Prospective Phase II trial of drug-eluting bead chemoembolization for liver transplant candidates with hepatocellular carcinoma and marginal hepatic reserve

Chemoembolization Plus Ablation: Current Status

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death worldwide. The treatment landscape for HCC has evolved significantly over the past decade, with several modalities available to treat various stages of disease. The Barcelona Clinic Liver Cancer (BCLC) system provides a foundation for treatment guidance. However, given the complex nature of HCC, a more nuanced approach is often required, especially for lesions sized between 3 and 5 cm. This review aims to analyze the available treatments for early-stage HCC lesions between 3 and 5 cm, with a focus on the therapeutic potential and efficacy of transarterial chemoembolization (TACE)-ablation. Additional therapies including TACE, ablation, transarterial radioembolization, and surgical resection are also reviewed and compared with TACE-ablation. TACE-ablation is a viable therapeutic option for early-stage HCC lesions between 3 and 5 cm. Surgical resection remains the gold standard. Although recent studies suggest radiation segmentectomy may be a curative approach for this patient population, further studies are needed to compare the relative efficacies between TACE-ablation and radiation segmentectomy.

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

BACKGROUND

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

METHODS

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

RESULTS

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

CONCLUSION

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

Role of Pretransplant Treatments for Patients with Hepatocellular Carcinoma Waiting for Liver Transplantation

Simple Summary

Hepatocellular carcinoma (HCC) is the fifth most common cancer in men worldwide and the second leading cause of cancer death. Liver transplantation (LT) is one of the treatment options for patients with HCC. Recently, there have been many reports of the usefulness of locoregional therapy, such as transarterial chemoembolization and radiofrequency ablation, for HCC as pretreatment before LT. In Western countries, locoregional therapy is used to bridge until transplantation to prevent drop-outs from the waiting list or for downstaging to treat patients with advanced HCC who initially exceed the criteria for LT. With the progress of locoregional therapy, new reports on the effects of bridging and downstaging locoregional therapy as pretransplant treatment are increasing in number.

Abstract

Recently, there have been many reports of the usefulness of locoregional therapy such as transarterial chemoembolization and radiofrequency ablation for hepatocellular carcinoma (HCC) as pretreatment before liver transplantation (LT). Locoregional therapy is performed with curative intent in Japan, where living donor LT constitutes the majority of LT due to the critical shortage of deceased donors. However, in Western countries, where deceased donor LT is the main procedure, LT is indicated for early-stage HCC regardless of liver functional reserve, and locoregional therapy is used for bridging until transplantation to prevent drop-outs from the waiting list or for downstaging to treat patients with advanced HCC who initially exceed the criteria for LT. There are many reports of the effect of bridging and downstaging locoregional therapy before LT, and its indications and efficacy are becoming clear. Responses to locoregional therapy, such as changes in tumor markers, the avidity of FDG-PET, etc., are considered useful for successful bridging and downstaging. In this review, the effects of bridging and downstaging locoregional therapy as a pretransplant treatment on the results of transplantation are clarified, focusing on recent reports.

The Key Role of Staging Definitions for Assessment of Downstaging for Hepatocellular Carcinoma

The success of liver transplant (LT) for hepatocellular carcinoma (HCC) is dependent on accurate tumor staging using validated imaging criteria, and adherence to acceptable criteria based on tumor size and number. Other factors including α-fetoprotein (AFP) and response to local regional therapy (LRT) have now played a larger role in candidate selection. Tumor downstaging is defined as reduction in the size of viable tumors using LRT to meet acceptable criteria for LT, and serves as a selection tool for a subgroup of HCC with more favorable biology. The application of tumor downstaging requires a structured approach involving three key components in tumor staging-initial tumor stage and eligibility criteria, tumor viability assessment following LRT, and target tumor stage prior to LT-and incorporation of AFP into staging and treatment response assessments. In this review, we provide in-depth discussions of the key role of these staging definitions in ensuring successful outcome.

Hepatic Toxicity After Selective Chemoembolization Is Associated With Decreased Survival Among Patients With Hepatocellular Carcinoma

OBJECTIVE. The purpose of this study was to identify risk factors for and outcomes of hepatotoxicity after selective chemoembolization of hepatocellular carcinoma. MATERIALS AND METHODS. This retrospective study included 182 patients (136 men and 46 women; median age, 63 years [interquartile range, 57-70 years]) who underwent 338 consecutive doxorubicin drug-eluting bead (DEB) chemoembolization procedures between 2011 and 2014. Outcomes were assessed until November 2019. In 97% of procedures, two or fewer segments were targeted. The Barcelona Clinic Liver Cancer (BCLC) stage was 0 or A for 77 procedures (22.8%), B for 75 (22.2%), C for 122 (36.1%), and D for 64 (18.9%). Hepatotoxicity was defined as worsened ascites or encephalopathy or as grade 3 or 4 elevations in liver function test results, creatinine levels, or the international normalized ratio within 30 days. Risk factors were assessed by univariate and multivariable generalized estimating equations. Transplant-free survival was assessed using Cox proportional hazard models. RESULTS. Hepatotoxicity was observed after 84 of 338 procedures (24.9%) performed for 70 of 182 patients (38.5%) and was irreversible for 40 procedures (11.8%). On multivariable analysis, risk factors for irreversible toxicity included Child-Pugh class C liver function (odds ratio [OR], 4.4; 95% CI, 1.0-19.0; p = .04), BCLC stage C (OR, 5.0; 95% CI, 1.6-16.0; p = .006) or D (OR, 7.4; 95% CI, 2.1-25.5; p = .002) disease, TIPS or hepatofugal portal venous flow (OR, 6.3; 95% CI, 2.3-17.0; p < .001), and a serum α-fetoprotein level of 200 ng/mL or greater (OR, 2.6; 95% CI, 1.1-6.1; p = .03). Irreversible toxicity was associated with reduced transplant-free survival among patients who were ineligible for liver transplant (hazard ratio, 2.5; standard error, 0.42; p = .03). CONCLUSION. Irreversible hepatotoxicity was common after selective chemoembolization in patients with advanced stage disease, an elevated serum α-fetoprotein level, or reduced hepatic portal venous perfusion, and it may hasten death among patients who are ineligible for liver transplant.

Drug-eluting Bead-Transcatheter Arterial Chemoembolization for Advanced Hepatocellular Carcinoma Refractory to Conventional Lipiodol-based Transcatheter Arterial Chemoembolization

Purpose

To evaluate the potential of drug-eluting bead (DEB)-transcatheter arterial chemoembolization (TACE) as a treatment option for patients with refractory to conventional lipiodol-based TACE (c-TACE) especially with decreased liver function.

Patients and Methods

We retrospectively evaluated the treatment results of DEB-TACE for 89 HCC nodules in 27 patients with c-TACE refractory according to liver function.

Results

Although overall survival was significantly better in Child–Pugh A patients than in Child–Pugh B patients (median survival time, MST: 561 vs 347 days, p=0.031), progression-free survival was almost similar in both patients between Child–Pugh A and B (MST: 79 vs 87 days, p=0.534). Regarding antitumor response, the objective response rate (ORR) and disease-control rate (DCR) were 5.3/12.5% and 52.7/87.5% in Child–Pugh A/B, respectively. In each 89 HCC nodules, ORR and DCR were almost similar between Child–Pugh A and B (ORR, 20.3 vs 13.3%; DCR, 77.0 vs 73.3%, respectively). Adverse events of DEB-TACE were well-tolerated, and liver function was reserved during DEB-TACE procedures.

Conclusion

DEB-TACE could be a therapeutic option for advanced HCC patients with c-TACE refractory and decreased liver function.

Radiopaque beads loaded with doxorubicin in the treatment of patients with hepatocellular carcinoma: A retrospective, multi-center study

BACKGROUND AND AIMS

Radiopaque drug-eluting beads are an emerging treatment option for patients with hepatocellular carcinoma (HCC). The primary objective of this study was to evaluate overall disease and target tumor response of non-resectable HCC after TACE with a doxorubicin-loaded radiopaque microsphere.

METHODS

Data were abstracted from records of patients with unresectable HCC who received TACE with doxorubicin-loaded radiopaque LC Bead LUMI^TM microspheres at one of five United States centers between February 2016 - November 2017. Response was measured using modified response criteria in solid tumors. Primary efficacy endpoints included objective response rate (ORR) and disease control rate (DCR) at first assessment post-treatment, both overall and for targeted tumors. ORR was the sum of complete and partial response. DCR was ORR plus stable disease. Toxicity was calculated using common terminology criteria for adverse events.

RESULTS

Eighty-two patients were included. Overall ORR and DCR were 47.6% (39/82) and 76.8% (63/82), respectively. ORR and DCR of target tumors were 56% and 98%, respectively. Five patients experienced adverse events (5/82, 6.1%). No grade 4-5 toxicities occurred.

CONCLUSIONS

TACE with drug-loaded radiopaque beads is a promising treatment for unresectable HCC. Prospective studies should evaluate whether radiopaque beads reduce off-target distribution of microspheres.

Locoregional Therapies in the Treatment of 3- to 5-cm Hepatocellular Carcinoma: Critical Review of the Literature

OBJECTIVE. Treatment options for hepatocellular carcinoma (HCC) continue to expand. However, given the complexity of the patients including factors such as codominant cirrhosis or portal hypertension and transplant status, it can be difficult to know which treatment is most advantageous. The choice of HCC treatment is perhaps most complex in the setting of HCCs that are 3-5 cm. This article reviews the evidence for locoregional therapies in treating 3- to 5-cm HCCs. CONCLUSION. Combination therapy with transarterial chemoembolization (TACE) and ablation has the most robust and highest level of evidence to support its efficacy and therefore should be considered first-line therapy for nonresectable HCCs that measure 3-5 cm. The studies support that TACE followed by ablation is superior to either TACE alone or ablation alone. Data for transarterial radioembolization (TARE) to treat HCCs in this specific size range are very limited. Additional data are needed about the comparative effectiveness of TACE-ablation combination and TARE and how the TACE-ablation combination compares with surgical resection.