New Insights on Liver-Directed Therapies in Hepatocellular Carcinoma

Abstract

The incidence of hepatocellular carcinoma (HCC) has been increasing over the past decades, but improvements in systemic and locoregional therapies is increasing survival. Current locoregional treatment options include ablation, transarterial chemoembolization (TACE), transarterial radioembolization (TARE), and stereotactic body radiotherapy (SBRT). There is ongoing research regarding the combination of systemic and local therapies to maximize treatment effect as well as in new non-invasive, image-guided techniques such as histotripsy. There is also active research in optimizing the delivery of therapy to tumors via nanostructures and viral-vector-mediated gene therapies. In many cases, patients require a combination of therapies to achieve tumor control and prolong survival. This article provides an overview of the most common liver-directed therapies for HCC as well as insight into more recent advances in personalized medicine and emerging techniques.

Keywords: ablation; chemoembolization; hepatocellular carcinoma; immunotherapy; interventional oncology; interventional radiology; radioembolization.

Figure 1

66-year-old woman with cirrhosis secondary to autoimmune hepatitis and HCC, treated with microwave ablation. (A) Arterial phase MRI showing a 3.5 cm arterially enhancing mass in the periphery of segment 7. (B) Delayed phase MRI demonstrating washout of the mass. Intraprocedural axial (C) and coronal (D) CT images demonstrating probe placement bracketing the mass. (E) Arterial phase MRI one month post ablation showing no residual viable tumor. (F) Arterial phase MRI one year post ablation demonstrating no residual or recurrent viable tumor and involution of the ablation cavity.

Figure 2

88-year-old woman with HCC on a background of cirrhosis secondary to autoimmune hepatitis treated with conventional TACE. (A) Arterial phase MRI showing a 2.2 cm arterially enhancing lesion in hepatic segment 8. (B) Delayed phase MRI showing washout of the lesion. (C) Intraprocedural CTA demonstrating supply to the hypervascular lesion from the segment 8 arterial branch. (D) Post procedure non-contrast CT demonstrating the ethiodized oil deposition within the tumor and surrounding segment 8 parenchyma. (E) Follow up arterial phase MRI one month after treatment demonstrating no arterial enhancement within the treated lesion consistent with complete response.

Figure 2

88-year-old woman with HCC on a background of cirrhosis secondary to autoimmune hepatitis treated with conventional TACE. (A) Arterial phase MRI showing a 2.2 cm arterially enhancing lesion in hepatic segment 8. (B) Delayed phase MRI showing washout of the lesion. (C) Intraprocedural CTA demonstrating supply to the hypervascular lesion from the segment 8 arterial branch. (D) Post procedure non-contrast CT demonstrating the ethiodized oil deposition within the tumor and surrounding segment 8 parenchyma. (E) Follow up arterial phase MRI one month after treatment demonstrating no arterial enhancement within the treated lesion consistent with complete response.

Figure 3

73-year-old man with non-cirrhotic HCC treated with ⁹⁰Y radiation segmentectomy. (A) Arterial phase MRI showing a 4 cm arterially enhancing lesion in hepatic segment 5. (B) Delayed phase MRI showing washout of the lesion. (C) Intraprocedural CTA demonstrating supply to the posterior aspect of the mass from one of the segment 5 branch arteries. (D) Intraprocedural CTA demonstrating supply to the anterior aspect of the mass from a separate segment 5 branch artery. The Y⁹⁰ dose was delivered as a split dose between these two arteries. (E) Follow up arterial phase MRI 3 months after treatment demonstrates wedge-shaped post-treatment changes in hepatic segment 5 with expected parenchymal enhancement and capsular retraction with no residual enhancement of the targeted tumor. (F) Follow up delayed phase MRI demonstrates no wash-out of the enhancing parenchyma to suggest residual viable tumor, consistent with complete response.

Figure 3

73-year-old man with non-cirrhotic HCC treated with ⁹⁰Y radiation segmentectomy. (A) Arterial phase MRI showing a 4 cm arterially enhancing lesion in hepatic segment 5. (B) Delayed phase MRI showing washout of the lesion. (C) Intraprocedural CTA demonstrating supply to the posterior aspect of the mass from one of the segment 5 branch arteries. (D) Intraprocedural CTA demonstrating supply to the anterior aspect of the mass from a separate segment 5 branch artery. The Y⁹⁰ dose was delivered as a split dose between these two arteries. (E) Follow up arterial phase MRI 3 months after treatment demonstrates wedge-shaped post-treatment changes in hepatic segment 5 with expected parenchymal enhancement and capsular retraction with no residual enhancement of the targeted tumor. (F) Follow up delayed phase MRI demonstrates no wash-out of the enhancing parenchyma to suggest residual viable tumor, consistent with complete response.

Figure 4

72-year-old man with HCV cirrhosis and HCC treated with combined cTACE and cryoablation as a bridge to transplant. (A) Arterial phase MRI demonstrates a 2.2 cm segment 4a hypervascular lesion. (B) Digital subtraction angiography images during cTACE procedure demonstrate that the tumor was supplied by both the segment 4a branch vessel (image shown) and segment 2 artery (not shown). cTACE was performed using doxorubicin 50 mg, cisplatin 100 mg, and mitomycin 10 mg followed by PVA 150–250 micron particles. (C) A non-contrast CT scan performed on post-operative day 1 demonstrates a heterogeneous uptake of ethiodized oil within the tumor. Cryoablation was then performed using two probes. Coronal and axial CT images from the procedure demonstrate the probes adjacent to the ethiodized oil staining (D) and the ice ball (E). (F) A follow up contrast enhanced MRI in the arterial phase demonstrates no residual viable tumor.