Performance Status Enhances the Selection of Treatment for Patients with Hepatocellular Carcinoma Within the Milan Criteria

Background

Performance status (PS) is closely linked with survival in patients with hepatocellular carcinoma (HCC). We investigated its impact on treatment strategy for small HCC(s).

Methods

A total of 360 and 362 HCC patients within the Milan criteria undergoing surgical resection (SR) and radiofrequency ablation (RFA), respectively, were prospectively enrolled. Patients were classified into PS 0 (n = 558) and PS ≥1 (n = 164) groups. Propensity score analysis was performed, and 168 and 35 matched pairs were selected from patients with PS 0 and ≥1, respectively.

Results

The SR group was younger and had a higher male-to-female ratio, higher prevalence of hepatitis B, lower prevalence of hepatitis C, better PS, better liver functional reserve, and larger tumor burden than the RFA group (all p < 0.05). Among patients with PS 0, the SR group was consistently younger, less cirrhotic, and had larger tumor burden (all p < 0.05). The long-term survival was comparable between SR and RFA group in patients with PS 0. After propensity score matching, SR provided significantly better long-term survival than RFA for patients within the Milan criteria classified as PS 0 (p = 0.016); the Cox proportional hazards model showed consistent results. There was no significant difference of overall survival between the SR and RFA group in patients with PS ≥1 before or after propensity score matching (both p > 0.05).

Conclusions

For HCC patients within the Milan criteria and classified as PS 0, SR provides a better long-term survival compared with RFA. Performance status may enhance treatment selection and stratify the risk of survival in these patients.     

Open Versus Thoracoscopic Esophagectomy in Patients with Esophageal Squamous Cell Carcinoma

Background

The impact of minimally invasive esophagectomy on patient prognosis, particularly disease-free survival (DFS), has not been well addressed. We compared the clinical outcomes of open and thoracoscopic esophagectomy in patients with esophageal squamous cell carcinoma (ESCC).

Methods

Sixty-three and 66 patients, nonrandomized, underwent open and thoracoscopic esophagectomies for ESCC between 2008 and 2011 were included. The clinicopathological data were reviewed retrospectively. Perioperative outcome, overall survival (OS), DFS, and the recurrence sites after open and thoracoscopic esophagectomy were compared.

Results

The open and thoracoscopic groups were comparable with regard to the total number of harvested lymph nodes and the percentage patients undergoing R0 resection. Fewer patients in the thoracoscopic group had pneumonia and wound complications. Intensive care unit (ICU) stay also was shorter in the thoracoscopic group. The recurrence pattern was similar in the two groups. In the open and thoracoscopic groups, the 3-year OS rates were 47.6 and 70.9 % (p = 0.031), respectively, and the 3-year DFS rates were 35 and 62.4 % (p = 0.007), respectively. However, the trends in better OS and DFS in the thoracoscopic group were not significant after stratification according to pathologic stage.

Conclusions

The perioperative benefit of thoracoscopic esophagectomy included fewer postoperative complications and shorter ICU stays. Mid-term OS and DFS associated with thoracoscopic techniques are at least equivalent to those associated with open procedures.     

Medium-Sized (3.1–5.0 cm) Hepatocellular Carcinoma: Transarterial Chemoembolization Plus Radiofrequency Ablation Versus Radiofrequency Ablation Alone

Purpose

This study was designed to retrospectively compare the effectiveness of combined transarterial chemoembolization (TACE) plus radiofrequency ablation (RFA) with that of RFA alone in patients with medium-sized (3.1–5.0 cm) hepatocellular carcinoma (HCC).

Methods

From March 2000 to April 2010, 57 patients, each with a single medium-sized HCC, were treated with combined TACE and RFA, and 66 were treated with RFA alone.

Results

During follow-up (mean, 42.5 ± 33.2 months; range, 2.6–126.2 months), local tumor progression was observed in 40% of treated lesions in the combined treatment group and in 70% in the RFA-alone group. The 1-, 3-, 5-, and 7-year local tumor progression rates were significantly lower in the TACE + RFA group (9%, 40%, 55%, and 66%, respectively) than in the RFA-alone group (45%, 76%, 86%, and 89%, respectively; P < 0.001). Multivariate analysis showed that treatment allocation (odds ratio [OR], 1.78; P = 0.016) and Child-Pugh class (OR, 1.96; P = 0.008) were significant independent factors associated with patient survival. The rates of major complications were 0% for the combined treatment group and 3% for the RFA-alone group.

Conclusions

The combination of TACE and RFA is safe and provides better local tumor control than RFA alone for the treatment of patients with medium-sized HCC. Our multivariate analysis showed that RFA-alone treatment and Child-Pugh class B were poor independent factors for determining the patient survival period.     

Intraoperative Ablation for Small HCC not Amenable for Percutaneous Radiofrequency Ablation in Child A Cirrhotic Patients

Background

Radiofrequency ablation (RFA) was initially started by radiologists as a percutaneous treatment, but surgeons started to use RFA by surgical approach for patients with tumors at locations difficult for the percutaneous procedure. The aim was to evaluate the results of intraoperative RFA for small hepatocellular carcinomas (HCCs) (<3 cm) in locations difficult for a percutaneous approach.

Methods

Two hundred forty-seven patients with small solitary HCC (<3 cm) were treated; 196 via percutaneous RFA while 51 patients presented at sites not amenable for percutaneous route. Twenty-seven out of 51 patients underwent surgical resection, while 24/51 patients underwent intraoperative RFA.

Results

The location and depth of the tumor from the liver capsule was the only significant factors in the choice of the surgeon between resection and RFA. RFA was successful in all tumors (complete ablation rate of 100 %). In the surgery group, all patients achieved R0 resection. Complication rate was comparable (p?=?1.0). After a median follow-up of 37 months (range, 10–45 months), no tumors showed neither local progression nor local recurrence and no significant difference was observed between two groups as regards early recurrence and number of de novo lesions (p?=?0.49). One-year and 3-year survival rates were 93 % and 81 %, respectively, in the resection group comparable to the corresponding rates of 92 % and 74 % in the RFA group (p?=?0.9).

Conclusion

For small HCC in locations difficult for a percutaneous approach, intraoperative RFA can be an alternative option for deep-seated tumors necessitating more than one segmentectomy achieving similar tumor control, and overall and disease-free survival.     

The laparoscopic approach for radiofrequency ablation of hepatocellular carcinoma—indication, technique and results

Background

The therapeutic regimen for patients suffering of HCC in liver cirrhosis must pay attention to the underlying liver disease. Surgical resection is often limited by liver function and transplantation, as an optimal therapy for many early diagnosed HCC, by the availability of organs. Due to three prospective, randomized trials radiofrequency ablation (RFA) is the standard method of local ablation. RFA compared with resection for HCC in liver cirrhosis yields similar results concerning overall survival but a lower rate of complications. The laparoscopic approach may be advantageous concerning the major drawback of RFA which is still the rate of local failure as shown by a meta-analysis of local recurrences.

Method

Indication for RFA was HCC in liver cirrhosis either as a definite therapy or as a bridging procedure for transplantation if the expected waiting time exceeded 6 months. Laparoscopic ultrasound, standardized algorithm of laparoscopic RFA procedure, track ablation and a Trucut biopsy were performed. The postoperative follow-up was done according to institutional standards. Patient data and parameters of laparoscopic RFA were prospectively documented, analyzed and compared with the results of previously published series found in a Medline search.

Results

34 patients were treated by laparoscopic RFA. The average time of follow-up was 36.9?±?28.3 months. There was no procedure-related mortality or surgical complications. An upstaging of the tumor stage by laparoscopic ultrasound was achieved in 32 % of the patients. The overall survival of these patients was 44.7?±?6.9 months. The intrahepatic recurrence rate was 61.8 % based on the number of patients treated. The results have been analyzed and compared with six independent papers identified in a Medline search that report on the treatment of patients with HCC in a liver cirrhosis by laparoscopic RFA with a mean follow-up of 12 or more months.

Conclusions

Laparoscopic RFA is a feasible and reliable therapy for unresectable HCCs in patients with cirrhosis. The laparoscopic RFA combines the advantage of a minimally invasive procedure concerning liver dysfunction with the ability of an accurate intraoperative staging by laparoscopic ultrasound.     

Influence of Nonclinical Factors on Choice of Therapy for Early Hepatocellular Carcinoma

Background

Initial therapy for early hepatocellular carcinoma (HCC) with well-compensated cirrhosis is controversial. While we previously reported on the effect of clinical factors and surgeon specialty on choice of therapy for early HCC, other nonclinical factors also may impact decision-making.

Methods

Surgeons who treat HCC were invited to complete a web-based survey that included ten case scenarios. Choice of therapy—liver transplantation (LT), liver resection (LR), or radiofrequency ablation (RFA)—was analyzed using regression models.

Results

There were 336 responses for analysis. Most respondents were in academic centers (86 %) that offered LT (71 %). The median number of patients annually evaluated for HCC was 30. Both practice type and HCC case volume were associated with choice of therapy, but these associations were not independent of surgeon specialty. LT surgeons who did not also perform RFA were less likely than those LT surgeons who did offer RFA to choose RFA over LT (relative risk ratios (RRR) 0.38, P < 0.001). Non-LT surgeons were more likely than LT surgeons who also offered RFA to choose RFA over LT (RRR 2.24, P < 0.001). Surgeons who worked at hospitals where LT was performed were much more likely to choose LT over LR and RFA even if they did not personally perform LT (RRR 1.27 and RRR 3.33, P < 0.001).

Conclusions

Surgeon- and institution-related factors impact choice of therapy for early HCC even after adjustment for differences in clinical presentation. These data suggest that choice of therapy for patients with early HCC varies across providers independent of case selection.     

γ-Glutamyltranspeptidase is a Prognostic Marker of Survival and Recurrence in Radiofrequency-Ablation Treatment of Hepatocellular Carcinoma

Purpose

Serum γ-glutamyltranspeptidase (GGT) level, which is often elevated in hepatocellular carcinoma (HCC), has now been found to be an oxidative stress marker which correlates with inflammation in the extracellular hepatic microenvironment. The aim of this study was to investigate the prognostic significance of GGT serum levels in patients undergoing radiofrequency ablation (RFA) therapy for the treatment of HCC.

Methods

This retrospective study included 254 patients with small liver cancer (tumor of ≤5 cm in diameter and nodule of ≤3 cm) who had been treated with RFA. Baseline serum GGT was examined before therapy, and overall survival (OS) and recurrence-free survival were evaluated by the Kaplan–Meier method. Univariate and multivariate analyses were used to analyze the significance of GGT and other serum markers as prognostic factors.

Results

After a median follow-up of 27 months, 51 patients had died and 123 had hepatic recurrence. After treatment with RFA, HCC patients with elevated GGT had a shorter OS versus those with normal GGT level (p = 0.001); they also had higher recurrence (p = 0.001). On multivariate analysis, albumin (p = 0.003), GGT (p = 0.035), and tumor size (p = 0.027) were independent risk factors for survival, and GGT (p = 0.010) and tumor size (p = 0.026) were significant risk factors for recurrence.

Conclusions

Serum GGT is a convenient prognostic biomarker related to OS and recurrence in HCC patients undergoing RFA treatment.     

Efficacy and survival analysis of percutaneous radiofrequency versus microwave ablation for hepatocellular carcinoma: an egyptian multidisciplinary clinic experience

Background

Hepatocellular carcinoma (HCC) is a primary tumor of the liver with poor prognosis. For early stage HCC, treatment options include surgical resection, liver transplantation, and percutaneous ablation. Percutaneous ablative techniques (radiofrequency and microwave techniques) emerged as best therapeutic options for nonsurgical patients.

Aims

We aimed to determine the safety and efficacy of radiofrequency and microwave procedures for ablation of early stage HCC lesions and prospectively follow up our patients for survival analysis.

Patients and methods

One Hundred and 11 patients with early HCC are managed in our multidisciplinary clinic using either radiofrequency or microwave ablation. Patients are assessed for efficacy and safety. Complete ablation rate, local recurrence, and overall survival analysis are compared between both procedures.

Results

Radiofrequency ablation group (n = 45) and microwave ablation group (n = 66) were nearly comparable as regards the tumor and patients characteristics. Complete ablation was achieved in 94.2 and 96.1 % of patients managed by radiofrequency and microwave ablation techniques, respectively (p value 0.6) with a low rate of minor complications (11.1 and 3.2, respectively) including subcapsular hematoma, thigh burn, abdominal wall skin burn, and pleural effusion. Ablation rates did not differ between ablated lesions ≤3 and 3–5 cm. A lower incidence of local recurrence was observed in microwave group (3.9 vs. 13.5 % in radiofrequency group, p value 0.04). No difference between both groups as regards de novo lesions, portal vein thrombosis, and abdominal lymphadenopathy. The overall actuarial probability of survival was 91.6 % at 1 year and 86.1 % at 2 years with a higher survival rates noticed in microwave group but still without significant difference (p value 0.49).

Conclusion

Radiofrequency and microwave ablations led to safe and equivalent ablation and survival rates (with superiority for microwave ablation as regards the incidence of local recurrence).     

Minimally invasive surgery versus percutaneous radio frequency ablation for the treatment of single small (≤3 cm) hepatocellular carcinoma: a case–control study

Background

Patients with single small hepatocellular carcinoma (HCC) can be managed by surgical resection or radio frequency ablation (RFA), with similar recurrence and survival rates. Recently, minimally invasive surgery (MIS) has been introduced in liver surgery, and the advantage/drawback balance between surgery and RFA needs reassessment.

Methods

Patients with Child-Pugh class A or B cirrhosis, and with single 1–3 cm HCC, undergoing MIS (laparoscopic or robot-assisted) or RFA from July 1998 to December 2012 were compared.

Results

Overall, 45 patients underwent MIS, and 60 underwent RFA. Groups were not statistically different regarding type of underlying liver disease, HCC size, and AFP. However, RFA patients showed worse liver synthetic function with lower albumin and higher bilirubin serum levels, and higher ASA scores. Patients with HCC in segments 2–6 were more often treated by MIS. The incidence of complications was similar between groups (RFA: 6/60, 10 % vs. MIS: 5/45, 11 %, p = 0.854), and there was no measurable difference in the rate of procedure-related blood transfusions (RFA: 1/60, 1.7 % vs. MIS: 3/45, 6.7 %, p = 0.185). Local recurrence was only detected after RFA (11.7 %, p = 0.056, log-rank). Overall survival was higher in the MIS group (p = 0.042), with median survivals of 100 ± 13.5 versus 68 ± 15.9 months.

Conclusion

The present data need further validation. Selected patients with single ≤3-cm HCCs can be safely treated by MIS, without increased risk of perioperative complication, and with a lower risk of local recurrence. MIS should be especially favoured in patients with peripheral HCCs in segments 2–6, and/or when a histological assessment is desirable.

     

Survival Advantage of Radiofrequency Ablation Over Transarterial Chemoembolization for Patients with Hepatocellular Carcinoma and Good Performance Status Within the Milan Criteria

Background

Performance status is closely linked with survival in patients with hepatocellular carcinoma (HCC). We evaluated the impact of performance status on patients with small HCC receiving radiofrequency ablation (RFA) versus transarterial chemoembolization (TACE).

Methods

A total of 424 and 282 patients within the Milan criteria undergoing RFA and TACE, respectively, were analyzed. Patients were classified as performance status 0 (n = 516) and performance status ≥1 (n = 190) groups. A propensity-score matching analysis with preset caliper width was used. A total of 167 and 68 matched pairs were selected from patients with a performance status of 0 and ≥1, respectively.

Results

Radiofrequency ablation provided significantly better long-term survival than TACE for patients within the Milan criteria (p < 0.01). After being stratified by performance status and matched in the propensity model, the baseline characteristics were similar between the RFA and TACE groups for patients with a performance status of 0 or ≥1. RFA provided significantly better long-term survival than TACE in patients with a performance status of 0 in the propensity model (p < 0.05); TACE was significantly associated with 1.784-fold increased risk of mortality (95 % confidence interval 1.075–2.506) by using the Cox proportional hazards model. TACE was not a significant prognostic predictor in patients with a performance status ≥1 in the propensity model.

Conclusions

For HCC patients within the Milan criteria with a performance status of 0, RFA provides better long-term survival than TACE. RFA should be considered a priority treatment in inoperable HCC patients within the Milan criteria. Performance status is a feasible surrogate marker to enhance treatment allocation.     

Radiofrequency Ablation of Hepatic Metastases: Factors Influencing Local Tumor Progression

Background

Although radiofrequency ablation (RFA) of nonresectable hepatic metastases has gained wide acceptance by showing survival benefit in selected patients, scattered reports are available regarding risk factors of local control of percutaneous RFA. The purpose of this study was to prospectively evaluate the factors influencing local tumor progression after percutaneous RFA of hepatic metastases.

Methods

Sixty-nine hepatic metastatic lesions in 54 patients were treated by percutaneous RFA. Efficacy was evaluated by contrast-enhanced computed tomography or magnetic resonance imaging at 1 month after ablation, then at 3-month intervals for the first year and biannually thereafter.

Results

The results of the log-rank test showed that tumor size of <3 cm (p = 0.024) and the absence of tumor contiguous with large vessels (p = 0.002) significantly correlated with local control for hepatic metastases. Cox regression analysis showed that the tumor size <3 cm and the absence of tumor contiguous with large vessels were independent factors (p = 0.055 and 0.009, respectively). The results of the log-rank test showed that neither the threshold post-ablation margin of 1.8 cm (p = 0.064) nor the presence of a tumor with subcapsular location (p = 0.134) correlated with the success of local control.

Conclusions

Percutaneous RFA is more effective in achieving local control in patients with hepatic metastases when the tumor size is <3 cm and not contiguous with large vessels.     

Trends and Patterns of Utilization in Post-treatment Surveillance Imaging Among Patients Treated for Hepatocellular Carcinoma

Background

Little is known about the patterns of utilization of surveillance imaging after treatment of hepatocellular carcinoma (HCC). We sought to define population-based patterns of surveillance and investigate if intensity of surveillance impacted outcome following HCC treatment.

Methods

The Surveillance, Epidemiology, and End Results-Medicare database was used to identify patients with HCC diagnosed between 1998 and 2007 who underwent resection, ablation, or intra-arterial therapy (IAT). The association between imaging frequency and long-term survival was analyzed.

Results

Of the 1,467 patients, most underwent ablation only (41.5 %), while fewer underwent liver resection only (29.6 %) or IAT only (18.3 %). Most patients had at least one CT scan (92.7 %) during follow-up, while fewer had an MRI (34.1 %). A temporal trend was noted with more frequent surveillance imaging obtained in post-treatment year 1 (2.5 scans/year) vs. year 5 (0.9 scans/year; P?=?0.01); 34.5 % of alive patients had no imaging after 2 years. Frequency of surveillance imaging correlated with procedure type (total number of scans/5 years, resection, 4.7; ablation, 4.9; IAT, 3.7; P?<?0.001). Frequency of surveillance imaging was not associated with a survival benefit (three to four scans/year, 49.5 months vs. two scans/year, 71.7 months vs. one scan/year, 67.6 months; P?=?0.01)

Conclusion

Marked heterogeneity exists in how often surveillance imaging is obtained following treatment of HCC. Higher intensity imaging does not confer a survival benefit.     

Prior Fundoplication Does not Improve Safety or Efficacy Outcomes of Radiofrequency Ablation: Results from the U.S. RFA Registry

Background

Ongoing gastroesophageal reflux may impair healing and re-epithelialization after radiofrequency ablation (RFA) of Barrett’s esophagus (BE). Because prior fundoplication may improve reflux control, our aim was to assess the relationship between prior fundoplication and the safety/efficacy of RFA.

Methods

We assessed the U.S. RFA Registry, a nationwide registry of BE patients receiving RFA at 148 institutions, to compare the safety and efficacy of ablation between those with prior fundoplication and those with medical management (proton pump inhibition).

Results

Among 5,537 patients receiving RFA, 301 (5.4 %) had prior fundoplication. Of fundoplication subjects, 1.0 % developed stricture and 1.0 % were hospitalized after RFA. Rates of stricture, bleeding, and hospitalization were not statistically different (p?=?ns) between patients with and without prior fundoplication. Complete eradication of intestinal metaplasia and complete eradication of dysplasia were achieved in 71 % and 87 % of fundoplication patients, and 73 % and 87 % of patients without fundoplication, respectively (p?=?ns for both). Patients with prior fundoplication needed similar numbers of RFA sessions for eradication compared with those without fundoplication.

Conclusions

Radiofrequency ablation, with or without prior fundoplication, is safe and effective in eradicating BE. Prior fundoplication was associated with similar adverse event and efficacy rates when compared with medical management.     

Complementary Use of Resection and Radiofrequency Ablation for the Treatment of Colorectal Liver Metastases: An Analysis of 395 Patients

Background

Liver resection and radiofrequency ablation (RFA) are two surgical options in the treatment of patients with colorectal liver metastases (CLM). The aim of this study was to analyze patient characteristics and outcomes after resection and RFA for CLM from a single center.

Methods

Between 2000 and 2010, 395 patients with CLM undergoing RFA (n = 295), liver resection (n = 94) or both (n = 6) were identified from a prospective IRB-approved database. Demographic, clinical and survival data were analyzed using univariate and multivariate analyses.

Results

RFA patients had more comorbidities, number of liver tumors and a higher incidence of extrahepatic disease compared to the Resection patients. The 5-year overall actual survival was 17 % in the RFA, 58 % in the Resection group (p = 0.001). On multivariate analysis, multiple liver tumors, dominant lesion >3 cm, and CEA >10 ng/ml were independent predictors of overall survival. Patients were followed for a median of 20 ± 1 months. Liver and extrahepatic recurrences were seen in 69 %, and 29 % of the patients in the RFA, and 40 %, and 19 % of the patients in the Resection group, respectively.

Conclusions

In this large surgical series, we described the characteristics and oncologic outcomes of patients undergoing resection or RFA for CLM. By having both options available, we were able to surgically treat a large number of patients presenting with different degrees of liver tumor burden and co-morbidities, and also manage liver recurrences in follow-up.     

Laparoscopic resection for hepatocellular carcinoma: a matched-pair comparative study

Background

Only a few series have demonstrated the safety of laparoscopic resection for hepatocellular carcinoma (HCC) and the benefits of this approach. Moreover, these studies reported mostly minor and nonanatomic hepatic resections. This report describes the results of a pair-matched comparative study between open and laparoscopic liver resections for HCC in a series of essentially anatomic resections.

Methods

Patients were retrospectively matched in pairs for the following criteria: sex, age, American Society of Anesthesiology (ASA) score, severity of liver disease, tumor size, and type of resection. A total of 42 patients undergoing laparoscopy were compared with patients undergoing laparotomy during the same period. Surgeons from the authors’ department not trained in laparoscopy performed open resections. Operative, postoperative, and oncologic outcomes were compared.

Results

The mean duration of surgery was similar in the two groups. Significantly less bleeding was observed in the laparoscopic group (364.3 vs. 723.7 ml; p < 0.0001). Transfusion was required for four patients (9.5%) in the laparoscopic group and seven patients (16.7%) in the open surgery group (p = 0.51). Postoperative ascites was less frequent after laparoscopic resections (7.1 vs. 26.1%; p = 0.03). General morbidity was similar in the two groups (9.5 vs. 11.9%; p = 1.00). The mean hospital stay was significantly shorter for the patients undergoing laparoscopy (6.7 vs. 9.6 days; p < 0.0001). The surgical margin and local recurrence adjacent to the liver stump were not affected by laparoscopy. The overall postoperative survival rates in the laparoscopic group were 93.1% at 1 year, 74.4% at 3 years, and 59.5% at 5 years and, respectively, 81.8, 73, and 47.4% in the open surgery group (p = 0.25). The postoperative disease-free survival rates in the laparoscopic group were at 81.6% at 1 year, 60.9% at 3 years, and 45.6% at 5 years, respectively, 70.2, 54.3, and 37.2% in the open surgery group (p = 0.29).

Conclusions

Laparoscopic resection of HCC for selected patients gave a better postoperative outcome without oncologic consequences. Prospective trials are required to confirm these results.     

Total Tumor Volume Is a Better Marker of Tumor Burden in Hepatocellular Carcinoma Defined by the Milan Criteria

Background

The Milan criteria are used to define small hepatocellular carcinoma (HCC) and to select patients for curative treatments. Total tumor volume (TTV) is an alternative parameter for tumor burden. We aimed to evaluate whether TTV is a feasible prognostic marker in HCC patients with upper boundary TTV of 65.5 cm³, which is equivalent to a single 5 cm tumor nodule defined by the Milan criteria.

Methods

A total of 774 HCC patients with TTV <65.5 cm³ receiving surgical resection, liver transplantation, or radiofrequency ablation (RFA) as the primary treatment were retrospectively analyzed.

Results

Of these patients, 50 (6.5 %) did not fulfill the Milan criteria. Patients beyond the Milan criteria more often had larger tumor size and TTV, as well as more tumor nodules (p values all <0.01). There was no significant survival difference between patients within and beyond the Milan criteria (p = 0.205). Patients with TTV >15 cm³ had a significantly poorer survival than patients with TTV <15 cm³ (p = 0.007). There was no survival difference between patients receiving surgical treatments versus RFA (p = 0.932). In the Cox proportional hazards model, TTV >15 cm³ [risk ratio (RR): 1.474, p = 0.005], serum bilirubin ≥1.5 mg/dL (RR: 1.663, p = 0.003), serum sodium <135 mmol/L (RR: 2.016, p = 0.01), and α-fetoprotein (AFP) ≥100 ng/mL (RR: 1.37, p = 0.033) were independent predictors of poor prognosis.

Conclusions

Total tumor volume, is an independent and better prognostic marker than the Milan criteria to indicate tumor burden in HCC patients who had tumor volume defined by the Milan criteria and underwent curative therapies.     

Feasibility of Laparoscopic Re-resection for Patients with Recurrent Hepatocellular Carcinoma

Background

Repeated resection via an open approach is an effective treatment for post-operative recurrent hepatocellular carcinoma (HCC). However, there are limited data on the application of laparoscopic approach for recurrent HCC in patients with prior liver resections. The aim of this study was to review our experience of laparoscopic re-resection in patients with postoperative tumor recurrence.

Materials and methods

A total of 11 patients received laparoscopic re-resections for postoperative tumor recurrence in our center. Data were reviewed for demographics, tumor characteristics, and perioperative outcomes. Case-match analysis with the open approach was performed in a 1:2 ratio.

Results

Six patients had their first liver resection carried out via the open approach and the remaining five patients received the laparoscopic approach. The recurrent tumor size was 20 mm (12–50 mm) and ten patients had a solitary recurrence. Two patients had laparoscopic left lateral sectionectomy and the remaining nine patients had sub-segmentectomies. There was no significant difference in patient characteristics, preoperative liver function, and tumor features between the laparoscopic and open groups. Perioperative blood loss was significantly reduced in the laparoscopic group (100 vs. 314 mL; p = 0.014) but the morbidity rate (18.2 vs. 4.5 %; p = 0.199) and length of hospitalization were comparable (6 vs. 5 days; p = 0.831). The 3-year overall survival rates for the laparoscopic and open groups were 60.0 and 89.3 %, respectively (p = 0.279).

Conclusion

Our study showed that laparoscopic re-resection for recurrent HCC was feasible with satisfactory postoperative and oncological outcomes, even in patients with previous major liver resections.     

Surgical Resection in Hepatocellular Carcinoma Patients with Minimal Background Fibrosis: A Strategy in the Era of Organ Shortage

Background

Surgical therapies for hepatocellular carcinoma (HCC) represent the potentially curative approaches and provide patients the greatest survival advantage. We sought to examine the outcomes of patients with HCC treated with surgical resection, transplantation, and local ablation.

Methods

The Surveillance, Epidemiology, and End Results database was queried for all patients with nonmetastatic HCC from 2004 to 2007 who underwent local ablation (LA), segmental resection (SR), hemihepatectomy or extended resection (ER), or transplantation (TP).

Results

Of 16,209 patients with HCC, 3,989 (24.6 %) met criteria for inclusion and received therapies: 1,550 LA (39 %), 703 SR (18 %), 619 ER (16 %), and 1,117 TP (28 %). AFP was elevated in 69 % (2,026 of 2,921), and fibrosis grade 0–4 was noted in 32 % (368 of 1,156). The 3-year survival by procedure was 34 % (LA), 50 % (SR), 54 % (ER), and 74 % (TP), p = .001. In patients with minimal fibrosis, 1-year survival for patients undergoing resection was similar to TP (85 vs. 92 %, p = .346), but greater than LA (69 %, p = .001).

Discussion

Survival after surgical resection for HCC patients without extensive fibrosis appears to be superior to ablation and non-inferior to transplantation. In an era of organ shortage, transplantation may be better reserved for patients with cirrhosis and/or unresectable disease.     

Comparison of alcohol ablation with repeated thermal radiofrequency ablation in medial branch neurotomy for the treatment of recurrent thoracolumbar facet joint pain

Purpose

Chemical denervation is not recommended as part of the routine care of chronic non-cancer pain. Physicians face a dilemma when it comes to repeated interventions in cases of recurrent thoracolumbar facet joint pain after successful thermal radiofrequency ablation (RFA) in medial branch neurotomy. This study was performed to compare the effects of alcohol ablation (AA) with thermal RFA in patients with recurrent thoracolumbar facet joint pain after thermal RFA treatment.

Methods

Forty patients with recurrent thoracolumbar facet joint pain after successful thermal RFA defined as a numeric rating scale (NRS) score of ≥7 or a revised Oswestry disability index (ODI) of ≥22 % were randomly allocated to two groups receiving either the same repeated RFA (n = 20) or AA (n = 20). The recurrence rate was assessed with NRS and ODI during the next 24 months, and adverse events in each group were recorded.

Results

During the 24-month follow-up after RFA and AA, one and 17 patients, respectively, were without recurring thoracolumbar facet joint pain. The median effective periods in the RFA and AA groups were 10.7 (range 5.4–24) and 24 (range 16.8–24) months, respectively (p < 0.000). No significant complications were observed with the exception of injection site pain, which occurred in both groups.

Conclusion

In our patient cohort, alcohol ablation in medial branch neurotomy provided a longer period of pain relief and better quality of life than repeated radiofrequency medial branch neurotomy in the treatment of recurrent thoracolumbar facet joint pain syndrome after successful thermal RFA without significant complications during the 24-month follow-up.     

Pre-treatment double- or triple-positive tumor markers are predictive of a poor outcome for patients undergoing radiofrequency ablation for hepatocellular carcinoma

Purposes

We evaluated the therapeutic effect of radiofrequency ablation (RFA) on hepatocellular carcinoma (HCC) according to the number of positive tumor markers.

Methods

The subjects of this study were 160 patients who underwent percutaneous and surgical RFA for HCC. Patients were divided into negative (n = 51), single- (n = 69), double- (n = 31), and triple-positive (n = 9) tumor marker groups according to the pre-treatment expression of these markers. We looked for any relationships among clinical parameters, outcomes, and tumor markers.

Results

The 3-year recurrence-free and overall survival rates of the negative, single-, double-, and triple-positive groups were 30, 19, 16, and 11 % (P = 0.02), and 94, 88, 67, and 37 % (P < 0.001), respectively. The 2-year local recurrence rates were 6.5, 0, 41.2, and 61.9 %, respectively (P < 0.001). Multivariate analysis revealed that a double- or triple-positive pre-treatment tumor marker profile was independently associated with local recurrence [hazard ratio (HR) 5.48, 95 % confidence interval (CI) 2.44–12.33, P < 0.001] and overall survival (HR 4.21, 95 % CI 1.89–9.37, P < 0.001).

Conclusion

RFA may not be suitable for patients with HCC who have pre-treatment expression of ≥two of these tumor markers.