Korean J Radiol.  2015 Dec;16(6):1283-1293. 10.3348/kjr.2015.16.6.1283.

The Safety and Clinical Outcomes of Chemoembolization in Child-Pugh Class C Patients with Hepatocellular Carcinomas

• Choi TW
• Kim HC
• Lee JH
• Yu SJ
• Kang B
• Hur S
• Lee M
• Jae HJ
• Chung JW

• KMID: 2344283
• DOI: http://doi.org/10.3348/kjr.2015.16.6.1283

Abstract

OBJECTIVE
To evaluate the safety and clinical outcomes of chemoembolization in Child-Pugh class C patients with hepatocellular carcinomas (HCC).
MATERIALS AND METHODS
The study comprised 55 patients with HCC who were classified as Child-Pugh class C and who underwent initial chemoembolization between January 2003 and December 2012. Selective chemoembolization was performed in all technically feasible cases to minimize procedure-related complications. All adverse events within 30 days were recorded using the Common Terminology Criteria for Adverse Events (CTCAE). The tumor response to chemoembolization was evaluated using the modified Response Evaluation Criteria In Solid Tumors.
RESULTS
Thirty (54.5%) patients were within the Milan criteria, and 25 (45.5%) were beyond. The mortality of study subjects at 30 days was 5.5%. Major complications were observed in five (9.1%) patients who were all beyond the Milan criteria: two hepatic failures, one hepatic encephalopathy, and two CTCAE grade 3 increases in aspartate aminotransferase/alanine aminotransferase abnormality. The mean length of hospitalization was 6.3 ± 8.3 days (standard deviation), and 18 (32.7%) patients were discharged on the next day after chemoembolization. The tumor responses of the patients who met the Milan criteria were significantly higher (p = 0.014) than those of the patients who did not. The overall median survival was 7.1 months (95% confidence interval: 4.4-9.8 months).
CONCLUSION
Even in patients with Child-Pugh class C, chemoembolization can be performed safely with a selective technique in selected cases with a small tumor burden.

Keyword

Hepatocellular carcinoma; Chemoembolization; Liver cirrhosis; Liver failure; Safety

MeSH Terms

Adult
Aged
Alanine Transaminase/metabolism
Aspartate Aminotransferases/metabolism
Carcinoma, Hepatocellular/mortality/*pathology/therapy
Chemoembolization, Therapeutic/adverse effects
Female
Hepatic Encephalopathy/etiology
Humans
Length of Stay
Liver Neoplasms/mortality/*pathology/therapy
Liver Transplantation
Male
Middle Aged
Proportional Hazards Models
Severity of Illness Index
Survival Rate
Treatment Outcome
Tumor Burden
Alanine Transaminase
Aspartate Aminotransferases

Figure

• 

  Fig. 1 52-year-old woman with Child-Pugh class C liver cirrhosis. A. Axial CT image obtained at arterial phase shows 4.5 cm arterial enhancing mass (arrowheads) in segment 4 of liver. Note cirrhotic liver and large amount of ascites. B. Celiac arteriography shows hypervascular tumor staining (arrowhead) that is supplied by two prominent feeding arteries from left hepatic artery. C. Tip of microcatheter (arrowhead) was placed at distal portion of one of tumor-feeding arteries and followed by infusion of iodized oil emulsion. D. Thereafter, other tumor-feeding branch from left hepatic artery was selected and catheterized with microcatheter (arrowhead), and chemoembolization was performed. Spot image obtained during chemoembolization shows additional dense accumulation of iodized oil in tumor and oily portogram around tumor. E. Arterial phase image of follow-up liver CT scan shows dense accumulation of iodized oil in previously noted hepatocellular carcinoma in segment 4 (arrowheads) with no evidence of viable tumor.

• 

  Fig. 2 Cumulative survival rates according to prognostic factors. A. Survival curves of patients whose ECOG performance status was 1 vs. more than 1 (median survival time, 12.9 months; 95% CI, 4.3-21.5 vs. 4.0 months; 95% CI, 0-8.2, p = 0.003). B. Survival curves of patients whose tumor burden was within Milan criteria vs. beyond Milan criteria (median survival time, 10.6 months; 95% CI, 6.2-15.0 vs. 3.3 months; 95% CI, 2.5-4.1, p < 0.001). C. Survival curves of patients with serum aspartate aminotransferase levels ≤ 80 IU/L vs. > 80 IU/L (median survival time, 9.8 months; 95% CI, 6.8-12.9 vs. 3.4 months; 95% CI, 2.4-4.4, p = 0.004). D. Survival curves of patients with presence of tumor response (complete or partial response) vs. absence of tumor response (stable or progressive disease) (median survival time, 13.4 months; 95% CI, 8.8-18.1 vs. 2.8 months; 95% CI, 1.8-3.9, p < 0.001). AST = aspartate aminotransferase, CI = confidence interval, CR = complete response, ECOG = Eastern Cooperative Oncology Group, PD = progressive disease, PR = partial response, SD = stable disease

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