**3. Extrahepatic recurrence**

132 Liver Tumors

Shim et al analysed data from 199 consecutive HCC patients who underwent curative liver resection and later received repeat TACE for intra-hepatic HCC recurrence. They found that complete tumor necrosis after repeated TACE offered favorable long-term survival outcomes to HCC-recurrent patients, with a median survival time after first TACE of 48.9 months. Despite this, unlike repeat hepatectomy and RFA, TACE cannot be regarded as a

Although it is not a surgical procedure, the problems of decreased liver reserves and anatomic changes due to previous operation still exist. Moreover, neovascularisation or collaterals that feed the recurrent tumour, damage to the non-tumorous liver tissue, and accumulation of drug toxicity from repeated TACE sessions are the main concern for the use of TACE. Post-embolization syndrome, which is a combination of fever, abdominal pain, nausea and vomiting, elevated liver enzymes and white cell counts for a few hours to a few days, is the most common complication of TACE. Although this syndrome is experienced after 80-90% of TACE procedures, it is mostly self-limited and the treatment is mainly symptomatic. Occasionally, more severe complications like acute cholecystitis, biliary tract necrosis, pancreatitis, gastric erosion or even ulcers can occur as a result of inadvertent injection of the chemotherapeutic and embolizing agents into these organs. Liver failure can develop after TACE and may result in mortality after TACE especially in patients with borderline liver function before treatment. Therefore, patients with portal vein thrombosis

Selective internal radiation treatment (SIRT) is the delivery of radiation treatment via intrahepatic arterial administration of yttrium 90 (Y-90) microspheres. This technique involved the administration of Y-90 microspheres into the hepatic arterial via the transfemoral route. The administered Y-90 microspheres are then entrapped within the microvasculature and release irradiation. The high tumor concentration of Y-90 microspheres results in an effective tumoricidal radiation-absorbed level while the radiation

Its role as a safe and effective therapeutic option for patients with unresectable hepatocellular carcinoma is increasingly recognized. Recently, Lau et al (Lau et al, 2011) reviewed the role of SIRT with Y-90 microspheres for hepatocellular carcinoma, including recurrent unresectable HCC. SIRT is a recommended option of palliative therapy for large or multifocal HCC without major portal vein invasion or extrahepatic spread. It can be used as a bridging therapy before liver transplantation or as a tumor downstaging treatment, or as a curative treatment for patients who are not fit for surgery. However, the evidence was limited to cohort studies and comparative studies with historical control and was mainly targeted on primary HCC. Future research may yield more information on its role on recurrent HCC and the efficacy when compared to chemoembolization or target therapy.

In contrary to chemoembolization, optimal perfusion is required to enhance the free radicaldependent cell death in SIRT. In order to minimize the treatment-related toxicity, hepatic scintigraphy with technetium Tc 99m (99mTc) macro-aggregate albumin (MAA) should be performed to determine the arterial anatomy and to calculate the shunt fraction delivered to the lungs before subjecting the patient to SIRT. Pulmonary shunt fraction greater than 15%

curative treatment for recurrent HCC yet.

or poor liver function are contraindication to TACE.

**2.4.2 Selective Internal Radiation Treatment (SIRT)** 

injury to the normal liver parenchyma is limited.

Extra-hepatic recurrence or extra-hepatic metastasis occurs as a result of tumor extension from the liver or direct spreading to adjacent structures such as the diaphragm, the bowel and the adrenal gland; haematogenous spread via the systemic circulation to the lung; lymphatic spread from the liver to the portal and abdominal lymph nodes; or peritoneal dissemination from tumor rupture. Lung and abdominal lymph nodes are the commonest sites of metastasis, followed by musculoskeletal system, adrenal gland and peritoneum (Katyal et al., 2000; Yang et al., 2007).

There were very few studies addressing the aggressive management of extra-hepatic recurrence after liver resection. This is probably related to the extremely poor prognosis in these patients before the introduction of sorafenib.
