Combined transarterial chemoembolization and thermal ablation in candidates to liver transplantation with hepatocellular carcinoma: pathological findings and post-transplant outcome.

OBJECTIVES: Evaluating the pathological response and the survival outcomes of combined thermal ablation (TA) and transarterial chemoembolization (TACE) as a bridge or downstaging for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) > 3 cm. MATERIALS AND METHODS: A retrospective review encompassed 36 consecutive patients who underwent combined TA-TACE as bridging or downstaging before LT. Primary objectives included necrosis of the target lesion at explant pathology, post-LT overall survival (OS) and post-LT recurrence-free survival (RFS). For OS and RFS, a comparison with 170 patients subjected to TA alone for nodules <3 cm in size was also made. RESULTS: Out of the 36 patients, 63.9% underwent TA-TACE as bridging, while 36.1% required downstaging. The average node size was 4.25 cm. All cases were discussed in a multidisciplinary tumor board to assess the best treatment for each patient. Half received radiofrequency (RF), and the other half underwent microwave (MW). All nodes underwent drug-eluting beads (DEB) TACE with epirubicin. The mean necrosis percentage was 65.9% in the RF+TACE group and 83.3% in the MW+TACE group (p-value = 0.099). OS was 100% at 1 year, 100% at 3 years and 94.7% at 5 years. RFS was 97.2% at 1 year, 94.4% at 3 years and 90% at 5 years. Despite the different sizes of the lesions, OS and RFS did not show significant differences with the cohort of patients subjected to TA alone. CONCLUSIONS: The study highlights the effectiveness of combined TA-TACE for HCC>3 cm, particularly for bridging and downstaging to LT, achieving OS and RFS rates significantly exceeding 80% at 1, 3 and 5 years.

The Role of Immediate Post-Procedural Cone-Beam Computed Tomography (CBCT) in Predicting the Early Radiologic Response of Hepatocellular Carcinoma (HCC) Nodules to Drug-Eluting Bead Transarterial Chemoembolization (DEB-TACE).

The purpose of this study was to evaluate the efficacy of unenhanced cone-beam computed tomography (CBCT) performed at the end of drug-eluting bead transarterial chemoembolization (DEB-TACE) in predicting HCC nodules' early radiologic response to treatment, assessed using mRECIST criteria with a 30−60 day four-phase contrast-enhanced CT follow-up. Fifty-nine patients (81 lesions) subjected to DEB-TACE as exclusive treatment for HCC lesions (naive/relapse) between February 2020 and October 2021 were prospectively enrolled. In a post-interventional unenhanced CBCT procedure, two experienced radiologists evaluated for each lesion the overall intensity of the contrast media deposit, the homogeneity of the enhancement, and the presence of smooth and complete margins. The univariate analysis found that lesions with complete response (CR+) had a significantly higher incidence of clear and complete margins than CR− lesions (76.9% vs. 17.2%, p = 0.003) and a higher intensity score (67.3% vs. 27.6%, p = 0.0009). A Dmax <30 mm was significantly more common among CR+ than CR− lesions (92.3% vs. 69%, p = 0.01). These features were confirmed as significant predictors for CR+ by multivariate binary logistic regression. The homogeneity of the enhancement did not affect the DEB-TACE outcome. Post-interventional unenhanced CBCT is effective in predicting early radiological response to DEB-TACE, since the presence of an intense contrast media deposit with clear and complete margins in treated HCC lesions is associated with CR.

The value of a combined radiological-surgical approach in allowing curative resection of a locally advanced type IIIa Klatskin tumor.

We report the case of a 53-year-old patient subjected to percutaneous embolization of right and middle hepatic veins to induce liver segments 2-3 hypertrophy before extended right hepatic resection for a locally advanced type IIIa perihilar cholangiocarcinoma. Hepatic vein embolization (HVE) was performed 3 weeks after surgical recanalization of left portal vein (severely narrowed at its origin due to tumor infiltration) interposing an internal jugular vein graft between main and distal left portal vein. Nine days after HVE, future liver remnant volume increased from 395 to 501 cc, i.e. 25.1% of standardized total liver volume, allowing to perform a radical right hepatic trisectionectomy plus caudatectomy. He was discharged home on postoperative day 15th after an uneventful postoperative course, with no sign of posthepatectomy liver failure.

Quantitative assessment of HCC wash-out on CT is a predictor of early complete response to TACE.

OBJECTIVES: To investigate the predictive value of four-phase contrast-enhanced CT (CECT) for early complete response (CR) to drug-eluting-bead transarterial chemoembolization (DEB-TACE), with a particular focus on the quantitatively assessed wash-in and wash-out. METHODS: A retrospective analysis of preprocedural CECTs was performed for 129 HCC nodules consecutively subjected to DEB-TACE as first-line therapy. Lesion size, location, and margins were recorded. For the quantitative analysis, the following parameters were computed: contrast enhancement ratio (CER) and lesion-to-liver contrast ratio (LLC) as estimates of wash-in; absolute and relative wash-out (WOabs and WOrel) and delayed percentage attenuation ratio (DPAR) as estimates of wash-out. The early radiological response of each lesion was assessed by the mRECIST criteria and dichotomized in CR versus others (partial response, stable disease, and progressive disease). RESULTS: All quantitatively assessed wash-out variables had significantly higher rates for CR lesions (WOabs p = 0.01, WOrel p = 0.01, and DPAR p = 0.00002). However, only DPAR demonstrated an acceptable discriminating ability, quantified by AUC = 0.80 (95% CI0.73-0.88). In particular, nodules with DPAR ≥ 120 showed an odds ratio of 3.3(1.5-7.2) for CR (p = 0.0026). When accompanied by smooth lesion margins, DPAR ≥ 120 lesions showed a 78% CR rate at first follow-up imaging. No significative association with CR was found for quantitative wash-in estimates (CER and LLC). CONCLUSIONS: Based on preprocedural CECT, the quantitative assessment of HCC wash-out is useful in predicting early CR after DEB-TACE. Among the different formulas for wash-out quantification, DPAR has the best discriminating ability. When associated, DPAR ≥ 120 and smooth lesion margins are related to relatively high CR rates. KEY POINTS: • A high wash-out rate, quantitatively assessed during preprocedural four-phase contrast-enhanced CT (CECT), is a favorable predictor for early radiological complete response of HCC to drug-eluting-bead chemoembolization (DEB-TACE). • The arterial phase of CECT shows great dispersion of attenuation values among different lesions, even when a standardized protocol is used, limiting its usefulness for quantitative analyses. • Among the different formulas used to quantify the wash-out rate (absolute wash-out, relative wash-out, and delayed percentage attenuation ratio), the latter (DPAR), based only on the delayed phase, is the most predictive (AUC = 0.80), showing a significant association with complete response for values above 120.

Incidence of hepatic encephalopathy after transjugular intrahepatic portosystemic shunt (TIPS) according to its severity and temporal grading classification.

OBJECTIVES: To evaluate hepatic encephalopathy (HE) incidence after transjugular intrahepatic portosystemic shunt (TIPS) and classify by gravity and frequency. METHODS: This is a retrospective study of 75 patients with no previous episodes of HE who underwent TIPS between 2008 and 2014 with clinical follow-up after 6 and 12 months. Patient risk factors evaluated include age, INR (international normalized ratio), creatinine, bilirubin, and MELD score (Model for End-of-stage Liver Disease). HE was reported using two classifications: (1) gravity divided in moderate (West-Haven grades I-II) and severe (III-IV); (2) frequency divided in episodic and recurrent/persistent. RESULTS: Overall HE incidence was 36% at 6 months, with 12 month incidence significantly decreased to 27% (p = 0.02). 13/75 (17%) patients had one episode of moderate HE, while 3/75 (4%) patients had severe recurrent/persistent HE. Age was the only pre-TIPS risk predictor. Post-TIPS bilirubin and INR showed variations from basal values only in the presence of diagnosed HE. Bilirubin significantly increased (p = 0.03) in correlation to HE severity, whereas INR changes correlated with temporal frequency (p = 0.04). HE distribution classified for severity is similar at 6 and 12 months, whereas when classified for frequency shows significant differences (p = 0.04). CONCLUSIONS: A classification by gravity and frequency attests post-TIPS HE as a manageable risk. Monitoring of bilirubin and INR may help on clinical management risk stratification.

Percutaneous treatment of Hepatocellular carcinoma exceeding 3 cm: combined therapy or microwave ablation? Preliminary results.

PURPOSE: To compare MWA and RFA combined with TACE for HCC nodules exceeding 3 cm. METHODS: 19 lesions submitted to MWA (G1) were retrospectively compared with a combined treatment group (G2) matching by tumor characteristics (mean size 43 and 45 mm in G1 and G2, respectively). Technical success, complications, complete ablation (CA), and maintained CA (mCA) were evaluated. RESULTS: Technical success was achieved in all cases. Overall mortality was zero, both in G1 and G2. No significant differences were found in complications rates (3 in G1 and 2 in G2). CA was obtained in 11 (58 %) HCC in G1 and 15 (79 %) in G2 (p = n.s.). CA was obtained in 75.5 % (G1) and 89 % (G2) nodules up to 4 cm, 45 % and 70 % nodules >4 cm, respectively. At statistical analysis, size resulted as predictor for CA only in G1 (mean diameter of CA vs non-CA 39.9 vs. 47.7 mm, p = 0.021). During follow-up (13.1 and 14.4 months in G1 and G2), mCA occurred in 6/19 (32 %) nodules in G1, 8/19 (42 %) in G2. CONCLUSION: MWA and combined therapy are comparable as for safety. No significant differences were found in terms of technique effectiveness. Larger randomized studies should be designed to confirm MWA as a valid alternative to combined therapy.