Hepatocellular carcinoma medical therapy

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [2] Associate Editor(s)-in-Chief: Dildar Hussain, MBBS [3]

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Overview

Patients with hepatocellular carcinoma are treated with sorafenib, ethanol injections, transcatheter arterial chemoembolization (TACE), sealed source radiotherapy, radiofrequency ablation (RFA), intra-arterial iodine-131-lipiodol administration, high intensity focused ultrasound (HIFU), hormonal therapy, and chemotherapy.

Medical Therapy

Medical therapy for hepatocellular carcinoma

Protein kinase inhibitors

Currently, Sorafenib has been approved as the sole management for systemic therapy of hepatocellular carcinoma in the advanced stages.[1][2] [3][4][5][6][7][8][9][10]

Molecular Targeted Agents for HCC

Percutaneous ethanol injection

  • Percutaneous ethanol injection (PEI) is best-known image-guided percutaneous ablation for hepatocellular carcinoma:[51][52][53][54][55][56][57]
    • It is well tolerated and is preferred in small (< 3 cm) solitary tumors.
    • It is an inexpensive procedure
    • It has few adverse effects
    • It can be repeated in patients with relapse
    • Survival is comparable with the patients who undergo surgical resection
    • Efficacy is comparable to radiofrequency ablation

Transcatheter arterial chemoembolization (TACE)

  • Transcatheter arterial chemoembolization is performed in the following conditions:[57][58][59][60][61][62][63][64]
  • Transcatheter arterial chemoembolization (TACE) is usually performed in the treatment of large tumors (larger than 3 cm and less than 4 cm in diameter), most frequently by intraarterially injecting an infusion of antineoplastic agents mixed with iodized oil (such as Lipiodol).
  • Combined PEI and TACE can be used for tumors larger than 4 cm in diameter.
  • TACE followed by sorafenib provides optimal results of progression-free survival and survival in patients with HCC who are non responsive to TACE.

Sealed source radiotherapy

  • Sealed source radiotherapy can be used to destroy the tumor from within (thus minimizing exposure to healthy tissue). TheraSphere is an FDA approved treatment which has been shown in clinical trials to increase survival rate of low-risk patients. This method uses a catheter (inserted by a radiologist) to deposit radioactive particles to the area of interest.[65]

Radiofrequency ablation (RFA)

Intra-arterial iodine-131–lipiodol administration

  • Intra-arterial iodine-131–lipiodol administration demonstrated some efficacy in unresectable tumors, especially in patients with portal vein thrombus. This treatment is also used as adjuvant therapy in resected patients. It is believed to raise the 3-year survival rate from 46 to 86%.

High intensity focused ultrasound (HIFU)

  • High intensity focused ultrasound (HIFU) is a new technique which uses much very powerful ultrasound to treat the tumour. Still at a very experimental stage. Most of the work has been done in China. Some early work is being done in Oxford and London in the UK.

Hormonal therapy

Chemotherapy

  • Oral synthetic retinoid for 12 months after resection/ablation maybe helpful in the treatment of hepatocellular carcinoma.[66]

Contraindicated medications

Hepatocellular carcinoma is considered an absolute contraindication to the use of the following medications:

Effectiveness of medical therapy

The effectiveness of medical therapy depends on the following:

  • Size
  • Involvement of liver vessels
  • Presence of a tumor capsule
  • Presence of extrahepatic metastases
  • Presence of daughter nodules
  • Vascularity of the tumor

References

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