Transarterial Chemoembolization Combined with Lenvatinib plus PD-1 Inhibitor for Advanced Hepatocellular Carcinoma: A Retrospective Cohort Study

Purpose To investigate the efficacy and safety of transarterial chemoembolization (TACE) combined with lenvatinib plus PD-1 inhibitor (TACE-L-P) versus TACE combined with lenvatinib (TACE-L) for patients with advanced hepatocellular carcinoma (HCC).Methods Data of advanced HCC patients treated with TACE-L-P or TACE-L from January 2019 to December 2020 were retrospectively analyzed. The differences in overall survival (OS), progression-free survival (PFS), tumor responses (based on modified Response Evaluation Criteria in Solid Tumors) and adverse events (AEs) were compared between the two groups. Potential factors affecting OS and PFS were determined.Results A total of 81 patients were included in this study (41 received TACE-L-P and 40 received TACE-L). The patients in TACE-L-P group had prolonged OS (median, 16.9 vs. 12.1 months, p=0.009), longer PFS (median, 7.3 vs. 4.0 months, p=0.002) and higher objective response rate (56.1% vs. 32.5%, p=0.033) and disease control rate (85.4% vs. 62.5%, p=0.019) than those in TACE-L group. Multivariate analyses revealed that the treatment option of TACE-L, main portal vein invasion and extrahepatic metastasis were the independent risk factors for OS, while TACE-L and extrahepatic metastasis were the independent risk factors for PFS. In subgroup analyses, a superior survival benefit was achieved with TACE-L-P in patients with extrahepatic metastasis or tumor number >3 but not in those with main portal vein invasion. The incidence and severity of AEs in TACE-L-P group were comparable to those in TACE-L group (any grade, 92.7% vs. 95.0%, p=1.000; grade 3, 36.6% vs. 32.5%, p=0.699).Conclusion TACE-L-P significantly improved survival over TACE-L with an acceptable safety profile in advanced HCC patients, especially those with extrahepatic metastasis or tumor number >3 but without main portal vein invasion.

Transarterial Chemoembolization in Unresectable Hepatocellular Carcinoma with Portal Vein Tumor Thrombosis: A Tertiary Care Center Experience

Background Portal vein tumor thrombosis (PVTT) is a common complication of hepatocellular carcinoma (HCC) occurring in 30 to 40% of cases. The presence of PVTT in HCC is regarded as an advanced disease that confers poor prognosis and survival. Transarterial chemoembolization (TACE) has traditionally been considered to be contraindicated in cases of PVTT, due to the risk of hepatic infarction, and further deteriorate liver function. We evaluated safety, technical efficacy, and outcomes of TACE in HCC with PVTT. Methods From search results of the hospital database, out of 652 patients who underwent TACE for HCC, 73 patients of HCC with PVTT were retrospectively evaluated. Post-TACE tumor response by computed tomography (CT)/magnetic resonance imaging (MRI) imaging as per modified response evaluation criteria in solid tumors (mRECIST) criteria, if any occurrence of acute hepatic failure was assessed. Prognostic factors influencing survival were also determined. Results In our study population, the mean age of the patients was 58 years. The 12- and 24-month survival rates were 59 and 14%, respectively, with an overall median survival of 12.3 months. A total of 58.9% patients had branch portal vein tumor thrombus and 41.1% had tumor thrombus in the main portal vein. We did not encounter any mortality or acute liver failure following TACE in a 30-day period. Both univariate and multivariate analysis revealed Child–Pugh score (p = 0.01) and the extent of tumoral thrombus (p 0.004) as a significant prognostic factor. Patients with branch PVTT, no ascites, and Child–Pugh A had better survival than those having main portal vein tumor thrombus, ascites, and Child–Pugh B. Conclusion Our study concluded that TACE can achieve good disease control and improved survival in HCC with portal vein invasion despite being considered as a relative contraindication. Technical expertise, selection of patients, such as superselective catheterization and preserved liver function, are the key factors for a safe therapeutic procedure. Child–Pugh score and extent of portal vein invasion were the significant prognostic factors determining survival.

Controlling Major Portal Vein Invasion Progression during Lenvatinib Treatment by Carbon-Ion Radiotherapy in Patients with Advanced Hepatocellular Carcinoma

Macrovascular invasion (MVI), including portal vein tumor thrombosis (PVTT), is strongly associated with poor prognosis in patients with hepatocellular carcinoma (HCC). While recommended standard treatment for patients with advanced HCC is systemic therapy, various treatment approaches, including resection, transarterial chemoembolization, and radiation, have been empirically suggested to improve prognosis by eliminating or controlling MVI. Herein, we report our experience of a case with advanced HCC where MVI was controlled by carbon-ion radiotherapy (CIRT) while on systemic therapy, resulting in a prolonged survival. A female patient with HCC in her early 60s had multiple intrahepatic lesions (maximum 60 mm in diameter) with PVTT. The PVTT of this patient had reached the main trunk of the portal vein despite the use of lenvatinib. The other intrahepatic lesions of the patient, except PVTT, had been controlled by lenvatinib. Therefore, hoping to control PVTT, we attempted CIRT. The patient resumed lenvatinib therapy after the irradiation. During lenvatinib re-treatment, no evident progression of PVTT was observed in the patient.

A prognostic model to predict survival after hepatic arterial infusion chemotherapy for hepatocellular carcinoma with portal vein invasion.

e16157 Background: We aimed to establish a prognostic model to predict survival for the patient with advanced hepatocellular carcinoma (HCC) after the treatment with hepatic arterial infusion chemotherapy (HAIC) of oxaliplatin plus fluorouracil/leucovorin. Methods: 164 patients diagnosed of HCC with portal vein invasion and treated with HAIC of oxaliplatin plus fluorouracil/leucovorin between 1/2018 and 1/2021 at the Guangdong provincial people’s hospital and were randomly divided to training(N=82) and validation(N=82) cohort. We investigated the impact of baseline characteristics and tumour load on overall survival (OS, log-rank test) and developed a prognostic model in the training cohort by using a stepwise Cox regression model and validated in validation cohort. Results: The final presentation of the model was “NCV-score= 0.974* serum neutrophil/lymphocyte ratio+ 1.239* Child-pugh stage+ 0.661* portal Vein invasion grade”, which further selected the first quartile of the linear predictor, namely 5.7, as cut-off values. The NCV-score differentiated two risk categories(≥5.7, ＜5.7) with distinct prognosis (median OS: 6.6 vs. 11.2 months, p <0.001). The prognostic model was used to develop nomogram for predicting individual survival of HAIC candidates and was validated in validation cohort to identify patients who obtain satisfying survival benefit for HAIC. Conclusions: The NCV-score identifies advanced HCC patients who obtain satisfying survival benefit for HAIC of oxaliplatin plus fluorouracil/leucovorin and provides individual survival predicting.[Table: see text]

Hepatectomy with simultaneous resection of portal vein for Bismuth IV perihilar cholangiocarcinoma: a case report

Background: Surgical resection is the only potential treatment choice for patients with cholangiocarcinoma. Portal vein invasion used to be a primary cause of irresectable tumor. Nowadays, portal vein resection and reconstruction has become a routine surgical procedure.Case presentation: A 65-year-old male patient, suffering from jaundice and abnormal liver function was referred to our hospital for intensive examination. Before admission to our center, the patient had been undergoing percutaneous transhepatic cholangial drainage (PTCD) for six days for the palliation of jaundice and liver function. A series of check-ups and examinations resulted in the diagnosis of Bismuth type IV perihilar cholangiocarcinoma. The patient later received right hemihepatectomy and Roux-en-Y choledochojejunostomy. As the portal vein was affected by tumor, it was partially removed and reconstructed. In addition, the portal vein thrombus (PVT) was removed, and a portal vein stent was placed. After surgery, the patient received six courses of chemotherapy. A gemcitabine-based regimen in combination with S-1 were used. Nineteen months after the surgery, the patient is still healthy.Conclusions: This report demonstrates that hepatectomy with simultaneous resection of portal vein for Bismuth type IV perihilar cholangiocarcinoma may contribute to a satisfactory result. Consequently, combined resection and reconstruction is often required when negative pathological resection (R0 resection) is performed.

Cost-Effectiveness Analysis of Hepatic Arterial Infusion of FOLFOX Combined Sorafenib for Advanced Hepatocellular Carcinoma With Portal Vein Invasion

BackgroundHepatic arterial infusion (HAI) of oxaliplatin, leucovorin, and fluorouracil (FOLFOX) plus sorafenib has a more desirable effect versus sorafenib for hepatocellular carcinoma (HCC) patients with portal vein invasion. However, considering the high cost of hepatic arterial infusion of chemotherapy (HAIC), this study evaluated the cost-effectiveness of HAIC plus sorafenib (SoraHAIC) versus standard care for HCC patients from the Chinese health system perspective.MethodsA Markov multi-state model was constructed to simulate the disease course and source consumption of SoraHAIC. Costs of primary therapeutic drugs were calculated based on the national bid price, and hepatic artery catheterization fee was collected from the Fujian Provincial Price Bureau. Clinical data, other costs, and utility values were extracted from references. Primary outcomes included life-years (LYs), quality-adjusted life years (QALYs) and incremental cost-effectiveness ratio (ICER). The robustness of model was verified by uncertainty sensitivity analyses.ResultsSoraHAIC gained 1.18 QALYs (1.68 LYs) at a cost of $65,254, while the effectiveness and cost of sorafenib were 0.52 QALYs (0.79 LYs) and $14,280, respectively. The ICER of SoraHAIC vs sorafenib was $77,132/QALY ($57,153/LY). Parameter that most influenced the ICER was utility of PFS state. The probabilistic sensitivity analysis (PSA) showed that SoraHAIC was not cost-effective in the WTP threshold of 3*Gross Domestic Product (GDP) per capita of China ($30,492/QALY). But about 38.8% of the simulations were favorable to SoraHAIC at the WTP threshold of 3*GDP per capita of Beijing ($72,000/QALY). When 3*GDP per capita of Fujian ($47,285/QALY) and Gansu Province ($14,595/QALY) were used as WTP threshold, the acceptability of SoraHAIC was 0.3% and 0%, respectively.ConclusionsThe study results indicated that SoraHAIC was not cost-effective in medium-, and low-income regions of China. In developed areas of China (Beijing), there was a 38.8% probability that the SoraHAIC regimen would be cost-effective.