New frontiers in endovascular therapies for locally advanced hepatocellular carcinoma

Hepatocellular carcinoma is the most common primary malignant liver tumour and is a leading cause of death worldwide. Despite the advent of screening programmes, most cases of hepatocellular carcinoma are diagnosed late (in an advanced stage) which precludes curative treatments such as surgery and ablation. Therefore, intra-arterial locoregional treatments now play a central role in the management of advanced hepatocellular carcinoma, such treatments ranging from trans-arterial chemo-embolisation to the more recently developed trans-arterial radio-embolisation technique. In this essay, we discuss the state of the art of intra-arterial treatment for locally advanced hepatocellular carcinoma and the future directions for such treatment.

Keywords:
Carcinoma, hepatocellular/therapy; Fibrosis; Liver/pathology; Medical oncology/methods; Chemoembolization, therapeutic; Liver neoplasms/radiotherapy

Authorship

Riccardo Inchingolo Correspondence: Riccardo Inchingolo, MD. Interventional Radiology Unit, "F. Miulli" Regional General Hospital, Acquaviva delle Fonti (BA), Italy. Email: riccardoin@hotmail.it.

Interventional Radiology Unit, "F. Miulli" Regional General Hospital, Acquaviva delle Fonti (BA), Italy."F. Miulli" Regional General HospitalItalyAcquaviva delle Fonti, BA, ItalyInterventional Radiology Unit, "F. Miulli" Regional General Hospital, Acquaviva delle Fonti (BA), Italy.

Radiology Department, King's College Hospital, London, UK.King's College HospitalUKLondon, UKRadiology Department, King's College Hospital, London, UK.

http://orcid.org/0000-0002-0253-5936

Stavros Spiliopoulos

2nd Radiology Department, National and Kapodistrian University of Athens, Athens, Greece.National and Kapodistrian University of AthensGreeceAthens, Greece2nd Radiology Department, National and Kapodistrian University of Athens, Athens, Greece.

http://orcid.org/0000-0003-1860-0568

Alessandro Posa

Department of Radiology, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy.Fondazione Policlinico Universitario A. GemelliItalyRome, ItalyDepartment of Radiology, Fondazione Policlinico Universitario A. Gemelli, Rome, Italy.

http://orcid.org/0000-0001-9617-3413

Tiago Kojun Tibana

Department of Interventional and Vascular Radiology, Universidade Federal de Mato Grosso do Sul (UFMS), Campo Grande, MS, Brazil.Universidade Federal de Mato Grosso do SulBrazilCampo Grande, MS, BrazilDepartment of Interventional and Vascular Radiology, Universidade Federal de Mato Grosso do Sul (UFMS), Campo Grande, MS, Brazil.

http://orcid.org/0000-0001-5930-1383

Thiago Franchi Nunes

http://orcid.org/0000-0003-0006-3725

Riccardo Memeo

Unit of Hepato-Pancreatic-Biliary Surgery, "F. Miulli" Regional General Hospital, Acquaviva delle Fonti (BA), Italy."F. Miulli" Regional General HospitalItalyAcquaviva delle Fonti, BA, ItalyUnit of Hepato-Pancreatic-Biliary Surgery, "F. Miulli" Regional General Hospital, Acquaviva delle Fonti (BA), Italy.

http://orcid.org/0000-0002-1668-932X

Correspondence: Riccardo Inchingolo, MD. Interventional Radiology Unit, "F. Miulli" Regional General Hospital, Acquaviva delle Fonti (BA), Italy. Email: riccardoin@hotmail.it.

SCIMAGO INSTITUTIONS RANKINGS

Radiology Department, King's College Hospital, London, UK.King's College HospitalUKLondon, UKRadiology Department, King's College Hospital, London, UK.

Figures

Figures (4)

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Figure 1
Conventional TACE of a large HCC. Contrast-enhanced computed tomography scan of a 71-year-old patient with liver cirrhosis and a large (8 cm) HCC involving the right liver lobe (red arrow). Right hepatic artery branch digital subtraction angiography showing the hypervascular lesion. Follow-up contrast-enhanced computed tomography scan, acquired one month later, demonstrating a partial response, with tumour necrosis (white arrow), lipiodol deposition, and residual tumour in the lower part of the nodule (arrowhead).

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Figure 2
DSM-TACE of multi-nodular HCC. Contrast-enhanced computed tomography scan of a 75-year-old patient with liver cirrhosis and a multi-nodular HCC involving the right liver lobe, showing enhancement in the arterial phase (arrow). Note the right portal vein thrombosis (arrow). Right hepatic artery digital subtraction angiography showing the multi-nodular hypervascular lesion. Follow-up contrast-enhanced computed tomography scan, acquired one month later, demonstrating a partial response, with tumour necrosis and a thrombus remaining in the right branch of the portal vein (arrow).

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Figure 3
A 54-year-old male patient with alcoholic cirrhosis presenting with an HCC measuring 10 cm and located in the inferior left medial segment (segment IVb) of the liver. DEB-TACE was performed with HepaSphere 150-200 µm (Merit Medical Systems, South Jordan, UT, USA) loaded with doxorubicin 75 mg. Arteriography demonstrating the tumour blood supply originating from branches of the right hepatic artery and lateral branches of the gastro-duodenal artery. Microbubble contrast-enhanced ultrasound performed 24 h after the procedure, showing necrosis in > 90% of the embolised tumour.

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Figure 4
An 82-year-old male patient with an HCC, of the fibrolamellar subtype, measuring 18 cm and located in the right postero-inferior and postero-superior lateral segments (segments VI and VII, respectively) of the liver, as seen on an unenhanced magnetic resonance imaging scan. DEB-TACE of the liver tumour was performed with two vials of HepaSphere 150-200 µm (Merit Medical Systems, South Jordan, UT, USA) loaded with doxorubicin 75 mg. The patient evolved to an excellent general health status, with no signs of infection. A follow-up computed tomography scan, acquired one month later, showing 100% necrosis with intratumoural gas related to the tumour necrosis.

Figure 1 Conventional TACE of a large HCC. Contrast-enhanced computed tomography scan of a 71-year-old patient with liver cirrhosis and a large (8 cm) HCC involving the right liver lobe (red arrow). Right hepatic artery branch digital subtraction angiography showing the hypervascular lesion. Follow-up contrast-enhanced computed tomography scan, acquired one month later, demonstrating a partial response, with tumour necrosis (white arrow), lipiodol deposition, and residual tumour in the lower part of the nodule (arrowhead).

Figure 2 DSM-TACE of multi-nodular HCC. Contrast-enhanced computed tomography scan of a 75-year-old patient with liver cirrhosis and a multi-nodular HCC involving the right liver lobe, showing enhancement in the arterial phase (arrow). Note the right portal vein thrombosis (arrow). Right hepatic artery digital subtraction angiography showing the multi-nodular hypervascular lesion. Follow-up contrast-enhanced computed tomography scan, acquired one month later, demonstrating a partial response, with tumour necrosis and a thrombus remaining in the right branch of the portal vein (arrow).

Figure 3 A 54-year-old male patient with alcoholic cirrhosis presenting with an HCC measuring 10 cm and located in the inferior left medial segment (segment IVb) of the liver. DEB-TACE was performed with HepaSphere 150-200 µm (Merit Medical Systems, South Jordan, UT, USA) loaded with doxorubicin 75 mg. Arteriography demonstrating the tumour blood supply originating from branches of the right hepatic artery and lateral branches of the gastro-duodenal artery. Microbubble contrast-enhanced ultrasound performed 24 h after the procedure, showing necrosis in > 90% of the embolised tumour.

Figure 4 An 82-year-old male patient with an HCC, of the fibrolamellar subtype, measuring 18 cm and located in the right postero-inferior and postero-superior lateral segments (segments VI and VII, respectively) of the liver, as seen on an unenhanced magnetic resonance imaging scan. DEB-TACE of the liver tumour was performed with two vials of HepaSphere 150-200 µm (Merit Medical Systems, South Jordan, UT, USA) loaded with doxorubicin 75 mg. The patient evolved to an excellent general health status, with no signs of infection. A follow-up computed tomography scan, acquired one month later, showing 100% necrosis with intratumoural gas related to the tumour necrosis.

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New frontiers in endovascular therapies for locally advanced hepatocellular carcinoma

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[1] Correspondence: Riccardo Inchingolo, MD. Interventional Radiology Unit, "F. Miulli" Regional General Hospital, Acquaviva delle Fonti (BA), Italy. Email: riccardoin@hotmail.it.