Randomized clinical trial of hepatic resection versus radiofrequency ablation for early-stage hepatocellular carcinoma

Radiotherapy for Hepatocellular Carcinoma

For patients with unresectable or medically inoperable hepatocellular carcinoma, there are many local and regional therapies available, including stereotactic body radiotherapy, radiofrequency ablation, and transcatheter embolic approaches. This article will describe these treatment options and review the current comparative literature, suggesting that stereotactic body radiotherapy provides similar or better tumor control and a favorable side effect profile.

1000 consecutive ablation sessions in the era of computer assisted image guidance - Lessons learned

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Computer assisted targeting techniques are simple to use and improve results in ablative tumour treatments.

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The indications for ablative soft tissue tumour ablation are increasing.

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Treatments are superior to resective surgery in terms of complications and hospitalization, oncological non-inferiority remains to be proven.

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An incomplete ablation can be retreated without negative effects on survival.

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Jet ventilation is an effective technique to minimize organ displacement during percutaneous or laparoscopic ablation.

Background

Ablation therapies for tumours are becoming more used as ablation modalities evolve and targeting solutions are getting better. There is an increasing body of long-term results challenging resection and proving lower morbidities and costs. The aim of this paper is to share the experiences from a high-volume centre in introducing computer assisted targeting solutions and efficient ablation modalities like microwave generators and irreversible electroporation.

Material and methods

One thousand consecutive treatments in one high-volume centre were evaluated retrospectively from prospectively collected data.

Results

The purpose of this paper is to present the benefits of going into computer assisted targeting techniques and microwave technology; pitfalls and overview of outcomes. The main target organ was the liver and the main indications were ablation of hepatocellular carcinomas and colorectal liver metastases. With the assistance of computer assisted targeting the local recurrence rate within 6 months has dropped from 30 to near 10%. The survival of patients with hepatocellular carcinoma and colorectal liver metastases is not worse if the tumour can be retreated after a local recurrence. Multiple colorectal liver metastases can be treated successfully.

Discussion

The incorporation of computer assisted targeting technologies for ultrasound-, ct guided- and laparoscopic tumour ablation has been very successful and without a noticeable learning curve. The same is true for switching from radiofrequency energies to microwave generators and irreversible electroporation.

Conclusion

It is well worthwhile upgrading ablation and targeting technologies to achieve excellent and reproducible results and minimizing operator dependency.

Design of a Novel Electrode of Radiofrequency Ablation for Large Tumors: In Vitro Validation and Evaluation

In the present study, a monopolar expandable electrode (MEE) in radiofrequency ablation (RFA) proposed in our previous study was validated and evaluated using the in vitro experiment and computer simulation. Two commercial RF electrodes (conventional electrode, CE and umbrella electrode, UE) was used to compare the ablation results with MEE using the in vitro egg white model (experiment and computer simulation) and in vivo liver tumor model (computer simulation) to verify the efficacy of MEE in the large tumor ablation. The sharp increase in impedance during RFA procedures was taken as the termination of RFA protocols. The volume and sphericity of ablation zone generated by MEE, CE, and UE in the in vitro egg white experiment were 75.3 1.6 cm3, 2.7 0.4 cm3, 12.4 1.8 cm3 (P <0.001), and 88.1 0.9%, 12.9 1.3%, 62.0 3.0% (P <0.001), respectively. Correspondingly, a similar result was obtained in the egg white simulation. In the liver tumor simulation, the volume and sphpericity of ablation zone generated by MEE, CE, and UE were 35.4 cm3 and 86.8%, 3.7 cm3 and 17.7%, and 12.7 cm3 and 59.6%, respectively. In summary, MEE has the potential to achieve complete ablation in the treatment of large tumors (>3 cm in diameter) compared with CE and UE due to the larger electrode-tissue interface and more round shape of hooks.

A network meta-analysis on the efficacy and prognosis of different interventional therapies for early-stage hepatocellular carcinoma

PURPOSE

It is unclear which kind of interventional therapies is the best when treating early-stage hepatocellular carcinoma (HCC). We conducted Bayesian network meta-analyses to compare local tumor progression (LTP), total tumor recurrence and survival rates and to rank the best intervention arm.

MATERIALS AND METHODS

A literature search of Pubmed, Embase, Cochrane library and Clinicaltrials.gov was conducted and randomized controlled trials (RCTs) comparing the outcomes of interventional therapies on early-stage HCC were enrolled. The quality assessment was conducted using Cochrane Collaboration's tool, while the outcome synthesis of the network meta-analysis was conducted using R-3.3.4 software.

RESULTS

A total of 35 RCTs were enrolled for further analysis. Using network meta-analysis, it was demonstrated that radiofrequency ablation (RFA) plus adjuvant therapies achieved the best performance in decreasing the LTP rate in early-stage HCC, while hepatic resection ranked as the best arm among all the interventional techniques for LTP at 3 years. Meanwhile, hepatic resection and RFA plus adjuvant therapies were the top two best arms in decreasing total recurrence. Furthermore, RFA plus adjuvant therapeutics ranked the best in achieving overall survival outcome, followed by hepatic resection. For disease-free survival, hepatic resection was the best, while for LTP-free survival, the difference among the included treatments was not significant.

CONCLUSIONS

Our network meta-analysis showed that RFA-based adjuvant therapies might be the most effective interventions in achieving the best outcomes, while hepatic resection exhibited the best performance in several situations in treating early-stage HCC. More RCTs are needed to draw more solid conclusions.

Tumor Location Influences Oncologic Outcomes of Hepatocellular Carcinoma Patients Undergoing Radiofrequency Ablation

Radiofrequency ablation (RFA) is recommended as a first-line therapy for small hepatocellular carcinoma (HCC). Tumor location is a potential factor influencing the procedure of RFA. To compare oncologic outcomes of RFA for different tumor locations, this retrospective study enrolled 194 patients with small HCC who had undertaken RFA. The HCC nodules were classified as peri-hepatic-vein (pHV) or non-pHV, peri-portal-vein (pPV) or non-pPV, and subcapsular or non-subcapsular HCC. The regional recurrence-free survival (rRFS), overall survival (OS), recurrence-free survival (recurrence in any location, RFS) and distant recurrence-free survival (dRFS) were compared. Operation failures were recorded in five pPV HCC patients, which was more frequent than in non-pPV HCC patients (p = 0.041). The 1-, 3-, and 5-year rRFS was 68.7%, 53.7%, and 53.7% for pHV patients and 85.1%, 76.1%, and 71.9% for non-pHV patients, respectively (p = 0.012). After propensity score matching, the 1-, 3-, and 5-year rRFS was still worse than that of non-pHV patients (p = 0.013). The OS, RFS, and dRFS were not significantly different between groups.

CONCLUSIONS

A pHV location was a risk factor for the regional recurrence after RFA in small HCC patients. The tumor location may not influence OS, RFS, and dRFS. Additionally, a pPV location was a potential high-risk factor for incomplete ablation.

Long-term survival comparison between primary transplant and upfront curative treatment with salvage transplant for early stage hepatocellular carcinoma

BACKGROUND

Whether primary liver transplantation (PLT) or upfront curative treatment with salvage liver transplantation (SLT) is a better treatment option for early hepatocellular carcinoma (HCC) is controversial. This study aims to compare the long-term survival starting from the time of primary treatment between the two approaches for early HCC using propensity score matching (PSM) analysis.

METHODS

From 1995 to 2014, 175 patients with early HCC undergoing either PLT (n = 149) or SLT (n = 26) were retrospectively reviewed in a prospectively collected database. Patients' demographic data, tumor characteristics, short-term and long-term outcome were compared between two groups after PSM.

RESULTS

After matching, the baseline characteristics were comparable between mPLT group (n = 45) and mSLT group (n = 25). The tumor recurrence rate after transplant was significantly higher in mSLT group than mPLT group (28% vs. 15.6%). Calculating from the time of primary treatment, the 1, 3, and 5-year overall survival rates were comparable between mPLT group (97.8%, 91.1% and 86.3%) and mSLT group (100%, 95% and 85%). However, the 1, 3, and 5-year recurrence-free survival rates were significantly better in mPLT group than mSLT group (95.6% vs. 90%, 86.6% vs. 80% and 84.3% vs. 70%). SLT approach and high pre-treatment serum alpha-fetoprotein level (>200 ηg/mL) were poor prognostic factors for recurrence-free survival after transplant.

CONCLUSIONS

PLT may be a better treatment option for early HCC, whereas SLT approach for HCC should be cautiously considered under the circumstance of organ shortage.

Evolution of nodule stiffness might predict response to local ablative therapy: A series of patients with hepatocellular carcinoma

BACKGROUND

Early information on treatment response of HCC to local ablative therapy is crucial. Elastography as a non-invasive method has recently been shown to play a potential role in distinguishing between benign and malignant liver lesions. Elastography of hepatocellular carcinoma (HCC) in early response to local ablative therapy has not been studied to date.

METHODS

We prospectively included a cohort of 14 patients with diagnosis of HCC who were treated with local ablative therapy (transarterial chemoembolization, TACE and/or radiofrequency ablation, RFA). We used 2D shear-wave elastography (RT 2D-SWE) to examine stiffness of HCC lesion before and 3, 30 and 90 days after local ablative therapy. Contrast-enhanced imaging after 90 days was performed to evaluate treatment response. Primary endpoint was stiffness of HCC in response to local ablative therapy. Secondary end point was tumor recurrence.

RESULTS

Stiffness of HCC nodules and liver showed no significant difference prior to local ablative therapy. As early as three days after treatment, stiffness of responding HCC was significantly higher compared to non-responding. Higher stiffness before treatment was significantly associated with tumor recurrence.

CONCLUSION

Nodule stiffness in general and RT 2D-SWE in particular could provide a useful tool for early prediction of HCC response to local ablative therapy.

Feasibility of Percutaneous Intrahepatic Split by Microwave Ablation (PISA) After Portal Vein Embolization for Hypertrophy of Future Liver Remnant: The Radiological Stage-1 ALPPS

PURPOSE

To assess the feasibility of radiological stage-1 ALPPS, associating liver partition and portal vein ligation for staged hepatectomy, by combining portal vein embolization (PVE) with percutaneous intrahepatic split by ablation (PISA).

MATERIALS AND METHODS

Three patients (mean age 65.0 ± 7.3 years) underwent PVE and PISA. PISA was performed 21 days after PVE by microwave ablation to create a continuous intrahepatic cutting plane. Abdominal CT examinations were performed before and after PVE and PISA. The future liver remnant (FLR) volume was calculated by semiautomatic segmentation, and increase was reported as a percentage of the pre-procedural volume. The FLR/body weight (FLR/BW) ratio was calculated; a ratio greater than 0.8% was considered sufficient for guaranteeing adequate liver function after surgery. The liver function before and after PISA was also evaluated by 99mTc-mebrofenin hepatobiliary scintigraphy. Patients' laboratory tests, performance status, ability to walk were assessed before and after PVE and PISA procedures.

RESULTS

No procedure-related complications were recorded. The FLR volume increase in each patient was 42.0, 33.1 and 30.4% within 21 days of PVE and 109.3, 68.1 and 71.7% within 10 days after PISA. The FLR/BW ratios were 0.76, 0.66, 0.63% and 1.13, 0.83, 0.83% after PVE and PISA procedures, respectively. Two patients underwent successful right hepatectomy; in one patient, despite 1.13% FLR/BW, surgery was not performed because of the absolute rejection of blood transfusion due to the patient's religious convictions.

CONCLUSION

Radiological stage-1 ALPPS is a feasible, minimally invasive option to be further investigated to become an effective alternative to surgical stage-1 ALPPS.