Abstract
BackgroundThe ultimate goal of locoregional therapy (LRT) to the liver is to induce total tumor necrosis. Trans-arterial chemoembolization (TACE) is the mainstay bridging therapy for patients with hepatocellular carcinoma (HCC) waiting for liver transplantation (LT). However, tumor response rate is variable. The purpose of this study was to correlate HCC radiological appearance with level of tumor necrosis during explant analysis from patients undergoing LT who received pre-LT TACE.MethodsFrom January 2000 to December 2018, a total of 66 patients with HCC who had been treated prior to LT by means of TACE were analyzed. Diagnosis of HCC was made based on AASLD guidelines and confirmed via histopathology explant analysis. Radiologic tumor response after TACE was based on modified Response Evaluation Criteria in Solid Tumors (mRECIST). Degree of tumor necrosis was determined by histopathology analysis of liver explants. HCC radiological appearances on CT before TACE were assessed and correlated with histological findings after LT.ResultsEighty nine TACE procedures (1.35 ± 0.67; 1–4) were performed, of which 18 were repeated TACE (27.3%) procedures. In 56.1% of the patients, ≥90% (near-complete) tumor necrosis was achieved. Concordance between mRECIST criteria and pathology was observed in 63% of the patients, with an underestimation of tumor response in 18 (27%) patients and an overestimation in 6 (9.1%). Near-complete tumor necrosis upon pathological analysis was associated with tumor hyper-enhancement in the arterial phase (P = 0.002), “typical tumor enhancement” (P = 0.010) and smooth tumor margins (p = 0.011). The multivariate analysis showed that well circumscribed HCCs with smooth margins and arterial hyper-enhancement independently correlated with post-TACE near-complete histological tumor necrosis.ConclusionsThe well circumscribed HCC lesions with arterial hyper-enhancement are more susceptible to TACE than lesions with arterial phase iso or hypo-enhancement and lesions with infiltrative appearance. Pre-TACE CT imaging may ease the selection of an optimal treatment strategy for bridging patients with HCC to liver transplantation.
Highlights
The ultimate goal of locoregional therapy (LRT) to the liver is to induce total tumor necrosis
While only 13% (2 patients) of type B and C tumors showed near complete necrosis in the explant analysis, the proportion was 5 to 6 times higher (69%, 35 patients) in their type A counterparts (p = 0.000). These findings suggest that the use of parameters related to enhancement and margin may aid in the prediction of the Transarterial chemoembolization (TACE) outcome, and it may be helpful to consider both variables concomitantly before subjecting patients to a procedure
Based on over 138 nodules in 66 patients, our results suggest that CT may tend to underestimate tumor necrosis, with a low positive predictive value (55.2%), but may offer an acceptable level of accurancy in detecting complete necrosis (76.2%)
Summary
The ultimate goal of locoregional therapy (LRT) to the liver is to induce total tumor necrosis. Transarterial chemoembolization (TACE) is the mainstay bridging therapy for patients with hepatocellular carcinoma (HCC) waiting for liver transplantation (LT). The purpose of this study was to correlate HCC radiological appearance with level of tumor necrosis during explant analysis from patients undergoing LT who received pre-LT TACE. Locoregional therapy (LRT) as a bridging strategy for patients on the waitlist aims to prevent tumor progression and shrink tumors to maintain transplant eligibility [4, 5]. Considering that incomplete necrosis can be a risk factor for post-LT HCC recurrence [7], the ultimate goal of TACE is to induce total tumor necrosis
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