*4.1.3. Transarterial radioembolization*

stage BCLC B HCC. TACE is indicated for asymptomatic patients in Child-Pugh class up to

A study found no significant difference in survival following TACE in patients with Child-Pugh Class 8–9 compared to class 7; however, patients with Child-Pugh 8–9 had a significant

TACE is not indicated for patients with signs of HCC vascular invasion, metastases, untreatable ascites, jaundice, thrombosis of a major portal vessel, and HCC nodules >10 cm. In these cases, due to an already compromised liver function, there is a high risk of liver failure and

Drug-eluting beads TACE (DEB-TACE) is a more recent variation of conventional TACE (cTACE) that uses embolizing beads eluted with doxorubicin as a chemotherapeutic agent. It has shown overall similar effectiveness, but less systemic side effects compared to cTACE. Randomized trials have found superior outcomes with DEB-TACE compared to cTACE in

Although contrast-enhanced CT (CECT) or MRI with hepatospecific contrast agent is recommended for TACE outcome evaluation, contrast-enhanced US (CEUS) could be an appropri-

If imaging follow-up detects residual or recurrent HCC nodules, TACE can be repeated up to three times per nodule. Treatment failure is considered when there are no signs of lesion response, as assessed using the mRECIST criteria, after two treatments or if there is no complete response after three treatments [42]; in eastern countries, different staging criteria,

TACE has been proved safe and effective in elderly as well as in younger patients. In particular, a prospective study found that elderly patients suffered from the same complication rates

More important than age is the liver functional status, and the patient's performance status that mostly affects the safety profile of TACE. Therefore, TACE can be an effective palliative treatment able to give benefits in terms of disease control and improved quality of life in

B7 and PS ≤ 1 [17] (**Table 4**).

eventually death.

42 Liver Cancer

worse prognosis and more dangerous side effects [38].

patients with Child-Pugh class B and/or PS ≥ 1 [39, 40].

ate alternative in patients with less than four nodules [41].

as nonelderly, while effectiveness rates were similar [44].

**Table 4.** Indications to Trans Arterial Chemo-Embolization.

RECICIL, are actually in use [43].

elderly patients with HCC.

Transarterial radioembolization (TARE) is a palliative brachytherapy for HCC. Radioactive substances (I131-lipidol or Y90-beads) are delivered into the tumor by injecting them selectively into its feeding arteries.

This is a complex technique that requires a high-level specialization and has potentially severe side effects such as hepatic, intestinal, and lung toxicity [17]. Therefore, it should only be performed in specialized centers, with high volume activity and experience with this procedure.

Given the fact that TARE has minimal embolizing effects, it can be safely performed even in patients with thrombosis of the portal vein or its branches.

It can be used as a first-line treatment when TACE is not recommended, such as in the case of large or multifocal HCC or if there are signs of portal thrombosis. However, liver function must be conserved (Child-Pugh ≤7, bilirubin ≤2.0 mg/dl, no ascites) [17].

TARE has also been shown to be an appropriate bridge or downstaging treatment in order to meet liver transplantation criteria [17, 46].

Furthermore, TARE can be used as a second-line treatment in patients who did not respond to TACE or who are intolerant to chemotherapy [17, 47].

Mean survival for Child-Pugh class A or B patients who underwent TARE is, respectively, 17.2 and 7.7 months [48, 49]. Mean survival for patients with portal vein thrombosis is 9 months, while for those with intrahepatic portal thrombosis is 17 months [50].

A study has revealed similar results in terms of overall survival (OS) and toxicity between cTACE and TARE in patients with nonresectable HCC [51]; another study has shown a better time-to-progression (TTP) and lower toxicity following TARE compared to TACE [52].

TARE cannot be performed in patients with a pulmonary shunt >20% or if other vascular anomalies may cause irradiation of visceral organs (stomach and intestine) [17].

Indications for this treatment are often controversial and should only be discussed in dedicated multidisciplinary teams. The difficulty in determining the precise indications of TARE is in part due to the lack of cost-effectiveness studies and the fact that its therapeutical equivalence to TACE has only been proved in selected patients. TARE is usually indicated in patients with stage BCLC C HCC, especially those with portal vein thrombosis and preserved liver function.

TARE is usually not indicated in elderly patients, who often have a compromised liver function, and therefore, risks of liver failure and death are high. TARE can be performed in elderly with good performance status and liver functionality as a second-line treatment in patients with treatment failure following TACE.

Local tissue properties, in particular perfusion, have a significant impact on the size of the ablation zone. Highly perfused tissue and large blood vessels act as a heat sink, since infrared energy is absorbed by erythrocytic heme and transported away from the target area. This phenomenon makes normal liver parenchyma relatively more resistant to LA than tumor tissue and this is the rationale for using hepatic inflow occlusion techniques such as arterial

HCC in Elderly Patients. Curative Intraoperative Strategies and Management in Recurrences

http://dx.doi.org/10.5772/intechopen.79748

45

Light transmission into tissues and the size of the ablation zone increase with higher laser power, as does the local tissue temperature reached during ablation, with consequent higher

The use of water-cooled laser application sheaths allows the use of a higher laser power output while preventing carbonization [58]. When using multiple water-cooled higher power

Major complications of LA are liver failure, segmental infarction, hepatic abscess, cholangitis, bile duct injury, and hemorrhage. The technique is considered safe by rates of 1.8% for major complications and a mortality rate of 0.1% [59] and can also be used safely in elderly patients with advanced liver disease up to Child–Pugh class B [57]. Tumor seeding after percutaneous biopsy and ablative therapies is a well-known phenomenon, but it has rarely been reported

A recent study compared LA and TACE in patients with a single large HCC and found a significant superiority in multifiber-LA vs. TACE in terms of recurrence rates, especially in

Ablation size is critical to predict outcome; patients with lesions >6 cm or with multifocal disease (more than five nodules) are usually managed with other treatment modalities.

LA can be used with a curative intent only in patients with early-stage HCC. In this setting, it

In patients with advanced local HCC, LA should only be used as a palliative treatment. The use of laser ablation is not currently extensively adopted for the treatment of HCC, but given the promising outcomes shown in recent studies and the expected technical advancements, it could become an increasingly more important treatment modality for HCC in the near future.

Systemic therapy is recommended for HCC patients in stage BCLC-C with conserved liver functionality (Child-Pugh A), good performance status, advanced disease, and/or extrahepatic diffusion. Systemic therapy is also recommended for patients with progressive HCC after locoregional treatments or HCC with vascular invasion not enrollable for other local

Target therapy with sorafenib proved to give survival benefits versus either placebo or cyto-

Observational studies suggest that sorafenib administration in Child-Pugh B patients is as

has shown similar outcomes compared to RFTA when treating nodules <3 cm [57, 60].

embolization (TACE) in conjunction with laser therapy [57].

risk of overheating and carbonization of the adjacent normal tissue.

fibers, ablation zones of up to 80 mm diameter can be obtained.

nodules >4 cm, while OS was similar between both groups [60].

following laser ablation [57].

**4.2. Chemotherapy**

treatments [17].

toxic and hormonal therapy [61].

safe as administration in class A patients [62].

TARE has not been shown superior to sorafenib in treating advanced HCC; therefore, sorafenib could be a safer treatment in elderly patients who can tolerate chemotherapy [53].
