Reason of Discontinuation After Transarterial Chemoembolization Influences Survival in Patients with Hepatocellular Carcinoma

Abstract

BackgroundTransarterial chemoembolization (TACE) for intermediate-stage hepatocellular carcinoma (HCC) is often repeated until unTACEable progression (UTP) occurs. There is little data on the various reasons for stopping TACE and its consequences for subsequent treatment and survival.AimTo assess the impact of the various reasons of UTP on survival and consequences for subsequent treatments.MethodsConsecutive HCC patients who underwent TACE between 2003 and 2016 were analyzed retrospectively for the reason of TACE discontinuation. UTP was defined according to the EASL guidelines, considering radiological pattern of progression, liver function and performance status (PS). Overall and post-progression survival (OS, PPS) for different reasons of TACE discontinuation were compared. The correlation between time to untreatable progression by chemoembolization (TTUPc) and OS was analyzed.ResultsOne hundred and sixty-six patients (BCLC-A 40%, BCLC-B 54%, BCLC-C: 7%) were included, undergoing a median of 2 TACE procedures with a median OS of 22.1 months (95% CI 17.4–26.7). UTP occurred in 116 patients (70%) after a median TTUPc of 11.6 months (95% CI 7.8–15.4). There was a strong positive correlation (ρ = 0.816, p < 0.001) between TTUPc and OS. The main reason of UTP was radiological progression (61%), which was mostly intrahepatic (75%). Hepatic decompensation and worsening of PS were independent predictors of OS and PPS.ConclusionThe majority of HCC patients treated with TACE have UTP due to intrahepatic tumor progression with preserved liver function and PS, making them potential candidates for subsequent liver-directed or systemic treatment. TTUPc may be a valuable surrogate endpoint for OS in patients treated with TACE.Level of EvidenceLevel II, prognosis study.Electronic supplementary materialThe online version of this article (10.1007/s00270-018-2118-6) contains supplementary material, which is available to authorized users.

ALBI and P-ALBI grade in Child-Pugh A patients treated with drug eluting embolic chemoembolization for hepatocellular carcinoma

“…The importance of retreatment is highlighted in current guidelines and as long as no significant reduction in performance score or liver function occurs it is recommended to perform at least two TACE procedures before evaluating a patient as a "non-responder" (141,223). Further, untreatable progression post TACE (so-called "unTACEable" progression) is related to radiological tumor progression, deterioration of liver function or performance status (41), where in a recent study intrahepatic tumor progression was the most common reason while the liver function and performance status more often were preserved (224). This is important as most of these patients can be considered for alternative treatments, and it is essential to consider the liver function when evaluating a patient for TACE retreatment.…”

Quantitative washout in patients with hepatocellular carcinoma undergoing TACE: an imaging biomarker for predicting prognosis?

“…This leads us to the hypothesis that, during the course of disease, especially the liver function becomes more important as a treatment-limiting factor. Several studies have previously shown that a worsening of Child-Pugh score and ALBI score after the initial TACE is correlated with an impaired median OS and progression-free survival [ 31 – 36 ]. Furthermore, previous results by Labeur et al indicate that patients with intrahepatic tumor progression but preserved liver function are more often able to receive further locoregional or systemic treatment beyond TACE, while patients with a worsening of the liver function are “unlikely to benefit from the currently available subsequent treatments” [ 36 ].…”

Expected outcomes and patients’ selection before chemoembolization—“Six-and-Twelve or Pre-TACE-Predict” scores may help clinicians: Real-life French cohorts results

“…Conversely, these different models identified a first group of patients accounting for around 50% of our population who benefit sustainably from TACE, as this treatment may sometimes lead to complete tumor necrosis[ 22 ]. However, local and/or distant intrahepatic recurrences are commonly observed including in patients who achieved complete response following TACE[ 5 ]. These recurrences sometimes have a more invasive pattern[ 23 ], and became TACE resistant.…”

“…However limitations in its ability both to guide this procedure and more generally to manage intermediate-stage HCCs are recognized[ 3 ]. Despite serious improvements in patient selection, TACE modalities, efficacy [using modified response evaluation criteria in solid tumors (mRECIST)][ 4 ] and discontinuation criteria[ 5 ], this treatment usually fails to achieve sustained control of the disease, despite an objective response in about 50% of patients[ 6 ]. Despite subclassification propositions for intermediate stages[ 7 , 8 ] using up-to-seven criteria arbitrarily, clinicians have also continued to promote scores both to refine individual prognosis and guide therapeutic decisions.…”