Interventional Radiology Procedures for Hepatocellular Carcinoma with Pathological Reduction in Cure
For hepatocellular carcinoma (HCC) cases where pathological reduction in cure is needed, transarterial chemoembolization (TACE), transarterial embolization (TAE), transarterial radioembolization (TARE), and percutaneous thermal ablation (radiofrequency or microwave ablation) are the recommended interventional radiology procedures, with selection based on tumor size, number, liver function, and vascular invasion status. 1, 2
Primary Liver-Directed Therapies by Clinical Scenario
For Intermediate-Stage HCC (BCLC Stage B)
- TACE remains the standard first-line locoregional therapy for patients with Child-Pugh A or B cirrhosis, multiple nodules without vascular invasion or extrahepatic metastases, and preserved liver function 1, 2
- TACE extends median survival from approximately 16 months to about 20 months in intermediate-stage disease 2
- TAE (bland embolization) is an alternative that uses embolic particles alone without chemotherapy, reducing immunosuppression risk 1, 2
- TARE with yttrium-90 microspheres shows longer time to disease progression compared to TACE, though with minimal impact on overall survival 2
For Early-Stage HCC (Single Tumors or Limited Disease)
- Percutaneous thermal ablation (radiofrequency ablation or microwave ablation) is recommended for tumors ≤3 cm as a potentially curative treatment 1, 3
- For tumors 3-5 cm, combination therapy with ablation and arterial embolization should be considered 2
- For tumors >5 cm, arterial embolic approaches (TACE/TAE/TARE) are recommended over ablation alone 2
- Ablation has accuracy rates exceeding 95% and is associated with favorable outcomes comparable to surgical resection for small tumors 1, 3
For Tumors with Portal Vein Involvement
- TARE is safer than TACE when portal vein thrombosis is present, as TACE increases the risk of liver failure in this setting 2
- Recent evidence suggests TACE may still provide survival benefit over conservative therapy even with portal vein thrombus, though benefit is less pronounced with advanced vascular invasion 2
Patient Selection Criteria
Ideal Candidates for Liver-Directed Therapy
- Child-Pugh A or B7 cirrhosis without ascites 2
- ECOG performance status <2 2
- Limited tumor burden: solitary nodule <7 cm or fewer than four tumors 2
- Absence of decompensated liver disease 2
Absolute Contraindications
- Decompensated liver disease (Child-Pugh C or decompensated Child-Pugh B) is an absolute contraindication for TACE/TAE 2
- Advanced liver dysfunction with severely reduced portal vein flow 2
Post-Treatment Surveillance Protocol
Imaging Schedule
- First follow-up imaging at 1 month post-treatment with multiphasic CT or MRI (non-contrast, arterial, portal venous, and delayed phases) 1, 4
- Imaging every 3 months for the first 2 years, then every 6-12 months thereafter 1
- Non-contrast phase is strongly recommended for patients who received liver-directed therapy to detect treatment-related changes 1, 4
Critical Surveillance Consideration
- HCC recurrence is 6.5 times more likely in the first year after treatment than in the second year, necessitating intensive early surveillance 1
- Ultrasound is not typically used for surveillance in the first 2 years after treatment due to low sensitivity 1
Common Pitfalls and Complications
Post-Embolization Syndrome
- Post-embolization syndrome (fever, abdominal pain) is the most common side effect following TACE/TAE 2
- Major complications include portal vein thrombosis, hepatic abscess, and liver failure 2
Treatment Selection Errors
- Avoid TACE in patients with macroscopic portal vein invasion due to significantly increased risk of liver failure 2
- Do not postpone procedures unnecessarily for older adults (>80 years) or those with comorbidities, but carefully assess liver reserve 1
- For TACE, consider alternatives (TAE, DEB-TACE, or TARE) to reduce immunosuppression risk in vulnerable patients 1