Neoadjuvant Transarterial Chemoembolization of Cirrhotomimetic Hepatocellular Carcinoma: An Interview With Peiman Habibollahi, MD

Peiman Habibollahi, MD, is a resident of radiology at the Hospital of the University of Pennsylvania in Philadelphia. At the 2016 annual scientific meeting of the Society for Interventional Radiology (SIR), he presented outcomes from a study he conducted with colleagues at the University of Pennsylvania on combined liver transplantation and transcatheter arterial chemoembolization (TACE) in patients with cirrhotomimetic (CMM) hepatocellular carcinoma (HCC). Interventional Oncology 360 spoke with Dr. Habibollahi about the results of the study at the SIR meeting.

IO360: Could you describe the question that you aimed to answer with this study

Habibollahi: Cirrhotomimetic hepatocellular carcinoma is an uncommon subtype of hepatocellular carcinoma (HCC) characterized by microscopic tumor nodules growing into the cirrhotic liver parenchyma beyond the tumor seen on imaging studies. Unfortunately, this area has not been fully explored given the difficulty of making this diagnosis using noninvasive imaging techniques. Its incidence is anywhere from 7% to 20% of all HCCs based on prior pathologic series. In our study, we wanted to find out how these patients respond to the standard of care for HCC and how do they compare to the rest of the patients. Prior studies have suggested that these patients may have an overall worse outcome following treatment, but there is no reliable data, especially in interventional radiology literature. 

IO360: How does this subtype differ from other types of HCC? 

Habibollahi: HCC tumors most commonly manifest as small or large tumors. These patients on the other hand, have very small nodules of tumoral tissue around the main lesion extending into the cirrhotic liver tissue beyond what we see on imaging. This is very hard to diagnose on imaging because of its subtle nature. This is what pathologists call cirrhotomimetic growth pattern. It can involve large parts of the liver, even a whole segment or lobe. This makes the diagnosis and treatment challenging.

IO360: How did you design the study?

Habibollahi: Because this is an uncommon subtype, we couldn’t do a prospective study, so this was a single-center, retrospective design. We have a very large transplant center at the Hospital of the University of Pennsylvania. A large group of hepatologists, transplant surgeons, pathologists, and interventional radiologists come together as one team and decide about the management of our patients. A large group of patients with HCC undergo liver transplantation at our center routinely. We looked at these patients from 2007 through 2013. After reviewing all of the pathology results, we found 30 patients with CMM HCC among those who had HCC. We then retrospectively gathered demographic, tumor response, and survival information. There was also a control group of 46 patients with conventional HCC who also underwent a combination of TACE and liver transplant.

IO360: What were some of the most important results that you found?

Habibollahi: Interestingly, immediately following TACE, which is neoadjuvant therapy before liver transplantation in these patients, both groups responded similarly to the treatment. However, when we looked at the imaging findings at 3 months following TACE, patients with cirrhotomimetic HCC had more recurrence compared to the control group. Also when we looked at the survival of these patients following combined TACE and liver transplantation, patients with cirrhotomimetic HCC had worse survival compared to the controls. Unfortunately, only 56.7% of them were alive at the end of 2-year follow-up compared to about 84.8% of the patients with conventional HCC (P=.0006).

IO360: Was there anything that surprised you about the results?

Habibollahi: We were surprised to see that these patients had similar outcomes compared to conventional HCC patients in the short-term follow-up imaging but more recurrence during later imaging follow up. This means that their response to neoadjuvant treatment is not as good as the rest of the HCC patients or their HCC is more aggressive in nature. 

IO360: What do you think the results mean for interventional oncology clinicians and their decision-making in the future for this group of patients?

Habibollahi: The fact that this subgroup of patients doesn’t respond very well to current available treatments means that we must ask ourselves, what else needs to be done? For example, many new chemoembolization techniques are currently under investigation using new chemoembolic agents. These novel approaches might be more successful in these patients. We also need to look into imaging findings associated with this subtype and identify imaging characteristics associated with it. 

IO360: So perhaps this is an imaging issue; if imaging is improved you may be able to treat sooner? 

Habibollahi: I don’t know the answer to that question, but the issue might be that either we are not detecting the disease early enough to initiate the treatment or disease is very aggressive and our current treatment is not sufficient. Based on our findings, I believe more research is definitely warranted in this field until we can answer some of these questions. 

Editor’s note: Dr. Habibollahi has completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. He reports no financial relationships or conflicts of interest regarding the content herein.

Suggested citation: Ford J. Neoadjuvant transarterial chemoembolization of cirrhotomimetic hepatocellular carcinoma: an interview with Peiman Habibollahi, MD. Intervent Oncol 360. 2016;4(10):E157-E159.