Preoperative Transcatheter Arterial Chemoembolization Research Articles

Neoadjuvant transcatheter arterial chemoembolization and systemic chemotherapy for treatment of clear cell sarcoma of the kidney in children

BackgroundClear cell sarcoma of the kidney (CCSK) is a rare and aggressive malignant renal tumor. We describe our experience with neoadjuvant transcatheter arterial chemoembolization (TACE) and systematic chemotherapy for the treatment of advanced CCSK in children. MethodsBetween January 2010 and December 2016, seven patients (3 boys and 4 girls; median 2.2 years) with advanced CCSK received preoperative TACE of renal artery and systemic chemotherapy. The chemoembolic emulsion for TACE consisted of cisplatin, pirarubicin, vindesine, and iodized oil. Preoperative systemic chemotherapy with vindesine, ifosfamide, and etoposide was administered three weeks after TACE. Nephrectomy was performed three weeks after systemic chemotherapy. After surgery, patients received radiotherapy and postoperative chemotherapy. ResultsNo cardiotoxicity, renal insufficiency, or hepatic dysfunction was found in any patients. Grade II–III marrow suppression developed in four patients. One patient with tumor progress during neoadjuvant therapy failed to successfully undergo surgery and died. Six patients underwent nephrectomy after neoadjuvant therapy. Median follow-up period was 49.5 months (range, 11–83 months). Five patients have recurrence-free survival. One patient is still in postoperative chemotherapy after nephrectomy, radiotherapy and thoracoscopic resection of lung metastases. ConclusionsNeoadjuvant TACE and systemic chemotherapy appeared to be feasible in the treatment of advanced CCSK in this pilot study. The type of studyA case series with no comparison group. Level of evidenceLevel IV.

Outcomes and Prognostic Factors of Spontaneously Ruptured Hepatocellular Carcinoma

BackgroundSpontaneous tumor rupture is a rare and life-threatening complication of hepatocellular carcinoma (HCC). The best treatment strategy remains unclear. MethodsThe clinical data of 137 patients with spontaneously ruptured HCC from 2010 to 2015 were reviewed retrospectively. We investigated the outcome and prognostic factors of various treatment strategies. ResultsOf the 137 patients, 53, 45, 3, and 36 patients underwent transcatheter arterial chemoembolization (TACE) alone, liver resection (LR) (LR alone or TACE + LR), surgical hemostasis, and conservative therapy. The patients undergoing LR had longest overall survival (OS). In the TACE alone group, independent factors affecting 30-day mortality were MELD score ≥ 12, AFP ≥ 1000 ng/ml, and largest tumor size ≥ 10 cm. AFP ≥ 1000 ng/ml, largest tumor size ≥ 10 cm, and no tumor capsule were significantly associated with poorer OS. In the LR group, largest tumor size ≥ 10 cm and no tumor capsule were the only independent prognostic factors for poorer OS and recurrence-free survival (RFS). Hypovolemic shock was an independent prognostic factor for poorer OS. The differences in OS between the TACE + LR group and LR alone group were not significant (P = 0.955). However, the RFS is significantly better in the LR alone group than those in the TACE + LR group (P = 0.031). ConclusionFor resectable tumor, LR is the treatment of choice for patients with spontaneous ruptured HCC and preserved liver function. The delay in LR due to preoperative TACE may account for its worse RFS compared with LR alone. In patients with an unresectable tumor, TACE therapy alone improved survival over conservative therapy.

Outcomes and prognostic factors of spontaneous ruptured hepatocellular carcinoma

Introduction: Spontaneous tumor rupture is a rare and life-threatening complication of HCC.This study aimed to investigate the outcomes of different management strategies and prognostic factors of patients with ruptured HCC. Methods: The clinical data of 137 patients with spontaneously ruptured HCC from January 2010 to December 2015 were analyzed retrospectively. Results: Of the 137 patients, 53, 45, 3, and 36 patients underwent transcatheter arterial chemoembolization (TACE) alone, liver resection (LR) (LR alone or TACE+LR combined), surgical hemostasis, or conservative therapy. The patients undergoing LR had longest overall survival (OS). In the LR group, largest tumor size≥10cm and no tumor capsule were the only independent prognostic factors for poorer OS and recurrence-free survival (RFS). Hypovolemic shock was an independent prognostic factor for poorer OS. The median time between diagnosis and LR was significantly longer in the TACE+LR group than in LR alone group (P< 0.01). The differences in OS between the TACE+LR group and LR alone group were not significant (P=0.955). However, the RFS is significantly better in the LR alone group than those in the TACE+LR group(P=0.031). In the TACE alone group, AFP≥1000 ng/ml, largest tumor size≥10cm, no tumor capsule and unsuccessful embolization were significantly associated with poorer OS. Conclusion: For resectable tumor, LR is the treatment of choice for patients with spontaneous ruptured HCC and preserved liver function. The delay in LR due to preoperative TACE may account for its worse RFS compared with LR alone. In patients with an unresectable tumor, TACE therapy alone improved survival over conservative therapy.

Diagnostic value of computed tomographic perfusion imaging of whole liver for quantitative assessment of blood flow state in liver cancer after transcatheter arterial chemoembolization

Objective: To investigate the diagnostic value of whole liver CT perfusion imaging in the quantitative evaluation of hemodynamic changes before and after transcatheter arterial chemoembolization (TACE). Methods: Twenty-six patients with hepatocellular carcinoma underwent TACE therapies were recruited. Whole -liver computed tomographic perfusion imaging (CTPI) was performed 2~3 days before TACE and 1 month after TACE. We measured the following perfusion parameters: hepatic arterial perfusion (HAP), portal venous perfusion (PVP), total liver perfusion (TLP), hepatic arterial perfusion index (HAPI), and time-to-peak (TTP).The F-test, t-test and Rank sum test were used for statistical analysis. Results: A total of 34 HCC lesions were detected. According to the deposition of lipiodol after TACE, they were divided into a lipiodol dense group (21) and a lipiodol light group (13). The length of hepatocellular carcinoma lesions after TACE showed a decreasing trend compared with preoperative TACE. The lesions in the lipiodol dense group had smaller lesions than those in the lipiodol light group. The preoperative and postoperative longitudinal diameters were (3.12 ± 0.58) cm vs. (1.93 ± 0.79) cm, (2.98 ± 2.01) cm vs. (2.58 ± 2.00) cm, the differences were statistically significant (t = 15.1, 8.65, P < 0.05). The preoperative HAP and HPI of the lipiodol dense group were the highest, and the peritumoral within 1cm was higher than that of the surrounding liver parenchyma. The PVP, TLP, and TTP were highest in the surrounding of liver parenchyma, and 1 cm higher than the tumor area in the background. The corresponding perfusion parameters were statistically significant (P < 0.05); HAP and HPI were 1 cm higher than the surrounding liver parenchyma. After the operation, PVP, TLP and TTP were lower than the background liver parenchyma, the difference was statistically significant (P < 0.05); HAP and HPI decreased by 1 cm after the operation, and the PVP, TLP, and TTP increased. There was no significant difference after operation in the blood perfusion of background liver parenchyma (P ˃ 0.05). The HAP and HPI decreased, and the PVP and TTP increased in the lipiodol light group after operation (P < 0.05). There was no significant difference between the other two regions (P ˃ 0.05). Conclusion: There was no blood perfusion in the lipiodol deposition area after TACE. The perfusion volume of hepatic artery in the peritumoral 1 cm and lipiodol light group decreased and the portal venous perfusion increased. CTPI can quantitatively evaluate blood perfusion state, which is of great significance for the determination of treatment plans before TACE treatment to assume the postoperative therapeutic effect in liver cancer.

Resection versus Resection with Preoperative Transcatheter Arterial Chemoembolization for Resectable Hepatocellular Carcinoma Recurrence.

The value of preoperative transcatheter arterial chemoembolization (TACE) for patients with recurrent hepatocellular carcinoma (rHCC) after liver resection is uncertain. We aimed to determine its effect on postoperative complication and survival. There were 33 patients who received preoperative TACE and repeated liver resection (TACE-LR) and 119 patients who received repeated liver resection (LR) alone for rHCC. Seventy-eight patients (TACE-LR, 28; LR, 50) were identified by propensity score matching (PSM) analysis for comparison of postoperative complication, disease-free survival (DFS) and overall survival (OS). Univariable and multivariable analyses were used to identify predictors for survival. Before matching, the TACE-LR group had more intraoperative blood loss than the LR group (P < 0.05). After matching, the TACE-LR group had more intraoperative blood loss and a longer operation time (Both P < 0.05). In all and matched patients, both groups had similar postoperative complications rate (TACE-LR, 21.2%; LR, 7.6%; P = 0.052 and TACE-LR, 21.4%; LR, 12.0%; P = 0.435), DFS (P = 0.81 and P = 0.41) and OS (P = 0.87 and P = 0.79). Preoperative TACE was not a predictor for DFS and OS in multivariable analyses. Preoperative TACE for resectable rHCC prolongs operating time and increases intraoperative blood loss without improving survival; thus, it should not be recommended as a routine procedure before repeated resection for patients with rHCCs.

Salvage Hepatectomy for Recurrent Hepatocellular Carcinoma after Radiofrequency Ablation and/or Transcatheter Arterial Chemoembolization: A Propensity Score-Matched Analysis

Aim: We aimed to evaluate the short- and long-term surgical outcomes of salvage hepatectomy for recurrent hepatocellular carcinoma (HCC) after radiofrequency ablation (RFA) and/or transcatheter arterial chemoembolization (TACE). Methods: We reviewed the surgical outcomes of 90 recurrent HCC patients after RFA and/or TACE (salvage group) and 490 HCC patients without preoperative treatment (primary group). We performed 1:1 propensity score matching (PSM) between the 2 groups and matched 87 patients in each group. Results: Before PSM, the salvage group was pathologically more advanced than the primary group. After PSM, there were no significant differences in the clinicopathological features between the groups. The outcomes of propensity score-matched groups were compared and there was no statistically significant difference between the 2 groups regarding perioperative outcomes and survival. Univariate and multivariate analyses of propensity score-matched HCC patients revealed that stage, tumor size, differentiation, and portal vein invasion were independent prognostic factors for survival. Preoperative RFA and/or TACE was not a prognostic factor in a propensity score-matched cohort. Conclusions: The short- and long-term surgical outcomes of the primary and salvage groups were similar under the matched clinicopathological background. Salvage hepatectomy might be an acceptable treatment for recurrent HCC patients after RFA and/or TACE.

Pre-operative trans-catheter arterial chemo-embolization increases hepatic artery thrombosis after liver transplantation - a retrospective study.

Little is known about nonsurgical risk factors for hepatic artery thrombosis (HAT) after liver transplantation (LT). We determined risk factors for HAT occurring within 90 days post-LT and analysed the effect of HAT on graft and patient survival. Donor and recipient demographics, surgery-related data and outcome in transplants complicated by thrombosis (HAT+) and their matched controls (HAT-) were compared. Risk factors were assessed by univariate logistic regression. Median (IQR) is given. A total of 25 HAT occurred among 1035 adult LT (1/1997-12/2014) and 50 controls were manually matched. Donor and recipient demographics were similar. Pre-LT trans-catheter arterial chemo-embolization (TACE) was more frequent in HAT+ (HAT+ 20% vs. HAT- 4%, P = 0.037). HAT+ had longer implantation [HAT+ 88 min (76-108) vs. HAT- 77 min (66-93), P = 0.028] and surgery times [HAT+ 6.25 h (5.18-7.47) vs. HAT- 5.25 h (4.33-6.5), P = 0.001]. Early graft dysfunction and sepsis were more frequent in HAT+ and hospitalization longer. TACE had the greatest odds ratio in unadjusted analysis (OR: 6, 95% CI: 1.07-33.53, P = 0.03). All but seven grafts were lost after HAT (HAT+ 72% vs. HAT- 36%, P = 0.003); however, patient survival was unaffected (HAT+ 79.8% vs. HAT- 76%, P = 0.75). LT candidates undergoing TACE are at risk of developing HAT early after transplant.

Sequential transcatheter arterial chemoembolization-portal vein embolization in hepatectomy for liver carcinoma

This article presented our experience on transcatheter arterial chemoembolization (TACE) and portal vein embolization (PVE) before hepatic resection for huge hepatocellular carcinoma with cirrhosis. The preoperative future liver remnant/total estimated liver volumn (FLR/TELV) ratios of 5 patients were less than 40%, and preoperative TACE was implemented 3 weeks after PVE. In all these patients, right hepatectomy was successfully implemented. Preoperative TACE and PVE expanded the indication of hepatectomy, increased the safety of surgery and improved the curative rate. Key words: Interventional treatment; Portal vein embolization; Hepatectomy

The Clinical Impact of Transcatheter Arterial Chemoembolization (TACE)-Induced c-Met Upregulation on TACE Refractoriness in Hepatocellular Carcinoma.

Transcatheter arterial chemoembolization (TACE) is a widely used and well-established treatment for hepatocellular carcinoma (HCC). However, TACE loses its therapeutic efficacy when performed repeatedly, a phenomenon termed TACE refractoriness. c-Met is associated with malignant potential and with resistance to anti-tumor therapies in some kinds of cancers. The aim of this study is to investigate the clinical impact of TACE on c-Met expression with the aim of understanding the mechanism underlying TACE refractoriness. The effect of TACE on the c-Met expression level was investigated in vitro in HCC cell lines, and it was shown that c-Met expression is upregulated in HCC cell lines cultured under hypoxia and/or exposed to chemotherapeutic agents. The in vitro results were validated using 82 clinical samples of HCC with and without preoperative TACE treatment. c-Met upregulation was observed significantly more frequently in clinical samples of HCC that were treated with preoperative TACE than in samples with no TACE treatment. Increased c-Met expression was significantly associated with poor prognosis. Furthermore, the incidence of c-Met-positive expression was significantly higher in TACE-refractory HCC samples. TACE treatment upregulates c-Met expression in HCC and the upregulated c-Met expression may be responsible for TACE refractoriness.

Absence of Benefit of Transcatheter Arterial Chemoembolization (TACE) in Patients with Resectable Solitary Hepatocellular Carcinoma

This study aimed to assess the prognostic impact of preoperative transcatheter arterial chemoembolization (TACE) on long-term survival outcomes in patients undergoing resection of small solitary hepatocellular carcinoma (HCC). Enrolled patients had undergone macroscopic curative resection of solitary 2-5 cm HCC with (n = 105) or without (n = 830; control group) preoperative TACE. TACE group was divided into subgroups A (n = 68, 1-2 TACEs within 12 months), B (n = 23, ≥ 3 TACEs within 12 months), and C (n = 14, TACE prior to 12 months). The number of TACE sessions was 1.8 ± 1.6. In TACE A-C subgroups, pathological response of tumor necrosis >50 % at median post-TACE period after final TACE was observed in 41 (60.3 %) at 1.9 months, 10 (43.5 %) at 2.1 months, and 2 (14.3 %) at 18.9 months, respectively. The 5-year tumor recurrence and patient survival rates were 62.8 and 70.4 % in TACE group and 51.4 and 83.4 % in control group, respectively (p ≤ 0.003). Median periods of postoperative tumor recurrence in TACE A-C subgroups and control group were 35, 13, 14, and 55 months, respectively (p < 0.001); and postoperative survival periods at 75 % survival rate were 51, 38, 51, and 98 months, respectively (p = 0.003). TACE-induced extensive tumor necrosis did not improve postoperative prognosis in TACE A subgroup (p ≥ 0.053). Postoperative prognosis after preoperative sequential TACE and portal vein embolization was comparable to that of the control group (p ≥ 0.052). Preoperative TACE for small solitary HCCs may adversely affect post-resection prognosis, irrespective of pathological responses. Preoperative TACE should be avoided for patients with resectable small HCCs.

Effect of preoperative transcatheter arterial chemoembolization on the perioperative outcome of patients with hepatocellular carcinoma

To explore the surgical risk, perioperative outcome and the response of patients with hepatocellular carcinoma (HCC) after preoperative transcatheter arterial chemoembolization (TACE). A retrospective case-matched study was conducted to compare the characteristics and corresponding measures of patients in the preoperative TACE group and the control group without TACE. A total of 105 patients (82 patients with selective and dynamic region-specific vascular occlusion to perform hepatectomy for patients with complex hepatocellular carcinoma) was included in this study, in which 35 patients underwent TACE therapy, and a 1:2 matched control group of 70 subjects. The patients of preoperative TACE therapy group had a higher level of γ-glutamyl transpeptidase before operation (119.52±98.83) U/L vs. (67.39±61.25) U/L (P=0.040). The operation time was longer in the TACE group than that in the control group but with a non-significant difference (232.60±95.43) min vs. (218.70±75.13) min (P=0.052). The postoperative recovery of liver function and severe complications in the preoperative TACE group were similar to that in the control group (P>0.05). There were no massive hemorrhage, biliary fistula and 30-d death neither in the treatment group and matched control group. Preoperative TACE therapy has certain negative effect on liver function. It is preferable to use selective and dynamic region-specific vascular occlusion technique during hepatectomy and combine with reasonable perioperative treatment for this group of patients, that can ensure safety of patients and promote their rapid recovery.

Magnetic resonance imaging for diagnosis and management of unruptured interstitial pregnancy.

The aim of this study was to evaluate the value of magnetic resonance imaging (MRI) for the diagnosis and management of suspicious unruptured interstitial pregnancy. Only patients with unruptured interstitial pregnancy evaluated by MRI and observed for at least a year after surgery were included. Initial evaluation was performed by measurement of serum β-human chorionic gonadotrophin level and ultrasonography. In suspicious cases, emergency MRI was performed to diagnose interstitial pregnancies with the exclusion of rudimentary horn pregnancy and angular pregnancy. Three-dimensional computed tomographic (CT) angiography was additionally performed if the uteroplacental neovascularization needed to be evaluated. Then, management procedures were individually determined along with the need for preoperative transcatheter arterial chemoembolization for immediate devascularization, and for the local or systemic administration of methotrexate. Either laparoscopic cornuostomy or cornual resection was chosen to excise the gestational mass. Five consecutive women with unruptured interstitial pregnancy were enrolled. One case each of rudimentary horn pregnancy and angular pregnancy was excluded. Three-dimensional CT angiography was performed in three cases due to increased vascular flow on color Doppler ultrasonography. Preoperative devascularization by transcatheter arterial chemoembolization was performed in two cases, in which a prominent neovascularized gestational mass was identified. Uterine preservation was achieved by cornuostomy or cornual resection in all cases. Two patients with a desire to become pregnant conceived spontaneously thereafter, followed by successful cesarean birth. This small case series emphasizes that precise localization of gestational products in the interstitial portion of the fallopian tube by MRI can facilitate the minimally invasive management of unruptured interstitial pregnancy for uterine preservation.

Prognostic effect of preoperative sequential transcatheter arterial chemoembolization and portal vein embolization for right hepatectomy in patients with solitary hepatocellular carcinoma.

Backgrounds/AimsBoth preoperative transcatheter arterial chemoembolization (TACE) alone and portal vein embolization (PVE) alone have a detrimental prognostic effect on the post-resection outcomes in patients with hepatocellular carcinoma (HCC). The main objective of this study was to assess the prognostic impact of preoperative TACE on the long-term survival outcomes in patients undergoing preoperative PVE and right liver resection for solitary HCC.MethodsPatients who underwent macroscopic curative right liver resection of solitary HCC that lied between 3.0 and 7.0 cm (n=113) with or without preoperative TACE and PVE were selected for the study, making these subjects were divided into three groups; the TACE-PVE group (n=27), the PVE-alone group (n=13), and the control group (n=73). The subjects in the three groups were followed up for ≥36 months or until death.ResultsThe 1-, 3-, 5-, and 10-year overall patient survival rates of all 113 patients were 96.5%, 88.2%, 81.3% and 65.0%, respectively. The 1-, 3-, 5-, and 10-year overall patient survival rates were 96.3%, 83.4%, 83.4% and 47.6% respectively in the TACE-PVE group; 84.6%, 76.9%, 57.7% and 19.2% respectively in the PVE-alone group; and 98.6%, 91.7%, 85.1% and 81.7% respectively in the control group (p=0.047). Patients were also sub-grouped according to tumor size, and those with a tumor of up to cutoff at 5 cm showed no prognostic difference (p=0.774), but tumor size >5 cm was associated with inferior patient survival only in the TACE-PVE group (p=0.018).ConclusionsPreoperative sequential TACE and PVE appear to be compliant to the conventional oncological concept in addition to induction of the future remnant liver regeneration. Therefore, we suggest that preoperative TACE should be come first whenever preoperative PVE for major hepatectomy is planned, especially in patients with hypervascular HCC tumors.

Preoperative transcatheter arterial chemoembolization for resectable hepatocellular carcinoma: a single center analysis

Background and aim. The effect of preoperative transcatheter arterial chemoembolization (TACE) on the short- and long-term outcome of resectable hepatocellular carcinoma (HCC) is controversial. We conducted a retrospective evaluation of this aspect using data from our center.Material and methods. A total of 656 consecutive patients who underwent curative resection of HCC were divided into two groups based on the preoperative TACE: the liver resection (LR) group (405 cases) and the TACE-LR group (183 cases). Overall and disease-free survival curves were constructed using the Kaplan-Meier method and compared with the log-rank test. The significance of differences in survival was tested using a log-rank test. Univariate and multivariate analyses were used to identify the factors that best predicted overall survival or tumorfree survival.Results. Although the cost of LR showed no difference between groups, the overall cost was significantly higher in the combined group than in the LR group (P < 0.001). The complication rate after resection was also comparable between the two groups. In regard to long-term outcome, the 1-, 3-, and 5-year overall survival rates were 83.7, 68.9 and 57.5%, respectively, after direct liver resection and 80.9, 65.0 and 54.1%, respectively, after combined TACE and resection (P = 0.739). The 1-, 3-, and 5-year recurrence-free survival rates were also comparable between two groups (P = 0.205). Both univariate analysis and multivariate analysis showed that macro-vascular invasion was the factor that best predicted overall survival or tumor-free survival rate.Conclusion. Preoperative TACE has comparable intraoperative and short-term outcomes but more overall cost due to repeated TACE, and the procedure did not significantly improve the overall or tumor-free survival rate. Preoperative TACE should not, therefore, be recommended as a routine procedure before resection for resectable HCCs particularly in cases due to underlying hepatitis B virus (HBV).

Efficacy of preoperative transcatheter arterial chemoembolization combined with systemic chemotherapy for treatment of unresectable hepatoblastoma in children.

The purpose of this study was to evaluate, retrospectively, the clinical efficacy of preoperative transcatheter arterial chemoembolization (TACE) combined with systemic chemotherapy for unresectable hepatoblastoma. Five boys and three girls (mean age 15.2 months) were treated with preoperative TACE combined with systemic chemotherapy for unresectable hepatoblastomas. Mean tumor diameter and mean alfa-fetoprotein (AFP) level were 11.8 cm and 549,386 ng/mL, respectively. Pretreatment, the extent of disease (PRETEXT) was: II, 1; III, 6; IV, 1. For all patients, preoperative systemic chemotherapy was administered before TACE. At each TACE, carboplatin and adriamycin mixed with iodized oil were infused into the feeding arteries. Tumor response and prognosis after treatment were evaluated. TACE resulted in few Grade 1 adverse effects (AEs), without G3 or more AEs, according to CTACAE 3.0. Mean tumor shrinkage was 60.9%, and the mean AFP decrease from initial levels was 94.8%. In all cases TACE combined with systemic chemotherapy enabled subsequent safe and complete surgical resection. After a mean follow-up of 59 months, tumor-free survival was 75%. Preoperative TACE combined with systemic chemotherapy was effective in inducing surgical resectability of unresectable hepatoblastoma.

Influence of preoperative transcatheter arterial chemoembolization on gene expression in the HIF-1α pathway in patients with hepatocellular carcinoma.

Although transcatheter arterial chemoembolization (TACE) is the most common treatment option in patients with hepatocellular carcinoma (HCC), its clinical benefits remain still controversial. Since TACE induces hypoxic necrosis in tumors, hypoxia-inducible factor 1α (HIF-1α) could critically affect biology in residual tumors after TACE treatment and subsequent prognosis. However, HIF-1α and its prognostic relevance in TACE have rarely been examined in human specimens. In the current study, we investigated the prognosis and expression of genes regulated by HIF-1α in HCC patients receiving preoperative TACE for the first time. In total, 35 patients with HCC (10 patients undergoing preoperative TACE) were retrospectively studied. The prognostic significance of TACE was analyzed using Kaplan-Meier and Cox regression models. Protein levels of HIF-1α and mRNA levels of HIF-1α-associated genes were examined using immunohistochemistry (IHC) and real-time RT-PCR, respectively. Preoperative TACE was significantly associated with increased 2-year recurrence rate (80 vs. 36%, P=0.00402) and shorter disease-free survival (DFS) time (11.9 vs. 35.7months, P=0.0182). TACE was an independent prognostic factor for recurrence (P=0.007) and poor DFS (P=0.010) in a multivariate analysis. Immunohistochemical staining revealed in vivo activation of HIF-1α in human specimens treated with TACE. Notably, protein levels of HIF-1α were significantly increased in TACE tissues demonstrated by IHC. Transcriptional targets of HIF-1α showed mRNA expression patterns consistent with activation of HIF-1α in TACE tissues. Our findings collectively demonstrate that preoperative TACE confers poor prognosis in HCC patients through activation of HIF-1α.

Preoperative Transcatheter Arterial Chemoembolization of Hepatoblastoma in Infants

PurposeTo evaluate the effect of preoperative transcatheter arterial chemoembolization of hepatoblastoma in infants. Materials and MethodsClinical data of 21 infants with hepatoblastoma treated between July 2008 and July 2012 in a single hospital were retrospectively analyzed. After preliminary diagnosis, surgical resection was performed in 9 infants (group I), and transcatheter arterial chemoembolization was performed in 12 infants (group II) before conventional resection. Surgical resection was performed when the tumor bulk appeared sufficiently reduced after transcatheter arterial chemoembolization alone or transcatheter arterial chemoembolization following chemotherapy in cases of pulmonary metastases. ResultsTumor shrinkage ranged from 25%–91% with a mean reduction of 69% (t = 3.816, P = .003) in group II. α-Fetoprotein levels were markedly decreased from 49%–99% with a mean level of 95% (t = 4.871, P = .000) in group II. Specimens in group II showed massive necrosis with a mean percentage of 72% with no significant treatment-related toxicity. In group II, the surgical time was significantly shorter (t = 3.438, P = .003), intraoperative blood loss was considerably less (t = 3.459, P = .003), and the weight of the resected liver was significantly less (t = 3.785, P = .001). Of 21 patients, 16 survived for 50 months without recurrence. ConclusionsTranscatheter arterial chemoembolization effectively reduced tumor volume, decreased α-fetoprotein, and reduced intraoperative hemorrhage. It represents a safe and effective adjuvant bridge to successful surgery for hepatoblastoma in infants.

An effective approach for treating unresectable hepatoblastoma in infants and children: Pre-operative transcatheter arterial chemoembolization

The objective of the present study was to investigate the feasibility and efficacy of pre-operative transcatheter arterial chemoembolization (TACE) for unresectable hepatoblastoma in infants and children. A total of 24 patients (14 males and 10 females) with unresectable hepatoblastoma, aged between 26 days and 41 months, were treated with pre-operative TACE between March 2007 and March 2011. All cases were confirmed by computed tomography (CT) and liver tumor biopsy prior to TACE. Arteriography was performed and the chemoembolization mixture (pirarubicin and cisplatin emulsified in lipiodol) was injected, followed by polyvinyl alcohol (PVA). The procedure was performed one to four times depending on the patient’s response. There was a significant reduction in tumor volume associated with decreased α-fetoprotein (AFP) levels following TACE. Tumor volumes decreased by between 46.1 and 90.2%, with a mean value of 72%. The AFP levels fell by between 63.8 and 99.9%, with a mean value of 95.7%. A total of 22 cases underwent subsequent safe complete surgical resection and the remaining two patients accepted a partial resection. To evaluate the toxicity of TACE, the alanine aminotransferase (ALT), serum creatinine (Cr) and creatine kinase (CK) levels of the patients were measured to assess liver, renal and cardiac function, respectively. The results showed that no marked chemotherapeutic agent-induced toxicity occurred during TACE. It may be concluded that TACE is an effective and feasible pre-operative therapeutic approach for treating unresectable hepatoblastoma and that it may improve the resectability of bulky liver tumors.

Meta-analysis: preoperative transcatheter arterial chemoembolization does not improve prognosis of patients with resectable hepatocellular carcinoma

BackgroundLong-term outcomes of partial liver resection of hepatocellular carcinoma (HCC) remain satisfactory due to high incidences of recurrence. This study was intended to see whether preoperative transcatheter arterial chemoembolization (TACE) reduces postoperative tumor recurrences and prolongs survival of patients with resectable HCC.MethodsA computerized literature search was performed to identify relevant articles. The quality of nonrandomized comparative studies (NRCTs) was assessed using the methodological index for nonrandomized studies (MINORS). Data synthesis was performed using Review Manager 5.0 software.ResultsTwenty-one studies (4 randomized controlled trials and 17 NRCTs) with a total of 3,210 participants were suitable for analysis. There was no significant difference in disease-free and overall survival at 5-year (32.1% vs. 30.0% and 40.2% vs. 45.2%), and intra- and extra-hepatic recurrence (51.2% vs.53.6% and 12.9% vs.10.3%) between patients with and without preoperative TACE. Postoperative morbidity (28.9% vs. 26.8%) and in-hospital mortality (4.1% vs. 3.1%) were also similar between the two groups.ConclusionsPreoperative TACE does not seem to improve prognosis and therefore it is prudent to recommend it as a preoperative routine procedure for resectable HCC.

Doxorubicin-eluting beadvsconventional transcatheter arterial chemoembolization for hepatocellular carcinoma before liver transplantation

To assess the possible effect of two different types of preoperative transcatheter arterial chemoembolization (TACE) on recurrence-free survival after liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) and to analyze the effects of TACE on tumor histology. We retrospectively analyzed the histological features of 130 HCC nodules in 63 native livers removed at transplantation. Patients who received any other type of treatment such as radiofrequency tumor ablation, percutaneous ethanol ablation or who were not treated at all were excluded. All patients in the present study were within the Milan Criteria at the last imaging findings before transplantation. Doxorubicin-eluting bead TACE (DEB-TACE) was performed in 22 patients (38 nodules), and conventional TACE (c-TACE) in 16 (25 nodules). Patients' and tumors' characteristics were retrospectively reviewed. We performed a per-nodule analysis of the explanted livers to establish the mean percentage of necrosis of any nodule treated by TACE (conventional or DEB) and a per-patient analysis to establish the percentage of necrosis in the cumulative tumor area, including 21 nodules not reached by TACE. Inflammatory and fibrotic changes in the tissue surrounding the tumor nodule were analyzed and categorized as poor/absent, moderate and enhanced reaction. Uni- and multivariate analysis of risk factors for HCC-recurrence were performed. The number and diameter of the nodules, the time spent on the waiting list and the number of treatments were similar in the two groups. A trend towards higher appropriate response rates (necrosis ≥ 90%) was observed in the DEB-TACE group (44.7% vs 32.0%, P = 0.2834). The mean percentage of necrosis in the cumulative tumor area was 58.8% ± 36.6% in the DEB-TACE group and 50.2% ± 38.1% in the c-TACE group (P = 0.4856). Fibrotic and inflammatory reactions surrounding the tumor nodule were markedly more common in the DEB-TACE group (P < 0.0001, for both the parameters). The three-year recurrence-free survival was higher in DEB-TACE-treated patients than in conventionally treated patients (87.4% vs 61.5%, P = 0.0493). Other factors affecting recurrence-free survival included viable tumor beyond Milan Criteria on histopathological examination, the percentage of necrosis on CTA ≤ 50% and a pre-transplant serum α-fetoprotein level greater than 70 ng/mL. On multivariate analysis, the lack of treatment with DEB-TACE, high levels of α-fetoprotein and viable tumor beyond Milan Criteria at histology examination were identified as independent predictors of tumor recurrence. DEB-TACE can effectively promote tumor necrosis and improves recurrence-free survival after LT in HCC.