Ablation for recurrent hepatocellular carcinoma: a systematic review of clinical efficacy and prognostic factors. World J Surg. 2015;39:1150-1160. [PMID: 25634340 DOI: 10.1007/s00268-015-2956-1]

The Role of Stereotactic Body Radiation Therapy in the Outcomes of Intrahepatic Recurrent Small Hepatocellular Carcinoma

Background and aim

To retrospectively evaluate the role of stereotactic body radiation therapy (SBRT) played for the outcomes of intrahepatic recurrent small hepatocellular carcinoma (HCC).

Methods

We collected 51 intrahepatic recurrent ≤5 cm small HCC patients between January 2016 and December 2021. SBRT was given as 4-5 fractions with 32.5-50Gy. The baseline data of the patients and the radiotherapy strategy data were collected and survival analyses were performed among these factors. The outcomes comprised overall survival (OS), freedom from local progression (FFLP), and progression-free survival (PFS), with the 95% confidence interval (95%CI). The follow-up time was calculated from the date of the SBRT to the date of the last follow-up communication, hospitalization, or death. Survival analysis was conducted by the Kaplan-Meier methods and log-rank test.

Results

The median follow-up time was 48 months (range: 4.8-90). The 1-year, 3-year, and 5-year OS rates of the overall cohort were 95.9% (95%CI: 0.905-1.000), 84.9% (95%CI: 0.751-0.959) and 69.1% (95%CI: 0.553-0.862), respectively. The 1-year, 3-year, and 5-year FFLP rates of the overall cohort were 97.5% (95%CI: 0.928-1.000), 82.0% (95%CI: 0.697-0.965), and 72.8% (95%CI: 0.578-0.918), respectively. The 1-year, 3-year, and 5-year PFS rates of the overall cohort were 85.7% (95%CI: 0.758-0.970), 43.4% (95%CI: 0.296-0.635), and 27.3% (95%CI: 0.149-0.498), respectively. The 5-year FFLP rate of lesions less than 2 cm [72.5% (95%CI: 0.52-1)] and those 2-5 cm [71.9% (95%CI: 0.514-0.976)] were similar. We suggested that the lesions received 45Gy/50Gy with 5 fractions were associated with a higher 5-year FFLP rate [74.6% (95%CI: 0.57-0.976)] than 40Gy/5F [40.0% (95%CI: 0.137-1)].

Conclusion

We found SBRT was effective in patients with lesion size of 2-5 cm, with similar results in those with tumor size of 0-2 cm. We suggested that the lesions received over 85.5Gy of biological effective dose with α/β = 10Gy were associated with a higher FFLP.

Effects of Interphase and Interpulse Delays on Tissue Impedance and Pulsed Field Ablation

PURPOSE

High-frequency irreversible electroporation (H-FIRE) is a pulsed field ablation (PFA) technique that employs a series of high-voltage, microseconds-long positive and negative pulses, separated by interphase (d1) and interpulse (d2) delays to non-thermally ablate tissue. Previous experimental and computational data suggest an impact of delays on nerve excitation and electrochemical effects. However, the impact of delays on PFA outcomes, such as change in resistance and ablation generation, has only recently started to be elucidated.

METHODS

While recording the applied voltage and currents, we delivered a series of increasing voltages, termed voltage ramps, into tuber and cardiac tissues using both needle electrode pairs and flat plate electrodes. Tissues were stained for metabolic activity to measure irreversible electroporation areas following treatment.

RESULTS

Our findings support previous in vitro data that delays do not significantly affect ablation areas. While there were significant differences in applied current, resistance, and conductivity between different pulse widths at sub-electroporation electric fields, we found no significant differences after inducing electroporation between different delays and pulse widths. Consequently, since delays do not affect ablation areas or local conductivity, the data suggests that delays should not affect the electric field threshold or Joule heating within the tissue.

CONCLUSION

The findings presented here provide critical insights into electroporation-dependent tissue conductivity changes from H-FIRE with implications for improving H-FIRE parameterization and computational models for treatment planning in cancer and cardiac pulsed field ablation.

Negative serum alpha-fetoprotein at recurrence predicts good prognosis in recurrent hepatocellular carcinoma patients receiving repeated hepatectomy:a single-center retrospective cohort study

BACKGROUND

The serum alpha-fetoprotein (AFP) serves as a crucial prognostic indicator in patients diagnosed with hepatocellular carcinoma (HCC). Examining the impact of baseline-AFP (b-AFP), recurrence -AFP (r-AFP), and changes in AFP levels on the prognosis of individuals with recurrent hepatocellular carcinoma (RHCC) who undergo repeated hepatectomy holds substantial clinical significance.

METHOD

A total of 400 RHCC patients who had undergone repeated hepatectomy in the Center of Hepato-Pancreato-Biliary Surgery at the First Affiliated Hospital of Sun Yat-Sen University between January 1, 2006, and December 31, 2019 were included in this study. The analysis focused on evaluating the impact of b-AFP, r-AFP, and changes in AFP levels on the prognosis of RHCC patients.

RESULTS

The recurrence rate among HCC patients who underwent hepatectomy was approximately 40.03 %. Among the 400 HCC patients who underwent twice hepatectomy, the 5-year mortality rate was 34.25 %, with an overall mortality rate of 38.75 %. Survival analysis indicated statistically significant disparities in overall survival (OS) and recurrence-free survival (RFS) between the b-AFP (-) group and the b-AFP (+) group, with the latter exhibiting shorter OS and RFS. The 3-year mortality rates for the two groups were 31.7 % and 42.5 %, respectively. The median overall survival (mOS) for the two groups were 107.4 months and 89.5 months, respectively. A statistically significant discrepancy in recurrence-death survival (RDS) was observed between the r-AFP (-) and r-AFP (+) groups (P < 0.0001), with patients in the r-AFP (+) category experiencing a shorter RDS. The median RDS for these two groups were 88.1 months and 31.7 months, respectively. Significant differences in both overall survival (OS) and RDS were observed among the AFP (+/+), AFP (±), AFP (-/+), and AFP (-/-) groups. The order of OS and RDS from lowest to highest was as follows: AFP (+/+) group < AFP (-/+) group < AFP (-/-) group < AFP (±) group. Irrespective of the b-AFP status, patients with positive r-AFP exhibited notably shorter OS and RFS compared to their r-AFP negative counterparts. The 3-year mortality rates for the four groups were 50.9 %, 26.1 %, 39.3 %, and 29.7 %, respectively. Median OS values were 42.4 months, not reached (NA), 77.1 months, and 107.4 months, respectively. Furthermore, an analysis of the cumulative 1-year, 3-year, and 5-year OS, RDS, and RFS rates for each group was conducted.

CONCLUSION

The b-AFP, r-AFP and AFP fluctuations serve as valuable prognostic indicators in individuals who have undergone hepatectomy for HCC on two occasions. These indicators can offer valuable insights for guiding the diagnosis and treatment strategies for HCC recurrence in such patients.

Multicenter Study on Transarterial Chemoembolization Combined with Radiofrequency Ablation for Early-Stage Hepatocellular Carcinoma: Primary versus Recurrent HCC

Purpose

To evaluate the efficacy of transarterial chemoembolization (TACE) combined with radiofrequency ablation (RFA) for both primary and recurrent early-stage hepatocellular carcinoma (HCC) and to analyze the significant prognostic factors.

Patients and Methods

Data from patients with early-stage primary or recurrent HCC who underwent TACE plus RFA between August 2019 and May 2024 were collected from three major general hospitals. 158 patients were divided into a primary group and a recurrent group on the basis of their baseline characteristics. Compared the objective response rate (ORR), 1-, 3-, and 5-year progression-free survival (PFS) rates, 1-, 3-, and 5-year overall survival (OS) rates, and complication rate between the two groups. Multivariate analyses were used to evaluate the factors influencing PFS and OS.

Results

One hundred fifty-eight patients were enrolled. The ORRs of the primary and recurrent groups were 98.2% and 95.1%, respectively, with no statistically significant difference (χ2= 2.032, Ρ = 0.362). The primary group having a significantly longer PFS time than the recurrent group (Ρ < 0.001). However, there was no significant difference in the 1-, 3-, and 5-year OS rates between the two groups (Ρ = 0.218). Multivariate analysis revealed that primary or recurrent HCC and the Child‒Pugh score were significant prognostic factors for PFS, whereas the serum albumin level was a significant prognostic factor for OS.

Conclusion

TACE plus RFA has similar clinical efficacy and safety for both primary and recurrent early HCC. Compared with patients with primary HCC, those with recurrent disease had significantly shorter PFS times.

Precise liver tumor ablation: the clinical potential of US-US overlay fusion guidance

Image-guided thermal ablation is a minimally invasive option for patients with early-stage hepatocellular carcinoma (HCC). However, the risk of local recurrence remains substantial because ultrasound (US) artifacts have a negative impact on the assessment of ablative margins during and immediately after ablation. Precise, real-time assessment of the ablation zone is key to reducing the risk of local tumor progression. With the advent of US image fusion technology, ablative margins can now be assessed three-dimensionally with greater accuracy. Therefore, US-US overlay fusion guidance has the potential to improve the local controllability of ablation in patients with HCC. This review discusses the US-US fusion guidance technique and its current clinical applications for hepatic interventions, with descriptions of its concept, methodology, and efficacy.

Prospects of Synergy: Local Interventions and CAR T Cell Therapy in Solid Tumors

Chimeric antigen receptor T cell therapy has been established in the treatment of various B cell malignancies. However, translating this therapeutic effect to treat solid tumors has been challenging because of their inter-tumoral as well as intratumoral heterogeneity and immunosuppressive microenvironment. Local interventions, such as surgery, radiotherapy, local ablation, and locoregional drug delivery, can enhance chimeric antigen receptor T cell therapy in solid tumors by improving tumor infiltration and reducing systemic toxicities. Additionally, ablation and radiotherapy have proven to (re-)activate systemic immune responses via abscopal effects and reprogram the tumor microenvironment on a physical, cellular, and chemical level. This review highlights the potential synergy of the combined approaches to overcome barriers of chimeric antigen receptor T cell therapy and summarizes recent studies that may pave the way for new treatment regimens.

The current role of radiofrequency ablation in the treatment of intrahepatic recurrent hepatocellular carcinoma

The incidence of recurrent hepatocellular carcinoma (HCC) after initial curative treatments is relatively high. However, there is still the lack of standard management of recurrent HCC. Among several treatment modalities for primary HCC, radiofrequency ablation (RFA) seems to be more widely used for intrahepatic recurrent lesions. Therefore, we provide a comprehensive review of the current and novel application of RFA for recurrent HCC in all stages after curative treatment of primary HCC.

Treatment of recurrent hepatocellular carcinoma following liver resection, ablation or liver transplantation

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and causes one third of cancer related deaths world-wide. Approximately one third of patients with HCC are eligible for curative treatments that include hepatic resection, liver transplantation or imaging guided tumor ablation. Recurrence rates after primary therapy depends on tumor biology and pre-treatment tumor burden with early recurrence rates ranging from 30%-80% following surgical resection and ablation. HCC recurs in over ten percent following liver transplantation for HCC. Treatment modalities for tumor recurrence following resection and ablation include repeat liver resection, salvage liver transplantation, locoregional therapies, and systemic chemotherapy/immunotherapy. Locoregional and immune mediated therapies are limited for patients with tumor recurrence following liver transplantation given potential immune related allograft rejection. Given the high HCC recurrence rates after primary tumor treatment, it is imperative for the clinician to review the appropriate treatment strategy for this disease entity. This article will review the current literature regarding HCC recurrence after primary curative therapies and will discuss the relevant future trends in the HCC field.

Combining local regional therapy and systemic therapy: Expected changes in the treatment landscape of recurrent hepatocellular carcinoma

Improvements in early screening, new diagnostic techniques, and surgical treatment have led to continuous downward trends in hepatocellular carcinoma (HCC) morbidity and mortality rates. However, high recurrence and refractory cancer after hepatectomy remain important factors affecting the long-term prognosis of HCC. The clinical characteristics and prognosis of recurrent HCC are heterogeneous, and guidelines on treatment strategies for recurrent HCC are lacking. Therapies such as surgical resection, radiofrequency ablation, and transhepatic arterial chemoembolization are effective for tumors confined to the liver, and targeted therapy is a very important treatment for unresectable recurrent HCC with systemic metastasis. With the deepening of the understanding of the immune microenvironment of HCC, blocking immune checkpoints to enhance the antitumor immune response has become a new direction for the treatment of HCC. In addition, improvements in the tumor immune microenvironment caused by local treatment may provide an opportunity to improve the therapeutic effect of HCC treatment. Ongoing and future clinical trial data of combined therapy may develop the new treatment scheme for recurrent HCC. This paper reviews the pattern of recurrent HCC and the characteristics of the immune microenvironment, demonstrates the basis for combining local treatment and systemic treatment, and reports current evidence to better understand current progress and future approaches in the treatment of recurrent HCC.

Surgical resection versus radiofrequency ablation for early recurrent hepatocellular carcinoma

BACKGROUND

Surgical resection (SR) and radiofrequency ablation (RFA) are reasonable treatment options for early recurrent hepatocellular carcinoma (rHCC), but it is still uncertain which treatment is better. The purpose of this study was to compare the therapeutic effects of SR and RFA on patients with early rHCC.

METHODS

This study enrolled 168 patients with early rHCC who underwent SR or RFA. The progression-free survival (PFS), overall survival (OS), and complications between the treatment groups for the total and propensity score-matched (PSM) cohorts were compared.

RESULTS

Before PSM, the 1-, 3-, 5-year OS (94.8%, 63.0%, 36.1% vs. 93.8%, 58.5%, 35.4%, P  = 0.580) and PFS (50.7%, 22.7%, 12.0% vs. 68.8%, 30.3%, 15.9%, P  = 0.224) were similar in RFA group and the SR group. After PSM, the 1-, 3-, 5-year OS (95.5%, 71.1%, 53.3% vs. 95.5%, 58.0%, 42.1%, P  = 0.285) and PFS (50%, 36.4%, 27.3% vs. 68.2%, 25.6%, 12.8%, P  = 0.999) were similar in the RFA group and the SR group. For patients with early recurrent tumors ≤3 cm, RFA and SR could achieve similar curative effects. However, SR was superior to RFA in terms PFS for patients with early recurrent tumors >3 cm, but the OS was similar. For all patients, RFA had significantly fewer complications and shorter hospitalization time compared with SR.

CONCLUSION

SR achieves better tumor control compared with RFA for patients with early rHCC (>3 cm) after SR. RFA had significantly fewer complications and shorter hospitalization time compared with SR for all patients.

The Dynamic Changes of AFP From Baseline to Recurrence as an Excellent Prognostic Factor of Hepatocellular Carcinoma After Locoregional Therapy: A 5-Year Prospective Cohort Study

Background

Although many studies have confirmed the prognostic value of preoperative alpha-fetoprotein (AFP) in patients with hepatocellular carcinoma (HCC), the association between AFP at baseline (b-AFP), subsequent AFP at relapse (r-AFP), and AFP alteration and overall survival in HCC patients receiving locoregional therapy has rarely been systematically elucidated.

Patients and Methods

A total of 583 subjects with newly diagnosis of virus-related HCC who were admitted to Beijing You ‘an Hospital, Capital Medical University from January 1, 2012 to December 31, 2016 were prospectively enrolled. The influence of b-AFP, subsequent r-AFP, and AFP alteration on relapse and post-recurrence survival were analyzed.

Results

By the end of follow-up, a total of 431 (73.9%) patients relapsed and 200 (34.3%) died. Patients with positive b-AFP had a 24% increased risk of recurrence compared with those who were negative. Patients with positive r-AFP had a 68% increased risk of death after relapse compared with those who were negative. The cumulative recurrence-death survival (RDS) rates for 1, 3, 5 years in patients with negative r-AFP were 85.6% (184/215), 70.2%(151/215), and 67.4%(145/215), while the corresponding rates were 75.1% (154/205), 51.2% (105/205), and 48.8% (100/205) in those with positive AFP (P<0.001). 35 (21.6%) of the 162 patients with negative b-AFP turned positive at the time of recurrence, and of this subset, only 12 (34.3%) survived. Of the 255 patients with positive b-AFP, 86 (33.7%) turned negative at the time of relapse, and of this subset, only 30 (34.9%) died. The 1-, 3-, and 5-year cumulative RDS rates were also compared among groups stratified by AFP at baseline and relapse. The present study found that patients with positive AFP at baseline and relapse, as well as those who were negative turned positive, had the shortest RDS and OS.

Conclusions

Not only AFP at baseline but also subsequent AFP at relapse can be used to predict a post-recurrence survival, which can help evaluate mortality risk stratification of patients after relapse.

The 10-year Survival Analysis of Radiofrequency Ablation for Solitary Hepatocellular Carcinoma 5 cm or Smaller: Primary versus Recurrent HCC

Background Although favorable outcomes have been reported with radiofrequency ablation (RFA) for limited hepatocellular carcinoma (HCC), the efficacy of this treatment for recurrent HCC has not been thoroughly investigated. Purpose To compare the long-term outcomes and analyze the prognostic factors for outcomes after RFA for initial HCC versus as a second-line treatment for recurrent HCC. Materials and Methods This retrospective study included 560 patients with solitary tumors 5 cm or smaller (263 initial HCCs, 297 -recurrent HCCs) who underwent percutaneous US-guided RFA from January 2005 to December 2016. Of 297 patients with -recurrent HCC, 134 had previously undergone hepatectomy, 128 had undergone transarterial chemoembolization (TACE), and 35 had undergone local ablation therapy. Overall survival (OS) between initial HCC and recurrent HCC was compared before and after propensity score matching. Prognostic factors for all patients were analyzed with the log-rank test and Cox proportional hazards model. Results A total of 560 patients (mean age, 60 years ± 12 [standard deviation]; 441 men) were evaluated. Before matching, the OS rates at 1, 3, 5, and 10 years were 92.6%, 73.9%, 59.3%, and 39.6%, respectively, in patients with recurrent HCC and 92.8%, 75.4%, 63.3%, and 44.7% in patients with initial HCC (P = .27). After matching, the OS rates at 1, 3, 5, and 10 years were 94.8%, 75.7%, 61.6%, and 47.3% in the initial HCC group and 91.9%, 71.2%, 58.7%, and 45.2% in the recurrent HCC group (P = .32). Among patients with recurrent HCC, no significant difference in mean OS was noted for local recurrence versus distant recurrence (81.6 months ± 5.1 vs 83.8 months ± 6.6, P = .82) or previous treatment modality (82.0 months ± 7.3 in the resection group, 82.7 months ± 5.3 in the TACE group, and 79.3 months ± 10.8 in the local ablation group; P = .83). Local tumor progression after previous local ablation (10 of 35 [28.6%]) was higher than that after previous hepatectomy (15 of 134 [11.2%], P = .04). Multivariable analysis demonstrated that tumor size (hazard ratio, 1.58; 95% CI: 1.06, 2.36; P = .02), portal hypertension (hazard ratio, 1.52; 95% CI: 1.03, 2.26; P = .04), Child-Pugh class (hazard ratio, 2.01; 95% CI: 1.02, 3.96; P = .045), and serum α-fetoprotein level (hazard ratio, 1.62; 95% CI: 1.10, 2.39; P = .01) were independent predictive factors for recurrent HCC outcomes. Conclusion Radiofrequency ablation provides similar long-term survival for solitary hepatocellular carcinoma of 5 cm or less, regardless of whether treatment is initial or salvage therapy. © RSNA, 2021 Online supplemental material is available for this article.

Intrahepatic recurrence of hepatocellular carcinoma after resection: an update

Hepatocellular carcinoma recurrence occurs in 40-70% of patients after hepatic resection. Despite the high frequency of hepatocellular cancer relapse, there is no established guidance for the management of such cases. The evaluation of prognostic factors that indicate a high risk of recurrence after surgery such as the tumor number and size and the presence of microvascular invasion may guide the therapeutic strategy and point out which patients should be strictly monitored. Additionally, the administration of adjuvant treatment or ab initio liver transplantation in selected patients with high-risk characteristics could have a significant impact on the prevention of relapse and overall survival. Once the recurrence has occurred in the liver remnant, the available therapeutic options include re-resection, salvage liver transplantation and locoregional treatments, although the therapeutic choice is often challenging and should be based on the characteristics of the recurrent tumor, the patient profile and most importantly the timing of relapse. Aggressive combination treatments are often required in challenging cases of early relapse. The results of the above treatment strategies are reviewed and compared to determine the optimal management of patients with recurrent hepatocellular cancer following liver resection.

A prediction model of major complications after radiofrequency ablation for recurrent hepatocellular carcinoma patients

BACKGROUND

Postoperative major complications are potentially fatal to recurrent hepatocellular carcinoma (RHCC) patients. We aimed to construct a prediction model of major complications after RFA for RHCC patients.

METHODS

We retrospectively reviewed the medical records of 407 RHCC patients who underwent RFA as second treatment. Patients were divided into two groups according to the date of RFA: training cohort (277 patients treated in 2010-2016) and validation cohort (130 patients treated in 2017-2019). 23 clinicopathological variables were recorded and analyzed. The logistic regression model was used to build a prediction model.

RESULT

Major complications developed in 3.6 % of RHCC patients after RFA. In the multivariate analysis, tumor adjacent vessels (p = 0.004) and hepatitis C (p = 0.022) were associated with postoperative complications. The prediction model was described as follow: Risk score (major complication) = 5.180 + 3.391*tumor location+3.389*hepatic etiology, the Youden index was 0.642, the best cut-off value of the model was 8.57 (sensitivity, 78.57 %, specificity, 84.03 %). The area under the receiver operating characteristic curve of the predictive model was 0.85 (95 % CI, 0.82 to 0.88). The validation of the model demonstrated acceptable results, the sensitivity was 80.00 %, specificity was 98.40 %.

CONCLUSIONS

This study developed a simple and reliable prediction model of postoperative major complications after RFA for RHCC patients.

Repeat hepatic resection VS radiofrequency ablation for the treatment of recurrent hepatocellular carcinoma: an updated meta-analysis

BACKGROUND

This paper evaluates the efficacy and safety of repeat hepatic resection and radiofrequency ablation in the treatment of recurrent hepatocellular carcinoma.

MATERIAL AND METHODS

We retrieved and collected all relevant articles from the inception to 8 March 2020. After data extraction, we conducted meta-analysis and carried out the heterogeneity test, sensitivity analysis, and publication bias test to evaluate reliability.

RESULTS

A total of 12 studies with 1746 patients (rHR 837, RFA 909) were included. rHR was similar to RFA in a one-year overall survival rate (OS), while rHR was superior to RFA in 3- and 5-year OS and 1-, 3-, and 5-year disease-free survival rates (DFS), but the procedure-related complications of RFA were significantly less than those of rHR. Among the subgroups with Milan criteria, rHR was similar to RFA in 1-, 3-, and 5-year OS and 1-year DFS, but superior to RFA in 3- and 5-year DFS.

CONCLUSIONS

RFA is the first choice for recurrent HCC meeting Milan criteria. When it does not meet the Milan criteria, minimally invasive treatment should not be carried out at the cost of survival, and rHR should be the first choice.

Role of Biomarkers and Biopsy in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is increasing in prevalence and is the third leading cause of cancer-related death worldwide. Unlike other malignancies, HCC can be diagnosed with dynamic imaging with very high accuracy, and tissue diagnosis is not needed for cancer therapy. There is a unique role of established as well as developing biomarkers in diagnosis, prognosis, and management of HCC. Sequencing HCC tumors has yielded substantial insights into HCC tumor biology and has raised the possibility of precision oncology in which therapy decisions are guided by cancer genetics. However, it is not ready for prime time yet.

Long-term prognostic factors of patients with hepatocellular carcinoma who survive over 10 years after hepatectomy

BACKGROUND AND OBJECTIVES

The aim was to evaluate long-term prognostic factors in hepatocellular carcinoma (HCC) patients who survived over 10 years after hepatectomy and compare prognostic factors between patients with recurrence who died and survived 10 years after initial hepatectomy.

METHODS

We analyzed the HCC patients without recurrence over 10 years after hepatectomy (n = 35), those with recurrence who survived over 10 years (n = 48), and those who died within 10 years (n = 132).

RESULTS

The rate of recurrence was 16.3%, 10-year overall survival rate was 38.6%, and the 10-year recurrence-free survival (RFS) rate was 16.7%. Nonviral, solitary tumor, well differentiation, and without severe fibrosis were independent favorable factors for long-term RFS. High cholinesterase levels, small tumors and without portal vein invasion were independent favorable factors for long-term survival among patients with recurrence. Long-term survivors with recurrence showed significantly low early recurrence, extrahepatic recurrence, multiple intrahepatic recurrences.

CONCLUSION

Important factors for long-term prognoses in HCC patients were a solitary tumor, small tumors, and no advanced fibrosis. A treatment for nonviral hepatitis is needed to achieve long-term RFS. Even patients who relapse might survive long term if they have a late or solitary intrahepatic recurrence, nonsevere cirrhosis, and curative treatment at recurrence.

Efficacy of surgical microwave ablation for recurrent hepatocellular carcinoma after curative hepatectomy

BACKGROUND

Little evidence exists regarding postrecurrence survival after microwave ablation for recurrent hepatocellular carcinoma (HCC) after curative hepatectomy; we aimed to evaluate the feasibility of surgical microwave ablation.

METHODS

In this retrospective review, we enrolled patients who underwent curative hepatectomy for primary HCC in our department and had intrahepatic recurrence. We analyzed overall survival according to treatment modality to clarify the prognostic factors for survival.

RESULTS

Of 257 patients, 119 had intrahepatic recurrence. Three patients underwent repeat hepatectomy; 75 patients underwent surgical microwave ablation, and 34 patients underwent transcatheter arterial chemoembolization or hepatic arterial infusion chemotherapy. The median postrecurrence survival time and 5-year postrecurrence survival after surgical microwave ablation were 37.4 months and 55.4%, respectively. The major complication rate (Clavien-Dindo classification IIIa or above) after surgical microwave ablation was 5.3% with no mortality. Multivariate analysis showed that microvascular invasion at primary tumors, and recurrent tumors within 3 cm and 3 nodules were independent prognostic factors for overall survival after surgical microwave ablation for recurrent HCC.

CONCLUSION

Our results suggested that surgical microwave ablation is safe and feasible for recurrent intrahepatic HCC after curative hepatectomy. Close follow-up and further curative treatment could be important for improving postrecurrence survival.

Percutaneous thermal ablation of subcapsular hepatocellular carcinomas: influence of tumor-surface contact and protrusion on therapeutic efficacy and safety

PURPOSE

To evaluate therapeutic efficacy and complication of percutaneous thermal ablation of subcapsular hepatocellular carcinomas (HCCs), and how these may be influenced by the degree of tumor to liver surface contact and tumor protrusion from liver surface.

MATERIALS AND METHODS

Our retrospective study was approved by the Institutional Review Board. Between January 2006 and December 2013, 290 patients (82 women, 208 men; mean age, 64.5 years; range, 33-89 years) with 474 subcapsular (within 1 cm to the liver surface) HCCs (mean size, 23.7 mm; range, 6-71 mm) underwent percutaneous thermal ablation. The HCCs were divided into surface contact group (n = 243) and non-surface contact group (n = 231). The former was further subdivided into exophytic and non-exophytic HCCs. Technical success, primary technique efficacy, local tumor progression (LTP), and secondary technique efficacy rates were analyzed and compared by the chi-square test or Fisher exact test. Prognostic factors for LTP and secondary technique efficacy were assessed using the Cox regression model. Major complications were also assessed.

RESULTS

With median follow-up of 15 months (range, 1-87 months), technical success and primary technique efficacy were 98.7% and 95.7% % in the non-surface contact group; 96.4% and 94.0% in the non-exophytic group; and 100% and 94.7% in the exophytic group (p > 0.05). Tumor size > 3 cm was a significant predictor for LTP, but not for secondary efficacy. Overall major complication rate was 3.8% (24/624) and was not different among the three groups.

CONCLUSION

Subcapsular HCCs can be effectively treated with thermal ablation techniques. Degree of tumor-surface contact including moderate protrusion does not appear to limit feasibility or procedure effectiveness.

KEY POINTS

• Subcapsular HCCs can be effectively treated with thermal therapy when proper image-guided technique and assistive techniques are applied. • Degree of tumor surface contact including moderate protrusion does not appear to limit feasibility or procedure effectiveness. • Major complications after percutaneous thermal ablation of subcapsular HCCs such as tumor seeding can be minimized by avoiding breach of the tumor capsule exposed to the peritoneal surface and use of tract ablation.

Simplified Non-Thermal Tissue Ablation With a Single Insertion Device Enabled by Bipolar High-Frequency Pulses

OBJECTIVE

To demonstrate the feasibility of a single electrode and grounding pad approach for delivering high frequency irreversible electroporation treatments (H-FIRE) in in-vivo hepatic tissue.

METHODS

Ablations were created in porcine liver under surgical anesthesia by adminstereing high frequency bursts of 0.5-5.0 μs pulses with amplitudes between 1.1-1.7 kV in the absence of cardiac synchronization or intraoperative paralytics. Finite element simulations were used to determine the electric field strength associated with the ablation margins (E_Lethal) and predict the ablations feasible with next generation electronics.

RESULTS

All animals survived the procedures for the protocol duration without adverse events. E_Lethal of 2550, 1650, and 875 V/cm were found for treatments consisting of 100x bursts containing 0.5 μs pulses and 25, 50, and 75 μs of energized-time per burst, respectively. Treatments with 1 μs pulses consisting of 100 bursts with 100 μs energized-time per burst resulted in E_Lethal of 650 V/cm.

CONCLUSION

A single electrode and grounding pad approach was successfully used to create ablations in hepatic tissue. This technique has the potential to reduce challenges associated with placing multiple electrodes in anatomically challenging environments.

SIGNIFICANCE

H-FIRE is an in situ tumor ablation approach in which electrodes are placed within or around a targeted region to deliver high voltage electrical pulses. Electric fields generated around the electrodes induce irrecoverable cell membrane damage leading to predictable cell death in the relative absence of thermal damage. The sparing of architectural integrity means H-FIRE offers potential advantages compared to thermal ablation modalities for ablating tumors near critical structures.

Small hepatocellular carcinoma suppressed by chemotherapy for synchronous gastric carcinoma after laparoscopy-assisted radical distal gastrectomy: A case report and literature review

RATIONALE

Synchronous gastric carcinoma and hepatocellular carcinoma (HCC) is rare. It is hard to distinguish synchronous HCC from metastatic liver cancer in this condition. The treatment and prognosis is quite different for synchronous HCC of gastric carcinoma and liver metastasis of gastric carcinoma.

PATIENT CONCERNS

A 68-year-old man with a chief complaint of epigastric pain for 1 year, accompanied by reflux and belching. The patient was diagnosed with gastric carcinoma (cT4NxM0) and laparoscopy-assisted radical distal gastrectomy was performed. This was followed by chemotherapy of FOLFOX regimen. However, a liver nodule growth was observed after postoperative systemic treatment.

DIAGNOSIS

The initial diagnosis was liver metastasis of gastric carcinoma. However after hepatectomy of segment VI and VII as well as thrombectomy of right hepatic vein, histology revealed intermediate to poor differentiated HCC. Hence this case was diagnosed as synchronous gastric carcinoma and HCC.

INTERVENTIONS

A preventive transcatheter arterial chemoembolization (TACE) was conducted at 4 weeks after hepatectomy. Another FOLFOX regimen was suggested, but was refused by the patient.

OUTCOMES

The patient survived without tumor recurrence for 9 months after the second surgery.

LESSONS

Synchronous HCC should be routinely distinguished from gastric carcinoma liver metastasis, especially for patients with hepatitis B virus (HBV) infection. The FOLFOX4 regimen for treating gastric carcinoma liver metastasis may have inhibited the progression of primary HCC in this case. This patient with HCC benefited from liver resection, inspite of hepatic vein tumor thrombosis.

Multidisciplinary management of recurrent and metastatic hepatocellular carcinoma after resection: an international expert consensus

Hepatocellular carcinoma (HCC) is the sixth-most common cancer and the third leading cause of cancer-related death in the world. However, 40-70% patients eventually suffer from postoperative recurrence within 5 years. HCC recurrence after surgery severely affects prognosis of the patients. Nevertheless, there is an opportunity to improve patients' prognosis if doctors and researchers can recognize the importance of a standardized perioperative management and study it in clinical and pre-clinical settings. Hence, based on our own experience and published studies from other researchers, we develop this consensus regarding multidisciplinary management of locally recurrent and metastatic hepatocellular carcinoma after resection. This consensus consists of the entire course of recurrent hepatocellular carcinoma (RHCC) management, including prediction of recurrence, prevention, diagnosis, treatment and surveillance of RHCC. Consensus recommendations are presented with grades of evidences (Ia, Ib, IIa, IIb, III and IV), and strength of recommendations (A, B, C, D and E). We also develop a decision-making path for RHCC treatment, which can intuitively demonstrate the management for RHCC. It is hoped that we may make some effort to standardize the management of RHCC and ultimately understand how to improve outcomes.

Salvage liver transplantation or repeat hepatectomy for recurrent hepatocellular carcinoma: An intent-to-treat analysis

The salvage liver transplantation (LT) strategy was conceived for initially resectable and transplantable hepatocellular carcinoma (HCC) to obviate upfront transplantation, with salvage LT in the case of recurrence. The longterm outcomes of a second resection for recurrent HCC have improved. The aim of this study was to perform an intention-to-treat analysis of overall survival (OS) comparing these 2 strategies for initially resectable and transplantable recurrent HCC. From 1994 to 2011, 391 patients with HCC who underwent salvage LT (n = 77) or a second resection (n = 314) were analyzed. Of 77 patients in the salvage LT group, 21 presented with resectable and transplantable recurrent HCC and 18 underwent transplantation. Of 314 patients in the second resection group, 81 presented with resectable and transplantable recurrent HCC and 81 underwent a second resection. The 5-year intention-to-treat OS rates, calculated from the time of primary hepatectomy, were comparable between the 2 strategies (72% for salvage transplantation versus 77% for second resection; P = 0.57). In patients who completed the salvage LT or second resection procedure, the 5-year OS rates, calculated from the time of the second surgery, were comparable between the 2 strategies (71% versus 71%; P = 0.99). The 5-year disease-free survival (DFS) rates were 72% following transplantation and 18% following the second resection (P < 0.001). Similar results were observed after propensity score matching. In conclusion, although the 5-year OS rates were similar in the salvage LT and second resection groups, the salvage LT strategy still achieves better DFS. Second resection for recurrent HCC might be considered to be the best alternative option to LT in the current organ shortage. Liver Transplantation 23 1553-1563 2017 AASLD.

A novel 3-dimensional electromagnetic guidance system increases intraoperative microwave antenna placement accuracy

BACKGROUND

Failure to locate lesions and accurately place microwave antennas can lead to incomplete tumor ablation. The Emprint™ SX Ablation Platform employs real-time 3D-electromagnetic spatial antenna tracking to generate intraoperative laparoscopic antenna guidance. We sought to determine whether Emprint™ SX affected time/accuracy of antenna-placement in a laparoscopic training model.

METHODS

Targets (7-10 mm) were set in agar within a laparoscopic training device. Novices (no surgical experience), intermediates (surgical residents), and experts (HPB-surgeons) were asked to locate and hit targets using a MWA antenna (10-ultrasound only, 10-Emprint™ SX). Time to locate target, number of attempts to hit the target, first-time hit rate, and time from initiating antenna advance to hitting the target were measured.

RESULTS

Participants located 100% of targets using ultrasound, with experts taking significantly less time than novices and intermediates. Using ultrasound only, successful hit-rates were 70% for novices and 90% for intermediates and experts. Using Emprint™ SX, successful hit rates for all 3-groups were 100%, with significantly increased first-time hit-rates and reduced time required to hit targets compared to ultrasound only.

DISCUSSION

Emprint™ SX significantly improved accuracy and speed of antenna-placement independent of experience, and was particularly beneficial for novice users.

Immunological effect of local ablation combined with immunotherapy on solid malignancies

Recent comprehensive investigations clarified that immune microenvironment surrounding tumor cells are deeply involved in tumor progression, metastasis, and response to treatment. Furthermore, several immunotherapeutic trials have achieved successful results, and the immunotherapeutic agents are available in clinical practice. To enhance their demonstrated efficacy, combination of immunotherapy and ablation has begun to emerge. Local ablations have considerable advantages as an alternative therapeutic option, especially its minimal invasiveness. In addition, local ablations have shown immune-regulatory effect in preclinical and clinical studies. Although the corresponding mechanisms are still unclear, the local ablations combined with immunotherapy have been suggested in the treatment of several solid malignancies. This article aims to review the published data on the immune-regulatory effects of local ablations including stereotactic body radiotherapy, cryoablation, radiofrequency ablation, and high-intensity-focused ultrasound. We also discuss the value of local ablations combined with immunotherapy. Local ablations have the potential to improve future patient outcomes; however, the effectiveness and safety of local ablations combined with immunotherapy should be further investigated.

Treatment and outcomes of recurrent hepatocellular carcinomas

PURPOSE

Surgery is one of the best options for curative treatment of hepatocellular carcinomas (HCC). Recurrences are nevertheless common (45-75%). This study aimed to compare overall survival (OS) of patients with recurrent HCC after primary resection to OS of patients without recurrence.

METHODS

A retrospective review of all HCC patients operated between 1993 and 2015 was performed. Median and 5-year OS were calculated.

RESULTS

This study included 147 HCC patients. Sixty-seven patients presented a recurrence (46%). Patients with recurrence had a worse prognosis than those without recurrence (median OS 63 vs. 82 months, 5-year OS 47 vs. 54%, p = 0.036). First-line performed treatments were radiofrequency ablation (18, RFA), chemo-embolization (16, TACE), repeat hepatectomy (10), systemic chemotherapy (4), radio-embolization (1), and alcoholization (1). Palliative care was performed in 17 patients. Median OS of patients treated by RFA, TACE, or repeat hepatectomy were similar (77, 71, and 84 months, p = 0.735). Patients treated with chemotherapy/palliative care had lower median OS compared to interventional treatments (20 vs. 77 months, p < 0.0001).

CONCLUSIONS

Recurrence after surgical HCC resection is frequent and negatively impacts OS. Interventional treatments of recurrences offered improved outcomes compared to medical care. In selected patients, RFA, TACE, and repeat hepatectomy allowed similar OS as non-recurrent cases.

High-Frequency Irreversible Electroporation: Safety and Efficacy of Next-Generation Irreversible Electroporation Adjacent to Critical Hepatic Structures

Irreversible electroporation (IRE) is a nonthermal ablation modality employed to induce in situ tissue-cell death. This study sought to evaluate the efficacy of a novel high-frequency IRE (H-FIRE) system to perform hepatic ablations across, or adjacent to, critical vascular and biliary structures. Using ultrasound guidance H-FIRE electrodes were placed across, or adjacent to, portal pedicels, hepatic veins, or the gall bladder in a porcine model. H-FIRE pulses were delivered (2250 V, 2-5-2 pulse configuration) in the absence of cardiac synchronization or intraoperative paralytics. Six hours after H-FIRE the liver was resected and analyzed. Nine ablations were performed in 3 separate experimental groups (major vessels straddled by electrodes, electrodes placed adjacent to major vessels, electrodes placed adjacent to gall bladder). Average ablation time was 290 ± 63 seconds. No electrocardiogram abnormalities or changes in vital signs were observed during H-FIRE. At necropsy, no vascular damage, coagulated-thermally desiccated blood vessels, or perforated biliary structures were noted. Histologically, H-FIRE demonstrated effective tissue ablation and uniform induction of apoptotic cell death in the parenchyma independent of vascular or biliary structure location. Detailed microscopic analysis revealed minor endothelial damage within areas subjected to H-FIRE, particularly in regions proximal to electrode insertion. These data indicate H-FIRE is a novel means to perform rapid, reproducible IRE in liver tissue while preserving gross vascular/biliary architecture. These characteristics raise the potential for long-term survival studies to test the viability of this technology toward clinical use to target tumors not amenable to thermal ablation or resection.

Percutaneous thermal ablation for the treatment of colorectal liver metastases and hepatocellular carcinoma: a comparison of local therapeutic efficacy

AIM

This study aimed to compare the local therapeutic efficacy of percutaneous thermal ablation for colorectal liver metastases (CRLM) and hepatocellular carcinoma (HCC).

METHODS

One hundred sixty-one CRLM nodules in 101 patients and 122 HCC nodules in 97 patients were treated with thermal ablation. Complications and local efficacy were retrospectively compared.

RESULTS

Major complications were observed in two (2.0%) patients in the CRLM group and one (1.0%) in the HCC group (p = 1.000). The complete ablation (CA) rate of lesions ≤ 3 cm was lower in the CRLM group than in the HCC group (p = 0.018). After a mean follow-up period of 21.1 ± 20.7 months in the CRLM group and 22.1 ± 17.6 months in the HCC group, the local tumour progression (LTP) rate of lesions > 3 cm was higher in the CRLM group than in the HCC group (p = 0.036). The multivariate analysis revealed that only safety margin (≤ 0.5 cm/> 0.5 cm) was a significant predictor of LTP in both CRLM and HCC.

CONCLUSIONS

To achieve better local tumour control, thermal ablation should be more aggressive for CRLM than for HCC, especially for large tumours in clinical.

Prognostic value of p53 mutation for poor outcome of Asian primary liver cancer patients: evidence from a cohort study and meta-analysis of 988 patients

Several previous studies have investigated the association between gene p53 (p53) mutation and the poor outcome of primary liver cancer (PLC) patients; however, the results remain inconsistent. In the present study, p53 mutation in 60 paired tumor and corresponding nontumor tissues derived from a cohort of 60 PLC patients was systematically analyzed. The results showed that p53 mutation was only an independent risk factor for overall survival (OS), not for recurrence-free survival (RFS), and a meta-analysis was performed to verify this. Online databases were searched up to July 1, 2016. Studies about the association between p53 mutation and the postsurgery survival of PLC patients were collected. A total of 988 patients from eight studies were analyzed; among them, 341 (34.51%) patients had p53 mutation. Pooled hazard ratios (HRs) and 95% confidence intervals (CIs) were 2.03 (1.64, 2.41) and 2.36 (1.31, 3.42) for OS and RFS, respectively. In conclusion, both the cohort study and meta-analysis suggested that the p53 mutation was associated with postsurgery OS in Asian PLC patients. However, the relationship between p53 mutation and recurrence should be confirmed by further studies.

Strategic overview on the best treatment option for intrahepaitc hepatocellular carcinoma recurrence

INTRODUCTION

The long-term survival after hepatectomy for HCC remains unsatisfactory because of the high incidence of recurrence. The cumulative 5-year recurrence rate ranged from 60-100% in previous studies and majority of them remains intrahepatic recurrence. The therapeutic modalities commonly used for primary tumors, including surgical resection, liver transplantation, TACE, local ablative therapy and radiotherapy have been used to treat recurrent tumors in the liver remnant and the outcomes with the heterogeneous therapeutic options are reviewed. It is important to note that the level of evidence for most therapeutic options is limited to cohort investigations with few RCTs and most were limited due to enrollment of various tumor stages and did not compare treatment modalities for specific tumor stages.

AREAS COVERED

A literature search for recurrent HCC was performed using Medline and PubMed up to May 2016. Expert commentary: The long term survival results after re-resection for recurrent HCC were favourable and aggressive management of postoperative intrahepatic recurrence remains the most important strategy in prolonging the survival of patients after resection of HCC.

Monitoring of tissue optical properties during thermal coagulation of ex vivo tissues

BACKGROUND AND OBJECTIVE

Real-time monitoring of tissue status during thermal ablation of tumors is critical to ensure complete destruction of tumor mass, while avoiding tissue charring and excessive damage to normal tissues. Currently, magnetic resonance thermometry (MRT), along with magnetic resonance imaging (MRI), is the most commonly used technique for monitoring and assessing thermal ablation process in soft tissues. MRT/MRI is very expensive, bulky, and often subject to motion artifacts. On the other hand, light propagation within tissue is sensitive to changes in tissue microstructure and physiology which could be used to directly quantify the extent of tissue damage. Furthermore, optical monitoring can be a portable, and cost-effective alternative for monitoring a thermal ablation process. The main objective of this study, is to establish a correlation between changes in tissue optical properties and the status of tissue coagulation/damage during heating of ex vivo tissues.

MATERIALS AND METHODS

A portable diffuse reflectance spectroscopy system and a side-firing fiber-optic probe were developed to study the absorption (μa (λ)), and reduced scattering coefficients (μ's (λ)) of native and coagulated ex vivo porcine, and chicken breast tissues. In the first experiment, both porcine and chicken breast tissues were heated at discrete temperature points between 24 and 140°C for 2 minutes. Diffuse reflectance spectra (430-630 nm) of native and coagulated tissues were recorded prior to, and post heating. In a second experiment, porcine tissue samples were heated at 70°C and diffuse reflectance spectra were recorded continuously during heating. The μa (λ) and μ's (λ) of the tissues were extracted from the measured diffuse reflectance spectra using an inverse Monte-Carlo model of diffuse reflectance. Tissue heating was stopped when the wavelength-averaged scattering plateaued.

RESULTS

The wavelength-averaged optical properties, <μ's (λ)> and <μa (λ)>, for native porcine tissues (n = 66) at room temperature, were 5.4 ± 0.3 cm(-1) and 0.780 ± 0.008 cm(-1) (SD), respectively. The <μ's (λ)> and <μa (λ)> for native chicken breast tissues (n = 66) at room temperature, were 2.69 ± 0.08 cm(-1) and 0.29 ± 0.01 cm(-1) (SD), respectively. In the first experiment, the <μ's (λ)> of coagulated porcine and chicken breast tissue rose to 56.4 ± 3.6 cm(-1) at 68.7 ± 1.7°C (SD), and 52.8 ± 1 cm(-1) at 57.1 ± 1.5°C (SD), respectively. Correspondingly, the <μa (λ)> of coagulated porcine (140.6°C), and chicken breast tissues (130°C) were 0.75 ± 0.05 cm(-1) and 0.263 ± 0.004 cm(-1) (SD). For both tissues, charring was observed at temperatures above 80°C. During continuous monitoring of porcine tissue (with connective tissues) heating, the <μ's (λ)> started to rise rapidly from 13.7 ± 1.5 minutes and plateaued at 19 ± 2.5 (SD) minutes. The <μ's (λ)> plateaued at 11.7 ± 3 (SD) minutes for porcine tissue devoid of connective tissue between probe and tissue surface. No charring was observed during continuous monitoring of thermal ablation process.

CONCLUSION

The changes in optical absorption and scattering properties can be continuously quantified, which could be used as a diagnostic biomarker for assessing tissue coagulation/damage during thermal ablation. Lasers Surg. Med. 48:686-694, 2016. © 2016 Wiley Periodicals, Inc.

Comparison of percutaneous radiofrequency ablation and CyberKnife® for initial solitary hepatocellular carcinoma: A pilot study

AIM: To compare therapeutic outcomes and adverse events in initial solitary hepatocellular carcinoma (HCC) treated with radiofrequency ablation (RFA) and CyberKnife^®.

METHODS: Seventy three consecutive patients with initial solitary HCC treated with RFA (38 patients; RFA group) and CyberKnife^® (35 patients; CK group) were enrolled in this study. Background factors were compared between the two groups. Local and intrahepatic distant recurrence control, and cumulative survival rates were compared between the two groups. These were determined using the Kaplan-Meier method, and the significance of differences was analyzed by log-rank test. The presence of more grade 3 on CTCAE ver. 4.0 early and late adverse events was investigated.

RESULTS: In background factors, age was significantly higher (P = 0.005) and the tumor diameter was significantly larger (P = 0.001) in the CK group. The 1-year local recurrence control rates were 97.4% and 97.1% in the RFA and CK groups, respectively (P = 0.71); the 1-year intrahepatic distant recurrence control rates were 85.6% and 86.1%, respectively (P = 0.91); and the 1-year cumulative survival rates were 100% and 95.2%, respectively (P = 0.075), showing no significant difference in any rate between the two groups. There were no late adverse event in the RFA group, but 11.4% in the CK group had late adverse events. In the CK group, the Child-Pugh score at 12 mo after treatment was significantly higher than that in the RFA group (P = 0.003) and significantly higher than the score before treatment (P = 0.034).

CONCLUSION: The occurrence of adverse events is a concern, but CyberKnife^® treatment is likely to become an important option for local treatment of early HCC.