Symptom clusters and nutritional status in primary liver cancer patients receiving transcatheter arterial chemoembolization.

Introduction: Introduction: symptom clusters (SCs) are highly prevalent among patients diagnosed with primary liver cancer. Malnutrition poses a heightened risk for a more pronounced total symptom cluster score. Objective: this study aimed to identify SCs and assess the nutritional status of patients undergoing transcatheter arterial chemoembolization (TACE). Furthermore, it aimed to investigate the association between nutritional status and symptom clusters. Methods: primary liver cancer patients who were scheduled to receive TACE were recruited. Symptoms data were collected using the MD Anderson Symptom Inventory (MDASI-C) and the Symptom Module specific to Primary Cancer (TSM-PLC). Nutritional assessment relied on the Nutritional Risk Screening-2002 (NRS-2002) and blood biochemistry. The SCs were extracted using exploratory factor analysis, while the relationship between SCs and nutritional status was evaluated using Spearman correlation analysis. Results: the study included 226 patients, four distinct symptom clusters emerged: emotional-psychological symptom cluster, upper gastrointestinal symptom cluster, post-embolization-related symptom cluster, and liver function impairment symptom cluster. 68.14 % of patients were found to be at high risk of malnutrition. Our study revealed significant differences in Scs scores between patients at risk of malnutrition and those without such risk (p < 0.050). Notably, we observed a positive correlation between NRS-2002 scores and the scores of all symptom clusters (r = 0.205 to 0.419, p < 0.001), while a negative correlation was observed between prealbumin levels and the scores of all symptom clusters (r = -0.183 to -0.454, p < 0.001). Conclusion: the study highlights the high risk of malnutrition among liver cancer patients receiving TACE and the positive correlation between high malnutrition risk and Scs scores.

Introducción: Introducción: los grupos de síntomas (SC, por sus siglas en inglés) son altamente prevalentes entre los pacientes diagnosticados de cáncer primario de hígado. La desnutrición aumenta el riesgo de que la puntuación total de los grupos de síntomas sea más pronunciada. Objetivo: este estudio estaba dirigido a identificar los SC y a evaluar el estado nutricional de los pacientes sometidos a quimioembolización arterial transcatéter (TACE, por sus siglas en inglés). Adicionalmente, estaba dirigido a investigar la asociación entre el estado nutricional y los grupos de síntomas. Métodos: se reclutaron pacientes con cáncer primario de hígado que tenían programado recibir TACE. Los datos de los síntomas se recolectaron mediante el Inventario de síntomas del MD Anderson (MDASI-C) y el Módulo de síntomas específicos del cáncer primario (TSM-PLC). La evaluación nutricional se basó en el cribado de riesgo nutricional 2002 (NRS-2002) y la bioquímica sanguínea. Los SC se extrajeron mediante un análisis factorial exploratorio, mientras que la relación entre los SC y el estado nutricional se evaluó mediante un análisis de correlación de Spearman. Resultados: el estudio incluyó 226 pacientes, de los cuales surgieron cuatro grupos de síntomas distintos: grupo de síntomas emocionales-psicológicos, grupo de síntomas gastrointestinales superiores, grupo de síntomas relacionados con la postembolización y grupo de síntomas de deterioro de la función hepática. El 68,14 % de los pacientes presentaban un alto riesgo de desnutrición. Nuestro estudio reveló diferencias significativas en las puntuaciones de los SC entre los pacientes con riesgo de desnutrición y aquellos sin dicho riesgo (p < 0,050). En particular, observamos una correlación positiva entre las puntuaciones del NRS-2002 y las puntuaciones de todos los grupos de síntomas (r = 0,205 a 0,419, p < 0,001), mientras que se observó una correlación negativa entre los niveles de prealbúmina y las puntuaciones de todos los grupos de síntomas (r = -0,183 a -0,454, p < 0,001). Conclusión: el estudio destaca el alto riesgo de desnutrición entre los pacientes con cáncer de hígado que reciben TACE y la correlación positiva entre el alto riesgo de desnutrición y las puntuaciones de los SC.

Papel de la imagen de movimiento incoherente intravóxel (IVIM) en la evaluación de la respuesta del carcinoma hepatocelular después de la quimioembolización transarterial (TACE): un estudio prospectivo / Role of intravoxel incoherent motion (IVIM) imaging in response assessment of hepatocellular carcinoma after transarterial chemoembolization (TACE): a prospective study

Introducción: La evaluación de la respuesta del carcinoma hepatocelular (CHC) se basa actualmente en el realce en la fase arterial, que no tiene en cuenta los cambios microestructurales en el tumor después de la quimioembolización transarterial (TACE). Objetivo: Este estudio prospectivo se llevó a cabo para evaluar la viabilidad y la eficacia de la imagen de movimiento incoherente intravóxel (IVIM) en la evaluación de la respuesta de CHC después de TACE. A 39 pacientes cirróticos con 48 CHC se les realizó una resonancia magnética (RM) 1 semana antes y 6 semanas después de la TACE. Se midieron parámetros IVIM como Dlenta (difusión verdadera), Drápida (seudodifusión), la fracción de perfusión y el ADC antes y después de la TACE. Los valores antes y después de la TACE en las lesiones LR-TR no viables y viables según la clasificación LI-RADS de categorías de respuesta al tratamiento se compararon mediante pruebas t emparejadas. Se realizó un análisis de la curva ROC para calcular la sensibilidad y la especificidad y proponer valores de corte.Resultado: Las lesiones no viables mostraron un aumento significativo de la Dlenta (1,208±0,581 frente a 1,560±0,494, valor de p=–0,0207) y de ADC (1,37±0,53 frente a 1,65±0,4287, valor de p=–0,016) después de la TACE. También se observó una disminución significativa de los valores de Drápida (33,7±10,4 frente a 23,75±12,13, valor de p=0,0005) y f (19,92±10,54 frente a 12,9±10,41, valor de p=0,012) después de la TACE en las lesiones no viables en comparación con las viables. El cambio en la difusión verdadera tuvo el mayor AUC (0,741) entre los parámetros IVIM, con un aumento superior a 0,075 entre los valores previos y posteriores a la TACE, con una sensibilidad y especificidad del 81,8 y el 60%, respectivamente, para la respuesta completa. Conclusión: La IVIM es factible para evaluar la respuesta en el CHC después de la TACE. La difusión verdadera es más sensible y específica que la difusión aparente para...(AU)

Introduction: Response evaluation of hepatocellular carcinoma (HCC) currently is based on arterial phase enhancement which doesn’t take into microstructural changes in the tumor after trans-arterial chemoembolization (TACE). Aim: This prospective study was conducted to assess the feasibility and efficacy of intravoxel incoherent motion imaging (IVIM) in response evaluation of HCC after TACE. 39 cirrhotic patients with 48 HCC underwent MR imaging 1 week within and 6weeks after TACE. IVIM parameters like Dslow (true diffusion), Dfast (pseudodiffusion), perfusion fraction and ADC were measured prior to and postTACE. The pre and postTACE values in LR-TR (LIRADS-treatment response) nonviable and viable lesions were compared using paired t-tests. ROC curve analysis was done to calculate sensitivity and specificity and propose cut-off values. Result: Non-viable lesions showed a significant increase in Dslow (1.208±0.581 vs. 1.560±0.494, p-value –0.0207) and ADC (1.37±0.53 vs. 1.65±0.4287, p-value 0.016) after TACE. There was also significant decrease in Dfast (33.7±10.4 vs. 23.75±12.13, p-value 0.0005) and f (19.92±10.54 vs. 12.9±10.41, p-value 0.012) values after TACE in non-viable lesions compared to viable lesions. The change in true diffusion had the highest AUC (0.741) among IVIM parameters with greater than 0.075 increase between preTACE and postTACE values having a sensitivity and specificity of 81.8% and 60% respectively for complete response. Conclusion: IVIM imaging is feasible to assess the response in HCC after TACE. True diffusion is more sensitive and specific than apparent diffusion in evaluating the response.(AU)

Role of intravoxel incoherent motion (IVIM) imaging in response assessment of hepatocellular carcinoma after transarterial chemoembolization (TACE) - A prospective study.

INTRODUCTION: Response evaluation of hepatocellular carcinoma (HCC) currently is based on arterial phase enhancement which doesn't take into microstructural changes in the tumor after trans-arterial chemoembolization (TACE). AIM: This prospective study was conducted to assess the feasibility and efficacy of intravascular incoherent motion imaging (IVIM) in response evaluation of HCC after TACE. 39 cirrhotic patients with 48 HCC underwent MR imaging 1 week within and 6weeks after TACE. IVIM parameters like Dslow (true diffusion), Dfast (pseudodiffusion), perfusion fraction and ADC were measured prior to and postTACE. The pre and post TACE values in LR-TR (LIRADS - treatment response) nonviable and viable lesions were compared using paired t-tests. ROC curve analysis was done to calculate sensitivity and specificity and propose cut-off values. RESULT: Non-viable lesions showed a significant increase in Dslow (1.208 ± 0.581 vs 1.560 ± 0.494, P-value -.0207) and ADC (1.37 ± 0.53 vs 1.65 ± 0.4287, P value .016) after TACE. There was also significant decrease in Dfast (33.7 ± 10.4 vs 23.75 ± 12.13, P value .0005) and f (19.92 ± 10.54 vs 12.9 ± 10.41, P value .012) values after TACE in non-viable lesions compared to viable lesions. The change in true diffusion had the highest AUC (0.741) among IVIM parameters with greater than 0.075 increase between preTACE and postTACE values having a sensitivity and specificity of 81.8% and 60% respectively for complete response. CONCLUSION: IVIM imaging is feasible to assess the response in HCC after TACE. True diffusion is more sensitive and specific than apparent diffusion in evaluating the response.

Occupational radiation exposure in anesthesia for hepatic chemoembolization: a prospective study

Introduction Anesthetists play an important role during interventional radiology procedures. Like the main operator, anesthetists may also be subject to significant radiation levels in the fluoroscopy suite. Due to its complexity, hepatic chemoembolization procedures demand high fluoroscopic times and digital subtraction angiography images, exposing patients and medical staff to high radiation doses. Objective To assess and quantify the radiation to which one anesthetist was exposed over the course of seven consecutive hepatic chemoembolization procedures, and compare it to the exposure received by the main operator. Methods Medical staff dosimetry was evaluated during seven consecutive hepatic chemoembolization procedures conducted in a private hospital in Recife (Brazil), using thermoluminiscent dosimeters placed in regions of the head and torso. Results For the seven procedures evaluated in this study, the anesthetist received, on average, absorbed doses to the glabella, left eyebrow, right eyebrow and effective dose of 142.4 ± 72 µSv, 117.3 ± 66 µSv, 137.8 ± 71 µSv and 12.4 ± 8.4 µSv, respectively. Conclusions In some cases, ocular dose and effective dose received by the anesthetist may be 4 and 4.7 times greater, respectively, when compared to the main operator. According to the results of this study, the current occupational annual dose limit to the lens of the eye of 20 mSv can be exceeded with only two hepatic chemoembolization procedures per week if adequate radiation protection conditions are not guaranteed.

Introducción El anestesiólogo desempeña un papel importante durante los procedimientos de radiología intervencionista. Al igual que el operador principal, el anestesiólogo también puede estar expuesto a niveles significativos de radiación en la sala de fluoroscopía. Debido a su complejidad, durante los procedimientos de quimioembolización hepática se deben utilizar imágenes de fluoroscopía y angiografía de sustracción digital por períodos prolongados, exponiendo a los pacientes y al personal médico a dosis elevadas de radiación. Objetivo Evaluar y cuantificar la radiación a la cual se expuso un anestesiólogo durante el transcurso de siete procedimientos consecutivos de quimioembolización hepática, y comparar con la exposición recibida por el operador principal. Métodos Evaluación de la dosimetría ocupacional durante siete procedimientos consecutivos de quimioembolización hepática realizados en un hospital privado de Recife (Brasil) por medio de dosímetros termoluminiscentes ubicados en regiones de la cabeza y el torso. Resultados Para los siete procedimientos evaluados en este estudio, el anestesiólogo recibió, en promedio, dosis absorbidas en el entrecejo, la ceja izquierda, la ceja derecha y dosis efectivas de 142,4 ± 72 µSv, 117,3 ± 66 µSv, 137,8 ± 71 µSv y 12,4 ± 8,4 µSv, respectivamente. Conclusiones En algunos casos, la dosis ocular y la dosis efectiva que recibe el anestesiólogo puede ser, respectivamente, entre 4 y 4,7 veces más alta que la que recibe el operador principal. De acuerdo con los resultados de este estudio, el límite ocupacional anual de dosis en cristalino (20 mSv) se puede superar con apenas dos procedimientos de quimioembolización hepática a la semana en caso de no garantizarse las condiciones adecuadas de protección contra la radiación.

Association between nutritional status and platelet-to-lymphocyte ratio in patients with hepatocellular carcinoma undergoing transcatheter arterial chemoembolization / Asociación entre el estado nutricional y el índice plaquetas-linfocitos en pacientes con carcinoma hepatocelular sometidos a quimioembolización transarterial

Introduction: nutritional status and platelet-to-lymphocyte ratio (PLR) have been found to be associated with prognosis in patients with hepatocellular carcinoma (HCC) undergoing transcatheter arterial chemoembolization (TACE).Objectives: to evaluate the association between nutritional status and PLR in patients with HCC undergoing TACE. Methods: a total of 152 HCC patients received TACE were enrolled. The nutritional status was evaluated by Patient-Generated Subjective Global Assessment (PG-SGA). Patients with PG-SGA A and PG-SGA (B or C) were classified as the well-nourished and malnourished groups. Results: according to the PG-SGA, 130 (85.5 %) patients were malnourished. The median PLR was significantly different between well-nourishedand malnourished groups (p = 0.008). A positive correlation was found between PLR and PG-SGA score (r = -0.265, p = 0.001). The optimalPLR cutoff value was 102.165 to predict malnutrition, with a sensitivity of 65.4 %, specificity of 72.7 %, and an area under the curve (AUC) of0.677 (95 % confidence interval (CI): 0.550-0.804; p = 0.008). A logistic stepwise regression model showed that the PLR was associated withnutritional status in Model 1 without adjustment, as well as if adjusted by age, sex, type of TACE (c-TACE/DEB-TACE) and Child–Pugh stage (oddsratio, 0.190; 95 % CI: 0.062-0.582; p=0.004). Conclusions: nutritional status measured by PG-SGA was significantly associated with PLR in patients with HCC undergoing TACE. (AU)

Introducción: se ha encontrado que el estado nutricional y el índice plaquetas-linfocitos (PLR) se asocian con el pronóstico en pacientes con carcinoma hepatocelular (CHC) sometidos a quimioembolización transarterial (TACE).Objetivos: evaluar la asociación entre el estado nutricional y la PLR en pacientes con CHC sometidos a TACE. Métodos: se evaluaron 152 pacientes con CHC que recibieron TACE. El estado nutricional fue evaluado por Evaluación Global Subjetiva Generada por el Paciente (PG-SGA). Los pacientes con PG-SGA A y PG-SGA (B o C) se clasificaron como los grupos bien nutridos y desnutridos. Resultados: según la PG-SGA, 130 (85,5 %) pacientes estaban desnutridos. La mediana de PLR fue significativamente diferente entre los grupos bien nutridos y desnutridos (p = 0,008). Se encontró una correlación positiva entre PLR y la puntuación PG-SGA (r = -0,265, p = 0,001). El valor de corte óptimo de PLR fue de 102,165 para predecir la malnutrición, con una sensibilidad del 65,4 %, una especificidad del 72,7 % y un área bajo la curva (AUC) de 0,677 (intervalo de confianza [IC] del 95 %: 0,550-0,804; p = 0,008). Un modelo de regresión logística escalonada mostró que el PLR se asoció con el estado nutricional en el Modelo 1 sin ajuste, así como cuando se ajustó por edad, sexo, tipo de TACE (c-TACE/DEB-TACE) y etapa Child-Pugh (odds ratio, 0,190; IC 95 %: 0,062-0,582; p = 0,004).Conclusiones: el estado nutricional medido por PG-SGA se asoció significativamente con PLR en pacientes con CHC sometidos a TACE. (AU)

Association between nutritional status and platelet-to-lymphocyte ratio in patients with hepatocellular carcinoma undergoing transcatheter arterial chemoembolization.

Introduction: Introduction: nutritional status and platelet-to-lymphocyte ratio (PLR) have been found to be associated with prognosis in patients with hepatocellular carcinoma (HCC) undergoing transcatheter arterial chemoembolization (TACE). Objectives: to evaluate the association between nutritional status and PLR in patients with HCC undergoing TACE. Methods: a total of 152 HCC patients received TACE were enrolled. The nutritional status was evaluated by Patient-Generated Subjective Global Assessment (PG-SGA). Patients with PG-SGA A and PG-SGA (B or C) were classified as the well-nourished and malnourished groups. Results: according to the PG-SGA, 130 (85.5 %) patients were malnourished. The median PLR was significantly different between well-nourished and malnourished groups (p = 0.008). A positive correlation was found between PLR and PG-SGA score (r = -0.265, p = 0.001). The optimal PLR cutoff value was 102.165 to predict malnutrition, with a sensitivity of 65.4 %, specificity of 72.7 %, and an area under the curve (AUC) of 0.677 (95 % confidence interval (CI): 0.550-0.804; p = 0.008). A logistic stepwise regression model showed that the PLR was associated with nutritional status in Model 1 without adjustment, as well as if adjusted by age, sex, type of TACE (c-TACE/DEB-TACE) and Child-Pugh stage (odds ratio, 0.190; 95 % CI: 0.062-0.582; p = 0.004). Conclusions: nutritional status measured by PG-SGA was significantly associated with PLR in patients with HCC undergoing TACE.

Introducción: Introducción: se ha encontrado que el estado nutricional y el índice plaquetas-linfocitos (PLR) se asocian con el pronóstico en pacientes con carcinoma hepatocelular (CHC) sometidos a quimioembolización transarterial (TACE). Objetivos: evaluar la asociación entre el estado nutricional y la PLR en pacientes con CHC sometidos a TACE. Métodos: se evaluaron 152 pacientes con CHC que recibieron TACE. El estado nutricional fue evaluado por Evaluación Global Subjetiva Generada por el Paciente (PG-SGA). Los pacientes con PG-SGA A y PG-SGA (B o C) se clasificaron como los grupos bien nutridos y desnutridos. Resultados: según la PG-SGA, 130 (85,5 %) pacientes estaban desnutridos. La mediana de PLR fue significativamente diferente entre los grupos bien nutridos y desnutridos (p = 0,008). Se encontró una correlación positiva entre PLR y la puntuación PG-SGA (r = -0,265, p = 0,001). El valor de corte óptimo de PLR fue de 102,165 para predecir la malnutrición, con una sensibilidad del 65,4 %, una especificidad del 72,7 % y un área bajo la curva (AUC) de 0,677 (intervalo de confianza [IC] del 95 %: 0,550-0,804; p = 0,008). Un modelo de regresión logística escalonada mostró que el PLR se asoció con el estado nutricional en el Modelo 1 sin ajuste, así como cuando se ajustó por edad, sexo, tipo de TACE (c-TACE/DEB-TACE) y etapa Child-Pugh (odds ratio, 0,190; IC 95 %: 0,062-0,582; p = 0,004). Conclusiones: el estado nutricional medido por PG-SGA se asoció significativamente con PLR en pacientes con CHC sometidos a TACE.

A novel nomogram based on the nutritional risk screening 2002 score to predict survival in hepatocellular carcinoma treated with transarterial chemoembolization.

Introduction: Objective: transarterial chemoembolization (TACE) is one of the common treatments for hepatocellular carcinoma (HCC). Predicting prognosis for HCC patients who received TACE is challenging because of huge differences in outcome. At present, the Nutritional Risk Screening 2002 (NRS-2002) is widely used to screen nutritional risk in hospitalized patients, which has been confirmed to be related to prognosis. Here, the objective of this research is to construct a prognostic nomogram using the NRS-2002 score for HCC patients receiving TACE. Methods: we enrolled 359 HCC patients who received TACE at the Xingtai People's Hospital between January 2015 and December 2020. According to the preoperative NRS-2002 score, patients were divided into an NRS ≥ 3 group (n = 190; 52.9 %) and an NRS < 3 group (n = 167, 47.1 %). Meanwhile, variables associated with survival were analyzed by univariate and multivariate Cox regression. Beyond that, a nomogram incorporating independent variables was established. The concordance index (C-index) and calibration curves were used to assess the prediction performance of the nomogram. Results: the median survival of the NRS ≥ 3 group was significantly lower than that of the NRS < 3 group. As shown by multivariate analysis, in the Barcelona Clinic Liver Cancer stage an NRS-2002 score ≥ 3, γ-glutamyl transpeptidase, and alpha-fetoprotein were significantly associated with survival in HCC patients after TACE. In addition, the C-index was 0.708 (95 % confidence interval: 0.672-0.743), and the calibration curves showed a good consistency between the observed and predicted survivals at 1, 2, and 3 years, respectively. Conclusions: NRS-2002 ≥ 3 could identify high-risk patients with HCC who received TACE. The NRS-2002-based nomogram model had good prognostic prediction accuracy. Keywords.

Introducción: Objetivo: La quimioembolización transarterial (TACE) es uno de los tratamientos comúnmente utilizados para el carcinoma hepatocelular (CHC). La predicción pronóstica en pacientes con CHC sometidos a TACE es un desafío debido a la gran variabilidad en el resultado. Detección de risgo nutricional 2002 (NRS-2002) se utiliza ampliamente en la actualidad para evaluar el riesgo nutricional de los pacientes hospitalizados y se ha demostrado que está relacionado con el pronóstico. Aquí, nuestro objetivo fue construir un nomograma pronóstico utilizando la puntuación NRS-2002 para pacientes con HCC que reciben TACE. Métodos: Reclutamos a 359 pacientes con CHC tratados con TACE en el Hospital Popular de Xingtai desde enero de 2015 hasta diciembre de 2020. Los pacientes se dividieron en un grupo NRS ≥3 (n = 190; 52,9%) y un grupo NRS <3 (n = 167, 47,1%) según la puntuación NRS-2002 preoperatoria. Las variables asociadas con la supervivencia se analizaron mediante regresión de Cox univariante y multivariante. Se estableció un nomograma que incorpora variables independientes. El rendimiento predictivo del nomograma se evaluaró mediante el índice de concordancia (índice C) y la curva de calibración. Resultados: La mediana de supervivencia del grupo NRS ≥3 fue significativamente menor que la del grupo NRS <3. El análisis multivariante mostró que el estadio del grupo de Clínica de Cáncer de Hígado de Barcelona, una puntuación NRS-2002 ≥3, laγ-glutamil transpeptidasa y la alfa-fetoproteína se asociaron significativamente con la supervivencia en pacientes con CHC después de la TACE. El índice C fue de 0,708 (intervalo de confianza del 95%: 0,672­0,743) y las curvas de calibración mostraron una buena concordancia entre las supervivencias observadas y predichas a 1, 2 y 3 años. Conclusiones: NRS-2002 ≥3 podría identificar pacientes con HCC de alto riesgo sometidos a TACE. El modelo de nomograma basado en NRS-2002 tuvo una buena precisión de predicción pronóstica.

A novel nomogram based on the nutritional risk screening 2002 score to predict survival in hepatocellular carcinoma treated with transarterial chemoembolization / Un nuevo nomograma basado en el puntaje de detección de riesgo nutricional 2002 para predecir la supervivencia en el carcinoma hepatocelular tratado con quimioembolización transarterial

Objective: transarterial chemoembolization (TACE) is one of the common treatments for hepatocellular carcinoma (HCC). Predicting prognosis for HCC patients who received TACE is challenging because of huge differences in outcome. At present, the Nutritional Risk Screening 2002 (NRS-2002) is widely used to screen nutritional risk in hospitalized patients, which has been confirmed to be related to prognosis. Here, the objective of this research is to construct a prognostic nomogram using the NRS-2002 score for HCC patients receiving TACE. Methods: we enrolled 359 HCC patients who received TACE at the Xingtai People's Hospital between January 2015 and December 2020. According to the preoperative NRS-2002 score, patients were divided into an NRS ≥ 3 group (n = 190; 52.9 %) and an NRS < 3 group (n = 167, 47.1 %). Meanwhile, variables associated with survival were analyzed by univariate and multivariate Cox regression. Beyond that, a nomogram incorporating independent variables was established. The concordance index (C-index) and calibration curves were used to assess the prediction performance of the nomogram. Results: the median survival of the NRS ≥ 3 group was significantly lower than that of the NRS < 3 group. As shown by multivariate analysis, in the Barcelona Clinic Liver Cancer stage an NRS-2002 score ≥ 3, γ-glutamyl transpeptidase, and alpha-fetoprotein were significantly associated with survival in HCC patients after TACE. In addition, the C-index was 0.708 (95 % confidence interval: 0.672-0.743), and the calibration curves showed a good consistency between the observed and predicted survivals at 1, 2, and 3 years, respectively. Conclusions: NRS-2002 ≥ 3 could identify high-risk patients with HCC who received TACE. The NRS-2002-based nomogram model had good prognostic prediction accuracy(AU)

Objetivo: la quimioembolización transarterial (TACE) es uno de los tratamientos comúnmente utilizados para el carcinoma hepatocelular (CHC). La predicción pronóstica en pacientes con CHC sometidos a TACE es un desafío debido a la gran variabilidad del resultado. La “Detección del riesgo nutricional 2002” (NRS-2002) se utiliza ampliamente en la actualidad para evaluar el riesgo nutricional de los pacientes hospitalizados y se ha demostrado que está relacionada con el pronóstico. Aquí, nuestro objetivo fue construir un nomograma pronóstico, utilizando la puntuación NRS-2002, para pacientes con HCC que reciben TACE. Métodos: reclutamos a 359 pacientes con CHC tratados con TACE en el Hospital Popular de Xingtai desde enero de 2015 hasta diciembre de 2020. Los pacientes se dividieron en un grupo NRS ≥ 3 (n = 190; 52,9 %) y un grupo NRS < 3 (n = 167, 47,1 %) según la puntuación NRS-2002 preoperatoria. Las variables asociadas con la supervivencia se analizaron mediante la regresión de Cox univariante y multivariante. Se estableció un nomograma que incorpora variables independientes. El rendimiento predictivo del nomograma se evaluó mediante el índice de concordancia (índice C) y la curva de calibración. Resultados: la mediana de supervivencia del grupo NRS ≥ 3 fue significativamente menor que la del grupo NRS < 3. El análisis multivariante mostró que el estadio del grupo de Clínica de Cáncer de Hígado de Barcelona, una puntuación NRS-2002 ≥ 3, la γ-glutamil transpeptidasa y la alfa-fetoproteína se asociaron significativamente con la supervivencia de los pacientes con CHC después de la TACE. El índice C fue de 0,708 (intervalo de confianza del 95 %: 0,672-0,743) y las curvas de calibración mostraron una buena concordancia entre las supervivencias observadas y las predichas a 1, 2 y 3 años. Conclusiones: la puntuación NRS-2002 ≥ 3 podría identificar a los pacientes con HCC de alto riesgo sometidos a TACE (AU)

The second Mexican consensus on hepatocellular carcinoma. Part II: Treatment.

Hepatocellular carcinoma (HCC) is more frequently manifesting as one of the main complications of cirrhosis of the liver, its principal risk factor. There have been modifications in its incidence over the past decade, related to an epidemiologic transition in the etiology of cirrhosis, with a decrease in the prevalence of hepatitis C and an increase in nonalcoholic fatty liver disease (NAFLD) as a cause, as well as the development of HCC in the non-cirrhotic liver due to NAFLD. Genetic markers associated with the disease have been identified, and surveillance and diagnosis have improved. Regarding treatment, surgical techniques, in both resection and transplantation, have advanced and radiologic techniques, at the curative stage of the disease, have enhanced survival in those patients. And finally, there have been radical changes in the systemic approach, with much more optimistic expectations, when compared with the options available a decade ago. Therefore, the Asociación Mexicana de Hepatología decided to carry out the Second Mexican Consensus on Hepatocellular Carcinoma, which is an updated review of the available national and international evidence on the epidemiology, risk factors, surveillance, diagnosis, and treatment of the disease, to offer the Mexican physician current information on the different topics regarding hepatocellular carcinoma. In this second part of the document, the topics related to the treatment of HCC are presented.

Úlcera gastroduodenal isquémica como complicación de la quimioembolización transarterial hepática de hepatocarcinoma / Ischemic gastroduodenal ulcer as a complication of hepatic hepatocarcinoma transarterial chemoembolization

La quimioembolización transarterial hepática es uno de los tratamientos del carcinoma hepatocelular irresecable en el que se han descrito de forma infrecuente lesiones isquémicas asociadas. Ante la aparición de sintomatología gastrointestinal alta inusual o que exceda el denominado síndrome postquimiembolización tras el procedimiento debe valorarse la realización de una gastroscopia para descartar la aparición de dichas complicaciones. Las variantes anatómicas con origen común de arterias gástricas y hepáticas pueden favorecer la migración de las microesferas hacia territorio gástrico obligando a valorar la eventual modificación de la técnica para prevenirlo.

Transarterial hepatic chemoembolization is one of the treatments of unresectable hepatocellular carcinoma in which associated ischemic lesions have been described infrequently. When unusual upper gastrointestinal symptoms or exceeding the so-called post-chemoembolization syndrome after the procedure, the performance of a gastroscopy should be assessed to rule out the occurrence of these complications. The anatomical variants with common origin of gastric and hepatic arteries can favor the migration of the microspheres into gastric territory, forcing the possible modification of the technique to prevent it.

Evaluating the response to locoregional and systemic treatment for hepatocellular carcinoma. / Evaluación postratamiento locorregional y sistémico del carcinoma hepatocelular.

Evaluating the response to different treatments is a decisive factor in the clinical management of patients with hepatocellular carcinoma because it can determine the efficacy of the treatment and because it can detect the recurrence of treated tumors or the appearance of new lesions that can be candidates for new treatments. When locoregional treatments that induce necrosis or molecular therapies are applied, the treated lesions usually change their behavior on imaging studies. It is important to point out that the size of the lesions does not usually decrease, at least initially, and some lesions can even appear to increase in size. For this reason, it is essential to know the mechanisms of action for each treatment applied and the spectrum of findings that these treatments can cause in the different imaging techniques used to assess the response.

Quimioembolización transarterial en carcinoma hepatocelular atípico

RESUMEN Una de las grandes controversias dentro del manejo médico integral del carcinoma hepatocelular es la estimación precisa de la efectividad de la terapia con quimioembolización transarterial. Las evidencias demuestran que la misma hace parte del núcleo de tratamiento para aquellos pacientes con tumores no resecables y, comparado con la resección hepática y ablación por radiofrecuencia, oferta supervivencia a largo plazo si cumplen las características de nódulo hasta 3 cm o menores sin invasión vascular. Presentamos un caso clínico de carcinoma hepatocelular atípico con manejo médico integral, mediante la quimioembolización transarterial, evidenciando por imágenes y macroscópicamente la efectividad de la misma hasta el trasplante hepático ortotópico.

ABSTRACT One of the major controversies within the comprehensive medical management of hepatocellular carcinoma is the accurate estimation of the effectiveness of transarterial chemoembolization therapy. Evidence shows that it is part of the treatment nucleus for patients with unresectable tumors and, compared to hepatic resection and radiofrequency ablation, offers long-term survival if the characteristics of nodules up to 3 cm or less without vascular invasion are met. We present a clinical case of atypical hepatocellular carcinoma with integral medical management, through transarterial chemoembolization, evidencing its effectiveness by images and macroscopically until the orthotopic liver transplantation.

Complications of transarterial chemoembolization (TACE) in the treatment of liver tumors. / Complicaciones de la quimioembolización transarterial (QETA) en el tratamiento de los tumores hepáticos.

INTRODUCTION: Transarterial chemoembolization (TACE) is considered a therapeutic option. It is mostly used in hepatocellular carcinoma or liver colorectal, neuroendocrine or melanoma metastases. Although it is considered a safe procedure, TACE presents complications, such as acute cholecystitis, which is the most common. Other procedure-related complications include pulmonary embolism, hepatic abscess, bile duct injury, gastric mucosa injury and, less frequently, acute pancreatitis. The aim of this study is to review the complications following TACE for liver tumors. METHODS: We performed a retrospective study including all the TACE procedures performed in a single center during the period between January 2013 and December 2016. RESULTS: Out of the 196 patients with liver tumors who had undergone 322 TACE, 258 (80%) were male and 64 (20%) were female. Mean patient age was 66.5years. Major complications after chemoembolization included: decompensation with edema/ascites (6patients), acute cholecystitis (4), acute pancreatitis (3), liver rupture (1), liver abscess (1) and renal failure (1). Postembolization syndrome appeared in 71 (20%) patients. On multivariate analysis, it was observed that concomitant cardiovascular disease (OR: 4.5; 95%CI: 1.2-17; P=.025) is a risk factor for the development of complications. CONCLUSIONS: TACE is a safe and effective procedure for liver tumor treatment. The majority of the complications are rare and present a low incidence of mortality.

HAP score as prognostic factor of hepatocellular carcinoma treated with transarterial chemoembolization in a Latin American center / HAP score como factor pronóstico del carcinoma hepatocelular tratado con quimioembolización transarterial en un centro de Latinoamérica

Introduction: Hepatocellular carcinoma (HCC) in cirrhosis is diagnosed, most of times, when it is not susceptible to curative treatment. Transarterial chemoembolization (TACE) is a palliative therapeutic option with heterogeneous results. The HAP score stratifies patients who will benefit from the first TACE. Objective: To evaluate if the HAP score is a prognostic factor of HCC treated with TACE. Materials and methods: Retrospective cohort study in cirrhotic patients with HCC and first TACE at the Edgardo Rebagliati Martins National Hospital, Lima-Peru, from June 2011 to June 20139. The HAP score was applied, mortality and survival were observed with a follow-up of 36 months. Results: We included 54 patients with age of 67.7±9.9 years, 59.3% Child-Pugh A and 40.7% Child-Pugh B, MELD score of 11±2.7; 51.9 and 40.7% were BCLC A and B, respectively; 66.7% had a single tumor and 70.4% had a predominant tumor <5cm. The HAP score classified 8, 14, 26 and 6 patients as HAP A, B, C and D, respectively. The overall survival was 19.5±11.2 months and 32.8±6.5 months for HAP A, 24.9±14.8 months for HAP B, 13.9±5.2 months for HAP C and 14±6.6 months for HAP D. There were no deaths at 12 months in HAP A. At 24 months, mortality for HAP C and D was 100%. At 36 months, the survival rate for HAP A and B was 75 and 42.9%, respectively. Conclusions: The HAP score is a useful tool to guide the management decisions of cirrhotic patients with HCC requiring TACE due to its value in predicting mortality and survival.

Introducción: El carcinoma hepatocelular (CHC) en cirrosis es diagnosticado, la mayoría de veces, cuando no es susceptible de tratamiento curativo. La quimioembolizacón transarterial (QETA) es una opción terapéutica paliativa con resultados heterogéneos. El HAP score estratifica a los pacientes que se beneficiarán con la primera QETA. Objetivo: Demostrar si el HAP score es un factor pronóstico del CHC tratado con QETA. Materiales y métodos: Estudio de cohortes retrospectivo en pacientes cirróticos con CHC y primera QETA en el Hospital Nacional Edgardo Rebagliati Martins, Lima-Perú, junio-2011 a junio-2013. Se aplicó el HAP score, y se observó la mortalidad y sobrevida con un seguimiento de 36 meses. Resultados: Se incluyeron 54 pacientes con edad de 67,7±9,9 años, 59,3% Child-Pugh A y 40,7% Child-Pugh B, MELD de 11±2,7; 51,9 y 40,7% fueron BCLC A y B, respectivamente; 66,7% tuvo tumor único y el 70,4% tumor predominante menor a 5 cm. Se clasificó como HAP A, B, C y D a 8, 14, 26 y 6 pacientes, respectivamente. La sobrevida general fue 19,5±11,2 meses; y 32,8±6,5 meses para HAP A, 24,9±14,8 meses para HAP B, 13,9±5,2 meses para HAP C y 14±6,6 meses para HAP D. A los 24 meses, la mortalidad para HAP C y D fue 100%. A los 36 meses, la sobrevida para HAP A y B fue 75 y 42,9%, respectivamente. Conclusiones: El HAP score es una herramienta útil que orienta al manejo del CHC tributario de QETA por su valor pronóstico de mortalidad y sobrevida.

Hepatocellular carcinoma treatment: ablation and arterial embolization. / Tratamiento del hepatocarcinoma: ablación y embolización arterial.

Percutaneous and endovascular techniques take an important role in the therapeutic management of patients with hepatocarcinoma. Different techniques of percutaneous ablation, especially indicated in tumors up to 2cm diameter offer, at least, similar results to surgical resection. Taking advantage of double hepatic vascularization and exclusive tumor nutrition by the artery, several endovascular techniques of treating the tumor have been developed. Intra-arterial administration of embolizing particles, alone or charged with drug (chemoembolization), will produce ischemia and consequent necrosis with excellent results in selected patients. Certain types of particles may exclusively be carriers of a therapeutic agent when they incorporate a radioisotope that facilitates the direct intratumoral selective irradiation (radioembolization). This technique has demonstrated its efficacy in lesions not susceptible to be treated with other methods and should be considered, together with ablation and chemoembolization, in the therapeutic algorithms of hepatocarcinoma.

The ART-SCORE is not an effective tool for optimizing patient selection for DEB-TACE retreatment. A multicentre Spanish study.

INTRODUCTION: The appropriate selection of hepatocellular carcinoma (HCC) patients who are eligible for transarterial chemoembolization (TACE) remains a challenge. The ART score has recently been proposed as a method of identifying patients who are eligible or not for a second TACE procedure. OBJECTIVE: To assess the validity of the Assessment for Retreatment with TACE (ART) score in a cohort of patients treated with drug-eluting bead TACE (DEB-TACE). SECONDARY OBJECTIVE: to identify clinical determinants associated with overall survival (OS). METHOD: A retrospective, multicentre study conducted in Spain in patients with HCC having undergone two or more DEB-TACE procedures between January 2009 and December 2014. The clinical characteristics and OS from the day before the second DEB-TACE of patients with a high ART score (ART≥2.5) and a low ART score (ART 0-1) were compared. Risk factors for mortality were identified using Cox's proportional hazards model. RESULTS: Of the 102 patients included, 51 scored 0-1.5 and 51 scored ≥2.5. Hepatitis C was more frequent in patients scoring ≥2.5. Median OS from the day before the second DEB-TACE was 21 months (95% CI, 15-28) in the group scoring 0-1.5, and 17 months (95% CI, 10-25) in the group scoring ≥2.5 (P=0.3562). Platelet count and tumour size, but not the ART score, were independent baseline predictors of OS. CONCLUSIONS: The ART score is not suitable for guiding DEB-TACE retreatment according to Spanish clinical practice standards.

Trans-arterial chemoembolization with doxorubicin-eluting particles versus conventional trans-arterial chemoembolization in unresectable hepatocellular carcinoma: A study of effectiveness, safety and costs.

OBJECTIVES: To compare the effectiveness, survival and cost in patients with unresectable hepatic cell carcinoma (HCC) treated with trans-arterial chemoembolization using doxorubicin-eluting beads (DEB-TACE) versus conventional TACE (cTACE) in clinical practice. MATERIAL AND METHODS: This single-centered retrospective observational study compared 60 consecutive HCC unresectable patients: 30 were treated with DEB-TACE and 30 used cTACE. Comparisons were with χ(2) test, Student t-test, and Kaplan Meier method. RESULTS: Of the 60 patients with HCC in non-curative stage, baseline characteristics were similar for both groups of treatment, and of these we observed lower survival in male patients and those who had hepatitis C virus (p=0.014 and p=0.003, respectively). No statistically significant differences were observed as a function of treatment employed with respect to overall survival (OS) at 5 years (29.99 months; 95%CI: 21.38-38.60 versus 30.67 months; 95%CI:22.65-38.70; p=0.626) and progression free survival (PFS) median of 11.57 months (95%CI: 0.97-22.18) versus 12.80 months (95%CI:0.00-32.37; p=0.618). The median length of hospital admission were 2.6 and 5.4 days (p<0.001) for DEB(-)TACE and cTACE, respectively. Toxicities grade 2-4 were higher in cTACE group (54 versus 31; p<0.001). The cost of the treatment was 1581 € for DEB(-)TACE and 514.63 € for cTACE. The overall mean cost of intervention was 3134 € and 3694.35 €, respectively (p=0.173). CONCLUSIONS: Chemoembolization in patients with unresectable HCC achieved OS close to 30 months at 5 years, independent of the technique employed. Similar overall costs but better tolerance of the DEB-TACE justified the higher costs of the procedure.

Histologic study of the effects of chemoembolization with preloaded doxorubicin beads in patients with hepatocellular carcinoma.

OBJECTIVE: To determine the degree of tumor necrosis in surgical specimens of hepatocellular carcinomas treated with microspheres preloaded with doxorubicin and to analyze the relationship between the degree of necrosis and a) morphologic factors and b) imaging biomarkers. MATERIAL AND METHODS: We studied the livers of 21 patients who had undergone selective arterial chemoembolization with DC beads (Biocompatibles, UK) before receiving liver transplants. RESULTS: Imaging techniques detected 43 nodules (mean size, 25 mm). Angiography showed 25 hypervascularized nodules, 12 slightly vascularized nodules, and 6 avascular nodules. A total of 81 hepatocellular carcinomas (mean size, 15 mm) were detected in the specimens: two were capsular and two had vascular infiltration. The mean degree of necrosis after chemoembolization was 39%; necrosis was greater than 60% in 28 hepatocellular carcinomas and less than 60% in 52. The degree of necrosis correlated significantly with the time elapsed between the last chemoembolization treatment and liver transplantation (the degree of necrosis decreased as time increased), with the number of nodules in the specimen, and with capsular infiltration. When imaging techniques detected 1 or 2 nodules, there was a greater probability of achieving greater than 90% necrosis. No relation with the degree of necrosis achieved was found for the size of the nodules detected at imaging, the enhancement pattern, or the number of chemoembolization treatments. CONCLUSION: The degree of necrosis achieved depends on the time spent on the waiting list, on the number of nodules in the specimen, and on whether capsular infiltration is present.

[Survival benefit with intraarterial techniques in hepatocellular carcinoma]. / Beneficio sobre la supervivencia con las técnicas intraarteriales en el carcinoma hepatocelular.

The two intraarterial techniques used in the treatment of hepatocellular carcinoma (HCC) are the transarterial chemoembolization (TACE) and radioembolization (RE). TACE includes various procedures whose objective is to expose tumor cells to a chemotherapy agent and induce acute ischemia in the tumor. The survival benefit obtained by adding a chemotherapy agent or lipiodol to simple particle embolization has not been demonstrated in 2 meta-analyses, which suggests that the antitumor effect is primarily ischemic. RE is a form of brachytherapy that consists of an intraarterial injection of microspheres loaded with yttrium 90 as the source of radiation, a pure beta emitter with a mean tissue penetration of 2mm. TACE is performed in several sessions every 4-8 weeks, while RE is generally a single procedure. The guidelines adopted by the main research societies support the use of TACE for the palliative treatment of patients with intermediate stage HCC. This is a level 1 recommendation based on the positive results of 2 randomized clinical trials and 3 meta-analyses and on several uncontrolled studies with thousands of patients with unresectable HCC. Survival in clinical practice studies is heterogeneous due to the heterogeneity of the treated population. The survival rate varies from 8% to 26% at 5 years, and the median is 16-40 months in the early stage and 15-27 months in the intermediate stage. TACE with drug-eluting beads (DEB-TACE) has not shown superiority versus conventional TACE in terms of improved survival or tumor response, but it decreases the severe chemotherapy-related adverse events. One of its advantages is the standardization of the procedure, while its primary disadvantage is the onset of biliary complications when used nonselectively. There is level 2 evidence to support the use of RE in HCC, evidence that comes from patient cohorts with consistent results and case-control studies. The treated population includes mainly patients with unresectable tumors, who are considered suboptimal candidates for TACE or are progressing toward this condition, and those for whom TACE was directly contraindicated by the presence of portal vein thrombosis. Consequently, these patients tend to have large or extensively bilobar tumors and other factors for a poor prognosis. The overall survival reported for patients in the intermediate and advanced stages is 16-18 months and 7-17 months, respectively. A number of retrospective studies have reported comparable survival for patients treated with TACE and RE in the same institution; however, these results should be interpreted as a generator of ideas and not as an equivalent efficacy test. Although the combination of systemic agents such as sorafenib with intraarterial techniques is attractive, the results to date are not encouraging. In the only available randomized trial that compared the combination of a continuous regimen of sorafenib started before the first session of DEB-TACE versus DEB-TACE alone, neither the time to progression nor the overall survival were significantly different between the 2 groups. TACE and RE are contraindicated in cases of decompensated cirrhosis. TACE is also contraindicated for patients with considerable tumor burden in whom the procedure cannot be performed selectively and in patients with portal vein invasion.

Diagnóstico y tratamiento del hepatocarcinoma: puesta a punto del tema y rol del internista / Diagnosis and therapy of hepatocarcinoma: update of the topic and the internist’s role

El carcinoma hepatocelular es el tumor hepático maligno más frecuente, el 5o más prevalente en el mundo y la tercera causa de mortalidad por cáncer. En más de un 90% de los casos está asociado a cirrosis, su incidencia en dicha población es del 3 al 5%, siendo la primera causa de muerte en este grupo de pacientes. Se espera un incremento de esta incidencia en las próximas 2 décadas. En los últimos años se han desarrollado nuevas estrategias diagnósticas y terapéuticas que han modificado radicalmente el pronóstico de esta enfermedad. Al asentar sobre una patología donde el manejo médico es primordial el internista cumple un rol fundamental en el adecuado abordaje de esta neoplasia. Tareas como la prevención, la vigilancia, el diagnostico precoz y el enfoque multi e interdisciplinario, en los distintos estadios evolutivos de la enfermedad, son algunos de los aspectos más relevantes. El accionar con el médico hepatólogo es fundamental, definiendo en conjunto las distintas conductas a seguir en las instancias pre y postratamiento...