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The role of adjuvant TACE after curative liver resection for HCC. Anthony Fong Prince of Wales Hospital. Hepatocellular Carcinoma. 1. Surgeon. 2005 Jun;3(3):210-5. The continuing challenge of hepatic cancer in Asia. Lai EC, Lau WY. J Am Coll Surg. 2007 Jul;205(1):27-36.

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the role of adjuvant tace after curative liver resection for hcc

The role of adjuvant TACE after curative liver resection for HCC

Anthony Fong

Prince of Wales Hospital

hepatocellular carcinoma
Hepatocellular Carcinoma

1. Surgeon. 2005 Jun;3(3):210-5.

The continuing challenge of hepatic cancer in Asia.

Lai EC, Lau WY. J Am Coll Surg. 2007 Jul;205(1):27-36.

2. Parkin DM, Bray F, Ferlay J, Pisani P. Global cancer statistics,

2002. CA Cancer J Clin 2005; 55: 74–108

5th most common cancer in the world

> 500,000 new cases per year

600,000 people die globally due to HCC each year

curative treatment for hcc
Curative treatment for HCC
  • Surgical resection / transplantation
  • Loco-regional ablation
    • Radiofrequency ablation
    • Microwave ablation
surgical resection
Surgical resection

1. Lang H, Sotiropoulos GC, Brokalaki EI, Schmitz KJ, Bertona C, Meyer G, Frilling A, Paul A, Malagó M, Broelsch CE.

Survival and recurrence rates after resection for hepatocellular carcinoma in noncirrhotic livers.

J Am Coll Surg. 2007 Jul;205(1):27-36.

2. Dupont-Bierre E, Compagnon P, Raoul JL, Fayet G, de Lajarte-Thirouard AS, Boudjema K.

Resection of hepatocellular carcinoma in noncirrhotic liver: analysis of risk factors for survival.

J Am Coll Surg 2005; 201: 663–70

3. mamura H, Matsuyama Y, Tanaka E et al.

Risk factors contributing to early and late phase intrahepatic recurrence of hepatocellular carcinoma after hepatectomy.

J Hepatol 2003; 38: 200–7.

  • Poor survival rate despite curative resection
    • 5-year survivals of 39% - 50%
  • High recurrence rate
    • 1,3,5 years recurrence rate : 30.1%, 62.3%, 79% respectively
adjuvant therapy1
Adjuvant Therapy
  • Adjuvant therapy:
    • TACE
    • Systemic chemotherapy
    • Immunotherapy
    • Interferon
    • Acyclic retinoid acid
slide7

TACE

TransArterial ChemoEmbolization

slide8
TACE

Llovet JM, Bruix J

Systematic review of randomized trials for unresectable hepatocellular carcinoma: Chemoembolization improves survival

Hepatology 37:429, 2003

Survival benefit in un-resectable HCC

? TACE as an adjuvant treatment

tace as adjuvant therapy
TACE as adjuvant therapy

Izumi R, Shimizu K, Iyobe T et al. Postoperative adjuvant hepatic arterial infusion of Lipiodol containing anticancer drugs in patients with hepatocellular carcinoma. Hepatology 1994; 20: 295–301.

Lai EC, Lo CM, Fan ST, Liu CL, Wong J. Postoperative adjuvant chemotherapy after curative resection of hepatocellular carcinoma: a randomized controlled trial. Arch Surg 1998; 133: 183–8.

Li Q, Wang J, Sun Y, Cui YL, Juzi JT, Qian BY, Hao XS.Postoperative transhepatic arterial chemoembolization and portal vein chemotherapy for patients with hepatocellular carcinoma: a randomized study with 131 cases.Dig Surg. 2006;23(4):235-40.

Zhong C, Guo RP, Li JQ et al. A randomized controlled trial of hepatectomy with adjuvant transcatheter arterial chemoembolization versus hepatectomy alone for Stage IIIA hepatocellular carcinoma. J Cancer Res Clin Oncol 2009; 135: 1437–45.

Peng BG, He Q, Li JP, Zhou F. Adjuvant transcatheter arterial chemoembolization improves efficacy of hepatectomy for patients with hepatocellular carcinoma and portal vein tumor thrombus. Am J Surg 2009; 198: 313–8.

tace as adjuvant therapy1
TACE as adjuvant therapy

Patient selection – tumor extent

Timing for TACE

Chemotherapy agent

Side effects

tmn staging for hcc
TMN Staging for HCC
  • T-staging
    • T1 - Solitary tumor without vascular invasion
    • T2 - Solitary tumor with vascular invasion or multiple tumors none more than 5 cm
    • T3 - Multiple tumors more than 5 cm or tumor involving a major branch of the portal or hepatic vein(s)
    • T4 - Tumor(s) with direct invasion of adjacent organs other than the gallbladder or with perforation of visceral peritoneum
  • N-staging
    • N0 - Indicates no nodal involvement
    • N1 - Indicates regional nodal involvement
  • M-staging
    • M0 - Indicates no distant metastasis
    • M1 - Indicates metastasis presence beyond the liver
slide14

p = 0.0237

p = 0.5327

p = 0.04

p = 0.10

p = 0.345

p = 0.004

p = 0.048

p = 0.0094

patient selection for adjuvant tace1
Patient selection for adjuvant TACE
  • High risk tumor
    • Tumor size (>5 cm)
    • Vascular invasion
    • Multiple tumor nodules
timing for tace2
Timing for TACE

4 weeks after hepatectomy

Single course already showed survival benefit

agent for tace
Agent for TACE

Doxorubicin

Cisplatin

Doxorubicin

Cisplatin

Carboplatin

Carboplatin

Epirubicin

Doxorubicin

agent for tace1
Agent for TACE

Doxorubicin (Adriamycin) / Epirubicin

Mitomycin

5-FU

Cisplatin / Carboplatin

agents for tace
Agents for TACE

Cleared rapidly by the liver. Large difference in concentration between the liver and systemic circulation

Effective primarily at high doses

side effects1
Side effects

Fever

Nausea / vomiting

Impaired liver function

Leukopenia

Pain

Local complications

our experience1
Our experience
  • 13 Patients underwent adjuvant TACE after liver resection of curative intent
  • Criteria of adjuvant TACE :
    • Large tumor (>5 cm)
    • Satellite nodules
    • Vascular invasion
    • Close surgical margin
our experience3
Our experience

2 Patients had recurrence (15%)

Both from lung metastasis

Disease free survival : 3 mths / 15 mths

1 mortality from recurrence (Overall survival 15mths)

conclusion
Conclusion

Role of adjuvant TACE after curative liver resection is still controversial

Some trials showed promising results in patients with advanced disease

TACE is well tolerated in most studies

Need further large scale study for evaluation