Bland Transarterial Embolization Research Articles

7960 Clinical Outcomes of Image-Guided Therapies In Patients With Adrenocortical Carcinoma: A Tertiary Referral Center Retrospective Study

Abstract Disclosure: B. Chahla: None. K. Pal: None. V. Balderrama Brondani: None. F. Yaylaci Mert: None. M. Campbell: None. R. Sheth: None. M.A. Habra: None. Background: Image-guided therapies (IGTs) such as cryoablation or embolization are commonly used in oncology, but their role in adrenocortical carcinoma (ACC) is not well-defined. Materials and Methods: A retrospective review of ACC patients treated with IGTs. We assessed time to next line of systemic therapy, disease control rate (DCR), local tumor progression-free survival (LTPFS), and complications of IGTs.Treatment efficacy was assessed based on RECIST v1.1. Complications were categorized based on the Common Terminology Criteria for Adverse Events (CTCAE) version 5.0. Results: The study cohort included 26 patients (median age 56 years [range 38-76]; n=18 female) who had 51 IGT sessions to treat 86 lesions. The median Ki-67 is 20 (range 2-79), and median Weiss score is 6 (range 3-9). Seventeen patients received systemic therapy including mitotane, chemotherapy, immunotherapy, and other treatments prior to the first IGT and 10 patients received systemic therapy concurrently with first IGT. IGT modalities included cryoablation (n = 49), microwave ablation (n = 21), combined microwave and bland transarterial embolization (n = 8), bland transarterial embolization alone (n = 3), radioembolization (n = 3), and radiofrequency ablation (n = 2). Treated sites included the liver (n=37), intraperitoneal (n=11), adrenalectomy bed (n=10), lung (n=6), lymph nodes (n=6), retroperitoneal soft tissue (n=6) and other soft tissues (n=10). The median largest pre-IGT anteroposterior tumor dimension was 2.3 cm (range 0.5-8.6). DCR was 81.4% (70 out of 86), of which 66.3% of tumors showed complete response, 18.6% showed progressive disease, 8.1% showed partial response, and 7.0% showed stable disease. LTPFS rates were 73% and 63% at 1 and 2 years, respectively. Fourteen lesions needed re-ablation. Ten patients did not require systemic therapy while 16 patients (61.5%) received new systemic therapy following IGT, with a median time from first IGT to systemic therapy of 12.5 months (95% CI: 8.6 months- upper limit not reached). There was 1 reported CTCAE grade 3 adverse event (biloma) following IGT. Conclusion: IGT use in properly selected ACC lesions is safe and associated with prolonged disease control and delay in the need for systemic therapy. Presentation: 6/2/2024

Locoregional Therapies for Hepatocellular Carcinoma in Patients with Nonalcoholic Fatty Liver Disease.

Hepatocellular carcinoma (HCC) is the third most common cause of cancer-related death worldwide with an average five-year survival rate in the US of 19.6%. With the advent of HBV and HCV treatment and prevention, along with the rising rates of obesity, nonalcoholic fatty liver disease (NAFLD) and metabolic syndrome are set to overtake infectious causes as the most common cause of HCC. While surgical resection and transplantation can be curative when amenable, the disease is most commonly unresectable on presentation, and other treatment approaches are the mainstay of therapy. In these patients, locoregional therapies have evolved as a vital tool in both palliation for advanced disease and as a bridge to surgical resection and transplantation. In this review, we will be exploring the primary locoregional therapies for HCC in patients with NAFLD, including transarterial chemoembolization (TACE), bland transarterial embolization (TAE), transarterial radioembolization (TARE), and percutaneous ablation.

Examining the Efficacy and Safety of Combined Locoregional Therapy and Immunotherapy in Treating Hepatocellular Carcinoma.

More than 800,000 people worldwide are diagnosed with HCC (hepatocellular carcinoma) each year, with approximately 700,000 deaths alone occurring in that same year. Treatment of HCC presents complex therapeutic challenges, particularly in intermediate and advanced stages. LRTs such as transarterial chemoembolization (TACE) and ablations have been the mainstay treatment for early to intermediate-stage HCC, and systemic therapies are used to treat intermediate-late-stage HCC. However, novel literature describing combining LRT with systemic therapies has shown promising results. This review explores recent advances in both liver-directed techniques for hepatocellular carcinoma, including bland transarterial embolization, chemoembolization, radioembolization, and ablative therapies in conjunction as well as with systemic therapies, with a focus on combination therapies, patient selection, procedural technique, periprocedural management, and outcomes. Our findings suggest that LRT combined with systemic therapies is a viable strategy for improving progression-free survival and time to progression for patients with intermediate-to-late-stage HCC. However, further investigation is required to refine treatment protocols and define patient cohorts that would benefit the most.

Clinical outcomes of image-guided therapies in patients with adrenocortical carcinoma: a tertiary referral center retrospective study.

Image-guided therapies (IGTs) are commonly used in oncology, but their role in adrenocortical carcinoma (ACC) is not well defined. A retrospective review of patients with ACC treated with IGTs. We assessed response to therapy using RECIST v1.1, time to next line of systemic therapy, disease control rate (DCR), local tumor progression-free survival (LTPFS), and complications of IGTs (based on the Common Terminology Criteria for Adverse Events [CTCAE] version 5.0). Our cohort included 26 patients (median age 56 years [range 38-76]; n = 18 female) who had 51 IGT sessions to treat 86 lesions. IGTs modalities included cryoablation (n = 49), microwave ablation (n = 21), combined microwave and bland trans-arterial embolization (n = 8), bland trans-arterial embolization alone (n = 3), radio-embolization (n = 3), and radiofrequency ablation (n = 2). DCR was 81.4% (70 out of 86), of which 66.3% of tumors showed complete response, 18.6% showed progressive disease, 8.1% showed partial response, and 7.0% showed stable disease. LTPFS rates were 73% and 63% at 1 and 2 years, respectively. Fourteen lesions underwent re-ablation for incomplete response on initial treatment. Sixteen patients (61.5%) received new systemic therapy following IGTs, with a median time to systemic therapy of 12.5 months (95% CI: 8.6 months upper limit not reached). There was 1 reported CTCAE grade 3 adverse event (biloma) following IGT. IGT use in properly selected patients with ACC is safe and associated with prolonged disease control and delay in the need for systemic therapy.

Combination Therapy of Bland Transarterial Embolization and Microwave Ablation for Hepatocellular Carcinoma within the Milan Criteria Leads to Significantly Higher Overall Survival.

A comparison of the combination therapy consisting of microwave ablation (MWA) after bland lipiodol-based transarterial embolization (TAE) with MWA alone in the treatment of hepatocellular carcinoma (HCC) within the Milan criteria. Forty-nine patients in the TAE-MWA group (12 women and 37 men; mean age: 63.3 ± 9.6 years) with 55 tumors and 63 patients in the MWA group (18 women and 45 men; mean age: 65.9 ± 10.5 years) with 67 tumors were retrospectively enrolled in this study. For the investigation of treatment protocols based upon both safety and efficacy, patients' cases were analyzed with regard to complications, local tumor progression (LTP), intrahepatic distant recurrence (IDR), overall survival (OS), and progression-free survival (PFS). There were no cases of major complications in either group. The LTP rate was 5.5% in the MWA-TAE group and 7.5% in the MWA group (p = 0.73). The rate of IDR was 42.9% in the MWA-TAE group and 52.4% in the MWA group (p = 0.42). The 12-, 24-, and 36-month OS rates starting at the date of tumor diagnosis were 97.7%, 85.1%, and 78.8% in the TAE-MWA group, and 91.9%, 71.4%, and 59.8% in the MWA group, respectively (p = 0.004). The 6-, 12-, and 24-month PFS rates were 76.5%, 55%, and 44.6% in the TAE-MWA group, and 74.6%, 49.2%, and 29.6% in the MWA group, respectively (p = 0.18). The combination therapy of TAE-MWA was significantly superior to MWA monotherapy according to OS in treating HCC within the Milan criteria.

Multidisciplinary, articular surface-preserving treatment strategy for locally aggressive epithelioid hemangioma of the acetabulum employing serial bland transarterial embolization.

Epithelioid hemangioma is a rare, histologically benign but locally aggressive primary vascular neoplasm that can rarely arise in bone. Mainstay treatment is surgical resection or curettage with bone grafting. We report a novel multidisciplinary, joint-sparing treatment approach for an epithelioid hemangioma of bone arising in the acetabulum causing severe thinning of the subchondral bone plate. After 4 sessions of transarterial bland particle and ethanol embolization, the resultant increased ossification of the tumor allowed preservation of the articular surface during surgical resection. Imaging follow-up 14 months after surgical resection showed no evidence of recurrence and continued ossification of the portions of the lesion treated only with embolization.

Metastatic disease to the liver: Locoregional therapy strategies and outcomes

Secondary cancers of the liver are more than twenty times more common than primary tumors and are incurable in most cases. While surgical resection and systemic chemotherapy are often the first-line therapy for metastatic liver disease, a majority of patients present with bilobar disease not amenable to curative local resection. Furthermore, by the time metastasis to the liver has developed, many tumors demonstrate a degree of resistance to systemic chemotherapy. Fortunately, catheter-directed and percutaneous locoregional approaches have evolved as major treatment modalities for unresectable metastatic disease. These novel techniques can be used for diverse applications ranging from curative intent for small localized tumors, downstaging of large tumors for resection, or locoregional control and palliation of advanced disease. Their use has been associated with increased tumor response, increased disease-free and overall survival, and decreased morbidity and mortality in a broad range of metastatic disease. This review explores recent advances in liver-directed therapies for metastatic liver disease from primary colorectal, neuroendocrine, breast, and lung cancer, as well as uveal melanoma, cholangiocarcinoma, and sarcoma. Therapies discussed include bland transarterial embolization, chemoembolization, radioembolization, and ablative therapies, with a focus on current treatment approaches, outcomes of locoregional therapy, and future directions in each type of metastatic disease.

Bland Embolization of Benign Liver Tumors: Review of the Literature and a Single Center Experience.

Transarterial embolization has shown promise as a safe, effective, and less invasive treatment modality for benign liver lesions (hemangioma, focal nodular hyperplasia (FNH), and hepatic adenoma (HA)) with fewer complications compared to surgical intervention. There is no consensus regarding the most appropriate embolization material(s) for the treatment of benign liver tumors. The purpose of this study was to review the current literature regarding the transarterial embolization of benign liver tumors and to share our single center experience. This was a non-blinded, retrospective, single-institution review of the bland embolization of benign liver tumors. Clinical data and imaging before and after embolization were used to evaluate lesion response to transarterial embolization. Twelve patients were included in the study. Five patients with six hemangiomas were treated. Pain was a presenting complaint in all five of these patients. The median change in tumor volume was −12.4% and ranged from −30.1% to +42.3%. One patient with two FNH lesions was treated, and both lesion volumes decreased by more than 50%. Six patients with 10 adenomas were treated. Pain was a presenting complaint in three patients, and five patients had a lesion >5 cm. The median change in tumor volume was −67.0% and ranged from −92.9% to +65.8%. Bland transarterial embolization of liver hemangiomas, FNH, and HA can be an effective and minimally invasive treatment modality to control the size and/or symptoms of these lesions. There is a variable response depending on tumor type and the embolization materials used.

Locoregional Therapy Approaches for Hepatocellular Carcinoma: Recent Advances and Management Strategies.

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and third leading cause of cancer-related mortality worldwide. While surgical resection and transplantation are the standard first-line treatments for early-stage HCC, most patients do not fulfill criteria for surgery. Fortunately, catheter-directed and percutaneous locoregional approaches have evolved as major treatment modalities for unresectable HCC. Improved outcomes have been achieved with novel techniques which can be employed for diverse applications ranging from curative-intent for small localized tumors, to downstaging or bridging to resection and transplantation for early and intermediate disease, and locoregional control and palliation for advanced disease. This review explores recent advances in liver-directed techniques for HCC including bland transarterial embolization, chemoembolization, radioembolization, and ablative therapies, with a focus on patient selection, procedural technique, periprocedural management, and outcomes.

Sarcopenia as a predictor of survival in patients undergoing bland transarterial embolization for unresectable hepatocellular carcinoma.

Sarcopenia has been associated with lower overall survival in patients with cirrhosis and hepatocellular carcinoma (HCC) undergoing surgical resection, TACE, TARE, or transplantation. This monocentric study evaluated the prognostic significance of sarcopenia in patients affected by HCC who received bland transarterial embolization (TAE) therapy, by analyzing its impact on survival and treatment-related complications. All consecutive patients who underwent the 1st TAE between March 1st 2011 and July 1st 2019 in our Institution were retrospectively studied. To evaluate sarcopenia, the skeletal muscle index (SMI) was calculated by normalizing the cross-sectional muscle area at the level of L3 on an abdominal CT scan prior to embolization (cm2) by patient height (m2). SMI cut-off values for sarcopenia were considered ≤ 39 cm2/m2 for women and ≤55 cm2/m2 for men. Data about age, gender, body mass index (BMI), underlying liver disease, liver function, MELD score, Child-Pugh score, multifocal disease, performance status, previous interventions, length of stay (LOS), complications after the procedure, readmission rate within 30 days, survival time from TAE and total number and type of TAE received following the first procedure were collected. From 2011 to 2019, 142 consecutive patients underwent 305 TAEs. Observation time ranged from 1.4 to 100.5 months (median 20.1 SD = 22). Sarcopenia at baseline was present in 121 (85%) patients. Overall 87 (61.2%) patients died during follow-up with survival rates at 1-, 2-, 3-, 4-, and 5-year of 71%, 41%, 22%, 16% and 11% respectively. After multivariate analysis sarcopenia (HR = 2.22, p = 0.046), previous ablation/resection (HR = 0.51, p = 0.005) and multifocal disease (HR = 1.84, p = 0.02) were associated with reduced survival. Sarcopenia did not influence the safety of TAE in terms of LOS (2 days vs 1.5 days, p = 0.2), early complications rate (8% vs 5%, p = 0.5) and readmission rate within 30 days (7% vs 5%, p = 0.74). Sarcopenia, estimated by the L3SMI method, is an emerging prognostic factor in patients with HCC undergoing bland TAE therapy as it is associated with increased mortality, without impairing the safety of the locoregional treatment. Measures to ameliorate the SMI, such as nutritional support and physical exercise, should be evaluated in clinical trials for HCC patients receiving liver embolization to determine their impact on overall survival.

Abstract No. 544 Locoregional therapies versus systemic therapy for hepatocellular carcinoma with portal vein tumor thrombus

To compare the efficacy and complication rates of locoregional therapies (LRT) versus systemic therapy (ST) for hepatocellular carcinoma (HCC) patients with portal vein tumor thrombus (PVTT). Following local institutional review board approval, we reviewed all HCC patients with PVTT treated at a single institution between 2005 and 2018. Baseline patient demographics, comorbidities, severity of liver disease, as well as tumor and treatment characteristics were compared between groups using Chi-squared or Student’s t-test. Overall survival (OS) and progression-free survival (PFS) were compared between groups using the log-rank test. Complications were assessed and graded per Society of Interventional Radiology (SIR) guidelines and compared using Chi-squared test. 17 HCC patients with PVTT were identified, 10 of whom received LRT and 7 who received ST. LRT patients received transarterial chemoembolization (TACE, 20%), transarterial radioembolization (TARE, 30%), and bland transarterial embolization (TAE, 50%). ST patients all received sorafenib. There were no significant differences between the LRT and ST groups in basic demographics, medical comorbidities, history of other malignancy, tumor characteristics, liver disease or performance status (table). Median OS was 444 days for the LRT group and 1147 days for the ST group (P = 0.7). Median PFS was 83 days following LRT and 67 days following ST (P = 0.3). Complication rates did not differ significantly between LRT and ST groups (50% vs. 28.6%, P = 0.62). In this comparative study, there were no significant differences in OS, PFS, or complications for HCC patients with PVTT receiving LRT versus ST. Additional larger, prospective studies are needed to further assess survival benefit and complication rates between these treatment modalities for this difficult-to-treat population.Tabled 1LRTSTP valueAge (yrs)63.5620.53Gender (% female)4028.61.00Diabetes Mellitus (%)1042.90.25Heart Disease (%)3000.23Other Malignancy History (%)2000.49Largest Tumor Diameter (cm)5.98.20.35Extrahepatic Disease (%)2028.61.00Child-Pugh Score (% C)028.60.28ECOG Performance Score (% stage 0)6028.60.53 Open table in a new tab

3:09 PM Abstract No. 238 Bland versus Y90 embolization: a retrospective analysis of outcomes in hepatic neuroendocrine metastases

Both transarterial radioembolization (TARE) and bland transarterial embolization (TAE) have been shown in single-institution studies to have a substantial radiologic response for a variety of liver tumors, including neuroendocrine metastases. However, randomized controlled trials have not yet been published comparing these modalities. The purpose of this study was to compare outcomes between TARE and TAE when performed for neuroendocrine metastases. Retrospective review of our procedural database demonstrated that 132 unique patients had been treated with embolotherapy for neuroendocrine metastases to the liver between 2005 and 2019. Of these, 106 were treated exclusively with one of the two modalities; patients who underwent both treatments during the review period were excluded. Radiologic response was assessed at the 3-month follow-up imaging based on mRECIST criteria and compared with the chi square test. Time to (hepatic) progression (TTP), (hepatic) progression-free survival (PFS), and overall survival (OS) were analyzed using the Kaplan-Meier technique and compared with the log rank test. Baseline demographics and tumor characteristics such as WHO grade, presence of bilobar disease, and prior resection of the primary tumor were similar between groups. Radiologic response rate at three months was 70% in the bland group and 73% in the Y90 group (P = 0.9). The median TTP was significantly longer after TARE than TAE (18.4 vs. 10.2 months, P = 0.025). The median hepatic PFS from first embolotherapy was 9.1 months in the TAE group and 10.2 months in the TARE group (P = 0.52). The median OS was 30.2 months in the TAE and 33 months in the TARE group (P = 0.34). Of the baseline characteristics compared between groups, only WHO grade was an independent predictor of OS (59.1 vs. 32.1 vs. 10.3 months in grade 1, 2, and 3 disease respectively; P <0.001). TARE and TAE demonstrated similar PFS and OS, despite a significantly longer TTP with TARE. WHO grading was the only significant predictor of survival in these patients undergoing embolotherapy.

Efficacy of combined bland embolization and chemoembolization for huge (≥10 cm) hepatocellular carcinoma

Introduction To assess the efficacy of combined therapy involving bland transarterial embolization using gelatin sponge particles (bland GS-TAE) followed by transarterial chemoembolization using lipiodol mixed with anticancer agents and GS particles (Lip-TACE) to reduce the adverse events and increase the therapeutic effect of Lip-TACE in the treatment of huge (≥10 cm) hepatocellular carcinoma (HCC). Material and methods Twenty-one consecutive patients with huge HCCs (≥10 cm in diameter) were enrolled in this study. First, bland GS-TAE was performed to reduce the tumor volume, and then Lip-TACE was performed to control the remaining tumor at intervals of around three weeks. Tumor response, survival, and adverse events of this combined therapy were assessed. Results The tumor response was assessed three months after combined TACE, with complete response in 38.1% and partial response in 57.1% of cases. Severe adverse events were seen in two patients, acute cholecystitis and tumor rupture. The median survival time was 2.7 years, and the one-, two-, three-, and five-year overall survival rates were 76.2%, 66.7%, 42.9%, and 25.0%, respectively. Conclusion Combined therapy involving bland GS-TAE followed by Lip-TACE can be performed safety and may improve survival in patients with huge HCCs.

Survival analysis of 230 patients with unresectable hepatocellular carcinoma treated with bland transarterial embolization.

Locoregional therapies for hepatocellular carcinoma (HCC) include endovascular treatments such as chemoembolization (TACE) and bland embolization (TAE). TACE is the most adopted technique, despite a lack of definitive evidence of superiority over TAE, which is less costly and better tolerated due to the absence of chemotherapy. However, few studies have reported data on TAE monotherapy for unresectable HCC. We report our results in a cohort of 230 patients with unresectable HCC treated with TAE (TAE with 40-100micron microparticles, TAE with microparticles plus n-butyl-2-cyanoacrylate, TAE with Lipiodol) over the course of seven years. Thirty-seven patients (14%) were down-staged during observation and also received a percutaneous ablation. We observed 1-, 2-, 3-, 4- and 5-year rates of 84,8%, 58,7%, 38,3%, 28,3%, and 18,7%. Patients who also received percutaneous treatment performed best. Our results broaden the body of evidence for the use of TAE in advanced HCC.

2262 Too Much TAE: A Case of Tumor Lysis Syndrome After Repeat Transarterial Embolization of Hepatocellular Carcinoma

INTRODUCTION: Hepatocellular carcinoma (HCC) is the sixth most common cancer in the world &amp; the second highest cause of cancer-related deaths globally. In the US, HCC incidence has almost tripled since the 1980s &amp; has become the fastest rising etiology of cancer-related deaths. Tumor lysis syndrome (TLS) is a condition that results when malignant cells release their intracellular contents, either spontaneously or in response to cytoxic treatment. The cellular contents result in hyperuricemia, hyperkalemia, hyperphosphatemia, &amp; hypocalcemia; these disturbances can lead to arrhythmias, AKI &amp; death. TLS is common in leukemias &amp; lymphomas but is rare in solid tumors. CASE DESCRIPTION/METHODS: A 50-year-old female with biopsy proven HCC without cirrhosis was admitted for planned transarterial chemoembolization (TACE) of her large right lobe &amp; medial left lobe HCC, measuring 13.3 × 17.9 × 21.8 cm (Image 1), as too advanced for surgical resection or transplant &amp; she had large liver-lung shunt preventing radioembolization treatment. Interventional Radiology (IR) placed two vials of LC beads containing doxirubicin 100mg &amp; bland transarterial embolization (TAE) via 2.5 vials of Embospheres into right hepatic artery. Afterwards, she had acute drop in Hgb with CTA revealing multiple areas of active bleeding in the liver &amp; new hematoma centrally in the mass. IR performed complete embolization of the right hepatic artery using coils &amp; gelfoam to achieve hemostasis; patient was transferred to ICU. She received blood products &amp; lab monitoring, the latter demonstrated new hyperkalemia of 5.5 mmol/L, previously normal. Creatinine increased from 0.55mg/dL to 1.23, thought to be multifactorial. Additional workup revealed uric acid of 12.5mg/dL, calcium 6.9mg/dL &amp; phosphorous 7.4mg/dL. TLS was diagnosed &amp; treated with intravenous fluids for dilution, rasburicase for hyperuricemia, furosemide for renal dysfunction &amp; minimal urine output, &amp; insulin for hyperkalemia. DISCUSSION: HCC is a growing health burden, &amp; advanced tumors that are not candidates for surgical resection are commonly treated with radiofrequency ablation, TACE, TAE, &amp; chemotherapy. Early recognition of TLS is key for treatment &amp; involves awareness of the propensity for development of TLS in large tumor burdens, rapidly dividing tumors, multiple treatment sessions, &amp; pretreatment renal dysfunction. Oliguria after IR treatment of HCC should raise the suspicion for possible TLS &amp; not be easily dismissed as the common but less fatal contrast induced nephropathy.

Abstract No. 528 Bland embolization versus radioembolization for the treatment of HCC in cirrhotic patients: propensity score analysis of the impact on hepatic function

Both bland transarterial embolization (TAE) and radioembolization (Y90) for the treatment of HCC have shown similar tumor responses and survival (excluding the radiation segmentectomy approach). While tumor control is a vital outcome, the degree of resulting hepatic impairment is important in this population who often have cirrhosis. The purpose of this study was to analyze the impact of TAE and Y90 on hepatic function based on the MELD score, with propensity score matching to optimally control potential confounders. Analysis was performed on 256 patients undergoing treatment of HCC in a lobar or bilobar fashion with Y90 (n= 100) or TAE (n=156) over a 10-year period. The total bilirubin, creatinine, and INR levels were ascertained immediately pre-procedure and at 1, 6, and 12 months after treatment to calculate MELD scores. Differences in MELD scores were compared using the paired or unpaired t-test and multivariate linear regression. Because confounders may result from selection bias, propensity score matching was performed with the following variables: treatment type, gender, age, unilobar versus bilobar, ECOG, AFP, maximum tumor diameter, viral hepatitis, presence of portal vein invasion, and initial MELD score. The mean baseline pretreatment MELD scores for patients undergoing TAE versus Y90 were 10.7 and 8.9, respectively (p<0.001). After TAE, the MELD score change at 1, 6, and 12 months were 0.8, 1.8, and 2.5 (p=0.036, 0.029, and 0.004), respectively. After Y90, the MELD score change was 2.6, 5.1, and 6.6 (p<0.001 for each). Using the propensity matched cohort, Y90 was associated with a higher change in MELD score at 1, 6, and 12 months (p=0.009, <0.001, and 0.001, respectively). Portal vein invasion was also associated with a higher change in MELD score at 6 months (p=0.004) and 12 months (p=0.04). In a propensity matched cohort of patients treated with lobar or bilobar TAE or Y90, Y90 was associated with significantly higher MELD score changes compared to TAE, and were most pronounced at 12 months. These findings may be important for patient selection and treatment planning, as well as understanding potential impact on liver transplant list status.

4:03 PM Abstract No. 188 Imaging predictors of radiologic response after bland transarterial embolization for hepatocellular carcinoma

Given the numerous locoregional treatment modalities available for the management of HCC, strategies are needed to determine the optimal therapy for a given patient. While predictors of response have been well studied for transarterial chemoembolization, they are poorly understood for transarterial embolization (TAE). Therefore, the purpose of this study was to identify whether there are predictors of radiologic response after TAE for HCC and whether imaging response correlates with survival. Retrospective review of our procedural database revealed 208 patients (156 males, 52 females mean age 61) who underwent first-time bland embolization for HCC and had 3-month imaging follow-up. The radiologic response at 3 months was categorized based on mRECIST criteria. Imaging features were ascertained from the preprocedural CT or MRI. Imaging predictors of radiologic response at 3 months was calculated with univariate and multivariate logistic regression analysis. The impact of radiologic response on survival was ascertained with the Kaplan-Meier technique and log rank test. A p-value less than 0.05 was considered statistically significant. Based on univariate analysis, predictors of a radiologic response (complete or partial response) at 3 months included presence of a capsule (p = 0.019), low number of lesions (0.002), and a lesion not at an interlobar location (0.011). Predictors of progressive disease at 3 months included a high AFP (0.002), larger tumor size (0.021), more tumors (0.001), and an interlobar location (0.001). On multivariate analysis, only the presence of a capsule predicted response (p = 0.002), whereas only a high AFP predicted progressive disease (p = 0.026). A positive radiologic response at 3 months correlated significantly with improved survival (45.3 versus 26.5 months). Progressive disease at 3 months correlated significantly with poorer survival (13.1 versus 40.1 months). The presence of an HCC capsule and AFP levels were predictors of a positive and negative radiologic response at 3 months after TAE, respectively. The radiologic response at 3 months correlated significantly with survival.

Recent advances in transarterial embolotherapies in the treatment of hepatocellular carcinoma.

Management of hepatocellular carcinoma (HCC) can be maximized with the utilization of multiple treatment modalities including transplant, surgical resection and locoregional therapies including ablative therapies and transarterial embolotherapies. Although transplant and surgical resection offer the best clinical outcomes, a limited number of patients are amenable to these surgical treatment options due to the advanced disease at presentation. Transarterial embolotherapies including conventional transarterial chemoembolization (cTACE), bland transarterial embolization (TAE), drug-eluting beads transarterial chemoembolization (DEB-TACE) and selective internal radiation therapy (SIRT) with Yttrium 90 (90Y) have played an increasingly important role for these patients with unresectable HCC. With a better understanding of different transarterial embolotherapies, more personalized and precise treatment should be implemented for these patients with unresectable HCC. In this review, the updated evidence on the current role of each embolotherapy in the treatment of HCC is summarized.

Comparative effectiveness of different transarterial embolization therapies alone or in combination with local ablative or adjuvant systemic treatments for unresectable hepatocellular carcinoma: A network meta-analysis of randomized controlled trials.

BackgroundThe optimal transcatheter embolization strategy for patients with unresectable hepatocellular carcinoma (HCC) remains elusive. We conducted a systematic review and network meta-analysis (NMA) of different embolization options for unresectable HCC.MethodsMedical databases were searched for randomized controlled trials evaluating bland transarterial embolization (TAE), conventional TACE, drug-eluting bead chemoembolization (DEB-TACE), or transarterial radioembolization (TARE), either alone or combined with adjuvant chemotherapy, or local liver ablation, or external radiotherapy for unresectable HCC up to June 2017. Random effects Bayesian models with a binomial and normal likelihood were fitted (WinBUGS). Primary endpoint was patient survival expressed as hazard ratios (HR) and 95% credible intervals. An exponential model was used to fit patient survival curves. Safety and objective response were calculated as odds ratios (OR) and accompanying 95% credible intervals. Competing treatments were ranked with the SUCRA statistic. Heterogeneity-adjusted effective sample sizes were calculated to evaluate information size for each comparison. Quality of evidence (QoE) was assessed with the GRADE system adapted for NMA reports. All analyses complied with the ISPOR-AMCP-NCP Task Force Report for good practice in NMA.FindingsThe network of evidence included 55 RCTs (12 direct comparisons) with 5,763 patients with preserved liver function and unresectable HCC (intermediate to advanced stage). All embolization strategies achieved a significant survival gain over control treatment (HR range, 0.42–0.76; very low-to-moderate QoE). However, TACE, DEB-TACE, TARE and adjuvant systemic agents did not confer any survival benefit over bland TAE alone (moderate QoE, except low in case of TARE). There was moderate QoE that TACE combined with external radiation or liver ablation achieved the best patient survival (SUCRA 86% and 96%, respectively). Estimated median survival was 13.9 months in control, 18.1 months in TACE, 20.6 months with DEB-TACE, 20.8 months with bland TAE, 30.1 months in TACE plus external radiotherapy, and 33.3 months in TACE plus liver ablation. TARE was the safest treatment (SUCRA 77%), however, all examined therapies were associated with a significantly higher risk of toxicity over control (OR range, 6.35 to 68.5). TACE, DEB-TACE, TARE and adjuvant systemic agents did not improve objective response over bland embolization alone (OR range, 0.85 to 1.65). There was clinical diversity among included randomized controlled trials, but statistical heterogeneity was low.ConclusionsChemo- and radio-embolization for unresectable hepatocellular carcinoma may improve tumour objective response and patient survival, but are not more effective than bland particle embolization. Chemoembolization combined with external radiotherapy or local liver ablation may significantly improve tumour response and patient survival rates over embolization monotherapies. Quality of evidence remains mostly low to moderate because of clinical diversity.Systematic review registrationCRD42016035796 (http://www.crd.york.ac.uk/PROSPERO).

Tarsal tunnel release: Medium-term outcomes and complications

To retrospectively compare the initial response, local recurrence, and complication rates of radiofrequency ablation (RFA) vs microwave ablation (MWA) when combined with neoadjuvant bland transarterial embolization (TAE) or drug-eluting microsphere chemoembolization (TACE) for the treatment of hepatocellular carcinoma (HCC).A total of 35 subjects with Barcelona Clinic Liver Cancer (BCLC) very early and early-stage HCC (range: 1.2-4.1 cm) underwent TAE (23) or TACE (12) with RFA (15) or microwave ablation (MWA) (20) from January 2009 to June 2015 as either definitive therapy or a bridge to transplant. TAE and TACE were performed with 40-400 μm particles and 30-100 μm plus either doxorubicin- or epirubicin-eluting microspheres, respectively. Initial response and local progression were evaluated using modified response evaluation criteria in solid tumors. Complications were graded using common terminology criteria for adverse events version 5.0.Complete response rates were 80% (12/15) for RFA + TAE/TACE and 95% (19/20) for MWA + TAE/TACE (P = 0.29). Local recurrence rate was 30% (4/12) for RFA + TAE/TACE and 0% (0/19) for MWA + TAE/TACE. Durability of response, defined as local disease control for duration of the study, demonstrated a significant difference in favor of MWA (P = 0.0091). There was no statistical difference in complication rates (3 vs 2).MWA and RFA when combined with neoadjuvant TAE or TACE have similar safety and efficacy in the treatment of early-stage HCC. MWA provided more durable disease control in this study; however, prospective data remain necessary to evaluate superiority of either modality.