Lack of Response to Transarterial Chemoembolization for Intermediate-Stage Hepatocellular Carcinoma: Abandon or Repeat?-猫眼课题宝

中期肝细胞癌经动脉化疗栓塞缺乏反应：放弃还是重复？

DOI：

10.1148/radiol.2021202289

发表时间：

2021-03-01

期刊：

RADIOLOGY

影响因子：

19.7

通讯作者：

中科院分区：

医学1区

文献类型：

--

作者：

Chen, Shuling;Peng, Zhenwei;Kuang, Ming

背景经动脉化疗栓塞术（TACE）是中期肝细胞癌（HCC）的标准治疗方法。目前尚不清楚中期HCC患者在初始无应答后是否应继续或放弃常规TACE（cTACE）。放弃cTACE前的最佳治疗次数仍有争议。目的：定义对治疗无应答的患者（以下称为无应答者，疾病稳定[SD]或疾病进展[PD]）在放弃cTACE前应接受的疗程数。材料与方法回顾性纳入了来自三个中心的中期HCC和Child-Pugh A肝功能患者，这些患者在2005年1月至2012年12月期间接受了连续的cTACE治疗。评价每次治疗的放射学缓解率及其与总生存率的相关性。根据改良的实体瘤疗效评价标准评估疗效。通过使用肿瘤大小、肿瘤包膜和甲胎蛋白构建的诺模图预测对治疗有反应的患者（以下称为反应者），并验证其灵敏度和特异性。结果本研究评估了4154例患者（平均年龄，58岁± 6岁[标准差]; 3777例男性;主要队列，3442例患者[平均年龄，58岁± 6岁; 3129例男性];验证队列，712例患者[平均年龄，58岁± 7岁; 648例男性]）。首次cTACE的缓解率为35.6%（3442例中的1227例，主要队列）和36.7%（712例中的261例，验证队列）。对于首次cTACE无应答的SD患者，第二次cTACE后的应答率为46.1%（719/1560）和48.4%（147/304）;对于第二次cTACE治疗无应答的SD患者，第三次cTACE治疗后的应答率分别为58.3%（591/1014）和48.5%（98/202）。对于第三、第四和第五次cTACE治疗无应答的SD患者，第四、第五和第六次cTACE治疗后的应答率低于10%。对下一次cTACE无应答的PD患者的所有应答率均低于5%。第一次、第二次和第三次cTACE的应答者的5年总生存率高于无应答者（均P <0.001），但第四次cTACE的应答者的5年总生存率则无差异（P = 0.21）。诺模图预测第三次cTACE应答者的灵敏度和特异性分别为：75.0%和79.4%（内部验证）以及78.6%和87.0%（外部验证）。结论中期肝癌患者在放弃常规肝动脉栓塞（cTACE）治疗前，应进行3次治疗。本研究中开发的列线图确定了第三次cTACE的应答者。© RSNA，2021可为本文提供在线补充材料。另见Georgiades在本期的社论。

Background Transarterial chemoembolization (TACE) is the standard treatment for intermediate-stage hepatocellular carcinoma (HCC). It is unknown whether conventional TACE (cTACE) should be continued or abandoned after initial nonresponse for intermediate-stage HCC. The optimal number of sessions before abandoning cTACE remains debated. Purpose To define the number of sessions that patients who do not respond to treatment (hereafter, nonresponders, with stable disease [SD] or progressive disease [PD]) should undergo before abandoning cTACE. Materials and Methods Patients with intermediate-stage HCC and Child-Pugh A liver function who underwent consecutive cTACE sessions between January 2005 and December 2012 were retrospectively included from three centers. Radiologic response rate to each session and its correlation with overall survival were evaluated. Response was assessed by modified Response Evaluation Criteria in Solid Tumors. A nomogram constructed by using tumor size, tumor capsule, and α-fetoprotein to predict patients who responded to treatment (hereafter, responders) was validated with sensitivity and specificity. Results This study evaluated 4154 patients (mean age, 58 years ± 6 [standard deviation]; 3777 men; primary cohort, 3442 patients [mean age, 58 years ± 6; 3129 men]; validation cohort, 712 patients [mean age, 58 years ± 7; 648 men]). Response rate to first cTACE was 35.6% (1227 of 3442, primary cohort) and 36.7% (261 of 712, validation cohort). For patients with SD who were nonresponders to first cTACE, the response rates after second cTACE were 46.1% (719 of 1560) and 48.4% (147 of 304); for patients with SD who were nonresponders to the second cTACE session, the response rates after the third cTACE session were 58.3% (591 of 1014) and 48.5% (98 of 202). For patients with SD who were nonresponders to third, fourth, and fifth cTACE sessions, response rates after fourth, fifth, and sixth cTACE sessions were less than 10%. All response rates in patients with PD who were nonresponders to the next cTACE were less than 5%. Responders to first, second, and third cTACE had higher 5-year overall survival than nonresponders (all P < .001) but responders to the fourth cTACE did not (P = .21). The sensitivity and specificity of a nomogram predicted responders to third cTACE: 75.0% and 79.4% (internal validation) and 78.6% and 87.0% (external validation), respectively. Conclusion Three sessions were recommended before abandoning conventional transarterial embolization (cTACE) for intermediate-stage hepatocellular carcinoma. The nomogram developed in this study identified responders to third cTACE. © RSNA, 2021 Online supplemental material is available for this article. See also the editorial by Georgiades in this issue.