Long-term Outcomes of Patients with Hepatocellular Carcinoma Who Underwent Microwave Ablation after Downstaging with Transarterial Chemoembolization to Barcelona Clinic Liver Cancer Stage A

PurposeTo compare the clinical results of microwave ablation (MWA) between patients downstaged to Barcelona Clinic Liver Cancer (BCLC) Stage A with transarterial chemoembolization (TACE) and those initially classified as BCLC Stage A.Materials and MethodsFrom January 2012 to May 2017, 1,087 patients were reviewed retrospectively using propensity score matching (1:1): 86 patients underwent MWA as a curative treatment after downstaging to BCLC Stage A by TACE (downstaging group) and 86 patients initially classified as BCLC Stage A underwent MWA (control group). The overall survival (OS) and disease-free survival (DFS) between the 2 groups were compared.ResultsThe 1-, 3-, and 5-year OS rates were 95.3%, 79.1%, and 58.1%, respectively, in the downstaging group and 93.0%, 81.4%, and 61.6%, respectively, in the control group (hazard ratio [HR], 0.75; 95% CI, 0.50–1.13; P = .162). The 1-, 3-, and 5-year DFS rates were 80.2%, 50.0%, and 24.4%, respectively, in the downstaging group and 77.9%, 52.3%, and 27.9%, respectively, in the control group (HR, 1.08; 95% CI, 0.76–1.53; P = .678). No significant differences were found in OS and DFS.ConclusionsThe long-term prognosis in patients with HCC who underwent MWA after downstaging to BCLC Stage A using TACE was similar to that in patients with initial BCLC Stage A.     

Transarterial Chemoembolization Monotherapy Versus Combined Transarterial Chemoembolization–Microwave Ablation Therapy for Hepatocellular Carcinoma Tumors ≤5 cm: A Propensity Analysis at a Single Center

Purpose

To compare effectiveness of transarterial chemoembolization (TACE) combined with microwave ablation (MWA; TACE–MWA) with TACE alone for treating hepatocellular carcinoma (HCC) tumors ≤5 cm.

Materials and Methods

We reviewed data of 244 patients treated for HCC by TACE–MWA or TACE from June 2014 to December 2015. Median follow-up period was 505 days (TACE–MWA group: 485 days; TACE group: 542 days). Patients were propensity score matched (1:2 ratio); outcomes of TACE–MWA and TACE groups were compared. Primary endpoints were tumor responses, including tumor necrosis rates after initial treatment, tumor responses at 6 months [per modified Response Evaluation Criteria in Solid Tumors (mRECIST)], and time to tumor progression (TTP). Secondary endpoints were overall survival (OS) and re-intervention times.

Results

After initial treatments, tumor necrosis rates were higher in the TACE–MWA group (n = 48; 92.1% [58/63]) than the TACE group (n = 96; 46.3% [56/121]; P < 0.001). At 6 months’ follow-up, the TACE–MWA group had better tumor responses (CR + PR + SD [per mRECIST]: TACE–MWA, 95.8%; TACE, 64.5%; P < 0.001). The TACE–MWA group had better TTP (P < 0.001), but did not significantly differ in OS (P = 0.317). TACE–MWA decreased re-TACE times from 1.90 to 0.52; and re-MWA times from 0.22 to 0.17. In subgroup analysis, TACE–MWA also showed better TTP in patients with tumors ≤3 cm (P < 0.001) and 3–5 cm (P = 0.004).

Conclusions

Compared with TACE, TACE–MWA leads to better responses for HCC tumors ≤5 cm.

     

Thermal ablation alone vs thermal ablation combined with transarterial chemoembolization for patients with small (<3 cm) hepatocellular carcinoma

PurposeThermal ablation (TA) and transarterial chemoembolization (TACE) may be used alone or in combination (TACE+TA) for the treatment of hepatocellular carcinoma (HCC). The aim of our study was to compare the time to tumor progression (TTP) and overall survival (OS) for patients who received TA alone or TACE+TA for HCC tumors under 3 cm.Materials and methodsThis HIPAA-compliant IRB-approved retrospective analysis included 85 therapy-naïve patients from 2010 to 2018 (63 males, 22 females, mean age 62.4 ± 8.5 years) who underwent either TA alone (n = 64) or TA in combination with drug-eluting beads (DEB)-TACE (n = 18) or Lipiodol-TACE (n = 3) for locoregional therapy of early stage HCC with maximum tumor diameter under 3 cm. Kaplan-Meier analysis was performed using the log-rank test to assess TTP and OS.ResultsAll TA and TACE+TA treatments included were technically successful. TTP was 23.0 months in the TA group and 22.0 months in the TACE+TA group. There was no statistically significant difference in TTP (p = 0.64). Median OS was 69.7 months in the TA group and 64.6 months in the TACE+TA group. There was no statistically significant difference in OS (p = 0.14). The treatment cohorts had differences in AFP levels (p = 0.03) and BCLC stage (p = 0.047). Complication rates between patient groups were similar (p = 0.61).ConclusionFor patients with HCC under 3 cm, TA alone and TACE+TA have similar outcomes in terms of TTP and OS, suggesting that TACE+TA may not be needed for these tumors unless warranted by tumor location or other technical consideration.     

Comparative study of post-transplant outcomes in hepatocellular carcinoma patients treated with chemoembolization or radioembolization

PurposeTo analyze long-term outcomes in patients bridged/downstaged to orthotopic liver transplantation (OLT) by transarterial chemoembolization (TACE) or yttrium-90 radioembolization (Y90) for hepatocellular carcinoma (HCC).Methods172 HCC patients who underwent OLT after being treated with transarterial liver-directed therapies (LDTs) (Y90: 93; TACE: 79) were identified. Pre-LDT and pre-OLT clinical/imaging/laboratory characteristics including United Network for Organ Sharing (UNOS) staging and alpha-fetoprotein values (AFP) were tabulated. Post-OLT HCC recurrence was assessed by imaging follow-up per standard of care. Recurrence-free (RFS) and overall survival (OS) were calculated. Uni/multivariate and sub-stratification analyses were performed.ResultsTime-to-OLT was longer in the Y90 group (Y90: 6.5 months; TACE: 4.8 months; p = 0.02). With a median post-OLT follow-up of 26.1 months (IQR: 11.1–49.7), tumor recurrence was found in 6/79 (8%) TACE and 8/93 (9%) Y90 patients. Time-to-recurrence was 26.6 (CI: 7.0–49.5) and 15.9 months (CI: 7.8–46.8) for TACE and Y90, respectively (p = 0.48). RFS (Y90: 79 months; TACE: 77 months; p = 0.84) and OS (Y90: 57% alive at 100 months; TACE: 84.2 months; p = 0.57) were similar. 54/155 patients (Y90: 29; TACE: 25) were downstaged to UNOS T2 or less. RFS hazard ratios for patients downstaged to ≤T2 versus those that were not were 0.6 (CI: 0.33–1.1) and 1.7 (CI: 0.9–3.1) respectively (p = 0.13). 17/155 patients (Y90: 8; TACE: 9) that were >T2 were downstaged to UNOS T2 or less (within transplant criteria). Distribution (unilobar/bilobar), AFP, and pre-transplant UNOS stage affected RFS on univariate analyses.ConclusionDespite longer time-to-OLT for Y90 patients, post-OLT outcomes were similar between patients bridged or downstaged by TACE or Y90. A trend towards improved RFS for downstaged patients was identified.     

放疗联合动脉化疗栓塞及酪氨酸激酶抑制剂治疗肝癌合并瘤栓的长期结果

目的 探讨调强放疗联合动脉化疗栓塞及酪氨酸激酶抑制剂（tyrosine kinase inhibitor,TKI）治疗肝细胞性肝癌合并静脉瘤栓患者的长期随访结果。方法 回顾性分析2015年10月至2018年10月北京大学肿瘤医院收治的63例肝细胞性肝癌合并静脉瘤栓且无远处转移患者,其中28例接受调强放疗联合动脉化疗栓塞及索拉非尼（A组）,35例接受调强放疗联合动脉化疗栓塞（B组）。采用倾向评分配比法,分析联合与不联合索拉非尼组的治疗疗效。结果 中位随访时间62个月。A组和B组的中位生存时间分别为19.0和15.2个月（χ²=3.15,P=0.076）,A组的中位无进展生存时间为10.7个月,高于B组的8.6个月（χ²=3.99,P=0.046）。经过倾向评分配比平衡组间差异后,A组的中位生存时间为30.6个月,明显高于B组的15.2个月（χ²=5.34,P=0.023）;A组的中位无进展生存时间12.5个月,仍然高于B组的8.3个月（χ²=4.79,P=0.026）。全组10例（15.9%）患者治疗中出现3级血液学毒性,7例（11.1%）患者出现3级肝功能异常。A组较B组的皮肤反应、手足综合征和腹泻发生率高,但均为1~2级不良反应。全组无4级不良反应,无放射诱发肝病及治疗相关死亡发生。结论 长期随访结果显示,肝细胞性肝癌合并静脉瘤栓患者在调强放疗加动脉化疗栓塞的基础上联合TKI提高了疗效。     

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

Objectives

To 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.

Methods

A 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.

Results

The 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.

Conclusions

TACE 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.

     

TACE+RFA和TACE+MWA应用于早期原发性肝细胞癌的疗效差异

目的探讨肝动脉化疗栓塞联合射频消融术(TACE+RFA)和肝动脉化疗栓塞联合微波消融术(TACE+MWA)应用于早期原发性肝细胞癌(PHC)的疗效差异。方法选取我院接受TACE+RFA或TACE+MWA治疗的68例早期PHC患者资料,其中TACE+RFA组31例,TACE+MWA组37例。比较两组患者的病灶消融率、并发症发生率,并对患者的生存情况进行分析。结果TACE+RFA组和TACE+MWA组病灶完全反应(CR)率差异无统计学意义(P>0.05)。在肿瘤直径≤3cm患者中,TACE+RFA组和TACE+MWA组病灶CR率差异无统计学意义(P>0.05);而在肿瘤直径3~5cm患者中,TACE+MWA组病灶CR率高于TACE+RFA组,差异有统计学意义(P<0.05)。两组患者的并发症(发热、腹痛、恶心&呕吐及额外镇痛)发生率比较,差异无统计学意义(P>0.05)。随访6.0~45.7个月,中位随访时间26.6个月。全组患者1年、2年、3年累积生存率分别为92.3%、85.2%、47.9%。其中,TACE+RFA组患者的1年、2年、3年累积生存率分别为87.1%、80.1%、43.1%,TACE+MWA组为96.8%、89.6%、52.9%,两组生存率差异无统计学意义(Log rankχ^2=3.506,P=0.061)。在肿瘤直径≤3cm患者中,TACE+RFA组患者1年、2年、3年累积生存率分别为90.0%、90.0%、60.0%,TACE+MWA组为88.9%、74.1%、74.1%,两组生存率差异无统计学意义(Log rankχ^2=0.010,P=0.922)。在肿瘤直径3~5 cm患者中,TACE+RFA组患者1年、2年、3年累积生存率分别为85.7%、75.6%、36.3%,TACE+MWA组为100.0%、95.2%、50.8%,TACE+MWA组生存率高于TACE+RFA组(Log rankχ^2=4.485,P=0.034)。结论TACE+RFA和TACE+MWA应用于早期PHC均是安全、有效的。肿瘤直径≤3 cm时,两种疗法疗效相当,而肿瘤直径3~5cm时,TACE+MWA的病灶消融率和生存率优于TACE+RFA。     

Effectiveness and safety of proton beam therapy for advanced hepatocellular carcinoma with portal vein tumor thrombosis

Purpose

To evaluate the clinical effectiveness and safety of proton beam therapy (PBT) in advanced hepatocellular carcinoma (HCC) patients with portal vein tumor thrombosis (PVTT).

Patients and methods

Twenty-seven HCC patients with PVTT underwent PBT, including 22 patients with modified International Union Against Cancer (mUICC) stage IVA,five patients with stage IVB primary tumors, and 16 with main PVTT. A median dose of 55 GyE (range, 50–66 GyE) in 20–22 fractions was delivered to a target volume encompassing both the PVTT and primary tumor.

Results

Overall, treatment was well tolerated, with no toxicity of grade ≥?3. Median overall survival (OS) times in all patients and in stage IVA patients were 13.2 months and 16 months, respectively. Assessments of PVTT response showed complete response in 0 of 27 (0?%) patients, partial response in 15 (55.6?%), stable disease in 10 (37?%), and progressive disease in 2 (7.4?%) patients, with an objective response rate of 55.6?%. PVTT responders showed significantly higher actuarial 1-year local progression-free survival (LPFS; 85.6?% vs. 51.3?%), relapse-free survival (RFS; 20?% vs. 0?%) and OS (80?% vs. 25?%) rates than nonresponders (p?Conclusion Our data suggest that PBT could improve LPFS, RFS, and OS in advanced HCC patients with PVTT and it is feasible and safe for these patients.     

Comparison of ultrasonography-guided percutaneous microwave ablation for subcapsular and nonsubcapsular hepatocellular carcinoma

PurposeTo compare the prognosis of subcapsular and nonsubcapsular hepatocellular carcinoma (HCC) after ultrasonography (US)-guided percutaneous microwave ablation (MWA).Materials and methodsFrom January 2012 to December 2015, 463 enrollment patients (382 men, 81 women; age range, 24–95 years) with a single HCC underwent US-guided percutaneous MWA. The patients were divided into two groups according to tumor location: subcapsular (n = 224) and nonsubcapsular (n = 239). Therapeutic efficacy was assessed by contrast enhanced imaging after MWA. The technique effectiveness rate, the local tumor progression (LTP) rate, overall survival (OS) rate and complication were compared between two groups.ResultsThere were no significant differences in the mean treatment sessions (p = 0.105) and the mean number of antenna insertions (p = 0.065) between two groups. No significant difference in the technique effectiveness rate was found between subcapsular and nonsubcapsular tumors (95.5% vs 98.3%, p = 0.089). The respective 1-, 2-, 3-, and 4-year cumulative LTP rates were 5.0%, 5.5%, 5.5% and 5.5% in subcapsular group and 6.4%, 6.4%, 6.4% and 6.4% in nonsubcapsular group, respectively(p = 0.861). The 1-, 2-, 3-, and 4-year OS rates were estimated to be 95.7%, 90.1%, 82.9%, and 71.1% in subcapsular group and 98.5%, 92.8%, 83.2%, and 73.6% in nonsubcapsular group, respectively (p = 0.426). There was no significant difference in major complication rates between the subcapsular group (2.2%) and nonsubcapsular group (1.3%) (p = 0.653). There was higher postoperative pain rate in subcapsular group (13.4%) than nonsubcapsular group (7.1%) (p = 0.025).ConclusionsThere were no significant differences in the technique effectiveness rate, cumulative LTP rate, OS rate and major complication rate between subcapsular and nonsubcapsular group after MWA for HCC.     

Effect of transjugular intrahepatic portosystemic shunt on transarterial chemoembolization for hepatocellular carcinoma: a systematic review and meta-analysis

PURPOSEHepatocellular carcinoma (HCC) usually occurs accompanied by portal hypertension. Transcatheter arterial chemoembolization (TACE) is recommended as an effective treatment in HCC. Recent studies had conflicting results regarding the effectiveness and safety of TACE for HCC in patients with transjugular intrahepatic portosystemic shunt (TIPS). This meta-analysis aimed to evaluate the influence of TIPS on the effectiveness and safety of TACE for patients with HCC.METHODSA comprehensive search of studies among PubMed, Web of Science and Cochrane Library was conducted, from the earliest publishing date to January 27^th, 2020. Statistical analyses were all performed using the Stata 13.0 software. I² index statistic was used to assess heterogeneity.RESULTSSix studies with a total of 536 patients with HCC were included in the analysis. The pooled response rate was 51% (95% CI: 25% to 77%) with a significant heterogeneity (I²=93.3%, p < 0.001). The TACE + TIPS group had an inferior response rate than the non-TIPS group, but the difference had no statistical significance (p = 0.171) and heterogeneity was low (I²=0.00%, p = 0.490). Pooled hepatic failure rate was 8.8% (95% CI: 5.2% to 12.4%) with low heterogeneity (I²=0.0%, p = 0.747). But the pooled hepatic failure rate increased to 12.7% (95% CI: 5.7% to 19.7%) with low heterogeneity (I2=11.5%, p = 0.323) if the patients who received TIPS after TACE were excluded.CONCLUSIONTIPS does not influence the effectiveness of TACE, but attention should be paid to the risk of hepatic failure.

Hepatocellular carcinoma (HCC) usually occurs accompanied by liver cirrhosis, and the relationship between them is close (1–3). For patients with liver cirrhosis, the transjugular intrahepatic portosystemic shunt (TIPS) can be used to relieve portal hypertension and clinical symptoms when it is combined with various medical conditions (4–6). Transarterial chemoembolization (TACE) has been recommended as the standard treatment strategy for intermediate-stage HCC (7, 8). However, as TIPS disrupts the arterial supply of liver and divert portal venous flow, there is concern for the risks of hepatic damage and transient portal pressure increase after TACE combined with TIPS (9). In this context, HCC patients with TIPS in need of locoregional therapy or those with portal hypertension are complicated cases waiting to be solved.In recent years, there have been conflicting results regarding the effectiveness and safety of TACE for HCC in patients with existing TIPS or waiting to receive TIPS because of portal hypertension (10–12). No randomized controlled trial comparing TACE + TIPS vs. non-TIPS exists. It is difficult to estimate the procedural feasibility, risks and long-term outcomes of this combined treatment strategy, because most of the evidence derives from retrospective cohort studies, case reports, or series. The present study aimed to explore hepatotoxicity, objective reaction rate, and overall survival using meta-analysis and a systematic review.     

Liver tumor ablation in difficult locations: Microwave ablation of perivascular and subdiaphragmatic hepatocellular carcinoma

AimTo assess the safety and efficacy of CT-guided microwave ablation (MWA) of hepatocellular carcinoma (HCC) near large blood vessels and the diaphragm by analyzing procedural complications and local tumor progression (LTP).MethodsFrom October 2013 through January 2019, 80 patients (54 males and 26 females) with 136 tumors who underwent CT-guided MWA of HCC were included in this retrospective analysis. MWA was performed on 43 perivascular HCC (≤5 mm from a vessel measuring ≥5 mm in diameter), 38 subdiaphragmatic HCC (≤5 mm from diaphragm), and 64 control HCC. Risk factors for local tumor progression (LTP), overall survival, and complications were analyzed using the Chi-square and Cox proportional hazards model methods.ResultsThe technical success rate of MWA was 100%. Complication incidence was not significantly different between perivascular and control tumors (20.9% vs 10.9%; p = 0.155) or between subdiaphragmatic and control tumors (21.1% vs 10.9%; p = 0.163). The effect of lesion location on LTP disappeared while controlling for age and lesion size. There was no significant difference in median survival time between patients who had only control tumors (38.8 months) compared to patients with at least one perivascular or subdiaphragmatic tumor (42.5 months; p = 0.098).ConclusionCT-guided percutaneous MWA of perivascular and subdiaphragmatic HCC tumors is safe and effective. The local tumor recurrence and survival was not significantly different compared to control tumors.     

Transarterial Chemoembolization Using Gelatin Sponges or Microspheres Plus Lipiodol-Doxorubicin versus Doxorubicin-Loaded Beads for the Treatment of Hepatocellular Carcinoma

ObjectiveTo retrospectively compare treatment of hepatocellular carcinoma (HCC) with transarterial chemoembolization (TACE) using gelatin sponges or microspheres plus lipiodol-doxorubicin vs. doxorubicin-loaded drug-eluting beads (DEB).ResultsNo significant difference was found at baseline among the three groups. The doxorubicin dosage in group C was significantly (p < 0.001) higher compared to the dose used in groups A or B (median, 50 mg vs. 31 mg or 25 mg). Significantly (p < 0.001) more patients in group C achieved complete response compared to those in groups A or B (32.1% vs. 6.3% or 2.4%). Significantly (p < 0.001) less patients in group C had progressive disease compared to those in groups A or B (34.0% vs. 57.8% or 68.3%). Minor AEs were more common in groups A and B compared to group C, with rates of 54.7%, 34.1%, and 5.7%, respectively.ConclusionIn patients with HCC, TACE with DEB offers better safety and efficacy profiles compared to either TACE with gelatin sponges or TACE with microspheres.     

不同治疗方案对晚期肝细胞性肝癌预后的影响及因素分析

目的：研究单纯和联合治疗方案对晚期肝细胞肝癌（HCC）预后的影响,分析影响预后的主要因素。 方法：回顾性分析2014年我院收治的133例晚期HCC患者,统计24项预后相关数据,采用Cox单因素和多因素回归模型分析预后影响因素。统计患者接受的所有治疗方式,并分为3种治疗方案：（1）保守治疗58例;（2）单纯肝动脉化疗栓塞术（TACE）治疗58例;（3）联合治疗17例：TACE联合索拉菲尼或者TACE联合立体定向放疗（SBRT）。Kaplan-Meier法绘制生存曲线,并使用Log-rank检验比较患者生存期差异。 结果：133例患者总体中位生存期为7.6个月,其中6个月、1年、2年的生存率分别为57%、30%、12%。多因素分析证明Child-Pugh分级、门静脉癌栓类型、肝外转移类型以及甲胎蛋白水平为影响预后的独立因素。治疗方案上,TACE联合索拉菲尼与TACE联合SBRT之间无明显差异,但均明显优于单纯TACE治疗,且单纯TACE治疗明显优于保守治疗。 结论：Child-Pugh分级、门静脉癌栓类型、肝外转移类型和甲胎蛋白水平是影响晚期HCC预后的独立因素。TACE联合索拉菲尼或TACE联合SBRT的预后均优于单纯TACE治疗,单纯TACE治疗优于保守治疗。     

Transjugular Intrahepatic Portosystemic Shunt for Portal Hypertension in Hepatocellular Carcinoma with Portal Vein Tumor Thrombus

Purpose

In patients with hepatocellular carcinoma (HCC), limited therapeutic options are available for portal hypertension resulted from portal vein tumor thrombus (PVTT). We aimed to determine safety and efficacy of TIPS for treatment of symptomatic portal hypertension in HCC with PVTT.

Methods

We evaluated clinical characteristics of 95 patients with HCC and PVTT out of 992 patients who underwent TIPS. The primary endpoints included success rate, procedural mortality, serious complications, decrease in portosystemic pressure gradient, and symptom relief. The secondary endpoints included recurrence of portal hypertension, overall survival, adverse events related to treatments for HCC, and quality of life measured by Karnofsky Performance Status Scale (KPS).

Results

Success rate of TIPS was 95.8% (91/95), with procedural mortality of 1.1%. Serious complications related to TIPS procedure occurred in 2.1% (2/95) of patients. The symptoms of portal hypertension were well relieved. Variceal bleeding was successfully controlled and terminated in 100% of patients, with a recurrence rate of 39.2% in 12 months. Refractory ascites/hydrothorax was controlled partially or completely in 92.9% of patients during 1 month after TIPS, with a recurrence rate of 17.9% in 12 months. Survival rate at 6, 12, 24, and 36 months was 75.8, 52.7, 26.4, and 3.3%, respectively. No unexpected adverse event related to treatments for HCC was observed. The KPS score was 49 ± 4.5 and 63 ± 4.7 before and 1 month after TIPS, respectively (p < 0.001).

Conclusions

TIPS is a safe and efficacious treatment for symptomatic portal hypertension in HCC with PVTT.

     

Angiographic evaluation of hepatic arterial injury after cisplatin and Gelfoam–based transcatheter arterial chemoembolization for hepatocellular carcinoma in a 205 patient cohort during a 6-year follow-up

Objective:

To evaluate the overall and cumulative incidence, degree, interval change and predictors of hepatic arterial injury (HAI) after cisplatin and Gelfoam® (Upjohn, Kalamazoo, MI)–based transcatheter arterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

Methods:

A total of 205 patients with HCC who underwent three or more sessions of TACE without additional surgical or local treatment were included. HAI was evaluated at each segment of the hepatic artery using a three-grade scale: 1 (slight wall irregularity), 2 (overt stenosis) and 3 (occlusion). HAI interval change was categorized into three groups: progression, stable state and improvement. Cumulative incidence of HAI was analysed using Kaplan– Meier method, and predictors of HAI (patient age, sex, portal vein thrombosis and Child–Pugh classification) were analysed by univariate logistic regression.

Results:

HAI occurred in 50 of the 205 study patients (24.4%). The cumulative incidence of HAI was 16.0% [95% confidence interval (CI), 10.21–21.77] during 5 sessions of TACE, 52.1% (95% CI, 37.83–66.29) during 10 sessions and 68.0% (95% CI, 67.62–88.46) during 15 sessions. Initial HAI was interpreted as grades 1, 2 and 3 in 11 (22.0%), 17 (34.0%) and 22 (44.0%) patients, respectively. When the interval change was assessed in 48 patients with available follow-up TACE, 40 (83.3%) were included in the progression, 2 (4.2%) in the stable state and 6 (12.5%) in the improvement groups. The univariate analysis used to determine the predictors of HAI revealed no significant predictors.

Conclusion:

In three or more sessions of TACE, the incidence of HAI was 24%. Increasing TACE causes increased incidence of HAI. The initial presentation was most commonly grade 3, and 12.5% of the patients with HAI showed improvement of the HAI grade during follow-up TACE.

Advances in knowledge:

In patients who underwent three or more sessions of cisplatin and Gelfoam–based TACE, the overall incidence of HAI was 24.4%, and increasing TACE causes increased incidence of HAI.Transcatheter arterial chemoembolization (TACE) is an effective method for the palliative treatment of hepatocellular carcinoma (HCC).¹ Patients with HCC frequently require repeated TACE for the treatment of residual viable tumour or local recurrence. However, TACE for HCC may cause damage to the hepatic arteries, which leads to hepatic artery spasm and inflammatory constriction, and severe cases may lead to occlusion, dissection, intrahepatic and extrahepatic collateralization and aneurysm formation in the hepatic artery.^2–4 A direct result of irreversible occlusion is the difficulty in selecting the artery for the next TACE procedure.⁵Maeda et al³ reported that the incidence of significant hepatic artery damage after TACE for HCC based on 33 patients and using epirubicin as a chemotherapeutic agent was 16% per artery and 48% per patient (mean follow-up period of 497 days). Geschwind et al⁶ also reported that subsequent arterial patency seen on follow-up angiography after TACE performed for liver cancer and based on 160 patients was 54.6–80.6% depending on the embolization protocol using oil, polyvinyl alcohol particles or Gelfoam pledgets. However, both of these previous reports had a limited number of study patients. To our knowledge, published reports regarding the incidence or predictors of hepatic arterial injury (HAI) in a large series of cisplatin and Gelfoam-based TACE treatments have been limited, although cisplatin is one of the widely used chemotherapeutic regimens for HCC. Gaba⁷ reported the results of an online survey replied to by 268 Society of Interventional Radiology members, regarding iodized oil chemoembolization for HCC. The preferred chemotherapeutic regimen consisted of 100 mg of cisplatin (44%), 50 mg of doxorubicin (58%) and 10 mg of mitomycin (59%) emulsified in 10 ml of iodized oil (71%).⁷ Moreover, follow-up changes in the hepatic artery after HAI have not yet been reported. Therefore, the purpose of this study was to evaluate the incidence, degree, interval change and predictors of HAI after cisplatin and Gelfoam–based TACE for HCC in a 205 patient cohort during a 6-year follow-up.     

Efficacy and safety of percutaneous microwave ablation for hepatocellular carcinomas <4 cm in difficult location

Objective:Tumor location is a critical factor for determining technical success and local recurrence following percutaneous ablation of hepatocellular carcinomas (HCC). The purpose of this retrospective study was to evaluate the safety and outcome measures of percutaneous microwave ablation (pMWA) for HCCs <4 cm in difficult locations.Methods:Retrospective review included 81 patients who underwent pMWA for HCCs <4 cm. Fourty-three patients (30 males and 13 females; mean age, 61 years) with 53 HCCs located near the diaphragm, heart, gallbladder, kidney, gastrointestinal tract, large vessel and exophytic location were included under difficult location group. Thirty-eight patients (29 males and nine females; mean age, 60 years) with 48 HCCs in other locations were included under control group. Baseline demographics were recorded. Technical efficacy, local tumor progression (LTP), and complication rates were evaluated.Results:Mean follow-up period was 3.4 months (range 1–7). There was no major complication in both the groups; two patients had a mild perihepatic hemorrhage in the difficult location group which was managed conservatively. There was no difference between the groups in the overall technical efficacy rate (84.9% vs 91.7%, p = 0.294), LTP rate (4.4% vs 2.2%. p = 0.57) or complication rate (4.6% vs 0%, p = 0.177).Conclusion:Our data suggest that there is no significant difference in technical efficacy, LTP or complication rates for MWA in both difficult and normal locations.Advances in knowledge:With proper patient selection, pre-procedural planning and appropriate technique, pMWA is feasible, safe, and effective for small HCCs in difficult location with an acceptable range of complications.     

Comparison of radiofrequency and microwave ablation and identification of risk factors for primary treatment failure and local progression

PurposeTo compare percutaneous radiofrequency ablation (RFA) and microwave ablation (MWA) for treatment of Hepatocellular carcinoma (HCC) and to identify risk factors for treatment failure and local progression.Methods145 unique HCC [87 (60%) RFA, 58 (40%) MWA] were retrospectively reviewed from a single tertiary medical center. Adverse events were classified as severe, moderate, or mild according to the Society of Interventional Radiology Adverse Event Classification system. Primary and secondary efficacy, as well as local progression, were determined using mRECIST. Predictors of treatment failure and time to local progression were analyzed using generalized estimating equations and Cox regression, respectively.ResultsTechnical success was achieved in 143/145 (99%) HCC. There were 1 (0.7%) severe and 2 (1.4%) moderate adverse events. Of the 143 technically successful initial treatments, 136 (95%) completed at least one follow-up exam. Primary efficacy was achieved in 114/136 (84%). 9/22 (41%) primary failures underwent successful repeat ablation, so secondary efficacy was achieved in 128/136 (90%) HCC. Local progression occurred in 24 (19%) HCC at a median of 25 months (95% CI = 19–32 months). There was no difference in technical success, primary efficacy, or time to local progression between RFA and MWA. In HCC treated with MWA, same-day biopsy was associated with primary failure (RR = 9.0, 95% CI: 1.7–47, P = 0.015), and proximity to the diaphragm or gastrointestinal tract was associated with local progression (HR = 2.40, 95% CI:1.5–80, P = 0.017).ConclusionThere was no significant difference in primary efficacy or time to local progression between percutaneous RFA and MWA.     

Effect of Stent Placement on Survival in Patients with Malignant Portal Vein Stenosis: A Propensity Score–Matched Study

ObjectivePercutaneous portal vein (PV) stent placement can be an effective treatment for symptoms associated with portal hypertension. This study aimed to evaluate the effect of PV stenting on the overall survival (OS) in patients with malignant PV stenosis.Materials and MethodsTwo groups of patients with malignant PV stenosis were compared in this retrospective study involving two institutions. A total of 197 patients who underwent PV stenting between November 2016 and August 2019 were established as the stent group, whereas 29 patients with PV stenosis who were treated conservatively between July 2013 and October 2016 constituted the no-stent group. OS was compared between the two groups before and after propensity score matching (PSM). Risk factors associated with OS were evaluated using the Cox proportional hazards model. Procedure-associated adverse events were also evaluated.ResultsThe stent group finally included 100 patients (median age, 65 [interquartile range, 58–71] years; 64 male). The no-stent group included 22 patients (69 [61–75] years, 13 male). Stent placement was successful in 95% of attempted cases, and the 1- and 2-year stent occlusion–free survival rate was 56% (95% confidence interval, 45%–69%) and 44% (32%–60%), respectively. The median stent occlusion–free survival time was 176 (interquartile range, 70–440) days. OS was significantly longer in the stent group than in the no-stent group (median 294 vs. 87 days, p < 0.001 before PSM, p = 0.011 after PSM). The 1- and 3-year OS rates before PSM were 40% and 11%, respectively, in the stent group. The 1-year OS rate after PSM was 32% and 5% in the stent and no-stent groups, respectively. Anemia requiring transfusion (n = 2) and acute thrombosis necessitating re-stenting (n = 1) occurred in three patients in the stent group within 1 week.ConclusionPercutaneous placement of a PV stent may be effective in improving OS in patients with malignant PV stenosis.     

Early Stage Hepatocellular Carcinomas Not Feasible for Ultrasound-Guided Radiofrequency Ablation: Comparison of Transarterial Chemoembolization Alone and Combined Therapy with Transarterial Chemoembolization and Radiofrequency Ablation

Purpose

To report the results of combined therapy with transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) for early stage hepatocellular carcinoma (HCC) considered infeasible for ultrasound (US)-guided RFA in comparison with those of TACE monotherapy.

Methods

From January 2007 through December 2010, 91 patients with early or very early stage HCC infeasible for US-guided RFA received either TACE alone (TACE group; n = 54) or TACE immediately followed by RFA (TACE–RFA group; n = 37) as a first-line treatment. 1-month tumor response, time to progression (TTP), and overall survival (OS) rates were calculated. Univariate and multivariate analyses were performed to identify prognostic factors.

Results

TACE–RFA group showed a better 1-month tumor response than TACE group (P < .001). The mean TTP was 29.7 ± 3.4 months (95 % confidence intervals [CIs] 23.0–36.5) in TACE group and 34.9 ± 2.8 months (95 % CIs 29.4–40.4) in TACE–RFA group. TACE–RFA group had a significantly longer TTP (P = .014). Cumulative 1-, 2-, and 3-year OS rates in the TACE and TACE–RFA groups were 91, 79, and 71 % and 100, 97, and 93 %, respectively (P = .008). Initial treatment of TACE was found to be the only significant risk factor for tumor progression and OS in multivariate analysis.

Conclusion

TACE–RFA combination therapy appears superior to TACE monotherapy in terms of 1-month tumor response, TTP, and OS when performed for early stage HCC infeasible for US-guided RFA.

     

Trans-Arterial Chemoembolization with 50 μm Degradable Starch Microspheres Versus 300–500 μm Drug Eluting Beads in Hepatocellular Carcinoma: A Comparative Analysis of Initial Treatment Outcomes

Background and Aims:Trans-arterial chemoembolization (TACE) has become a widely accepted treatment in unresectable hepatocellular carcinoma (HCC). We aimed at comparing the efficacy of Degradable Starch Microspheres (DSMs)-TACE with 50 ± 7 µm versus 300–500 μm Drug Eluting Beads (DEB)-TACE in terms of initial clinical and radiological treatment response parameters.Material and Methods:A total of 54 patients with unresectable HCC who underwent DEB-TACE (n = 25) or DSMs-TACE (n = 29) were included in this retrospective study. Baseline demographic and clinical characteristics, duration of follow-up, local recurrence and survival status, as well as treatment outcome including treatment response via modified Response Evaluation Criteria in Solid Tumors (mRECIST) criteria, viable and total tumor diameter and serum alpha-fetoprotein (AFP) levels were analyzed in both study groups.Results:No significant difference was noted between the two groups in terms of local recurrence (31.6 vs. 16.7%) or mortality (73.9 vs. 85.7%) rates after 36-month and 12-month follow-up, respectively. DSMs-TACE vs. DEB-TACE was associated with significantly higher complete response rate (27.6 vs. 0.0%, p = 0.011) and significant decrease in serum AFP levels (p = 0.013).Conclusion:Both DSMs-TACE with 50 ± 7 µm microspheres and 300–500 μm DEB-TACE are effective for local control of unresectable HCC. Our findings revealed superiority of DSMs-TACE over DEB-TACEnin terms of initial clinical and radiological tumor response; though no significant difference was noted between the two patient groups in terms of local recurrence or mortality during follow up.