|ECR 2018 / C-3043|
|Imaging features of hepatic malignancies during and after interventional radiological procedures: a practical guide for radiologists|
HCC, cholangiocarcinoma and metastases may require interventional radiology treatments for their management.
Hepatocellular carcinoma (HCC) is one of the most common cancers in the world. Surgical resection and liver transplantation are the only potentially curative options for HCC, but less than 20% of patients are eligible for these treatments because of advanced disease with multifocal tumour spread or gross vascular invasion, extrahepatic tumour spread or inadequate functional liver reserve related to co-existent cirrhosis.
Other available imaging guided tools for the treatment of HCC are RFA (RadioFrequency Ablation), MWA (MicroWaves Ablation), PEI (Percutaneous Ethanol Instillation), TACE (TransArterial ChemoEmbolization), TAE (TransArterial Embolization) and TARE (TransArterial RadioEmbolization). These options are not curative, but they increase survival and are used to downstage patients .
The survival results obtained in these two treatments groups are extremely different, however these treatments are not exclusive and a patient could benefit from the complementarity of the various treatment options available. 
The Barcelona Clinic Liver Cancer (BCLC) system not only allows a prognostic evaluation of patients, but links the staging of HCC with best treatment options available. 
The Barcelona Clinic Liver Cancer (BCLC) system has been the most common staging system, but it has some limits: only one kind of treatment for each stage and no indications regarding sequential or combined treatments, the ECOG’s Performance status is very subjective, heterogeneous population in the intermediate stage and limited possibility to apply it to patients with HCC HBV related (that have a better residual liver function compared to patients with HCC HCV related). These are the reasons why new staging systems have been proposed and the HKLC classification seems to show a better prognostic value than the BCLC classification, This classification is able to better stratify patients in the BCLC B and C stages into distinct groups, with better survival outcomes based on more aggressive treatment recommendations than those observed in the BCLC treatment algorithm. .
As far as metastases are concerned, chemoembolization does not lead to prolongation of survival with a response rate of 22%, according some studies. When surgical resection is not possible, cryotherapy and radiofrequency treatment can ablate metastases in 50±90% of cases and are relatively safe. Cryotherapy is the oldest of the local thermal ablation techniques, treatment is limited to those with four or fewer metastases and, at present, it'is primarily an open surgical technique, with fewer than 10% of patients treated laparoscopically. Most investigators are limiting treatment with RF ablation to patients with four or fewer, 5 cm or smaller malignant lesions, with no evidence of extrahepatic disease. Ideal tumours are smaller than 3cm in diameter, completely surrounded by hepatic parenchyma, 1 cm or more deep to the liver capsule, and 2cm or more away from large hepatic or portal veins.
Tumors smaller than 2 cm in diameter can be treated with one or two ablations.
Patients with unresectable metastatic liver disease, involvement of both liver lobes, at least 3 recognizable metastases of at least 1 cm in size, secondary progressive after appropriate systemic therapy, without prior intra-arterial therapies, can be eligible for Trans Arterial RadioEmbolization (TARE). 
Only about 30% of patients with intrahepatic cholangiocarcinoma can benefit from curative surgical resection, because of locally advanced disease, distant metastases or comorbidity in elderly patients. Furthermore, after resection the recurrence rate is approximately 60%, resulting in a low 5-year overall survival. Loco-regional therapies, such as radiofrequency ablation (RFA) or Trans Arterial Chemio Embolization, have been shown to be effective also in these patients and to be able to prolong overall survival. 
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