Cost-effectiveness of percutaneous radiofrequency ablation for malignant hepatic neoplasms

Cost Analysis of Radiofrequency Ablation for Adrenal Adenoma in Patients with Primary Aldosteronism and Hypertension: Results from the ADERADHTA Pilot Study and Comparison with Surgical Adrenalectomy

PURPOSE

Primary Aldosteronism (PA) is increasingly considered as a common disease affecting up to 10% of the hypertensive population. Standard of care comprises laparoscopic total adrenalectomy but innovative treatment such as RadioFrequency Ablation (RFA) constitutes an emerging promising alternative to surgery. The main aim of this study is to analyse the cost of RFA versus surgery on aldosterone-producing adenoma patient from the French National Health Insurance (FNHI) perspective.

METHODS

The ADERADHTA study was a prospective pilot study aiming to evaluate both safety and efficacy of the novel use of adrenal RFA on the patients with PA. This study conducted on two French sites and enrolled adult patients, between 2016 and 2018, presenting hypertension and underwent the RFA procedure. Direct medical (inpatient and outpatient) and non-medical (transportation, daily allowance) costs were calculated over a 6-month follow-up period. Moreover, the procedure costs for the RFA were calculated from the hospital perspective. Descriptive statistics were implemented.

RESULTS

Analysis was done on 21 patients in RFA groups and 27 patients in the surgery group. The difference in hospital costs between the RFA and surgery groups was €3774 (RFA: €1923; Surgery: €5697 p < 0.001) in favour of RFA. Inpatient and outpatient costs over the 6-month follow-up period were estimated at €3,48 for patients who underwent RFA. The production cost of implementing the RFA procedure was estimated at €1539 from the hospital perspective.

CONCLUSION

Our study was the first to show that RFA is 2 to 3 times less costly than surgery. The trial is registered at ClinicalTrials.gov under the number NCT02756754.

A computational framework to simulate the thermochemical process during thermochemical ablation of biological tissues

Thermochemical ablation (TCA) is a thermal ablation therapy that utilises heat released from acid-base neutralisation reaction to destroy tumours. This procedure is a promising low-cost solution to existing thermal ablation treatments such as radiofrequency ablation (RFA) and microwave ablation (MWA). Studies have demonstrated that TCA can produce thermal damage that is on par with RFA and MWA when employed properly. Nevertheless, TCA remains a concept that is tested only in a few animal trials due to the risks involved as the result of uncontrolled infusion and incomplete acid-base reaction. In this study, a computational framework that simulates the thermochemical process of TCA is developed. The proposed framework consists of three physics, namely chemical flow, neutralisation reaction and heat transfer. An important parameter in the TCA framework is the neutralisation reaction rate constant, which has values in the order of 10⁸ m³/(mol⋅s). The present study will demonstrate that since the rate constant impacts only the rate and direction of the reaction but has little influence on the extent of reaction, it is possible to replicate the thermochemical process of TCA by employing significantly smaller values of rate constant that are numerically tractable. Comparisons of the numerical results against experimental studies from the literature supports this. The aim of this framework is for researchers to advance and develop TCA to gain an in-depth understanding of the fundamental mechanisms of TCA and to develop a safe treatment protocol of TCA in the hope of advancing TCA into clinical trials.

A Systematic Review of Cost-Effectiveness Analyses for Hepatocellular Carcinoma Treatment

BACKGROUND

Hepatocellular carcinoma (HCC) is associated with significant financial burden for patients and payers. The objective of this study was to review economic models to identify, evaluate, and compare cost-effectiveness estimates for HCC treatments.

METHODS

A systematic search of the PubMed, Embase, and Cochrane Library databases to identify economic evaluations was performed and studies that modeled treatments for HCC reporting costs and cost effectiveness were included. Risk of bias was assessed qualitatively, considering costing approach, reported study perspective, and funding received. Intervention costs were adjusted to 2021 US dollars for comparison. For studies reporting quality-adjusted life-years (QALYs), we conducted analyses stratified by comparison type to assess cost effectiveness at the time of the analysis.

RESULTS

A total of 27 studies were included. Non-curative versus non-curative therapy comparisons were used in 20 (74.1%) studies, curative versus curative comparisons were used in 5 (18.5%) studies, and curative versus non-curative comparisons were used in 2 (7.4%) studies. Therapy effectiveness was estimated using a QALY measure in 20 (74.1%) studies, while 7 (25.9%) studies only assessed life-years gained (LYG). A health sector perspective was used in 26 (96.3%) of the evaluations, with only 1 study including costs beyond this perspective. Median intervention cost was $53,954 (range $4550-$4,760,835), with a median incremental cost of $6546 (range - $72,441 to $1,279,764). In cost-utility analyses, 11 (55%) studies found the intervention cost effective using a $100,000/QALY threshold at the time of the study, with an incremental cost-effectiveness ratio (ICER) ranging from - $1,176,091 to $1,152,440 when inflated to 2021 US dollars.

CONCLUSION

The majority of HCC treatments were found to be cost effective, but with significant variation and with few studies considering indirect costs. Standards for value assessment for HCC treatments may help improve consistency and comparability.

Cost effectiveness and the role of the National Institute of Health and Care Excellence (NICE) in interventional radiology

Healthcare expenditure is continually increasing and projected to accelerate in the future, with an increasing proportion being spent on interventional radiology. The role of cost effectiveness studies in ensuring the best allocation of resources is discussed, and the role of National Institute of Health and Care Excellence (NICE) in determining this. Issues with demonstrating cost effectiveness have been discussed, and it has been found that there is significant scope for improving cost effectiveness, with suggestions made for how this can be achieved. In this way, more patients can benefit from better treatment given limited healthcare budgets.

Contrast-Enhanced Ultrasonography for Screening and Diagnosis of Hepatocellular Carcinoma: A Case Series and Review of the Literature

Background: Contrast-enhanced ultrasound (CEUS) is a safe and noninvasive imaging technique that can characterize and evaluate liver lesions, and has been approved for this use in the Unites States since 2016. CEUS has been shown to be similar in accuracy to computed tomography (CT) and magnetic resonance imaging (MRI) for noninvasive diagnosis of hepatocellular carcinoma (HCC) and offers several advantages in certain patient populations who have contraindications for CT or MRI. However, CEUS has inherent limitations and has not been widely employed for evaluation of HCC. Methods: We present three retrospective cases of liver lesions in patients with cirrhosis, who underwent screening for HCC using concurrent, well-timed CT and CEUS. Results: In these cases, the liver lesions were better visualized and then diagnosed as malignancy via CEUS, whereas the lesions were best appreciated on CT only in retrospect. Conclusions: In some cirrhotic patients, a focal lesion may be more easily identifiable via CEUS than on CT and thus accurately characterized, suggesting an important and complementary role of CEUS with CT or MRI. Further studies are indicated to support the use of CEUS for the diagnosis and characterization of liver lesions in screening patients at risk for developing HCC.

Image-guided tumor ablation: standardization of terminology and reporting criteria--a 10-year update

Image-guided tumor ablation has become a well-established hallmark of local cancer therapy. The breadth of options available in this growing field increases the need for standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison among treatments that use different technologies, such as chemical (eg, ethanol or acetic acid) ablation, thermal therapies (eg, radiofrequency, laser, microwave, focused ultrasound, and cryoablation) and newer ablative modalities such as irreversible electroporation. This updated consensus document provides a framework that will facilitate the clearest communication among investigators regarding ablative technologies. An appropriate vehicle is proposed for reporting the various aspects of image-guided ablation therapy including classification of therapies, procedure terms, descriptors of imaging guidance, and terminology for imaging and pathologic findings. Methods are addressed for standardizing reporting of technique, follow-up, complications, and clinical results. As noted in the original document from 2003, adherence to the recommendations will improve the precision of communications in this field, leading to more accurate comparison of technologies and results, and ultimately to improved patient outcomes.

Image-guided tumor ablation: standardization of terminology and reporting criteria--a 10-year update

Image-guided tumor ablation has become a well-established hallmark of local cancer therapy. The breadth of options available in this growing field increases the need for standardization of terminology and reporting criteria to facilitate effective communication of ideas and appropriate comparison among treatments that use different technologies, such as chemical (eg, ethanol or acetic acid) ablation, thermal therapies (eg, radiofrequency, laser, microwave, focused ultrasound, and cryoablation) and newer ablative modalities such as irreversible electroporation. This updated consensus document provides a framework that will facilitate the clearest communication among investigators regarding ablative technologies. An appropriate vehicle is proposed for reporting the various aspects of image-guided ablation therapy including classification of therapies, procedure terms, descriptors of imaging guidance, and terminology for imaging and pathologic findings. Methods are addressed for standardizing reporting of technique, follow-up, complications, and clinical results. As noted in the original document from 2003, adherence to the recommendations will improve the precision of communications in this field, leading to more accurate comparison of technologies and results, and ultimately to improved patient outcomes. Online supplemental material is available for this article .

Cost-effectiveness analysis on the surveillance for hepatocellular carcinoma in liver cirrhosis patients using contrast-enhanced ultrasonography

AIM

  Sonazoid is a new contrast agent for ultrasonography (US). Contrast-enhanced ultrasonography (CEUS) using Sonazoid enables Kupffer imaging, which improves the sensitivity of hepatocellular carcinoma (HCC) detection. However, there are no studies on the cost-effectiveness of HCC surveillance using Sonazoid.

METHODS

  We constructed a Markov model simulating the natural history of HCV-related liver cirrhosis (LC) patients, and compared three strategies (no surveillance, US surveillance and CEUS surveillance). The transition probability and cost data were obtained from published data. The simulation and analysis were performed using TreeAge pro 2009 software.

RESULTS

  When compared to the no surveillance group, the US and CEUS surveillance groups increased the life expectancy by 1.67 and 1.99 quality-adjusted life-years (QALY), respectively, and the incremental cost effectiveness ratio (ICER) were 17 296 $US/QALY and 18 384 $US/QALY, respectively. These results were both less than the commonly-accepted threshold of $US 50 000/QALY. Even if the CEUS surveillance group was compared with the US surveillance group, the ICER was $US 24 250 and thus cost-effective. Sensitivity analysis showed that the annual incidence of HCC and CEUS sensitivity were two critical parameters. However, when the annual incidence of HCC is more than 2% and/or the CEUS sensitivity is more than 80%, the ICER was also cost-effective.

CONCLUSIONS

  Contrast-enhanced ultrasonography surveillance for HCC is a cost-effective strategy for LC patients and gains their longest additional life years, with similar degree of ICER in the US surveillance group. CEUS surveillance using Sonazoid is expected to be used not only in Japan, but also world-wide.

[Process-oriented cost calculation in interventional radiology. A case study]

PURPOSE

Currently used costing methods such as cost centre accounting do not sufficiently reflect the process-based resource utilization in medicine. The goal of this study was to establish a process-oriented cost assessment of percutaneous radiofrequency (RF) ablation of liver and lung metastases.

MATERIAL AND METHODS

In each of 15 patients a detailed task analysis of the primary process of hepatic and pulmonary RF ablation was performed. Based on these data a dedicated cost calculation model was developed for each primary process. The costs of each process were computed and compared with the revenue for in-patients according to the German diagnosis-related groups (DRG) system 2010.

RESULTS

The RF ablation of liver metastases in patients without relevant comorbidities and a low patient complexity level results in a loss of EUR 588.44, whereas the treatment of patients with a higher complexity level yields an acceptable profit. The treatment of pulmonary metastases is profitable even in cases of additional expenses due to complications.

CONCLUSION

Process-oriented costing provides relevant information that is needed for understanding the economic impact of treatment decisions. It is well suited as a starting point for economically driven process optimization and reengineering. Under the terms of the German DRG 2010 system percutaneous RF ablation of lung metastases is economically reasonable, while RF ablation of liver metastases in cases of low patient complexity levels does not cover the costs.

Time and dose dependence of pluronic bioactivity in hyperthermia-induced tumor cell death

Pluronic block copolymers have been shown to sensitize cancer cells resulting in an increased activity of antineoplastic agents. In the current study we examined a new application of Pluronic bioactivity in potentiating hyperthermia-induced cancer cell injury. DHD/K12/TRb rat adenocarcinoma cells were exposed to low-grade hyperthermia at 43 degrees C with or without Pluronic P85 or Pluronic L61. A range of Pluronic doses, pre-exposure and heat exposure durations were investigated, and the test conditions were optimized. Treatment efficacy was assessed by measurement of intracellular ATP and mitochondrial dehydrogenase activity. Both P85 and L61 in synergy with heat reduced cell viability appreciably compared to either heat or Pluronic alone. Under optimal conditions, P85 (10 mg/ml, 240 mins) combined with 15 mins heat reduced intracellular ATP to 60.1 +/- 3.5% of control, while heat alone and P85 without heat caused a negligible decrease in ATP of 1.2% and 3.8%, respectively. Similarly, cells receiving 120 mins pre-exposure of L61 (0.3 mg/ml) showed reduction in intracellular ATP to 14.1 +/- 2.1% of control. Again, heat or L61 pre-exposure alone caused a minor decrease in levels of intracellular ATP (1.5% and 4.4%, respectively). Comparable results were observed when viability was assessed by mitochondrial enzyme activity. Survival studies confirmed that the loss of viability translates to a long-term reduction in proliferative activity, particularly for L61 treated cells. Based on these results, we conclude that Pluronic is effective in improving hyperthermic cancer treatment in vitro by potentiating heat-induced cytotoxicity in a concentration and time dependent manner.

Cost of radiofrequency ablation in the treatment of hepatic malignancies

OBJECTIVES

Our primary objective was to assess the cost of radio-frequency ablation (RFA) of hepatic malignancies and to compare it to hospital reimbursement paid in the French Prospective Payment System (PPS).

PATIENTS AND METHODS

A series of 305 patients were enrolled into a prospective study. All resources used during the RFA-related hospital stay were recorded. Costs were assessed from the perspective of the health care providers and computed for four groups of patients: percutaneous RFA in an outpatient setting (group Ia, N=44), percutaneous RFA in an inpatient setting (group Ib, N=94), laparoscopic RFA (group II, N=44) and intraoperative RFA combined with resection (group III, N=120).

RESULTS

Mean hospital costs were estimated at euro 1581 (group Ia), euro 3824 (group Ib), euro 8194 (group II) and euro 12967 (group III). Costs per stay without intensive care in these groups were respectively euro 1581, euro 3635, euro 6622 and euro 10905 and reimbursement (intensive care excluded) was euro 560, euro 3367, euro 9084 and euro 11780.

CONCLUSION

In the French PPS, the cost of RFA is covered by lump sums paid to hospitals exclusively for intraoperative and laparoscopic RFA. For percutaneous RFA, which is the most frequent approach, reimbursement is highly insufficient.

Cost-effectiveness of the surveillance program of hepatocellular carcinoma depends on the medical circumstances

BACKGROUND AND AIM

The clinical features of hepatocellular carcinoma (HCC) and the medical environment are diverse in different geographic areas. The aim of this study is to evaluate the cost-effectiveness of the surveillance of HCC in different medical circumstances.

METHODS

The Markov model focused on variables that differ from country to country and may change in the future, especially in regards to the proportion of small HCC detected incidentally. The target population was 45-year-old patients with Child-Pugh class A cirrhosis, and the intervention was surveillance with ultrasonography every 6 months.

RESULTS

The additional cost of the surveillance was $US15 100, the gain in quality-adjusted life years (QALYs) was 0.50 years, and the incremental cost-effectiveness ratio (ICER) was $US29 900/QALY in a base-case analysis (annual incidence of HCC = 4%). If 40% of small HCC were detected incidentally without surveillance, the gain in QALY decreased to 0.15 and the ICER increased to $US47 900/QALY. The increase in the annual incidence of HCC to 8% resulted in the increase of QALYs to 0.81, and the decrease of the ICER to $US25 400/QALY. The adoption of liver transplantation increased the gain in QALYs and the ICER to 0.84 and $US59 900/QALY, respectively.

CONCLUSIONS

The gain in QALYs and the ICER due to the surveillance of HCC varies between different patient subgroups and it critically depends on the rate of small HCC detected incidentally without surveillance, as well as the annual incidence of HCC and the adoption of liver transplantation.

Palliative radiofrequency ablation for recurrent prostate cancer

Percutaneous radiofrequency ablation (RFA) is a minimally invasive local therapy for cancer. Its efficacy is now becoming well documented in many different organs, including liver, kidney, and lung. The goal of RFA is typically complete eradication of a tumor in lieu of an invasive surgical procedure. However, RFA can also play an important role in the palliative care of cancer patients. Tumors which are surgically unresectable and incompatible for complete ablation present the opportunity for RFA to be used in a new paradigm. Cancer pain runs the gamut from minor discomfort relieved with mild pain medication to unrelenting suffering for the patient, poorly controlled by conventional means. RFA is a tool which can potentially palliate intractable cancer pain. We present here a case in which RFA provided pain relief in a patient with metastatic prostate cancer with pain uncontrolled by conventional methods.

Hepatocellular carcinoma: current treatment strategies

Hepatocellular carcinoma (HCC) is an increasingly prevalent clinical problem. The presence of cirrhosis in the majority of patients makes treatment difficult because both the stage of the tumor and the stage of cirrhosis must be taken into account. This is compounded by the difficulty in diagnosing HCC in the early stages, where treatment is most effective, and the lack of a globally accepted treatment policy. Liver transplantation and liver resection are the optimal treatments, with resection being preferred in patients with small lesions, clinically well-preserved liver function, and absence of portal hypertension. Patients unsuitable for these procedures, due to localized but large tumor bulk, are only treatable by ablative and palliative therapies. Ablation involves either thermal (preferably radiofrequency ablation) or chemical methods, with the choice of method being dependent on both the size and placement of the tumor and the operator. Ablation may also be used as a bridge to transplantation in centers where significant waiting times are anticipated. Tumors that are too large in size or number to ablate are treated with transarterial chemoembolization, involving the distribution of chemotherapeutic agents and the blocking of the blood supply to the tumor; this is not considered a curative therapy. Combination therapies may also be used. These treatment options need further evaluation for determination of the optimal course of therapy for individual patients.

Precision targeting of liver lesions using a novel electromagnetic navigation device in physiologic phantom and swine

Radiofrequency ablation of primary and metastatic liver tumors is becoming a potential alternative to surgical resection. We propose a novel system that uses real-time electromagnetic position sensing of the needle tip to help with precision guidance into a liver tumor. The purpose of this study was to evaluate this technology in phantom and animal models. Using an electromagnetic navigation device, instrumented 18 g needles were advanced into radioopaque tumor targets in a respiratory liver phantom. The phantom featured a moving liver target that simulated cranio-caudal liver motion due to respiration. Skin-to-target path planning and real-time needle guidance were provided by a custom-designed software interface based on pre-operative 1 mm CT data slices. Needle probes were advanced using only the electromagnetic navigation device and software display. No conventional real-time imaging was used to assist in advancing the needle to the target. Two experienced operators (interventional radiologists) and two inexperienced ones (residents) used the system. The same protocol was then also used in two anesthetized 45 kg Yorkshire swine where radioopaque agar nodules were injected into the liver to serve as targets. A total of 76 tumor targeting attempts were performed in the liver phantom, and 32 attempts were done in the swine. The average time for path planning was 30 s in the phantom, and 63 s in the swine. The median time for the actual needle puncture to reach the desired target was 33 s in the phantom, and 42 s in the swine. The average registration error between the CT coordinate system and electromagnetic coordinate system was 1.4 mm (SD 0.3 mm) in the phantom, and 1.9 mm (SD 0.4 mm) in the swine. The median distance from the final needle tip position to the center of the tumor was 6.4 mm (SD 3.3 mm, n=76) in the phantom, and 8.3 mm (SD 3.7 mm, n=32) in the swine. There was no statistical difference in the planning time, procedure time, or accuracy of needle placement between experienced and inexperienced operators. The novel electromagnetic navigation system allows probe delivery into hepatic tumors of a physiologic phantom and live anesthetized swine. The system allows less experienced operators to perform equally well as experienced radiologists in terms of procedure time and accuracy of needle probe delivery.

Concepts, Considerations, and Concerns on the Cutting Edge of Radiofrequency Ablation

Radiofrequency (RF) ablation is rapidly expanding from a tool to treat isolated hepatic malignancy to a therapy for patients with renal, adrenal, skeletal, breast, lung, and other soft-tissue neoplasms. The purpose of this article is to review the status of RF ablation outside the liver and lung and compare outcomes with current clinical standards when appropriate. The author also reviews how differences in local tissue environments play a role in creation of a thermal lesion and achievement of subsequent clinical success.

Focal hyperthermia produces progressive tumor necrosis independent of the initial thermal effects

Focal hyperthermia, produced using laser, radio frequency, and microwave, is used to treat liver tumors. The exact mechanisms of tissue destruction using focal hyperthermia are, however, unknown. Clinical and experimental studies suggest a progression of injury after cessation of the initial heat stimulus. This study investigates the mechanisms and time sequence of progressive tissue necrosis induced using focal hyperthermia in a murine model of colorectal liver metastases. Focal hyperthermia produced using a neodymium-yttrium aluminum garnet (Nd-YAG) laser source was applied to the normal liver and colorectal cancer liver metastases in inbred male CBA strain mice. The extent of direct lethal thermal injury was assessed histochemically using vital stain for nicotinamide adenine dinucleotide (NADH) diaphorase immediately after laser application. Tissue injury at subsequent time points was assessed using both NADH diaphorase staining and routine histology to determine the temporal relationship between tissue necrosis and time. Thermal injury occurring immediately after the application of 100 joules of energy was greater in the tumor tissue than in the normal liver (mean [standard error of the mean (SEM)]), measuring 23.5 (3.4) and 16.3 (2.6) mm(3), respectively (P=0.046), despite similar tissue temperature profiles. There was a significant increase in tissue necrosis after initial injury that was greater in the normal liver than in the tumor tissue. In the normal liver, the peak volume of necrosis was 137.4 (9.8) mm(3) and occurred at 3 days, whereas in the tumor tissue the peak was 49.0 (3.5) mm(3) at 4.5 days (P < 0.001). Focal hyperthermia produces tissue necrosis that occurs in two phases. The first phase is caused by the direct lethal thermal injury followed by a second phase involving a progression of necrosis beyond the initial thermal effects. The normal liver and the tumor tissue responded differently to focal hyperthermia. In the tumor tissue, the direct injury is more pronounced, whereas the progression of injury is more rapid and extensive in the normal liver.

Non-resection approaches for colorectal liver metastases

The field of in situ destruction of liver tumors has expanded rapidly with various institutions' results suggesting that these methods represent viable palliative options, primarily because of the low associated morbidity and mortality. Despite this enthusiasm, clinical trials are needed to determine the true nature and degree of palliation. Treating a systemic disease such as colorectal liver metastases with local therapy strategies alone is of dubious value. In fact, it has been shown by most reports that the limiting factor inpatient outcome is disease progression rather than technical failure. For optimal results, physicians performing in situ ablation of liver lesions should be familiar with tumor biology and the natural history of the malignancy, and possess expertise in proper integration of other therapeutic modalities (eg, systemic chemotherapy and hepatic artery chemotherapy). Patients with liver metastases from colorectal carcinoma should therefore be evaluated for curability by a surgical oncologist within the context of a multidisciplinary team, as surgical resection remains the best treatment to achieve long-term survival. Such an assessment offers the patient the opportunity of a tailored therapy that may consist of hepatic resection, intravenous or regional chemotherapy, and local ablative therapy. Furthermore, results of RF ablation should be reported in terms of well-established oncological outcomes (eg, overall survival, disease-free survival, progression-free survival) that are more meaningful to the patient, rather than lesion-oriented outcomes. Because most of the ablative techniques have not yet been validated, it is imperative that well-designed clinical trials are conducted under the auspices of national cooperative groups. To consider them standard independent therapies otherwise would be premature.

Radiofrequency ablation for cancer-associated pain

Many treatment options are available for the management of cancer pain including drugs, local excision, radiation, brachytherapy, and nerve blocks. Percutaneous radiofrequency ablation has been used to treat painful neurologic and bone lesions and thus could potentially be used to treat cancer pain in other sites. Two superficial subcutaneous metastatic nodules were treated with percutaneous radiofrequency ablation. The patient received significant pain relief and improved quality of life.

The emergent role of focal liver ablation techniques in the treatment of primary and secondary liver tumours

Only 20% of patients with primary or secondary liver tumours are suitable for resection because of extrahepatic disease or the anatomical distribution of their disease. These patients could be treated by ablation of the tumour, thus preserving functioning liver. This study presents a detailed review of established and experimental ablation procedures. The relative merits of each technique will be discussed and clinical data regarding the efficacy of the techniques evaluated. A literature search from 1966 to 2003 was undertaken using Medline, Pubmed and Web of Science databases. Keywords were Hepatocellular carcinoma, liver metastases, percutaneous ethanol injection, cryotherapy, microwave coagulation therapy, radiofrequency ablation, interstitial laser photocoagulation, focused high-intensity ultrasound, hot saline injection, electrolysis and acetic acid injection. Ablative techniques offer a promising therapeutic modality to treat unresectable tumours. Large-scale randomised controlled trials are required before widespread acceptance of these techniques can occur.

Skin Implant Metastasis after Percutaneous Radio-Frequency Therapy of Liver Metastasis of a Colorectal Carcinoma

Percutaneous radio-frequency ablation (RFA) of liver tumors has been reported to be an effective approach. Skin implant metastases have been described after RFA of hepatocellular carcinoma. A 56-year-old man underwent resection of the transverse colon for an adenocarcinoma (pT3N2M0) following by adjuvant chemotherapy. He developed multiple liver metastases and underwent RFA. Six weeks after RFA, the patient noticed a painful skin lesion at the entrance side of the probe in the right upper abdominal quadrant. Ultrasound examination and computed tomography scan revealed an intracutaneous tumor of 2-cm diameter. The tumor was excised and revealed a metastasis of the previously described adenocarcinoma. CPT-11 monotherapy was started; however, due to tumor progression, the patient died 35 months after colonic resection and 10 months after RFA. This is the first case of an implant skin metastasis after RFA of secondary liver tumors. Although RFA is a promising option in the palliation of such tumors, such rare complications have to be considered.

Indications and limitations of liver transplantation for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a common cause of cancer-related death worldwide, yet remains difficult to treat, with dismal overall long-term survival rates. Recent strategies using liver transplantation for carefully selected patients with stage I and II HCC and cirrhosis have shown promising results, with 5-year survival rates comparable to survival rates for transplantation patients without malignancy. Currently, however, limited resources and a severe organ shortage make liver transplantation an option for only a limited number of patients with HCC in the United States. Future studies must document the long-term success of this therapy and improve methods for disease control before and after transplantation.

Percutaneous radiofrequency thermal ablation of hepatocellular carcinoma: a safe and effective bridge to liver transplantation

The incidence of hepatocellular carcinoma (HCC) is increasing in the United States. Although liver transplantation is an effective means of treating selected patients, pretransplantation tumor progression may preclude some patients from undergoing transplantation. The aim of this study is to determine the safety and efficacy of percutaneous radiofrequency thermal ablation (RFA) in 33 consecutive patients with nonresectable HCC and advanced cirrhosis. Mean subject age was 57.2 +/- 10.6 years, mean Child-Turcotte-Pugh score was 7.0 +/- 1.4, and mean maximal tumor diameter was 3.6 +/- 1.1 cm. Using contrast-enhanced computed tomography and magnetic resonance imaging, 22 patients (66%) had a complete radiological response at 3 months post-RFA, whereas 11 patients (33%) had an incomplete radiological response. During follow-up, 18 patients (54%) experienced tumor progression and 9 subjects underwent repeated ablation for either residual disease or tumor progression. The overall actuarial patient survival rate of the 33 patients was 58% at 2 years, whereas the transplantation-free patient survival rate was 34% at 2 years. Fifteen of 23 transplant candidates were successfully bridged to liver transplantation after a mean post-RFA follow-up of 7.9 +/- 6.7 months. The extent of tumor necrosis in the explant varied, but no subjects had evidence of tumor seeding on post-RFA imaging, at liver transplantation, or in the explant. The 3-year actuarial posttransplantation patient survival rate was 85%. Two patients have developed posttransplantation recurrence, and both had microscopic vascular invasion in their explants. In summary, our data show that RFA is a safe and effective treatment modality for patients with advanced cirrhosis and nonresectable HCC. Although the ability of RFA to prevent or delay tumor progression requires further prospective study, its favorable safety profile and promising efficacy make it an attractive treatment option for liver transplant candidates with nonresectable HCC.

Nonsurgical methods for liver metastases including cryotherapy, radiofrequency ablation, and infusional treatment: what's new in 2001?

Surgical resection is now well accepted as the standard treatment in 10 to 20% of patients with liver metastases. Tumor ablative techniques have been developed in recent years. The basic idea is to use them in patients with a limited number of intrahepatic deposits that are not totally resectable. Several papers published in 2001 have addressed cryotherapy. Cryotherapy can be considered an effective method for local destruction of liver metastases up to 3 to 4 cm in diameter but is also associated with a significant rate of complications. In many centers, cryoablation has now been replaced by radiofrequency ablation, the most widely used method for ablation of unresectable liver metastases. It can be performed during laparotomy, at laparoscopy, or percutaneously. Tumors less than 3 cm in their greatest diameter can be destroyed with one placement of the needle electrode. Metastases larger than 3 cm require several placements. Both cryotherapy and radiofrequency ablation are effective methods to induce necrosis of liver metastases. It is likely that in the near future, most patients with liver metastases will receive a multimodality treatment: a local treatment such as surgical resection or tumor ablation, and a general treatment such as hepatic infusional or systemic chemotherapy. Trials published in 2001 have shown that oral prodrugs of fluorouracil were probably equivalent to fluorouracil bolus administration. Regimens containing oxaliplatin or irinotecan have also been evaluated for efficacy and tolerance and by the intravenous route alone or in combination with hepatic artery infusion. Effective systemic chemotherapy regimens have resulted in increased survival rates and improved quality of life and in some cases have allowed resection of initially unresectable liver metastases.