Combined locoregional treatment of patients with hepatocellular carcinoma: State of the art

Abstract

In recent years, a combination of intervention therapies has been widely applied in the treatment of hepatocellular carcinoma (HCC). One such combined strategy is based on the combination of the percutaneous approach, such as radiofrequency ablation (RFA), and the intra-arterial locoregional approach, such as trans-arterial chemoembolization (TACE). Several types of evidence have supported the feasibility and benefit of combined therapy, despite some studies reporting conflicting results and outcomes. The aim of this review was to explain the technical aspects of different combined treatments and to comprehensively analyze and compare the clinical efficacy and safety of this combined treatment option and monotherapy, either as TACE or RFA alone, in order to provide clinicians with an unbiased opinion and valuable information. Based on a literature review and our experience, combined treatment seems to be a safe and effective option in the treatment of patients with early/intermediate HCC when surgical resection is not feasible; furthermore, this approach provides better results than RFA and TACE alone for the treatment of large HCC, defined as those exceeding 3 cm in size. It can also expand the indication for RFA to previously contraindicated "complex cases", with increased risk of thermal ablation related complications due to tumor location, or to "complex patients" with high bleeding risk.

Combined transcatheter arterial chemoembolization and radiofrequency ablation in single‐session for solitary hepatocellular carcinoma larger than 7 cm

“…Data related to LTP rates in patients with large HCC (> 7.0 cm) following the combination treatment are rare in the literature. 11,13,33 In our study, the estimated 1-, 3-and 5-year LTP rates was 0%, 29.9% and 55.2%, respectively. Given that HCC treated in our study was larger than 7 cm in diameter (7.1-13.5 cm), the LTP rates shown in our study are acceptable.…”

“…Currently, the combined TACE and RFA in single-session has rarely been performed in the treatment large HCC, 13 because of concerning about the risk of complications such as hepatic arterial bleeding and hepatic dysfunction. 9,20 Theoretically, the rate of complications should be higher in the combined TACE and RFA than that of TACE or RFA monotherapy.…”

“…The time intervals are based on the assumption that the effect of TACE would last until the time of RF ablation. 13 However, numerous variables may affect the duration of the embolization effect, including characteristics of tumoral vascularity, the presence of an arteriovenous shunt, the severity of cirrhosis, the collaterals establishment and the embolic materials used in chemoembolization. Based on our experience, establishment of collaterals may occur at 1 week or even 24 hours after embolization and lead to decreasing the effectiveness of RFA; therefore, the embolization effect might not be optimal at the time of RFA.…”

“…Currently, there has been no consensus about the time interval between TACE and RFA for balancing local therapeutic efficacy and safety. 13 In several published papers related the combined therapy, TACE and RFA were performed during different sessions, separated by a timeinterval of 1-3 weeks. [6][7][8][9][10][11][12][13][14] Choe et al 34 suggested that the time-…”

“…[3][4][5] Recently, the use of TACE combined with RFA is gaining acceptance as a therapeutic strategy for the treatment of intermediate-sized (3-5 cm) HCCs because TACE decreases hepatic blood flow to tumors, making subsequent RFA more effective. [6][7][8][9][10][11][12][13] After TACE, the intratumoral retention of radio-opaque iodized oil can allow guidance for subsequent RFA by making the tumor depicted on fluoroscopy, unenhanced CT, or cone-beam CT (CB-CT). [14][15][16] Currently, treatment of large HCC (> 7 cm) is still a challenging problem.…”