Wensou Huang

Hepatocellular Carcinoma with Portal Vein Tumor Thrombus: Treatment with Transarterial Chemoembolization Combined with Sorafenib—A Retrospective Controlled Study

PURPOSE To determine the safety and efficacy of transarterial chemoembolization (TACE) combined with sorafenib (hereafter, TACE-sorafenib) in patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT). MATERIALS AND METHODS This study was approved by the institutional review board, and the requirement for informed consent was waived. The medical records of consecutive patients with HCC and PVTT who underwent TACE-sorafenib or TACE alone from January 2010 to December 2012 were retrospectively evaluated. Sorafenib (400 mg) was administered twice daily. Outcomes of patients who underwent TACE-sorafenib were compared with outcomes of patients who underwent TACE by using the Kaplan-Meier method according to types of PVTT: PVTT in the main portal vein (type A), PVTT in the first-order portal vein branch (type B), and PVTT in second- or lower-order portal vein branches (type C). RESULTS Ninety-one patients were included in the analysis; 46 patients underwent TACE-sorafenib and 45 underwent TACE. TACE-sorafenib showed significant survival benefits compared with TACE in patients with type B (median survival, 13 months vs 6 months; P = .002) or type C (median survival, 15 months vs 10 months; P = .003) PVTT. TACE-sorafenib and main PVTT were the independent prognostic factors for survival at uni- and multivariate analysis. Liver function after TACE-sorafenib worsened only in patients with main PVTT. Sorafenib-related adverse events of grade 3 or higher occurred in 16 patients (35%). CONCLUSION TACE-sorafenib side effects were acceptable, and this treatment may improve overall survival in patients with HCC with first-order or lower-branch PVTT when compared with patients who underwent TACE alone.

Percutaneous Transsplenic Portal Vein Catheterization: Technical Procedures, Safety, and Clinical Applications

PURPOSE To evaluate the safety and feasibility of percutaneous transsplenic portal vein catheterization (PTSPC) by retrospective review of its use in patients with portal vein (PV) occlusion. MATERIALS AND METHODS From July 2004 to December 2010, 46 patients with a history of uncontrolled gastroesophageal variceal bleeding secondary to portal hypertension underwent endovascular PV interventions via a percutaneous transsplenic approach. All patients had occlusion of the main PV or central intrahepatic PV branches, which prevented the performance of a transhepatic approach. A vein within the splenic parenchyma was punctured under fluoroscopic guidance by referencing preoperative computed tomography images. PTSPC-related complications and clinical applications were analyzed. RESULTS PTSPC was successfully performed in 44 of 46 patients (96%); two failures were caused by inaccessible small intrasplenic veins. PTSPC-related major bleeding complications occurred in three patients (6.5%), including large intraperitoneal hemorrhage in one patient and large splenic subcapsular hemorrhage in two patients. Two of the three patients developed hypotension, and one developed severe anemia. All three of the patients required blood transfusions. PTSPC-related minor bleeding complications occurred in six patients (13%) as a result of a small splenic subcapsular hemorrhage. In addition, three patients exhibited mild left pleural effusion, which subsided spontaneously 1 week later. All 44 patients successfully treated via PTSPC received gastroesophageal variceal embolization. Eight patients received PV stents, five for treatment of PV occlusion and three during transjugular intrahepatic portosystemic shunt placement. CONCLUSIONS PTSPC is a safe and effective access for endovascular PV interventions in patients without a transhepatic window.

Portal Vein Thrombosis after Partial Splenic Embolization in Liver Cirrhosis: Efficacy of Anticoagulation and Long-term Follow-up

PURPOSE To investigate the treatment and long-term outcome of portal vein thrombosis (PVT) after partial splenic embolization (PSE). MATERIALS AND METHODS From January 2006 to December 2011, 145 patients with hypersplenism caused by cirrhotic portal hypertension underwent PSE. In 11 cases, PVT was detected 13-42 days after PSE. Among the 11 patients, 5 underwent anticoagulant therapy because of clinical symptoms, and 6 did not receive anticoagulation because they were symptom-free (4 patients) or experienced variceal bleeding (2 patients). The long-term follow-up data from these 11 patients were analyzed retrospectively. RESULTS The 11 patients with PVT had a mean splenic infarction ratio of 71.5%. The mean duration of follow-up was 37.6 months. During the follow-up period, none of the 5 patients who underwent anticoagulation developed variceal hemorrhage despite presenting with large esophagogastric varices. Four of the five patients achieved complete resolution of thrombosis, and one did not develop thrombus progression. However, among the 6 patients who did not undergo anticoagulation, 2 developed esophagogastric variceal hemorrhage secondary to thrombus progression, 3 developed cavernous transformation of the portal vein and variceal progression, and 1 had partial calcification of the thrombus. Two patients who had variceal bleeding or rebleeding underwent a transjugular intrahepatic portosystemic shunt. Complete recanalization of the portal vein was achieved after the procedures. CONCLUSIONS PVT is a severe, potentially fatal complication of PSE. Early detection of PVT and prompt anticoagulation are effective to avoid serious consequences of PVT.

Role of multi-detector computed tomography for biliary complications after liver transplantation

AIM To investigate the diagnostic performance of multi-detector computed tomography (MDCT) in detecting biliary complications after orthotopic liver transplantation (OLT). METHODS Eighty-three consecutive OLT recipients, who presented with clinical or biochemical signs of biliary complications, underwent MDCT examination. Two experienced radiologists assessed MDCT images in consensus to determine biliary complications. Final confirmation was based on percutaneous transhepatic cholangiography or endoscopic retrograde cholangiography in 58 patients, surgery in four patients, liver biopsy in 10, and clinical and sonography follow-up in 11 patients. RESULTS Biliary complications were eventually confirmed in 62 of 83 patients (74.7%), including anastomotic biliary strictures in 32, nonanastomotic biliary strictures in 21, biliary stones in nine (5 with biliary strictures), anastomotic bile leak in five, and biloma in six (all with nonanastomotic strictures, and 2 with biligenic hepatic abscess). Twenty-one patients had no detection of biliary complications. The sensitivity, specificity, accuracy, positive predictive value and negative predictive value of MDCT for detecting biliary strictures were 90.6%, 86.7%, 89.2%, 92.3% and 83.9%, respectively. For detecting biliary stones, anastomotic bile leak and biloma, the sensitivity, specificity, accuracy, positive predictive value and negative predictive value of MDCT were all 100%. CONCLUSION MDCT is a useful screening tool for detecting biliary complications after OLT.

Hepatic resection after transarterial chemoembolization increases overall survival in large/multifocal hepatocellular carcinoma: a retrospective cohort study

To investigate the prognosis of transarterial chemoembolization (TACE) followed by hepatic resection (HR) in large/multifocal hepatocellular carcinoma (HCC), the medical records of consecutive HCC patients who underwent TACE between January 2006 and December 2010 were retrospectively analyzed. Patients who received TACE alone comprised the T group (61 patients), while those who received HR after TACE comprised the T+R group (49 patients). All the resections were successfully performed, and only one class V complication occurred. While liver function was altered from baseline within 1 week after HR, it recovered within 1 month. Overall survival (OS) of the T+R and T groups were compared, and sub-group analyses were performed based on baseline α-fetoprotein (AFP) levels, the reduction of AFP, and tumor response before HR. Overall survival (OS) in the T+R group was longer than in the T group (47.00 ± 2.87 vs. 20.00 ± 1.85 months, P < 0.001). OS in the T+R group with AFP reduction was less than 50%, and OS among those with a poor tumor response before HR did not differ from the T group (P > 0.05). These patients may not benefit from the combined treatment. Our findings suggest HR after TACE is safe and effective for large/multifocal HCC, and prolongs OS when compared to TACE alone.

Early prediction of survival in hepatocellular carcinoma patients treated with transarterial chemoembolization plus sorafenib

AIM To identify clinical biomarkers that could early predict improved survival in patients with advanced-stage hepatocellular carcinoma (HCC) treated with transarterial chemoembolization combined with sorafenib (TACE-S). METHODS We retrospectively evaluated the medical records of consecutive patients with advanced-stage HCC who underwent TACE-S from January 2012 to December 2015. At the first follow-up 4-6 wk after TACE-S (median, 38 d; range, 33-45 d), patients exhibiting the modified Response Evaluation Criteria in Solid Tumors (mRECIST)-evaluated complete response, partial response, and stable disease were categorized as early disease control. At this time point, multiple variables were analyzed to identify the related factors affecting survival. RESULTS Ninety-five patients were included in this study, and 60 of these patients achieved early disease control, with an overall disease control rate (DCR) of 63.2%. Patients who got sorafenib at the first TACE (no previous TACE) and patients without portal vein tumor thrombus (PVTT) had a higher DCR than those who underwent previous TACE before TACE-S (72.4% vs 48.6%, P = 0.019) and those with PVTT (75.5% vs 50.0%, P = 0.010). Early disease control after TACE-S, no previous TACE, and no PVTT were the independent prognostic factors for survival in the uni- and multivariate analyses. CONCLUSION The first follow-up 4-6 wk after TACE-S can be used as the earliest time point to assess the response to TACE-S, and patients with mRECIST-evaluated early disease control, no previous TACE, and no PVTT had better survival.

Medium or Large Hepatocellular Carcinoma: Sorafenib Combined with Transarterial Chemoembolization and Radiofrequency Ablation

Purpose To determine the safety and efficacy of sorafenib combined with transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) (hereafter, S-TACE-RFA) in patients with medium or large (range, 3.1-7.0 cm in diameter) hepatocellular carcinoma (HCC). Materials and Methods This retrospective study evaluated the medical records of consecutive patients with medium or large HCC who underwent S-TACE-RFA or combined TACE and RFA (hereafter, TACE-RFA) from January 2010 to December 2014. Sorafenib was started 3-5 days after TACE, and RFA was performed 1-2 weeks after TACE. Treatment complications, recurrence-free survival (RFS), and overall survival (OS) in patients who underwent S-TACE-RFA were compared with those in patients who underwent TACE-RFA. Results Of the 174 patients who underwent S-TACE-RFA or TACE-RFA, 106 who met the eligibility criteria were included in this study. Among them, 40 underwent S-TACE-RFA and 66 underwent TACE-RFA. The patients who underwent S-TACE-RFA had longer RFS (median, 24.0 vs 10.0 months; P = .04) and better OS (median, 63.0 vs 36.0 months, P = .048) than those who underwent TACE-RFA. S-TACE-RFA and α-fetoprotein level were independent prognostic factors for survival in uni- and multivariable analyses. The rate of complications in patients who underwent S-TACE-RFA was similar to that in patients who underwent TACE-RFA (22.5% vs 18.2%, P = .59). Conclusion S-TACE-RFA resulted in longer RFS and better OS than did TACE-RFA in patients with medium or large HCC.

Safety and Efficacy of Transarterial Chemoembolization Combined with CT-Guided Radiofrequency Ablation for Hepatocellular Carcinoma Adjacent to the Hepatic Hilum within Milan Criteria

PURPOSE To retrospectively evaluate safety and efficacy of conventional transarterial chemoembolization with ethiodized oil (Lipiodol) combined with CT-guided radiofrequency (RF) ablation for hepatocellular carcinoma (HCC) adjacent to the hepatic hilum. MATERIALS AND METHODS Between January 2007 and December 2010, conventional transarterial chemoembolization combined with CT-guided RF ablation was performed in 40 patients with HCC adjacent to the hepatic hilum within Milan criteria (group A). Major complications, complete tumor ablation rate, local tumor progression rate, and overall survival were compared with 107 patients with HCC nonadjacent to the hepatic hilum (group B) treated by conventional transarterial chemoembolization combined with CT-guided RF ablation during the same period. RESULTS Major complications included one case of large hepatic artery-portal vein fistula in group A (2.5%; 1/40) and one case of acute portal vein thrombosis, left heart failure, and tumor seeding in group B (2.8%; 3/107); the difference was not significant between the two groups (P = 1.000). There were no significant differences between the two groups in complete tumor ablation rate (80.0% vs 86.0%; P = .374), local tumor progression rates (1-year, 12.5% vs 14.1%; 2-year, 28.2% vs 24.2%; 3-year, 32.0% vs 27.6%; P = .723), and overall survival (1-year, 92.3% vs 91.8%; 3-year, 79.1% vs 79.3%; 5-year, 59.5% vs 58.4%; P = .555). CONCLUSIONS Conventional transarterial chemoembolization combined with CT-guided RF ablation was safe and effective in selected patients with HCC adjacent to the hepatic hilum within Milan criteria.