Combined endovascular brachytherapy, sorafenib, and transarterial chemobolization therapy for hepatocellular carcinoma patients with portal vein tumor thrombus

Abstract

Aim: To evaluate the safety and efficacy of combined endovascular brachytherapy (EVBT), transarterial chemoembolization (TACE), and sorafenib to treat hepatocellular carcinoma (HCC) patients with main portal vein tumor thrombus (MPVTT).

Methods: This single-center retrospective study involved 68 patients with unresectable HCC or those who were unfit for liver transplantation and percutaneous frequency ablation according to the BCLC classification. All patients had Child-Pugh classification grade A or B, Eastern Cooperative Oncology Group (ECOG) performance status of 0-2, and MPVTT. The patients received either EVBT with stent placement, TACE, and sorafenib (group A, n = 37), or TACE with sorafenib (group B, n = 31). The time to progression (TTP) and overall survival (OS) were evaluated by propensity score analysis.

Results: In the entire cohort, the 6-, 12-, and 24-mo survival rates were 88.9%, 54.3%, and 14.1% in group A, and 45.8%, 0%, and 0% in group B, respectively (P < 0.001). The median TTP and OS were significantly longer in group A than group B (TTP: 9.0 mo vs 3.4 mo, P < 0.001; OS: 12.3 mo vs 5.2 mo, P < 0.001). In the propensity score-matched cohort, the median OS was longer in group A than in group B (10.3 mo vs 6.0 mo, P < 0.001). Similarly, the median TTP was longer in group A than in group B (9.0 mo vs 3.4 mo, P < 0.001). Multivariate Cox analysis revealed that the EVBT combined with stent placement, TACE, and sorafenib strategy was an independent predictor of favorable OS (HR = 0.18, P < 0.001).

Conclusion: EVBT combined with stent placement, TACE, and sorafenib might be a safe and effective palliative treatment option for MPVTT.

Keywords: Endovascular brachytherapy; Hepatocellular carcinoma; Main portal vein tumor thrombus; Sorafenib; Transarterial chemoembolization.

Figure 1

Images from a 50-year-old man who had hepatocellular carcinoma with main portal vein tumor thrombus. A: Contrast-enhanced abdominal magnetic resonance imaging before therapy. Diffuse hepatocellular carcinoma (white arrow) was detected in the left lobe. B: The second order of the right portal vein (black arrow) was patent. Tumor thrombus (white arrow) was observed in the left portal vein, the first order of the right portal vein, and the main portal vein. C: Contrast-enhanced abdominal CT image 24 mo after first therapy. Deposition of iodized oil (white arrow) within tumor was observed and the left lobe was atrophied. D: The stent was still patent (white arrow).

Figure 2

Images of iodine-125 seed strand and stent placement. A: After the patent second-order branch of the left portal vein was catheterized, a 5-F calibrated pigtail catheter (white arrow) was placed in the splenic vein. Tumor thrombus (black arrows) in the proximal MPV and sagittal segment of right portal vein was shown clearly on portography, but the right portal vein did not develop. B: A 14-mm x 80-mm self-expandable stent (black arrow) and ¹²⁵I seed strand (white arrow) with 20 seeds loaded were placed precisely in the obstructed MPV. C: Images of SPECT/CT scan 1 d after therapy. MPV: Main portal vein.

Figure 3

Patient selection and cohorting. MPVTT: Main portal vein tumor thrombus; HCC: Hepatocellular carcinoma; TACE: Transarterial chemoembolization; EVBT: Endovascular brachytherapy.

Figure 4

Overall survival of the overall cohort and matched cohort. A: Kaplan-Meier curves for the overall patient cohort. OS differed between the two groups (OS, 12.3 vs 5.2 mo; P < 0.001); B: Kaplan-Meier curves for disease free survival in the overall patient cohort. C: Kaplan-Meier curves for OS in propensity score-matched patiens. Median OS was longer in group A than in group B (10.3 vs 6.0 mo; P < 0.001); D: Kaplan-Meier curves for disease free survival in propensity score-matched