Liver resection or combined chemoembolization and radiofrequency ablation improve survival in patients with hepatocellular carcinoma

Ablative and non-surgical therapies for early and very early hepatocellular carcinoma: a systematic review and network meta-analysis

Background

A wide range of ablative and non-surgical therapies are available for treating small hepatocellular carcinoma in patients with very early or early-stage disease and preserved liver function.

Objective

To review and compare the effectiveness of all current ablative and non-surgical therapies for patients with small hepatocellular carcinoma (≤ 3 cm).

Design

Systematic review and network meta-analysis.

Data sources

Nine databases (March 2021), two trial registries (April 2021) and reference lists of relevant systematic reviews.

Review methods

Eligible studies were randomised controlled trials of ablative and non-surgical therapies, versus any comparator, for small hepatocellular carcinoma. Randomised controlled trials were quality assessed using the Cochrane Risk of Bias 2 tool and mapped. The comparative effectiveness of therapies was assessed using network meta-analysis. A threshold analysis was used to identify which comparisons were sensitive to potential changes in the evidence. Where comparisons based on randomised controlled trial evidence were not robust or no randomised controlled trials were identified, a targeted systematic review of non-randomised, prospective comparative studies provided additional data for repeat network meta-analysis and threshold analysis. The feasibility of undertaking economic modelling was explored. A workshop with patients and clinicians was held to discuss the findings and identify key priorities for future research.

Results

Thirty-seven randomised controlled trials (with over 3700 relevant patients) were included in the review. The majority were conducted in China or Japan and most had a high risk of bias or some risk of bias concerns. The results of the network meta-analysis were uncertain for most comparisons. There was evidence that percutaneous ethanol injection is inferior to radiofrequency ablation for overall survival (hazard ratio 1.45, 95% credible interval 1.16 to 1.82), progression-free survival (hazard ratio 1.36, 95% credible interval 1.11 to 1.67), overall recurrence (relative risk 1.19, 95% credible interval 1.02 to 1.39) and local recurrence (relative risk 1.80, 95% credible interval 1.19 to 2.71). Percutaneous acid injection was also inferior to radiofrequency ablation for progression-free survival (hazard ratio 1.63, 95% credible interval 1.05 to 2.51). Threshold analysis showed that further evidence could plausibly change the result for some comparisons. Fourteen eligible non-randomised studies were identified (n ≥ 2316); twelve had a high risk of bias so were not included in updated network meta-analyses. Additional non-randomised data, made available by a clinical advisor, were also included (n = 303). There remained a high level of uncertainty in treatment rankings after the network meta-analyses were updated. However, the updated analyses suggested that microwave ablation and resection are superior to percutaneous ethanol injection and percutaneous acid injection for some outcomes. Further research on stereotactic ablative radiotherapy was recommended at the workshop, although it is only appropriate for certain patient subgroups, limiting opportunities for adequately powered trials.

Limitations

Many studies were small and of poor quality. No comparative studies were found for some therapies.

Conclusions

The existing evidence base has limitations; the uptake of specific ablative therapies in the United Kingdom appears to be based more on technological advancements and ease of use than strong evidence of clinical effectiveness. However, there is evidence that percutaneous ethanol injection and percutaneous acid injection are inferior to radiofrequency ablation, microwave ablation and resection.

Study registration

PROSPERO CRD42020221357.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment (HTA) programme (NIHR award ref: NIHR131224) and is published in full in Health Technology Assessment; Vol. 27, No. 29. See the NIHR Funding and Awards website for further award information.

Liver targeted therapies for hepatocellular carcinoma prior to transplant: contemporary management strategies

Hepatocellular carcinoma (HCC) is an aggressive neoplastic disease that has been rapidly increasing in incidence. It usually occurs in the background of liver disease, and cirrhosis. Definitive therapy requires surgical resection. However, in majority of cases surgical resection is not tolerated, especially in the presence of portal hypertension and cirrhosis. Orthotopic liver transplant (OLT) in well selected candidates has been accepted as a viable option. Due to a relative scarcity of donors compared to the number of listed recipients, long waiting times are anticipated. To prevent patients with HCC from dropping out from the transplant list due to progression of their disease, most centers utilize loco-regional therapies. These loco-regional therapies(LRT) include minimally invasive treatments like percutaneous thermal ablation, trans-arterial chemoembolization, trans-arterial radio-embolization or a combination thereof. The type of therapy or combination used is determined by the size and location of the HCC and Barcelona Clinic Liver Cancer (BCLC) classification. The data regarding the efficacy of LRT in reducing post-transplant recurrence or disease-free survival is limited. This article reviews the available therapies, their strengths, limitations, and current use in the management of patients with hepatocellular carcinoma awaiting transplant.

Loco-regional treatment of HCC: current status

Hepatocellular carcinoma (HCC) represents one of the few cancers for which locoregional treatments are recognised as being able to cure and/or prolong survival and are included in international guidelines. This is due to the unique nature of HCC, in most cases occurring in patients with underlying virus- or alcohol-related cirrhosis. The treatment choice in patients with HCC is therefore driven not only by tumour staging, as in the great majority of cancers, but also by careful evaluation of liver function and physical status. Another specific feature of HCC is that it is the only tumour that can be cured by organ transplantation, with the aim of treating both the cancer and underlying liver disease. These characteristics configure a complex scenario and prompt the need for close cooperation among interventional oncologists, surgeons, hepatologists, and anaesthesiologists. In patients with limited hepatic disease, preserved hepatic function and good performance status, categorised as very early and early-stage HCC according to the Barcelona Clinic Liver Cancer (BCLC) classification, image-guided tumour ablation is included among the curative treatments. More than half of patients with HCC are, however, diagnosed late, despite the widespread implementation of surveillance programmes, when curative treatments cannot be applied. For patients presenting with multinodular HCC and relatively preserved liver function, absence of cancer-related symptoms, and no evidence of vascular invasion or extrahepatic spread transcatheter arterial chemoembolisation (TACE) is the current standard of care. Although anti-tumour activity and promising survival results has been reported in cohorts of patients with advanced HCC treated with radio-embolisation, systemic treatment with the multi-kinase inhibitor, sorafenib, is still recommended for patients at this stage. In this article, current treatment strategies for HCC according to tumour stage are discussed, underlining the latest advances in the literature and technical developments.

Radiofrequency ablation combined with transarterial chemoembolization versus hepatectomy for patients with hepatocellular carcinoma within Milan criteria: a retrospective case-control study

PROPOSAL

To compare the effectiveness of TACE + RFA with hepatectomy in patients with HCC within Milan criteria.

METHODS

It is a retrospective matched case-control study from January 2006 to December 2010 in a tertiary cancer center. 74 patients with HCC within Milan criteria initially treated with TACE + RFA were identified and compared with 148 matched controls selected from a pool of 782 patients who received hepatectomy. Patients were matched with respect to age, gender, tumor size and number, AFP and liver function test.

RESULTS

The 1, 3, and 5 years overall survival (OS) was 94.6, 75.1 and 55.3%, respectively, in the combination group, and 91.2, 64.4, and 47.7%, respectively, in the hepatectomy group (P = 0.488). The 1, 3, and 5 years disease-free survival (DFS) in the combination group was 87.8, 48.3, and 33.5%, respectively, and 68.9, 49.2, and 40.9%, respectively, in the hepatectomy group (P = 0.619). In subgroups analyses according to the tumor size and number, no significant difference was identified in either OS or DFS for patients with single tumor smaller than 3.0 cm, 3.0-5.0 cm, and multiple tumors. Multivariate analysis showed that tumor size, ALT, and CLIP score were significant prognostic factors for OS, and ALT and Child-Pugh class were significant prognostic factors for DFS.

CONCLUSION

TACE + RFA is safe and as effective as hepatectomy for patients with HCC within Milan criteria.

A Recent Advance in Image-Guided Locoregional Therapy for Hepatocellular Carcinoma

BACKGROUND

Hepatocellular carcinoma (HCC) is the fifth most common cancer worldwide and the third most common cause of cancer-related deaths. Hepatic resection and liver transplantation are considered to be the preferred treatment for HCC. However, as novel therapeutic options such as image-guided locoregional therapies have emerged and been refined, the manner in which HCC is treated has changed dramatically compared with what it was considered just 2 decades earlier.

SUMMARY

This study reviews the current results of various image-guided locoregional therapies for treating HCC, especially focusing on thermal ablative and transarterial techniques.

KEY MESSAGE

Advances in image-guided locoregional therapies, including local ablative therapy and transarterial therapy, have led to a major breakthrough in the management of HCC. Both survival rates and cure rates of patients with HCC have improved markedly since the introduction of these techniques.

PRACTICAL IMPLICATIONS

Radiofrequency ablation is currently considered as an alternative to surgical resection for patients with early-stage HCC. A newer technique of ablation such as microwave ablation is increasingly being used, especially for large HCC. Transarterial chemoembolization has become a standard care for asymptomatic patients with multinodular tumors in intermediate-stage disease, and transarterial radioembolization has become the method of choice in HCC cases with portal vein thrombosis. Moreover, combination treatment modalities, such as thermal-based ablation combined with transarterial chemoembolization or ¹²⁵I seed implant brachytherapy, may further broaden their clinical indications for HCC. Moreover, use of localized radiation in combination with thermal ablation has been reported to improve tumor control and long-term survival.

New treatment modalities for hepatocellular cancer

Heptatocellular (HCC) is a rapidly progressive fatal malignancy often presenting at an advanced stage at the time of initial diagnosis. Loco-regional therapies for early-stage HCC including surgical options (surgical resection and liver transplant) and percutaneous ablations could be potentially curative. Recent technological advances in percutaneous image-guided ablations have provided clinicians with a range of options which have proven to be equal to or better than surgical resection. For intermediate- and advanced-stage HCC, palliative therapies are available which significantly increase overall and progression-free survival. These palliative therapies include intra-arterial chemo- or radioembolization as monotherapy or in combination with percutaneous ablation or antiangiogenic drugs. Availability of a multitude of treatment options for various stages of HCC as well as conflicting data comparing their safety and efficacy presented in the several randomized controlled trials poses a significant challenge to hepatologists, surgeons, and interventional radiologists in selecting optimal therapy for their patients. The aim of this article is to review and discuss currently available therapies at each stage of HCC along with presenting clinical data published in most recent and relevant randomized controlled trials.

Hepatic resection versus transarterial chemoembolization for the initial treatment of hepatocellular carcinoma: A systematic review and meta-analysis

BACKGROUND & AIMS

According to the Barcelona Clinic Liver Cancer (BCLC) staging system, hepatic resection and transarterial chemoembolization (TACE) should be recommended in patients with hepatocellular carcinoma (HCC) within and beyond the BCLC stage A, respectively. We conducted a systematic review and meta-analysis to compare the overall survival between HCC patients undergoing hepatic resection and TACE.

METHODS

PubMed, EMBASE, and Cochrane library databases were searched. All relevant studies were considered, if they reported the survival data in HCC patients undergoing hepatic resection and TACE. Hazard ratios (HRs) with 95% confidence intervals (CIs) were calculated for the comparison of cumulative overall survival. Odds ratios (ORs) with 95%CIs were calculated for the comparison of 1-, 3-, and 5-year survival rates. Subgroup analyses were performed according to the BCLC stages and portal vein tumor thrombus (PVTT). Sensitivity analyses were performed in moderate- and high-quality studies and in studies published after 2005.

RESULTS

Fifty of 2029 retrieved papers were included. One, 15, and 34 studies were of high-, moderate-, and low-quality, respectively. The overall meta-analysis demonstrated a statistically significantly higher overall survival in hepatic resection group than in TACE group (HR=0.60, 95%CI=0.55-0.66). Additionally, 1-, 3-, and 5-year survival rates were statistically significantly higher in hepatic resection group than in TACE group (OR=1.82, 95%CI=1.56-2.14; OR=3.09, 95%CI=2.60-3.67; OR=3.48, 95%CI=2.83-4.27). The subgroup meta-analyses confirmed the statistical significance in HCC within the BCLC stage A (HR=0.72, 95%CI=0.64-0.80), in HCC beyond the BCLC stage A (HR=0.60, 95%CI=0.51-0.69), in HCC within the BCLC stage B alone (HR=0.48, 95%CI=0.25-0.90), and in HCC with PVTT (HR=0.78, 95%CI=0.68-0.91). The statistical significance was also confirmed by sensitivity analyses in moderate- and high-quality studies (HR=0.62, 95%CI=0.53-0.71) and in studies published after 2005 (HR=0.59, 95%CI=0.53-0.66).

CONCLUSIONS

Based on a systematic review and meta-analysis, hepatic resection may be considered in HCC beyond the BCLC stage A. However, given the limitations of study quality, more well-designed randomized controlled trials should be warranted to confirm these findings.

High-powered microwave ablation of larger hepatocellular carcinoma: evaluation of recurrence rate and factors related to recurrence

AIM

To evaluate the safety and efficacy of high-powered (80-100 W) percutaneous microwave ablation (MWA) at a frequency of 2450±10 MHz for treating larger hepatocellular carcinoma (HCC) and to predict the risk factors of local recurrence after high-powered MWA.

MATERIALS AND METHODS

The study was approved by the Institutional Review Board, and informed consent was waived because of the retrospective study design. Forty-five patients with a total of 60 lesions received high-power (80-100 W) MWA at a frequency of 2450±10 MHz through a percutaneous approach that was guided by ultrasound. Of the 60 lesions with a maximum tumour measuring 3-8 cm, 46 lesions were 3-5 cm and 14 were 5-8 cm. The complete ablation rates, local recurrence rates, complications, and short-term survival were analysed. Ten possible risk factors for local recurrence were analysed.

RESULTS

The complete ablation rates were 82.61% for the first ablation and 100% for the second ablation for 3-5 cm lesions. The complete ablation rates were 64.29% (82.61% versus 64.29%, p=0.037) for the first ablation and 85.71% (100% versus 85.71%, p=0.055) for the second ablation for 5-8 cm lesions. Local recurrence was observed in 11 out of the 45 (24.44%) successfully treated patients. The 1-year and 2-year survival rates were 95.56% (43/45) and 86.67% (39/45), respectively. No procedure-related mortality was observed and no major bleeding, liver rupture, or liver abscesses occurred. Univariate analysis showed that a positive correlation existed between the number of lesions (p=0.022), proximity to the risk area (p=0.001), pre-ablation alpha-fetoprotein (AFP) levels (p=0.025), hepatitis B virus (HBV)-DNA replication (p=0.027) and local recurrence. Multivariate analysis identified HBV-DNA (p=0.031) and proximity to the risk area (p=0.039) as the independent prognosis factors causing postoperative HCC local recurrence.

CONCLUSION

High-powered MWA of larger hepatocellular carcinomas appears to be a safe and effective treatment. HBV-DNA and proximity to the risk area appear to be independent predictors of local tumour recurrence.

Transarterial chemoembolization and bland embolization for hepatocellular carcinoma

Transarterial chemoembolization (TACE) is the first line treatment for patients with intermediate stage hepatocellular carcinoma but is also increasingly being used for patients on the transplant waiting list to prevent further tumor growth. Despite its widespread use, TACE remains an unstandardized procedure, with variation in type and size of embolizing particles, type and dose of chemotherapy and interval between therapies. Existing evidence from randomized controlled trials suggest that bland transarterial embolization (TAE) has the same efficacy with TACE. In the current article, we review the use of TACE and TAE for hepatocellular carcinoma and we focus on the evidence for their use.

Radiofrequency ablation combined with transarterial chemoembolization for intermediate hepatocellular carcinoma

AIM

Radiofrequency ablation therapy (RFA) combined with transarterial chemoembolization (TACE) (combination therapy) is effective for early-stage hepatocellular carcinoma (HCC). The aim of this study was to compare the long-term effects of combination therapy with supportive care alone for intermediate HCC.

METHODS

The study included 58 patients with intermediate HCC who received combination therapy (n = 34) or supportive care alone (n = 24). The inclusion criteria were a single nodule of more than 50 mm in diameter or two to three nodules, each measuring more than 30 mm in diameter, or more than three nodules, no vascular invasion and no extrahepatic metastasis.

RESULTS

The overall survival rates at 1, 2, 3 and 5 years of the combination therapy group (91%, 65%, 53% and 27%, respectively) were significantly better (P < 0.0001) than those of the supportive care group (42%, 8%, 8% and 0%, respectively). Multivariate analysis identified treatment modality (combination therapy vs supportive care alone: P < 0.0001, risk ratio [RR] = 4.290 [95% confidence interval [CI] = 2.157-8.529]) and serum α-fetoprotein (P = 0.017, RR = 2.318 [95% CI = 1.166-4.610]) as independent and significant factors of overall survival.

CONCLUSION

The combination of TACE and RFA is a safe and effective therapy in patients with intermediate HCC.

Radiofrequency ablation combined with transcatheter arterial chemoembolization for the treatment of single hepatocellular carcinoma of 2 to 5 cm in diameter: comparison with surgical resection

OBJECTIVE

To compare the effectiveness of radiofrequency ablation (RFA) combined with transcatheter arterial chemoembolization (TACE) with surgical resection in patients with a single hepatocellular carcinoma (HCC) ranging from 2 to 5 cm.

MATERIALS AND METHODS

The study participants were enrolled over a period of 29 months and were comprised of 37 patients in a combined therapy group and 47 patients in a surgical resection group. RFA was performed the day after TACE, and surgical resection was performed by open laparotomy. The two groups were compared with respect to the length of hospital stay, rates of major complication, and rates of recurrence-free and overall survival.

RESULTS

Major complications occurred more frequently in the surgical resection group (14.9%) than in the combined therapy group (2.7%). However, there was no statistical significance (p = 0.059). The rates of recurrence-free survival at 1, 2, 3 and 4 years were similar between the combined therapy group (89.2%, 75.2%, 69.4% and 69.4%, respectively) and the surgical resection group (81.8%, 68.5%, 68.5% and 65%, respectively) (p = 0.7962, log-rank test). The overall survival rates at 1, 2, 3 and 4 years were also similar between groups (97.3%, 86.5%, 78.4% and 78.4%, respectively, in the combined therapy group, and 95.7%, 89.4%, 84.3% and 80.3%, respectively, in the surgical resection group) (p = 0.6321, log-rank test).

CONCLUSION

When compared with surgical resection for the treatment of a single HCC ranging from 2 to 5 cm, RFA combined with TACE shows similar results in terms of recurrence-free and overall survival rates.

Image-guided ablation for hepatocellular carcinoma

Image-guided ablation is accepted as the best therapeutic choice for patients with early-stage hepatocellular carcinoma (HCC) when surgical options-including resection and transplantation-are precluded. The term image-guided tumor ablation is defined as the direct application of chemical substances or sources of energy to a focal tumor in an attempt to achieve eradication or substantial tumor destruction. Over the past 25 years, several methods for local tumor destruction have been developed and clinically tested. Radiofrequency ablation (RFA) has shown superior anticancer effect and greater survival benefit with respect to the seminal percutaneous technique, ethanol injection, in meta-analyses of randomized controlled trials, and is currently established as the standard ablative modality. Nevertheless, novel thermal and nonthermal techniques for tumor ablation-including microwave ablation and irreversible electroporation-seem to have potential to improve the efficacy of RFA and are currently undergoing clinical investigation.

Effectiveness of impedance monitoring during radiofrequency ablation for predicting popping

AIM: To retrospectively evaluate the effectiveness of impedance monitoring for predicting popping during radiofrequency ablation (RFA) using internally cooled electrodes.

METHODS: We reviewed 140 patients (94 males, 46 females; age range 73.0 ± 11.1 year) who underwent RFA between February 2006 and November 2008 with a modified protocol using a limited power delivery rather than a conventional one to avoid popping. All the patients provided their written informed consent, and the study was approved by the institutional review board. Intraprocedural impedances were measured for the study subjects, and the tumors were classified into three types according to the characteristics of their impedance curves: increasing, flat, or decreasing. The tumors were further sorted into seven subtypes (A-G) depending on the curvature of the impedance curve’s increase or decrease. Relative popping rates were determined for the three types and seven subtypes. A chi-square test was performed to estimate statistical significance.

RESULTS: A total of 148 nodules treated by RFA were analyzed. The study samples included 132 nodules of hepatocellular carcinoma, 14 nodules of metastatic liver cancer, and two nodules of intrahepatic cholangiocarcinoma. The numbers of nodules with each impedance curve type were as follows: 37 increasing-type nodules, 43 flat-type nodules, and 68 decreasing-type nodules. Popping occurrence rates were 24.3%, 46.5% and 64.7%, respectively. Flat-type nodules exhibited a significantly higher rate of popping compared to increasing-type nodules (P = 0.039). Decreasing-type nodules exhibited a significantly higher rate of popping compared to increasing-type nodules (P < 0.0001). Notably, nodules that showed a sharp decrease in impedance in the latter ablation period (subtype E) exhibited a significantly higher rate of popping compared to other subtypes.

CONCLUSION: Intraprocedural impedance monitoring can be a useful tool to predict the occurrence of popping during liver tumor RFA performed with internally cooled electrodes.

Transarterial therapies for hepatocellular carcinoma

Transarterial therapies for hepatocellular carcinoma are considered palliative and should be offered to patients with intermediate stage multinodular disease without extra-hepatic metastases and sufficient liver reserve. They mainly include transarterial chemoembolisation and transarterial embolisation. While transarterial therapy is now a validated treatment for unresectable HCC, there is still a lack of conclusive evidence as to which type and schedule is the optimal procedure. This is mainly due to the lack of standardisation. Combining local therapies or intra-arterial therapies with systemic targeted therapies might prove more effective strategies in the future. In the present article, we review transarterial therapies and critically comment on their indications, complications and outcomes.

Modelling survival in hepatocellular carcinoma

OBJECTIVES

To identify the pattern of the risk of death over long-term in unresectable hepatocellular carcinoma by determining the appropriate distribution to extrapolate overall survival and to assess the role of the Weibull distribution as the standard survival model in oncology.

RESEARCH DESIGN AND METHODS

To select the appropriate distribution, three types of data sources have been analysed. Patient level data from two randomized controlled trials and published Kaplan-Meier curves from a systematic literature review provided short term follow-up data. They were supplemented with patient level data, with long-term follow-up from the Cancer Institute New South Wales, Australia. Published Kaplan-Meier curves were read in and a time-to-event dataset was created. Distributions were fitted to the data from the different sources separately. Their fit was assessed visually and compared using statistical criteria based on log-likelihood, the Akaike information criterion (AIC), and the Bayesian information criterion (BIC).

RESULTS

Based on both published and patient-level, and both short- and long-term follow-up data, the Weibull distribution, used very often in cost-effectiveness models in oncology, does not seem to offer a good fit in hepatocellular carcinoma among the different survival models. The best fitting distribution appears to be the lognormal, with loglogistic as the second-best fitting function. Results were consistent between the different sources of data.

CONCLUSIONS

In unresectable hepatocellular carcinoma, the Weibull model, which is often treated at the gold standard, does not appear to be appropriate based on different sources of data (two clinical trials, a retrospective database and published Kaplan-Meier curves). Lognormal distribution seems to be the most appropriate distribution for extrapolating overall survival.

Thermal ablation of unresectable liver tumors: factors associated with partial ablation and the impact on long-term survival

Background

Thermal ablation procedures, including radiofrequency ablation (RFA) or laser-induced interstitial thermotherapy (LITT), are now well established in the treatment of malignant unresectable hepatic tumors. But the impact of partial ablation (PA) on long-term survival following computed tomography (CT)-guided radiofrequency ablation and laser- induced interstitial thermotherapy of unresectable malignant liver lesions and the associated risk factors of PA remain partially unknown.

Material/Methods

This study included 254 liver tumors in 91 consecutive patients (66 men and 25 women; age 60.9±10.4 years; mean tumor size 25±14 mm [range 5–70 mm]) who underwent thermal ablation (RFA or LITT) between January 2000 and December 2007. Mean follow-up period was 21.1 month (range 1–69 months). Survival rate and local progression-free survival (PFS) were calculated for patients with complete ablation (CA) vs. patients with partial ablation (PA) to assess the impact on long-term survival.

Results

Median survival after CA was 47 months compared to 25 months after PA (P=0.04). The corresponding 5-year survival rates were 44% vs. 20%. Median PFS for CA was 11 months compared to 7 months for PA (P=0.118). The sole statistically significant risk factor for PA was tumor size (>30 mm; P=0.0003). Sustained complete ablation was achieved in 71% of lesions ≤30 mm vs. 47% of lesions >30 mm.

Conclusions

We conclude that achievement of complete ablation is a highly important predictor of long-term survival and that tumor size is by far the most important predictor of the likelihood of achieving complete ablation.

Local-regional treatment of hepatocellular carcinoma

Local-regional treatments play a key role in the management of hepatocellular carcinoma (HCC). Image-guided tumor ablation is recommended in patients with early-stage HCC when surgical options are precluded and can replace resection in selected patients. Radiofrequency (RF) ablation has shown superior anticancer effects and greater survival benefit with respect to the seminal percutaneous technique, ethanol injection, in meta-analyses of randomized controlled trials and is currently established as the standard method for local tumor treatment. Novel thermal and nonthermal techniques for tumor ablation, including microwave ablation and irreversible electroporation, seem to have potential to overcome the limitations of RF ablation and warrant further clinical investigation. Transcatheter arterial chemoembolization (TACE) is the standard of care for patients with asymptomatic noninvasive multinodular tumors in intermediate-stage disease. Embolic microspheres that have the ability to release a drug in a controlled and sustained fashion have been shown to substantially increase the safety and efficacy of TACE in comparison to conventional ethiodized oil-based regimens. The available data for radioembolization with yttrium 90 suggest that this is a potential new option for patients with HCC, and future studies should be devoted to assessments of the role of radioembolization in the treatment algorithm for HCC.

Systematic review and meta-analysis of survival and disease recurrence after radiofrequency ablation for hepatocellular carcinoma

BACKGROUND

Despite being one of the commonest causes of cancer-related death around the world, only 20 per cent of hepatocellular carcinomas (HCCs) are amenable to curative treatment (surgical resection or liver transplantation). Radiofrequency ablation (RFA) has emerged as a popular therapy for unresectable HCC. There is evidence that the disparity in survival after curative RFA and surgery for HCC, especially tumours smaller than 3 cm in diameter, is narrowing. This review examined the survival and disease recurrence rates after RFA for HCC over the past decade.

METHODS

A systematic review was conducted using MEDLINE, Embase, Cochrane Central Register of Controlled Trials, Cochrane Database of Systematic Reviews, Cochrane Methodology Register and the Database of Abstracts of Reviews of Effects from January 2000 until November 2010. Papers reporting on patients with HCC who were treated with RFA, either in comparison or in combination with other interventions, such as surgery or percutaneous ethanol injection (PEI), were eligible for inclusion. Outcome data collected were overall survival, disease-free survival and disease recurrence rates. Only randomized controlled trials (RCTs), quasi-RCTs and non-randomized comparative studies with more than 12 months' follow-up were included.

RESULTS

Forty-three articles, including 12 RCTs, were included in the review. The majority of the articles reported the use of RFA for unresectable HCC, often in combination with other treatments such as PEI, transarterial chemoembolization and/or surgery. Overall and disease-free survival rates continue to improve, despite an increase in the size and numbers of tumours treated. More recently some clinicians have used RFA to treat selected patients with resectable HCC, with good outcomes.

CONCLUSION

RFA provides a valuable treatment option for patients with unresectable HCC. It improves survival in those previously considered to have advanced disease. As progress continues to be made, RFA is gradually being used to treat resectable HCC.

MR-guided radiofrequency ablation of hepatocellular carcinoma: long-term effectiveness

PURPOSE

To evaluate long-term effectiveness of magnetic resonance (MR)-guided radiofrequency (RF) ablation of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This prospective study was approved by the institutional review board. In 20 patients, 28 HCCs (mean diameter, 28.0 mm; range, 6-58 mm) were treated with 25 sessions of MR-guided RF ablation. Previous chemoembolization had been performed in nine HCCs with diameters greater than 3 cm. The entire RF ablation procedures were carried out on a 0.2-T open MR system. Placement of MR-compatible internally cooled electrodes was performed under MR fluoroscopic imaging with fast gradient-echo sequences. Therapeutic assessment was based on dynamic MR-imaging (1.5 T) at a mean follow-up of 24.2 months (range, 6-52 mo).

RESULTS

MR-guided RF ablation was technically successful in all 25 sessions (100%), as assessed at the end of each session. T2-weighted sequences were accurate to monitor the ablation zone and supported guidance of overlapping ablations if necessary. Technique effectiveness, defined as complete ablation confirmed at MR imaging 4 months after RF ablation, was achieved in 27 of 28 HCCs (96.4%). To achieve complete ablation, 25 of 27 tumors (92.6%) were treated in a single session and two tumors were treated twice. In one tumor initially defined as having been treated with technically effective RF ablation, local tumor progression was detected more than 4 months after ablation. Consequently, the available follow-up indicated complete ablation in 26 of 28 HCCs (92.9%). There was one major complication (4.0%) and one minor complication (4.0%).

CONCLUSIONS

On a long-term basis, MR-guided RF ablation is an effective therapy option in the treatment of HCC.

Prognosis of patients with hepatocellular carcinoma after hepatic resection: are elderly patients suitable for surgery?

AIM

The indication for hepatectomy is still controversial in elderly patients with hepatocellular carcinoma (HCC). We examined the clinicopathological features and survival of 188 HCC patients who underwent hepatectomy.

PATIENTS/METHODS

Patients were divided into four age groups: Age(<50) group (young patients <50 years of age, n = 9), Age(50-69) group (between 50-69 years, n = 110), Age(70-79) group (70-79 years, n = 57), and Age(≥80) group (≥80 years, n = 12). Physiologic ability and surgical stress (E-PASS) score, including preoperative risk score (PRS), surgical stress score (SSS), and comprehensive risk score (CRS) were assessed.

RESULTS

Proportion of patients of Age(70-79) and Age(≥80) groups increased significantly in the last 5 years (P < 0.01). Co-morbidity, performance status, and American Society of Anesthesiologists score significantly increased with age (P < 0.05). Proportions of patients with irregular findings and necro-inflammatory activity were significantly lower in Age(70-79) and Age(≥80) groups than in other groups (P < 0.05). Systemic postoperative complications were high in Age(70-79) and Age(≥80) groups. PRS increased significantly with age (P < 0.05). Multivariate analysis identified PRS ≥0.32 and age ≥70 years as significant determinants of systemic complications (P < 0.05). There were no significant differences in postoperative survivals among the groups.

CONCLUSIONS

Careful follow-up and proper decision on hepatectomy upon assessment of PRS are important in elderly HCC patients.

Loco-regional treatment of hepatocellular carcinoma

Loco-regional treatments play a key role in the management of hepatocellular carcinoma (HCC). Image-guided tumor ablation is recommended in patients with early-stage HCC when surgical options are precluded. Radiofrequency ablation has shown superior anticancer effects and greater survival benefit with respect to the seminal percutaneous technique, ethanol injection, in meta-analyses of randomized controlled trials, and is currently established as the standard method for local tumor treatment. Novel thermal and nonthermal techniques for tumor ablation--including microwave ablation, irreversible electroporation, and light-activated drug therapy--seem to have potential to overcome the limitations of radiofrequency ablation and warrant further clinical investigation. Transcatheter arterial chemoembolization (TACE) is the standard of care for patients with asymptomatic, noninvasive multinodular tumors at the intermediate stage. The recent introduction of embolic microspheres that have the ability to release the drug in a controlled and sustained fashion has been shown to significantly increase safety and efficacy of TACE with respect to conventional, lipiodol-based regimens. The available data for radioembolization with yttrium-90 suggests that this is a potential new option for patients with HCC, which should be investigated in the setting of randomized controlled trials. Despite the advances and refinements in loco-regional approaches, the long-term survival outcomes of patients managed with interventional techniques are not fully satisfactory, mainly because of the high rates of tumor recurrence. The recent addition of molecular targeted drugs with antiangiogenic and antiproliferative properties to the therapeutic armamentarium for HCC has prompted the design of clinical trials aimed at investigating the synergies between loco-regional and systemic treatments. The outcomes of these trials are eagerly awaited, because they have the potential to revolutionize the treatment of HCC.

Transarterial embolisation of hepatocellular carcinoma with doxorubicin-eluting beads: single centre early experience

Purpose:

This is a retrospective study to evaluate the results of our early experience of using doxorubicin eluting beads (DEB) to treat patients with early and intermediate hepatocellular carcinoma (HCC).

Material and methods: A cohort of 19 patients (84.2% male; 15.8% female; mean age 59.2 years ± 11.0; range, 32-80 years) with documented HCC of size 1.8-10cm (mean, 4.0cm ± 1.8 ) undergoing DEB transarterial chembolisation (TACE) was reviewed. All patients had at least one image examination (multiphase computed tomography or magnetic resonance imaging) after embolisation.

Results:

A total of 32 procedures were performed. The objective response according to the European Association for the Study of the Liver criteria was 57.9% at 1-month, 42.8% at 6-month and 50.0% at 1-year follow up. There were 4 (21.1%) treatment-related complications (1 liver abscess, 2 pancreatitis and 1 tumour rupture) which resulted in 2 deaths. One death occurred 3 weeks after second embolisation, due to ruptured pancreatic pseudocyst, giving a 5.3% 30-day mortality rate. Another patient died 2 months after embolisation caused by tumour rupture. Eight patients received radiofrequency ablation after embolisation for residual or recurrent tumours. The 1-year survival rate in the DEB TACE only group was 80% while the 1- and 2-year survival rate in the group that received radiofrequency after DEB TACE was 85.7% and 100% respectively.

Conclusion:

DEB TACE is safe and effective in select group of patients. Survival may be improved when combined with other treatment modality.

Single-session combined therapy with chemoembolization and radiofrequency ablation in hepatocellular carcinoma less than or equal to 5 cm: a preliminary study. J Vasc Interv Radiol. 2009;20:1570-1577. [PMID: 19879777 DOI: 10.1016/j.jvir.2009.09.003]

PURPOSE

To evaluate the efficacy and safety of a single-session combined chemoembolization and radiofrequency (RF) ablation for hepatocellular carcinomas (HCCs) less than or equal to 5 cm.

MATERIALS AND METHODS

Between June 1, 2004, and January 1, 2006, 50 patients (41 men, nine women; age range, 35-77 years; mean age, 61.5 years) with 57 HCCs (1.5-4.5 cm; mean, 2.4 cm) underwent single-session combined therapy. Chemoembolization was performed by using a doxorubicin hydrochloride/iodized oil emulsion with or without gelatin sponge particles. Immediately following chemoembolization, RF ablation was performed under fluoroscopy or ultrasonographic guidance. Initial tumor response and local tumor progression were determined with follow-up computed tomography or magnetic resonance imaging. The recurrence-free and overall survival rates as well as procedure-related complications were evaluated.

RESULTS

At 1-month follow up, complete necrosis was achieved in all index tumors; however, nonindex intrahepatic recurrences were found in two patients (complete response in 48 patients and progressive disease in two patients). The estimated 1- and 3-year local tumor progression rates during the follow-up period (range, 13.1-51.6 months; mean, 29.0 months) were 1.8% and 9.4%, respectively. The 1- and 3-year recurrence-free and overall survival rates were 64.6% and 30.5% and 100% and 79.7%, respectively. Three of the 50 patients (6%) had major complications, including segmental hepatic infarction (n = 2) and hepatic arterial bleeding (n = 1).

CONCLUSIONS

Single-session combined therapy is an effective and safe treatment for HCCs less than or equal to 5 cm.

Activation of tumor-specific T lymphocytes after laser-induced thermotherapy in patients with colorectal liver metastases

PURPOSE

To asses if laser-induced thermotherapy (LITT) induces a specific cytotoxic T cell response in patients treated with LITT for colorectal cancer liver metastases.

METHODS

Eleven patients with liver metastases of colorectal cancer underwent LITT. Blood was sampled before and after LITT. Peripheral T cell activation was assessed by an interferon gamma (IFNg) secretion assay and flow cytometry. Test antigens were autologous liver and tumor lysate obtained from each patient by biopsy. T cells were stained for CD3/CD4/CD8 and IFNg to detect activated T cells. The ratio of IFNg positive to IFNg negative T cells was determined as the stimulation index (SI). To assess cytolytic activity, T cells were co-incubated with human colorectal cancer cells (CaCo) and cytosolic adenylate kinase release was measured by a luciferase assay.

RESULTS

IFNg secretion assay: before LITT SI was 12.73 (+/-4.83) for CD3+, 4.36 (+/-3.32) for CD4+ and 3.64 (+/-1.77) for CD8+ T cells against autologous tumor tissue. Four weeks after LITT SI had increased to 92.09 (+/-12.04) for CD3+ (P < 0.001), 42.92 (+/-16.68) for CD4+ (P < 0.001) and 47.54 (+/-15.68) for CD8+ T cells (P < 0.001) against autologous tumor tissue. No increased SI was observed with normal liver tissue at any time point. Cytotoxicity assay: before LITT activity against the respective cancer cells was low, with RLU = 1,493 (+/-1,954.68), whereas after LITT cytolytic activity had increased to RLU = 7,260 [+/-3,929.76 (P < 0.001)].

CONCLUSION

Patients with liver metastases of colorectal cancer show a tumor-specific cytotoxic T cell stimulation and a significantly increased cytolytic activity of CD3+, CD4+ and CD8+ T cells after LITT against an allogenic tumor (CaCo cell line).

Doxorubicin-eluting bead-enhanced radiofrequency ablation of hepatocellular carcinoma: a pilot clinical study

BACKGROUND/AIMS

Experimental studies have shown synergy between radiofrequency (RF) ablation and adjuvant chemotherapy in animal tumour models. We aimed to assess safety and efficacy of doxorubicin-eluting bead (DEB)-enhanced RF ablation in the treatment of human hepatocellular carcinoma (HCC).

METHODS

Twenty patients with single HCC ranging 3.3-7.0 cm (mean, 5.0 cm+/-1.4) showing evidence of residual viable tumour after standard RF ablation underwent intraarterial DEB administration (50-125 mg doxorubicin; mean, 60.2 mg+/-21.8). Follow-up period ranged 6-20 months (mean, 12 months+/-5).

RESULTS

No major complication occurred. No deterioration of liver function was observed. The volume of treatment-induced necrosis--as measured on imaging--increased from 48.1 cm3+/-35.7 after RF ablation to 75.5 cm3+/-52.4 after DEB administration, with an increase of 60.9%+/-39.0. The enhanced effect resulted in confirmed complete response (CR) of the target lesion in 12 (60%) of 20 patients. Incomplete response with persistence of <10% of initial tumour volume was observed in 6 (30%) of 20 patients, and local tumour progression in 2 (10%) of 20.

CONCLUSIONS

Intraarterial DEB administration substantially enhances the effect of RF ablation. DEB-enhanced RF ablation is safe and results in a high rate of CR in patients refractory to standard RF treatment.