Morbidity and mortality following transarterial liver chemoembolization in patients with hepatocellular carcinoma and synthetic hepatic dysfunction

Departments of Radiology and Biomedical Imaging, University of California San Francisco.
Liver Transplantation (Impact Factor: 4.24). 02/2013; 19(2). DOI: 10.1002/lt.23552
Source: PubMed


PURPOSE: To determine the rate and risk factors for development of irreversible hepatotoxicity following transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) and synthetic hepatic dysfunction. MATERIALS AND METHODS: 251 consecutive patients with HCC and hepatic dysfunction who underwent 443 TACE procedures from 2005 - 2009 were retrospectively reviewed. Included patients met one of the following criteria: pre-TACE bilirubin >2mg/dl, international normalized ratio (INR) >1.5, creatinine >1.2 mg/dL, platelet count <60,000/mL, Model for End-Stage Liver Disease (MELD) score >15, Child-Turcotte-Pugh class B or C, ascites, or portal venous thrombus. Hepatotoxicity was defined as new or worsening ascites, encephalopathy, or NCI Common Terminology Criteria for Adverse Events grade 3 or 4 toxicity of bilirubin, AST, ALT, creatinine or INR. Rate and risk factors for death or urgent liver transplantation within 6 weeks of TACE and irreversible hepatotoxicity were determined using generalized estimating equation analysis. RESULTS: Reversible hepatotoxicity developed after 90 procedures (20%) in 78 patients (31%). Irreversible hepatotoxicity developed after 41 procedures (9%) in 37 patients (15%). Six patients (2%) received urgent liver transplants, and 11 (4%) died within 6 weeks of TACE. Patients at increased risk for procedure-related mortality or urgent liver transplantation within 6 weeks from TACE had baseline serum bilirubin over 4.0mg/dL (p=0.012), elevated INR (p<0.0001), hypoalbuminemia less than 2.0g/L (p=0.014), serum creatinine over 2.0mg/dl (p=0.017), large ascites (p=0.002), encephalopathy (p=0.0047), or MELD >20 (p<0.0004). CONCLUSION: TACE can be performed safely in patients with baseline hepatic dysfunction. However, poor hepatic reserve increases the risk of irreversible hepatotoxicity, which may lead to death or require urgent liver transplantation. Liver Transpl, 2012. © 2012 AASLD.

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    ABSTRACT: Background Transarterial chemoembolization (TACE) is recommended as a treatment for unresectable hepatocellular carcinoma (HCC) in patients with normal underlying liver function. The efficacy of TACE in cirrhotic patients with compromised liver function is unknown. Methods All ‘first’ TACE interventions for HCC performed at a single institution from 2008 to 2012 were retrospectively reviewed (n = 190). Liver function was quantified via the Child's score. Tumour necrosis after TACE was quantified via the mRECIST criteria. ResultsThe ‘first’ TACE procedures of 100 Child's A and 90 Child's B/C cirrhotic patients were evaluated. As expected, the lab-model for end-stage liver disease (MELD) score was significantly higher in the Child's B/C group. Although the number of tumours were similar between the groups, both the size of the largest tumour and the total tumour diameter were greater in the Child's A group. There were no significant differences in post-TACE tumour necrosis between groups. The median survival after TACE was significantly longer in the Child's A compared with Child's B/C patients (21.9 versus 13.7 months, P = 0.03). ConclusionsTACE appears to be equally efficacious in cirrhotic patients regardless of their Child's classification based upon equivalent mRECIST measures of tumour necrosis. However, inferior survival after TACE was observed in the Child's B/C group.
    No preview · Article · Dec 2013 · HPB
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    ABSTRACT: To investigate sequential changes in laboratory markers after radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) and the relationship of these changes to the severity of the underlying liver disease. This retrospective analysis included 65 patients (44 males, 21 females) who underwent RFA of HCC. Hematologic and biochemical markers were assessed at the pre-RFA period and 1 day, 2-3 days, and 1-2 weeks after RFA. We classified the subjects into two groups: Child-Pugh A (n=41) and Child-Pugh B (n=24). The ablative margin volume (AMV) of each patient was measured. We analyzed the changes in laboratory profiles from the baseline, and investigated whether these laboratory changes were correlated with the AMV and the Child-Pugh classification. Most of the laboratory values peaked at 2-3 days after RFA. AMV was significantly correlated with changes in WBC count, hemoglobin level, and serum total bilirubin level (Pearson's correlation coefficient, 0.324-0.453; P<0.05). The alanine aminotransferase (ALT) level varied significantly over time (P=0.023). Most of the measured laboratory markers changed from baseline, peaking at 2-3 days. The ALT level was the only parameter for which there was a significant difference after RFA between Child-Pugh A and B patients: it increased significantly more in the Child-Pugh A patients.
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    ABSTRACT: Introduction: Hepatocellular carcinoma (HCC) is a leading cause of mortality among cirrhotic patients , and current guidelines recommend single-treatment modalities according to patient and liver disease classifications. New studies have shown promising results from combining locore-gional and systemic treatments, but most of them were limited to Child-Pugh A patients due to toxicity concerns. Aim: The objective of this study was to analyze survival rates of Child-Pugh A and B patients with intermediate HCC tumors treated with transarterial chemoembolization (TACE) followed by full-dose sorafenib usage. Material and methods: a retrospective analysis of 37 cirrhotic patients (Child-Pugh A and B rates = 23/14) treated with TACE and TACE followed by so-rafenib usage (17 and 20 patients, respectively). Results: The mean survival was 379 days in the combined treatment group and 151 days in the single-treatment group (p = 0.007). There were no differences in survival according to the Child-Pugh classification. Conclusions: sorafenib after TACE can be an option for selected cirrhotic patients with intermediate HCC tumors if this com
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