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Role of image-guided therapies in hepatocellular carcinoma
Every patient whith the early stage not treated with liver transplantation is destined to present, in due time, the intermediate stage, unless portal thrombosis appears contemporaneously rendering the stage advanced. Thus, intermediate HCC is often an obligatory phase during the natural course of the disease in patients cured with resection or other therapies for early HCC, or the phase at which detection of the disease is first made. There is no standard therapy for patients with this kind of stage.
For them, the usual therapeutic option is whole-liver or lobar TACE, even though not a general consensus guaranties such therapeutic approach. In fact the most randomized studies, however weak for some bias, were not able to demonstrate a clear improvement of survival, and the lack of benefit was related to a counterbalance between local tumor control and damage to non-neoplastic tissue, which can hasten liver insufficiency.
However, the two more recent trials were able to demonstrate a benefit after TACE, one reporting a 2- and 3-year survival of 63% and 29% for treated patients stringently selected (the best survival so far reported) versus the 27% and 17% for the control group (P=0.009).
A recent study using a tailored multimodal image-guided treatment obtained a 3-year survival better than the best survival obtained with conventional TACE, i.e. 43% vs 29%. The more important advantages using such therapeutic approach were the lower damage for nonneoplastic tissue and the higher local efficacy (figure 6).