New approach for hepatocellular carcinoma treatment

Abstract

Hepatocellular carcinoma (HCC) is the fifth most common cancer, with an increasing incidence in recent years. The prognosis is unfavorable, representing the third most frequent cause of cancer-related death worldwide. This is because it generally develops in patients with pre-existing liver pathology, thus limiting therapeutic options. The role of ablative therapies is well-established in nodules smaller than 3 cm, but for nodules from 3 to 5 cm, the best therapeutic management is not well defined. Recent studies reported that combining minimally invasive procedures like transarterial chemoembolization (TACE) with microwave ablation (MWA) or radiofrequency ablation is superior to each alone. However, there is no consensus regarding the timing and the order in which each procedure should be performed. We report a case of an 86 years old male with HCV-related compensated hepatic cirrhosis and multiple cardiac comorbidities diagnosed with a 47/50 mm HCC. Pre-surgical evaluation of the associated pathologies determined that the risk for the surgical approach outweighs the benefits, so the committee decided to treat it in a less invasive manner. We performed MWA and TACE in a single session with technical success according to the modified Response Evaluation Criteria in Solid Tumors (m-RECIST). This case illustrates the first case of simultaneous MWA and TACE performed in our center. This new approach of hepatocellular carcinoma appears to be a good alternative to more invasive methods, with good results even in older people that are unfit for surgery.

Keywords: AFP – alpha-fetoprotein; HCC – hepatocellular carcinoma; MWA – microwave ablation; PEI – percutaneous alcohol injection; RFA – radiofrequency ablation; TACE – transarterial chemoembolization; hepatocellular carcinoma; microwave ablation; transarterial chemoembolization.

Figure 1.

Enhanced CT, arterial and portal phase. A large hepatic nodule (5 cm) is seen in the VIIth segment, with arterial enhancement and rapid washout in portal phase (arrow), a typical CT appearance of HCC.

Figure 2.

An MW probe (arrowhead) is placed under US guidance. A microcatheter (arrow) is placed in the posterior right hepatic artery for the deployment of DEB in the TACE procedure.

Figure 3.

MW ablation probe placement in the nodule during ablation.

Figure 4.

After the ablation, a large area of lack of enhancement is seen in ¾ of the tumor, with residual enhancement on the medial side (arrow) for which DEB-TACE is performed immediately. Large arterioportal shunt (arrowhead) is seen in the dynamic acquisition.

Figure 5.

CT scan with intravenous contrast at 12 months post-procedure (arterial and venous phase) – complete tumor necrosis.