Early experience of transarterial chemoembolization and stereotactic body radiotherapy as neoadjuvant therapy in treating solitary right‐lobe hepatocellular carcinoma greater than 10 cm

Abstract

For good liver reserve patients with large (≥ 10 cm) right‐lobe solitary hepatocellular carcinoma (HCC), resection is technically difficult. Moreover, inadequate future liver remnant volume might preclude major surgical resection. In this case series, we report our early experience in managing a group of such patients using transarterial chemoembolization (TACE) and stereotactic body radiotherapy (SBRT) as a downstaging neoadjuvant therapy before resection. From July 2012 to November 2013, we treated five patients with large right‐lobe, solitary HCC (10–24 cm) by this regime. Portal vein thrombosis was seen in two cases. The tumour showed significant reduction in size, and the left lobe showed significant enlargement. All tumours were successfully resected. Technical difficulty due to post‐TACE and ‐SBRT fibrosis and adhesion can be overcome by using the anterior approach and hanging technique with mild modification. There was one mortality reported in this series, but a post‐mortem study showed acute myocardial infarction without any surgical complications. Radiation‐induced myocardial injury was also excluded. TACE and SBRT are a safe option to downstage large, right‐lobe solitary HCC greater than 10 cm, with or without portal vein thrombosis. Surgical resection after this neoadjuvant therapy can be carried out safely with some modification of technique.

Transarterial chemoembolisation plus stereotactic body radiotherapy as conversion therapy for large right lobe hepatocecullar carcinoma

“…In our study, most patients in the conversion therapy group showed significant hypertrophy in left lateral section, and all patients had reduction in the tumour size. We have proposed in our previous case series study 9 that this could be due to the fact that the main bulk of the right lobe ± segment IV had already been replaced by the large tumour, together with the fact that the right portal vein had already been markedly stretched, compressed or thrombosed. On top of this, the suppressive therapeutic effect by TACE + SBRT on the tumour can then allow enough time for the left lobe to hypertrophy, just like what happens after right hepatectomy and right portal vein ligation.…”

“…6 Based on early experience in our centre, where some initially inoperable large right lobe HCCs were successfully resected after receiving TACE + SBRT, we proved that this can be a safe and feasible treatment option. 9 However, there are questions still not yet answered such as any survival benefit, how long we will delay the surgery, any increase in recurrence or even occurrence of metastasis when we treated patients with this treatment option. In this study, we report our results for conversion therapy with TACE + SBRT first comparing with direct surgery in treating solitary large right lobe HCC.…”