Transcatheter arterial chemoembolization for hepatocellular carcinoma in cirrhosis

Elia, Chiara; Venon, Wilma Debernardi; Stradella, Davide; Martini, Silvia; Brunello, F.; Marzano, Alfredo; Saracco, Giorgio Maria; Rizzetto, M.

doi:10.1097/meg.0b013e32834701f5

Cited by 11 publications

(4 citation statements)

References 22 publications

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“…13–15 In our study, we neither observed an increase of HVPG within days after the first TACE nor after two months and repeated TACE, suggesting that the acute increase in portal flow after embolization as measured with ultrasound did not translate into a clinically meaningful increase in portal pressure. Our results are in line with a small pilot study 22 showing that in 15 patients with HCC undergoing TACE, HVPG did not change within three days after TACE. However, no long-term effects on HVPG were investigated in this study.…”

Section: Discussionsupporting

confidence: 92%

Short‐ and long‐term effects of transarterial chemoembolization on portal hypertension in patients with hepatocellular carcinoma

et al. 2019

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Background Transarterial chemoembolization (TACE) affects hepatic perfusion, and might have an impact on portal pressure in patients with hepatocellular carcinoma (HCC). Objective The objective of this article is to report the secondary outcome “hepatic hemodynamics” from the AVATACE trial, a prospective randomized, placebo-controlled trial on the efficacy of conventional TACE in combination with bevacizumab or placebo. Methods Hepatic venous pressure gradient (HVPG) was measured at baseline (prior to first TACE), within nine days (“acute effects”), two months (“intermediate effects”) and six months (“long-term effects”) after the first TACE. Results Of 28 patients with early-intermediate stage HCC, n = 20 (71%) had clinically significant portal hypertension (CSPH, HVPG ≥ 10 mmHg) at baseline (median, 12 (interquartile range (IQR): 9–19) mmHg). TACE had neither “acute effects” nor “intermediate effects” on HVPG. However, in 13 patients with available HVPG measurement at month 6, there was a significant increase in HVPG (median, 16 (IQR: 11–19) mmHg) compared with baseline (median, 10 (IQR: 5–12) mmHg; p = 0.007). Portal hypertension-related complications occurred exclusively in patients with CSPH (8 (40%) vs 0). Conclusions Repeated TACE was associated with a significant long-term increase in HVPG. This should be considered when deciding whether to continue with TACE or switch to systemic treatment, since CSPH drives the development of complications.

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Section: Discussionsupporting

confidence: 92%

Short‐ and long‐term effects of transarterial chemoembolization on portal hypertension in patients with hepatocellular carcinoma

et al. 2019

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“…Circulatory changes in the portal/splanchnic venous system seem to appear immediately post-TACE and may remain elevated for some weeks (9,(12)(13)(14). However, these early modifications in PVBF measured on ultrasound do not necessarily translate in changes in HVPG (10,11) and systematic increase in variceal pressure (12). These changes are part of a complex homeostatic process in which the embolization-related decrease in the hepatic arterial blood flow is compensated by a PVBF increase (12).…”

Section: Discussionmentioning

confidence: 99%

“…Scarce and contradictory data exists about portal hemodynamic changes post-TACE. Invasive measurements using percutaneous transhepatic (9) or transvenous (HVPG) (10) routes performed immediately before and after TACE have not demonstrated any significant change post-procedure in HCC patients. HVPG measured within 9 days and 2 months after TACE did not significantly change from measurements prior therapy, but did increase at 6 months (11).…”

Section: Introductionmentioning

confidence: 99%

Longitudinal Analysis of the Effect of Repeated Transarterial Chemoembolization for Liver Cancer on Portal Venous Pressure

et al. 2021

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ObjectivesInvestigate long-term effects of repeated transarterial chemoembolization (TACE) on portal venous pressure (PVP) using non-invasive surrogate markers of portal hypertension.MethodsRetrospective, Institutional Review Board-approved study. 99 patients [hepatocellular carcinoma (HCC) group (n=57); liver metastasis group (n=42)] who underwent 279TACEs and had longitudinal pre-/post-therapy contrast-enhanced-MRI (n=388) and complete blood work were included. Outcomes of interest were platelet count (PC), spleen volume, ascites and portosystemic collaterals. Variables included TACE type/number, tumor type, microcatheter location, Child-Pugh, baseline tumor burden (tumor number/total/largest size), vessel invasion, alpha-fetoprotein, Eastern Cooperative Oncology Group (ECOG) performance status, and Model for End-Stage Liver Disease (MELD) score. Generalized Estimating Equations assessed the associations between TACE and outcomes. Power analysis determined the sample size was sufficient.ResultsNo significant change in PC over time was observed in either groups, regardless of liver function (P>0.05). Baseline spleen volume was 226 cm3 for metastatic group, and was larger by 204 cm3 for HCC group (P<0.001). Spleen volume increased by 20 cm3 (95%CI: 8-32; P=0.001) for both groups after 1stTACE and by 16cm3/TACE (P=0.099) over the full follow-up (up to 9TACEs). Spleen volume also tended to increase by 23cm3 (95%CI: -1–48; P=0.064) with higher tumor burden. Odds of developing moderate/severe ascites for metastatic patients was decreased by 0.5 (95%CI: 0.3–0.9; P=0.014), regardless of the Child-Pugh, and increased by 1.5 (95%CI: 1.2–1.9; P<0.001) among HCC patients with unstable Child-Pugh, whereas no change was noted with stable Child-Pugh. HCC patients with unstable Child-Pugh demonstrated a significant increase in portosystemic collaterals number over time (P=0.008). PVP-related complications such as variceal bleeding post-TACE were low (0.4%).ConclusionRepeated TACEs did seem to have an impact on PVP. However, the increase in PVP had marginal effects with low portal hypertension-related complications.

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“…Even if patients are well selected, liver decompensation can occur after any HCC treatment and thus worsen PHT, meaning that a new PHT screening should be discussed for these specific patients, especially those without primary prophylaxis before HCC treatment. Interestingly, although HVPG was unchanged before and within 3 days by transarterial chemoembolization, 48 repeated transarterial chemoembolization was associated with a significant long-term increase in HVPG 49 . PHT occurrence was also noted in patients without cirrhosis treated by intra-arterial radiotherapy with yttrium-90 for metastatic disease within the liver, 50 but no data regarding HCC are available.…”

Section: Pht Screening and Primary Prophylaxis In Patients With Hccmentioning

confidence: 99%

Portal hypertension and variceal bleeding in patients with liver cancer: Evidence gaps for prevention and management

Allaire

Thabut

2023

Hepatology

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Background and Aims: Portal hypertension (PHT) and HCC are 2 major complications of cirrhosis that often coexist in the same patient and impact the prognosis, especially in patients with acute variceal bleeding. In this review, we aim to discuss the best strategy for PHT screening and primary prophylaxis, as well as the management of acute variceal bleeding, to improve the management of PHT in HCC patients. Results: Recent therapeutic advances observed in the management of HCC, notably through the advent of immunotherapy, have led to a clear improvement in the survival of patients. The prevention of complications related to underlying cirrhosis, such as PHT and acute variceal bleeding, is now part of the management of HCC patients. The Baveno VII conference recently redefined screening and prophylaxis in patients with cirrhosis. However, data regarding the applicability of these criteria in patients with HCC have been sparse. From our point of view, the Baveno criteria are not appropriate to exclude high-risk esophageal varices (EV) in HCC patients, and endoscopy should be performed except in HCC patients with a liver stiffness measurement (LSM) ≥25 kPa, who should benefit from nonselective beta-blockers (NSSBs) without performing endoscopy. We are also in favor of using NSBBs as primary prophylaxis in patients with EV regardless of the size and with gastric varices since these patients display clinically significant PHT. Conclusions: Appropriate evaluation and treatment of PHT remain major issues in improving the outcomes of HCC patients. Many questions remain unanswered, opening the field to many areas of research.

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Transcatheter arterial chemoembolization for hepatocellular carcinoma in cirrhosis

Abstract: In our series portal hypertension-related complications after TACE were rare and did not result in higher mortality. As TACE did not influence HVPG, the preventive ligation of esophageal varices before TACE does not seem justified.

Cited by 11 publications

References 22 publications

Short‐ and long‐term effects of transarterial chemoembolization on portal hypertension in patients with hepatocellular carcinoma

Short‐ and long‐term effects of transarterial chemoembolization on portal hypertension in patients with hepatocellular carcinoma

Longitudinal Analysis of the Effect of Repeated Transarterial Chemoembolization for Liver Cancer on Portal Venous Pressure

Portal hypertension and variceal bleeding in patients with liver cancer: Evidence gaps for prevention and management

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