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CASE REPORT
Year : 2020  |  Volume : 16  |  Issue : 5  |  Page : 1186-1190

Safety and efficacy of the combination therapy of transcatheter arterial chemoembolization and ablation for hepatocellular carcinoma with inferior vena cava tumor thrombus: A consecutive case series


1 Cancer Center, Beijing Ditan Hospital, Capital Medical University, Beijing, China
2 Center of Interventional Oncology and Liver Diseases, Beijing Youan Hospital, Capital Medical University, Beijing, China

Date of Submission20-Nov-2019
Date of Decision13-Jul-2020
Date of Acceptance20-Nov-2019
Date of Web Publication29-Sep-2020

Correspondence Address:
Jiasheng Zheng
No. 8, Xi Tou Tiao, Youanmen Wai, Fengtai District, Beijing
China
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/jcrt.JCRT_1005_19

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 > Abstract 


This study was designed to propose a classification of inferior vena cava tumor thrombus (IVCTT) and retrospectively evaluate the safety and efficacy of the combination therapy of transcatheter arterial chemoembolization (TACE) and sequential percutaneous ablation for hepatocellular carcinoma (HCC) with IVCTT. All HCC patients with IVCTT who underwent the combination therapies of TACE and sequential percutaneous ablation therapy between January 2015 and December 2017 in Beijing Youan Hospital were included in the study. The demographic, clinical, and pathological data were recorded. The response rate and overall survival (OS) rate were statistically analyzed. A classification system of IVCTT types was proposed based on the anatomical structure and ablation technique, which contained five types of IVCTT. Different types of IVCTT require different ablation strategies. For the response rate of IVCTT, complete response was achieved in all six patients. The 1- and 2-year OS rates were 88.3% and 55.6%, respectively. The new classification system and corresponding ablation strategies proposed in this study provided guidance for the use of ablation therapy for IVCTT. The combination therapy of TACE and ablation is effective and safe for treating HCC with IVCTT.

Keywords: Ablation, classification, hepatocellular carcinoma, inferior vena cava tumor, thrombus, transcatheter arterial chemoembolization


How to cite this article:
Liu B, Li W, Zheng J. Safety and efficacy of the combination therapy of transcatheter arterial chemoembolization and ablation for hepatocellular carcinoma with inferior vena cava tumor thrombus: A consecutive case series. J Can Res Ther 2020;16:1186-90

How to cite this URL:
Liu B, Li W, Zheng J. Safety and efficacy of the combination therapy of transcatheter arterial chemoembolization and ablation for hepatocellular carcinoma with inferior vena cava tumor thrombus: A consecutive case series. J Can Res Ther [serial online] 2020 [cited 2020 Oct 26];16:1186-90. Available from: https://www.cancerjournal.net/text.asp?2020/16/5/1186/296420




 > Introduction Top


Hepatocellular carcinoma (HCC) is a highly aggressive neoplasm with a high rate of extrahepatic metastasis and macroscopic vascular invasion.[1] HCC presents with inferior vena cava tumor thrombus (IVCTT) in 3.8% of cases.[2] Without treatment, the median overall survival (OS) is 3 months.[3],[4]

The aim of this article was to propose a new classification for the IVCTT based on the ablation strategy and retrospectively evaluate the safety and efficacy of the combination of transcatheter arterial chemoembolization (TACE) and sequential percutaneous ablation therapy for HCC with IVCTT.


 > Case Report Top


A total of six consecutive HCC patients with IVCTT who underwent the combination treatments of TACE and sequential percutaneous ablation at the Center of Interventional Oncology and Liver Diseases, Beijing Youan Hospital, at Capital Medical University between January 2015 and October 2017 were included in this study. The diagnosis of IVCTT was confirmed by the observation of an intraluminal filling defect on venous phase contrast-enhanced computed tomography (CT) or dynamic magnetic resonance imaging (MRI). In addition, to distinguish tumor thrombus (TT) and bland thrombus, we followed the methods introduced by Rohatgi et al.[5] and used either contrast-enhanced CT or MRI. The clinical characteristics of all patients are reported in [Table 1].
Table 1: Basic characteristics of all involved patients

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The 1- and 2-year OS rates following treatment were 88.3% and 55.6%, respectively. During the follow-up time, two of six patients died. However, there were no IVCTT-related deaths. The median follow-up time was 23 months. Reasons for the two deaths include poor physical condition and intrahepatic tumor progression. The poor physical condition was mainly attributable to the biloma induced by one of the ablation applications for subsequent intrahepatic recurrence. The intrahepatic tumor progression included tumor recurrence and the formation of portal vein TT. The second death was attributable to multiple intrahepatic recurrences in both left and right lobes.

The response rates of IVCTT to combined TACE and ablation treatments were evaluated according to the modified response evaluation criteria in solid tumors, based on the arterial phase of the contrast-enhanced CT/MRI images, which were performed 4 months after the last ablation. For the response of IVCTT, complete response (CR) was achieved in all six patients, and the CR rate of IVCTT was 100% [Figure 1] and [Figure 2].
Figure 1: Preoperative and intraoperative images of a 67-year-old patient. (a) The image of venous phase in the axial view which shows the inferior vena cava tumor thrombus. (b) The image of the tumor in segment I in axial view. (c) The image of the tumor and the inferior vena cava tumor thrombus that was above the diaphragm in coronal view. (d) The front three-dimensional image of the abdomen in coronal view, showing the tumor and inferior vena cava tumor thrombus. (e) The lateral three-dimensional image of the abdomen in the coronal view, showing the tumor and inferior vena cava tumor thrombus. (f) The ablation of the inferior vena cava tumor thrombus. (g) The ablation of the tumor.

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Figure 2: The postoperative computed tomography scans of a 67-year-old patient. (A) One month after the last ablation showing a low density of tumor area. (B) Four months after the last ablation, which shows a low density of tumor area. (C) Seventeen months after the last ablation which shows an obvious reduction of the low-density area

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No serious adverse event was observed in any of the six patients. All complications were resolved after conservative therapy within 12 days. The average postoperative hospital stay was 8 days. There were no deaths related to treatment.

Here, we illustrate a classification system of IVCTT based on the anatomical structure, placement, and intrusion and the corresponding ablation strategy, note that the anatomical structure provides guidance for the associated ablation therapy [Figure 3].
Figure 3: The classification of inferior vena cava tumor thrombus (A: Type, B: Type II, C: Type III, D: Type IV, and E: Type V) and the ablation strategies for different types of inferior vena cava tumor thrombus (A-1 to A-5: ablation strategy for Type II VCTT, B-1 to B-4: ablation strategy for Type II inferior vena cava tumor thrombus, C-1 to C-3: ablation strategy for Type III inferior vena cava tumor thrombus, and D-1 to D-2: ablation for Type IV inferior vena cava tumor thrombus)

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  • Type I: the IVCTT is under, or at, the hepatic vein TT level in the sagittal view
  • Type II: the IVCTT is above the hepatic vein TT level and under the diaphragm level in the sagittal view
  • Type III: the IVCTT is above the diaphragm level but outside the right atrium (RA) entrance
  • Type IV: the IVCTT extends into RA, and the length of TT within the RA is less than 2 cm
  • Type V: the IVCTT extends into RA, and the length of TT within RA is more than 2 cm.



 > Discussion Top


This study revealed that the combination therapy of TACE and sequential percutaneous ablation had a remarkable efficacy for treating HCC with IVCTT, with the CR rate of IVCTT at 100%. To the best of our knowledge, the CR rate of IVCTT reported in this study exceeds any other published reports (2%–37%).[6],[7],[8] What is more, significant survival benefit was achieved, with a median OS of 27 months and the 1- and 2-year OS rates of 88.3% and 55.6%, respectively; this far exceeds that of sorafenib (10 months and 27%, respectively), the recommended treatment of the Barcelona Clinic Liver Cancer staging system.[9] The survival outcome reported in this study exceeded that of the two most effective therapies among all reported treatments: resection (15–19 months and 53%)[4],[10],[11],[12],[13] and radiotherapy (13–25 months and 68%).[7],[14],[15]

To date, we lack a worldwide standard treatment modality for HCC with IVCTT. The most two prevalent treatments are surgery and radiotherapy. While surgery significantly increases survival, only a small number of HCC patients with IVCTT are viable surgical candidates.[13] Radiotherapy is another widespread therapy for treating HCC with IVCTT.[16] Some studies report that particle radiotherapy was effective for tumor, node, and metastasis (TNM) Stage III B patients, with a median OS of 25.4 months.[15] However, for TNM Stage IV patients with HCC, this same treatment resulted in a median OS of only 8 months.[15]

The new classification system and corresponding ablation strategies proposed in this study provide formal guidance for ablation therapy for IVCTT. We also report a consecutive case series documenting that the combination treatments of TACE and ablation are safe and highly effective for treating HCC with IVCTT.

Acknowledgment

Prof. Jiasheng Zheng received a grant, which is the National Major Scientific Instruments and Equipments Development Project (ZDYZ2015-2).

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

This study was financially supported by the National Major Scientific Instruments and Equipments Development Project (ZDYZ2015-2).

Conflicts of interest

There are no conflicts of interest.



 
 > References Top

1.
Yuan C, Yuan Z, Cui X, Gao W, Zhao P, He N, et al. Efficacy of ultrasound-, computed tomography-, and magnetic resonance imaging-guided radiofrequency ablation for hepatocellular carcinoma. J Cancer Res Ther 2019;15:784-92.  Back to cited text no. 1
    
2.
Lee IJ, Chung JW, Kim HC, Yin YH, So YH, Jeon UB, et al. Extrahepatic collateral artery supply to the tumor thrombi of hepatocellular carcinoma invading inferior vena cava: The prevalence and determinant factors. J Vasc Interv Radiol 2009;20:22-9.  Back to cited text no. 2
    
3.
Le Treut YP, Hardwigsen J, Ananian P, Saïsse J, Grégoire E, Richa H, et al. Resection of hepatocellular carcinoma with tumor thrombus in the major vasculature. A European case-control series. J Gastrointest Surg 2006;10:855-62.  Back to cited text no. 3
    
4.
Wang Y, Yuan L, Ge RL, Sun Y, Wei G. Survival benefit of surgical treatment for hepatocellular carcinoma with inferior vena cava/right atrium tumor thrombus: Results of a retrospective cohort study. Ann Surg Oncol 2013;20:914-22.  Back to cited text no. 4
    
5.
Rohatgi S, Howard SA, Tirumani SH, Ramaiya NH, Krajewski KM. Multimodality imaging of tumour thrombus. Can Assoc Radiol J 2015;66:121-9.  Back to cited text no. 5
    
6.
Koo JE, Kim JH, Lim YS, Park SJ, Won HJ, Sung KB, et al. Combination of transarterial chemoembolization and three-dimensional conformal radiotherapy for hepatocellular carcinoma with inferior vena cava tumor thrombus. Int J Radiat Oncol Biol Phys 2010;78:180-7.  Back to cited text no. 6
    
7.
Xi M, Zhang L, Zhao L, Li QQ, Guo SP, Feng ZZ, et al. Effectiveness of stereotactic body radiotherapy for hepatocellular carcinoma with portal vein and/or inferior vena cava tumor thrombosis. PLoS One 2013;8:e63864.  Back to cited text no. 7
    
8.
Zheng JS, Long J, Sun B, Lu NN, Fang D, Zhao LY, et al. Transcatheter arterial chemoembolization combined with radiofrequency ablation can improve survival of patients with hepatocellular carcinoma with portal vein tumour thrombosis: Extending the indication for ablation? Clin Radiol 2014;69:e253-63.  Back to cited text no. 8
    
9.
Bruix J, Raoul JL, Sherman M, Mazzaferro V, Bolondi L, Craxi A, et al. Efficacy and safety of sorafenib in patients with advanced hepatocellular carcinoma: Subanalyses of a phase III trial. J Hepatol 2012;57:821-9.  Back to cited text no. 9
    
10.
Li AJ, Zhou WP, Lin C, Lang XL, Wang ZG, Yang XY, et al. Surgical treatment of hepatocellular carcinoma with inferior vena cava tumor thrombus: A new classification for surgical guidance. Hepatobiliary Pancreat Dis Int 2013;12:263-9.  Back to cited text no. 10
    
11.
Kokudo T, Hasegawa K, Yamamoto S, Shindoh J, Takemura N, Aoki T, et al. Surgical treatment of hepatocellular carcinoma associated with hepatic vein tumor thrombosis. J Hepatol 2014;61:583-8.  Back to cited text no. 11
    
12.
Kasai Y, Hatano E, Seo S, Taura K, Yasuchika K, Okajima H, et al. Proposal of selection criteria for operative resection of hepatocellular carcinoma with inferior vena cava tumor thrombus incorporating hepatic arterial infusion chemotherapy. Surgery 2017;162:742-51.  Back to cited text no. 12
    
13.
Kokudo T, Hasegawa K, Matsuyama Y, Takayama T, Izumi N, Kadoya M, et al. Liver resection for hepatocellular carcinoma associated with hepatic vein invasion: A Japanese nationwide survey. Hepatology 2017;66:510-7.  Back to cited text no. 13
    
14.
Hou JZ, Zeng ZC, Wang BL, Yang P, Zhang JY, Mo HF. High dose radiotherapy with image-guided hypo-IMRT for hepatocellular carcinoma with portal vein and/or inferior vena cava tumor thrombi is more feasible and efficacious than conventional 3D-CRT. Jpn J Clin Oncol 2016;46:357-62.  Back to cited text no. 14
    
15.
Komatsu S, Kido M, Asari S, Toyama H, Ajiki T, Demizu Y, et al. Particle radiotherapy, a novel external radiation therapy, versus liver resection for hepatocellular carcinoma accompanied with inferior vena cava tumor thrombus: A matched-pair analysis. Surgery 2017;162:1241-9.  Back to cited text no. 15
    
16.
Duan F, Yu W, Wang Y, Liu FY, Song P, Wang ZJ, et al. Trans-arterial chemoembolization and external beam radiation therapy for treatment of hepatocellular carcinoma with a tumor thrombus in the inferior vena cava and right atrium. Cancer Imaging 2015;15:7.  Back to cited text no. 16
    


    Figures

  [Figure 1], [Figure 2], [Figure 3]
 
 
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