Prognostic factors for survival after transarterial chemoembolization combined with microwave ablation for hepatocellular carcinoma

Outcome of transarterial radioembolization in patients with hepatocellular carcinoma as a first-line interventional therapy and after a previous transarterial chemoembolization

Purpose

Due to a lack of data, there is an ongoing debate regarding the optimal frontline interventional therapy for unresectable hepatocellular carcinoma (HCC). The aim of the study is to compare the results of transarterial radioembolization (TARE) as the first-line therapy and as a subsequent therapy following prior transarterial chemoembolization (TACE) in these patients.

Methods

A total of 83 patients were evaluated, with 38 patients having undergone at least one TACE session prior to TARE [27 male; mean age 67.2 years; 68.4% stage Barcelona clinic liver cancer (BCLC) B, 31.6% BCLC C]; 45 patients underwent primary TARE (33 male; mean age 69.9 years; 40% BCLC B, 58% BCLC C). Clinical [age, gender, BCLC stage, activity in gigabecquerel (GBq), Child-Pugh status, portal vein thrombosis, tumor volume] and procedural [overall survival (OS), local tumor control (LTC), and progression-free survival (PFS)] data were compared. A regression analysis was performed to evaluate OS, LTC, and PFS.

Results

No differences were found in OS (95% CI: 1.12, P = 0.289), LTC (95% CI: 0.003, P = 0.95), and PFS (95% CI: 0.4, P = 0.525). The regression analysis revealed a relationship between Child-Pugh score (P = 0.005), size of HCC lesions (>10 cm) (P = 0.022), and OS; neither prior TACE (Child-Pugh B patients; 95% CI: 0.120, P = 0.729) nor number of lesions (>10; 95% CI: 2.930, P = 0.087) correlated with OS.

Conclusion

Prior TACE does not affect the outcome of TARE in unresectable HCC.

Efficacy and Safety of Microwave Ablation Assisted by Ultrasound Fusion Imaging for Primary and Secondary Liver Cancers with a Diameter of 3-7 Cm

Purpose

To investigate the efficacy and safety of microwave ablation (MWA) assisted by ultrasound fusion imaging (FI) for primary and secondary liver cancers with a diameter of 3-7 cm.

Patients and Methods

A retrospective analysis was conducted on patients with primary and secondary liver cancers (3-7 cm) who underwent MWA with ultrasound FI assistance in our hospital from April 2020 to May 2022. Technical success, technique efficacy, local tumor progression (LTP), major complication, intrahepatic distant recurrence (IDR), and overall survival (OS) were assessed during the follow-up period. In addition, the ablation results of tumors between the medium-sized group (3.1-5.0 cm) and large-sized group (5.1-7.0 cm) were compared.

Results

31 patients with 35 primary and secondary liver cancers were treated with MWA assisted by ultrasound FI. Complete ablation was achieved in 34 lesions with a technical success rate of 97.1%. Major complications occurred in 6.5% of patients (2/31), while no ablation-related deaths were reported. The median follow-up time of this study was 24 months (range:10 to 35 months). The technique efficacy rate was 97.1% (34/35), with LTP occurring in three lesions at a rate of 8.8% (3/34). The incidence of IDR was 38.7% (12/31) and the 2-year cumulative OS rate reached 96.7%. Moreover, there were no statistical differences in technique efficacy rate (p=0.286), LTP rate (p=0.328), major complication rate (p=0.503), IDR (p=0.857), and OS (p=0.118) between medium-sized group and large-sized group.

Conclusion

Ultrasound FI-assisted MWA has the potential to be an effective and safe therapeutic strategy for primary and secondary liver cancers ranging from 3-7 cm in size.

Complications and local recurrence of malignant liver tumor after ablation in risk areas: a retrospective analysis

INTRODUCTION

Microwave ablation (MWA) is an effective local treatment for malignant liver tumors; however, its efficacy and safety for liver tumors adjacent to important organs are debatable.

PATIENTS AND METHODS

Forty-three cases with liver tumors adjacent to important organs were the risk group and 66 cases were the control group. The complications between two groups were compared by chi-square test and t-test. Local tumor recurrence (LTR) was analyzed by log-rank test. Factors affecting complications were analyzed by logistic regression and Spearman analyses. Factors affecting LTR were analyzed by Cox regression analysis. A receiver operating characteristic curve predicted pain treated with drugs and LTR.

RESULTS

We found no significant difference in complications and LTR between two groups. The risk group experienced lower ablation energy and more antennas per tumor than control group. Necrosis volume after MWA was positively correlated with pain; necrosis volume and ablation time were positively correlated with recovery duration. Major diameter of tumor >3 cm increased risk of LTR by 3.319-fold, good lipiodol deposition decreased risk of LTR by 73.4%. The area under the curve (AUC) for necrosis volume in predicting pain was 0.74, with a 69.1 cm3 cutoff. AUC for major diameter of tumor in predicting LTR was 0.68, with a 27.02 mm cutoff.

CONCLUSION

MWA on liver tumors in at-risk areas is safe and effective, this is largely affected by proper ablation energy, antennas per tumor, and experienced doctors. LTR is primarily determined by major diameter of tumor and lipiodol deposition status.

Efficacy and safety of computed tomography-guided microwave ablation with fine needle-assisted puncture positioning technique for hepatocellular carcinoma

BACKGROUND

In microwave ablation (MWA), although computed tomography (CT) scanning can overcome gas interference, it cannot achieve real-time localization. Therefore, the puncture technique is more important in CT-guided ablation.

AIM

To compare the fine needle-assisted puncture (FNP) positioning technique and the conventional puncture (CP) technique for the safety and efficacy of CT-guided MWA in treating hepatocellular carcinoma (HCC).

METHODS

This retrospective study included 124 patients with 166 tumor nodules from February 2018 and June 2021. Seventy patients received CT-guided MWA under the FNP technique (FNP group), and 54 patients received MWA under the CP technique (CP group). Intergroup comparisons were made regarding local tumor progression (LTP), recurrence-free survival (RFS), overall survival (OS), and complications. The influencing variables of LTP and RFS were analyzed through univariate and multivariate regressions.

RESULTS

The 1-, 2-, and 3-year cumulative incidences of LTP in the FNP group were significantly lower than those in the CP group (7.4%, 12.7%, 21.3% vs 13.7%, 32.9%, 36.4%; P = 0.038). The 1-, 2-, and 3-year RFS rates in the FNP group were significantly higher than those in the CP group (80.6%, 73.3%, 64.0% vs 83.3%, 39.4%, and 32.5%, respectively; P = 0.008). The FNP technique independently predicted LTP and RFS. Minor complications in the FNP group were lower than those in the CP group (P < 0.001). The difference in median OS was insignificant between the FNP and CP groups (P = 0.229).

CONCLUSION

The FNP technique used in CT-guided MWA may improve outcomes in terms of LTP, RFS, and procedure-related complications for HCC.

A Nomogram Based on Preoperative Lipiodol Deposition after Sequential Retreatment with Transarterial Chemoembolization to Predict Prognoses for Intermediate-Stage Hepatocellular Carcinoma

(1) Background: Conventional transarterial chemoembolization (cTACE) is the mainstay treatment for patients with Barcelona Clinic Liver Cancer (BCLC) B-stage hepatocellular carcinoma (HCC). However, BCLC B-stage patients treated with cTACE represent a prognostically heterogeneous population. We aim to develop and validate a lipiodol-deposition-based nomogram for predicting the long-term survival of BCLC B-stage HCC patients after sequential cTACE. (2) Methods: In this retrospective study, 229 intermediate-stage HCC patients from two hospitals were separately allocated to a training cohort (n = 142) and a validation cohort (n = 87); these patients underwent repeated TACE (≥4 TACE sessions) between May 2010 and May 2017. Lipiodol deposition was assessed by semiautomatic volumetric measurement with multidetector computed tomography (MDCT) before cTACE and was characterized by two ordinal levels: ≤50% (low) and >50% (high). A clinical lipiodol deposition nomogram was constructed based on independent risk factors identified by univariate and multivariate Cox regression analyses, and the optimal cutoff points were obtained. Prediction models were assessed by time-dependent receiver-operating characteristic curves, calibration curves, and decision curve analysis. (3) Results: The median number of TACE sessions was five (range, 4−7) in both cohorts. Before the TACE-3 sessions, the newly constructed nomogram based on lipiodol deposition achieved desirable diagnostic performance in the training and validation cohorts with AUCs of 0.72 (95% CI, 0.69−0.74) and 0.71 (95% CI, 0.68−0.73), respectively, and demonstrated higher predictive ability compared with previously published prognostic models (all p < 0.05). The prognostic nomogram obtained good clinical usefulness in predicting the patient outcomes after TACE. (4) Conclusions: Based on each pre-TACE lipiodol deposition, two sessions are recommended before abandoning cTACE or combining treatment for patients with intermediate-stage HCC. Furthermore, the nomogram based on pre-TACE-3 lipiodol deposition can be used to predict the prognoses of patients with BCLC B-stage HCC.

Hepatic resection versus microwave ablation for the treatment of early hepatocellular carcinoma: a comparative analysis of treatment outcomes and survival predictors

Introduction

Liver resection and local ablation are the two primary curative treatments for early-stage hepatocellular carcinoma (HCC). Microwave ablation (MWA) shows promising performance in terms of early tumor response, recurrence, and survival. This study aims to determine whether MWA would be comparable to liver resection in treating early-stage HCC.

Methods

This study included patients with hepatitis C-related HCC attending the multidisciplinary HCC clinic, Kasr Al-Ainy Hospital (March 2018 to September 2020). We included adults with early-stage HCC (BCLC stages 0-A). We studied patients and tumor characteristics, HCC treatment response, recurrence, and overall survival.

Results

Thirty-one patients were treated with liver resection and 41 patients were treated with MWA, including 4 patients who received intraoperative MWA. By the end of the study, 21 patients (28.77%) died. Patients who underwent MWA were younger compared to the hepatectomy group with lower baseline AFP (21 (6.7–54) versus 77 (31.3–136.0), respectively, (P value 0.024) and tumor size (2.78 (0.87) cm versus 3.77 (0.97) cm, respectively, (P value < 0.001). We found no differences between the studied groups in terms of treatment response, post-treatment decompensation, recurrence, or overall survival. One-year survival probability in the MWA and resection groups was 75.5% and 76.3% respectively. Post-procedure hepatic decompensation was the only independent predictor of lower survival by multivariate logistic regression analysis (OR 37.74, 95%CI 6.251–227.87, P value < 0.001) after adjusting for age, AFP, and tumor size.

Conclusion

Liver resection and MWA showed similar satisfactory results in the treatment of early-stage HCC, in terms of treatment response, recurrence, and overall survival.

Recent Perspectives on the Mechanism of Recurrence After Ablation of Hepatocellular Carcinoma: A Mini-Review

Hepatocellular carcinoma (HCC) is one of the most common malignant tumors. Hepatectomy, liver transplantation, and ablation are the three radical treatments for early-stage hepatocellular carcinoma (ESHCC), but not all patients are fit for or can tolerate surgery; moreover, liver donors are limited. Therefore, ablation plays an important role in the treatment of ESHCC. However, some studies have shown that ablation has a higher local recurrence (LR) rate than hepatectomy and liver transplantation. The specific mechanism is unknown. The latest perspectives on the mechanism of recurrence after ablation of HCC were described and summarized. In this review, we discussed the possible mechanisms of recurrence after ablation of HCC, including epithelial–mesenchymal transition (EMT), activating autophagy, changes in non-coding RNA, and changes in the tumor microenvironment. A systematic and comprehensive understanding of the mechanism will contribute to the research and development of related treatment, combined with ablation to improve the therapeutic effect in patients with ESHCC.

The Efficacy and Prognostic Factors of the Combination of TACE and Apatinib for the Treatment of BCLC Stage C Hepatocellular Carcinoma

Objective: Apatinib is a inhibitor of vascular endothelial growth factor receptor-2. To explore the efficacy and prognostic factors of transarterial chemoembolization (TACE) combined with apatinib in the treatment of Barcelona Clinic Liver Cancer stage C (BCLC C) hepatocellular carcinoma (HCC).

Methods: Clinical data of 146 HCC patients with BCLC stage C admitted to our hospital were collected and analyzed retrospectively, of which 76 cases were treated with TACE combined with apatinib (TACE-apatinib) and 70 with TACE alone. The tumor response, survival time, and adverse events were compared between the two groups, and the factors affecting the prognosis were analyzed.

Results: The objective response rate (ORR) and disease control rate (DCR) in the TACE-apatinib group were higher than in the TACE-alone group (ORR: 42.10 vs. 25.71%, P = 0.03; DCR: 84.21 vs. 55.71%, P = 0.001). The median time to progression (TTP) and overall survival (OS) in the TACE-apatinib group were longer than in the TACE-alone group (TTP: 5.5 vs. 3.7 months, P = 0.02; OS: 10.0 vs. 6.2 months, P = 0.01). Univariate and multivariate Cox regression analysis showed that tumor size, Child-Pugh class, and the presence of the portal vein tumor thrombus affect the prognosis of patients. Subgroup analysis revealed that TACE-apatinib therapy resulted in a higher OS in patients with tumor size <10 cm, without portal vein tumor thrombus, and with Child-Pugh class A (P < 0.05). The likelihood of adverse events (hand-foot syndrome, hypertension, oral ulcer) was significantly higher in the increased in the TACE-apatinib group than in the TACE alone group (P < 0.05).

Conclusion: TACE-apatinib is an effective and safe method for the treatment of BCLC stage C HCC. Tumor size, Child-Pugh class, and portal vein tumor thrombus affect survival time in HCC patients with BCLC stage C.

Hepatocellular carcinoma locoregional therapies: Outcomes and future horizons

Hepatocellular carcinoma (HCC) is the most common primary cancer of the liver and has an overall five-year survival rate of less than twenty percent. For patients with unresectable disease, evolving liver-directed locoregional therapies provide efficacious treatment across the spectrum of disease stages and via a variety of catheter-directed and percutaneous techniques. Goals of locoregional therapies in HCC may include curative intent in early-stage disease, bridging or downstaging to surgical resection or transplantation for early or intermediate-stage disease, and local disease control and palliation in advanced-stage disease. This review explores the outcomes of chemoembolization, bland embolization, radioembolization, and percutaneous ablative therapies. Attention is also given to prognostic factors related to each of the respective techniques, as well as future directions of locoregional therapies for HCC.

Improvement in the condition of patients with primary liver cancer with transcatheter arterial chemoembolization before and after microwave ablation interventional therapy

BACKGROUND

We compared the clinical efficacy and safety of transcatheter arterial chemoembolization (TACE) combined with microwave ablation (MWA) and TACE alone for the treatment of patients with primary liver cancer (PLC).

MATERIALS AND METHODS

A total of 160 patients with PLC were enrolled and randomized into a study group (n=80) and a control group (n=80). Patients in the study group were treated with TACE combined with MWA, whereas those in the control group were treated with TACE alone. Treatment efficacy, changes in hepatic function indices after the treatment, incidence of adverse reactions, quality of life after treatment, and 3-year survival rates of the two groups were compared. Cox proportional hazards model was used for analyzing the patients' prognostic factors.

RESULTS

The total effective rate in the study group was higher than that in the control group (P<0.05). Patients in the study group had lower alanine aminotransferase and total bilirubin levels (P<0.05) and higher albumin levels (P<0.05) than those in the control group. The 1-, 2-, and 3-year overall survival rates in the study group were higher than those in the control group (P<0.05). Cox proportional hazards model showed that tumor size, extrahepatic metastasis, portal vein tumor thrombosis, severity of liver cirrhosis, and therapeutic methods were independent risk factors for patients with PLC.

CONCLUSIONS

TACE combined with MWA is more effective than TACE alone in treating PLC, reducing the damage to the patients' cardiac function and prolonging survival.

Microwave ablation versus sorafenib for intermediate-Stage Hepatocellular carcinoma with transcatheter arterial chemoembolization refractoriness: a propensity score matching analysis

Purpose: To compared the benefits of sorafenib with microwave ablation (MWA) in intermediate-stage hepatocellular carcinoma (HCC) patients with tumor size ≤7 cm and tumor number ≤5 after Transcatheter Arterial Chemoembolization (TACE) failure.Methods: A retrospective, single-center study was conducted using a one-to-one propensity score matching (PSM) analysis and involved 52 intermediate-stage HCC patients with absence of evidence of intrahepatic vascular invasion and extrahepatic metastasis after TACE failure and underwent treatment with MWA or sorafenib between 2007 and 2019. The overall survival (OS) and progression-free survival (PFS) were evaluated by the Kaplan-Meier method. The factors with OS and PFS were determined by Cox regression.Results: Of the 52 patients included in our study, 30 (57.7%) underwent MWA and 22 (42.3%) received sorafenib. After PSM, 22 pairs were enrolled into different groups for further analysis. Patients in the MWA-group had a significantly longer median PFS than patients in the sorafenib-group on both before (median, 9.3 vs. 2.8 months, p = .001) and after PSM (median, 9.0 vs. 2.8 months, p = .006). They also had a significantly longer median OS than patients in the sorafenib-group on before (median, 48.8 vs. 16.6 months, p = .001) and after PSM (median, Not reached vs. 16.6 months, p = .001). Besides, Cox regression analysis showed that the treatment and age were the independent prognostic factors of OS and PFS (p＜0.05).Conclusions: MWA was superior to sorafenib in improving survival for intermediate-stage hepatocellular carcinoma (HCC) patients with tumor size ≤7 cm and tumor number ≤5 after TACE failure.Key PointsCompared with sorafenib, microwave ablation may be a more reasonable alternative treatment for intermediate-stage hepatocellular carcinoma (HCC) patients with tumor size ≤7 cm and tumor number ≤5 after TACE refractoriness.The treatment (MWA vs sorafenib) and the age of patients were the independent prognostic factors of OS and PFS.

TACE combined with microwave ablation therapy vs. TACE alone for treatment of early- and intermediate-stage hepatocellular carcinomas larger than 5 cm: a meta-analysis

There are many therapeutic options for primary hepatocellular carcinoma (HCC), but very limited options for unresectable HCC with a single lesion larger than 5 cm (Barcelona Clinic Liver Cancer [BCLC] stage A) or with 2-3 nodules beyond 5 cm (BCLC stage B). Transcatheter arterial chemoembolization (TACE) is considered the first-line treatment for these patients, and combination therapy has also been tried. However, the effectiveness of microwave ablation (MWA) combined with TACE in the treatment of the above tumors remains to be further confirmed. Therefore, this meta-analysis aimed to compare the effectiveness of combination therapy and TACE monotherapy on these patients. PubMed, Cochrane Library, Embase, China National Knowledge Infrastructure, and the Wan Fang electronic databases were retrieved to search for studies comparing combination therapy and TACE monotherapy, published between the earliest available date and August 20, 2019. A total of 20 articles (reporting 1736 patients) were included. Meta-analysis showed that, compared to TACE alone, TACE + MWA resulted in significantly higher 1-, 2-, and 3-year overall survival (OS) (1-year OS rate: RR = 1.36, 95% CI 1.28-1.44, P < 0.001; 2-year OS rate: RR = 1.56, 95% CI 1.40-1.74, P < 0.001 and 3-year OS rate: RR = 2.07, 95% CI: 1.67-2.57, P < 0.001). Complete response, partial response, and objective response rates were significantly higher in TACE + MWA than those in TACE alone (P < 0.001). Meanwhile, publication bias and sensitivity analysis were performed and did not show statistical significance.

Unresectable Hepatocellular Carcinoma: Transcatheter Arterial Chemoembolization Combined With Microwave Ablation vs. Combined With Cryoablation

Background: Transcatheter arterial chemoembolization (TACE) combined with ablation has been widely used for treating unresectable hepatocellular carcinoma (HCC). However, the technique with which TACE should be combined for it to be more effective remains unknown. Purpose: To retrospectively evaluate the efficacy and safety of TACE combined with microwave ablation (MWA) vs. TACE combined with cryoablation (CRA) in treating unresectable HCC. Materials and Methods: From January 2011 to December 2018, 108 patients diagnosed with unresectable HCC were divided into either the TACE-MWA group (n = 48) or TACE-CRA group (n = 60). Overall survival (OS) and time to progression (TTP) were compared between the two groups. To reduce potential bias, a propensity score matching (PSM) was performed. Complications were observed. Kaplan-Meier survival curves were constructed and compared using the log-rank test. Results : The baseline characteristics of the two groups were balanced. The median OS was 20.9 months (95% CI 14.3-27.6 months) in the TACE-MWA group and 13.0 months (95% CI 8.8-17.1 months) in the TACE-CRA group (P = 0.096). The median TTP was 8.8 months (95% CI 4.3-13.4 months) in the TACE-MWA group and 9.3 months (95% CI 7.1-11.5 months) in the TACE-CRA group (P = 0.675). After PSM, 48 patients remained in each group. The median OS in the TACE-MWA and TACE-CRA groups was 20.9 months (95% CI 14.3-27.6 months), and 13.5 months (95% CI 8.4-18.6 months, P = 0.100), respectively. The median TTP in the TACE-MWA and TACE-CRA groups was 8.8 months (95% CI 4.3-13.4 months), and 8.6 months (95% CI 3.1-14.2 months, P = 0.909), respectively. The overall incidence rate of ablation-related complications was lower in the TACE-MWA group than in the TACE-CRA group (66.7 vs. 88.3%, P = 0.006). Multivariate analysis showed that the presence of portal vein tumor thrombus (PVTT) and the maximum diameter of intrahepatic tumor were significant prognostic factors for OS and TTP. Conclusion: The efficacy of TACE-MWA and TACE-CRA in the treatment of unresectable HCC was comparable. TACE-MWA was more promising because of a lower complication rate, especially with regard to thrombocytopenia. Further prospective randomized controlled trials are required to validate our findings.

Locoregional Therapy Approaches for Hepatocellular Carcinoma: Recent Advances and Management Strategies

Hepatocellular carcinoma (HCC) is the most common primary liver malignancy and third leading cause of cancer-related mortality worldwide. While surgical resection and transplantation are the standard first-line treatments for early-stage HCC, most patients do not fulfill criteria for surgery. Fortunately, catheter-directed and percutaneous locoregional approaches have evolved as major treatment modalities for unresectable HCC. Improved outcomes have been achieved with novel techniques which can be employed for diverse applications ranging from curative-intent for small localized tumors, to downstaging or bridging to resection and transplantation for early and intermediate disease, and locoregional control and palliation for advanced disease. This review explores recent advances in liver-directed techniques for HCC including bland transarterial embolization, chemoembolization, radioembolization, and ablative therapies, with a focus on patient selection, procedural technique, periprocedural management, and outcomes.

Factors to transcatheter arterial chemoembolization Liver Cancer stage C

Introduction: To establish a predictive model to demonstrate that transcatheter arterial chemoembolization (TACE) prolonged survival time in patients with Barcelona Clinic Liver Cancer (BCLC) stage-C HCC.Material and methods: Patients with BCLC stage C HCC treated between January 2009 and April 2016 were included. The training group (n = 336) and control group (n = 141) underwent TACE as a first or supportive treatment. Factors related to survival time were retrospectively analyzed by multivariate logistic regression to establish a predictive model. Validation of the model was undertaken prospectively in a validation group (n = 159) that underwent TACE as first treatment between May 2016 and December 2017.Results: Classification of portal vein tumor thrombus, maximum tumor size, Child-Pugh score, and log alphafoetoprotein levels were independent risk factors included in the mathematical model. Receiver operating characteristic curves confirmed the model was helpful in predicting survival time. The area under the curve was 0.714 (95% confidence interval, 0.659-0.769). A cutoff value of 7.1 months had maximum Youden indeces of 0. 458, sensitivity 62.4%, and specificity 83.8%. The validation group supported the model.Conclusions: Portal vein tumor thrombus, maximum tumor size, Child-Pugh score, and log alphafoetoprotein levels helped predict survival time in patients with BCLC stage-C HCC.

A nomogram to predict survival of patients with intermediate-stage hepatocellular carcinoma after transarterial chemoembolization combined with microwave ablation

OBJECTIVES

To develop a prognostic nomogram based on the albumin-bilirubin (ALBI) grade for prediction of the long-term survival of patients with intermediate-stage hepatocellular carcinoma (HCC) after transarterial chemoembolization combined with microwave ablation (TACE-MWA).

METHODS

We retrospectively studied 546 consecutive patients with intermediate-stage HCC according to the Barcelona Clinic Liver Cancer guidelines who underwent TACE-MWA between January 2000 and December 2016. Overall survival (OS) and progression-free survival (PFS) were analyzed. The predictive value of the ALBI grade was investigated. The prognostic nomogram was constructed using the independent predictors assessed by the multivariate Cox proportional hazards model.

RESULTS

After a median follow-up of 35.0 months (range, 4.0-221.0 months), 380 patients had died. The median OS was 35.0 months (95% confidence interval (CI), 30.84-39.16 months), and the median PFS was 6.5 months (95% CI, 6.13-6.87 months). The ALBI grade was validated as an independent predictor of OS (p < 0.001). Multivariate analyses showed that Eastern Cooperative Oncology Group performance status score more than 0, presence of liver cirrhosis, a-fetoprotein level above 400 ng/mL, tumor size greater than 5 cm, tumor number more than 3, advanced ALBI grade, and treatment sessions of TACE or MWA fewer than 3 were independently associated with overall mortality. The prognostic nomogram incorporating these eight predictors achieved good calibration and discriminatory abilities with a concordance index of 0.770 (95% CI, 0.746-0.795).

CONCLUSIONS

The prognostic nomogram based on the ALBI grade resulted in reliable efficacy for prediction of individualized OS in patients with intermediate-stage HCC after TACE-MWA.

KEY POINTS

• TACE-MWA was associated with a median overall survival of 35.0 months for patients with intermediate-stage HCC. • A prognostic nomogram was built to predict individualized survival of patients with intermediate-stage HCC after TACE-MWA. • The prognostic nomogram incorporating eight predictors achieved good calibration and discriminatory abilities with a concordance index of 0.770.

Individualized Ablation of Hepatocellular Carcinoma: Tailored Approaches across the Phenotype Spectrum

Ablation is now recommended by international guidelines for the definitive treatment of hepatocellular carcinoma (HCC). Extensive clinical studies have demonstrated outcomes comparable to surgical resection with shorter hospital stays, decreased costs, and improved quality of life. Successful ablation requires complete treatment of both tumor and margin while preserving critical adjacent structures. HCC exhibits highly variable presentations in both anatomic involvement and biology which have significant implications on choice of ablative therapy. There are now abundant ablation modalities and adjunctive techniques which can be used to individualize ablation and maximize curative results. This article provides a patient-centered summary of approaches to HCC ablation in the context of patient performance, hepatic reserve, tumor phenotype and biology, intra- and extrahepatic anatomy, and ablation technology.

Locoregional treatments for hepatocellular carcinoma: Current evidence and future directions

Liver cancers are the second most frequent cause of global cancer-related mortality of which 90% are attributable to hepatocellular carcinoma (HCC). Despite the advent of screening programmes for patients with known risk factors, a substantial number of patients are ineligible for curative surgery at presentation with limited outcomes achievable with systemic chemotherapy/external radiotherapy. This has led to the advent of numerous minimally invasive options including but not limited to trans-arterial chemoembolization, radiofrequency/microwave ablation and more recently selective internal radiation therapy many of which are often the first-line treatment for select stages of HCC or serve as a conduit to liver transplant. The authors aim to provide a comprehensive overview of these various image guided minimally invasive therapies with a brief focus on the technical aspects accompanied by a critical analysis of the literature to assess the most up-to-date evidence from comparative systematic reviews and meta-analyses finishing with an assessment of novel combination regimens and future directions of travel.

Multibipolar Radiofrequency Ablation for the Treatment of Mass-Forming and Infiltrative Hepatocellular Carcinomas > 5 cm: Long-Term Results

AIMS AND BACKGROUND

Only few patients with cirrhosis and hepatocellular carcinoma (HCC) larger than 5 cm are amenable to resection or straight liver transplantation, and in such circumstances, multibipolar radiofrequency ablation (mbp-RFA) could be a reliable alternative. This study was aimed to assess the long-term outcome in patients treated with mbp-RFA for unresectable HCC > 5 cm.

METHODS

Eighty-three consecutive patients with cirrhosis (median age 70 years [37-93 years], 67 males, BCLC A/B/C: 54/21/8, 74 naive) with up to three HCCs, the largest > 5 cm in diameter (median: 6.2 cm, 5.1-9 cm, 22 infiltrative forms, 12 with segmental portal invasion of which 10 were infiltrative forms) were treated with mbp-RFA. Overall (OS) and recurrence-free (RFS) survival and their associated predictive factors were assessed.

RESULTS

Complete ablation was observed in 78/83 (94%) patients. Thirty-one side effects occurred, including 6 (7%) severe complications. After a median follow-up of 26.1 months (1-112 months), in naive patients the 3- and 5-year OS was 51% (38-62) and 24% (13-36), 63 and 30% for mass-forming and 25 and 6% for infiltrative form, respectively. Infiltrative form (HR: 2.5 [1.33-4.69], p = 0.004) was the only independent OS predictor. In naive patients with mass-forming and infiltrative form, the 3- and 5-year RFS were 47 and 17 and 18 and 18%, respectively. Alpha-fetoprotein (HR: 2.86 [1.32-6.21], p = 0.008), multinodular form (HR: 2.74 [1.4-5.38], p = 0.003) and infiltrative form (HR: 3.43 [1.67-7.01], p = 0.0007) were independent RFS predictors.

CONCLUSIONS

mbp-RFA offers good OS in inoperable patients with cirrhosis and large HCC, with acceptable safety profile. For infiltrative forms, although mbp-RFA leads to complete responses in more than 80% cases, few only remain tumor progression-free in long-term.

Percutaneous microwave ablation combined with simultaneous transarterial chemoembolization for hepatocellular carcinoma with macrovascular invasion or extrahepatic metastases

Objective

To evaluate the safety and efficacy of percutaneous microwave ablation (MWA) combined with simultaneous transarterial chemoembolization (TACE) in patients with hepatocellular carcinoma (HCC) patients with microvascular invasion (MVI) or extrahepatic metastases (EHM).

Methods

Between August 2012 and April 2017, 101 patients with MVI/EHM of HCC underwent percutaneous MWA combined with simultaneous TACE at our center. The clinical data were collected and analyzed for survival and prognostic factors.

Results

The mean follow-up time was 23.6 ± 14.7 months. One patient had grade 3 complications, and the median overall survival was 12.0 months (95% confidence interval 9.7–14.3). Multivariate analysis showed that Child-Pugh class, serum alpha-fetoprotein level, and Eastern Cooperative Oncology Group performance status were independent factors of survival.

Conclusion

Our results suggest that percutaneous MWA combined with simultaneous TACE is a safe and effective treatment for HCC with MVI/EHM.

Clinical outcome in elderly Chinese patients with primary hepatocellular carcinoma treated with percutaneous microwave coagulation therapy (PMCT): A Strobe-compliant observational study

Percutaneous microwave ablation therapy (PMCT) has been recommended for elderly hepatocellular carcinoma (HCC) patients who cannot tolerate surgery due to their age or presence of comorbidities. Few studies have investigated efficacy and treatment outcomes for PMCT treatment in these patients, especially in China, where patients are more often diagnosed and treated early in life. This study evaluated the safety and efficacy of ultrasound-guided PMCT in treatment-naive elderly HCC patients, and analyzed risk factors associated with poor treatment outcomes.The 65 HCC patients in this retrospective study were divided into 2 groups: <65 years old or ≥65 years old. Patients received PMCT every month until tumor was unobservable and were then followed for 1 month after ablation. The primary clinical endpoint was the rate of complete tumor ablation, and secondary endpoints were progression-free survival and overall survival.Patients ≥65 years old had significantly poorer performance status than younger patients, but similar rates of complete ablation. Multiple tumors and hypertension were associated with a significantly higher risk of death, while higher postoperative alanine aminotransferase levels were associated with a significantly lower risk of death. Patients with tumor sizes >5 to ≤ 10 cm were at a significantly higher risk for disease progression than patients with tumor sizes >1 to ≤ 3 cm. Complete ablation significantly lowered the risk of disease progression.PMCT is safe and effective for patients ≥65 years of age, achieving total ablation in more than 90% of patients. Age and comorbidities did not affect clinical outcome.

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.

Porous PLGA microspheres with recruited ions and doxorubicin for triple-combination therapy of larger hepatocellular carcinoma

Easy recurrence of large hepatocellular carcinoma (HCC) after microwave (MW) ablation or transarterial chemoembolization (TACE) is still very challenging. In this study, porous polylactide-co-glycolide (PLGA) microspheres as a MW-susceptible TACE agent (P-PLGA@DN microspheres) for triple-combination therapy of large HCC were developed via the double emulsion technique using recruited ions (Na⁺ and Cl^-) and doxorubicin hydrochloride (DOX·HCl) to enhance the efficiency of MW absorption and DOX chemotherapy after tumor embolization. The as-prepared microspheres with superior MW-heat conversion can enlarge the ablation area by >53% in a simulated physiological environment. The in vivo efficiencies of chemotherapy and thermal therapy for ICR mice bearing H22 tumor cells under the assistance of P-PLGA@DN microspheres reach to 100%. In the experiments of synergistic therapy combining TACE with MW ablation on VX2 tumor-bearing New Zealand white rabbits, PLGA@DN microspheres can increase ablation area by more than 50%, enhancing the necrosis of tumor cells and effectively inhibiting tumor growth. These results demonstrate that the potential application of P-PLGA@DN microspheres in synergistic therapy of large HCC can be envisioned.

Microwave ablation combined with attenuated Salmonella typhimurium for treating hepatocellular carcinoma in a rat model

We aim to investigate the safety and efficacy of microwave ablation (MWA) combined with attenuated Salmonella typhimurium strain VNP20009 in treating hepatocellular carcinoma. Portions of tumor tissues were orthotopically implanted in the livers of 40 male rats weighed 150~200 g to establish tumor models. Three weeks later, the rats were randomly divided into four groups: (A) MWA plus VNP20009 group; (B) MWA group; (C) VNP20009 group; and (D) control group. Incomplete MWA was performed (20~30 W, 1~2 min) after the hepatic carcinoma was properly exposed. VNP20009 (about 1×10⁷ cfu) was directly injected into the tumor immediately. MRI scans were performed to assess the tumor responses 7 and 14 days later, respectively. Micro CT was used to observe the lung metastases. After the animals were sacrificed or died, the tumors were cut off for the purpose of pathological and immunohistochemical analyses. The results showed that the mean tumor volumes of MWA plus VNP20009 group on the 7th and 14th day post treatment were obviously smaller than those of other groups (P < 0.05). Lung metastases rates were 20%, 60%, 30% and 100% in MWA plus VNP20009 group, MWA group, VNP20009 group and control group, respectively. The median survival of the rats in MWA plus VNP20009 group was distinctly longer than those in other groups (P < 0.05). In summary, MWA combined with VNP20009 produced better effects than MWA or VNP20009 alone in treating hepatic carcinoma. This strategy might have potential ability to decrease lung metastases and prolong the overall survival.

Interventional Oncology in Hepatocellular Carcinoma: Progress Through Innovation

The clinical management of hepatocellular carcinoma has evolved greatly in the last decade mostly through recent technical innovations. In particular, the application of cutting-edge image guidance has led to minimally invasive solutions for complex clinical problems and rapid advances in the field of interventional oncology. Many image-guided therapies, such as transarterial chemoembolization and radiofrequency ablation, have meanwhile been fully integrated into interdisciplinary clinical practice, whereas others are currently being investigated. This review summarizes and evaluates the most relevant completed and ongoing clinical trials, provides a synopsis of recent innovations in the field of intraprocedural imaging and tumor response assessment, and offers an outlook on new technologies, such as radiopaque embolic materials. In addition, combination therapies consisting of locoregional therapies and systemic molecular targeted agents (e.g., sorafenib) remain of major interest to the field and are also discussed. Finally, we address the many substantial advances in immune response pathways that have been related to the systemic effects of locoregional therapies. Knowledge of these new developments is crucial as they continue to shape the future of cancer treatment, further establishing interventional oncology along with surgical, medical, and radiation oncology as the fourth pillar of cancer care.

Therapeutic efficacy of novel microwave-sensitized mPEG-PLGA@ZrO2@(DOX + ILS) drug-loaded microspheres in rabbit VX2 liver tumours

The use of nanomaterials as drug delivery systems shows good effects in treating tumors. However, the effective dose of drugs targeted to tumor tissues is very low because of the effect of the reticuloendothelial system (RES) in removing such foreign substances. In order to eliminate the RES effect, we developed mPEG-PLGA@ZrO₂@(DOX + ILS) (mPEG-PLGA@ZrO₂@[DOX + ILS]) drug-loaded microspheres. These microwave (MW)-sensitized microspheres directly embolized the blood-supply vessels of tumors to induce tumor ischemia and hypoxia, as well as to aggregate drugs within tumor tissues in a long-lasting manner. Additionally, combination with MW ablation can triple the effects for the inhibition of tumor growth. The MW sensitive ionic liquid (ILS) in microspheres can rapidly produce a high temperature in a MW field on the basis of MW sensitization, thus accelerating the degradation of microspheres to release DOX-loaded ZrO₂ into the lesions to kill tumors. Microspheres can also prolong the pharmacological time and effect of drugs through the enhanced permeability and retention (EPR) effect of nanocarriers, as well as the sustained release of nanomaterials. Studies performed in vivo revealed that mPEG-PLGA@ZrO₂@(DOX + ILS) showed good biosafety. We undertook sensitized microsphere embolism therapy using novel mPEG-PLGA@ZrO₂@(DOX + ILS) microspheres in a rabbit VX₂ liver tumor model. Three, 6 and 9 d after treatment, computed tomography indicated no significant change in tumor size, and diffusion weighted imaging showed a marked decrease of residual tumor tissues. With the multiple functions of inducing embolisms, sensitization, and the sustained release of chemotherapeutics, novel mPEG-PLGA@ZrO₂@(DOX + ILS) microspheres can achieve good therapeutic efficacy, in combination with MW ablation and chemotherapy, while embolizing the blood vessels of arterial tumors.

Transarterial Chemoembolization Combined with Either Radiofrequency or Microwave Ablation in Management of Hepatocellular Carcinoma

Introduction: Local ablative therapy and trans arterial chemoembolization (TACE) are applied to ablate non resectable hepatocellular carcinoma (HCC). Combination of both techniques has proven to be more effective. We aimed to study combined ablation techniques and assess survival benefit comparing TACE with radiofrequency (RFA) versus TACE with microwave (MWA) techniques. Methods: We retrospectively studied 22 patients who were ablated using TACE-RFA and 45 with TACE-MWA. All were classified as Child A-B and lesions did not exceed 5 cm in diameter. TACE was followed within two weeks by either RFA or MWA. We recorded total and partial ablation rates and complication rates. Survival analysis was then performed. Results: TACE-MWA showed a higher tendency to provide complete response rates than TACE-RFA (P 0.06). This was particularly evident with lesions sized 3-5 cm (P 0.01). Rates of complications showed no significant difference between the groups. Overall median survival was 27 months. The overall actuarial probability of survival was 80.1% at 1 year, 55% at 2 years, and 36.3% at 3 years. The recurrence free survival at 1 year, 2years and 3 years for the TACE-RFA group was 70%, 42% and 14% respectively and for TACE-MWA group 81.2%, 65.1% and 65.1% without any significant difference (P 0.1). In relation to the size of focal lesions, no statistically significant difference in the survival rates was detected between the groups. Conclusion: TACE-MWA led to better response rates than TACE-RFA with tumors 3-5 cm, with no difference in survival rates.

Status and advancement of microwave ablation in China

Tumour ablation is defined as the direct application of chemical or thermal therapy to eradicate or substantially destroy a tumour. Currently, minimally invasive ablation techniques are available for the local destruction of focal tumours in multiple organ sites. Microwave ablation (MWA) is premised on the biological response of solid tumours to tissue hyperthermia, and it is a relatively low-risk procedure. Due to several advantages of MWA, including higher thermal efficiency, higher capability for coagulating blood vessels, faster ablation time and the simultaneous application of multiple antennae, MWA could be a promising minimally invasive ablation technique for the treatment of solid tumours. Therefore, the use of MWA has developed rapidly in China during the last decade. Many successful studies have been performed, and widespread use has been achieved for multiple types of tumours in China, especially for liver cancer. This review will describe the state-of-the-art of MWA in China, including the development of MWA equipment and its application in the treatment of multiple types of tumours.

Polyvinyl alcohol terminal chemoembolization for hepatocellular carcinoma with hepatic arteriovenous shunts: Safety, efficacy, and prognostic factors

PURPOSE

To evaluate the safety and efficacy of polyvinyl alcohol (PVA) terminal chemoembolization and to identify the prognostic factors associated with survival in hepatocellular carcinoma (HCC) patients with hepatic arteriovenous shunts (HAVS).

MATERIALS AND METHODS

Of 133 patients' managements were retrospectively analyzed. HAVS was classified into three types: slow-flow, intermediate-flow and high-flow. The size of the PVA used was determined following the scheme: slow-flow HAVS: 300-500μm PVA; intermediate-flow HAVS: 500-710μm PVA; high-flow HAVS: 710-1000μm PVA. The HCCs with slow-flow and intermediate-flow HAVS were embolized by PVA plus chemotherapeutic agents lipiodol emulsion, while the high-flow HAVS were treated by PVA with chemotherapeutic agents. Survival curves were calculated by Kaplan-Meier method and compared by log-rank test. The influence of possible prognostic factors on survival were analyzed by multivariate Cox proportional-hazards method.

RESULTS

The median overall survival (OS) of 133 patients was 9.1 months. The median OS of the slow-flow type, intermediate-flow type and high-flow type patients were 10.8, 9.1 and 7.3 months, respectively. There was no statistically significant difference among different HAVS types (P=0.239). The 30-day mortality was 3.8%. Cox multivariate survival analysis revealed that initial preoperative AFP value≥400ng/ml (HR=2.105, P=0.006) was an independent risk factor. While multiple embolization (HR=0.482, P=0.011), tumor remission (HR=0.431, P=0.041) and multimodality therapy (HR=0.416, P=0.004) were independent protection factors.

CONCLUSION

It is safe and effective for HCCs with HAVS treated by terminal chemoembolization therapy with PVA plus chemotherapeutic agents lipiodol emulsion (or PVA plus chemotherapeutic agents). The HCCs with HAVS achieves good prognosis with multiple embolization, tumor remission and multimodality therapy, while achieves poor prognosis with inital preoperative high AFP value (≥400ng/ml).

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

BACKGROUND

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

AIM OF THIS WORK

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

PATIENTS AND METHODS

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

RESULTS

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

CONCLUSION

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

Advances in local ablation of malignant liver lesions

Local ablation of liver tumors matured during the recent years and is now proven to be an effective tool in the treatment of malignant liver lesions. Advances focus on the improvement of local tumor control by technical innovations, individual selection of imaging modalities, more accurate needle placement and the free choice of access to the liver. Considering data found in the current literature for conventional local ablative treatment strategies, virtually no single technology is able to demonstrate an unequivocal superiority. Hints at better performance of microwave compared to radiofrequency ablation regarding local tumor control, duration of the procedure and potentially achievable larger size of ablation areas favour the comparably more recent treatment modality; image fusion enables more patients to undergo ultrasound guided local ablation; magnetic resonance guidance may improve primary success rates in selected patients; navigation and robotics accelerate the needle placement and reduces deviation of needle positions; laparoscopic thermoablation results in larger ablation areas and therefore hypothetically better local tumor control under acceptable complication rates, but seems to be limited to patients with no, mild or moderate adhesions following earlier surgical procedures. Apart from that, most techniques appear technically feasible, albeit demanding. Which technology will in the long run become accepted, is subject to future work.

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.