Interventional treatment for unresectable hepatocellular carcinoma

Abstract

Hepatocellular carcinoma (HCC) is the sixth most common cancer and third leading cause of cancer-related death in the world. The Barcelona clinic liver cancer classification is the current standard classification system for the clinical management of patients with HCC and suggests that patients with intermediate-stage HCC benefit from transcatheter arterial chemoembolization (TACE). Interventional treatments such as TACE, balloon-occluded TACE, drug-eluting bead embolization, radioembolization, and combined therapies including TACE and radiofrequency ablation, continue to evolve, resulting in improved patient prognosis. However, patients with advanced-stage HCC typically receive only chemotherapy with sorafenib, a multi-kinase inhibitor, or palliative and conservative therapy. Most patients receive palliative or conservative therapy only, and approximately 50% of patients with HCC are candidates for systemic therapy. However, these patients require therapy that is more effective than sorafenib or conservative treatment. Several researchers try to perform more effective therapies, such as combined therapies (TACE with radiotherapy and sorafenib with TACE), modified TACE for HCC with arterioportal or arteriohepatic vein shunts, TACE based on hepatic hemodynamics, and isolated hepatic perfusion. This review summarizes the published data and data on important ongoing studies concerning interventional treatments for unresectable HCC and discusses the technical improvements in these interventions, particularly for advanced-stage HCC.

Keywords: Advanced-stage; Hepatocellular carcinoma; Intermediate-stage; Interventional; Unresectable.

Figure 1

Selective arteriography with and without balloon-occluded feeding artery in a 72 year-old man with multiple hepatocellular carcinomas. A: Celiac arteriography revealed multiple hepatocellular carcinomas (HCCs) in the liver; B: Opacified HCCs were shown by medial segmental arteriography without balloon-occluded feeding artery; C: In contrast, the arteriography with balloon occlusion showed faint opacification of HCCs and nontumoral liver parenchyma was opacified. Arrow indicated an inflated microballoon.

Figure 2

Two-step balloon-occluded transarterial chemoembolization. A 76-year old woman characterized as Child-Pugh class C underwent transjugular intrahepatic portosystemic shunt (TIPS) for massive ascites before several transarterial chemoembolization (TACE) sessions. Celiac arteriography in the venous phase (A) showed a small hepatocellular carcinoma (HCC) (arrow). A microballoon catheter was advanced into the tumor feeding artery. Then, two-step balloon-TACE (B-TACE) was performed. First, tumors were sufficiently embolized by TACE without balloon occlusion of the tumor feeding artery (B); Second, a microballoon catheter was inflated to occlude the feeding artery (C, black arrow), and B-TACE was performed to fully embolize the peritumoral liver parenchyma (C, white arrows). Common hepatic arteriography showed no proximal migration or leakage of embolization materials (D). Following the two-step B-TACE procedure, computed tomography showed dense lipiodol accumulation in the HCC (E, black arrow). There was no evidence of proximal migration or leakage of embolization materials. White arrows indicated a stent for TIPS.

Figure 3

Multiple hepatocellular carcinomas with significant arterioportal shunts in a 71-year-old woman. Enhanced computed tomography (CT) imaging revealed viable hepatocellular carcinomas (HCCs) (A, black arrow) with lipiodol deposit HCCs (A, white arrows). Common hepatic arteriography in the arterial phase (B) demonstrated HCC with significant arterioportal shunts (B, arrows), consisting of P8 and P4. Common hepatic arteriography under balloon occlusion of the portal vein branches of P8 and P4 showed an opacified tumor with non-visualized arterioportal shunts (C). CT images 2 mo after transcatheter arterial chemoembolization under occlusion of the 2 portal vein branches (D) demonstrated a dense lipiodol deposit in the HCC and a complete response, according to modified Response Evaluation Criteria in Solid Tumors.

Figure 4

Transportal chemoembolization for hepatocellular carcinoma with an arterioportal shunt in a 70-year-old man. Enhanced abdominal computed tomography (CT) examination (A) demonstrated a recurrent hepatocellular carcinoma (HCC) (A, arrow) in the posterior segment with a lipiodol deposit (arrowhead). Hepatic arteriography via the anterior branch (B) revealed a HCC (B, white arrow) fed by the cystic artery (B, black arrows) and an intratumoral arterioportal shunt (B, arrowhead). A 5-French sheath was inserted into the portal vein via the lateral superior branch of the left portal vein. Direct portography via the portal vein branch contributed an arterioportal shunt showed a tumor stain (C, arrow). Following transcatheter portal chemoembolization, proper hepatic arteriography showed non-visualized tumor stain and arterioportal shunt (D). Non-enhanced CT 7 d after therapy (E) showed a dense accumulation of lipiodol in the tumor and peritumoral liver parenchyma.

Figure 5

Retrograde-outflow percutaneous isolated hepatic perfusion for multiple hepatocellular carcinomas in a 64-year-old man. A patients received 2 sessions of transcatheter arterial chemoembolization for multiple hepatocellular carcinomas (HCCs) at other hospital. Computed tomography (CT) during arterial portography (A) and hepatic arteriography (B) demonstrated multiple HCCs with portal vein invasion (arrows). Retrograde-outflow percutaneous isolated hepatic perfusion (C, arterial phase; D, venous phase) was performed twice (arrow of D indicated a portal branch), and enhanced CT imaging 6 mo after therapy (E) revealed that the HCC was diminished.