METHODS:
This ‑is a descriptive study, with analysis of the medical records of a patient with liver cirrhosis secondary to hepatitis C and hepatocellular carcinoma measuring 9.1 cm, outside curative therapeutic possibilities, submitted to chemoembolization to reduce tumor size and thus being within the criteria of eligibility for liver transplantation.
This study is presented in the form of a case report, which consists of a detailed description of a clinical case with specific characteristics of the case in question, reporting the procedures studied.
Written informed consent was obtained from the patient to publish this report in accordance with the journal’s patient consent policy.
RESULTS AND DISCUSSION :
CASE REPORT
Male patient, 55 years old, with liver cirrhosis secondary to hepatitis C, co-infected with the human immunodeficiency virus. Previous decompensation with upper gastrointestinal bleeding due to esophageal varices in January/2021. Magnetic resonance imaging of the abdomen was performed at the same time as the first decompensation and evidence of a lesion with hyper-enhancement artery and late wash -out in segments VI and VII, compatible with hepatocarcinoma, measuring 9.1 x 5.8 cm. Laboratory tests: alpha-fetoprotein 345, total bilirubin 1.5.
In March/2021, the patient underwent the first TACE session, uneventfully, with a reduction of the lesion to 5.3x2.9cm. In May/21, a new TACE session was performed, after the procedure, the patient evolved with complications of upper digestive hemorrhage, atrial fibrillation and presented a reduction of the lesion to 1.8 cm in the control exam. Thus becoming eligible, according to the Milan criteria, for liver transplantation.
DISCUSSION
Most HCCs occur in patients with underlying liver disease, mainly as a result of hepatitis B or C virus (HBV or HCV) infection, alcohol abuse, and non-alcoholic fatty liver disease (NAFLD) (RAOUL et al.,2019 ) . It represents up to 90% of all primary liver malignancies, and its incidence continues to progressively increase in the world (CHEDID et al. , 2017).
Liver transplantation is a curative option for patients who are not candidates for tumor resection and the Milan criteria have been proposed, validated and widely used as eligibility criteria for consideration of transplantation in the treatment of HCC (PARIKH et al.,2015 ) . Studies have shown that tumor size consistently influences survival, with a larger tumor volume being associated with a greater risk of vascular invasion and distant metastasis. (KADALAYIL et al, 2013).
Unfortunately, only a minority of patients with HCC meet the Milan criteria (SAN MIGUEL et al. , 2015). It is necessary to fit the following criteria: 1 tumor with less than 5 cm or up to 3 tumors with less than 3 cm in size (PARIKH et al. , 2015) . If patients present outside these criteria, liver transplantation is generally not an option in many transplant centers and patients are left with no other curative options (ALTEKRUSE et al. , 2014) . For selected patients, downstaging is attempted to bring tumors within the Milan criteria using liver-targeted therapy (FACCIORUSSO et al. , 2015).
Options for downstaging include radiofrequency ablation (RFA), chemoembolization transarterial (TACE), radioembolization transarterial radiation (TARE), stereotactic body radiation (SBRT) or a combination of therapies (CHEDID et al. , 2017) .
The predominant blood supply for HCCs is through the hepatic artery, unlike the normal hepatic parenchyma, which obtains 75% of its blood supply from the portal vein (TOWNSEND et al. , 2019 ). In patients undergoing conventional TACE, this selective arterial perfusion is taken advantage of by administering a chemotherapy drug such as doxorubicin or cisplatin locally into the tumor, subsequently followed by injection of an embolic agent. (HABIB et al. , 2015). The combination of direct cytotoxicity of chemotherapeutic agents and ischemia by selective embolization induces tumor necrosis and consequent size reduction. (LENCIONE, 2012), in addition to contributing to the control of alpha-fetoprotein serum levels and the patient’s survival time.
Studies have shown that high values of bilirubin (> 17μmol/l) and alpha-fetoprotein (AFP) (>400ng/ml), in addition to large tumor size (>7cm) were associated with a two- to three-fold increase in the risk of death, and generally chemoembolization is discouraged. (KADALAYIL et al, 2013).
Our patient in the clinical case has HCC measuring 9.1cm, but with normal bilirubin and alpha-fetoprotein , in addition to having his liver disease very well controlled. Aiming at curative therapy, chemoembolization was successfully performed to reduce staging, and thus the eligibility criteria for liver transplantation were met.