Comparison of Transarterial Chemoembolization and Hepatic Resection for Large Solitary Hepatocellular Carcinoma: A Propensity Score Analysis

Hepatic resection is considered the treatment of choice for solitary hepatocellular carcinoma (HCC) without macrovascular or extrahepatic spread, however not all patients are candidates because of associated cirrhosis and risk for hepatic decompensation. Furthermore, current staging systems fail to allocate patients with large (≥5 cm) solitary HCCs and portal hypertension to optimal treatment. This study was designed to compare long-term survival after hepatic resection and transarterial chemoembolization (TACE) of large solitary HCCs while controlling for treatment selection bias using a propensity scoring method. This was a retrospective analysis of 159 consecutive patients treated over a 5-year period, 91 treated with resection and 68 with TACE. All patients were Child-Pugh A and the two groups were similar in performance status, tumor size, AFP levels, and signs of portal hypertension. TACE was performed as selectively as possible with a microcatheter utilizing first iodized oil and doxorubicin emulsion followed by particles with mitomycin C or doxorubicin until stasis of blood flow was achieved. Statistical analysis demonstrated patients after hepatic resection to have higher time-to-progression (TTP) (P < .001) and higher overall survival (P < .023). However, after one-to-one propensity score matching, the median TTP remained significantly longer in the hepatic resection group (P = .001), but the overall survival distributions between the two groups did not differ significantly (P = .291) and the median overall survival was 76.4 and 60.7 months after hepatic resection and TACE, respectively.

Comment:

The results of this study begin to challenge the conventional treatment algorithm for large solitary HCC in the setting of portal hypertension demonstrating that overall survival after TACE is not inferior to that of hepatic resection. The authors apply a propensity scoring method with noteworthy effort in order to adjust for treatment-selection bias and underlying prognostic factors, which balances some limitation from a retrospective analysis. Continuing research could help to establish TACE as an alternative initial treatment in the setting of large resectable HCC.


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Kaplan-Meier analysis of overall survival and TTP. Patients in the hepatic resection group showed (a) a higher overall survival rate (P ¼ .023) and (b) longer TTP than patients in the transarterial chemoembolization group (P o .001).


Citation: Lee, Y. B. et al. Comparison of Transarterial Chemoembolization and Hepatic Resection for Large Solitary Hepatocellular Carcinoma: A Propensity Score Analysis. Journal of Vascular and Interventional Radiology 26, 651–659 (2015).


Post author: Dmitry Goldin MD, Fellow in Vascular and Interventional Radiology, Medical University of South Carolina

R.E.N.A.L. Nephrometry Score Predicts Early Tumor Recurrence and Complications after Percutaneous Ablative Therapies for Renal Cell Carcinoma: A 5-Year Experience

The R.E.N.A.L. (radius, exophytic/endophytic, nearness to collecting system or sinus, anterior/posterior, and location relative to polar lines) nephrometry score analyzes anatomical variables and has been shown to correlate with outcomes and complications in the surgical treatment of RCC, but has remained controversial when applied to ablation. This was a retrospective study of 87 consecutive patients who underwent RF or cryoablation of 101 RCC lesions staged 1A (organ confined, <4cm), aimed at evaluating the usefulness of the R.E.N.A.L. scoring system in ablative therapy. All patients underwent CECT immediately after the procedure to document technical success, and follow up (mean 34.6 months) was performed on either CT or MR. The median R.E.N.A.L. score was 7 in the cryoablation (range 4-10) cohort and 5 in the RF cohort, with higher risk lesions generally being treated more often with cryoablation. Technical success was 100%, with overall recurrence of 16.84%, and complication rate of 9.9%. R.E.N.A.L. scores of >8 correlated with increased early (1st year) recurrence (p=0.001), overall recurrence (p=0.0001), and associated periprocedural complications (p=0.001) despite treatment method. The R.E.N.A.L. nephrometry score has been validated in the urological literature in surgical treatment of RCC (including partial nephrectomy and laparoscopic cryoablation) and the authors argue that this study validates this scoring system when applied to percutaneous ablation of RCC as it included patients with RCC exclusively.

Comment:

Although retrospective in design, and relatively small in numbers, the study was well designed and the statistical analyses were appropriate. While the study identified a higher incidence of recurrence and complications in the cryoablation group, these patients had higher risk lesions. The authors found that R.E.N.A.L. scores >8 were correlated with increased overall and early recurrence as well as increased complication rates independent of the technique used. This study validates the use of the R.E.N.A.L score in the setting of percutaneous ablative therapies and its use as a screening tool for patient selection and prediction of complications.


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Early recurrence after ablation procedure. (a) A 63-year-old man presented initially for ablation of an anterior lower 1.5-cm lesion (R.E.N.A.L. score 8a) (arrow). (b) Technical success was determined immediately after ablation (arrow). (c) The patient presented 12 months after the procedure with a predominantly exophytic lesion (R.E.N.A.L. score 6x) within the lower pole of the right kidney. Additional cryoablation was performed with a successful outcome (arrow).


Citation:  Camacho, J. C. et al. R.E.N.A.L. (Radius, Exophytic/Endophytic, Nearness to Collecting System or Sinus, Anterior/Posterior, and Location Relative to Polar Lines) Nephrometry Score Predicts Early Tumor Recurrence and Complications after Percutaneous Ablative Therapies for Renal Cell Carcinoma: A 5-Year Experience. Journal of Vascular and Interventional Radiology 26, 686–693 (2015).


Post author: Andre Uflacker MD,   Fellow in Vascular and Interventional Radiology, University of Virginia

Quantification of Inherent HCC Gene Expression May Allow Predictability of Tumor Response to Chemoembolization

The presence of viable or recurrent tumor after transarterial chemoembolization of HCC is thought to be in part attributable to chemotherapy resistance and ischemia-induced angiogenesis via a principle mechanism of tumor gene expression. This study was performed to evaluate the relationship between expression of tumor biomarker genes in HCC cells and subsequent treatment response to transarterial chemoembolization.

In this retrospective feasibility pilot study, 19 pretreatment HCC biopsy specimens from 19 patients treated with conventional chemoembolization between 2007 and 2013 were analyzed for the presence and expression of 60 genes related to chemotherapy sensitivity, mitosis, inflammation, hypoxia, and angiogenesis. Quantification of gene expression based on measurement of mRNA levels was compared to post-treatment tumor response by imaging at a mean of 116 days after treatment.

Tumors with a complete response (N=13) showed a significant increase in or trend toward greater (range, 1.49-3.50 fold) pre-treatment mRNA expression of a number of chemotherapy-sensitivity and mitosis genes compared with tumors with a partial response (N=6). Tumors with a complete response also showed significantly higher VEGFA levels compared to those with partial response, which may indicate an association between greater pre-treatment tumor vascularity and susceptibility to transarterial locoregional therapies.

Comment:

Establishment of the relationship between inherent pre-treatment HCC gene expression and treatment response to transarterial chemoembolization may allow better pre-treatment predictability of individual tumor response and better inform locoregional HCC management decisions at the level of the individual, or amongst multiple tumors within an individual. Further studies to identify additional markers, better understand and quantify their relationships with tumor response, and establish the reliability of predictions based upon these relationships will be an important step forward in the further individualization of HCC management.


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Citation: Gaba, R. C., Groth, J. V., Parvinian, A., Guzman, G. & Casadaban, L. C. Gene Expression in Hepatocellular Carcinoma: Pilot Study of Potential Transarterial Chemoembolization Response Biomarkers. Journal of Vascular and Interventional Radiology 26, 723–732 (2015).


Post author: Laura Traube, MD, MPH. Interventional Radiology Fellow, UCLA Medical Center