Pseudoaneurysm formation following transarterial embolization of traumatic carotid-cavernous fistula with detachable balloon:An institutional cohort long-term study

BACKGROUND The goal of therapy for traumatic carotid-cavernous fistula(TCCF)is the elimination of fistula while maintaining patency of the parent artery.The treatment for TCCF has evolved from surgery to endovascular management using detachable balloons,coils,liquid embolic agents,covered stents,or flow-diverter stent through arterial or venous approaches.Despite the withdrawal of detachable balloons from the market in the United States since 2004,transarterial embolization with detachable balloons has currently remained the best initial treatment for TCCF in several countries.However,the pseudoaneurysm formation following transarterial detachable balloon embolization has rarely been observed in long-term follow-up.AIM To determine the occurrence and long-term follow-up of pseudoaneurysm after transarterial detachable balloon for TCCF.METHODS Between January 2009 and December 2019,79 patients diagnosed with TCCF were treated using detachable latex balloons(GOLDBAL)of four sizes.Pseudoaneurysm sizes were stratified into five grades for analysis.Initial and follow-up assessments involved computed tomography angiography at 1 month,6 month,1 year,and longer intervals for significant cases.Clinical follow-ups occurred semi-annually for 2 years,then annually.Factors analyzed included sex,age,fistula size and location,and balloon size.RESULTS In our cohort of 79 patients treated for TCCF,pseudoaneurysms formed in 67.1%,with classifications ranging from grade 0 to grade 3;no grade 4 or giant pseudoaneurysms were observed.The majority of pseudoaneurysms did not progress in size,and some regressed spontaneously.Calcifications developed in most large pseudoaneurysms over 5-10 years.Parent artery occlusion occurred in 7.6%and recurrent fistulas in 16.5%.The primary risk factors for pseudoaneurysm formation were identified as the use of specific balloon sizes,with balloon SP and No.6 significantly associated with its occurrence(P=0.005 and P=0.002,respectively),whereas sex,age,fistula size,location,and the number of balloons used were not significant predictors.CONCLUSION Pseudoaneurysm formation following detachable balloon embolization for TCCF is common,primarily influenced by the size of the balloon used.Despite this,all patients with pseudoaneurysms remained asymptomatic during long-term follow-up.

Transarterial embolization is an acceptable bridging therapy to hepatocellular carcinoma prior to liver transplantation

BACKGROUND Hepatocellular carcinoma(HCC)is an aggressive malignant neoplasm that requires liver transplantation(LT).Despite patients with HCC being prioritized by most organ allocation systems worldwide,they still have to wait for long periods.Locoregional therapies(LRTs)are employed as bridging therapies in patients with HCC awaiting LT.Although largely used in the past,transarterial embolization(TAE)has been replaced by transarterial chemoembolization(TACE).However,the superiority of TACE over TAE has not been consistently shown in the literature.AIM To compare the outcomes of TACE and TAE in patients with HCC awaiting LT.METHODS All consecutive patients with HCC awaiting LT between 2011 and 2020 at a single center were included.All patients underwent LRT with either TACE or TAE.Some patients also underwent percutaneous ethanol injection(PEI),concom-itantly or in different treatment sessions.The choice of LRT for each HCC nodule was determined by a multidisciplinary consensus.The primary outcome was waitlist dropout due to tumor progression,and the secondary outcome was the occurrence of adverse events.In the subset of patients who underwent LT,complete pathological response and post-transplant recurrence-free survival were also assessed.RESULTS Twelve(18.5%)patients in the TACE group(only TACE and TACE+PEI;n=65)and 3(7.9%)patients in the TAE group(only TAE and TAE+PEI;n=38)dropped out of the waitlist due to tumor progression(P log-rank test=0.29).Adverse events occurred in 8(12.3%)and 2(5.3%)patients in the TACE and TAE groups,respectively(P=0.316).Forty-eight(73.8%)of the 65 patients in the TACE group and 29(76.3%)of the 38 patients in the TAE group underwent LT(P=0.818).Among these patients,complete pathological response was detected in 7(14.6%)and 9(31%)patients in the TACE and TAE groups,respectively(P=0.145).Post-LT,HCC recurred in 9(18.8%)and 4(13.8%)patients in the TACE and TAE groups,respectively(P=0.756).Posttransplant recurrence-free survival was similar between the groups(P log-rank test=0.71).CONCLUSION Dropout rates and posttransplant recurrence-free survival of TAE were similar to those of TACE in patients with HCC.Our study reinforces the hypothesis that TACE is not superior to TAE as a bridging therapy to LT in patients with HCC.

Right trisegmentectomy with thoracoabdominal approach after transarterial embolization for giant hepatic hemangioma

Hepatic hemangiomas need to be treated surgically in cases where they are accompanied with symptoms, have a risk of rupture, or are hardly distinguishable from malignancy. The present authors conducted embolization of the right hepatic artery one day before an operation for a huge hemangioma accompanied with symptoms and confirmed a decrease in its size. The authors performed a right trisegmentectomy through a J-shape incision, using a thoracoabdominal approach, and safely removed a giant hemangioma of 32.0 cm × 26.5 cm × 8.0 cm in size and 2300 g in weight. Even for inexperienced surgeons, a J-shape incision with a thoracoabdominal approach is considered a safe and useful method when right-side hepatectomy is required for a large mass in the right liver.

Post-radiation survival time in hepatocellular carcinoma based on predictors for CT-determined, transarterial embolization and various other parameters

AIM: In this retrospective study of unresectable hepatocellular carcinoma (HCC), we have investigated the efficacy of CT-derived parameters, laboratory measurements, clinical assessment and associated transarterial embolization (TAE) as predictors of post-radiotherapy survival time. METHODS: Sixty-six patients diagnosed with unresectable HCC that had undergone radiotherapy at two medical university hospitals in Taipei were enrolled in the study. Using multivariant analysis, pre-treatment parameters including tumor number and CT confirmation of PVT and ascites were compared. Multivariant analysis was also used for comparison of the mean pretreatment values for laboratory measurements, including alpha-fetoprotein, direct/total bilirubin and GOT/GPT levels, and clinical history of chronic hepatitis across the three survival-time categories. The x2 was used to test the significance of the relationship between survival time and TAE procedure. The P values for the above tests were deemed statistically significant where P<0.05. RESULTS: Portal vein thrombosis (P= 0.032) and ascites (P><0.05) were negative predictors of post-radiation survival time. Low-grade liver cirrhosis (A or B), lower tumor volume and low levels of AFT, GOT/GPT, and total bilirubin were predictors of longer post-radiation survival time (P<0.05). CONCLUSION: The CT and clinical and laboratory assessment provide a reference for, and enable estimation of, probable survival times in HCC patients after radiotherapy. Tumor volume, severity of liver cirrhosis, status with respect to portal vein thrombosis and ascites and AFT, GOT/GPT and total bilirubin values were significant predictors of survival in this study.

Impact of pre-operative transarterial embolization on the treatment of hepatocellular carcinoma with liver transplantation

AIM: To determine the effectiveness of pre-liver transplant (LT) transarterial embolization (TAE) in treating hepatocellular carcinoma (HCC) and the patient categories,which are likely to have a good outcome after LT.METHODS: Twenty-nine patients with hepatitis-related cirrhosis and unresectable HCC after LT were studied over a 7-year period. The patients were divided into two groups: group A patients (19/29) received pre-LT TAE,whereas group B (10/29) underwent LT without prior TAE.According to Milan criteria, group A patients were further subdivided into: group A1 (12/19) who met the criteria,and group A2 (7/19) who did not. Patient survivals were compared.RESULTS: In the explanted liver, CT images correlated well with pathological specimens showing that TAE induced massive tumor necrosis (＞85%) in 63.1% of patients in group A and all 7 patients in group A2 exhibited tumor downgrading that met Milan criteria. The overall 5-year actuarial survival rate was 80.6%. The TAE group had a better survival (84% at 5 years) than the non-TAE (75% at 4 years). The 3-year survival of group A2 (83%)was also higher than that of group A1 (79%). Tumor necrosis ＞85% was associated with excellent survival of 100% at 3 years, which was significantly better than the others who showed ＜85% tumor necrosis (57.1% at 3 years) or who did not have TAE (75% at 3 years).CONCLUSION: TAE is an effective treatment for HCC before LT. Excellent long-term survival was achieved in patients that did not fit Milan criteria. Our results broadened and redefined the selection policy for LT among patients with HCC. Meticulous pre-LT TAE helps in further reducing the rate of dropout from waiting lists and should be considered for patients with advanced HCC.

Anatomic and technical skill factor of gastroduodenal complication in post-transarterial embolization for hepatocellular carcinoma: A retrospective study of 280 cases

AIM: To reduce the possibility of gastroduodenal complications. The purpose of this retrospective study was to survey the literature and compare and discuss the incidence of post-transarterial embolization (TAE)gastroduodenal complications.METHODS: We found reports describing 280 cases of hepatocellular carcinoma with TAE procedures done during the past 4 years and selected all of them for our study.Amongst these cases, 86 were suspected of suffering gastroduodenal complications within one month of postTAE treatment. Fifteen of these cases were proved by pan-endoscopy to have gastroduodenal erosions or ulcerations. We reviewed the angiographic pictures in patient records to evaluate the possibility that anatomic and technical skill factors could explain the complications.RESULTS: Amongst the 15 cases, 9 were primary lesions of the antrum and prepylorus; 4 had duodenal ulcer or erosions; 2 had mid-body lesions; none showed a lesion at the fundus or cardia region. Three cases had not received TAEs using our ideal method, and may be associated with possible regurgitation of gel-foam pieces into the right or left gastric arteries. Two cases involved sub-selective embolization at a distal point on the hepatic artery; one case was found by angiography to have complete occlusion of the celiac trunk.CONCLUSION: Comparing our results with past cases of post-TAE gastroduodenal complications, we surmise that our relatively low incidence (5.3%) of gastric complications might be explained by our concerted efforts to improve our technical skills in multi-sequential, selective and superselective approaches to the embolization of tumor vessels.

Increased extrinsic apoptotic pathway activity in patients with hepatocellular carcinoma following transarterial embolization

AIM： TO determine the apoptosis pathway in residual viable hepatocellular carcinoma （HCC） tissues following transarterial embolization （TAE）.andα fetoprotein （AFP） levels after TAE. All tissue samples were taken from the residual tumors. The expression of various apoptotic proteins was evaluated via immunoblotting procedures. The results were analyzed using a Student＇s t test. RESULTS： Tumor size and the AFP level decreased by 46.2% and 55.3% after TAE, respectively. There was no significant difference detected for the Bcl-2/Bax ratio or the cleaved caspase-9 expression levels in either group. However, extrinsic apoptopic pathway-related expression of Fas and cleaved caspase-8 expression were significantly higher in the study group than in the control group （P 〈 0.05）. In addition, cleaved caspase-3 expression in the study group was higher （1.62-fold） than in control group （P 〈 0.05）. CONCLUSION： TAE is an effective palliative therapy that decreases tumor size and AFP levels via an increase in extrinsic apoptosis pathway in patients with unresectable HCC.

Rupture of hepatocellular carcinoma following transarterial embolization/chemoembolization: two cases report and systematic review

Objective: Rupture of hepatocellular carcinoma (HCC) following transarterial embolization/chemoembolization (TAE/TACE) is a rare but life-threatening complication. The aim of the study was to explore the incidence, risk factors, clinical characteristics, treatment, and outcomes of this complication. Methods: We described two cases and reviewed all cases of ruptured HCC after TAE/TACE reported in the literature. Results: Our search yielded 32 cases of ruptured HCC after TAE/TACE. The overall incidences were 0.45% per patient and 0.21% per session. The mean age of the patients was 57.4 years (range 28-90 years, n=26, No. of cases with available information). Males accounted for 81% of cases (21/26). The 50% of the cases had histories of primary hypertension, diabetes or peripheral artery disease (6/12). Mean diameter of the tumors was 11.4 cm (range 3-20 cm, n=27). The 100% of cases had superficial or exophytic tumors (23/23). Portal vein thrombosis was presented in 61.5% of patients (8/13). The median interval between TAE/TACE and rupture was 2 days (range 0 hour-30 days, n=31). Management choices included emergency TAE, surgery, and conservative treatment. The overall median survival time was 7 days (n=19). Conclusion: Rupture of HCC following TAE/TACE is relatively rare but potentially life-threatening. The management is difficult and prognosis is poor. Large tumor size, superficial or exophytic tumors as well as portal vein thrombosis and comorbidities such as primary hypertension, diabetes or peripheral artery disease may be predisposing factors for rupture.

Computed tomography-guided radiofrequency ablation of the retained iodized oil after simultaneous combination with transarterial embolization in small recurrent or residual hepatocellular carcinoma

Objective:To assess the clinical efficacy and safety of transarterial embolization(TAE)in simultaneous combination with computed tomography(CT)-guided radiofrequency ablation(RFA)for recurrent or residual hepatocellular carcinoma(HCC),and to determine the risk factors influencing local tumor progression following this procedure.Methods:One hundred eighteen patients with recurrent or residual HCC(tumor size,10–30 mm)underwent RFA.During the 19-month follow-up,59 patients received RFA only(RFA group),and the remaining 59 received RFA immediately after TAE(TAE+RFA group).All patients were followed up to observe the short-term therapeutic effects and complications.The cumulative local tumor progression rates in both groups were calculated using unpaired Student’s t tests and the Kaplan-Meier method.Results:The rate of major complications was 5.08%in the TAE+RFA group and 3.39%in the RFA group.The overall response rate was 96.61%in the TAE+RFA group and 79.66%in the RFA group(P=0.008).The disease control rate was significantly higher in the TAE+RFA group than in the RFA group(94.92%vs.79.66%,P=0.024).The median time to local tumor progression was 4.8 months in the RFA group and 9.6 months in the TAE+RFA group.The cumulative local tumor progression rate at 1 year was 10.60%in the RFA group and 23.60%in the TAE+RFA group(P=0.016).Conclusion:TAE in simultaneous combination with CT-guided RFA was effective and safe against recurrent or residual HCC.Local tumor progression can be minimized by the complete ablation of targeted iodized oil deposits after simultaneous TAE.

Transarterial embolization chemotherapy at early stage after hepatectomy of 45 patients with large hepatocellular carcinoma

Objective: To investigate the effect of transarterial embolization (TAE) at early stage postoperatively to prevent rumor recurrence after hepatectomy in patients with large hepatocellular carcinoma (HCC). Methods: Forty-five volunteer patients with large HCC received TAE 2 to 4 weeks after the hepatectomy. Another 48 patients with large HCC without postoperative TAE treatment served as control. Results: No severe complications associated with TAE or hepatectomy occurred, and follow-up visit of all patients revealed that 1-year recurrence rate for patients with PAL was markedly lower than those without (43.24%vs 70.73%, P＜0.05＝. Conclusion: The treatment with TAE at early stage after hepatectomy is safe and feasible for the patients with liver function Child-Pugh score not higher than 8, and it may help reduce the postoperative recurrence of hepatocellular carcinoma.

Transarterial embolization of carotid-cavernous sinus fistula associated with a primitive trigeminal artery-case report

BACKGROUND AND PURPOSE We evaluated our experience in placing detachable coils in the management of spontaneous CCFs due to rupture of a primitive trigeminal artery. Methods A 48-year-old female presented with right conjunctival chemosis and right abducens nerve paresis. Cerebral angiography demonstrated a right carotid-cavernous sinus fistula associated with persistent primitive trigeminal artery. Transvenous routes to the sinus were failed due to the tortuous facial vein. The fistula was treated by Matrix detachable coils and Fibered detachable coils through the transarterial approach. Results The patient was successfully treated by means of transarterial embolization, and symptoms improved within a week. Conclusions Although other techniques using a transvenous approach may also be useful, transarterial embolization with detachable coils should be a safe and effective method to immediately occlude the fistula.

Is transarterial embolization plus two-stage hepatectomy the optimal strategy for the treatment of spontaneous rupture of hepatocellular carcinoma?

We were intrigued to read the retrospective study by Wang et al.“Propensity score matching study of 325 patients with spontaneous rupture of hepatocellular carcinoma”(1)published in the latest issue of Hepatobiliary Surgery Nutrition.The authors elaborated the extremely significant conclusion that transarterial embolization(TAE)plus two-stage hepatectomy might be the optimal treatment for spontaneous rupture of hepatocellular carcinoma(RHCC)patients,whose overall survival(OS)and disease-free survival(DFS)aren’t significantly different compared with non-ruptured hepatocellular carcinoma(NHCC)patients undergoing hepatectomy,and had a better prognosis than other treatment,including TAE alone and one-stage hepatectomy.We highly appreciate the author’s research results.However,when we read the document,there were some shortcomings.

Current research status of transarterial therapies for hepatocellular carcinoma

With continuous advancements in interventional radiology,considerable progress has been made in transarterial therapies for hepatocellular carcinoma(HCC)in recent years,and an increasing number of research papers on transarterial therapies for HCC have been published.In this editorial,we comment on the article by Ma et al published in the recent issue of the World Journal of Gastrointestinal Oncology:“Efficacy and predictive factors of transarterial chemoembolization combined with lenvatinib plus programmed cell death protein-1 inhibition for unresectable HCC”.We focus specifically on the current research status and future directions of transarterial therapies.In the future,more studies are needed to determine the optimal transarterial local treatment for HCC.With the emergence of checkpoint immunotherapy modalities,it is expected that the results of trials of transarterial local therapy combined with systemic therapy will bring new hope to HCC patients.

Efficacy and safety analysis of transarterial chemoembolization and transarterial radioembolization in advanced hepatocellular carcinoma descending hepatectomy

BACKGROUND Hepatocellular carcinoma(HCC)is one of the most common malignant tumors in the world,which is seriously threatening the lives of patients.Due to the rapid development of the disease,patients were in the middle and advanced stages at the time of diagnosis and missed the best time for treatment.With the development of minimally invasive medicine,interventional therapy for advanced HCC has achieved promising results.Transarterial chemoembolization(TACE)and transarterial radioembolization(TARE)are currently recognized as effective treatments.This study aimed to investigate the clinical value and safety of TACE alone and combined with TACE in the treatment of progression in patients with advanced HCC and to find a breakthrough for the early diagnosis and treatment of patients with advanced HCC.AIM To investigate the efficacy and safety of hepatic TACE and TARE in advanced descending hepatectomy.METHODS In this study,218 patients with advanced HCC who were treated in the Zhejiang Provincial People’s Hospital from May 2016 to May 2021 were collected.Of the patients,119 served as the control group and received hepatic TACE,99 served as the observation group and were treated with hepatic TACE combined with TARE.The patients in two groups were compared in terms of lesion inactivation,tumor nodule size,lipiodol deposition,serum alpha-fetoprotein(AFP)level in different periods,postoperative complications,1-year survival rate,and clinical symptoms such as liver pain,fatigue,and abdominal distension,and adverse reactions such as nausea and vomiting.RESULTS The observation group and the control group had good efficacy in treatment efficiency,reduction of tumor nodules,reduction of postoperative AFP value,reduction of postoperative complications,and relief of clinical symptoms.In addition,compared with the control group,the treatment efficiency,reduction of tumor nodules,reduction of AFP value,reduction of postoperative complications,and relief of clinical symptoms in the observation group were better than those in the TACE group alone.Patients in the TACE+TARE group had a higher 1-year survival rate after surgery,lipiodol deposition was significantly increased and the extent of tumor necrosis was expanded.The overall incidence of adverse reactions in the TACE+TARE group was lower than that in the TACE group,and the difference had statistical significance(P<0.05).CONCLUSION Compared with TACE alone,TACE combined with TARE is more effective in the treatment of patients with advanced HCC.It also improves postoperative survival rate,reduces adverse effects,and has a better safety profile.

Transarterial chemoembolization and bland embolization for hepatocellular carcinoma

Transarterial chemoembolization(TACE)is the first line treatment for patients with intermediate stage hepatocellular carcinoma but is also increasingly being used for patients on the transplant waiting list to prevent further tumor growth.Despite its widespread use,TACE remains an unstandardized procedure,with variation in type and size of embolizing particles,type and dose of chemotherapy and interval between therapies.Existing evidence from randomized controlled trials suggest that bland transarterial embolization(TAE)has the same efficacy with TACE.In the current article,we review the use of TACE and TAE for hepatocellular carcinoma and we focus on the evidence for their use.

Is transarterial embolization a valuable treatment option for spontaneous rupture of hepatocellular carcinoma: experience from a tertiary care hospital of South-Asia

Aim:Transarterial embolization(TAE)has been found beneficial in treatment of ruptured Hepatocellular carcinoma(HCC)in earlier studies.So far no data is available from Pakistan.The aim of this study was to evaluate clinicopathological characteristics,outcomes of patients presented with spontaneously ruptured,unresectable HCC treated with or without TAE and to evaluate the factors associated with 30-day mortality.Methods:This was a cross sectional study.Patients≥18 years old,presented with spontaneous rupture of unresectable HCC,were evaluated.The outcome measures were control of bleeding,in-hospital mortality,30-day mortality and factors associated with 30-days mortality.Results:Out of 850 patients,24 patients were diagnosed with spontaneously ruptured HCC.Mean age was 58.29±15.26 years.A total of 11(45.8%)patients were treated conservatively and 13(54.2%)underwent TAE.Control of bleeding due to ruptured HCC was significantly higher for those treated via TAE as compared to those who were treated conservatively(92.3%vs.36.4%,P=0.008).Overall median duration for which the patients remained alive after HCC rupture was longer for TAE group(39 days vs.5 days,P=0.03).In-hospital mortality(30.8% vs.72.7%,P=0.04)and 30-day mortality was also lower in TAE group(38.5%vs.90.9%,P=0.01).Those who underwent TAE had lower risk of mortality then conservative group odds ratio(OR)0.25,95% confidence interval(CI0.07-0.90,P=0.03).Failure to control bleeding was associated with higher 30-day mortality(OR 2.14,95% CI 1.24-3.68,P=0.009).Conclusion:Ruptured HCC is a life threatening complication requiring early diagnosis and treatment.TAE is an effective and well-tolerated treatment in the management of ruptured HCC.

Effect of hepatic artery embolization on liver hypertrophy response in a rabbit liver VX2tumor model

BACKGROUND:Portal vein embolization not only induces hypertrophy of the non-embolized liver,but also enhances tumor growth.The latter could be prevented by embolizing the hepatic arteries supplying the tumor-bearing liver segments.This study aimed to determine the effects of transcatheter arterial embolization(TAE)on tumor volume and liver regeneration in a rabbit VX2 tumor model.METHODS:Twenty-three rabbits underwent subcapsular tumor implantation with a VX2 tumor.Two weeks after implantation,18 rabbits were used for TAE experiments,5were for sham controls.Tumor response and liver regeneration response of the embolized cranial and non-embolized caudal liver lobes were assessed by CT volumetry,liver to body weight index,and the amount of proliferating hepatocytes.RESULTS:All super-selective arterial tumor embolization procedures were performed successfully.Despite embolization,the tumor volume increased after an initial steady state.The tumor volume after embolization was smaller than that of the sham group,but this difference was not significant.Massive necrosis of the tumor,however,was seen after embolization,without damage of the surrounding liver parenchyma.There was a significant atrophy response of the tumor bearing cranial lobe after super-selective arterial embolization of the tumor with a concomitant hypertrophy response of the non-embolized,caudal lobe.This regeneration response was confirmed histologically by a significantly higher number of proliferating hepatocytes on the Ki-67 stained slides.CONCLUSIONS:Super-selective,bland arterial coil embolization causes massive necrosis of the tumor,despite increase of volume on CT scan.Atrophy of the tumor bearing liver lobe is seen after arterial embolization of the tumor with a concomitant hypertrophy response of the non-embolized lobe,despite absence of histological damage of the tumor-surrounding liver parenchyma.

Large focal nodular hyperplasia is unresponsive to arterial embolization: A case report

BACKGROUND Focal nodular hyperplasia(FNH)commonly occurs in women;it is usually asymptomatic and sometimes difficult to differentiate from hepatocellular carcinoma(HCC).CASE SUMMARY A large space-occupying lesion in the right lobe of the liver was incidentally detected in an adult man and diagnosed as HCC.Transcatheter arterial chemoembolization was applied once monthly for 2 years,but the lesion did not decrease in size.It was revealed by biopsy to be FNH.Eleven years later,the patient underwent liver resection due to hemorrhage and the pathological examination confirmed FNH.CONCLUSION For a space-occupying lesion,it is prerequisite to pathologically confirm the diagnosis and the corresponding intervention can be effective.

Salvage locoregional therapies for recurrent hepatocellular carcinoma

Hepatocellular carcinoma(HCC)is the second most common cause of cancerrelated death worldwide.Despite the advent of screening efforts and algorithms to stratify patients into appropriate treatment strategies,recurrence rates remain high.In contrast to first-line treatment for HCC,which relies on several factors,including clinical staging,tumor burden,and liver function,there is no consensus or general treatment recommendations for recurrent HCC(R-HCC).Locoregional therapies include a spectrum of minimally invasive liver-directed treatments which can be used as either curative or neoadjuvant therapy for HCC.Herein,we provide a comprehensive review of recent evidence using salvage loco-regional therapies for R-HCC after failed curative-intent.

Hepatocellular carcinoma: Therapy and prevention

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors worldwide. The major etiologies and risk factors for the development of HCC are well defined and some of the multiple steps involved in hepatocarcinogenesis have been elucidated in recent years. Despite these scientific advances and the implementation of measures for the early detection of HCC in patients at risk, patient survival has not improved during the last three decades. This is due to the advanced stage of the disease at the time of clinical presentation and limited therapeutic options. The therapeutic options fall into five main categories: surgical interventions including tumor resection and liver transplantation, percutaneous interventions including ethanol injection and radiofrequency thermal ablation, transarterial interventions including embolization and chemoembolization, radiation therapy and drugs as well as gene and immune therapies. These therapeutic strategies have been evaluated in part in randomized controlled clinical trials that are the basis for therapeutic recommendations. Though surgery, percutaneous and transarterial interventions are effective in patients with limited disease (1-3 lesions, ＜5 cm in diameter) and compensated underlying liver disease (cirrhosis Child A), at the time of diagnosis more than 80% patients present with multicentric HCC and advanced liver disease or comorbidities that restrict the therapeutic measures to best supportive care. In order to reduce the morbidity and mortality of HCC, early diagnosis and the development of novel systemic therapies for advanced disease, including drugs, gene and immune therapies as well as primary HCC prevention are of paramount importance. Furthermore, secondary HCC prevention after successful therapeutic interventions needs to be improved in order to make an impact on the survival of patients with HCC. New technologies, including gene expression profiling and proteomic analyses, should allow to further elucidate the molecular events underlying HCC development and to identify novel diagnostic markers as well as therapeutic and preventive targets.