Clinical

Not every liver cancer patient should receive repeat TACE

Last Updated: 2013-01-23 11:45:14 -0400 (Reuters Health)

By Will Boggs, MD

NEW YORK (Reuters Health) - Repeat transarterial chemoembolization (TACE) should be restricted to hepatocellular cancer (HCC) patients with a good prognosis, researchers from Austria say. And they have developed a score (the ART score) to help with the decision.

"TACE, albeit the standard of care in patients with liver cancer stage BCLC B, helps roughly half of the patients in this disease stage, while other patients in this group either are not being helped by this treatment or even suffer harm," Dr. Markus Peck-Radosavljevic from the Medical University of Vienna told Reuters Health by email.

He and his colleagues sought to establish a clinically usable point score (the Assessment for Retreatment with TACE (ART) score) to guide the decision for retreatment with TACE in patients with HCC.

"We want to communicate that not everything that technically can be done in such patients will always be to the patients' benefit and therefore should be avoided in patients with an ART-score of 2.5 or above," Dr. Peck-Radosavljevic said.

According to the new report, online January 12 in Hepatology, the researchers included 107 patients in the training cohort used to establish the ART score. The validation cohort included 115 patients.

A stepwise Cox regression model established radiologic tumor response, AST increase of >25%, and increase of Child-Pugh score of 1 point or at least 2 points as the significant predictors of overall survival. The researchers doubled the calculated regression coefficients and rounded them in order to facilitate the calculation of the ART score (1 point for absent radiologic tumor response; 4 points for AST increase >25%; 1.5 points for Child-Pugh score increase of 1 point; 3 points for Child-Pugh score increase of at least 2 points).

Among the 97 patients in the training cohort with all three parameters available, those with an ART score between 0 and 1.5 points had a median overall survival of 23.7 months, but those with an ART score of 2.5 points and higher had a median overall survival of only 6.6 months (p<0.001).

The ART score retained prognostic significance in the training cohort regardless of whether patients received more or fewer than 3 TACE cycles.

Results were similar in the independent external validation cohort. The median overall survival was 27.6 months for patients with an ART score of 0-1.5 points and 8.1 months for patients with an ART score of 2.5 or more points (p<0.001).

Higher ART scores were also associated with more documented clinical adverse events within the four weeks after a second TACE in both cohorts.

"We believe that the score should be calculated in every patient (usually in the disease stage BCLC B) undergoing TACE before undergoing a second TACE," Dr. Peck-Radosavljevic said. "Patients in the good prognostic group should undergo further TACE's, while patients in the poor prognostic groups should in our opinion be treated according to the 'stage migration' scheme of the EASL clinical practice guidelines. That means they should be treated just like a patients within the next higher disease stage (BCLC C), and that would be drug treatment with sorafenib."

"This very question, what to do with the patients in the poor prognostic groups needs further investigation," Dr. Peck-Radosavljevic added. "Theoretically, several treatment options would be available (e. g., SIRT (selective internal radiation therapy), drug treatment, etc.), and the optimal treatment for those patients needs to be determined."

The researchers cautioned that the retrospective nature of their study and the heterogeneous TACE types in the training cohort are potential limitations.

"The study is further stressing the need to define how to apply TACE to obtain the optimal results in HCC patients," Dr. Jordi Bruix from the University of Barcelona in Spain told Reuters Health by email. "As a whole, the study (shows) the value of the concept named 'untreatable tumor progression' that serves to avoid treatment repetitions that would have no value or even be deleterious."

Dr. Bruix, who was not involved in the new work, said his group discussed this concept in a 2011 special article published in Hepatology.

SOURCE: http://bit.ly/WKuXol

Hepatology 2013.