Transarterial Chemoembolization Procedures Research Articles

Outcomes of transarterial chemoembolization (TACE) of the liver in patients with metastatic triple-negative breast cancer (TNBC).

e13107 Background: TACE is widely used in oncology in patients with metastasis in liver from GI tumors, meanwhile its opportunities in management pts with TNBC are unknown. The purpose of the study was to analyze the results of TACE of the liver metastases from TNBC. Methods: The study included 60 TNBC pts with unresectable liver metastases. 34 pts of the main group underwent chemotherapy including taxanes in standard regimens. After 6-12 chemotherapy cycles, the main group received 1-2 TACE procedures (doxorubicin 30 mg/m², 5-fluorouracil 600 mg/m², 10 ml of lipiodol and 1-2 ml of 300-500 µm HepaSphere microspheres). The control group (n = 32) received only 6-12 cycles of taxane-containing chemotherapy. Pts were aged 32-66 years, mean age in the main group 49.4, in controls 55 years. Primarily advanced breast cancer with unresectable liver metastases was diagnosed in 6 (17.6%) pts of the main group and in 5 (15.6%) controls. Progression after previous treatment was observed in 91.2% (31) main group and 90.6% (29) controls. Sizes of metastatic foci were 2.7-7.3 cm, average number 7.5. Bilobar metastases were most common. Liver metastases were own accompanied by metastases to the bones, intrathoracic lymph nodes, lungs and pleura. Obtained data were processed with software package “Statistica 7.0”. Results: Main group received a total of 46 TACE procedures performed for a maximal number of metastatic lesions, especially for those progressing after systemic therapy and the largest ones, when possible. Post-embolization syndrome after performing TACE, was observed in 60.86% (28) of cases, managed with conservative therapy for 2-7 days. Icterus was not observed. The tumor response rate was 94.1% in the main group vs. 80.6% in controls, with significant differences in PR (44.1% and 15.3% respectively, p < 0.05). Median of duration treatment response was 13.4 months in the main group and 9.3 months in control group (p < 0.05). CR was not achieved. Median follow-up was 17 months. 3-year disease-free survival was 63.2% in the main group and 43.8% in controls (p = 0.039). Conclusions: TACE resulted in better response to the therapy as well as improved disease-free survival in pts with TNBC. TACE is possible to be used to consolidate the achieved effect of the chemotherapy.

Impact of tumor anatomic characteristics on patient radiation dose during transarterial chemoembolization

Objective: The aim of the study was to determine the association between anatomic tumor characteristics and the radiation dose in patients with hepatocellular carcinoma undergoing transarterial chemoembolization (TACE). Materials and Methods: A retrospective study was performed over a 42 months period. A total of 51 TACE procedures were included in the study. Information collected included: Gender, BMI, height, weight, cumulative dose area product (KAP), cumulative reference air kerma (RAK), maximum tumor diameter, multinodular tumors, and embolization material. Parametric univariate and simple linear regression analysis were used to determine associations between quantitative variables. Results: A total of 51 procedures in 37 patients, 19 women (51%) and 18 men (49%), with a mean age of 56 years (±17.3 years) and a mean BMI of 24 kg/m2 were included in the study. Overall, patient radiation dose was as follows: Mean KAP of 542.2 Gy* cm2 (±307 Gy* cm2) with a mean RAK of 2930.2 mGy (±1776.5 mGy). Higher patient radiation doses were observed in men (581.6 ± 262.9 Gy* cm2 vs. 497.8 ± 350.5 Gy* cm2) (P = 0.06) and in patients with higher BMIs (KAP: r = 0.37 [P = 0.01]; RAK: r = 0.4 [P = 0.01]). Patients with multinodular disease were found with lower radiation dose according to RAK (1710.7 ± 1118.6 mGy vs. 3227.7 ± 1789.1 mGy, P = 0.03). Furthermore, logistic regression analysis demonstrated that patients with multinodular disease received 10% lower dose, according to RAK, when compared to patients with single tumors (odds ratio 1.001, 95% confidence interval [CI], 1–1.002) (P = 0.02). Conclusion: TACE is an effective method to treat patients with HCC that may be performed within acceptable radiation dose limits. Anatomic tumor characteristics were found to be associated with patient radiation dose. Interestingly, multi-tumor disease was found to cause a radiation dose reduction of 10%.

Conversion factors for effective dose and organ doses with the air kerma area product in patients undergoing percutaneous transhepatic biliary drainage and trans arterial chemoembolization

Conversion factors used to estimate effective (E) and organ doses (HT) from air Kerma area product (KAP) are required to estimate population doses in percutaneous transhepatic biliary drainage (PTBD) and trans arterial chemoembolization (TACE) interventional procedures.In this study, E and HT for ten critical organs/tissues, were derived in 64 PTBD and 48 TACE procedures and in 14,540 irradiation events from dosimetric, technical and geometrical information included in the radiation dose structured report using the PCXMC Monte Carlo model, and the ICRP 103 organ weighting factors. Conversion factors of: 0.13; 0.19; 0.26 and 0.32 mSv Gy−1 cm−2 were established for irradiation events characterized by a Cu filtration of 0.0; 0.1; 0.4 and 0.9 mm, respectively. While a single coefficient of conversion is not able to provide estimates of E with enough accuracy, a high agreement is obtained between E estimated through Monte Carlo methods and E estimated through E/KAP conversion factors accounting separately for the different modes of fluoroscopy and the fluorography component of the procedures.An algorithm for the estimation of effective and organ doses from KAP has been established in biliary procedures which considers the Cu filtration in the X-ray irradiation events. A similar algorithm could be easily extended to other interventional procedures and incorporated in radiation dose monitoring systems to provide dosimetric estimates automatically with enough accuracy to assess population doses.

The Model to Estimate Survival in Ambulatory Hepatocellular Carcinoma Patients Aids in the Decision for TACE Retreatment.

Transarterial chemoembolization (TACE) is a major therapeutic modality for patients with unresectable hepatocellular carcinoma, which needs repeated treatments. Model to Estimate Survival in Ambulatory Hepatocellular carcinoma patients (MESIAH) was recently developed as a model for predicting survival. We aimed to develop a novel index for TACE retreatment using MESIAH scores. From 2005 to 2008, 783 patients with hepatocellular carcinoma who had undergone 1 previous TACE procedure were enrolled. We calculated their pre-TACE and post-TACE-MESIAH and calculated the MESIAH ratio by dividing the post-TACE by pre-TACE score. The discriminatory abilities of the MESIAH ratio and post-TACE-MESIAH were compared with ART and ABCR scores. Among 783 patients, 355 (45.3%) received a second TACE (test set), and 195 (24.9%) patients received a third TACE treatment (validation set). In the test set, patients with a MESIAH ratio <0.9 obtained longer overall survival than patients with a MESIAH ratio ≥0.9 [26.0 vs. 9.0 mo, respectively; hazard ratio 1.66 (1.29-2.14)], and patients with a post-TACE-MESIAH<4.5 showed longer overall survival than patients with a post-TACE-MESIAH≥4.5 [38.0 vs. 7.0 mo, respectively; hazard ratio, 3.17 (2.45-4.09)]. The post-TACE-MESIAH [C-index 0.663 (0.628-0.697)] was better than the ART [C-index 0.596 (0.554-0.638)] and ABCR scores [C-index 0.576 (0.536-0.617)] at estimating prognosis. Our results were confirmed by the validation set. A MESIAH score ≥4.5 after TACE identifies patients with a poor prognosis. Randomized studies are needed to establish whether additional TACE may affect survival.

Evaluation of transarterial chemoembolization refractoriness in patients with hepatocellular carcinoma.

Background & aimIn clinical practice, transarterial chemoembolization (TACE) has been widely used for the treatment of hepatocellular carcinoma (HCC) beyond as well as within guideline recommendations. Here we aimed to verify whether two consecutive non-responses could be an optimal criterion for creating a rule to stop TACE being performed on these patients.MethodsThis study evaluated 200 patients with HCC beyond the Milan criteria, initially treated with TACE. TACE response was determined using the mRECIST criteria via dynamic CT or MRI. Median follow-up duration was 23.9 months.ResultsWithin the 200 patients analyzed, 183 (91.5%) were male, with a total median age of 59.8 years. The mean size of the largest tumor was 6.8 cm, with 80 (40.0%) patients with ≥4 tumors. After the first TACE procedure, complete response, partial response, stable disease, or progressive disease were observed in 48 (24.0%), 87 (43.5%), 59 (29.5%) and 6 (3.0%) of patients, respectively. 45 (22.5%) patients showed no objective response (OR) following two consecutive TACE sessions. Of these, 28 received a subsequent TACE, with a 10.7% OR rate. Patients without OR showed poorer survival when compared to patients who achieved OR after repeated TACE. Multivariable analysis showed that size of the largest tumor >5cm and high alpha-fetoprotein of >200 ng/mL were significant factors associated with failure of OR to two consecutive TACE sessions.ConclusionPatients showing no OR to two consecutive TACE sessions will present a poor OR to subsequent TACE procedures. Early transition to systemic therapy may be advocated in such cases.

Applicability of scoring systems predicting outcome of transarterial chemoembolization for hepatocellular carcinoma

PurposeSeveral scoring systems have been proposed to predict the outcome of transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC). However, the application of these scores to a bridging to transplant setting is poorly validated. Evaluation of the applicability of prognostic scores for patients undergoing TACE in palliative intention vs. bridging therapy to liver transplantation (LT) is necessary.MethodsBetween 2008 and 2017, 148 patients with HCC received 492 completed TACE procedures (158 for bridging to transplant; 334 TACE procedures in palliative treatment intention at our center and were analyzed retrospectively. Scores (ART, CLIP, ALBI, APRI, SNACOR, HAP, STATE score, Child–Pugh, MELD, Okuda and BCLC) were calculated and evaluated for prediction of overall survival. ROC analysis was performed to assess prediction of 3-year survival and treatment discontinuation.ResultsIn patients receiving TACE in palliative intention most scores predicted OS in univariate analysis but only mSNACOR score (p = 0.006), State score (p < 0.001) and Child–Pugh score (p < 0.001) revealed statistical significance in the multivariate analysis. In the bridging to LT cohort only the BCLC score revealed statistical significance (p = 0.002).ConclusionsClinical usability of suggested scoring systems for TACE might be limited depending on the individual patient cohorts and the indication. Especially in patients receiving TACE as bridging to LT none of the scores showed sufficiently applicability. In our study Child–Pugh score, STATE score and mSNACOR score showed the best performance assessing OS in patients with TACE as palliative therapy.

Fabrication of radiopaque drug-eluting beads based on Lipiodol/biodegradable-polymer for image-guided transarterial chemoembolization of unresectable hepatocellular carcinoma

New radiopaque/biodegradable drug-eluting beads (DEBs) for transarterial chemoembolization (TACE) were fabricated using Lipiodol and polycaprolactone (PCL) (Lipiodol/PCL beads) through a microfluidic device. TACE is the most extensively-applied therapy for unresectable hepatocellular carcinoma (HCC). DEBs are embolic microspheres with sustained and tumor-selective drug-delivery characteristics for tumor-feeding arteries. As the conventional DEBs are not radiopaque by themselves and not biodegradable, it is difficult to monitor bead localization and attenuation through CT images after DEB-TACE procedures, and the complication after non-target embolization becomes potentially more serious. In this work, we found that our new biodegradable Lipiodol/PCL lost 63.5% of their weight 11 days after immersion, simultaneously releasing 0.94 μg of miriplatin (a lipophilic platinum-based anticancer drug) from the Lipiodol/PCL beads in 11 days. We also found that the degradation speed could be controlled from 18.2% to 63.5% of the weight loss in 11 days by changing the molecular weight of PCL and the ratio of Lipiodol/PCL. The mean diameter of the bead could be well controlled by changing the flow-rate ratio of the microfluidic device. Regarding the radiopacity in vitro, the Lipiodol/PCL beads were clearly visualized through CT imaging, with a mean attenuation of over 5600 HU. Furthermore, it was found from the radiopacity experiments in vivo, that the embolization by the Lipiodol/PCL beads in the rabbit vessel was clearly recognized through CT images, indicating high potential of the newly synthesized biodegradable beads to improve the current TACE procedures by providing refined locational information on drug and embolic particles.

Abstract No. 540 Usefulness of Dyna computed tomography in hepatocellular carcinoma: transarterial chemoembolization for segment 1 of the liver

To evaluate usefulness of the Dyna-CT in hepatocellular carcinoma treated by transarterial chemoembolization (TACE) for segment 1 (S1) of the liver. Total 24 session of TACE was performed in 20 patients (mean age, 63.0; range, 48-86 years) to treat HCC in S1 from March 2017 to July 2019. Multiplanar reconstruction (MPR) images and embolization guidance program by 3-dimensional reconstruction of the Dyna-CT were used for diagnosis of HCC and superselection of the feeding artery with microcatheter set. TACE procedures were done by conventional method with doxorubicin, ethiodized oil, and gelatin sponge. Digital subtraction angiogram (DSA) and Dyna-CT Images obtained during TACE including medical records were reviewed to evaluate detection of the HCC, tumor size, characteristics of the feeding artery, superselected artery, and radiation dose for Dyna-CT. Follow-up liver dynamic CT images were also reviewed to evaluate success of treatment. HCCs were visualized 14 cases (58.3%) on DSA and all cases on MPR images of the Dyna-CT. Mean size of HCCs was 16.1 mm(range, 5-94 mm) on Dyna-CT. Numbers of the feeding artery were one in 22 cases (91.7%) and two in 2 cases (8.3%). Among of 26 feeding arteries, they were originated from territory of the right hepatic artery (RHA) in 14 and left hepatic artery (LHA) in 12. Most common origin of the segment 1 hepatic artery (S1HA) was RHA (n = 11, 42.3%). Superselective TACE of the S1HA was successful in 15 arteries (57.7%) and TACE was done at proximal artery to origin of the S1HA in 11 arteries (42.3%). Dense uptake of ethiodized oil was detected in all cases after superselective TACE of the S1HA and in 2 cases (18.1%) after proximal TACE. Mean cumulative dose of radiation by Dyna-CT was 201.9 mGy. Dyna-CT was useful to detect the HCC in S1 compared with DSA. Embolization guidance seems to be helpful for superselective TACE and uptake of the ethiodized oil in the HCC.

EUS-aided diagnosis and treatment of bleeding gastric Dieulafoy's lesion (with video).

Dieulafoy's lesion is an uncommon life-threatening condition, accounting for 1.5% of upper gastrointestinal (GI) bleeding.[1] This is due to tortuous arterioles (1–3 mm) seen in the submucosal layer,[2] also known as “persistent caliber arteries.” Usually, arteries narrow as they branch out toward the mucosa, and submucosal end arteries are normally 0.12–0.2 mm in diameter.[1] A 64-year-old diabetic and hypertensive male patient was being treated for chronic liver disease with portal hypertension. He underwent a transarterial chemoembolization procedure for hepatocellular carcinoma 2 years ago. He had a history of variceal band ligation. He was referred from a nearby general hospital where he presented with three episodes of hematemesis in the past 6 months. Endoscopy showed a vascular malformation (0.5 cm × 0.5 cm) with central ulcer in the fundus, with a small fundal vessel nearby [Figure 1a]. EUS showed a persistent caliber feeding arteriole with a diameter of 1.7 mm, suggestive of Dieulafoy's lesion, with a prominent vein nearby [Figure 2a]. Endoscopic hemoclipping was attempted, but hemostasis could not be attained because of the difficult position of the lesion. An Ovesco clip (OTSC®, Ovesco Endoscopy AG, Germany), which facilitates effective full circumferential tissue closure, including the vascular malformation, was used. Following deployment of the Ovesco clip, the Dieulafoy's lesion oozing was controlled, but there was separate new oozing from the vein nearby, which was possibly caused by one of the prongs of the Ovesco clip injuring the fundal vein. This was managed by injection of 0.5 ml of cyanoacrylate glue. Endoscopy repeated the following day showed the clip in situ with no active ooze [Figure 1b]. EUS after the procedure showed the clip at the Dieulafoy's lesion impeding flow in the artery [Figure 2b and Video 1]. The patient was under our follow-up for nearly 1 year without further episodes of GI bleeding. In our patient, the Ovesco clip was efficient in achieving hemostasis, as its design aids complete circumferential tissue closure including the vessel involved. There are few case reports for Ovesco clip use in Dieulafoy's in the stomach or duodenum.[34] Angiographic embolization and surgical interventions are reserved for cases when endoscopic interventions fail.Figure 1: (a) Endoscopic picture showing 5x5 mm sized vascular malformation with a small central ulcer (yellow arrow) with a small fundal vessel (white arrow) nearby. (b) Endoscopic picture showing Dieulafoy's lesion after OVESCO clipping (yellow arrow)Figure 2: (a) EUS showing a 1.7 mm sized persistent caliber artery in submucosa (pink arrow) with arterial Doppler pattern. (b) EUS showing OVESCO clip in situ (pink arrow) with abrupt cut off of the arteriole. Doppler suggests arterial patternDeclaration of patient consent The authors certify that they have obtained all appropriate patient consent forms. In the form the patient has given his consent for his images and other clinical information to be reported in the journal. The patient understands that his names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed. Financial support and sponsorship Nil. Conflicts of interest There are no conflicts of interest.

Intra-procedural dual phase cone beam computed tomography has a better diagnostic accuracy over pre-procedural MRI and MDCT in detection and characterization of HCC in cirrhotic patients undergoing TACE procedure

PurposeThis study was directed to compare diagnostic accuracy of dual-phase cone beam computed tomography (DP-CBCT) vs pre-procedural second line imaging modality (SLIM [multidetector computed tomography and magnetic resonance imaging]) to detect and characterize hepatocellular carcinoma (HCC) in cirrhotic patients with indication for trans-arterial chemoembolization (TACE). MethodsThis is a single centre, retrospective, and observational study. Exclusion criteria were not-assisted DP-CBCT TACE, and unavailable follow-up SLIM. We evaluated 280 consecutive patients (January/2015-Febraury/2019). Seventy-two patients were eligible. Three radiologists in consensus reviewed: pre-procedural SLIM, DP-CBCT, and SLIM at follow-up, with 4 months of interval between each reading. Hyper-vascular foci (HVF) were detected and characterized. Diameter was recorded. Radiological behaviour, according to LI‐RADS criteria, of HFV throughout follow-up time was the reference standard. Diagnostic accuracy was calculated for pre-procedural SLIM and DP-CBCT and evaluated through receiver operating characteristic curve. HVF only visible on DP-CBCT (defined as occult) were analysed. Tumour diameters were compared. ResultsMedian time between pre-procedural SLIM and DP-CBCT and between DP-CBCT and definitive radiological diagnosis of HVF were 46.0 days (95%CI 36.5–55.0) and 30.5 days (95%CI 29.0–33.0), respectively.DP-CBCT had a better diagnostic performance than pre-examination SLIM (sensitivity 99%vs78%; specificity 89%vs85%; PPV 99%vs99%; NPV 92%vs30%; and accuracy 94%vs79%). DP-CBCT diagnosed 63 occult HVF. Occult HCC were 54/243 (22.2%). Six were occult angiomas. Three were false positive. Mean diameter was significantly higher in DP-CBCT vs pre-procedural SLIM (+7.5% [95%CI 3.7–11.3], p < 0.05). ConclusionsDP-CBCT has a better diagnostic accuracy and NPV than pre-procedural SLIM in cirrhotic patients with indication for TACE.

Value of dynamic and DWI MRI in evaluation of HCC viability after TACE via LI-RADS v2018 diagnostic algorithm

BackgroundDetection of the value of DCE (dynamic contrast enhanced) MRI and DWI (diffusion-weighted imaging) in follow-up of treatment response for HCC (hepatocellular carcinoma) lesions post TACE (trans-arterial chemo-embolization) through LI-RADS v2018 algorithmic approach.ResultsA prospective study was performed on 30 patients with 41 treated hepatic focal lesions. The patients underwent DCE MRI with DWI in less than 1-month duration following TACE procedure and were radiologically assessed to observe tumoral post treatment response; then, another follow-up after another 3 months later was done for non-viable, equivocal, and non-evaluable post treatment response categories. Statistical analysis showed that DCE MRI had 100% level of sensitivity, specificity of 95.24%, PPV of 95.00%, and NPV of 100% with an overall agreement of 97.50%. While on the other hand, statistics showed that DWI has 52.63% level of sensitivity, specificity of 90.48%, PPV of 83.33%, PPV of 67.86%, and NPV of 72.50%.The difference between non-viable and viable groups’ ADC variables was found statistically significant at P value < 0.001, and best cut off value that augments sensitivity and specificity is 1.35. At this ADC value, sensitivity reaches 78.9% and specificity is 85.7%.ConclusionsOur study showed that DCE MRI has 100% level of sensitivity via application of LI-RADS v2018 diagnostic algorithmic approach while DWI alone has 52.63% level of sensitivity, yet it can enhance the diagnostic confidence of DCE MRI for post treatment response viability detection.

Radiological appearance of hepatocellular carcinoma predicts the response to trans-arterial chemoembolization in patients undergoing liver transplantation

BackgroundThe ultimate goal of locoregional therapy (LRT) to the liver is to induce total tumor necrosis. Trans-arterial chemoembolization (TACE) is the mainstay bridging therapy for patients with hepatocellular carcinoma (HCC) waiting for liver transplantation (LT). However, tumor response rate is variable. The purpose of this study was to correlate HCC radiological appearance with level of tumor necrosis during explant analysis from patients undergoing LT who received pre-LT TACE.MethodsFrom January 2000 to December 2018, a total of 66 patients with HCC who had been treated prior to LT by means of TACE were analyzed. Diagnosis of HCC was made based on AASLD guidelines and confirmed via histopathology explant analysis. Radiologic tumor response after TACE was based on modified Response Evaluation Criteria in Solid Tumors (mRECIST). Degree of tumor necrosis was determined by histopathology analysis of liver explants. HCC radiological appearances on CT before TACE were assessed and correlated with histological findings after LT.ResultsEighty nine TACE procedures (1.35 ± 0.67; 1–4) were performed, of which 18 were repeated TACE (27.3%) procedures. In 56.1% of the patients, ≥90% (near-complete) tumor necrosis was achieved. Concordance between mRECIST criteria and pathology was observed in 63% of the patients, with an underestimation of tumor response in 18 (27%) patients and an overestimation in 6 (9.1%). Near-complete tumor necrosis upon pathological analysis was associated with tumor hyper-enhancement in the arterial phase (P = 0.002), “typical tumor enhancement” (P = 0.010) and smooth tumor margins (p = 0.011). The multivariate analysis showed that well circumscribed HCCs with smooth margins and arterial hyper-enhancement independently correlated with post-TACE near-complete histological tumor necrosis.ConclusionsThe well circumscribed HCC lesions with arterial hyper-enhancement are more susceptible to TACE than lesions with arterial phase iso or hypo-enhancement and lesions with infiltrative appearance. Pre-TACE CT imaging may ease the selection of an optimal treatment strategy for bridging patients with HCC to liver transplantation.

2344 A Case of TACE: A Rare Complication of Transarterial Chemoembolization

INTRODUCTION: Transarterial chemoembolization (TACE) represents a proven therapy providing survival advantage in patients with large, unresectable hepatocellular carcinoma (HCC) not amenable to transplant or ablative therapies. Here we discuss a case of post-TACE liver abscess, a rare complication of this procedure. CASE DESCRIPTION/METHODS: A 65-year-old male with 10-year history of alcoholic cirrhosis (MELD-Na 12) presented for follow-up after a recent TACE procedure. Despite initial HCC isolation to segment 3, the patient had refused surgical intervention at the time of initial diagnosis. The mass rapidly enlarged, with new satellite lesions in segments 5 and 6. TACE of the left gastric artery supplying the HCC was performed 7 months after initial diagnosis, with subsequent ultrasound-guided HCC microwave ablation of a 7 cm segment 3 mass. One month after TACE, the patient presented to the emergency department with 2 weeks of weakness, fevers, and an episode of dizziness leading to a fall. Admission studies were notable for marked leukocytosis and blood cultures yielding Streptococcus lutetiensis. The patient was started on broad-spectrum antibiotics and scheduled for further imaging for evaluation of bacteremia source. CT abdomen revealed multifocal hepatic abscesses and a large 7 cm abscess communicating with distal stomach/proximal duodenum. On day 6 of hospitalization, IR placed a CT-guided hepatic abscess drain. Abscess culture was positive for E.coli and Enterococcus, and blood cultures from day after the procedure grew out extended spectrum beta-lactamase E.coli. He was started on a 3-week course of Ertapenem and discharged home with JP drain in place for follow-up in 3 weeks. JP drain was removed 10 days after discharge, and follow-up CT showed a significant decrease in the left hepatic lobe abscess with a small residual collection several centimeters above the drain. Ertapenem was discontinued after total of 5 weeks of antibiotic therapy. DISCUSSION: Liver abscess is an uncommon complication of TACE, occurring in about 2% of cases. Here our patient received the recommended therapy of percutaneous abscess drainage and parenteral antibiotics, resulting in a resolution of symptoms. Recognition of this complication is critical, as post-TACE liver abscess mortality has been estimated to be as high as 13.3%. Recent studies have even suggested prophylactic antibiotics when performing chemoembolization, with results showing promise, though this is not currently a routine or recommended practice.

1315 Groove Pancreatitis as a Rare Complication of TACE

INTRODUCTION: Transarterial chemoembolization (TACE) is often performed for hepatocellular carcinoma. Side effects can occur due to arterial ischemia and cytotoxicity from chemotherapy delivery. TACE can be complicated via inadvertent embolization of arteries supplying the liver, gallbladder, stomach and pancreas. The association of acute pancreatitis with TACE is rare. The proposed mechanism involves regurgitation of embolic beads from the hepatic artery into the arterial supply of the pancreas. Acute pancreatitis can develop up to 15 days after TACE. Herein we present a case of groove pancreatitis occurring after TACE. Groove pancreatitis is a rare variant of focal chronic pancreatitis affecting the area between the head of the pancreas, duodenum, and the common bile duct. Functional and anatomical obstruction of the minor papilla from viscous pancreatic secretions leads to impaired pancreatic enzyme outflow and proliferation of Brunner's glands causing pancreatitis. Imaging may show a submucosal mass which may confound the diagnosis since pathologies including leiomyoma, gastrointestinal stromal tumor and ampullary carcinoma may have similar imaging findings. Groove pancreatitis remains largely unfamiliar to most physicians thus making its true incidence a challenge. CASE DESCRIPTION/METHODS: This is the case of a 69-year-old male patient with multicentric hepatoma secondary to chronic Hepatitis C, status-post TACE who presented to ER with a nine-day history of epigastric abdominal pain and nausea. The patient had received TACE nine days prior and was admitted with the diagnostic impression of acute pancreatitis. The physical exam was remarkable for flank pain, negative murphy's sign. Labs showed stable hemoglobin and platelet levels. Liver chemistry showed a mixed pattern with AST minimally elevated and ALT at 102, Alk Phos at 225, Amylase slightly elevated at 135 and lipase elevated at 161. Imaging studies showed acute pancreatitis with possible necrotic collection of 2.1 cm at the pancreatic head and uncinate process, duodenitis, mild gallbladder wall thickening and no ductal dilation. Likely etiology was pancreatitis secondary to recent TACE. DISCUSSION: Pancreatitis is a rare complication of TACE. Although elevated pancreatic enzymes may be seen in up to 40% of TACE cases, the incidence of symptomatic pancreatitis after TACE is low at 2%-4%. Despite this low incidence, it is a complication that one should be aware of in patients undergoing TACE procedure given its high morbidity and mortality.

Tenofovir and Entecavir Have Similar Renal Adverse Events on Hepatocellular Carcinoma Patients Treated with Transarterial Chemoembolization

Background/Aims: Tenofovir disoproxil fumarate (TDF) is potentially nephrotoxic in chronic hepatitis B patients. Hepatocellular carcinoma (HCC) patients treated using transarterial chemoembolization (TACE) are at an increased risk of renal injury. The aim of this study was to determine whether TDF is associated with more renal adverse events than entecavir (ETV) in HCC patients treated with TACE. Methods: In this retrospective single-center study, we selected 53 HCC patients who were treated with TDF from January 2012 to July 2013 and had their first TACE procedure in the same period. These patients were matched by age and sex to patients treated with ETV. Results: There were no significant differences in baseline characteristics, including HCC factors, and nephrotoxic drug use, between the two groups. The median follow-up period was 17.0 and 20.0 months for the TDF and ETV groups, respectively. There was no difference during the follow-up period between the TDF and ETV groups in the increase in creatinine over 0.5 mg/dL (17.0% and 17.0%, P=1.00, respectively) and the decrease in eGFR over 25% (43.4% and 41.5%, P=0.84, respectively). Multivariate analysis revealed that Child-Pugh class over B (hazard ratio [HR], 7.30; 95% confidence interval [CI] 2.79-19.10; P<0.01) was associated with increase in creatinine, and Child-Pugh class over B (HR, 82.74; 95% CI 12.31-555.83; P<0.01) and Barcelona-Clinic Liver Cancer stage over B (HR, 14.93; 95% CI 1.60-139.51; P=0.02) were associated with decrease in eGFR. Conclusions: TDF has comparable safety to that of ETV for HCC patients undergoing TACE. (J Liver Cancer 2019;19:128-135)

Monitoring Liver Function of Patients Undergoing Transarterial Chemoembolization (TACE) by a 13C Breath Test (LiMAx).

Transarterial chemoembolization (TACE) is associated with the risk of deteriorating liver function, especially in patients with preexisting liver damage. Current liver function tests may fail to accurately predict the functional liver reserve. Aim of this study was to investigate whether changes of liver function caused by TACE are associated with detectable changes of LiMAx values. Forty patients with primary or secondary liver cancer underwent TACE and LiMAx test on the day before, the day after, and 4weeks after TACE. LiMAx results were evaluated, referenced to liver volume (CT/MR volumetry), correlated with the respective TACE volume (subsegmental vs. segmental vs. lobar), established liver function tests, and Child-Pugh and ALBI scores. The individual LiMAx values were significantly reduced by 10% (p = 0.01) on the day after TACE and fully recovered to baseline 1month after treatment. Similar changes were observed regarding levels of bilirubin, transaminases, albumin, INR, and creatinine. LiMAx did not correlate significantly with the treated liver volume, but did correlate with the baseline liver volume (< 1200ml vs. > 1200ml; p < 0.01). No significant changes were observed in the Child-Pugh score or ALBI score. LiMAx is capable of detecting changes in liver function, even modulations caused by superselective TACE procedures. Accordingly, it could be used as a tool for patient selection and monitoring of transarterial therapy. In comparison, Child-Pugh and ALBI scores did not reflect any of these changes. Some biochemical parameters also changed significantly after TACE, but they tend to be less specific in providing sufficient information on actual cellular dysfunction.

The value of dynamic subtraction MRI technique in the assessment of treatment response of hepatocellular carcinoma to transcatheter arterial chemoembolization

BackgroundHepatocellular carcinoma is considered to be the fifth most common cancer worldwide. Resection and liver transplantation have a high survival in the correct clinical scenarios; however, locoregional therapy has many advantages over tumor resection like preservation of hepatic parenchyma and overall less morbidity and mortality. Our aim was to present the role of dynamic subtraction MRI technique in the assessment of treatment response of hepatocellular carcinoma to transarterial chemoembolization.MethodsThe study consisted of 43 patients with 55 hepatocellular carcinoma lesions who underwent transarterial chemoembolization procedure and followed up by dynamic MRI of the liver with post processing to obtain subtraction images 1–1.5 months after the procedure. If no signs of disease activity, another follow up study was preformed 2–4 months later. Five patients were excluded due to misregistration artifact at the subtraction images. The final cohort is 38 patients having 50 lesions. Precontrast T1, T2, dynamic contrast enhanced, and diffusion-weighted images were acquired. Subtracted dynamic images were created on the workstation. Sequences were assessed by three experienced readers in hepatic imaging. The sensitivity, specificity, positive predictive value, negative predictive value, 95% confidence interval, and overall agreement were calculated for the dynamic and subtracted dynamic images.ResultsThe subtraction images have sensitivity of 96%, specificity of 100%, PPV of 100%, and NPV of 100% Compared to 96%, 100%, 100%, 96%, and 96%, 100%, 100% 96% for the three readers respectively. On the other hand, the dynamic images has sensitivity of 92%, specificity of 96%, PPV of 95%, and NPV of 92.3% compared to 92%, 96%, 95%, 92.3% and 80%, 68%, 71.4%, and 77.2% for the three readers respectively.ConclusionSubtraction technique is a useful confirmative tool as it had higher sensitivity, specificity, PPV, and NPV values compared to the dynamic and diffusion images with high level of agreement between the readers and also associated with significantly higher reader confidence levels.

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.

Intra arterial treatment of hepatocellular carcinoma: Comparison of MELD score variations between radio-embolization and chemo-embolization

PurposeThe purpose of this study was to assess liver function deterioration, as assessed using the model for end-stage liver disease (MELD) score variations, following transarterial chemo-embolization (TACE) versus selective internal radiation therapy (SIRT) in patients with unresectable unilobar hepatocellular carcinomas (HCC). Patients and methodsWe retrospectively evaluated all patients who underwent a single conventional TACE or SIRT procedure in our department from May 2013 to May 2018 for unilobar unresectable HCC. A total of 86 patients (76 men, 20 women; mean age, 65.5 years) were included. There were 63 patients in the TACE group [56 men, 7 women; mean age, 65.1±9.6 (SD) years] and 23 patients in the SIRT group [20 men, 3 women; mean age, 70±9.2 (SD) years]. Delta MELD, defined as post treatment minus pre-treatment MELD score, was considered for liver function deterioration and compared between patients who underwent single lobar treatment of SIRT versus TACE. ResultsPatients in SIRT group had significant higher tumor burden, alpha-fetoprotein serum level, and rates of macroscopic vessel invasion. Mean pre-treatment MELD scores did not differ between TACE [mean, 8.41±1.71 (SD); range: 7.24–9.24] and SIRT groups [mean, 8.36±1.74 (SD); range: 7.07–9.21] (P=0.896) as well as Child-Pugh class and albumin-bilirubin (ALBI) grade distribution. However, following treatment, mean DeltaMELD was greater in TACE group (mean, 0.83±1.83 [SD]; range: −0.30–−1.31) than in SIRT group (mean, −0.13±1.06 [SD]; range: −0.49–0.32) (P=0.021). At multivariate analysis, SIRT treatment was independently associated with a lower DeltaMELD score than TACE (R=−0.955 [−1.68; −0.406]; P=0.017;). ConclusionWhereas performed in patients with higher tumor burden, SIRT resulted in lower degrees of liver function worsening as assessed using MELD score variations.

Stereotactic body radiotherapy as the initial treatment for hepatocellular carcinoma with extensive inferior vena cava and atrium tumor thrombus.

Hepatocellular carcinoma (HCC) with inferior vena cava (IVC) tumor thrombus rarely occurs, its prognosis is extremely poor. A 49-year-old locally advanced HCC male with tumor thrombus extension into the IVC and the right atrium was successfully treated with stereotactic body radiotherapy (SBRT). A radiation dose of 40 Gy/5 fractions was delivered to the thrombus in 5 days. Contrast-enhanced magnetic resonance imaging one month after SBRT demonstrated no thrombus in IVC and the right atrium, and the huge lesion on right lobe also shrank. No severe adverse effect, eg, pulmonary embolism, was encountered. After controlling the thrombus, this patient has the opportunity to receive subsequent transarterial chemoembolization procedure in time, and avoided disease progression outside the irradiation volume. We reported a HCC case with extensive IVC and atrium tumor thrombus successfully treated by SBRT, the effectiveness and potential severe adverse effects were discussed.