Observational Study
Copyright ©The Author(s) 2020. Published by Baishideng Publishing Group Inc. All rights reserved.
World J Hepatol. Jan 27, 2020; 12(1): 21-33
Published online Jan 27, 2020. doi: 10.4254/wjh.v12.i1.21
Imaging response predictors following drug eluting beads chemoembolization in the neoadjuvant liver transplant treatment of hepatocellular carcinoma
Francisco Leonardo Galastri, Felipe Nasser, Breno Boueri Affonso, Leonardo Guedes Moreira Valle, Bruno Calazans Odísio, Joaquim Mauricio Motta-Leal Filho, Paolo Rogério Salvalaggio, Rodrigo Gobbo Garcia, Márcio Dias de Almeida, Ronaldo Hueb Baroni, Nelson Wolosker
Francisco Leonardo Galastri, Felipe Nasser, Breno Boueri Affonso, Leonardo Guedes Moreira Valle, Rodrigo Gobbo Garcia, Department of Interventional Radiology, Hospital Israelita Albert Einstein, São Paulo 05652-000, Brazil
Bruno Calazans Odísio, Department of Diagnostic Radiology, The University of Texas MD Anderson Cancer Center, Houston, TX 77230, United States
Joaquim Mauricio Motta-Leal Filho, Radiology Department, Radiology Department, Heart Institute (InCor), University of São Paulo, São Paulo 05403-900, Brazil
Paolo Rogério Salvalaggio, Teaching and Research Institute, São Paulo, Brazil, Hospital Israelita Albert Einstein, São Paulo 05652-000, Brazil
Márcio Dias de Almeida, Department of Liver Transplant, Hospital Israelita Albert Einstein, São Paulo 05652-900, Brazil
Ronaldo Hueb Baroni, Department of Radiology, Hospital Israelita Albert Einstein, São Paulo 05652-000, Brazil
Nelson Wolosker, Department of Vascular Surgery, Hospital Israelita Albert Einstein, São Paulo 05652-000, Brazil
Author contributions: Galastri FL designed the research study, performed procedures and wrote the paper; Nasser F, Affonso BB and Valle LGM contributed equally to this work, performed procedures and participated in the research; Odísio BC contributed to the project and review; Motta-Leal Filho JM and Salvalaggio PR contributed equally with research and statistical analysis; Garcia RG and Baroni RH contributed equally to radiological evaluation and analytical tools; de Almeida MD contributed to the clinical evaluation and follow-up of patients; Wolosker N contributed to the study project and writing of the paper.
Institutional review board statement: This study was approved by the local institutional review board (CAAE 0199.0.028.000-11).
Informed consent statement: Written informed consent was obtained from all patients in this study.
Conflict-of-interest statement: The authors declare that they have no conflicts of interest.
STROBE statement: The authors have read the STROBE statement, and the manuscript was prepared and revised according to the STROBE statement.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Corresponding author: Francisco Leonardo Galastri, MD, PhD, Staff Physician, Department of Interventional Radiology, Hospital Israelita Albert Einstein, Avenida Albert Einstein, 627, São Paulo 05652-000, Brazil. leogalastri@gmail.com
Received: July 12, 2019
Peer-review started: July 16, 2019
First decision: August 7, 2019
Revised: October 2, 2019
Accepted: December 6, 2019
Article in press: December 6, 2019
Published online: January 27, 2020
Processing time: 181 Days and 8.8 Hours
Abstract
BACKGROUND

Drug-eluting bead transarterial chemoembolization (DEB-TACE) is an endovascular treatment to release chemotherapeutic agents within a target lesion, minimizing systemic exposure and adverse effects to chemotherapeutics. Therefore, identifying which patient characteristics may predict imaging response to DEB-TACE can improve treatment results while selecting the best candidates. Predictors of the response after DEB-TACE still have not been fully elucidated. This is the first prospective study performed with standardized DEB-TACE technique that aim to identify predictors of radiological response, assessing patients clinical and laboratory characteristics, diagnostic imaging and intraprocedure data of the hepatocellular carcinoma treated in the neoadjuvant context for liver transplantation.

AIM

To identify pre- and intraoperative clinical and imaging predictors of the radiological response of drug-eluting bead transarterial chemoembolization (DEB-TACE) for the neoadjuvant treatment of hepatocellular carcinoma (HCC).

METHODS

This is prospective, cohort study, performed in a single transplant center, from 2011 to 2014. Consecutive patients with HCC considered for liver transplant who underwent DEB-TACE in the first session for downstaging or bridging purposes were recruited. Pre and post-chemoembolization imaging studies were performed by computed tomography or magnetic resonance. The radiological response of each individual HCC was evaluated by objective response using mRECIST and the percentage of necrosis.

RESULTS

Two hundred patients with 380 HCCs were examined. Analysis of the objective response (nodule-based analysis) demonstrated that HCC with pseudocapsules had a 2.01 times greater chance of being responders than those without pseudocapsules (P = 0.01), and the addition of every 1mg of chemoembolic agent increased the chance of therapeutic response in 4% (P < 0.001). Analysis of the percentage of necrosis through multiple linear regression revealed that the addition of each 1mg of the chemoembolic agent caused an average increase of 0.65% (P < 0.001) in necrosis in the treated lesion, whereas the hepatocellular carcinoma with pseudocapsules presented 18.27% (P < 0.001) increased necrosis compared to those without pseudocapsules.

CONCLUSION

The presence of a pseudocapsule and the addition of the amount of chemoembolic agent increases the chance of an objective response in hepatocellular carcinoma and increases the percentage of tumor necrosis following drug-eluting bead chemoembolization in the neoadjuvant treatment, prior to liver transplantation.

Keywords: Hepatocellular carcinoma; Liver transplantation; Response evaluation criteria in solid tumors; Neoadjuvant therapy; Liver neoplasms

Core tip: This is the first prospective study performed with standardized drug-eluting bead transarterial chemoembolization technique that aim to identify predictors of radiological response, assessing patients clinical and laboratory characteristics, diagnostic imaging and intraprocedure data of the hepatocellular carcinoma treated in the neoadjuvant context for liver transplantation. Two hundred patients with 380 hepatocellular carcinomas were examined and we could conclude that the presence of a pseudocapsule and the addition of the amount of chemoembolic agent increases the chance of an objective response and increases the percentage of tumor necrosis in hepatocellular carcinoma following drug-eluting bead chemoembolization in the neoadjuvant treatment, prior to liver transplantation.