In practice, commonly used criteria comprise platelet count of 50 000/µL or more, prothrombin time of 50% or more and serum bilirubin of 3 mg/dL or less. For tumors more than 3 cm in diameter, TACE is frequently performed first, followed by additional RFA.8 According to the report of the 18th follow-up survey, 1-, 3- and 5-year survival rates for RFA were 95.0%, 76.7%

and 56.3%, respectively.9 Radiofrequency ablation is usually performed percutaneously; however, this method can be adapted by performing RFA laparoscopically for lesions on the liver surface or touching neighboring organs such as the intestines or diaphragm,23 and can also be carried out with artificial pleural effusion for lesions under Ixazomib chemical structure the diaphragm or when the lungs intrude on the puncture route.24,25 Artificial ascites can also be used to prevent perforation of the

digestive tract for lesions touching the intestines,24–28 and an endoscopic nasobiliary drainage tube can be used to cool the bile duct before treatment when the lesion is close to the bile duct and the latter is at risk of damage.24,29 For lesions in which the tumor boundaries are not clearly demarcated and that are difficult to visualize under b-mode USG, or when performing additional treatment to secure ablative margins around the target lesion, treatment can be assisted using contrast USG using Sonazoid24,30,31 or a real-time virtual sonography system that synchronizes image data from or multidetector-row computed PtdIns(3,4)P2 tomography with the position of the USG probe, and Angiogenesis inhibitor simultaneously

displays the USG images and virtual images from CT data.32 TRANSCATHETER ARTERIAL CHEMOEMBOLIZATION is widely used in Japan to treat HCC.9 Usually, an adequate amount of emulsion containing oil-based contrast agent Lipiodol and anticancer agents is injected through a catheter then the selected arteries are embolized by embolic agents. Formerly, the embolic agents used in Japan were the absorbent gelatin sponge materials Gelfoam or Spongel treated to create fine fragments, but Gelpart porous gelatin granules were approved for health insurance coverage in 2006 and are now in common use. Superselective TACE is generally used in Japan to minimize damage to non-tumorous areas by using a microcatheter to embolize only the cancerous subsegment.33–35 Epirubicin and cisplatin are commonly used as anticancer agents, and miriplatin, a new platinum drug, came into use in 2010.36,37 Indications for TACE are wide-ranging, and the procedure is generally performed in patients with hypervascular HCC who are not indicated for surgery or local therapy for reasons such as multiple bilobar HCC, liver dysfunction, old age or comorbidity, and in whom the first branch from the main portal vein is not occluded.