Interventional Radiology in the Management of Hepatocellular Carcinoma in Liver Cirrhosis

Introduction

Liver cirrhosis represents the final stage in the spectrum of chronic liver disease and constitutes an important healthcare burden worldwide because of its association with high morbidity and mortality. Histopathologically, cirrhosis is a diffuse process characterized by architectural distortion, fibrosis, and regenerative nodules. The increased morbidity and mortality linked with cirrhosis is a consequence of its gradual progression to portal hypertension, hepatocellular dysfunction, liver failure, gastrointestinal hemorrhage, and hepatocellular carcinoma (HCC). Improved management of cirrhosis-related complications, such as variceal hemorrhage, and reduction in two major recognized causes of cirrhosis, hepatitis infection (B and C virus) and alcohol abuse, have led to a recent decline in the mortality related to cirrhosis in the United States and worldwide. The improved survival of patients with cirrhosis has, on the other hand, rendered them susceptible to the increased risk of developing cirrhosis-related HCC.

Abstract

Liver cirrhosis represents the final stage in the spectrum of chronic liver disease and constitutes an important healthcare burden worldwide because of its high morbidity and mortality. Management of hepatocellular carcinoma (HCC) in cirrhotic patients is often challenging because of the presence of underlying liver disease. Image-guided diagnosis and intervention has a crucial role in the surveillance, diagnosis, treatment, and post-treatment follow-up of HCC in these patients. Image-guided biopsy has a dual role, which comprises of non-targeted liver biopsy for diagnosis and staging of cirrhosis and targeted biopsy of nodules suspicious for HCC. Surgical resection and transplantation are deemed curative therapies for treatment of HCC in cirrhosis while percutaneous image-guided ablative techniques are often used to treat patients with non-resectable and non-transplantable disease, as a bridge to transplantation, or with palliative intent. Radiofrequency ablation (RFA) is among the most effective percutaneous ablative technique while ethanol injection is an effective alternative to RFA in treatment of HCCs smaller than 2 cm. Transarterial chemoembolization (TACE) offers a non-curative or palliative therapy for nonsurgical patients with large or multifocal HCC without vascular invasion or extrahepatic disease and prolongs survival in comparison to standard supportive care. There has been an emerging trend to combine TACE with ethanol injection or RFA to reduce recurrence and improve survival in patients with HCC. In this review article we discuss the key concepts in the oncological management of cirrhotic patients from the perspective of the interventional radiologist.

Keywords

cirrhosis, HCC, RFA, imaging, TACE