Selective Chemoembolization Research Articles

Combined Surgical/Interventional-Radiological Cytoreduction in a Patient with Disseminated Highly Differentiated Neuroendocrine Ileal Tumor

A combined approach to cytoreduction in a patient with a neuroendocrine tumor G1 the ileum with multiple bilobar metastases G2 in the liver, originally considered as a candidate only for drug therapy, has been demonstrated. The first stage was laparoscopic resection of the ileocecal segment of the intestine, followed by interventional radiological intervention — a two-stage selective transarterial oil chemoembolization of the liver with bleomycin. As a result, 90 % cytoreduction, suppression of clinical manifestations, normalization of chromogranin A and serotonin were achieved. The patient continues to be observed without signs of progression for more than 4 years from the moment of diagnosis. It is shown that multidisciplinary treatment of patient with timely inclusion of interventional-radiological interventions allows achieving long-term favorable results in patients with advanced stage of disease.

Role of hepatic arterial chemoembolization in the treatment of elderly and geriatric patients with metastatic colorectal cancer

Aim . To improve the results of the treatment of colorectal cancer with hepatic metastases in patients over 60 years old by applying selective chemoembolization of the hepatic artery. Materials and methods. At the Central Clinical Hospital “Railways-Medicine“, 20 patients over 60 years old with colorectal cancer liver metastases were treated. Ten patients in the control group received systemic chemotherapy. In the main group, 10 patients underwent chemoembolization of the hepatic artery using microspheres saturated with doxorubicin. Treatment results were assessed using the RECIST 1.1 scale. We considered the immediate and long- term results up to 12 months after the treatment. Results . A partial response according to the RECIST 1.1 scale was detected in 4 patients from the main group (40%), stabilization of the oncological process in the liver in 2 (20%) patients, progression of the metastatic process was detected in 4 (40%) patients. There were no deaths within 12 months after the chemotherapy. In the control group, stabilization was observed in 2 (20%) patients after systemic chemotherapy according to the RECIST 1.1 scale, and progression was diagnosed in 8 (80%) patients. One death (10%) was noted during the observation period. Conclusion . The use of selective chemoembolization of the hepatic artery in the main group of patients has shown its effectiveness while preserving a satisfactory quality of life (QLP).

Hepatic Toxicity After Selective Chemoembolization Is Associated With Decreased Survival Among Patients With Hepatocellular Carcinoma.

OBJECTIVE. The purpose of this study was to identify risk factors for and outcomes of hepatotoxicity after selective chemoembolization of hepatocellular carcinoma. MATERIALS AND METHODS. This retrospective study included 182 patients (136 men and 46 women; median age, 63 years [interquartile range, 57-70 years]) who underwent 338 consecutive doxorubicin drug-eluting bead (DEB) chemoembolization procedures between 2011 and 2014. Outcomes were assessed until November 2019. In 97% of procedures, two or fewer segments were targeted. The Barcelona Clinic Liver Cancer (BCLC) stage was 0 or A for 77 procedures (22.8%), B for 75 (22.2%), C for 122 (36.1%), and D for 64 (18.9%). Hepatotoxicity was defined as worsened ascites or encephalopathy or as grade 3 or 4 elevations in liver function test results, creatinine levels, or the international normalized ratio within 30 days. Risk factors were assessed by univariate and multivariable generalized estimating equations. Transplant-free survival was assessed using Cox proportional hazard models. RESULTS. Hepatotoxicity was observed after 84 of 338 procedures (24.9%) performed for 70 of 182 patients (38.5%) and was irreversible for 40 procedures (11.8%). On multivariable analysis, risk factors for irreversible toxicity included Child-Pugh class C liver function (odds ratio [OR], 4.4; 95% CI, 1.0-19.0; p = .04), BCLC stage C (OR, 5.0; 95% CI, 1.6-16.0; p = .006) or D (OR, 7.4; 95% CI, 2.1-25.5; p = .002) disease, TIPS or hepatofugal portal venous flow (OR, 6.3; 95% CI, 2.3-17.0; p < .001), and a serum α-fetoprotein level of 200 ng/mL or greater (OR, 2.6; 95% CI, 1.1-6.1; p = .03). Irreversible toxicity was associated with reduced transplant-free survival among patients who were ineligible for liver transplant (hazard ratio, 2.5; standard error, 0.42; p = .03). CONCLUSION. Irreversible hepatotoxicity was common after selective chemoembolization in patients with advanced stage disease, an elevated serum α-fetoprotein level, or reduced hepatic portal venous perfusion, and it may hasten death among patients who are ineligible for liver transplant.

The initial experience of selective x-ray endovascular chemoembolization of bladder arteries in combined treatment of patients with metastatic bladder cancer, which was complicated by refractory macrohematuria in «Feofaniya» clinical hospital

The objective of study is retrospective analysis, estimate and publish the initial experience of selective chemoembolization of the bladder arteries in the combined treatment of a patient with metastatic bladder cancer complicated by refractory macrohematuria. Material and methods. In the course of the work the results of treatment of metastatic bladder cancer with the use of X-ray endovascular selective chemoembolization of the bladder arteries in the conditions of the «Feofaniya» clinical hospital were studied. Simmons/Sidewinder 3 and UFE Type 1 (Terumo) catheters with an outer diameter of 5 F were used during the intervention. Vascular chemoembolization was performed with LifePearl (Terumo) microspheres with a diameter of 200±50 nm in a volume of 2 ml, which were saturated with the chemotherapeutic agent Doxorubicin “Ebeve” at a dose of 50 mg. The results were studied immediately and after three months. Results. According to control intraoperative angiography all arterial branches feeding the tumor were excluded from the blood supply. After the intervention, the patient retained an independent act of urination, the need for catheterization of the bladder or other methods urine derivation after surgery did not arise. Three months later, according to the results of the control examination, signs of regression of the bladder tumor were revealed while maintaining the reservoir potential of the bladder. No recurrences of macrohematuria occurred during the follow-up period. Conclusions. The technique of X-ray endovascular selective chemoembolization seems promising to us, and the initial experience of its use motivates the further introduction of such operations in patients with locally advanced or metastatic (mostly hypervascular) neoplasias of different localizations. In addition, this process is actualized by the possibility of effective and minimally invasive prevention of the occurrence or cessation of existing tumor-associated bleeding, which in this work is successfully illustrated by the example of refractory macrohematuria.

Comparison of Opioid Medication Use after Conventional Chemoembolization versus Drug-Eluting Embolic Chemoembolization

PurposeTo assess the use of opioid analgesics and/or antiemetic drugs for pain and nausea following selective chemoembolization with doxorubicin-based conventional (c)-transarterial chemoembolization versus drug-eluting embolic (DEE)-transarterial chemoembolization for hepatocellular carcinoma (HCC). Materials and MethodsFrom October 2014 to 2016, 283 patients underwent 393 selective chemoembolization procedures including 188 patients (48%) who underwent c-transarterial chemoembolization and 205 (52%) who underwent DEE-transarterial chemoembolization. Medical records for all patients were retrospectively reviewed. Administration of postprocedural opioid and/or antiemetic agents were collated. Time of administration was stratified as phase 1 recovery (0–6 hours) and observation (6–24 hours). Logistic regression model was used to investigate the relationship of transarterial chemoembolization type and use of intravenous and/or oral analgesic and antiemetic medications while controlling for other clinical variables. ResultsMore patients treated with DEE-transarterial chemoembolization required intravenous analgesia in the observation (6–24 hours) phase (18.5%) than those treated with c-transarterial chemoembolization (10.6%; P = .033). Similar results were noted for oral analgesic agents (50.2% vs. 31.4%, respectively; P < .001) and antiemetics (17.1% vs. 7.5%, respectively; P = .006) during the observation period. Multivariate regression models identified DEE-transarterial chemoembolization as an independent predictor for oral analgesia (odds ratio [OR], 1.84; P = .011), for intravenous and oral analgesia in opioid-naïve patients (OR, 2.46; P = .029) and for antiemetics (OR, 2.56; P = .011). ConclusionsCompared to c-transarterial chemoembolization, DEE-transarterial chemoembolization required greater amounts of opioid analgesic and antiemetic agents 6–24 hours after the procedure. Surgical data indicate that a persistent opioid habit can develop even after minor surgeries, therefore, caution should be exercised, and a regimen of nonopiate pain medications should be considered to reduce postprocedural pain after transarterial chemoembolization.

Stereotactic body radiotherapy in patients with hepatocellular carcinoma in amultimodal treatment setting.

Retrospective evaluation of stereotactic body radiation therapy (SBRT) in patients with hepatocellular carcinoma (HCC). We retrospectively analyzed 36 patients (45 lesions) treated between 2011 and 2017. Twenty-seven had previous treatments. Current treatment consisted of SBRT alone (n = 15) or selective transarterial chemoembolization (TACE) followed by SBRT to the same lesions (n = 21). Eight patients received additional local treatments to different lesions. Liver function was predominantly moderately restricted (ChildA: 29, ChildB: 6, ChildC: 1). Treatment planning was based on 4D-computed tomography, dose/fractionation varied depending on location and size, most commonly 3 fractions of 12.5 Gy (65% isodose) and 5 fractions of 8Gy (80% isodose). Median follow-up was 15months. Local recurrence was observed in 3lesions (7%), resulting in 1‑and 2‑year local control rates of 93%. The only significantly predicting factor was the use of abdominal compression. New hepatic lesions occurred in 19patients (52%), 1‑ and 2‑year freedom-from-hepatic-failure (FFHF) was 39% and 32%, respectively. Only the number of treated lesions was predictive for FFHF. Sixteen patients have died, resulting in 1‑ and 2‑year overall survival (OS) of 64% and 41%, respectively, significantly impacted by the number of treated lesions and Child-Pugh class. Severe acute and late toxicity (≥grade 3) was observed in 3% and 8%, respectively. 6patients (17%) received liver transplantation (OLT) after SBRT, of whom 5 showed pathological complete remission. SBRT (±TACE) in highly pretreated HCC is effective and associated with excellent LC and low toxicity. SBRT may be used as definitive or bridging treatment prior to OLT. Patients with multifocal lesions have significantly decreased 1‑ and 2‑year FFHF and OS.

Effectiveness, complications and reproductive outcome of selective chemoembolization with methotrexate followed by suction curettage for caesarean scar pregnancy - A prospective observational study

ObjectiveCaesarean scar pregnancy (CSP) is a rare form of ectopic pregnancy implanted in a previous caesarean scar. Selective chemoembolization with methotrexate (SCEM) followed by suction curettage (SC) is one of the treatment options for CSP. The aim of the study was to assess the effectiveness, complications and reproductive outcome of SCEM followed by SC in the treatment of CSP. Study designAll cases of CSP treated with SCEM followed by SC between 2015 and 2018 were prospectively followed-up to assess short and long-term outcome. All patients hospitalized with the suspicion of CSP during the study period were included in the study. Gelatine sponge was used as embolic material to avoid permanent damage of the uterus and minimise the possible impact on fertility. Haemoglobin (Hb) and beta human chorionic gonadotropin (β-hCG) levels, normalization of menstrual cycle, complications after the procedure and subsequent fertility were assessed. ResultsTwenty-two patients diagnosed with CSP underwent SCEM followed by SC. The procedure was effective in 20 cases (91%). In two cases additional SCEM was required before attempting SC due to persistent vascularity on ultrasound in one case and abnormal uterine bleeding in the second one. No complications were observed during the procedures, none of the patients required a hysterectomy. Follow-up ranged from 9 to 36 months. In short-term follow-up no significant complications occurred, only minor ailments such as uterine cramping and nausea were reported by 8 patients. In long-term follow-up 8 patients reported at least one complication, such as hypomenorrhea, amenorrhoea or were diagnosed with Asherman syndrome. Ten patients tried to conceive and 4 out of them achieved a pregnancy (all in less than 12 months) and delivered by caesarean sections between 35 and 39 weeks. One patient reported recurrent miscarriage. ConclusionSCEM followed by SC appears to be an effective treatment option for CSP. The method seems to be safe in short-term follow-up. However, complications were observed in long-term follow-up. Therefore, patients should be informed about the risk of complications interfering with future fertility, such as intrauterine adhesions and/or amenorrhea.

Selective TACE with irinotecan-loaded 40 \u03bcm microspheres and FOLFIRI for colorectal liver metastases: phase I dose escalation pharmacokinetic study

BackgroundEfficacy of treatments for colorectal liver metastases after failure of first-line chemotherapy is limited. The aim of this study was to prospectively evaluate the feasibility, tolerability, and pharmacokinetics of selective transarterial chemoembolization (TACE) with irinotecan-loaded 40 μm microspheres combined with systemic FOLFIRI for colorectal liver metastases refractory to oxaliplatin regimen.MethodsThe dose escalation study was conducted in three patient groups with different amounts of irinotecan loaded (50, 75 and 100 mg per mL-microspheres). Selective catheterization was performed to embolize subsegments or segments of located tumors using TACE navigation system. FOLFIRI was administrated 7 days after TACE. Plasma concentration was measured before and time points after administration.ResultsNine patients successfully underwent a total of 22 TACE procedures. Dose-limiting toxicity did not appear at any level. The overall response rate was 55.6%. The median progression free and overall survival were 8.1 and 18.2 months, respectively. The AUC and Cmax of plasma SN-38 per 1 mg injected irinotecan dose were significantly higher in irinotecan-loaded microspheres compared with FOLFIRI (P = 0.009 and P < 0.001, respectively).ConclusionSelective TACE using 40 μm irinotecan-loaded microspheres combined with systemic FOLFIRI was feasible and safe even when a high dose of irinotecan was loaded. Irinotecan-loaded microspheres resulted in a higher plasma concentration and AUC of SN-38 than treatment with FOLFIRI. Further large scale trials to evaluate the efficacy are mandatory.Trial registrationUniversity Hospital Medical Information Network (UMIN) Clinical Trials Registry, Registration number; UMIN000015367; Registered date; 08,10,2014.

Comparative evaluation of treatment methods of neoadjuvant intra-arterial chemotherapy and chemoembolization by drug-saturated embospheres in II–IVa stages cervical cancer

Objective: comparative evaluation of treatment methods for neoadjuvant intra-arterial chemotherapy and chemoembolization by drug-saturated microspheres followed by surgical treatment in II–IVa stages cervical cancer.Materials and methods. This study presents the results of complex treatment in 209 patients (average age – 40.57 ± 8 years) with II– IVa stages cervical cancer and 384 endovascular interventions as the first stage of complex treatment in the period from 2010 to 2016. The scheme neoadjuvant intra-arterial chemotherapy was carboplatin (AUC6 intra-arterial) + irinotecan (200 mg/m2 intravenously on day 1) every 21 days. Radical surgical treatment was performed basically after 2 cycles of chemotherapy. Patients who did not respond sufficiently to neoadjuvant intra-arterial chemotherapy underwent a radical course of chemoradiation therapy according to the standard scheme.Results. The overall response to neoadjuvant intra-arterial chemotherapy was 84.8 % and 79 % of patients in groups of chemoinfusion and trans-arterial chemoembolization, respectively (p &gt;0.05). Operability was higher in group of chemoinfusion (69 % versus 46.4 %) (p &lt;0.01), and fewer patients with metastases to regional lymph nodes were revealed in this group (30.2 % versus 42 %), p &lt;0.05. Overall and survival rate is statistically significantly better in group of chemoinfusion – 63.9 % and 61 % versus 43 % and 42 %, respectively, p &lt;0.05. At the same time, statistically significant differences between the groups were revealed only at stages III–IVа cervical cancer. Radically operated patients, as expected, had a better prognosis (p &lt;0.001). The age of patients, tumor differentiation and therapeutic pathomorphosis did not affect the prognosis of life.Conclusions. Neoadjuvant intra-arterial chemoinfusion and chemoembolization using irinotecan + carboplatin scheme are relatively safe treatment methods with acceptable toxicity and have a high cytotoxic effect. Patients in chemoinfusion group have a better prognosis compared with patients in chemoembolization group. Selective chemoembolization with subsequent surgical treatment or radiation therapy may be the treatment of choice for stage II cervical cancer complicated by bleeding.

Selective Transvenous Chemoembolization of Primary Pancreatic Tumors

Selective Transvenous Chemoembolization of Primary Pancreatic Tumors

Selective Chemoembolization of Caudate Lobe Hepatocellular Carcinoma: Anatomy and Procedural Techniques

Transarterial chemoembolization is the most common treatment for unresectable hepatocellular carcinomas (HCCs). However, when an HCC is located in the caudate lobe, many interventional radiologists are reluctant to perform chemoembolization and percutaneous ablation owing to the tumor's complex vascular supply and deep location. With the advent of C-arm CT, rendering the three-dimensional display of the hepatic artery and detecting the tumor-feeding vessels are possible and can help guide interventional radiologists to the tumor. The common origins of the caudate artery include the right hepatic artery, left hepatic artery, right anterior hepatic artery, and right posterior hepatic artery. The origins of the tumor-feeding arteries of a caudate lobe HCC can vary depending on the tumor's subsegmental location. Caudate lobe HCCs are commonly fed by multiple caudate arteries that are connected. In addition, extrahepatic collateral arteries frequently supply recurrent tumors in the caudate lobe. The caudate artery can supply portal vein thrombi or biliary tumor thrombi in patients with HCC. Several techniques such as preshaping the microcatheter or using the shepherd's hook technique are needed to catheterize the caudate artery in complex cases. Although uncommon, bile duct stricture is a serious complication following selective chemoembolization through the caudate artery. Identification and catheterization of the caudate artery have become possible in most patients by using C-arm CT and a fine microcatheter system, respectively. The authors review the anatomy of the caudate artery with C-arm CT and describe basic technical considerations in selective chemoembolization for caudate lobe HCCs. Unusual circumstances that require catheterization and techniques used for catheterizing the caudate artery are also described. Online supplemental material is available for this article. ©RSNA, 2019.

Selective chemoembolization of liver arteries as a stage of complex treatment of patients with unresectable cancer metastases (Own Experience)

Purpose: Chemoembolization is one of the methods of local treatment. Due to hydrophilicity and biocompatibility with the tissues of microspheres filled with cytostatics, one can achieve a long-term effect by controlling tumor growth. The differentiation of the sizes of the microcatheter and the microspheres allows them to be injected into the vessels associated with neoangiogenesis and tumor progression. Methods: Between January 2015 and December 2017, 17 patients underwent arterial chemoembolization with drug-saturated microspheres as a part of the treatment of metastatic cancer of various primary localizations. There were 8 men (age from 52 to 75 years, mean 63.6), and 9 women (age from 43 to 68 years, mean 55.3). In 9 cases, femoral artery access was used, and in 8 cases, radial artery access was used. In 15 patients, one vial of HepaSphere (in 6 cases saturated with 50 mg, and in 9 cases of 75 mg of Doxorubicin) was co-administered in the hepatic arteries. Two patients required the introduction of two vials of microspheres. Results: Partial reduction of tumor size was achieved in all patients, that allowed to continue specialized treatment. In 1 case, there was complete regression of the tumor node. In 3 cases, arterial chemoembolization was performed twice at an interval of 197, 329 and 371 days. Conclusion: The method of arterial chemoembolization of the liver with drug-saturated microspheres allows a deep cytotoxic effect on the metastasis of cancer in the liver, improving the immediate results of treatment, manifested in regression and stabilization of the tumor process.

NEW POSSIBILITIES OF COMPLEX TREATMENT FOR METASTATIC AND LOCALLY ADVANCED NEUROENDOCRINE TUMORS OF THE PANCREAS

During the period 2006 to 2017 years 86 patients with neuroendocrine pancreatic tumors were observed and treated. 25 (29,1%) patients underwent only chemotherapy due to generalized tumor process or severe concomitant somatic status. 61 (70,9%) patients with neuroendocrine pancreatic tumors underwent surgical treatment. In 34 patients tumors were localized in the body and tail, in 27 - in the head of the pancreas. Women predominated among patients (n = 41), the average age of the patients was 51 ± 3.1 years. Synchronous metastatic liver metastases were detected in 33 (54,1%) of 61 patients, with the size of the primary tumor from 10 to 73 mm. In 47 (77%) neuroendocrine pancreatic tumors were regarded as non-functioning. Radical surgery was performed in 24 patients of 61 (39,3%) with tumor sizes from 11 to 128 mm (average 56 ± 21 mm), cytoreductive surgery was performed in 37 (60.7%) patients. Patients with locally advanced neuroendocrine pancreatic tumors (n = 13) and neuroendocrine pancreatic tumors with synchronous liver metastases (n = 33) undergone combined treatment (n = 46). Combined treatment was performed by means of intra-arterial selective oil chemoembolization and chemoinfusion, supplemented with one or several local methods effects: cytoreductive surgery and radiofrequency ablation (n = 8). 6 (12.2%) of patients with high, moderately and low-grade tumors died after the operation in period from 7 to 63 months from progression of disease. 43 (87.8%) patients survived in period from 4 to 112 months, 32 patients still alive without signs of disease progression. Because of recurrence in five patients (11.9%) repeated operations were performed. One patient (2.4%) underwent conformal radiation therapy. Life expectancy after surgery in patients with low-grade neuroendocrine cancer of the pancreas ranged from 3 to 16 months, and the median survival was 8.3 ± 1.2 months.

Radiation Segmentectomy versus Selective Chemoembolization in the Treatment of Early-Stage Hepatocellular Carcinoma

PurposeTo compare outcomes of radiation segmentectomy (RS) and segmental transarterial chemoembolization in treatment of unresectable, solitary hepatocellular carcinoma (HCC) ≤ 3 cm. Materials and MethodsFrom January 2012 to January 2016, 534 and 877 patients were treated with radioembolization and transarterial chemoembolization, respectively. A cohort of 112 (radiation segmentectomy [RS], 55; chemoembolization, 57) locoregional therapy–naïve patients with solitary HCC ≤ 3 cm without vascular invasion or metastasis was retrospectively identified and stratified according to baseline patient demographics, tumor characteristics, and laboratory values. Propensity score matching (PSM) was conducted using a nearest neighbor algorithm (1:1). Outcomes analyzed included laboratory toxicities, imaging response, time to secondary therapy (TTST), and overall survival. ResultsBefore PSM, complete response (CR) rate was 81.2% for RS and 49.1% for chemoembolization (odds ratio 2.2; 95% confidence interval [CI], 1.4–3.3; P < .001). Median (95% CI) TTST after initial therapy was 246 days (135–250 d) in chemoembolization group and 700 days (308–812 d) in RS group (hazard ratio 0.71; 95% CI, 0.55–0.92; P = .009). Overall survival before PSM was not significantly different between the 2 groups (P = .29). Overall CR rate after PSM was 92.1% in RS group and 52.6% in chemoembolization group (P = .005). Median (95% CI) TTST after matching was 161 days (76–350 d) in chemoembolization group and 812 days (363–812 d) in RS group (P = .001). Overall survival after matching was not significantly different between the 2 groups (P = .71). ConclusionsRS results in improved imaging response and longer TTST compared with transarterial chemoembolization in treatment of early-stage HCC.

The Role of Interventional Oncology in the Management of Lung Cancer.

Interventional radiological procedures for diagnosis and treatment of lung cancer have become increasingly important. Imaging-guided percutaneous biopsy has become the modality of choice for diagnosing lung cancer, and in the era of target therapies, it is an useful tool to define earlier patient-specific tumor phenotypes. In functionally inoperable patients, especially the ablative procedures are potentially curative alternatives to surgery. In addition to thermally ablative treatment, selective chemoembolization by a vascular access allows localized therapy. These treatments are considered for patients in a reduced general condition which does not allow systemic chemotherapy. The present article reviews the role of interventional oncology in the management of primary lung cancer, focusing on the state of the art for each procedure.

Evaluation of Surefire’s precision direct-to-tumor embolization device to augment therapeutic response to intra-arterial, liver-directed therapies for patients with primary and secondary liver cancers

ABSTRACTPatients with primary and secondary liver cancers generally have a poor prognosis with limited potentially curative options. Liver-directed, intra-arterial therapies such as selective internal radiotherapy (SIRT) and trans-arterial chemoembolization (TACE) are taking a larger role in the management of these patients. The current standard of therapy is for delivery of SIRT or TACE particles through an end-hole microcatheter. Antireflux microcatheters (ARM) are a novel class of microcatheters designed to enhance intra-arterial therapies. These catheters are designed with a flexible tip at the end of the microcatheter, which partially collapses during systole and expands during diastole, reducing antegrade and retrograde particle reflux while allowing for forward flow. Initially designed to reduce the risk of particle reflux during SIRT, there is evidence that ARMs may lead to improved particle distribution to tumors during SIRT. Furthermore, ARMs improve embolization efficiency which may lead to improved disease response from TACE for patients with hepatocellular carcinoma.

The Safety and Clinical Outcomes of Chemoembolization in Child-Pugh Class C Patients with Hepatocellular Carcinomas.

ObjectiveTo evaluate the safety and clinical outcomes of chemoembolization in Child-Pugh class C patients with hepatocellular carcinomas (HCC).Materials and MethodsThe study comprised 55 patients with HCC who were classified as Child-Pugh class C and who underwent initial chemoembolization between January 2003 and December 2012. Selective chemoembolization was performed in all technically feasible cases to minimize procedure-related complications. All adverse events within 30 days were recorded using the Common Terminology Criteria for Adverse Events (CTCAE). The tumor response to chemoembolization was evaluated using the modified Response Evaluation Criteria In Solid Tumors.ResultsThirty (54.5%) patients were within the Milan criteria, and 25 (45.5%) were beyond. The mortality of study subjects at 30 days was 5.5%. Major complications were observed in five (9.1%) patients who were all beyond the Milan criteria: two hepatic failures, one hepatic encephalopathy, and two CTCAE grade 3 increases in aspartate aminotransferase/alanine aminotransferase abnormality. The mean length of hospitalization was 6.3 ± 8.3 days (standard deviation), and 18 (32.7%) patients were discharged on the next day after chemoembolization. The tumor responses of the patients who met the Milan criteria were significantly higher (p = 0.014) than those of the patients who did not. The overall median survival was 7.1 months (95% confidence interval: 4.4-9.8 months).ConclusionEven in patients with Child-Pugh class C, chemoembolization can be performed safely with a selective technique in selected cases with a small tumor burden.

Metastatic Periampullary Tumor from Hepatocellular Carcinoma Presenting as Gastrointestinal Bleeding.

Periampullary tumors constitute a number of diverse neoplastic lesions located within 2 cm of the major duodenal papilla; among these, metastatic lesions account for only a small proportion of the periampullary tumors. To our knowledge, a metastatic periampullary tumor from hepatocellular carcinoma has never been reported. A 62-year-old male reported to our institute for fatigue and low hemoglobin. His medical history was remarkable for multifocal hepatocellular carcinoma (HCC) treated with selective transcatheter arterial chemoembolization (TACE). An esophagogastroduodenoscopy (EGD) was performed which revealed a periampullary mass. Histopathology was consistent with metastatic moderately differentiated HCC. Two endoloops were deployed around the base of the mass one month apart. The mass eventually sloughed off and patient's hemoglobin level stabilized. We postulated that periampullary metastasis in this patient was the result of tumor fragments migration through the biliary tracts and that TACE which increases tumor fragments burden might have played a contributory role. Metastasis of HCC to the gastrointestinal (GI) tract should be considered as a cause of GI bleeding.

Cost of selective internal radiation therapy versus other modalities.

Evaluation of comparative effectiveness and cost–effectiveness is an essential component in the integration of new technologies into medical management, with data from prospective clinical trials (e.g., health-related quality of life using validated tools) being mandated by most health authorities. Health economics has its own vocabulary and so a glossary of terms is provided in Table 1 for the uninitiated. One of the key issues in assessing the comparative costs and cost–effectiveness of locoregional therapies for primary and secondary cancers in the liver is the limited number prospective trials. Health economic models, however, are valuable tools for overcoming such limitations that bring together information from different sources in order to assess the expected costs and outcomes. Such information is essential for healthcare reimbursement agencies and payers at national, regional and local levels when making funding decisions in order to ensure that the allocation of limited resources is optimized. Selective internal radiation therapy versus conventional transarterial chemoembolization One of the most detailed studies comparing the cost–effectiveness of selective internal radiation therapy (SIRT) versus conventional transarterial chemoembolization (TACE) was conducted by a group from Cleveland (OH, USA) in patients with unresectable hepatocellular carcinoma (HCC) [1]. This study recorded significantly greater costs associated with conventional TACE than SIRT, largely due the greater number of mean hospital days for the initial procedure (3.5 ± 0.7 vs 0.5 ± 0.2; p < 0.001) and for readmissions (7.9 ± 1.7 vs 3.6 ± 0.6; p = 0.03) with TACE. While the rates of postembolization syndrome were similar between the procedures in this study, the severity of postembolization syndrome was significantly worse with TACE, as would be expected from a purely embolic approach, and required additional hospitalization and treatment in a significantly greater number of patients compared with SIRT (p = 0 .02) [1]. Otherwise, there were no significant differences between the groups in major or minor complication rates (p = 0.58) or 30-day mortality (p = 0.07) [1]. Subsequently, a systematic review of the literature examining the comparative safety and effectiveness of SIRT and conventional TACE for the treatment of HCC concluded that the two procedures had a similar efficacy (defined by tumor response and patient survival), with significantly longer time to progression and lower toxicity with SIRT [2]. Compared with SIRT, the meta-analysis found that conventional TACE was associated with a statistically greater overall toxicity, as well as a higher rate of abdominal pain and hepatic transaminase elevation postprocedure. Numerous studies have also consistently observed a significantly shorter postprocedure hospital stay with SIRT compared with conventional TACE [2]. Although conventional TACE costs less in the majority of cases, SIRT was less expensive in 33.4% of cost analysis simulations that compared the two procedures [2].

SIR-Spheres yttrium-90 radioembolization for the treatment of unresectable liver cancers.

Transarterial radioembolization with yttrium-90 resin microspheres (SIR-Spheres; Sirtex Medical Limited, Sydney, Australia) is a liver-directed therapy that is gaining recognition as a treatment option for liver-dominant primary and metastatic cancers. The incidence of complications is low and can be further reduced by patient selection and rigorous pretreatment assessment. Ideal candidates for radioembolization have preserved liver function without ascites or encephalopathy, Child-Pugh score <7 and limited lung shunting. Phase III randomized controlled trials (RCTs) against other liver-directed therapies are lacking for intermediate-stage hepatocellular carcinoma. However, preliminary data from a recent RCT has suggested that radioembolization has a similar time-to-progression and comparable toxicity to selective chemoembolization. Phase II/III RCTs are now ongoing to evaluate the combination of radioembolization with systemic therapies in advanced-stage hepatocellular carcinoma and metastatic liver-dominant colorectal cancer in order to expand the treatment opportunities for patients with cancers in the liver.