Uticaj COVID-19 pandemije na ishod transarterijske hemoembolizacije kod pacijenata sa hepatocelularnim karcinomom

Abstract

Uvod: Zbog pandemijom redukovanih terapijskih opcija za lečenje bolesnika sa hepatocelularnim karcinomom, a ujedno i neophodnosti smanjenja rizika od zaražavanja SARS-CoV-2 virusom, predložena su određena odstupanja od standarda u lečenju. Tokom rane faze pandemije, imajući u vidu ograničene medicinske resurse za pružanje zdravstvene zaštite nekovid bolesnicima, postignut je konsenzus da treba redukovati broj elektivnih operacija te da bolesnike sa hepatocelularnim karcinomom treba lečiti primenom lokoregionalne terapije. Transarterijska hemoembolizacija (TACE) je najčešće korišćena metoda lokoregionalnog tretmana bolesnika sa hepatocelularnim karcinomom. Jedan od razloga za primenu ove metode je to što se ona može koristiti i kao „bridžing terapija“ za bolesnike koji su kandidati za operativni tretman, a da su pri tom bolesnici izloženi manjem riziku od COVID-19 infekcije u zdravstvenim ustanovama. U pojedinim slučajevima TACE je i definitivni tretman. Cilj rada: Cilj ovog istraživanja bio je da se utvrdi uticaj COVID-19 pandemije na ishod transarterijskih hemoembolizacija kod bolesnika sa hepatocelularnim karcinomom, kako bi se validirale aktuelne preporuke za bezbednu primenu TACE procedure tokom COVID-19 pandemije. Metod: U ovu retrospektivno/prospektivnu kohortnu studiju uključeno je 97 bolesnika sa hepatocelularnim karcinomom hospitalizovanih u Klinici za digestivnu hirurgiju Univerzitetskog kliničkog centra Srbije kod kojih je u Odseku interventne radiologije Centra za Radiologiju, počev od septembra meseca 2018. godine do decembra 2021. godine učinjena konvencionalna transarterijska hemoembolizacija. U zavisnosti od vremena kada je učinjena TACE procedura bolesnici su podeljeni u dve grupe: studijsku grupu čine bolesnici lečeni tokom pandemije dok su u kontrolnoj grupi bolesnici lečeni pre pandemije. Obe grupe su analizirane na inter i intragrupnu varijabilnost, tehnički uspeh, komplikacije i dužinu preživljavanja. Podaci o bolesnicima lečenim pre pandemije su kontinuirano prospektivno prikupljani te je formirana baza podataka bolesnika lečenih TACE procedurom u Klinici za digestivnu hirurgiju Univerzitetskog kliničkog centra Srbije (Odeljenje za hepato-bilio-pankreasnu hirurgiju). Rezultati rada: Tokom pandemije vreme čekanja bolesnika na TACE proceduru bilo je značajno duže u odnosu na vreme čekanja pre pandemije (p<0.001). Nema statistički značajne razlike u demografskim karakteristikama između grupa, kao ni u pogledu kliničko-patoloških i laboratorijskih analiza. Mediana praćenja iznosila je 14 meseci, a u tom intervalu 65% bolesnika je bilo živo. Statističkom analizom dužine preživljavanja nije uočena značajna razlika među grupama (p=0.823). Cox-ova regresiona analiza je pokazala u modelu da je povećanje MELD faktor rizika za fatalni ishod što je potvrđeno i multivarijantnom analizom. Zaključak: Rezultati ove studije ukazuju da COVID-19 pandemija nije imala uticaj na krajnji ishod TACE procedura primenjenih u lečenju bolesnika sa hepatocelularnim karcinomom. Nije bilo statistički značajne razlike u preživljavanju bolesnika lečenih u prepandemijskom periodu u odnosu na bolesnike lečene tokom COVID-19 pandemije. MELD skor je prediktivni faktor mortaliteta kod bolesnika sa HCC-om. U uslovima pandemije, kada je pružanje zdravstvene zaštite nekovid bolesnicima organičeno, racionalno je usmeriti interventno radiološke resurse ka lečenju onih bolesnika kod kojih postoji veća verovatnoća za dobar terapijski ishod.

Introduction: The reduced therapeutic options for the treatment of patients with hepatocellular carcinoma due to the pandemic, and at the same time the necessity of reducing the risk of infection with the SARS-CoV-2 virus, a certain updates on the treatment standards have been proposed. During the early phase of the pandemic, bearing in mind the limited medical resources for providing health care to non-covid patients, a consensus was reached that the number of elective surgeries should be reduced and that patients with hepatocellular carcinoma should be treated using locoregional therapy. Transarterial chemoembolization (TACE) is the most commonly used method of locoregional treatment of patients with hepatocellular carcinoma. One of the reasons for using this method is that it can be used as a "bridging therapy" for patients who are candidates for surgical treatment, while patients are exposed to a lower risk of COVID-19 infection in healthcare facilities. In some cases, TACE is the definitive treatment. Objective: The main objective of this study was to determine the impact of the COVID-19 pandemic on the outcome of transarterial chemoembolization in patients with hepatocellular carcinoma, in order to validate the current recommendations for the safe use of the TACE procedure during the COVID- 19 pandemic. Materials and methods: In this retrospective/prospective cohort study, 97 patients with hepatocellular carcinoma hospitalized in the Clinic for Digestive Surgery of the University Clinical Centre of Serbia, who underwent conventional transarterial chemoembolization in the Department of Interventional Radiology of the Center for Radiology, from September 2018 to December 2021, were included. Depending on the time when the TACE procedure was performed, the patients were divided into two groups: the study group consisted of patients treated during the pandemic, while the control group consisted of patients treated before the pandemic. Both groups were analyzed for inter- and intragroup variability, technical success, complications and length of survival. Data on patients treated before the pandemic were continuously prospectively collected in the database of patients treated with the TACE procedure in the Clinic for Digestive Surgery of the University Clinical Centre of Serbia (Department of Hepato-Bilio-Pancreatic Surgery). Results: During the pandemic, the waiting time of patients for the TACE procedure was significantly longer compared to the waiting time before the pandemic (p<0.001). There is no statistically significant difference in the demographic characteristics between the groups, as well as in terms of clinical-pathological and laboratory analyses. The median follow-up was 14 months, and in that interval 65% of patients were alive. Statistical analysis of the length of survival did not reveal a significant difference between the groups (p=0.823). Cox's regression analysis showed in the model that an increase in MELD is a risk factor for a fatal outcome, which was also confirmed by multivariate analysis. Conclusions: The results of this study indicate that the COVID-19 pandemic had no impact on the final outcome of TACE procedures applied in the treatment of patients with hepatocellular carcinoma. There was no statistically significant difference in the survival of patients treated in the pre-pandemic period compared to patients treated during the COVID-19 pandemic. MELD score is proven to be a predictive factor of mortality in patients with HCC. In the conditions of a pandemic, when the provision of health care to non-covid patients is limited, it is rational to direct interventional radiological resources towards the treatment of those patients in whom there is a higher probability of a good therapeutic outcome.