Transcatheter Hepatic Arterial Embolization Research Articles

A STUDY OF SPONTANEOUS RUPTURE OF HEPATOCELLULAR CARCINOMA -PROGNOSIS AND THE CASE OF SURGICAL TREATMENT-

This study was made of 32 cases of ruptured hepatocellular carcinoma (HCC) concerning clinical findings, prognostic factors, and surgically resected cases. The most common complaint was abdominal pain which occurred in 24 cases (75.0%), and relatively few cases (seven cases; 21.9%) were associated with shock. As the initial therapy, emergency transcatheter hepatic artery embolization (TAE) was performed in 20 cases (62.5%), followed by surgical resection in 3 cases after the gain of hepatic function. Six patients (18.8%) encountered with re-rupture. The prognosis after rupture was poor, and a mean survival period was 130 days in non-recected cases. Whereas the longest survival for 8 years and 4 months was sttained in one patient who underwent a surgical resection. In the patients group with conditions including liver cirrhosis, diffuse type tumor, portal vein tumor thrombus positive, PT<70%. T-Bil≥2mg/dl, and Alb<3g/dl, the prognosis was significantly poorer than other patients groups. These factors may be available for prospecting the clinical course after the rupture of HCC.

Non-surgical treatment of hepatocellular carcinoma.

A decade ago, surgery was the only satisfactory treatment modality for hepatocellular carcinoma (HCC), but it was limited only to selected cases. For the majority of cases of HCC, systemic chemotherapy was one of the few treatment alternatives, but provided only marginal benefit. In the past 20 years, diagnostic methods have improved to an extent that small HCC less than 1 cm can be detected. Moreover, non-surgical treatment is available, of which regional therapy has been shown to prolong patients' survival, and may even replace surgical resection in some cases. Regional therapy is indicated for the treatment of HCC when there is no extrahepatic metastasis and the patient has adequate liver function reserve, thus permitting repeated therapy. Transcatheter hepatic arterial embolization (TAE) using various embolizers has been well documented to include controlled studies. However, it is not indicated for patients with thrombosed main portal veins. Its therapeutic effect is also doubtful when the tumour is infiltrative in nature or is hypovascular, too large or too small. Additional chemotherapeutic agents mixed into the embolizer with lipiodol and degraded starch microspheres or styrene-maleic acid-neocarzinostatin in which chemotherapeutic agents are embedded, are used with a better response, but the survival rate has not shown significant improvement. Ultrasound-guided local injection therapy is another new method of treatment of HCC. Of these techniques, percutaneous ethanol injection therapy (PEIT) is widely used with excellent results for small, encapsulated tumours in livers with less than three HCC. Percutaneous ethanol injection therapy can also be used in cases with portal vein thrombosis, but it is not suitable for patients having coagulopathy or ascites. Using acetic acid, OK-432, interferon or anti-cancer drugs in the injection therapy shows no further benefit over ethanol alone. Transcatheter echoguided thermotherapy or cryotherapy has been reported in small series of patients, as has target therapy with immune or radiotherapy and conformal radiotherapy. Preliminary studies show encouraging results. Systemic therapy with either single drug or multidrugs is ineffective, with a response rate of less than 20%. Immunotherapy, such as with interferon or other cytokines, is not beneficial. Hormone therapy has not been promising, except for treatment with tamoxifen, which has been reported to show some beneficial effect. Gene therapy is still in its infancy. In summary, recent progress in non-surgical treatment of HCC has resulted in a breakthrough of regional therapy looking quite promising. Moreover, a combination of different types of regional therapies may yield better outcomes in selected individuals.

Partial splenic embolization for hypersplenism concomitant with or after arterial embolization of hepatocellular carcinoma in 30 patients

To study the value of partial splenic embolization (PSE) for the treatment of hypersplenism in patients undergoing embolization of hepatocellular carcinoma (HCC). Transcatheter hepatic arterial embolization (THAE) combined with PSE was performed in 30 patients with HCC complicating liver cirrhosis, portal hypertension, and hypersplenism. Gelfoam sponge was used as the embolic material for PSE and limited to 100-150 pieces. More than 50% of splenic parenchyma was infarcted in 27 patients. Leukopenia and thrombocytopenia were corrected by PSE in 25 of 27 patients with hypersplenism. In 26 patients with esophageal varices, including 5 patients with bleeding, no rebleeding occurred during a 6-17 month follow-up. Hypersplenism was not corrected in 2 of 3 patients whose infarcted splenic parenchyma was less than 50%. No splenic abscesses or other severe complications were observed. Of the 30 patients treated, 19 are still alive after 1 year. THAE combined with PSE is a safe and effective measure for patients with HCC.

Reactive oxygen species and progression of metastasis of VX2 carcinoma implanted in liver

We examined the electron spin resonance (ESR) spectra, tissue superoxide dismutase (SOD) activity, and the capacity of neutrophils to produce active oxygen in a liver metastasis model of VX2 carcinoma. The ESR spectra were similar to the signal of the oxygen radical recognized in liver tissue subjected to transcatheter hepatic arterial embolization. The signal intensity was lower in the metastatic than in the non-metastatic region, and there was a significant difference between the regions 2 weeks after the injection of the carcinoma cells. There were no differences between the SOD activity of the metastatic and non-metastatic regions, assayed weekly. The capacity of neutrophils to produce active oxygen decreased with the progression of metastasis. Our results suggest that the injection of VX2 carcinoma cells into the portal vein induces ischemia after injection. Metastatic cancer cells generated active oxygen (endogenous), at levels that were virtually constant, from 2 to 4 weeks after the injection of cancer cells. After the injection, the progress of metastasis was affected by endogenous active oxygen and by the capacity of neutrophils to produce active oxygen.

Gastrointestinal bleeding after hepatic transcatheter arterial embolization in patients with hepatocellular carcinoma

Background: Transcatheter arterial embolization is a popular palliative treatment for patients with hepatocellular carcinoma, but the incidence of post-treatment gastrointestinal bleeding is not well-defined.Methods: We retrospectively analyzed 206 patients with hepatocellular carcinoma who received transcatheter arterial embolization and compared them with 193 patients with hepatocellular carcinoma who underwent angiography alone.Results: Twenty-three episodes (8.5%) of gastrointestinal bleeding occurred within 3 months of hepatic transcatheter arterial embolization following 269 procedures involving 206 patients with hepatocellular carcinoma. Eight episodes (3.0%) of esophageal variceal bleeding and 15 episodes (5.5%) of nonvariceal bleeding were found. The sites of the nonvariceal bleeding episodes were the stomach (n = 7), duodenum (n = 5), and colon (n = 3). When compared with other sources, bleeding from esophageal varices took place earlier, required intensive treatment, and led to a higher mortality. Among another 193 patients with hepatocellular carcinoma who received angiography only, 6 patients developed gastrointestinal bleeding within 3 months (3.1%), and all bled from esophageal varices.Conclusions: This study suggests that esophageal variceal bleeding may occur after both angiography and transcatheter arterial embolization. Nonvariceal bleeding episodes, which were usually milder than episodes of variceal bleeding, may be related to the embolization procedure itself. (Gastrointest Endosc 1996;43:132-7.)

Histopathological study of hepatocellular carcinoma after transcatheter hepatic arterial embolization

Histopathological study of hepatocellular carcinoma after transcatheter hepatic arterial embolization

The role of microwave coagulation therapy for hepatocellular carcinoma

Recent years, we experienced various treatment procedures for hepatocellular carcinoma (HCC), including hepatic resection, transcatheter hepatic artery embolization and percutaneous ethanol injection. However, Some patients could not receive these treatments because of the liver dysfunction and the location of the tumors. In such cases, we have developed the microwave coagulation therapy (MCT) for HCC. From June 1992, 53 patients have received MCT : 8 cases received laparoscopic-MCT (L-MCT), 19 cases received open-MCT (O-MCT) and 26 cases received percutaneous-MCT (P-MCT). Liver function of L, O-MCT patients was worse than that of patients who received partial resection of the liver. The actual and disease-free 3-years survival rate were identical between the patients who received L, O-MCT and those who had partial hepatectomy. Out of 13 cases with tumor size greater than 2 cm in diameter receiving P-MCT, 7 cases should remaining enhanced area by a follow up dynamic CT, although none of 13 cases with tumor size less than 2 cm in diameter should enhancement. MCT is a possible choice of treatment for some HCCs.

A case performed effectually thoracoscopic and open thoracotomic microwave coagulo-necrotic therapy for TAE resistant type of hepatocellular carcinoma recurrence

Recurrent lesion of hepatocellular carcinoma (HCC-R) just below the dyaphragm which resists to transcatheter hepatic arterial embolization therapy (TAE) is also difficult to perform percutaneous ethanol injection therapy (PEI) according to its anatomical relationship. Recently, we have performed thoracoscopic and open thoracotomic microwave coagulo-necrotic therapy (MCN) on this type of HCC-R and successfully suppressed the proliferation of the tumor.The case was 62 years old man being HBV carrier. In June 1992, subsegmentectomy of the liver (S6) was performed for the HCC with liver cirrhosis. In August 1993, HCC-R was pointed out on S7, however, the resection of this lesion was considered to be impossible because of inadequate hepatic functional reserve. Therefore, TAE was performed and the control of tumorous proliferation was found to be incomplete. The third TAE performed in July 1994 was failed because its feeding right hepatic artery, which branched from superior mesenteric artery, was occulded by preceding TAE. In August 1994, after the identification of tumor-occupied lesion by the CT imaging, thoracoscopic MCN was performed for this intractable recurrent tumor. Preoperative intrathoracic 3-D reconstraction image produced by helical CT scan was useful for detection of infra-diaphragmatic tumorous location. However, an additional damage due to MCN may be induced on the right cardiac atrium and inferior vena cava which is neighboring the tumor, and thus the control of the tumor was still incomplete. In December 1994 another new HCC-R lesion was found near the previous treated part on S7, and open thoracotomic MCN therapy was performed again in June 1995. The follow-up CT image showed an adequate control of this tumor after three weeks of this operation.MCN is very useful in treating unresectable HCC, and it is suggested the possibility making up defects between surgical hepatic resection and other interventional therapy.

Portal vein embolization with steel coils and absolute ethanol: A comparative experimental study with canine liver

Portal vein embolization (PVE) is expected to have an adjuvant effect on the treatment of human liver tumors with transcatheter hepatic arterial embolization (TAE). In this experimental study, PVE was tried using two kinds of embolic materials, steel coils (coils) and absolute ethanol (ethanol). The aim of this article is to compare the effectiveness between the two methods. Five dogs and 12 dogs were treated with coils and ethanol, respectively. The second order portal branches were embolized. Embolization effects of each embolic material on the hepatic vessels and the liver parenchyma were studied angiographically and histologically. PVE with coils achieved immediate occlusion of the embolized vessels in all dogs. Unexpectedly, unembolized vessels were also constricted and/or obstructed in 4 of 5 dogs during a 4-week follow-up period. Histological examination showed no hepatic necrosis in all dogs. By contrast, in the dogs treated with ethanol, venous occlusion was achieved immediately after embolization with ethanol of 0.4 mL/kg or more. The embolized vessels remained occluded and no obstruction of unembolized vessels was observed until 4 weeks after embolization. Hepatic necrosis was observed in the segments where portal veins were occluded. The degree of parenchymal damage was proportional to the injected ethanol dose. Judging from these results, ethanol is likely to be more suitable than coils as an embolic material for PVE. PVE with coils is often dangerous because unembolized vessels might be occluded unexpectedly. For the clinical use of PVE with ethanol, the appropriate dose of injection should be investigated.

Portal vein embolization with steel coils and absolute ethanol: A comparative experimental study with canine liver

Portal vein embolization (PVE) is expected to have an adjuvant effect on the treatment of human liver tumors with transcatheter hepatic arterial embolization (TAE). In this experimental study, PVE was tried using two kinds of embolic materials, steel coils (coils) and absolute ethanol (ethanol). The aim of this article is to compare the effectiveness between the two methods. Five dogs and 12 dogs were treated with coils and ethanol, respectively. The second order portal branches were embolized. Embolization effects of each embolic material on the hepatic vessels and the liver parenchyma were studied angiographically and histologically. PVE with coils achieved immediate occlusion of the embolized vessels in all dogs. Unexpectedly, unembolized vessels were also constricted and/or obstructed in 4 of 5 dogs during a 4-week follow-up period. Histological examination showed no hepatic necrosis in all dogs. By contrast, in the dogs treated with ethanol, venous occlusion was achieved immediately after embolization with ethanol of 0.4 mL/kg or more. The embolized vessels remained occluded and no obstruction of unembolized vessels was observed until 4 weeks after embolization. Hepatic necrosis was observed in the segments where portal veins were occluded. The degree of parenchymal damage was proportional to the injected ethanol dose. Judging from these results, ethanol is likely to be more suitable than coils as an embolic material for PVE. PVE with coils is often dangerous because unembolized vessels might be occluded unexpectedly. For the clinical use of PVE with ethanol, the appropriate dose of injection should be investigated.

P-508 Efficacy of percutaneous acetic acid injection (PAI) alone and PAI following transcatheter hepatic arterial embolization (TAE) for large hepatocellular carcinoma (HCC)

P-508 Efficacy of percutaneous acetic acid injection (PAI) alone and PAI following transcatheter hepatic arterial embolization (TAE) for large hepatocellular carcinoma (HCC)

Hepatocellular carcinoma cases with five-year survival and prognostic factors affecting the survival time.

Between 1980 and 1994, 178 patients were confirmed to have hepatocellular carcinoma (HCC) in our hospital. The 5-year survival rates in patients with HCC of stage I, II and IVA were 38.1%, 31.8% and 3.9%, respectively. No patient in stage III or IVB survived for more than four years. The 5-year survival rates of the patients treated by hepatic resection, ultrasonically guided percutaneous ethanol injection and transcatheter hepatic arterial embolization were 53.7%, 38.7% and 13.5%, respectively. The logrank test showed a significant difference in cumulative survival rates obtained in patients with HCC according to the tumor stage (p < 0.001) or principal treatment procedure (p < 0.001). Twelve patients survived for more than five years. We employed a Cox's proportional hazards model to estimate the factors significantly affecting the survival time. Variables with statistical significance were the clinical stage (p < 0.001), tumor size (maximal tumor diameter) (p < 0.001) and patient's age (p < 0.05). Conclusively, patients in the early stage of HCC associated with mild liver cirrhosis have a significantly better chance for long survival.

Hepatocellular carcinoma after transcatheter hepatic arterial embolization. A histopathologic study of 84 resected cases.

Recently, transcatheter arterial embolization (TAE) has been used to treat hepatocellular carcinoma (HCC), yet much is still unknown regarding its optimal use. Eighty-four patients with HCC after TAE underwent surgical resection. Fifty of the tumors were less than 3 cm (small HCC [S-HCC]), and 34 were 3 cm or larger (large HCC [L-HCC]). Necrosis rate, distribution of residual HCC, histopathology of the main tumor, and proliferating activity of residual HCC by means of proliferative cell nuclear antigen (PCNA) were examined. Twenty-two randomly selected patients with HCC treated with standard chemotherapy were used as non-TAE control subjects. A necrosis rate of greater than 95% was seen in 35 cases of S-HCC and in 15 of L-HCC. All five nonencapsulated tumors were L-HCC and had a much lower necrosis rate. No tumors in the control group showed a necrosis rate of greater than 95%. Encapsulated tumors were categorized according to their tumor interiors, capsules, and extracapsular zones. Complete necrosis of the tumor interior was 80.0% and 35.3% in S-HCC and L-HCC, respectively. Viable residual tumors were found mainly in the extracapsular zone in S-HCC, whereas in L-HCC they were located primarily in the tumor interior. Most capsules were affected by tumor necrosis and the subsequent healing process, resulting in a thick secondary capsule. Tumor interior necrosis was uniform and coagulative in S-HCC, in contrast to L-HCC, in which necrotic regions comprised several necrosis units of differing texture and were divided by fibrous septa. In contrast, the control group revealed spotty, sparse necrosis. Non-TAE tumor capsules were thin and pathologically characteristic of those naturally occurring in tumors, as opposed to the thick fibrous capsules, which are inducible by TAE therapy. In the TAE group, the PCNA positivity rates were 37.5%, 52.5%, and 100% in Grades 1, 2, and 3/4 combined, respectively. At the tumor-nontumor boundary of the extracapsular region, PCNA-positive cells were detected in 55.0% of the cases. The thickened tumor capsule serves as a good postoperative indicator of TAE response. Small tumors seem to be affected in the tumor interior, whereas extracapsular invasion undermines the TAE effect. PCNA was helpful in detecting the tumor-nontumor boundary and useful as a parameter of viability of HCC after TAE.

Obstructive jaundice secondary to ruptured hepatocellular carcinoma into the common bile duct. Surgical experiences of 20 cases.

Hepatocellular carcinoma (HCC) presenting as obstructive jaundice caused by floating tumor debris in common bile duct is rare. Taiwan has a high incidence of HCC and cirrhosis. The authors report their clinical experiences and evaluate the results of different treatment modalities for this disease. A retrospective study was undertaken to review 20 patients with obstructive jaundice secondary to ruptured HCC into common bile duct during the 12 years period. All patients on initial examination had recurrent episodic jaundice or cholangitis. Jaundice was relieved by nonsurgical, percutaneous transhepatic biliary stenting in 4 patients and surgical intubation with T-tube drainage in 16. Types of treatment for those who were treated nonsurgically were percutaneous transhepatic biliary stenting in two patients, followed by transcatheter hepatic arterial embolization in another two patients. For the 16 patients who were treated surgically, the types of treatment were T-tube or Y-tube drainage in 11, T-tube drainage followed by hepatic resection in 2, T-tube drainage and hepatic arterial ligation in 1, and T-tube drainage followed by transcatheter hepatic arterial embolization in the other 2. Liver cirrhosis was the associated disease in 12 (75%). Four patients (20%) died in the hospital. The mean survival time for 12 patients with only surgical or nonsurgical biliary stenting was 3.9 months. For the three patients with percutaneous hepatic arterial embolization, the mean survival time was 8.0 months. Two patients who had undergone hepatic resection had a better postoperative survival time, with one surviving for more than 5 years. Clinical features, types of management, operative findings, and survival in 20 patients with HCC obstructing the common bile duct by tumor thrombi were reviewed. Not all patients with this disease were terminally ill. With proper management, good palliation and occasional cure are possible.

Outcomes of 116 patients with hepatocellular carcinoma.

We studied the outcomes of 116 patients with hepatocellular carcinoma (HCC) diagnosed in our hospital between January 1980 and August 1992. The patients were divided into groups according to the principal treatment procedure. The 3-year survival rates in the patients treated by percutaneous ultrasonically guided ethanol injection (PEI), operation (hepatic resection), and transcatheter hepatic arterial embolization (TAE) were 90.9%, 53.6%, and 29.0%, respectively. None of the patients treated by one-shot injection of an anticancer agent into the hepatic artery and chemotherapy survived for more than 2 years. The outcomes of the patients treated by PEI and hepatic resection were significantly better than those of the patients treated by the other procedures. There was no significant difference when the patients were stratified according to the year of detection. The 3-year survival rate was 57.3% for 19 patients in whom HCCs were detected during clinical follow-up for chronic liver disease and 17.3% for the other 97 patients. We concluded that hepatic resection in patients with good liver function and PEI for early HCC yielded significantly better survival rates than the other procedures. Moreover, for early detection and treatment of HCC, we recommend clinical follow-up of patients with chronic liver disease.

HCCに対する腹腔鏡下Microwave coagulonecrotic therapyの経験

In recent years. We have various treatment options for hepatocellular carcinoma (HCC), including hepatic resection, transcatheter hepatic artery embolization (TAE), and percutaneous ethanol injection (PEI). However, some cases of HCCs are not suitable for these therapies due to their liver function and location of tumors. For some of these HCCs, we have developed laparoscopic microwave coagulonecrotic therapy (L-MCNT). The case of this report was 57-year-old man. The tumor was located in segment 8. The duration of MCNT was 30 minutes. The period of hospitalization after MCNT was 14days. Coagulated area involving tumor and surrounding tissue was not enhanced by postoperative dynamic CAT scan. L-MCNT is useful therapy for some HCCs.

骨盤腫ように対するＣｏｔｒｅｌ Ｄｕｂｏｕｓｓｅｔ Ｉｎｓｔｒｕｍｅｎｔａｔｉｏｎ（ＣＤＩ）による脊椎骨盤再建術の小経験

Case 1. A fifty-four-year-old man reported a severe pair from the perineum radiating to the left leg. A hepatocellular carcinoma and a metastatic tumor of the sacrum was diagnosed by his local doctor. The patient was admitted to our hospital for treatment of the hepatocellular carcinoma. He was treated with transcatheter hepatic arterial embolization and was irradiated with 50Gy to his pelvis. Two years later, he began complaining of severe low back pain when in a sitting position. He received surgical intervention for decompression of the cauda equina, as well as stabilization of the pelvic ring with CDI. Postoperatively the severe low back pain disappeared.Case 2. A fifty-year-old women noted severe pain radiating from the perinuem to the left leg. She had been operated on in 1977, 1981, 1984 and 1988 for pelvic chondrosarcoma. X-rays examination showed lytic destruction from the fifth lumbar vertebra, sacrum to the iliac bone. Recurrence of the pelvic chondrosacoma was diagnosed and intralesional resection of the pelvic tumor and reconstruction of the pelvic ring with CDI was performed.Limb salvage for patients with malignant pelvic tumors remains a problem from the reconstructive standpoint. CDI consists of a rod, and hooks and screws and the transverse traction device and dominos. CDI achieve stable vertebral and pelvic osteosynthesis.

Preoperative transcatheter hepatic arterial embolization for hepatic malignancy.

This retrospective study was undertaken to determine clinically and histopathologically the efficacy of preoperative transcatheter hepatic arterial embolization (PTHAE) in liver malignancies. Ten patients underwent either single or multiple episodes of PTHAE with lipiodol in an emulsion with chemotherapeutic agents. Four of the patients were thought to be unresectable before embolotherapy. Eight patients had hepatocellular carcinoma, one had cholangiocarcinoma, and one metastatic colon carcinoma. All patients subsequently underwent surgical resection. Histologic observations were made in all resected specimens. No viable tumor cells were recognized in three of the ten specimens, whereas extensive necrosis (70%-95%) was seen in the remaining seven patients. The four patients with tumors that were that to be unresectable before PTHAE had significant reduction in tumor burden (60%-80%) and were thought to be resectable after their embolization. Effectiveness on satellite nodules, thrombi in the portal veins, and intracapsular infiltration was histologically verified. The mean and median survival times to date have been 24.8 and 24.5 months, respectively. Preoperative transcatheter hepatic arterial embolization is a useful procedure that, in this small patient series, converted unresectable liver tumors into potentially resectable lesions.

Segmental embolotherapy for hepatic cancer: keys to success.

Transcatheter chemoembolization using Lipiodol (Lp) mixed with chemotherapeutic agents followed by Gelfoam particle injection only to the tumor-bearing hepatic segment (segmental Lp transcatheter hepatic artery embolization) (TAE) was applied to more than 100 patients with hepatocellular carcinoma and metastatic liver cancer. For segmental Lp-TAE, knowledge of the variations of intrahepatic arterial anatomy is important. Furthermore, the catheters and guidewires, volume of Lp, kinds and dose of chemotherapy, preparation of the mixture of Lp and chemotherapy (Lp-emulsion), method of injection of Lp-emulsion and Gelfoam particles, as well as the follow-up computed tomography examination are key items to the success of the procedure and are reviewed.

Experience with liver resection after hepatic arterial chemoembolization for hepatocellular carcinoma.

The use of percutaneous transcatheter hepatic arterial chemotherapy and embolization in the treatment of primary liver cancer has become increasingly popular in recent years. The authors employed this method, using a combination of cisplatin, mitomycin C, 5-fluorouracil, and ethiodized oil (Lipiodol) or absorbable gelatin sponge in 30 patients with huge liver cancers (diameter range, 5.6-12.0 cm) as a preliminary treatment before liver resection. Significant tumor regression occurred after this treatment, converting these tumors into resectable lesions that were excised successfully later. Before surgery, chemoembolization was done once every 4-6 weeks. The patients underwent 1-5 treatment sessions (mean, 2.9) and then waited 1-4 months (mean, 2.4 months) before undergoing surgery. Alpha-fetoprotein levels decreased to normal in seven patients. The tumor diameters were reduced by 31.6 +/- 15.2% (2.3 +/- 1.2 cm) and the percent tumor necrotic area ranged from 40-100%. Adhesions of the tumor to the diaphragm and thickening of the hepatoduodenal ligament and gallbladder wall were the primary operative findings, but they did not significantly complicate the surgery. There was one postoperative death from acute pulmonary embolism. The 1-year, 2-year, and 3-year survival rates were 88.89%, 77.03%, and 77.03%, respectively. Although these patients still are being followed to assess their long-term survival, this treatment appears promising for patients with advanced huge liver cancers who hitherto have been denied surgery on grounds of unresectability.