Interventional Oncology in Hepatocellular Carcinoma: Progress Through Innovation

Abstract

The clinical management of hepatocellular carcinoma has evolved greatly in the last decade mostly through recent technical innovations. In particular, the application of cutting-edge image guidance has led to minimally invasive solutions for complex clinical problems and rapid advances in the field of interventional oncology. Many image-guided therapies, such as transarterial chemoembolization and radiofrequency ablation, have meanwhile been fully integrated into interdisciplinary clinical practice, whereas others are currently being investigated. This review summarizes and evaluates the most relevant completed and ongoing clinical trials, provides a synopsis of recent innovations in the field of intraprocedural imaging and tumor response assessment, and offers an outlook on new technologies, such as radiopaque embolic materials. In addition, combination therapies consisting of locoregional therapies and systemic molecular targeted agents (e.g., sorafenib) remain of major interest to the field and are also discussed. Finally, we address the many substantial advances in immune response pathways that have been related to the systemic effects of locoregional therapies. Knowledge of these new developments is crucial as they continue to shape the future of cancer treatment, further establishing interventional oncology along with surgical, medical, and radiation oncology as the fourth pillar of cancer care.

Figure 1. LUMI™ beads applied in a rabbit with VX2 tumor implanted in the liver

Three dimensional volume rendered CBCT imaging, acquired post-euthanasia, was windowed to highlight the 1.1 mL of LUMI™ Beads (0.055 mL packed bead volume). The beads were suspended in iodinated soluble contrast medium and delivered intra-arterially. Note the hepatic arteries, non-target delivery, and the tumor located in the right hepatic lobe. CBCT: cone-beam computed tomography.

Figure 2. qEASL showing tumor response after DEB-TACE

A 58-year-old male with hepatocellular carcinoma underwent 1 session of DEB-TACE. Based on pre- and post-procedure magnetic resonance imaging, qEASL showed that the tumor volume reduced from 297.3 cm³ with 71.9% enhancement down to 197.1 cm³ with 2.7% enhancement. DEB-TACE: transarterial chemoembolization with drug-eluting beads.

Figure 3. CBCT imaging post TACE in comparison to MR imaging

A 55-year-old male with biopsy-proven hepatocellular carcinoma underwent 2 sessions of TACE with immediate post-procedure CBCT imaging that illustrates embolization endpoints, in comparison to MR imaging 4-6 weeks after TACE. CBCT: cone-beam computed tomography; DSA: digital subtraction angiography; MR: magnetic resonance; TACE: transarterial chemoembolization.