**6. Perspectives**

peritoneal bleeding or pleural effusion [69–72]. RFA can be performed by percutaneous under ultrasound guidance, open surgical approach or laparoscopic approach (**Figure 5a** and **b**).

**Figure 5.** (a) US-guided intraoperative RFA of a liver tumor (from the personal archive of the authors). (b) Laparoscopic

*Transarterial embolization and chemoembolization* are types of treatment which have developed over the last years because HCC exhibits intense neo-angiogenic activity and should be considered for patients who are not suitable for surgical resection or percutaneous ablation [61]. In patients with early-stage HCC, the blood supply comes from the portal vein and only when the tumor is larger it has an arterial blood supply from hepatic artery. This treatment purpose is to obstruct the hepatic artery to induce ischemia to the tumor. Hepatic artery obstruction is performed during an angiographic procedure and is known as transarterial embolization (TAE). If the transarterial embolization (TAE) is associated with the injection of chemotherapeutic agents in the hepatic artery, the procedure is known as transarterial chemoembolization (TACE). The procedure needs advanced catheterization of the hepatic artery and the specific lobar and segmental branches to be as selective as possible and to reduce the damages of the nontumoral liver parenchyma. Chemotherapic agents such as adriamycin or cisplatin must be injected prior to arterial obstruction [73]. Contraindication for TAE/TACE is the lack of portal blood flow due to portal vein thrombosis, portosystemic anastomoses or hepatofugal flow [61]. Also, patients which advanced staged disease (Child-Pugh B and C) should not be considered for this treatment due to the high risk of hepatic failure. Side effects of intraarterial injection of the chemotherapeutic agents are nausea, vomiting, alopecia and sometimes, renal failure. After the transarterial embolization, the so-called post-embolization syndrome can appear, which consists of fever, abdominal pain and ileus. Post-embolization syndrome is usually selflimited in less than 48 hours, but sometimes patients can develop hepatic abscess or cholecystitis. Regarding the response to this treatment there are no significant differences between TAE and TACE, the reported rate of objective response ranging from 16 to 60%, with a significant

Treatment algorithm is described in the next figure based on the Barcelona Clinic Liver Cancer

Also, disease

chemotherapeutic are the transarterial the so-called

consists of usually than develop

due to hepatic

the between

rate

Some of the HCC cannot undergo for RFA due to their localization.

(TACE). of

can HCC cannot last activity patients who suitable resection with early-stage blood supply tumor arterial from This obstruct the artery to performed during and the embolization with the hepatic the transarterial

lobar segmental to as selective reduce liver to for lack

or

RFA of a HCC nodule. Intraoperative aspect (from the personal archive of the authors).

improvement in survival [43, 73].

improvement in survival [43, 73].

146 Liver Research and Clinical Management

(BCLC) staging classification [74]:

There are several areas where active research is needed, starting from molecular pathogenesis, to detection, diagnosis and treatment. Despite recent progress in the management of HCC, treatment of patients with portal vein thrombosis remains still a challenging area. Current clinical guidelines recommend Sorafenib only. However, besides Sorafenib, various therapies including surgery, TACE, external radiation therapy, hepatic artery infusion chemotherapy (HAIC) and radio-embolization may be considered in selected patients; the usefulness of combined treatment needs to be verified. Newer therapeutic options such as immunotherapeutic agent and oncolytic virus are under investigation [75].
