Despite remarkable advancement in the surveillance and treatment of hepatocellular carcinoma (HCC) and the availability of novel curative options, a great proportion of HCC patients are still not eligible for curative treatment due to an advanced tumor stage or poor hepatic functional reserve. Therefore, there is a continuing need for effective palliative treatments. Although practiced widely, it has only recently been demonstrated that the use of transarterial chemoembolization (TACE) provides a survival benefit based on randomized controlled studies. Hence, TACE has become standard treatment in selected patients. TACE combines the effect of targeted chemotherapy with the effect of ischemic necrosis induced by arterial embolization. Most of the TACE procedures have been based on iodized oil utilizing the microembolic and drug-carrying characteristic of iodized oil. Recently, there have been efforts to improve the delivery of chemotherapeutic agents to a tumor. In this review, the basic principles, technical issues and complications of TACE are reviewed and recent advancement in TACE technique and clinical applicability are briefed.
Hepatocellular carcinoma (HCC) is the fifth most common malignancy in the world and is responsible for ~500,000 deaths worldwide annually.1 The incidence almost equals the mortality. It is the most common cause of death in patients with compensated liver cirrhosis. HCC usually arises in the setting of chronic liver disease, commonly from hepatitis B, C, or alcohol abuse. In fact, 80% of HCC arises in the setting of cirrhosis. Despite available treatment, survival rates of HCC remain poor, with an estimation of 54% at 1 year, 40% at 2 years, and 28% at 3 years.2 The only definitive therapy is liver transplantation. Resection, when possible, is not curative as cirrhosis remains a comorbidity. Even with transplantation in early HCC associated with cirrhosis, there is still a potential risk for HCC recurrence.3 Typically, transplantation is reserved for candidates with a single lesion up to 5 cm in diameter, or multiple lesions up to three with a total diameter of 9 cm, with no vascular invasion and no regional or distant nodal metastatic disease. The 4-year survival rate for transplantation is ~80%. Similar survival rates have been reported for larger HCCs.4
Hepatocellular carcinoma (HCC) is the fifth most common cancer in men and eighth most common cancer in women worldwide. Its crude incidence in the European Union is 8.29/100 000. Areas such as Asia and sub-Saharan Africa with high rates of infectious hepatitis have incidences as high as 120 cases per 100 000. It is 4–8 times more common in men and usually associated with chronic liver injury (hepatitis B, hepatitis C and alcoholic cirrhosis). Chronic infection with hepatitis B virus in the setting of cirrhosis increases the risk of hepatocellular carcinoma 1000-fold. Some 5–30% of individuals with HCV infection develop chronic liver disease, about 30% progress to cirrhosis, and in these, 1–2% per year develop hepatocellular carcinoma. Co-infection with HBV further increases the risk. Alcohol abuse in the setting of chronic HCV infection doubles the risk of hepatocellular carcinoma compared with HCV infection alone. Median age at diagnosis is between 50 and 60 years. In Africa and Asia, age at diagnosis is substantially younger, occurring in the fourth and fifth decades of life, respectively.
Purpose: To evaluate local tumor control and survival data after transarterial chemoembolization with different drug combinations in the palliative treatment of liver metastases in patients with colorectal cancer.
Introduction. Transcatheter arterial embolization (TAE) and chemoembolization (TACE) are increasingly used to treat unresectable primary and metastatic liver tumors. The purpose of this study was to determine the objective response to TAE and TACE in unresectable hepatic malignancies and to identify clinicopathologic predictors of response. Materials and methods. Seventy-nine consecutive patients who underwent 119 TAE/TACE procedures between 1998 and 2006 were reviewed. The change in maximal diameter of 121 evaluable lesions in 56 patients was calculated from pre and post-procedure imaging. Response rates were determined using Response Evaluation Criteria in Solid Tumors (RECIST) guidelines. The Kaplan-Meier method was used to compare survival in responders vs. non-responders and in primary vs. metastatic histologies. Results. TAE and TACE resulted in a mean decrease in lesion size of 10.3%±1.9% (p<0.001). TACE (vs. TAE) and carcinoid tumors were associated with a greater response (p<0.05). Lesion response was not predicted by pre-treatment size, vascularity, or histology. The RECIST partial response (PR) rate was 12.3% and all partial responders were in the TACE group. Neuroendocrine tumors, and specifically carcinoid lesions, had a significantly greater PR rate (p<0.05). Overall survival, however, was not associated with histology or radiologic response. Discussion. TAE and TACE produce a significant objective treatment response by RECIST criteria. Response is greatest in neuroendocrine tumors and is independent of vascularity and lesion size. TACE appears to be superior to TAE. Although an association of response with improved survival was not demonstrated, large cohort studies are necessary to further define this relationship.
Purpose: Angiographic endpoints for chemoembolization of hepatocellular carcinoma (HCC) are subjective, and optimal endpoints remain unknown. Transcatheter intraarterial perfusion (TRIP) magnetic resonance (MR) imaging, when performed in a combined MR/interventional radiology (MR-IR) suite, offers an objective method to quantify intraprocedural tumor perfusion changes, but was previously limited to two spatial dimensions. This study prospectively tested the hypothesis that a new volumetric acquisition over time, four-dimensional TRIP MR imaging, can measure HCC perfusion changes during chemoembolization.
Purpose: Angiographic endpoints for transcatheter arterial chemoembolization (TACE) of hepatocellular carcinoma (HCC) are subjective, and optimal endpoints remain unknown. Transcatheter intraarterial perfusion magnetic resonance imaging (TRIP-MRI), when performed in a combined MR-interventional radiology (MR-IR) suite, offers an objective method to quantify intra-procedural tumor perfusion changes, but was previously limited to two spatial dimensions. We prospectively tested the hypothesis that a new volumetric acquisition over time, 4D TRIP-MRI, can measure HCC perfusion changes during TACE.
Most patients with hepatocellular carcinoma (HCC) are not eligible for curative treatment, which is resection or transplantation. Two recent series have emphasized the potential benefits of preoperative arterio-portal embolization prior to surgical resection of such tumours. This preoperative strategy offers a better disease free survival rate and a higher rate of total tumor necrosis. In case of non resectable HCC it is now widely accepted that transarterial chemoembolization (TACE) leads to a better survival when compared to conservative treatment. Thus, the question remains whether combined portal vein embolization (PVE) may enhance the proven efficiency of TACE in patients with unresectable HCC. We herein report the case of a 56-year-old cirrhotic woman with a voluminous HCC unsuitable for surgical resection. Yet, complete tumour necrosis and prolonged survival could be achieved after a combined porto-arterial embolization. This case emphasizes the potential synergistic effect of a combined arterio-portal embolization and the hypothetical survival benefit of such a procedure, in selected patients, with HCC not suitable for surgery or local ablative therapy.
Hepatocellular carcinoma (HCC) ranks fifth in frequency of cancers worldwide. The incidence of HCC in the United States is rising, primarily due to the number of patients who were infected by hepatitis in the 1960s and 1970s coupled with the rising migrant population from Asia, where hepatitis is widely prevalent. Up to 80% of the patients present with multicentric HCC and advanced liver disease or comorbidities that restrict the option of resection or liver transplantation. The dual blood supply (arterial and portal) to the liver with predominantly arterial supply to the tumor has made embolotherapy a cornerstone in the management of inoperable HCC. The techniques have become refined not only due to the development of microcatheter angiographic capabilities, but also in the ability to deliver a wide variety of therapeutic agents to these tumors. This article reviews the fundamental principles of bland embolization, chemoembolization, and radioembolization in the management of HCC.
Objective: We wanted to investigate the prevalence and causative factors of extrahepatic arterial blood supply to hepatocellular carcinoma (HCC) at its initial presentation and during chemoembolization.
This document, on the diagnosis and treatment of patients with hepatocellular carcinoma (HCC), was commissioned by the British Society of Gastroenterology as part of a wider initiative to develop guidelines for clinicians in several areas of clinical practice.
PURPOSE: To review the available evidence of chemoembolization for unresectable hepatocellular carcinoma (HCC).
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