Editing Hepatocellular carcinoma (section)

=== '''Locoregional therapy''' ===

* Considerations
** Generally should be ECOG 2 or less to qualify
** Doesn't confer a survival benefit if extrahepatic spread
** Unacceptable morbidity risk if more than half liver parenchyma involved
* Other factors to consider:
** Proximity to vessels/bile duct/liver capsule
** Vascular invasion
** Tumour size
* Indications:
** Curative (only RFA is curative)
** Bridging (prevent increase in tumour burden and therefore patient dropping off transplant list)
** Downstaging (if transplant candidate apart from tumour burden, can attempt to downstage to bring back within Milan criteria)
** Palliative - ineligible for transplant either due to comorbidities or stage. Survival benefit and symptom control.
* Types
** '''Trans-arterial''' (takes advantage of fact that HCC gets most blood supply from HA)
*** Select asymptomatic multi-nodular tumours without vascular invasion for best results
*** TAE (trans-arterial embolization)
**** Good for haemostasis in presentation of acute haemorrhage from HCC rupture
**** Shown to be as effective as DEB-TACE in survival
*** HAIC
*** '''TACE''' (trans-arterial chemo-embolization)
**** Injected directly into feeding hepatic artery
**** Can be paired with ablation for down-staging then curative treatment
**** Overall response rate around 50%, but disease control 75-80%
**** Not considered curative alone
**** Uses chemicals such as ethiodol
**** Complications
***** Post-embolisation syndrome
****** 2-7% of patients
****** Abdo pain, nausea, vomiting, mild fever
****** Supportive care only
***** Hepatic insufficiency - 20%
***** Cerebral lipiodil embolism
***** PE
*** DEB-TACE
*** TARE (trans-arterial radio-embolization)
*** SIRT
**** Intra-tumoural brachytherapy
**** No survival benefit over systemic therapy
**** Only used for very select patients
** '''Percutaneous ablative''' - appropriate for tumours <3cm, equivalent outcomes to surgery for tumours <2cm
*** Contraindications
**** Tumour >3cm
**** Close to large bile duct - can cause strictures
**** Exophytic tumour - risk of rupture, or ablating other adjacent organs
**** Vascular invasion
**** Close to GB/stomach/large vessels
*** Complications
**** Post-ablation syndrome - occurs 2 days to 3 weeks afterwards - flu-like syndrome including fever. Self-resolving.
**** Liver failure
**** Abscess
**** Bleeding
**** Bile duct injury
**** Hollow viscus perforation
*** Ethanol - recurrence 40% and 67.5% at one and two years respectively
**** Good for tumours <2cm, mostly works with one treatment
**** Good for patients with technical contraindications for RFA/MFA
*** Acetic acid
**** Stronger necrotizing abilities than ethanol - good for septated tumours
*** '''RFA''' - five-year survival rates of 55-82%
**** Best in small tumours up to 3cm
**** Does not ablate well near blood vessels due to heat-sink effect
*** '''Microwave ablation''' - five-year survival 59.8%
**** Less heat-sink effect than RFA
**** More frequently used than RFA now for this reason
*** Cryoablation - not in widespread use
*** Irreversible electroporation - limited data, novel, expensive
** Portal vein embolisation can be performed pre-op to induce hypertrophy of future liver remnant in patients with borderline future liver volume