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Mo1050 The Liver Protection Effect of L-Carnitine Administration After TACE on Intermediate-Stage Hepatocellular Carcinoma Patients
Mo1049
peripheral feeding artery was embolized by small particules of gelatin sponge. Resulted simultaneous embolization of portal veins and peripheral feeding artery occurred and looked like after peripheral anatomical resection. Practically the thinnest micro-catheter(1.6Fr. Nano) was brought into peripheral feeding artery(sub-sub segment level) under angio-CT system and 3~5ml suspension(from 10ml iodized oil and 50mg epirubicin or 100mg arterial infusion cisplatin) injected until peripheral portal veins well seen and peripheral feeding artery was embolized completely by 1mm-sized particles of gelatin sponge. Object, 225 patients with HCCs had been performed by AS and followed. Patients with stage I and II were 134 and patients with stage I and II HCCs treated by AS firstly were 101. In background, there was no significant difference between total patients on both stage I and II of HCC and patients by AS firstly on both stage I and II of HCC. Results: 5 year survival rate of total stage I and II HCC patients and stage I and II of HCC patients by AS firstly were 61.27% and 71.02% respectively. 10 year survival rate were 27.78% and 30.65% respectively. P-value on the Wilcoxon signed-rank test was 0.05. The survival rate of patients with stage I and II of HCC treated by AS firstly was significantly better than total patients with stage I and II of HCC. Effectiveness of AS on patients with stage I and II HCC was almost equal to surgical resection. Conclusion: AS was recommended as a first line treatment method of patients with HCC on stage I and II.
AASLD Abstracts
Distribution of Venous Thrombosis in Hepatocellular Carcinoma Is Similar to Cholangiocarcinoma Nataliya Razumilava, Badr Al Bawardy, Vitali Fiadosau, Patrick S. Kamath Background: Hepatocellular (HCC) and Cholangiocellular carcinomas (CCA) are the two most common primary liver malignancies affecting the population worldwide and associated with dismal outcomes. Venous thrombosis is often present in patients with liver malignancies and complicates clinical management. It is not clear whether HCC and CCA are associated with different patterns of venous thrombosis since HCC is usually associated with cirrhosis which by itself promotes hypercoagulability. The true frequency and distribution of venous thrombosis in the patients with HCC and CCA is also poorly described. Aim: The goal of the study was to assess the differences in frequency and distribution of portal and nonportal venous thrombosis (PVT and NPVT) in patients with HCC and CCA. Methods: We conducted the retrospective review of the medical records of the 1185 consecutive patients with pathology proven HCC and 559 with pathology proven CCA seen at a tertiary care medical center (Mayo Clinic, Rochester, MN, USA) between 2000 and 2013. The frequency of the venous thrombosis and baseline demographic characteristics were analyzed. Results: Among patients with HCC, 45.6% (540/1185) had associated venous thrombosis. This was comparable to patients with CCA (35.4%; 198/559). Portal venous thrombosis was present in 31% of patients with HCC and 23.4% of patients with CCA. Non-portal venous thrombosis was observed twice less frequently as compared to portal VT and was present in 14.2% of patients with HCC and 12% of patients with CCA. The average age of patients with HCC was similar in portal and non-portal venous thrombosis groups (60 versus 59.5 years respectively) and was comparable to those patients with HCC who did not have venous thrombosis (62 years). This was also true for the patients with CCA where average age of patients with portal venous thrombosis was 61.5 years and non-portal venous thrombosis 62.5 years as compared to average age of 61 years in patients with CCA without venous thrombosis. Across all patient groups (HCC: PVT; HCC:NPVT; CCA:PVT; and CCA:NPVT) male to female ratio was approximately 1:2. Interestingly, females with non-portal venous thrombosis were slightly younger in the HCC group as compared to the CCA group (59 and 65 years respectively). Conclusions: The frequencies of portal and non-portal venous thrombosis are similar in patients with HCC and CCA making radiological and clinical differentiation of these malignancies based only on the distribution of venous thrombosis difficult. The similarity in the venous thrombotic pattern in HCC and CCA points toward a common pathogenesis, and is not likely to be increased by the underlying cirrhosis in HCC.
Mo1052 Acute Ischemic Cholecystitis After Transarterial Chemoembolization in Hepatocellular Carcinoma Dong Hee Koh, Sun Man Park, Min Ho Choi, Hyun Joo Jang, Sea Hyub Kae, Jin Lee Background/Aims: The gallbladder, unlike the liver, dose not have dual vascularization. The cystic artery is susceptible to non-target embolization during transarterial chemoembolization (TACE), which can potentially cause ischemic complications in the gallbladder. This study is to determine the incidence, risk factors and clinical outcome of acute ischemic cholecystitis after TACE of hepatocellular carcinoma. Methods: Between January 2000 and July 2012, 1102 sessions of TACE with adriamycin mixed with lipiodol, and gelatin sponge particles were performed in 451 patients with hepatocellular carcinoma. Post-TACE monitoring included laboratory findings, US and CT. Results: Of the 451 patients who underwent TACE, 9 patients(1.9%) presented with radiological features indicative of acute cholecystitis, which developed within 15 days in 6 patients and within the first month after TACE in 3 patients. Review of the TACE procedures revealed that 3 cases had undergone lobar right hepatic embolization, 3 cases right and left hepatic artery embolization and 3 cases additional gelfoam embolization. 2 of 9 patients required laparoscopic cholecystecomy due to gangrenous cholecystitis and gallbladder perforation, remaining 7 patients were managed conservatively and none required surgical or interventional management. Conclusions: Acute ischemic cholecystitis after TACE occur in 1.9% in this study. Non-selective techniques and additional gelfoam embolization, which have a higher likelihood of cystic artery embolization and result in a higher incidence of cholecystitis. Although most studies of cholecystitis after TACE have reported conservative management, urgent cholecystectomy or percutaneous cholecystostomy has been required occasionally.
Mo1050 The Liver Protection Effect of L-Carnitine Administration After TACE on Intermediate-Stage Hepatocellular Carcinoma Patients Yasuhiro Tsuda, Hideko Ohama, Keisuke Yokohama, Tetsuya Sujishi, Yusuke Tsuchimoto, Akira Asai, Shinya Fukunishi, Kazuhide Higuchi Background: L-carnitine (4-N-trimethyl ammonium 3-hydroxybutyric acid) is a naturally occurring amino acid that functions to transfer long-chain fatty acids across the mitochondrial membrane, enabling oxidative release of energy. We have already reported the clinical benefit of l-carnitine supplement on muscle cramp, liver dysfunction and peripheral blood cell abnormality in patients with liver cirrhosis. In this study, we examined the protective effect of l-carnitine against the damage to liver function after transcatheter arterial chemoembolization (TACE) in intermediate-stage hepatocellular carcinoma (HCC) patients. Methods: A total of 33 cirrhotic patients at Osaka Medical College from December 2012 to July 2013 were enrolled in this study (25 male, mean age 71±8 Y/O, mean Child Pugh score 5.8±1.0). All patients have diagnosed as intermediate-stage HCC by imaging test or liver biopsy. All patients received TACE for treatment of HCC. Seventeen consecutive HCC patients were administrated a 300mg of l-carnitine tablet twice a day from 2 week before to 12 weeks after treatment. As controls, the last 16 consecutive HCC patients received TACE without carinitine were prepared. The evaluation of liver function parameters were examined before, 1, 4, 12 weeks after treatment and compared with control patients. Results: The deterioration of serum albumin (ALB) levels and prothrombin time 1 and 4 weeks after TACE were relieved by l-carnitine administration. And the elevation of total bilirubin (TB) and alanine aminotransferase (ALT) 1 and 4 weeks after TACE were also suppressed by l-carinite. Child Pugh (CP) score was improved 4 and 12 weeks after TACE by l-carnitne. These liver protection effects were enhanced by the combination use of branched-chain amino acid (BCAA). In BCAA administrated HCC patients, the ALB deterioration was significantly relieved 1 week after TACE (3.0±0.4 vs. 2.8±0.6 mg/dl, p < 0.05). The elevation of TB 12 weeks after TACE was significantly improved (0.9±0.5 vs. 1.6±0.3 mg/dl, p < 0.05). CP score was also improved 12 weeks after TACE by l-carnitine (6.0±0.9 vs. 7.8±1.5 p < 0.05). Moreover, C-reactive protein 1 week after TACE was significantly lower compared with control group (0.7±1.0 vs. 2.5±2.5 mg/dl, p < 0.05). Any side effects did not appeared by carnitine administration in all clinical courses. Discussion: Patients with the intermediatestage of HCC have been performed TACE repeatedly in Japan. In these patients, conservation of liver function is very important because of the influence of therapy continuance. The lcarnitine and BCAA combination therapy may offer the possibility as a new liver support tool in patients with HCC.
Mo1054 Poor Quality of Life in Patients With Hepatocellular Carcinoma Associated With Worse Prognosis Adam Meier, Adam Yopp, Pragathi Kandunoori, Akbar K. Waljee, Jorge A. Marrero, Amit G. Singal Background: HCC patients can suffer from symptoms related to cirrhosis, HCC, or both conditions. Few studies have evaluated quality of life (QOL) and its prognostic significance in patients with HCC. Aims: 1) To characterize and identify factors associated with QOL among patients with cirrhosis and HCC using an HCC-specific survey and 2) to evaluate the prognostic significance of QOL in these patients. Methods: A self-administered validated survey (EORTC QLQ-C30 and EORTC HCC18) was given to patients with HCC seen at Parkland Hospital between April 2011 and September 2013. HCC was diagnosed using AASLD criteria and staging performed using Barcelona Clinic Liver Cancer (BCLC) staging system. Two authors abstracted demographic, lab, and clinical data for patients from medical records using standardized forms. Generalized linear models were used to identify predictors of QOL. Survival curves were generated using Kaplan-Meier analysis and compared using log rank test. Results: We enrolled 130 treatment-naïve HCC patients, with median age 57 years and 78% male. 38% of patients were Black, 33% Hispanic, and 23% Caucasian. Majority of patients (72%) had hepatitis C cirrhosis. Median Child Pugh score was 7, with 43% Child A cirrhosis, 35% Child B, and 22% Child C. 40% of patients had BCLC stage A tumors, 17% BCLC B, 20% BCLC C, and 23% BCLC stage D. Patients reported good cognitive (median 67%) and social (median 67%) functioning, but median scores for role and physical functioning were lower at 50% and 60% respectively. Median global health score was 50%, with only 12% of responders having scores greater than 75%. There was no difference in global health by age (p=0.35), gender (p=0.39), race (p=0.32), or etiology of cirrhosis (p=0.65). Significant predictors of global health in multivariable analysis included BCLC stage (p=0.03) and HIV status (p=0.03). The four HIV-positive patients had global health score of 71% compared to 47% among HIV-negative patients. Patients with BCLC A tumors had global health scores of 54%, 47% for BCLC B and C tumors, and 39% for BCLC D tumors. When evaluating components of BCLC stage, this association was related to both Child Pugh score (p=0.02) and the presence of advanced HCC (p=0.02). In univariate analysis, QOL was a significant predictor of overall survival (HR 0.41, 95%CI 0.18 - 0.89, p=0.02), although this became a non-significant trend (HR 0.59, 95%CI 0.27 - 1.26) after adjusting for tumor stage. Conclusions: Patients with HCC report poor overall QOL, driven both by liver function and tumor factors. QOL is important to assess in these patients given its potential prognostic significance.
Mo1051 The Effectiveness of Angiographic Subsegmentectomy As a Treatment Method Using the Hemodynamics of Hepatocellular Carcinoma Shozo Iwamoto, Taizo Yamaguchi, Osamu Hongo, Hideki Iwamoto AIM: We have performed Angiographic subsegmentectomy(AS) as a treatment method for patients with hepatocellular carcinomas since 1998. The excellent outcomes of AS was already published on Cancer 2010. In this time we'll report the further investment of AS. Method: HCC had a hemodynamics that HCCs were fed by hepatic arteries and drained into portal veins via drainage vessels. Therefore the suspension of iodized oil and carcinostatics injecting from the peripheral feeding artery flew into portal veins via drainage vessels and
AASLD Abstracts
S-996
peripheral feeding artery was embolized by small particules of gelatin sponge. Resulted simultaneous embolization of portal veins and peripheral feeding artery occurred and looked like after peripheral anatomical resection. Practically the thinnest micro-catheter(1.6Fr. Nano) was brought into peripheral feeding artery(sub-sub segment level) under angio-CT system and 3~5ml suspension(from 10ml iodized oil and 50mg epirubicin or 100mg arterial infusion cisplatin) injected until peripheral portal veins well seen and peripheral feeding artery was embolized completely by 1mm-sized particles of gelatin sponge. Object, 225 patients with HCCs had been performed by AS and followed. Patients with stage I and II were 134 and patients with stage I and II HCCs treated by AS firstly were 101. In background, there was no significant difference between total patients on both stage I and II of HCC and patients by AS firstly on both stage I and II of HCC. Results: 5 year survival rate of total stage I and II HCC patients and stage I and II of HCC patients by AS firstly were 61.27% and 71.02% respectively. 10 year survival rate were 27.78% and 30.65% respectively. P-value on the Wilcoxon signed-rank test was 0.05. The survival rate of patients with stage I and II of HCC treated by AS firstly was significantly better than total patients with stage I and II of HCC. Effectiveness of AS on patients with stage I and II HCC was almost equal to surgical resection. Conclusion: AS was recommended as a first line treatment method of patients with HCC on stage I and II.
AASLD Abstracts
Distribution of Venous Thrombosis in Hepatocellular Carcinoma Is Similar to Cholangiocarcinoma Nataliya Razumilava, Badr Al Bawardy, Vitali Fiadosau, Patrick S. Kamath Background: Hepatocellular (HCC) and Cholangiocellular carcinomas (CCA) are the two most common primary liver malignancies affecting the population worldwide and associated with dismal outcomes. Venous thrombosis is often present in patients with liver malignancies and complicates clinical management. It is not clear whether HCC and CCA are associated with different patterns of venous thrombosis since HCC is usually associated with cirrhosis which by itself promotes hypercoagulability. The true frequency and distribution of venous thrombosis in the patients with HCC and CCA is also poorly described. Aim: The goal of the study was to assess the differences in frequency and distribution of portal and nonportal venous thrombosis (PVT and NPVT) in patients with HCC and CCA. Methods: We conducted the retrospective review of the medical records of the 1185 consecutive patients with pathology proven HCC and 559 with pathology proven CCA seen at a tertiary care medical center (Mayo Clinic, Rochester, MN, USA) between 2000 and 2013. The frequency of the venous thrombosis and baseline demographic characteristics were analyzed. Results: Among patients with HCC, 45.6% (540/1185) had associated venous thrombosis. This was comparable to patients with CCA (35.4%; 198/559). Portal venous thrombosis was present in 31% of patients with HCC and 23.4% of patients with CCA. Non-portal venous thrombosis was observed twice less frequently as compared to portal VT and was present in 14.2% of patients with HCC and 12% of patients with CCA. The average age of patients with HCC was similar in portal and non-portal venous thrombosis groups (60 versus 59.5 years respectively) and was comparable to those patients with HCC who did not have venous thrombosis (62 years). This was also true for the patients with CCA where average age of patients with portal venous thrombosis was 61.5 years and non-portal venous thrombosis 62.5 years as compared to average age of 61 years in patients with CCA without venous thrombosis. Across all patient groups (HCC: PVT; HCC:NPVT; CCA:PVT; and CCA:NPVT) male to female ratio was approximately 1:2. Interestingly, females with non-portal venous thrombosis were slightly younger in the HCC group as compared to the CCA group (59 and 65 years respectively). Conclusions: The frequencies of portal and non-portal venous thrombosis are similar in patients with HCC and CCA making radiological and clinical differentiation of these malignancies based only on the distribution of venous thrombosis difficult. The similarity in the venous thrombotic pattern in HCC and CCA points toward a common pathogenesis, and is not likely to be increased by the underlying cirrhosis in HCC.
Mo1052 Acute Ischemic Cholecystitis After Transarterial Chemoembolization in Hepatocellular Carcinoma Dong Hee Koh, Sun Man Park, Min Ho Choi, Hyun Joo Jang, Sea Hyub Kae, Jin Lee Background/Aims: The gallbladder, unlike the liver, dose not have dual vascularization. The cystic artery is susceptible to non-target embolization during transarterial chemoembolization (TACE), which can potentially cause ischemic complications in the gallbladder. This study is to determine the incidence, risk factors and clinical outcome of acute ischemic cholecystitis after TACE of hepatocellular carcinoma. Methods: Between January 2000 and July 2012, 1102 sessions of TACE with adriamycin mixed with lipiodol, and gelatin sponge particles were performed in 451 patients with hepatocellular carcinoma. Post-TACE monitoring included laboratory findings, US and CT. Results: Of the 451 patients who underwent TACE, 9 patients(1.9%) presented with radiological features indicative of acute cholecystitis, which developed within 15 days in 6 patients and within the first month after TACE in 3 patients. Review of the TACE procedures revealed that 3 cases had undergone lobar right hepatic embolization, 3 cases right and left hepatic artery embolization and 3 cases additional gelfoam embolization. 2 of 9 patients required laparoscopic cholecystecomy due to gangrenous cholecystitis and gallbladder perforation, remaining 7 patients were managed conservatively and none required surgical or interventional management. Conclusions: Acute ischemic cholecystitis after TACE occur in 1.9% in this study. Non-selective techniques and additional gelfoam embolization, which have a higher likelihood of cystic artery embolization and result in a higher incidence of cholecystitis. Although most studies of cholecystitis after TACE have reported conservative management, urgent cholecystectomy or percutaneous cholecystostomy has been required occasionally.
Mo1050 The Liver Protection Effect of L-Carnitine Administration After TACE on Intermediate-Stage Hepatocellular Carcinoma Patients Yasuhiro Tsuda, Hideko Ohama, Keisuke Yokohama, Tetsuya Sujishi, Yusuke Tsuchimoto, Akira Asai, Shinya Fukunishi, Kazuhide Higuchi Background: L-carnitine (4-N-trimethyl ammonium 3-hydroxybutyric acid) is a naturally occurring amino acid that functions to transfer long-chain fatty acids across the mitochondrial membrane, enabling oxidative release of energy. We have already reported the clinical benefit of l-carnitine supplement on muscle cramp, liver dysfunction and peripheral blood cell abnormality in patients with liver cirrhosis. In this study, we examined the protective effect of l-carnitine against the damage to liver function after transcatheter arterial chemoembolization (TACE) in intermediate-stage hepatocellular carcinoma (HCC) patients. Methods: A total of 33 cirrhotic patients at Osaka Medical College from December 2012 to July 2013 were enrolled in this study (25 male, mean age 71±8 Y/O, mean Child Pugh score 5.8±1.0). All patients have diagnosed as intermediate-stage HCC by imaging test or liver biopsy. All patients received TACE for treatment of HCC. Seventeen consecutive HCC patients were administrated a 300mg of l-carnitine tablet twice a day from 2 week before to 12 weeks after treatment. As controls, the last 16 consecutive HCC patients received TACE without carinitine were prepared. The evaluation of liver function parameters were examined before, 1, 4, 12 weeks after treatment and compared with control patients. Results: The deterioration of serum albumin (ALB) levels and prothrombin time 1 and 4 weeks after TACE were relieved by l-carnitine administration. And the elevation of total bilirubin (TB) and alanine aminotransferase (ALT) 1 and 4 weeks after TACE were also suppressed by l-carinite. Child Pugh (CP) score was improved 4 and 12 weeks after TACE by l-carnitne. These liver protection effects were enhanced by the combination use of branched-chain amino acid (BCAA). In BCAA administrated HCC patients, the ALB deterioration was significantly relieved 1 week after TACE (3.0±0.4 vs. 2.8±0.6 mg/dl, p < 0.05). The elevation of TB 12 weeks after TACE was significantly improved (0.9±0.5 vs. 1.6±0.3 mg/dl, p < 0.05). CP score was also improved 12 weeks after TACE by l-carnitine (6.0±0.9 vs. 7.8±1.5 p < 0.05). Moreover, C-reactive protein 1 week after TACE was significantly lower compared with control group (0.7±1.0 vs. 2.5±2.5 mg/dl, p < 0.05). Any side effects did not appeared by carnitine administration in all clinical courses. Discussion: Patients with the intermediatestage of HCC have been performed TACE repeatedly in Japan. In these patients, conservation of liver function is very important because of the influence of therapy continuance. The lcarnitine and BCAA combination therapy may offer the possibility as a new liver support tool in patients with HCC.
Mo1054 Poor Quality of Life in Patients With Hepatocellular Carcinoma Associated With Worse Prognosis Adam Meier, Adam Yopp, Pragathi Kandunoori, Akbar K. Waljee, Jorge A. Marrero, Amit G. Singal Background: HCC patients can suffer from symptoms related to cirrhosis, HCC, or both conditions. Few studies have evaluated quality of life (QOL) and its prognostic significance in patients with HCC. Aims: 1) To characterize and identify factors associated with QOL among patients with cirrhosis and HCC using an HCC-specific survey and 2) to evaluate the prognostic significance of QOL in these patients. Methods: A self-administered validated survey (EORTC QLQ-C30 and EORTC HCC18) was given to patients with HCC seen at Parkland Hospital between April 2011 and September 2013. HCC was diagnosed using AASLD criteria and staging performed using Barcelona Clinic Liver Cancer (BCLC) staging system. Two authors abstracted demographic, lab, and clinical data for patients from medical records using standardized forms. Generalized linear models were used to identify predictors of QOL. Survival curves were generated using Kaplan-Meier analysis and compared using log rank test. Results: We enrolled 130 treatment-naïve HCC patients, with median age 57 years and 78% male. 38% of patients were Black, 33% Hispanic, and 23% Caucasian. Majority of patients (72%) had hepatitis C cirrhosis. Median Child Pugh score was 7, with 43% Child A cirrhosis, 35% Child B, and 22% Child C. 40% of patients had BCLC stage A tumors, 17% BCLC B, 20% BCLC C, and 23% BCLC stage D. Patients reported good cognitive (median 67%) and social (median 67%) functioning, but median scores for role and physical functioning were lower at 50% and 60% respectively. Median global health score was 50%, with only 12% of responders having scores greater than 75%. There was no difference in global health by age (p=0.35), gender (p=0.39), race (p=0.32), or etiology of cirrhosis (p=0.65). Significant predictors of global health in multivariable analysis included BCLC stage (p=0.03) and HIV status (p=0.03). The four HIV-positive patients had global health score of 71% compared to 47% among HIV-negative patients. Patients with BCLC A tumors had global health scores of 54%, 47% for BCLC B and C tumors, and 39% for BCLC D tumors. When evaluating components of BCLC stage, this association was related to both Child Pugh score (p=0.02) and the presence of advanced HCC (p=0.02). In univariate analysis, QOL was a significant predictor of overall survival (HR 0.41, 95%CI 0.18 - 0.89, p=0.02), although this became a non-significant trend (HR 0.59, 95%CI 0.27 - 1.26) after adjusting for tumor stage. Conclusions: Patients with HCC report poor overall QOL, driven both by liver function and tumor factors. QOL is important to assess in these patients given its potential prognostic significance.
Mo1051 The Effectiveness of Angiographic Subsegmentectomy As a Treatment Method Using the Hemodynamics of Hepatocellular Carcinoma Shozo Iwamoto, Taizo Yamaguchi, Osamu Hongo, Hideki Iwamoto AIM: We have performed Angiographic subsegmentectomy(AS) as a treatment method for patients with hepatocellular carcinomas since 1998. The excellent outcomes of AS was already published on Cancer 2010. In this time we'll report the further investment of AS. Method: HCC had a hemodynamics that HCCs were fed by hepatic arteries and drained into portal veins via drainage vessels. Therefore the suspension of iodized oil and carcinostatics injecting from the peripheral feeding artery flew into portal veins via drainage vessels and
AASLD Abstracts
S-996