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Research Article| Volume 68, ISSUE 4, P724-732, April 2018

Development of a prognostic score to predict response to Yttrium-90 radioembolization for hepatocellular carcinoma with portal vein invasion

Published:January 10, 2018DOI:https://doi.org/10.1016/j.jhep.2017.12.026

      Highlights

      • A prognostic score for post-TARE survival in patients with HCC and PVTT is proposed.
      • Bilirubin, PVTT extension and tumor burden were independently related to survival.
      • The combination of these factors enabled identification of three prognostic categories.
      • The proposed prognostic categorization may allow better treatment allocation.

      Background & Aims

      Yttrium-90 transarterial radioembolization (TARE) has shown promising efficacy in the treatment of patients with hepatocellular carcinoma (HCC), associated with portal vein tumor thrombus (PVTT). The aim of this study is to identify prognostic factors for survival in patients with HCC and PVTT undergoing TARE, and build a prognostic classification for these patients.

      Methods

      This is a single center retrospective study conducted over six years (2010–2015), on consecutive patients undergoing TARE. Patients were included if they met the following criteria: presence of at least one measurable HCC, presence of PVTT not occluding the main portal trunk, absence of extrahepatic metastases, Child-Pugh score within B7, Eastern Cooperative Oncology Group performance status 0–1. Uni- and multivariable analysis was used to explore the variables that showed an independent relationship with survival. A prognostic score was then derived, and three prognostic categories were identified.

      Results

      A total of 120 patients were included in the study. Median overall survival (OS) was 14.1 months (95% CI 10.7–17.5) and median progression-free survival (PFS) was 6.5 months (95% CI 3.8–9.2). The only variables independently correlated with OS were bilirubin, extension of PVTT and tumor burden. Three prognostic categories were identified: favourable prognosis (0 points), intermediate prognosis (2–3 points) and dismal prognosis (>3 points). Median OS in the three categories was 32.2 months, 14.9 months and 7.8 months respectively (p <0.0001). PFS (p = 0.045) and the risk of liver decompensation (p <0.0001) also significantly differed along the same prognostic categories.

      Conclusions

      Radioembolization with Yttrium-90 is an effective therapy for patients with HCC and PVTT. The proposed prognostic stratification may help to better identify good candidates for the treatment, and those for whom TARE may be futile.

      Lay summary

      Yttrium-90 transarterial radioembolization (TARE) is a microembolic procedure that minimizes alterations to hepatic arterial flow, and thus can be safely performed in patients with hepatocellular carcinoma (HCC) and portal vein tumor thrombus (PVTT). In this study, we retrospectively evaluated the independent predictors of long-term outcomes in patients with HCC and PVTT treated with TARE. Bilirubin level, extension of PVTT and tumor burden were independently related to post-treatment survival: the combination of these factors allowed us to build a prognostic stratification that may help to better identify good candidates for the treatment, and those for whom TARE may be futile.

      Graphical abstract

      Keywords

      Linked Article

      • Validation of response to yttrium-90 radioembolization for hepatocellular carcinoma with portal vein invasion
        Journal of HepatologyVol. 69Issue 1
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          We read with interest the study from Spreafico and colleagues recently published in Journal of Hepatology.1 In this study, the authors retrospectively evaluated predictors of outcome in 120 patients with hepatocellular carcinoma (HCC) and portal vein tumour thrombosis (PVTT) treated with trans-arterial radio-embolization (TARE) over five years. Bilirubin level, extension of PVTT and tumour burden were significant predictors of post-treatment survival. The combination of these factors allowed a prognostic stratification that the authors claimed may help to better identify good candidates as well as poor candidates for this high-cost treatment.
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      • Reply to: “Validation of response to yttrium-90 radioembolization for hepatocellular carcinoma with portal vein invasion”
        Journal of HepatologyVol. 69Issue 1
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          We thank Dr Cucchetti and colleagues for their letter on our recently published proposal of prognostic stratification for patients with hepatocellular carcinoma (HCC) and tumoral portal vein thrombosis (PVTT) undergoing Yttrium-90 trans-arterial radioembolization (TARE).1 By combining three easily available baseline parameters (bilirubin levels, PVTT extension and tumor burden) we found that it is possible to markedly stratify prognosis of patients undergoing TARE, and thus to refine treatment allocation, avoiding futile treatments.
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