Combined treatment of hepatocellular carcinoma with partial splenic embolization and transcatheter hepatic arterial chemoembolization

Abstract

INTRODUCTIONTranscatheter hepatic arterial chemoembolization (TACE) has become the first choice of treatment for unresectable hepatocellular carcinoma (HCC) [1][2][3][4] . Since 70%-90% of HCC patients are associated with liver cirrhosis, portal hypertension and hypersplenism, treatment of HCC is usually affected by low peripheral blood cell counts (leukcytes, platelets and red blood cells) and high incidence of hemorrhagic complications due to treatment and/or portal hypertension [5][6][7][8] . Moreover, chemotherapeutics during TACE is another cause for low peripheral blood cell counts because of myelosuppression. Partial splenic embolization (PSE), which is thought to be an effective alternative to splenomegaly [9,10] because of its milder injury and fewer complications, has been widely used in treatment of leukocytopenia and thrombocytopenia caused by splenomegaly since the report of Maddison in 1973 [11] . MATERIALS AND METHODS PatientsFrom December 2002 to May 2006, 50 consecutive patients with HCC associated with hypersplenism caused by liver cirrhosis and portal hypertension were enrolled in this study. The diagnosis of HCC was established on the basis of clinical laboratory data, computed tomography and biopsy. The diagnosis of hypersplenism and splenomegaly was made in the light of clinical laboratory data and computed tomography. The enrolling criteria for this study were patients with splenomegaly and thrombocytopenia (platelet count ≤ 60 × 10 9 /L) and/or leukocytopenia (leukocyte count ≤ 3.0 × 10 9 /L). Adequate supporting therapies were performed for patients having severe peritonealgia before treatment with PSE and TACE or TACE alone in order to decrease the amount of ascites. Patients meeting the above criteria were randomly assigned to either group A or group B based on the computergenerated randomization sequences. Of the 50 patients, METHODS:Fifty patients suffering from primary HCC associated with hypersplenism caused by cirrhosis were randomly assigned to 2 groups: group A receiving PSE combined with TACE (n = 26) and group B receiving TACE alone (n = 24). Follow-up examinations included calculation of peripheral blood cells (leukcytes, platelets and red blood cells) and treatment-associated complications. RESULTS:Prior to treatment, there was no significant difference in sex, age, Child-Pugh grade, tumor diameter, mass pathology type and peripheral blood cell counts between the 2 groups. After treatment, leukocyte and platelet counts were significantly higher in group A during the 3-mo follow-up period (P < 0.05), but lower in group B (P < 0.05). Severe complications occurred in 3 patients (11.5%) of group A and in 19 patients (79.2%) of group B (P < 0.05), and there was no significant difference in symptoms of post-embolization syndrome, including abdominal pain, fever, mild nausea and vomiting between the 2 groups (P > 0.05).CONCLUSION: PSE combined with TACE is more effective and safe than TACE alone for patients with HCC associated with hypersplenism caused by cirrhosis.

Causes of peripheral cytopenia in hepatitic cirrhosis and portal hypertensive splenomegaly

“…In 1979, Spigos et al 40 first successfully used partial splenic arterial embolization (PSE) to treat hypersplenism. Subsequently, more clinicians [41][42][43] used PSE to treat portal hypertension, hypersplenism, and hemorrhage from esophageal and gastric fundal varices. PSE not only enhances PLT and WBC counts, 44,45 but also decreases splenic size, improves pancytopenia, 46 and induces immune function.…”

Partial Splenic Embolization with Transarterial Chemoembolization in Patients with Hepatocellular Carcinoma Accompanied by Thrombocytopenia

“…PSE is a useful procedure to improve hypersplenism and portal hypertension and their complications [ 13 – 18 ]. However, there are only a few reports that are available about PSE in patients with HCC [ 19 – 21 ]. In those reports, PSE with TACE was mainly performed to decrease complications of portal hypertension such as variceal bleeding.…”

“…Considering that the extent of splenic infarcted area after PSE was relatively high (77.0%), not only TACE but also PSE may have been involved in liver failure. Previous reports demonstrated that severe complications of PSE often develop when the extent of infarcted area is >70.0% [ 13 , 21 , 22 ]. Therefore, liver failure might develop after PSE even without simultaneous TACE in this case.…”

Impact of total splenectomy on peripheral lymphocytes and their subsets in patients with hypersplenism associated with cirrhotic portal hypertension

“…Partial splenic arterial embolization (PSE) was first described by Spigos and colleagues 42 to treat hypersplenism. It has also been used to treat portal hypertension and esophagogastric variceal bleeding 43 , 44 . PSE not only can increase the counts of platelets and WBCs 45 – 48 , but can also reduce splenic volume and improve immune function 49 .…”