Transarterial Chemoembolization and Microwave Ablation for Early Hepatocellular Carcinoma in a Nigerian
Ninalowo Hammed1, Oluyemi Aderemi2, Balogun Babatunde3
1IRDOC interventional Radiology Consulting Limited, Euracare Multispecialty Hospital, Victoria Island, Lagos State, Nigeria
2ReMay Consultancy & Medical Services, Ikeja, Lagos State, Nigeria
3Lagos State University College of Medicine, Ikeja, Lagos State, Nigeria
Correspondence to: Dr. Oluyemi Aderemi; email: firstname.lastname@example.org
Received: 19 Dec 2020; Revised: 5 Aug 2021; Accepted: 23 Aug 2021; Available online: 26 Sep 2021
The West African subregion has a high number of cases of hepatocellular carcinoma (HCC), and this is partly because of a lack of expertise and health infrastructure for the delivery of effective locoregional therapies for patients who present with early disease. This report documents the successful treatment of a case of early HCC in a Nigerian patient using a combination of transarterial chemoembolization and microwave ablation techniques. We showed that, despite difficulties, such techniques are possible. It is our hope that this publication will help stimulate discussion, policy changes, and other alterations necessary to establish beneficial high-end techniques for the alleviation of the health burden of HCC patients in Nigeria.
Keywords: Early hepatocellular carcinoma, Nigeria, Transarterial Chemoembolization, Microwave Ablation, Interventional Radiology
Ann Afr Surg. 2022; 19(1): 58-61
Conflict of interest: None
© 2022 Author. This work is licensed under the Creative Commons Attribution 4.0 International License
The African continent and other developing countries, have a disproportionately higher burden of hepatocellular cancer (HCC) (1). The dearth of expertise and health infrastructure to deliver effective locoregional therapies for early HCC are part of the reasons why West Africa continues to have a high number of HCC cases (2). Early HCC treatment strategies (whether singly or in combination) have been shown to definitively impact HCC patient outcomes (3). It is rather unfortunate that such beneficial interventions are not readily available in our locality. This report is unique in that it documents the first case in Nigeria of successful locoregional therapy for HCC using a combination of transcatheter arterial chemoembolization (TACE) and microwave ablation (MWA). It also highlights the clinical and radiological details of the patient’s presentation as well as the interventional procedures and their outcomes.
A 60-year-old man with a 5-month history of unintentional weight loss, anorexia, and malaise was referred to the hepatology clinic after an abdominal ultrasound scan had revealed a hyperechogenic, intrahepatic lesion on a background of cirrhotic disease. He had no family history of liver ailment nor was there any history of alcohol ingestion. A 15-year history of well-controlled type 2 diabetes mellitus was noted. Two years earlier, he had been informed of a liver “condition” after he underwent computed tomography (CT), but was not followed up with any consultation or therapy at that time. A review of the previous CT scan showed that it had reported features of cirrhosis and portal hypertension as well. On examination, he was lucid and not obese. Hepatitis A, B, and C screens were negative, and his hemoglobin, transaminase, and alpha-fetoprotein levels were normal. Further evaluation with a repeat CT image confirmed the cirrhotic disease and a 1.5x1.5x1.9-cm arterially enhancing lesion in segment VIII with associated portal venous washout on delayed imaging (Figure 1).
Click to view figure 1: CT scan showing cirrhotic disease and an arterially enhancing lesion in segment VIII
Pugh score was 6, indicating the least severe, compensated cirrhotic liver disease.
In view of the Barcelona Clinic Liver Cancer (BCLC) classification of stage 0 (early HCC), the option of liver resection along with the possibility of other locoregional interventions that had potential for cure, were discussed with the patient. The patient refused surgery. Thus, an interventional radiology (IR) specialist was consulted, who recommended dual therapy with simultaneous TACE and MWA for this case.
The intraoperative selective arteriogram of the segment VIII branch of the right hepatic artery confirmed that the tumor was highly vascularized. This access allowed for the lipiodol and doxorubicin mixture to be injected under fluoroscopic visualization to this branch of the right hepatic artery. Post-embolization arteriography of the treated vessel and real-time ultrasound scan of the liver showed stasis of blood flow within the treated vascular territory and staining of tumor with lipiodol.
Subsequently, a 14-gauge ECO medical MWA needle was advanced into the tumor from a left approach. Ablation was then performed initially for 3 minutes, then for an additional 1 minute. Track cauterization was performed. Appropriate cloud-type pattern in real-time post-ablative ultrasound was seen following ablation (Figure 2).
Click to view figure 2: Ultrasound image showing cloud-type pattern post-ablation
The patient returned after 10 weeks with a follow-up magnetic resonance imaging (MRI) (Figure 3), which showed a pre-contrast ablation cavity in the same area of the previously treated lesion and T1 hyperintensity around the tumor, representing hemorrhage and ablation margins. The post-contrast image shows an ablation cavity in the same area as the previously treated lesion, with no evidence of residual enhancement.
Click to view figure 3: MRI images showing pre-contrast ablation cavity in the same area of the previously treated lesion and T1 hyperintensity around the tumor. The post-contrast image shows an ablation cavity in the same area as the previously treated lesion, with no evidence of residual enhancement.