Percutaneous radio-frequency thermal ablation of nonresectable hepatocellular carcinoma after occlusion of tumor blood supply

Combined transarterial chemoembolization and thermal ablation in candidates to liver transplantation with hepatocellular carcinoma: pathological findings and post-transplant outcome

OBJECTIVES

Evaluating the pathological response and the survival outcomes of combined thermal ablation (TA) and transarterial chemoembolization (TACE) as a bridge or downstaging for liver transplantation (LT) in patients with hepatocellular carcinoma (HCC) > 3 cm.

MATERIALS AND METHODS

A retrospective review encompassed 36 consecutive patients who underwent combined TA-TACE as bridging or downstaging before LT. Primary objectives included necrosis of the target lesion at explant pathology, post-LT overall survival (OS) and post-LT recurrence-free survival (RFS). For OS and RFS, a comparison with 170 patients subjected to TA alone for nodules <3 cm in size was also made.

RESULTS

Out of the 36 patients, 63.9% underwent TA-TACE as bridging, while 36.1% required downstaging. The average node size was 4.25 cm. All cases were discussed in a multidisciplinary tumor board to assess the best treatment for each patient. Half received radiofrequency (RF), and the other half underwent microwave (MW). All nodes underwent drug-eluting beads (DEB) TACE with epirubicin. The mean necrosis percentage was 65.9% in the RF+TACE group and 83.3% in the MW+TACE group (p-value = 0.099). OS was 100% at 1 year, 100% at 3 years and 94.7% at 5 years. RFS was 97.2% at 1 year, 94.4% at 3 years and 90% at 5 years. Despite the different sizes of the lesions, OS and RFS did not show significant differences with the cohort of patients subjected to TA alone.

CONCLUSIONS

The study highlights the effectiveness of combined TA-TACE for HCC>3 cm, particularly for bridging and downstaging to LT, achieving OS and RFS rates significantly exceeding 80% at 1, 3 and 5 years.

Self-fueling ferroptosis-inducing microreactors based on pH-responsive Lipiodol Pickering emulsions enable transarterial ferro-embolization therapy

Lipiodol chemotherapeutic emulsions remain one of the main choices for the treatment of unresectable hepatocellular carcinoma (HCC) via transarterial chemoembolization (TACE). However, the limited stability of Lipiodol chemotherapeutic emulsions would lead to rapid drug diffusion, which would reduce the therapeutic benefit and cause systemic toxicity of administrated chemotherapeutics. Therefore, the development of enhanced Lipiodol-based formulations is of great significance to enable effective and safe TACE treatment. Herein, a stable water-in-oil Lipiodol Pickering emulsion (LPE) stabilized by pH-dissociable calcium carbonate nanoparticles and hemin is prepared and utilized for efficient encapsulation of lipoxygenase (LOX). The obtained LOX-loaded CaCO3&hemin-stabilized LPE (LHCa-LPE) showing greatly improved emulsion stability could work as a pH-responsive and self-fueling microreactor to convert polyunsaturated fatty acids (PUFAs), a main component of Lipiodol, to cytotoxic lipid radicals through the cascading catalytic reaction driven by LOX and hemin, thus inducing ferroptosis of cancer cells. As a result, such LHCa-LPE upon transcatheter embolization can effectively suppress the progression of orthotopic N1S1 HCC in rats. This study highlights a concise strategy to prepare pH-responsive and stable LPE-based self-fueling microreactors, which could serve as bifunctional embolic and ferroptosis-inducing agents to enable proof-of-concept transarterial ferro-embolization therapy of HCC.

Thermal ablation of hepatocellular carcinoma

Percutaneous treatment of hepatocellular carcinoma (HCC) by means of thermal ablation (TA) has been introduced in clinical guidelines as a potentially curative treatment for the early stages of the disease since the early 2000s. Due to its safety profile and cost-effectiveness, TA can be offered as a first-line treatment for patients with HCC smaller than 3 cm. Thermal ablative techniques are in fact widely available at many centres worldwide and include radiofrequency (RF) and microwave (MW) ablation, with the latter increasingly applied in clinical practice in the last decade. Pre-clinical studies highlighted, as potential advantages of MW-based ablation, the ability to achieve higher temperatures (>100°C) and larger ablation zones in shorter times, with less susceptibility to blood flow-induced heat sink effects. Despite these advantages, there is no evidence of superior overall survival in patients treated with MW as compared to those treated with RF ablation. Local control has been proven to be superior to MW ablation with a similar complication rate. It is expected that further improvement of TA results in the treatment of HCC will result from the refinement of guidance and monitoring tools and the careful assessment of ablation margins. Thermal ablative treatments may also be performed on nodules larger than 3 cm by applying multiple devices or combining percutaneous and intra-arterial approaches. The role of novel immunotherapy regimens in combination with ablation is also currently under evaluation in clinical trials, with several potential benefits. In this review, indications, technical principles, results, and future prospects of TA for the treatment of HCC will be examined.

Recent Advances in Image-Guided Locoregional Therapies for Primary Liver Tumors

Primary liver cancer is the leading cause of cancer-related deaths worldwide. with incidences predicted to rise over the next several decades. Locoregional therapies, such as radiofrequency or microwave ablation, are described as image-guided percutaneous procedures, which offer either a curative intent for early-stage hepatocellular carcinoma or bridging/downstaging for surgical resection or transplantation. Catheter-driven locoregional therapies, such as transarterial chemoembolization and radioembolization, induce tumor hypoxia, can be palliative, and improve survival for early-to-intermediate hepatocellular carcinoma and unresectable intrahepatic cholangiocarcinoma. Herein, we provide a comprehensive overview of the antineoplastic mechanisms underpinning locoregional therapies, different treatment approaches, and the current state of the literature for the efficacy of locoregional therapies for primary liver cancer. We also discuss emerging advancements, such as the adjuvant use of immunotherapies and molecular targeting agents with locoregional therapy, for the treatment of primary liver cancer.

Ablative Therapy in Non-HCC Liver Malignancy

Surgical extirpation of liver tumors remains a proven approach in the management of metastatic tumors to the liver, particularly those of colorectal origin. Ablative, non-resective therapies are an increasingly attractive primary therapy for liver tumors as they are generally better tolerated and result in far less morbidity and mortality. Ablative therapies preserve greater normal liver parenchyma allowing better post-treatment liver function and are particularly appropriate for treating subsequent liver-specific tumor recurrence. This article reviews the current status of ablative therapies for non-hepatocellular liver tumors with a discussion of many of the clinically available approaches.

Optical Fiber Distributed Sensing Network for Thermal Mapping in Radiofrequency Ablation Neighboring a Blood Vessel

Radiofrequency ablation (RFA) is a minimally invasive form of thermotherapy with great potential in cancer care, having the capability of selectively ablating tumoral masses with a surface area of several cm². When performing RFA in the proximity of a blood vessel, the heating profile changes due to heat dissipation, perfusion, and impedance changes. In this work, we provide an experimental framework for the real-time evaluation of 2D thermal maps in RFA neighboring a blood vessel; the experimental setup is based on simultaneous scanning of multiple fibers in a distributed sensing network, achieving a spatial resolution of 2.5 × 4 mm² in situ. We also demonstrate an increase of ablating potential when injecting an agarose gel in the tissue. Experimental results show that the heat-sink effect contributes to a reduction of the ablated region around 30-60% on average; however, the use of agarose significantly mitigates this effect, enlarging the ablated area by a significant amount, and ablating an even larger surface (+15%) in the absence of blood vessels.

Transcatheter arterial chemoembolization alone versus combined with microwave ablation for recurrent small hepatocellular carcinoma after resection: a retrospective comparative study

Purpose

To compare the efficacy and safety of transcatheter arterial chemoembolization combined with microwave ablation (TACE–MWA) versus TACE alone for the treatment of recurrent small hepatocellular carcinoma (sHCC) after resection.

Materials and methods

From June 2015 to January 2020, a total of 45 patients with recurrent sHCC (size ≤ 3 cm) treated by TACE–MWA or TACE were included in this study. The radiological response at 1-, 3-, 6-month after initial treatment [modified Response Evaluation Criteria in Solid Tumors (mRECIST)], progression-free survival (PFS), overall survival (OS), and complications were evaluated.

Results

The TACE–MWA group showed better 1-, 3-, 6-month tumor response rates than TACE group. The corresponding 1-, 3-, and 5-year PFS rates were 76.5%, 70.6%, and 70.6% for the TACE–MWA group, and 56.1%, 15.0%, and 15.0% for the TACE group (P = 0.003). The 1-, 3-, and 5-year OS rates were 100.0%, 82.1%, and 61.5% for the TACE–MWA group, and 89.0%, 58.1%, and 50.8% for the TACE group (P = 0.389), respectively. Moreover, no major complications related to treatment were observed in either of the groups. Compared with the TACE group, the TACE–MWA group had a significantly lower number of re-TACE sessions (P = 0.003).

Conclusions

Although TACE alone provides equivalent effectiveness for recurrent sHCC in terms of OS rates, TACE–MWA had better 1-, 3-, 6-month tumor response rates and may prolong tumor PFS time.

Percutaneous Radiofrequency Ablation with or without Chemolipiodolization for Hepatocellular Carcinoma: A Propensity-Score-Matched Analysis

Chemolipiodolization (CL) is less invasive than transarterial chemoembolization (TACE) for managing hepatocellular carcinoma (HCC) because it helps avoid embolization. However, the treatment outcomes of percutaneous radiofrequency ablation (PRFA) with or without CL for HCC remain unclear. Herein, we compared the prognostic factors for overall survival (OS) following PRFA with or without CL for HCC using propensity-score-matched analysis. A total of 221 patients with HCC treated with PRFA at Saga Central Hospital between April 2004 and October 2020, with or without CL, were enrolled. No significant difference was observed in OS between PRFA with and without CL cohorts (median survival time (MST): 4.5 vs. 5.4 years; p = 0.0806). To reduce the confounding effects of 12 variables, we performed propensity-score-matched analysis to match patients treated with PRFA with or without CL. No significant difference was observed in OS between PRFA with and without CL cohorts (MST: 4.0 vs. 3.6 years; p = 0.5474). After stratification according to tumor size, no significant difference was observed in OS for patients with tumor size ≥20 mm between PRFA with and without CL cohorts (MST: 3.5 vs. 3.4 years; p = 0.8236). PRFA with CL was not a significant prognostic factor in both univariate and multivariate analyses (p = 0.5477 and 0.9600, respectively). Our findings suggest that PRFA with CL does not demonstrate more favorable prognosis than PRFA without CL for HCC, regardless of tumor size.

Green-Synthesized Silver Nanoparticle-Assisted Radiofrequency Ablation for Improved Thermal Treatment Distribution

Thermal ablation therapy is known as an advantageous alternative to surgery allowing the treatment of multiple tumors located in hard-to-reach locations or treating patients with medical conditions that are not compatible with surgery. Appropriate heat propagation and precise control over the heat propagation is considered a weak point of thermal ablation therapy. In this work, silver nanoparticles (AgNPs) are used to improve the heat propagation properties during the thermal ablation procedure. Green-synthesized silver nanoparticles offer several attractive features, such as excellent thermal conductivity, biocompatibility, and antimicrobial activity. A distributed multiplexed fiber optic sensing system is used to monitor precisely the temperature change during nanoparticle-assisted radiofrequency ablation. An array of six MgO-based nanoparticles doped optical fibers spliced to single-mode fibers allowed us to obtain the two-dimensional thermal maps in a real time employing optical backscattering reflectometry at 2 mm resolution and 120 sensing points. The silver nanoparticles at 5, 10, and 20 mg/mL were employed to investigate their heating effects at several positions on the tissue regarding the active electrode. In addition, the pristine tissue and tissue treated with agarose solution were also tested for reference purposes. The results demonstrated that silver nanoparticles could increase the temperature during thermal therapies by propagating the heat. The highest temperature increase was obtained for 5 mg/mL silver nanoparticles introduced to the area close to the electrode with a 102% increase of the ablated area compared to the pristine tissue.

Radiofrequency ablation combined with transarterial chemoembolization in treatment of hepatocellular carcinoma adjacent to the second hepatic hilus

Purpose

To explore the efficacy and safety of using radiofrequency ablation (RFA) combined with transarterial chemoembolization (TACE) for treating hepatocellular carcinoma (HCC) adjacent to the second hepatic hilus.

Methods

Between February 2011 and June 2013, 17 patients with HCC underwent combination therapy of TACE and RFA under DSA and CT guidance at our institution. The 17 patients had a total of 23 hepatic tumors, 17 of which were adjacent to the second hepatic hilus.

Results

TACE combined with RFA was performed successfully in all 17 patients with no mortalities or major morbidities. During the 1-month follow-up, tumors of 15 patients (88.2%) were completely ablated after one therapy session and 2 patients had detectable tumor residue. During the follow-up time period (range 6–52 months), local tumor progression developed in 1 patient (1/17, 5.9%) and both local tumor progression and new tumors appeared in 1 patient (1/17, 5.9%). Also, new tumors developed in the untreated portions of the liver in 8 patients (8/17, 47.1%). No distant metastasis was found. Of the 17 patients, 6 (35.3%) died due to tumor progression (3/17, 17.6%), liver failure (2/17, 11.8%), or massive hemorrhage of the gastrointestinal tract (1/17, 5.9%). The overall survival rates were 94.1% (16/17), 82.4% (14/17), and 61.8% (11/17) at 12, 18, and 24 months, respectively, and the median survival time was 25 months (95% CI 18–27).

Conclusion

Treatment using combination of TACE and RFA is an effective and safe therapeutic strategy for treating HCC with tumor(s) adjacent to the second hepatic hilus.

Drug development of lyso-thermosensitive liposomal doxorubicin: Combining hyperthermia and thermosensitive drug delivery

We review the drug development of lyso-thermosensitive liposomal doxorubicin (LTLD) which is the first heat-activated formulation of a liposomal drug carrier to be utilized in human clinical trials. This class of compounds is designed to carry a payload of a cytotoxic agent and adequately circulate in order to accumulate at a tumor that is being heated. At the target the carrier is activated by heat and releases its contents at high concentrations. We summarize the preclinical and clinical experience of LTLD including its successes and challenges in the development process.

LI-RADS treatment response assessment of combination locoregional therapy for HCC

HCC incidence continues to increase worldwide and is most frequently discovered at an advanced stage when limited curative options are available. Combination locoregional therapies have emerged to improve patient survival and quality of life or downstage patients to curative options. The increasing options for locoregional therapy combinations require an understanding of the expected post-treatment imaging appearance in order to assess treatment response. This review aims to describe the synergy between TACE combined with thermal ablation and TACE combined with SBRT. We will also illustrate expected imaging findings that determine treatment efficacy based on the mechanism of tissue injury using the LI-RADS Treatment Response Algorithm.

Challenges Facing Percutaneous Ablation in the Treatment of Hepatocellular Carcinoma: Extension of Ablation Criteria

As an emerging minimally invasive treatment method, percutaneous ablation is more and more widely used in the treatment of liver tumors. It has been recommended by guidelines for diagnosis and treatment of hepatocellular carcinoma (HCC) as a curative treatment alongside surgical resection and liver transplantation. In recent years, with the continuous advancement and innovation of percutaneous ablation technologies, their clinical efficacy and safety have been significantly improved, which has led to the expanded application of percutaneous ablation in the treatment of HCC—more and more patients who were previously considered unsuitable for ablation therapies are now being treated with percutaneous ablation. Obviously, percutaneous ablation can reduce the risk of treatment changes from curative strategies to palliative strategies. Based on clinical practice experience, this review enumerates the advantages and disadvantages of different ablative modalities and summarizes the existing combinations of ablation techniques, thus will help clinicians choose the most appropriate ablative modality for each patient and will provide scientific guidance for improving prognosis and making evidence-based treatment decisions. In addition, we point out the challenges and future prospects of the ablation therapies, thereby providing direction for future research.

Optimizing Loco Regional Management of Oligometastatic Colorectal Cancer: Technical Aspects and Biomarkers, Two Sides of the Same Coin

Colorectal cancer (CRC) is the third most common cancer worldwide and has a high rate of metastatic disease which is the main cause of CRC-related death. Oligometastatic disease is a clinical condition recently included in ESMO guidelines that can benefit from a more aggressive locoregional approach. This review focuses the attention on colorectal liver metastases (CRLM) and highlights recommendations and therapeutic locoregional strategies drawn from the current literature and consensus conferences. The different percutaneous therapies (radiofrequency ablation, microwave ablation, irreversible electroporation) as well as trans-arterial approaches (chemoembolization and radioembolization) are discussed. Ablation margins, the choice of the imaging guidance as well as characteristics of the different ablation techniques and other technical aspects are analyzed. A specific attention is then paid to the increasing role of biomarkers (in particular molecular profiling) and their role in the selection of the proper treatment for the right patient. In conclusion, in this review an up-to-date state of the art of the application of locoregional treatments on CRLM is provided, highlighting both technical aspects and the role of biomarkers, two sides of the same coin.

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.

A review on radiofrequency, microwave and high-intensity focused ultrasound ablations for hepatocellular carcinoma with cirrhosis

Importance

Hepatocellular carcinoma (HCC) is usually accompanied by liver cirrhosis, which makes treatment of this disease challenging. Liver transplantation theoretically provides an ultimate solution to the disease, but the maximal surgical stress and the scarcity of liver graft make this treatment option impossible for some patients. In an ideal situation, a treatment that is safe and effective should provide a better outcome for patients with the dilemma.

Objective

This article aims to give a comprehensive review of various types of loco-ablative treatment for HCC.

Evidence Review

Loco-ablative treatment bridges the gap between surgical resection and transarterial chemotherapy. Various types of ablative therapy have their unique ability, and evidence-based outcome analysis is the most important key to assisting clinicians to choose the most suitable treatment modality for their patients.

Findings

Radiofrequency ablation (RFA) has a relatively longer history and more evidence to support its effectiveness. Microwave ablation (MWA) is gaining momentum because of its shorter ablation time and consistent ablation zone. High-intensity focused ultrasound (HIFU) ablation is a relatively new technology that provides non-invasive treatment for patients with HCC. It has been carried out at centers of excellence and it is a safe and effective treatment option for selected patients with HCC and liver cirrhosis.

Conclusion and Relevance

Selective use of different loco-ablative therapies will enhance clinicians' treatment options for treatment of HCC.

Individual or combined transcatheter arterial chemoembolization and radiofrequency ablation for hepatocellular carcinoma: a time-to-event meta-analysis

Background

There is still some debate as to whether transcatheter arterial chemoembolization (TACE) plus radiofrequency ablation (RFA) is better than TACE or RFA alone. This meta-analysis aimed to compare the efficacy and safety of TACE plus RFA for hepatocellular carcinoma (HCC) with RFA or TACE alone.

Methods

We searched PubMed, MEDLINE, Embase, Cochrane Library, and CNKI (China National Knowledge Infrastructure) for all relevant randomized controlled trials and retrospective studies reporting overall survival (OS), recurrence-free survival (RFS), and complications of TACE plus RFA for HCC, compared with RFA or TACE alone.

Results

Twenty-one studies involving 3413 patients were included. TACE combined with RFA was associated with better OS (hazard ratio [HR]=0.62, 95% confidence intervals [CI] = 0.55–0.71, P < 0.001) and RFS (HR = 0.52, 95% CI = 0.39–0.69, P < 0.001) than TACE alone; compared with RFA alone, TACE plus RFA resulted in longer OS (HR = 0.63, 95% CI = 0.53–0.75, P < 0.001) and RFS (HR = 0.60, 95% CI = 0.51–0.71, P < 0.001). Subgroup analyses by tumor size also showed that combined treatment resulted in better OS and RFS compared with RFA alone in patients with HCC larger than 3 cm. Combined treatment resulted in similar rate of major complications compared with TACE or RFA alone (OR = 1.78, 95% CI = 0.99–3.20, P = 0.05; OR = 1.00, 95% CI = 0.42–2.38, P = 1.00, respectively).

Conclusions

TACE combined with RFA was more effective for HCC than TACE alone. For patients with a tumor larger than 3 cm, the combined treatment also achieved a better effect than RFA alone.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02188-4.

Distributed Sensing Network Enabled by High-Scattering MgO-Doped Optical Fibers for 3D Temperature Monitoring of Thermal Ablation in Liver Phantom

Thermal ablation is achieved by delivering heat directly to tissue through a minimally invasive applicator. The therapy requires a temperature control between 50-100 °C since the mortality of the tumor is directly connected with the thermal dosimetry. Existing temperature monitoring techniques have limitations such as single-point monitoring, require costly equipment, and expose patients to X-ray radiation. Therefore, it is important to explore an alternative sensing solution, which can accurately monitor temperature over the whole ablated region. The work aims to propose a distributed fiber optic sensor as a potential candidate for this application due to the small size, high resolution, bio-compatibility, and temperature sensitivity of the optical fibers. The working principle is based on spatial multiplexing of optical fibers to achieve 3D temperature monitoring. The multiplexing is achieved by high-scattering, nanoparticle-doped fibers as sensing fibers, which are spatially separated by lower-scattering level of single-mode fibers. The setup, consisting of twelve sensing fibers, monitors tissue of 16 mm × 16 mm × 25 mm in size exposed to a gold nanoparticle-mediated microwave ablation. The results provide real-time 3D thermal maps of the whole ablated region with a high resolution. The setup allows for identification of the asymmetry in the temperature distribution over the tissue and adjustment of the applicator to follow the allowed temperature limits.

Transarterial chemoembolization combined with iodine 125 seeds versus transarterial chemoembolization combined with radiofrequency ablation in the treatment of early- and intermediate-stage hepatocellular carcinoma

Background

Transarterial chemoembolization (TACE), radiofrequency ablation (RFA), and iodine 125 seeds implantation are optional treatments for hepatocellular carcinoma (HCC). The aim of this study is to compare the efficacy of the combined treatment of TACE with iodine 125 seeds implantation (TACE-iodine 125) with TACE with RFA (TACE-RFA) in patients with early- and intermediate-stage HCC.

Methods

The study included 112 patients who were diagnosed with early- and intermediate-stage HCC from January 1, 2014, to May 31, 2018. Among them, 38 patients were treated with TACE-Iodine 125, and 74 with TACE-RFA. The efficacy of the two treatment groups was retrospectively analyzed. To reduced the selective bias, a propensity score matching (PSM) analysis and inverse probability of treatment weighting (IPTW) method were used to compare the outcomes between the two groups.

Results

In the absence of PSM and IPTW, the median overall survival (OS) and progression-free survival (PFS) of the TACE-RFA group were slightly longer than those of the TACE-Iodine 125 group (OS: 41 months vs. 36 months; PFS: 18 months vs. 15 months). However, there were no statistically significant differences in the median OS, PFS, and objective response rate (ORR) between the two groups (P > 0.05). After adjusting the age, gender, Child-Pugh class, Barcelona Clinic Liver Cancer (BCLC) stage, and Alpha-fetoprotein (AFP), TACE-Iodine 125 treatment was not associated with a significant increasing the risks of death (HR: 0.763; 95%CI: 0.403,1.345, P = 0.320) and recurrence (HR: 1.020; 95%CI: 0.645,1.611, P = 0.934). After PSM, 35 matched pairs of patients were obtained, and there were no statistically significant differences in the median OS and PFS between the two groups. After IPTW, similar results presented.

Conclusions

The combination of TACE with iodine 125 seeds implantation may represent an effective treatment for patients with early- and intermediate-stage HCC.

Transcatheter arterial chemoembolization alone or combined with ablation for recurrent intermediate-stage hepatocellular carcinoma: a propensity score matching study

PURPOSE

The recurrence after curative hepatectomy is common. Limited data have investigated the effect of transcatheter arterial chemoembolization (TACE) combined with ablation in treating recurrent intermediate-stage hepatocellular carcinoma (HCC) after hepatectomy. We aim to compare the efficacy of TACE combined with ablation versus TACE alone in treating recurrent intermediate-stage HCC after hepatectomy.

METHODS

A total of 183 patients with recurrent intermediate-stage HCC after hepatectomy were enrolled at Sun Yat-sen University Cancer Centre, including 111 patients who underwent TACE alone and 72 patients who underwent TACE combined with ablation (TACE-Ablation). Overall survival (OS) and progression-free survival (PFS) were compared by the log-rank test. Propensity score matching (PSM) was used to reduce the confounding bias.

RESULTS

Before PSM, the 5-year OS rates were 43.3% vs. 27.9% (P = 0.001), and the 5-year PFS rates were 21.7% vs. 13.0% (P < 0.001) for TACE-Ablation and TACE-alone groups, respectively. After PSM, TACE-Ablation still resulted in better 5-year OS (41.6% vs. 30.2%, P = 0.028) and 5-year PFS rate (21.3% vs. 15.8%, P = 0.024) than that of TACE alone. Patients in TACE-Ablation group exhibited similar major complication rates to TACE-alone group but higher minor complication rates both before and after PSM. Cox regression analysis identified TACE-alone modality as an independently unfavourable predictor for OS and PFS (both P < 0.05).

CONCLUSION

TACE combined with ablation is safe and superior to TACE alone in tumour control and prolonging overall survival in recurrent intermediate-stage HCC after hepatectomy.

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.

Combined conventional transarterial chemoembolization with Mitomycin and percutaneous ablation for unresectable hepatocellular carcinoma

Background

Conventional transarterial chemoembolization (cTACE) has been the standard treatment for intermediate stage hepatocellular carcinoma (HCC). For early stage HCC, percutaneous ablation is a curative option. There is growing evidence to support combined therapy to improve tumor response and overall survival (OS) in patients with unresectable HCC. The goal of this study is to retrospectively review a single institution patient population who underwent the combined approach to determine its efficacy and safety, and possible predictive factors for OS and tumor response.

Methods

Retrospective analysis identified all patients that underwent c-TACE with Mitomycin followed by percutaneous ablation from 2011 to 2016 at our institution. Efficacy was assessed by OS, time to progression (TTP), and tumor response according to mRECIST criteria. Initial imaging was obtained 1 month after each treatment and after complete response was achieved, every 3 months for 2 years. Percentage of Lipiodol uptake was determined at 30-day follow-up with contrasted abdominal CT. Safety was assessed using Common Terminology Criteria for Adverse Events (CTCAE) v4.0. Multiple linear regressions were conducted to predict OS and number of progression-free survival days based on potential predictive factors.

Results

A total of 50 patients were identified. At 1-month follow-up, objective response (CR + PR) was achieved in 44 patients (88%). The median OS was 26.6 months and median TTP was 9.7 months (n=50). There was no statistically significant difference in median OS between patients with different lesion size (P=0.95), BCLC stage (P=0.84) or Lipiodol uptake (P=0.36). Higher albumin/bilirubin ratio was significantly correlated with improved OS (P=0.024).

Conclusions

Combined c-TACE and PTA is a safe and effective approach for patients with unresectable HCC. Elevated albumin/bilirubin ratio was a predictor for improved OS.

Long-Term Outcomes of Transarterial Chemoembolization Combined with Radiofrequency Ablation Versus Transarterial Chemoembolization Alone for Recurrent Hepatocellular Carcinoma After Surgical Resection

BACKGROUND

There is lack of data for identifying optimal local therapy for the management of recurrent hepatocellular carcinoma (HCC) after hepatic resection.

AIMS

A retrospective study was performed to compare the effectiveness of transarterial chemoembolization (TACE) plus radiofrequency ablation (RFA) with that of TACE alone for recurrent HCC.

METHODS

From 2007 to 2013, patients with recurrent HCC ≤ 5 cm were treated with either TACE plus RFA (n = 96) or TACE (n = 63). Inverse probability of treatment weighting was used to make allowances for imbalances in treatment assignment. The disease-free survival (DFS) and overall survival (OS) were retrospectively analyzed.

RESULTS

The TACE group had lower pretreatment Child-Pugh class (P = 0.025) and shorter pretreatment interval of recurrence (P = 0.028). The 1-, 3-, and 5-year DFS rates for the TACE-RFA group were 55.1%, 22.5%, and 9.7%, respectively, and 41.1%, 9.9%, and 4.9%, respectively, for the TACE group. The OS rates at 1, 3, and 5 years were 82.3%, 42.7%, and 16.5%, respectively, in the TACE-RFA group, and 75.9%, 30.7%, and 11.3%, respectively, in the TACE group. Cirrhosis was significantly associated with disease progression (hazard ratio [HR] 1.53; 95% CI 1.09-2.14; P = 0.014).

CONCLUSIONS

In patients with recurrent HCC ≤ 5 cm, TACE-RFA shows better DFS than TACE alone as a first-line local therapy.

Risk factors of intrahepatic biloma and secondary infection after thermal ablation for malignant hepatic tumors

Objective: This study aimed to evaluate the risk factors of biloma formation and secondary infection after thermal ablation for malignant hepatic tumors. Patients and methods: A total of 58 patients with 68 bilomas after thermal ablation were recruited as the complication group, and 61 patients with 72 lesions without major complications were selected randomly as the control group. The potential risk factors for biloma formation were analyzed with the chi-square test and multivariate logistic regression analysis. To determine the optimum management method for biloma, patients with secondary infection were included for the subgroup analysis of risk factors. Results: A history of transcatheter arterial chemoembolization (TACE) treatment (odds ratio [OR]: 3.606, 95% confidence interval [CI]: 1.165-11.156, p = .026) and tumor location (OR: 37.734, 95% CI: 13.058-109.034, p = .000) were independent predictors of biloma formation. Among the 58 patients with biloma, 49 (84.5%) showed no symptoms (i.e., the asymptomatic group), while the remaining 9 (15.5%) developed symptoms related to secondary infections (i.e., the symptomatic group). There were significant differences in the history of biliary manipulation (p = .031) between the symptomatic and asymptomatic groups. Conclusion: A history of TACE treatment and the distance from the biliary tract were independent predictors of biloma formation after thermal ablation. Therefore, protecting the bile duct (i.e., cooling of the bile duct and combing thermal ablation with chemical ablation) should be considered for high-risk patients. Moreover, active monitoring and management should be performed for patients with bilomas who underwent biliary surgery before.

Computed tomography-guided radiofrequency ablation of the retained iodized oil after simultaneous combination with transarterial embolization in small recurrent or residual hepatocellular carcinoma

Objective

To assess the clinical efficacy and safety of transarterial embolization (TAE) in simultaneous combination with computed tomography (CT)-guided radiofrequency ablation (RFA) for recurrent or residual hepatocellular carcinoma (HCC), and to determine the risk factors influencing local tumor progression following this procedure.

Methods

One hundred eighteen patients with recurrent or residual HCC (tumor size, 10-30 ​mm) underwent RFA. During the 19-month follow-up, 59 patients received RFA only (RFA group), and the remaining 59 received RFA immediately after TAE (TAE ​+ ​RFA group). All patients were followed up to observe the short-term therapeutic effects and complications. The cumulative local tumor progression rates in both groups were calculated using unpaired Student's t tests and the Kaplan-Meier method.

Results

The rate of major complications was 5.08% in the TAE ​+ ​RFA group and 3.39% in the RFA group. The overall response rate was 96.61% in the TAE ​+ ​RFA group and 79.66% in the RFA group (P ​= ​0.008). The disease control rate was significantly higher in the TAE ​+ ​RFA group than in the RFA group (94.92% vs. 79.66%, P ​= ​0.024). The median time to local tumor progression was 4.8 months in the RFA group and 9.6 months in the TAE ​+ ​RFA group. The cumulative local tumor progression rate at 1 year was 10.60% in the RFA group and 23.60% in the TAE ​+ ​RFA group (P ​= ​0.016).

Conclusion

TAE in simultaneous combination with CT-guided RFA was effective and safe against recurrent or residual HCC. Local tumor progression can be minimized by the complete ablation of targeted iodized oil deposits after simultaneous TAE.

Thermal Ablation of Metastatic Colon Cancer to the Liver

Colorectal cancer (CRC) is responsible for approximately 10% of cancer-related deaths in the Western world. Liver metastases are frequently seen at the time of diagnosis and throughout the course of the disease. Surgical resection is often considered as it provides long-term survival; however, few patients are candidates for resection. Percutaneous ablative therapies are also used in the management of this patient population. Different thermal ablation (TA) technologies are available including radiofrequency ablation, microwave ablation (MWA), laser, and cryoablation. There is growing evidence about the role of interventional oncology and image-guided percutaneous ablation in the management of metastatic colorectal liver disease. This article aims to outline the technical considerations, outcomes, and rational of TA in the management of patients with CRC liver metastases, focusing on the emerging role of MWA.

Ablation plus Transarterial Embolic Therapy for Hepatocellular Carcinoma Larger than 3 cm: Science, Evidence, and Future Directions

Thermal ablation is widely regarded as definitive therapy for early-stage hepatocellular carcinoma, but its efficacy decreases in tumors greater than 3 cm. Extensive clinical studies have supported improved outcomes provided through combining transarterial embolic therapy with ablation in the treatment of larger tumors. This article will provide a survey of the science and data for combination therapy in both thermal and nonthermal ablation modalities, as well as describe emerging applications.

Microscopic Assessment of Healing and Effectiveness of a Foam-Based Peripheral Occlusion Device

The IMPEDE Embolization Plug is a catheter-delivered vascular occlusion device that utilizes a porous shape memory polymer foam as a scaffold for thrombus formation and distal coils to anchor the device within the vessel. In this study, we investigated the biological response of porcine arteries to the IMPEDE device by assessing the extent of healing and overall effectiveness in occluding the vessel at 30, 60, and 90 days. Compared to control devices (Amplatzer Vascular Plug and Nester Embolization Coils), the host response to IMPEDE showed increased cellular infiltration (accommodated by the foam scaffold), which led to advanced healing of the initial thrombus to mature collagenous connective tissue (confirmed by transmission electron microscopy (TEM)). Over time, the host response to the IMPEDE device included degradation of the foam by multinucleated giant cells, which promoted fibrin and polymer degradation and advanced the healing response. Device effectiveness, in terms of vessel occlusion, was evaluated histologically by assessing the degree of recanalization. Although instances of recanalization were often observed at all time points for both control and test articles, the mature connective tissue within the foam scaffold of the IMPEDE devices improved percent vessel occlusion; when recanalization was observed in IMPEDE-treated vessels, channels were exclusively peri-device rather than intradevice, as often observed in the controls, and the vessels mostly remained >75% occluded. Although total vessel occlusion provides the optimal ischemic effect, in cardiovascular pathology, there is a progressive ischemic effect on the downstream vasculature as a vessel narrows. As such, we expect a sustained ischemic therapeutic effect to be observed in vessels greater than 75% occluded. Overall, the current study suggests the IMPEDE device presents advantages over controls by promoting an enhanced degree of healing within the foam scaffold, which decreases the likelihood of intradevice recanalization and ultimately may lead to a sustained ischemic therapeutic effect.

Impact of an ultrasound-guided radiofrequency ablation training program on the outcomes in patients with hepatocellular carcinoma

PURPOSE

The aim of this study was to retrospectively evaluate the impact of a training program on the safety and efficacy of percutaneous ultrasound-guided radiofrequency ablation (RFA) for the treatment of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

A total of 227 patients with 296 HCC nodules who underwent percutaneous RFA with or without transcatheter arterial chemoembolization at our institution were included. There were 163 men and 64 women with a mean age of 74.2±8.3 (SD) years (range: 41-89 years). Percutaneous ultrasound-guided RFA was performed by three trainees (205 HCC nodules in 157 patients) or a mentor (91 HCC nodules in 70 patients) after preprocedural preparation including planning ultrasonography. We compared background-related, tumor-related, and treatment-related factors, and local recurrence and complication rates between the trainee group and the mentor group. Similarly, we compared these variables among the years 2015, 2016, and 2017 for trainee group.

RESULTS

The proportion of easy-to-treat tumors in the trainee group (109/205; 53.2%) was greater than that in the mentor group (33/91; 36.3%) (P=0.020). No significant differences were observed in procedure difficulty among the years 2015, 2016, and 2017 for trainee group (easy-to-treat HCC nodules: 25/47; 53.2% vs. 39/79; 49.4% vs. 45/79; 57.0%. P=0.775). The local recurrence rate in the trainee group was 8.8% (18/205 HCC nodules) which was equivalent to 7.7% in the mentor group (7/91 HCC nodules). No significant differences were observed in local recurrence rate (8.8% vs. 7.7%, respectively; P=0.621) and major complication rate (1.3% vs. 1.4%, respectively; P=0.999) between the trainee group and the mentor group. No significant differences were observed in local recurrence rates ([5/47; 10.6%] vs. [11/79; 13.9%] vs. [2/79; 2.5%]) (P=0.109) and major complication rates ([1/36; 2.8%] vs. [1/62; 1.6%] vs. [0/59; 0%]) (P=0.701) between the years 2015, 2016, and 2017 for trainee group.

CONCLUSION

A well supervised training program that includes planning ultrasonography fosters the efficacy and treatment quality of RFA for HCC.

Combined ultrasound/computed tomography guidance in percutaneous radiofrequency ablation after transarterial chemoembolization for hepatocellular carcinoma in the hepatic dome

Purpose

To assess the value of the combined ultrasound (US)/computed tomography (CT) guidance (US guidance was firstly used for puncture with the electrode needle to the site close to the tumor, and subsequently, CT guidance was used for precise positioning of the electrode tips) in percutaneous radiofrequency ablation (RFA) after transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC) in the hepatic dome.

Methods

From January 1, 2013 to June 30, 2017, medical records of 65 patients with HCCs in the hepatic dome who received TACE treatment before RFA procedure were retrospectively analyzed. Among them, 34 patients with 35 liver tumors underwent percutaneous RFA under combined US/CT guidance, and 31 patients with 35 liver tumors received percutaneous RFA under CT guidance alone. The efficacy of combined US/CT-guided RFA was analyzed, and the procedure time and safety between the two groups were compared.

Results

In the combined US/CT-guided RFA group, the 1-, 3-, and 5-year local recurrence rates were 3%, 6%, 9%, respectively, and the 1-, 3-, and 5-year overall survival rates were 100%, 97%, 94%, respectively. The mean procedure time in the CT-guided RFA group was significantly longer than that of the combined US/CT-guided RFA group (P<0.001). Although the overall complication rates between the two groups were not statistically significant, there were no occurrences of RFA-related complications in the combined US/CT-guided RFA group. The incidence of postoperative adverse reaction of right upper quadrant pain in the CT-guided RFA group was greater than that of the combined US/CT-guided RFA group (P=0.01).

Conclusion

Percutaneous RFA under the combined US/CT guidance was helpful for HCC in the hepatic dome.

In Vitro Bovine Liver Experiment of Cisplatin-Infused and Normal Saline-Infused Radiofrequency Ablation with an Internally Cooled Perfusion Electrode

PURPOSE

To evaluate the efficacy of cisplatin-infused and normal saline-infused radiofrequency ablation (RFA) with internally cooled perfusion (ICP) electrode.

MATERIALS AND METHODS

Using a 200 W generator, thirty ablation zones were created and divided into three groups of 10 each as follows: group A, RFA alone with 16 gauge monopolar internally cooled (IC) electrode; group B, cisplatin-infused RFA with 16 gauge ICP electrode; and group C, normal saline-infused RFA with 16 gauge ICP electrode. Radiofrequency was applied to the explanted bovine liver for 12 min. During RFA, cisplatin and normal saline were injected into tissue at a rate of 0.5 mL/min through the ICP electrode by injection pump. Dimensions of the ablation zone and technical parameters were compared between the three groups.

RESULT

In the cisplatin-infused RFA group, the ablation zone size was significantly larger than that of the RFA-alone group but significantly smaller than normal saline-infused RFA group. The width of longitudinal section and volume were 3.39 ± 0.22 cm² and 26.55 ± 4.62 cm³ in RFA-alone group, 3.88 ± 0.32 cm² and 36.45 ± 5.46 cm³ in cisplatin-infused RFA group, and 4.52 ± 0.50 cm² and 49.44 ± 7.55 cm³ in normal saline-infused RFA group, respectively (p < 0.05 between any two groups). The mean impedance in group A, B, and C were 60.0 ± 7.2, 50.3 ± 2.5, and 40.3 ± 4.0 Ω, respectively (p < 0.05 between any two groups).

CONCLUSION

Cisplatin-infused RFA with ICP electrode created the larger size of ablation zone than that of monopolar RFA with an IC electrode, but created the smaller size of ablation zone than that of normal saline-infused RFA.

Efficacy of combination therapy with transcatheter arterial chemoembolization and radiofrequency ablation for intermediate-stage hepatocellular carcinoma

OBJECTIVES

Transcatheter arterial chemoembolization (TACE) is the standard therapy for patients with intermediate-stage hepatocellular carcinoma (HCC). This study aimed to determine whether combination therapy with radiofrequency ablation (RFA) and TACE was superior to TACE monotherapy for intermediate-stage HCC and identify cases in which this technique was the most effective.

MATERIALS AND METHODS

We selected patients with intermediate HCC who met the following eligibility criteria: (1) ≥ 20 years of age, (2) receiving initial therapy, (3) ≤7 tumors, and (4) maximum tumor diameter <5 cm. We performed propensity score matching (PSM) using potential confounding factors. We retrospectively compared the cumulative overall survival rate and recurrence-free survival rate between the TACE + RFA and TACE groups. Additionally, a sub-group analysis was performed for preoperative factors.

RESULTS

Among the 103 patients, 92 were selected using PSM. The cumulative overall survival rates at 1, 3, and 5 years for the TACE + RFA group were 97.4%, 70.4%, and 60.4%, respectively, which were significantly higher than those for the TACE group (92.7%, 55.7%, and 22.8%, respectively, p = .045). The recurrence-free survival rates at 0.5, 1, and 2 years for the TACE + RFA group were 80.0%, 58.6%, and 33.3%, respectively, which were significantly higher than those for the TACE group (34.5%, 8.8%, and 2.9%, respectively, p < .01). For the sub-group with α-fetoprotein (AFP) <100 ng/mL, the TACE + RFA group demonstrated a significantly improved prognosis than the TACE group (p = .036).

CONCLUSIONS

The addition of RFA to TACE improved cumulative overall and recurrence-free survival in patients with intermediate-stage HCC, especially in patients with AFP <100.

Comparison of Combined Therapy Using Conventional Chemoembolization and Radiofrequency Ablation Versus Conventional Chemoembolization for Ultrasound-Invisible Early-Stage Hepatocellular Carcinoma (Barcelona Clinic Liver Cancer Stage 0 or A)

Objective

To compare the therapeutic efficacy between conventional transarterial chemoembolization (cTACE) and combined therapy using cTACE and radiofrequency ablation (RFA) in ultrasound (US)-invisible early stage hepatocellular carcinoma (HCC).

Materials and Methods

From January 2008 to June 2016, 167 patients with US-invisible early stage HCCs were treated with cTACE alone (cTACE group; n = 85) or cTACE followed by immediate fluoroscopy-guided RFA targeting intratumoral iodized oil retention (combined group; n = 82). Procedure-related complications, local tumor progression (LTP), time to progression (TTP), and overall survival (OS) were compared between the two groups. Multivariate analyses were performed to identify prognostic factors.

Results

There was no major complication in either group. The cTACE group showed higher 1-, 3-, and 5-year LTP rates than the combined group; i.e., 12.5%, 31.7%, and 37.0%, respectively, in the cTACE group; compared to 7.3%, 16.5%, and 16.5%, respectively, in the combined group; p = 0.013. The median TTP was 18 months in the cTACE group and 24 months in the combined group (p = 0.037). Cumulative 1-, 3-, and 5-year OS rates were 100%, 93.2%, and 87.7%, respectively, in the cTACE group and 100%, 96.6%, and 87.4%, respectively, in the combined group (p = 0.686). Tumor diameter > 20 mm and cTACE monotherapy were independent risk factors for LTP and TTP.

Conclusion

Combined therapy using cTACE followed by fluoroscopy-guided RFA is a safe and effective treatment in US-invisible early stage HCCs. It provides less LTP and longer TTP than cTACE alone.

Hepatitis C virus treatment by direct-acting antivirals in successfully treated hepatocellular carcinoma and possible mutual impact

BACKGROUND AND AIMS

Treatment of hepatitis C virus (HCV) after successfully treated hepatocellular carcinoma (HCC) becomes possible with the introduction of direct-acting antivirals because of their favorable efficacy, safety, and short period of treatment. Few data are available on the results of treatment using different direct-acting antiviral regimens in successfully treated HCC and a lot of debate about its role in tumor recurrence.

METHODS

Sixty-two HCV-related HCC patients were enrolled in the study after successfully treated HCC; the studied population included either Child-Pugh 'A' or 'B7'. The patients were subcategorized to receive one of the following regimens: group 1: sofosbuvir (SOF)+ribavirin (RBV) for 24 weeks, group 2: SOF+simeprevir for 12 weeks, group 3: SOF+daclatasvir for 24 weeks, and group 4: SOF+daclatasvir+RBV for 12 weeks. The overall median follow-up period is 12 months after treatment initiation.

RESULTS

All treatment regimens were tolerable for all patients, with no reported major adverse events during treatment. The overall sustained virologic response rate was 64.5%, with the highest result in group 4 and the lowest result in group 1; 87.5 and 26.7%, respectively. HCC recurrence was observed in 42% of patients; 80.7% of these patients developed recurrence within 6 months of treatment initiation.

CONCLUSION

Treatment of HCV in successfully treated HCC is feasible, with the best results achieved using multiple direct-acting antivirals and RBV; a high rate of HCC recurrence was observed, especially within the first 6 months of treatment initiation (ClinicalTrials.gov no: NCT02771405).

Comparative analysis of tumor-associated vascular changes following TACE alone or in combination with sorafenib treatment in HCC: A retrospective study

The objective of the present study was to investigate the tumor-associated vascular changes in hepatocellular carcinoma (HCC) following treatment with transarterial chemoembolization (TACE) combined with sorafenib. The data of 20 patients were retrospectively analyzed. Patients underwent treatment depending on their chosen regimens (orally administered sorafenib was recommended, however the cost prevented some study articipants from selecting this course). Based on this, the patients were divided into TACE combined with sorafenib (TS) (n=10) and TACE-only treatment groups (n=10). Digital subtraction angiography images of all patients were analyzed by 2 radiologists who were blind to the type of treatment administered. The diameters of the hepatic and proper hepatic arteries, and hepatic artery branches (tumor-associated arteries), the splenic, left gastric and gastroduodenal arteries or portal veins (non-tumor-associated arteries) and the number of microvascular vessels were compared prior to and following sorafenib treatment in the TS group, between the first and second sessions of TACE in the TACE-only group and between the TS and TACE-only groups. In the TS group, the diameters of the hepatic and proper hepatic arteries, their branches and the number of microvascular vessels were significantly decreased following sorafenib treatment (P<0.05), while the diameters of the splenic, gastroduodenal and left gastric arteries were not significantly altered (P>0.05). In the TACE-only group, the diameters of the hepatic, proper hepatic, splenic, left gastric and gastroduodenal arteries were not significantly different between the first and second TACE sessions (P>0.05), while the diameters of the hepatic artery branches and the number of microvascular vessels were significantly altered (P<0.05). TACE combined with sorafenib significantly decreased the diameters of the tumor-associated arteries and the number of tumor microvascular vessels when compared with TACE treatment alone (P<0.05). No significant difference in the diameters of the portal vein and its branches between the two groups was observed (P>0.05). Treatment with TACE combined with sorafenib may significantly affect the tumor-associated vasculature compared with treatment with TACE alone in HCC.

Effect of Microbubble-Enhanced Ultrasound on Radiofrequency Ablation of Rabbit Liver

Microbubble-enhanced ultrasound (MEUS) can non-invasively disrupt and block liver blood perfusion. It may potentially overcome the heat sink effect during a thermal ablation and consequently enhance radiofrequency ablation (RFA) of the liver. We propose a new strategy combining RFA with MEUS. For ultrasound treatment, an 831-kHz air-backed focused transducer directed 400-cycle bursts at 4.3 MPa to the liver at a 9-Hz rate. The treatment was nucleated by a lipids microbubble forming MEUS. Eighteen surgically exposed rabbit livers were treated using MEUS combined with RFA; the other 32 livers were treated using MEUS (n = 14) or RFA (n = 18) alone and served as the controls. Contrast ultrasound imaging confirmed that MEUS treatment significantly reduced liver blood perfusion by cutting contrast peak intensities in half (44.7%-54.1%) without severe liver function damage. The ablated liver volume treated using MEUS combined with RFA was 2.8 times greater than that treated using RFA alone. In conclusion, RFA of the liver can be safely and greatly enhanced by combination with MEUS pre-treatment.

Radiofrequency Ablation Combined With Transarterial Chemoembolization for Specially Located Small Hepatocellular Carcinoma

OBJECTIVE

To investigate the safety and efficacy of radiofrequency ablation combined with transarterial chemoembolization in patients with specially located small hepatocellular carcinoma.

MATERIALS AND METHODS

Between March 2014 and March 2017, a total of 26 patients with 26 lesions (10 perivascular, 6 subdiaphragmatic, 5 subcapsular, 5 perivascular, and subdiaphragmatic location; mean diameter 2.12 (0.62) cm), who received radiofrequency ablation-transarterial chemoembolization treatment, were retrospectively analyzed. Local tumor response was assessed by computed tomography/magnetic resonance imaging 1 month after the procedure. Tumor-free survival was also assessed according to the modified Response Evaluation Criteria in Solid Tumors. Complications were evaluated according to the National Cancer Institute's Common Terminology Criteria for Adverse Events (version 4.0).

RESULTS

Complete response was achieved in all patients 1 month after the procedure. During a median follow-up duration of 16.76 months (95% confidence interval: 7.78-25.73 months), local tumor recurrence occurred in 2 patients and new intrahepatic lesions developed in 7 patients. The 1-, 2-, and 3-year cumulative local tumor progression rates were 3.84%, 7.69%, and 7.69%, respectively. The median tumor-free survival duration was 21.96 months (95% confidence interval: 17.58-26.34 months). The 1-, 2-, and 3-year tumor-free survival rates were 67.4%, 46.1%, and 39.3%, respectively.

CONCLUSION

The radiofrequency ablation-transarterial chemoembolization combination therapy appears to be safe and effective and might be a treatment option for specially located small hepatocellular carcinoma lesions that have a risk of incomplete ablation or major complications.

Chemolipiodolization with or without embolization in transcatheter arterial chemoembolization combined with radiofrequency ablation for hepatocellular carcinoma-propensity score matching analysis

To retrospectively compare the outcome of chemolipiodolization with or without embolization in transcatheter arterial chemoembolization (TACE) combined with radiofrequency ablation (RFA) in Patients with hepatocellular carcinoma (HCC) within the Milan criteria. From August 2002 to December 2014, 112 patients (median age, 56.7 years; age range, 22–80 years; 97 men, 15 women) underwent TACE with gelatin sponge particle embolization, and 125 patients (median age, 56.6 years; age range, 23–82 years; 109 men, 16 women) underwent TACE without embolization. RFA was performed within 2 weeks after the TACE. Cumulative overall survival (OS) and disease-free survival (DFS) rates were compared before and after propensity score matching. Before matching, the 1-, 3-, and 5-year OS rate were 96%, 80%, and 62% for embolization group and 94%, 76%, and 59% for non-embolization group. The 1-, 3-, and 5-year DFS rate were 77%, 38%, and 30% for embolization group and 75%, 35%, and 26% for non-embolization group. After matching, the 1-, 3-, and 5-year OS rate were 97%, 82%, and 62% for embolization group and 92%, 74%, and 56% for non-embolization group. The 1-, 3-, and 5-year DFS rate were 79%, 36%, and 30% for embolization group and 74%, 33%, and 26% for non-embolization group. There were no significant difference in OS and DFS rates between the two groups before matching (P =0.999 and P =0.654) and after matching (P =0.951 and P =0.670). In conclusion, embolization in TACE combined with RFA could not improve the survival for patients with HCC within the Milan criteria.

Multimodality locoregional treatment strategies for bridging HCC patients before liver transplantation

BACKGROUND

It is current practice that patients with hepatocellular carcinoma (HCC) listed for liver transplantation should receive locoregional treatment if the suspected waiting time for transplantation is longer than 6 months, even in the absence of prospective randomized data. Aim of this study was the comparison of single versus multimodality locoregional treatment strategies on outcomes after liver transplantation.

METHODS

This is a retrospective analysis of 150 HCC patients listed for liver transplantation at our center between 2004 and 2011. Outcomes were analyzed according to modified Response Evaluation Criteria in Solid Tumors (mRECIST) in relation to intention-to-treat and overall survival after liver transplantation.

RESULTS

Overall, 92 patients (63%) were transplanted in this cohort. The intention-to-treat 1‑, 3‑, 5‑year waiting list survival was 80, 59, and 50% respectively. In RFA-(radiofrequency ablative) and TACE-(transarterial chemoembolisation)-based regimens, rates of transplanted patients were comparable (69 vs. 58%, p = ns). No difference was seen in overall survival after liver transplantation when comparing TACE- and RFA-based regimens. Patients receiving multimodality locoregional therapy had lower overall survival after transplantation (p = 0.05).

CONCLUSION

TACE- and RFA-based regimens showed equal outcomes in terms of transplantation rate, tumor response, and post-transplant survival. Patients in need of more than one treatment modality might identify a cohort with poorer post-transplant survival.

POINTS OF NOVELTY

Direct comparison of TACE and RFA in a multimodality setting, analysis according to mRECIST.

Enhanced efficacy of radiofrequency ablation for hepatocellular carcinoma using a novel vascular disrupting agent, CKD-516

BACKGROUND

CKD-516 is a novel vascular disrupting agent that shuts down intratumoral blood flow. We therefore hypothesized that concomitant administration of CKD-516 would enhance the therapeutic efficacy of radiofrequency ablation (RFA) by reducing heat sink effects. We assessed the effects of the combination of CKD-516 and RFA in a rat orthotopic hepatocellular carcinoma (HCC) model.

METHODS

Rat HCC cells (N1-S1) were engrafted into the hepatic lobe of Sprague-Dawley (SD) rats. Mice were randomly divided into two groups: RFA-only and CKD-RFA. In the CKD-RFA group, CKD-516 was administered by intraperitoneal injection 2 h before RFA. Ablation zone size was measured on triphenyltetrazolium chloride-stained specimens. Terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining was performed to evaluate the area of apoptosis/necrosis in the ablation zone. Immunohistochemistry with anti-CD31 antibody was performed to evaluate the effect of CKD-516 on tumor vessels.

RESULTS

Ablation zone size was significantly larger in the CKD-RFA group than in the RFA-only group (243.10 ± 74.39 versus 123.30 ± 28.17 mm², p < 0.001). On TUNEL staining, the area of apoptosis/necrosis was also significantly larger in the CKD-RFA group than in the RFA-only group (274.44 ± 140.78 versus 143.74 ± 90.13 mm²; p = 0.006). Immunohistochemistry with anti-CD31 antibody revealed patent tumor vessels in the RFA-only group, while collapsed vessels were seen in the CKD-RFA group, indicating a vascular shutdown effect of CKD-516.

CONCLUSION

Concomitant administration of CKD-516 during RFA can increase the ablation zone of tumors due to its vascular disrupting effect.

Parametric response mapping of dynamic CT: enhanced prediction of survival in hepatocellular carcinoma patients treated with transarterial chemoembolization

PURPOSE

The aim of this study was to evaluate the prognostic significance of parametric response mapping (PRM) analysis for hepatocellular carcinoma (HCC) patients undergoing transarterial chemoembolization (TACE).

METHODS

We recruited 65 HCC patients who underwent TACE. These patients underwent longitudinal multiphasic CT before and after TACE. We applied PRM analysis to the baseline CT before TACE and first/second follow-up CTs. The results of PRM analyses were used to stratify patients into responders and non-responders. Overall survival was compared between the two groups. An independent survival analysis using conventional radiological assessments was performed, and the results were compared with PRM results. Univariate and multivariate analyses were performed to identify clinical factors affecting survival.

RESULTS

The PRM analyses demonstrated that the responding group had a median survival of 529 days, while the non-responding group had a median survival of 263 days [hazard ratio (HR) 12.9, p < 0.05 for differences in survival]. The manual analyses indicated median survivals of 491 and 329 days for the responding and non-responding groups, respectively (HR 2.7, p < 0.05). Tumor size, albumin level, and PRM values were found to be significantly related to overall survival after univariate and multivariate analyses.

CONCLUSIONS

The PRM analysis could be a better predictor of overall survival for patients with HCC undergoing TACE than conventional radiological assessments.

Thermal Ablation in the Management of Colorectal Cancer Patients with Oligometastatic Liver Disease

BACKGROUND

Surgical resection of limited colorectal liver disease improves long-term survival and can be curative in a subset of selected cases. Image-guided percutaneous ablation therapies have emerged as safe and effective alternative options for selected patients with unresectable colorectal liver metastases (CLM) that can be ablated with margins. Ablation causes focal destruction of tissue and has increasingly been shown to provide durable eradication of tumors.

METHODS

A selective review of literature was conducted in PubMed, focusing on recent studies reporting on the safety, efficacy, and long-term outcomes of percutaneous ablation modalities in the treatment of CLM. The present work gives an overview of the different ablation techniques, their current clinical indications, and reported outcomes from most recently published studies. The 'test of time' concept for using ablation as a first local therapy is also described.

RESULTS

There are several thermal ablative tools currently available, including radiofrequency ablation (RFA), microwave ablation, and cryoablation. Most data to date originated from the application of RFA. Adjuvant thermal ablation in the treatment of oligometastatic colon cancer liver disease offers improved oncologic outcomes. The ideal CLM amenable to percutaneous ablation is a solitary tumor with the largest diameter up to 3 cm that can be completely ablated with a sufficient margin. 5-year overall survival rates up to 70% after ablation of unresectable CLM have been reported. Pathologic confirmation of complete tumor necrosis with margins over 5 mm provides best long-term local tumor control by thermal ablation.

CONCLUSION

Current evidence suggests that percutaneous ablation as adjuvant to chemotherapy improves oncologic outcomes of patients with CLM. For small tumors that can be ablated completely with clear margins, percutaneous ablation may offer outcomes similar to those of surgery.

Early treatment response to transcatheter arterial chemoembolization is associated with time to the development of extrahepatic metastasis and overall survival in intermediate-stage hepatocellular carcinoma

PURPOSE

Transcatheter arterial chemoembolization (TACE) is the treatment of choice for intermediate-stage hepatocellular carcinoma (HCC). The absence of an early response to TACE might indicate alternative therapeutic strategies early in the course of the disease, thus improving outcomes. Therefore, our purpose was to identify the relationship between treatment response after two sessions of TACE and the time to the development of extrahepatic metastasis and overall survival.

METHODS

In total, 108 treatment-naïve intermediate-stage HCC patients who received at least two consecutive sessions of TACE as the first-line treatment were analyzed.

RESULTS

The median follow-up duration was 28.5 months. Extrahepatic metastasis developed in 32 patients (29.6%). Patient age >60 years (P = 0.027), alpha-fetoprotein (AFP) >200 ng/ml (P = 0.039), and objective response after two TACE treatments (P = 0.001) were the predictive factors for time to the development of metastasis. The median survival time for the patients who achieved objective response after two sessions of TACE was 45.9 and 14.4 months for the patients who failed to achieve objective response (P = 0.0001). Objective response after two TACE treatments (P = 0.0001) and the occurrence of extrahepatic metastasis (P = 0.002) were associated with overall survival.

CONCLUSIONS

Early objective tumor response after two sessions of TACE was associated with prolonged time to metastasis and improved survival. Therefore, surveillance for metastasis should be performed more frequently when an objective response is not obtained after two sessions of TACE and in younger intermediate-stage HCC patients with high AFP levels.

Minimally invasive image-guided therapies for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most frequently occurring cancer globally and predominantly develops in the setting of various grades of underlying chronic liver disease, which affects management decisions. Image-guided percutaneous ablative or transarterial therapies have acquired wide acceptance in HCC management as a single treatment modality or combined with other treatment options in patients who are not amenable for surgery. Recently, such treatment modalities have also been used for bridging or downsizing before definitive treatment (ie, surgical resection or liver transplantation). This review focuses on the use of minimally invasive image-guided locoregional therapies for HCC. Additionally, it highlights recent advancements in imaging and catheter technology, embolic materials, chemotherapeutic agents, and delivery techniques; all lead to improved patient outcomes, thereby increasing the interest in these invasive techniques.

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.

Sequential Use of Transhepatic Arterial Chemoembolization and Bipolar Radiofrequency Ablation in the Clinical Therapy of Hepatocellular Carcinoma

This retrospective study investigated the clinical application of sequential therapy with transarterial chemoembolization (TACE) and CT-guided radiofrequency ablation (RFA) using a bipolar needle in treating hepatocellular carcinoma (HCC) tumors of different sizes. The study included patients (N = 46) with HCC from Shengjing Hospital of China Medical University who had received TACE and RFA from November 2012 to November 2013. Eligible patients had an Eastern Cooperative Oncology Group (ECOG) score of 0-1, a Child-Pugh grade of A-B, and no contradictions for TACE and/or RFA. Fifty one hepatic lesions of varying sizes were treated with TACE followed by RFA. Clinical response and 1- and 2-year survival rates were assessed. The frequency of complete and incomplete ablation following therapy was significantly different across the varying RFA pin numbers and the maximum diameter of the lesion (p ≤ 0.001). A greater percentage (97.3%) of lesions that were ≤3 cm in diameter were completely ablated compared with lesions that were 3-5 cm (88.9%) and >5 cm in diameter (20%). The median survival time of patients was 16.5 months, and the 1- and 2-year survival rates were 95.7% and 69.3%, respectively. There were only a limited number of complications, all of which were minor. These included hemothorax (4.3%), abdominal hemorrhage (10.9%), and abdominal hemorrhage with minor pneumothorax (2.2%). This study found that the sequential treatment with TACE and CT-guided RFA using a bipolar needle is effective and well tolerated in patients with HCC and that the effectiveness of treatment is dependent on tumor size.

Radio-frequency ablation-based studies on VX2rabbit models for HCC treatment

Hepatocellular carcinoma (HCC) is the fifth most frequent cancer worldwide with high morbidity, mortality and increasing incidence. It is of note that the main curative therapies for HCC are hepatic resection and transplantation although the majority of patients at the time of presentation are not eligible for resection or orthotopic liver transplantation (OLT) due to the underlying cirrhosis. Currently, a variety of loco-regional therapies, including radiofrequency ablation (RFA), percutaneous ethanol injection (PEI), microwave coagulation therapy (MCT), transarterial chemoembolization (TACE) and others, have been developed as alternative treatment options for HCC. Among these techniques, RFA is currently the most widely used treatment, due to its several advantages, such as safety and efficacy. To date, the effectiveness of RFA for HCC is reduced by the presence of residual tumor as a consequence of insufficient treatment. In order to ameliorate the effects of RFA on HCC, several in vivo studies, have been performed on its application as single or in combination treatment with drugs or others loco-regional therapies, by using rabbit VX2 liver model. This represents an ideal model of liver cancers and is widely used for imaging and other experimental studies due to the rapid growth of these tumors and their similarity to human hepatocellular carcinoma. In order to elucidate the therapeutic potential of RFA with adjuvant treatments for HCC, we reviewed the latest findings on the RFA-based studies in rabbit VX2 hepatocarcinoma models.