Predicting Outcomes After Chemo-Embolization in Patients with Advanced-Stage Hepatocellular Carcinoma: An Evaluation of Different Radiologic Response Criteria.

PURPOSE: The purpse of this study was to evaluate the ability of various radiologic response criteria to predict patient outcomes after trans-arterial chemo-embolization with drug-eluting beads (DEB-TACE) in patients with advanced-stage (BCLC C) hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Hospital records from 2005 to 2011 were retrospectively reviewed. Non-infiltrative lesions were measured at baseline and on follow-up scans after DEB-TACE according to various common radiologic response criteria, including guidelines of the World Health Organization (WHO), Response Evaluation Criteria in Solid Tumors (RECIST), the European Association for the Study of the Liver (EASL), and modified RECIST (mRECIST). Statistical analysis was performed to see which, if any, of the response criteria could be used as a predictor of overall survival (OS) or time-to-progression (TTP). RESULTS: 75 patients met inclusion criteria. Median OS and TTP were 22.6 months (95 % CI 11.6-24.8) and 9.8 months (95 % CI 7.1-21.6), respectively. Univariate and multivariate Cox analyses revealed that none of the evaluated criteria had the ability to be used as a predictor for OS or TTP. Analysis of the C index in both univariate and multivariate models showed that the evaluated criteria were not accurate predictors of either OS (C-statistic range: 0.51-0.58 in the univariate model; range: 0.54-0.58 in the multivariate model) or TTP (C-statistic range: 0.55-0.59 in the univariate model; range: 0.57-0.61 in the multivariate model). CONCLUSION: Current response criteria are not accurate predictors of OS or TTP in patients with advanced-stage HCC after DEB-TACE.

Yttrium-90 Radioembolization as Salvage Therapy for Liver Metastases From Colorectal Cancer.

PURPOSE: To report safety and survival outcomes of Yttrium-90 (Y-90) radioembolization when used as salvage therapy for chemotherapy-resistant liver metastases from colorectal cancer. METHODS: In this IRB-approved retrospective study, 45 patients with hepatic metastases from colorectal cancer underwent Y-90 radioembolization after failure of systemic chemotherapy. Toxicities were assessed as per NCI-CTCAE and response based on RECIST and PET. Kaplan-Meier survival analysis was performed to calculate median survival, prognostic factors on univariate analysis, and Cox regression analysis for independent predictors of survival. RESULTS: Y-90 radioembolization was technically successful in all (100%). Twenty-three patients (51%) had no toxicities, whereas 6 patients (13%) had grade 3 toxicities, and no patients had grade 4 toxicity. Two patients died within 30 days of treatment from renal failure unrelated to the procedure. Per RECIST, 1 patient (2%) had partial response, 34 (71%) had stable disease, and 6 (13%) had progressive disease. PET response was seen in 46% of patients with 2 patients (4%) demonstrating complete and 22 (42%) demonstrating partial metabolic response. The median survival was 186 days (95% CI, 149-277 d). Response on PET was the only independent predictor of superior overall survival. Patients who had response on PET following Y-90 therapy had a median overall survival of 317 days (10.6 mo) (95% CI, 193-564 d), whereas patients with no response on PET had a median overall survival of 163 days (5.4 mo) (95% CI, 64-283 d). CONCLUSIONS: Y-90 radioembolization as a salvage therapy for chemotherapy-resistant hepatic metastases from colon cancer was safe and resulted in disease stability. Response on PET was an independent predictor of superior overall survival.

Segmental arterial mediolysis.

Segmental arterial mediolysis (SAM) is an uncommon, nonatherosclerotic, noninflammatory, large- to medium-sized arteriopathy first described in 1976. It is characterized histologically by vacuolization and lysis of the outer arterial media leading to dissecting aneurysms and vessel rupture presenting clinically with self-limiting abdominal pain or catastrophic hemorrhages in the abdomen. Patients of all ages are affected with a greater incidence at the fifth and sixth decades. There is a slight male predominance. Imaging findings overlap with inflammatory vasculitis, collagen vascular disease, and fibromuscular dysplasia. The presence of segmental dissections involving the celiac, mesenteric, and/or renal arteries is the key distinguishing features of SAM. Inflammatory markers, genetic tests for collagen vascular disorders, and hypercoagulable studies are negative. Anti-inflammatory agents and immunosuppressants are not effective. A mortality rate of 50 % has been attributed to the acute presentation with aneurysmal rupture necessitating urgent surgical or endovascular treatments; in the absence of the acute presentation, SAM is a self-limiting disease and is treated conservatively. There are no established guidelines on medical therapy, although optimal control of blood pressure is considered the main cornerstone of medical therapy. The long-term prognosis is not known.

Safety and effectiveness of chemoembolization with drug-eluting beads for advanced-stage hepatocellular carcinoma.

BACKGROUND: According to the Barcelona Clinic Liver Cancer (BCLC) algorithm, patients with advanced stage (BCLC-C) hepatocellular carcinoma (HCC) are recommended for systemic treatment or palliative therapy. However, chemoembolization with drug-eluting beads (DEB-TACE) has been shown to be safe in high-risk patients. The purpose of our study was to evaluate the safety and effectiveness of DEB-TACE in patients with an advanced-stage HCC. METHODS: In this institutional review board-approved, retrospective study, 80 patients with advanced-stage HCC underwent DEB-TACE with doxorubicin. Patients were evaluated for median hospital stay, incidence of Grade 3/4 toxicities, 30-day mortality, progression-free survival (PFS), and overall survival (OS) following DEB-TACE. Univariate and multivariate analysis were performed for predictors of better OS. RESULTS: The median hospital stay following DEB-TACE was 1 day (range: 1-11). The median PFS and OS were 5.1 months [95% confidence interval (CI): 4.1-7.7] and 13.3 months (95% CI: 10.1-18.6) respectively. On multivariate analysis ECOG PS ≤ 1 and >2 DEB-TACE procedures were associated with better OS. Patients with ECOG PS ≤ 1 demonstrated a median survival of 17.7 months compared with 5.6 months for patients with ECOG PS > 1 (p = 0.025). Multiple DEB-TACE procedures (>2 procedures) were associated with improved survival (26.8 months) compared with patients with one or two procedures (11.4 months, p = 0.01). Portal vein thrombosis or extrahepatic disease had no statistically significant association with OS. CONCLUSIONS: DEB-TACE is safe and effective in patients with advanced HCC. ECOG PS ≤ 1 and >2 DEB-TACE procedures were associated with better OS.