13th Annual Global Embolization Symposium & Technologies
Purpose : Transarterial chemoembolization (TACE) is a mainstay of treatment for hepatocellular carcinoma (HCC). One of the relative contraindications for TACE is a bilirubin above 3 mg/dL. However, limited alternative treatment options and adaptation of super selective TACE has led some to investigate the safety of TACE in these patients, with several authors demonstrating positive outcomes. This raises the question of whether or not a more accurate predictor for a patient’s ability to tolerate TACE can be found. A possible indicator which has yet to be investigated is direct versus indirect bilirubin. In cirrhosis, direct bilirubin elevates after indirect bilirubin. Therefore, patients with an elevated total bilirubin but a relatively normal direct bilirubin may have sufficient hepatic reserve to withstand selective TACE. The goal of this retrospective review was to evaluate the ability of direct bilirubin to predict outcomes following TACE.
Material and Methods : 208 patients who underwent TACE at a single academic hospital were reviewed. The patients’ charts were reviewed for pre and post treatment lab values, complications, and overall survival (OS). In addition to univariate and logistic regression analysis, a multinomial model utilizing Akaike Information Criterion (AIC) was performed to determine whether direct or total bilirubin better predicted complications at 1 month and overall survival. Smaller AIC numbers indicate superior prediction.
Results : When evaluating ability to predict complications at 1 month, direct bilirubin (AIC=707.1) outperformed total bilirubin (AIC=720.0). When comparing those who survived 6 months to those who did not, the direct bilirubin was significantly different (OS<6 months 0.58 ± 0.46 mg/dL vs 0.40 ± 0.31 mg/dL OS>6 months, p=0.04) while the total bilirubin was not different (p=0.16). Logistic regression analysis of 6 month OS found that a direct bilirubin >1 was associated with reduced survival (OR 0.32, p=0.04). OS prediction analysis with AIC demonstrated that direct bilirubin (AIC=941.2) more accurately predicted OS than total bilirubin (AIC=1000.5).
Conclusions : Direct bilirubin more accurately predicts complications at 1 month and OS of TACE patients with HCC as compared to total bilirubin. For patients with elevated total bilirubin, a relatively preserved direct bilirubin may indicate an ability to tolerate TACE.