Transarterial Chemoembolization In Patients Research Articles

Transarterial Chemoembolization for Metastatic Neuroendocrine Tumors With Massive Hepatic Tumor Burden: Is the Benefit Worth the Risk?

Neuroendocrine tumors (NETs) have a propensity to metastasize to the liver, often resulting in massive tumor burden and hepatic dysfunction. While transarterial chemoembolization (TACE) is effective in treating patients with NET metastatic to the liver, there are limited data on its utility and benefit in patients with large hepatic involvement. The aim of our study was to determine the clinical benefit and complication rate of TACE in patients with massive hepatic tumor burden. Medical records were reviewed in patients with grade 1 or 2 NETs with hepatic metastasis at our institution from January 2000 to September 2014 who underwent TACE. Of 201 total patients, 68 had massive hepatic tumor burden involving >75% of liver parenchyma. Carcinoid syndrome was present in 40 (59%) patients, and 57 (84%) of the 68 patients were symptomatic from their disease. Complications beyond post-TACE syndrome occurred in 21.7% of patients, with the most common complication being cardiac arrhythmias. The 30-day mortality rate was 7%. Biochemical response was observed in 78% of patients, while symptomatic relief and radiographic response was achieved in 85 and 82% of patients, respectively. Median overall survival following TACE was 28months, with 1-, 2-, and 5-year overall survival of 76, 54, and 26%, respectively. In spite of massive tumor burden, clinical and biochemical improvements were seen in the majority of patients. Morbidity was acceptable and reversible but with a fairly high mortality rate of 7%. TACE should still be considered in selective patients with massive hepatic tumor burden from metastatic NET for symptom control and palliation.

TACE vs DEB-TACE: Who wins?

Transarterial chemoembolization (TACE) is the recommended reatment modality for patients with intermediate stage hepatoellular carcinoma (HCC), or stage B as defined by the Barcelona linic Liver Cancer (BCLC) classification system [1]. According to he EASL/EORTC clinical practice guidelines for the management f HCC, the use of TACE is indicated in patients with unresectable, ultinodular cancers who are asymptomatic and do not display vidence of vascular invasion or extrahepatic spread of the tumour 2]. The rationale behind the use of TACE is based on the concept hat, since HCC growth is characterized by a marked increase in rterial neovascularization, the selective intra-arterial infusion of chemotherapeutic agent to be delivered in proximity of tumour odules, followed by the permanent embolization of the arterial essel supporting the blood supply, would determine both a cytooxic and an ischaemic effect, leading to tumoral necrosis. Studies ave shown that the combination of a chemotherapeutic agent with n ischaemic agent exerts greater effects compared to chemotherpy alone, although debate remains about the effectiveness of rterial embolization alone [3]. Conventional TACE (c-TACE) is based on the use of different hemotherapeutic agents, most commonly doxorubicin, epirubicin, r mytomycin. TACE is seldom curative in patients with intermedite HCC, but several randomized controlled trials (RCT) have shown ts use to be associated with delayed tumoral progression, reduced ascular invasion, and improved patient survival, with an averge life gain of 4 months (i.e., from a median survival of 16–20 onths) [4]. These favourable data, despite being disputed by a ecent Cochrane review [5], have driven the current EASL/EORTC uidelines, recommending the use of TACE in patients with interediate (BCLC stage B) HCC. Notably, this recommendation has een established by the highest level, both for the supporting evience as for the strength of recommendation. Yet, several questions remain unanswered about the use of ACE. First, TACE is not a standardized procedure: it is still unclear hich is the preferred chemotherapeutic agent to be used, the ost appropriate size of the embolizing particles, and the maxium number and the timing of procedures that can be performed. econd, there is a clear need to better select the patient population eserving TACE treatment, as patients with previous decompen-

Efficacy and Safety of Intensity-Modulated Radiotherapy Following Transarterial Chemoembolization in Patients With Unresectable Hepatocellular Carcinoma.

Three-dimensional conformal radiotherapy in combination with transarterial chemoembolization (TACE) has been beneficial in patients with unresectable hepatocellular carcinoma (HCC). There have been few clinical reports on the use of intensity-modulated radiotherapy (IMRT) in combination with TACE for these patients. The purpose of this study was to assess the efficacy and toxicity of IMRT following TACE in unresectable HCC.The medical records of consecutive patients with unresectable HCC, who underwent IMRT following TACE from January 2009 to June 2014, were retrospectively reviewed in order to assess the overall survival (OS), progression-free survival (PFS), tumor response, and treatment-associated toxicity.A total of 64 lesions in 54 patients were included in the analysis. IMRT was delivered at a median dose of 50 Gy (range 44–70 Gy) at 1.8 to 2.0 Gy per fraction. The overall response rate was achieved in 64.8% of patients with complete response in 20.4% of patients at 3 months after completion of IMRT. The median OS was 20.2 months (95% CI = 8.6–31.9), and the actuarial 1-, 2-, and 3-year OS rates were 84.6%, 49.7%, and 36.7%, respectively. The median PFS was 10.5 months (95% CI = 7.3–13.7) and the 1-, 2-, and 3-year PFS rates were 44.2%, 23.4%, and 14.6%, respectively. The responders had a significantly higher OS rate than the nonresponders (3-year OS 48.0% vs 14.4%, P = 0.001). During and the first month following IMRT, 10 (18.5%) patients developed grade 3 hematological toxicity, and 3 (5.6%) developed grade 3 hepatic toxicity. No patient experienced grade 4 or 5 toxicity. Radiation-induced liver disease was not observed.Our findings suggest that IMRT following TACE could be a favorable treatment option for both its safety profile and clinical benefit in patients with unresectable HCC.

Role of TACE in Patients with Hepatocellular Carcinoma before Liver Transplantation

Transarterial chemoembolization (TACE) can prevent tumor progression in patients with hepatocellular carcinoma awaiting liver transplantation. This article introduces the effect of TACE before liver transplantation in terms of dropout rate, improvement in overall survival, prediction of survival, and its application as down-stage therapy.

Laser Ablation with or without Chemoembolization for Unresectable Neuroendocrine Liver Metastases: A Pilot Study

Aim: To evaluate the effectiveness of laser ablation (LA) with or without selective transarterial chemoembolization in patients with large, isolated or oligonodular unresectable neuroendocrine liver matastases. Materials & methods: Ten patients (mean age: 53.6 years ± 14.1; range: 24–79) with neuroendocrine tumors (NETs) and 13 liver matastases (mean diameter: 4.3 ± 2.8 cm; range: 1.5–12) underwent LA alone (n = 9) or LA followed by selective transarterial chemoembolization (n = 3). Results: Complete response was obtained in six patients with LA alone and in two patients with combined treatment. The 5-year overall survival rates from the initial diagnosis and post-treatment were 80 and 50%, respectively. Conclusion: This treatment modality may provide effective control of tumor burden and general symptoms improvement in patients with limited but unresectable disease.

Cancer of the Liver Italian Program score helps identify potential candidates for transarterial chemoembolization in patients with Barcelona Clinic Liver Cancer stage C

The Barcelona Clinic Liver Cancer (BCLC) staging system for hepatocellular carcinoma (HCC) recommends transarterial chemoembolization (TACE) as the first line therapy for stage B patients and sorafenib treatment for stage C patients. However, stage C patients exhibit variations in terms of tumor burden, liver function, and extrahepatic metastasis, which could potentially affect disease outcome. Here, we assessed whether the Cancer of the Liver Italian Program (CLIP) scores can help identify stage C patients likely to benefit from TACE. Out of 295 BCLC stage C HCC patients enrolled between January 2009 and December 2011, those with platelet counts >30 X 10(9) cells/L, total bilirubin <51 μmoL/L, and an unobstructed main portal vein were scheduled for TACE (n=195). The remaining patients received best supportive care (BSC, n=100). All the patients were followed up for symptoms, performance status, and Child-Pugh classification scores every 4 weeks until death or December 2013. The prognosis of each group was evaluated by using the log-rank test and Cox-Mantel test. The median overall survival (OS) was 6 months [95% confidence interval (CI): 4.64-7.36]. The OS was 9 months for the TACE group and 4 months for the BSC group. The TACE group had a longer OS than the BSC subgroup for CLIP scores 0-2 [13 months (95% CI: 8.55-17.45) vs 4 months (95% CI: 0.00-10.96), P=0.001]. No significant differences were found between the TACE and BSC groups for CLIP scores 3-5. The CLIP score and treatment methods were found to be independent prognostic factors. BCLC stage C HCC patients exhibit definite disease heterogeneity and can be reclassified by using the CLIP scoring system. Moreover, patients with CLIP scores 0-2 are likely to benefit from TACE. However, additional studies with long-term follow-up will be required to validate these findings.

Pathologic response to preoperative transarterial chemoembolization for resectable hepatocellular carcinoma may not predict recurrence after liver resection

Pathologic response (PR) predicts survival after preoperative chemotherapy and resection of a malignancy. Occasionally, transarterial chemoembolization (TACE) may be selected for preoperative management of resectable hepatocellular carcinoma (HCC). This study investigated whether PR to preoperative TACE can predict recurrence after resection for resectable HCC. We conducted analysis of 106 HCC patients who underwent TACE followed by liver resection with a curative intent. The PR was evaluated as the mean percentage of non-viable tumor area within each tumor. We divided the patients into three groups according to response rate: complete PR (CPR), major response (MJR: PR≥50%) and minor response (MNR: PR<50%). The primary endpoint was disease-free survival, and the secondary endpoints were predicting factors for tumor recurrence and MJR+CPR. Among the 121 TACE patients, PR could be measured in 106 (87.6%). The mean interval between TACE and liver resection was 33.1 days. The 5-year disease-free survival rates by PR status were as follows: 40.6% CPR, 43.7% MJR, and 49.0% MNR (P=0.815). There were also no significant differences in overall survival between the three groups. Multivariate analyses revealed that microvascular invasion and capsular invasion (hazard ratio [HR]=11.224, P=0.002 and HR=2.220, P=0.043) were independent predictors of disease-free survival. Multivariate analysis of the predictors of above 50% PR revealed that only hepatitis B was an independent factor. These data could reflect that the PR after TACE for resectable HCC may not be useful for predicting recurrence of HCC after resection.

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.

Comparison of surgical resection and transarterial chemoembolization for patients with intermediate stage hepatocellular carcinoma

ObjectiveCurrent guidelines recommend transarterial chemoembolization (TACE) as the standard treatment for patients with intermediate stage hepatocellular carcinoma (HCC). However, choosing the optimal treatments for patients with intermediate stage HCC still remains challenging for clinicians. The purpose of our study was to compare the long-term survival of intermediate stage HCC patients treated with surgical resection or TACE. MethodsWe obtained the baseline characteristics of 210 intermediate stage HCC patients that were recruited for this study. Survival analysis was performed by Kaplan–Meier method and a comparison was made by log-rank test. Factors associated with survival rate were analyzed by Cox's regression. ResultsThere were 164 men and 46 women in the study group, with a mean age of 63 ± 11 years (range, 31–92 years). Among them, 67 patients (31.9%) received surgical resection and 143 patients (68.1%) received TACE. Patients receiving surgical resection had a significantly larger mean of maximum tumor size (6.8 ± 2.8 vs. 5.8 ± 3.2 cm, P = 0.016), higher ratio of solitary tumor (68.7% vs. 17.5%, P < 0.001), and Child-Pugh class A (97% vs. 85%, P = 0.009) than those with TACE. Patients receiving surgical resection had a significantly higher 1, 3, and 5 year survival rate compared with those treated with TACE (87.4%, 62.8% and 57.3% vs. 58.1%, 29.9% and 16.6%, P < 0.001). Multivariate analysis revealed that AFP level >400 ng/ml [hazard ratio (HR):2.141, 95% CI: 1.091–4.203, P = 0.027], Child B cirrhosis (HR: 4.726, 95% CI: 1.021–21.884, P = 0.047), and TACE (HR:3.391, 95% CI: 1.625–7.076, P = 0.001) were independent risk factors associated with poor prognosis. ConclusionsOur results indicated that surgical resection provided superior survival benefit than TACE to patients with intermediate-stage HCC. This is in part attributable to advances in liver surgery which make the resection of intermediate-stage HCC possible. Surgical resection should be considered first for patients with preserved liver function.

Contrast enhanced ultrasonography in assessing the treatment response to transarterial chemoembolization in patients with hepatocellular carcinoma.

The last decades have known continuous development of therapeutic strategies in hepatocellular carcinoma (HCC). Unfortunately the disease it still not diagnosed until it is already at an intermediate or even an advanced disease. In these circumstances transarterial chemoembolization (TACE) is considered an effective treatment for HCC. The most important independent prognostic factor of both disease free survival and overall survival is the presence of complete necrosis. Therefore, treatment outcomes are dictated by the proper use of radiological imaging. Current guidelines recommend contrast enhanced computer tomography (CECT) as the standard imaging technique for evaluating the therapeutic response in patients with HCC after TACE. One of the most important disadvantage of CECT is the overestimation of tumor response. As an attempt to overcome this limitation contrast enhanced ultrasound (CEUS) has gained particular attention as an imaging modality in HCC patients after TACE. Of all available imaging modalities, CEUS performs better in the early and very early assessment of TACE especially after lipiodol TACE. As any other imaging techniques CEUS has disadvantages especially in hypovascular tumors or in cases of tumor multiplicity. Not far from now the current limitations of CEUS will be overcome by the new CEUS techniques that are already tested in clinical practice such as dynamic CEUS with quantification, three-dimensional CEUS or fusion techniques.

Sorafenib combined with transarterial chemoembolization in patients with hepatocellular carcinoma: a meta-analysis and systematic review.

Combination therapy of sorafenib and transarterial chemoembolization (TACE) has shown benefits in treating advanced hepatocellular carcinoma (HCC). This study evaluated the efficacy and safety of TACE+sorafenib. MEDLINE, the Cochrane Library, EMBASE, and the ISI Web of Knowledge were searched (until 31 December 2013) for studies comparing TACE and TACE+sorafenib in treating patients with advanced HCC. Sensitivity and quality assessments were performed. Five comparative studies (2 were randomized control trials) that included 899 patients were used in the meta-analysis. Patients treated with TACE+sorafenib had better prognoses in terms of time to progression (TTP) compared to those with TACE+placebo or TACE alone; hazard ratios (HRs) ranged from 0.40 to 0.87, with the combined HR 0.61 (95% CI 0.39-0.95, p=0.031). However, the combined HR for overall survival (OS) did not differ significantly between patients treated with TACE+sorafenib and those with TACE+placebo or TACE alone (combined HR=0.79, 95% CI=0.54-1.16, p=0.235). Sensitivity analysis indicated the findings for TTP may be overly influenced by at least one of the studies. In summary, our meta-analysis found that TACE+sorafenib can improve TTP. We did not find the combined therapy improved OS. Additional randomized controlled studies are necessary to further investigate the clinical benefit of TACE+sorafenib in treating advanced HCC.

Survival benefit of chemoembolization plus Iodine125 seed implantation in unresectable hepatitis B-related hepatocellular carcinoma with PVTT: a retrospective matched cohort study.

ObjectivesTo investigate the survival benefit of transarterial chemoembolization (TACE) plus Iodine125 seed implantation (TACE-Iodine125) in hepatitis B-related HCC patients with portal vein tumour thrombus (PVTT) and the underlying prognostic factors.MethodsA retrospective matched cohort study was performed on consecutive HCC patients with PVTT from January 2011 to June 2014. Seventy patients (TACE-Iodine125 group) who underwent TACE-Iodine125 were compared with a historical case-matched control group of 140 patients (TACE group) who received TACE alone. The survival of patients and the underlying prognostic factors were analysed.ResultsThe median survival times of the TACE-Iodine125 and TACE groups were 11.0 and 7.5 months, respectively (p < 0.001). The survival probability at 12, 24, and 36 months was 50 %, 14.5 %, and 14.5 % vs. 25 %, 9 %, and 5 % in the TACE-Iodine125 and TACE groups, respectively (p < 0.001). The PVTT responders had better survival than the PVTT non-responders (p < 0.001). For the PVTT non-responders, there were no differences in the survival curves between the groups (p = 0.353). Multivariate analysis showed that type III PVTT (p < 0.001) and APS (p < 0.001) were independent predictors of poor prognosis. In contrast, the treatment modality of TACE-Iodine125 (p < 0.001) and PVTT response (p = 0.001) were favourable prognostic features.ConclusionsTACE combined with Iodine125 seed implantation may be a good choice for selected HB-HCC patients with PVTT.Key Points• TACE-Iodine125 was more effective than TACE for patients with HCC-PVTT.• The TACE-Iodine125 procedure was safe.• TACE-Iodine125 was conditional for patients with HCC-PVTT.• TACE-Iodine125 resulted in a better PVTT response compared to TACE alone.• A good PVTT response is a favourable prognostic factor.

The Changes of HIF-1α and VEGF Expression After TACE in Patients With Hepatocellular Carcinoma.

As a common malignant tumor, hepatocellular carcinoma (HCC) has a high prevalence and is a serious threat to human health. The surgical resection rate of HCC is low, and the prognosis is poor. Although transarterial chemoembolization (TACE) is the main treatment for HCC patients who are not candidates for surgical resection, it is not considered a curative procedure. For HCC, poor TACE efficacy or TACE failure may be related to tumor angiogenesis of the residual disease. Among the many regulatory factors in tumor angiogenesis, hypoxia-inducible factor-1α (HIF-1α) and vascular endothelial growth factor (VEGF) play vital roles in this process. In this paper, we conducted a review of the dynamic change and relevance of HIF-1α and VEGF levels after TACE of HCC patients.

Transarterial chemoembolization for patients with metastatic uveal melanoma in the liver

Objective: to evaluate the safety and efficacy of transarterial chemoembolization method (TACE) in the treatment of inoperable patients with uveal melanoma with isolated liver metastases with cured the primary focus. Material and methods. In N.N. Blokhin RCRC since 2000, 31 patients received treatment with metastatic uveal melanoma in the liver. Among them: men – 13 (42%), women – 18 (58%). The average age of 45.12 ± 13.22 years, range 23–71 years. Time detection of liver metastases after treatment of the primary tumor ranged from 2 to 180 months, median – 23 months. Liver lesion volume to 25% was in 11 patients, to 50% in 13, to 75% in 7 patients. Total 62 TACE intervention was performed. As used embolizing materials: Lipiodol 10 ml in 45 cases, microspheres – in 11 cases (particle sizes ranged from 100 to 500 microns), combinations presented embolizing materials have been used in 6 patients. As the chemotherapy Doxorubicin performed at a dosage of 100 mg, or Gemzar 1–2 g, or Carboplatin 450 mg. Results. 100% of the TACE was technically successful. Complications related to the technical implementation not observed. Local response was observed in 21 (67.7%) patients with metastatic uveal melanoma. Duration of monitoring of patients after TACE was held from 2 to 60 months. Median follow-up in this case was 10 months. Overall survival in this group of patients was calculated by Kaplan–Meier. 1-year was 51.0 ± 9.5%, 2-year 34.0 ± 15.2%. The median survival – 12.9 months. 20 patients were alive at the time of the study, 11 died from progression. Conclusion. In this study transarterial chemoembolization in patients with metastatic uveal melanoma in the liver has established itself as an effective and well-tolerated treatment. Objective response or stabilization process in the liver was observed in 68% of patients. A median overall survival was comparable to that provided in the literature.

SAT-097 - Targeted Proteomics Predicts Sustained Complete Response after Transarterial Chemoembolization in Patients with Hepatocellular Carcinoma

SAT-097 - Targeted Proteomics Predicts Sustained Complete Response after Transarterial Chemoembolization in Patients with Hepatocellular Carcinoma

Child B 등급 진행성 간세포암종 환자에서 메트로놈 항암주입술과 간동맥항암색전술과의 비교연구

Child B 등급 진행성 간세포암종 환자에서 메트로놈 항암주입술과 간동맥항암색전술과의 비교연구

Propensity score-based comparison of hepatic resection and transarterial chemoembolization for patients with advanced hepatocellular carcinoma.

For patients with advanced hepatocellular carcinoma (HCC), official guidelines recommend palliative treatments such as transarterial chemoembolization (TACE) but not hepatic resection (HR). This study compared short- and long-term outcomes in patients with advanced HCC treated by either HR or TACE. A retrospective analysis was performed for a consecutive series of 444 patients with advanced HCC who underwent HR (n = 339) or TACE (n = 205). Analyses were performed over all participants as well as for propensity score-matched patients to adjust for any baseline differences. When all patients were included in the analysis, the HR and TACE groups showed similar postoperative complication rate and mortality at 30 and 90days (all P > 0.05). However, median survival time was significantly higher in the HR group (16.4months) than in the TACE group (11.8months; P = 0.012). Overall survival at 1, 3, 5, and 7years was 58, 26, 18, and 18% in the HR group, higher than the corresponding rates of 49, 14, 12, and 7% in the TACE group. Similar results were obtained in the analysis of propensity score-matched patients. Therefore, HR can be safe and effective for patients with advanced HCC. Randomized controlled trials are warranted to confirm this finding.

Biliary complications of arterial chemoembolization of hepatocellular carcinoma.

Transarterial chemoembolization (TACE) is the most frequently used palliative therapy for unresectable hepatocellular carcinoma (HCC). It is a safe and effective procedure with few major and minor complications. Rarely, biliary complications are also encountered following TACE. The goal of our study was to investigate the incidence and the presentation of biliary complications following TACE in patients with HCC. In this retrospective study, data of patients with HCC who underwent TACE between June 2002 to December 2014 were obtained from the records. Their detailed information about the procedure of TACE, diagnosis of biliary complications and subsequent management details were reviewed. One hundred and sixty-eight patients with HCC underwent 305 procedures of TACE. Of these, biliary complications of various severities developed in 6 (3.6%) patients leading to an incidence of 1.9% (6/305). Minimal intrahepatic biliary dilatation (IHBD) occurred in three, biliary stricture in one and intrahepatic biloma in two patients. Supportive management was undertaken for IHBD patients while percutaneous aspiration and naso-biliary drainage was performed for the infected bilomas. Biliary complications following TACE are infrequent. Diagnosis should be suspected clinically and confirmed with imaging. Treatment depends on the severity. Enforcing specific measures can minimize its frequency.

Safety and efficacy of transarterial chemoembolization in patients with transjugular intrahepatic portosystemic shunts

BackgroundTransarterial chemoembolization (TACE) for the treatment of hepatocellular carcinoma (HCC) is an important option as the majority of patients present with advanced disease. Data regarding treatment outcomes in patients who have undergone transjugular intrahepatic portosystemic shunts (TIPS) are limited. The present study seeks to evaluate the safety and efficacy of TACE in HCC patients with a TIPS. MethodsA retrospective review identifying patients with HCC and concomitant TIPS who were treated with TACE was performed. ResultsFrom 1999 to 2014, 16 patients with HCC underwent a total of 27 TACE procedures; eight patients required multiple treatments. The median patient age at the time of the initial TACE was 60.5 years [interquartile range (IQR) : 52.5–67.5] with the majority being male (n = 12, 75%) and Childs–Pugh Class B (n = 12, 75%). At 6 weeks after TACE, 56.3% of patients achieved an objective response rate (complete and partial response) by mRECIST criteria. Clavien Grade 3 or higher complications occurred in 11.1% of TACE procedures. There were no peri-procedural deaths. The median progression-free (PFS) and overall survival (OS) were 9 and 22 months, respectively, when censored for liver transplantation (median follow-up: 11.5 months). ConclusionTACE is an effective treatment strategy for HCC in TIPS patients; albeit may be associated with higher complication rates.

Hepatology highlights

Hepatology highlights