Large (>or=5.0-cm) HCCs: multipolar RF ablation with three internally cooled bipolar electrodes--initial experience in 26 patients

Alteration of laboratory findings after radiofrequency ablation of hepatocellular carcinoma: relationship to severity of the underlying liver disease and the ablation volume

BACKGROUND/AIMS

To investigate sequential changes in laboratory markers after radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) and the relationship of these changes to the severity of the underlying liver disease.

METHODS

This retrospective analysis included 65 patients (44 males, 21 females) who underwent RFA of HCC. Hematologic and biochemical markers were assessed at the pre-RFA period and 1 day, 2-3 days, and 1-2 weeks after RFA. We classified the subjects into two groups: Child-Pugh A (n=41) and Child-Pugh B (n=24). The ablative margin volume (AMV) of each patient was measured. We analyzed the changes in laboratory profiles from the baseline, and investigated whether these laboratory changes were correlated with the AMV and the Child-Pugh classification.

RESULTS

Most of the laboratory values peaked at 2-3 days after RFA. AMV was significantly correlated with changes in WBC count, hemoglobin level, and serum total bilirubin level (Pearson's correlation coefficient, 0.324-0.453; P<0.05). The alanine aminotransferase (ALT) level varied significantly over time (P=0.023).

CONCLUSIONS

Most of the measured laboratory markers changed from baseline, peaking at 2-3 days. The ALT level was the only parameter for which there was a significant difference after RFA between Child-Pugh A and B patients: it increased significantly more in the Child-Pugh A patients.

Radiofrequency ablation versus transarterial chemoembolization for unresectable solitary hepatocellular carcinomas sized 5-8 cm

OBJECTIVES

This retrospective review was conducted to compare the efficacy of radiofrequency ablation (RFA) with that of transarterial chemoembolization (TACE) in treating large (5-8 cm) unresectable solitary hepatocellular carcinomas (HCCs).

METHODS

Patients with large unresectable solitary HCCs primarily treated by RFA or TACE were reviewed. The primary endpoint was overall survival. Secondary endpoints were tumour response, time to disease progression, and treatment-related morbidity and mortality.

RESULTS

There were 15 patients in the RFA group. Of these, 12 achieved complete ablation, one had ablation site recurrence, and five developed complications. Median disease-free survival in this group was 13.0 months (range: 2.8-38.0 months). The TACE group included 26 patients, of whom four obtained a partial response, none achieved a complete response, and five developed complications. The median time to disease progression in this group was 8.0 months (range: 1.0-68.0 months). There were no hospital deaths in this series. Median survival was 39.8 months in the RFA group and 19.8 months in the TACE group (P = 0.257). Rates of 1-, 2- and 5-year survival were 93.3%, 86.2% and 20.9%, respectively, in the RFA group and 73.1%, 40.6% and 18.3%, respectively, in the TACE group.

CONCLUSIONS

Both RFA and TACE are feasible treatments for large unresectable solitary HCCs. Both modes show comparable rates of complications and longterm survival, but RFA achieves better initial tumour control and results in better short-term survival.

Laser ablation for small hepatocellular carcinoma: State of the art and future perspectives

During the last two decades, various local thermal ablative techniques for the treatment of unresectable hepatocellular carcinoma (HCC) have been developed. According to internationally endorsed guidelines, percutaneous thermal ablation is the mainstay of treatment in patients with small HCC who are not candidates for surgical resection or transplantation. Laser ablation (LA) represents one of currently available loco-ablative techniques. In this article, the general principles, technique, image guidance, and patient selection are reported. Primary effectiveness, long-term outcome, and complications are also discussed. A review of published data suggests that LA is equivalent to the more popular and widespread radiofrequency ablation in both local tumor control and long-term outcome in the percutaneous treatment of early HCC. In addition, the LA technique using multiple thin laser fibres allows improved ablative effectiveness in HCCs greater than 3 cm. Reference centres should be equipped with all the available techniques so as to be able to use the best and the most suitable procedure for each type of lesion for each patient.

Radiofrequency ablation of liver VX2 tumor: experimental results with MR diffusion-weighted imaging at 3.0T

PURPOSE

To evaluate the value of DWI in detecting the lesions of pre- and post-radiofrequency ablation (RFA) of the rabbit liver VX2 tumors.

MATERIALS AND METHODS

Twenty-two New Zealand White rabbits were tested. The protocol was approved by the Committee on the Ethics of Animal Experiments. Twenty separate tumor fragments were implanted into the livers of 20 rabbits, the liver was exposed by performing midline laparotomy. 3.0T MR DWI (b = 0, 200, 400, 600, 800,1000 s/mm2) were performed 14-21 days after tumor implantation (mean, 17 days) in the 18 tumor-bearing animals. Then RFA was performed in the 18 tumor-bearing animals and in the two healthy animals. 3.0T MR DWI was performed 7-10 days after RFA (mean, 8 days). Pathology exam was performed immediately after the completion of post- RFA MR imaging. Analyzing the features of MRI and ADC values in the pre- and post- RFA lesions of the VX2 tumors, and histopathologic results were compared with imaging findings.

RESULTS

The difference of ADC value between viable tumor and normal liver parenchyma was significant (P<.001). After RFA, when b = 200, 400, 600, 800, 1000 s/mm2, the differences of ADC values of viable tumor, granulation tissue, necrosis, normal liver parenchyma were significant (P<.001). At the time the animals were sacrificed after RFA and MR imaging, histopathologic results of local viable tumors were found in 9 (50%) of the 18 treated tumors. Macroscopic viable tumors were found at the RFA sites in 3 (17%), all 3 macroscopic viable tumors were visualized at the periphery of the RFA areas.

CONCLUSIONS

3.0T MR DWI can be used to follow up the progress of the RFA lesion, it is useful in detecting different tissues after RFA, and it is valuable in the further clinical research.

Role of local ablative therapy for hepatocellular carcinoma

Percutaneous local ablation (PLA) techniques are currently considered as the best treatment option for patients with early-stage hepatocellular carcinoma (HCC) who are not candidates for surgical resection. They are safe, minimally invasive, efficacious and cost-effective. Radiofrequency ablation (RFA) is considered as the first line treatment in some centers, though most of the guidelines recommend it for small HCCs, where surgical resection is not feasible. In developing countries percutaneous ethanol injection (PEI) and percutaneous acetic acid injection (PAI) may be used instead of RFA. For large HCCs, advances in electrode designs and newer techniques of ablation, including microwave ablation, are increasingly been used. Combination treatment modalities have shown promising results as compared to single modality for large tumors. The selection of the most appropriate modality depends on the size, number of lesions, the liver function status, patient's financial resources, availability of a particular technique and the expertise available.

Comparison of percutaneous ablation technologies in the treatment of malignant liver tumors

Tumor ablation is a minimally invasive technique used to deliver chemical, thermal, electrical, or ultrasonic damage to a specific focal tumor in an attempt to achieve substantial tumor destruction or complete eradication. As the technology continues to advance, several image-guided tumor ablations have emerged to effectively manage primary and secondary malignancies in the liver. Percutaneous chemical ablation is one of the oldest and most established techniques for treating small hepatocellular carcinomas. However, this technique has been largely replaced by newer modalities including radiofrequency ablation, microwave ablation, laser-induced interstitial thermotherapy, cryoablation, high-intensity-focused ultrasound ablation, and irreversible electroporation. Because there exist significant differences in underlying technological bases, understanding each mechanism of action is essential for achieving desirable outcomes. In this article, the authors review the current state of each ablation method including technological and clinical considerations.

Hepatocellular carcinoma in 2014: current situation and future prospects

The leading causes of chronic liver disease associated with HCC are hepatitis B and C viruses throughout the world, and alcohol and NASH in France. After increasing for 20-30 years in France, the rise in the incidence of HCC appears to be slowing and the death rates appear to be falling. Screening for HCC by liver ultrasound is performed every 6 months. Assay of serum alpha-fetoprotein has no benefit. In developed countries, failure to identify patients with cirrhosis and inadequate adherence to guidelines greatly reduces the effectiveness of screening for HCC.

Histopathologic comparison of monopolar versus no-touch multipolar radiofrequency ablation to treat hepatocellular carcinoma within Milan criteria

PURPOSE

To compare histopathologically the completeness of radiofrequency (RF) ablation to treat hepatocellular carcinoma (HCC) with monopolar or multipolar technique.

MATERIALS AND METHODS

Thirty-five consecutive patients (mean age, 59 y) with cirrhosis and HCC (n = 59) within Milan criteria received RF ablation and subsequently underwent liver transplantation (LT) for tumor progression or liver failure. Data were extracted retrospectively from a prospective database. Thirty nodules were treated with a monopolar device with internally cooled (n = 17) or perfused (n = 13) electrodes, and 29 were treated with a multipolar technique with internally cooled electrodes based on the "no-touch" concept. This consisted of inserting two or three straight electrodes around the nodule to avoid intratumor puncture to the greatest extent possible. Effectiveness of the three devices was compared by histopathologic examination of explants. Fisher exact and χ(2) tests and multivariate logistic regression analysis were performed.

RESULTS

Mean sizes of nodules ablated (25, 22, and 21.6 mm) and median times from ablation to LT (11, 7.5, and 8.4 months) for patients treated with the monopolar internally cooled electrode device (MoICD), monopolar perfused electrode device (MoPED), and multipolar internally cooled electrode device (MuICD), respectively, were similar (P = .8 and P = .9, respectively). Pathologic examination showed complete necrosis for eight of 17 and six of 13 nodules treated with the MoICD and MoPED, respectively, versus 26 of 29 treated with the MuICD (P = .0019). In multivariate analysis, RF technique remained the predictive factor for complete necrosis (P = .005).

CONCLUSIONS

Ablation of small HCCs with multipolar RF ablation based on the no-touch concept improves the rate of complete necrosis during pathologic examination compared with monopolar techniques.

Comparison of long-term effectiveness and complications of radiofrequency ablation with hepatectomy for small hepatocellular carcinoma

BACKGROUND AND AIM

To determine and compare the adverse events and long-term effectiveness for patients with small hepatocellular carcinoma (HCC) (≤ 3 cm) treated by percutaneous radiofrequency ablation (RFA) or hepatectomy.

METHODS

Small HCC from 120 patients were randomized into either percutaneous RFA therapy or hepatectomy group, and the effectiveness and complications of two treatment modalities were analyzed. The complications of post-RFA or hepatectomy, the complete treatment rate, treatment-related mortality, and disease-free and overall survival rate were followed up and conducted.

RESULTS

In patients with small HCC, complete remission rates were achieved in 95% and 96.7% in the percutaneus RFA and hepatectomy groups, respectively (P > 0.05). Hepatic function at day-7 status post-treatment, including albumin and bilirubin levels, were significantly worse in the hepatectomy group (P < 0.01). Compared with the RFA group, the incidence of postoperative complications (27.5% vs 5.0%) and hospital stay (11.8 ± 3.1 vs 4.3 ± 1.5) were significantly higher in the hepatectomy group (P < 0.01). After a mean follow-up of 40 months, 22 patients (36.6%) in the RFA group and 21 patients (35.0%) in the hepatectomy group developed a recurrence (P > 0.05). There was no significant difference of the disease-free and overall survival rates at 1, 2, and 3 years between the RFA group and the surgical hepatectomy group (P = 0.443 and P = 0.207, respectively).

CONCLUSIONS

In patients with small HCC, percutaneous RFA showed similar local control and long-term survival compared with hepatectomy. Importantly, percutaneous RFA are accompanied with a lower complication rate and shorter hospital stay day.

Cost-effectiveness of hepatic resection versus percutaneous radiofrequency ablation for early hepatocellular carcinoma

BACKGROUND & AIMS

Both hepatic resection and radiofrequency ablation (RFA) are considered curative treatments for hepatocellular carcinoma (HCC), but their economic impact still remains not determined. Aim of the present study was to analyze the cost-effectiveness (CE) of these two strategies in early stage HCC (Milan criteria).

METHODS

As first step, a meta-analysis of the pertinent literature of the last decade was performed. Seventeen studies fulfilled the inclusion criteria: 3996 patients underwent resection and 4424 underwent RFA for early HCC. Data obtained from the meta-analysis were used to construct a Markov model. Costs were assessed from the health care provider perspective. A Monte Carlo probabilistic sensitivity analysis was used to estimate outcomes with distribution samples of 1000 patients for each treatment arm.

RESULTS

In a 10-year perspective, for very early HCC (single nodule <2 cm) in Child-Pugh class A patients, RFA provided similar life-expectancy and quality-adjusted life-expectancy at a lower cost than resection and was the most cost-effective therapeutic strategy. For single HCCs of 3-5 cm, resection provided better life-expectancy and was more cost-effective than RFA, at a willingness-to-pay above €4200 per quality-adjusted life-year. In the presence of two or three nodules ≤3 cm, life-expectancy and quality-adjusted life-expectancy were very similar between the two treatments, but cost-effectiveness was again in favour of RFA.

CONCLUSIONS

For very early HCC and in the presence of two or three nodules ≤3 cm, RFA is more cost-effective than resection; for single larger early stage HCCs, surgical resection remains the best strategy to adopt as a result of better survival rates at an acceptable increase in cost.

Radiofrequency ablation combined with transcatheter arterial chemoembolization for the treatment of single hepatocellular carcinoma of 2 to 5 cm in diameter: comparison with surgical resection

OBJECTIVE

To compare the effectiveness of radiofrequency ablation (RFA) combined with transcatheter arterial chemoembolization (TACE) with surgical resection in patients with a single hepatocellular carcinoma (HCC) ranging from 2 to 5 cm.

MATERIALS AND METHODS

The study participants were enrolled over a period of 29 months and were comprised of 37 patients in a combined therapy group and 47 patients in a surgical resection group. RFA was performed the day after TACE, and surgical resection was performed by open laparotomy. The two groups were compared with respect to the length of hospital stay, rates of major complication, and rates of recurrence-free and overall survival.

RESULTS

Major complications occurred more frequently in the surgical resection group (14.9%) than in the combined therapy group (2.7%). However, there was no statistical significance (p = 0.059). The rates of recurrence-free survival at 1, 2, 3 and 4 years were similar between the combined therapy group (89.2%, 75.2%, 69.4% and 69.4%, respectively) and the surgical resection group (81.8%, 68.5%, 68.5% and 65%, respectively) (p = 0.7962, log-rank test). The overall survival rates at 1, 2, 3 and 4 years were also similar between groups (97.3%, 86.5%, 78.4% and 78.4%, respectively, in the combined therapy group, and 95.7%, 89.4%, 84.3% and 80.3%, respectively, in the surgical resection group) (p = 0.6321, log-rank test).

CONCLUSION

When compared with surgical resection for the treatment of a single HCC ranging from 2 to 5 cm, RFA combined with TACE shows similar results in terms of recurrence-free and overall survival rates.

Clinical effectiveness of bipolar radiofrequency ablation for small liver cancers

BACKGROUND

Radiofrequency ablation (RFA) is minimally invasive and can achieve a high rate of cure of liver cancer. This study was conducted to evaluate the efficacy and safety of a bipolar RFA device (CelonPOWER System) in the treatment of Japanese liver cancer patients.

METHODS

The study was a multicenter, single-group, open-label trial. The indications for RFA were based on the Japanese guidelines for the management of liver cancer. The subjects had a Child-Pugh classification of A or B, and the target tumors were defined as nodular, numbering up to 3 lesions, each of which was 3 cm or less in diameter, or solitary lesions up to 4 cm in diameter. To test for the non-inferiority of the CelonPOWER System, this system was compared with the Cool-tip RF System, which has already been approved in Japan, in terms of the complete necrosis rate (CNR).

RESULTS

The CNR obtained with the CelonPOWER System was 97.8 % (88/90 patients). The CNR obtained with the Cool-tip RF System was 86.2 % (50/58 patients), confirming the non-inferiority of the CelonPOWER System (p < 0.001, Fisher's exact test based on binomial distribution). Throughout the treatment and follow-up periods, there were no adverse events regarding safety that were uniquely related to the CelonPOWER System and there were no cases of device failure.

CONCLUSIONS

The CelonPOWER System was confirmed to be an effective and safe RFA device. It could become extensively used as a safe next-generation RFA device, reducing the physical burden on patients.

Radiofrequency coil for the creation of large ablations: ex vivo and in vivo testing

PURPOSE

Various radiofrequency (RF) ablation electrode designs have been developed to increase ablation volume. Multiple heating cycles and electrode positions are often required, thereby increasing treatment time. The objective of this study was to evaluate the performance of a high-frequency monopolar induction coil designed to produce large thermal lesions (>3 cm) with a single electrode insertion in a treatment time of less than 10 minutes.

MATERIALS AND METHODS

A monopolar nitinol interstitial coil operated at 27.12 MHz and 200 W was evaluated. Ex vivo performance was tested in excised bovine liver (n = 22). In vivo testing (n = 10) was conducted in livers of seven Yorkshire pigs. Visual inspection, contrast-enhanced computed tomography (CT), and pathologic evaluation of ablation zones were performed.

RESULTS

Average ablation volumes in ex vivo and in vivo tests were 60.5 cm(3) ± 14.1 (5.9 × 4.4 × 4.4 cm) and 57.1cm(3) ± 13.8 (6.1 × 4.5 × 4.1cm), with average treatment times of 9.0 minutes ± 3.0 and 8.4 minutes ± 2.7, respectively. Contrast-enhanced CT ablation volume measurements corresponded with findings of gross inspection. Pathologic analysis showed morphologic and enzymatic changes suggestive of tissue death within the ablation zones.

CONCLUSIONS

The RF ablation coil device successfully produced large, uniform ablation volumes in ex vivo and in vivo settings in treatment times of less than 10 minutes. Ex vivo and in vivo lesion sizes were not significantly different (P = .53), suggesting that the heating efficiency of this higher-frequency coil device may help to minimize the heat-sink effect of perfusion.

Diaphragmatic necrosis after radiofrequency ablation of hepatocellular carcinoma: a successful surgical repair

We report a case of complete hemidiaphragmatic necrosis with liver abscess complicating radiofrequency ablation of a large subdiaphragmatic hepatocellular carcinoma in a patient with unrecognized history of endoscopic oddi sphincterotomy. At 2-year follow-up after surgical repair using a pedicled latissimus dorsi flap, clinical examination and imaging did not show complication or cancer recurrence. The risk of complete hemidiaphragmatic necrosis resulting from both thermal and septic injuries should be considered when radiofrequency ablation is performed for liver dome tumors, particularly in patients with impaired oddi sphincter. In this septic situation, a latissimus dorsi flap appears as the unique opportunity to repair the injured hemidiaphragm.

Local ablation for hepatocellular carcinoma in taiwan

Hepatocellular carcinoma (HCC) is the second commonest cancer in Taiwan. The national surveillance program can detect HCC in its early stages, and various curative modalities (including surgical resection, orthotopic liver transplantation, and local ablation) are employed for the treatment of small HCC. Local ablation therapies are currently advocated for early-stage HCC that is unresectable because of co-morbidities, the need to preserve liver function, or refusal of resection. Among the various local ablation therapies, the most commonly used modalities include percutaneous ethanol injection and radiofrequency ablation (RFA); percutaneous acetic acid injection and microwave ablation are used less often. RFA is more commonly employed than other local ablative modalities in Taiwan because the technique is highly effective, minimally invasive, and requires fewer sessions. RFA is therefore advocated in Taiwan as the first-line curative therapy for unresectable HCC or even for resectable HCC. However, current RFA procedures are less effective against tumors that are in high-risk or difficult-to-ablate locations, are poorly visualized on ultrasonography (US), or are large. Recent advancements in RFA in Taiwan can resolve these issues by the creation of artificial ascites or pleural effusion, application of real-time virtual US assistance, use of combination therapy before RFA, or use of switching RF controllers with multiple electrodes. This review article provides updates on the clinical outcomes and advances in local ablative modalities (mostly RFA) for HCC in Taiwan.

Image-guided tumor ablation: emerging technologies and future directions

As the trend continues toward the decreased invasiveness of medical procedures, image-guided percutaneous ablation has begun to supplant surgery for the local control of small tumors in the liver, kidney, and lung. New ablation technologies, and refinements of existing technologies, will enable treatment of larger and more complex tumors in these and other organs. At the same time, improvements in intraprocedural imaging promise to improve treatment accuracy and reduce complications. In this review, the latest advancements in clinical and experimental ablation technologies will be summarized, and new applications of image-guided tumor ablation will be discussed.

Ablative zone size created by radiofrequency ablation with and without chemoembolization in small hepatocellular carcinomas

PURPOSE

We retrospectively evaluated whether combined use of chemoembolization expands ablative zone sizes created by radiofrequency (RF) ablation in patients with small hepatocellular carcinomas (HCCs).

MATERIALS AND METHODS

Fifty-seven patients treated with single RF ablation for solitary HCC measuring ≤2 cm were assessed. RF ablation alone was done in nine patients and in 48 patients following chemoembolization, with an interval of 0 days in 6, 1-14 days in 27, 15-28 days in 6, and ≥4 weeks in 9. Ablative zone sizes, disappearance of tumor enhancement, and creation of sufficient ablative margins (>5 mm) were evaluated on contrast-enhanced computed tomography (CT) images.

RESULTS

Both mean long-axis (4.2-4.7 vs. 3.6 ± 0.4 cm, p < 0.04) and short-axis (3.3-3.8 vs. 2.3 ± 0.5 cm, p < 0.03) diameters were expanded significantly when RF ablation was done until 4 weeks after chemoembolization than with RF ablation alone. Tumor enhancement disappeared in all patients. Frequency of achieving sufficient ablative margins was significantly higher when RF ablation was done until 4 weeks after chemoembolization than with RF ablation alone (74.0-83.3 vs. 22.2 %, p < 0.05).

CONCLUSION

Ablative zones created by RF ablation with chemoembolization become larger than RF ablation alone, leading to secure ablative margins.

Comparison of microwave ablation and multipolar radiofrequency ablation in vivo using two internally cooled probes

OBJECTIVE

The objective of our study was to compare the effectiveness of microwave ablation (MWA) and multipolar radiofrequency ablation (RFA) in vivo using two internally cooled probes.

MATERIALS AND METHODS

MWA (n=24) was performed by simultaneous application of double internally cooled-shaft antennae. Three power settings (60, 70, and 80 W) were used. Multipolar RFA (n=16) was also performed by simultaneously using two internally cooled bipolar applicators (lengths: 3-cm T30 and 4-cm T40) at 60 and 80 W. Probe spacing was 2 cm. Each power setting was applied for eight ablations with a 10-minute duration for each. The cooled-shaft probes were inserted approximately 7 cm into the liver parenchyma of seven adult Wuzhishan pigs under ultrasound guidance, and ablations were performed in various segments of porcine liver. The long-axis diameter (Dl), short-axis diameter (Ds) and the ratio Ds/Dl for each ablation was measured. Temperature curves at 0, 2, and 3 cm from the middle of the two probes and the time to reach 60°C at 0 cm from the parallel central line between the two probes were recorded.

RESULTS

The long-axis diameter and short-axis diameter for all the power settings of MWA were significantly larger than that of both kinds of multipolar RFA (p<0.05). The rates of temperature rise to 60°C at 0 cm from the parallel central line between the two probes for all MWA power settings were significantly faster compared with RFA.

CONCLUSION

MWA, by the simultaneous application of double antennae, can generate a larger ablation zone, in vivo, compared with multipolar RFA.

Multipolar radiofrequency ablation using 4-6 applicators simultaneously: a study in the ex vivo bovine liver

In this study the volume and shape of coagulation zones after multipolar radiofrequency ablation (RFA) with simultaneous use of 4-6 applicators in the ex vivo bovine liver were investigated. The RF-applicators were positioned in 13 different configurations to simulate ablation of large solitary tumors and simultaneous ablation of multiple lesions with 120 kJ of applied energy/session. In total, 110 coagulation zones were induced. Standardized measurements of the volume and shape of the coagulation zones were carried out on magnetic resonance images and statistically analyzed. The coagulation zones induced with solitary applicators and with 2 applicators were imperceptibly small and incomplete, respectively. At 20mm applicator distance, the total ablated volume was significantly larger if all applicators were arranged in a single group compared to placement in 2 distant applicator groups, each consisting of 3 applicators (p=.001). The mean total coagulated volume ranged from immeasurably small (if 6 solitary applicators were applied simultaneously) to 74.7 cc (if 6 applicators at 30 mm distance between neighboring applicators were combined to a single group). Applicator distance, number and positioning array impacted time and shape. The coagulation zones surrounding groups with 4-6 applicators were regularly shaped, homogeneous and completely fused, and the axial diameters were almost constant. In conclusion, multipolar RFA with 4-6 applicators is feasible. The multipolar simultaneous mode should be applied for large and solitary lesions only, small and multiple tumors should be ablated consecutively in standard multipolar mode with up to 3 applicators.

Survival after radiofrequency ablation and salvage transplantation in patients with hepatocellular carcinoma and Child-Pugh A cirrhosis

BACKGROUND & AIMS

In patients with hepatocellular carcinoma (HCC) within the Milan criteria, liver transplantation (LT) may be the best therapeutic option. However, the shortage of grafts, leads to attempt liver resection (LR) or radiofrequency ablation (RFA) as a first-line treatment for patients with Child-Pugh A cirrhosis.

METHODS

We report results, obtained between 2000 and 2007 from a single center, involving 67 patients (mean age: 57 years) eligible for LT, who were treated with RFA, followed by LT if there was recurrence or liver failure.

RESULTS

Eighty three tumors were treated (mean size: 29±9 mm; 16 binodular forms). RFA achieved complete ablation in 96% of nodules. No mortality occurred. During a post-RFA median follow-up of 48 months, 38 patients experienced recurrence, corresponding to a 5-year recurrence rate of 58%. Of these, 14 patients did not receive a transplant because they fell outside the Milan criteria, 21 were transplanted, and 3 were treated by RFA after refusing LT. Binodularity (95% CI HR=2, 1.0-4.0; p=0.049) was the unique risk factor for recurrence. By the study's end-point, 24 patients had undergone LT (21 for HCC recurrence and three for liver failure). No HCC recurrence occurred after LT. Among the 43 non-transplant patients, 12 died due to HCC progression, and 27 were alive without detectable viable tumor. The probability rates for 5-year overall and tumor-free survival were 74% and 69%, respectively.

CONCLUSIONS

First line RFA followed by salvage LT allows survival figures that are at least as good as a first-line LT, while limiting the number of grafts.

Serum alpha-fetoprotein response can predict prognosis in hepatocellular carcinoma patients undergoing radiofrequency ablation therapy

AIMS

To evaluate the clinical inference of serum alpha-fetoprotein (AFP) response in hepatocellular carcinoma (HCC) patients undergoing percutaneous radiofrequency ablation (RFA).

MATERIALS AND METHODS

Three hundred and thirteen previously untreated HCC patients were enrolled in the study. The optimal AFP response was defined as >20% decrease from baseline after 1 month of RFA for those with a baseline AFP level of ≥100 ng/ml. The impact of AFP response on prognosis was analysed and prognostic factors were assessed.

RESULTS

After a median follow-up of 26.7 ± 19.1 months, 49 patients died and 264 patients were alive. The cumulative 5 year survival rates were 75.3 and 57.4% in patients with an initial AFP of <100 ng/ml and ≥100 ng/ml, respectively (p = 0.003). In the 58 patients with a baseline AFP of ≥100 ng/ml and initial completed tumour necrosis after RFA, the cumulative 5 year survival rates were 62.4 and 25.7% in optimal and non-optimal AFP responders, respectively (p = 0.001). By multivariate analysis, the prothrombin time international normalized ratio >1.1 (p = 0.009), non-optimal AFP response (p = 0.023), and creatinine >1.5 mg/dl (p = 0.021) were independent risk factors predictive of poor overall survival. Besides, the cumulative 5 year recurrence rates were 83.4 and 100% in optimal and non-optimal AFP responders, respectively (p < 0.001). Multivariate analysis demonstrated platelet count ≤10(5)/mm(3) (p = 0.048), tumour size >2 cm (p = 0.027), and non-optimal AFP response (p < 0.001) were independent risk factors associated with tumour recurrence after RFA.

CONCLUSIONS

Serum AFP response may be a useful marker for predicting prognosis in HCC patients undergoing RFA.

Stereotactic radiofrequency ablation of unresectable intrahepatic cholangiocarcinomas: a retrospective study

PURPOSE

To evaluate treatment effects, complications, and outcome of percutaneous stereotactic radiofrequency ablation (SRFA) of intrahepatic cholangiocarcinoma (ICC).

PATIENTS AND METHODS

Eleven consecutive patients (nine men and two women) with a total of 36 inoperable ICCs (18 initial lesions, 16 lesions newly detected during follow-up, and two local recurrences) underwent SRFA between December 2004 and June 2010. Two different radiofrequency ablation (RFA) devices with internally cooled electrodes were used. Tumor diameters ranged from 0.5 to 10 cm (median 3.0 cm). A total of 23 SRFA sessions were performed. The efficacy of SRFA was evaluated by contrast-enhanced computed tomography or magnetic resonance imaging 1 month after treatment and then every 3 months.

RESULTS

Primary technical effectiveness rate was 92%. Further follow-up every 3 months revealed three local recurrences (8%), two of which were successfully retreated, resulting in a secondary technical effectiveness rate of 98%. After a total of 23 RFA sessions, three major complications occurred (13%) that could be managed interventionally. Mean follow-up time was 35 months (range 12-81 months). One- and 3-year overall survival rates were 91 and 71%, respectively. The median overall survival was 60 months (according to the life table method). Eight (73%) of 11 patients were still alive at the end of follow-up.

CONCLUSION

SRFA is effective in the treatment of unresectable ICC even if the tumor is large and located close to major vessels. SRFA shows a survival benefit compared to other palliative treatment options and may also be considered as the first-line local treatment of ICCs in selected patients.

[Percutaneous radiofrequency and other liver ablation techniques: 2011 update]

Percutaneous ablation of liver tumors was initially limited to patients that were not surgical candidates and with a limited number of relatively small liver lesions. Because of the diversification of techniques and technologies, percutaneous liver ablation has progressively been integrating to more and more complex therapeutic strategies available to a wider group of patients. Local knowledge and expertise with these techniques, largely dominated by radiofrequency ablation, often dictate the role of these techniques in the management of patients with liver tumors. We will review the clinical indications of percutaneous ablation techniques for liver tumors based on clinical considerations as well as ablation techniques.

Stereotactic radiofrequency ablation (SRFA) of liver lesions: technique effectiveness, safety, and interoperator performance

PURPOSE

To evaluate technique effectiveness, safety, and interoperator performance of stereotactic radiofrequency ablation (SRFA) of liver lesions.

METHODS

Retrospective review including 90 consecutive patients from January 2008 to January 2010 with 106 computed tomography-guided SRFA sessions using both single and multiple electrodes for the treatment of 177 lesions: 72 hepatocellular carcinoma (HCC) and 105 metastases with a mean size of 2.9 cm (range 0.5-11 cm). Technique effectiveness and 1-year local recurrence were evaluated by computed tomographic scans. Complications, mortality, and hospital days were recorded. The performance between an experienced and inexperienced interventional radiologist was compared.

RESULTS

The overall technique effectiveness after a single SRFA was 95.5% (93.1% for HCC and 97.1% for metastases). Four of the eight unsuccessfully treated lesions could be retreated (secondary technique effectiveness of 97.7%). Local recurrence at 1 year was 2.9%. Technique effectiveness was significantly different for lesions<5 cm (96.7%) and >5 cm (87.5%) (P=0.044) but not for lesions<3 cm (95.9%) and 3-5 cm (100%). Compared to clear parenchymal property (97.3%), vessel vicinity (93.3%) (P=0.349) and subcapsular (95.2%) (P=0.532) had no, but hollow viscera vicinity (83.3%) had a significantly lower technique effectiveness (P=0.020). Mortality rate was 0.9%. Major complications and hospital days were higher for cirrhosis Child-Pugh B (20%, 7.2 days) than Child-Pugh A (3.1%, 4.7 days) patients and for metastases (5.1%, 4.3 days). There was no significant difference in interoperator performance.

CONCLUSION

SRFA allowed for efficient, reliable, and safe ablation of large-volume liver disease.

Conformal radiofrequency ablation of hepatocellular carcinoma with a multi-pin bipolar system

BACKGROUND

To retrospectively evaluate the effectiveness and safety of radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) with a multi-pin bipolar system.

METHODS

Between August 2005 and December 2006, 18 patients with 30 HCCs (3.40 ± 1.24 cm, range 1.30-6.0 cm; median number of treated lesions is two per patient, range, 1-3) underwent percutaneous RFA with a multi-pin bipolar system under ultrasound guidance. The primary end-point were treatment efficacy, major and minor complications, and the secondary end-point were overall survival and tumor-free survival.

RESULTS

Complete ablation with conformed shape to the index tumor was achieved in 16 of 18 patients, and 28 of the 30 tumors were completely ablated. On follow-up, local and distant intrahepatic tumor progression rates were 12.5% (2 of 16 patients) and 62.5% (10 of 16 patients). There was no patient who developed extrahepatic metastasis. There were no major complications. The 1-, 2-year overall survival rates for all patients were 83.3%, 55.6%, respectively, and the corresponding tumor-free survivals were 50.0%, 22.2%, respectively.

CONCLUSION

RFA with a multi-pin bipolar system was effective and safe for HCC. A large ablation volume could be achieved which conformed to the shape of the index tumor.

Percutaneous ablation of hepatocellular carcinoma: current status

Hepatocellular carcinoma (HCC) is an increasingly common disease with dismal long-term survival. Percutaneous ablation has gained popularity as a minimally invasive, potentially curative therapy for HCC in nonoperative candidates. The seminal technique of percutaneous ethanol injection has been largely supplanted by newer modalities, including radiofrequency ablation, microwave ablation, cryoablation, and high-intensity focused ultrasound ablation. A review of these modalities, including technical success, survival rates, and complications, will be presented, as well as considerations for treatment planning and follow-up.

Current status of radiofrequency ablation of hepatocellular carcinoma

Loco-regional treatments for hepatocellular carcinoma (HCC) are important alternatives to curative transplantation or resection. Among them, radiofrequency ablation (RFA) is accepted as the most popular technique showing excellent local tumor control and acceptable morbidity. The current role of RFA is well documented in the evidence-based practice guidelines of European Association of Study of Liver, American Association of Study of the Liver Disease and Japanese academic societies. Several randomized controlled trials have confirmed that RFA is superior to percutaneous ethanol injections in terms of local tumor control and survival. The overall survival after RFA is comparable to after surgical resection in a selected group of patients with smaller (< 3 cm) tumors. Currently, the clinical benefits of combined RFA with transarterial chemoembolization for intermediate stage HCC are increasingly being explored. Here we review the ongoing technical advancements of RFA and future potential.

A comparison of microwave ablation and bipolar radiofrequency ablation both with an internally cooled probe: results in ex vivo and in vivo porcine livers

PURPOSE

The purpose of this study was to compare the effectiveness of microwave (MW) ablation and radiofrequency (RF) ablation using a single internally cooled probe in a hepatic porcine model.

MATERIALS AND METHODS

In the ex vivo experiment, MW ablations (n=40) were performed with a 2450MHz and 915MHz needle antenna, respectively at 60W, 70W power settings. Bipolar RF ablations (n=20) were performed with a 3-cm (T30) and 4-cm (T40) active tip needle electrodes, respectively at a rated power 30W and 40W according to automatically systematic power setting. In the in vivo experiment, the 2450 MHz and 915 MHz MW ablation both at 60W and T30 bipolar RF ablation at 30 W were performed (n=30). All of the application time were 10 min. Long-axis diameter (Dl), short-axis diameter (Ds), ratio of Ds/Dl, the temperature data 5mm from the needle and the time of temperature 5mm from the needle rising to 54°C were measured.

RESULTS

Both in ex vivo and in vivo models, Ds and Dl of 915 MHz MW ablations were significantly larger than all the RF ablations (P<0.05); the Ds for all the 2450MHz MW ablations were significantly larger than that of T30 RF ablations (P<0.05). 2450MHz MW and T30 RF ablation tended to produce more elliptical-shaped ablation zone. Tissue temperatures 5mm from the needle were considerably higher with MW ablation, meanwhile MW ablation achieved significantly faster rate of temperature rising to 54°C than RF ablation. For in vivo study after 10 min of ablation, the Ds and Dl of 2450 MHz MW, 915 MHz MW and Bipolar RF were 2.35±0.75, 2.95±0.32, 1.61±0.33 and 3.86±0.81, 5.79±1.03, 3.21±0.51, respectively. Highest tissue temperatures 5mm from the needle were 80.07±12.82°C, 89.07±3.52°C and 65.56±15.31°C and the time of temperature rising to 54°C were respectively 37.50±7.62s, 24.50±4.09s and 57.29±23.24s for three applicators.

CONCLUSION

MW ablation may have higher potential for complete destruction of liver tumors than RF ablation.

Radiofrequency ablation of hepatocellular carcinoma: long-term results and prognostic factors in 235 Western patients with cirrhosis

For the treatment of small hepatocellular carcinoma (HCC), radiofrequency ablation (RFA) is in some centers considered a first-line therapeutic option. However, such a strategy is still under debate with regard to tumor and patient characteristics. In this single-center study we assessed the 5-year survival and prognosis factors in 235 consecutive patients with cirrhosis (Child-Pugh A/B: 205/30) who received RFA as first-line treatment for up to three HCC <or=5 cm (307 tumors; mean diameter: 29 +/- 10 mm; 53 multinodular forms). Among these patients, 67 satisfied the criteria for resection according to the Barcelona Clinic Liver Cancer. Complete ablation was obtained in 222 patients (94%). Overall, 337 RFA sessions were performed including iterative RFA for recurrence. Major complications occurred in three patients (0.9%), including one treatment-related death. After 27 +/- 20 months of mean follow-up, local or distant, or both, tumor recurrence occurred in 16, 88, and 11 patients, respectively. Twenty-nine patients underwent transplantation and were removed from the study at this point. Overall 5-year, recurrence-free, and tumor-free (including results of iterative RFA) survival rates were, respectively, 40%, 17%, and 32%. The overall 5-year survival rate was 76% for operable patients. Factors associated with overall survival were prothrombin activity (hazard ratio [HR] = 0.97, 0.96-0.98; P < 0.0001) and serum levels of alpha-fetoprotein (AFP) (HR = 1.02, 1.02-1.02; P < 0.0001), and factors associated with tumor recurrence were multinodular forms (HR = 2.34; 1.52-3.6; P = 0.0001) and serum AFP levels (HR = 1.015, 1.014-1.016; P = 0.015). Tumor size was associated with local recurrence but not with overall and tumor-free survival.

CONCLUSION

RFA is a safe and effective first-line treatment of HCC up to 5 cm in diameter, especially for patients with a single tumor, a low serum AFP level, and well-preserved liver function.

Hepatocellular carcinoma with cirrhosis: are patients with neoplastic main portal vein invasion eligible for percutaneous radiofrequency ablation of both the nodule and the portal venous tumor thrombus?

OBJECTIVE

The purpose of this study was to examine the results of percutaneous radiofrequency ablation of both medium-sized hepatocellular carcinoma (HCC) and the accompanying main portal venous tumor thrombus in patients with cirrhosis.

SUBJECTS AND METHODS

From January 2005 to January 2008, among 1,837 consecutively registered patients with HCC seen at our institution, 412 had HCC and portal venous invasion; 27 of the 412 had a single HCC nodule accompanied by main portal venous tumor thrombus. Thirteen patients (10 men, three women; mean age, 70 years; range, 66-74 years) with 13 HCC nodules 3.7-5 cm in diameter extending into the main portal trunk underwent percutaneous radiofrequency ablation. Fourteen matched patients (10 men, four women; mean age, 69 years; range, 67-73 years) with 14 HCC nodules 3.6-4.8 cm in diameter extending into the main portal trunk refused radiofrequency ablation and composed the control group. Diagnosis of main portal venous tumor thrombus was made with fine-needle biopsy in all cases. Radiofrequency ablation was performed first on the main portal venous tumor thrombus and then on the HCC nodule. Efficacy of radiofrequency was defined as complete necrosis of HCC and complete recanalization of the main portal trunk and its branches. HCC necrosis was evaluated with enhanced CT. Recanalization of portal vessels was analyzed with color Doppler and contrast-enhanced ultrasound. Radiofrequency ablation was performed under ultrasound guidance with a perfused needle electrode.

RESULTS

Complete necrosis of the HCC associated with complete recanalization of the main portal vein and its branches was achieved in 10 patients (efficacy, 77%). In the other three patients, necrosis of the HCC ranged from 70% to 90%, and recanalization of the main portal trunk was not complete. No major complications occurred. In three cases, mild to moderate ascites and increased aspartate aminotransferase and alanine aminotransferase levels were found. The follow-up periods ranged from 3 to 36 months among the treated patients and 2 to 10 months among the untreated patients. The cumulative survival rate was 77% 6, 12, and 36 months after procedure in the treated group and 43% and 0% 6 and 12 months after diagnosis in the untreated group (p < 0.0001). All 10 successfully treated patients were alive and the portal system was patent at the end of the follow-up period. All three untreated patients died of progressive disease within 5 months of diagnosis.

CONCLUSION

Radiofrequency ablation can destroy both single intraparenchymal medium-sized HCCs and the accompanying main portal venous tumor thrombus with high efficacy and safety and a low rate of complications.

Pilot study for a new bipolar radiofrequency ablation/aspirator device in the management of primary and secondary liver cancers

BACKGROUND

In the US, the thermal ablation workload for cancer involving the liver is predicted to more than double in the next 5 years, emphasising the need to develop and improve the current technology.

STUDY DESIGN

A multicentre nonrandomised prospective clinical trial (NCT00514930) was undertaken, to assess the efficacy and safety of a new bipolar radiofrequency ablation/aspirator device, in the treatment of primary and secondary cancers of the liver.

RESULTS

A total of 34 lesions in 16 patients were ablated at laparotomy and followed up at 4 weeks. The mean diameter of lesion before ablation was 3.2+/-2.22 (range 1-10) cm, the mean volume aspirated during ablation was 9.25+/-7.3 (range 0-25) ml and the mean operative time was 145.95+/-40.7 (range 60-215) min. There was one major complication of a pleural effusion, which required drainage. The mean length of stay was 8+/-3.2 (range 3-14) days. In 11 patients, the ablated tumour was resected. On histological assessment, there was no evidence of viable cancer at the tumour edge. On follow-up computed tomography, the ablation zone fully encompassed the targeted tumour and there were no local complications related to ablation.

CONCLUSION

Initial analysis of the data from this small cohort, with only a short-term follow-up, shows this device to be safe and effective.

Radiofrequency ablation of hepatocellular carcinoma extended into the portal vein: Preliminary results

INTRODUCTION

We report our preliminary results of radiofrequency (RF) ablation of hepatocellular carcinoma (HCC) and neoplastic portal thrombus (NPT) in cirrhotic patients.

METHODS

Ten patients (7 males and 3 females; mean age 68 yrs) with 10 HCC nodules (37-49 mm) extended into the main portal vein (MPV) underwent RF ablation. Diagnosis of NPT was achieved by fine-needle biopsy. RF ablation was performed firstly on the NPT and then on the HCC. RF ablation was considered successful when complete necrosis of the HCC and complete recanalization of the MPV were achieved. HCC necrosis was evaluated using contrast-enhanced CT. Recanalization of the portal vessels (PV) was analyzed using Color Doppler (CD). RF ablation was performed under ultrasonographic (US) guidance using a perfused electrode needle.

RESULTS

Complete necrosis of the HCC with complete recanalization of the PV was observed in 7 patients (success rate: 70%). In the remaining 3, necrosis of the HCC ranged from 70% to 95%, and recanalization of the PV was not complete. No major complications occurred. In 2 cases, mild ascites and increased aspartate aminotransferase/alanine aminotransferase (AST/ALT) values were observed. The follow-up ranged from 4 to 24 months; 1 and 2-year survival rates were 77% and 77%, respectively. At the last follow-up, the 7 successful patients were alive and the portal system was still patent. The 3 unsuccessful patients died within 5 months due to progressive disease.

CONCLUSION

RF ablation can destroy HCC and NPT achieving a high rate of efficacy and low rate of complications. However, to confirm these results a control group and a longer follow-up are required.