[Hepatocellular carcinoma: treatment with arterial chemo-embolization]

Abstract

Due to extensive tumoural invasion, less than 10% of the patients with hepatocellular carcinoma can benefit from surgery. A variety of proposed palliative procedures, including general chemotherapy and radiotherapy, have given quite less than satisfactory results. Percutaneous alcoolization and hormone therapy are currently being evaluated. Increased use of intra-arterial embolization has developed over the last 10 years, initially in Asia and now in Europe. The aim of intra-arterial chemotherapy is to increase the concentration of anticancer agents within the tumour. Adding lipiodol with certain agents would increase the duration of cancer cell exposure. Arterial embolization aims at creating tumour necrosis by ischaemia and relies on the fact that the main blood supply from hepatocellular carcinomas comes from arteries while non-tumoural hepatic tissue is supplied by the portal vein. Numerous reports on intra-arterial treatment protocols combining chemotherapy and embolization have demonstrated that this technique can produce partial or total tumour necrosis. However, due to the variable nature of the natural history of hepatocellular carcinoma the clinically beneficial effect in terms of survival rate has not been established and would not appear to be highly significant, probably due to chemoresistance which cannot be overcome by intra-arterial administration. Indeed, the necrotic effect appears to result from hepatic embolization itself. In two randomized studies necrosis was significantly greater in patients who underwent repeated embolizations than in those receiving general or intra-arterial chemotherapy. It is generally accepted that intra-arterial chemoembolization is contraindicated in cases of portal thrombosis or major liver failure. In addition, each procedure requires at least one week hospitalization with the inherent effect on patient comfort and quality of life. Nevertheless, should intra-arterial, chemoembolization be abandoned? Probably not because there is no alternative method, at least for inoperable patients. Efforts should be made to improve the technique which should be reserved for carefully selected patients. New, more liposoluble drugs and possible combinations with glycoprotein inhibitors could be studied. Until an effective treatment for hepatocellular carcinoma has been developed, the role of palliative care must be evaluated in terms of survival rate, cost and quality of life.