J Liver Cancer.  2021 Mar;21(1):97-103. 10.17998/jlc.21.1.97.

Advanced Stage Hepatocellular Carcinoma Successfully Treated with Liver-directed Concurrent Chemoradiotherapy and Sequential Transarterial Radio-embolization

• Noh M
• Kim BK
• Kim SU

• KMID: 2514241
• DOI: http://doi.org/10.17998/jlc.21.1.97

Abstract

Optimal treatment strategies for patients with advanced hepatocellular carcinoma (HCC) is yet to be determined. Herein, we present a case of advanced HCC with tumor invasion into the right anterior portal vein and right hepatic vein where complete response (CR) was achieved via a multidisciplinary approach. This patient had a 10.5 cm-sized HCC invading segment VI, without extrahepatic spread. Liver function was classified as Child-Pugh class A, and the performance status was good. Transarterial radio-embolization (TARE) was performed 6 weeks after the completion of liver-directed concurrent chemoradiotherapy, and CR was confirmed 3 months post-TARE. Adoptive cell therapies were performed as adjuvant therapy and CR was maintained for over 15 months, until the local recurrence of a 2 cm-sized HCC was found. Therefore, in selected cases with preserved liver function, combination therapies, including LRTs and systemic therapy, can be a useful therapeutic option for advanced HCC.

Keyword

Hepatocellular carcinoma; Concurrent chemoradiotherapy; Radioembolization; Yttrium-90

Figure

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  Figure 1 Initial liver dynamic magnetic resonance imaging findings. A single 10.5 cm-sized mass in segment VI showed enhancement in the arterial phase (A), and washout in the portal (B) and delayed phase (C). Tumor thrombosis was seen in the right hepatic vein and right anterior portal vein (D).

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  Figure 2 Technetium-macroaggregated albumin scintigram of the patient revealed 61.59% lung shunt fraction (LSF), before liver-directed concurrent chemoradiotherapy (LD-CCRT) (A). Five weeks after LD-CCRT, LSF was decreased to 12.15% (B).

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  Figure 3 Follow-up liver dynamic computed tomography (CT) and magnetic resonance imaging (MRI) findings. (A) CT at delayed phase, 3-weeks post-liver-directed concurrent chemoradiotherapy: decreased size of the mass in the right lobe with right hepatic vein thrombosis, from 10.5 cm to 8 cm. (B) CT at delayed phase, 3-weeks post-transarterial radio-embolization (TARE): markedly decreased tumor vascularity without remarkable change of overall size of the treated tumor in the right posterior liver, 7.6 cm. Diffuse parenchymal atrophy of the right liver observed. (C) CT at delayed phase, 6-weeks post-TARE: change in post-treatment infarction and markedly decreased attenuation of the right hemiliver. (D) T2 weighted MRI image, 3-months post-TARE: total necrosis of the right liver with focal capsular disruption.

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  Figure 4 Chest high-resolution computed tomography images showing bilateral ground glass opacities and interlobular septal thickening at 19-weeks post-transarterial radio-embolization (A), remnant radiation pneumonitis after 4 months of steroid therapy (B).

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  Figure 5 Findings on liver dynamic computed tomography images. Newly noted recurrent tumor at liver S7, about 2 cm at 19-months post-transarterial radio-embolization (A). Compact lipiodol uptake in the recurrent tumor at liver S7 without new or residual tumor, 1-month post-transarterial chemoembolization (B).

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  Figure 6 Cinical course of the patient with alpha-fetoprotein (AFP), prothrombin induced by vitamin K absence (PIVKA)-II. A biological complete response was achieved at 3-weeks post-transarterial radio-embolization. CCRT, concurrent chemoradiotherapy; TARE, transarterial radio-embolization; ACT, adoptive cell transfer; TACE, transarterial chemoembolization.

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