Intrahepatic tumor recurrence after partial hepatectomy: value of percutaneous radiofrequency ablation

Effect of Radiofrequency Ablation with Interventional Therapy of Hepatic Artery on the Recurrence of Primary Liver Cancer and the Analysis of Influencing Factors

Background

The probability of liver cancer recurring in patients after surgery is a serious threat to liver cancer patients. Radiofrequency ablation is widely employed in liver cancer cases. We explored the therapeutic effects and influencing factors of radiofrequency ablation combined with hepatic artery intervention in patients with recurrence of primary liver cancer surgery.

Methods

90 patients with primary liver cancer postoperative recurrence admitted to our hospital from January 2014 to February 2017 were selected as the research objects. The patients were randomly divided into the control group (n = 45) and combined treatment group (n = 45). The combined treatment group received radiofrequency ablation combined with hepatic artery interventional therapy, and the control group received hepatic artery interventional therapy. The short-term efficacy, AFP levels before and after treatment, and long-term survival results of the two groups were compared. Single-factor and multifactor analyses of the clinical information of the combined treatment group were carried out to find out the factors affecting the therapeutic effect of radiofrequency ablation combined with hepatic artery intervention on patients with recurrence of primary liver cancer.

Results

The total effective rate of short-term curative effect of the combined treatment group was higher than the control group, and there was a statistically significant difference existing (P < 0.05). After treatment, two groups of patients' AFP levels were greatly lower than before treatment, the AFP levels of the combined treatment group were significantly lower than the control group, and there was a statistically significant difference (P < 0.05). The survival rates of patients in the combined treatment group at the sixth month, the first year, and the second year after treatment were significantly higher than those of the control group, and there was a statistically significant difference (P < 0.05). The univariate results showed that, in the combined treatment group, there were statistically significant differences between the effective group and the ineffective group in tumor diameter, intact capsule, liver cirrhosis, intrahepatic spread, and tumor adjacent to large blood vessels (P < 0.05). The outcomes of multivariate analysis indicated that tumor diameter ≥ 3 cm, incomplete capsule, intrahepatic spread, and tumor adjacent to large blood vessels were risk factors for ineffective recurrence of patients with primary liver cancer after radiofrequency ablation combined with hepatic artery intervention (P < 0.05). Discussion. Tumor diameter ≥ 3 cm, incomplete capsule, intrahepatic spread, and tumor adjacent to large blood vessels are risk factors for the ineffectiveness of radiofrequency ablation combined with hepatic artery interventional therapy for patients with recurrence of primary liver cancer. It is necessary to increase the range of radiofrequency treatment, increase the temperature of the radiofrequency needle, and strengthen postoperative follow-up interventions based on the specific conditions of the patient's tumor.

Repeat hepatectomy justified in patients with early recurrence of colorectal cancer liver metastases: A systematic review and meta-analysis

BACKGROUND

The benefit of repeat hepatectomy in patients with early recurrence of colorectal cancer liver metastases (CRLM) is questioned, in particular in those suffering from recurrence within three to six months following initial hepatectomy. The aim of this review was therefore to assess whether disease-free interval was associated with overall survival in patients undergoing repeat hepatectomy for recurrent CRLM.

METHODS

A systematic review and meta-analysis was conducted, according to PRISMA guidelines. PubMed, Embase and Cochrane Library databases were searched from database inception to 6th June 2020. Observational studies describing results of repeat hepatectomy for recurrent CRLM, including (disease-free) interval between hepatic resections and overall survival were included. Patients undergoing repeat hepatectomy within three months or additional resection of extrahepatic disease were excluded from meta-analysis.

RESULTS

The initial search identified 2159 records, of which 28 were included for qualitative synthesis. A meta-analysis of 15 cohort studies was performed, comprising 1039 eligible patients. Median overall survival of 54.0 months [95 %-CI: 38.6-69.4] was observed after repeat hepatectomy in patients suffering from recurrent CRLM between three to six months compared to 53.0 months [95 %-CI: 44.3-61.6] for patients with recurrent CRLM between seven to twelve months (adjusted HR = 0.89, 95 %-CI: 0.66-1.18; p = 0.410), and 60.0 months [95 %-CI: 52.7-67.3] for patients with recurrent CRLM after twelve months (adjusted HR = 0.70, 95 %-CI: 0.53-0.92; p = 0.012).

CONCLUSIONS

Disease-free interval is considered a prognostic factor for overall survival, but should not be used as selection criterion per se for repeat hepatectomy in patients suffering from recurrent CRLM.

The actual management of colorectal liver metastases

Colorectal cancer is one of the most frequent cancers in the world and between 50% and 60% of patients will develop colorectal liver metastases (CRLM) during the disease. There have been great improvements in the management of CRLM during the last decades. The combination of modern chemotherapeutic and biological systemic treatments with aggressive surgical resection strategies is currently the base for the treatment of patients considered unresectable until few years ago. Furthermore, several new treatments for the local control of CRLM have been developed and are now part of the arsenal of multidisciplinary teams for the treatment of these complex patients. The aim of this review was to summarize and update the management of CRLM, its controversies and relevant evidence.

Ablative therapies for hepatic and biliary tumors: endohepatology coming of age

Ablative therapies refer to minimally invasive procedures performed to destroy abnormal tissue that may arise with many conditions, and can be achieved clinically using chemical, thermal, and other techniques. In this review article, we explore the different ablative therapies used in the management of hepatic and biliary malignancies, namely hepatocellular carcinoma (HCC) and cholangiocarcinoma (CCA), with a particular focus on radiofrequency ablation (RFA) and photodynamic therapy (PDT) techniques.

Hepatic metastasis from colorectal cancer

Colorectal cancer (CRC) is one of the most common cancers in the world. About two third of patients with CRC will develop distant recurrence at some point in time. Liver is the most common site where distant metastasis takes place. While the overall survival (OS) of patients with metastatic CRC was poor about 3 decades ago, there has been tremendous improvement in this area in the recent years. With the advent of effective systemic chemotherapy and biologic agents and better understanding of the biological behaviour of the tumour, aggressive treatment strategies such as metastatectomy of the liver metastases (or lung metastases) are now acceptable. More importantly, it has transformed the way how stage IV CRCs are being managed. From predominantly palliative as the primary aim, a comprehensive multidisciplinary approach is now the mainstay of treatment with very successful outcomes. Combination of systemic therapies with liver resection has been shown to be effective in providing promising survival benefits. In addition, other adjunctive modalities in targeting the liver metastases such as ablation, combining resection and ablation, transarterial chemoembolization, stereotactic body radiotherapy (SBRT), hepatic artery perfusion, etc. have also been demonstrated variable outcome in treating colorectal liver metastasis (CRLM). Very recently, transplant oncologists have also explored using liver transplantation as a treatment modality for unresectable CRLM, which has demonstrated very good long-term survival in well selected cases. The new paradigm in the treatment of metastatic CRC has dawned.

Liver-directed treatments for metastatic colorectal cancer

OPINION STATEMENT

When possible, surgical resection remains the "gold standard" for the treatment of hepatic colorectal metastases. Liver resection should be considered when complete removal of all macroscopic disease can be achieved safely. For those patients with unresectable metastases, or when a patient may not be a candidate for liver resection, many choices are available to the clinician in an attempt to achieve locoregional control, including tumor ablation, intra-arterial therapies, and radiation therapy. Whereas with surgical resection, durable local control can be considered potentially curable, other liver-directed approaches currently are mostly palliative. Ongoing trials are being undertaken to evaluate the role of such cytoreductive therapies. During the initial evaluation of any patient who might be a candidate for liver-directed therapy, particularly when the intent may be curative, complete assessment with high-quality imaging should be done before any therapy to determine the full extent of disease. Most importantly, the establishment of a multidisciplinary team upon initial diagnosis can optimize the choice and sequencing of the various systemic and locoregional choices available to the colorectal cancer patient.

Non-operative therapies for colorectal liver metastases

Locoregional therapies for colorectal liver metastases complement systemic therapy by providing an opportunity for local control of hepatic spread. The armamentarium for liver-directed therapy includes ablative therapies, embolization, and stereotactic body radiation therapy. At this time, prospective studies comparing these modalities are limited and decision-making relies on a multidisciplinary approach for optimal patient management. Herein, we describe multiple therapeutic non-surgical procedures and an overview of the results of these treatments.

Optimal management of colorectal liver metastases in older patients: a decision analysis

BACKGROUND

Comparative trials evaluating management strategies for colorectal cancer liver metastases (CLM) are lacking, especially for older patients. This study developed a decision-analytic model to quantify outcomes associated with treatment strategies for CLM in older patients.

METHODS

A Markov-decision model was built to examine the effect on life expectancy (LE) and quality-adjusted life expectancy (QALE) for best supportive care (BSC), systemic chemotherapy (SC), radiofrequency ablation (RFA) and hepatic resection (HR). The baseline patient cohort assumptions included healthy 70-year-old CLM patients after a primary cancer resection. Event and transition probabilities and utilities were derived from a literature review. Deterministic and probabilistic sensitivity analyses were performed on all study parameters.

RESULTS

In base case analysis, BSC, SC, RFA and HR yielded LEs of 11.9, 23.1, 34.8 and 37.0 months, and QALEs of 7.8, 13.2, 22.0 and 25.0 months, respectively. Model results were sensitive to age, comorbidity, length of model simulation and utility after HR. Probabilistic sensitivity analysis showed increasing preference for RFA over HR with increasing patient age.

CONCLUSIONS

HR may be optimal for healthy 70-year-old patients with CLM. In older patients with comorbidities, RFA may provide better LE and QALE. Treatment decisions in older cancer patients should account for patient age, comorbidities, local expertise and individual values.

Value of radiofrequency ablation in the treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is a malignant disease that substantially affects public health worldwide. It is especially prevalent in east Asia and sub-Saharan Africa, where the main etiology is the endemic status of chronic hepatitis B. Effective treatments with curative intent for early HCC include liver transplantation, liver resection (LR), and radiofrequency ablation (RFA). RFA has become the most widely used local thermal ablation method in recent years because of its technical ease, safety, satisfactory local tumor control, and minimally invasive nature. This technique has also emerged as an important treatment strategy for HCC in recent years. RFA, liver transplantation, and hepatectomy can be complementary to one another in the treatment of HCC, and the outcome benefits have been demonstrated by numerous clinical studies. As a pretransplantation bridge therapy, RFA extends the average waiting time without increasing the risk of dropout or death. In contrast to LR, RFA causes almost no intra-abdominal adhesion, thus producing favorable conditions for subsequent liver transplantation. Many studies have demonstrated mutual interactions between RFA and hepatectomy, effectively expanding the operative indications for patients with HCC and enhancing the efficacy of these approaches. However, treated tumor tissue remains within the body after RFA, and residual tumors or satellite nodules can limit the effectiveness of this treatment. Therefore, future research should focus on this issue.

Evolving ablative therapies for hepatic malignancy

The liver is a common site for both primary and secondary malignancy. Hepatic resection and transplantation are the two treatment modalities that have been shown to achieve complete cure, but only 10 to 20% of patients are candidates for these treatments. For the remaining patients, tumor ablation has emerged as the most promising alternative modality. In addition to providing local control and improving survival outcomes, tumor ablation also helps to down stage patients for potential curative treatments, both alone as well as in combination with other treatments. While tumor ablation can be achieved in multiple ways, the introduction of newer ablative techniques has shifted the focus from palliation to potentially curative treatment. Because the long-term safety and survival benefits are not substantive at present, it is important that we strive to evaluate the results from these studies using appropriate comparative outcome methodologies.

Current oncologic applications of radiofrequency ablation therapies

Radiofrequency ablation (RFA) uses high frequency alternating current to heat a volume of tissue around a needle electrode to induce focal coagulative necrosis with minimal injury to surrounding tissues. RFA can be performed via an open, laparoscopic, or image guided percutaneous approach and be performed under general or local anesthesia. Advances in delivery mechanisms, electrode designs, and higher power generators have increased the maximum volume that can be ablated, while maximizing oncological outcomes. In general, RFA is used to control local tumor growth, prevent recurrence, palliate symptoms, and improve survival in a subset of patients that are not candidates for surgical resection. It’s equivalence to surgical resection has yet to be proven in large randomized control trials. Currently, the use of RFA has been well described as a primary or adjuvant treatment modality of limited but unresectable hepatocellular carcinoma, liver metastasis, especially colorectal cancer metastases, primary lung tumors, renal cell carcinoma, boney metastasis and osteoid osteomas. The role of RFA in the primary treatment of early stage breast cancer is still evolving. This review will discuss the general features of RFA and outline its role in commonly encountered solid tumors.

Recurrent hepatocellular carcinoma successfully treated with laparoscopic thermal ablation

BACKGROUND

Aggressive treatment of intrahepatic recurrence of hepatocellular carcinoma (HCC) increases patients' survival. This study aimed to evaluate laparoscopic thermal ablation (TA) in the treatment of intrahepatic HCC recurrences.

METHODS

A retrospective analysis was performed on 88 patients (REC group) who underwent laparoscopic TA after prior TA (66 patients.) or partial hepatic resection (HR) (22 patients) as initial local treatment. Another 170 patients with primary HCC tumors (PRIM group) were regarded as the control group.

RESULTS

The postoperative morbidity rates were similar for the patients with prior TA (18%) and those with prior HR (21%) (nonsignificant difference [NS]). The overall survival rates were not significantly different between the two groups (3-year survival rates of 59 and 78%, respectively; P = 0.1662). Moreover, the disease-free survival (DFS) rates did not differ significantly between the patients with prior TA and those with prior HR (3-year DFS of 21 and 8%, respectively; P = 0.1911). The incidences of morbidity in the whole REC (21%) and PRIM (20%) groups were similar (P = NS), and no mortality occurred in either group (0%). The cumulative 3-year survival rate was 63% in the REC group and 59% in the PRIM group (P = 0.5739), whereas the 3-year DFS rate was 17% in the REC group and 22% in the PRIM group (P = 0.5266).

CONCLUSION

Laparoscopic TA can be performed safely and may be effective for intrahepatic HCC recurrence after prior TA or HR. It leads to survival and DFS rates similar to those obtained using laparoscopic TA for primary HCC without increasing morbidity. Laparoscopic TA could be proposed as first-line treatment of intrahepatic HCC recurrence for selected patients.

Repeat hepatectomy for recurrent colorectal liver metastases is associated with a high survival rate

BACKGROUND

The outcome after a repeat hepatectomy for recurrent colorectal liver metastases (CLM) is not well defined. The present study examined the morbidity, mortality and long-term survivals after a repeat hepatectomy for recurrent CLM.

METHODS

Data on patients who underwent surgery for recurrent CLM between 1993 and 2009 were retrospectively evaluated. Patients who underwent radiofrequency ablation at the time of first treatment or at recurrence of CLM were excluded.

RESULTS

Forty-three patients underwent a repeat hepatectomy for recurrent CLM. At the time of recurrence, patients had a median of 1 (1-3) lesions and the median tumour size was 2 (0.5-8.7) cm. The post-operative morbidity and mortality rates were 12% and 0%, respectively. After a median follow-up of 33 months from a repeat hepatectomy, 5-year overall and progression-free survival rates were 73% and 22%, respectively. Using multivariate analysis, the largest initial CLM ≥5 cm and positive surgical margins at initial resection were independently associated with a worse survival after surgery for recurrent CLM. Positive surgical margins at repeat hepatectomy were a predictive factor for an increased risk of further recurrence.

DISCUSSION

A repeat hepatectomy for recurrent CLM was associated with excellent survival, low morbidity and no mortality. Surgeon-controlled variables, including margin-negative resection at first and repeat hepatectomy, contribute to good oncological outcome.

Concurrent and subsequent radiofrequency ablation combined with hepatectomy for hepatocellular carcinomas

Partial hepatectomy has long been the standard treatment modality for patients with hepatocellular carcinoma (HCC), although the majority of patients with HCCs are not candidates for curative resection. Radiofrequency ablation (RFA) has been widely used as the preferred locoregional therapy. RFA and hepatectomy can be complementary to each other for the treatment of multifocal HCCs. Combining hepatectomy with RFA permits the removal of larger tumors while simultaneously ablating any smaller residual tumors. By using this combination treatment, more patients might become candidates for curative resection. For treating recurrent tumors involving the liver after hepatectomy, RFA has been performed recently instead of transcatheter arterial chemoembolization or ethanol ablation. Many retrospective studies on the combination of RFA and hepatectomy demonstrate favorable results of effectiveness and safety. However, further investigation of prospective design will be needed to confirm these encouraging results.

American Society of Clinical Oncology 2009 clinical evidence review on radiofrequency ablation of hepatic metastases from colorectal cancer

PURPOSE

To review the evidence about the efficacy and utility of radiofrequency ablation (RFA) for hepatic metastases from colorectal cancer (CRHM).

METHODS

The American Society of Clinical Oncology (ASCO) convened a panel to conduct and analyze a comprehensive systematic review of the RFA literature from Medline and the Cochrane Collaboration Library.

RESULTS

Because data were considered insufficient to form the basis of a practice guideline, ASCO has instead published a clinical evidence review. The evidence is from single-arm, retrospective, and prospective trials. No randomized controlled trials have been included. The following three clinical issues were considered by the panel: the efficacy of surgical hepatic resection versus RFA for resectable tumors; the utility of RFA for unresectable tumors; and RFA approaches (open, laparoscopic, or percutaneous). Evidence suggests that hepatic resection improves overall survival (OS), particularly for patients with resectable tumors without extrahepatic disease. Careful patient and tumor selection is discussed at length in the literature. RFA investigators report a wide variability in the 5-year survival rate (14% to 55%) and local tumor recurrence rate (3.6% to 60%). The reported mortality rate was low (0% to 2%), and the major complications rate was commonly reported to be between 6% and 9%. RFA is currently performed with all three approaches.

CONCLUSION

There is a compelling need for more research to determine the efficacy and utility of RFA to increase local recurrence-free, progression-free, and disease-free survival as well as OS for patients with CRHM. Clinical trials have established that hepatic resection can improve OS for patients with resectable CRHM.

Prognosis of patients with intrahepatic recurrence after hepatic resection for hepatocellular carcinoma: a retrospective study

AIMS

Hepatic resection is the most effective therapy for hepatocellular carcinoma (HCC); however, intrahepatic recurrence is common. Predictors of survival after intrahepatic recurrence have not been fully investigated. To clarify the prognosis and choice of treatment of intrahepatic recurrence after hepatic resection, we conducted a comparative retrospective analysis of 147 patients with HCC who underwent hepatic resection.

METHODS

We retrospectively examined the relations between clinicopathologic factors, including the number of recurrent intrahepatic tumors and long-term prognosis after recurrence in 147 HCC patients who underwent resection. We also examined long-term survival after recurrence based on treatment types and recurrence pattern.

RESULTS

Patients with multiple tumors (n=83) showed less tumor differentiation, more frequent portal invasion, a higher alpha-fetoprotein level, and larger tumors than did patients with solitary tumor (n=64). In the solitary tumor group, local ablation therapy and repeat hepatic resection were performed in 25 and 10, respectively. In the multiple tumor group, 59 were treated by transarterial chemoembolization. Multivariate analysis showed intraoperative blood transfusion and multiple tumors to be independent risk factors for poor cancer-related survival after recurrence. By subset analysis based on treatment types and recurrence pattern, survival after recurrence was significantly better in patients treated by local ablation therapy than those treated by other therapies in both solitary and multiple tumor groups.

CONCLUSIONS

For patients with solitary recurrence, a good prognosis is predicted. Local ablation therapy is a best candidate for treatment of solitary and multiple intrahepatic recurrences after hepatic resection.

Selection of treatment modality for hepatocellular carcinoma according to the modified Japan Integrated Staging score

AIM: To compare the prognosis of patients who underwent hepatectomy and ablation using the modified Japan Integrated Staging score (mJIS).

METHODS: We examined the clinicopathologic records and patient outcomes in 278 HCC patients including 226 undergoing hepatectomy and 52 undergoing ablation therapy.

RESULTS: Cirrhosis was more frequent in the ablation group. Tumor size, number and presence of vascular invasion were significantly higher in the operation group compared to the ablation group. The local recurrence rate adjacent to treated lesions was significantly higher in the ablation group compared to the operation group (P < 0.05). The 3- and 5-year survival rates in the ablation and the operation group were 66% and 78%, and 50% and 63%, respectively, but not significantly different. Over 50% survival rates were observed in patients with a mJIS score of 0-2 in both groups. However, survival rates with a score of 3-5 in both groups were significantly lower.

CONCLUSION: According to the mJIS system, both local treatments could be selected for patients with a score of 0-2. However, for patients with a score more than 3, liver transplantation might be a better option in patients with HCC.

Radiofrequency ablation versus resection for resectable colorectal liver metastases: time for a randomized trial?

BACKGROUND

Surgical resection is the gold standard in the treatment of resectable colorectal liver metastases (CRLM). In several centers, resection is being replaced by radiofrequency ablation (RFA), even though there is no evidence yet from randomized trials to support this. The aim of this study was to critically review the oncological evidence for and against the use of RFA for resectable CRLM.

METHODS

An exhaustive review of RFA of colorectal metastases was carried out.

RESULTS

Five-year survival data after RFA for resectable CRLM are not available. Percutaneous RFA is associated with worse local control, worse staging, and a small risk of electrode track seeding when compared with resection (level V evidence). For tumors </=3 cm, local control after surgical RFA is equivalent to resection, especially if applied by experienced physicians to nonperivascular tumors (level V evidence). There is indirect evidence for profoundly different biological effects of RFA and resection.

CONCLUSIONS

A subgroup of patients has been identified for whom local control after RFA might be equivalent to resection. Whether this is true, and whether this translates into equivalent survival, remains to be proven. The time has come for a randomized trial.

Practical questions in liver metastases of colorectal cancer: general principles of treatment

Liver metastases of colorectal cancer are currently treated by multidisciplinary teams using strategies that combine chemotherapy, surgery and ablative techniques. Many patients classically considered non-resectable can now be rescued by neoadjuvant chemotherapy followed by liver resection, with similar results to those obtained in initial resections. While many of those patients will recur, repeat resection is a feasible and safe approach if the recurrence is confined to the liver. Several factors that until recently were considered contraindications are now recognized only as adverse prognostic factors and no longer as contraindications for surgery. The current evaluation process to select patients for surgery is no longer focused on what is to be removed but rather on what will remain. The single most important objective is to achieve a complete (R0) resection within the limits of safety in terms of quantity and quality of the remaining liver. An increasing number of patients with synchronous liver metastases are treated by simultaneous resection of the primary and the liver metastatic tumours. Multilobar disease can also be approached by staged procedures that combine neoadjuvant chemotherapy, limited resections in one lobe, embolization or ligation of the contralateral portal vein and a major resection in a second procedure. Extrahepatic disease is no longer a contraindication for surgery provided that an R0 resection can be achieved. A reverse surgical staged approach (liver metastases first, primary second) is another strategy that has appeared recently. Provided that a careful selection is made, elderly patients can also benefit from surgical treatment of liver metastases.