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

Early experience of combination therapy of transarterial chemoembolization and radiofrequency ablation for hepatocellular carcinoma measuring 3-7 cm

Background of the Article:

Hepatocellular carcinoma (HCC) is one of the most common human malignancies worldwide. Radiofrequency ablation (RFA) is considered curative option in selected patients; efficacy is severely limited by lesion size and lesions bordering a large vessel. On the other hand, transarterial chemoembolization (TACE) is not limited by lesion size and arterial occlusion of the tumor feeding vessels leads to increase the volume of the ablative zone. Combination treatments using both intraarterial liver-directed therapy and percutaneous ablation seek to overcome the disadvantages of the individual treatments alone, theoretically improving response to therapy and survival.

Material and Methods:

This is a single-center retrospectively study in which patients who received TACE plus RFA for HCC were evaluated for technical success, local tumor progression rates, distant intra and extrahepatic recurrences and survival.

Results:

The study included 22 patients, 21 patients had a solitary HCC of size 3–7 cm and one patient had three target lesions. Technical success achieved after first session of combination treatment was 100% (24/24). At 1 and 3 months follow-up 100% patients (24 target lesions) had complete response and at 6 months; 21 (87.5%) had complete response, one (4.2%) had local tumor progression and two patients (8.3%) developed progressive disease. No major difference in complication was noted. The event-free survival as shown by Kaplan–Meier graph analysis at 6 and 12 months were 90.7% and 66.4% with mean time to event-free survival was 11.1 months.

Conclusion:

The combined use of TACE and RFA is a safe and effective option in the treatment of patients with single large or multinodular HCC when surgical resection is not feasible and this approach provides better results than RFA or TACE alone.

Sequential transarterial chemoembolization and early radiofrequency ablation improves clinical outcomes for early-intermediate hepatocellular carcinoma in a 10-year single-center comparative study

Background

Transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) are effective treatment methods for unresectable hepatocellular carcinoma (HCC). However, there is still a lack of clinical research on whether early sequential RFA, compared with late combination therapy, can improve the long-term efficacy of initial TACE treatment.

Methods

This retrospective study investigated a cohort of patients who underwent combination therapy using TACE and RFA (TACE followed by RFA) from January 2010 to January 2020 at our medical centre. A total of 96 patients underwent TACE combined with early RFA (usually during the first hospitalization), which was called TACE + eRFA. Thirty-four patients received 1–2 palliative TACE treatments first and then underwent TACE treatment combined with late RFA (TACE + lRFA). All patients continued to receive palliative TACE treatments after intrahepatic lesion progression until reaching intolerance. The overall survival (OS) rate, time to tumour progression (TTP), tumour response rate and major complication rates were compared between the two groups.

Results

There were significant differences in the median OS (46 months vs 33 months; P = 0.013), median TTP (28 months vs 14 months; P < 0.00), objective response rate (ORR) (89.6% vs 61.8%, P = 0.000) and disease control rate (DCR) (94.8% vs 73.5% P = 0.002) between the two groups. Multivariable analysis revealed that the Barcelona Clinic Liver Cancer stage was an independent risk factor for OS. Meanwhile, multivariable analysis revealed that TACE + eRFA was associated with an enhanced TTP.

Conclusion

Early sequential RFA treatment in patients with early-intermediate HCC can improve local tumour control and clinical outcomes while reducing the frequency of TACE treatment. In clinical practice, in HCC patients initially treated with TACE, it is recommended to combine RFA as soon as possible to obtain long-term survival.

Current status of the combination therapy of transarterial chemoembolization and local ablation for hepatocellular carcinoma

PURPOSE OF REVIEW

To review the current status and ideal time interval of the combination therapy of transarterial chemoembolization (TACE) and local ablation for patients with HCCs.

RECENT FINDINGS

In recent years, local ablation has been proposed as an alternative curative treatment in the management of HCC. Additionally, many treatment options are available including TACE molecular targeted agents and immune checkpoint inhibitors. Similar overall survival rates and prognoses have been obtained with radiofrequency ablation (RFA) microwave ablation (MWA) and cryoablation for patients with HCCs up to 3 cm in diameter. Yet, MWA has shown superiority in treating large HCCs while cryoablation has several advantages compared with RFA or MWA. Furthermore, the treatment strategy of TACE combined with local ablation is widely accepted by many physicians in order to further increase the survival rate and improve the prognosis of patients with HCCs. However, the time interval between the two sessions of combination therapy remains uncertain in the current guidelines. Combination therapy of TACE and local ablation has advantages on survival and prognosis in patients with HCC compared with monotherapy. Good patient selection for the right modality needs to be carried out to guarantee the most efficacious treatment for HCC patients. Further studies are needed to find the ideal time interval between TACE and local ablation for HCC patients.

Computational simulation of the predicted dosimetric impact of adjuvant yttrium-90 PET/CT-guided percutaneous ablation following radioembolization

Background

⁹⁰Y PET/CT post-radioembolization imaging has demonstrated that the distribution of ⁹⁰Y in a tumor can be non-uniform. Using computational modeling, we predicted the dosimetric impact of post-treatment ⁹⁰Y PET/CT-guided percutaneous ablation of the portions of a tumor receiving the lowest absorbed dose. A cohort of fourteen patients with non-resectable liver cancer previously treated using ⁹⁰Y radioembolization were included in this retrospective study. Each patient exhibited potentially under-treated areas of tumor following treatment based on quantitative ⁹⁰Y PET/CT. ⁹⁰Y PET/CT was used to guide electrode placement for simulated adjuvant radiofrequency ablation in areas of tumor receiving the lowest dose. The finite element method was used to solve Penne’s bioheat transport equation, coupled with the Arrhenius thermal cell-death model to determine 3D thermal ablation zones. Tumor and unablated tumor absorbed-dose metrics (average dose, D50, D70, D90, V100) following ablation were compared, where D70 is the minimum dose to 70% of tumor and V100 is the fractional tumor volume receiving more than 100 Gy.

Results

Compared to radioembolization alone, ⁹⁰Y radioembolization with adjuvant ablation was associated with predicted increases in all tumor dose metrics evaluated. The mean average absorbed dose increased by 11.2 ± 6.9 Gy. Increases in D50, D70, and D90 were 11.0 ± 6.9 Gy, 13.3 ± 10.9 Gy, and 11.8 ± 10.8 Gy, respectively. The mean increase in V100 was 7.2 ± 4.2%. All changes were statistically significant (P < 0.01). A negative correlation between pre-ablation tumor volume and D50, average dose, and V100 was identified (ρ < − 0.5, P < 0.05) suggesting that adjuvant radiofrequency ablation may be less beneficial to patients with large tumor burdens.

Conclusions

This study has demonstrated that adjuvant ⁹⁰Y PET/CT-guided radiofrequency ablation may improve tumor absorbed-dose metrics. These data may justify a prospective clinical trial to further evaluate this hybrid approach.

Comparison of single-session transarterial chemoembolization combined with microwave ablation or radiofrequency ablation in the treatment of hepatocellular carcinoma: a randomized-controlled study

BACKGROUND

Globally, hepatocellular carcinoma (HCC) is the third most frequent cause of cancer-related mortality. In recent years, transarterial chemoembolization, radiofrequency ablation, and microwave ablation (MWA) have been accepted as treatment modalities for patients with surgically unresectable HCC.

AIM OF THIS WORK

This study aimed to compare combination treatment with radiofrequency or MWA, followed by transarterial chemoembolization, and performed in a single session.

PATIENTS AND METHODS

This study was carried out on 50 patients with nonresectable single-lesion HCC, who were divided into three groups: group A included 20 patients treated by transcatheter hepatic arterial chemoembolization, group B included 20 patients treated by radiofrequency thermal ablation combined with transcatheter arterial chemoembolization, and group C included 10 patients treated by MWA combined with transcatheter arterial chemoembolization. The combined treatments were performed in a single session, with the ablation performed first.

RESULTS

The total success rate in this study at 6 months following the procedure was 50% in group A, 70% in group B, and 80% in group C. Major complications were recorded in 22% of patients. The number of complications was the highest in group A.

CONCLUSION

Combined ablation with chemoembolization is superior in the treatment of nonresectable single masses larger than 4 cm. Transcatheter arterial chemoembolization and ablation can be performed safely and successfully during a single session, which has not been found to decrease the response rates to treatment. Combined treatment with MWA is more effective in terms of tumor response, and results in the same complication rate as with radiofrequency, but less than chemoembolization alone.

Technical and practical considerations for device selection in locoregional ablative therapy

Percutaneous ablation therapy is an essential component of contemporary interventional oncologic therapy of primary and secondary malignancies. The growing armamentarium of available ablation technologies calls for thorough understanding of the different ablation modalities to optimize device selection in individual clinical settings. The goal of the current article is to provide direction on ablative device selection by reviewing device mechanisms of action, advantages and disadvantages, and practical considerations in real-life case scenarios.

Role of Oncoprotein 18 in metastasis of hepatocellular carcinoma

AIM: To explore the role of Oncoprotein 18 (Op18) in metastasis of hepatocellular carcinoma (HCC).

METHODS: Op18 expression was repressed in HCCLM3 cells by RNA interference, and interference effect was evaluated by RT-PCR and Western blot. Cell adhesion, migration and invasion were analyzed by cell adhesion assay and Transwell assay in vitro. Op18 expression was detected by RT-PCR and immunohistochemistry in 96 HCC specimens with or without metastasis.

RESULTS: Op18 expression was effectively inhibited by RNA interference in HCCLM3 cells. Cell adhesion was significantly suppressed in the RNAi group compared to the mock group (20 min: 0.616 ± 0.057 vs 0.944 ± 0.068; 40 min: 0.740 ± 0.0713 vs 1.196 ± 0.115; 60 min: 1.001 ± 0.083 vs 1.441 ± 0.053; all P < 0.05). Transwell assay revealed that cell migration and invasion decreased in the RNAi group compared to the mock group (migration: 0.145 ± 0.011 vs 0.206 ± 0.008; invasion: 0.127 ± 0.008 vs 0.168 ± 0.012; both P < 0.01). Op18 expression was detected in 96 HCC tissues with or without metastasis. RT-PCR demonstrated that Op18 was overexpressed in HCC tissues with metastasis (n = 48) compared with HCC tissues without metastasis (n = 48, Op18/GAPDH relative ratio: 0.560 ± 0.128 vs 0.414 ± 0.086); and IHC results also indicated that Op18 expression was up-regulated in HCC tissues with metastasis in comparison with HCC tissues without metastasis (integrated density: 624.771 ± 100.032 vs 413.786 ± 71.833, P < 0.01).

CONCLUSION: Overexpression of Op18 may play an important role in HCC metastasis.