2.3. Results

In patients with HCC, RFA was shown to have complete tumor necrosis in 83% for lesions less than 3 cm and 88% for lesions in non-perivascular locations [9]. RFA had higher efficacy compared to ethanol ablation. The complete response rate is close to 97% with 5-year survival rates of 68% [10]. A study conducted by Cho et al. showed that RFA was just as effective as surgical resection for very early stage HCC [11]. A study conducted by Lencioni et al. showed that surgical resection remains the most effective treatment for patients with early stage HCC when compared to RFA [12]. A meta-analysis of over 21,000 patients demonstrated that surgery has higher post-operative mortality but improved 5 year overall survival compared to ablation. Of note, this study combined chemical and thermal ablation even though chemical ablation is known to be less efficient [13].

The studies comparing MWA to RFA have varying results. A study by Abdelaziz reported local recurrence rates of MWA, 3.9%, to be superior to RFA, 13.5%. Another study reported decreased recurrence rates with RFA, 9%, compared to MWA, 19% [14]. A review of multiple studies demonstrate overall comparable rates for MWA and RFA in terms of overall survival and local recurrence.

emulsifies the chemotherapeutic agents in oil droplets, which helps with drug delivery. In a meta-analysis of multiple randomized control trials, lipiodol was shown to be a safe, effective

Liver Directed Therapies

55

http://dx.doi.org/10.5772/intechopen.75163

Embolic microspheres loaded with doxorubicin for HCC or irinotecan for CRC are injected in the tumor feeding artery in DEE-TACE. Studies have shown slower, more sustained drug

Bland embolization is also performed for HCC and neuroendocrine tumors. It can be accom-

The main role for TACE is reserved for patients with stage B disease based on the Barcelona Clinic Liver Cancer (BCLC) staging system. Stage B disease is defined as patients with large, multinodular disease with good functional status and a Child-Pugh A-B score. Other indica-

Absolute contraindications would be reserved for patients with poorly compensated advanced liver disease since TACE may exacerbate patient's symptoms and increase risks of progression into liver failure. Other absolute contraindications include refractory bleeding diathesis, large metastatic disease burden outside the liver, active infection, main, right and left portal vein

TACE is commonly performed under moderate sedation. Pre-procedural hydration may be performed to decrease risk of contrast/chemotherapy-induced nephropathy. Pre-operative antibiotics are only given for patients with high risk for infection such as disrupted biliary drainage

Patients are usually admitted overnight post-procedure to monitor for potential complications. Most often, patients develop minor symptoms that can be managed medically such as postembolization syndrome. This self-limiting syndrome is comprised of abdominal pain, fever, and nausea and usually occurs within the first 72 h post-procedure. This can be seen in up to 80% of patients. Post-procedural transaminitis is more frequent with cTACE compared to DEE-TACE. Patients are typically discharged the next day. The criteria for discharge include appropriate pain control, ambulation, adequate urine production, and tolerating PO intake. TACE may be repeated for tumor control. Multiple treatments are often required until either the MRI shows greater than 90% tumor necrosis, the patient is downstaged, there is a lack of tumor response after at least two

treatments, or the development of disease progression or a contraindication to treatment.

There are varying criteria in determining patients who are at high risk for post-TACE liver failure. High-risk patients include a total bilirubin greater than 2 mg/dL, INR greater than 1.5,

tions would include downstaging patient's tumor burden to allow for transplantation.

plished either by injecting a mixture of Lipiodol and Gelfoam or with bland beads.

agent in the treatment of HCC [22].

3.1. Indications and contraindications

release with decreased systemic concentrations.

thrombosis as well as refractory encephalopathy.

3.2. Management

3.3. Complications

pathways.

A study by Wang compared cryoablation to RFA in patients with HCC lesions less than or equal to 4 cm. Results demonstrated significantly lower local tumor progression rates with cryoablation, 5.6%, compared to RFA, 10% [15]. For lesions larger than 3 cm, the difference became more apparent with progression rates of 7.7% for cryoablation and 18.2% for RFA. The recurrence free survival and overall survival rates were not significantly different between cryoablation and RFA [15].

In patients with metastatic CRC, RFA was shown to have a complete response rate of 91–97% [16]. In patients with five or fewer lesions less than 5 cm, the 5-year survival rate was between 24 and 44% [17]. For patients who had complete tumor ablation, 98% did not require further surgical resection either due to remaining disease free or developing disease progression [18].
