Caren van Roekel

54 Chapter 2 hepatitis B virus infection and alcohol abuse. These risk factors can cause chronic liver disease, possibly leading to the development of fibrosis and/or cirrhosis and HCC. (109) Patients with HCC are classified according to the BCLC staging system. This system is divided in five categories: 0-D, based on performance status, liver function and tumor dimensions. Patients are treated according to the proposed treatment strategy for each BCLC stage (110). Although radioembolization is not incorporated in the treatment algorithm yet, several trials on radioembolization in HCC patients have been conducted. For selected patients, radioembolization could be positioned between TACE and sorafenib (Figure 10). For patients with BCLC stage 0-A, ablation, resection or liver transplantation are the treatment options of choice. There is a possible role for radioembolization in these stages in the form of radiation segmentectomy. Padia et al. have described superselective radioembolization for patients with unresectable HCC, with a median dose to the treated segments of 254 Gy. Response rates were excellent, with 95% CR and 5% PR. There was no significant hepatoxicity (111). Recently, a retrospective analysis of Biederman et al. has been published. In a cohort of 121 patients with solitary HCC up to 3 cm, 41 patients were treated with radiation segmentectomy and 80 patients were treated with a combination of TACE and microwave ablation (MWA). Target lesion complete response was 87.5% in both groups. Median time to progression was 11.6 months in the TACE MWA group and 11.1 months in the radiation segmentectomy group (p=0.83). Overall progression and overall survival rates were similar in both groups. These findings show that radiation segmentectomy is just as effective as the combination of TACE and MWA in BCLC stage A patients (112). Radioembolization can be used for down-staging or as a bridge to transplantation. Many patients do not meet the Milan criteria for transplantation (≤5 cm for single lesion or no more than 3 lesions with the largest measuring ≤ 3 cm) (113). Radioembolization can be used to induce a shrinkage of the lesions to render patients eligible for transplantation. Since waiting times for the transplantation list are long, many patients develop progressive disease and are no longer candidates for transplantation. To overcome this, radioembolization can be used to delay progression.