Downstaging disease in patients with hepatocellular carcinoma outside up-to-seven criteria: Strategies using degradable starch microspheres transcatheter arterial chemo-embolization

AIM: To evaluate the downstaging rates in hepatitis C virus-patients with hepatocellular carcinoma(HCC), treated with degradable starch microspheres transcatheter arterial chemoembolization(DSM-TACE), to reach new-Milan-criteria(nM C) for transplantation. METHODS: This study was approved by the Ethics Committee of our institution. From September 2013 to March 2014 eight patients(5 men and 3 women) with liver cirrhosis and multinodular HCC, that did not meet n MC at baseline, were enrolled in this study. Patients who received any other type of treatment such as termal ablation or percutaneous ethanol injection were excluded. DSM-TACE was performed in all patients using Embo Cept? S and doxorubicin. Baseline and follow-up computed tomography or magnetic resonance imaging was assessed measuring the longest enhancing axial dimension of each tumor according to the modified Response Evaluation Criteria In Solid Tumors measure-ments, and medical records were reviewed.RESULTS: DSM-TACE was successfully performed in all patients without major complication. We treated 35 lesions(mean 4.3 per patient). Six of eight patients(75%) had their HCC downstaged to meet nM C. Every patient whose disease was downstaged eventually underwent transplantation. The six patients who received transplant were still living at the time of this writing, without recurrence of HCC. Baseline age(P = 0.25), Model for End-stage Liver Disease score(P = 0. 77), and α-fetoprotein level(P = 1.00) were similar between patients with and without downstaged HCC. CONCLUSION: DSM-TACE represents a safely and effective treatment option with similar safety and efficacy of conventional chemoembolization and could be successfully performed also for downstaging disease in patients without n MC, allowing them to reach liver transplantation.

Local recurrence is an important prognostic factor of hepatocellular carcinoma

AIM： To clarify the importance of complete treatment by PELT. METHODS： A total of 140 previously untreated cases of HCC were enrolled in this study from 1988 to 2002. The inclusion criteria were： a solitary tumor less than 4 cm in diameter or multiple tumors, fewer than four in number and less than 3 cm in diameter, without extrahepatic metastasis or vessel invasion. As general principles for the treatment of HCC, the patients underwent transcatheter arterial chemoembolization （TACE） prior to PEIT. After the initial treatment of the patients, ultrasonography and computed tomography were performed, and measurement of serum levels of α- fetoprotein （AFP） was determined. When tumor recurrences were detected, PEIT and/or TACE were repeated whenever the hepatic functional reserve of the patient permitted. We then analyzed the variables that could influence prognosis, including tumor size and number, the serum levels of AFP, the parameters of hepatic function （albumin, bilirubin, ALT, hepaplastin test, platelet number, and indocyanine green retention at 15 rain [ICG-R15]）, combined therapy with TACE, distant recurrence, and local recurrence. RESULTS： Univariate analysis identified the ICG test, serum levels of AFP and albumin, tumor size and number, and local recurrence, but not distant recurrence, as significant prognostic variables. In multivariate analysis using those five parameters, the ICG test, tumor size, tumor number, and local recurrence were identified as significant prognostic factors. In both univariate and multivariate analyses, the relative risk for the ICG test was the highest, followed by local recurrence. CONCLUSION： We found that local recurrence is an independent prognostic factor of HCC, indicating that achieving complete treatment for HCC on first treatment is important for improving the prognosis of patients with HCC. 2005 The WJG Press and Elsevier Inc. All rights reserved.

Transcatheter arterial infusion for advanced hepatocellular carcinoma: Who are candidates?

AIM: To elucidate anticancer effects of transcatheter arterial infusion chemotherapy(TAI) in patients with hepatocellular carcinoma(HCC). METHODS: Data from a total of 95 patients with HCC who received TAI were analyzed retrospectively. The efficacy of TAI was evaluated according to the Response Evaluation Criteria in Cancer of the Liver. Overall survival was calculated from the date of initial treatment to the date of death or last follow-up. Survival curves were calculated by the Kaplan-Meier method, and differences in survival were evaluated by the log rank test. Clinical variables that were identified as statistically different by a univariate analysis were included into the Cox proportional hazard regression model for multivariate analysis. A prognostic index based on the regression coefficients derived from variables identified by the multivariate analysis was constructed. Stratification of the patients was conducted using this prognostic index. RESULTS: The patient group was comprised of 76 men and 19 women with an average age of 68 years(range: 37-82 years). Six patients(6.3%) showedcomplete response and 18 patients(18.9%) showed partial response, for an overall response rate of 25.2%. The median overall survival was 27.6 mo, and the proportions of survivors at 1, 2, and 5 years were 67.4%, 54.0%, and 17.4%, respectively. Multivariate analysis demonstrated that no prior transcatheter arterial chemoembolization, lactate dehydrogenase < 230 IU/L, and performance status of 0 were the independent favorable prognostic factors. The development of a 0-3-point prognostic score index was based on the sum of these three prognostic factors. Subsequently, the patients were categorized into three groups: those with a good(prognostic index = 0-1; n = 54), intermediate(prognostic index = 2; n = 26), or poor(prognostic index = 3; n = 15) prognosis. The median survival times in these three groups were 41.0, 21.2, and 6.8 mo, respectively(P < 0.01). CONCLUSION: Our simple prognostic index may be helpful for management of patients in determining treatment strategies for advanced HCC in the era of molecularly targeted therapy.

Arterial embolization is the best treatment for pancreaticojejunal anastomotic bleeding after pancreatoduodenectomy

Massive pancreaticojejunal anastomotic bleeding, mainly from the gastroduodenal stump, is one of the most common complications of pancreato-duodenectomy. Selective angiography should be systematically the first step of investigative procedure in such situations. Pharmacoarteriography may be used if the bleeding point is not spontaneously identified, and allows safe and effective treatment with transcatheter arterial embolization compared to blind open surgical hemostasis. Coil embolization of the common or proper hepatic artery on either side of the bleeding point with "sandwich technique" is then the preferred technique to prevent retrograde filling. Surgery should be performed only as a last resort.

AN EVALUATION OF THE EFFECT OF THE ACCESSORY PREOPERATIVE ARTERIAL EMBOLIZATION FOR MAXILLOFACIAL VASCULAR MALFORMATION

Eleven patients with maxillofacial vascular malformations were reported and their treatment was discussed. Our results demonstrated that the accessory preoperative transcatheter arterial embolization with gelfoam for vascular malformations could effectively decrease blood loss and blood transfusion, keep the operative feild clear, shorten operative time, Facilitate radical resection of the lesion and improve the successful rate of operation. The ligation of afferent vessels and external carotid artery was in futility and even deleterious effects.