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

Higher Indocyanine Green Retention Is Associated with Improved Prognosis in Patients with Hepatocellular Carcinoma Treated with Transcatheter Arterial Chemoembolization

PURPOSE

To test indocyanine green retention rate at 15 minutes (ICG-R15) as a prognostic biomarker in patients with hepatocellular carcinoma (HCC) treated with transcatheter arterial chemoembolization (TACE) therapy.

MATERIALS AND METHODS

This retrospective cohort study was performed on the data of 278 consecutive patients with HCC treated with TACE after ICG-R15 testing at a single university hospital. Cox proportional hazard model analysis was performed to identify independent prognostic factors. After adjusting for age, sex, stage of HCC, albumin-bilirubin score, etiologies, and baseline year by propensity score matching, the prognostic impact of higher ICG-R15 was evaluated using the Kaplan-Meier curve.

RESULTS

Univariate and multivariate analyses identified higher ICG-R15 as a positive prognostic factor for overall survival. Propensity score matching generated two 77-patient cohorts: ICG-R15 <20% group and ICG-R15 >20% group. The overall survival of the ICG-R15 >20% group was significantly better than that of the ICG-R15 <20% group.

CONCLUSIONS

Higher ICG-R15 acted as a positive long-term prognostic factor in patients with HCC treated with TACE.

Efficacy and Safety of Transarterial Chemoembolization with a Three-Stage Mixed Chemoembolic Regimen for Large Unresectable Hepatocellular Carcinoma

Objective

This study aimed to assess the treatment response, survival outcomes, and safety of a novel transarterial chemoembolization (TACE) technique with a three-stage mixed chemoembolic regimen (M-TACE) in patients with large unresectable hepatocellular carcinoma (HCC) measuring more than 5 cm in maximum diameter.

Methods

Between January 2017 and March 2023, a total of 82 patients were enrolled in this retrospective cohort study. Treatment response was assessed in the first month after M-TACE; progression-free survival and overall survival (OS) were evaluated. The prognostic factors associated with patient survival were statistically analyzed by the Cox regression model. Adverse events were recorded.

Results

The maximum diameter of the tumors ranged from 5.3 cm to 20.0 cm (mean 10.71 cm). The objective response (OR) and disease control rates were 74.4 and 92.7%, respectively, at 1-month follow-up. The median survival time was 22 months (95% CI, 13.10-30.90 months). The OS rates were 82.0% at six months, 62.5% at one year, and 43.0% at two years. Targeted therapy and/or immunotherapy (P=0.001) and tumor response at one month (P=0.020) were protective factors for OS. In terms of safety, no major complications occurred and the only observed decrease within the normal range occurred in albumin and platelet levels one month after the embolization procedure. This decrease in levels did not show a significant relationship with the OR rates.

Conclusion

M-TACE demonstrated a promising objective tumor response, making it a viable and effective treatment option for patients with large unresectable HCC.

Prognosis of Patients with Hepatocellular Carcinoma Treated with Transarterial Chemoembolization(MC-hccAI 001): Development and Validation of the ALFP Score

Background

Transarterial chemoembolization (TACE) is the recommended first-line treatment for intermediate-stage Hepatocellular carcinoma (HCC) patients. However, predicting the survival of HCC patients receiving TACE remains challenging.

Methods

In this retrospective study, we analyzed a total of 1805 HCC patients who received TACE. The patients were randomly divided into a training set (n = 1264) and a validation set (n = 541). We examined various prognostic factors within the training set and developed a simple ALFP (ALBI grade, AFP, and Prothrombin time) score, which was subsequently validated using the independent validation set.

Results

Our multivariate analysis revealed that baseline ALBI grade 2 or 3, AFP ≥ 100 ng/mL, and PT > 13.1 s were independent unfavorable prognostic factors for HCC patients receiving TACE (p < 0.05). Based on these findings, we constructed the ALFP score, which assigns 1 point each for ALBI grade 2 or 3, AFP ≥ 100 ng/mL, and PT > 13.1 s. The score has a range of 0 to 3, and higher scores are associated with poorer outcomes. The median overall survival (OS) varied significantly among different ALFP score groups, both in the training set and the validation set (p < 0.001). We further examined the ALFP score in subgroups based on tumor diameter and the number of intrahepatic lesions. In each subgroup, higher ALFP scores were consistently associated with lower OS (p < 0.05).

Conclusion

Our study confirms the prognostic value of the ALFP score in predicting the survival of HCC patients undergoing TACE. The score incorporates easily obtainable baseline parameters and provides a simple and practical tool for risk stratification and treatment decision-making in HCC patients.

Intravoxel incoherent motion diffusion-weighted imaging and shear wave elastography for evaluating peritumoral liver fibrosis after transarterial chemoembolization in a VX2 rabbit liver tumor model

In this study, we sought to evaluate changes in peritumoral fibrosis after transarterial chemoembolization (TACE) in a rabbit VX2 liver tumor model using intravoxel incoherent motion diffusion-weighted imaging (IVIM DWI) and ultrasound shear wave elastography (SWE). A total of 20 rabbits underwent implantation of VX2 tumor tissues in the left lobe of the liver. The rabbits were randomly divided into an experimental group (n = 10) or a control group (n = 10). Those in the experimental group were treated with an emulsion of lipiodol and pirarubicin through a microcatheter 2–3 weeks after implantation; those in the control group were treated with sterile water. Compared with the control group, the true diffusion coefficient (D) and pseudodiffusion coefficient (D*) values in liver tissues were significantly lower (p < 0.05 for all) and liver stiffness values (LSV) (10.58 ± 0.89 kPa) were higher in the experimental group (7.65 ± 0.86 kPa; p < 0.001). The median stage of liver fibrosis based on METAVIR scores was 1 (1,1) in the control group and 2 (2,3) in the experimental group (Z = 4.15, p < 0.001). D, D*, and LSV were significantly correlated with pathologic staining in the assessment of liver fibrosis (r = −0.54 p = 0.015; r = −0.50, p = 0.025; r = 0.91, p < 0.001; respectively). These data suggest that TACE aggravates liver injury and liver fibrosis, especially surrounding the tumor, in a rabbit VX2 liver tumor model. IVIM DWI and SWE can be used to evaluate the change in liver fibrosis.

Practical utility of liver segmentation methods in clinical surgeries and interventions

Clinical imaging (e.g., magnetic resonance imaging and computed tomography) is a crucial adjunct for clinicians, aiding in the diagnosis of diseases and planning of appropriate interventions. This is especially true in malignant conditions such as hepatocellular carcinoma (HCC), where image segmentation (such as accurate delineation of liver and tumor) is the preliminary step taken by the clinicians to optimize diagnosis, staging, and treatment planning and intervention (e.g., transplantation, surgical resection, radiotherapy, PVE, embolization, etc). Thus, segmentation methods could potentially impact the diagnosis and treatment outcomes. This paper comprehensively reviews the literature (during the year 2012–2021) for relevant segmentation methods and proposes a broad categorization based on their clinical utility (i.e., surgical and radiological interventions) in HCC. The categorization is based on the parameters such as precision, accuracy, and automation.

Preparation of microspheres encapsulating sorafenib and catalase and their application in rabbit VX2 liver tumor

BACKGROUND

Transcatheter arterial chemoembolization (TACE) is extensively used in the treatment of advanced hepatocellular carcinoma (HCC). However, the efficacy of TACE is usually limited to secondary tumor hypoxia and hypoxia-related tumor angiogenesis.

METHODS

In this study, poly(lactic-co-glycolic acid) (PLGA) microspheres (SOR-CAT-PLGA MSs) encapsulating sorafenib (SOR) and catalase (CAT) were prepared by double-emulsion solvent diffusion method. Sorafenib inhibits tumor angiogenesis, and catalase decomposes hydrogen peroxide (H₂O₂) to generate oxygen in the tumor.

RESULTS

In vitro and in vivo, SOR -CAT-PLGA MSs could significantly improve the efficacy of hepatic artery embolization in the treatment of rabbit VX2 liver tumors, regulate tumor hypoxia and immunosuppressive microenvironment, then achieved near-complete and rapid necrosis of liver tumors.

CONCLUSIONS

The application of new SOR -CAT-PLGA MSs in hepatic artery chemoembolization of rabbit VX2 liver tumor is a promising approach to improve the therapeutic effect of liver tumors and has a broad clinical application prospect.

Reversed Lipid-Based Nanoparticles Dispersed in Iodized Oil for Transarterial Chemoembolization

Transarterial chemoembolization (TACE) is a promising treatment for patients suffering from unresectable liver malignancy. A coarse emulsion of doxorubicin solution and iodized oil is widely used in clinical practice. However, this coarse emulsion lacks sufficient physical stability and can split into water and oil very quickly. Furthermore, most chemotherapeutics are quickly released into systematic circulation, causing serious adverse effects. In this study, we aimed to prepare reversed lipid-based nanoparticles (RLBNs) dispersed in iodized oil as nanocarriers for the delivery of hydrophilic chemotherapeutics. Unlike a simple mixture of drug solution and oil, RLBN is a homogenous system and possesses a hydrophobic nanostructure that has high dispersibility in oils. Hydrophilic chemotherapeutics were entrapped in the polar core juxtaposed by highly biocompatible lipid materials, such as egg phospholipids. A sustained drug-release profile was observed in both in vitro and in vivo pharmacokinetics studies. The results of computed tomography showed that RLBN-doxorubicin-iodized oil could remain in the tumor region for more than 14 days and that the growth of tumors was effectively suppressed. Thus, the current results suggest that RLBN is a promising drug delivery system and is compatible with TACE treatment.

Long-term follow-up after conventional transarterial chemoembolization (c-TACE) with mitomycin for hepatocellular carcinoma (HCC)

Background

Conventional transarterial chemoembolization (c-TACE) is a common treatment for unresectable hepatocellular carcinoma (HCC). It is associated with increased overall survival (OS) when compared to conservative management. The purpose of this study is to analyze all c-TACE with mitomycin in patients with HCC at a single institution to determine safety, efficacy, and prognostic factors in a long-term follow-up.

Methods

Retrospective analysis of patients with HCC treated only with c-TACE with Mitomycin between 2007 and 2012. Efficacy was determined by OS at 1, 3, and 5 years, censored by date of death or last known follow-up. Treatment response was assessed according to mRECIST criteria and the degree of lipiodol uptake by the lesions was assessed by CT at 1-month follow-up. Prognostic factors were analyzed by multiple linear regression analysis, significance levels set at 0.05.

Results

A total of 60 patients were identified. OS rate at 1, 3 and 5 years was 72.1%, 47.8% and 39.3%, respectively. Median OS was 15 months. Tumor response by mRECIST criteria was complete; objective response, defined as combination of complete response (CR) and partial response (PR) patients, was 76%. When stratified by tumor response, risk of death in patients with progressive disease in 5 years was significantly higher compared to patients with objective response [hazard ratio (HR): 2.531, 95% confidence interval (CI): 1.110-5.778, P=0.0273]. Lipiodol uptake analysis was available in 51 patients; there was no statistically significant difference in OS in patients with higher lipiodol uptake compared to less uptake (<50% versus >50% uptake; HR: 0.713, 95% CI: 0.316-1.611, P=0.4161].

Conclusions

c-TACE with mitomycin was effective and safe in this long-term follow-up study. Risk of death was significantly higher in patients without objective tumor response.

Transarterial chemoembolization for unresectable hepatocellular carcinoma: A comparison of the efficacy and safety of 2 embolic agents

The aim of this study was to compare the efficacy and safety of 2 different embolic agents, namely gelatin sponge particle (GSP) and Lipiodol, for transarterial chemoembolization (TACE) of unresectable hepatocellular carcinoma (HCC).We retrospectively reviewed 87 consecutive patients with unresectable HCC who underwent Lipiodol TACE with lobaplatin and 87 consecutive patients with unresectable HCC who underwent GSP TACE with lobaplatin between January 2013 and June 2017 in our institution as the initial treatment. Both groups were compared considering the clinical and laboratory outcomes and imaging findings before and after TACE. Tumor response and adverse events were also evaluated.There was significant difference in the rate of complete and overall response between the groups (P = .029 and .001, respectively), specifically when the tumor size was >5 cm (P = .001). The disease control rate was significantly better in the GSP group than in the Lipiodol group (94.3% vs. 86.4%, P = .011). The response differences in higher stages were significant between the 2 groups (P = .035 and .007, respectively). The grades of adverse events were also significantly different between the groups (P = .000).GSP-as an embolic agent in TACE for HCC-could significantly increase the rate of tumor response 1 month after treatment, especially in large tumors, without any significant increase in severe adverse events, when compared to Lipiodol.

Transarterial chemoembolization combined with Huaier granule for the treatment of primary hepatic carcinoma: Safety and efficacy

To evaluate the safety and efficacy of transarterial arterial chemoembolization (TACE) with gelatin sponge particles (GSPs-TACE) and Huaier granule to treat primary hepatic carcinoma (PHC).A series of 62 patients with PHC were included between June 2009 and December 2011, and randomly assigned to a control (n = 31) or an experimental group (n = 31). The control patients received TACE with 350 to 560 μm GSPs plus lobaplatin chemotherapy. Patients in the experimental group received TACE plus Huaier granule. Treatment safety and mid-to-long-term efficacy were evaluated.Follow-up ranged from 12 to 24 months with a mean of 28.7 months. The 6- and 12-month overall survivals were 100% and 93.5% in the experimental group and 90.3% and 80.6% in control group, respectively. The difference in overall survival at 12 months was significant (χ = 5.213, P < .05), but the difference in median survival in the experimental group (20.6 months) and control group (17.1 months) patients was not significant (χ = 0.745, P > .05). The number of TACE procedures in the experimental group (2.9 ± 8.7) and control group (4.1 ± 7.3) patients was significantly different (χ = 7.262, P < .05). The 6-month (87.1% vs. 73.3%, χ = 5.945) and 12-month (72.4% vs. 64.3%, χ = 6.384) tumor objective response rates in the experimental and control groups were significantly different (P < .05). There were no statistically significant differences in the occurrence of treatment-related adverse reactions in the 2 groups.Transarterial chemoembolization with GSPs and Huaier granule was safe and effective for treating PHC patients.

Management of people with intermediate-stage hepatocellular carcinoma: an attempted network meta-analysis

BACKGROUND

There is significant uncertainty in the treatment of intermediate-stage hepatocellular carcinoma which is defined by the Barcelona Clinic Liver Cancer (BCLC) as hepatocellular carcinoma stage B with large, multi-nodular, Child-Pugh status A to B, performance status 0 to 2, and without vascular occlusion or extrahepatic disease.

OBJECTIVES

To assess the comparative benefits and harms of different interventions used in the treatment of intermediate-stage hepatocellular carcinoma (BCLC stage B) through a network meta-analysis and to generate rankings of the available interventions according to their safety and efficacy. However, we found only one comparison. Therefore, we did not perform the network meta-analysis, and we assessed the comparative benefits and harms of different interventions versus each other, or versus placebo, sham, or no intervention (supportive treatment only) using standard Cochrane methodology.

SEARCH METHODS

We searched the Cochrane Central Register of Controlled Trials (CENTRAL), MEDLINE, Embase, Science Citation Index Expanded, World Health Organization International Clinical Trials Registry Platform, and randomised clinical trials registers to September 2016 to identify randomised clinical trials on hepatocellular carcinoma.

SELECTION CRITERIA

We included only randomised clinical trials, irrespective of language, blinding, or publication status, in participants with intermediate-stage hepatocellular carcinoma, irrespective of the presence of cirrhosis, size, or number of the tumours (provided they met the criteria of intermediate-stage hepatocellular carcinoma), of presence or absence of portal hypertension, of aetiology of hepatocellular carcinoma, and of the future remnant liver volume. We excluded trials which included participants who had previously undergone liver transplantation. We considered any of the various interventions compared with each other or with no active intervention (supportive treatment only). We excluded trials which compared variations of the same intervention: for example, different methods of performing transarterial chemoembolisation.

DATA COLLECTION AND ANALYSIS

We used standard methodological procedures expected by Cochrane. We calculated the hazard ratio (HR) with 95% confidence intervals (CI) using both fixed-effect and random-effects models based on available-participant analysis with Review Manager. We assessed risk of bias according to Cochrane, controlled risk of random errors with Trial Sequential Analysis using Stata, and assessed the quality of the evidence using GRADE.

MAIN RESULTS

Three randomised clinical trials, including 430 participants, met the inclusion criteria for this review; however, data from two trials with 412 participants could be included in only one primary outcome (i.e. mortality). All three trials were at high risk of bias. All three trials included supportive care as cointervention. The comparisons included in the two trials reporting on mortality were: systemic chemotherapy with sorafenib versus no active intervention; and transarterial chemoembolisation plus systemic chemotherapy with sorafenib versus transarterial chemoembolisation alone. The trials did not report the duration of follow-up; however, it appeared that the participants were followed up for a period of about 18 to 30 months. The majority of the participants in the trials had cirrhotic livers. The trials included participants with intermediate-stage hepatocellular carcinoma arising from viral and non-viral aetiologies. The trials did not report the portal hypertension status of the participants. The mortality was 50% to 70% over a median follow-up period of 18 to 30 months. There was no evidence of difference in mortality at maximal follow-up between systemic chemotherapy versus no chemotherapy (hazard ratio 0.85, 95% CI 0.60 to 1.18; participants = 412; studies = 2; I² = 0%; very low quality evidence). A subgroup analysis performed by stratifying the analysis by the presence or absence of transarterial chemoembolisation as cointervention did not alter the results. None of the trials reported on serious adverse events other than mortality, health-related quality of life, recurrence of hepatocellular carcinoma, or length of hospital stay. One of the trials providing data was funded by the pharmaceutical industry, the other did not report the source of funding, and the trial with no data for the review was also funded by the pharmaceutical industry. We found two ongoing trials.

AUTHORS' CONCLUSIONS

Currently, there is no evidence from randomised clinical trials that people with intermediate-stage hepatocellular carcinoma would benefit from systemic chemotherapy with sorafenib either alone or when transarterial chemoembolisation was used as a cointervention (very low quality evidence). We need high-quality randomised clinical trials designed to measure differences in clinically important outcomes (e.g. all-cause mortality or health-related quality of life).

Lipiodol transarterial chemoembolization for hepatocellular carcinoma: A systematic review of efficacy and safety data

Transarterial chemoembolization (TACE) using lipiodol-based regimens, including the administration of an anticancer-in-oil emulsion followed by embolic agents, is widely used in the treatment of hepatocellular carcinoma (HCC). This approach has been supported by meta-analyses of randomized, controlled trials (RCTs) performed more than a decade ago. We performed a systematic review to understand current efficacy and safety data of lipiodol TACE in treatment of HCC. A search of the literature published between January 1, 1980 and June 30, 2013 was performed using MEDLINE and EMBASE databases. All potentially relevant publications were reviewed and articles were selected based on predefined inclusion and exclusion criteria. Of a total of 1,564 articles reviewed, 101 articles, including a total of 10,108 patients treated with lipiodol TACE, were selected for the efficacy analysis. Objective response rate was 52.5% (95% confidence interval [CI]: 43.6-61.5). Overall survival (OS) was 70.3% at 1 year, 51.8% at 2 years, 40.4% at 3 years, and 32.4% at 5 years. Median OS was 19.4 months (95% CI: 16.2-22.6). A total of 217 articles presenting precise description on numbers of adverse events (AEs) were selected for the safety review: In these studies, a total of 21,461 AEs were reported in 15,351 patients. Liver enzyme abnormalities were the most commonly observed AE, followed by the symptoms associated with postembolization syndrome. Overall mortality rate was 0.6% and the most common cause of death was related to acute liver insufficiency.

CONCLUSIONS

In a systematic literature review, survival figures of HCC patients undergoing lipiodol TACE appear to be in line with those reported in previous RCTs, and no new or unexpected safety concerns were identified. (Hepatology 2016;64:106-116).

Transarterial administration of integrin inhibitor loaded nanoparticles combined with transarterial chemoembolization for treating hepatocellular carcinoma in a rat model

AIM: To compare the effect of transarterial chemoembolization (TACE) plus GRGDSP (Gly-Arg-Gly-Asp-Ser-Pro, integrin-inhibitor) loaded nanoparticles with TACE alone or TACE + GRGDSP in a rat model of liver tumor.

METHODS: Morris hepatoma 3924A tumors were implanted in the livers of 30 ACI rats. The ACI rats were divided randomly into three groups (10 animals each). Tumor volume before treatment (V1) was examined by magnetic resonance imaging (MRI), and then, after laparotomy and placement of a PE-10 catheter into the hepatic artery, the following interventional protocols were performed: TACE (mitomycin C + lipiodol + degradable starch microspheres) + GRGDSP loaded nanoparticles for group A; TACE + GRGDSP for group B (control group 1); TACE alone for group C (control group 2). Tumor volume (V2) was assessed by MRI and the mean ratio of the post-treatment to pretreatment tumor volumes (V2/V1) was calculated. Immunohistochemical analysis was performed to assess the quantification of matrix metalloprotein 9 (MMP-9) and vascular endothelial growth factor (VEGF) positive tumor cells in each treatment group.

RESULTS: The mean tumor growth ratios (V2/V1) were 1.3649 ± 0.1194 in group A, 2.0770 ± 0.1595 in group B, and 3.2148 ± 0.1075 in group C. Compared with groups B and C, group A showed a significant reduction in tumor volume. Lower expression of MMP-9 and VEGF in hepatocellular carcinoma was observed in group A than in groups B and C. The angiogenesis of tumor was evaluated using anti-VEGF antibodies, and the metastasis of tumor was assessed using anti-MMP-9 antibody. MMP-9 and VEGF were expressed in all specimens. The immunoexpression of these proteins was confirmed by the presence of red cytoplasmic staining in tumor cells. Lower expression of MMP-9 and VEGF in hepatocellular carcinoma was observed in group A than in groups B and C.

CONCLUSION: Transarterial administration of integrin inhibitor loaded nanoparticles combined with TACE evidently retards tumor growth and intrahepatic metastases compared with TACE alone or TACE plus integrin inhibitor in an animal model of hepatocellular carcinoma.

Derived neutrophil to lymphocyte ratio predicts prognosis for patients with HBV-associated hepatocellular carcinoma following transarterial chemoembolization

The derived neutrophil to lymphocyte ratio (dNLR) has been proposed as an easily determinable prognostic factor for cancer patients, but the prognostic significance of the dNLR in hepatocellular carcinoma (HCC) has not been investigated. The present study aimed to validate the prognostic power of the NLR and dNLR in HCC patients undergoing transarterial chemoembolization (TACE). The data of 279 consecutive patients who underwent TACE for unresectable HBV-associated HCC between September 2009 and November 2011 at the Department of Hepatobiliary Surgery, Sun Yat-sen University Cancer Center (Guangzhou, China) were retrieved from a prospective database. The cut-off values for the NLR and dNLR were determined by receiver operating characteristic (ROC) analysis. The association between the NLR and dNLR and the clinicopathological characteristics and overall survival (OS) rates and times of patients was analyzed. The area under the curve (AUC) was calculated to evaluate the discriminatory ability of the NLR and dNLR. The median follow-up period was 446 days, the 1, 2 and 3-year OS rates were 38.8, 18.5 and 11.1% respectively, and the median OS time was 264 days. The cut-off values were determined as 2.6 and 1.8 for the NLR and dNLR, respectively. The NLR and dNLR were each associated with patient age, presence of vascular invasion, tumor size, AST level and ALP level. Multivariate analysis showed that the NLR, dNLR, ALT level and AFP level were independent prognostic factors for OS. An elevated NLR or dNLR was associated with a poor prognosis (P=0.001 and P=0.002, respectively). The prognostic power of NLR [AUC=0.539; 95% confidence interval (CI), 0.423-0.656] and dNLR (AUC=0.522; 95% CI, 0.406-0.638) was similar. Elevated dNLR predicted poor prognosis for patients with HBV-associated HCC undergoing TACE, with similar prognostic power to NLR. The dNLR may be used as an alternative to the NLR, as it is easily available and inexpensive.

Lipiodol versus diaphragm in 4D-CBCT-guided stereotactic radiotherapy of hepatocellular carcinomas

PURPOSE

The purpose of this work was to investigate the potential of lipiodol as a direct tumor surrogate alternative to the diaphragm surrogate on four-dimensional cone-beam computed tomography (4D-CBCT) image guidance for stereotactic radiotherapy of hepatocellular carcinomas.

METHODS

A total of 29 hepatocellular carcinomas (HCC) patients treated by stereotactic radiotherapy following transarterial chemoembolization (TACE) with homogeneous or partial defective lipiodol retention were included. In all, 4-7 pretreatment 4D-CBCT scans were selected for each patient. For each scan, either lipiodol or the diaphragm was used for 4D registration. Resulting lipiodol/diaphragm motion ranges and position errors relative to the reconstructed midventilation images were analyzed to obtain the motion variations, and group mean (ΔM), systematic (Σ), and random (σ) errors of the treatment setup.

RESULTS

Of the lipiodolized tumors, 55 % qualified for direct localization on the 4D-CBCT. Significant correlations of lipiodol and diaphragm positions were found in the left-right (LR), craniocaudal (CC), and anteroposterior (AP) directions. ΔM and σ obtained with lipiodol and diaphragm were similar, agreed to within 0.5 mm in the LR and AP, and 0.3 mm in the CC directions, and Σ differed by 1.4 (LR), 1.1 (CC), and 0.6 (AP) mm. Variations of diaphragm motion range > 5 mm were not observed with lipiodol and in one patient with diaphragm. The margin required for the tumor prediction error using the diaphragm surrogate was 6.7 (LR), 11.7 (CC), and 4.1 (AP) mm.

CONCLUSION

Image-guidance combining lipiodol with 4D-CBCT enabled accurate localization of HCC and thus margin reduction. A major limitation was the degraded lipiodol contrast on 4D-CBCT.

Downregulation of matrix metalloproteinases contributes to the inhibition of cell migration and invasion in HepG2 cells by sodium valproate

Histone deacetylation levels are closely associated with the genesis and development of tumors. However, the anti-tumor effect and mechanism of class I histone deacetylase inhibitor sodium valproate (VPA) on hepatocellular carcinoma cells has not been demonstrated clearly. In the present study, HepG2 hepatocellular carcinoma cells were exposed to VPA, and the effects of VPA on the proliferation, apoptosis, metastasis and invasion of the cells were evaluated. The MTT method and colony assays were used to detect cell proliferation, and cell migration and Transwell invasion were also evaluated. In addition, the protein expression levels of matrix metalloproteinase (MMP)-2 and MMP-9 were measured by flow cytometric analysis. The results indicated that VPA was able to inhibit proliferation and reverse the malignant phenotypes of hepatocellular carcinoma cells by inducing cell apoptosis. Furthermore, the colony formation and migration abilities of HepG2 cells were downregulated by VPA. Protein expression levels of MMP-2 and MMP-9 in HepG2 cells were also downregulated following VPA treatment, which contributed to suppression of the migration and invasion ability of HepG2 cells.

Radiofrequency ablation combined with transcatheter therapy in rabbit VX2 liver tumors: effects and histopathological characteristics

BACKGROUND

Transarterial chemoembolization (TACE) combined with radiofrequency ablation (RFA) treatment (TACE-RFA) has been confirmed superior to TACE or RFA alone in animal liver tumors. TACE before RFA was shown to increase hepatocellular damage. Further optimization of the combination strategy for transcatheter arterial embolization (TAE) or TACE combined with RFA is warranted.

PURPOSE

To determine the optimal strategy for radiofrequency ablation combined with transcatheter therapies in VX2 liver tumors in a rabbit model.

MATERIAL AND METHODS

Twenty-four Japanese White rabbits with VX2 liver tumors were randomly divided into four groups: TACE-RFA (TACE-RFA group), transcatheter arterial embolization (TAE) combined with RFA treatment (TAE-RFA group), RFA only group, and TACE only group. Blood samples were collected 1 day before the operation and at 3 and 7 days postoperatively. Seven days after the operation, maximal diameters of coagulation or infarcted zones in the gross specimens, CT images, histopathological characteristics, tumor necrotic rate, and growth rate were compared.

RESULTS

Significantly larger mean long-axis (P < 0.05) and short-axis (P < 0.05) diameters of coagulation and infarction were observed in the TACE-RFA group compared with the TAE-RFA, RFA, and TACE groups on day 7; and the TAE-RFA group showed a significant (P < 0.05) increase versus the RFA and TACE groups on day 7. There were no significant differences in tumor growth rate (109.3 ± 37.5 vs. 119.0 ± 43.1%, P = 0.45) and necrotic rate (89.5 ± 12.0 vs. 83.5 ± 9.3%, P = 0.73) between the TACE-RFA and TAE-RFA groups. TACE-RFA was more effective for achieving tumor destruction than the other treatment strategies, but led to increased rabbits discomfort and more severe liver dysfunction compared with TAE-RFA.

CONCLUSION

TAE-RFA appears to be a beneficial therapeutic modality for treating VX2 liver tumors in a rabbit model.

Activation of the intrinsic apoptosis pathway contributes to the induction of apoptosis in hepatocellular carcinoma cells by valproic acid

The level of histone deacetylation is closely associated with the genesis and development of tumors, but the antitumor effect and mechanism of the class I histone deacetylase inhibitor (HDACI) valproate acid sodium (VPA) on hepatocellular carcinoma cells has not been clearly demonstrated. In the present study, the antitumor effect and mechanism of VPA were measured in vitro. Firstly, it was found that, as an HDAC inhibitor, VPA could inhibit HDAC activity and HDAC1 gene expression in hepatocellular carcinoma cells and, as a result, an inhibition of cell proliferation was detected by MTT assay. Subsequently, the cell cycle and cell apoptosis profiles were analyzed using flow cytometry (FCM). The expression of the mRNA and protein of cyclins A, D1 and E and P21^Waf/cip1 was measured by reverse transcription-polymerase chain reaction and FCM analysis to determine the molecular mechanism of VPA-induced cell cycle arrest. The activity and mRNA and protein expression of caspases 3, 8 and 9 were detected to determine the apoptotic pathway. Caspase expression was blocked by caspase inhibitors in order to observe whether the intrinsic or extrinsic pathway contributed to HepG2 cell apoptosis. The results revealed that the mRNA and protein expression of cyclins A and D1 was downregulated while the expression of P21^Waf/cip1 was upregulated by VPA. The expression of cyclin E was only slightly affected by VPA. The mRNA and protein expression and activity of caspases 3 and 9 were upregulated by VPA. By contrast, inhibitors of caspases 3 and 9 could reverse cell apoptosis and there was no notable change in caspase 8 expression in any of these experiments. The intrinsic apoptosis pathway, but not the death receptor pathway, contributed to the induction of apoptosis in hepatocellular carcinoma cells. Furthermore, VPA could inhibit the proliferation of hepatocellular carcinoma cells by inducing G₁ phase arrest and cell apoptosis. These effects were attributed to the change in the caspase level.

Nonsurgical treatment for localized hepatocellular carcinoma

The most common non-surgical approaches for the treatment of localized hepatocellular carcinoma remain hepatic artery-delivered particles laden with chemotherapy (TACE), or radioactive microparticles (TARE). External beam radiotherapy has been an effective option in many parts of the world for selected HCC patients, but now has an expanded role with stereotactic and proton beam technologies. This review focuses on existing evidence and current guidance for utilizing these modalities for localized, but unresectable, non-transplantable HCC patients.x.

Treatment of intermediate-stage hepatocellular carcinoma

Hepatocellular carcinoma (HCC)-closely associated with liver cirrhosis and, in fact, the main cause of death in patients with such disease-is now recognized as one of the most-prevalent and lethal neoplasms worldwide. Prognosis and allocation of the multiple available treatment options for patients with HCC are influenced not only by tumour stage, but also by the degree of liver-function impairment. Therefore, accurate assessment and classification of disease is important for patient management. According to the Barcelona Clinic Liver Cancer (BCLC) algorithm, intermediate-stage HCC is defined as extensive multifocal disease without vascular invasion in patients with preserved liver function and absence of cancer-related symptoms; in this context, transarterial chemoembolization (TACE) is considered the standard treatment. The use of drug-eluting beads has enabled standardization of this procedure, resulting in higher reproducibility and tolerability of the treatment. Nevertheless, not all patients with intermediate-stage HCC are good candidates for TACE and, for such patients in whom TACE is not appropriate or has failed, other treatments can be considered, including sorafenib. Radioembolization is a promising alternative that deserves further prospective studies. Herein, we review the current approaches used to accurately stratify patients with intermediate-stage HCC and subsequently allocate the most-appropriate treatments. The key developments in therapeutic strategies are also discussed.

Treatment of intermediate-stage hepatocellular carcinoma

Hepatocellular carcinoma (HCC)-closely associated with liver cirrhosis and, in fact, the main cause of death in patients with such disease-is now recognized as one of the most-prevalent and lethal neoplasms worldwide. Prognosis and allocation of the multiple available treatment options for patients with HCC are influenced not only by tumour stage, but also by the degree of liver-function impairment. Therefore, accurate assessment and classification of disease is important for patient management. According to the Barcelona Clinic Liver Cancer (BCLC) algorithm, intermediate-stage HCC is defined as extensive multifocal disease without vascular invasion in patients with preserved liver function and absence of cancer-related symptoms; in this context, transarterial chemoembolization (TACE) is considered the standard treatment. The use of drug-eluting beads has enabled standardization of this procedure, resulting in higher reproducibility and tolerability of the treatment. Nevertheless, not all patients with intermediate-stage HCC are good candidates for TACE and, for such patients in whom TACE is not appropriate or has failed, other treatments can be considered, including sorafenib. Radioembolization is a promising alternative that deserves further prospective studies. Herein, we review the current approaches used to accurately stratify patients with intermediate-stage HCC and subsequently allocate the most-appropriate treatments. The key developments in therapeutic strategies are also discussed.

[Thermoablative therapy of hepatocellular carcinoma. Indications, technique and results]

Hepatocellular carcinoma (HCC) is one of the most frequent malignancies worldwide. Besides liver transplantation, which is only feasible in few patients and surgical resection, the scope of potential treatment options has considerably expanded in recent years. Thermoablative therapies are now well established in early HCC due to the low rate of complications and short hospital stay. The disadvantage of higher relapse rates compared to surgical resection will be further diminished through technical advances regarding radiofrequency ablation and microwave ablation, as well as growing experience of users and thorough multidisciplinary selection of potential candidates for thermoablative therapy.

Effect of Cantharidins in Chemotherapy for Hepatoma: A Retrospective Cohort Study

This study aimed to evaluate the effects of cantharidins, a traditional Chinese medicine, in chemotherapy for the treatment of hepatoma. From August 2011 to December 2012, 96 patients with hepatoma, who were eligible for transcatheter hepatic arterial chemoembolization and received cantharidins, were selected for comparison with the control group of 95 patients without cantharidins. The treatment effect, clinical symptoms and adverse effects were analyzed. The results of the study showed that the cantharidins group had a higher overall efficient rate than the control group (p < 0.001). The improvement rate of the Karnofsky score in the cantharidins group was significantly higher than that of the control group (p = 0.014). In the cantharidins group, there was a decrease in white blood cell (WBC) count and gastrointestinal response rates were lower than those of the control group (p < 0.05). Therefore, the traditional Chinese medicine cantharidins showed effects of easing the progress of liver cancer, relieving side effects of chemotherapy and improving the quality of life in the treatment of hepatoma.

Therapeutic effect and tolerability of gelatin sponge particle-mediated chemoembolization for colorectal liver metastases: a retrospective study

Background

Colorectal cancer (CRC) is one of the most common cancers worldwide. The majority (approximately 60%) of patients with CRC will eventually develop liver metastases, which remain the most common cause of mortality in these patients. This study aimed to evaluate the therapeutic effect and tolerability of gelatin sponge particle (GSP)-mediated chemoembolization in the treatment of colorectal liver metastases after systemic chemotherapy failure.

Methods

This was a single-center retrospective study of 15 patients with colorectal liver metastases, who underwent GSP-mediated chemoembolization with 50 mg of lobaplatin during the period December 2009 to December 2010 in the Department of Interventional Radiology, Affiliated Zhongshan Hospital of Dalian University. Clinical data were retrieved, and the therapeutic effect and tolerability of the treatment were evaluated.

Results

All 15 patients with colorectal liver metastases completed the GSP-mediated chemoembolization. The therapeutic effect and tolerability were evaluated 3 months after the initial procedure. The tumor lesions in all patients showed various levels of necrosis and shrinkage. According to the Response Evaluation Criteria in Solid Tumors (RECIST), one patient achieved complete response (CR), eleven patients achieved partial response (PR), and three patients achieved stable disease (SD). The overall response rate (CR + PR) was 80%.

Conclusions

GSP-mediated chemoembolization is well tolerated and has a good short-term response rate (80%) in the treatment of colorectal liver metastases after systemic chemotherapy failure. Collectively, further study of the long-term effect of GSP-mediated chemoembolization in colorectal liver metastasis in a large cohort is warranted.

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.

Simultaneous injection of autologous mononuclear cells with TACE in HCC patients; preliminary study

BACKGROUND

The discovery of the pluripotent stem cells made the prospect of cell therapy and tissue regeneration a clinical reality, especially with the evidence of contribution of the stem cells of bone marrow origin in hepatic regeneration. Infusion of bone marrow stem cells before trans-arterial chemoembolization may help to increase liver volume and consequently increase hepatic reserve in patients with HCC, and this may improve the outcome of this procedure.

MATERIALS AND METHODS

Four Child B class patients with unresectable hepatocellular carcinoma treated by transarterial chemoembolization were injected with autologous bone marrow mononuclear layer containing stem cell in the hepatic artery feeding the contralateral lobe of the liver in the same session, follow-up of the patients was done by doing liver profile and CT liver volumetry before the surgery and 3 months later.

RESULTS

We observed that patients receiving stem cell therapy simultaneously with TACE had shown a significant improvement in biological and volumetric parameters of liver function compared to those historically reported of patients receiving TACE only who usually shows deterioration of liver parameters.

CONCLUSION

BMC infusion into the hepatic artery synchronized with TACE for patients with chronic liver disease complicated with HCC is safe, feasible, and demonstrated an improvement in both biological and radiological volumetric parameters.

Hepatic arterial iodine-131-labeled metuximab injection combined with chemoembolization for unresectable hepatocellular carcinoma: interim safety and survival data from 110 patients

Few options are available to treat patients with hepatocellular carcinoma (HCC). It was tested whether the combination of iodine-131(¹³¹I)-metuximab with chemoembolization could improve outcomes in patients with intermediate HCC. Between April 2008 and April 2009, 110 patients with unresectable HCC were treated with 113 intra-arterial ¹³¹I-metuximab injections combined with chemoembolization (mean, 1.03 per patient; median, 1; range, 1-2), followed by 264 sessions of transcatheter arterial chemoembolization (mean, 2.4 per patient; median, 3; range, 1-6). The survival rates at 6, 12, and 18 months were 88.2%, 79.1%, and 57.4%, respectively, by the Kaplan-Meier method. Of these patients, 12% exhibited grade 3/4 bilirubin toxicity, 5% exhibited grade 3/4 white blood count toxicity, and 7% exhibited grade 3/4 platelet toxicity. Response rates based on World Health Organization and European Association for the Study of the Liver criteria were 42.73% and 61.82%, respectively. The combination of ¹³¹I-metuximab and chemoembolization appeared to extend survival in patients with unresectable HCC compared with historical controls, as well as being well tolerated by patients with Child-Pugh A and B. This combination may represent a promising treatment modality for patients with intermediate HCC.

Safety profile of sequential transcatheter chemoembolization with DC Bead™: results of 237 hepatocellular carcinoma (HCC) patients

INTRODUCTION

Complications of chemoembolization performed with DC Bead(™) loaded with doxorubicin (DEBDOX) of diameters 100-300 μm and 300-500 μm are presented in this paper. These diameters are currently the smallest available in drug-eluting technology.

METHODS

Included are 237 patients who were treated with sequential DEBDOX with doxorubicin loaded at 37.5 mg/ml of DC Bead. The National Cancer Institute Common Terminology Criteria for Adverse Events (version 3.0) were used to categorize complications.

RESULTS

Thirty-day mortality was 1.26% (3/237). Incidence of grade 5 complications was 1.26% (3/237). Overall, grade 4 complications resulted in 5.48% (13/237) (irreversible liver failure, cholecystitis). Grade 2 liver function deterioration developed in 10 patients (4.2%). Cholecystitis/grade 2 and 4 incidents were observed in 3.6-5.06% across sessions (overall 13 patients; 5.48%). Postembolization Syndrome (PES) grade 1 or 2 was observed in up to 86.5%; however, grade 2 was observed in 25-42.19% across treatments. Pleural effusion was seen in eight patients (overall 3.37%; grade 1 in 1.8-3.7% across treatments; grade 3 in 0.42%). Grade 1 procedure-related laboratory pancreatitis was seen in 0.45%, and grade 2 gastrointestinal bleeding was seen in 0.84%. Procedure-associated skin erythema/grade 1 was seen in 0.84%. There was no correlation of liver failure or transient liver function deterioration with the diameter of the beads (p = 0.25-0.37 and p = 0.14-0.89, respectively). Stratifying with the diameter of the beads correlation values was: for cholecystitis (p = 0.11-0.96 across treatments), PES (p = 0.35-0.83), temporary/grade 1 elevation of liver enzymes (p = 0.002-0.0001), and bilirubin (p = 0.04-0.99).

CONCLUSIONS

DEBDOX chemoembolization is safe and small calibres do not result in increased complication rates compared with results of series using larger diameters of beads.

Usefulness of C-arm angiographic computed tomography for detecting iodized oil retention during transcatheter arterial chemoembolization of hepatocellular carcinoma

Transcatheter arterial chemoembolization (TACE) with iodized oil and anticancer agents is widely used for hepatocellular carcinoma (HCC) treatment. To assess C-arm angiographic computed tomography (CCT) for detecting iodized oil retention during TACE, CCT images were obtained of 40 tumours (24 HCC patients). The primary CCT images showed complete iodized oil retention patterns (type I) in 29/40 (73%) tumours, at which point embolization was terminated; incomplete iodized oil retention requiring further iodized oil embolization occurred in 11/40 (28%) tumours and, of these, complete iodized oil retention patterns were achieved in eight tumours. Conventional CT scanning employed 1 week later showed the same iodized oil retention patterns as demonstrated in the latest CCT images (37/40 [93%] tumours). In 24 additional HCC patients who underwent TACE but not CCT (control group), conventional CT scans obtained 1 week after TACE showed complete iodized oil retention in 32/42 (76%) tumours. The rate of complete iodized oil retention pattern was significantly higher in patients undergoing CCT. It is concluded that the distribution of iodized oil within HCC lesions can be demonstrated on CCT images during TACE, helping to achieve complete iodized oil filling of tumours and, thereby, improving therapeutic effects.

Multiple ischemic strokes after transcatheter arterial chemoembolization for hepatocellular carcinoma with a radiographic and pathological correlate

INTRODUCTION

Transcatheter arterial chemoembolization (TACE) is a widely used form of therapy in advanced hepatocellular carcinoma. We report the first pathological data from an autopsy case of multiple cerebral emboli occurring during TACE.

METHODS

A Medline search for previous cases of cerebral embolism and TACE revealed 11 other cases.

FINDINGS

Multiple microscopic subacute infarcts were found in the cerebrum, midbrain, and cerebellum of our patient on autopsy, but no embolic material was seen. Embolic material was noted in dilated vessels throughout the fibrotic right diaphragm and in the upper lobe of the right lung. Combining the literature search with our patient, the mortality of cerebral embolism after TACE is 25% (n = 12). Intracardiac shunts were seen in 20% of the cases (n = 10). Hyperdense lesions were seen on head CT in 80% of the patients evaluated (n = 10). Chest imaging revealed infiltrate or consolidation in 60% of the cases (n = 5). Pulmonary emboli were reported in 100% of the cases (n = 8).

CONCLUSIONS

Cerebral embolism after TACE is devastating. Brain pathology supports embolization of ethiodized oil rather than DC beads as the mechanism of cerebral injury. Further pathological studies are needed to better understand the pathophysiology of this condition. Lung pathology confirmed the presence of embolic material in the distal lung, suggestive of a hepatopulmonary shunt undetectable by current modalities. Evaluation for such shunts with emerging modalities such as TCD with emboli detection may be an area of future research.

Comparison of survival rates between patients treated with transcatheter arterial chemoembolization and hepatic resection for solitary hepatocellular carcinoma

The present study aimed to retrospectively compare the survival rates between patients treated with transcatheter arterial chemoembolization and hepatic resection for solitary hepatocellular carcinoma (HCC). According to our database, derived from three affiliated hospitals, the inclusion criteria for this study were: solitary HCC [Child-Pugh class A and International Union Against Cancer (UICC) stage T1-3N0M0] treated between July 1990 and October 2001. Subsequently, hepatic resection (149 patients) as well as chemoembolization (102 patients) groups were selected. Following stratification according to tumor stage [UICC, Cancer of the Liver Italian Program (CLIP) and Milan criteria], survival rates were compared between the treatment groups. Survival rates were calculated using the Kaplan-Meier method. Age, gender and size of the HCC did not differ significantly between the groups. Moreover, no significant difference in the survival rates (average hepatic resection, 58.9 months; average chemoembolization, 45 months; P=0.1697) was observed between the groups. In the subgroup analysis, according to tumor stage, the survival rate was significantly higher for the hepatic resection group than for the chemoembolization group in the UICC T3N0M0 (P=0.017) subgroup. However, no significant differences in survival rates were observed between the hepatic resection and chemoembolization groups for UICC T1 (P=0.7329), T2N0M0 (P=0.5741), CLIP0 (P=0.3593), CLIP1-2 (P=0.3287) and within (>5 cm; P=0.4429) and beyond Milan criteria (≤5 cm; P=0.4003) subgroups. Chemoembolization is as effective as hepatic resection in treating solitary HCC in subpopulations with UICC T1-2N0M0 or CLIP 0-2 HCC or Milan criteria and adequate liver function. In the subgroup with UICC T3N0M0 HCC, hepatic resection is superior to chemoembolization.

Chemoembolization of hepatic malignancy

Treatment of primary and secondary hepatic malignancies with transarterial chemoembolization represents an essential component of interventional oncology. This article discusses patient selection, procedure technique, results, and complications associated with transarterial chemoembolization.

CD24 is a novel predictor for poor prognosis of hepatocellular carcinoma after surgery

PURPOSE

To investigate the role of CD24 in tumor invasion and prognostic significance in hepatocellular carcinoma (HCC).

EXPERIMENTAL DESIGN

CD24 expression was measured in stepwise metastatic HCC cell lines, tumor, peritumoral tissues, and normal liver tissues by quantitative real-time PCR and Western blot. The role of CD24 in HCC was investigated by CD24 depletion using small interfering RNA. Tumor tissue microarrays of 314 HCC patients who underwent resection between 1997 and 2000 were used to detect expression of CD24, beta-catenin, and proliferating cell nuclear antigen. Prognostic significance was assessed using Kaplan-Meier survival estimates and log-rank tests.

RESULTS

CD24 was overexpressed in the highly metastatic HCC cell line and in tumor tissues of patients with recurrent HCC. Depletion of CD24 caused a notable decrease in cell proliferation, migration, and invasiveness in vitro. Univariate and multivariate analyses revealed that CD24 was a significant predictor for overall survival and relapse-free survival. CD24 expression was correlated with poor prognosis independent of alpha-fetoprotein, tumor-node-metastasis stage, and Edmondson stage. High CD24 expression was significantly associated with cytoplasmic and nuclear accumulation of beta-catenin (P = 0.023), high tumor proliferative status (P = 0.018), and diffused intrahepatic recurrence and distant metastasis (P = 0.026). Adjuvant transcatheter arterial chemoembolization after surgery reduced the rate of early recurrence (<or=1 year) in CD24(+) HCC patients (P = 0.024) but had no significant effect in CD24(-) patients (P = 0.284).

CONCLUSIONS

Overexpression of CD24 in HCC was associated with high invasiveness and metastatic potential, high tumor proliferation status, and activation of the Wnt/beta-catenin pathway. CD24 may be a novel predictor for poor prognosis of HCC patients after surgery.

[Cerebral lipiodol embolism after transcatheter arterial chemoembolization of hepatocellular carcinoma]

Transcatheter arterial chemoembolization (TACE) is the mainstay of treatment for unresectable hepatocellular carcinoma (HCC). Although various complications of TACE have been reported, cerebral lipiodol embolism after TACE is rare. We report a 67-year-old man, who had patent foramen ovale and developed cerebral lipiodol embolism after TACE via the inferior phrenic artery. At 20 months after third TACE of 3 cm sized HCC in the left hepatic lobe, computed tomography (CT) revealed about 1.6 cm newly developed HCC in the anterior superior segment of right hepatic lobe. The angiogram revealed the HCC was supplied from the right inferior phrenic artery. Toward the end of TACE, there were accumulations of the iodized oil in the pulmonary vasculature. Immediately after TACE, he complained of weakness in right upper and lower limbs and sensory decrease in right limbs and right hemitrunk. Magnetic resonance imaging revealed a cerebral lipiodol embolism. Transesophageal echocardiography revealed no visible thrombi but contrast-echocardiography using hand agitated saline revealed an intracardiac right to left shunt consistent with patent foramen ovale. Motor weakness and sensory decrease were gradually improved, and all neurological symptoms disappeared over 4 weeks.

Arterial chemoembolization/embolization and early complications after hepatocellular carcinoma treatment: a safe standardized protocol in selected patients with Child class A and B cirrhosis

PURPOSE

To assess the safety of transarterial treatments of hepatocellular carcinoma (HCC), and the statistical correlation of various patient factors with the frequency of complications, in selected patients with cirrhosis when adhering to well-standardized protocols.

MATERIALS AND METHODS

Three hundred twenty consecutive patients with unresectable HCC were treated with transarterial chemoembolization, oil chemoembolization, and embolization. A total of 712 treatments were performed, with an average of 2.3 treatments for each patient. The epirubicin dose was adjusted according to defined laboratory criteria. An early complication was defined as one that occurred within 4 weeks of treatment. Complications were classified as minor and major and assessed by using clinical and laboratory data.

RESULTS

Of the 712 procedures, 21 complications (2.9%) occurred in 17 of the 320 patients (5.3%). Major complications included acute liver failure (n = 1, 0.1%), variceal bleeding (n = 2, 0.3%), moderate-to-severe ascites (n = 4, 0.6%), sepsis (n = 3, 0.4%), cholecystitis (n = 1, 0.1%), and diverticulitis (n = 1, 0.1%). Minor complications were hepatic artery damage, including spontaneously resolved dissection (n = 3, 0.4%), mild encephalopathy (n = 1, 0.1%), and aspartate aminotransferase/alanine aminotransferase levels greater than 500 U/L (n = 5, 0.7%). The 30-day mortality rate was 0.003% (n = 1). Constitutional syndrome (P = .0001), Child-Pugh score (P = .0001), ascites (P = .037), and the Model for End-Stage Liver Disease score (P = .02) were found to have a statistically significant correlation with complications after univariate analysis. Child-Pugh score (P = .012) and constitutional syndrome (P = .003) were found to have a statistically significant correlation with complications after logistic regression analysis.

CONCLUSIONS

Transarterial treatments can be considered safe in patients with Child class A and B cirrhosis when an adjusted dose of epirubicin is used according to body surface, severity of liver disease, and white blood cell count. Accurate patient selection and procedure-related factors may reduce the frequency of complications and help preserve liver function.

Drug-eluting particles in the treatment of HCC: chemoembolization with doxorubicin-loaded DC Bead

The advantage of chemoembolization of the liver as an antineoplastic treatment for hepatocellular carcinoma is that it achieves high intratumoral concentrations of the chemotherapeutic agent locally that cannot be reached with systemic chemotherapy in nontoxic doses. However, chemotherapeutic release and local concentrations cannot be standardized by this technique. Drug-eluting beads have predictable pharmacokinetics and can achieve higher doses of the chemotherapeutic and prolonged contact time with cancer cells. The DC Bead is a drug-eluting bead that has proven favorable kinetics and clinical characteristics. This review describes the features of the DC Bead loaded with doxorubicin for the treatment of hepatocellular carcinoma.

TACE versus TAE as therapy for hepatocellular carcinoma

Transarterial chemoembolization (TACE) improves survival in cirrhotic patients with hepatocellular carcinoma (HCC). The optimal schedule, best anticancer agent and best technique are still unclear. TACE may not be better than transarterial embolization (TAE). HCC is very chemoresistant, thus embolization may be more important than chemotherapy. Lipiodol cannot be considered as an embolic agent and there are no data to show that it can release chemotherapeutic agents slowly. It can mask residual vascularity on CT imaging and its use is not recommended. Both TACE and TAE result in hypoxia, which stimulates angiogenesis, promoting tumor growth; thus combination of TACE with antiangiogenic agents may improve current results. To date, there is no evidence that TACE pre-liver transplantation or resection helps to expand current selection criteria for patients with HCC, nor results in less recurrence after surgery. Combination with other techniques, such as radiofrequency ablation and drugs, may enhance the effect of TACE. New trials are being conducted to clarify these issues.

Cerebral and pulmonary embolisms after transcatheter arterial chemoembolization for hepatocellular carcinoma

A cerebral lipiodol embolism is an extremely rare complication of transcatheter arterial chemoembolization for hepatocellular carcinoma. We present a case of cerebral lipiodol embolism that occurred after the third arterial chemoembolization, report the clinical and radiological findings, and review the medical literature.

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

OBJECTIVE

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

MATERIAL AND METHODS

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

RESULTS

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

CONCLUSIONS

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

Transcatheter arterial chemoembolization (TACE) with lipiodol to treat hepatocellular carcinoma: survey results from the TACE study group of Japan

The purpose of this study was to retrospectively clarify the current status in Japan of TACE using Lipiodol together with anticancer agents to treat hepatocellular carcinoma (HCC). We retrospectively surveyed 4,659 (average annual total) procedures for HCC over the years 2002-2004 at 17 institutions included in the TACE Study Group of Japan. The survey included six questions that were related mainly to TACE and Lipiodol for HCC treatment. The most frequently applied among the 4,659 procedures at the 17 institutions were TACE (2,310; 50%) and local ablation (1,395; 30%). Five of the institutions applied 201-300 procedures and 4 applied 101-200. Lipiodol was used in "all procedures" and in "90% or more" at seven and nine institutions, respectively. Almost all institutions applied 4-6 (mean, 5) ml of Lipiodol during TACE to treat tumors 5 cm in diameter. In conclusion, this survey clarified that TACE using Lipiodol and anticancer agents is a popular option for HCC treatment in Japan.