Okuda Stage Research Articles

Back to basics: Staging and prognosis in HCC for medical oncologist

Several different prognostic systems are currently in use worldwide to predict the outcome of patients with hepatocellular carcinoma. Some of them have been widely publicized [1,2] while others have not been acknowledged by a wider audience so far [3]. All of the systems currently in use, except for the TNM-system, have taken care of the fact that prognosis in patients with HCC is decided not only by the tumor burden but, to a very significant part, also by the degree of the underlying liver cirrhosis. The oldest of the prognostic systems still in use today, the Okuda system, has simply taken three parameters of the Child-Pugh Score and supplemented it with a very crude estimation of the tumor size on imaging, thereby deriving a very simple but also for many patients today inaccurate three-stage prognostic system [4]. In particular, Okuda staging is mostly helpful for estimating the prognosis of the early as well as the most advanced stages of disease, while leaving the majority of patients in the intermediate Okuda stage II with a very rough estimate of the survival, which made it a system of very low practical value for the management of patients with HCC. In their recently published manuscript, Huitzil-Melendez and colleagues retrospectively compare the predictive power of seven different prognostic systems with regards to the outcome of patients with advanced stage HCC, destined to undergo medical therapy for their disease [5]. Their conclusion after evaluating TNM sixth edition, Okuda, BCLC, CLIP, CUPI, JIS, and GETCH in 187 eligible patients is that CLIP, CUPI, and GETCH were the most informative systems, while BCLC and TNM lacked discriminatory power in their patients. Looking at individual parameters, the addition of performance status, AST, abdominal pain, and esophageal varices to CLIP would be able to improve its prognostic accuracy even further. The general idea of the authors was to find

Experience Using Doxorubicin-Loaded DC Beads® During Hepatic Chemoembolisation

IntroductionHepatocellular carcinoma is the most common and aggressive liver and biliary tumour. Hepatic chemoembolisation with doxorubicin-loaded DC Beads® is a local therapy for patients with localised nodes, which are not suitable for surgery. The objective of this study is to describe the clinical situations in which this procedure has been used and its early toxicity. MethodsRetrospective descriptive study of patients treated with doxorubicin-loaded DC Beads® undergoing hepatic chemoembolisation from October 2006 until July 2009. Data were taken from the Farhos Oncología® programme and clinical histories. ResultsTwenty-two patients were treated during the study period, 15 men and 6 women, with an average age of 66 years. This technique was used for patients diagnosed with unresectable liver cancer. Out of the patient total, 6 were on the liver transplant waiting list. Patients were assessed using the Child–Pugh score: 15 patients in group A, 5 in group B and 1 in group C; and according to Okuda staging system: 14 were in group I, 6 in group II and 1 in group III. The most common toxicity was post-chemoembolisation in 16 patients, who were treated with symptomatic medication. DiscussionUsing doxorubicin-loaded microspherical DC Beads® during transarterial chemoembolisation has been adapted to use with scientific evidence and tolerated by all patients. Incidences during administration were mild and were resolved with symptomatic medication.

Comparison of staging systems of hepatocellular carcinoma.

Many staging systems of hepatocellular carcinoma (HCC) were established; however, there is no consensus on which is proper in predicting prognosis. This study aims to evaluate various commonly used staging systems of HCC. Patients who underwent surgery during 2001–2007 were included. All patient data were retrospectively staged using six staging systems, that are American Joint Committee on Cancer (AJCC) Tumour-Node-Metastasis (TNM), Okuda staging, Cancer of the Liver Italian Program (CLIP), Barcelona Clinic Liver Cancer (BCLC), Chinese University Prognostic Index (CUPI), and Japan Integrated Staging (JIS). Child-Pugh classification was also evaluated. The staging systems were compared by mean of overall and disease-free survival. Total of 99 patient data were enrolled in the analyses. All staging systems except Okuda were significant in determining overall survival in univariate analyses. In multivariate analyses, TNM and Child-Pugh demonstrated better predictive power for overall survival. In terms of disease-free survival, univariate analyses revealed that TNM, CLIP, BCLC, CUPI, and JIS were significant, and TNM was the best predictive staging system in multivariate analyses. In our study, TNM and Child-Pugh are the representative systems in predicting survival of HCC patients who undergo surgical resection. Moreover, they are practical and easily assessable in clinical practice.

Prognostic Factors in Patients with Advanced Hepatocellular Carcinoma Treated with Sorafenib: A Retrospective Comparison with Previously Known Prognostic Models

Background: Sorafenib, a multitargeted tyrosine kinase inhibitor, is now the treatment of choice for systemic therapy of patients with advanced hepatocellular carcinoma (HCC). Herein, we present the clinical characteristics and outcomes of patients with advanced HCC who were treated with sorafenib. Methods: Data of 201 sorafenib-treated, metastatic HCC patients were collected from a single institution tumor registry. The primary and secondary endpoints were overall survival (OS) and failure-free survival (FFS). Results: Chronic hepatitis B was the predominant cause of HCC (84%). Of 162 evaluable patients, 4 partial responses were recorded. With a median follow-up of 15.7 months, the median FFS and OS were 2.5 months (95% CI 2.3–2.7) and 5.3 months (95% CI 4.4–6.3), respectively. In multivariate analysis, the prognostic factors associated with FFS were the presence of ascites, portal venous thrombosis, serum α-fetoprotein ≧400 ng/ml, albumin, bilirubin, tumor size and number, and performance status. Likewise, the presence of ascites, portal venous thrombosis, tumor size and number, performance status and baseline levels of α-fetoprotein, albumin and bilirubin were significantly related with OS. After adjusting for performance status, the Cancer of the Liver Italian Program scoring system and Okuda stages can better predict the hazard of failure or death than the Child-Pugh classification. Conclusions: Our results suggest that Cancer of the Liver Italian Program scores or Okuda stages, along with performance status, can be useful in stratifying patients with advanced HCC treated with sorafenib.

Zunahme und verbessertes Überleben des hepatozellulären Karzinoms im Zeitraum von 1988 – 2007: Daten einer deutschen Universitätsklinik

Hepatocellular carcinoma (HCC) ranks sixth regarding prevalence and third regarding mortality among malignant tumours worldwide. The aim of the present study was to determine changes of clinical-epidemiological parameters and survival rates during two decades. A total of 441 consecutive patients with HCC admitted to the University Clinic Düsseldorf between January 1988 and December 2007 were included. For comparison, this time period was divided into two decades (1988 - 1997 and 1998 - 2007). The number of newly diagnosed HCCs has tripled in the years 1998 - 2007 compared to the years 1988 - 1997. HCV-associated HCCs increased from 28 % in the years 1988 - 1997 to 38 % (p < 0.05) in the years 1998 - 2007. Tumour size, Okuda and BCLC stages decreased during the observation period (both p < 0.001 and p < 0.05). Median overall survival improved during the observation period from 6 [95 % CI: 4.83 - 7.17] to 9 months ]95 % CI: 7.31 - 10.69]; p < 0.0001) as did the 1-year and 5-year survival rates from 22 % to 42 % (p < 0.019) and from 0 % to 9 % (p < 0.001), respectively. The proportion of treated patients compared to patients with best supportive care as well as the proportion of patients receiving a multimodal therapy compared to patients with a single treatment regimen increased in the second decade (55 % vs. 79 %: p < 0.005; 5.4 % vs. 23 %: p < 0.0001). Multimodal therapy was an independent predictor for prolonged survival in a multivariate analysis including Child-Pugh score, BCLC stage, tumour size, and gender (odds ratio 2,77; 95 % CI: 1.44 - 5.31). Improved screening as well as broader and improved treatment options may have contributed to the increasing survival rates.

Predicting prognosis of patients with advanced hepatocellular carcinoma treated with antiangiogenic therapy using the CUPI and CLIP staging systems.

e14669 Background: Antiangiogenic therapy, especially sorafenib, has become the most important treatment for advanced hepatocellular carcinoma (HCC). Staging systems that correlate best with the prognosis of this group of patients are unclear. Methods: Advanced HCC patients who had been enrolled in three prospective phase II trials of first-line anti-angiogenic therapies were analyzed. Clinicopathologic characteristics, as well as corresponding staging scores according to AJCC, BCLC, Okuda, CLIP, JIS, CUPI, Tokyo, and GETCH staging systems, were analyzed for their correlation with overall survival (OS). Results: A total of 122 patients were included; 110 (90%) were male and 91 (75%) had chronic hepatitis B virus infection. All patients were of Child-Pugh class A liver reserve. The median OS was 6.0 months (95% C.I., 4.4-7.6). In multivariate analysis of clinicopathologic characteristics for prognostic prediction, male, liver involvement over 50% or infiltrative disease, hepatitis B/C virus co-infection, ECOG 1, high AFP and high ALP were independent predictors for poorer OS. By log rank test, CLIP (p < 0.001), CUPI (p < 0.001), Okuda (p < 0.001), Tokyo (p = 0.001), and GETCH (p = 0.005) staging systems were capable of differentiating OS. GETCH, CUPI, and CLIP had the highest concordance indexes (C-indexes) (0.80, 0.78 and 0.74, respectively). When all the staging systems were examined together for prediction of OS by Cox’s proportional hazards model, CUPI and CLIP stood out in the final model as best staging systems for the prediction of OS. Conclusions: Among current staging systems of HCC, CUPI and CLIP have the best prognosis-prediction power in this patient group. This study was supported by the grants of DOH98-TD-B-111-001 and DOH99-TD-B-111-001.

Experiencia de uso de partículas DC Bead ® cargadas con doxorrubicina en quimioembolización hepática

Introduction Hepatocellular carcinoma is the most common and aggressive liver and biliary tumour. Hepatic chemoembolisation with doxorubicin-loaded DC Beads ® is a local therapy for patients with localised nodes, which are not suitable for surgery. The objective of this study is to describe the clinical situations in which this procedure has been used and its early toxicity. Methods Retrospective descriptive study of patients treated with doxorubicin-loaded DC Beads ® undergoing hepatic chemoembolisation from October 2006 until July 2009. Data were taken from the Farhos Oncología ® programme and clinical histories. Results Twenty-two patients were treated during the study period, 15 men and 6 women, with an average age of 66 years. This technique was used for patients diagnosed with unresectable liver cancer. Out of the patient total, 6 were on the liver transplant waiting list. Patients were assessed using the Child-Pugh score: 15 patients in group A, 5 in group B and 1 in group C; and according to Okuda staging system: 14 were in group I, 6 in group II and 1 in group III. The most common toxicity was post-chemoembolisation in 16 patients, which were treated with symptomatic medication. Discussion Using doxorubicin-loaded microspherical DC Beads ® during transarterial chemoembolisation has been adapted to uses with scientific evidence and tolerated by all patients. Incidences during administration were mild and were resolved with symptomatic medication.

Single centre experience of use of transarterial chemoembolization (TACE) with doxorubicin eluting beads (DEB) for the treatment of hepatocellular carcinoma (HCC)

IntroductionThere is evidence that TACE can prolong survival in patients with inoperable HCC, and DEB may provide even further benefit, with a favourable side effect profile. This is the first...

Prognostic factors in patients with advanced hepatocellular carcinoma treated with sorafenib: A comparison with previously known prognostic models.

323 Background: Sorafenib, a multiple-targeted tyrosine kinase inhibitor, is now the treatment of choice for systemic therapy of patients with advanced hepatocellular carcinoma (HCC). Herein we present the clinical characteristics and outcomes of patients with advanced HCC who were treated with sorafenib. Methods: Data of 201 sorafenib-treated, metastatic HCC patients were collected from a single institution tumor registry. The primary and secondary endpoints were overall survival (OS) and failure-free survival (FFS). Results: Chronic hepatitis B was the predominant cause of HCC (84%).Of 162 evaluable patients, four partial responses were recorded. With a median follow-up of 15.7 months, the median FFS and OS were 2.5 months (95% confidence interval [CI], 2.3-2.7 months) and 5.3 months (95% CI, 4.4-6.3 months), respectively. In multivariate analysis, the prognostic factors associated with FFS were the presence of ascites, portal venous thrombosis, serum alpha- fetoprotein (AFP) ≥400 ng/mL, albumin, bilirubin, tumor size and number, and performance status. Likewise, the presence of ascites, portal venous thrombosis, tumor size and number, performance status, and baseline levels of AFP, albumin and bilirubin were significantly related with OS. After adjusting for performance status, the Cancer of the Liver Italian Program (CLIP) scoring system and Okuda stages can better predict the hazard of failure or death than Child-Pugh classification. Conclusions: Our results suggest that CLIP scores or Okuda stages, along with performance status, can be useful in stratifying patients with advanced HCC treated with sorafenib. No significant financial relationships to disclose.

Optimal technique and response of doxorubicin beads in hepatocellular cancer: bead size and dose

Background/AimsIt has been shown that the drug-eluting beads loaded with doxorubicin (DEBDOX) are effective for the treatment of hepatocellular carcinoma (HCC). However, the optimal safety and efficacy still remain to be established by using various bead sizes, doxorubicin doses, and the degree of stasis.The aim of this study was to determine the optimal safety and efficacy of DEBDOX in the treatment of HCC.MethodsAnalysis of a 503-patient prospective, multicenter, multinational Bead Registry Database from 2007 to 2010 identified 206 patients who had been treated for HCC with DEBDOX. Primary endpoints were to compare safety, tolerance, response rates, and overall survival based on bead size (100-300, 300-500, 500-700, and 700-900 µm), number of vials, doxorubicin dose, and degree of stasis.ResultsIn total, 206 patients underwent 343 treatments. The use of all four bead sizes was similar based on Child-Pugh class and Okuda stage, with a significantly higher use (50%) of beads of size 100-300 µm in patients with portal vein thrombosis (P=0.05). Significant differences were seen for the number of median treatments, median doxorubicin dose, lobar infusion), and degree of complete stasis. The rate of adverse events was higher for larger beads than for smaller beads (28% vs. 16%; P=0.02).ConclusionsBead size and dose may vary according to disease distribution. Smaller beads offer the opportunity for repeated treatments, a larger cumulative dose delivery, a lesser degree of complete stasis, and fewer adverse events.

Trans-arterial chemo-embolization (TACE), with either lipiodol (traditional TACE) or drug-eluting microspheres (precision TACE, pTACE) in the treatment of hepatocellular carcinoma: efficacy and safety results from a large mono-institutional analysis

More data about TACE and pTACE seem necessary to better define the global treatment strategy for HCC. Aim of our analysis was to evaluate the role of TACE, either with lipiodol (traditional) or drug-eluting microspheres in terms of response rate (RR), time to progression (TTP), overall survival (OS) and toxicity in HCC.Patients with HCC undergoing traditional TACE or pTACE (either alone or in combination with other treatment options) were eligibleOne hundred and fifty patients were analyzed. In the global patient population median OS was 46 months for lipiodol TACE and 19 months for pTACE (p < 0.0001), TTP was 30 months versus 16 months for patients receiving TACE or pTACE respectively (p = 0.003). These results were confirmed also among the group of patients who received exclusive TACE or pTACE. Neither RR nor toxicity was different between TACE or pTACE.At multivariate analysis, age, the Okuda stage, type of TACE and number of TACE proved to be independent prognostic factors influencing overall survival.In our experience, lipiodol TACE showed a better OS and TTP over pTACE, without difference in toxicity profile and RR. Among the staging systems analyzed only the Okuda stage seemed able to reliably predict patients outcome.

Outcome of supraselective transarterial chemoembolization in patients with hepatocellular carcinoma

Objective. Hepatocellular carcinoma (HCC) is the most common tumor in cirrhotic patients with a median survival of only 8–10 months if untreated. Supraselective transarterial chemoembolization (STACE) is supposed to be a well-established method for treating HCC patients. In the present study, we evaluated the effect of STACE on post-transplant survival in patients with HCC. Material and Methods. The charts of 53 HCC patients were retrospectively analyzed. Twenty-seven patients had STACE as a bridging therapy while 26 patients were scheduled for liver transplantation (LTX) without prior STACE therapy. A total of 53% of the patients who underwent LTX preoperatively fulfilled the Milan criteria, while 70.6% fulfilled the expanded University of California, San Francisco (UCSF) transplant criteria. Primary endpoint was the post-transplant survival. Statistical analysis included Kaplan-Meier-method, log rank, and chi square tests. Results. Between the LTX groups (STACE vs. non-STACE), there was no significant difference in terms of age, Child classification, Okuda stage, co-morbidities, underlying disease, and post-transplant survival (p > 0.05). Independent of prior STACE, however, disease-free survival after LTX was highly significantly prolonged if LTX was performed within 3 months after initial diagnosis of HCC (p < 0.01) or if patients met the expanded transplant UCSF criteria (p = 0.02). Post-transplant survival did not depend on tumor size. Conclusions. We conclude that STACE performed prior to LTX does not secure any post-transplant survival benefit, while early LTX, i.e. within 3 months after HCC diagnosis, does improve survival regardless of whether STACE was performed or not. Additionally, fulfillment of the expanded transplant UCSF criteria leads to a prolonged post-transplant survival.

Clinical Presentation of Hepatocellular Carcinoma (HCC) in Asian-Americans Versus Non-Asian-Americans

The incidence of HCC is rising worldwide. Studies on ethnicity-based clinical presentation of HCC remain limited. The aim is to compare the clinical presentation and stage of HCC between Asian-Americans and non-Asian-Americans. This retrospective study assessed ethnicity-based differences in HCC presentation, including demographics, laboratory results, diagnosis of underlying liver disease, and stage of HCC. Of 276 patients, 162 were Asian-Americans and 114 were non-Asian-Americans. Compared to non-Asian-Americans, Asian-Americans had a significantly higher incidence of history of hepatitis B virus (HBV) infection (55.0% vs. 4.9%, P < 0.001), family history of HBV infection (12.5% vs. 0.0%, P < 0.001) and HCC (15.2% vs. 2.9%, P = 0.002), but lower incidence of history of hepatitis C virus (HCV) infection (37.5% vs. 61.6%, P < 0.001). At diagnosis of HCC, Asian-American patients had a significantly lower frequency of hepatic encephalopathy (8.9% vs. 29.3%, P = 0.001), and ascites (26.7% vs. 57.3%, P < 0.001). Asian-Americans had lower Child-Pugh scores (class A: 62.0% vs. 31.4%, P < 0.001), and MELD scores (9.2 ± 4.4 vs. 12.0 ± 6.4, P = 0.02), and presented with a lower stage of HCC by Okuda staging (I: 43.8% vs. 22.8%, P = 0.001). Asian-American patients with HCC presented with a higher incidence of history and family history of HBV infection, lower incidence of hepatic decompensation, lower Child and MELD scores, and an early stage HCC disease.

Hepatocellular carcinoma: a clinicopathological study.

To describe the clinico-pathological and radiological profile of hepatocellular carcinoma. A case series. Medical Unit-III Ward-7, Jinnah Postgraduate Medical Centre, Karachi, from January to December 2008. All consecutive patients suspected of having hepatocellular carcinoma (HCC), were admitted and included in this study. Diagnosis of HCC was established by clinical, biochemical, ultrasonographic and histopathologic findings. Patients with primary carcinoma elsewhere in the body, metastatic in the liver, fibrolamellar carcinoma and benign tumours were excluded from the study. At ultrasonography, the details of tumour size and number, portal vein thrombosis and presence of ascites were recorded. Patients were staged according to Okuda staging system. Results were described in mean and percentage values. There were 82 patients with hepatocellular carcinoma including 58 males and 24 females, with male to female ratio of 2.8:1. The mean age of patients was 56.24+/-13.65 years. Right hypochondrial pain was the main symptom in 52 (63.4%) patients. The duration of symptoms varied from 1 month to 2 years. Tumour size was larger than 50% of liver size in 42 (51.2%) with portal vein thrombosis in 10 (12.19%). Anti HCV was positive in 44 (53.7%), HBsAg in 26 (31.7%) and both were found positive in 2 (2.44%) patients. Ten patients (12.2/%) found negative both for anti-HCV and HBsAg. According to Okuda staging system 18 patients had stage 1, 50 had stage 2 and 14 had stage 3 hepatocellular carcinoma. The mean age of presentation of hepatocellular carcinoma was younger as compared to western countries with potentially large non-resectable lesions. Chronic hepatitis C and B was found to be the major known factors. Patients with chronic hepatitis C and B should undergo vigorous HCC surveillance to detect early, potentially respectable HCC.

Prognosis evaluation in alpha-fetoprotein negative hepatocellular carcinoma after hepatectomy: Comparison of five staging systems

Aims Alpha-fetoprotein (AFP) loses its potentials in treatment evaluation and prognosis prediction in patients with AFP negative (≤20 ng/ml) hepatocellular carcinoma (HCC). The present study was to identify the risk factors affecting postoperative survival of AFP negative patients and to determine the optimal staging system in predicting the survival of these patients. Methods The data of 306 in total and 98 AFP negative patients amongst were retrospectively reviewed. The risk factors affecting survivals of the patients were identified. And various staging systems were compared, including the sixth tumor node metastasis (TNM) system, Okuda staging, Cancer of the Liver Italian Program (CLIP) score, the Barcelona Clinic Liver Cancer (BCLC) staging system, and the Japan Integrated Staging (JIS) score. Results AFP negative patients tended to have intact tumor capsule and earlier staged tumor by TNM, CLIP and BCLC. The independent risk factors worsening overall survival of AFP negative patients were absence of tumor capsule, Child-Pugh classification B, hepatitis B surface antigen positive and BCLC stage B–C. The risk factors promoting tumor recurrence were tumor size of >3 cm, distribution in two lobes, Okuda stage B–C and BCLC stage B–C. Conclusion Normal AFP level implies earlier staged tumors. BCLC has the strongest potential in prognosis evaluation in AFP negative patients.

Predicting the Prognosis of Hepatocellular Carcinoma Using Gene Expression

Many risk factors affect survival after liver resection for hepatocellular carcinoma (HCC), but these lack specificity for the prognosis. Studies of gene expression profiles successfully predicted the survival of HCC. To date, few studies have focused on HBV-associated HCC. Therefore, we investigated the genes involved in tumor prognosis in patients with HBV-associated HCC. We analyzed clinical data and microarray test results in 51 patients who underwent liver resection for HBV-associated HCC between August 1998 and December 2002. We used Kaplan-Meier plots to analyze survival rates and some well-known clinical staging systems. In addition, we performed microarray survival analysis using Cox univariate regression. Then, we devised a scoring system that adds the survival-associated gene expression signature to one or two independent clinical risk factors for survival. The mean follow-up period was 61.4 mo. Thirty-six patients had recurrence during this period, and 22 died. The 5-y survival rate was 58.0%. Multivariate analysis showed that tumor size was an independent risk factor for survival. We identified 194 spots on the microarray in survival analysis. These genes were clustered into two groups and showed a statistically significant difference in the survival rates. In the clinical analysis, the CLIP and Okuda staging systems showed statistically significant relationships. When we added the survival-associated gene expression signature to tumor size, our new method showed a more statistically significant relationship between stage and survival. We propose that adding the results of microarray survival analysis to the staging system predicts survival more precisely.

Long-term survival after locoregional therapy in patients with unresectable hepatocellular carcinoma: Improvements over two decades.

e14559 Background: Locoregional therapy (LRT) has long been used as palliative care for patients with unresectable hepatocellular carcinoma (HCC). Current study explores long-term survival after LRT in patients with unresectable hepatocellular carcinoma over a period of two decades. Methods: Consecutive patients who underwent LRT for unresectable hepatocellular carcinoma between 1990 and 2008 were included in the study. Clinical, laboratory and procedural data was collected for all patients by retrospective review. Patients were chronologically divided into 2 groups based on the year of first LRT (group 1 1990-99; group 2 2000-08). Chi square test was used to compare categorical variables and student t test to compare continuous variables. Kaplan Meier method was used for survival analysis. Survival curves were compared using the log-rank test. Results: 309 patients (mean age 60.5 years SD 11.6) had received LRT over the study period and were included in the study. Demongraphics were as follows- mean age of the study group was 60.5 yrs (SD 11.6); 73% (224/309) were male; and 71% were Caucasian. Tumor stagings included Okuda stages I, II and II of 44%, 45% and 10% and Child class A, B and C of 48%, 39% and 12%. The mean MELD score was 11.8 (SD 4.7). 22% (67/309) patients in group 1 and 78% (242/309) in group 2 -were statistically similar for age, sex, race, Child Pugh class, Okuda stage, MELD score and cumulative tumor size (p > 0.05). The median long-term survival in group 1 was 311 days (95% CI 212-409) and in group 2 it was 513 days (382-643) (p = 0.001). The survival rates at 6 months, 1 year and 3 years in group 1 were 72%, 41% and 16%, and those for group 2 were 78%, 63% and 30% (p = 0.001). Conclusions: There has been a significant improvement of long-term survival in the current decade for patients with unresectable HCC who undergo locoregional therapy, compared to the previous decade. No significant financial relationships to disclose.

Prognostic factors for survival in patients with unresectable hepatocellular carcinoma undergoing chemoembolization with doxorubicin drug-eluting beads: a preliminary study

BackgroundTransarterial chemoembolization (TACE) with drug-eluting beads (DEB) is a new treatment modality. Little is known about prognostic factors affecting survival after DEB TACE for patients with hepatocellular carcinoma (HCC). MethodsPatients who underwent TACE with doxorubicin DEB for unresectable HCC during 2006–2008 were studied. Survival was calculated from the day of first transcatheter therapy. Survival analysis was performed using Kaplan–Meier estimations. Survival curves were compared using the log-rank test. ResultsFifty patients underwent chemoembolization with doxorubicin DEB. They included 39 women and 11 men, with a median age of 57.5 years (range 28–91 years). Eighteen patients died during the study period and 32 remained alive. Overall survival rates at 6 months, 1 year and 2 years from the first administration of doxorubicin DEB TACE were 71%, 65% and 51%, respectively. Prognostic factors found to be significant on univariate analysis were Child–Pugh class, Okuda staging, bilirubin > 2mg/dl, albumin < 3.0g/dl, Model for End-stage Liver Disease (MELD) score, serum alphafetoprotein (AFP), Cancer of the Liver Italian Programme (CLIP) score, tumour satisfying Milan criteria, Eastern Cooperative Oncology Group (ECOG) performance status (PS) and Barcelona Clinic Liver Cancer (BCLC) staging. ConclusionsChild–Pugh class, Okuda staging, bilirubin > 2mg/dl, albumin < 3g/dl, MELD score, serum AFP, CLIP score, Milan criteria, ECOG PS and BCLC staging were found to be prognostic markers of survival after treatment with doxorubicin DEB TACE in patients with unresectable HCC.

Effect of surveillance for hepatocellular carcinoma on tumor staging and treatment decisions in Egyptian patients

Egyptian hepatocellular carcinoma (HCC) patients present at advanced stages. We aimed to study the influence of surveillance versus non-surveillance on HCC staging and the potential therapeutic options. A retrospective study to evaluate the effect of surveillance on early detection of HCC among cirrhotic patients from 2003 to 2008. Patients examined every 6 months using ultrasound and α-fetoprotein (α-FP) (group A) and those diagnosed with those that present for the first time symptomatically or incidentally (group B). Groups were compared for α-FP level, tumour characteristics, severity of liver disease; tumour staging was evaluated by Okuda, CLIP and BCLC staging systems, in addition to the potential therapeutic options. Group A comprised 122 HCC cases and group B 473. Surveillance improved HCC detection: at the stage of single nodule in 62.3% in group A versus 52.2% in group B, (P=0.046) and reduced the percentage of HCC with portal vein thrombosis in 16.4 versus 33.8%, (P= 0.000) and the percentage of α-FP >400 ng/ml in 19.5 versus 32.6%, (P= 0.006) in groups A and B, respectively. Surveillance doubled the detection of HCC at early stage of BCLC (25.4 vs. 11.9% P=0.000) and doubled the patients' chance for loco-regional ablation (12.3 vs. 5.9%, P=0.015) and liver transplantation (10.7 vs. 3.2%, P=0.001) in groups A and B, respectively. HCC surveillance increases early detection of HCC and doubled the chances for curative options. Implementation of both HCC surveillance and cadaveric liver transplantation programs should be recommended in Egypt.

Comparison of conventional transarterial chemoembolization (TACE) and chemoembolization with doxorubicin drug eluting beads (DEB) for unresectable hepatocelluar carcinoma (HCC)

Chemoembolization with doxorubicin drug eluting beads (DEB) is a novel locoregional treatment modality for unresectable hepatocellular carcinoma (HCC). Initial animal studies and clinical trials suggest that treatment with DEB may provide safer and more effective short-term outcomes than conventional chemoembolization. Current study explores long-term survival benefits. Consecutive patients who received transcatheter therapy with DEB or conventional chemoembolization as sole therapy between 1998 and 2008 were studied. Statistical analysis was performed using Kaplan-Meier estimator with log-rank testing, chi-squared, and independent t-tests. Seventy-one patients were included in this study, 45 (63.4%) received therapy with DEB (group A) and 26 (36.6%) underwent conventional chemoembolization (group B). Median survival from diagnosis of HCC in groups A and B were 610 (351-868) and 284 days (4-563; P = 0.03), respectively. In Okuda stage I, survival in groups A and B were 501 (421-528) and 354 days (148-560, P = 0.02). In Child-Pugh classes A and B, survival in groups A and B were 641 (471-810) and 323 days (161-485, P = 0.002). Median survival in patients with Cancer of Liver Italian Program (CLIP) score <or=3 in groups A and B were 469 (358-581) and 373 days (195-551, P = 0.03). NCI CTCAEv3 Grade 5 clinical toxicity was similar. In our study, transcatheter therapy with DEB offers a survival advantage over conventional chemoembolization for patients with unresectable HCC.