Transarterial chemoembolization for hepatocellular carcinoma: an evidence-based review of its place in therapy

Comparison of the Treatment Response of Drug-Eluting Bead Transarterial Chemoembolization and Conventional Transarterial Chemoembolization in Patients With Hepatocellular Carcinoma

Introduction Hepatocellular carcinoma (HCC) is a common primary hepatic cancer. Its early diagnosis can aid in its treatment by curative means such as surgery or ablation. Advanced-stage diagnosis limits these treatment options, and such cases can be treated with transarterial chemoembolization (TACE). Conventional transarterial chemoembolization (cTACE) and drug-eluting bead transarterial chemoembolization (DEB-TACE) are usually used, and follow-up response is evaluated using modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria. This study was done to compare the treatment response of cTACE and DEB-TACE in patients with HCC. Materials and methods A retrospective review of electronic medical records of all patients diagnosed with HCC from January 2021 to August 2022 who underwent cTACE or DEB-TACE was undertaken at the Department of Interventional Radiology, Indus Hospital and Health Network. Both male and female patients aged 18 years or above with Child-Pugh class A and B were included. DEB-TACE or cTACE was performed by a fellowship-trained interventional radiologist, and the response was evaluated at six weeks follow-up using mRECIST criteria. Results A total of 129 patients were included in this study, with a mean age of 54.1 ± 10.8 years. The mean size of HCC was 3.1 ± 1.7 cm. Seventy-eight (60.5%) patients underwent cTACE, and 51 (39.5%) underwent DEB-TACE. Out of the 78 patients who underwent cTACE, complete response (CR) was found in 28 (35.9%), partial response (PR) was found in 33 (42.3%), stable disease (SD) was found in 12 (15.4%), and progressive disease (PD) was found in five (6.4%) patients. Of the 51 patients who underwent DEB-TACE, CR was found in 13 (25.5%), PR was found in 20 (39.2%), SD was found in 11 (21.6%), and PD was found in seven (13.7%) patients. Conclusion The response rate of TACE in the form of complete or partial response was higher with a lower frequency of stable or progressive disease. cTACE has a high response rate as compared to DEB-TACE.

Callispheres® drug-eluting beads transarterial chemoembolization might be an efficient and safety down-staging therapy in unresectable liver cancer patients

PURPOSE

The purpose was to explore the effect of drug-eluting beads transarterial chemoembolization (DEB-TACE) on down-staging in unresectable liver cancer patients.

METHODS

A total of 180 patients with PHC treated by TACE were retrospectively analyzed. These included 80 cases in the DEB-TACE group and 100 cases in the cTACE group. Of these, 56 had complete clinical data (DEB-TACE: 24, cTACE: 32), and 23 patients received hepatectomy after TACE as a down-staging therapy (DEB-TACE: 15, cTACE: 8). Data (including clinical characteristics, clinical efficacy, tumor response, tumor diameters, residual liver volume, and liver function indexes before and after TACE, RFS, OS, and complications were collected and compared. Treatment response was evaluated at 1 month after TACE. Tumor diameter was evaluated by abdominal computed tomography scan. The residual liver volume was evaluated by IQQA liver system, and relapse-free survival (RFS) and overall survival (OS) were calculated by Kaplan-Meier curves.

RESULTS

The conversion rate in DEB-TACE group was higher than cTACE group (18.8% vs 8%, p = 0.032). In DEB-TACE group, 17 patients achieved objective response rate (ORR) which was higher than cTACE group (70.8% vs 34.4%, p = 0.007). The tumor necrosis rate was higher in DEB-TACE group, but there was no significant difference between the two groups (p = 0.053). Tumor diameter was decreased after TACE compared to before TACE (DEB-TACE: 9.4 ± 3.3 vs. 5.4 ± 3.5 cm, p = 0.003; cTACE: 9.7 ± 2.6 vs. 6.9 ± 2.2, p = 0.036). As to residual liver volume, it was increased after TACE compared to before TACE (1066.2 cm3 vs. 1180.3 cm3, p = 0.007) in DEB-TACE group, while there was no significant difference in cTACE group (1046.4 cm3 vs. 1170 cm3, p = 0.339) compared by paired-sample t-test, but there was no significant difference before and after TACE when compared by unpaired-sample t-test (p > 0.05). After TACE at 1 month, the AFP level in the DEB-TACE group was significantly lower than that in the cTACE group (p = 0.003). For survival, the median RFS was 26.0 months in DEB-TACE group and 15 months in cTACE group; there was significant difference between the two groups (p = 0.0465). As to OS, the median OS in DEB-TACE group was higher than that in cTACE group, but there was no significant difference between the two groups (p = 0.165). For safety profiles, in terms of liver function and adverse events, there was no significant difference between the two groups.

CONCLUSION

Compared with cTACE, DEB-TACE might be a more efficient and safety down-staging treatment in unresectable liver cancer patients.

Clinical effects and safety of different transarterial chemoembolization methods for bridging and palliative treatments in hepatocellular carcinoma

Purpose

We assessed and compared clinical effects and safety endpoints of three methods of transarterial chemoembolization (TACE), conventional (cTACE), with drug-eluting beads (DEB-TACE), and with degradable starch microspheres (DSM-TACE), used in patients with hepatocellular carcinoma (HCC) in the bridging to liver transplant (LT) and the palliative setting.

Methods

In our center, 148 patients with HCC underwent 492 completed TACE procedures between 2008 and 2017 (158 for bridging to LT; 334 for palliative treatment) which we analyzed retrospectively. Of these procedures, 348 were DEB-TACE, 60 cTACE, and 84 DSM-TACE.

Results

The cTACE procedure revealed a significantly longer period of hospitalization (p = 0.02), increased occurrence of nausea (p = 0.025), and rise in alanine transaminase (ALT) levels (p = 0.001), especially in the palliative setting. In the bridging to LT cohort, these clinical endpoints did not reach statistical significance.

Conclusions

The clinical safety of different TACE methods for HCC in both the palliative and the bridging to LT setting was equivalent. In the palliative setting, the cTACE procedure revealed an increased risk for adverse clinical effects such as nausea, elevation of ALT, and a prolonged period of hospitalization what might either be related to the systemic effects of the chemotherapeutic agent or to the differences in both collectives. Thus, further studies must be conducted on a larger number of TACE procedures to effectively explore the clinical side effects of the various TACE variants.

Transcatheter arterial chemoembolization followed by surgical resection for hepatocellular carcinoma: a focus on its controversies and screening of patients most likely to benefit

Surgical resection (SR) is recommended as a radical procedure in the treatment of hepatocellular carcinoma (HCC). However, postoperative recurrence negatively affects the long-term efficacy of SR, and preoperative adjuvant therapy has therefore become a research hotspot. Some clinicians adopt transcatheter arterial chemoembolization (TACE) as a preoperative adjuvant therapy in patients undergoing SR to increase the resection rate, reduce tumor recurrence, and improve the prognosis. However, the findings of the most relevant studies remain controversial. Some studies have confirmed that preoperative TACE cannot improve the long-term survival rate of patients with HCC and might even negatively affect the resection rate. Which factors influence the efficacy of preoperative TACE combined with SR is a topic worthy of investigation. In this review, existing clinical studies were analyzed with a particular focus on several topics: screening of the subgroups of patients most likely to benefit from preoperative TACE, exploration of the optimal treatment regimen of preoperative TACE, and determination of the extent of tumor necrosis as the deciding prognostic factor.

Arsenic trioxide-loaded CalliSpheres: In vitro study of drug release and antitumor activity, and in vivo study of pharmacokinetics, treatment efficacy and safety in liver cancer

The aim of the present study was to investigate the arsenic trioxide (ATO) loading/releasing efficiency of CalliSphere beads (CBs), as well as the in vitro anticancer activity, in vivo pharmacokinetics, treatment efficacy and safety of ATO-eluting CBs in liver cancer. The ATO loading and releasing efficiencies in CBs were evaluated. Furthermore, cell viability, invasion, apoptosis, VEGF expression and MMP9 expression were determined in liver cancer cells treated with ATO-eluting CBs or ATO solution. Rabbit liver models were established and underwent TACE with ATO-eluting CBs or ATO/lipiodol emulsion. Subsequently, their ATO pharmacokinetics were determined and macroscopic/microscopic examinations were conducted. In vitro, CB-loaded ATO increased during 40 min with an optimal loading efficiency of 23.0±2.5%, and released ATO rapidly within the first 30 min (31.40±10.0%) then slowed down within the latter 48 h (47.20±4.70%). ATO-eluting CBs exhibited decreased cell viability to some extent and similar invasive cell count, apoptosis rate, VEGF and MMP9 levels compared with ATO solution at various concentrations and time-points. In vivo, ATO concentration was lower in plasma, but higher in tumor tissues, and necrosis was more complete in tumor tissue while milder in normal liver parenchyma after rabbit liver was embolized with ATO-eluting CBs compared with ATO/lipiodol emulsion. ATO-eluting CBs may be a novel and promising therapeutic option in treating liver cancer.

Drug-eluting bead chemoembolization for the treatment of nonresectable hepatic carcinoma in dogs: A prospective clinical trial

Background

Effective treatment options for nonresectable hepatic carcinoma (HC) in dogs are limited.

Hypothesis/Objective

Objectives were to report outcomes, complications, and tumor responses via computed tomography (CT) assessment after drug‐eluting bead transarterial chemoembolization (DEB‐TACE) for nonresectable HC in dogs. The authors hypothesized that major complications would be uncommon and short‐term CT assessment would demonstrate stable disease or partial response.

Animals

Client‐owned dogs (n = 16) with nonresectable HC.

Methods

Prospective, single‐arm clinical trial. Drug‐eluting bead transarterial chemoembolization was performed to varying levels of blood flow stasis. Computed tomography imaging was compared before and approximately 12 weeks after initial treatment.

Results

Drug‐eluting bead transarterial chemoembolization was successfully administered in all attempts. Based on percent change in elliptical tumor volume response (mL), stable disease (8/13; 62%) was the most common outcome followed by partial response (3/13; 23%) and progressive disease (2/13; 15%) with a median of 74 days (range, 39‐125) after initial treatment. Median tumor volume (mL) after DEB‐TACE decreased in volume by 13% (range, 56% decrease to 77% increase). Mild complications consistent with postembolization syndrome occurred after 7/27 (26%) treatments. Major complications occurred after 3/27 (11%) treatments: hepatic abscess/septicemia (2) and cholecystitis/death (1), resulting in treatment‐induced death after 2/27 (7%) treatments. Median survival time after treatment was 337 days (range, 22‐1061). Dogs with a presenting complaint of weight loss (P = .02) had a significantly shorter median survival time (126 days; range, 46‐337) than those dogs without prior history of weight loss (582 days; range, 22‐1061).

Conclusions

Drug‐eluting bead transarterial chemoembolization for nonresectable HC is a feasible procedure, which promoted stable disease or partial response in 85% of dogs in this study sample.

Evaluation of the Therapeutic Effect of Adjuvant Transcatheter Arterial Chemoembolization Based on Ki67 After Hepatocellular Carcinoma Surgery

Background and aims

This study aimed to determine the relationship between Ki67 expression and the efficacy of postoperative adjuvant transcatheter arterial chemoembolization (PA-TACE) in patients with hepatocellular carcinoma.

Methods

The Kaplan-Meier method was used to analyze the recurrence-free survival (RFS) and overall survival (OS) rates between the sub-groups in the ki67 low expression group and the ki67 high expression group and analyze the relationship between the expression of Ki67 and the efficacy of TACE.

Results

After PSM, there was no significant difference in the RFS and OS between the surgery + TACE and surgery subgroups after 1, 2, or 3 years (RFS: 63.9%, 55.6%, and 42.9% vs. 83.3%, 63.9%, and 55.6%, respectively, P = 0.279; OS: 91.7%, 83.3%, and 74.3% vs. 91.7%, 88.9%, and 71.4%, respectively, P = 0.890) in the Ki67 low-expression group. The RFS and OS were higher in the surgery + TACE subgroup than the surgery subgroup after 1, 2, and 3 years (RFS: 80.0%, 77.5%, and 69.2% vs. 53.5%, 39.5%, and 32.6%, respectively, P<0.001; OS: 97.5%, 85.0%, and 79.5% vs. 79.1%, 48.8%, and 42.9%, respectively, P = 0.001) in the Ki67 high expression group. The RFS was higher in the Ki67 high-expression subgroup than the low-expression subgroup after 1, 2, and 3 years, and OS had no significant difference (RFS: 80.0%, 79.5%, and 69.2% vs. 67.4%, 56.5%, and 46.7%, respectively, P = 0.035; OS: 97.5%, 85.0%, and 79.5% vs. 93.5%, 82.6%, and 75.6%, respectively, P = 0.665) in the surgery + TACE group.

Conclusions

For patients with hepatocellular carcinoma and high expression of Ki67 (Ki67≥20%), adjuvant hepatic artery chemoembolization after radical liver tumor resection effectively reduced the probability of tumor recurrence after surgery and prolonged the OS of patients. High Ki67 expression during the post-operative follow-up evaluation of hepatocellular carcinoma patients is an indicator for adjuvant TACE therapy.

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.

Biocompatibility of a New Kind of Polyvinyl Alcohol Embolic Microspheres: In Vitro and In Vivo Evaluation

The aim of this study is to investigate the biocompatibility of polyvinyl alcohol (PVA) embolic microspheres by in vivo and in vitro evaluations. Two specifications of PVA microspheres including colorless microspheres (1 g microspheres with 7 mL 0.9% sodium chloride (SC) per vial, size: 500-700 µm) and blue microspheres (2 g microspheres with 7 mL 0.9% SC per vial, size: 500-700 µm) were assessed for biocompatibility. The vitro cytotoxicity was evaluated in L929 cells by MTT assay. Acute systemic toxicity and 28-repeat dose intravenous subchronic toxicity were assessed in 20 ICR mice and 40 SD rates, respectively. Skin sensitization was conducted in 30 adult albino guinea pigs by maximization test, in addition, intracutaneous reaction test was performed in New Zealand white rabbits. Hemolysis ratio of PVA microspheres was evaluated with rabbit blood. Moreover, test for genotoxicity was assessed by bacterial reverse mutation test and mouse lymphoma mutagenesis assay. No cytotoxicity, hemolysis, or acute toxicity of PVA microspheres was found, and slight fluctuations of biochemical indexes were observed in test of 28-day repeat dose intravenous subchronic toxicity, while these changes remained within our historical permitted range. Maximization test and intracutaneous reactivity test disclosed no irritation to skin or tissues. According to bacterial reverse mutation test and mouse lymphoma mutagenesis assay, no genotoxicity of PVA microspheres was observed. PVA microspheres showed excellent biocompatibility both in vivo and in vitro, and they were promising embolic materials for drug-eluting beads transarterial chemoembolization (DEB-TACE) therapy.

Comparison of Treatment Response and Survival Profiles Between Drug-Eluting Bead Transarterial Chemoembolization and Conventional Transarterial Chemoembolization in Chinese Hepatocellular Carcinoma Patients: A Prospective Cohort Study

This study evaluated the difference in treatment response and survival profiles between drug-eluting bead transarterial chemoembolization (DEB-TACE) and conventional transarterial chemoembolization (cTACE) treatments in Chinese hepatocellular carcinoma (HCC) patients. A total of 120 HCC patients were consecutively enrolled in this prospective cohort study, which showed that DEB-TACE achieved higher complete response (CR) (30.8%) compared with cTACE (7.4%) with no difference in overall response rate (ORR) for patients treated with DEB-TACE and cTACE (80.8% vs. 73.5%). In addition, DEB-TACE was associated with a lower rate of progressive disease (PD) compared with cTACE (1.9% vs. 11.8%). With respect to survival, patients in the DEB-TACE group achieved median progression-free survival (PFS) of 15 months (95% CI 12-18 months), which was longer than the cTACE group [median PFS 11 months (95% CI 10-12 months)]. Median overall survival (OS) was also longer with DEB-TACE [25 months (95% CI 22-28 months)] when compared with cTACE [21 months (95% CI 18-24 months)]. Univariate and multivariate logistic regression analysis showed that DEB-TACE was an independent predictive factor for achieving CR. Univariate Cox's regression analysis revealed that DEB-TACE was a predictive factor for prolonged PFS and OS, while multivariate analysis demonstrated that DEB-TACE was not an independent factor for predicting PFS or OS. In conclusion, we found that DEB-TACE achieved higher treatment response and prolonged survival compared with cTACE in Chinese HCC patients.

CalliSpheres® drug-eluting beads (DEB) transarterial chemoembolization (TACE) is equally efficient and safe in liver cancer patients with different times of previous conventional TACE treatments: a result from CTILC study

PURPOSE

To assess the efficacy and safety of drug-eluting beads transarterial chemoembolization (DEB-TACE) in liver cancer patients with different times of previous conventional transarterial chemoembolization (cTACE) treatments.

METHODS

367 liver cancer patients about to receive DEB-TACE treatment were enrolled in this prospective cohort study. All patients were divided into no previous cTACE group (NPC group), 1-2 times previous cTACE group (PC group) and triple or above previous cTACE group (TPC group) according to the times of previous cTACE treatments.

RESULTS

There was no difference in complete response (CR) (P = 0.671) and objective response rate (ORR) (P = 0.062) among three groups. Additionally, no difference in overall survival (OS) among groups (P = 0.899) was found. As to liver function, most liver function indexes were deteriorative at 1 week after DEB-TACE operation, but returned to baseline at 1-3 months after DEB-TACE operation in all three groups, while percentage of abnormal total bile acid (TBA) patients was higher in TPC group than NPC and PC groups at 1-3 month post-DEB-TACE (P = 0.018). As for safety profiles, the incidence of pain during DEB-TACE operation was lower in TPC group compared to NPC and PC groups (P = 0.005), while no difference of other adverse events was found during and 1 month post-DEB-TACE treatment among three groups.

CONCLUSION

DEB-TACE treatment was equally efficient and tolerated in liver cancer patients with different times of previous cTACE treatments.