The high mortality rate for hepatocellular carcinoma (HCC) relative to its prevalence underscores the need for curative-intent therapies. Multidisciplinary treatment decisions are required to craft optimal treatment strategies considering tumor size, location and underlying liver cirrhosis. Surgical resection of anatomically limited tumors with adequate hepatic reserve provides long-term survival in more than half of patients and remains a standard first-line therapy. Eligibility for resection among newly diagnosed patients is low and recurrences in the remaining cirrhotic liver are common. Transplantation offers a higher chance of cure. Long wait times for the limited door pool require neoadjuvant loco-regional therapies to maintain transplant eligibility. Image-guided therapies such as ablation and embolization have an established role as primary or neoadjuvant preparing patients for curative treatment. Percutaneous ablation in appropriately selected patients offers long-term survival similar to resection. New and evolving techniques such as stereotactic body radiotherapy (SBRT), radiation segmentectomy and lobectomy, and combination therapies employing both trans-arterial and ablative approaches show promise for curative-intent treatment but require further prospective data before they can be integrated into treatment algorithms. For palliativeintent therapy, conventional trans-arterial chemoembolization with lipiodol-based emulsions remains the only technique supported by clinical trials. Newer platforms such as drug-eluting embolics failed to improve survival over bland embolization in randomized trials and showed increased hepatobiliary toxicity. Transarterial radioembolization offers similar overall survival (OS) to transarterial chemoembolization (TACE) and non-inferiority to sorafenib in meta-analyses. The more favorable clinical toxicity profile makes it an appealing technique for patients willing to accept the longer time to response.
Metastatic liver disease is one of the major causes of cancer-related morbidity and mortality. Locoregional therapies offered by interventional oncologists alleviate cancer-related morbidity and in some cases improve survival. Locoregional therapies are often palliative in nature but occasionally can be used with curative intent. This review will discuss important factors to consider prior to palliative and curative intent treatment of metastatic liver disease with locoregional therapy. These factors include those specific to the tumor, liver function, liver reserve, differences between treatment modalities, and patient-specific considerations.
Background: Pseudocirrhosis is defined by radiologic changes of the liver parenchyma secondary to metastatic disease and/or cancer treatments, and portends a high rate of morbidity and mortality from sequelae of portal hypertension. Transjugular intrahepatic portosystemic shunt (TIPS) is an effective treatment for portal hypertension; however, TIPS is relatively contraindicated in the setting of hepatic metastases. The study aims to determine the technical efficacy and clinical outcomes of patients undergoing TIPS for symptomatic pseudocirrhosis.Methods: Retrospective analysis of patients with hepatic malignancy who underwent TIPS between 2008 and 2020 at a single tertiary care center. Patients with imaging findings of pseudocirrhosis and without history of primary liver malignancy or confounding causes of cirrhosis were included. West Haven scores assessing hepatic encephalopathy were obtained from chart review. Technical success was defined as successful TIPS creation with reduction in the portosystemic gradient (PSG). Clinical success was defined as resolution of variceal bleeding and/or ascites.Results: Nine patients (4 female/5 male), average (± SD) age 61.2±9.5 years with metastatic pseudocirrhosis were included for analysis. Primary malignancy was colorectal adenocarcinoma (n=5), neuroendocrine tumor (n=3), and malignant endothelial hemangioendothelioma (n=1). Average Model for End Stage Liver Disease (MELD-Na) score was 15.7±3.7. Technical success was 8/9 (89%) with average PSG reduced from 23.5±11.0 to 6.5±2.8 mmHg (P=0.001). Clinical success was 6/9 (67%). Two patients required TIPS revision after initial clinical success. Mild-moderate HE occurred in 6/9 patients post TIPS (67%), with a highest West Haven score of 2. Time from TIPS to death for acute variceal bleeding and ascites was 4.9±4.2 and 12± 16.5 months, respectively. Cause of death was disease progression (n=5), variceal bleeding (n=1), or unavailable (n=2).Conclusions: TIPS in the setting of malignant pseudocirrhosis can be created safely with similar clinical outcomes to TIPS performed for benign disease. Rates of low-grade hepatic encephalopathy may be higher amongst patients undergoing TIPS for pseudocirrhosis.
SIRT is a safe and effective therapy for certain patients with unresectable colorectal liver metastases. This case series supports our opinion that selected patients should be offered SIRT in concert with their medical oncologist, concomitant with their chemotherapy. Larger multi-center studies are required to more clearly define the patient groups that will derive most benefit from SIRT.
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