Minimally Invasive Therapy & Allied Technologies

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Efficacy of combined bland embolization

and chemoembolization for huge (≥10 cm)
hepatocellular carcinoma

Teruyuki Hidaka, Hiroshi Anai, Hiroshi Sakaguchi, Satoru Sueyoshi, Toshihiro

Tanaka, Kiyosei Yamamoto, Kengo Morimoto, Hideyuki Nishiofuku, Shinsaku
Maeda, Takeshi Nagata & Kimihiko Kichikawa

To cite this article: Teruyuki Hidaka, Hiroshi Anai, Hiroshi Sakaguchi, Satoru Sueyoshi,
Toshihiro Tanaka, Kiyosei Yamamoto, Kengo Morimoto, Hideyuki Nishiofuku, Shinsaku Maeda,
Takeshi Nagata & Kimihiko Kichikawa (2020): Efficacy of combined bland embolization and
chemoembolization for huge (≥10 cm) hepatocellular carcinoma, Minimally Invasive Therapy &
Allied Technologies, DOI: 10.1080/13645706.2020.1725580

To link to this article: https://doi.org/10.1080/13645706.2020.1725580

Published online: 07 Feb 2020.

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MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES
https://doi.org/10.1080/13645706.2020.1725580

ORIGINAL ARTICLE

Efficacy of combined bland embolization and chemoembolization for huge

(
10 cm) hepatocellular carcinoma
Teruyuki Hidaka, Hiroshi Anai, Hiroshi Sakaguchi, Satoru Sueyoshi, Toshihiro Tanaka, Kiyosei Yamamoto,
Kengo Morimoto, Hideyuki Nishiofuku, Shinsaku Maeda, Takeshi Nagata and Kimihiko Kichikawa
Department of Radiology, Nara Medical University, Kashihara, Japan

ABSTRACT ARTICLE HISTORY

Introduction: To assess the efficacy of combined therapy involving bland transarterial emboliza- Received 5 January 2020
tion using gelatin sponge particles (bland GS-TAE) followed by transarterial chemoembolization Accepted 6 January 2020
using lipiodol mixed with anticancer agents and GS particles (Lip-TACE) to reduce the adverse
KEYWORDS
events and increase the therapeutic effect of Lip-TACE in the treatment of huge (
10 cm) hepa-
huge hepatocellular
tocellular carcinoma (HCC). carcinoma; transarterial
Material and methods: Twenty-one consecutive patients with huge HCCs (
10 cm in diameter) chemoembolization; bland
were enrolled in this study. First, bland GS-TAE was performed to reduce the tumor volume, embolization
and then Lip-TACE was performed to control the remaining tumor at intervals of around three
weeks. Tumor response, survival, and adverse events of this combined therapy were assessed.
Results: The tumor response was assessed three months after combined TACE, with complete
response in 38.1% and partial response in 57.1% of cases. Severe adverse events were seen in
two patients, acute cholecystitis and tumor rupture. The median survival time was 2.7 years, and
the one-, two-, three-, and five-year overall survival rates were 76.2%, 66.7%, 42.9%, and 25.0%,
respectively.
Conclusion: Combined therapy involving bland GS-TAE followed by Lip-TACE can be performed
safety and may improve survival in patients with huge HCCs.

Introduction attempted combined therapy involving bland GS-TAE

and Lip-TACE and retrospectively investigated its
Transarterial chemoembolization (TACE) using
iodized oil (LipiodolV; Guerbet, Villepinte, France)
R efficacy and adverse events.
mixed with an anticancer agent and gelatin sponge
(GS) (Gelfoam; Upjohn, Kalamazoo, MI) particles Material and methods
(Lip-TACE) is a widely used treatment for hepatocel-
lular carcinoma (HCC) [1–6]. Furthermore, Lip- In all procedures, written, informed consent was
TACE is also effective for inoperable HCC even obtained from each patient before each bland GS-
>5 cm in diameter [7]. However, Lip-TACE has not TAE, Lip-TACE, and other therapeutic procedures.
been established in the treatment of huge HCC Indications for treatment of each patient were deter-
(
10 cm), and there is concern that the use of more mined by a tumor board, which included several hep-
than 10 ml of Lipiodol in one session may induce atic surgeons and hepatologists in our institution.
adverse events such as deterioration of liver function, This retrospective study was approved by the institu-
acute tumor lysis syndrome and pulmonary embolism tional review board of our institution. The data were
through shunts [8,9]. extracted from the medical charts and diagnostic
We hypothesized that Lip-TACE after bland trans- imaging records of this institution.
arterial embolization using GS particles without an
anticancer agent (bland GS-TAE) would not require a
Patients
high volume of Lipiodol and, as a result, would con-
tribute to reducing the adverse events and enhancing Between 1998 and 2013, TAE was performed as an
the therapeutic effect of the Lip-TACE in the treat- initial treatment for inoperable HCC for 793 patients.
ment of huge (
10 cm) HCCs. Therefore, we Of these patients, 21 consecutive cases fulfilled the

CONTACT Teruyuki Hidaka [email protected] Nara Medical University – Radiology, 840 Shijo-cho Kashihara City Nara, Kashihara 634-8522, Japan
ß 2020 Society of Medical Innovation and Technology
2 T. HIDAKA ET AL.

following criteria: (i) HCC with a diameter of The clinical diagnosis of HCC was based on imaging

10 cm, without infiltrative type tumor (in the gross studies including contrast-enhanced computed tomog-
classification of HCC that was accepted by the Liver raphy (CECT) with bolus contrast injection. A lesion
Cancer Study Group of Japan (LCSGJ) [10]) that that was seen as a hypervascular nodule in the arterial
spread to the whole liver; (ii) no previous treatment phase and as a relatively low density on the portal ven-
for HCC; and (iii) no major portal vein tumor throm- ous phase was diagnosed as HCC. Ten patients (47.6%)
bus extending into the first portal branch (i.e., Vp3 or had a solitary tumor, and another eleven (52.4%) had
4 of the general rules for the clinical and pathological multiple tumors. The mean diameter of the largest
study of primary liver cancer stated by the LCSGJ). tumor was 12.3 ± 2.2 (range, 10–16) cm.
The following conditions were also considered contra- Three patients had portal venous invasion (Vp1:
indications to embolization: severe thrombocytopenia invasion distal to the second order branches of the
(platelet count <30,000/mL), hyperbilirubinemia portal vein, but not of the second order branches, or
(serum bilirubin >3 mg/dL), and severe hepatic dys- Vp2: invasion of second order branches of the portal
function (Child-Pugh class C). The characteristics vein) [10], and another three patients had invasion to
and disease profiles of the 21 patients are shown in the inferior vena cava (Vv3) [10]. Extrahepatic meta-
Table 1. There were 19 men and two women, with an stases were observed in three patients (thoracic spine,
average age of 65.2 years (range, 47–89 years). All lumbar spine, and right adrenal gland). According to
patients had underlying cirrhosis that was related to the Barcelona Clinic Liver Cancer (BCLC) staging
hepatitis C virus in 11 patients and hepatitis B virus classification [11], eight patients had stage A tumors,
in six patients (with both in one patient). The liver six had stage B, and seven had stage C. These seven
function of 20 patients (95.2%) was classified as patients with BCLC-C had been enrolled in this com-
Child-Pugh A, and one (4.8%) was Child-Pugh B.
bined therapy, because all of them were thought to
have huge intrahepatic masses as the most critical fac-
tor affecting their prognosis, and we believed that
Table 1. Patient and disease profiles (n ¼ 21).
control of the huge tumor could contribute to
Characteristic Value (%)
improving their prognosis despite the presence of
Sex
Male 19 (90.5) extrahepatic lesions or vascular invasion. Serum
Female 2 (9.5) alpha-fetoprotein (AFP) levels exceeded the upper
Age (year)
Mean 65.2 normal limit (20 ng/mL) in 14 patients (median:
Range 47–89 29,285 ng/mL, range: 23.8–89,273 ng/mL). The serum
Cause of liver disease
HBV 5 (23.8) protein induced by vitamin K absence or antagonist-
HCV 10 (47.6) II (PIVKA-II), also known as des-gamma-carboxy
HBV þ HCV 1 (4.8)
Others 5 (23.8) prothrombin (DCP) [12], level exceeded the upper
Child-Pugh score normal limit (40 mAU/mL) in 20 patients (median:
A 20 (95.2)
B 1 (4.8) 13,811 mAU/mL, range: 529–297,300 mAU/mL).
Tumor size (cm)
Mean 12.3
Range 10–16 Concept of combined therapy
No. of tumors
1 10 (47.6) Bland GS-TAE was performed first to reduce tumor
2 5 (23.8)
3 1 (4.8) volume to decrease the volume of Lipiodol at the fol-
>4 5 (23.8) lowing Lip-TACE. Lip-TACE was then performed to
Vascular invasion
No 15 (71.4) the remaining viable tumor within about three weeks
Vp1 1 (4.8) after bland GS-TAE, waiting for improvement of liver
Vp2 2 (9.5)
Vv3 3 (14.3) function, if residual tumor was confirmed by CECT
Metastasis one to two weeks after GS-TAE. The end point of
No 18 (85.7)
Yes 3 (14.3) treatment was the disappearance of tumor enhance-
BCLC staging ment after bland GS-TAE or subsequent Lip-TACE.
A 8 (38.1)
B 6 (28.6)
C 7 (33.3)
Methods of combined therapy
HBV: hepatitis B virus; HCV: hepatitis C virus; Vp1: invasion distal
to the second order branches of the portal vein; Vp2: invasion
of the second order branches of the portal vein; Vv3: invasion of
Bland GS-TAE was performed using a catheter with a
the inferior vena cava; BCLC: Barcelona Clinic Liver Cancer. long, tapered tip (5.5-and 4.5- Fr or 5-and 4- Fr outer
 MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES 3

diameters of the shaft and tip, respectively) placed Tumor thrombus in the portal vein or inferior vena
into the right and/or left hepatic artery. Then, 2-mm cava and distant metastases were controlled by
GS particles soaked in contrast medium were injected. radiotherapy.
The end point of bland GS-TAE was complete
occlusion or stagnation of arterial flow in the feed-
Assessments
ing artery.
Inside the embolized tumor, a non-enhanced low Early tumor response was assessed by CECT at one to
density area suggested a necrotic area on CECT. An two weeks after bland GS-TAE, and tumor response
enhanced high-density area was defined as remaining to combined therapy was assessed by CECT three
viable tumor. Subsequent Lip-TACE to the remaining months after combined therapy, according to the
viable tumor was planned about three weeks after modified Response Evaluation Criteria in Solid
bland GS-TAE. However, when deterioration of a Tumors (mRECIST) [13]. Overall survival was also
patient’s condition and/or liver functions or markedly assessed. Univariate analysis to identify predictors of
effective CT findings were seen, the time of subse- survival was performed by the Kaplan–Meier method
quent Lip-TACE exceeded three weeks. and compared by the log-rank test. Fourteen variables
Subsequent Lip-TACE was performed using a were assessed, including sex, age, presence of hepatitis
microcatheter placed as selectively as possible to the B (HBV), presence of hepatitis C (HCV), Child–Pugh
tumor-supplying arterial branches. Lipiodol mixed score, tumor size, number of tumors, vascular inva-
with epirubicin (Farmorbicin; Pfizer, Tokyo, Japan) sion, metastases, AFP, PIVKA II, BCLC staging,
was used with the dosages determined based on the extrahepatic collateral vessels, and tumor response to
remaining viable tumor size and liver function, with combined therapy. All statistical analyses were per-
up to 10 ml of Lipiodol and 60 mg of epirubicin formed using SPSS statistics 21.0 (IBM Japan,
[3,5,6]. Lipiodol emulsion was prepared by pumping Tokyo, Japan).
the mixture 20–30 times using a three-way stopcock, Adverse events of bland GS-TAE and Lip-TACE
mixing Lipiodol inside one syringe with a small were evaluated by the Common Terminology Criteria
amount of nonionic contrast medium and saline- for Adverse Events (CTCAE) version 3.0 [14].
dissolved epirubicin inside another syringe [6]. Then,
1-mm GS particles were injected until the occlusion
Results
or stagnation of the feeding artery. Lip-TACE was
repeated until complete tumor response was obtained GS-TAE was technically successful in all patients.
in the whole intrahepatic tumor. Two patients (9.5%) achieved complete tumor necro-
sis by bland GS-TAE alone as the planned procedure,
and these patients therefore did not receive the subse-
Follow-up after combined therapy and additional
quent Lip-TACE. They underwent Lip-TACE for local
treatments for recurrences and
recurrence after 229 and 446 days, respectively. The
extrahepatic metastases
remaining 19 patients underwent combined therapy
All patients were sequentially followed using clinical involving bland GS-TAE and Lip-TACE. Of these 19
data such as AFP and PIVKA-II and diagnostic patients, 16 had one session of Lip-TACE for treat-
imaging such as CECT, contrast-enhanced magnetic ment of all intrahepatic tumors, two patients had two
resonance imaging, and enhanced ultrasound at sessions of Lip-TACE, and one patient had three ses-
three-month intervals. When local tumor recurrence sions of Lip-TACE. The mean amounts of drug per
and/or new tumors were observed, they were treated session in combined therapy were Lipiodol 7.5 (2–10)
by Lip-TACE or local ablation therapy such as radio- mL and epirubicin 45.0 (20–60) mg. The mean inter-
frequency ablation (RFA) as soon as possible. val between bland GS-TAE and the first Lip-TACE
Repeated Lip-TACE was performed by superselective was 24.8 (8–50) days.
techniques for target vessels including various collat- Six of seven patients with BCLC-C had radiation
erals as the extrahepatic blood supply. Local ablation therapy for the extrahepatic lesions and/or vascular
therapy was indicated for patients when it seemed invasion after this combined therapy.
more suitable because of poor vascularity or small Follow-up duration after this combined therapy
tumor recurrence. When intrahepatic viable tumors was from 4.8 to 84.3 months (mean: 33.8 ± 24.0,
became disseminated and uncontrollable by Lip- median: 32.6 months). Nineteen patients had
TACE, arterial infusion chemotherapy was indicated. already died (from 4.8 to 84.3 (mean: 33.8 ± 24.0,
4 T. HIDAKA ET AL.

Figure 1. A 65-year-old man with HCC of 10 cm in diameter. (a) Contrast-enhanced CT (CECT) shows a large hypervascular tumor
in the right lobe. (b) Common hepatic arteriogram shows a large tumor with hypervascular tumor vessels. Selective right hepatic
arterial bland GS-TAE was performed, and 20 days later Lip-TACE was performed to the tiny residual tumor vessels. (c) CT obtained
6 months after Lip-TACE shows markedly reduced tumor size and disappearance of tumor enhancement. Tumor response was
assessed as complete response.

median: 32.6) months) by the year 2014 when the Survival and factors affecting survival
survey was conducted, and the remaining two
Cumulative overall survival rates at one, two, three,
patients were alive. The causes of death of the 19
and five years were 76.2% (95% confidence interval
patients were hepatic failure in seven, advanced
(CI), 58.0–94.4%), 66.7% (95% CI, 46.5–86.9%), 42.9%
cancer in nine, intestinal bleeding in one, and
(95% CI, 21.7–64.1%), and 25.0% (95% CI,
pneumonia in two patients.
5.2–44.8%), respectively, and median survival time
A representative case is shown in Figure 1(a–c).
(MST) was 2.7 years (95% CI 1.8–3.6 years) (Table 2,
Figure 2). Determinants of cumulative survival rates
are shown in Table 2. Child–Pugh score (Child A
Tumor response
group vs. a single Child B case, p < 0.001), BCLC
Early tumor response assessed by CECT after bland staging (stage A vs. stage B or C, p ¼ 0.039), and
GS-TAE showed complete response (CR) in two tumor response to combined therapy (CR vs. not CR,
patients and partial response (PR) in 19 patients. p ¼ 0.006) were significantly related to survival. The
Tumor response assessed by CECT 3 months after other factors were not significantly related to survival.
combined therapy showed that eight patients (38.1%)
had achieved CR, 12 patients (57.1%) had achieved
Adverse events of combined therapy
PR, and one patient (4.8%) had achieved stable dis-
ease (SD). No patients showed progressive disease Severe adverse events after bland GS-TAE were seen
(PD). The response rate was 95.2% (20/21). in two of 21 patients. The one with acute cholecystitis
 MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES 5

Table 2. Determinants of cumulative survival rates: univariate analysis.

No. of Median/95%CI 1 year survival 2 year survival 3 year survival 5 year survival
patien-ts (years) rate (%) rate (%) rate (%) rate (%) p Value
All patients 21 2.7/ 76.2/ 66.7/ 42.9/ 25.0/
95%CI 1.8–3.6 58.0–94.4 46.5–86.9 21.7–64.1 5.2–44.8
Sex
Male 19 2.7/1. 4–4.0 78.9 68.4 47.4 27.6 .204
Female 2 0.5 50.0 50.0 0 0
Age (year)
<70 15 2.2/0. 6–3.8 66.7 53.3 33.3 20.0 .091

70 6 3.1/2. 4–3.7 100 100 66.7 44.4
HBV
 15 2.8/1.5–4.0 73.3 66.7 46.7 19.4 .891
þ 6 2.4/1.5–3.2 83.3 66.7 33.3 33.3
HCV
 10 2.4/1.2–3.5 80.0 60.0 40.0 30.0 .616
þ 11 2.8/1.3–4.2 72.7 72.7 45.5 15.2
Child-Pugh score
A 20 2.7/1.8–3.6 80.0 70.0 45.0 26.3 <.001
B 1 0. 5 0 0 0 0
Tumor size (cm)
12 12 2.4/1.4–3.3 83.3 75.0 33.3 25.0 .896
>12 9 3.1/0.0–8.0 66.7 55.6 55.6 20.8
No. of tumors
1 10 2.8/0.9–4.6 90.0 70.0 50.0 37.5 .181
>1 11 2.2/0.1–4.2 63.6 63.6 36.4 12.1
Vascular invasion
 15 3.1/1.6–4.6 80.0 73.3 53.3 36.6 .088
þ 6 2.0/0.5–3.5 66.7 50.0 16.7 0
Metastasis
 18 2.7/1.9–3.6 77.8 66.7 44.4 30.5 .510
þ 3 2.2/0.0–4.3 66.7 66.7 33.3 0
AFP (ng/ml)
0-20 7 3.7/2.2–5.2 100 100 71.4 35.7 .268
>20 14 2.0/0.2–3.8 64.3 50.0 28.6 19.0
PIVKA-II (mAU/ml)
0-40 1 6.2 100 100 100 100 .303
>40 20 2.4/1.1–3.6 75.0 65.0 40.0 20.6
BCLC staging
A 8 3.7/0.1–7.3 100 87.5 62.5 46.9 .039
B or C 13 2.1/0.5–3.7 61.5 53.8 30.8 10.3
Extrahepatic collateral vessels
 10 2.4/1.4–3.3 70.0 70.0 40.0 30.0 .756
þ 11 2.8/1.7–3.9 81.8 63.6 45.5 17.0
Tumor response
CR 8 4.0/1.0–7.0 100 100 75.0 50.0 .006
not CR 13 2.0/0.4–3.6 61.5 46.2 23.1 11.5
HBV: hepatitis B virus; HCV: hepatitis C virus; AFP: alpha-fetprotein; PIVKA-II: protein induced by vitamin K absence or antagonist-II; BCLC: Barcelona
Clinic Liver Cancer; CR: complete response.

(grade 3) was treated by temporary gallbladder drain-

age. The other one was tumor rupture (grade 4) the
day after bland GS-TAE, and re-embolization was
performed immediately. However, a liver abscess
occurred 18 days after additional TAE, and temporary
drainage was required. Lip-TACE was performed
50 days after initial bland GS-TAE.
Postembolization fever, grade 1 (38.0–39.0  C) or
grade 2 (>39.0–40.0  C), occurred in 16 (85%) of 21
patients, and it continued for an average of 3.7 days
(0–13 days). Other minor adverse events such as nau-
sea and slight abdominal pain resolved with conserva-
tive therapies.
No severe adverse events occurred after the initial
Figure 2. Cumulative survival rates of all patients after initial
bland GS-TACE. The 1, 2, 3, and 5-year survival rates are 76.2%, Lip-TACE following bland GS-TAE. Postembolization
66.7%, 42.9%, and 25.0%, respectively, and the MST is 2.7 years. fever, grade 1 or grade 2, was seen in 14 (60%) of
6 T. HIDAKA ET AL.

21 patients, and continued for an average of 3.0 days However, the ordinary method of Lip-TACE for
(0–16 days). Other minor adverse events such as nau- huge HCC (>10cm), larger than the cases reported
sea and slight abdominal pain resolved with conserva- by Miyayama, has not yet been established, because
tive therapies. the dose of Lipiodol required for adequate emboliza-
tion to the entire huge tumor must be much greater
and must exceed 10 ml. As mentioned, administra-
Discussion tion of such a large dose of Lipiodol may cause
Recently, although advances in diagnostic imaging severe complications. Therefore, the rationale of our
techniques and the widespread application of screen- combined therapy is that, as the first step, TAE is
ing programs for high-risk groups have facilitated the performed with only 2-mm gelatin sponge particles,
detection of small HCC, HCCs with a diameter of which may not induce severe complications related

10 cm are still occasionally discovered in clinical to Lipiodol, and an anticancer agent, which can
practice. In the 18th follow-up survey of primary liver obtain tumor volume reduction. The 2-mm gelatin
cancer in Japan, huge HCC (
10 cm) was reported to sponge particles may be distributed predominantly
account for 5.7% of all HCCs in Japan [15]. Though into the larger feeding arteries and may have less
surgical resection seems to be the best therapy for effect on the tiny peribiliary vessels, and serious
huge HCCs (
10 cm) [16–20], curative resection has adverse events such as acute tumor lysis syndrome,
been performed for only limited numbers of patients abscess, and biloma may be avoided. Then, as the
because of tumor extension, multicentricity, and the second step, Lip-TACE mixed with an anticancer
presence of liver cirrhosis. agent could be performed for the residual viable
TACE has been accepted as effective treatment for portion without such a large volume of Lipiodol to
inoperable advanced HCC to prolong survival [1]. In obtain a good therapeutic result. If residual tumor
paticular, selective or superselective Lip-TACE has remained after the first step, GS-TAE, we would per-
been promising as an effective and safe locoregional form repeated Lip-TACE as the second step in
treatment for small HCC. The criteria in many some cases.
The tumor response assessed by CECT three
Japanese institutions for the dose of Lipiodol used for
months after combined therapy was CR in eight
selective or superselective TACE state that the average
patients (38.1%) (including two patients with CR as
dose (mL) of Lipiodol is roughly equal to the tumor
the early tumor response to bland GS-TAE), and PR
diameter (cm) to obtain a good therapeutic effect
in 12 patients (57.1%). On the basis of these results,
[4–7]. However, more than such a predicted amount
our combined therapy involving bland GS-TAE fol-
of Lipiodol is needed for large HCC, since a tumor
lowed by Lip-TACE seems to show good results.
with a diameter of 10 cm has a volume of 500 ml. On
Min [22] reported in a comparative study that
the other hand, use of a large amount of Lipiodol
the one-, three- and five-year overall survival rates
(>10 ml) may cause the following complications. of surgical treatment and TACE were 73.8%, 54.8%,
Chung [8] reported that the use of >20 ml of and 39.8% vs. 37.8%, 16.3%, and 9.7%, respectively,
Lipiodol causes pulmonary oily embolism after Lip- and after propensity score matching, the surgery
TACE for HCC, and Sakamoto [9] also reported acute group showed higher one- and three-year overall
tumor lysis syndrome caused by Lip-TACE in a survival rates than the TACE group (69.7% and
patient with a large HCC, in whom 10 ml of Lipiodol 51.7% vs. 40.2% and 18.5%, respectively). Despite
were given once, and 15 ml were given once. Poon the present series involving various types of huge
[21] reported that patients who have inoperable HCC HCCs, some of which were not indicated for surgi-
>10 cm and poor liver function (serum albumin cal resection, the cumulative overall survival rates of
<35 g/L) may not be suitable candidates for TACE 76.2%, 42.9%, and 25.0% at one, three, and five
treatment using lipiodol of up to 30 ml because of a years, respectively, are considered much higher
high mortality rate (20%). Although a large volume of and acceptable.
Lipiodol is needed in Lip-TACE for large HCC, According to reports of the surgical resection of
Miyayama [7] reported that stepwise Lip-TACE, huge HCCs (
10 cm), significant prognostic factors
which can reduce the volume of Lipiodol per one varied and included solitary tumor [16–19], vascular
chemoembolization session to avoid the complications invasion [17,19,20], absence of portal vein tumor
related to too much volume of Lipiodol, could be thrombus [16,18], serum AFP level [17,19], absence of
effective for large HCC. tumor rupture, and curative surgery [18], among
 MINIMALLY INVASIVE THERAPY & ALLIED TECHNOLOGIES 7

others. On the other hand, according to reports of Declaration of interest

Lip-TACE for HCC, significant prognostic factors
The authors report no conflicts of interest. The
were degree of liver damage, tumor size, number of
authors alone are responsible for the content and
tumors, vascular invasion [6,23], and serum AFP level
writing of the paper.
[23]. In the present study, although a significant dif-
ference in survival rates was seen between the Child
A and Child B groups, this significant difference was References
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