title: Transarterial chemoembolization using degradable starch microspheres and iodized oil in the treatment of advanced hepatocellular carcinoma: evaluation of tumor response, toxicity, and survival.
abstract: BACKGROUND
  In a multidisciplinary conference patients with advanced non-resectable hepatocellular carcinoma (HCC) were stratified according to their clinical status and tumor extent to different regional modalities or to best supportive care. The present study evaluated all patients who were stratified to repeated transarterial chemoembolization (TACE) from 1999 until 2003 in terms of tumor response, toxicity, and survival. A moderate embolizing approach was chosen using a combination of degradable starch microspheres (DSM) and iodized oil (Lipiodol) in order to combine anti-tumoral efficiency and low toxicity.
  
  
  METHODS
  Fourty-seven patients were followed up prospectively. TACE treatment consisted of cisplatin (50 mg/m(2)), doxorubicin (50 mg/m(2)), 450-900 mg DSM, and 5-30 ml Lipiodol. DSM and Lipiodol were administered according to tumor vascularization. Patient characteristics, toxicity, and complications were outlined. In multivariate regression analyses of pre-treatment variables from a prospective database, predictors for tumor response and survival after TACE were determined.
  
  
  RESULTS
  112 TACE courses were performed (2.4+/-1.5 courses per patient). Mean maximum tumor size was 75 (+/-43) mm, in 68% there was bilobar disease. Best response to TACE treatment was: progressive disease (PD) 9%, stable disease (SD) 55%, partial remission (PR) 36%, and complete remission (CR) 0%. Multivariate regression analyses identified tumor size <or=75 mm, tumor number <or=5, and tumor hypervascularization as predictors for PR. The overall 1-, 2-, and 3-year-survival rates were 75%, 59%, and 41%, respectively, and the median survival was 26 months. Low alpha-fetoprotein levels (<400 ng/ml) (Odds ratio=3.3) and PR as best response to TACE (Odds ratio=6.7) were significantly associated with long term survival (>30 months, R(2)=36%). Grade 3 toxicity occurred in 7.1% (n=8), and grade 4 toxicity in 3.6% (n=4) of all courses in terms of reversible leukopenia and thrombocytopenia. The incidence of major complications was 5.4% (n=6). All complications were managed conservatively. The mortality within 6 weeks after TACE was 2.1% (one patient).
  
  
  CONCLUSIONS
  DSM and Lipiodol were combined successfully in the palliative TACE treatment of advanced HCC resulting in high rates of tumor response and survival at limited toxicity. Favourable tumor response was associated with tumor extent and vascularization. TACE using DSM and Lipiodol can be considered a suitable palliative measure in patients who might not tolerate long acting embolizing agents.
authors.affiliation: Department of Diagnostic Radiology, Hannover Medical School, Hannover, Germany. kirchhoff.timm@mh-hannover.de
authors.forename: Timm D
authors.initials: TD
authors.lastname: Kirchhoff
authors.forename: Joerg S
authors.initials: JS
authors.lastname: Bleck
authors.forename: Arne
authors.initials: A
authors.lastname: Dettmer
authors.forename: Ajay
authors.initials: A
authors.lastname: Chavan
authors.forename: Herbert
authors.initials: H
authors.lastname: Rosenthal
authors.forename: Sonja
authors.initials: S
authors.lastname: Merkesdal
authors.forename: Bernd
authors.initials: B
authors.lastname: Frericks
authors.forename: Lars
authors.initials: L
authors.lastname: Zender
authors.forename: Nisar P
authors.initials: NP
authors.lastname: Malek
authors.forename: Tim F
authors.initials: TF
authors.lastname: Greten
authors.forename: Stefan
authors.initials: S
authors.lastname: Kubicka
authors.forename: Michael P
authors.initials: MP
authors.lastname: Manns
authors.forename: Michael
authors.initials: M
authors.lastname: Galanski
mesh_terms: D000328:Adult; D000368:Aged; D000971:Antineoplastic Combined Chemotherapy Protocols / Q000008:administration & dosage*; D006528:Carcinoma, Hepatocellular / Q000188:drug therapy* / Q000401:mortality; D016461:Chemoembolization, Therapeutic / Q000009:adverse effects; D002945:Cisplatin / Q000008:administration & dosage; D004317:Doxorubicin / Q000008:administration & dosage; D005260:Female; D006801:Humans; D007459:Iodized Oil / Q000008:administration & dosage*; D008113:Liver Neoplasms / Q000188:drug therapy* / Q000401:mortality; D008297:Male; D008863:Microspheres; D008875:Middle Aged; D013213:Starch
chemical_list: D007459:Iodized Oil; D004317:Doxorubicin; D013213:Starch; D002945:Cisplatin