Locoregional treatments for hepatocellular carcinoma: Current evidence and future directions

Abstract

Liver cancers are the second most frequent cause of global cancer-related mortality of which 90% are attributable to hepatocellular carcinoma (HCC). Despite the advent of screening programmes for patients with known risk factors, a substantial number of patients are ineligible for curative surgery at presentation with limited outcomes achievable with systemic chemotherapy/external radiotherapy. This has led to the advent of numerous minimally invasive options including but not limited to trans-arterial chemoembolization, radiofrequency/microwave ablation and more recently selective internal radiation therapy many of which are often the first-line treatment for select stages of HCC or serve as a conduit to liver transplant. The authors aim to provide a comprehensive overview of these various image guided minimally invasive therapies with a brief focus on the technical aspects accompanied by a critical analysis of the literature to assess the most up-to-date evidence from comparative systematic reviews and meta-analyses finishing with an assessment of novel combination regimens and future directions of travel.

Keywords: Ablation; Cirrhosis; Hepatocellular carcinoma; Interventional oncology; Liver; Selective internal radiation therapy; Trans-arterial chemo embolization.

Figure 1

Drug Eluting Beads-Trans Arterial Chemo Embolization of 3 cm hepatocellular carcinoma. A: Gd-EOB- DTPA enhanced MR image of a 73 years old cirrhotic patient with a 3-cm exophytic liver nodule in segment VI (arrow), showing enhancement in the arterial phase; B: the nodule is hypointense in comparison to the surrounding liver parenchyma in coronal hepatobiliary phase, in keeping with HCC. C and D: Celiac axis DSA showing the hypervascular lesion (arrow); selective microcatheterization of the feeding vessel with infusion of doxorubicin-loaded drug-eluting beads (200 µm). E and F: 2-mo follow-up Gd-EOB- DTPA enhanced MR image demonstrating absence of arterial enhancement of the nodule and marked hypointensity in coronal hepatobiliary phase (arrow).

Figure 2

US-guided radiofrequency ablation Radio-Frequency Ablation of hepatocellular carcinoma. A: Gd-EOB- DTPA enhanced MR image of a 57 years old cirrhotic patient with a 1.5-cm liver nodule in segment VIII (arrow), showing enhancement in the arterial phase, in keeping with HCC. B: US image demonstrating the RF needle, with a 3 cm exposed tip, crossing the lesion (arrow). C: 1-mo follow-up portal-venous phase Gd-EOB- DTPA enhanced MR image demonstrating the oval shaped ablation zone (arrow).

Figure 3

Tc-99m Macro-Aggregates of albumin mapping procedure prior to Y-90 radioembolization. A: Selective common hepatic artery DSA following coil embolization of the gastroduodenal artery (arrow); and B: subsequent infusion of MAA with documentation of the exact position of the tip of the microcatheter at the right hepatic artery (arrow).