Due to extensive tumoural invasion, less than 10% of the patients with
hepatocellular carcinoma can benefit from surgery. A variety of proposed palliative procedures, including general
chemotherapy and
radiotherapy, have given quite less than satisfactory results. Percutaneous alcoolization and
hormone therapy are currently being evaluated. Increased use of intra-arterial embolization has developed over the last 10 years, initially in Asia and now in Europe. The aim of intra-arterial
chemotherapy is to increase the concentration of
anticancer agents within the tumour. Adding
lipiodol with certain agents would increase the duration of
cancer cell exposure. Arterial embolization aims at creating tumour
necrosis by ischaemia and relies on the fact that the main blood supply from
hepatocellular carcinomas comes from arteries while non-tumoural hepatic tissue is supplied by the portal vein. Numerous reports on intra-arterial treatment protocols combining
chemotherapy and embolization have demonstrated that this technique can produce partial or total tumour
necrosis. However, due to the variable nature of the natural history of
hepatocellular carcinoma the clinically beneficial effect in terms of survival rate has not been established and would not appear to be highly significant, probably due to chemoresistance which cannot be overcome by intra-arterial administration. Indeed, the necrotic effect appears to result from hepatic embolization itself. In two randomized studies
necrosis was significantly greater in patients who underwent repeated embolizations than in those receiving general or intra-arterial
chemotherapy. It is generally accepted that intra-arterial chemoembolization is contraindicated in cases of portal
thrombosis or major
liver failure. In addition, each procedure requires at least one week hospitalization with the inherent effect on patient comfort and quality of life. Nevertheless, should intra-arterial, chemoembolization be abandoned? Probably not because there is no alternative method, at least for inoperable patients. Efforts should be made to improve the technique which should be reserved for carefully selected patients. New, more liposoluble drugs and possible combinations with
glycoprotein inhibitors could be studied. Until an effective treatment for
hepatocellular carcinoma has been developed, the role of
palliative care must be evaluated in terms of survival rate, cost and quality of life.