Patient selection
From January 2016 to November 2020, data on all patients who received TACE in our institution were retrospectively reviewed (Figure 1). The following characteristics were included in the analysis: age, alanine aminotransferase (ALT), aspartate aminotransferase (AST), hemoglobin, platelets, lymphocytes, neutrophils, leukocytes, creatine, γ-glutamyl transpeptidase (GGT), tumor size, sex, HBV infection, tumor number, Barcelona Clinic Liver Cancer (BCLC) stage, cirrhosis, Child-Pugh grade, Eastern Cooperative Oncology (ECOG) performance status, and number of TACE sessions. This study was approved by the ethics committee of Union Hospital Affiliated to Tongji Medical College, Huazhong University of Science and Technology (UHCT-IEC-SOP-017-03-01). The informed consent of the patient was waived by the board because the study was a retrospective study.
Diagnosis of liver abscess
Patients were diagnosed with liver abscess based on clinical symptoms, laboratory tests, or imaging signs. Patients usually present with fever and pain in the liver area or chills. The laboratory test showed increased leukocytes and/or lymphocytes in patients. Imaging showed a hypoattenuating lesion with peripheral rim enhancement in the liver on CT imaging, a typical hyperintense signal on T2-weighted MRI, a central hypointense lesion on T1-weighted MRI, or a dominantly hypoechoic to hyperechoic signal or gas bubbles within the lesion on ultrasound imaging. If the patients had two signs clinical symptoms, laboratory test results, or imaging signs, they were diagnosed with liver abscess.
TACE procedure
The TACE procedure was performed by three experienced radiologists with a minimum of 10 years of experience in interventional therapy. A 5F catheter (Cook, Bloomington, IN, USA) was inserted into the hepatic artery. Arteriography was conducted to show the feeding artery of the tumor. Then, a 3F microcatheter (Progreat, Terumo, Tokyo, Japan) was inserted into the tumor feeding arteries. Subsequently, lipiodol (Lipiodol Ultrafluido, Guerbet, Villepinte, France) was mixed with doxorubicin hydrochloride at a ratio of 1 ml/2 mg to create an emulsion. Depending on the size of the tumor and liver function, a 5-20 ml emulsion was injected slowly into the tumor feeding arteries until stasis. If necessary, supplement embolization was performed using gelatin sponge particles (300–700 µm, Cook, USA).
Molecular targeted drugs
In the study, 78patients received TACE-M. Among these patients, 20 received sorafenib and 8 received lenvatinib. Patients with advanced-staged liver cancer were recommended to receive TACE combined with molecular targeted drugs. Sorafenib (Bayer Healthcare, Leverkusen, Germany) was administered at an initial dose of 400 mg twice daily within 3–7 days after every TACE procedure and ceased the day before every TACE procedure. Dose reductions to 200 mg twice daily and then 200 mg once daily or temporary interruptions were allowed due to drug-related toxicity. Sorafenib was discontinued in the event of disease progression or unacceptable toxicity. Patients received oral lenvatinib (Eisai Inc., Woodcliff Lake, NJ, USA) (12 mg/day for bodyweight ≥60 kg or 8 mg/day for bodyweight <60 kg) or sorafenib (Bayer, Leverkusen, Germany) (400 mg twice daily in 28-day cycles). Dose interruptions followed by reductions in lenvatinib-related toxicities (to 8 mg and 4 mg/day or 4 mg every other day) were permitted. Modifications to sorafenib doses were implemented according to prescribing information in each region (all patients in the sorafenib arm received a starting dose of 400 mg orally twice daily).
Immunotherapy
In the institution, patients with advanced-staged liver cancer were recommended to receive molecular targeted drugs. When the tumor progressed, patients were recommended to receive camrelizumab. Camrelizumab which made in china is a novel humanised, high-affinity, IgG4/isotype anti-PD-1 mAb, in the treatment of therapy-resistant advanced HCC in a population majorly consisting of HBV-related HCC(11). A fixed dose of 200 mg camrelizumab was administered intravenously every 3 weeks. Camrelizumab administration continued until intolerable toxicity or disease progression occurred. In the event of an AE, laboratory test abnormality or intercurrent disease, camrelizumab treatment was delayed, but the dosage was not reduced. Treatment interruption was allowed for no more than 12 weeks (either continuously or intermittingly); otherwise, the patients were withdrawn from the study. Patients with progressive disease continued treatment if the investigator predicted that they may still obtain a clinical benefit and were reevaluated after each cycle (6 weeks).
Liver abscess treatment
Once the patients were diagnosed with liver abscess, intravenous antibiotic therapy was routinely initiated. All patients diagnosed with liver abscess received percutaneous abscess drainage. The drainage fluid was used for bacterial culture. After determining the nature of the abscess, patients received symptomatic treatment.
Follow-up
In our institution, every patient was followed up after they received TACE. When patients with liver abscess recovered, they were required to come to our hospital for review once every 2-3 weeks in the first 3 months and then every 3 months thereafter. If the tumor progressed, they were recommended to receive TACE again. CT, MRI or ultrasound was used to evaluate the tumor based on mRECIST criteria and the state of liver abscess. Laboratory tests were also conducted when the patients revisited our hospital. The endpoint time of the study was December 31, 2020.
Statistical analysis
All statistical analysis of the study were conducted by GraphPad Prim 8.0 and SPSS 24.0. The Cox proportional risk model was used to evaluate the potential factors which might influence the time of drainage of patients. The factors with P<0.2 in univariable analysis were included into multivariable analysis.