Local Recurrence after Radiofrequency Ablation of Hepatocellular Carcinoma: Treatment Choice and Outcome

Radiofrequency ablation versus laparoscopic hepatectomy for hepatocellular carcinoma: a systematic review and meta-analysis

BACKGROUND

Although laparoscopic hepatectomy (LH) and radiofrequency ablation (RFA) are the 2 principal minimally invasive surgical approaches and the first line of treatments for patients with hepatocellular carcinoma (HCC). It is not clear which one has greater safety and efficacy. In this meta-analysis, we aim to compare the safety and effectiveness of LH versus RFA for patients with HCC, especially where perioperative and postoperative outcomes differrent.

METHODS

In PROSPERO, a meta-analysis with registration number CRD42021257575 was registered. Using an established search strategy, we systematically searched Web of Science, PubMed, and Embase to identify eligible studies before June 2023. Data on operative times, blood loss, length of stay, overall complications, overall survival (OS) and recurrence-free survival (RFS) were subjected to meta-analysis.

RESULTS

Overall, the present meta-analysis included 8 retrospective and 6 PSM studies comprising 1,848 patients (810 and 1,038 patients underwent LH and RFA). In this meta-analysis, neither LH nor RFA showed significant differences in 1-year and 3-year OS rate and 5-year RFS rate. Despite this, in comparison to the RFA group, LH resulted in significantly higher 1-year(p<0.0001) and 3-year RFS rate (p = 0.005), higher 5-year OS rate (p = 0.008), lower local recurrence rate (p<0.00001), longer length of stay(LOS) (p<0.0001), longer operative time(p<0.0001), more blood loss (p<0.0001), and higher rate of complications (p=0.001).

CONCLUSIONS

Comparative studies indicate that LH seemed to provide better OS and lower local recurrence rate, but higher complication rate and longer hospitalization.

Nanocomposites of iron oxide, sodium alginate, and eugenol induce apoptosis via PI3K/Akt/mTOR signaling in Hep3 cells and in vivo hepatotoxicity in the zebrafish model

Hepatic cancer is among the most recurrently detected malignancies worldwide and one of the main contributors to cancer-associated mortality. With few available therapeutic choices, there is an instant necessity to explore suitable options. In this aspect, Nanotechnology has been employed to explore prospective chemotherapeutic approaches, especially for cancer treatment. Nanotechnology is concerned with the biological and physical properties of nanoparticles in the therapeutic use of drugs. In the current work, formulation, and characterization of α-Fe2O3-Sodium Alginate-Eugenol nanocomposites (FSE NCs) using several approaches like SEM and TEM, UV-visible, FTIR, and PL spectroscopy, XRD, EDAX, and DLS studies have been performed. With an average size of 50 nm, the rhombohedral structure of NCs was identified. Further, their anticancer activity against Hep3B liver cancer cell lines has been performed by cell viability, dual staining, DCFH-DA, Annexin-V/-FITC/PI, cell cycle analysis methods, and PI3K/Akt/mTOR signaling proteins were studied to assess the anticancer effects of the NCs in Hep3B cells. Also, anti-cancer activity on animal modeling in-vivo using zebra fishes to hematological parameters, liver enzymes, and histopathology study effectiveness was noticed. Moreover, the NCs reduced the viability, elevated the ROS accumulation, diminished the membrane integrity, reduced the antioxidants, blocked the cell cycle, and triggered the PI3K/Akt/mTOR signaling axis that eventually resulted in cell death. As a result, FSE NCs possess huge potential for use as a possible anticancer candidate.

Salvage Hepatectomy for Recurrent Hepatocellular Carcinoma after Radiofrequency Ablation: A Retrospective Cohort Study with Propensity Score-Matched Analysis

BACKGROUND AND OBJECTIVES

Although radiofrequency ablation (RFA) is a well-established locoregional treatment modality for hepatocellular carcinoma (HCC), the optimal strategy to handle local recurrence after ablation is still debated. This study aims to investigate the role of salvage hepatectomy (SH) as a rescue therapy for recurrent HCC after RFA.

MATERIALS AND METHODS

Between January 2004 and December 2020, 1161 patients were subject to surgical resection for HCC. Among them, 47 patients who underwent SH for local recurrence after ablation were retrospectively analyzed and compared to a propensity score-matched group of controls (n = 47) who received primary hepatectomy (PH). Short-term and long-term outcomes were analyzed between the two groups.

RESULTS

After matching, operation time, intraoperative blood loss, postoperative hospital stay, and postoperative morbidity rates showed no statistically significant difference. Tumors in the SH group were associated with poor differentiation (SH 9 (19.1%) vs. PH 1 (2.1%), p < 0.001). The 5-year disease-free survival rates (31.6% vs. 73.4%, p < 0.001) and overall survival rates (80.3% vs. 94.2%, p = 0.047) were significantly lower in the SH group. In multivariable analysis, less extensive resection compared to the initial plan (hazard ratio (HR) 4.68, p = 0.024), higher grade (HR 5.38, P < 0.001), negative but close (<0.1 cm) resection margin (HR 22.14, p = 0.007), and R1 resection (HR 3.13, p = 0.006) were significant predictors for recurrence.

CONCLUSIONS

SH for recurrent tumors after ablation showed safety and effectiveness equivalent to primary resection. As recurrent tumors show a higher grade and more aggressive behavior, more extensive resections with wide surgical margins are necessary to prevent recurrence.

Comparison of Open versus Laparoscopic Approaches in Salvage Hepatectomy for Recurrent Hepatocellular Carcinoma after Radiofrequency Ablation

Background and Objectives: Although radiofrequency ablation (RFA) is widely used as an effective local treatment for hepatocellular carcinoma (HCC), evidence on salvage hepatectomy for local recurrence after RFA is limited. This study aims to compare open and laparoscopic approaches in salvage hepatectomy for recurrent HCC after RFA. Materials and Methods: Among patients who underwent hepatectomy between January 2004 and August 2022 at a single tertiary referral center, 55 patients who underwent salvage hepatectomy for marginal recurrence after RFA were selected. An open approach was used in 23 (41.8%) patients, while 32 (58.2%) patients underwent laparoscopic surgery. Short-term and long-term outcomes were compared between the two groups. Results: Major hepatectomy was more often performed in the open group (9 [39.1%] vs. 4 [12.5%], p = 0.022). Intraoperative blood loss was also greater in the open group (450 (325-750) vs. 300 (200-600), p = 0.034). Operation time (p = 0.144) and postoperative morbidity rates (p = 0.639) were similar, and there was no postoperative mortality in either group. Postoperative hospital stay was significantly longer in the open group compared to the laparoscopy group (8 (6-11) days vs. 5 (4-7) days, p = 0.028). The 1-, 3-, and 5-year disease-free survival rates showed no difference between the two groups (44.6% vs. 62.5%, 16.5% vs. 13.5%, and 8.3% vs. 13.5%, respectively; p = 0.154). The 1-, 3-, and 5-year overall survival rates between the two groups were also similar (85.7% vs. 96.8%, 79.6% vs. 86.0%, and 79.6% vs. 79.4%, respectively; p = 0.480). Conclusions: Laparoscopic salvage hepatectomy shows oncologic outcomes comparable to the open approach with faster postoperative recovery rates. Considering that recurrence rates are high after RFA, the laparoscopic approach should be considered as a first-line option in selected patients.

Rescue therapy for local tumor progression after radiofrequency ablation of small hepatocellular carcinoma: a comparison between repeated ablation and transcatheter arterial chemoembolization

OBJECTIVE

To compare the therapeutic outcomes of repeated radiofrequency ablation (RFA) and transcatheter arterial chemoembolization (TACE) as rescue therapy for the treatment of local tumor progression (LTP) after initial RFA for hepatocellular carcinoma (HCC).

METHODS

This retrospective study evaluated 44 patients who had LTP as initial tumor recurrence after RFA and underwent repeated RFA (n = 23) or TACE (n = 21) for local disease control. Local disease control and overall survival rates were evaluated using the Kaplan-Meier method. A Cox proportional-hazards regression model was used to identify the independent prognostic factors. The local disease control rate after the first rescue therapy and the number of rescue therapies applied until the last follow-up were also evaluated.

RESULTS

Local disease control after rescue therapy for LTP was significantly higher with repeated RFA than with TACE (p < 0.001). Treatment type was a significant factor for local disease control (p < 0.001). The overall survival rates after rescue therapy were not significantly different between the two treatments (p = 0.900). The local disease control rate after the first rescue therapy was significantly higher with RFA than with TACE (78.3% vs 23.8%, p < 0.001). The total number of rescue therapies applied was significantly higher in the TACE group than that in the repeated RFA group (median 3 vs 1, p < 0.001).

CONCLUSION

Repeated RFA as rescue therapy for LTP after initial RFA for HCC was more efficient and had significantly better local disease control than TACE.

ADVANCES IN KNOWLEDGE

Even if LTP occurs after initial RFA, it should not be considered a failure of RFA, and repeated RFA should be performed over TACE if possible for more effective local disease control.

Interventional radiological therapies in colorectal hepatic metastases

Colorectal malignancy is the third most common cancer and one of the prevalent causes of death globally. Around 20-25% of patients present with metastases at the time of diagnosis, and 50-60% of patients develop metastases in due course of the disease. Liver, followed by lung and lymph nodes, are the most common sites of colorectal cancer metastases. In such patients, the 5-year survival rate is approximately 19.2%. Although surgical resection is the primary mode of managing colorectal cancer metastases, only 10-25% of patients are competent for curative therapy. Hepatic insufficiency may be the aftermath of extensive surgical hepatectomy. Hence formal assessment of future liver remnant volume (FLR) is imperative prior to surgery to prevent hepatic failure. The evolution of minimally invasive interventional radiological techniques has enhanced the treatment algorithm of patients with colorectal cancer metastases. Studies have demonstrated that these techniques may address the limitations of curative resection, such as insufficient FLR, bi-lobar disease, and patients at higher risk for surgery. This review focuses on curative and palliative role through procedures including portal vein embolization, radioembolization, and ablation. Alongside, we deliberate various studies on conventional chemoembolization and chemoembolization with irinotecan-loaded drug-eluting beads. The radioembolization with Yttrium-90 microspheres has evolved as salvage therapy in surgically unresectable and chemo-resistant metastases.

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

Effectiveness of Repeated Stereotactic Body Radiation Therapy for Hepatocellular Carcinoma-Consideration of the Locations of Target Lesions

The present study retrospectively evaluated the efficacy of stereotactic body radiation therapy (SBRT), including repeated SBRT, for hepatocellular carcinoma. Participants comprised 220 HCC patients treated with SBRT in Hiroshima University Hospital between December 2008 and December 2021. Median overall survival (OS) and disease-free survival were 52 months (range, 45-64 months) and 17 months (range, 14-23 months), respectively. The 5-year local tumor recurrence rate was 3.4% (95% confidence interval (CI), 1.3-6.9%). Fifty-three patients underwent repeated SBRT (twice, 53 cases; three times, 10 cases; four times, 4 cases; five times, 1 case). Median interval between first and second SBRT was 20 months. Median OS from first SBRT was 76 months (95% CI, 50-102 months). Among patients with repeated SBRT, only one case showed local recurrence after second SBRT. Albumin-bilirubin score increased significantly from 6 to 12 months after repeated SBRT, both in the same segment and in remote segments, but the increase was not significant in the same segment. Only one case of grade 3 bile duct stricture was observed in patients who were treated with repeated SBRT. In conclusion, repeated SBRT provides good local control and a low risk of side effects.

Clinical efficacy of CT-guided 125I brachytherapy in patients with local residual or recurrent hepatocellular carcinoma after thermal ablation

OBJECTIVES

Treatment methods of local residual or recurrent hepatocellular carcinoma (HCC) after thermal ablation are limited. Therefore, our study aimed to explore the efficacy and prognostic factors of ¹²⁵I brachytherapy for local residual or recurrent lesion after thermal ablation.

METHODS

A total of 114 patients with 212 local residual or recurrent HCC tumors after thermal ablation underwent ¹²⁵I brachytherapy. Local progression-free survival (LPFS) and prognostic factors were analyzed by Kaplan-Meier curves and the Cox model.

RESULTS

After a 6-month follow-up, the percentage of patients who achieved complete response (CR), partial response (PR), and stable disease (SD) was 57%, 13.2%, and 5.2%, respectively. The 1-, 2-, and 3-year LPFS rates were 58.7%, 50.0%, and 41.2%, respectively. Portal vein tumor thrombus (PVTT) (p = 0.03), the number of intrahepatic tumors (p = 0.01), and AFP level (p = 0.02) were independent risk factors for local tumor progression (LTP). The median LPFS in patients without PVTT (22 months) was much longer compared to those with PVTT (10 months). The median LPFS in patients with less than three intrahepatic lesions improved from 17 to 24 months. The median LPFS was only 5 months in the high AFP group, but was prolonged with a decrease in AFP level (24 months). No severe complications were recorded. All complications were controllable and treatable.

CONCLUSIONS

CT-guided ¹²⁵I brachytherapy was a safe and effective treatment for patients with local residual or recurrent HCC after thermal ablation to improve local control rate.

2022 KLCA-NCC Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

Safety and efficacy of pentazocine–midazolam combination for pain and anxiety relief in radiofrequency ablation therapy for hepatocellular carcinoma

Background and Aim

Radiofrequency ablation (RFA) therapy is frequently used as first‐line treatment for small hepatocellular carcinoma (HCC). RFA is often associated with pain; however, no definitive solution has been established for its relief. We retrospectively analyzed the safety and efficacy of the combination of pentazocine and midazolam to relieve pain experienced by HCC patients undergoing RFA.

Methods

We studied 77 patients with 98 HCCs treated with RFA between January 2015 and August 2019. Patients were divided into two groups: the sedative‐free group, which included those who received pentazocine alone, and the pentazocine–midazolam group, which included those who received a combination of pentazocine and midazolam. The degrees of analgesia and sedation were evaluated using the numerical rating scale (NRS) and the Richmond Agitation‐Sedation Scale (RASS), respectively. Other parameters such as treatment time, awakening time, midazolam dosage, vital signs, local recurrence rate, and time to recurrence were also examined.

Results

The median NRS score and RASS score were significantly lower in the pentazocine–midazolam group. Ninety‐five percent of patients in the pentazocine–midazolam group had no memory of the RFA session. The treatment time and awakening time were prolonged for the pentazocine–midazolam group. No significant differences in oxygen saturation, recurrence rates, and time to local recurrence were observed between groups.

Conclusion

A combination of pentazocine and midazolam is safe and effective for pain and anxiety relief experienced by patients undergoing RFA for local treatment of HCC.

All-trans retinoic acid (ATRA) inhibits insufficient radiofrequency ablation (IRFA)-induced enrichment of tumor-initiating cells in hepatocellular carcinoma

OBJECTIVE

Local recurrence of hepatocellular carcinoma (HCC) after radiofrequency ablation (RFA) treatment remains a serious problem. Tumor-initiating cells (TICs) are thought to be responsible for tumor relapse. Here, we investigated the effect of the TIC differentiation inducer, all-trans retinoic acid (ATRA), on RFA and explored the potential molecular mechanisms.

METHODS

The proportions of CD133+ and epithelial cell adhesion molecule (EpCAM)+ TICs in recurrent HCC after RFA and primary HCC were first determined in clinic. Then, the effect of heat intervention or insufficient RFA (IRFA) on the malignant potential of HCC cells, including cell migration, sphere formation ability, tumor growth, the proportion of CD133+ and EpCAM+ TICs and expression of stem cell-related genes, was evaluated in vitro andin vivo. Finally, the effect of ATRA on the tumor growth and the proportion of TICs was evaluated.

RESULTS

In clinical data, a higher proportion of CD133+ and EpCAM+ TICs was found in recurrent tumors than in primary tumors. In vitro heat intervention promoted the cell migration and sphere formation ability. Additionally, it increased the proportion of CD133+ and EpCAM+ TICs and the expression of stem cell-related genes. In addition, after IRFA the residual tumors in xenografts grew faster and had more TICs than untreated tumors. ATRA remarkably inhibited residual tumor growth after IRFA by elimination of TICs though the PI3K/AKT pathway. Combination treatment with ATRA resulted in longer survival outcomes in mouse xenografts than RFA alone.

CONCLUSIONS

ATRA, as a TIC differentiation inducer, could help to improve the effect of RFA treatment, which was partially attributed to its effect against TICs. The data indicated its potential as an alternative drug in the development of better therapeutic strategies for use in combination with RFA.

Recent Advances in Local Thermal Ablation Therapy for Hepatocellular Carcinoma

Image-guided local thermal ablation (LTA) plays an important role in the treatment of hepatocellular carcinoma (HCC), especially in patients with HCC who are not suitable for hepatectomy. Radiofrequency ablation (RFA) and microwave ablation (MWA) are the most widely used LTA clinically. Radiofrequency ablation can achieve the best result; that is, a similar therapeutic effect as hepatectomy if the tumor ≤3 cm, while MWA can effectively ablate tumors ≤5 cm. Local thermal ablation has an advantage over liver resection in terms of minimally invasive surgery and can achieve a comparable prognosis and efficacy to liver resection. For borderline liver function, selecting LTA as the first-line therapy may bring more benefits to patients with cirrhosis background. In addition, a combination of multiple therapies for HCC is a good choice, such as LTA combined with transcatheter arterial chemoembolization (TACE), which can achieve a better prognosis than single therapy for larger tumors. For patients who are awaiting liver transplantation, LTA is a good choice. The main problem of LTA needed to be solved is to prevent the local tumor recurrence after ablation in patients with HCC.

Recent Advances in Local Thermal Ablation Therapy for Hepatocellular Carcinoma

Image-guided local thermal ablation (LTA) plays an important role in the treatment of hepatocellular carcinoma (HCC), especially in patients with HCC who are not suitable for hepatectomy. Radiofrequency ablation (RFA) and microwave ablation (MWA) are the most widely used LTA clinically. Radiofrequency ablation can achieve the best result; that is, a similar therapeutic effect as hepatectomy if the tumor ≤3 cm, while MWA can effectively ablate tumors ≤5 cm. Local thermal ablation has an advantage over liver resection in terms of minimally invasive surgery and can achieve a comparable prognosis and efficacy to liver resection. For borderline liver function, selecting LTA as the first-line therapy may bring more benefits to patients with cirrhosis background. In addition, a combination of multiple therapies for HCC is a good choice, such as LTA combined with transcatheter arterial chemoembolization (TACE), which can achieve a better prognosis than single therapy for larger tumors. For patients who are awaiting liver transplantation, LTA is a good choice. The main problem of LTA needed to be solved is to prevent the local tumor recurrence after ablation in patients with HCC.

Initial Incomplete Thermal Ablation Is Associated With a High Risk of Tumor Progression in Patients With Hepatocellular Carcinoma

Purpose

To investigate whether incomplete thermal ablation is associated with a high risk of tumor progression in patients with hepatocellular carcinoma (HCC), and to compare the efficacy of repeated thermal ablation and transarterial chemoembolization (TACE) for residual tumor after incomplete ablation.

Methods

This retrospective study included 284 patients with unresectable HCC who underwent thermal ablation from June 2014 to September 2020. The response of the initially attempted ablation was classified into complete (n=236) and incomplete (n=48). The progression-free survival (PFS) and overall survival (OS) were compared between patients with complete and incomplete responses, before and after a one-to-one propensity score-matching (PSM), and between patients in whom repeated ablation or TACE was performed after a first attempt incomplete ablation.

Results

After PSM of the 284 patients, 46 pairs of patients were matched. The PFS was significantly higher in the complete response group than in the incomplete response group (P<0.001). No difference in OS was noted between two groups (P=0.181). After a first attempt incomplete ablation, 29 and 19 patients underwent repeated ablation and TACE, respectively. There were no significant differences in PFS (P=0.424) and OS (P=0.178) between patients who underwent repeated ablation and TACE. In multivariate Cox regression analysis, incomplete response (P<0.001) and Child-Pugh class B (P=0.017) were independent risk factors for tumor progression, while higher AFP level (P=0.011) and Child-Pugh class B (P=0.026) were independent risk factors for poor OS.

Conclusion

Although patients with incomplete ablation are associated with tumor progression compared with those with complete ablation, their OS is not affected by incomplete ablation. When patients present with residual tumors, TACE may be an alternative if repeated ablation is infeasible.

Four types of tumor progression after microwave ablation of single hepatocellular carcinoma of ≤5 cm: incidence, risk factors and clinical significance

OBJECTIVES

To evaluate the incidence, risk factors and clinical significance of four types of tumor progression (TP) after microwave ablation (MWA) of single hepatocellular carcinoma (HCC) of <5 cm.

METHODS

The data of 340 treatment-naïve, HCC patients with a single HCC of <5 cm underwent MWA between April 2012 and November 2017 were retrospectively reviewed. TPs including local tumor progression (LTP), intrahepatic distant recurrence (IDR), aggressive intrasegmental recurrence (AIR) and extrahepatic distant recurrence (EDR) were reviewed and compared between BCLC stage 0 and A. Univariate and multivariate analysis were performed on clinicopathological variables and different TPs to identify factors affecting long-term overall survival (OS).

RESULTS

In a median follow-up period of 25.6 months (range, 3.1-61.4 months), the rate of LTP, IDR, AIR and EDR was 6.2% (21/340), 29.1% (98/340), 3.2% (11/340) and 7.9% (27/340). The four types of TP occurrence rates in BCLC stage 0 were comparable to those in BCLC stage A (p = 0.492, 0.971, 0.681 and 0.219). Univariate analysis showed that age (p < 0.001, hazard ratio [HR] = 2.783), comorbidities (p = 0.042, HR = 1.864), IDR, AIR and EDR (p = 0.027, HR = 1.719; p = 0.001, HR = 3.628; p = 0.009, HR = 2.638) were independently associated with OS. Multivariate analysis showed older age (p < 0.001, HR = 2.478), the occurrence of AIR (p < 0.001, HR = 2.648) and the occurrence of EDR (p = 0.002, HR = 2.222), were associated with poor OS.

CONCLUSIONS

The occurrence rate of IDR is the highest of all TPs following MWA of a single HCC of <5cm. Old age, AIR and EDR had an adverse effect on long-term OS.

Radiofrequency ablation with four electrodes as a building block for matrix radiofrequency ablation: Ex vivo liver experiments and finite element method modelling. Influence of electric and activation mode on coagulation size and geometry

PURPOSE

Radiofrequency ablation (RFA) is increasingly being used to treat unresectable liver tumors. Complete ablation of the tumor and a safety margin is necessary to prevent local recurrence. With current electrodes, size and shape of the ablation zone are highly variable leading to unsatisfactory local recurrence rates, especially for tumors >3 cm. In order to improve predictability, we recently developed a system with four simple electrodes with complete ablation in between the electrodes. This rather small but reliable ablation zone is considered as a building block for matrix radiofrequency ablation (MRFA). In the current study we explored the influence of the electric mode (monopolar or bipolar) and the activation mode (consecutive, simultaneous or switching) on the size and geometry of the ablation zone.

MATERIALS AND METHODS

The four electrode system was applied in ex vivo bovine liver. The electric and the activation mode were changed one by one, using constant power of 50 W in all experiments. Size and geometry of the ablation zone were measured. Finite element method (FEM) modelling of the experiment was performed.

RESULTS

In ex vivo liver, a complete and predictable coagulation zone of a 3 × 2 × 2 cm block was obtained most efficiently in the bipolar simultaneous mode due to the combination of the higher heating efficacy of the bipolar mode and the lower impedance by the simultaneous activation of four electrodes, as supported by the FEM simulation.

CONCLUSIONS

In ex vivo liver, the four electrode system used in a bipolar simultaneous mode offers the best perspectives as building block for MRFA. These results should be confirmed by in vivo experiments.

Ultrasound-guided secondary radiofrequency ablation combined with chemotherapy in gastric cancer with recurrent liver metastasis

Background

The incidence and mortality of gastric cancer are in the second and third place of malignant tumor in China, respectively. Liver metastasis is an important cause of death of these patients. This study is to explore whether the secondary radiofrequency ablation (RFA) treatment can prolong the survival period and improve the life quality of patients with gastric cancer and recurrent liver metastases.

Methods

A total of 87 patients with gastric cancer and recurrent liver metastases were retrospective analyzed, 46 cases were assigned into study group and 41 cases in control group. The efficacy of the two groups was observed, and the prognostic factors were analyzed.

Results

The median survival time in the study group was significantly longer than that in the control group (P<0.05). The survival rate of the study group was significantly higher than that of the control group (both P<0.05). The life quality scores of the study group were significantly higher than the control group (both P<0.05).

Conclusions

Ultrasound-mediated secondary RFA combined with chemotherapy is superior to chemotherapy alone in the treatment of gastric cancer with recurrent liver metastases.

Performance of LI-RADS version 2018 CT treatment response algorithm in tumor response evaluation and survival prediction of patients with single hepatocellular carcinoma after radiofrequency ablation

BACKGROUND

The Liver Imaging Reporting and Data System treatment response algorithm (LI-RADS TRA) was developed to evaluate the tumor response of patients with hepatocellular carcinoma (HCC) after locoregional treatments. This study aimed to evaluate the performance of LI-RADS computed tomography (CT) TRA version 2018 in tumor response assessment and survival prediction of patients with single HCC after radiofrequency ablation (RFA).

METHODS

Forty patients who underwent RFA for single HCC between 2010 and 2016 were included in this retrospective study. The overall survival (OS) data from all the patients after the first therapy was collected. Two readers independently assessed the pretreatment (within 7 d) and posttreatment (within 90 d after RFA) CT manifestations using the LI-RADS version 2018 CT TRA. Inter-reader agreement was assessed. Another radiologist re-evaluated any divergent results and came to the final conclusion. The performance of LI-RADS version 2018 CT TRA for tumor response assessment and predicting survival of patients with single HCC after RFA was evaluated.

RESULTS

Interobserver agreement was moderate between the 2 readers [κ=0.602, 95% confidence interval (CI): 0.390-0.814] when using LI-RADS version 2018 TRA to evaluate tumor response for patients with single HCC after RFA. Patients classified as LR-TR viable had significantly lower OS than those classified as LR-TR nonviable (P=0.005) and LR-TR equivocal (P=0.036). However, the OS between LR-TR nonviable and LR-TR equivocal did not differ significantly (P=0.901).

CONCLUSIONS

LI-RADS version 2018 CT TRA can be applied to predict viable or nonviable HCC after RFA. Patients with LR-TR viable had significantly lower OS than those with LR-TR nonviable and LR-TR equivocal. More research is needed to validate the performance of LI-RADS version 2018 TRA in HCC tumor response evaluation, to better grasp the use of the tie-breaking rule, and to improve the accuracy of prediction for tumor viability.

Single Hepatocellular Carcinoma approached by curative-intent treatment: A propensity score analysis comparing radiofrequency ablation and liver resection

INTRODUCTION

Patients with a single small Hepatocellular Carcinoma (HCC) may be definitively treated by Radiofrequency ablation (RFA) with a very low rate of peri-operative morbidity. However, results are still controversial comparing RFA to Liver Resection (LR).

METHODS

All consecutive patients treated by RFA or LR for a single untreated small HCC on liver cirrhosis between January 2006-December 2016 were enrolled. Patients were matched 1:1 basing on: age, MELD-score, platelet count, nodule's diameter, HCV status, α-fetoprotein level, and Albumin-Bilirubin score. First analysis compered LR to RFA. Second analysis compared Laparoscopic LR (LLR) to RFA.

RESULTS

Of 484 patients with single small HCC, 91 patients were selected for each group after a 1:1 propensity score matching (PS-M). The 5-years OS was 70% and 60% respectively for LR and RFA group (P = 0.666). The 5-year RFS was 36% and 21% respectively for LR and RFA group (P < 0.001). Patients treated by LR had a significantly longer hospital stay and higher complications rate. Comparing 50 cases of LLR and 50 of RFA, the 5-years OS was 79% and 56% respectively for LLR and RFA group (P = 0.22). The 5-year RFS was 54% and 19% respectively for LR and RFA group (P < 0.001). Post-operative complications were not significantly different.

CONCLUSIONS

LLR confers similar peri-operative complications rate compared to RFA. LLR should be considered as a first-line approach for the treatment of a single small HCC as it combines the effectiveness of open LR and the safety profile of RFA.

Efficacy of transarterial chemoembolization compared with radiofrequency ablation for the treatment of recurrent hepatocellular carcinoma after radiofrequency ablation

Purpose: To compare the efficacy and outcome of transarterial chemoembolization (TACE) with radiofrequency ablation (RFA) in the treatment of recurrent hepatocellular carcinoma (HCC) after initial RFA.Material and methods: From January 2008 to December 2014, 199 consecutive patients with primary HCC underwent percutaneous RFA as initial treatment. One hundred and fourteen patients developed intrahepatic recurrent HCC after initial RFA. The patients with recurrent tumor size ≤3 cm and tumor numbers ≤3 who underwent RFA (n = 47) or TACE (n = 31) were included in study. Progression-free survival (PFS), tumor response to treatment and overall survival (OS) were assessed. Prognostic factors for OS were analyzed using multivariate Cox proportional hazard models.Results: The baseline data of initial HCC and the first recurrence of HCC were comparable in both groups. The complete response (CR) rate in the RFA group and the TACE group was 95.7% and 50%, respectively (p < .001). The PFS time in the RFA group and the TACE group was 424 days and 275 days, respectively (p = .004). The one-year and three-year cumulative overall survival rate was 93.5% and 45% in the TACE group, 91.3% and 68.8% in the RFA group (p = .49), respectively. Significant predictive factors for OS were tumor size (HR = 1.951, 95%CI 1.061-3.687, p = .032), prothrombin time (HR = 1.59, 95%CI 1.012-2.498, p = .044) and response to treatment (HR = 0.267, 95%CI 0.092-0.78, p = .016).Conclusion: Repeated RFA is still considered to be the first treatment choice for patients with post-RFA intrahepatic recurrence. However, TACE should also be considered due to comparable overall survival benefits. The advantages of being less invasive and highly repeatable may render TACE to be a preferred treatment for some patients with recurrent HCC after RFA.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology, and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

Impact of the Uridine⁻Cytidine Kinase Like-1 Protein and IL28B rs12979860 and rs8099917 SNPs on the Development of Hepatocellular Carcinoma in Cirrhotic Chronic Hepatitis C Patients-A Pilot Study

Background and objectives: The hepatitis C virus (HCV) is the major causative agent of hepatocellular carcinoma (HCC) in the western world. The efficacy of surveillance programs for early detection of HCC is not satisfactory: many tumors are diagnosed at the late, incurable stages. Therefore, there is a need in reliable prognostic markers for the proper follow-up of HCV-positive patients. The aim of the present study was to assess the prognostic value of the uridine⁻cytidine kinase-like protein 1 (UCKL-1), a putative oncoprotein, together with genetically determined polymorphisms in the interleukin 28B (IL28B) gene (rs12979860, rs8099917) in the development of HCC in HCV-positive cirrhotic patients. Materials and Methods: We included 32 HCV cirrhotic patients, 21 (65.6%) of whom had HCC. The expression of UCKL-1 was assessed in liver tissue sections, using immunohistochemistry. For IL28B rs12979860 and rs8099917 genotype analysis, the corresponding genomic regions were amplified by polymerase chain reaction (PCR) with appropriate primers. Results: We have found that UCKL-1 expression was significantly increased in HCC (p = 0.003). The presence of rs8099917 TT single-nucleotide polymorphism (SNP) elevated the chances of HCC manifestation more than sevenfold (OR = 7.3, p = 0.0273). The presence of rs12979860 CC SNP also heightened HCC chances more than sevenfold (OR = 7.5, p = 0.0765). Moreover, in the HCC group, a combination of IL28B rs12979860 non-TT and rs8099917 TT genotypes was observed more often, compared with the non-HCC group. Other combinations of IL28B rs12979860 and rs8099917 SNIPs were associated with a reduced risk of HCC development, approximately at the same extent. Conclusions: The presence of IL28B rs8099917 TT and rs12979860 CC SNPs, but not the intensity of UCKL-1 expression, is strongly associated with increased chances of HCC development in HCV-positive cirrhotic patients.

Effect of silver nanoparticles in the induction of apoptosis on human hepatocellular carcinoma (HepG2) cell line

Silver nanoparticles (Ag NPs) serve numerous chief functions in cosmetics, engineering, textile, food technology and medicine. These nanoparticles are also utilized in the pharmaceutical industry particularly in the production of novel antimicrobial agents. However, despite the various studies of Ag NPs induced toxicity, there is a lack of information concerning cellular toxicity mechanisms of these nanoparticles on human cells. In the current project, we investigate the anti-cancer effects of Ag NPs in HepG2 (liver hepatocellular adenocarcinoma) cells. The mean particle size and morphology for the prepared nanoparticles were determined by dynamic light scattering (DLS) and transmission electron microscopy (TEM), respectively. Cell viability, reactive oxygen species (ROS) formation, cytochrome c amount and expression level of BAX/CASP 3/CASP 8/CASP 9 were assayed in HepG2 cells after incubation with Ag NPs. The prepared nanoparticles showed the mean particle size of 30.71 nm with polydispersity index (PDI) of 0.21. Our results revealed decreased cell viability in a concentration-dependent manner and the IC50 of 75 μg/mL for Ag NPs. Ag NPs cytotoxicity was associated with induction of ROS and cell apoptosis in HepG2 cell line. According to our findings, Ag NPs could be considered as potential chemotherapeutic agents in the treatment of liver hepatocellular carcinoma.

Insufficient radiofrequency ablation promotes proliferation of residual hepatocellular carcinoma via autophagy

Radiofrequency ablation (RFA) is considered to be a potentially curative therapy for hepatocellular carcinoma (HCC). However, insufficient RFA (IRFA) can promote rapid progression of the residual tumor. The mechanisms underlying IRFA-induced tumor promotion remain poorly understood. In the present study, we have established a subcutaneous xenograft mouse model and monitored the location and extent of IRFA by dual monitoring with ultrasonography and a thermal imager. For the first time, we provide evidence of the activation of autophagic pathways in mice exposed to IRFA. We show that autophagy plays an important role in relapse and proliferation after IRFA and that hydroxychloroquine (HCQ) can suppress these effects. Our findings indicate that autophagy is involved in experimental IRFA and that inhibition of autophagy may be a novel approach in the treatment of local recurrences of HCC after IRFA in the clinic.

Diagnostic accuracy of different magnetic resonance imaging sequences for detecting local tumor progression after radiofrequency ablation of hepatic malignancies

OBJECTIVE

To evaluate the diagnostic accuracy of the individual sequences of a clinical routine liver MRI protocol for the detection of local tumour progression after radiofrequency (RF) ablation of hepatic malignancies.

MATERIAL AND METHODS

A cohort of 93 patients treated for 140 primary and secondary hepatic malignancies with RF ablation was assembled for this retrospective study. The cohort contained 31 cases of local tumour progression, which occurred 8.3±6.2months (range: 4.0-28.2 months) after treatment. All patients underwent clinical routine follow-up MRI at 1.5T including following sequences: unenhanced T1-weighted fast low angle shot (FLASH-2D), T2-weighted turbo-spin-echo sequence, contrast-enhanced (CE) T1-weighted volume-interpolated breath-hold examination (VIBE), diffusion-weighted imaging (DWI). Follow-up was 32.7±22.5months (range: 4.0-138.3 months). Two readers independently evaluated the individual sequences separately for signs of local tumour progression. Diagnostic confidence was rated on a 4-point scale. Inter-reader agreement was assessed with Coheńs kappa. Long-term follow-up and histological specimen served as standard of reference.

RESULTS

Both readers reached the highest sensitivity for detection of local tumour progression with unenhanced T1-FLASH 2D (88.2% and 94.1%, respectively) and the highest specificity with CE T1-VIBE (96.2% and 97.2%, respectively). Highest inter-reader agreement was reached with T1-FLASH-2D (kappa=0.83). Typical pitfalls for false-positive diagnoses were focal cholestasis and vasculature adjacent to the ablation zone. Diagnostic confidence was highest with CE T1-VIBE for reader 1 and DWI for reader 2.

CONCLUSION

Unenhanced T1-FLASH-2D is an essential sequence for follow-up imaging after tumour ablation with a high sensitivity for detection of local progression and a high inter-reader agreement.

Radiofrequency ablation for HCC patients with multifocal tumours meeting the Milan criteria: A single-centre experience

BACKGROUND

Radiofrequency ablation (RFA) has been recommended as a curative treatment for patients with single early-stage unifocal hepatocellular carcinomas (HCCs) for years; however, the effect of this treatment on multifocal tumours has remained uncertain.

AIMS

We conducted a retrospective study to evaluate the overall survival (OS) and recurrence-free survival (RFS) rates of early HCC patients with multiple tumours subjected to different RFA modalities.

METHODS

One hundred fifty-four HCC patients with multifocal tumours who met the Milan criteria and underwent RFA were enrolled in this study. We divided the patients into 3 groups according to the surgical approach utilised (percutaneous, laparoscopic and open RFA; selection was based on the locations of the tumours for whether they were adhered to the subhepatic inferior vena cava or the gastrointestinal tract) and into 2 subgroups according to the tumour numbers and locations.

RESULTS

No deaths occurred in the 30-day post-operation period, and there were no significant differences in the complication, OS or RFS rates between the 3 groups. The 1-, 3- and 5-year OS rates were 88.9%, 75.5% and 50.9% in the subgroup with 2 tumours, respectively, versus 91.3%, 56.3% and 17.5% in the subgroup with 3 tumours, respectively (P=0.001). The corresponding values were 93.2%, 77.4% and 50.8% in the subgroup with tumours in the same segment and 82.4%, 54.8% and 23.0% in the subgroup with tumours in different segments (P=0.001).

CONCLUSION

RFA was proven to be an effective and safe method for the treatment of multifocal HCCs. Among the patients with 2 tumours within the same segment, RFA achieved better long-term outcomes in terms of both overall and recurrence-free survival.

Electric Ablation with Irreversible Electroporation (IRE) in Vital Hepatic Structures and Follow-up Investigation

Irreversible electroporation (IRE) with microsecond-pulsed electric fields (μsPEFs) can effectively ablate hepatocellular carcinomas in animal models. This preclinical study evaluates the feasibility and safety of IRE on porcine livers. Altogether, 10 pigs were included. Computed tomography (CT) was used to guide two-needle electrodes that were inserted near the hilus hepatis and gall bladder. Animals were followed-up at 2 hours and at 2, 7 and 14 days post-treatment. During and after μsPEF ablation, electrocardiographs found no cardiovascular events, and contrast CT found no portal vein thrombosis. There was necrosis in the ablation zone. Mild cystic oedema around the gall bladder was found 2 hours post-treatment. Pathological studies showed extensive cell death. There was no large vessel damage, but there was mild endothelial damage in some small vessels. Follow-up liver function tests and routine blood tests showed immediate liver function damage and recovery from the damage, which correlated to the pathological changes. These results indicate that μsPEF ablation affects liver tissue and is less effective in vessels, which enable μsPEFs to ablate central tumour lesions close to the hilus hepatis and near large vessels and bile ducts, removing some of the limitations and contraindications of conventional thermal ablation.