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Meyers BM, Knox J, Cosby R, Beecroft JR, Chan KKW, Coburn N, Feld J, Jonker D, Mahmud A, Ringash J. Nonsurgical management of advanced hepatocellular carcinoma: a clinical practice guideline. ACTA ACUST UNITED AC 2020; 27:e106-e114. [PMID: 32489260 DOI: 10.3747/co.27.5891] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Background Practice guidelines based on a systematic review of the literature regarding the nonsurgical management of hepatocellular carcinoma (hcc) in North America are lacking. Resection and transplantation are the foundations for cure of hcc; however, most patients are diagnosed at an advanced stage, precluding those curative treatments. A number of local or regional therapies are used and are followed by systemic therapy for advanced or progressive disease. Other treatments are available, but their efficacy, compared with those standards, is not well known. Methods First, systematic review questions were developed. Literature searches of the medline, embase, and Cochrane library databases (January 2000 to July 2018 or January 2005 to July 2018 depending on the question) were conducted; in addition, abstracts from the 2018 annual meeting of the American Society of Clinical Oncology were reviewed. A practice guideline was drafted that was then scrutinized by internal and external reviewers. Results Seventy-seven studies were included in the guideline: no guidelines, two systematic reviews, and seventy-five primary studies published in full (including one pooled analysis). Five recommendations were developed. Conclusions There is no evidence for or against the use of local or regional interventions other than transarterial chemoembolization for the treatment of intermediate- or advanced-stage hcc. Furthermore, there is no evidence to support the addition of sorafenib to any local or regional therapy. Sorafenib or lenvatinib are recommended for first-line systemic treatment of intermediate-stage hcc. Regorafenib or cabozantinib provide survival benefits when given as second-line treatment. Antiviral treatment is recommended in individuals with advanced hcc who are positive for the hepatitis B surface antigen.
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Affiliation(s)
- B M Meyers
- Juravinski Cancer Centre, Department of Oncology, McMaster University, Hamilton, ON
| | - J Knox
- Princess Margaret Cancer Centre, Toronto, ON
| | - R Cosby
- Program in Evidence-Based Care, Department of Oncology, McMaster University, Hamilton, ON
| | - J R Beecroft
- Department of Medical Imaging, Mount Sinai Hospital, and University Health Network, Toronto, ON
| | - K K W Chan
- Sunnybrook Odette Cancer Centre, Toronto, ON
| | - N Coburn
- Sunnybrook Odette Cancer Centre, Toronto, ON
| | - J Feld
- Toronto General Hospital Research Institute, Toronto, ON
| | - D Jonker
- The Ottawa Hospital Cancer Centre, Ottawa, ON
| | - A Mahmud
- Cancer Centre of Southeastern Ontario, Kingston, ON
| | - J Ringash
- Princess Margaret Cancer Centre, Toronto, ON.,Department of Radiation Oncology, University of Toronto, Toronto, ON
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Clinical feasibility and efficacy of stereotactic body radiotherapy for hepatocellular carcinoma: A systematic review and meta-analysis of observational studies. Radiother Oncol 2018; 131:135-144. [PMID: 30773180 DOI: 10.1016/j.radonc.2018.12.005] [Citation(s) in RCA: 97] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2018] [Revised: 11/05/2018] [Accepted: 12/04/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND AND PURPOSE Stereotactic body radiotherapy (SBRT) is an emerging ablative modality for hepatocellular carcinoma (HCC). This study aimed to synthesize available evidence to evaluate the clinical feasibility and efficacy of SBRT for HCC. MATERIALS AND METHODS A systematic search was performed of the PubMed, Medline, Embase, and Cochrane Library databases. Primary endpoints were overall survival (OS) and local control (LC), and the secondary endpoint was grade ≥3 complications. RESULTS Thirty-two studies involving 1950 HCC patients who underwent SBRT were included. Pooled 1-, 2-, and 3-year OS rates were 72.6% (95% confidence interval [CI]: 65.7-78.6), 57.8% (50.9-64.4), and 48.3% (40.3-56.5), respectively. Pooled 1-, 2-, and 3-year LC rates were 85.7% (95% CI: 80.1-90.0), 83.6% (77.4-88.3), and 83.9% (77.6-88.6), respectively. The median value of median tumor sizes among studies was 3.3 cm (range: 1.6-8.6). Median radiation doses, calculated in dose equivalent with 2 Gy per fraction, ranged from 48 to 114.8 Gy10 (median 83.3 Gy10). Subgroup comparison regarding tumor size showed significant differences for 1- and 2-year OS rates and 1-, 2-, and 3-year LC rates, and that regarding radiation dose showed no difference for OS and a marginal difference for 1-year LC rate. Pooled rates of hepatic and gastrointestinal grade ≥3 complications were 4.7% (95% CI: 3.4-6.5) and 3.9% (2.6-5.6), respectively. Child-Pugh class was significantly correlated with hepatic complication of grade ≥3 in meta-regression analysis (p = 0.013). CONCLUSION SBRT for HCC was a feasible option conferring excellent LC persisting up to 3 years. Both OS and LC were affected by tumor size, and radiation dose marginally affected LC. Severe complications rarely occurred, but liver function should be considered to avoid serious hepatic toxicity.
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Wang Y, Deng T, Zeng L, Chen W. Efficacy and safety of radiofrequency ablation and transcatheter arterial chemoembolization for treatment of hepatocellular carcinoma: A meta-analysis. Hepatol Res 2016; 46:58-71. [PMID: 26265000 DOI: 10.1111/hepr.12568] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Revised: 07/27/2015] [Accepted: 07/29/2015] [Indexed: 12/11/2022]
Abstract
AIM To investigate the efficacy and safety of radiofrequency ablation (RFA) and transcatheter arterial chemoembolization (TACE) for treatment of patients with hepatocellular carcinoma (HCC). METHODS All eligible studies were collected from PubMed, the Cochrane Libraries and Embase. The evaluation indices included overall survival (OS) rate, recurrence-free survival rate, local tumor progression rate and major complications. All statistical analysis was performed by RevMan version 5.2 software. RESULTS There were 21 studies with 3073 patients included in this meta-analysis. The RFA monotherapy was associated with higher 3- and 5-year OS rates (OR3-year = 2.33, 95% confidence interval [CI] = 1.34-4.05; OR5-year = 2.05, 95% CI = 1.48-2.85) compared with TACE alone. The combination of RFA and TACE was associated with higher 1-, 3- and 5-year OS rates (OR1-year = 1.94, 95% CI = 1.28-2.96; OR3-year = 1.56, 95% CI = 1.19-2.04; OR5-year = 1.53, 95% CI = 1.13-2.07) compared with RFA alone. CONCLUSION The combination of TACE with RFA could obviously improve the short- and long-term survival rates and significantly provide a better prognosis for patients with intermediate-size HCC. RFA was associated with a higher long-term OS rate than that of TACE-treated patients with HCC.
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Affiliation(s)
- Yulan Wang
- Department of Gastroenterology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Tianxing Deng
- Department of Urology, Second Affiliated Hospital, Third Military Medical University, Chongqing, China
| | - Li Zeng
- Department of Gastroenterology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Weiqing Chen
- Department of Gastroenterology, Second Affiliated Hospital of Chongqing Medical University, Chongqing, China
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Chok KSH. Management of recurrent hepatocellular carcinoma after liver transplant. World J Hepatol 2015; 7:1142-1148. [PMID: 26052403 PMCID: PMC4450191 DOI: 10.4254/wjh.v7.i8.1142] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/05/2014] [Revised: 01/27/2015] [Accepted: 02/12/2015] [Indexed: 02/06/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is the leading cause of deaths in patients with hepatitis B or C, and its incidence has increased considerably over the past decade and is still on the rise. Liver transplantation (LT) provides the best chance of cure for patients with HCC and liver cirrhosis. With the implementation of the MELD exception system for patients with HCC waitlisted for LT, the number of recipients of LT is increasing, so is the number of patients who have recurrence of HCC after LT. Treatments for intrahepatic recurrence after transplantation and after other kinds of surgery are more or less the same, but long-term cure of posttransplant recurrence is rarely seen as it is a “systemic” disease. Nonetheless, surgical resection has been shown to be effective in prolonging patient survival despite the technical difficulty in resecting graft livers. Besides surgical resection, different kinds of treatment are also in use, including transarterial chemoembolization, radiofrequency ablation, high-intensity focused ultrasound ablation, and stereotactic body radiation therapy. Targeted therapy and modulation of immunosuppressants are also adopted to treat the deadly disease.
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Dai WC, Cheung TT, Chok KSH, Chan ACY, Sharr WW, Tsang SHY, Yuen WK, Chan SC, Fan ST, Lo CM, Poon RTP. Radiofrequency ablation versus transarterial chemoembolization for unresectable solitary hepatocellular carcinomas sized 5-8 cm. HPB (Oxford) 2015; 17:226-31. [PMID: 25284590 PMCID: PMC4333783 DOI: 10.1111/hpb.12324] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/15/2014] [Accepted: 07/02/2014] [Indexed: 12/12/2022]
Abstract
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.
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Affiliation(s)
- Wing Chiu Dai
- Department of Surgery, Queen Mary Hospital, University of Hong KongHong Kong, China,Correspondence, Wing Chiu Dai, L4, 102 Pok Fu Lam Road, Hong Kong, China. Tel: + 852 2255 3025. Fax: + 852 2816 5284. E-mail:
| | - Tan To Cheung
- Department of Surgery, Queen Mary Hospital, University of Hong KongHong Kong, China
| | - Kenneth S H Chok
- Department of Surgery, Queen Mary Hospital, University of Hong KongHong Kong, China
| | - Albert C Y Chan
- Department of Surgery, Queen Mary Hospital, University of Hong KongHong Kong, China
| | - William W Sharr
- Department of Surgery, Queen Mary Hospital, University of Hong KongHong Kong, China
| | - Simon H Y Tsang
- Department of Surgery, Queen Mary Hospital, University of Hong KongHong Kong, China
| | - Wai Key Yuen
- Department of Surgery, Queen Mary Hospital, University of Hong KongHong Kong, China
| | - See Ching Chan
- Department of Surgery, Queen Mary Hospital, University of Hong KongHong Kong, China
| | - Sheung Tat Fan
- Department of Surgery, Queen Mary Hospital, University of Hong KongHong Kong, China
| | - Chung Mau Lo
- Department of Surgery, Queen Mary Hospital, University of Hong KongHong Kong, China
| | - Ronnie T P Poon
- Department of Surgery, Queen Mary Hospital, University of Hong KongHong Kong, China
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Gashin L, Tapper E, Babalola A, Lai KC, Miksad R, Malik R, Cohen E. Determinants and outcomes of adherence to recommendations from a multidisciplinary tumour conference for hepatocellular carcinoma. HPB (Oxford) 2014; 16:1009-15. [PMID: 24888730 PMCID: PMC4487752 DOI: 10.1111/hpb.12280] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/18/2014] [Accepted: 04/23/2014] [Indexed: 12/12/2022]
Abstract
BACKGROUND The multidisciplinary tumour conference (MTC) represents the standard of care in the management of hepatocellular carcinoma (HCC). Clinical outcomes in relation to adherence and non-adherence to MTC recommendations have not been studied. METHODS A total of 137 patients with HCC and cirrhosis whose cases were submitted to a first MTC discussion between 1 January 2009 and 31 December 2010 were identified. Clinical data, management recommendations, adherence, treatment regimens and overall survival were reviewed. RESULTS There were 419 MTC discussions on 137 patients with cirrhosis and HCC. The MTC recommendations made in 145 discussions on 90 separate patients were not followed. Patient-related reasons for deviation from MTC recommendations included failure to attend for follow-up (n = 24, 16.6%), clinical deterioration (n = 19, 13.1%) and patient preference (n = 13, 9.0%). Physician-related reasons for discordance included treating physician preference (n = 43, 29.7%) and finding that the patient was not a candidate for the recommended intervention (n = 37, 25.5%). After the first MTC discussion, 62.0% of patients received the recommended treatment; these patients were more likely to be alive at 1 year compared with those who did not receive the recommended treatment (P = 0.007). More of the patients who followed recommendations underwent liver transplantation (25.6% versus 14.4%; P = 0.10). CONCLUSIONS There are patient-related as well as physician-related reasons for non-adherence to recommendations. Non-adherence affects clinical outcomes and can be avoided in selected cases.
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Affiliation(s)
- Laurie Gashin
- Department of Internal Medicine, Beth Israel Deaconess Medical CenterBoston, MA, USA,Correspondence, Laurie Gashin, 330 Brookline Avenue, Boston, MA 02215, USA. Tel: + 1 617 754 9600. Fax: + 1 617 632 8261. E-mail:
| | - Elliot Tapper
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical CenterBoston, MA, USA
| | - Atinuke Babalola
- Division of Haematology and Oncology, Beth Israel Deaconess Medical CenterBoston, MA, USA
| | - Kuan-Chi Lai
- Division of Haematology and Oncology, Beth Israel Deaconess Medical CenterBoston, MA, USA
| | - Rebecca Miksad
- Division of Haematology and Oncology, Beth Israel Deaconess Medical CenterBoston, MA, USA
| | - Raza Malik
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical CenterBoston, MA, USA
| | - Eric Cohen
- Division of Gastroenterology and Hepatology, Beth Israel Deaconess Medical CenterBoston, MA, USA
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Chok KSH, Cheung TT, Lo RCL, Chu FSK, Tsang SHY, Chan ACY, Sharr WW, Fung JYY, Dai WC, Chan SC, Fan ST, Lo CM. Pilot study of high-intensity focused ultrasound ablation as a bridging therapy for hepatocellular carcinoma patients wait-listed for liver transplantation. Liver Transpl 2014; 20:912-21. [PMID: 24753206 DOI: 10.1002/lt.23892] [Citation(s) in RCA: 32] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/10/2013] [Accepted: 04/09/2014] [Indexed: 12/18/2022]
Abstract
The objective of this study was to investigate the outcomes of high-intensity focused ultrasound (HIFU) ablation as a bridging therapy for patients with hepatocellular carcinoma (HCC) who had been wait-listed for deceased donor liver transplantation (DDLT). Adult patients with unresectable and unablatable HCCs within the University of California San Francisco criteria who had been wait-listed for DDLT were screened for their suitability for HIFU ablation as a bridging therapy if they were not suitable for transarterial chemoembolization (TACE). Treatment outcomes for patients receiving HIFU ablation, TACE, and best medical treatment (BMT) were compared. Fifty-one patients were included in the analysis. Before the introduction of HIFU ablation, only 39.2% of the patients had received bridging therapy (TACE only, n = 20). With HIFU ablation in use, the rate increased dramatically to 80.4% (TACE + HIFU, n = 41). The overall dropout rate was 51% (n = 26). Patients in the BMT group had a significantly higher dropout rate (P = 0.03) and significantly poorer liver function as reflected by higher Model for End-Stage Liver Disease scores and higher Child-Pugh grading. Clinically relevant ascites was found in 5 patients in the HIFU group and 2 patients in the BMT group, but none was found in the TACE group (P = 0.01 and P = 0.03, respectively). The TACE and HIFU groups had comparable percentages of tumor necrosis in excised livers (P = 0.35), and both were significantly higher than that in the BMT group (P = 0.01 and P = 0.02, respectively). In conclusion, HIFU ablation was safe even for HCC patients with Child-Pugh C disease. Its adoption increased the percentage of patients receiving bridging therapy from 39.2% to 80.4%. A randomized controlled trial for further validation of its efficacy is warranted.
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Affiliation(s)
- Kenneth S H Chok
- Department of Surgery, University of Hong Kong, Hong Kong SAR, China
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Abstract
Radiofrequency ablation (RFA) is an alternative therapy for hepatocellular carcinoma and liver metastases when resection cannot be performed or, in the case of hepatocellular carcinoma, when transplant cannot be performed in a timely enough manner to avoid the risk of dropping off the transplant list. RFA has the advantage of being a relatively low-risk minimally invasive procedure used in the treatment of focal liver tumors. This review article discusses the current evidence supporting RFA of liver tumors, as well as the indications, complications, and follow-up algorithms used after RFA.
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Affiliation(s)
- Shaunagh McDermott
- Division of Abdominal Imaging and Interventional Radiology, Department of Radiology
| | - Debra A Gervais
- Division of Abdominal Imaging and Interventional Radiology, Department of Radiology ; Division of Pediatric Imaging, Department of Radiology, Massachusetts General Hospital, Boston, Massachusetts
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Nationwide study of 4741 patients with non-B non-C hepatocellular carcinoma with special reference to the therapeutic impact. Ann Surg 2014; 259:336-45. [PMID: 23673768 DOI: 10.1097/sla.0b013e31829291e9] [Citation(s) in RCA: 50] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To examine the prognostic factors and outcomes after several types of treatments in patients with hepatocellular carcinoma (HCC) negative for hepatitis B surface antigen and hepatitis C antibody, so-called "non-B non-C HCC" using the data of a nationwide survey. BACKGROUND The proportion of non-B non-C HCC is rapidly increasing in Japan. METHODS A total of 4741 patients with non-B non-C HCC, who underwent hepatic resection (HR, n = 2872), radiofrequency ablation (RFA, n = 432), and transcatheter arterial chemoembolization (TACE, n = 1437) as the initial treatment, were enrolled in this study. The exclusion criteria included extrahepatic metastases and/or Child-Pugh C. Significant prognostic variables determined by a univariate analysis were subjected to a multivariate analysis using a Cox proportional hazard regression model. RESULTS The degree of liver damage in the HR group was significantly lower than that in the RFA and TACE groups. The HR and TACE groups had significantly more advanced HCC than the RFA group. The 5-year survival rates after HR, RFA, and TACE were 66%, 49%, and 32%, respectively. Stratifying the survival rates, according to the TNM stage and the Japan Integrated Staging (JIS) score, showed the HR group to have a significantly better prognosis than the RFA group in the stage II and in the JIS scores "1" and "2." The multivariate analysis showed 12 independent prognostic factors. HR offers significant prognostic advantages over TACE and RFA. CONCLUSIONS The findings of this large prospective cohort study indicated that HR may be recommended, especially in patients with TNM stage II and JIS scores "1" and "2" of non-B non-C HCC.
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Kanso F, Nahon P, Blaison D, Trinchet JC, Beaugrand M, Seror O, Martinod E. Diaphragmatic necrosis after radiofrequency ablation of hepatocellular carcinoma: a successful surgical repair. Clin Res Hepatol Gastroenterol 2013; 37:e59-63. [PMID: 23137756 DOI: 10.1016/j.clinre.2012.09.011] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/11/2012] [Revised: 09/10/2012] [Accepted: 09/25/2012] [Indexed: 02/04/2023]
Abstract
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.
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Affiliation(s)
- Frederic Kanso
- Université Paris 13, UPRES Sorbonne Paris Cité, 93206 Saint-Denis, France
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Dhanasekaran R, Khanna V, Kooby DA, Kauh JS, Carew JD, Kim HS. Chemoembolization Combined with RFA for HCC:Survival Benefits and Tumor Treatment Response. ACTA ACUST UNITED AC 2013. [DOI: 10.4236/jct.2013.42060] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Guy J, Kelley RK, Roberts J, Kerlan R, Yao F, Terrault N. Multidisciplinary management of hepatocellular carcinoma. Clin Gastroenterol Hepatol 2012; 10:354-62. [PMID: 22083023 DOI: 10.1016/j.cgh.2011.11.008] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2011] [Revised: 10/31/2011] [Accepted: 11/02/2011] [Indexed: 12/14/2022]
Abstract
Hepatocellular carcinoma is a leading cause of death in patients with cirrhosis. Management algorithms continually are increasing in sophistication and involve application of single and multimodality treatments, including liver transplantation, hepatic resection, ablation, transarterial chemoembolization, radioembolization, and systemic chemotherapy. These treatments have been shown to increase survival times. As many as 75% of patients with limited-stage disease who are given curative therapies survive 5 years, whereas less than 20% of untreated patients survive 1 year. Treatment can be optimized based on the patient's tumor stage, hepatic reserve, and functional status. However, because of the heterogeneity in presentation among patients, a multidisciplinary approach is required to treat hepatocellular carcinoma, involving hepatologists, surgeons, interventional radiologists, and oncologists. We present each specialist's viewpoint on controversies and advances in the management of hepatocellular carcinoma.
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Affiliation(s)
- Jennifer Guy
- Department of Medicine, University of California San Francisco, San Francisco, California, USA.
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Berry K, Ioannou GN. Are patients with Child's A cirrhosis and hepatocellular carcinoma appropriate candidates for liver transplantation? Am J Transplant 2012; 12:706-17. [PMID: 22123435 DOI: 10.1111/j.1600-6143.2011.03853.x] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
Abstract
We aimed to estimate the survival benefit derived from transplantation in patients with stage II hepatocellular carcinoma (HCC) and Child's A cirrhosis, defined as the mean lifetime with transplantation minus the mean lifetime with treatments other than transplantation. We calculated the posttransplantation survival of all adult, first-time, deceased-donor, liver transplant recipients in the United States since the introduction of the Model for End-Stage Liver Disease based priority system in February 2002 (n = 36,791). We estimated the posttreatment survival of patients with Child's A cirrhosis and stage II HCC treated by radiofrequency ablation (RFA) ± transarterial chemoembolization (TACE) or surgical resection by conducting a systematic review of the medical literature. In patients with Child's A cirrhosis and stage II HCC, the estimated median survival benefit of liver transplantation compared to RFA ± TACE was 1.5 months at 3 years (range -3.5 to 5.6) and 5.7 months at 5 years (range 0.7-11.4), whereas compared to surgical resection it was 0.7 months at 3 years (range -2.9 to 3) and 2.8 months at 5 years (range -4.4 to 5.7). Liver transplantation in patients with stage II HCC and Child's A cirrhosis results in a very low survival benefit and may not constitute optimal use of scarce liver donor organs.
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Affiliation(s)
- K Berry
- Department of Biostatistics, University of Washington, Seattle, WA, USA
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Ray CE, Haskal ZJ, Geschwind JFH, Funaki BS. The use of transarterial chemoembolization in the treatment of unresectable hepatocellular carcinoma: a response to the Cochrane Collaboration review of 2011. J Vasc Interv Radiol 2011; 22:1693-6. [PMID: 22035882 PMCID: PMC4332810 DOI: 10.1016/j.jvir.2011.09.014] [Citation(s) in RCA: 30] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2011] [Accepted: 09/06/2011] [Indexed: 02/07/2023] Open
Abstract
This commentary is written in response to a recent Cochrane Collaboration review published in March 2011 (1). The authors of this commentary would like to express their concerns over the conclusions of the Cochrane review, which state, "There is no firm evidence to support or refute transarterial chemoembolization (TACE) or transarterial embolization (TAE) for patients with unresectable hepatocellular carcinoma (HCC)."
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MESH Headings
- Antineoplastic Agents/administration & dosage
- Carcinoma, Hepatocellular/drug therapy
- Carcinoma, Hepatocellular/mortality
- Chemoembolization, Therapeutic/adverse effects
- Chemoembolization, Therapeutic/methods
- Chemoembolization, Therapeutic/mortality
- Embolization, Therapeutic/adverse effects
- Embolization, Therapeutic/methods
- Embolization, Therapeutic/mortality
- Evidence-Based Medicine
- Humans
- Infusions, Intra-Arterial/adverse effects
- Infusions, Intra-Arterial/methods
- Liver Neoplasms/drug therapy
- Liver Neoplasms/mortality
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Affiliation(s)
- Charles E Ray
- University of Colorado, Department of Radiology, Aurora, CO 80045, USA.
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Tiong L, Maddern GJ. Systematic review and meta-analysis of survival and disease recurrence after radiofrequency ablation for hepatocellular carcinoma. Br J Surg 2011; 98:1210-24. [PMID: 21766289 DOI: 10.1002/bjs.7669] [Citation(s) in RCA: 200] [Impact Index Per Article: 15.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/27/2011] [Indexed: 12/14/2022]
Abstract
BACKGROUND Despite being one of the commonest causes of cancer-related death around the world, only 20 per cent of hepatocellular carcinomas (HCCs) are amenable to curative treatment (surgical resection or liver transplantation). Radiofrequency ablation (RFA) has emerged as a popular therapy for unresectable HCC. There is evidence that the disparity in survival after curative RFA and surgery for HCC, especially tumours smaller than 3 cm in diameter, is narrowing. This review examined the survival and disease recurrence rates after RFA for HCC over the past decade. METHODS A systematic review was conducted using MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Register and the Database of Abstracts of Reviews of Effects from January 2000 until November 2010. Papers reporting on patients with HCC who were treated with RFA, either in comparison or in combination with other interventions, such as surgery or percutaneous ethanol injection (PEI), were eligible for inclusion. Outcome data collected were overall survival, disease-free survival and disease recurrence rates. Only randomized controlled trials (RCTs), quasi-RCTs and non-randomized comparative studies with more than 12 months' follow-up were included. RESULTS Forty-three articles, including 12 RCTs, were included in the review. The majority of the articles reported the use of RFA for unresectable HCC, often in combination with other treatments such as PEI, transarterial chemoembolization and/or surgery. Overall and disease-free survival rates continue to improve, despite an increase in the size and numbers of tumours treated. More recently some clinicians have used RFA to treat selected patients with resectable HCC, with good outcomes. CONCLUSION RFA provides a valuable treatment option for patients with unresectable HCC. It improves survival in those previously considered to have advanced disease. As progress continues to be made, RFA is gradually being used to treat resectable HCC.
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Affiliation(s)
- L Tiong
- University of Adelaide Department of Surgery, Queen Elizabeth Hospital, Woodville, Adelaide, South Australia 5011, Australia
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Andolino DL, Johnson CS, Maluccio M, Kwo P, Tector AJ, Zook J, Johnstone PAS, Cardenes HR. Stereotactic body radiotherapy for primary hepatocellular carcinoma. Int J Radiat Oncol Biol Phys 2011; 81:e447-53. [PMID: 21645977 DOI: 10.1016/j.ijrobp.2011.04.011] [Citation(s) in RCA: 257] [Impact Index Per Article: 19.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2011] [Revised: 03/29/2011] [Accepted: 04/04/2011] [Indexed: 12/13/2022]
Abstract
PURPOSE To evaluate the safety and efficacy of stereotactic body radiotherapy (SBRT) for the treatment of primary hepatocellular carcinoma (HCC). METHODS AND MATERIALS From 2005 to 2009, 60 patients with liver-confined HCC were treated with SBRT at the Indiana University Simon Cancer Center: 36 Child-Turcotte-Pugh (CTP) Class A and 24 CTP Class B. The median number of fractions, dose per fraction, and total dose, was 3, 14 Gy, and 44 Gy, respectively, for those with CTP Class A cirrhosis and 5, 8 Gy, and 40 Gy, respectively, for those with CTP Class B. Treatment was delivered via 6 to 12 beams and in nearly all cases was prescribed to the 80% isodose line. The records of all patients were reviewed, and treatment response was scored according to Response Evaluation Criteria in Solid Tumors v1.1. Toxicity was graded according to the Common Terminology Criteria for Adverse Events v4.0. Local control (LC), time to progression (TTP), progression-free survival (PFS), and overall survival (OS) were calculated according to the method of Kaplan and Meier. RESULTS The median follow-up time was 27 months, and the median tumor diameter was 3.2 cm. The 2-year LC, PFS, and OS were 90%, 48%, and 67%, respectively, with median TTP of 47.8 months. Subsequently, 23 patients underwent transplant, with a median time to transplant of 7 months. There were no ≥Grade 3 nonhematologic toxicities. Thirteen percent of patients experienced an increase in hematologic/hepatic dysfunction greater than 1 grade, and 20% experienced progression in CTP class within 3 months of treatment. CONCLUSIONS SBRT is a safe, effective, noninvasive option for patients with HCC ≤6 cm. As such, SBRT should be considered when bridging to transplant or as definitive therapy for those ineligible for transplant.
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Affiliation(s)
- David L Andolino
- Department of Radiation Oncology, Indiana University School of Medicine, Indianapolis, IN 46202, USA.
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Yeh CT, Chen HC, Sung CM, Hsu CL, Lin CC, Pan KT, Tseng JH, Hung CF. Retrospective comparison between a regular and a split-dose protocol of 5-fluorouracil, cisplatin, and mitoxantrone for the treatment of far advanced hepatocellular carcinoma. BMC Cancer 2011; 11:117. [PMID: 21453495 PMCID: PMC3079691 DOI: 10.1186/1471-2407-11-117] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/07/2009] [Accepted: 03/31/2011] [Indexed: 12/22/2022] Open
Abstract
BACKGROUND In patients with advanced hepatocellular carcinoma (HCC), combination chemotherapy using 5- fluorouracil, cisplatin, and mitoxantrone (FMP) could achieve a response rate > 20%, but the beneficial effect was compromised by formidable adverse events. Chemotherapy given in a split-dose manner was associated with reduced toxicities. In this retrospective study, we compared the efficacies and side effects between a regular and a split-dose FMP protocol approved in our medical center. METHODS From 2005 to 2008, the clinical data of 84 patients with far advanced HCC, who had either main portal vein thrombosis and/or extrahepatic metastasis, were reviewed. Of them, 65 were treated by either regular (n = 27) or split-dose (n = 38) FMP and had completed at least one therapeutic course. The remaining 19 patients were untreated. Clinical parameters, therapeutic responses, survivals and adverse events were compared. RESULTS The median overall survival was 6.0, 5.2, and 1.5 months, respectively, in patients receiving regular FMP, split-dose FMP, and no treatment (regular versus split-dose group, P = 0.447; regular or split-dose versus untreated group; P < 0.0001). Patients receiving split-dose treatment had a significantly lower risk of grade 3/4 neutropenia (51.9 versus 10.5%, P = 0.0005). When the two treated groups were combined, the median overall survival was 10.6 and 3.8 months respectively for patients achieving disease control and progressive disease (P < 0.001). Cox proportion hazard model identified Child-Pugh stage B (hazard ratio [HR], 2.216; P = 0.006), presence of extrahepatic metastasis (HR, 0.574; P = 0.048), and achievement of disease control (HR, 0.228; P < 0.001) as independent factors associated with overall survival. Logistic regression analysis revealed that anti-hepatitis C virus antibody (odds ratio [OR], 9.219; P = 0.002) tumor size (OR, 0.816; P = 0.036), and previous anti-cancer therapy (OR, 0.195; P = 0.017) were significantly associated with successful disease control. CONCLUSIONS Comparable overall survival was observed between patients receiving regular and split-dose FMP therapies. Patients receiving split-dose therapy had a significantly lower risk of grade 3/4 neutropenia. Positive anti-hepatitis C virus antibody, smaller tumor size, and absence of previous anti-cancer therapy were independent predictors for successful disease control.
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Affiliation(s)
- Chau-Ting Yeh
- Molecular Medicine Research Center, Chang Gung University, Taoyuan, Taiwan.
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Yang MJ, An SY, Moon EJ, Lee MS, Hwang JA, Cheong JY, Won JH, Kim JK, Wang HJ, Cho SW. [Comparison of radiofrequency ablation and transarterial chemoembolization for the treatment of a single hepatocellular carcinoma smaller than 4 cm]. THE KOREAN JOURNAL OF HEPATOLOGY 2010; 15:474-85. [PMID: 20037266 DOI: 10.3350/kjhep.2009.15.4.474] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
BACKGROUND/AIMS Radiofrequency ablation (RFA) is an established curative therapeutic modality for unresectable hepatocellular carcinoma (HCC), and transarterial chemoembolization (TACE) has been used as a palliative treatment for inoperable HCC. It is still unknown whether RFA and TACE are equally effective for improving the survival of patients with unresectable HCC that is amenable to either treatment. The aim of this retrospective study was to compare the clinical impacts of two treatments, and analyze the prognostic factors for recurrence and survival. METHODS Ninety-three patients with a single HCC smaller than 4 cm who showed complete responses (complete ablation or complete lipiodol tagging) after treatment with RFA (n=43) or TACE (n=50) between January 2002 and February 2009 were investigated. Univariate and multivariate analyses were performed for 13 potential prognostic factors using the Cox proportional-hazards model. RESULTS The time-to-recurrence rates at 1, 2, and 3 years after treatment were 32.9%, 44.3%, and 55.4%, respectively, for the RFA group, and 42%, 68.3%, 71.7% for the TACE group. The probability of survival at 1, 2, and 3 years was 97.7%, 77.4%, and 63.1%, respectively, for the RFA group, and 95.9%, 76.1%, and 60.2% for the TACE group. The time-to-recurrence and overall survival rates did not differ significantly between the two treatment groups. A multivariate Cox proportional-hazards model revealed that a tumor size larger than 3 cm and lower serum albumin levels were independent risk factors for recurrence, and that being male, being seropositive for hepatitis B surface antigen, and having a higher serum albumin level were independent favorable prognostic factors for survival. CONCLUSIONS TACE and RFA exhibited similar therapeutic effects in terms of recurrence and survival for patients with a single HCC smaller than 4 cm, if they could exhibited complete responses.
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Affiliation(s)
- Min Jae Yang
- Department of Gastroenterology, Ajou University School of Medicine, Suwon, Korea
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Kim JH, Kim JH, Choi JH, Kim CH, Jung YK, Yim HJ, Yeon JE, Park JJ, Kim JS, Bak YT, Byun KS. Value of the model for end-stage liver disease for predicting survival in hepatocellular carcinoma patients treated with transarterial chemoembolization. Scand J Gastroenterol 2009; 44:346-57. [PMID: 18991165 DOI: 10.1080/00365520802530838] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The aim of this study was to evaluate the prognostic value of the model for end-stage liver disease (MELD) and its modified forms, and to compare these scoring systems with other staging systems for hepatocellular carcinoma (HCC) patients treated with transarterial chemoembolization (TACE). MATERIAL AND METHODS A total of 325 patients who underwent TACE for the initial treatment of HCC between January 2000 and May 2007 were enrolled in the study. Before TACE was carried out, MELD, MELD-Na, Child-Pugh score, Okuda stage, CLIP score, JIS score, BCLC stage, and UICC stage were checked. After one month, delta MELD and delta MELD-Na were calculated. RESULTS Mean MELD/MELD-Na/delta MELD/delta MELD-Na scores were 7.5+/-3.7, 8.0+/-4.7, -0.2+/-3.5 and 0.04+/-4.5, respectively. MELD (p=0.009) and MELD-Na (p=0.017) significantly correlated with survival, but delta MELD and delta MELD-Na did not (p >0.05). The Child-Pugh score and other staging systems correlated significantly with survival (p <0.05). The AUROC values for 3, 12, and 36 months' survival were 0.633, 0.545, and 0.615 for MELD; 0.655, 0.555, and 0.612 for MELD-Na; 0.639, 0.616, and 0.691 for Child-Pugh score; 0.714, 0.662, and 0.717 for the Okuda score; 0.837, 0.86, and 0.792 for the CLIP score; 0.859, 0.814, and 0.808 for the JIS score; 0.846, 0.833, and 0.749 for BCLC stage; and 0.878, 0.812, and 0.735 for UICC stage, respectively. CONCLUSIONS MELD and MELD-Na showed good correlations with survival, especially for patients with early-stage disease. However, these were not superior to those of other staging systems or Child-Pugh score. These parameters should only be used as supportive data.
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Affiliation(s)
- Jeong Han Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Korea University College of Medicine, Seoul, Korea
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The current role of radiofrequency ablation in the management of hepatocellular carcinoma: a systematic review. Ann Surg 2009; 249:20-5. [PMID: 19106671 DOI: 10.1097/sla.0b013e31818eec29] [Citation(s) in RCA: 232] [Impact Index Per Article: 15.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE To review the current status of radiofrequency ablation (RFA) in the management of hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA The development of local ablative therapy has been 1 of the major advances in the treatment of HCC. Its role in the management of HCC is still rapidly evolving. METHODS Studies were identified by searching Medline, and PubMed databases for articles from January 1997 to April 2008 using the keywords "radiofrequency ablation," "hepatocellular carcinoma" and "ablation of HCC." Additional papers were identified by a manual search of the references from the key articles. Randomized controlled trials, nonrandomized comparative studies, cohort studies, were reviewed. Cohort studies with follow-up of less than 12 months and case reports were excluded. RESULTS Five aspects of RFA were analyzed: (1) RFA in comparison with other local ablative therapies; (2) RFA for unresectable HCC; (3) RFA as bridging therapy before liver transplantation; (4) RFA as primary treatment for resectable HCC; and (5) RFA for recurrent HCC after partial hepatectomy. Ten RCTs, 8 nonrandomized controlled trials and 26 cohort studies were included in this analysis. CONCLUSIONS The evidence in the medical literature showed RFA was more effective than other local ablative therapies, and supported its use in the treatment of unresectable small HCC, recurrent small HCC, and as bridging therapy before liver transplantation, and as a primary treatment in competition with partial hepatectomy for resectable small HCC.
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Pleguezuelo M, Germani G, Marelli L, Xiruochakis E, Misseri M, Manousou P, Arvaniti V, Burroughs AK. Evidence-based diagnosis and locoregional therapy for hepatocellular carcinoma. Expert Rev Gastroenterol Hepatol 2008; 2:761-84. [PMID: 19090737 DOI: 10.1586/17474124.2.6.761] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Early identification of hepatocellular carcinoma (HCC) is crucial to improving the results of therapy and for patients to be eligible for liver transplantation. Recent advances in noninvasive imaging technology include various techniques of harmonic ultrasound, new ultrasound contrast agents, multislice helical computed tomography and rapid high-quality magnetic resonance. The imaging diagnosis relies on the hallmark of arterial hypervascularity with portal venous washout. Since the use of better radiological techniques has improved the accuracy of noninvasive diagnosis, the role of liver biopsy in the diagnosis of HCC has declined. With recent advances in genomics and proteomics, a great number of potential markers have been identified and developed as new candidate markers for HCC. Locoregional therapies currently constitute the best options for early nonsurgical treatment of HCC. Percutaneous ethanol injection shows similar results to resection surgery for single tumors less than 3 cm in diameter. Radiofrequency ablation is superior to percutaneous ethanol injection in terms of local recurrence. Transarterial chemoembolization is currently the most common approach for the management of HCC without curative options since it improves patient survival, but the optimal embolizing agent, length of interval between sessions and whether the chemotherapeutic agent has any effect have not yet been determined. Combining transarterial chemoembolization with antiangiogenic agents, as well as with other techniques, such as radiofrequency ablation, may improve the results. Injection of radioisotopes such as yttrium-90, via the hepatic artery, may be particularly useful in patients with portal vein thrombosis. Comparisons with other transarterial techniques are needed.
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Affiliation(s)
- Maria Pleguezuelo
- The Royal Free Sheila Sherlock Liver Centre, Royal Free Hospital, Pond Street, London, NW3 2QG, UK.
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Kooby DA, Egnatashvili V, Graiser M, Delman KA, Kauh J, Wood WC, Staley III CA. Changing management and outcome of hepatocellular carcinoma: Evaluation of 501 patients treated at a single comprehensive center. J Surg Oncol 2008; 98:81-8. [DOI: 10.1002/jso.21049] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
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Kim YS, Rhim H, Lim HK, Choi D, Lee WJ, Jeon TY, Joh JW, Kim SJ. Intraoperative radiofrequency ablation for hepatocellular carcinoma: long-term results in a large series. Ann Surg Oncol 2008; 15:1862-70. [PMID: 18463926 DOI: 10.1245/s10434-008-9941-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2008] [Revised: 04/01/2008] [Accepted: 04/02/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND Intraoperative radiofrequency (RF) ablation with or without surgical resection currently plays one of important roles in modern hepatocellular carcinoma (HCC) therapy. We evaluated long-term follow-up results including prognostic factors of intraoperative RF ablation for HCC that was difficult to treat percutaneously. METHODS A total of 133 patients (male, 22 female, mean age 55.8 years) underwent intraoperative RF ablations for 200 HCCs (follow-up period 3.0-79.7 months, median 22.3 months). Hepatic resection was also performed in 29 patients. Reasons for the intraoperative procedure included no safe electrode path (n = 59), excessive tumor burden (n = 41), nonvisualization of the HCC on ultrasonography (n = 20), and risk of collateral thermal damage to adjacent organs (n = 13). We evaluated the technique effectiveness rate at 1 month computed tomography (CT), cumulative local tumor progression rate, cumulative disease-free and overall survival rates, and complications. We also sought significant prognostic factors for overall survival. RESULTS The technique effectiveness at 1 month was 94.7% (126/133). The cumulative local tumor progression rates at 1 and 3 years were 4.9% and 8.8%, respectively. The cumulative disease-free and overall survival rates at 1, 3 and 5 years were 51.8%, 21.3%, and 16.0% and 92.3%, 72.6%, and 46.5%, respectively. Major complications occurred in nine patients (6.8%). Procedure-related mortality was 1.5% (2/133). The patients treated for recurrent HCC (P = 0.003) or with high serum alpha-fetoprotein levels (P = 0.009) had poor survival by multivariate analysis. CONCLUSION The results of this study showed that intraoperative radiofrequency ablation with or without hepatic resection is a safe and effective treatment for hepatocellular carcinoma in patients who are not candidates for the percutaneous approach.
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Affiliation(s)
- Young-Sun Kim
- Department of Radiology and Center for Imaging Science, Samsung Medical Center, Sungkyunkwan University School of Medicine, 50 Ilwon-dong, Kangnam-gu, Seoul, 135-710, Korea
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Abstract
PURPOSE OF REVIEW This review primarily focuses on new developments in the field of hepatocellular carcinoma. RECENT FINDINGS Potential preventive strategies in the development of hepatocellular carcinoma are being recognized. Novel molecular markers identified may aid in the diagnosis of early hepatocellular carcinoma in patients with chronic hepatitis C virus. Prognostic information gained by preoperative tumor biopsy is being investigated. Treatment of early hepatocellular carcinoma with resection versus primary or salvage transplantation continues to be debated. Expansion of selection criteria beyond the Milan criteria appears feasible. The role of living donor liver transplantation in hepatocellular carcinoma will require further study to determine the risk of recurrence. Improvements in chemoembolization with drug eluting beads appear promising. SUMMARY Further insight into the pathogenesis of hepatocellular carcinoma will result in the continued evolution of our approach and management of the disease. Tailored therapies based on tumor biology are needed to improve treatment response and ultimately patient survival.
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Abstract
Hepatocellular carcinoma is the fifth most common cancer in the world and is the third cause of cancer-related death with varying prevalence according to endemic risk factors. Despite therapeutic advances, there has not been significant improvement in the overall survival of patients who have hepatocellular cancer in the last 2 decades. Treatment selection should be based on tumor characteristics and the underlying liver disease.
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Affiliation(s)
- Ana Carolina Del Pozo
- Recanati Miller Transplantation Institute, Mount Sinai Medical Center, One Gustave L Levy Place, Box 1106, New York, NY 10026, USA.
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