Efficacy and Safety of Radiofrequency Ablation Combined with Transcatheter Arterial Chemoembolization for Hepatocellular Carcinomas Compared with Radiofrequency Ablation Alone: A Time-to-Event Meta-Analysis

Anatomic sub-segmentectomy with single-session combined transcatheter arterial embolization/microwave ablation for the treatment of hepatocellular carcinoma: preliminary results

PURPOSE

This retrospective study aimed to confirm the safety and long-term efficacy of a single-session combined treatment approach with transcatheter arterial embolization (TAE) and microwave ablation (MWA) for inoperable small-to intermediate-sized hepatocellular carcinomas (HCC), focusing on their combined benefits for improving local control.

MATERIALS AND METHODS

All consecutive patients with up to 2 small-to-intermediate HCC lesions (≤ 5 cm) treated with a combined single-session MWA-TAE approach were enrolled between April 2020 and October 2023. All procedures were performed in two stages: TAE and MWA. Clinical and radiological follow-up was performed 3, 6, and 12 months after treatment.

RESULTS

In the 21 enrolled patients (15 males, mean age 75.9 years), post-procedural contrast-enhanced CT scans confirmed a satisfactory ablation zone in all patients (100%), with minor peri-procedural complications reported in three patients (14%). At the last 12-month follow-up, one patient (8%) displayed local tumor progression, previously classified as LR-TR equivocal at the 6-month follow-up, and half of the patients (6 patients, 50%) exhibited distant tumor progression, predominantly in the form of intra-hepatic recurrence.

CONCLUSION

The combined approach of TAE and MWA is a promising method to enhance the percutaneous treatment of small to intermediate-sized HCCs with a resulting anatomic ablation area resembling a surgical sub-segmentectomy. This technique can potentially reduce the gap between percutaneous treatment and liver resection outcomes, allowing for a safe and effective option for oncological control in patients with > 3 cm lesions.

Embolic and Ablative Therapy for Hepatocellular Carcinoma

Embolic and ablative locoregional therapies (LRTs) for hepatocellular carcinoma are widely used to cure, bridge, or downstage patients for more definitive therapies. Common ablative therapies include microwave ablation and radiofrequency ablation, while embolic options include transarterial chemoembolization and 90Y transarterial radioembolization. While these therapies can be highly effective for the appropriate stage of disease, LRTs can suffer from a high rate of posttreatment recurrences. Considerations for administration of specific therapies include disease burden and underlying liver function. Recent data on concomitant or adjuvant systemic therapy, with LRT, have the potential to improve disease control and improve outcomes in this high-risk patient population.

Current Treatment Methods in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a prevalent malignant tumour worldwide. Depending on the stage of the tumour and liver function, a variety of treatment options are indicated. Traditional radiotherapy and chemotherapy are ineffective against HCC; however, the U.S. Food and Drug Administration (FDA) has approved radiofrequency ablation (RFA), surgical resection, and transarterial chemoembolization (TACE) for advanced HCC. On the other hand, liver transplantation is recommended in the early stages of the disease. Tyrosine kinase inhibitors (TKIs) like lenvatinib and sorafenib, immunotherapy and anti-angiogenesis therapy, including pembrolizumab, bevacizumab, tremelimumab, durvalumab, camrelizumab, and atezolizumab, are other treatment options for advanced HCC. Moreover, to maximize outcomes for patients with HCC, the combination of immune checkpoint inhibitors (ICIs) along with targeted therapies or local ablative therapy is being investigated. This review elaborates on the current status of HCC treatment, outlining the most recent clinical study results and novel approaches.

Survival benefit of sequential curative treatment for TACE suitable BCLC stage B HCC patients

To clarify the survival benefit of sequential curative treatment post transcatheter arterial chemoembolization (TACE) for Barcelona Clinic Liver Cancer (BCLC) stage B hepatocellular carcinoma (HCC), we retrospectively analyzed HCC patients at a hospital. From July 2017 to July 2020, 787 treatment-naïve HCC patients underwent initial treatment; 77 (9.8%) meeting inclusion criteria were enrolled. Their initial treatments were TACE only (n = 68, 88.3%) or TACE with other treatments (n = 9, 11.7%). Median survival of the TACE-only group was 30 months. Treatment response was evaluated after 2 or 3 consecutive TACEs for patients (54/68, 79.4%) with available pre-/post-TACE computerized tomography (CT) or magnetic resonance imaging (MRI). Treatment responses was divided into 4 groups: complete (n = 14, 26%, group (Gr) 1), incomplete without new tumor growth (n = 28, 52.0%, Gr2), incomplete with new growth (n = 6, 11%, Gr3), and progression (n = 6, 11%, Gr4). Of Gr2, further treatment after TACE were had radiofrequency ablation (n = 13, Gr2a), TACE (n = 9, Gr2b), other modalities (n = 6, Gr2c. Gr2a's median survival was longer than Gr2b's (> 60 vs. 20 months, p = 0.007). Nine patients in Gr2a (69%, 9/13) achieved a complete response, but none in Gr2b (p = 0.001). Conclusively, in TACE-suitable BCLC stage B HCC patients, a partial response without new tumor growth can serve as an indicator of treatment effectiveness following initial TACE treatment. This can facilitate the selection of appropriate candidates to receive RFA, potentially resulting in improved patient survival.

Local Ablation for Hepatocellular Carcinoma: 2024 Expert Consensus-Based Practical Recommendations of the Korean Liver Cancer Association

Local ablation for hepatocellular carcinoma, a non-surgical option that directly targets and destroys tumor cells, has advanced significantly since the 1990s. Therapies with different energy sources, such as radiofrequency ablation, microwave ablation, and cryoablation, employ different mechanisms to induce tumor necrosis. The precision, safety, and effectiveness of these therapies have increased with advances in guiding technologies and device improvements. Consequently, local ablation has become the first-line treatment for early-stage hepatocellular carcinoma. The lack of organized evidence and expert opinions regarding patient selection, preprocedure preparation, procedural methods, swift post-treatment evaluation, and follow-up has resulted in clinicians following varied practices. Therefore, an expert consensus-based practical recommendation for local ablation was developed by a group of experts in radiology and hepatology from the Research Committee of the Korean Liver Cancer Association in collaboration with the Korean Society of Image-Guided Tumor Ablation to provide useful information and guidance for performing local ablation and for the pre- and post-treatment management of patients.

Local Ablation for Hepatocellular Carcinoma: 2024 Expert Consensus-Based Practical Recommendations of the Korean Liver Cancer Association

Local ablation for hepatocellular carcinoma (HCC), a non-surgical option that directly targets and destroys tumor cells, has advanced significantly since the 1990s. Therapies with different energy sources, such as radiofrequency ablation, microwave ablation, and cryoablation, employ different mechanisms to induce tumor necrosis. The precision, safety, and effectiveness of these therapies have increased with advances in guiding technologies and device improvements. Consequently, local ablation has become the first-line treatment for early-stage HCC. The lack of organized evidence and expert opinions regarding patient selection, pre-procedure preparation, procedural methods, swift post-treatment evaluation, and follow-up has resulted in clinicians following varied practices. Therefore, an expert consensus-based practical recommendation for local ablation was developed by a group of experts in radiology and hepatology from the Research Committee of the Korean Liver Cancer Association in collaboration with the Korean Society of Image-guided Tumor Ablation to provide useful information and guidance for performing local ablation and for the pre- and post-treatment management of patients.

Local ablation for hepatocellular carcinoma: 2024 expert consensus-based practical recommendation of the Korean Liver Cancer Association

Local ablation for hepatocellular carcinoma (HCC), a non-surgical option that directly targets and destroys tumor cells, has advanced significantly since the 1990s. Therapies with different energy sources, such as radiofrequency ablation, microwave ablation, and cryoablation, employ different mechanisms to induce tumor necrosis. The precision, safety, and effectiveness of these therapies have increased with advances in guiding technologies and device improvements. Consequently, local ablation has become the firstline treatment for early-stage HCC. The lack of organized evidence and expert opinions regarding patient selection, pre-procedure preparation, procedural methods, swift post-treatment evaluation, and follow-up has resulted in clinicians following varied practices. Therefore, an expert consensus-based practical recommendation for local ablation was developed by a group of experts in radiology and hepatology from the Research Committee of the Korean Liver Cancer Association in collaboration with the Korean Society of Image-guided Tumor Ablation to provide useful information and guidance for performing local ablation and for the pre- and posttreatment management of patients.

Microwave ablation followed by cTACE in 5-cm HCC lesions: does a single-session approach affect liver function?

PURPOSE

Microwave ablation (MWA) and conventional transarterial chemoembolization (cTACE) are locoregional treatments commonly performed in very early, early and intermediate stages of hepatocellular carcinoma (HCC). Despite combined locoregional approaches have shown encouraging results in obtaining complete tumor necrosis, their application in a single session is poorly described. Our aim was to evaluate the safety and efficacy of single-session MWA and cTACE treatment in 5-cm HCCs and its influence on liver function.

MATERIALS AND METHODS

All 5-cm HCCs treated by MWA and cTACE performed in a single-session in our Interventional Radiology unit between January 2020 and December 2022 were retrospectively recorded and analyzed. Patients with poor or missing pre- and post-treatment imaging were excluded. Technical success, clinical success, and complications rate were examined as primary endpoints. Pre- and post-treatment liver function laboratory parameters were also evaluated.

RESULTS

A total of 15 lesions (mean lesion diameter, 5.0 ± 1.4 cm) in 15 patients (11 men; mean age, 67.1 ± 8.9 years) were retrospectively evaluated. Technical and clinical success were 100% and 73%, respectively. Four (27%) cases of partial response and no cases of progressive or stable disease were recorded. AST and ALT values have found to be significantly higher in post-treatment laboratory tests. No other significant differences between pre- and post-treatment laboratory values were registered. AST and ALT pre- and post-treatment higher differences (ΔAST and ΔALT) were significantly associated with a lower clinical success rate.

CONCLUSION

MWA and cTACE single-session approach is safe and effective for 5-cm HCCs, without significant liver function impairment. A post-treatment increase in AST and ALT values may be a predictor for clinical failure.

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.

Therapeutic options in hepatocellular carcinoma: a comprehensive review

Hepatocellular carcinoma (HCC) is a chronic liver disease that is highly fatal if not detected and treated early. The incidence and death rate of HCC have been increasing in recent decades despite the measures taken for preventive screening and effective diagnostic and treatment strategies. The pathophysiology of HCC is multifactorial and highly complex owing to its molecular and immune heterogeneity, and thus the gap in knowledge still precludes making choices between viable therapeutic options and also the development of effective regimens. The treatment of HCC demands multidisciplinary approaches and primarily depends on tumor stage, hepatic functional reserve, and response to treatment by patients. Although curative treatments are limited but critical in the early stages of cancer, there are numerous palliative treatments available for patients with intermediate and advanced-stage HCC. In recent times, the use of combination therapy has succeeded over the use of monotherapy in the treatment of HCC by achieving effective tumor suppression, increasing survival rate, decreasing toxicity, and also aiding in overcoming drug resistance. This work focuses on reviewing the current and emerging treatment strategies for HCC.

The management of hepatocellular carcinoma. Current expert opinion and recommendations derived from the 24th ESMO/World Congress on Gastrointestinal Cancer, Barcelona, 2022

This article summarises expert discussion on the management of patients with hepatocellular carcinoma (HCC), which took place during the 24th World Gastrointestinal Cancer Congress (WGICC) in Barcelona, July 2022. A multidisciplinary approach is mandatory to ensure an optimal diagnosis and staging of HCC, planning of curative and therapeutic options, including surgical, embolisation, ablative strategies, or systemic therapy. Furthermore, in many patients with HCC, underlying liver cirrhosis represents a challenge and influences the therapeutic options.

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

How Biology Guides the Combination of Locoregional Interventional Therapies and Immunotherapy for Hepatocellular Carcinoma: Cytokines and Their Roles

As most patients with hepatocellular carcinoma (HCC) are diagnosed at the intermediate or advanced stage and are no longer eligible for curative treatment, the overall survival rate of HCC remains unsatisfactory. Locoregional interventional therapies (LITs), and immune checkpoint inhibitor (ICI)-based immunotherapy, focus on treating HCC, but the efficacy of their individual application is limited. Therefore, the purpose of this review was to discuss the biological roles of cytokines and their therapeutic potential in the combination therapy of LITs and ICI-based immunotherapy. The two common techniques of LITs are ablative and transarterial therapies. Whether LITs are complete or incomplete can largely affect the antitumor immune response and tumor progression. Cytokines that induce both local and systemic responses to LITs, including interferons, interleukins, chemokines, TNF-α, TGF-β, VEGF, and HGF, and their roles are discussed in detail. In addition, specific cytokines that can be used as therapeutic targets to reduce immune-related adverse events (irAEs) are introduced. Overall, incomplete LITs in a tumor, combined with specific cytokines, are thought to be effective at improving the therapeutic efficacy and reducing treatment-induced irAEs, and represent a new hope for managing unresectable HCC.

2022 KLCA-NCC Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

2022 KLCA-NCC Korea practice guidelines for the management of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the fourth most common cancer among men in South Korea, where the prevalence of chronic hepatitis B infection is high in middle and old age. The current practice guidelines will provide useful and sensible advice for the clinical management of patients with HCC. A total of 49 experts in the fields of hepatology, oncology, surgery, radiology, and radiation oncology from the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2018 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions. These guidelines provide useful information and direction for all clinicians, trainees, and researchers in the diagnosis and treatment of HCC.

Priming of Sorafenib Prior to Radiofrequency Ablation Does Not Increase Treatment Effect in Hepatocellular Carcinoma

BACKGROUND

Preclinical studies have shown that modulation of the tumor microvasculature with anti-angiogenic agents decreases tumor perfusion and may increase the efficacy of radiofrequency ablation (RFA) in hepatocellular carcinoma (HCC). Retrospective studies suggest that sorafenib given prior to RFA promotes an increase in the ablation zone, but prospective randomized data are lacking.

AIMS

We conducted a randomized, double-blind, placebo-controlled phase II trial to evaluate the efficacy of a short-course of sorafenib prior to RFA for HCC tumors sized 3.5-7 cm (NCT00813293).

METHODS

Treatment consisted of sorafenib 400 mg twice daily for 10 days or matching placebo, followed by RFA on day 10. The primary objectives were to assess if priming with sorafenib increased the volume and diameter of the RFA coagulation zone and to evaluate its impact on RFA thermal parameters. Secondary objectives included feasibility, safety and to explore the relationship between tumor blood flow on MRI and RFA effectiveness.

RESULTS

Twenty patients were randomized 1:1. Priming with sorafenib did not increase the size of ablation zone achieved with RFA and did not promote significant changes in thermal parameters, although it significantly decreased blood perfusion to the tumor by 27.9% (p = 0.01) as analyzed by DCE-MRI. No subject discontinued treatment owing to adverse events and no grade 4 toxicity was observed.

CONCLUSION

Priming of sorafenib did not enhance the effect of RFA in intermediate sized HCC. Future studies should investigate whether longer duration of treatment or a different antiangiogenic strategy in the post-procedure setting would be more effective in impairing tumor perfusion and increasing RFA efficacy.

Local and Regional Therapies for Hepatocellular Carcinoma and Future Combinations

Simple Summary

Percutaneous interventional radiological techniques offer many alternatives for treatment of Hepatocellular Carcinoma (HCC) using local anesthesia and sedation. These methods aim to destroy the malignant tumors locally without affecting the non-malignant liver. In this way, complications are kept low and patient recovery is quick. Indications depend on tumor size, type and stage, as well as patient’s condition, liver function and co-morbidities. In recent years, a lot of research has been made in combining such approaches with immune therapy, but there is still much work to be done. This manuscript tries to analyze where we stand today and explain, using a comprehensive algorithm, the treatment options for each different clinical condition.

Abstract

Background: Hepatocellular carcinoma (HCC) can be treated by local and regional methods of percutaneous interventional radiological techniques. Indications depend on tumor size, type and stage, as well as patient’s condition, liver function and co-morbidities. According to international classification systems such as Barcelona Clinic Liver Cancer (BCLC) classification, very early, early or intermediate staged tumors can be treated either with ablative methods or with transarterial chemoembolization (TACE), depending on tumor characteristics. The combination of both allows for individualized forms of treatment with the ultimate goal of improving response and survival. In recent years, a lot of research has been carried out in combining locoregional approaches with immune therapy. Although recent developments in systemic treatment, especially immunotherapy, seem quite promising and have expanded possible combined treatment options, there is still not enough evidence in their favor. The aim of this review is to provide a comprehensive up-to-date overview of all these techniques, explaining indications, contraindications, technical problems, outcomes, results and complications. Moreover, combinations of percutaneous treatment with each other or with immunotherapy and future options will be discussed. Use of all those methods as down-staging or bridging solutions until surgery or transplantation are taken into consideration will also be reviewed. Conclusion: Local and regional therapies remain a mainstay of curative and palliative treatment of patients with HCC. Currently, evidence on potential combination of the local and regional treatment options with each other as well as with other treatment modalities is growing and has the potential to further individualize HCC therapy. To identify the most suitable treatment option out of these new various options, a repeated interdisciplinary discussion of each case by the tumor board is of utmost importance.

Quality Reporting of Systematic Review and Meta-Analysis According to PRISMA 2020 Guidelines: Results from Recently Published Papers in the Korean Journal of Radiology

OBJECTIVE

To evaluate the completeness of the reporting of systematic reviews and meta-analyses published in a general radiology journal using the Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA) 2020 guidelines.

MATERIALS AND METHODS

Twenty-four articles (systematic review and meta-analysis, n = 18; systematic review only, n = 6) published between August 2009 and September 2021 in the Korean Journal of Radiology were analyzed. Completeness of the reporting of main texts and abstracts were evaluated using the PRISMA 2020 statement. For each item in the statement, the proportion of studies that met the guidelines' recommendation was calculated and items that were satisfied by fewer than 80% of the studies were identified. The review process was conducted by two independent reviewers.

RESULTS

Of the 42 items (including sub-items) in the PRISMA 2020 statement for main text, 24 were satisfied by fewer than 80% of the included articles. The 24 items were grouped into eight domains: 1) assessment of the eligibility of potential articles, 2) assessment of the risk of bias, 3) synthesis of results, 4) additional analysis of study heterogeneity, 5) assessment of non-reporting bias, 6) assessment of the certainty of evidence, 7) provision of limitations of the study, and 8) additional information, such as protocol registration. Of the 12 items in the abstract checklists, eight were incorporated in fewer than 80% of the included publications.

CONCLUSION

Several items included in the PRISMA 2020 checklist were overlooked in systematic review and meta-analysis articles published in the Korean Journal of Radiology. Based on these results, we suggest a double-check list for improving the quality of systematic reviews and meta-analyses. Authors and reviewers should familiarize themselves with the PRISMA 2020 statement and check whether the recommended items are fully satisfied prior to publication.

Locoregional Treatments for Bridging and Downstaging HCC to Liver Transplantation

Liver transplantation (LT) is the first-line treatment for patients diagnosed with unresectable early-stage hepatocellular carcinoma (HCC) in the setting of cirrhosis. It is well known that HCC patients within the Milan criteria (solitary tumour ≤ 5 cm or ≤3 tumours, each <3 cm) could undergo LT with excellent results. However, there is a growing tendency to enlarge inclusion criteria since the Milan criteria are nowadays considered too restrictive and may exclude patients who would benefit from LT. On the other hand, there is a persistent shortage of donor organs. In this scenario, there is consensus about the role of loco-regional therapy (LRT) during the waiting list to select patients who would benefit more from LT, reducing the risk of drop off from the waiting list as well as decreasing tumour dimension to meet acceptable criteria for LT. In this review, current evidence on the safety, efficacy and utility of LRTs as neoadjuvant therapies before LT are summarized.

Thermal ablation of medium-sized hepatocellular carcinomas using intraoperative ultrasound fusion imaging: A propensity score-matched analysis

OBJECTIVE

To explore the value of ultrasound fusion imaging for the thermal ablation of medium-sized hepatocellular carcinomas (HCCs).

MATERIALS AND METHODS

From December 2010 to June 2018, patients with medium-sized (3.1-5.0cm) HCCs who underwent radiofrequency ablation (RFA) or microwave ablation (MWA) with the assistance of ultrasound fusion imaging were enrolled in this retrospective study. Technical efficacy, local tumor progression (LTP), intrahepatic distant recurrence (IDR), overall survival (OS), tumor-free survival (TFS) and major complications were evaluated during the follow-up period. The therapeutic outcomes were compared between the RFA/MWA combined with trans-arterial chemoembolization (TACE) group and the RFA/MWA alone group with propensity-score matching (PSM) analysis.

RESULTS

A total of 112 patients with 115 medium-sized HCCs were finally enrolled in this study. The median duration of follow-up was 33 months (range, 2-104 months). The technique efficacy was 100% (115/115). The 1-, 3-, 5-year OS rates and TFS rates were 95.5%, 76.7%, 71.5% and 74.1%, 48.7%, 41.8%, respectively. The corresponding LTP rates and IDR rates were 5.4%, 7.3%, 7.3% and 21.8%, 46.9%, 50.3%, respectively. The incidence of major complications was 5.4% (6/112). After PSM analysis (19 patients in each group), the therapeutic outcomes, including the OS, TFS, and LTP rates, were comparable in the two groups (P > 0.05).

CONCLUSIONS

With the assistance of ultrasound fusion imaging, thermal ablation of medium-sized HCC could achieve a satisfactory local control rate and long-term survival. The outcomes were comparable in the stratified analysis between the RFA/MWA alone group and the RFA/MWA+TACE group after PSM analysis.

Consensus of Minimally Invasive and Multidisciplinary Comprehensive Treatment for Hepatocellular Carcinoma - 2020 Guangzhou Recommendations

In China, the majority of patients with hepatocellular carcinoma (HCC) result from long-term infection of hepatitis B. Pathologically, HCC is characterized by rich blood supply, multicentric origins, early vascular invasion and intrahepatic metastasis. Therefore, HCC is not a local disease but a systemic disease at the beginning of its occurrence. For this reason, a comprehensive treatment strategy should be adopted in the management of HCC, including local treatments (such as surgical resection, radiofrequency ablation, microwave ablation, chemical ablation and cryoablation, etc.), organ-level treatments [such as transcatheter arterial infusion of chemotherapy and transcatheter arterial chemoembolization (TACE)], and systemic treatments (such as immunotherapy, antiviral therapy and molecular targeted therapy, etc.). This consensus sets forth the minimally-invasive and multidisciplinary comprehensive guideline of HCC, focusing on the following eight aspects (1) using hepaticarteriography, CT hepatic arteriography (CTHA), CT arterial portography (CTAP), lipiodol CT (Lp-CT), TACE-CT to find the intrahepatic lesion and make precise staging (2) TACE combined with ablation or ablation as the first choice of treatment for early stage or small HCC, while other therapies are considered only when ablation is not applicable (3) infiltrating HCC should be regarded as an independent subtype of HCC (4) minimally-invasive comprehensive treatment could be adopted in treating metastatic lymph nodes (5) multi-level subdivision of M-staging should be used for individualized treatment and predicting prognosis (6) HCC with severe hepatic decompensation is the only candidate criterion for liver transplantation (7) bio-immunotherapy, traditional Chinese medicine therapy, antiviral therapy, and psychosocial and psychopharmacological interventions should be advocated through the whole course of HCC treatment (8) implementation of multicenter randomized controlled trials of minimally-invasive therapy versus surgery for early and intermediate stage HCC is recommended.

High rate of complete histopathological response in hepatocellular carcinoma patients after combined transarterial chemoembolization and stereotactic body radiation therapy

BACKGROUND

Liver transplantation (LT) presents a curative treatment option in patients with early stage hepatocellular carcinoma (HCC) who are not eligible for resection or ablation therapy. Due to a risk of up 30% for waitlist drop-out upon tumor progression, bridging therapies are used to halt tumor growth. Transarterial chemoembolization (TACE) and less commonly stereotactic body radiation therapy (SBRT) or a combination of TACE and SBRT, are used as bridging therapies in LT. However, it remains unclear if one of those treatment options is superior. The analysis of explant livers after transplantation provides the unique opportunity to investigate treatment response by histopathology.

AIM

To analyze histopathological response to a combination of TACE and SBRT in HCC in comparison to TACE or SBRT alone.

METHODS

In this multicenter retrospective study, 27 patients who received liver transplantation for HCC were analyzed. Patients received either TACE or SBRT alone, or a combination of TACE and SBRT as bridging therapy to liver transplantation. Liver explants of all patients who received at least one TACE and/or SBRT were analyzed for the presence of residual vital tumor tissue by histopathology to assess differences in treatment response to bridging therapies. Statistical analysis was performed using Fisher-Freeman-Halton exact test, Kruskal-Wallis and Mann-Whitney-U tests.

RESULTS

Fourteen patients received TACE only, four patients SBRT only, and nine patients a combination therapy of TACE and SBRT. There were no significant differences between groups regarding age, sex, etiology of underlying liver disease or number and size of tumor lesions. Strikingly, analysis of liver explants revealed that almost all patients in the TACE and SBRT combination group (8/9, 89%) showed no residual vital tumor tissue by histopathology, whereas TACE or SBRT alone resulted in significantly lower rates of complete histopathological response (0/14, 0% and 1/4, 25%, respectively, P value < 0.001).

CONCLUSION

Our data suggests that a combination of TACE and SBRT increases the rate of complete histopathological response compared to TACE or SBRT alone in bridging to liver transplantation.

Quality of Life after Transcatheter Arterial Chemoembolization Combined with Radiofrequency Ablation in Patients with Unresectable Hepatocellular Carcinoma Compared with Transcatheter Arterial Chemoembolization alone

AIM

The aim of this study was to assess quality of life (QoL) in patients with unresectable hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE) compared to TACE plus radiofrequency ablation (RFA) done at the same sitting, and to assess tumor therapy response after these 2 palliative interventions.

METHODS

73 patients with unresectable HCC (BCLC-B) were included. Patients with tumor ≤ 5 cm were subjected to TACE (N = 45) while patients with tumors > 5 cm were subjected to TACE followed immediately by RFA (N = 28). QoL was evaluated with two validated questionnaires (EORTC QLQ-30 and EORTC HCC18). These questionnaires were filled out before intervention, 2 weeks and 2 months after intervention. Pre/post interventional changes were analyzed. The modified response evaluation criteria in solid tumor (mRECIST) were employed for the evaluation of therapeutic efficacy.

RESULTS

Baseline global health status/QoL was significantly higher in TACE group (64.1%) compared to TACE-RFA group (51.2%). Two weeks after intervention: the absolute decrease in global health state was higher in TACE-RFA (- 12.1%) compared to TACE (- 6.3%, p = 0.411). Less impairment was found in TACE group compared to TACE-RFA group for physical/social functioning, fatigue and pain but it was statistically insignificant. Two months after intervention; TACE-RFA group showed significant improvement in global health score, social and physical functioning scores, as well as significant improvement in pain and fatigue compared to TACE group. The therapeutic efficacy of TACE-RFA was better than TACE alone: complete remission, partial remission, stable disease and progressive disease were 17.9%, 32.1%, 42.9% and 7.1% Vs11.1%, 22.2%, 48.9% and 17.8%, respectively).

CONCLUSION

Neither TACE nor TACE-RFA showed a significant decrease in QoL in patients with unresectable HCC two weeks after intervention. However, two months after intervention; TACE-RFA showed significant improvement in global health score compared to TACE monotherapy. TACE-RFA appeared safe, effective and more favorable than TACE monotherapy.
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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.

Radiofrequency ablation and stereotactic body radiotherapy for hepatocellular carcinoma: should they clash or reconcile?

Until a few decades ago, surgical resection was the only valid option for treating hepatocellular carcinoma (HCC). However, various locoregional modalities including arterial-directed therapy, radiofrequency ablation (RFA), and radiotherapy have been recently shown to be effective. RFA is now established as a standard treatment for small localized HCCs, showing oncological results comparable to those of surgical resection in randomized studies. Stereotactic body radiotherapy (SBRT) is a modern radiotherapeutic modality that targets tumors with precision and delivers high radiation doses over a short period of time; it has particularly attracted clinical interest after its therapeutic efficacy was found to be similar to that of surgery in early-stage lung cancer. Given its potent disease control capability, SBRT has also been applied to early HCCs and demonstrated promising results in recent studies. It has also been noted for its suitability to treat tumors located in anatomical locations where RFA would be challenging. However, since its effectiveness has not been compared to that of RFA in randomized studies of patients eligible for RFA, the use of SBRT has been debated. This review was conducted to guide physicians from all fields involved in the treatment of early HCC. The therapeutic characteristics and indications of both SBRT and RFA are described, and recent comparative studies between the two modalities are discussed. In addition, we examined the factors that should be considered when selecting the appropriate treatments, and offer our recommendations.

Management of patients with intermediate stage hepatocellular carcinoma

Hepatocellular carcinoma (HCC) causes a significant health burden globally and its impact is expected to increase in the coming years. Intermediate stage HCC, as defined by the Barcelona Clinic Liver Cancer (BCLC) system stage B, represents up to 30% of patients at diagnosis and encompasses a broad spectrum of tumor burden. Several attempts have been made to further subclassify this heterogenous group. The current standard of care recommended by BCLC for intermediate stage HCC patients is transarterial chemoembolization (TACE), with modest outcomes reported. While refinements have been made to TACE technique and patient selection, it remains non-curative. In the real-world setting, only 60% of patients with intermediate stage HCC receive TACE, with the remainder deviating to a range of other therapies that have shown promise in select patient subgroups. These include curative treatments (resection, ablation, and liver transplantation), radiotherapy (stereotactic and radioembolization), systemic therapies, and their combination. In this review, we summarize the classifications and current management for patients with intermediate stage HCC as well as highlight recent key developments in this space.

Pretreatment Apparent Diffusion Coefficient as a Predictor of Response to Transcatheter Arterial Chemoembolization Immediately Combined with Radiofrequency Ablation for Treatment of Solitary Large Hepatocellular Carcinoma

Purpose

To evaluate whether the pretreatment apparent diffusion coefficient (ADC) measured with diffusion weighted imaging (DWI) of tumor can be used as an imaging biomarker for predicting prognosis in solitary large hepatocellular carcinomas (HCCs) treated with transcatheter arterial chemoembolization (TACE) immediately combined with radiofrequency ablation (RFA).

Patients and Methods

In this single institution retrospective study, 40 solitary large HCCs that underwent treatment with TACE immediately combined with RFA were analyzed. All patients underwent abdominal dynamic contrast-enhanced magnetic resonance imaging within one month before treatment with DWI, and ADC values in the lesions were measured by two independent radiologists. Associations among patients’ preoperative ADC values and objective response (OR), progression-free survival (PFS) and overall survival (OS) were examined. Survival curves were drawn with the Kaplan–Meier method, and differences were determined with the Log rank test. The Cox proportional-hazards model was used for univariate and multivariate analyses of PFS and OS.

Results

Forty solitary large HCCs (mean 9.54 cm, range 5.04–16.06 cm) were successfully treated with TACE in immediate combination with RFA (OR 75%). The ADC values were significantly higher in the response group than the non-response group (1.51±0.32×10⁻³ mm²/s vs 1.09±0.17×10⁻³ mm²/s; P<0.001). As predicted on the basis of the ADC values, the optimal cutoff value for the efficacy of TACE combined with RFA was 1.32×10⁻³ mm²/s, with a predictive sensitivity of 0.63 and a specificity of 1.00. Patients with high ADC had longer PFS than those with low ADC (14.9 months vs 5.3 months; P<0.001) and had significantly longer survival rates (22.6 months vs 12.1 months; P=0.004).

Conclusion

Preoperative ADC values <1.32×10⁻³ mm²/s are an independent predictor of poorer prognosis in patients with solitary large HCCs who have undergone TACE immediately combined with RFA.

Thermal Ablation Versus Stereotactic Body Radiotherapy After Transarterial Chemoembolization for Inoperable Hepatocellular Carcinoma: A Propensity Score-Weighted Analysis

BACKGROUND. Transarterial chemoembolization (TACE) has synergistic properties when combined with ablative therapies for hepatocellular carcinoma (HCC). OBJECTIVE. The purpose of our study was to compare outcomes for inoperable HCC between TACE with percutaneous thermal ablation (TACE-TA) and TACE with stereotactic body radiotherapy (TACE-SBRT) using propensity score-weighted cohorts. METHODS. This retrospective study included 190 patients with a single inoperable HCC treated from 2007 to 2018 by either TACE-SBRT (n = 90) or TACE-TA (n = 100). The primary outcome was overall survival (OS). Secondary outcomes included progression-free survival (PFS) and hepatotoxicity (defined as Child-Pugh score elevation of ≥ 2 within 2-6 months after treatment). Fine-Gray competing risk models with propensity score weighting and transplant as the competing risk factor were used to model OS and PFS. RESULTS. The median follow-up time was 48.2 months. Both OS and PFS were significantly higher for TACE-TA (77% and 76%, respectively, at 2 years) than TACE-SBRT (49% and 50%, respectively, at 2 years) in the propensity score-weighted multivariate model (OS: subdistribution hazard ratio [sHR] = 2.70, p < .001; PFS: sHR = 1.71, p = .02). Treatment-related hepatotoxicity occurred in 9% of patients who underwent TACE-TA versus 27% of those who underwent TACE-SBRT (p = .01). For the subset of patients with Barcelona Clinic Liver Cancer A HCC and Child-Pugh A cirrhosis (TACE-SBRT, n = 36 patients; TACE-TA, n = 55 patients), OS (p = .11) and PFS (p = .19) were not significantly different between the two treatment modalities. CONCLUSION. Compared with TACE-SBRT, TACE-TA showed superior OS and PFS, possibly from its lesser hepatotoxicity. The two strategies did not differ in OS and PFS for patients with the earliest-stage HCC and preserved liver function. CLINICAL IMPACT. Across all patients, TACE-TA may be superior to TACE-SBRT for inoperable HCC.

Stereotactic Image-Guided Microwave Ablation for Malignant Liver Tumors-A Multivariable Accuracy and Efficacy Analysis

Background: Therapeutic success of thermal ablation for liver tumors depends on precise placement of ablation probes and complete tumor destruction with a safety margin. We investigated factors influencing targeting accuracy and treatment efficacy of percutaneous stereotactic image-guided microwave ablation (SMWA) for malignant liver neoplasms. Materials and methods: All consecutive patients treated with SMWA for malignant liver tumors over a 3-year period were analyzed. A computed tomography-based navigation system was used for ablation probe trajectory planning, stereotactic probe positioning, and validation of probe positions and ablation zones. Factors potentially influencing targeting accuracy [target positioning error (TPE)] and treatment efficacy within 6 months [ablation site recurrence (ASR)] were analyzed in a multivariable regression model, including challenging lesion locations (liver segments I, VII, and VIII; subphrenic location). Results: Three hundred one lesions (174 hepatocellular carcinomas, 87 colorectal liver metastases, 17 neuroendocrine tumors, and 23 others) were targeted in 191 interventions in 153 patients. The median TPE per ablation probe was 2.9 ± 2.3 mm (n = 384). Correction of ablation probe positions by repositioning was necessary in 4 out of 301 lesions (1%). Factors significantly influencing targeting accuracy were cirrhosis (R 0.67, CI 0.22-1.12) and targeting trajectory length (R 0.21, CI 0.12-0.29). Factors significantly influencing early ASR were lesion size >30 mm (OR 5.22, CI 2.44-11.19) and TPE >5 mm (OR 2.48, CI 1.06-5.78). Challenging lesion locations had no significant influence on targeting accuracy or early ASR. Conclusions: SMWA allows precise and effective treatment of malignant liver tumors even for lesions in challenging locations, with treatment efficacy depending on targeting accuracy in our model. Allowing for many tumors to be safely reached, SMWA has the potential to broaden treatment eligibility for patients with otherwise difficult to target tumors.

Curative-Intent Therapies in Localized Hepatocellular Carcinoma

PURPOSE OF REVIEW

The high mortality rate for hepatocellular carcinoma (HCC) relative to its prevalence underscores the need for curative-intent therapies. Image-guided therapies such as ablation and embolization have an established role as primary or neoadjuvants preparing patients for curative treatment.

RECENT FINDINGS

For HCC < 3 cm, percutaneous thermal ablation provides oncologic outcomes similar to surgical resection and is now a recommended first-line therapy in the EASL guidelines. Both ablation and embolization are recommended as bridging therapies for HCC patients awaiting liver transplantation. T3 HCC can be downstaged by embolization to T2, allowing liver transplantation with similar outcomes to patients transplanted within Milan criteria. New and evolving techniques such as SBRT, radiation segmentectomy and lobectomy, and combination therapies show promise but require further prospective data before they can be integrated into treatment algorithms. Combinations of embolic, ablative, and extirpative therapies can increase access to curative-intent treatment of HCC. Multidisciplinary treatment decisions are required to craft optimal treatment strategies considering tumor size, location, and underlying liver cirrhosis.

A new substage classification strategy for Barcelona Clinic Liver Cancer stage B patients with hepatocellular carcinoma

BACKGROUND AND AIM

Patients with Barcelona Clinic Liver Cancer stage B hepatocellular carcinoma are a heterogeneous population, and the classifications available could not predict the prognosis accurately. Herein, we proposed a new substage classification method, Scoring Method for Intermediate Stage, for precise classification and clinical guidance in hepatocellular carcinoma patients within Barcelona Clinic Liver Cancer stage B.

METHODS

A total of 1026 stage B patients of hepatocellular carcinoma who underwent transcatheter arterial chemoembolization as a first-line treatment in Liver Cancer Institute, Zhongshan Hospital, Fudan University were retrospectively enrolled. The prognostic evaluation ability of the new substage classification criteria was analyzed, in comparison with the existing substage classification criteria.

RESULTS

Using Scoring Method for Intermediate Stage, 1026 stage B patients were subclassified into three subgroups, based on Child-Pugh score and up-to-7 grade, as B1 (scoring 2), B2 (scoring 3 or 4), and B3 (scoring 5 or 6). The median survival time of the three substages was 29 (95% confidence interval [CI]: 25-36), 19 (95% CI: 16-21), and 10 (95% CI: 8-12) months, respectively. More favorable discrimination efficacy was identified by the new criteria in comparison with the existing substage classification criteria, including Bolondi, Kinki, MICAN, and Kim's criteria. Moreover, multivariate analyses indicated that the novel classification was highly associated with prognosis (Hazard ratio(s) = 1.63, 95% CI: 1.43-1.86, P < 0.001).

CONCLUSIONS

Scoring Method for Intermediate Stage demonstrates satisfying capacity in classifying patients with stage B hepatocellular carcinoma and predicting prognosis.

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology, and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

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

PURPOSE OF REVIEW

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

RECENT FINDINGS

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

2018 Korean Liver Cancer Association-National Cancer Center Korea Practice Guidelines for the Management of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is the fifth most common cancer globally and the fourth most common cancer in men in Korea, where the prevalence of chronic hepatitis B infection is high in middle-aged and elderly patients. These practice guidelines will provide useful and constructive advice for the clinical management of patients with HCC. A total of 44 experts in hepatology, oncology, surgery, radiology and radiation oncology in the Korean Liver Cancer Association-National Cancer Center Korea Practice Guideline Revision Committee revised the 2014 Korean guidelines and developed new recommendations that integrate the most up-to-date research findings and expert opinions.

Controversies in the management of hepatocellular carcinoma

The management of hepatocellular carcinoma (HCC) has evolved considerably over the last decade. Surveillance of cirrhotic patients and refinements to imaging techniques have enabled a relevant proportion of patients to be diagnosed at an early stage, when effective therapies are feasible. Resection, transplantation and ablation are all options in patients with early stage HCC. Thus, there is some controversy regarding which is the best treatment approach in challenging scenarios. There have also been major developments in locoregional therapies, particularly in intra-arterial approaches. Finally, the systemic treatment for HCC has changed dramatically following the demonstration of a survival benefit with sorafenib; there are currently several first-line (sorafenib and lenvatinib) and second-line (regorafenib, cabozantinib and ramucirumab) treatments that have shown a survival benefit. Expectations for immune checkpoint inhibitors are high, with the results of the ongoing phase III trials eagerly awaited. In this review we discuss some of the controversies in the management of HCC, focussing in particular on systemic therapy.

Radiofrequency ablation following artificial ascites and pleural effusion creation may improve outcomes for hepatocellular carcinoma in high-risk locations

PURPOSE

To investigate the outcomes of radiofrequency ablation (RFA) following artificial ascites (AA) and artificial pleural effusion (AP) creation for hepatocellular carcinoma (HCC) in high-risk locations.

MATERIALS AND METHODS

Eligible patients were divided into 2 study periods (non-AAAP and AAAP groups) with AAAP performed in the latter period. Local tumor progression, primary technique effectiveness and complications were compared between patients with and without AAAP. Cumulative probability of local tumor progression and overall survival were estimated with Kaplan-Meier curves.

RESULTS

One hundred thirty-eight patients with 195 tumors were evaluated. AAAP was performed in 48 patients with 76 tumors. Local tumor progression rates at 12 and 24 months were 9.3% and 22.2% in the non-AAAP group versus 5.5% and 9% in the AAAP group (p < 0.0001). Primary technique effectiveness was achieved in 76.5% of the non-AAAP group versus 89.5% of the AAAP group (p = 0.046). Night (7.6%) major complications occurred in the non-AAAP group and 2 (2.6%) cases occurred in the AAAP group. Therapy-oriented severity grading system after RFA was lower in the AAAP group (p = 0.02). Overall survival rates at 12 and 24 months were 85.6% and 77.7% in the non-AAAP group versus 97.2% and 89.7% in the AAAP group (p = 0.033).

CONCLUSION

RFA following AA and AP for high-risk located HCC may improve outcomes.

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.

Transcatheter arterial chemoembolization combined with radiofrequency or microwave ablation for hepatocellular carcinoma: a review

Hepatocellular carcinoma (HCC) is the sixth most common type of malignancy. Several therapies are available for HCC and are determined by stage of presentation, patient clinical status and liver function. Local–regional treatment options, including transcatheter arterial chemoembolization, radiofrequency ablation or microwave ablation, are safe and effective for HCC but are accompanied by limitations. The synergistic effects of combined transcatheter arterial chemoembolization and radiofrequency ablation/microwave ablation may overcome these limitations and improve the therapeutic outcome. The purpose of this article is to review the current literature on these combined therapies and examine their efficacy, safety and influence on the overall and recurrence-free survival in patients with HCC.

Transcatheter Arterial Chemoembolization Combined with Simultaneous Computed Tomography-guided Radiofrequency Ablation for Large Hepatocellular Carcinomas

BACKGROUND

Currently, the treatment of large hepatocellular carcinoma (HCC) is still a challenging problem. Transcatheter arterial chemoembolization (TACE) is the main treatment for intermediate end-stage HCC, while it is only a palliative and not a curative treatment due to the existence of residual tumors, and radiofrequency ablation (RFA) has limitations in complete ablation of large HCC. We hypothesized that TACE combined with simultaneous RFA (herein referred to as TACE + RFA) could improve the efficacy and survival of large HCC. This study aimed to investigate the feasibility, efficacy, and safety of TACE + RFA on single large HCC.

METHODS

A total of 66 patients with single large HCC (≥5 cm in diameter) were recruited between February 2010 and June 2016. TACE was first performed and computed tomography was performed immediately after TACE, and the lesions with poor lipiodol deposition were subjected to simultaneous RFA. The success rate, technique-related complications, liver and kidney functions, serum alpha-fetoprotein (AFP) levels, progression-free survival (PFS), median survival time (MST), focal control rate, and long-term survival rate were evaluated.

RESULTS

TACE + RFA were performed smoothly in all the patients with the success rate of 100%. Intra- and post-operative severe complications were not observed. There were no marked differences in mean alanine transaminase or aspartate transaminase before TACE + RFA compared with 7 days after TACE + RFA (all P > 0.05). In 57 AFP-positive patients, the levels of serum AFP were reduced by 100.0%, 100.0%, and 94.7% at 1, 3, and 6 months after TACE + RFA, respectively; the tumor control rates (complete remission + partial remission) were 100.0% (66/66), 92.4% (61/66), 87.9% (58/66), and 70.1% (39/55) at 1, 3, 6, and 12 months after TACE + RFA, respectively. Patients were followed up for 7-82 months after TACE + RFA. The MST was 18.3 months, PFS was 14.2 ± 6.2 months, and the 1-, 3-, and 5-year survival rates were 93.2% (55/59), 42.5% (17/40), and 27.2% (9/33), respectively.

CONCLUSION

TACE + RFA is safe, feasible, and effective in enhancing the focal control rate and survival rate of patients with large HCC.

Radiofrequency Ablation Combined with Transcatheter Arterial Chemoembolization Therapy Versus Surgical Resection for Hepatocellular Carcinoma within the Milan Criteria: A Meta-Analysis

Objective

To meta-analytically compare combined transarterial chemoembolization (TACE) plus radiofrequency ablation (RFA) and surgical resection (SR) for the treatment of hepatocellular carcinoma (HCC) within the Milan criteria.

Materials and Methods

PubMed, Medline, Embase, and Cochrane Library were searched for studies comparing these two therapies that were published between January 2006 and August 2017. Overall survival rate (OS), recurrence-free survival rate (RFS), major complications and the average length of hospital stay were compared between these two therapies. Meta-analytic pooled odds ratio (OR) was calculated using TACE plus RFA as the base category.

Results

Seven case-control studies and one randomized trial were identified. Meta-analytic results revealed that, compared with SR, TACE plus RFA had significantly higher 1-year OS (OR for survival = 0.50, p = 0.009) and lower major complications (OR = 1.88, p = 0.02) after therapy. Three studies reported on the length of hospital stay. The average length ± standard deviation reported in individual studies for SR and TACE plus RFA groups was 19.8 ± 8.4 days and 7.4 ± 2.2 days, respectively; 18.7 ± 4.9 days and 11.5 ± 6.9 days, respectively; and 16.6 ± 6.7 days and 8.5 ± 4.1 days, respectively (p < 0.0001 for all studies). Three or 5-year OS and 1-, 3-, or 5-year RFS did not significantly differ between the two therapies.

Conclusion

Combined TACE plus RFA may be an alternative to SR for the treatment of patients with HCC within Milan the criteria. Non-randomized design in most of the original studies was a limitation.

Recent Advances in the Image-Guided Tumor Ablation of Liver Malignancies: Radiofrequency Ablation with Multiple Electrodes, Real-Time Multimodality Fusion Imaging, and New Energy Sources

Radiofrequency ablation (RFA) has emerged as an effective loco-regional treatment modality for malignant hepatic tumors. Indeed, studies have demonstrated that RFA of early stage hepatocellular carcinomas can provide comparable overall survival to surgical resection. However, the incidence of local tumor progression (LTP) after RFA is significantly higher than that of surgical resection. Thus, to overcome this limitation, multiple electrode radiofrequency (RF) systems that use a multi-channel RF generator have been developed, and they demonstrate better efficiency in creating larger ablation zones than that using the conventional RFA with a single electrode. Furthermore, RFA with multiple electrodes can allow the “no-touch” ablation technique which may also help to reduce LTP. Another technique that would be helpful in this regard is multi-modality-ultrasound fusion imaging, which helps to not only more accurately determine the target lesion by enabling the RFA of small, poorly visible or invisible tumors, but also improve the monitoring of procedures and determine the appropriateness of the ablation margin. In addition, new energy sources, including microwave and cryoablation, have been introduced in imaging-guided tumor ablation. In this review, these recently introduced ablation techniques and the results of the most current animal and clinical studies are discussed.

Multi-Operational Selective Computer-Assisted Targeting of hepatocellular carcinoma-Evaluation of a novel approach for navigated tumor ablation

Objective

To facilitate precise local ablation of hepatocellular carcinoma (HCC) in a setting of combined ablation and transarterial chemoembolization (TACE), we evaluated accuracy and efficiency of a novel technique for navigated positioning of ablation probes using intrahepatic tumor referencing and electromagnetic (EM) guidance, in a porcine model.

Methods

An angiographic wire with integrated EM reference sensor at its tip was inserted via a transarterial femoral access and positioned in the vicinity of artificial liver tumors. The resulting offset distance between the tumor center and the intrahepatic endovascular EM reference was calculated. Subsequently, EM tracked ablation probes were inserted percutaneously and navigated toward the tumor center, relying on continuous EM guidance via the intrahepatic reference. Targeting accuracy was assessed as the Euclidean distance between the tip of the ablation probe and the tumor center (Target Positioning Error, TPE). Procedural efficiency was assessed as time efforts for tumor referencing and tumor targeting.

Results

In 6 animals, 124 targeting measurements were performed with an offset distance < 30 mm (clinically most feasible position), resulting in a mean TPE of 2.9 ± 1.6 mm. No significant correlation between the TPE and different intrahepatic offset distances (range 21 to 61 mm, n = 365) was shown as long as the EM reference was placed within the liver. However, the mean TPE increased when placing the EM reference externally on the animal skin (p < 0.01). TPE was similar when targeting under continuous ventilation or in apnea (p = 0.50). Mean time for tumor referencing and navigated targeting was 6.5 ± 3.8 minutes and 14 ± 8 seconds, respectively.

Conclusion

The proposed technique allows precise and efficient navigated positioning of ablation probes into liver tumors in the animal model. We introduce a simple approach suitable for combined ablation and TACE of HCC in a single treatment session.

Comparison of the Efficacy and Prognostic Factors of Transarterial Chemoembolization Plus Microwave Ablation versus Transarterial Chemoembolization Alone in Patients with a Large Solitary or Multinodular Hepatocellular Carcinomas

Objective

To evaluate the efficacy and prognostic factors associated with transcatheter arterial chemoembolization (TACE) combined with microwave ablation (MWA) versus TACE alone for a large solitary or multinodular hepatocellular carcinomas (HCCs).

Materials and Methods

This retrospective study involved 258 patients with a large solitary or multinodular HCCs (not more than 10 tumors) who underwent TACE + MWA (n = 92) or TACE alone (n = 166) between July 2011 and April 2015. Local tumor control, survival outcomes, and complications were compared between the two groups. Prognostic factors for time to progression (TTP) and overall survival (OS) were evaluated by univariate and multivariate analyses.

Results

The median duration of follow-up was 21.2 months (range, 4–45 months). The median TTP and OS were 12.5 months and 26.6 months, respectively, for the TACE + MWA group and 6.7 months and 17.1 months, respectively, for the TACE group (p < 0.001). The 1-, 2-, and 3-year OS rates were 85.9, 59.8, and 32.6%, respectively, for the TACE + MWA group and 59.0, 40.4, and 11.4%, respectively, for the TACE group (p < 0.001). The corresponding recurrence rates were 47.8, 78.3, and 94.6% for the TACE + MWA group, respectively, and 74.7, 96.4, and 97.6%, respectively, for the TACE group (p < 0.001). Logistic regression analyses showed that the treatment method, tumor size, and tumor number were significant prognostic factors for TTP and OS.

Conclusion

TACE + MWA appears to have more advantages compared to TACE in prolonging OS, with a satisfactory TTP, for inpatients with solitary large or multinodular HCCs. Treatment method, tumor size, and tumor number are significant prognostic factors for TTP and OS. Further randomized, multi-center, prospective trials are required to confirm the findings of this study.

Ultrasound-Guided Intraoperative Radiofrequency Ablation and Surgical Resection for Liver Metastasis from Malignant Gastrointestinal Stromal Tumors

Objective

To evaluate the effectiveness, safety, and feasibility of intraoperative radiofrequency ablation (IORFA) under ultrasound guidance for the treatment of liver metastases from gastrointestinal stromal tumors (GISTs).

Materials and Methods

From August 2009 to February 2017, 24 patients with liver metastases of GISTs underwent IORFA, 14 underwent concurrent IORFA and primary GIST resection, and 10 underwent IORFA to treat hepatic recurrence after previous primary GIST resection. Seventy-six hepatic metastases were treated, of which 47 were surgically resected and 29 underwent IORFA. All included patients received imatinib therapy as standard treatment before and after IORFA or surgical resection. A retrospective medical record review was conducted, and follow-up data were collected. Technical success and effectiveness, overall and GIST-specific survival, and complications were assessed.

Results

The mean follow-up duration was 50.7 ± 34.7 months. The technical success rate of IORFA was 100%. New metastases developed in three of the 24 patients (12.5%) following a complete response 16, 51, and 95 months after IORFA, respectively. The cumulative one-, three-, and five-year overall survival rates were 100, 94.4, and 87.7%, respectively. The one-, three-, and five-year GIST-related survival rates were 100, 94.4, and 94.4%, respectively. Two major complications (biliary stricture and hepatic abscess) were observed.

Conclusion

IORFA appears to be a feasible and safe treatment option for liver metastasis in patients with primary GISTs. In addition, IORFA and surgical resection may be complementary, helping to obtain complete response in cases of otherwise inoperable liver metastases secondary to GISTs.

A concept for electromagnetic navigated targeting of liver tumors using an angiographic approach

BACKGROUND

The benefits of using navigation technology for percutaneous local ablation of selected hepatocellular carcinoma (HCC) have been shown. Due to additional efforts in the procedural workflow, barriers to introducing navigation systems on a broad clinical level remain high. In this work, initial steps toward a novel concept for simple and precise targeting of HCC are evaluated.

MATERIAL AND METHODS

The proposed technique is based on an angiographic approach using an intrahepatic electromagnetic (EM) reference, for consecutive percutaneous navigated positioning of ablation probes. We evaluated the environmental influence of the angiography suite on EM tracking accuracy, the measurement of a 3 D offset from two 2 D fluoroscopy images, and the accuracy and efficiency of the proposed approach in a porcine liver model.

RESULTS

The C-arm had a major influence on EM tracking accuracy, with an error up to 3.8 mm. The methodology applied for measurement of a 3 D offset from 2 D fluoroscopy images was confirmed to be feasible with a mean error of 0.76 mm. In the porcine liver model experiment, the overall target positioning error (TPE) was 2.0 mm and time for navigated targeting was 17.9 seconds, when using a tracked ablation probe.

CONCLUSIONS

The initial methodology of the proposed technique was confirmed to be feasible, introducing a novel concept for simple and precise navigated targeting of HCC.