Microwave ablation versus surgical resection for subcapsular hepatocellular carcinoma: a propensity score-matched study of long-term therapeutic outcomes

MRI-based prediction of the need for wide resection margins in patients with single hepatocellular carcinoma

OBJECTIVES

To develop an MRI-based score that enables individualized predictions of the survival benefit of wide over narrow resection margins.

MATERIALS AND METHODS

This single-center retrospective study (December 2011 to May 2022) included consecutive patients who underwent curative-intent resection for single Barcelona Clinic Liver Cancer (BCLC) 0/A HCC and preoperative contrast-enhanced MRI. In patients with narrow resection margins, preoperative demographic, laboratory, and MRI variables independently associated with early recurrence-free survival (RFS) were identified using Cox regression analyses, which were employed to develop a predictive score (named "MARGIN"). Survival outcomes were compared between wide and narrow resection margins in a propensity-score matched cohort for the score-stratified low- and high-risk groups, respectively.

RESULTS

Four hundred nineteen patients (median age, 54 years; 361 men) were included, 282 (67.3%) undergoing narrow resection margins. In patients with narrow resection margins, age, alpha-fetoprotein (AFP) > 400 ng/mL, protein induced by vitamin K absence or antagonist-II (PIVKA-II) > 200 mAU/mL, radiological involvement of liver capsule, and infiltrative appearance were associated with early RFS (p values, 0.002-0.04) and formed the MARGIN score with a testing dataset C-index of 0.75 (95% CI: 0.65-0.84). In the matched cohort, wide resection margin was associated with improved early RFS rate for the high-risk group (MARGIN score ≥ - 1.3; 71.1% vs 41.0%; p = 0.02), but not for the low-risk group (MARGIN score < - 1.3; 79.7% vs 76.1%; p = 0.36).

CONCLUSION

In patients with single BCLC 0/A HCC, the MARGIN score may serve as promising decision-making to indicate the need for wide resection margins.

CLINICAL RELEVANCE STATEMENT

The MARGIN score has the potential to identify patients who would benefit more from wide resection margins than narrow resection margins, improving the postoperative survival of patients with single BCLC 0/A hepatocellular carcinoma (HCC).

KEY POINTS

Age, AFP, PIVKA-II, radiological involvement of liver capsule, and infiltrative appearance were associated with early RFS and formed the MARGIN score. The MARGIN score achieved a testing dataset C-index of 0.75. Wide resection margins were associated with improved early RFS for the high-risk group, but not for the low-risk group.

Irreversible Electroporation vs. Radiofrequency Ablation for Subcapsular Hepatocellular Carcinoma: A Propensity Score Analysis

RATIONALE AND OBJECTIVES

The therapeutic efficacy of irreversible electroporation (IRE) for treating subcapsular hepatocellular carcinoma (HCC) remains under-explored. The current study aimed to compare IRE and radiofrequency ablation (RFA) outcomes in an HCC patient group.

MATERIALS AND METHODS

In this retrospective cohort study, we analyzed 213 patients with subcapsular HCC who met the Milan criteria and underwent either IRE (n = 80) or RFA (n = 133). We assessed local tumor progression (LTP), recurrence-free survival (RFS), overall survival (OS), and complications rates, using inverse probability of treatment weighting (IPTW).

RESULTS

After a median follow-up of 22 months, patients in the IRE group showed significantly lower LTP rates (1-year: 6.2% [95% CI: 2.1-14.0%], 2-year: 8.8% [95% CI: 3.6-17.2%] vs. RFA 18.0% [95% CI: 11.9-25.6%], 21.1% [95% CI: 14.5-29.0%]; P = 0.008) and higher RFS rates (1-year: 75.0% [95% CI: 64.1-84.0%], 2-year: 67.5% [95% CI: 56.1-77.6%] vs. RFA 60.9% [95% CI: 52.1-69.2%], 51.9% [95% CI: 43.1-60.6%]; P = 0.003). However, 2-year OS remained comparable across groups (IRE 100% [95.5-100%] vs. RFA 99.1% [95.9-100%]; P = 0.990). IPTW-adjusted analyses confirmed these findings. We determined that treatment modality was an independent influencing factor for LTP (RFA vs. IRE HR [95% CI]: 2.46 [1.05, 5.74], P = 0.037) and RFS (RFA vs. IRE HR [95% CI]: 1.62 [1.01, 2.61], P = 0.046). However, the complication rate (6.3% vs. 9.8%) and median hospital stay (3 vs. 3 days) were similar across groups (both P > 0.05).

CONCLUSION

For patients with subcapsular HCC meeting the Milan criteria, IRE demonstrated significantly improved LTP and RFS compared to RFA. These results may suggest that IRE is a viable therapeutic alternative for this tumor subtype.

Localized hepatocellular carcinoma: Is liver-directed therapy alone as efficacious as surgical resection?

OBJECTIVE

Studies of the efficacy of nonsurgical methods of liver-directed therapy (percutaneous microwave or radiofrequency ablation, transarterial bland embolization, chemoembolization, and/or radioembolization) in the treatment of hepatocellular cancer lack contemporaneous comparative surgical cohorts. The role of these methods of liver-directed therapy as destination treatment in hepatocellular cancer is not well defined.

METHODS

We queried our institutional registry for patients undergoing resection or liver-directed therapy alone for clinical stage I to IVa hepatocellular cancer between 2012 and 2022. Multivariable regression and Cox modeling were used to identify factors associated with resection and all-cause mortality. Patients undergoing resection were 1:3 propensity matched for age, Mayo End-Stage Liver Disease score and clinical stage to those undergoing liver-directed therapy. Kaplan-Meier methods were used to compare 5-year disease-specific and overall survival for matched cohorts.

RESULTS

Three hundred thirty patients met inclusion criteria; 45 underwent resection, and 285 liver-directed therapy. On multivariable regression, factors associated with resection included age (adjusted odds ratio: 0.96, P = .007) and Mayo End-Stage Liver Disease score (adjusted odds ratio: 0.92, P = .033). On Cox modeling, factors associated with mortality-risk included Mayo End-Stage Liver Disease score (adjusted hazards ratio: 1.03, P = .01), advanced clinical stage (stage III adjusted hazards ratio: 1.9, P = .002), and resection (adjusted hazards ratio: 0.43, P = .001). Forty-five patients undergoing resection were matched to 135 undergoing liver-directed therapy. On Kaplan-Meier comparison of matched cohorts, patients undergoing resection demonstrated improved overall survival (38.1 vs 8.4%, P = .015) but disease-specific survival similar to that for those undergoing liver-directed therapy (84.0 vs 74.0%, P = .095).

CONCLUSION

Liver-directed therapy is effective as treatment for patients with localized hepatocellular cancer providing disease-specific survival similar to that provided by surgical resection.

Therapeutic outcomes of thermal ablation versus repeated hepatic resection for recurrent hepatocellular carcinoma by using propensity score analysis: a multicenter real-world study

BACKGROUND

The therapeutic value of thermal ablation (TA) versus repeat hepatic resection (RHR) for recurrent hepatocellular carcinoma (rHCC) after initial hepatic resection is uncertain. This study aimed to investigate the prognosis of TA and RHR.

MATERIALS AND METHODS

In this multicenter real-world retrospective study, 473 patients were enrolled between January 2015 and August 2023, with 340 in the TA group and 133 in the RHR group. Propensity score matching (PSM) and inverse probability of treatment weighting (IPTW) were employed to reduce selection bias. Local tumor progression (LTP), recurrence-free survival (RFS), and post-recurrence survival (PRS) were compared before and after PSM and IPTW.

RESULTS

A total of 473 patients (231 aged ≥ 60 years; 393 men) were evaluated. LTP, RFS, and PRS rates did not differ significantly between groups before (P = 0.940, P = 0.180, and P = 0.700) and after matching (P = 0.420, P = 0.680, and P = 0.810) and weighting (P = 0.940, P = 0.180, and P = 0.700). Multivariable Cox analysis identified tumor number (HR: 2.28; P < 0.001) and PLT (HR: 0.73; P = 0.038) as independent prognostic factors for RFS in the entire rHCC cohort. And tumor location, size, number, ascites, AST, and AFP (HR: 0.55-2.18; P = 0.004-0.046) were independent prognostic factors for PRS. Subgroup analysis showed both TA and RHR were effective treatments for rHCC, regardless of tumor size, number, subcapsular, or perivascular lesions.

CONCLUSIONS

The cumulative LTP, RFS, and PRS were not significantly different between TA and RHR for rHCC within the Milan criteria. TA may be a viable curative option for early-stage rHCC patients.

Radiofrequency ablation for peribiliary hepatocellular carcinoma: propensity score matching analysis

OBJECTIVES

At present, there are no established clinical guidelines for radiofrequency ablation (RFA) of peribiliary hepatocellular carcinoma (HCC). Therefore, the aim of this study was to compare the long-term outcomes of RFA for peribiliary vs. non-peribiliary HCC.

METHODS

This retrospective study included 282 patients with peribiliary HCC (n = 109) or non-peribiliary HCC (n = 173) who received RFA between February 2013 and May 2021. Local tumor progression (LTP), overall survival (OS), disease-free survival (DFS), and complications were compared before and after propensity score matching (PSM).

RESULTS

Before PSM, there were no significant differences in 5-year LTP rates (26.3% vs. 23.6%, p = 0.602), OS rates (56.6% vs. 68.0%, p = 0.586), or DFS rates (22.9% vs. 25.7%, p = 0.239) between the peribiliary and non-peribiliary groups. After PSM, there were no significant differences in the 1-, 3-, and 5-year LTP rates (13.0%, 23.1%, and 26.3% vs. 12.1%, 25.1%, and 28.2%, respectively, p = 0.857), OS rates (97.2%, 73.5%, and 56.6% vs. 95.3%, 79.5%, and 70.6%, p = 0.727), or DFS rates (59.4%, 29.4%, and 22.9% vs. 64.2%, 33.1%, and 23.8%, p = 0.568) between the peribiliary non-peribiliary groups. Peribiliary location was not a significant prognostic factor for LTP (p = 0.622) or OS (p = 0.587). In addition, mild intrahepatic bile duct dilatation was more frequent in the peribiliary group (9.2% vs. 2.8%, p = 0.045).

CONCLUSION

Long-term outcomes of RFA were similar for peribiliary and non-peribiliary HCC. RFA is a viable alternative for treatment of peribiliary HCC.

CRITICAL RELEVANCE STATEMENT

The local tumor progression (LTP), overall survival (OS), and disease-free survival (DFS) rates after radiofrequency ablation (RFA) were similar for peribiliary and non-peribiliary hepatocellular carcinoma (HCC).

KEY POINTS

There are currently no clinical guidelines for radiofrequency ablation (RFA) of peribiliary hepatocellular carcinoma (HCC). Local tumor progression, overall survival, and disease-free survival after RFA were similar for peribiliary and non-peribiliary HCC. RFA is a viable alternative for the treatment of peribiliary HCC.

Imaging-based prediction of hepatocellular carcinoma recurrence after microwave ablation as bridge therapy: A glimpse into the future

Liver transplantation (LT) remains the treatment of choice for early-stage hepatocellular carcinoma (HCC) and offers the best long-term oncological outcomes. However, the increasing waiting list for LT has led to a significant dropout rate as patients experience tumor progression beyond the Milan criteria. Currently, locoregional therapies, such as microwave ablation (MWA), have emerged as promising bridge treatments for patients awaiting LT. These therapies have shown promising results in preventing tumor progression, thus reducing the dropout rate of LT candidates. Despite the efficacy of MWA in treating HCC, tumoral recurrence after ablation remains a major challenge and significantly impacts the prognosis of HCC patients. Therefore, accurately diagnosing tumoral recurrence post-ablation is crucial. Recent studies have developed novel imaging features based on magnetic resonance imaging of HCC, which could provide essential information for predicting early tumoral recurrence after MWA. These advancements could address this unresolved challenge, improving the clinical outcomes of patients on the LT waiting list. This article explored the current landscape of MWA as a bridge therapy for HCC within the Milan criteria, highlighting the emerging role of novel imaging-based features aimed at improving the prediction of tumor recurrence after MWA.

Cryoablation versus microwave ablation in the treatment of hepatocellular carcinoma: A Systematic Review and meta-analysis

To evaluate the efficacy and safety of cryoablation (CRA) versus microwave ablation (MWA) for hepatocellular carcinoma (HCC). The PubMed, Embase, Cochrane Library, CNKI, Wan Fang and VIP databases were searched to obtain all related studies on CRA and MWA from the inception dates to July 2022. The Meta-analysis was performed by the RevMan5.3 software. Five studies comparing CRA with MWA were eligible and 470 HCC patients were included in the analysis. No statistically significant differences in complete ablation rate (OR = 1.17, 95 % CI: 0.36-3.79, P > 0.05), local recurrence rate (OR = 0.25, 95 % CI: 0.05-1.29, P = 0.10), 1-year survival rate (OR = 2.07, 95 % CI: 0.89-4.79, P > 0.05) and postoperative decreased value of AFP (MD = -1.63, 95 % CI: -83.13-79.87, P > 0.05) were observed; however, CRA was associated with a significantly lower major complication rate (OR = 0.06, 95 % CI: 0.01-0.31, P < 0.05) compared with MWA. CRA had comparable outcomes to MWA in terms of complete ablation, local recurrence, 1-year survival and postoperative reduced AFP, meanwhile, CRA demonstrated favorable safety, and CRA may be a recommended ablation treatment for HCC.

Primary treatments for solitary hepatocellular carcinoma ≤ 3 cm: A systematic review and network meta-analysis

Various treatment modalities are available for small solitary hepatocellular carcinoma (HCC), yet the optimal primary treatment strategy for tumors ≤ 3 cm remains unclear. This network meta-analysis investigates the comparative efficacy of various interventions on the long-term outcomes of patients with solitary HCC ≤ 3 cm. A systematic search of electronic databases from January 2000 to December 2023 was conducted to identify studies that compared at least two of the following treatments: surgical resection (SR), radiofrequency ablation (RFA), microwave ablation (MWA), and transarterial chemoembolization (TACE). Survival data were extracted, and pooled hazard ratios with 95% confidence intervals were calculated using a frequentist network meta-analysis. A total of 30 studies, comprising 2 randomized controlled trials and 28 retrospective studies, involving 8,053 patients were analyzed. Surgical resection showed the highest overall survival benefit with a p-score of 0.95, followed by RFA at 0.59, MWA at 0.23, and TACE, also at 0.23. Moreover, SR provided the most significant recurrence-free survival advantage, with a p-score of 0.95, followed by RFA at 0.31 and MWA at 0.19. Sensitivity analyses, excluding low-quality or retrospective non-matched studies, corroborated these findings. This network meta-analysis demonstrates that SR is the most effective first-line curative treatment for single HCC ≤ 3 cm, followed by RFA in patients with preserved liver function. The limited data on MWA and TACE underscore the need for further studies.

Microwave ablation versus laparoscopic resection for hepatocellular carcinoma in patients with clinically significant portal hypertension: a propensity score-matched study of postoperative liver decompensation

OBJECTIVES

The study of postoperative liver decompensation after microwave ablation (MWA) for hepatocellular carcinoma (HCC) in patients with clinically significant portal hypertension (CSPH) is still lacking. The purpose of the present study was to compare the postoperative liver decompensation after MWA and laparoscopic resection (LR) for HCC in patients with CSPH.

METHODS

The present retrospective study enrolled 222 HCC patients with CSPH who underwent MWA (n = 67) or LR (n = 155). Postoperative liver decompensation, complications, postoperative hospital stays, and overall survival were analyzed. Factors associated with postoperative liver decompensation were identified.

RESULTS

After propensity score matching, the postoperative liver decompensation rate was significantly lower in the MWA group than that in the LR group (15.5% versus 32.8%, p = 0.030). The multivariable regression analysis identified that type of treatment (MWA vs. LR, odds ratio [OR] 0.44; 95% confidence interval [CI], 0.21-0.91; p = 0.026) and Child-Pugh B (OR, 2.86; 95% CI, 1.24-6.61; p = 0.014) were independent predictors for postoperative liver decompensation. The rate of complications for patients in the MWA group was significantly lower than that in the LR group (p < 0.001). And MWA showed shorter postoperative hospital stays than LR (3 days vs. 6 days, p < 0.001). Overall survival rate between the two groups was not significantly different (p = 0.163).

CONCLUSION

Compared with laparoscopic resection, microwave ablation has a lower rate of postoperative liver decompensation and might be a better option for HCC patients with CSPH.

CLINICAL RELEVANCE STATEMENT

Microwave ablation exhibited a lower incidence of postoperative liver decompensation in comparison to laparoscopic resection, thereby conferring greater advantages to hepatocellular carcinoma patients with clinically significant portal hypertension.

KEY POINTS

•Postoperative liver decompensation rate after microwave ablation was lower than that of laparoscopic resection for hepatocellular carcinoma in patients with clinically significant portal hypertension. •Microwave ablation showed shorter postoperative hospital stays than laparoscopic resection. •Microwave ablation had fewer complications than laparoscopic resection.

Integrating Navigation-Assisted Ablation in the Locoregional Treatment of Hepatocellular Carcinoma

Importance

With the increasing prevalence of hepatocellular carcinoma (HCC), ablative therapy is a critical treatment option to achieve a cancer-free state. The anatomic location of the tumor can be a challenge, and select hepatic locations of a tumor require laparoscopic-assisted strategies to safely reach and treat the lesion.

Objective

To assess the association of real-time ultrasonography-augmented navigation for HCC ablation with patient survival, operative time, and rate of incomplete ablations.

Design, Setting, and Participants

This retrospective case-control study was conducted among a prospectively collected database of more than 750 patients with HCC who were treated with ablation therapy with and without the use of navigation at a single quaternary medical center from June 2011 to January 2021. Data were analyzed from October 2022 through June 2023.

Exposure

Real-time ultrasonography-augmented navigation.

Main Outcomes and Measures

The primary outcome was rate of incomplete ablations in patients undergoing HCC ablation with vs without navigation. Secondary outcomes included overall survival (OS), progression-free survival (PFS), and operative time.

Results

The analytic cohort included 467 patients (mean [SD] age, 62.4 [7.8] years; 355 male [76.0%]; 21 Hispanic [4.5%], 67 non-Hispanic Black [14.5%], and 347 Non-Hispanic White [75.0%] among 463 patients with race and ethnicity data). The most common etiology of liver disease was hepatitis C infection (187 patients with etiology data [40.0%]), and 348 of 458 patients with TMN staging data (76.0%) had TNM stage 1 disease. There were 187 individuals treated with navigation and 280 individuals treated without navigation. Patients who underwent navigation-assisted ablation were more likely to have stage 2 disease based on TNM staging (62 of 183 patients [33.9%] vs 47 of 275 patients [17.1%] with TMN data; P < .002) and had a higher mean (SD) number of lesions (1.3 [0.5] vs 1.2 [0.5] lesions; P = .002) and a longer mean (SD) operation time (113.2 [29.4] vs 109.6 [32.3] minutes; P = .04). Patients who underwent navigation were also more likely to have tumors in segment 8 (59 patients [32.1%] vs 53 of 275 patients with segment data [19.3%] with segment data; P = .005) and less likely to have tumors in segment 4 (20 patients [10.9%] vs 54 patients with segment data [19.6%]; P = .005). Overall mean (SD) time to recurrence after treatment was 10.0 (12.5) months, with similar rates for patients with navigation vs no navigation. There were no differences in incomplete ablation rate (10 patients [9.2%] vs 10 patients [10.5%]; P = .32), OS, or PFS between patients undergoing ablation with and without navigation.

Conclusions and Relevance

In this study, use of navigation was associated with comparable outcomes to undergoing ablation without navigation, although patients with navigation had more locally advanced disease. These findings suggest that use of real-time navigation in laparoscopic-assisted ablation of liver cancer should be considered as a useful tool for treating challenging tumors.