Non-surgical management of advanced hepatocellular carcinoma: A systematic review by Cancer Care Ontario.

Background: Hepatocellular carcinoma (HCC) is a global health problem, accounting for 4.7% of all new cancer cases and 8.2% of all cancer deaths worldwide in 2018. Resection and transplantation are the only modalities that offer a cure for HCC; however, most patients are diagnosed at an advanced stage, precluding these curative treatments. A number of local (ie, ablative therapies) and/or local-regional therapies (ie, chemo-embolization) are used and followed by systemic therapy for advanced or progressive disease. Other treatments are available, but their efficacy compared with these standards is not well known. Methods: Literature searches (1/2000 to 1/2020 or 1/2005 to 1/2020, depending on the specific systematic review question) were conducted, including MEDLINE, Embase and the Cochrane Database of Systematic Reviews. Results: Over 30,000 articles were identified. In total, 49 studies were included in the systematic review. Conclusions: There is no evidence to support the addition of sorafenib to any local or regional therapy. First-line systemic therapy options for unresectable or metastatic HCC include sorafenib, lenvatinib, and atezolizumab + bevacizumab. Regorafenib or cabozantinib provide survival benefits when given as second-line treatment.

Regional Therapies for Colorectal Liver Metastases: Systematic Review and Clinical Practice Guideline.

BACKGROUND: Resection is the foundation for cure for colorectal cancer (CRC) liver metastases; however, only 20% of patients are suitable for surgery. Those suitable would be considered for resection or local therapies before being considered for regional therapies. Noncurative treatment is usually systemic chemotherapy. For patients with liver-only or liver-predominant metastases that are unresectable, regional therapies [conventional transarterial chemoembolization (cTACE), drug-eluting bead transarterial chemoembolization (DEB-TACE), and transarterial radioembolization (TARE)] may be considered. We review the current evidence for regional therapies for CRC liver metastases. PATIENTS AND METHODS: Literature searches (January 2000 to March 2019 or January 2010 to March 2019 depending on the specific systematic review question) were conducted, including Medline, Embase, Cochrane Library, and 2018 American Society of Clinical Oncology (ASCO) abstracts. RESULTS: A total of 4100 articles were identified; 15 studies were included in the review. There were no comparative data regarding the resectable population. There was either insufficient evidence (cTACE or DEB-TACE) or evidence against (TARE) the addition of regional therapies to systemic therapy in the first line in the unresectable population. There was either no evidence (cTACE) or weak evidence (DEB-TACE or TARE) for the addition of regional therapies with or without systemic therapy in the second line or later in the unresectable population. CONCLUSION: Limited evidence supports the delivery of percutaneous regional therapies in patients with unresectable CRC liver metastases. There are strong data demonstrating positive effects of TARE within the liver, but they do not translate to a benefit in patient-important outcomes. DEB-TACE appears to offer a survival benefit in the second-line setting, although the evidence is limited by small sample size and larger trials are needed.

Nonsurgical management of advanced hepatocellular carcinoma: a clinical practice guideline.

Background: Practice guidelines based on a systematic review of the literature regarding the nonsurgical management of hepatocellular carcinoma (hcc) in North America are lacking. Resection and transplantation are the foundations for cure of hcc; however, most patients are diagnosed at an advanced stage, precluding those curative treatments. A number of local or regional therapies are used and are followed by systemic therapy for advanced or progressive disease. Other treatments are available, but their efficacy, compared with those standards, is not well known. Methods: First, systematic review questions were developed. Literature searches of the medline, embase, and Cochrane library databases (January 2000 to July 2018 or January 2005 to July 2018 depending on the question) were conducted; in addition, abstracts from the 2018 annual meeting of the American Society of Clinical Oncology were reviewed. A practice guideline was drafted that was then scrutinized by internal and external reviewers. Results: Seventy-seven studies were included in the guideline: no guidelines, two systematic reviews, and seventy-five primary studies published in full (including one pooled analysis). Five recommendations were developed. Conclusions: There is no evidence for or against the use of local or regional interventions other than transarterial chemoembolization for the treatment of intermediate- or advanced-stage hcc. Furthermore, there is no evidence to support the addition of sorafenib to any local or regional therapy. Sorafenib or lenvatinib are recommended for first-line systemic treatment of intermediate-stage hcc. Regorafenib or cabozantinib provide survival benefits when given as second-line treatment. Antiviral treatment is recommended in individuals with advanced hcc who are positive for the hepatitis B surface antigen.

Which G-Tube to Use in Pullers: Assessment of Pull Pressures on Skin Models to Determine Optimal Catheter Choice in Patients with Recurrent Pulled Gastrostomy Tubes.

INTRODUCTION: Pulled or dislodged gastrostomy catheters represent a common complication associated with percutaneous gastrostomy and are a common cause of recurrent visits in patients with altered mental status. We intended to perform an experiment to compare the pull forces required to dislodge different commonly used gastrostomy catheters. MATERIALS AND METHODS: We used a digital force gauge device to measure the pull forces required to dislodge three types of 20 French gastrostomy catheters in double-layer skin models. These included the Flow 20 Pull Method (Cook Medical, Bloomington, IN, USA), Entuit Gastrostomy BR Balloon Retention feeding tube (Cook Medical, Bloomington, IN, USA), and Ponsky Non-Balloon Replacement Gastrostomy Tube (CR Bard Inc, Salt Lake City, Utah, USA). The catheters were inserted into the skin model using the same technique as would be utilized in a patient. RESULTS: The mean forces measured to dislodge the per-oral Flow 20 Pull Method, Entuit Thrive Balloon Retention, and button-type retention Ponsky replacement catheters were 35.6, 22.8, and 20.6 Newtons, respectively. The pull method per-oral gastrostomy catheter required significantly more pull force to dislodge than both the Ponsky button-type retention catheter and the Entuit balloon retention catheters. There was no significant difference in the pull force required to dislodge the Ponsky replacement catheter and the Entuit balloon retention catheter. CONCLUSIONS: Per-oral image-guided gastrostomy with pull-method button-type retention catheters may be the ideal choice in patients at high risk of tube dislodgment.

Clinical utility of ultrasound versus magnetic resonance imaging for deciding to proceed with uterine artery embolization for presumed symptomatic fibroids.

AIM: To compare the diagnostic utility of pelvic ultrasound (US) and magnetic resonance imaging (MRI) on the clinical decision to proceed with uterine artery embolization (UAE). MATERIALS AND METHODS: Over 2 years, 180 consecutive women (mean age 43) sought consultation for UAE, 116 underwent pelvic US and MRI before possible UAE. US was performed prior to MRI. Imaging was analysed for leiomyoma quantity, size and location, uterine volume, and the presence of potential contraindications to UAE. Discrepancies between imaging methods and cases where discrepancies could have altered management, were recorded. RESULTS: For the 116 patients who completed imaging, the average uterine volume was 701 cm(3) using MRI versus 658 cm(3) using US (p=0.48). The average dominant leiomyoma volume was 292 cm(3) using MRI versus 253 cm(3) using US (p=0.16). In 14 (12.1%) patients US did not correctly quantify or localize leiomyomas compared with MRI (p=0.0005). Thirteen patients did not undergo UAE (patient preference n=9, pre-procedural imaging findings n=4). In the four cases where UAE was not performed due to imaging findings, relevant findings were all diagnosed by MRI compared with two by US (p=0.5). The two cases not detected by ultrasound were adenomyosis and a pedunculate subserosal leiomyoma. Of the 103 patients who underwent UAE, 14 were treated (without complication) despite the presence of a relative contraindication; all 14 relative contraindications were identified by MRI compared with 13 by US (p=1.0). CONCLUSION: MRI is more accurate than US for characterizing uterine leiomyomas. In a small but statistically insignificant number of cases, MRI identified findings that were missed by US, which changed management. For patients that are unsuitable to be assessed with MRI, ultrasound alone is sufficient for pre-UAE assessment.

Transjugular liver biopsy with use of the shark jaw needle: diagnostic yield, complications, and cost-effectiveness.

PURPOSE: Obtaining transjugular liver biopsy specimens with use of single-use needle systems is expensive, whereas biopsy specimens obtained with use of reusable needle systems are frequently associated with inadequate core specimens. The authors report their experience with the reusable Cook Shark Jaw biopsy needle, including diagnostic yield, complications, and cost-effectiveness. MATERIALS AND METHODS: A retrospective audit was performed of a cohort of 134 patients who underwent 136 transjugular liver biopsies with use of a reusable 16-gauge Shark Jaw needle during a 30-month period. Specimen adequacy and complication rates were assessed and direct costs of expendable components calculated. Cost-effectiveness was expressed as cost-per-successful biopsy. RESULTS: Biopsies were technically successful in 126 of 136 (93%) patients, with diagnostic histologic core specimens obtained in 124 of 126 (98%) patients, for an overall success rate of 91%. Complications included capsular penetration in six (4.4%) patients, cardiac arrhythmia in two (1.5%) patients, and puncture site hematoma or bleeding in 10 (7.4%) patients. Three tract embolizations were performed for capsular penetration. No instances of subcapsular hematoma, hemoperitoneum, or sepsis occurred, and no deaths were attributed to the procedure. The cost of expendable components totaled $103 per biopsy, corresponding to a cost-effectiveness of $113/successful biopsy. CONCLUSION: Transjugular liver biopsy specimens obtained with use of the Shark Jaw needle have a diagnostic yield comparable to those obtained with use of single-use biopsy systems, at a substantially lower cost with no increase in serious complications.