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Transvaskuläre Ablation des hepatozellulären Karzinoms

Ist Chemotherapie alles?

Transarterial ablation of hepatocellular carcinoma

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Zusammenfassung

Das hepatozelluläre Karzinom (HCC) ist weltweit betrachtet das fünfthäufigste Malignom und die Haupttodesursache bei Patienten mit Leberzirrhose in Europa. Während kurative Therapieansätze (Resektion, Lebertransplantation sowie perkutane Ablation) bei nur 30–40% der Patienten mit einem HCC möglich sind, erfordern die meisten Patienten lokoregionäre bzw. palliative Therapieansätze.

Die Rationale der transvaskulären Ablation des HCC liegt darin, dass die stark hypervaskulären HCC-Knoten ihre Blutversorgung überwiegend über die Leberarterien akquirieren. Der Begriff der transvaskulären Ablation beschreibt sehr unterschiedliche Therapieregime, die in 4 Hauptgruppen unterteilt werden können: 1. cTACE (konventionelle transarterielle Chemoembolisation), 2. TAE (blande Embolisation oder transarterielle Embolisation), 3. DEB-TACE (TACE mittels „drug-eluting beads“, DEB) und 4. SIRT (selektive interne Radiotherapie).

Die konventionelle cTACE ist die am häufigsten eingesetzte transvaskuläre Ablation. Sie stellt eine Kombination aus einer intraarteriellen Chemotherapie und einer Embolisation mit daraus folgendem Verschluss des arteriellen Tumorgefäßbetts dar. Dabei sind die Wahl des Chemotherapeutikums, des Embolisats, der Einsatz von Lipiodol, das Intervall zwischen den TACE-Sitzungen und sogar der genaue Ablauf einer cTACE (Reihenfolge zwischen Chemotherapie und Embolisation) nicht standardisiert. Speziell die Frage nach der Notwendigkeit des Einsatzes der intraarteriellen Chemotherapie konnte noch nicht abschließend beantwortet werden. So bietet die blande Embolisation (ohne die intraarterielle Gabe eines Chemotherapeutikums) unter Einsatz kleinster, eng kalibrierter, sphärischer Partikel aktuell Nekroseraten, die mit denen aus cTACE-Studien vergleichbar sind.

Die DEB-TACE verbindet durch die Beladbarkeit der Embolisationspartikel mit Chemotherapeutika die Vorteile der cTACE und der blanden Embolisation und verspricht durch eine länger wirkende Chemotherapie im Tumorgefäßbett eine weitere Steigerung der intratumoralen Zytotoxizität bei gleichzeitig gesenkter systemischer Toxizität.

Abstract

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and represents the main cause of death among European patients with liver cirrhosis. Only 30–40% of patients diagnosed with HCC are candidates for curative treatment options (e.g. surgical resection, liver transplantation or ablation). The remaining majority of patients must undergo local regional and palliative therapies.

Transvascular ablation of HCC takes advantage of the fact that the hypervascularized HCC receives most of its blood supply from the hepatic artery. In this context transvascular ablation describes different therapy regimens which can be assigned to four groups: cTACE (conventional transarterial chemoembolization), bland embolization (transarterial embolization TAE), DEB-TACE (TACE with drug-eluting beads, DEB) and SIRT (selective internal radiation therapy, radioembolization).

Conventional TACE is the most common type of transvascular ablation and represents a combination of intra-arterial chemotherapy and embolization with occlusion of the arterial blood supply. However, there is no standardized regimen with respect to the chemotherapeutic drug, the embolic agent, the usage of lipiodol and the interval between the TACE procedures. Even the exact course of a cTACE procedure (order of chemotherapy or embolization) is not standardized. It remains unclear whether or not intra-arterial chemotherapy is definitely required as bland embolization using very small, tightly calibrated spherical particles (without intra-arterial administration of a chemotherapeutic drug) shows tumor necrosis comparable to cTACE.

For DEB-TACE microparticles loaded with a chemotherapeutic drug combine the advantages of cTACE and bland embolization. Thereby, a continuing chemotherapeutic effect within the tumor might cause a further increase in intratumoral cytotoxicity and at the same time a decrease in systemic toxicity.

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Abbreviations

BSC:

Best supportive care

CEUS:

Kontrastverstärkter Ultraschall

CR:

Complete response

cTACE:

Konventionelle transarterielle Chemoembolisation

DC:

Disease control

DEB:

Drug-eluting beads

HCC:

Hepatozelluläres Karzinom

MDCT:

Multidetektor-CT

OR:

Objective response rate

PD:

Progressive disease

PES:

Postembolisationssyndrom

PR:

Partial response

PVA:

Polyvinylalkohol

RCT:

Kontrollierte randomisierte Studie

RILD:

Radiation-induced liver disease

SD:

Stable disease

SIRT:

Selektive interne Radiotherapie

TACE:

Transarterielle Chemoembolisation

TAE:

Transarterielle Embolisation

TTP:

Time to progression

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Authors and Affiliations

  1. Abt. Diagnostische und Interventionelle Radiologie, Radiologische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 110, 69120, Heidelberg, Deutschland

    B.A. Radeleff, U. Stampfl, C.M. Sommer, N. Bellemann & H.U. Kauczor

  2. Abt. für Allgemein-, Viszeral- und Transplantationschirurgie, Chirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland

    K. Hoffmann

  3. Medizinische Klinik IV, Gastroenterologie, Infektionskrankheiten, Vergiftungen, Universitätsklinikum Heidelberg, Heidelberg, Deutschland

    T. Ganten & R. Ehehalt

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  1. B.A. Radeleff
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Radeleff, B., Stampfl, U., Sommer, C. et al. Transvaskuläre Ablation des hepatozellulären Karzinoms. Radiologe 52, 44–55 (2012). https://doi.org/10.1007/s00117-011-2211-1

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