Latest Developments in Chemoembolisation and Ablation for HCC

Chemoembolization and ablation are important therapeutic options for HCC. Professor Jordi Bruix, from Hospital Clinic, University of Barcelona, Spain, presented a report on chemoembolization and ablation for HCC. Surveillance of patients with liver cirrhosis aims to detect hepatocellular carcinoma (HCC) at an early stage when effective therapies can be successfully applied and provide a benefit in survival. These options include surgical resection, liver transplantation, percutaneous ablation and chemoembolization.

Professor Bruix pointed out that according to the BCLC staging and treatment strategy, surgical resection and transplantation are the first treatments to be considered. If these patients are unfeasible for percutaneous ablation and if tumor burden exceeds the criteria for successful ablation, patients are considered for chemoembolization.

As for percutaneous ablation, destruction of tumor cells can be achieved by the injection of chemical substances (ethanol, acetic acid, boiling saline) or by modifying the temperature (radiofrequency, microwave, laser, cryotherapy). The efficacy of percutaneous ablation is assessed by dynamic CT 1 month after therapy. Absence of contrast uptake within the tumor reflects tumor necrosis, while the persistence of contrast uptake indicates treatment failure. The recurrence rate after ablation is as high as for resection. Some recurrences will occur in the vicinity of the treated nodule and are due to the presence of microscopic satellites not included in the ablation zone.

Radiofrequency is now the first-line technique as it is highly effective and predictable. Child-Pugh A patients with successful tumor necrosis may achieve a 50% survival at 5 years.

As for chemoembolization, the survival benefits of transarterial embolization alone or combined with chemotherapy have been very controversial until recently. Two trials coming from Hong Kong and Barcelona reported a significant survival benefit for patients treated with chemoembolization and this was further confirmed by a cumulative meta-analysis. It has to be pointed out that the published studies are rather heterogeneous in terms of treatment schedule - interval between sessions, chemotherapy used - but in all of them, treatment is associated with a marked antitumoral effect, delay in tumor progression and even prevention of vascular involvement. All in all, these data reinforce the usefulness of chemoembolization for palliation in patients with HCC. The beneficial effect is restricted to patients with preserved liver function (Child-Pugh A) without cancer-related symptoms and thus, only a minor proportion of individuals (around 10%~15% of the whole HCC population) will be optimal candidates for this treatment.

Finally, he concluded that current research aimed to increase the efficacy of treatment, reduce the toxicity related to chemotherapy administration and expand the duration of the response. Since ischemia is in the basis of the treatment, it is expected that antiangiogenic agents (i.e. Sorafenib) have the highest potential for effective combination therapy.