Case report 329 Repeated courses of transarterial embolization with polyvinyl alcohol particles: ‘long life elixir’ in a cirrhotic patient with unresectable hepatocellular carcinoma Laura Marelli a , Vibhakorn Shusang a , Marco Senzolo a , Evangelos Cholongitas a , Antony Goode b,c , Dominic Yu b,c , David W. Patch a and Andrew K. Burroughs a Chemoembolization improves survival in selected cirrhotic patients with hepatocellular carcinoma, but prolonged survival is unusual. In this study, a 70-year-old cirrhotic patient, who had a histologically proven hepatocellular carcinoma of 5 cm diameter, embolization with polyvinyl alcohol particles alone, without chemotherapeutic agent, has resulted in continued survival, of 5 years to date, with virtual elimination of residual hypervascularity following 10 sessions of embolization, and with continued patency of the injected branch of the hepatic artery. Provided liver function is maintained, embolization alone appears a feasible long term and effective therapy for unresectable hepatocellular carcinoma. Eur J Gastroenterol Hepatol 19:329–332  c 2007 Lippincott Williams & Wilkins. European Journal of Gastroenterology & Hepatology 2007, 19:329–332 Keywords: embolization, hepatic artery patency, hepatocellular carcinoma, polyvinyl alcohol particles, repeated courses a Liver Transplantation and Hepatobiliary Medicine Unit, Departments of b Radiology and c Oncology, Royal Free Hospital, London, UK Correspondence to Professor Andrew K. Burroughs, MB ChB Hons, FRCP, Liver Transplantation and Hepatobiliary Medicine Unit, Royal Free Hospital, Pond Street, NW3 2QG, London, UK Tel: +44 20 7472 6229; fax: +44 20 7472 6226; e-mail: Andrew.Burroughs@royalfree.nhs.uk Received 2 October 2006 Accepted 4 December 2006 Introduction Hepatocellular carcinoma (HCC) is the fifth most common cause of cancer-related death in the world. In the Western countries, the annual incidence of HCC in patients with hepatic cirrhosis is 3–5% [1]. Currently, radical therapy for HCC, such as liver resection, transplantation and percutaneous ablation, is only applic- able in 30% or less of patients [1]. Therefore, palliative treatments are used most. Transarterial chemoemboliza- tion (TACE) is the only noncurative treatment for HCC that has been shown to improve survival [2]. In addition, considering three randomized trials, it seems that embolization alone (TAE, transarterial embolization), without injecting chemotherapeutic drugs, achieves the same survival benefit as TACE [3]. We present the case of an elderly patient with cirrhosis diagnosed with a 6-cm-diameter nodule of histologically proven HCC treated with 10 sessions of TAE without complications. Five years later he is still alive with no evidence of residual hypervascularity or lesion on imaging, good liver function and good quality of life. Patient’s presentation When 70 years old, our male patient, having recently lost a brother diagnosed with HCC, was referred to our Unit following an ultrasound and a dynamic magnetic reson- ance imaging (MRI) showing a mass in the right lobe of the liver in segment 6, of approximately 5 cm diameter (Fig. 1). Nine years ago he had cirrhosis diagnosed histologically, most likely because of progression of nonalcoholic fatty liver disease. He also suffered with type II diabetes mellitus, hypertension, arthritis and benign prostatic hypertrophy. He was obese (BMI = 40) and there were no cutaneous markers of chronic liver disease. His Eastern Cooperative Oncology Group performance status was 1. The aspartate transaminase was 65 U/l, alanine transaminase 87 U/l, g-glutamyl transferase 96 U/l, total bilirubin 8 mmol/l, alkaline phosphatase 137 U/l, albumin 45 g/l, glycated Hb 7.6% and a-fetoprotein less than 2 kU/l. He had some renal impairment with a creatinine of 166 mmol/l. Child– Pugh score was A [4]. Initial biopsy did not confirm hepatocellular carcinoma, but confirmed cirrhosis in the nontumourous part. A second ultrasound-guided biopsy (the lesion had grown to a maximum diameter of 6 cm) confirmed the presence of a moderately differentiated HCC: moderately pleo- morphic hepatoid cells with nuclear vacuolation and multiple mitoses – immunostaining for polyclonal carci- noembryonic antigen was present and 10% of the abnormal cells expressed thick Ki-67 antigen. On 20 June 2002, the patient received the first session of embolization with injection of PVA particles (50–250 mm) selectively injected into the branches of the hepatic artery 0954-691X  c 2007 Lippincott Williams & Wilkins Copyright © Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.