Combined resection and radiofrequency ablation for multifocal hepatocellular carcinoma: Prognosis and outcomes

Liver resection is superior to tumor ablation in patients with multifocal hepatocellular carcinoma

INTRODUCTION

The management of T2 multifocal hepatocellular carcinoma (MHCC) is controversial, and the comparative impact of liver resection (LR) versus tumor ablation (TA) on survival continues to be debated. The aim of our study was to examine short- and long-term survival for LR and TA in a nationally representative cohort. We hypothesized that patients who underwent LR would have improved survival.

METHODS

We utilized the National Cancer Database (2004-2015) to identify patients diagnosed with non-metastatic T2 MHCC. Kaplan-Meier survival curves were generated to compare 10-year overall survival (OS) between LR and TA patients. Kaplan-Meier analysis with stratification was also performed based on lymphovascular invasion, resection margin status, and Charlson-Deyo score. Cox proportional hazard models were used in multivariable analyses.

RESULTS

A total of 1225 patients met the inclusion criteria. 991 patients received LR, and 234 received TA. The majority of patients were male, White, and older than ≥60 years old. Clinicodemographic characteristics were generally similar between LR and TA patients. Among patients who underwent LR, 84% had negative margins, and 17% had lymphovascular invasion. Mortality at 30 days was significantly higher among LR patients compared to TA patients (5.4% vs 0.0%, p < 0.001), with those having a Charlson-Deyo score ≥2 facing the highest risk at 7.3%. Nevertheless, 10-year OS for the LR cohort was 27.5% (95% confidence interval [CI]: 24.4%-30.8%) versus 14.7% (95% CI: 9.8%-20.7%, p < 0.001) for TA patients. In stratified analysis, survival benefit was statistically significant only among those with negative resection margin, no lymphovascular invasion, and Charlson-Deyo score ≤1. In multivariable Cox analysis, LR was independently associated with improved survival compared to TA (hazard ratio: 0.80; 95% CI = 0.67-0.95).

CONCLUSION

LR poses a higher long-term survival benefit than TA. Prospective studies are warranted to confirm these findings. Although our study patients are a highly selected group of multifocal T2 patients, it gives us a good insight into the fact that LR provides better outcomes if a transplant option is unavailable.

The Hong Kong consensus statements on unresectable hepatocellular carcinoma: narrative review and update for 2021

BACKGROUND AND OBJECTIVE

Hong Kong, like many parts of Asia, faces a high burden of hepatocellular carcinoma (HCC) caused by high endemic rates of hepatitis B virus infection. Hong Kong clinicians have developed a high level of expertise in HCC treatment across surgical, transarterial, ablative, radiotherapeutic and systemic modalities. This publication summarizes the latest evidence-based recommendations on how these modalities should be used.

METHODS

In two meetings held in 2020, a multidisciplinary panel of surgeons, oncologists and interventional radiologists performed a narrative review of evidence on the management of HCC, with an emphasis on treatment of HCC not amenable to surgical resection. Close attention was paid to new evidence published since the previous version of these statements in 2018.

KEY CONTENT AND FINDINGS

The expert panel has formulated 60 consensus statements to guide the staging and treatment of unresectable HCC. Since the previous version of these statements, considerable additions have been made to the recommendations on use of targeted therapies and immunotherapies because of the large volume of new evidence.

CONCLUSIONS

Our consensus statements offer guidance on how to select HCC patients for surgical or non-surgical treatment and for choosing among non-surgical modalities for patients who are not candidates for resection. In particular, there is a need for more evidence to aid physicians in the selection of second-line systemic therapies, as currently most data are limited to patients with disease progression on first-line sorafenib.

Radiofrequency ablation in the treatment of hepatocellular carcinoma

OBJECTIVE

The purpose of this article is to discuss the use, comparative efficacy, and research progress of radiofrequency ablation (RFA), alone or in combination with other therapies, for the treatment of hepatocellular carcinoma (HCC).

METHOD

To search and summarize the basic and clinical studies of RFA in recent years.

RESULTS

RFA is one of the radical treatment methods listed in the guidelines for the diagnosis and treatment of HCC. It has the characteristics of being minimally invasive and safe and can obtain good local tumor control, and it can improve the local immune ability, improve the tumor microenvironment and enhance the efficacy of chemotherapy drugs. It is commonly used for HCC treatment before liver transplantation and combined ALPPS and hepatectomy for HCC. In addition, the technology of RFA is constantly developing. The birth of noninvasive, no-touch RFA technology and equipment and the precise RFA concept have improved the therapeutic effect of RFA.

CONCLUSION

RFA has good local tumor control ability, is minimally invasive, is safe and has other beneficial characteristics. It plays an increasingly important role in the comprehensive treatment strategy of HCC. Whether RFA alone or combined with other technologies expands the surgical indications of patients with HCC and provides more benefits for HCC patients needs to be determined.

Surgical Resection plus Intraoperative Radiofrequency Ablation versus Chemoembolization for the Treatment of Intermediate-Stage (BCLC B) Hepatocellular Carcinoma with Preserved Liver Function: A Propensity Score-Matched Analysis

Simple Summary

Surgical resection plus intraoperative radiofrequency ablation showed better survival outcomes than transarterial chemoembolization in selected patients with intermediate-stage hepatocellular carcinoma and Child–Pugh class A liver function. These findings suggest that surgical resection plus intraoperative radiofrequency ablation may provide an opportunity for curative treatment to selected patients deemed eligible only for palliative treatment.

Abstract

The purpose of this study was to compare the efficacy and safety of surgical resection (SR) plus intraoperative radiofrequency ablation (IORFA) with transarterial chemoembolization (TACE) in patients with intermediate-stage HCC and Child–Pugh class A liver function. Treatment-naïve patients who received SR plus IORFA (n = 104) or TACE (n = 513) were retrospectively evaluated. Patients were subjected to a maximum 1:3 propensity score matching (PSM), yielding 95 patients who underwent SR plus IORFA and 252 who underwent TACE. Evaluation of the entire study population showed that progression-free survival (PFS) and overall survival (OS) were significantly better in the SR plus IORFA than in the TACE group. After PSM, the median PFS (18.4 vs. 15.3 months) and OS (88.6 vs. 56.2 months) were significantly longer, and OS rate significantly higher (HR: 0.65, p = 0.026), in the SR plus IORFA group than in the TACE group. Stratified Cox regression analysis and doubly robust estimation revealed that treatment type was significantly associated with both OS and PFS. Rates of major complications were similar in the SR plus IORFA and TACE groups. In conclusion, SR plus IORFA showed better survival outcomes than TACE. SR plus IORFA may provide curative treatment to patients with intermediate-stage HCC with ≤4 tumors and Child–Pugh class A.

Hepatic Resection Combined with Intraoperative Radiofrequency Ablation Versus Hepatic Resection Alone for Selected Patients with Moderately Advanced Multifocal Hepatocellular Carcinomas

BACKGROUND

The role of hepatic resection (HR) combined with radiofrequency ablation (RFA) versus HR alone remains unclear for patients with multifocal hepatocellular carcinomas (HCCs). The aim of this study was to assess the outcomes of selected patients with moderately advanced multifocal HCCs after HR combined with intraoperative RFA versus HR alone.

METHODS

A total of 304 selected patients with multifocal HCCs (three or fewer lesions, with the largest lesion > 4.5 cm and the residual lesion[s] ≤ 3 cm) who underwent HR plus RFA (HR+RFA group) or HR alone (HR group) were included. Propensity score matching (PSM) was used to adjust for baseline differences. Multivariable and subgroup analyses estimated the effects of clinical factors on survival.

RESULTS

Both overall survival (OS) and recurrence-free survival (RFS) were comparable between both groups before and after PSM. Subgroup analysis showed that HR was associated with better RFS than HR+RFA for those patients with two tumors, or with all lesions located in the same lobe or without microvascular invasion (MVI) [all p < 0.05]. Moreover, en bloc resection provided a higher RFS than separate resection for those with all lesions in the same lobe (p = 0.039).

CONCLUSION

For selected patients with moderately advanced multifocal HCCs, HR+RFA may offer similar OS and RFS as HR alone. However, HR may be more suitable for those with two tumors, or with all lesions in the same lobe or without MVI. Moreover, en bloc resection may be recommended for those with all lesions in the same lobe.

Predictors of mortality within the first year post-hepatectomy for hepatocellular carcinoma

BACKGROUND

Hepatic resection (HR) for hepatocellular carcinoma (HCC) is safe with good perioperative and long-term oncologic outcomes. There is a paucity of data with regards to intermediate-term outcomes (i.e., beyond 90-day and within 1-year mortality). This paper studies the risk factors for within 1-year mortality after elective HR with curative intent in patients with HCC.

METHODS

An audit of patients who underwent curative HR for HCC from January 2007 to April 2016 was conducted. Univariate and multivariate analysis were sequentially performed on perioperative variables using Cox-regression analysis to identify factors predicting intermediate-term outcomes defined as within 1-year mortality. Kaplan-Meier survival curves and hazard ratios were obtained.

RESULTS

Three hundred forty-eight patients underwent HR during the study period and 163 patients had curative hepatectomy for HCC. Fifteen patients (9.2%) died within 1-year after HR. Multivariate analysis identified Child-Pugh class B/C (HR 5.5, p = 0.035), multinodularity (HR 7.1, p = 0.001), macrovascular invasion (HR 4.2, p = 0.04) postoperative acute renal failure (HR 5.8, p = 0.049) and posthepatic liver failure (HR 9.6, p = 0.009) as significant predictors of 1-year mortality.

CONCLUSION

One-year mortality following HR for HCC remains high and can be predicted preoperatively by multinodularity, Child-Pugh class, and macrovascular invasion. Postoperative acute renal failure and liver failure are associated with 1-year mortality.

Fat Quantification Imaging and Biophysical Modeling for Patient-Specific Forecasting of Microwave Ablation Therapy

Computational tools are beginning to enable patient-specific surgical planning to localize and prescribe thermal dosing for liver cancer ablation therapy. Tissue-specific factors (e.g., tissue perfusion, material properties, disease state, etc.) have been found to affect ablative therapies, but current thermal dosing guidance practices do not account for these differences. Computational modeling of ablation procedures can integrate these sources of patient specificity to guide therapy planning and delivery. This paper establishes an imaging-data-driven framework for patient-specific biophysical modeling to predict ablation extents in livers with varying fat content in the context of microwave ablation (MWA) therapy. Patient anatomic scans were segmented to develop customized three-dimensional computational biophysical models and mDIXON fat-quantification images were acquired and analyzed to establish fat content and determine biophysical properties. Simulated patient-specific microwave ablations of tumor and healthy tissue were performed at four levels of fatty liver disease. Ablation models with greater fat content demonstrated significantly larger treatment volumes compared to livers with less severe disease states. More specifically, the results indicated an eightfold larger difference in necrotic volumes with fatty livers vs. the effects from the presence of more conductive tumor tissue. Additionally, the evolution of necrotic volume formation as a function of the thermal dose was influenced by the presence of a tumor. Fat quantification imaging showed multi-valued spatially heterogeneous distributions of fat deposition, even within their respective disease classifications (e.g., low, mild, moderate, high-fat). Altogether, the results suggest that clinical fatty liver disease levels can affect MWA, and that fat-quantitative imaging data may improve patient specificity for this treatment modality.

High-intensity focused ultrasound ablation of liver tumors in difficult locations

High-intensity focused ultrasound (HIFU) has been shown to be a valuable tool in the management of small liver tumors such as hepatocellular carcinoma (HCC). It has been shown to be a safe and effective means to ablate small HCC even in the presence of advanced cirrhosis. This review examines the challenges faced during HIFU ablation when the target tumors are located in difficult locations such as the liver dome, close to the rib cage, near large blood vessels or the heart, or adjacent to hollow viscera; and the special maneuvers employed to tackle such lesions.

A systematic review and meta-analysis of radio frequency ablation and routine resection in the treatment of small hepatocellular carcinoma

Background

This study sought to conduct a meta-analysis of the relevant literature on radiofrequency ablation (RFA) and routine resection in the treatment of small hepatocellular carcinoma (SHCC) in recent years, and to examine the clinical efficacy and safety of different schemes.

Methods

PubMed, The Cochrane Library, Embase, CNKI, Chinese biomedical literature, VIP Chinese journal and the Wanfang Database were used to comprehensively search for relevant papers on clinical control studies of RFA and the routine resection SHCC published between January 2008 and December 2019. The clinical efficacy and safety of different schemes in the treatment of SHCC were compared, including the overall survival rate within 1, 3, and 5 years, and the incidence of complications during treatment. A meta-analysis was undertaken using methods provided by the Cochrane Collaboration and RevMan 5.3 software.

Results

A total of 13 publications of studies were retrieved in which 2,384 patients participated. Of these patients, 1,256 (52.68%) were allocated to the RFA group and 1,128 patients (47.32%) to the conventional resection group. The effect size of the 1-year overall survival rate for the two groups was odds ratio (OR): 0.78 [95% confidence interval (CI), 0.43-1.38]; Z test: P=0.32. The effect size of the overall survival rate within 3 years was OR: 0.71 (95% CI, 0.48-1.05); Z test: P=0.07. The difference was not statistically significant. The 5-year overall survival rate of the RFA group and conventional resection group was OR: 0.55 (95% CI, 0.40-0.72). The OR value fell within the CI, excluding 1; Z test: P<0.0001. The difference was statistically significant. The incidence of complications in the RFA group during treatment was lower than that in the conventional resection group (OR: 0.45; 95% CI, 0.32-0.69). The OR value was within the CI, excluding 1; Z test: P=0.0002. The difference was statistically significant.

Conclusions

The short-term effect of RFA in the treatment of SHCC is basically the same as that of routine resection; however, the long-term effect is significantly lower than that of routine resection. RFA has a lower incidence of complications during treatment, and thus better clinical safety.

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.

Intrahepatic recurrence of hepatocellular carcinoma after resection: an update

Hepatocellular carcinoma recurrence occurs in 40-70% of patients after hepatic resection. Despite the high frequency of hepatocellular cancer relapse, there is no established guidance for the management of such cases. The evaluation of prognostic factors that indicate a high risk of recurrence after surgery such as the tumor number and size and the presence of microvascular invasion may guide the therapeutic strategy and point out which patients should be strictly monitored. Additionally, the administration of adjuvant treatment or ab initio liver transplantation in selected patients with high-risk characteristics could have a significant impact on the prevention of relapse and overall survival. Once the recurrence has occurred in the liver remnant, the available therapeutic options include re-resection, salvage liver transplantation and locoregional treatments, although the therapeutic choice is often challenging and should be based on the characteristics of the recurrent tumor, the patient profile and most importantly the timing of relapse. Aggressive combination treatments are often required in challenging cases of early relapse. The results of the above treatment strategies are reviewed and compared to determine the optimal management of patients with recurrent hepatocellular cancer following liver resection.

An overview in management of hepatocellular carcinoma in Hong Kong using the Hong Kong Liver Cancer (HKLC) staging system

In Hong Kong, liver cancer is the fifth most common cancer and the third most common cause of cancer deaths. The prevalence of hepatitis B is high in Hong Kong because of the high rate of hepatitis B virus infection, and chronic hepatitis B has remained the leading cause of hepatocellular carcinoma in the city, accounting for 80% of all cases in the period from 1992 to 2016. In view of the different etiologies of hepatocellular carcinoma around the world, a group of liver experts in Hong Kong developed the Hong Kong Liver Cancer staging system in order to provide more aggressive treatment guidance (predominantly a wider use of surgical resection) for Asian patients of hepatocellular carcinoma. In this article focussing on the Hong Kong Liver Cancer staging system, we briefly reviewed the screening criteria adopted in Hong Kong for liver resection, local ablation, transcatheter arterial chemoembolization, transcatheter arterial radioembolization, stereotactic body radiation therapy, and systemic therapy.

Living donor liver transplantation or hepatic resection combined with intraoperative radiofrequency ablation for Child-Pugh A hepatocellular carcinoma patient with Multifocal Tumours Meeting the University of California San Francisco (UCSF) criteria

BACKGROUND

How much difference there is between hepatic resection (HR) combined with intraoperative radiofrequency ablation (RFA) and living donor liver transplantation (LDLT) in treatment of multifocal hepatocellular carcinomas (HCCs) remains unclear. This study compared outcomes for patients with multifocal HCCs meeting the University of California San Francisco (UCSF) criteria treated by LDLT or HR + RFA.

METHODS

A total of 126 consecutive Child-Pugh A patients with multifocal HCCs meeting the UCSF criteria, who underwent LDLT (n = 51) or HR + RFA (n = 75), were included. Propensity score (PS) matching was performed to adjust for baseline differences. Overall survival (OS) and recurrence-free survival (RFS) were calculated, and subgroup, multivariate and nomogram analyses were performed.

RESULTS

LDLT provided significantly better OS and RFS than did HR + RFA before and after PS matching and reduced the dropout rate on waiting list, but HR + RFA was more convenient, less invasive and less cost. Patients with all lesions located in the same lobe had better OS and RFS than those located in the different lobes after HR + RFA. Multivariate and nomogram analyses revealed that HR + RFA, alpha-fetoprotein ≥ 400 ng/mL, the major tumour size > 3 cm and microvascular invasion were independent predictors of poor prognosis.

CONCLUSION

For Child-Pugh A patients with multiple HCCs meeting the UCSF criteria, LDLT may offer significantly better long-term results than did HR + RFA, and HR + RFA may still be considered as an acceptable curative therapy for those without considering transplantation or as a bridge treatment for a patient, with a plan for transplantation in the future.

Combined hepatectomy and microwave ablation for multifocal hepatocellular carcinoma: Long-term outcomes and prognostic factors

BACKGROUND

It remains to be clarified whether combined hepatectomy and microwave ablation for multifocal hepatocellular carcinoma (HCC) is feasible. This aim of this study was to examine the perioperative and oncological outcomes after combined hepatectomy and microwave ablation for multifocal HCC.

METHODS

This retrospective study included 81 patients who underwent combined hepatectomy and microwave ablation for multifocal HCC in our institute between June 1998 and December 2017. We analyzed overall survival (OS) and recurrence-free survival (RFS), and evaluated factors related to prognosis.

RESULTS

Median follow-up time was 45.6 months for the entire cohort. OS rates were 1-year: 96%, 3-year: 72%, and 5-year: 54%; RFS rates were 1-year: 77%, 3-year: 37%, and 5-year: 22%. The major complication rate (Clavien-Dindo classification IIIa or above) after surgery was 10%, with one patient of in-hospital mortality. Multivariate analysis revealed that des-γ-carboxy prothrombin level >200 mAU/mL and >5 tumors were independent risk factors for OS, and des-γ-carboxy prothrombin level >200 mAU/mL, > 5 tumors, and maximum tumor size >5 cm were independent risk factors for RFS.

CONCLUSIONS

Our results indicate that combined hepatectomy and microwave ablation is safe and feasible for selected patients with multifocal HCC.

Hepatic Resection Is Associated With Improved Long-Term Survival Compared to Radio-Frequency Ablation in Patients With Multifocal Hepatocellular Carcinoma

Background: The prognosis of patients with hepatocellular carcinoma (HCC) is of major public health interest. However, studies comparing hepatic resection (HR) and radio-frequency ablation (RFA) applied to multifocal HCC are limited. This study aimed to compare the efficacies of HR and RFA in patients with multifocal HCC.

Methods: We retrospectively analyzed a cohort from the Surveillance, Epidemiology, and End Results database between 2004 and 2015. Disease-specific survival and overall survival rates were assessed before and after propensity score matching (PSM).

Results: In total, 2,201 patients with multifocal HCC treated with HR (n = 1,095) or RFA (n = 1,106) were included; 1,096 patients were identified after nearest-neighbor PSM at a ratio of 1:1 (HR: n = 548; RFA: n = 548). In the multivariate Cox regression model, HR was associated with significantly improved disease-specific survival [before PSM: hazard ratio 0.67, 95% confidence interval (CI) 0.57–0.79, p < 0.001; after PSM: hazard ratio 0.69, 95% CI 0.58–0.82, p < 0.001] and overall survival (before PSM: hazard ratio 0.67, 95% CI 0.58–0.78, p < 0.001; after PSM: hazard ratio 0.69, 95% CI 0.59–0.80, p < 0.001) compared to RFA in patients with multifocal HCC. In the survival curve analysis, the disease-specific survival of the HR group was similar to that of the RFA group before PSM (p = 0.936, log-rank test) but was significantly longer after PSM (p < 0.001) in all patients. Multivariate analyses revealed that differentiation grade, alpha-fetoprotein, tumor size, and tumor extension were independent predictors of poor prognosis in patients with multifocal HCC.

Conclusions: The long-term survival rate of HR is better than that of RFA in patients with multifocal HCC. HR may serve as a first-line treatment for patients with multifocal HCC. The presence of large tumors and vascular invasion are not contraindications for HR.

Comparison of Hepatic Resection Combined with Intraoperative Radiofrequency Ablation, or Hepatic Resection Alone, for Hepatocellular Carcinoma Patients with Multifocal Tumors Meeting the University of California San Francisco (UCSF) Criteria: A Propensity Score-Matched Analysis

BACKGROUND

Whether hepatic resection (HR) combined with radiofrequency ablation (RFA) or HR alone is the treatment of choice for early or moderately advanced multifocal hepatocellular carcinomas (HCCs) is a matter of debate. This study compared the short- and long-term outcomes of patients with multifocal tumors meeting the University of California San Francisco (UCSF) criteria after HR plus intraoperative RFA or HR alone.

METHODS

A total of 261 consecutive patients with multifocal HCCs meeting the UCSF criteria from January 2010 to January 2018, who underwent combined treatment (n = 51) or HR (n = 210), were included. Propensity score matching was performed to adjust for baseline differences. Overall survival (OS) and recurrence-free survival (RFS) were calculated, and subgroup analysis, along with univariate and multivariate analyses, were performed.

RESULTS

The 1-, 3-, and 5-year OS rates after combined treatment or HR alone were 86.3%, 66.6%, and 34.2%, and 92.8%, 67.1%, and 37%, respectively (p = 0.423); combined treatment provided similar RFS rates as HR at 1, 3, and 5 years (78.4%, 35.8% and 20.9% vs. 82.6%, 50.4% and 24.5%, respectively; p = 0.076). The propensity matching model showed similar results. Subgroup analysis showed that HR was associated with better RFS than HR plus RFA for patients with two tumors or major tumors ≤ 3 cm. Multivariate analysis revealed that portal hypertension and three tumors are independent risk factors.

CONCLUSIONS

For multifocal HCC patients meeting the UCSF criteria, combined treatment may offer similar OS and RFS as HR; however, HR may be more suitable than combined treatment for patients with two tumors or major tumors ≤ 3 cm.

Surgical Resection plus Radiofrequency Ablation versus Radical Surgery for Hepatocellular Carcinoma: A Propensity Score Matching Analysis

Objective: To evaluate the efficacy and safety of surgical resection plus radiofrequency ablation (SR-RFA) for multifocal hepatocellular carcinoma (HCC) with 2 or 3 nodules compared with surgical resection (SR).

Method: We retrospectively evaluated 824 consecutive HCC patients (SR, n = 754; SR-RFA, n = 70) from January 2009 to December 2015 and performed propensity score matching (PSM) to adjust for patient imbalances at a ratio of 1:4.

Results: At baseline, patients in the SR-RFA group had a smaller tumour size and worse liver function (including more ascites, a higher total bilirubin level, and a longer prothrombin time) than patients in the SR group. However, the two groups had similar overall survival (OS) and recurrence-free survival (RFS) rates (P = 0.209 and P = 0.332). The local recurrence rate of the SR-RFA group was significantly higher than that of the SR group (25.71% and 14.32%, P = 0.011). More patients in the SR-RFA group had postoperative complications (P = 0.003). In the propensity model, there was no intergroup difference in OS or RFS (P = 0.229 and P = 0.311, respectively).

Conclusion: SR-RFA provides a similar long-term survival to that on SR in HCC patients with 2 or 3 nodules, and its application should be carefully considered.

Surgical resection plus radiofrequency ablation for the treatment of multifocal hepatocellular carcinoma

Background

To compare the efficacy and safety of surgical resection plus radiofrequency ablation (SR-RFA) with transarterial chemoembolization (TACE) in patients with multifocal hepatocellular carcinoma (HCC) beyond the Milan criteria.

Methods

From 2009 to 2015, a total of 469 consecutive patients with multifocal HCC beyond the Milan criteria (≤5 nodules) treated with SR-RFA (n=59) or TACE (n=410) were analyzed. Their overall survival (OS) rate was compared through propensity score matching (PSM) analysis at a ratio of 1:2, and 141 patients were identified (SR-RFA, n=47; TACE, n=94). Subgroup analysis was conducted according to factors associated with treatment options.

Results

Before PSM, the 1-, 2- and 3-year OS rates were 81.5%, 68.3% and 64.3% in the SR-RFA group and 58.7%, 35.5% and 24.4% in the TACE group, respectively (all P<0.001). After PSM, the 1-, 2- and 3-year OS rates in the SR-RFA group were 81.8%, 68.7% and 63.4%, whereas those in the TACE group were 59.3%, 36.1% and 19.4%, respectively (all P<0.001). Subgroup analysis also revealed a survival advantage of SR-RFA over TACE in each subgroup. The 30-day mortality rate was 1.22% in the TACE group and nil in the SR-RFA group (P=0.861).

Conclusions

SR-RFA provides better a long-term survival rate than TACE for patients with multifocal HCC beyond the Milan criteria. SR-RFA may serve as an alternative treatment for patients with multifocal HCC in a selected patient population.

Surgical Treatment of Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is a major cause of cancer-related death worldwide. In select patients, surgical treatment in the form of either resection or transplantation offers a curative option. The aims of this review are to (1) review the current American Association for the Study of Liver Diseases/European Association for the Study of the Liver guidelines on the surgical management of HCC and (2) review the proposed changes to these guidelines and analyze the strength of evidence underlying these proposals. Three authors identified the most relevant publications in the literature on liver resection and transplantation for HCC and analyzed the strength of evidence according to the Grading of Recommendations Assessment, Development and Evaluation (GRADE) classification. In the United States, the liver allocation system provides priority for liver transplantation to patients with HCC within the Milan criteria. Current evidence suggests that liver transplantation may also be indicated in certain patient groups beyond Milan criteria, such as pediatric patients with large tumor burden or adult patients who are successfully downstaged. Patients with no underlying liver disease may also benefit from liver transplantation if the HCC is unresectable. In patients with no or minimal (compensated) liver disease and solitary HCC ≥2 cm, liver resection is warranted. If liver transplantation is not available or contraindicated, liver resection can be offered to patients with multinodular HCC, provided that the underlying liver disease is not decompensated. Many patients may benefit from surgical strategies adapted to local resources and policies (hepatitis B prevalence, organ availability, etc). Although current low-quality evidence shows better overall survival with aggressive surgical strategies, this approach is limited to select patients. Larger and well-designed prospective studies are needed to better define the benefits and limits of such approach.

Hong Kong Consensus Statements for the Management of Unresectable Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is highly prevalent in Hong Kong due to the high prevalence of chronic hepatitis B infection. Liver cancer is the fourth most common cancer and the third most common cause of cancer death. Due to the high case load, there is a high level of local expertise in treating HCC, and the full spectrum of treatment modalities is available. This document summarizes how these modalities should be used based on the latest evidence.

SUMMARY

In 2 meetings held in early 2017, a multidisciplinary group of Hong Kong clinicians, including liver surgeons, interventional radiologists, clinical oncologists, and medical oncologists, met to update local consensus statements for management of HCC. These statements are based on the latest evidence and give detailed guidance on how to deploy these modalities, in particular for cases of HCC which are not suited to surgical resection.

KEY MESSAGES

These statements give detailed information on how to decide if a patient is a candidate for resection, methods to improve candidacy for resection, and guidance for use of various nonsurgical interventions to manage patients ineligible for resection.

Hepatic resection combined with radiofrequency ablation versus hepatic resection alone for multifocal hepatocellular carcinomas: A meta-analysis

This meta-analysis aimed to comprehensively assess the efficacy and safety of hepatic resection combined with radiofrequency ablation versus hepatic resection (HR) alone for the treatment of multifocal hepatocellular carcinomas (HCC). A literature search was conducted from the database including MEDLINE, Embase, Cochrane Central Register of Controlled Trials (CENTRAL) and China Biology Medicine (CBM) disc. The primary outcomes included the 1-, 3-, 5-year overall survival (OS) and disease-free survival (DFS) rate. The secondary outcomes contained the intraoperative parameters and postoperative adverse events (AEs). These parameters were all analyzed by RevMan 5.3 software. After carefully screening relevant studies, four retrospective studies of high quality involving 466 patients (197 in the combined group and 269 in the HR group) were included in this study. The pooled results showed that the 1-, 3-, 5-year OS rate in the combined group were comparable with those in the HR group (OR=0.77, 0.96, 0.88; P=0.33, 0.88, 0.70, respectively). Similarly, there was no significant difference in 1-, 3-, 5-year DFS rate between the combined group and the HR alone group (OR=0.57, 0.83, 0.72; P=0.17, 0.37, 0.32, respectively). And the intraoperative parameters and postoperative AEs were also comparable between the above two cohorts. However, two included studies reported that tumor often recurred in the ablation site in the combined group. The present meta-analysis indicated that the HR combined with RFA could reach a long-term survival outcome similar to curative HR for multifocal HCC patients. And this therapy may be a promising alternative for these patients with marginal liver function or complicated tumor distribution. Furthermore, high quality randomized controlled trials (RCTs) are imperative to verify this conclusion.

The role of liver resection in the management of intermediate and advanced stage hepatocellular carcinoma. A systematic review

BACKGROUND

The ideal management for patients with intermediate and advanced stage hepatocellular carcinoma (HCC) is controversial. The main purpose of this systematic review is to examine the role of liver resection in patients with intermediate stage HCC (multinodular HCCs) and in advanced stage HCC [mainly patients with portal vein tumor thrombosis (PVTT)].

METHODS

A systematic search of the literature was performed in Pud Med and the Cochrane Library from 01.01.2000 to 30.06.2016.

RESULTS

Twenty-three articles with 2412 patients with multinodular HCCs were selected. Also, 29 studies with 3659 patients with HCCs with macrovascular invasion were selected. In patients with multinodular HCCs the median post-operative morbidity was 25% and the 90-day mortality was 2.7%. The median survival was 37 months and the 5-year survival 35%. The 5-year survival was much better for patients with a number of HCCs ≤3 vs. HCCs >3 (49% vs. 23%). In patients with macrovascular invasion, who underwent hepatic resection, the median post-operative morbidity was 33% and the in-hospital mortality 2.7%. The median survival was 15 months. The 3 and 5year survival was 33% and 20% respectively. Moreover a significant difference in survival was noted according to PVTT stage: 5- year survival for distal PVTT, PVTT of the main intrahepatic PV branch and PVTT extending to the main PV was 45%, 19% and 14.5% respectively.

CONCLUSIONS

Liver resection in patients with multinodular HCCs and HCCs with PVTT offers satisfactory long-term survival and should be considered in selected patients.

Knockdown of LncRNA ANRIL suppresses cell proliferation, metastasis, and invasion via regulating miR-122-5p expression in hepatocellular carcinoma

OBJECTIVE

Previous studies reported that lncRNA antisense non-coding RNA in the INK4 locus (ANRIL) was upregulated in hepatocellular carcinoma (HCC) tissues and decreased expression of ANRIL could suppress cell proliferation, metastasis, and invasion and induce apoptosis of HCC cells. However, the molecular mechanism of ANRIL involved in HCC tumorigenesis is still unknown.

METHODS

The expressions of ANRIL and miR-122-5p in HCC tissues and cells were quantified by qRT-PCR. MTT assay, colony formation assay, wound healing assay, and transwell invasion assay were performed to evaluate cell growth, metastasis, and invasion, respectively. RNA immunoprecipitation (RIP) assay and luciferase reporter assay were performed to determine whether ANRIL could directly bind to miR-122-5p in HCC cells. Xenograft tumor experiment was conducted to confirm the biological role and underlying mechanism of ANRIL in vivo.

RESULTS

The results showed that ANRIL was upregulated and miR-122-5p was downregulated in HCC tissues and cells. ANRIL was negatively correlated with miR-122-5p expression in HCC tissues. Knockdown of ANRIL or miR-122-5p overexpression suppressed HCC cell viability, colony formation ability, metastasis, and invasion. ANRIL was demonstrated to directly bind to miR-122-5p and inhibit its expression. Forced expression of ANRIL abolished the inhibitory effect of miR-122-5p overexpression on HCC progression. In vivo experiment demonstrated that ANRIL knockdown impeded tumor growth in vivo and increased miR-122-5p expression.

CONCLUSION

Our finding suggested that knockdown of ANRIL suppressed cell proliferation, metastasis and invasion via regulating miR-122-5p expression in HCC, illustrating the underlying mechanism of the oncogenic role of ANRIL in HCC.

Combined resection and radiofrequency ablation versus transarterial embolization for intermediate-stage hepatocellular carcinoma: A propensity score matching study

BACKGROUND/PURPOSE

This study aimed to compare the outcomes of combined hepatic resection (HR) plus intraoperative radiofrequency ablation (RFA) and transarterial embolization (TAE) for Barcelona Clinic Liver Cancer (BCLC) stage B hepatocellular carcinoma (HCC) in case-controlled patient groups using the propensity score.

METHODS

A total of 179 patients with multifocal HCC treated with HR plus RFA (n = 26) or TAE (n = 153) were retrospectively studied. All patients were classified as BCLC stage B and Child-Pugh class A. Analyses were performed over all participants as well as for propensity score-matched (1:3) patients to adjust for baseline differences. Cumulative overall survival (OS) and time to progression (TTP) were compared between the two groups using the Kaplan-Meier method, and independent predictors were identified by multivariate Cox regression analysis.

RESULTS

Patients treated with HR plus RFA had better OS and longer TTP than those with TAE (p = 0.011 and p < 0.001, respectively). Multivariate Cox regression analysis showed that combined therapy (hazard ratio 0.31; 95% confidence interval (CI), 0.12-0.78; p = 0.013), BCLC substage B2 (hazard ratio 1.82; 95% CI, 1.13-2.92; p = 0.013) and alpha-fetoprotein ≥ 400 ng/ml (hazard ratio 1.85; 95% CI, 1.12-3.05; p = 0.016) were independent factors associated with OS. After propensity score matching, combined therapy was the significant factor associated with OS and TTP by univariate and multivariate analyses.

CONCLUSION

Combined HR plus RFA may provide survival advantage compared to TAE in patients with BCLC stage B HCC.

Expression quantitative trait loci for PAX8 contributes to the prognosis of hepatocellular carcinoma

Paired-box family member PAX8 encodes a transcription factor that has a role in cell differentiation and cell growth and may participate in the prognosis of hepatocellular carcinoma (HCC). By bioinformatics analysis, we identified several single nucleotide polymorphisms (SNPs) within a newly identified long non-coding RNA (lncRNA) AC016683.6 as expression quantitative trait loci (eQTLs) for PAX8. Hence, we hypothesized that PAX8eQTLs in lncRNA AC016683.6 may influence the HCC prognosis. We then performed a case-only study to assess the association between the two SNPs as well as the prognosis of HCC in 331 HBV-positive HCC patients without surgical treatment. Cox proportional hazard models were used for survival analysis with adjustments for the age, gender, smoking status, drinking status, Barcelona-Clinic Liver Cancer (BCLC) stage, and chemotherapy or TACE (transcatheter hepatic arterial chemoembolization) status. We found that the G allele of rs1110839 and the T allele of rs4848320 in PAX8was significantly associated with a better prognosis compared with the T allele of rs1110839 and the C allele of rs4848320 (adjusted HR = 0.74, 95% CI = 0.61–0.91, P = 0.004 for rs1110839 and adjusted HR = 0.71, 95% CI = 0.54–0.94, P = 0.015 for rs4848320 in the additive model). Furthermore, the combined effect of the variant genotypes for these two SNPs was more prominent in patients with the BCLC-C stage orpatients with chemotherapy or TACE. Although the exact biological function remains to be explored, our findings suggest a possible association of PAX8eQTLs in lncRNA AC016683.6 with the HCC prognosis inthe Chinese population. Further large and functional studies are needed to confirm our findings.

Technical note on ALPPS for a patient with advanced hepatocellular carcinoma associated with invasion of the inferior vena cava

Patients with hepatocellular carcinoma have a very short life expectancy if they receive no surgical intervention. A relatively new surgical technique termed "Associating Liver Partition and Portal Vein Ligation for Staged Hepatectomy" (ALPPS) has been employed for inducing rapid hypertrophy of the future liver remnant for patients waiting for hepatectomy. As portal vein embolization may not result in satisfactory hypertrophy before tumor progression occurs, ALPPS can be an alternative for patients with advanced hepatocellular carcinoma. Herein we describe an ALPPS procedure with tumor thrombectomy for a patient who had a small left liver lobe and a large hepatocellular carcinoma involving the whole right liver lobe and the middle hepatic vein and extending into the inferior vena cava. In the first-stage operation, the right portal vein was controlled and divided with a Hemolock. The right hepatic artery was well protected. Hepatic transection was performed with a 1-cm margin from the tumor. The middle hepatic vein trunk was preserved. Ten days afterwards, there was significant hypertrophy of the left lateral section of the liver, and the second-stage operation was conducted. Extended right hepatectomy and tumor thrombectomy were performed under sternotomy and total vascular exclusion. The patient had good recovery and was free of disease 10 months after the operation. ALPPS may be a good treatment option even for patients with advanced disease if carried out at high-volume centers.

Intraoperative radiofrequency ablation for hepatocellular carcinoma in 112 patients with cirrhosis: a surgeon's view

Purpose

This retrospective study was an investigation of overall survival (OS), disease-free survival (DFS) and prognostic factors affecting OS and DFS in cirrhotic patients who received intraoperative radiofrequency ablation (IORFA).

Methods

Between April 2009 and November 2013, 112 patients (94 men, 84%; 18 women, 16%) underwent IORFA for 185 cases of hepatocellular carcinomas (HCC). Repeat IORFA was done in 9 patients during the same period (total of 121 treatments).

Results

All patients were followed-up for at least 12 months (mean follow-up, 32 months). Surgical resection combined with IORFA was performed in 20 patients. The technical effectiveness at 1 week was 91.78% (111 of 121). Readmission was 9.1% (11 of 121) and the most common cause was ventral hernia. Procedure-related mortality was 2.7% (3 of 112) and continued fatal biliary leakage was 1.8% (2 of 112). Local recurrence developed in 10 patients (8.9%). Most recurrence was intrahepatic. Cumulative survival was assessed in 33 patients who received IORFA as primary treatment (naive patients) and 79 non-naive patients. The cumulative DFS and OS rate at l and 3 years was 54% and 24%, and 87% and 66%, respectively. Moderate ascites (P = 0.001), tumor located segment I (P = 0.001), portal vein thrombosis (P = 0.001) had poor survival were significant factors by multivariate analysis.

Conclusion

IORFA alone or in combination with surgical resection extends the spectrum of liver surgery. A fundamental understanding of RFA, additional comorbidities, and postablation complication are necessary to maximize the safety and efficacy of IORFA for treating HCC with cirrhosis.

Low expression of GNAI3 predicts poor prognosis in patients with HCC

PURPOSES

This study was performed with an aim to explain the underlying role of GNAI3 on the prognosis of patients with HCC.

METHODS

The expression of GNAI3 at protein level was detected with the utilization of Immunohistochemistry (IHC). Chi-square test was conducted to assay the relationship between GNAI3 expression and clinical parameters of HCC patients. The correlation between expression level of GNAI3 and survival time after surgeries of HCC patients was evaluated by Kaplan-Meier method. Finally, the Cox regression was established to evaluate the relationship between GNAI3 expression and the prognosis of patients with HCC.

RESULTS

In this study, the negative rate of GNAI3 expression in HCC samples was about 76.6%, which was significantly higher than that in paired normal specimens (12.5%). Result showed that there was no correlation between GNAI3 expression and age, gender, liver cirrhosis and vein invasion (P>0.05), but tight relationship between GNAI3 expression and TNM stage and tumor size was found (P<0.05). The following Kaplan-Meier analysis result illustrated that negative expression of GNAI3 induced high mortality of HCC patients. Cox regression result revealed that GNAI3 might be a biomarker for prognosis of patients with HCC (HR: 0.218, P=0.016, 95% CI 0.063-0.750).

CONCLUSION

Generally, results of this study demonstrated that expression of GNAI3 shared a tight relationship with the prognosis of patients with HCC. Therefore, GNAI3 could be considered as a novel index for prognosis of patients with HCC.

The role of intraoperative ultrasonography in the diagnosis and management of focal hepatic lesions

Intraoperative ultrasonography (IOUS) has been widely utilized in hepatic surgery both as a diagnostic technique and in the course of treatment. Since IOUS involves direct-contact imaging of the target organ, it can provide high spatial resolution without interference from the surrounding structures. Therefore, IOUS may improve the detection, characterization, localization, and local staging of hepatic tumors. IOUS is also a real-time imaging modality capable of providing interactive information and valuable guidance in a range of procedures. Recently, contrast-enhanced IOUS, IOUS elastography, and IOUS-guided hepatic surgery have attracted increasing interest and are expected to lead to the broader implementation of IOUS. Herein, we review the various applications of IOUS in the diagnosis and management of focal hepatic lesions.

Hong Kong consensus recommendations on the management of hepatocellular carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is particularly prevalent in Hong Kong because of the high prevalence of chronic hepatitis B (CHB) infection; HCC is the fourth commonest cancer in men and the seventh commonest in women, and it is the third leading cause of cancer death in Hong Kong. The full spectrum of treatment modalities for HCC is available locally; however, there is currently no local consensus document detailing how these modalities should be used.

SUMMARY

In a series of meetings held between May and October 2013, a multidisciplinary group of Hong Kong clinicians - liver surgeons, medical oncologists, clinical oncologists, hepatologists, and interventional radiologists - convened to formulate local recommendations on HCC management. These recommendations consolidate the most current evidence pertaining to HCC treatment modalities, together with the latest thinking of practicing clinicians engaged in HCC management, and give detailed guidance on how to deploy these modalities effectively for patients in various disease stages.

KEY MESSAGES

Distinct from other regional guidelines, these recommendations provide guidance on the use of antiviral therapy to reduce the incidence of HCC in CHB patients with cirrhosis and to reduce recurrence of CHB-related HCC.

Number of nodules, Child-Pugh status, margin positivity, and microvascular invasion, but not tumor size, are prognostic factors of survival after liver resection for multifocal hepatocellular carcinoma

BACKGROUND

Presently, the role of liver resection (LR) for multifocal hepatocellular carcinoma (HCC) remains controversial. However, in many regions worldwide, LR remains the only treatment modality available to such patients which offers the possibility of long-term cure. The aim of this study is to determine the outcomes and prognostic factors of patients with multifocal HCC after LR.

METHODS

This is a retrospective analysis of 110 patients who underwent potentially curative LR for pathologically proven multifocal HCC between 2000 and 2011.

RESULTS

The median age was 64 (range, 18-84) years, and there were 88 males (80.0 %). Sixty-one patients underwent a major hepatectomy, and the overall postoperative mortality was 1.8 %. Sixty-eight patients had liver cirrhosis, of which, 58 were child's A and 10 were child's B. The 1- and 5-year overall survival (OS) was 82 and 44 %, respectively. The corresponding 1- and 5-year recurrence-free survival (RFS) was 57 and 19 %, respectively. Multivariate analysis demonstrated that the number of nodules (>3) and presence of microvascular invasion were associated with RFS. Number of nodules (>3), margin positivity, Child-Pugh status, and presence of microvascular invasion were independent prognostic factors of OS.

CONCLUSIONS

LR followed by treatment of recurrences may result in reasonable long-term survival and should be considered in a selected group of patients with multifocal HCC. Number of nodules (>3), margin positivity, Child-Pugh status, and presence of microvascular invasion, but not tumor size, were independent negative predictors of OS. These findings have potential implications on the AJCC staging for multifocal HCC.

Value of radiofrequency ablation in the treatment of hepatocellular carcinoma

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

Outcomes after hepatic resection and subsequent multimodal treatment of recurrence for multifocal hepatocellular carcinoma

BACKGROUND

The role of liver resection in patients with multifocal hepatocellular carcinoma (HCC) with well preserved liver function is controversial. This study was conducted to evaluate the outcomes of such patients.

METHODS

This was a retrospective analysis of patients who underwent liver resection for multifocal HCC between 1992 and 2011. Postoperative outcomes, survival and predictors of outcomes were analysed.

RESULTS

Of 46 patients who underwent hepatic resection for multifocal HCC, 38 had Barcelona Clinic Liver Cancer stage B disease. Major hepatectomy was performed in 27 patients, and major complications occurred in nine (20 per cent). The 90-day postoperative mortality rate was 7 per cent. Overall 1-, 2-, 3- and 5-year survival rates were 78, 64, 59 and 53 per cent respectively (median 70 months), whereas corresponding recurrence-free survival rates were 53, 32, 30 and 27 per cent (median 14 months). Recurrence developed in 28 (61 per cent) of the 46 patients, affecting the liver only in 22. Three-quarters of patients with recurrence underwent further therapy. Major hepatectomy (hazard ratio (HR) 0.37, 95 per cent confidence interval 0.14 to 0·95; P = 0·038), microvascular (HR 3·44, 1·35 to 8·74; P = 0·009) and macrovascular (HR 2·68, 1·11 to 6·43; P = 0·028) invasion, and cirrhosis (HR 3·15, 1·12 to 8·86; P = 0·029) were associated with overall survival. Microvascular invasion (HR 2·81, 1·06 to 7·40; P = 0·037), cirrhosis (HR 3·12, 1·41 to 6·88; P < 0·001) and bilobar disease (HR 2·93, 1·09 to 7·88; P = 0·033) were associated with recurrence-free survival.

CONCLUSION

In selected patients with multifocal HCC and well preserved liver function, long-term survival is possible after liver resection and subsequent aggressive treatment of recurrence.

Hepatic resection for hepatic metastases from gastric adenocarcinoma

PURPOSE

The effects of hepatic resection on patients with metastatic tumors from gastric adenocarcinomas are unclear. Therefore, we analyzed early clinical outcomes in patients who underwent surgical resection for hepatic metastases from gastric adenocarcinomas.

MATERIALS AND METHODS

From January 2003 to December 2010, 1,508 patients with primary gastric cancers underwent curative gastric resections at the Korea Cancer Center Hospital. Of these patients, 12 with liver-only metastases underwent curative hepatic resection. Their clinical data were analyzed retrospectively.

RESULTS

The median follow-up period was 12.5 months (range, 1~85 months); no operative mortalities or major complications were observed. Three patients underwent synchronous resections, and 9 underwent metachronous resections. In the latter group, the median interval between gastrectomy and hepatectomy for hepatic metastasis was 10.5 months (range, 5~47 months). The overall 1- and 5-year survival rates of these 12 patients were 65% and 39%, respectively, with a median overall survival of 31.0 months; 2 patients survived for >5 years.

CONCLUSIONS

Hepatic resection can be a feasible procedure for treating hepatic metastases from gastric adenocarcinomas. Although this study was small and involved only selected cases, the outcomes of the hepatic resections were comparable and long-term (>5 years) survivors were identified. Surgical resection of the liver can be considered a feasible option in managing hepatic metastases from gastric adenocarcinomas.

Tolerance of high-intensity focused ultrasound ablation in patients with hepatocellular carcinoma

Background

High-intensity focused ultrasound (HIFU) ablation is a relatively new, noninvasive way of ablation for treating hepatocellular carcinoma (HCC). Emerging evidence has shown that it is effective for the treatment of HCC, even in patients with poor liver function. There is currently no data on the safety limit of HIFU ablation in patients with cirrhosis. However, this information is vital for the selection of appropriate patients for the procedure. We analyzed HCC patients who had undergone HIFU ablation and determined the lower limit of liver function and other patient factors with which HCC patients can tolerate this treatment modality.

Methods

Preoperative variables of 100 patients who underwent HIFU ablation for HCC were analyzed to identify the risk factors in HIFU intolerance in terms of stress-induced complications. Factors that may contribute to postablation complications were compared.

Results

Thirteen (13 %) patients developed a total of 18 complications. Morbidity was mainly due to skin and subcutaneous tissue injuries (n = 9). Five patients had first-degree skin burn, one had second-degree skin burn, and three had third-degree skin burn. Four complications were grade 3a in the Clavien classification and 14 were below this grade. Univariate analysis showed that age (p = 0.022) was the only independent factor in HIFU intolerance.

Conclusions

HIFU ablation is generally well tolerated in HCC patients with cirrhosis. It is safe for Child-Pugh A and B patients and selected Child-Pugh C patients. With this new modality, HCC patients who were deemed unsalvageable by other surgical means in the past because of simultaneous Child-Pugh B or C disease now have a new hope.

More than just tumor destruction: immunomodulation by thermal ablation of cancer

Over the past decades, thermoablative techniques for the therapy of localized tumors have gained importance in the treatment of patients not eligible for surgical resection. Anecdotal reports have described spontaneous distant tumor regression after thermal ablation, indicating a possible involvement of the immune system, hence an induction of antitumor immunity after thermoinduced therapy. In recent years, a growing body of evidence for modulation of both adaptive and innate immunity, as well as for the induction of danger signals through thermoablation, has emerged. Induced immune responses, however, are mostly weak and not sufficient for the complete eradication of established tumors or durable prevention of disease progression, and combination therapies with immunomodulating drugs are being evaluated with promising results. This article aims to summarize published findings on immune modulation through radiofrequency ablation, cryoablation, microwave ablation therapy, high-intensity focused ultrasound, and laser-induced thermotherapy.

Therapeutic options for intermediate-advanced hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common malignancies, ranking the sixth in the world, with 55% of cases occurring in China. Usually, patients with HCC did not present until the late stage of the disease, thus limiting their therapeutic options. Although surgical resection is a potentially curative modality for HCC, most patients with intermediate-advanced HCC are not suitable candidates. The current therapeutic modalities for intermediate-advanced HCC include: (1) surgical procedures, such as radical resection, palliative resection, intraoperative radiofrequency ablation or cryosurgical ablation, intraoperative hepatic artery and portal vein chemotherapeutic pump placement, two-stage hepatectomy and liver transplantation; (2) interventional treatment, such as transcatheter arterial chemoembolization, portal vein embolization and image-guided locoregional therapies; and (3) molecularly targeted therapies. So far, how to choose the therapeutic modalities remains controversial. Surgeons are faced with the challenge of providing the most appropriate treatment for patients with intermediate-advanced HCC. This review focuses on the optional therapeutic modalities for intermediate-advanced HCC.