Hepatic arterial damage after transarterial chemoembolization for the treatment of hepatocellular carcinoma: comparison of drug-eluting bead and conventional chemoembolization in a retrospective controlled study

A Prospective, Single-Arm, Phase 2 Study of Modified Transarterial Chemoembolization Using Low-Dose Chemotherapy with Blank Microspheres Plus Low-Dose Lenvatinib and Microwave Ablation in Patients with Large (≥7 cm) Unresectable Hepatocellular Carcinoma: The TALEM Trial

Introduction

For patients with large unresectable hepatocellular carcinoma (HCC), the effectiveness of conventional transarterial chemoembolization (cTACE) remains suboptimal. This study investigated the efficacy and safety of modified TACE using low-dose chemotherapy with blank microspheres (BMS-TACE) plus low-dose lenvatinib (LD-LEN) and microwave ablation (MWA) in patients with large unresectable HCC.

Methods

In this prospective, single-arm, phase 2 study, patients with unresectable HCC exceeding the up-to-seven criteria, with maximum tumor diameter ≥7 cm, and without macrovascular invasion or extrahepatic metastases, received initial BMS-TACE (lipiodol, low-dose doxorubicin, and lobaplatin up to 30 mg each, and blank microspheres; subsequently modified and repeated in most patients) plus LD-LEN (4-8 mg/day) and MWA. The primary endpoint was downstaging rate (DSR); secondary endpoints were objective response rate (ORR), progression-free survival (PFS), overall survival (OS), and adverse events.

Results

From November 2019 to March 2022, 43 patients were enrolled. Median follow-up was 21.2 months. Median largest tumor diameter was 11.2 cm (interquartile range [IQR], 7-25). Following BMS-TACE and LD-LEN, downstaging occurred in 37 (86.0%) patients, 32 of whom received MWA, and 8 of whom had a complete response (CR) without MWA. ORR was 93.0% (CR in 32 [74.4%] and partial response in 8 [18.6%] patients). The 1-, 2-, and 3-year PFS rates were 57.5%, 25.9%, and 18.1%, respectively (median PFS, 14.7 months [95% CI: 8.1-19.5]). The 1-, 2-, and 3-year OS rates were 85.8%, 67.7%, and 61.6%, respectively (median OS, 36.4 months [95% CI: 26.8-not reached]). After BMS-TACE, a significant decline in CD11b+/CD33+/HLA-DR- myeloid-derived suppressor cells and early elevation in CXCR5+/CD8+ and CXCR5+/CD4+ T cells were observed (both p < 0.05).

Conclusion

BMS-TACE plus LD-LEN and MWA resulted in promising efficacy and tolerable toxicity in patients with large unresectable HCC exceeding the up-to-seven criteria with a maximum tumor diameter ≥7 cm and without macrovascular invasion or extrahepatic metastases.

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

AIM

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

METHODS

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

RESULTS

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

CONCLUSION

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

Machine Learning-Based Development of Nomogram for Hepatocellular Carcinoma to Predict Acute Liver Function Deterioration After Drug-Eluting Beads Transarterial Chemoembolization

RATIONALE AND OBJECTIVES

Acute liver function deterioration (ALFD) following drug-eluting beads transarterial chemotherapy embolism (DEB-TACE) was considered a risk factor for prognosis in patients with hepatocellular carcinoma (HCC). In this study, we aimed to develop and validate a nomogram for the prediction of ALFD after DEB-TACE.

MATERIALS AND METHODS

A total of 288 patients with HCC from a single center were randomly divided into a training dataset (n = 201) and a validation dataset (n = 87). The univariate and multivariate logistic regression analyses were performed to determine risk factors for ALFD. The least absolute shrinkage and selection operator (LASSO) was applied to identify the key risk factors and fit a model. The performance, calibration, and clinical utility of the predictive nomogram were assessed using receiver operating characteristic curves, calibration curves, and decision curve analysis (DCA).

RESULTS

LASSO regression analysis determined six risk factors with fibrosis index based on four factors (FIB-4) as the independent factor for the occurrence of ALFD after DEB-TACE. Gamma-glutamyltransferase, FIB-4, tumor extent, and portal vein invasion were integrated into the nomogram. In both the training and validation cohorts, the nomogram demonstrated promising discrimination with AUC of 0.762 and 0.878, respectively. The calibration curves and DCA revealed good calibration and clinical utility of the predictive nomogram.

CONCLUSION

The nomogram-based risk of ALFD stratification may improve clinical decision-making and surveillance protocols for patients with a high risk of ALFD after DEB-TACE.

Risk of Hepatic Artery Complications After Liver Transplantation in Patients Who Received Pretransplant Transarterial Chemoembolization Therapy: A Single-Center Experience

BACKGROUND

Pretransplant transarterial chemoembolization (TACE) for patients with hepatocellular carcinoma (HCC) has been associated with an increased risk of hepatic artery thrombosis (HAT) after liver transplantation (LT). Innovative surgical LT and interventional vascular radiology TACE techniques may mitigate the risk of HAT. We sought to investigate the incidence of HAT after LT in patients who received pre-transplant TACE at our center.

METHODS

We performed a single-center retrospective review of all LT patients, >18 years of age, from October 1, 2012, to May 31, 2018. Outcomes were compared between patients who received pre-LT TACE and those who did not. Median follow-up was 26 months.

RESULTS

Among the 162 LT recipients, 110 (67%) patients did not receive pre-LT TACE (Group I), while 52 (32%) received pre-LT TACE (Group II). The <30-day incidence rates of post-LT HAT were as follows: Group I = 1.8% and Group II = 1.9% (P = .9). Most hepatic arterial complications occurred >30 days after LT. Based on competing risks regression analysis, TACE was not associated with an increased risk of HAT. Patient or graft survivals were comparable between the 2 groups (P = .1 and .2, respectively).

CONCLUSIONS

Our study shows a similar incidence of hepatic artery complications post-LT in patients who received TACE before LT compared with those who did not. In addition, we suggest that the surgical technique of early vascular control of the common hepatic artery during LT, in combination with a super-selective vascular intervention radiology approach, has clinical utility in reducing the risk of HAT in patients requiring pre-transplant TACE.

[Global trends in endovascular treatment of patients with malignant neoplasms and metastatic liver damage]

OBJECTIVE

To analyze the results of endovascular embolization of malignant tumors and liver metastases.

MATERIAL AND METHODS

We analyzed international studies on the treatment of patients with neoplastic liver lesions and complications after regional endovascular embolization following leakage of chemotherapeutic drugs from the target vessel and negative systemic effects. The results of embolization of liver arteries without chemotherapeutic drugs were also analyzed. We reviewed the PubMed, The Cochrane Library, Web of Science databases, as well as Russian scientific and practical journals.

CONCLUSION

Literature data indicate high clinical effectiveness of interventional treatment of patients with malignant neoplasms and metastatic liver damage.

General Surgery Clinical Information Management System Based on Intelligent Data Management

In order to improve the effect of surgical clinical information management, this paper combines the intelligent data management technology to construct the general surgery clinical information management system. Based on the design and development of general surgery clinical medical case information management system, this paper studies the mutual conversion between XML data and relational data, and designs a clinical medical case information management system based on the design idea of layered architecture. The clinical medical case information management system mainly adopts the modular design idea and adopts a digital microscopic image storage mode based on HDFS architecture. After building the system function structure, the system effect is verified by simulation test. From the experimental statistical results, it can be seen that the general surgery clinical information management system based on intelligent data management proposed in this paper has a good effect.

Recent advances and applications of microspheres and nanoparticles in transarterial chemoembolization for hepatocellular carcinoma

Transarterial chemoembolization (TACE) is a recommended treatment for patients suffering from intermediate and advanced hepatocellular carcinoma (HCC). As compared to the conventional TACE, drug-eluting bead TACE demonstrates several advantages in terms of survival, treatment response, and adverse effects. The selection of embolic agents is critical to the success of TACE. Many studies have been performed on the modification of the structure, size, homogeneity, biocompatibility, and biodegradability of embolic agents. Continuing efforts are focused on efficient loading of versatile chemotherapeutics, controlled sizes for sufficient occlusion, real-time detection intra- and post-procedure, and multimodality imaging-guided precise treatment. Here, we summarize recent advances and applications of microspheres and nanoparticles in TACE for HCC. This article is categorized under: Therapeutic Approaches and Drug Discovery > Nanomedicine for Oncologic Disease.

THE MANAGEMENT OF POST-TRANSPLANTATION RECURRENCE OF HEPATOCELLULAR CARCINOMA

The annual incidence of hepatocellular carcinoma (HCC) continues to rise. Over the last two decades, liver transplantation (LT) has become the preferable treatment of HCC, when feasible and strict selection criteria are met. With the rise in HCC-related LT, compounded by downstaging techniques and expansion of transplant selection criteria, a parallel increase in number of post-transplantation HCC recurrence is expected. Additionally, in the context of an immunosuppressed transplant host, recurrences may behave aggressively and more challenging to manage, resulting in poor prognosis. Despite this, no consensus or best practice guidelines for post-transplantation cancer surveillance and recurrence management for HCC currently exist. Studies with adequate population sizes and high-level evidence are lacking, and the role of systemic and locoregional therapies for graft and extrahepatic recurrences remains under debate. This review seeks to summarize the existing literature on post-transplant HCC surveillance and recurrence management. It highlights the value of early tumour detection, re-evaluating the immunosuppression regimen, and staging to differentiate disseminated recurrence from intrahepatic or extrahepatic oligo-recurrence. This ultimately guides decision-making and maximizes treatment effect. Treatment recommendations specific to recurrence type are provided based on currently available locoregional and systemic therapies.

Investigation of the Physical Properties and Clinical Application of Embosphere Microspheres

BACKGROUND

The aim of this study was to understand physical characteristics of Embosphere microspheres for the clinical use of microsphere chemotherapy embolization of liver cancer.

METHODS

The morphology of Embosphere microspheres in different states, including static, oscillating, and in a magnetic field was observed with the naked eye. Ninety-five patients diagnosed with primary hepatocellular carcinoma (HCC) were separated into 3 groups based on the types of embolic material as follows: 32 cases of sole microspheres, 34 cases of iodinated oil (17 cases with additional application of gelatin sponge particle), and 29 cases of iodinated oil + Embosphere microspheres.

RESULTS

The diameter of the microspheres ranged from 100 to 300 μm, with a sedimentation rate υ = 0.0375 cm/s in physiological saline. The diameter of microspheres ranged from 300 to 500 μm, with a sedimentation rate υ = 0.1875 cm/s. The swelling rate of microspheres was 90%. Microspheres showed nondirectional movement in a 1.5- or 3.0-T magnetic field during magnetic resonance imaging. A volumetric ratio of 1:1.4-1:1.5 between microspheres and contrast agent resulted in optimal suspension properties. Microspheres appeared circular with a smooth surface upon water adsorption. Microsphere embolism was observable in blood vessels of pathological sections. The surface of microspheres can adsorb 5-fluorouracil and arsenic trioxide. There are statistically significant differences in local-regional tumor control conditions among patients treated with sole microspheres, iodinated oil, and iodinated oil + microspheres during transarterial chemoembolization.

CONCLUSIONS

Embosphere microspheres can be used to embolize patients with rupture and hemorrhage of HCC. Embosphere microsphere embolization is superior to iodinated oil and iodinated oil + microsphere for HCC.

Tumor Growth Suppression With Novel Intra-arterial Chemotherapy Using Epirubicin-entrapped Water-in-oil-in-water Emulsion In Vivo

BACKGROUND/AIM

A mixture of anticancer agents and iodized poppy seed oil (IPSO) has been widely used for intra-arterial chemotherapy of hepatocellular carcinoma. However, the anticancer agents can easily separate from IPSO, so the therapeutic potential is limited. We developed epirubicin-entrapped water-in-oil-in-water emulsion (WOW-Epi) using a double-membrane emulsification technique.

MATERIALS AND METHODS

We delivered WOW-Epi through a hepatic arterial injection to VX2 hepatic tumor rabbit model (1.2 mg/kg).

RESULTS

VX2 tumor growth was selectively suppressed in the WOW-Epi-treated group compared with the control treated groups. The accumulation of WOW in nearby cancer cells was confirmed via electron-microscopy. Endocytosis seemed to be the mechanism underlying the uptake of WOW.

CONCLUSION

WOW-Epi led to tumour growth suppression in vivo. WOW does not cause toxicity to arterial vessels. WOW-Epi will be hopefully used for repeated intra-arterial chemotherapy to HCC patients in the near future.

Value of Gd-EOB-DTPA-Enhanced MRI and Diffusion-Weighted Imaging in Detecting Residual Hepatocellular Carcinoma After Drug-Eluting Bead Transarterial Chemoembolization

RATIONALE AND OBJECTIVES

To investigate the value of gadolinium ethoxybenzyl diethylenetriamine pentaacetic acid (Gd-EOB-DTPA)-enhanced magnetic resonance imaging (MRI) and diffusion-weighted imaging (DWI) in diagnosing residual hepatocellular carcinoma (HCC) after drug-eluting bead transarterial chemoembolization (DEB-TACE).

MATERIALS AND METHODS

Sixty-two patients (50 men, 12 women; mean age, 56.8 ± 1.4 years) with 74 HCCs who underwent Gd-EOB-DTPA-enhanced MRI and DWI in 1-2-month intervals after DEB-TACE were retrospectively studied. Imaging features derived from Gd-EOB-DTPA-enhanced MRI and DWI were analyzed and compared between residual HCCs and necrotic tumors. The sensitivity and specificity of Gd-EOB-DTPA-enhanced MRI and DWI with quantitative apparent diffusion coefficient (ADC) values in diagnosing residual HCCs were calculated and compared, based on the reference standard of pathology and/or angiography.

RESULTS

Thirty-three residual HCCs and 41 necrotic tumors were diagnosed. Residual HCCs presented characteristics of arterial hypervascularity (90.91%) and DWI hyperintensity (78.78%), which were of importance in differentiating necrotic tumors (p< 0.05). DWI showed lower sensitivity (78.79% vs. 96.97%, p< 0.001) and specificity (78.05% vs. 100%, p< 0.001) than Gd-EOB-DTPA-enhanced MRI in diagnosing residual HCCs after DEB-TACE. Residual HCCs had a significantly higher mean ADC value than necrotic tumors (1.30 ± 0.32 × 10^-3 mm²/s vs. 1.55 ± 0.50 × 10^-3 mm²/s, p< 0.001). Receiver operating characteristic curve analysis for identifying residual HCCs demonstrated that the threshold ADC value of 1.25 × 10^-3 mm²/s had 84.85% sensitivity and 87.80% specificity.

CONCLUSION

Gd-EOB-DTPA-enhanced MRI is superior to DWI in diagnosing residual HCCs after DEB-TACE, and arterial hypervascularity and DWI hyperintensity are important imaging features in distinguishing residual HCCs from necrotic tumors.

Initial Transarterial Chemoembolization (TACE) Using HepaSpheres 20-40 µm and Subsequent Lipiodol TACE in Patients with Hepatocellular Carcinoma > 5 cm

Purpose: To investigate clinical outcomes of drug-eluting bead transarterial chemoembolization (DEB-TACE) using HepaSpheres 20–40 µm in diameter and subsequent cisplatin-based lipiodol TACE (Cis-TACE) in patients with hepatocellular carcinoma (HCC) > 5 cm. Materials and Methods: This study included 39 consecutive patients (34 men, 5 women; mean age, 63.5 years; range, 39–80 years) who underwent DEB-TACE using HepaSpheres 20–40 µm as first-line treatment for HCC > 5 cm (mean diameter, 8.2 cm; range, 5.1–13 cm) between September 2018 and August 2019. Patients with new tumors, residual tumors, or tumor growth after initial DEB-TACE underwent subsequent Cis-TACE. Results: All 39 patients underwent initial DEB-TACE successfully, with 35 (89.7%) and three (7.7%) patients experiencing minor and major complications, respectively. After initial DEB-TACE, one patient (2.6%) achieved complete response (CR), 35 (89.7%) achieved partial response (PR), and three (7.7%) experienced progressive disease (PD). During a median follow-up period of 14.4 months (range, 0.6–23 months), 23 patients underwent Cis-TACE, with 11, three, and nine achieving CR, PR, and PD, respectively. The median overall survival time was 20.9 months (95% confidence interval (CI), 18.6–23.2 months), the median time to progression was 8.8 months (95% CI, 6.5–11.1 months), and the median time to local tumor recurrence was 16 months (95% CI, 7.4–24.6 months). Conclusions: DEB-TACE using HepaSpheres 20–40 µm in diameter can be a safe and effective initial treatment method in patients with HCC > 5 cm. Subsequent Cis-TACE constitutes a good adjuvant method to enhance tumor response after initial DEB-TACE.

Recent Updates of Transarterial Chemoembolilzation in Hepatocellular Carcinoma

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

Advances in the treatment of hepatocellular carcinoma using drug-eluting beads

Hepatocellular carcinoma (HCC) is one of the most common types of malignant tumor. Although radical surgery and liver transplantation are possible cures for the disease, most patients are beyond the optimum stage for radical treatment at the time of diagnosis. Transarterial chemoembolization (TACE) is the first choice of treatment for advanced HCC. Owing to the widespread use of conventional TACE (cTACE), the problems with this treatment cannot be ignored. Drug-eluting beads (DEBs), a new type of embolization material, appear to overcome the problems of cTACE, and they have other advantages such as synchronous controlled continuous drug release after chemotherapy and embolization and low blood concentrations after treatment. This review summarizes the recent advances in the use of DEB-TACE to treat HCC.

The safety and efficacy of balloon-occluded transcatheter arterial chemoembolization for hepatocellular carcinoma refractory to conventional transcatheter arterial chemoembolization

OBJECTIVES

To evaluate the safety and efficacy of balloon-occluded transcatheter arterial chemoembolization (B-TACE) for the treatment of HCC refractory to conventional TACE (C-TACE).

METHODS

This single-center retrospective analysis included 60 consecutive patients who underwent B-TACE (mean age, 61.4 years; male:female ratio, 4.5:1) for the treatment of residual viable (n = 40) or recurrent HCC (n = 20) refractory to C-TACE between November 2017 and November 2018. Technical success, radiologic response rate (proportion of the patients achieving complete response [CR] or partial response [PR] on first follow-up CT according to m-RECIST), major complication rate, and time to progression (TTP) were evaluated. The TTP of B-TACE was also compared with that of the last C-TACE. Factors associated with achieving CR and TTP were explored.

RESULTS

B-TACE resulted in 100% technical success and radiologic response rate (CR in 45 and PR in 15 patients). The major complication rate was 6.7% (4/60). The median TTP after B-TACE was 5.3 months (95% confidence interval [CI], 4.0-6.9 months). The TTP of B-TACE for treating residual HCC was significantly longer than that of the last C-TACE (median [95% CI], 4.4 [3.2-6.9] vs. 2.7 [2.3-4.4] months; p = 0.013). BCLC stage C (adjusted OR, 4.448; 95% CI, 1.691-11.700; p = 0.002) and multiplicity of HCC (adjusted OR, 2.746; 95% CI, 1.206-6.251; p = 0.016) were significantly associated with tumor progression after B-TACE.

CONCLUSIONS

B-TACE is safe and effective for the treatment of HCC refractory to C-TACE. BCLC stage C and multiplicity of HCC were independent factors associated with TTP after B-TACE.

KEY POINTS

• B-TACE for the treatment of HCC refractory to C-TACE showed a 100% radiologic response at first follow-up and a significantly longer TTP than the last C-TACE when treating residual tumor. • The major complication rate after B-TACE was 6.7%. Although AST, ALT, and total bilirubin increase were more profound in B-TACE than in the last C-TACE, these were normalized at the first follow-up. • Tumor size, multiplicity of HCC, and hepatic arterial injury were independent factors associated with achieving a complete response. BCLC stage C and multiplicity of HCC were significantly associated with TTP after B-TACE.

Safety and Efficacy of Drug-Eluting Bead Transarterial Chemoembolization Combined with Apatinib in Patients with Advanced Hepatocellular Carcinoma

RATIONALE AND OBJECTIVE

The goal of this study was to determine the clinical efficacy and safety of drug-eluting bead (DEB) transarterial chemoembolization (TACE) in combination with apatinib administration in patients with advanced hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

From December 2015 to May 2017, a total of 32 patients with advanced HCC treated with DEB-TACE combined with apatinib were consecutively enrolled in this study. The treatment response and laboratory outcomes were assessed at the first- and third month after DEB-TACE therapy. Overall survival, progression-free survival, and adverse events were also analyzed and assessed.

RESULTS

The objective response rate and disease control rate were 62.5% and 96.9% at the first month after treatment, respectively. At the third month after the first therapy, a slightly higher objective response rate (68.8%) and lower disease control rate (90.6%) were achieved. There were no differences in the levels of aspartate aminotransferase, alanine aminotransferase, serum albumin, or total bilirubin at M1 or M3 compared to M0 (all p> 0.05) The median progression-free survival was 9.5 months (95% confidence interval, 8.1-10.9 months), and the median overall survival was 22.0 months (95% confidence interval, 20.2-23.9 months). Among the 32 patients, 2 had hypertension and 1 had grade 3 diarrhea; the rest of the patients had mild to moderate adverse reactions that were acceptable, and no serious adverse reactions occurred.

CONCLUSION

DEB-TACE combined with apatinib is a safe and promising treatment approach for patients with advanced HCC.

The Comprehensive Analysis of Efficacy and Safety of CalliSpheres® Drug-Eluting Beads Transarterial Chemoembolization in 367 Liver Cancer Patients: A Multiple-Center, Cohort Study

This study aimed to investigate the efficacy, safety, and prognostic factors of drug-eluting beads transarterial chemoembolization (DEB-TACE) in treating Chinese patients with liver cancer. A total of 367 liver cancer patients from 24 medical centers were consecutively enrolled in this multiple-center, prospective cohort study, including 275 hepatocellular carcinoma (HCC) cases, 37 intrahepatic cholangiocarcinoma (ICC) cases, and 55 secondary liver cancer cases. All the patients received CalliSpheres^® DEB-TACE treatment. Treatment response, overall survival (OS), change of liver function, and adverse events (AEs) were assessed. DEB-TACE treatment achieved 19.9% complete response (CR) and 79.6% objective response rate (ORR), with mean OS of 384 days [95% confidence interval (CI): 375–393 days]. CR and ORR were both higher in HCC patients compared with primary ICC patients and secondary liver cancer patients, while no difference was discovered in OS. Portal vein invasion was an independent risk factor for CR, while portal vein invasion, previous conventional TACE (cTACE) treatment, and abnormal blood creatinine (BCr) were independent risk factors for ORR. In addition, largest nodule size ≥5.0 cm, abnormal albumin (ALB), and abnormal total bilirubin (TBIL) independently correlated with unfavorable OS. Most liver function indexes were recovered to baseline levels at 1–3 months after DEB-TACE. Common AEs were pain, fever, vomiting, and nausea; most of them were at mild grade. CalliSpheres^® DEB-TACE is efficient and well tolerated in Chinese liver cancer patients. Portal vein invasion, previous cTACE treatment, largest nodule size, abnormal BCr, ALB, and TBIL correlate with worse prognosis independently.

Diagnosis of recurrent HCC: intraindividual comparison of gadoxetic acid MRI and extracellular contrast-enhanced MRI

PURPOSE

To compare the efficacy of magnetic resonance imaging (MRI) with hepatobiliary agents (HBA-MRI) and MRI with extracellular contrast agents (ECA-MRI) for detection of recurrent hepatocellular carcinoma (HCC) after multiple treatments.

METHODS

The institutional review board approved this retrospective study and waived the requirement for informed patient consent. A total of 135 patients with suspected HCC recurrence after 2-5 treatments (surgery, transarterial chemoembolization, and/or radiofrequency ablation) underwent both HBA-MRI and ECA-MRI within a 1 month interval. HBA-MRI and ECA-MRI were analyzed for HCC detection by two observers using a five-point scale. The diagnostic performances according to MRI modality were compared.

RESULTS

A total of 136 liver lesions (121 HCCs and 15 benign lesions; median size, 1.9 cm) were identified. ECA-MRI showed greater sensitivity (90.9% vs. 76.9% for observer 1; 91.7% vs. 78.5% for observer 2) and accuracy (91.2% vs. 78.7% for observer 1; 91.9% vs. 80.2% for observer 2) than HBA-MRI for both observers (P = 0.002, 0.003). Fifteen (12.4%) HCCs were correctly diagnosed with ECA-MRI but not with HBA-MRI by both observers. Interobserver agreement was excellent (0.885) for ECA-MRI and substantial (0.749) for HBA-MRI.

CONCLUSIONS

For detection of recurrent HCC, ECA-MRI was superior to HBA-MRI in terms of sensitivity and accuracy. Therefore, ECA-MRI could be the preferred imaging modality over HBA-MRI for assessing HCC recurrence following multiple treatments.

Identification of the feeding arteries of hepatocellular carcinomas by performing dual arterial phase CT during pre-transarterial chemoembolization angiography

PURPOSE

This study evaluated the usefulness of performing dual arterial phase computed tomography (CT) during pre-transarterial chemoembolization (TACE) angiography for identifying the feeding arteries of hepatocellular carcinomas (HCC).

MATERIALS AND METHODS

Dual arterial phase CT was performed during pre-TACE angiography in 73 patients with 139 HCC. Ten HCC underwent this procedure twice, so the total number of examined HCC was 149. Early and late arterial phase images were obtained 6 seconds after injection of an iodinated contrast material serially during a single breath-hold. The feeding artery was defined as the branch of the hepatic artery that was connected to the enhanced areas of the tumor. For HCC that could not be visualized on the early arterial phase images, fusion images superimposing the early and late arterial phase images were constructed. Furthermore, technical success defined as successful catheterization of the subsegmental or more distal feeding artery was evaluated.

RESULTS

The feeding artery was correctly identified on dual arterial phase CT in 146 of the 149 tumors (98.0%). In two HCC, the feeding arteries could not be identified due to severe motion artifacts, and in one, due to the presence of anastomosis between the right and left hepatic arteries. Catheterization of the subsegmental feeding artery was successful in all TACE procedures (technical success rate: 100%).

CONCLUSION

Performing dual arterial phase CT during angiography appears to be useful for identifying the feeding arteries of HCC.

Update on Transarterial Chemoembolization with Drug-Eluting Microspheres for Hepatocellular Carcinoma

Conventional transcatheter arterial chemoembolization (c-TACE) is a widely used first-line palliative treatment for patients with unresectable hepatocellular carcinoma (HCC). Despite the effectiveness of c-TACE, to date, technique and procedure scheduling has not yet been standardized. Drug-eluting microspheres (DEMs) were therefore introduced to ensure more sustained and tumor-selective drug delivery for permanent embolization. These DEMs can load various drugs and release them in a sustained manner over a prolonged period. This approach ensures the delivery of high concentrations of chemotherapeutic agents to tumors, without increasing systemic concentrations, and promote tumor ischemia and necrosis. This review summarizes the recent advances in the use of DEM-TACE to treat HCC.

Updated use of TACE for hepatocellular carcinoma treatment: How and when to use it based on clinical evidence

Hepatocellular carcinoma (HCC) is the most common primary liver cancer, representing the sixth leading cause of cancer and the third leading cause of cancer-related mortality. Patient stratification and treatment allocation are based on tumor stage, liver function, and performance status. According to the Barcelona Clinic Liver Cancer (BCLC) staging system, transarterial chemoembolization (TACE) is the first-line treatment for patients with intermediate stage HCC, including those with large or multinodular HCC, well-preserved liver function, and no cancer-related symptoms or evidence of vascular invasion or extrahepatic spread. Two TACE techniques have been used since 2004, conventional TACE (cTACE) and TACE with drug-eluting beads (DEB-TACE). cTACE was evidenced first to treat intermediate stage HCC patients. It combines the transcatheter delivery of chemotherapy using Lipiodol-based emulsion plus an embolizing agent to achieve strong cytotoxic and ischemic effects. Drug-eluting beads (DEBs) were developed in order to slowly release chemotherapeutic agents, and to increase ischemia intensity and duration. Recent advances allow TACE treatment of both early stage patients (i.e. those with a solitary nodule or up to 3 nodules under 3 cm) and some advanced stage patients. Here we review recent clinical evidence related to TACE treatment of patients with early, intermediate, and advanced stage HCC. Based on the 2014 TACE algorithm of Raoul et al., this international expert panel proposes an updated TACE algorithm and provides insights into TACE use for patients at any HCC stage.

Efficacy and safety profile of drug-eluting beads transarterial chemoembolization by CalliSpheres® beads in Chinese hepatocellular carcinoma patients

BACKGROUND

This study aimed to investigate the efficacy and safety of drug eluting beads transarterial chemoembolization (DEB-TACE) treatment by CalliSpheres® in Chinese patients with hepatocellular carcinoma (HCC) as well as the predicting factors for response.

METHODS

99 patients with HCC were consecutively enrolled in this study. All participants were treated by CalliSpheres® DEB-TACE. Clinical response was evaluated according to modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria. Common Terminology Criteria for Adverse Events (CTCAE) was used to assess the adverse events and liver dysfunction during and after the operation.

RESULTS

Post treatment, 16 patients (16.2%) achieved CR and 59 (59.6%) achieved PR, the ORR was 75.8%. Subgroup analysis showed that patients with higher BCLC stage were of worse CR and ORR rates, and the CR as well as ORR between patients with cTACE history and patients without cTACE history were similar. Univariate logistic regression analysis displayed that number of nodules > 3, higher BCLC stage and previous cTACE might be correlated with worse ORR but with no statistical significance. As to liver function, CTCAE grades of laboratory indexes for liver function were increased at 1 week compared to baseline and recovered to the baseline grades at 1-3 months post operation. Besides, most of the common adverse events were light and moderate in our study.

CONCLUSIONS

In conclusion, DEB-TACE by CalliSpheres® was efficient and well tolerated in Chinese HCC patients, and BCLC stage, number of nodules and cTACE history were possibly correlated with treatment response.

Conventional vs drug-eluting beads transarterial chemoembolization for hepatocellular carcinoma

Transarterial chemoembolization (TACE) is the current standard of therapy for patients with intermediate-stage hepatocellular carcinoma (HCC) according to the Barcelona Clinic Liver Cancer classification. The concept of conventional TACE (cTACE) is the selective obstruction of tumor-feeding artery by injection of chemotherapeutic agents, leading to ischemic necrosis of the target tumor via cytotoxic and ischemic effects. Drug-eluting beads (DEBs) have been imposed as novel drug-delivering agents for TACE, which allows for higher concentrations of drugs within the target tumor and lower systemic concentrations compared with cTACE. Despite the theoretical advantages of DEB-TACE, it is still controversial in clinical practice as to whether DEB-TACE is superior to cTACE in regard to overall survival and treatment response. In this review article, we summarize the clinical efficacy and safety of DEB-TACE for patients with intermediate or advanced stage HCC in comparison with cTACE.