Transarterial Ethanol Ablation(TEA) for Unresectable Hepatocellular Carcinoma(HCC)

Study Overview
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Brief Summary
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The objective of this trial was to evaluate the clinical outcome, treatment toxicity and tumor response of TEA for unresectable HCC.

Detailed Description
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Transarterial therapy has been playing an important role in the treatment algorithm for patients with multifocal or large intrahepatic lesions not eligible for surgical resection, transplantation, or local ablative therapy. Among the various options of transarterial therapy including chemoembolization (TACE), bland embolization, radioembolization, and TEA, chemoembolization is the only one that has been proven to be of survival benefits versus best supportive care in randomized controlled trials. TEA is a hybrid of bland embolization and chemical ablation. Utilizing a liquid agent of Lipiodol-ethanol mixture consisting of 33% ethanol by volume, TEA offers complete and long lasting embolization of both the arterioles and portal venules supplying the tumor and could possibly be more effective than particulate embolic agents in tumor vessel embolization. The component of ethanol very likely offers synergistic effect to embolization and causes tumor ablation.

Official Title
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A Comprehensive Analysis of Clinical Outcome, Treatment Toxicity and Tumor Response of Transarterial Ablation(TEA) for Unresectable Hepatocellular Carcinoma(HCC)

Conditions
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Hepatocellular Carcinoma

Intervention / Treatment
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* Procedure: TEA


Participation Criteria
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Eligibility Criteria
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Inclusion Criteria: Signed informed consent by patient Age above 18 years Child-Pugh A or B cirrhosis Eastern Cooperative Oncology Group(ECOG) performance score 2 or below No serious concurrent medical illness No prior treatment or surgery for HCC Histologically or cytologically proven HCC except for lesions of size 1 to 2 cm, with typical features of HCC on two dynamic imaging techniques, or lesions larger than 2cm, with typical features on one dynamic imaging techniques, or lesions larger than 2cm with alpha feto protein(AFP) level > 200 ng/mL Unresectable disease without extra-hepatic involvement on chest X-ray(CXR) and CT Massive expansive tumor type with measurable lesion on CT Total tumor mass < 50% liver volume Tumor size ≤ 15cm in largest dimension Tumor number ≤ 5 Exclusion Criteria: History of prior malignancy except on the condition that the patient has been disease free for ≥ 3 years Concurrent ischemic heart disease or heart failure History of acute tumor rupture presenting with hemo-peritoneum Serum creatinine level > 180 umol/L Biliary obstruction not amenable to percutaneous drainage Child-Pugh C cirrhosis History of hepatic encephalopathy Intractable ascites not controllable by medical therapy History of variceal bleeding within last 3 months; serum total bilirubin level ≥ 50 umol/L Serum albumin level < 25g/L International normalized ratio(INR) > 1.5 Extrahepatic metastasis Infiltrative or diffuse tumor Tumor number > 5 Thrombosis of target hepatic artery Partial or complete thrombosis of the main portal vein; tumor invasion of portal branch of contralateral lobe Hepatic vein tumor thrombus Significant arterio-portal venous shunt Significant arterial-hepatic venous shunt

Ages Eligible for Study
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Minimum Age: 18 Years

Sexes Eligible for Study
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All

Accepts Healthy Volunteers
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No

Study Plan
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How is the study designed?
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Design Details

Primary Purpose: Treatment
Intervention Model: Single Group Assignment
Masking: None (Open Label)


Arms and Interventions

| Participant Group/Arm | Intervention/Treatment |
| --- | --- |
| Other: Transarterial Ethanol Ablation (TEA)<br>Two treatment sessions at 2 months apart were given and started within 4 weeks after randomization. | Procedure: TEA<br>* Arterial feeders to tumors were identified and catheterized with a microcatheter to a branch supplying a Couinaud segment or subsegmental level for delivery of the therapeutic agent, which was Lipiodol-ethanol mixture at 2:1 ratio by volume for TEA (Lipiodol Ultrafluide, Guerbet, France; Dehydrated alcohol [absolute alcohol], Martindale Pharmaceuticals, United Kingdom). The agents were delivered under fluoroscopic control to completely fill up the vasculature of all tumors. The maximum total volume of Lipiodol-ethanol mixture or cisplatin emulsion to be delivered in one treatment session was 60 mL.<br>|

What is the study measuring?
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Primary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| overall survival and treatment-related toxicity | Overall survival was defined as date of treatment to date of death from any cause. Patients alive at the end of follow-up were censored. Clinical and laboratory data were documented prospectively at baseline, during hospitalization, and at 7, 14, and 30 day, and 3, 6, 9, and 12 months. Laboratory findings were graded according to the National Cancer Institute Common Terminology Criteria for Adverse Events Version 3. | Overall survival is studied from treatment to death from any cause, for an estimated period of up to 60 months. Treatment-related toxicity is studied up to 3 months after treatment | 

Secondary Outcome Measures

| Outcome Measure | Measure Description | Time Frame |
| --- | --- | --- |
| Time to progression(TTP) | TTP was defined as date of treatment to date of first CT evidence of disease progression. Patient death during follow-up without CT progression was censored. | Time to progression is studied from treatment to disease progression, for an estimated period of up to 60 months. | 
| Progression free survival(PFS) | PFS was defined as date of treatment to date of either first CT evidence of disease progression or death from any cause. Patients alive and free of progression at the end of follow-up were censored. | Progression free survival is studied from treatment to disease progression or death from any cause, for an estimated period of up to 60 months. | 
| Tumor response | Treatment response of individual treated tumor lesions was evaluated with CT and classified according to a system combining the recommendation of European Association for the Study of the Liver and the guidelines of World Health Organization, which was considered a preferred method of response assessment following transarterial or locoregional therapies for HCC. Tumor response was classified into 4 categories: 1) complete response (CR), 2) partial response (PR), 3) static disease (SD), or 4) intralesional progression. | Tumor response is studied at 6 months after treatment |