This 63-year-old gentleman is a known case of chronic liver disease, found to have a relatively large right lobe of liver segment V HCC with dense tumoural thrombosis in segment V & VIII branch of the portal vein. His Sr. Bilirubin wall was within normal limits & Sr. AFP was approximately 1260 IU. On CT scan the entire lesions show typical bright arterial phase enhancement with venous washout along with typical features of chronic liver disease like irregularity of the liver surface, significant pleural nodularity, volume redistribution with a small right lobe of liver along with foci of bland thrombus in the main & right portal vein branches.
However, the rest of the portal vein branches are not occluded. No ascites were detected. He had a history of variceal bleeding for which she underwent several sessions of endoscopic ligation & glue INJ. About 10 years back & on follow-up since then.

After discussion, it was decided to go for a combined approach to treat this lesion in totality. Initially microwave ablation of the Maximum part of the tumour followed by SBRT of portal vein thrombosis is planned & after few weeks for residual tumour TACE planned if required. He was taken up for CT guided microwave ablation of the segment V tumour which was abutting on gallbladder. The procedure was performed in right paravertebral block which was a novel approach for the bodily intervention & at Apollo PR making it work for fissure patient was not given any general anaesthesia but a regional block at the paravertebral region making the procedure completely painless & patient can cooperate during the procedure with almost immediate recovery after the procedure can have his normal food & no need for significant monitoring. Hydro dissection was done between the plane of the tumour & the gallbladder to make a thick section followed by ablation for about 4.5 x 4.5 cm nearly completely abutting the lesion. This was followed by SBRT of the segment LVIII temporal thrombosis following which patient was discharged from the hospital in stable condition. After 3 weeks in follow up CT scan the tumoural thrombus completely disappeared & huge part of the tumour completely seen necrosed in nature with minimal patchy residual nodular areas of arterial phase enhancement & venous washout still existing along the rim of the lesion. He was again admitted & taken up for the transarterial chemoembolisation. Before the procedure his S. AFP was dropped up to 163 IU. The segmental supply f from the segment V branch to the tumour excised & embolised with combination of Doxorubicin seen & Lipiodol Andy Toogood tumour cast obtained. 2 months after the TACE, S. AFP dropped further to approximately 20 IU suggestive of excellent tumour
response.

HCC of liver, although is a different difficult proposition to treat & despite choose number of modalities available non proved completely successful in their Endeavour. There are several treatment more dialysis modalities available out of which TACE is well established & considered as gold standard for HCC. However, in recent years ablative techniques establishing themselves well especially when tumour is < 5 cm in size with RFA beyond doubt up to 3 cm sized liver tumours. For 3-5 cm sized liver tumours & a smaller tumours which are adjacent to vessels are heat zinc can come in picture, microwave ablation established itself very well. Similarly SBRT also having its own advantages over the tumour size up to 5 cm or in cases of portal venous thrombosis due to tumour involvement. Large tumours always treated by either TACE or nowadays tear have come in a big way especially for tumour with portal vein thrombosis & where liver function also bit deranged. With Advent of numerous newer drugs & immunotherapy protocols especially with Lenvatinib, scenario started changing significantly. However, still 1 single modality may not be able to treat enter disease & its expressions. So nowadays, using different modalities for there are advantages combinedly to treat a lesion is becoming more
frequent.

In this patient who was apparently only can be treated for palliative intent, we tried combined modality with possible curative intent. TACE although is well established but is well known for post embolisation syndrome & derangement in liver function especially if larger tumours with portal vein thrombosis is present. To negate that we used microwave ablation with a primary objective of debulking the tumour which possibly will not cause significant liver derangement & we might get away with lesser post embolisation syndrome alongwith less liver function derangement. SBRT done as a OPD procedure for the tumoural portal vein thrombosis which usually never responds to the established other lines of treatment whether it is medical therapy, ablation or TARE.

Serial measurement of Sr. AFP showed that this combined approach word well & his tumour burden come down almost nearly 0 with may be a little bit foci of residual tumour at the junction of the portal vein branches may still remaining which will be followed up & treated if required after 3 months of observation.