Update on Embolization Therapies for Hepatocellular Carcinoma
- 723 Downloads
Purpose of Review
The purpose of the review is to summarize the latest applications for embolotherapy in the management of patients with HCC according to BCLC stage.
While traditionally reserved for patients with unresectable HCC and stage B disease, there is an important role for embolization therapies in earlier stage patients as an adjunct to ablation, bridging, or downstaging therapy, as a means to improve safety of resection, and potentially as an arterial ablative option in the case of radioembolization. Newer applications of radioembolization such as radiation segmentectomy have the potential to provide cure in localized unifocal disease, and transarterial chemoembolization–portal vein embolization and radiation lobectomy may provide a combination of treatment and future liver remnant hypertrophy for planned hepatic resection. There is also an increasing role for embolization in the treatment of stage C disease, and recent data suggest it can be used in combination with sorafenib with the potential for survival benefit over sorafenib alone, even in the case of portal vein tumor thrombus.
Embolization therapies play an increasingly important role in patients with BCLC stage A–C hepatocellular carcinoma. While different therapies may be offered on a patient-specific basis, there are limited prospective RCT data to support superiority of one technique over another.
KeywordsHepatocellular carcinoma Embolotherapy Bland embolization Chemoembolization Radioembolization Locoregional therapy
Compliance with Ethics Guidelines
Conflict of Interest
The authors declare that they have no conflicts of interest.
Human and Animal Rights and Informed Consent
This article does not contain any studies with human or animal subjects performed by any of the authors..
Papers of particular interest, published recently, have been highlighted as: •• Of major importance
- 5.•• Vouche M, Habib A, Ward TJ, et al. Unresectable solitary hepatocellular carcinoma not amenable to radiofrequency ablation: multicenter radiology-pathology correlation and survival of radiation segmentectomy. Hepatol Baltim Md. 2014;60:192–201. Two-center study evaluating safety and efficacy of Y90-radiation segmentectomy as curative option in very early-early stage HCC CrossRefGoogle Scholar
- 6.•• Yang H-J, Lee J-H, Lee DH, et al. Small single-nodule hepatocellular carcinoma: comparison of transarterial chemoembolization, radiofrequency ablation, and hepatic resection by using inverse probability weighting. Radiology. 2014;271:909–18. Retrospective analysis demonstrating similar results of TACE to other standard curative options after attempting to control for selection bias CrossRefPubMedGoogle Scholar
- 7.Hsu K-F, Chu C-H, Chan D-C, Yu J-C, Shih M-L, Hsieh H-F, Hsieh T-Y, Yu C-Y, Hsieh C-B. Superselective transarterial chemoembolization vs hepatic resection for resectable early-stage hepatocellular carcinoma in patients with Child-Pugh class A liver function. Eur J Radiol. 2012;81:466–71.CrossRefPubMedGoogle Scholar
- 9.•• Elnekave E, Erinjeri JP, Brown KT, et al. Long-term outcomes comparing surgery to embolization-ablation for treatment of solitary HCC <7 cm. Ann Surg Oncol. 2013;20:2881–6. Combined TAE-ablation can have comparable outcomes to surgical resection in tumors as large as 7 cm CrossRefPubMedGoogle Scholar
- 12.•• Lewandowski RJ, Donahue L, Chokechanachaisakul A, Kulik L, Mouli S, Caicedo J, Abecassis M, Fryer J, Salem R, Baker T. (90) Y radiation lobectomy: outcomes following surgical resection in patients with hepatic tumors and small future liver remnant volumes. J Surg Oncol. 2016;114:99–105. Single center series assessing safety and efficacy of radiation lobectomy as a pre-operative technique for planned curative hepatic lobectomy with post-operative follow-up CrossRefPubMedGoogle Scholar
- 14.Ronot M, Cauchy F, Gregoli B, Breguet R, Allaham W, Paradis V, Soubrane O, Vilgrain V. Sequential transarterial chemoembolization and portal vein embolization before resection is a valid oncological strategy for unilobar hepatocellular carcinoma regardless of the tumor burden. HPB. 2016;18:684–90.CrossRefPubMedPubMedCentralGoogle Scholar
- 15.•• Piardi T, Memeo R, Renard Y, Ammendola M, Bruno O, Habersetzer F, Baumert T, Pessaux P, Sommacale D. Management of large hepatocellular carcinoma by sequential transarterial chemoembolization and portal vein embolization: a systematic review of the literature. Minerva Chir. 2016;71:192–200. Systematic review assessing safety and efficacy of PVE-TACE prior to planned curative hepatic lobectomy PubMedGoogle Scholar
- 16.Yoo H, Kim JH, Ko G-Y, Kim KW, Gwon DI, Lee S-G, Hwang S. Sequential transcatheter arterial chemoembolization and portal vein embolization versus portal vein embolization only before major hepatectomy for patients with hepatocellular carcinoma. Ann Surg Oncol. 2011;18:1251–7.CrossRefPubMedGoogle Scholar
- 17.•• Pauwels X, Azahaf M, Lassailly G, et al. Drug-eluting beads loaded with doxorubicin (DEBDOX) chemoembolisation before liver transplantation for hepatocellular carcinoma: an imaging/histologic correlation study. Cardiovasc Intervent Radiol. 2015;38:685–92. Evaluation of DEB-TACE in the bridge-to-transplant setting with pathologic correlation and clinical follow-up post-transplant CrossRefPubMedGoogle Scholar
- 19.•• Hodavance MS, Vikingstad EM, Griffin AS, Pabon-Ramos WM, Berg CL, Suhocki PV, Kim CY. Effectiveness of transarterial embolization of hepatocellular carcinoma as a bridge to transplantation. J Vasc Interv Radiol JVIR. 2016;27:39–45. Study demonstrating that TAE is a valid option in the bridge to transplant setting with outcomes comparable to TACE and radioembolization CrossRefPubMedGoogle Scholar
- 25.Jin Y-J, Lee J-W, Park S-W, Lee JI, Lee DH, Kim YS, Cho SG, Jeon YS, Lee KY, Ahn S-I. Survival outcome of patients with spontaneously ruptured hepatocellular carcinoma treated surgically or by transarterial embolization. World J Gastroenterol. 2013;19:4537–44.CrossRefPubMedPubMedCentralGoogle Scholar
- 29.•• de la Torre MA, Buades-Mateu J, de la Rosa PA, et al. A comparison of survival in patients with hepatocellular carcinoma and portal vein invasion treated by radioembolization or sorafenib. Liver Int Off J Int Assoc Study Liver. 2016;36:1206–12. Radioembolization can improve outcomes in advanced stage HCC and can be an alternative or adjunctive therapy to sorafenib in patients with preserved liver function and funtional status Google Scholar
- 32.•• Zhu K, Chen J, Lai L, Meng X, Zhou B, Huang W, Cai M, Shan H. Hepatocellular carcinoma with portal vein tumor thrombus: treatment with transarterial chemoembolization combined with sorafenib—a retrospective controlled study. Radiology. 2014;272:284–93. Retrospective analysis showing that TACE can be used safely in patients with portal vein tumor thrombus with and without sorafenib CrossRefPubMedGoogle Scholar
- 40.Poon RTP, Tso WK, Pang RWC, Ng KKC, Woo R, Tai KS, Fan ST. A phase I/II trial of chemoembolization for hepatocellular carcinoma using a novel intra-arterial drug-eluting bead. Clin Gastroenterol Hepatol Off Clin Pract J Am Gastroenterol Assoc. 2007;5:1100–8.Google Scholar
- 47.Luo J, Peng Z-W, Guo R-P, Zhang Y-Q, Li J-Q, Chen M-S, Shi M. Hepatic resection versus transarterial lipiodol chemoembolization as the initial treatment for large, multiple, and resectable hepatocellular carcinomas: a prospective nonrandomized analysis. Radiology. 2011;259:286–95.CrossRefPubMedGoogle Scholar
- 50.Oligane HC, Xing M, Kim HS. Effect of bridging local-regional therapy on recurrence of hepatocellular carcinoma and survival after orthotopic liver transplantation. Radiology. 2016 160288.Google Scholar
- 53.Seehofer D, Nebrig M, Denecke T, Kroencke T, Weichert W, Stockmann M, Somasundaram R, Schott E, Puhl G, Neuhaus P. Impact of neoadjuvant transarterial chemoembolization on tumor recurrence and patient survival after liver transplantation for hepatocellular carcinoma: a retrospective analysis. Clin Transpl. 2012;26:764–74.CrossRefGoogle Scholar
- 54.Otto G, Herber S, Heise M, Lohse AW, Mönch C, Bittinger F, Hoppe-Lotichius M, Schuchmann M, Victor A, Pitton M. Response to transarterial chemoembolization as a biological selection criterion for liver transplantation in hepatocellular carcinoma. Liver Transplant Off Publ Am Assoc Study Liver Dis Int Liver Transplant Soc. 2006;12:1260–7.Google Scholar
- 57.Facciorusso A, Di Maso M, Muscatiello N. Drug-eluting beads versus conventional chemoembolization for the treatment of unresectable hepatocellular carcinoma: a meta-analysis. Dig Liver Dis Off J Ital Soc Gastroenterol Ital Assoc Study Liver. 2016;48:571–7.Google Scholar
- 58.Marelli L, Stigliano R, Triantos C, Senzolo M, Cholongitas E, Davies N, Tibballs J, Meyer T, Patch DW, Burroughs AK. Transarterial therapy for hepatocellular carcinoma: which technique is more effective? A systematic review of cohort and randomized studies. Cardiovasc Intervent Radiol. 2007;30:6–25.CrossRefPubMedGoogle Scholar
- 59.Kluger MD, Halazun KJ, Barroso RT, et al. Bland embolization versus chemoembolization of hepatocellular carcinoma before transplantation. Liver Transplant Off Publ Am Assoc Study Liver Dis Int Liver Transplant Soc. 2014;20:536–43.Google Scholar
- 61.•• Brown KT, Do RK, Gonen M, et al. Randomized trial of hepatic artery embolization for hepatocellular carcinoma using doxorubicin-eluting microspheres compared with embolization with microspheres alone. J Clin Oncol. 2016;34:2046–53. RCT showing no added benefit of DEB-TACE over TAE in unresectable HCC CrossRefPubMedPubMedCentralGoogle Scholar
- 63.•• Salem R, Gordon AC, Mouli S, et al. Y90 Radioembolization significantly prolongs time to progression compared with chemoembolization in patients with hepatocellular carcinoma. Gastroenterology. 2016; doi: 10.1053/j.gastro.2016.08.029. Phase II single-center study comparing outcomes of radioembolization to chemoembolization in stage A–C disease PubMedGoogle Scholar