Narayanan Anish, Garza-Berlanga Andres, Lopera Jorge
Department of Radiology, University of Texas Health Science Center at San Antonio (UTHSCSA), San Antonio, TX, USA.
Ann Palliat Med. 2023 Nov;12(6):1244-1259. doi: 10.21037/apm-23-294. Epub 2023 Aug 9.
It is estimated that 35-40% of hepatocellular carcinoma (HCC) patients present with multiple nodules at the time of diagnosis. Treating multifocal disease is difficult given patient population heterogeneity. Multiple interventional radiological (IR) options, including ablation, transarterial chemoembolization (TACE), and transarterial radioembolization (TARE), are available, each with its own merits and limitations. Our aim is to explore the current state of the literature to identify where each of these options is best applied to multifocal HCC management.
A narrative literature review of 107 papers was performed in PubMed. Articles from 2010 and newer were used for clinical data and for classification/scoring system details. The majority of the keywords for searches include the treatment modality name alongside terms such as "HCC", "multifocal", or "multinodular".
Ablation is a curative option for Barcelona Clinic Liver Cancer (BCLC) A disease and is appropriate when liver transplantation (LT) is impractical. It is ideal in disease with ≤3 nodules (each <3 cm) preferably confined to one segment. TACE [conventional TACE (cTACE), drug-eluting bead TACE (DEB-TACE), balloon-occluded TACE (B-TACE), and less so hepatic arterial infusion chemotherapy (HAIC)] is the major workhorse for multifocal BCLC B disease, in pre-transplant downstaging, and in advanced disease palliation. The Kinki BCLC B subclassification can guide TACE subtype selection. TACE response can be assessed over 2-3 sessions per modified Response Evaluation Criteria in Solid Tumors (mRECIST) and patient session tolerance. TARE is an option for BCLC C disease, with BCLC A/B applications limited by radiation induced liver disease (RILD). Pseudo-ablative techniques like sub-selective TARE (sTARE) are promising but are unproven and less useful in multinodular disease. Finally, combination therapies [TACE + ablation, liver resection (LR) + ablation/TACE] are an exciting option but warrant further study.
Multifocal HCC remains challenging to manage. While BCLC is a useful starting point, the patient's tumor imaging characteristics and clinical circumstances must be considered when selecting the appropriate treatment modality.
据估计，35%-40%的肝细胞癌（HCC）患者在确诊时就已出现多个结节。鉴于患者群体的异质性，治疗多灶性疾病颇具难度。多种介入放射学（IR）方法可供选择，包括消融、经动脉化疗栓塞术（TACE）和经动脉放射性栓塞术（TARE），每种方法都有其优缺点。我们的目的是探究当前文献的现状，以确定这些方法中每种方法在多灶性HCC治疗中的最佳应用场景。
在PubMed上对107篇论文进行了叙述性文献综述。使用2010年及以后发表的文章获取临床数据以及分类/评分系统的详细信息。大多数搜索关键词包括治疗方式名称以及“肝细胞癌”“多灶性”或“多结节性”等术语。
消融是巴塞罗那临床肝癌（BCLC）A期疾病的一种根治性选择，当肝移植（LT）不可行时适用。对于结节≤3个（每个<3 cm）且最好局限于一个肝段的疾病，消融是理想的治疗方法。TACE[传统TACE（cTACE）、载药微球TACE（DEB-TACE）、球囊闭塞TACE（B-TACE），以及肝动脉灌注化疗（HAIC）应用较少]是多灶性BCLC B期疾病、移植前降期以及晚期疾病姑息治疗的主要方法。京都BCLC B亚分类可指导TACE亚型的选择。可根据实体瘤改良疗效评价标准（mRECIST）每2至3个疗程评估一次TACE疗效以及患者对疗程的耐受性。TARE是BCLC C期疾病的一种选择，BCLC A/B期应用时受放射性肝病（RILD）限制。亚选择性TARE（sTARE）等准消融技术前景广阔，但未经证实，在多结节性疾病中的应用价值较低。最后，联合治疗方法（TACE + 消融、肝切除术（LR） + 消融/TACE）是一个令人兴奋的选择，但有待进一步研究。
多灶性HCC的治疗仍然具有挑战性。虽然BCLC分期是一个有用的起点，但在选择合适的治疗方式时，必须考虑患者的肿瘤影像学特征和临床情况。
