Endovascular Brachytherapy In Hepatocellular Carcinoma With Portal Vein Tumour Thrombus

Chapter Ⅰ Endovascular Brachytherapy with Portal Vein Irradiation Stent plus Chemoembolization in Hepatocellular Carcinoma with Portal Vein Tumour Thrombus: A Retrospective StudyObjective: To evaluate the clinical efficacy of endovascular brachytherapy with portal vein irradiation stent implantation combined transcatheter hepatic artery chemoembolization(TACE)in hepatocellular carcinoma(HCC)with portal vein tumour thrombus(PVTT).Methods: From January 2012 to December 2021 at the Affiliated Zhongda Hospital of Southeast University and the Affifiliated Hospital of Jiangsu University,90 patients with HCC complicated by PVTT treated with portal vein irradiation stent implantation plus TACE(n=63)or treated with external radiotherapy plus TACE(n=27)were included in this retrospective study.The primary outcome measure was overall survival,and the secondary outcome was the stent patency period.Multivariate analysis on prognostic factors was carried out through Cox proportional hazard model.Complications were evaluated.Results: At a median follow-up of 11.7(IQR,7～18)months,the median OS was10.8(95% CI: 9.4～15.9)months in the portal vein irradiation stent plus TACE group compared to 7.9(95% CI: 6.7～12.5)months in the external radiotherapy plus TACE group(p=0.030).The technical success rate was 100% and stent occlusion rate was16% with a median patency time of 8.0(IQR: 4～12)months.Multivariate analysis revealed that extrahepatic metastasis,portal vein tumor thrombus in the main trunk,none response and external radiotherapy were independent risk factors affecting the prognosis of this group of patients.No serious adverse events have been observed in both groups.Conclusions: This study shows that portal vein irradiation stent combined with TACE can prolong the survival time of HCC patients with portal vein tumor thrombus(Cheng’s classification Types Ⅱ and Ⅲ).Portal vein irradiation stent combined with TACE is safe and feasible.Chapter ⅡEndovascular Brachytherapy with Portal Vein Irradiation Stent plus TACE and MKI in Hepatocellular Carcinoma with Main Portal Vein Tumor Thrombus:A Retrospective StudyObjective: This part focusing on the safety and clinical effects of endovascular brachytherapy with portal vein irradiation stent combined multitargeted kinase inhibitors(MKI)in the treatment of patients with unresectable hepatocellular carcinoma(HCC)and portal vein tumor thrombus in the main trunk(MPVTT).Methods: From January 2012 to December 2021 at the Affiliated Zhongda Hospital of Southeast University,77 patients with unresectable HCC and MPVTT treated with portal vein irradiation stent implantation plus MKI(Stent+MKI,n=29)or treated with portal vein irradiation stent alone(Stent,n=48)were included in this retrospective study.The primary outcome measure was overall survival,and the secondary outcome was the stent patency period and occurrence of massive gastrointestinal bleeding.The cumulative survival curves of the two groups was created using the Kaplan-Meier method,and the differences were compared using a log rank test.Multivariate analysis on prognostic factors was carried out through Cox proportional hazard model.We carried out a subgroup analysis to explore the sub-populations who may benefit or benefit more from portal vein irradiation stent implantation plus MKI.Results: At a median follow-up of 10(IQR,6~17)months,the median OS was12.7 months in the portal vein irradiation stent implantation plus MKI group compared to 8.2 months in the portal vein irradiation stent group(p=0.025).Multivariate analysis revealed that the liver cirrhosis,left approach and without MKI were independent risk factors affecting the prognosis of this group of patients.The survival benefit of stent combined with MKI group was more obvious in analyzed subgroup,such as no liver cirrhosis,Child-Pugh class A,infiltrative HCC,no extrahepatic metastasis,left approach and Cheng’s classification Types Ⅳ.Stent occlusion was observed in 15patients(15/77,19.5%)with a median patency time of 8.0(IQR: 4~12)months.The incidence of stent blockage was no significant difference between the Stent+MKI and Stent group by Fine-Gray competing risk analysis,17.2% and 20.8%,respectively(p=0.689).There were no diffrenece in deaths related to gastrointestinal bleeding between the Stent group and Stent+MKI group,20.8%(10/48)and 4.5%(1/22),respectively(p=0.154).Conclusions: Endovascular brachytherapy with portal vein irradiation stent combined MKI and TACE can prolong the survival time of HCC patients with main portal vein tumor thrombus.This study reveals that combination therapy does not increase the risk of death related to gastrointestinal bleeding.Chapter ⅢEfficacy Evaluation of Endovascular brachytherapy with Iodine-125 Seeds Strand in Hepatocellular Carcinoma with Extensive Portal Vein Tumor ThrombusObjective: The aim of this part is to investigate the feasibility and effectiveness of endovascular brachytherapy with iodine 125 seeds strand for the treatment of extensive portal vein tumor thrombus in patients with hepatocellular carcinoma.Methods: A total of 40 patients with HCC complicated by extensive portal vein tumor thrombus who received iodine 125 seeds strand from January 2015 to December2021 at the Affiliated Zhongda Hospital of Southeast University were analyzed retrospectively.The primary outcome measure was overall survival,and the secondary outcomes were postoperative complications,gastrointestinal bleeding and causes of death.Results: The successful rate of operation was 100%,and there was no operation-related death.Among the 40 patients,15 received iodine 125 seeds strand implantation combined with MKI and the remaining 25 received iodine 125 seeds strand implantation alone.At a median follow-up of 3.5(IQR,2~8.5)months,the median OS of all patients was 92 days(95% CI: 77~108).The median OS of patients who received iodine 125 seeds strand implantation alone and iodine 125 seeds strand implantation combined with MKI or immune checkpoint inhibitor was 75 days(95%CI: 36~114)and 128 days(95% CI: 101~155),respectively(p=0.037).Multivariate analysis revealed that without MKI were independent risk factors affecting the prognosis of this group of patients.In this study,6 patients died of upper gastrointestinal bleeding: 4 patients with iodine 125 seed strip implantation alone and 2patients with iodine 125 seed strip implantation combined with MKI.Conclusions: The study shows that endovascular brachytherapy with iodine 125 seeds strand implantation is a safe and effective local treatment method for hepatocellular carcinoma with extensive portal vein tumor thrombus.The combination of MKI and iodine 125 seeds strand implantation can prolong the survival time of in HCC with extensive portal vein tumor thrombus.