Staged partial hepatectomy versus transarterial chemoembolization for the treatment of spontaneous hepatocellular carcinoma rupture: a multicenter analysis in Korea

PURPOSE: The aim of this study was to identify the prognostic factors and compare the long-term outcomes of staged hepatectomy and transarterial chemoembolization (TACE) for patients with spontaneous rupture of hepatocellular carcinoma (HCC). METHODS: This study is a multicenter, retrospective analysis of patients with newly diagnosed ruptured HCC. To compare overall survival between staged hepatectomy group and TACE alone group, we performed propensity score-matching to adjust for significant differences in patient characteristics. To identify prognostic factors, the clinical characteristics at the time of diagnosis of tumor rupture were investigated using Cox-regression analysis. RESULTS: From 2000 to 2014, 172 consecutive patients with newly diagnosed ruptured HCC were treated in 6 Korean centers. One hundred seventeen patients with Child-Pugh class A disease were identified; of which 112 were initially treated with transcatheter arterial embolization (TAE) for hemostasis and five underwent emergency surgery for bleeder ligation. Of the 112 patients treated with TAE, 44 underwent staged hepatectomy, 61 received TACE alone, and 7 received conservative treatment after TAE. Those that underwent staged hepatectomy had significantly higher overall survival than those that underwent TACE alone before matching (P 1,200 mL, and tumor size >5 cm were associated with poor overall survival. CONCLUSION: Staged hepatectomy may offer better long-term survival than TACE alone for spontaneous rupture of HCC. Staged hepatectomy should be considered in spontaneous rupture of HCC with resectable tumor and preserved liver function.

Quimioembolización transarterial en carcinoma hepatocelular atípico

RESUMEN Una de las grandes controversias dentro del manejo médico integral del carcinoma hepatocelular es la estimación precisa de la efectividad de la terapia con quimioembolización transarterial. Las evidencias demuestran que la misma hace parte del núcleo de tratamiento para aquellos pacientes con tumores no resecables y, comparado con la resección hepática y ablación por radiofrecuencia, oferta supervivencia a largo plazo si cumplen las características de nódulo hasta 3 cm o menores sin invasión vascular. Presentamos un caso clínico de carcinoma hepatocelular atípico con manejo médico integral, mediante la quimioembolización transarterial, evidenciando por imágenes y macroscópicamente la efectividad de la misma hasta el trasplante hepático ortotópico.

ABSTRACT One of the major controversies within the comprehensive medical management of hepatocellular carcinoma is the accurate estimation of the effectiveness of transarterial chemoembolization therapy. Evidence shows that it is part of the treatment nucleus for patients with unresectable tumors and, compared to hepatic resection and radiofrequency ablation, offers long-term survival if the characteristics of nodules up to 3 cm or less without vascular invasion are met. We present a clinical case of atypical hepatocellular carcinoma with integral medical management, through transarterial chemoembolization, evidencing its effectiveness by images and macroscopically until the orthotopic liver transplantation.

Fluoroscopy-induced Subacute Radiation Dermatitis in Patient with Hepatocellular Carcinoma / 대한소화기학회지

Radiation dermatitis can develop after fluoroscopy-guided interventional procedures. Cases of fluoroscopy-induced radiation dermatitis have been reported since 1996, mostly documented in the fields of radiology, cardiology and dermatology. Since diagnosis and treatment of fluoroscopy-induced radiation dermatitis can be difficult, high grade of suspicion is required. The extent of this reaction is determined by radiation dose, duration of exposure, type of procedure, and host factors and can be aggravated by concomitant use of photosensitizers. Follow-up is important after long and complicated procedures and efforts to minimize radiation exposure time will be necessary to prevent radiation dermatitis. Herein, we report a case of a 58-year-old man with hepatocellular carcinoma presenting with subacute radiation dermatitis after prolonged fluoroscopic exposure during transarterial chemoembolization and chemoport insertion. Physicians should be aware that fluoroscopy is a potential cause of radiation dermatitis.

Addition of n-butyl cyanoacrylate to classic transarterial chemoembolization may improve the radiological response in patients with hepatocellular carcinoma

OBJECTIVE: Transarterial chemoembolization is the treatment of choice for intermediate-stage hepatocellular carcinoma. However, there are no clear data supporting transarterial chemoembolization vs . transarterial embolization or regarding the best chemotherapeutic agent, which may suggest a preponderant role of ischemia over chemotherapeutic action. This study sought to evaluate the radiological response and outcome of transarterial chemoembolization modified by n-butyl cyanoacrylate addition compared to conventional transarterial chemoembolization in hepatocellular carcinoma patients. MATERIALS AND METHODS: A retrospective review identified forty-seven patients who underwent modified chemoembolization and thirty-three who underwent conventional chemoembolization between June 2006 and December 2011. The radiological response was reassessed using the modified Response Evaluation Criteria in Solid Tumors. The sustained complete response, time to progression and overall survival rates were also analyzed. RESULTS: Complete response rates were significantly higher in patients who had undergone modified chemoembolization compared to those who had undergone conventional treatment (61.7% and 24.3%, respectively; p <0.001). The rate of sustained complete response was significantly higher in the modified chemoembolization group compared to the conventional chemoembolization group (median of 236 and 37 days, respectively; p <0.001). Time to progression was significantly higher in the modified chemoembolization group compared to the conventional chemoembolization group (median of 424 and 201 days, respectively; p =0.042). Overall survival rates revealed no difference between patients who received modified chemoembolization and conventional chemoembolization (median of 483 and 399 days, respectively; p =0.316). CONCLUSION: Transarterial chemoembolization modified by n-butyl cyanoacrylate addition was superior to conventional transarterial chemoembolization in terms of the radiological response in the first imaging control. Although the sustained complete response and time to progression rates were higher for the modified chemoembolization group, no differences in overall survival rates were observed.

Spontaneous Regression of Recurred Hepatocellular Carcinoma with Multiple Lung Metastases

Hepatocellular carcinoma (HCC) is the most common form of liver malignancy. Spontaneous regression of HCC is extremely rare phenomenon and mechanism of regression remains ob-scure. 75-year-old woman previously diagnosed with hepatitis C virus-related liver cirrhosis was found to have single mass in liver with elevation of alpha-fetoprotein level to 10,320 ng/mL. Transarterial chemoembolization (TACE) was performed. 27 months after TACE recurred HCC with multiple lung nodules were confirmed. The patient refused any therapeutic modality. The patient underwent follow-up without any anti-cancer treatment. 8 months after recur-rence follow up computed tomography scan revealed spontaneous regression of HCC and completely disappeared lung nodules. The patient is currently doing well and without any evidence of recurrence. The causes of spontaneous regression of HCC are not well understood. Proposed mechanisms are ischemic injury, biological factors, herbal medicine, immunological variations. Further studies are necessary to improve our understanding of this rare phenom-enon.

Lipiodol-induced pneumonitis following transarterial chemoembolization for ruptured hepatocellular carcinoma / 영남의대학술지

Transarterial chemoembolization (TACE) is a widely accepted nonsurgical modality used for the treatment of multinodular hepatocellular carcinoma (HCC). The careful selection of the candidate is important due to the risk of developing various side effects. Fever, nausea, abdominal pain, and liver enzyme elevation are commonly known side effects of TACE. Hepatic failure, ischemic cholecystitis, and cerebral embolism are also reported, although their incidence might be low. Pulmonary complication after TACE is rare, and the reported cases of lipiodol pneumonitis are even rarer. A 53-year-old man was treated with TACE for ruptured HCC associated with hepatitis B virus infection. On day 19 after the procedure, the patient complained of dyspnea and dry cough. Chest computed tomography showed diffuse ground glass opacities in the wholelung fields, suggesting lipiodol-induced pneumonitis. After 2 weeks of conservative management, the clinical symptoms and radiologic abnormalities improved. Reported herein is the aforementioned case of lipiodol-induced pnemonitis after TACE, with literature review.

Transarterial chemoembolization combined with sorafenib in treatment of middle stage hepatocellular carcinoma: Efficacy and safety / 第二军医大学学报

Objective To evaluate the efficacy and safety of transarterial chemoembolization (TACE) combined with sorafenib in treatment of patients with non-resected middle stage hepatocellular carcinoma (HCC). Methods From July 2009 to July 2011, 38 middle stage HCC patients treated with TACE plus sorafenibwere included in the TACE+ sorafenib group and the other 38 patients with similar baseline characteristics receiving TACE alone were selected in the TACE group. All the patients belonged to the Barcelona Clinic Liver Cancer (BCLC) stage B. The adverse events of the TACE+ sorafenib group and the overall survival of the two groups were analyzed. Results All the patients treated with sorafenib experienced at least one drug-related adverse event during the study, including 7 (18.4%) experienced drug-related grade 3adverse events, with no grade 4 or higher adverse events occurred. The median overall survival time was 11 months (95% CI: 7.4-14.6 months) for the TACE group and15 months (95% CI: 8.4-21.6 months) for the TACE+ sorafenib group, showing significant difference between the two groups (P=0.019). Conclusion T he combination of sorafenib with TACE is well tolerated in non-resected middle stage HCC patients, with no severe adverse events and can effectively improve the overall survival time of patients.

A case of necrotizing pancreatitis subsequent to transcatheter arterial chemoembolization in a patient with hepatocellular carcinoma

Necrotizing pancreatitis is one of the rare complications of transcatheter arterial chemoembolization (TACE). Necrotizing pancreatitis after TACE may result from the development of ischemia caused by regurgitation of embolic materials into the vessels supplying the pancreas. We report a case of post-TACE necrotizing pancreatitis with abscess formation in a patient with hepatocellular carcinoma. The patient had suffered hepatic artery injury due to repetitive TACE; during his 25th TACE procedure he had submitted to selective catheterization of the feeding vessel from the dorsal pancreatic artery with a cytotoxic agent and Gelfoam particles. The patient complained of abdominal pain after the TACE procedure, and a CT scan led to a diagnosis of necrotizing pancreatitis with abscess formation. The pancreatic abscess progressed despite general management of the pancreatitis, including antibiotics. Percutaneous catheter drainage was performed, and the symptoms of the patient improved.

Hepatic arterial embolization with glycolic acid-ethylcellulose microspheres in treatment of hepatic tumor in rabbits / 第二军医大学学报

Objective To evaluate the therapeutic effects of glycolic acid-ethylcellulose microspheres infused via hepatic artery on hepatocarcinoma in rabbits. Methods Thirty New Zealand white rabbits were implanted with VX2 liver tumor and received CT examination after 13 days. The tumor volumes were calculated; the tumors were numbered according to volume and were divided into 3 groups by random number table. 3 F catheters were inserted via right femoral artery to hepatic artery in all animals; the nutrition arteries of the tumor were observed by injecting contrast media; and then therapeutic agents were given through the catheter. Group A (n=10) was given glycolic acid-ethylcellulose microspheres (0.023 g/1 ml), Group B (n=10) was given lipiodol (1 ml), and Group C (n=10) was given normal saline (1 ml). The liver function and tumor growth were observed before and after treatment; the pathological changes of tumor tissues and the survival of rabbits were observed with 5 randomly selected animals in each group. Results The liver function and the tumor volumes were not significantly different among groups. One week after treatment, AST and ALT levels were significantly higher in Group A and B compared with those in Group C (P<0.05). CT results showed that the tumor growth rates in group A and B were significantly smaller than that in Group C (P<0.01), and that in group A was significantly smaller than that in Group B(P<0.01). Pathological examination showed greatly thickened tumor fibrous capsule and large necrotic area in tumors in Group A and B, with loosely arranged tumor cells, pyknosis and greatly decreased pathologic mitosis. VEGF expression and proliferation activity in Group A were weaker than those in Group B. Compared with Group B and C, animals in Group A had a significantly longer survival time compared with group B and C(P<0.05, P<0.01). Conclusion Transcatheter infusion of glycolic acid-ethylcellulose microspheres is a safe and effective chemoembolization agent for treatment of rabbit hepatic tumors.

Postoperative adjuvant transcatheter arterial chemoembolization for hepatocellular carcinoma: A prospective study / 第二军医大学学报

Objective To evaluate the clinical value of postoperative adjuvant transcatheter arterial chemoembolization (TACE) on the prognosis of hepatocellular carcinoma (HCC) patients after radical hepatectomy using a prospective cohort study. Methods A total of 220 HCC patients underwent radical hepatectomy from Jan. 2008 to Dec. 2008 and 104 were recruited in the present study. Fifty-six patients (TACE group) received adjuvant TACE one month after hepatectomy, and 48 (control group) did not receive any adjuvant therapies. Follow-up was done regularly. The disease-free survival (DFS) time and total survival (TS) were statistically analyzed. Results The median DFS time in TACE group was significantly shorter than that in the control group (11 [2-38] months vs 13 [2-59] months, P = 0. 005). The 1-year, 2-year and 3-year recurrence rates were 50%, 85. 7%, and 89. 3% in TACE group and 46. 8%, 58. 3%, and 62. 5% in the control group(P = 0. 005), respectively. Multivariate COX regression analysis indicated that TACE, AFP, intact tumor peplos, liver cirrhosis, vascular invasion and tumor Edmondson-Steiner grade were the risk factors for recurrence (P<0. 05). The median TS time periods in TACE group and control group were 29 (4-41) months and 24 (5-59) months (P = 0. 789), respectively. The 1-year, 2-year and 3-year survival rates were 85. 6%, 59. 5%, and 36. 5% in TACE group and 75%, 50%, and 41. 7% in the control group (P = 0.789), respectively. Multivariate COX regression analysis indicated that AFP, intact tumor peplos and tumor Edmondson-Steiner grade were correlated with the total survival of patients (P<0. 05). Conclusion Adjuvant TACE can not improve DFS and TS of HCC patients after radical hepatectomy, and it may even contribute to a poor prognosis. Therefore more attention should be paid in choosing treatment strategy.

Is postoperative adjuvant transchatheter arterial chemoembolization necessary for small hepatocellular carcinoma patients: A randomized controlled trial / 第二军医大学学报

Objective To evaluate whether adjuvant transchatheter arterial chemoembolization (TACE) can reduce early recurrence of small hepatocellular carcinoma (SHCC) patients after surgical treatment using randomized controlled trial. Methods A total of 117 patients, who underwent radical hepatectomy from Sept. 2008 to Dec. 2009, were randomly divided into 2 groups. Fifty-nine patients (group A or TACE group) received adjuvant TACE one month after hepatectomy, and 58 (group B or control group) did not receive any adjuvant therapies. Follow-up was done regularly. The disease-free survival (DFS) time and recurrence rate within the following two years were analyzed. Results The median follow-up duration was 29 months in our study. Twenty-two recurrences happened within one year and all recurrences happened within two years. The mean DFS periods were (28. 93 ± 1. 40) months (range: 5-29 months) and (26. 94 ± 1. 62) months (range: 3-35 months) (P = 0. 443) in group A and B, respectively. The half-year, 1-year and 2-year recurrence rates of group A vs group B were 10. 2% vs 13.8%, 20. 3% vs 20. 7%, 25.7% vs 31. 2% (P = 0.443), respectively. Univariate analysis showed that infection of HBV DNA, blood transfusion, Edmondson-Steiner grade and tumor diameter (3 cm as cut-off point) were correlated with tumor recurrence (P<0. 05). Multivariate COX regression analysis indicated that HBV DNA, blood transfusion, and tumor diameter (3 cm as cut-off point) were independent factors of early recurrence. Conclusion Adjuvant TACE can not reduce early recurrence of SHCC with a low risk of recurrence, so it is not recommended as a routine therapy to prevent early tumor recurrence. Further study is needed to verify whether TACE can benefit the long-term recurrence and overall survival of patients.

Long-term survival in a case of hepatocellular carcinoma with portal vein thrombosis treated with transarterial chemoembolization Kwan / 대한내과학회지

Hepatocellular carcinoma (HCC) is the third most common malignancy in Korea and the prognosis of patients with HCC is generally poor. Most patients with HCC have unresectable disease at presentation and only a small proportion of patients diagnosed early receive curative treatment. Transarterial chemoembolization (TACE) is a widely used palliative treatment for advanced HCC and its prognostic benefit has been proven in several studies. TACE is contraindicated for patients with portal vein tumor thrombosis (PVT) because it carries a potential risk of acute hepatic failure. Recently, however, a few studies have provided evidence of a survival benefit after TACE in patients with PVT if they have good hepatic reserve and collateral circulation around the portal trunk. We experienced a case of HCC with PVT, with long-term survival and no evidence of recurrence or hepatic failure after TACE, and present this case with a review of the relevant literature.

Preventive Interventional Management Following the Focus Radical Resection in Patients with Small Hepatocellular Carcinoma / 介入放射学杂志

20?g/L) after surgery in one month.The survival rate for 1,3,5yr were 100%(n=17),91.5%(n=16) and 84.7% (n=14) respectively in the therapy group,and in the control group 95.45% (n=21),72.7% (n=16),40.91%(n=9) respectively.Sur- vival rate between two groups showed significant difference (P