosis was found on DWI with b1000 and b2000 (P = 0.002 and 0.006, respectively).

CONCLUSION: An increasing b value of up to 600 s/mm² would increase ADC contrast pre- and post-treatment, but decrease image quality. Taking into account both CNR and ADC measurement, diffusion-weighted imaging obtained with a b value of 1000 s/mm² is recommended for monitoring early hepatic tumor response to TACE.

Computed tomography perfusion in evaluating the therapeutic effect of transarterial chemoembolization for hepatocellular carcinoma

AIM: To prospectively assess the changes in parameters of computed tomography (CT) perfusion pre- and post-transarterial chemoembolization (TACE) of hepatocellular carcinoma (HCC) in different treatment response groups, and to correlate the changes with various responses of HCC to TACE.

METHODS: Thirty-nine HCC patients underwent CT perfusion examinations pre-(1 d before TACE) and post-treatment (4 wk after TACE). The response evaluation criteria for solid tumors (RECIST) were referred to when treatment responses were distributed. Wilcoxon-signed ranks test was used to compare the differences in CT perfusion parameters pre- and post-TACE for different response groups.

RESULTS: Only one case had treatment response to CR and the CT perfusion maps of post-treatment lesion displayed complete absence of signals. In the PR treatment response group, hepatic artery perfusion (HAP), hepatic arterial fracture (HAF) and hepatic blood volume (HBV) of viable tumors post-TACE were reduced compared with pre-TACE (P = 0.001, 0.030 and 0.001, respectively). In the SD group, all CT perfusion parameters were not significantly different pre- and post-TACE. In the PD group, HAP, HAF, portal vein perfusion (PVP) and hepatic blood flow (HBF) of viable tumors post-TACE were significantly increased compared with pre-TACE (P = 0.005, 0.012, 0.035 and 0.005, respectively).

CONCLUSION: Changes in CT perfusion parameters of viable tumors are correlated with different responses of HCC to TACE. Therefore, CT perfusion imaging is a feasible technique for monitoring response of HCC to TACE.

Double-contrast magnetic resonance imaging of hepatocellular carcinoma after transarterial chemoembolization

BACKGROUND

The purpose of this study was to assess the accuracy of double-contrast magnetic resonance (MR) imaging for the treatment response evaluation of hepatocellular carcinoma (HCC) in cirrhotic liver after transarterial chemoembolization (TACE).

METHODS

Twenty-two patients with 30 HCC nodules treated by TACE underwent double-contrast MR imaging 1 month after treatment. MR images were obtained before and after the sequential administration of superparamagnetic iron oxide (SPIO) and gadopentetate dimeglumine contrast agent within the same imaging session. Two observers retrospectively assessed all treated nodules for evidence of residual viable tumor after TACE. The diagnostic performance of gadolinium-enhanced, SPIO-enhanced, and double-contrast enhanced images was calculated. Histopathological and angiographical findings served as standard of reference. Receiver operating characteristic curves and areas under the curves (A (z)) were calculated.

RESULTS

Double-contrast technique (A (z) = 0.95) was significantly (p = 0.036) more accurate than SPIO-enhanced technique (A (z) = 0.92) and gadolinium-enhanced technique (p = 0.005) (A (z) = 0.81) in viable tumor detection after TACE. Double-contrast technique was significantly more sensitive (92%) than SPIO-enhanced technique (80%) and gadolinium-enhanced technique (68%). Kappa values for interobserver agreement ranged from 0.67 to 0.87 and were significantly different from zero (all p < 0.001).

CONCLUSIONS

Compared to gadolinium-enhanced and SPIO-enhanced techniques, double-contrast technique significantly improves the detection of viable tumor in HCC after TACE.

Useful detection of CD147 (EMMPRIN) for pathological diagnosis of early hepatocellular carcinoma in needle biopsy samples

AIM: To make clear whether CD147 (EMMPRIN) expression in pathological tumor samples with a fine-needle aspiration biopsy is useful for pathological diagnosis of early hepatocellular carcinoma (HCC).

METHODS: Twenty-two patients (15 men and 7 women; median age 68 years, range 56-81 years) underwent a liver tissue biopsy in order to make a diagnosis of HCC. Paraffin-embedded liver biopsy tissue samples from 22 patients were stained with anti-CD147 antibody, murine monoclonal antibody 12C3 (MAb12C3) for immunohistochemical analysis. An immunohistochemical analysis of CD147 was performed and the degree of staining compared between tumor and non-tumor tissue. In addition, the degree of staining within tumor tissue was compared according to a number of clinicopathological variables.

RESULTS: The degree of staining of CD147 was significantly higher in tumor tissues than non-tumor tissues, even in tumors less than 15 mm in diameter. The expression of this protein was significantly elevated in HCC tissue specimens from patients with a low value of serum AST and γ-GTP.

CONCLUSION: CD147 serves potentially as a pathological target for cancer detection of early HCC.

Prognostic significance of simultaneous measurement of three tumor markers in patients with hepatocellular carcinoma

BACKGROUND & AIMS

We conducted a prospective study to evaluate the significance of simultaneous measurement of 3 currently used tumor markers in the evaluation of tumor progression and prognosis of patients with hepatocellular carcinoma (HCC).

METHODS

Three tumor markers for HCC, alpha-fetoprotein (AFP), Lens culinaris agglutinin A-reactive fraction of AFP (AFP-L3), and des-gamma-carboxy prothrombin (DCP), were measured in the same serum samples obtained from 685 patients at the time of initial diagnosis of HCC. Positivity for AFP >20 ng/dL, AFP-L3 >10% of total AFP, and/or DCP >40 mAU/mL was determined. In addition, tumor markers were measured after treatment of HCC.

RESULTS

Of the 685 patients, 337 (55.8%) were positive for AFP, 206 (34.1%) were positive for AFP-L3, and 371 (54.2%) were positive for DCP. In a comparison of patients positive for only 1 tumor marker, patients positive for AFP-L3 alone had a greater number of tumors, whereas patients positive for DCP alone had larger tumors and a higher prevalence of portal vein invasion. When patients were compared according to the number of tumor markers present, the number of markers present clearly reflected the extent of HCC and patient outcomes. The number of markers present significantly decreased after treatment.

CONCLUSIONS

Tumor markers AFP-L3 and DCP appear to represent different features of tumor progression in patients with HCC. The number of tumor markers present could be useful for the evaluation of tumor progression, prediction of patient outcome, and treatment efficacy.

Quantitative analysis of plasma HBV DNA for early evaluation of the response to transcatheter arterial embolization for HBV-related hepatocellular carcinoma

AIM: To assesse changes in plasma HBV DNA after TAE in HBV-related HCC and correlate the levels with the pattern of lipiodol accumulation on CT.

METHODS: Between April and June 2001, 14 patients with HBV-associated HCC who underwent TAE for inoperable or recurrent tumor were studied. Levels of plasma HBV DNA were measured by real-time quantitative PCR daily for five consecutive days after TAE. More than twofold elevation of circulating HBV DNA was considered as a definite elevation. Abdominal CT was performed 1-2 mo after TAE for the measurement of lipiodol retention.

RESULTS: Circulating HBV DNA in 10 out of 13 patients was elevated after TAE, except for one patient whose plasma HBV DNA was undetectable before and after TAE. In group I patients (n = 6), the HBV DNA elevation persisted for more than 2 d, while in group II (n = 7), the HBV DNA elevation only appeared for 1 d or did not reach a definite elevation. There were no significant differences in age or tumor size between the two groups. Patients in group I had significantly better lipiodol retention (79.31±28.79%) on subsequent abdominal CT than group II (18.43±10.61%) (P = 0.02).

CONCLUSION: Patients with durable HBV DNA elevation for more than 2 d correlated with good lipiodol retention measured 1 mo later, while others associated with poor lipiodol retention. Thus, circulating HBV DNA may be an early indicator of the success or failure of TAE.

Assessment of renal cell carcinoma after cryoablation using contrast-enhanced gray-scale ultrasound

We performed contrast-enhanced gray-scale harmonic ultrasound (CUS) in three patients with renal cell carcinoma after cryoablation. CUS showed the decreased enhancement similar to the findings of CT or MRI. It identified feeding vessels more distinctly and found a larger number compared with CT or MRI. A persistent feeder in one case was related to recurrence. CUS may potentially be an alternative to CT and MRI and a useful method in the prediction of recurrent and residual tumors.

Phase II trial of intra-arterial chemotherapy using a novel lipophilic platinum derivative (SM-11355) in patients with hepatocellular carcinoma

SM-11355, a lipophilic platinum derivative, is a novel intra-arterial chemotherapeutic agent for hepatocellular carcinoma (HCC). A phase II study of SM-11355 was conducted to evaluate the antitumor activities and the toxicity in chemotherapy-naive patients with HCC. Sixteen patients were treated with transcatheter arterial injection of SM-11355-lipiodol emulsion (20-120 mg/body). The responses were evaluated by computed tomography 3 months after treatment. Complete response (CR) was defined as disappearance or 100% necrosis of all tumors, and lipiodol accumulation in tumors was regarded as indicating necrosis. Nine patients achieved CR (56%; 95% confidence interval, 29.9-80.2%). The grade 3 toxicities were neutropenia (19%), total bilirubin elevation (19%), AST elevation (44%), and ALT elevation (19%). None of the patients showed grade 4 toxicities or episodes of renal dysfunction. Other common adverse effects were eosinophilia (100%) and pyrexia (94%). Intra-arterial chemotherapy with SM-11355, which was well tolerated, showed promising antitumor activity in patients with HCC.

Multidetector CT in evaluating blood supply of hepatocellular carcinoma after transcatheter arterial chemoembolization

AIM: To assess the value of multidetector-row computed tomography (MDCT) in choosing retreatment methods of hepatocellular carcinoma (HCC) through evaluating the blood supply of low-density area of HCC after transcatheter arterial chemoembolization (TACE).

METHODS: Thirty-two patients with HCC after TACE treatment were examined by plain scanning and hepatic multidetector-row CT. The location of low-density area on plain scanning and the enhancement patterns on dynamic contrast-enhanced scanning were observed. At the same time, three-dimensional CT (3D CT) models of the volume rendering, curved multiplanar reformations, surface shaded display and maximum intensity projection reconstruction of the hepatic artery and portal vein were performed in 6 cases.

RESULTS: In CT plain scanning data, low density areas of 32 cases of HCC after TACE treatment were divided into three types: peripheral, one-side-located and mixed types. In contrast-enhanced CT scans, the blood supply of low-density area was classified into four types: arterial blood supply (20 cases), portal blood supply (5 cases), arterial combined with portal blood supply (5 cases) and poor blood supply (2 cases). In 6 cases, the relationship between the low-density area and branches of hepatic artery as well as portal vein was shown by 3D CT.

CONCLUSION: Hepatic MDCT is an effective method for evaluating the blood supply of low-density area and therapeutic effect of HCC after TACE treatment. Types of blood supply is helpful for the selection of retreatment.

Transcatheter arterial chemotherapy with and without embolization in patients with hepatocellular carcinoma

OBJECTIVE

This study compared the antitumor effect, adverse effects and survival between transcatheter arterial embolization (TAE) and transcatheter arterial infusion chemotherapy (TAI) in patients with hepatocellular carcinoma (HCC).

METHODS

The study population consisted of 168 consecutive patients with advanced HCC treated with transcatheter arterial treatments using cisplatin suspended in lipiodol. Among these, 74 patients were treated with TAE, and the remaining 94 patients were treated with TAI.

RESULTS

There were no significant differences in any baseline characteristics except hemoglobin, platelets, albumin, and glutamic pyruvic transaminase. Complete or partial tumor response was achieved in 54 patients (73%) in the TAE group and in 48 patients (51%) in the TAI group (p < 0.01). There were two treatment-related deaths caused by acute hepatic failure and acute renal failure in the TAE group. Nausea and deterioration of serum transaminase after TAE were significantly more severe than after TAI. Median survival time and survival rates at 5 years were 3.1 years and 25% in the TAE group, and 2.5 years and 18% in the TAI group (p = 0.37).

CONCLUSION

TAE has a higher antitumor effect than TAI, but does not significantly improve the survival of patients with HCC.

Phase I clinical study of a novel lipophilic platinum complex (SM-11355) in patients with hepatocellular carcinoma refractory to cisplatin/lipiodol

SM-11355 is a platinum complex developed to treat hepatocellular carcinoma (HCC). It is administered via the hepatic artery, using a carrier, lipiodol, that consists of ethyl esters of iodized poppy seed oil. We have performed a phase I clinical trial of an SM-11355-lipiodol formulation in 11 HCC patients, in order to investigate the maximum allowable dose and to maximize the efficacy and safety of the drug in the treatment of HCC. The SM-11355 arterial infusion suspension was administered at doses of 6, 12 and 20 mg ml⁻¹ in a maximum lipiodol volume of 6 ml. An antitumour efficacy rating of complete response was achieved for one patient and a partial response rating was achieved for a second patient, giving an overall response rate of 18.2%. Anorexia, nausea and vomiting, pyrexia, thrombocytopenia and increases in AST, ALT and total bilirubin were observed as adverse effects, but each was transient and each patient had recovered completely by 4 weeks after drug administration. Hence, we concluded that the maximum allowable dose was not reached in this study. Overall, our results suggest that SM-11355 is effective in treating HCC and we suggest that the dose for early phase II trials should be 20 mg ml⁻¹.

Transcatheter arterial chemoembolization of hepatocellular carcinoma: usefulness of coded phase-inversion harmonic sonography

OBJECTIVE

The purpose of our study was to assess the value of coded phase-inversion harmonic sonography performed approximately 1 week after the patients had undergone transcatheter arterial chemoembolization with iodized oil for hepatocellular carcinoma.

SUBJECTS AND METHODS

We studied 40 patients with 44 nodules measuring 1.5-11.0 cm in diameter (mean +/- SD, 3.9 +/- 2.0 cm) who underwent transcatheter arterial chemoembolization. Coded phase-inversion harmonic sonography, a technique based on a combination of phase-inversion harmonics and coded technology, was performed with a contrast agent approximately 1 week after chemoembolization. The results were compared with those obtained using dynamic CT (n = 44 lesions) and dynamic MR imaging (n = 20 lesions). We also evaluated the recurrence of hepatocellular carcinoma during clinical follow-up in 17 patients who did not undergo additional local therapy.

RESULTS

The detection rates of intratumoral vascularity of coded phase-inversion harmonic sonography, dynamic CT, and dynamic MR imaging were, respectively, 38 (86%) of 44 lesions, 19 (43%) of 44 lesions, and 10 (50%) of 20 lesions. Of 19 nodules of hepatocellular carcinoma treated only by transcatheter arterial chemoembolization, 17 nodules showed enhancement on coded phase-inversion harmonic sonography, suggesting incomplete responses. In all 17 nodules, apparent recurrence was noted on dynamic CT during clinical follow-up, even in nodules that had been observed to be completely filled with iodized oil 1 week after the chemoembolization.

CONCLUSION

We found coded phase-inversion harmonic sonography to be highly sensitive and accurate for evaluating the treatment response in patients with hepatocellular carcinoma even shortly after treatment. Consequently, it allows early recognition of the need for additional local ablation therapy and estimation of the risk of hepatocellular carcinoma recurrence.

Transcatheter arterial embolization with zinostatin stimalamer for hepatocellular carcinoma

Zinostatin stimalamer (SMANCS) is a lipophilic intra-arterial chemotherapeutic agent for hepatocellular carcinoma (HCC). In our previous study, transcatheter arterial infusion chemotherapy using SMANCS for HCC showed a response rate of 20%. In an effort to obtain a superior anti-tumor effect against HCC, we conducted a phase II study of transcatheter arterial embolization (TAE) using SMANCS and gelatin sponge in 50 chemotherapy-naive patients with HCC. Four milligrams SMANCS plus 4 ml lipiodol emulsion was injected into the hepatic artery, followed by an injection of gelatin sponge. The responses were evaluated by computed tomography (CT) 1 month after treatment and thereafter every 3-4 months. One patient (2%) showed complete response and 15 patients (30%) had partial response resulting in an overall response rate of 32% (16/50; 95% confidence interval 19-45%). In 33 patients (66%), the disease remained stable, and 1 patient (2%) showed progressive disease. In 35 patients (70%), the rate of necrotic area to whole tumor was more than 50% according to the evaluation method using lipiodol accumulation in CT. The 1-, 3- and 5-year survival rates were 90, 55 and 19%, respectively. Grade 3 hematological toxicity was observed as thrombocytopenia in 2 patients (4%). Grade 3 and 4 non-hematological toxicity (liver dysfunction) occurred in 17 (34%) and 7 patients (14%), respectively. TAE using SMANCS, which was well tolerated, may be an effective treatment for advanced HCC.

High-dose iodized oil transcatheter arterial chemoembolization for patients with large hepatocellular carcinoma

AIM: To conduct a randomized trial to evaluate the role of using high-dose iodized oil transcatheter arterial chemoembolization(TACE) in the treatment of large hepatocellular carcinoma (HCC).

METHODS: From January 1993 to June 1998, 473 patients with unresectable hepatocellular carcinoma were divided into two groups: 216 patients in group A received more than 20mL iodized oil during the first TACE treatment; 257 patients in group B received 5-15 mL iodized oil in the same way. The Child’s classification and ICG-R15 for evaluating the liver function of the patients were done before the treatment. During the TACE procedure the catheters was inserted into the target artery selectively and the tumor vessels were demonstrated with contrast medium in the hepatic angiography. The anticancer drug mixed with iodized oil (Lipiodol) were Epirubicin and Mitomycin. In group A, 112 cases received 20-29 mL Lipiodol in the first procedure, 85 cases 30-39 mL, 19 cases more than 40 mL. The largest dose was 53 mL and the average dose was 28.3 mL. In group B, 119 cases received 5-10 mL Lipiodol, 138 cases received 11-15 mL, and the average dose was 11.8 mL.

RESULTS: High-dose Lipiodol chemoembolization caused tolerable side effects and a little hurt to the liver function in the patients with Child grade A or ICG-R15 < 20. But the patients with child grade B or ICG-R15 > 20 had higher risk of liver failure after high-dose TACE. More type I and type II lipiodol accumulations in CT scan after 4 weeks of TACE were seen in the group A patients than those in the group B patients (P < 0.01). The resection rate and complete tumor necrosis rate in group A were higher than those of group B (P < 0.05). The 1-,2-,3-year survival rates of group A patients with Child grade A were 79.2%, 51.8% and 34.9%, respectively, better than those of group B (P < 0.001).

CONCLUSION: High-dose Lipiodol can result in more complete tumor necrosis by blocking both arteries and small portal vein of the tumor. High-dose TACE for treatment of large and hypervascular hepatocellular carcinoma is practically acceptable with the better effect than the routine dose. For the patients with large and hypervascular tumor of Child grade A liver function or ICG-R15 less than 20%, oily chemoembolization with 20-40 mL Lipiodol is recommended.

Increased cytotoxicity and stability of Lipiodol-pirarubicin emulsion compared to classical doxorubicin-Lipiodol: potential advantage for chemoembolization of unresectable hepatocellular carcinoma

There is no well-defined curative treatment for advanced and unresectable hepatocellular carcinoma. The widely used transarterial chemoembolization (TACE) with a doxorubicin-Lipiodol emulsion has not been shown to improve survival in randomized studies. Further, obstruction of the hepatic artery used in the procedure is badly tolerated in patients with cirrhosis. Drugs with a more rapid penetration into the cancer cells are likely to eliminate the need for obstruction of the hepatic artery. We therefore compared the cytotoxicity of another anthracycline pirarubicin with that of the commonly used doxorubicin. In this report, we show that pirarubicin has a greater in vitro cytotoxic effect than doxorubicin on the HepG2 and Hu-H7 human hepatoma cell lines. Pirarubicin emulsion with Lipiodol is more stable at 37 degrees C than doxorubicin-Lipiodol. Moreover, pirarubicin accumulates at a greater extent in the oil phase, permitting Lipiodol to act as a slow-releasing vector for the anthracycline. Further, amiodarone, a multidrug resistance inhibitor, was shown to decrease the intrinsic resistance of HepG2 and Hu-H7 cells to both anthracyclines, and the presence of polysorbate 80 in the amiodarone preparation increased the stability of the anthracycline-Lipiodol emulsions. We therefore conclude that pirarubicin is a better candidate for TACE than doxorubicin. The rapid and increased cytotoxicity of pirarubicin on hepatoma cancer cells and the stability of the pirarubicin-Lipiodol amiodarone emulsion could avoid the complete obstruction of the hepatic artery by Gelfoam sponges, and provide a better tolerated method of TACE in patients with latent liver insufficiency.