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[31]
ranging in maximum diameter from 100 to 900 μm. minimal embolization. TACI with maximally selective
SAP HepaSphere microspheres (BioSphere Medical) are catheterization and highly concentrated chemotherapy
biocompatible, hydrophilic (absorbent), non-resorbable, preparations minimizes the risk of hepatocellular
and acrylic copolymer microspheres designed for hepatic ischemic and cytotoxic complications and maximizes
arterial embolization with an ability to absorb fluids at up chemotherapy delivered to tumor tissue. TACI with super
to 64 times their dry state volume. The expansion rate is selective catheterization, although labor intensive, has
dependent on the ionic concentration of its surrounding been shown to be safe. The eligibility criteria for TACI
media. The size of dry particles ranges between 50 and are similar to those for TACE. Portal venous thrombosis
200 μm, corresponding to an expanded size range of 200 is not a contraindication. Caution should be exercised
and 800 μm. The SAP microspheres can be loaded with to avoid injecting large volumes (> 10 mL) of lipiodol.
doxorubicin or cisplatin for drug delivery during TACE. Moreover, patients with poor hepatic function and tumors
[29]
Initial in vitro and in vivo studies showed encouraging with diameters of > 9 cm have a high risk of irreversible
[32]
results, and these microspheres now have CE mark approval hepatic failure. A recent retrospective study by Kim et al.
for TACE of HCC in combination with doxorubicin. compared clinical outcomes of patients treated with TACE
(n = 49) vs. TACI (n = 61) in HCC patients with major portal
DEB-TACE appears to be a relatively safe procedure, with vein occlusion. The morbidity rate was similar for both
few long-term serious complications associated with its TACE (6.1%) and TACI (6.5%) patients, and complications
administration. Although symptoms of post-embolization were adequately managed by medical treatment. Median
syndromes, such as fever, nausea, vomiting, and abdominal survival for TACE was longer than for TACI (14.9 vs. 4.4
pain appears to occur in most patients, these symptoms months, respectively, P < 0.001).
are associated with short hospital stays averaging 2.3
days among publications, which is significantly lower Radiotherapy-based therapies
than conventional TACE procedures. The most frequent Yttrium-90 radioembolization
major complication associated with this procedure is liver Transarterial radioembolization (TARE) with intra-arterial
abscess, which occurred in approximately 0.75-1.58% of injection of yttrium-90 microspheres (Y-90) is another
publications. Other complications are infrequent, although form of hepatic arterial therapy that is available as glass
some are quite severe. Overall mortality is potentially (TheraSpheres; Theragenics Corp., Ottawa, Canada) or
lower than the reported values (2.06-4.74%) because resin (Sirtex; Sirtex Medical, Wilmington, MA, USA) and
reported mortality rates include both procedure-related can be delivered to single or multiple segments based on
causes of death, such as sepsis and hepatic failure, and selective arterial cannulation. Its small size (20-60 μm)
death secondary to progressive disease, cardiovascular results in preferential trapping in the tumor capillary
disease, pulmonary embolism, and other causes. Patients bed. These spheres can safely deliver up to 150 Gy of
selected for most of these studies are predisposed to co- β radiation to induce tumor necrosis by radiation and
morbidities as a result of their diminished hepatic function microscopic embolization once they obstruct the tumor
and potentially other age or lifestyle-related conditions, capillary bed. This limits radiation exposure to adjacent
which should be taken into consideration. [30] healthy tissue, given its half-life of 62 h and radius of
action of up to 1 cm. Patient selection requires pre-
[33]
The current results show that DEB-TACE produces treatment procedures, including an angiogram to perform
beneficial tumor response and has exceptionally low prophylactic embolization in which variant anatomy
complication rates. The technique has the potential to is identified to avoid non-target delivery of Y-90, and a
become an effective alternative therapy or palliative macro-aggregated albumin scan to confirm that hepatic
measure in the treatment of HCC, but both delivery artery-to-lung shunting is < 16% to prevent lung
[34]
and data collection must be standardized in order to injury. An advantage of this treatment over TACE is its
clarify efficacy. It is a safe alternative for the treatment applicability in patients with portal vein thrombosis and
of unresectable HCC but is unproven as an adjunctive potential complications caused by non-target delivery
treatment for other standard therapies such as resection of Y-90 include gastrointestinal ulcerations, pancreatitis,
[36]
[35]
and RFA. Further investigation is essential to better define pneumonitis, and cholecystitis. Salem et al. recently
its role as an adjunct in treating HCC. published a comprehensive study on the long-term
outcomes after intra-arterial radiotherapy for unresectable
Transcatheter arterial chemoinfusion HCC. In this study, 291 patients with HCC were treated with
Transcatheter arterial chemoinfusion (TACI) is a catheter- Y-90 as part of a single-center, prospective, longitudinal
based intra-arterial therapy that traps high concentrations cohort study. Response rate and time to progression were
of chemotherapeutic agents in tumor tissues followed by determined by the World Health Organization (WHO) and

Hepatoma Research | Volume 2 | Issue 1 | January 15, 2016 3