Unresectable Hepatocellular Carcinoma (unresectable + hepatocellular_carcinoma)

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Selected Abstracts

A randomized controlled trial of transcatheter arterial chemoembolization with lipiodol, doxorubicin and cisplatin versus intravenous doxorubicin for patients with unresectable hepatocellular carcinoma

M. MABED md, professor
Hepatocellular carcinoma (HCC) is a major and often therapeutically frustrating oncological problem. A total of 100 patients with unresectable HCC were recruited and randomized to be treated with either transcatheter arterial chemoembolization (TACE) or systemic chemotherapy. Fifty patients were treated with TACE using lipiodol, doxorubicin and cisplatin, while 50 patients were treated with systemic doxorubicin alone. Patients treated with TACE achieved a significantly higher response rate, with partial response achieved in 16 patients (32%) versus five patients (10%) in the chemotherapy arm (P = 0.007). A significantly more favourable tumour response to chemoembolization was found in patients with single lesions (P = 0.02), Child class A (P = 0.007), Okuda stage 1 (P = 0.005) and ,-feto protein less than 400 ng/mL (P < 0.001). The probability of tumour progression was significantly lower in cases treated with TACE where the median progression free survival was 32 weeks (range, 16,70 weeks) versus 26 weeks (range, 14,54 weeks) for patients treated with systemic chemotherapy (P = 0.03). However, the median overall survival did not differ significantly in cases treated with TACE (38 weeks) compared with those treated with chemotherapy (32 weeks) (P = 0.08), except for patients with serum albumin >3.3 g/dL (60 vs. 36 weeks; P = 0.003). Multivariate Cox regression analysis showed that a rise of serum albumin by 1 g/dL is associated with a decrease in the risk of death by 33% (95% confidence interval: 0.12,0.94, P = 0.038). Mortality in the chemoembolization arm was due to tumour progression in 18 patients (53%), liver failure in 11 patients (32%) and gastro intestinal tract (GIT) bleeding in 5 patients (15%). Mortality in the chemotherapy arm was due to tumour progression in 23 patients (64%), liver failure in 9 patients (25%) and GIT bleeding in 4 patients (11%). Treatment-related mortality was 4% in the TACE arm versus 0% in the chemotherapy arm. In conclusion, the overall survival benefits of TACE and systemic doxorubicin are similar for patients with unresectable HCC amenable to either treatment. It is crucial to optimize the benefit,risk ratio of TACE. In this setting, serum albumin level is a candidate marker for selection of cases who may benefit from this procedure. [source]

Impact of evidence-based medicine on the treatment of patients with unresectable hepatocellular carcinoma

Aliment Pharmacol Ther,31, 493,501 Summary Background, A randomized controlled trial performed by the Barcelona Clinic Liver Cancer (BCLC) published in 2002 demonstrated that transcatheter arterial chemoembolisation (TACE) is an effective treatment for well-selected patients with unresectable hepatocellular carcinoma (HCC). Aim, To access whether this information has modified the use of TACE in clinical practice. Methods, From 2042 HCC patients included in the Italian Liver Cancer database, we selected 336 cases diagnosed over two 4-year periods (1999,2002, n = 161 and 2003,2006, n = 175), fulfilling the inclusion criteria of the BCLC study. These groups were compared for TACE application rate, patient characteristics and survival. Results, Patients undergoing TACE increased in the 2003,2006 period (from 62% to 73%, P = 0.035), with an increase in of Child-Pugh class A (from 64% to 77%, P = 0.048) and advanced HCC patients (from 54% to 69%, P = 0.041). In the 1999,2002 period, there was no significant difference in survival between TACE-treated and untreated patients, while in the 2003,2006 period, TACE-treated patients survived longer (P < 0.0001). Conclusions, Following the publication of studies providing evidence of a survival benefit of TACE in selected patients with unresectable HCC, significantly more patients with well-compensated cirrhosis underwent TACE within this very homogenous population, leading to an increased survival despite a more advanced tumour stage. [source]

Transcatheter arterial chemoembolization vs. chemoinfusion for unresectable hepatocellular carcinoma in patients with major portal vein thrombosis

Summary Background, Transcatheter arterial chemoembolization (TACE) has been limited in palliative treatment of unresectable hepatocellular carcinoma (HCC) with major portal vein (PV) invasion due to the possibility of liver failure following embolization. Transcatheter arterial chemoinfusion (TACI) has been an option in such cases. Aim To compare clinical outcomes after TACE vs. TACI in HCC patients with major PV occlusion. Methods, We compared clinical outcomes after TACE vs. TACI in HCC patients with major PV occlusion. From 2005 to 2007, 110 HCC patients with major PV thrombosis were treated with TACE (n = 49) or TACI (n = 61). Results, The morbidity rate was similar for both TACE (6.1%) and TACI (6.5%) patients, and complications were adequately managed using medical treatment. The Kaplan,Meier survival analysis showed that the survival period was significantly longer for the TACE group (median: 14.9 months) than for the TACI (median: 4.4 months) group (P < 0.001). There was a higher probability of death in the TACI group than in the TACE group in both our multivariate Cox-proportional hazards (OR 3.09, P < 0.001) and the propensity score-matched (27 pairs) cohort analyses (OR 2.27, P = 0.024). Conclusions, Transcatheter arterial chemoembolization can be safely performed in HCC patients with main PV occlusion. Compared with TACI, TACE may result in longer survival of HCC patients with major PV occlusion. [source]

Long-term survival of patients with unresectable hepatocellular carcinoma treated with transcatheter arterial chemoinfusion

B. Y. HA
Summary Background Transcatheter arterial chemoembolization (TACE) has become one of the most common treatments for unresectable hepatocellular carcinoma. Published studies of TACE report a 5,16% risk of serious complications. Compared with TACE, transcatheter arterial chemoinfusion (TACI) may have similar efficacy and fewer side effects. Aim To examine the clinical outcomes of TACI. Methods We performed a retrospective cohort study of 345 consecutive TACI cases in 165 patients performed at a single United States medical center between 1998 and 2002. Primary outcomes were tumour response and survival rates. Results Only seven patients were hospitalized for more than 24 h after the procedure, and only three patients had worsening of liver function within 30 days of TACI. Survival was significantly poorer for patients with tumour-node-metastasis (TNM) IV compared to those with TNM I,III and also for patients with Child's class B/C vs. A. Following adjustment for age, gender, ethnicity and aetiology of liver diseases, independent predictors of poor survival were Child's class B/C [Hazard Ratio (HR) = 1.69, P = 0.024] and TNM IV staging (HR = 1.63, P = 0.014). Conclusions TACI appears to be safe and effective for unresectable hepatocellular carcinoma with TNM stage I,III; randomized controlled trials are needed to compare TACI to TACE. [source]

Predictors of outcome in patients with unresectable hepatocellular carcinoma receiving transcatheter arterial chemoembolization

Summary Background, Transcatheter arterial chemoembolization (TACE) has been shown to improve survival in patients with unresectable hepatocellular carcinoma (HCC). Aim, To identify pretreatment factors that predicts increased mortality in HCC patients receiving TACE. Methods, Retrospective review of all patients who underwent TACE for HCC from January 1999 to November 2004. Patient demographics, aetiology of liver disease, laboratory and imaging data regarding tumour characteristics were obtained. Results, Eighty-eight patients (57 1 years age) received 1,4 sessions of TACE (1.4 0.1). Tumour size was 3.3 0.2 cm (range 1,13 cm, median 3 cm) with mean number of lesions 1.9 0.1 (range 1,7). Mean model for the end stage liver disease score: 11 0.4; cancer of the liver Italian program score: 1.3 0.1. Survival post-TACE (excluding those underwent orthotopic liver transplantation) was 12 0.3 months. By multivariate analysis, tumour size (HR = 1.37, 95% CI: 1.11,1.68, P = 0.003), hypovascularity (HR = 12.62, 95% CI: 1.79,88.92, P = 0.01) and elevated international normalized ratio (HR = 1.46, 95% CI: 1.10,1.92 P = 0.008) are shown to be significant risk factors for increased mortality. Conclusion, TACE therapy leads to a mean survival of 12 months in patients not receiving orthotopic liver transplantation. Tumour size, hypovascularity on imaging, and elevated international normalized ratio are predictors of increased mortality after TACE therapy for HCC. [source]

Survival benefit of transcatheter arterial chemoembolization in patients with hepatocellular carcinoma larger than 10 cm in diameter

Summary Background The safety and survival benefit of transcatheter arterial chemoembolization for patients with huge hepatocellular carcinoma is uncertain. Aim To evaluate the role of embolization in unresectable hepatocellular carcinomas larger than 10 cm. Methods Twenty-six consecutive patients who had an unresectable hepatocellular carcinoma larger than 10 cm and refused aggressive treatment, were enrolled as the control group. Another 31 patients matching with the control cases and undergoing embolization for huge unresectable hepatocellular carcinoma served as the embolization group. Survival between the two groups was compared. Results Two patients (7%) died from embolization-related complications. Patients in embolization group had longer survival than those in control group (median survival: 9.13 vs. 2.1 months). The 1-, 3- and 5-year survival rates in embolization group were 42%, 13% and 7% respectively. The 1- and 3-year survival rates for patients in control group were 8% and 0% respectively. In multivariate analysis, embolization and prothrombin ratio ,1.2 were two independent factors associated with a better survival. Conclusions Embolization-related mortality is low for huge hepatocellular carcinoma, and the technique provides survival benefit in patients with unresectable hepatocellular carcinomas larger than 10 cm in diameter. [source]

Treatment of HCC in Patients Awaiting Liver Transplantation

M. Schwartz
Liver transplantation (LT) is the treatment of choice for many patients with unresectable hepatocellular carcinoma (HCC), but long waiting time due to the shortage of donor organs can result in tumor progression and drop-out from LT candidacy. Furthermore, even in candidates meeting the restrictive Milan criteria there is risk of HCC recurrence; this risk rises significantly when patients with more advanced HCC are included. In an effort to address these issues, treatment of HCC in patients awaiting LT has become widespread practice. In this review the various modalities employed in the pre-LT setting are presented, and the evidence for benefit with regard to (1) improvement of post-LT survival, (2) down-staging of advanced HCC to within Milan criteria and (3) preventing waiting list drop-out is considered. Chemoembolization, radiofrequency ablation and ethanol injection all have well-documented antitumor activity; however, there is no high level evidence that waiting list HCC treatment with these modalities is effective in achieving any of the three above-mentioned aims. Nevertheless, particularly in the United States, where continued waiting list priority depends on maintaining HCC within Milan criteria, use of nonsurgical HCC treatment will likely continue in an effort to forestall tumor progression and waiting list drop-out. [source]

Factors predictive of 5-year survival after transarterial chemoembolization for inoperable hepatocellular carcinoma,

C. B. O'Suilleabhain
Background: Transarterial chemoembolization (TACE) is widely used for unresectable hepatocellular carcinoma (HCC), but the long-term survival benefit remains unclear. Methods: Pretreatment variables were analysed for factors predictive of actual 5-year survival from a prospective database of patients with inoperable HCC treated by TACE between 1989 and 1996. Results: Complete 5-year follow-up (median 91 months) was obtained for 320 patients who underwent a median of 4 (range 1,41) TACEs. Median tumour size was 9 (range 1,28) cm. There were 25 5-year survivors (8 per cent), including eight with tumours larger than 10 cm in diameter and three with portal vein branch involvement. On univariate analysis, female gender (P = 0037), absence of ascites (P = 0028), platelet count below 150 109 per litre (P = 0011), albumin concentration greater than 35 g/l (P = 004), ,-fetoprotein level below 1000 ng/ml (P = 0007), unilobar tumour (P = 0027), fewer than three tumours (P = 0015), absence of venous invasion (P = 0011), and tumour diameter less than 8 cm (P = 0021) were significant predictors of 5-year survival. Albumin concentration greater than 35 g/l (P = 0011), unilobar tumour (P = 0012) and ,-fetoprotein level below 1000 ng/ml (P = 0014) were independent prognostic factors on multivariate analysis. Conclusion: Five-year survival is possible with TACE for inoperable HCC, even in some patients with advanced tumours. Unilobar tumours, ,-fetoprotein level below 1000 ng/ml and albumin concentration greater than 35 g/l were factors predictive of 5-year survival. Copyright 2003 British Journal of Surgery Society Ltd. Published by John Wiley & Sons, Ltd. [source]