Cryosurgery after chemoembolization for hepatocellular carcinoma in patients with cirrhosis

Combination therapy: Meta-analysis of the effects of TACE and cryoablation on hepatocellular carcinoma

BACKGROUND

This study systematically reviews the data for transcatheter arterial chemoembolization (TACE) alone or combined TACE and cryoablation therapy of hepatocellular carcinoma, aiming to provide clinical choice references for treatment of cancer.

METHODS

Electronic databases (PubMed, EMBASE, China National Knowledge Infrastructure, and Google Scholar) were systematically searched to include relevant studies published in English and Chinese between Jan 1, 2000, to July 31, 2017. The analysis was conducted in RevMan 5.3 based on random effects models.

RESULTS

Nineteen trials (n = 1427) were included. Combined TACE and cryoablation therapy had higher survival rate (1-year survival [RR 1.37; 95%-CI 1.26,1.49], 2-year survival [RR 1.50; 95%-CI 1.25,1.79], 3-year survival [RR 1.67; 95%-CI 1.16,2.40]), complete necrosis [RR 2.53; 95%-CI 2.07,3.10] and tumor control [RR 1.57; 95%-CI 1.40,1.75], which is more favorable for long-term efficacy of non-surgical hepatocellular carcinoma. Tumor recurrence of control group was above combination therapy [RR 0.27; 95%-CI 0.17, 0.43]. Compared with transcatheter arterial chemoembolization, effect of combination therapy occurred mainly in the survival, complete necrosis, tumor control, and recurrence. Taking combination therapy was generally more effective than taking TACE only.

CONCLUSION

Compared with TACE only used to treat cancer, combination therapy had the best effect profile in general, and it had better survival in HCC when taking an integrated approach. The prognosis of treatments based on combination therapy is modulated by cryoablation.

Cryoablation with drug-loaded bead embolization in the treatment of unresectable hepatocellular carcinoma: safety and efficacy analysis

This study aimed to explore the efficacy and safety of drug-eluting bead (DEB) embolization (DEB-TACE) when combined with cryoablation in the treatment of unresectable hepatocellular carcinoma (HCC). The study was a single-center randomized controlled trial comprised of 60 patients with HCC conducted between August 2015 and October 2017. The patients were randomly divided into two groups: DEB-TACE combined with cryoablation (DEB-TACE-Cryo group) or cryoablation alone (Cryo group). Inter-group differences in overall survival, progression-free survival, and adverse reactions were assessed. The operative success rates were 82.7% and 77.4% in the DEB-TACE-Cryo group and Cryo group, respectively, with no operative mortality. The overall survival and progression-free survival in the DEB-TACE-Cryo group were significantly higher than those in the Cryo group (16.8 months vs.13.4 months, P = 0.0493; 8.1 months vs. 6.0 months, P = 0.0089, respectively). The postoperative complications in the two groups were rated as grade 1 or grade 2, according to guidelines set by the National Cancer Institute Common Terminology Criteria for Adverse Events Version 4.0 (CTCAE V4.0). We demonstrated that DEB-TACE combined with cryoablation was effective, well tolerated, and had a low complication rate. Therefore, this combination therapy may be a better choice for the treatment of unresectable hepatocellular carcinoma.

Progress toward Optimization of Cryosurgery

Cryosurgery for diverse neoplastic and non-neoplastic diseases has expanded in applicability in recent years, especially since intraoperative ultrasound became available as a method of monitoring the process of tissue freezing. However, persistence of disease after presumably adequate cryosurgical treatment has disclosed deficiencies in the technique, perhaps due to faulty application of the freeze-thaw cycles or due to shortcomings in the imaging method. Clearly cryosurgical technique is less than optimal. The optimal dosimetry for tissue freezing, the recent improvements in imaging techniques, and the need for adjunctive therapy are defined in this review, which assesses the progress toward improving the efficacy of cryosurgery.

HCC-Associated Liver Transplantation - Where Are the Limits and What Are the New Regulations?

BACKGROUND

Hepatocellular carcinoma (HCC) represents an increasing health burden worldwide and a challenging disease both in terms of diagnosis and treatment.

METHODS

The literature available on PubMed for the period of 1990-2016 was reviewed with reference to liver allocation, HCC, liver transplantation (LT), and prediction, and the allocation rules of the German Transplant Act were reviewed.

RESULTS

Due to etiological and geographical diversity, HCC is not a homogeneous disease. In the vast majority of patients, HCC develops as a complication of chronic liver disease and cirrhosis. While most patients present with advanced HCC for which palliative strategies are the only available option, LT is the best treatment approach as it not only eliminates the diseased liver and the underlying hepatocarcinogenic mechanisms but also the cancer. The decision for LT is not an easy one to make, because outcome prediction, staging, bridging therapy, and recurrence prevention are difficult and are estimated against the background of the scarce resource of donor organs which are also competitively sought after by patients suffering from non-neoplastic terminal liver diseases, raising the issue of equality of chances in a rationed therapeutic modality. Currently, the Milan criteria are the best evaluated decision tool for LT, but many issues such as down-staging, favorable biological behavior during treatment, expansion of the morphological classification, molecular predictors, and individualized approaches are not yet satisfactorily addressed.

CONCLUSION

In order to provide a fair and effective approach to LT in HCC, the employed allocation rules require continuous development and scientific evaluation. Recently, the allocation rules for standard exception priority according to the German Transplant Act have been revised to improve patient selection for LT in HCC.

Ablation Strategies for Locally Advanced Pancreatic Cancer

With the advent of novel and somewhat effective chemotherapy against pancreas cancer, several groups developed a new interest on locally advanced pancreatic cancer (LAPC). Unresectable tumors constitute up to 80% of pancreatic cancer (PC) at the time of diagnosis and are associated with a 5-year overall survival of less than 5%. To control those tumors locally, with perhaps improved patients survival, significant advances were made over the last 2 decades in the development of ablation methods including cryoablation, radiofrequency ablation, microwave ablation, high intensity focused ultrasound and irreversible electroporation (IRE). Many suggested a call for caution for possible severe or lethal complications in using such techniques on the pancreas. Most fears were on the heating or freezing of the pancreas, while non-thermal ablation (IRE) could offer safer approaches. The multimodal therapies along with high-resolution imaging guidance have created some enthusiasm toward ablation for LAPC. The impact of ablation techniques on primarily non-resectable PC remains, however, unclear.

Sorafenib combined with cryoablation to treat unresectable hepatocellular carcinoma

Objective

To evaluate the efficacy and tolerability of sorafenib combined with cryoablation in treating unresectable hepatocellular carcinoma (HCC).

Methods

Patients with unresectable advanced HCC received cryoablation and sorafenib at a dose of 400 mg twice daily in 4-week cycles on the same day of the cryoablation. Tumor response, median overall survival and the median time to radiological progression were calculated and the toxicity was evaluated.

Results

Seventy-eight patients with unresectable HCC were involved in this study. The median age was 52 years (range, 22-81 years). The Eastern Cooperative Oncology Group (ECOG) performance status scores were 0 (39.7%), 1 (55.1%), and 2 (5.1%). Nine (11.5%) patients were at Barcelona clinic liver cancer (BCLC) stage A, twenty-four (30.8%) patients were at stage B and 45 (57.7%) patients were at stage C. Five (6.4%) achieved partial responses, and 34 (43.6%) achieved stable disease. The median time to progression (TTP) for all enrolled patients was 6.6 months and the median overall survival (OS) was 12.2 months.

Conclusion

Cryoablation combined with sorafenib demonstrates good efficacy and acceptable tolerability in treating unresectable advanced HCC patients.

Combination percutaneous and intraarterial therapy for the treatment of hepatocellular carcinoma: a review

Transcatheter arterial chemoembolization (TACE) and percutaneous ablation therapies have been shown to provide effective therapy and afford survival prolongation for patients with unresectable hepatocellular carcinoma (HCC). Both treatments, however, have inherent limitations that restrict their benefit; TACE is not a curative therapy and ablation efficacy is significantly limited by lesion size. Current treatment strategies aim to combine intraarterial and percutaneous liver-directed therapies synergistically to improve tumor response, and by extension improve patient survival. This article reviews the current literature on combination treatments, and examines the circumstances in which therapeutic combinations would improve tumor response and patient survival.

Hepatic tumor ablation

Ablation of liver tumors is part of a multimodality liver-directed strategy in the treatment of various tumors. The goal of ablation is complete tumor destruction, and ultimately improvement of quality and quantity of life for the patient. Technology is evolving rapidly, with important improvements in efficacy. The current state of ablation technology and indications for ablation are described in this review.

Sequential use of transarterial chemoembolization and percutaneous cryosurgery for hepatocellular carcinoma

AIM: To evaluate the efficacy of sequential use of transarterial chemoembolization (TACE) and percutaneous cryosurgery for unresectable hepatocellular carcinoma (HCC).

METHODS: Four hundred and twenty patients were enrolled in this study. The patients, who were considered to have unresectable tumors due to their location or size or comorbidity, were divided into sequential TACE-cryosurgery (sequential) group (n = 290) and cryosurgery alone (cryo-alone) group (n = 130). Patients in the sequential group tended to have larger tumors and a greater number of tumors than those in the cryo-alone group. Tumors larger than 10 cm in diameter were only seen in the sequential group. TACE was performed with the routine technique and percutaneous cryosurgery was conducted under the guidance of ultrasound 2-4 wk after TACE.

RESULTS: During a mean follow-up period of 42 ± 17 mo (range, 24-70 mo), the local recurrence rate at the ablated area was 17% for all patients, 11% and 23% for patients in sequential group and cryo-alone groups, respectively (P = 0.001). The overall 1-, 2-, 3-, 4- and 5-year survival rate was 72%, 57%, 47%, 39% and 31%, respectively. The 1- and 2-year survival rates (71% and 61%) in sequential group were similar to those (73% and 54%) in cryo-alone group (P = 0.69 and 0.147), while the 4- and 5-year survival rates were 49% and 39% in sequential group, higher than those (29% and 23%) in cryo-alone group (P = 0.001). Eighteen patients with large HCC (> 5 cm in diameter) survived for more than 5 years after sequential TACE while no patient with large HCC (> 5 cm in diameter) survived more than 5 years after cryosurgery. The overall complication rate was 24%, and the complication rates were 21% and 26% for the sequential and cryo-alone groups, respectively (P = 0.06). The incidence of hepatic bleeding was higher in cryo-alone group than in sequential group (P = 0.02). Liver crack only occurred in two patients of the cryo-alone group.

CONCLUSION: Pre-cryosurgical TACE can increase the cryoablation efficacy and decrease its adverse effects, especially bleeding. Sequential TACE and cryosurgery may be the better procedure for unresectable HCC, especially for large HCC.

Cryosurgery for hepatocellular carcinoma

Cryosurgery is an important treatment modality for unresectable hepatocellular carcinoma (HCC). There are different forms of cryosurgery for HCC including intraoperative cryoablation with or without excision, laparoscopic liver cryosurgery, percutaneous liver cryoablation under the guidance of ultrasonography, CT or MRI. Cryoablation, as a local therapy for HCC, has certain advantages over other forms of treatment. It is able to destroy only tumor tissue in the liver while sparing more noninvolved tissues. Tumors close to the vessel systems can safely undergo cryoablation due to the warming effect of circulating blood in large blood vessels. Liver cryoablation is more effective than surgical resection for multiple liver tumors. Cryosurgery in combination with transarterial chemoembolization (TACE), alcohol injection or ¹²⁵iodine seed implantation has a complementary efficacy. Clinically, cryosurgery for HCC is performed according to the following principles. Intraoperative or percutaneous cryosurgery may be performed for liver tumors < 5 cm or ≤3 cm, TACE for liver tumors > 5 cm followed by percutaneous cryosurgery. Liver tumors > 5 cm with an irregular margin, may also undergo intraoperative or percutaneous cryosurgery followed by alcohol injection or ¹²⁵iodine seed implantation in the margins of tumors.

Clinicopathological features, post-surgical survival and prognostic indicators of elderly patients with hepatocellular carcinoma

AIM

Comprehensive data regarding elderly patients with hepatocellular carcinoma (HCC) were limited. The present study aims to widen the knowledge based on patients in China.

METHODS

Fifty-four elderly (> or =65 years) and 125 non-elderly HCC patients undergoing hepatectomy were enrolled in this retrospective study. Clinicopathological features and post-surgical survival were compared between two groups. Prognostic indicators of elderly patients were defined by uni- and multivariate analyses.

RESULTS

Contrast to non-elderly patients, the elderly presented significantly lower rates of HBsAg positivity, Child-Pugh grade A, alpha-fetoprotein (AFP) marked elevation, portal vein tumour thrombosis (PVTT), satellite nodule, and intrahepatic recurrence, smaller tumour sizes, earlier TNM staging and better histological differentiation. No significant differences were found in perioperative mortality rate and post-surgical survival between two groups. PVTT and Edmondson-Steiner grading were identified as independent prognostic indicators of both overall and disease-free survival by multivariate analysis, whereas Child-Pugh grading independently affected the overall survival.

CONCLUSIONS

HCC in the elderly seemed to be less HBV-associated, less progressive and less aggressive than that in the non-elderly. Hepatectomy for the elderly could make a satisfactory prognosis and be well tolerated. Some tumour-related factors independently predict the prognosis of elderly HCC patients, and their liver function status should be further valued.

Management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common tumors globally, with varying prevalence based on endemic risk factors. In high-risk populations, including those with hepatitis B or C or with cirrhosis, serum alpha-fetoprotein (AFP) and screening ultrasound have improved detection of resectable HCC. Treatment options, including surgical resection, for patients with HCC must be selected based on the number and size of hepatic tumors, underlying hepatic function, patient condition, and available resources. An approach, which has been summarized shows the corresponding treatment choices under given clinical circumstances. For cirrhotic patients with less than three tumor nodules of a size less than 3 cm or a solitary HCC less than 5 cm, liver transplantation offers long-term survival similar to that observed in patients transplanted for nonmalignant disease. Ablative treatment using either chemical or thermal techniques provides locally effective tumor destruction. Transcatheter arterial chemoembolization (TACE) is commonly used for palliation of unresectable tumors as well as an adjunct to surgical resection, treatment of tumors before transplant, and in conjunction with other ablative therapies in a multimodality approach. Regional approaches to chemotherapy have produced more encouraging results than systemic chemotherapy, although both remain ineffective for long-term tumor control. Several newer treatment modalities are under investigation, including gene therapy, tagged antibodies, isolated perfusion, and novel radiotherapy techniques.

Surgical therapy of hepatocellular carcinoma

There is no worldwide consensus of an algorithm for the radical treatment of hepatocellular carcinoma (HCC). Surgical resection, liver transplantation and, recently, local ablation therapies achieve high curative rates in selected patients. However, recurrence of HCC remains a major problem. This review provides an overview of the current surgical treatment options available for patients with HCC.

N/A

N/A

N/A

N/A

Combined transarterial chemoembolization and arterial administration of Bletilla striata in treatment of liver tumor in rats

AIM: To evaluate and compare the effect of combined transarterial chemoembolization (TACE) and arterial administration of Bletilla striata (a Chinese traditional medicine against liver tumor) versus TACE alone for the treatment of hepatocellular carcinoma (HCC) in ACI rats.

METHODS: Subcapsular implantation of a solid Morris hepatoma 3924A (2 mm³) in the liver was carried out in 30 male ACI rats. Tumor volume (V1) was measured by magnetic resonance imaging (MRI) on day 13 after implantation. The following different agents of interventional treatment were injected after retrograde catheterization via gastroduodenal artery (on day 14), namely, (A) TACE (0.1 mg mitomycin + 0.1 ml Lipiodol) + Bletilla striata (1.0 mg) (n = 10); (B) TACE + Bletilla striata (1.0 mg) + ligation of hepatic artery (n = 10), (C) TACE alone (control group, n = 10). Tumor volume (V2) was assessed by MRI (on day 13 after treatment) and the tumor growth ratio (V2/V1) was calculated.

RESULTS: The mean tumor volume before (V1) and after (V2) treatment was 0.0355 cm³ and 0.2248 cm³ in group A, 0.0374 cm³ and 0.0573 cm³ in group B, 0.0380 cm³ and 0.3674 cm³ in group C, respectively. The mean ratio (V2/V1) was 6.2791 in group A, 1.5324 in group B and 9.1382 in group C. Compared with the control group (group C), group B showed significant inhibition of tumor growth (P < 0.01), while group A did not (P > 0.05). None of the animals died during implantation or in the postoperative period.

CONCLUSION: Combination of TACE and arterial administration of Bletilla striata plus ligation of hepatic artery is more effective than TACE alone in the treatment of HCC in rats.

Combined interventional therapies of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignancies in the world, responsible for an estimated one million deaths annually. It has a poor prognosis due to its rapid infiltrating growth and complicating liver cirrhosis. Surgical resection, liver transplantation and cryosurgery are considered the best curative options, achieving a high rate of complete response, especially in patients with small HCC and good residual liver function. In nonsurgery, regional interventional therapies have led to a major breakthrough in the management of unresectable HCC, which include transarterial chemoembolization (TACE), percutaneous ethanol injection (PEI), radiofrequency ablation (RFA), microwave coagulation therapy (MCT), laser-induced thermotherapy (LITT), etc. As a result of the technical development of locoregional approaches for HCC during the recent decades, the range of combined interventional therapies has been continuously extended. Most combined multimodal interventional therapies reveal their enormous advantages as compared with any single therapeutic regimen alone, and play more important roles in treating unresectable HCC.

Percutaneous cryoablation in treatment of liver cancer: a report of 31 cases

AIM

To describe the indication, efficacy and clinical significance of percutaneous cryoablation in the treatment of liver malignancy.

METHODS

Total 31 patients with histologically or clinically confirmed primary or metastatic malignancies were treated pucutaneously under ultrasound guidance using the cryocare surgical system from July 2001 to January 2002. All patients were followed up to determine the serum tumor marker, and reveal CT scans, MRI images or utra-sound images.

RESULTS

This therapy was performed in 31 patients including 26 cases with Child A liver reserve, 4 cases with Child B and 1 cases with Child C. There were 21 cases of primary liver cancer and 10 metastastic liver cancer. AFP positive small liver cancer became AFP negative in 80% patients. The rate of completely concreted necrosis in small hepatic cancer with negative AFP was 66.7%, shown by CT or MRI. The curative rate for metastasis liver cancer was 50% at CT, MRI or tumor marker level.

CONCLUSION

Percutaneous cryoablation is a kind of new palliative treatment for liver carcinoma. It is minimally invasive, safe and effective especially for patients with unresectable liver cancer.