Transarterial Chemoembolization and CT-Guided Ablation for Hepatic and Infrarenal Masses

Abstract: We report a case of a 60-year-old patient with dyslipidemia, obesity, Child B alcoholic liver cirrhosis, and hepatocellular carcinoma (HCC). Magnetic resonance imaging revealed a 3.5 cm HCC located at liver segment VI and an increased alpha-fetoprotein (AFP) of 2,700 IU/mL. After treatment there was also a finding of an infrarenal mass, which was identified as HCC by biopsy. According to the most commonly used HCC criteria (the BCLC classification) this patient would have been classified as advanced HCC and been given sorafenib. But this patient’s liver tumor was treated with drug-eluting bead transarterial chemoembolization (DEB-TACE) and the infrarenal mass was treated with CT-guided percutaneous radiofrequency ablation. These procedures were carried out successfully and with no complications. At up to 9 months follow-up all the imaging studies were compatible with complete response. At 1 year, the hepatic tumor and the infrarenal mass were still avascular but there were some grown lymph nodes at the hepatic hilum and anterior to the vena cava. 

Key words: TACE, chemoembolization, transarterial chemoembolization, hepatocellular carcinoma, cirrhosis, ablation

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A 60-year-old patient with dyslipidemia, obesity, and Child B alcoholic liver cirrhosis was referred to our cancer hospital for evaluation. The patient had traveled a long distance and brought a lung, abdominal,and pelvic CT, which showed a hepatic lesion. This CT was performed 2 months before he arrived at our hospital. During routine surveillance, a hyperechoic nodule on ultrasound study and an increased alpha-fetoprotein (AFP 2,700 IU/mL) were detected. On magnetic resonance (MR) imaging the nodule was described as a 3.5 cm hypervascular mass in liver segment VI during the arterial phase with contrast wash-out in the venous phase compatible with HCC (Figure 1).

Treatment

The patient had contraindications for surgery (portal hypertension, Child B, 30,000 platelets and diabetes) and was referred to interventional radiology for treatment. Transarterial chemoembolization (TACE) was performed (Figure 2).

An MR study was performed 30 days after the TACE procedure and showed only minimal enhancement at the edge of the lesion (Figure 3). This finding could be related to perfusion changes but because the AFP level remained high (2,600 IU/mL) a residual tumor could not be excluded. A decision was made to perform a computed tomography (CT)-guided ablation, which was conducted 7 weeks after the chemoembolization procedure (Figure 4).

Follow-up

Within 30 days, an MR study showed that the hepatic mass was now avascular, compatible with complete response (Figure 5). However, AFP remained high at 2,500 IU/mL. 

A new chest CT and bone scan were performed with no evidence of metastatic disease. A new CT of the abdomen and pelvis revealed a preexisting infrarenal solid mass located lateral to the right psoas muscle (Figure 6). Because this mass was in an unusual location, a percutaneous biopsy was done that yielded HCC. After discussion with the multidisciplinary team, this patient was referred to receive CT-guided ablation of this infrarenal mass (Figure 6). The procedure was completed with no complications and the patient was discharged from the hospital the next day.

Magnetic resonance imaging performed at 30 days’ follow-up showed that the hepatic tumor and the infrarenal mass were avascular (Figure 7). At this time AFP had a significant decline to 2.2 IU/mL and the patient was started on sorafenib.

At the 9-month follow-up there was an increase in the AFP to 39 IU/mL and a repeat MR of the liver as well as chest CT was performed that had no malignant findings. At 12-month follow-up the patient’s AFP level was at 53 IU/mL, and a new CT study showed again that the hepatic tumor and the infrarenal mass were avascular, but there was evidence of new lymph nodes at the hepatic hilum and anterior to the vena cava (Figure 8).

Interventional radiology treatments were not indicated at this time and an effort is now being made to increase the patient’s sorafenib dosage from 600 mg daily to 800 mg daily.

Discussion

This patient had an imaging work-up after the first TACE procedure, which included whole-body CT, nuclear medicine bone scans, and MRI searching for extrahepatic disease. Retrospectively considering these 

images the infra-renal tumor was already there but was not appreciated. The awkward location of this mass also contributed to overlooking it. Patients with solitary small HCC and high levels of AFP will almost always have portal invasion and/or extrahepatic disease. Miyayama et al published his experience using TACE in 30 patients with HCC larger than 5 cm, and only 3 patients had AFP above 400ng/mL.¹ Sala et al describes AFP concentration as a powerful prognostic parameter and argues that it should be used to establish priority policies to diminish the risk of liver transplant list patient drop-out.² Santi et al evaluated the efficacy of semiannual surveillance vs annual surveillance. In this study he stated that once again AFP is a poor surveillance test being normal in half of cases at the HCC diagnosis, however its elevation has a robust adverse prognostic meaning, suggesting that this oncomarker should be incorporated in prognostic systems.³ Finally another study in which they analyzed which response criteria best help predict survival of patients with hepatocellular carcinoma following chemoembolization, almost 40% of the BCLC B patients had AFP levels greater than 200 ng/mL (200 mg/L) before TACE.⁴

If we consider that this patient had an advanced HCC (BCLC C staging) upon arrival and that the mean survival for this type of patient is in the range of 7 months, this patient seems to have benefited from locoregional therapies. 

Editor’s note: Disclosure: The authors have completed and returned the ICMJE Form for Disclosure of Potential Conflicts of Interest. The authors report no disclosures related to the content herein. 

Manuscript submitted April 8, 2014; provisional acceptance given April 18, 2014; final version accepted May 19, 2014.

Suggested citation: Luz JH, Castro L, Gouveia HR, Martin HS, Nepomuceno T, Nogueira FD, Braz-Levigard R. Transarterial chemoembolization and CT-guided ablation for hepatic and infrarenal masses. Intervent Onc 360. 2014;2(10):73-78.

References

1. Miyayama S, Yamashiro M, Okuda M, et al. Chemoembolization for the treatment of large hepatocellular carcinoma. J Vasc Interv Radiol. 2010;21(8):1226-1234.
2. Sala M, Forner A, Varela M, Bruix J. Prognostic Prediction in Patients with Hepatocellular Carcinoma. Semin Liver Dis. 2005;25(2):171-180.
3. Santi V, Trevisani F, Gramenzi A, et al. Semiannual surveillance is superior to annual surveillance for the detection of early hepatocellular carcinoma and patient survival. J Hepatol. 2010;53(2):291-297.
4. Shim JH, Lee HC, Kim SO, et al. Which response criteria best help predict survival of patients with hepatocellular carcinoma following chemoembolization? A validation study of old and new models. Radiology. 2012;262(2):708-718.