Usefulness of contrast-enhanced ultrasonography with dynamic flow imaging to evaluate therapeutic effects for hepatocellular carcinoma

BACKGROUND/AIMS: To examine the usefulness of dynamic flow imaging in identifying the therapeutic effects for hepatocellular carcinoma, we performed contrast-enhanced ultrasonography with Levovist. METHODOLOGY: Tumor vascularity of 48 hepatocellular carcinoma nodules in 27 patients infected with hepatitis C virus was assessed before and after radiofrequency ablation therapy by dynamic flow imaging with a wide-band power Doppler technology. RESULTS: All patients showed hypervascular enhancement of hepatocellular carcinoma on contrast-enhanced ultrasonography and/or dynamic computed tomography. The dynamic flow was obtained as vascular and perfusion images of hepatic tumors. The diameters of tumors were 1.1-2.0 cm in 12 nodules, 2.1-3.0 cm in 28, and 3.1-5.0 cm in 8, respectively. We were able to assess the tumor vascularities in 45 of 48 nodules before radiofrequency ablation by the dynamic flow. Three nodules showed insufficient dynamic flow which was located approximately 9 cm in depth from the body surface. The dynamic flow study for the therapeutic efficacy indicated that the tumor vessels disappeared in 43 of the 45 visible nodules. The tumor vascularities were noted in the remaining 2 nodules, and they were successfully retreated by radiofrequency ablation. The frequencies detecting positive enhancement in pretreatment and post-treatment were almost equivalent between vascular phase of dynamic flow on ultrasonography and early phase on helical dynamic computed tomography, although 5 nodules gave different findings; 2 were positive only on ultrasonography, and 3 were positive only on computed tomography. A major complication of radiofrequency ablation procedure was noted in only one case associated with intestinal edema, but it was cured by medical treatment. CONCLUSIONS: The results indicated that contrast-enhanced dynamic flow imaging on ultrasonography is a reliable tool to evaluate intratumoral vascularity both before and after radiofrequency ablation treatment in patients with hepatocellular carcinoma.     

Therapy of HCC-radiofrequency ablation

Radiofrequency interstitial hyperthermia has been used for percutaneous ablation of hepatocellular carcinoma, under ultrasound guidance in local anesthesia. Conventional needle electrodes require a mean number of 3 sessions to treat tumors of diameter < or = 3 cm. Tumors up to 3.5 cm in diameter can be treated in 1 or 2 sessions by expandable needle electrodes. With both methods in all treated cases, ablation of tumors was obtained. In a group of patients with long follow-up, survival rate at 5 years was 40%. In a mean follow-up of 23 months 41% of patients had recurrences (local recurrences in 5%; new lesions in 36%), which often could be retreated by a new course of radiofrequency application. In recent experience large hepatocellular carcinomas (up to 6.8 cm in diameter) were treated by a combination of segmental transcatheter arterial embolization followed by radiofrequency application. In this way most tumors were ablated in one session of radiofrequency therapy. No fatal complications were observed. Major complications were: strong pain due to capsular necrosis in one patient; hemotorax in one case; a fluid collection in the site of ablated tumor in one patient treated by combination of transcatheter arterial embolization and radiofrequency application.     

Radiofrequency ablation of hepatocellular carcinoma in cirrhotic patients

BACKGROUND/AIMS: Radiofrequency ablation is useful for local destruction of primary and secondary hepatic tumors. However there is little information about long-term outcome for patients with hepatocellular carcinoma and cirrhosis. The aims of this study included the analysis of efficacy in local control of tumors, patterns of recurrence and survival rate related to severity of cirrhosis and tumor features. METHODOLOGY: From January 1998 to January 2001 we ablated 65 hepatocellular carcinomas in 53 patients with cirrhosis. Cirrhosis was related to HCV, HBV and alcohol intake in 32, 4 and 17 patients, respectively. According to Child-Pugh classification 24 and 29 patients belong to A and B class, respectively. Patients in Child-Pugh C class were excluded from the study. The mean diameter of lesions was 4 cm (range: 1-7 cm). In all cases radiofrequency ablation was performed with the percutaneous approach under ultrasound guidance. Treatment efficacy was estimated with dual phase computed tomography and alpha-fetoprotein dosage. RESULTS: Complete necrosis rate after first treatment was 90.9, 74.4 and 36.4% in hepatocellular carcinoma smaller than 3 cm, between 3 and 5 cm and larger than 5 cm, respectively (p = 0.01). After multiple treatment complete necrosis was achieved in 100, 93 and 63.6% (p = 0.01). The mean number of treatments was 1.5 (range: 1-4) per patients. Four lesions of 58 (6.8%) developed local recurrence during a mean follow-up of 18 months. No local recurrence was observed in tumors smaller than 4 cm. New tumors were observed in 15 patients (28.3%). There were no treatment-related deaths and 11 patients (20.7%) suffered minor complications. The survival rate of patients after treatment was 87, 63 and 45% at 12, 24 and 36 months, respectively. Survival was significantly related to Child-Pugh class (p = 0.01). CONCLUSIONS: Radiofrequency ablation is a safe and effective treatment of hepatocellular carcinoma smaller than 5 cm with complete necrosis in most lesions. No local recurrences were observed in lesions smaller than 4 cm. After 3 years survival was 83% in Child-Pugh A cirrhotic patients and 31% in Child-Pugh B patients.     

Hepatocellular carcinoma in a case of Wilson's disease treated with radiofrequency ablation therapy

A 37-year-old Japanese man was diagnosed with liver cirrhosis due to Wilson's disease in 2001 and treated with D-penicillamine. Thereafter, he was admitted to our hospital for further examination of a space occupying lesion in the liver. The patient was diagnosed with hepatocellular carcinoma (HCC) (7th segment, 2.5 cm in diameter) in May 2010 and treated with radiofrequency ablation therapy. Biopsy findings from a non-cancerous area revealed a fatty liver, though cirrhotic nodules were not found. Long-term treatment for Wilson's disease may improve hepatic fibrosis, and careful screening for HCC by abdominal imaging is needed in such cases.     

EFFICACY OF LAPAROSCOPIC RADIOFREQUENCY ABLATION FOR HEPATOCELLULAR CARCINOMA COMPARED TO PERCUTANEOUS RADIOFREQUENCY ABLATION WITH ARTIFICIAL ASCITES

Aim: Hepatocellular carcinoma (HCC) nodules close to the liver surface exhibit high recurrence compared to those in distal parts of the liver. Moreover, when nodules remain adjacent to the gastrointestinal tract or gallbladder, severe complications such as perforation of those organs may occur due to invasive therapy. Percutaneous radiofrequency ablation (PRFA) with artificial ascites or laparoscopic radiofrequency ablation (LRFA) are used to treat these patients to avoid complications. The purpose of the present study was to assess the efficacy and safety of these two methods. Methods: Subjects comprised 74 patients (48 men, 26 women; mean age, 68.5 ± 8.0 years; range, 46–89 years) with 86 HCC nodules. PRFA with artificial ascites was carried out for 37 patients (44 nodules) and LRFA was used for 37 patients (42 nodules). Clinical profiles were compared between groups. Results: No significant differences in clinical profiles were found between patients treated by PRFA or LRFA. Mean number of treatments was significantly lower for LRFA (1.0 ± 0.0) than for PRFA (2.1 ± 1.0, P < 0.001). Mean number of PRFA treatments was 2.2 ± 1.0 in patients with HCC nodules >2 cm in diameter, whereas all tumors were completely ablated with only one session of LRFA. The safety margin was significantly wider for LRFA than for PRFA. Conclusion: LRFA is a better treatment option for ablation of HCC nodules >2.0 cm in diameter.     

Local/regional and systemic treatments of hepatocellular carcinoma

Screening programs for patients with cirrhosis are designed to detect hepatocellular carcinoma at an early stage when effective treatment is feasible and may provide long-term survival benefits. However, only a minority of these patients will be considered candidates for liver transplantation or surgical resection and hence, most cases will be evaluated for other medical options. While systemic therapy has never been shown to bear a relevant antitumoral activity with an impact on survival, there are several locoregional options that can achieve a high rate of objective responses (this includes complete necrosis or partial reduction in tumor burden). Percutaneous ablation by any of the available methods (ethanol injection, radiofrequency, microwave, acetic acid injection, laser) is extremely useful in patients with small solitary tumors. Results indicate that 90% of tumors < 2 cm will be completely ablated using the percutaneous approach. However, when tumor size exceeds 3 cm and/or the number of nodules is greater than 3, the rate of treatment success is significantly reduced. In patients with large/multifocal disease, the sole option that has been shown to provide treatment efficacy with moderate improvement in survival is chemoembolization. New therapeutic agents should target biological mechanisms in a tailored strategy, and the demonstration of beneficial results for patients should be obtained by large, randomized, controlled trials comparing active intervention versus no treatment.     

Treatment of large and/or multiple hepatic malignancies: open surgical approaches of radiofrequency ablation

BACKGROUND/AIMS: Patients with hepatic malignancies are often poor candidates for resection because of the lack of hepatic reserve as a result of coexisting cirrhosis or the presence of multiple tumors. The purpose of this study was to determine the safety and efficacy of open intraoperative radiofrequency ablation of unresectable hepatic malignancies with size larger than 4 cm in diameter and/or more than three in number. METHODOLOGY: Between May 2000 and September 2003, 30 patients (24 men, 6 women; age range, 59-72 years; mean age, 63 years) with 51 hepatic malignancies. The maximal diameter of all tumors ranged from 1.0 to 10cm (mean +/- SD, 3.2 +/- 1.8). RESULTS: All tumors achieved necrosis completely in a single session. The mean follow-up from the initial ablation in this study was 18.9 +/- 10.1 months (range, 0-41). The 1-, 2 and 3-year overall survival rates were 86.1%, 71.6% and 71.6%, respectively. The 1-, 2 and 3-year disease-free survival rates were 70.9%, 37.6% and 25.1%, respectively. CONCLUSIONS: Open radiofrequency ablation is a safety and efficient approach for hepatic malignancies sized more than 4 cm in diameter and/or located more than three in number.     

Prospective analysis of risk factors for early intrahepatic recurrence of hepatocellular carcinoma following ethanol injection

BACKGROUND/AIM: Time-dependent intrahepatic recurrence of hepatocellular carcinoma is frequent after different treatment modalities, including percutaneous ethanol injection. We attempted to prospectively analyze the possible risk factors for early intrahepatic recurrence of hepatocellular carcinoma after percutaneous ethanol injection. METHODS: Sixty-five patients with 65 solitary hepatocellular carcinoma nodules < or =6 cm in diameter underwent initial treatment with percutaneous ethanol injection and were examined to ascertain the factors related to recurrence, local and distant, within the liver. A number of clinical and tumor parameters were analyzed. RESULTS: Cumulative overall recurrence rates 12 and 24 months after percutaneous ethanol injection were 15.6% and 45.1%, respectively, irrespective of clinical and tumor parameters. Overall recurrence rates 12 and 24 months after percutaneous ethanol injection were 40% and 67.5%, for tumor > or =3 cm and 7.5% and 37.5%, for tumor <3 cm. Cumulative local recurrence rates at 12 and 24 months were 26.3% and 43.5%, respectively, for tumor > or =3 cm and 11.7% and 18.2%, respectively, for tumor <3 cm. The log-rank test indicated that a tumor size of > or =3 cm and the presence of capsule for a tumor of <3 cm in diameter were significant risk factors for intrahepatic recurrence. A pretreatment serum PIVKA-II level of > or =0.02 AU/ml was the only clinical parameter associated with overall recurrence (p=0.0041) and distant intrahepatic recurrence (p=0.0307). Distant intrahepatic recurrence rates 12 and 24 months after percutaneous ethanol injection were 22.5% and 31.4%, respectively, for PIVKA-II levels of > or =0.02 AU/ml and 8% and 17.8%, for PIVKA-II of <0.02 AU/ml. Cox's proportional hazard model identified that tumor size, tumor capsule and baseline serum PIVKA-II levels were independently related to intrahepatic recurrence. CONCLUSIONS: These data demonstrate that tumor size and peritumoral capsule were associated with overall and local recurrence of hepatocellular carcinoma. Moreover, pretreatment serum levels of PIVKA-II can indicate the risk of early intrahepatic recurrence and may assist in patient selection and appropriate therapy.     

Long-term effectiveness of radiofrequency ablation for hepatocellular carcinoma of 3.5 cm or less

BACKGROUND/AIMS: Hepatocellular carcinoma is one of the leading causes of death for cirrhosis, and patients are often not eligible for surgery. To evaluate the effectiveness of radiofrequency ablation in single (less than 3.5cm in diameter) or multiple nodules (up to 3, sized less than 3cm) in respect of acceptability, applicability, primary ablation rate, local recurrence, complications, and long-term patients outcome. METHODOLOGY: 184 hepatic nodules detected in 156 consecutive patients recruited from a local sonographic screening were treated. In 10.2% of patients under study, a laparoscopic or laparotomy guided technique was preferred to the percutaneous approach. Overall and tumor-free survivals were estimated by Kaplan-Meier method. For the multivariate analysis, the hazard ratios and their 95 percent confidence intervals were computed by Cox model regression analysis. RESULTS: No treatment-related deaths and a severe complication rate of 3.2% were recorded. Primary complete ablation was obtained in 83.7% of nodules (87.1% of patients), and in a significantly higher rate for nodules up to 2cm (91.3%; p<0.013). Acceptability was 100%, and eligibility was very high (156 out of 160 cases). Local recurrence rate at 1 and 3 years was 10% and 25% respectively. The overall 3- and 5-year survival rates after treatment were 69.3% and 34.6%. Higher survival rates were obtained in the Child A cirrhosis subgroup (p<0.03) after complete response (p<0.001) and in the absence of new lesions (p<0.023). CONCLUSIONS: Radiofrequency ablation has great acceptability and applicability, and is a safe and effective treatment to be used after sonographic screening for small hepatocellular carcinomas.     

Microwave coagulation therapy for unresectable hepatocellular carcinoma

BACKGROUND/AIMS: Surgical resection is not always feasible for patients with hepatocellular carcinoma. We used microwave coagulation therapy (MCT) as an alternative to resection and evaluated its efficacy. METHODOLOGY: Twenty-four patients with unresectable hepatocellular carcinoma underwent microwave coagulation therapy by laparotomy (n=18), laparoscopy (n=4), or thoracoscopy (n=2) because of advanced liver cirrhosis and/or intrahepatic metastases. One nodule was treated in 11 patients, 2 nodules were treated in 7, 3 nodules were treated in 3, 6 nodules were treated in 1, and 7 nodules were treated in 2. Tumor size ranged from 10 to 50 mm. Liver function was analyzed at the time of initial MCT and at treatment for recurrence. Patient outcomes were studied. RESULTS: Two patients died postoperatively after initial MCT. Other patients showed rapid recovery without hepatic dysfunction. Liver function just before MCT was equivalent to that measured just before treatment for recurrence. One patient developed local recurrence at the margin of the treated tumor. Recurrent nodules in different segments were detected in 15 patients. Transcatheter arterial embolization was performed in 13 recurrences, percutaneous ethanol injection therapy was performed in 1 recurrence, and MCT was performed in 1 recurrence. The 3-year cancer-free survival rate was 9.9%, and the 3-year cumulative survival rate was 83.9%. CONCLUSIONS: Because MCT is indicated for hepatocellular carcinoma patients with advanced liver cirrhosis, intrahepatic recurrences are frequent. Since, liver function is preserved after MCT, however, locoregional therapy can be selected when intrahepatic recurrence is detected, thus improving patient survival rate.     

Transpulmonary radiofrequency ablation for hepatocellular carcinoma under real-time computed tomography-fluoroscopic guidance

BACKGROUND/AIMS: Radiofrequency ablation has been accepted as a safe treatment for unresectable malignant hepatic tumors. Tumors beneath the diaphragmatic dome may be difficult to visualize with ultrasonography. The aim of this study was to assess the use of transpulmonary radiofrequency ablation under real-time computed tomography-fluoroscopic guidance for hepatocellular carcinoma. METHODOLOGY: Twenty-four radiofrequency ablation treatments by means of a transpulmonary approach were performed in 22 patients under computed tomography-fluoroscopic guidance between December 2002 and April 2006. Every patient had a hepatocellular carcinoma less than 3cm in size beneath the diaphragmatic dome. RESULTS: Transpulmonary radiofrequency ablation under real-time computed tomography-fluoroscopic guidance was successfully performed in every procedure. There was no local tumor recurrence in 22 cases (92%) on follow-up dynamic computed tomography performed an average of 8 months after radiofrequency ablation. The major complication was pneumothorax after 9 procedures (38%): pneumothorax in 6 patients had completely resolved on follow-up chest radiographs, and was treated with manual aspiration immediately after radiofrequency ablation in 3 patients, and no patients required chest-tube placement. CONCLUSION: Transpulmonary radiofrequency ablation under computed tomography-fluoroscopic guidance is a useful method for the accurate and safe ablation of hepatocellular carcinoma that is not detectable with ultrasonography.     

Radiofrequency ablation for treatment of hepatocellular carcinoma with cirrhosis

BACKGROUND/AIMS: The majority of hepatocellular carcinoma patients with cirrhosis are not candidates for surgical resection, and local thermal therapy producing destruction of cancer cells was one of the ideal options for treatment. Heat from radiofrequency ablation is generated through agitation caused by an alternating electrical current. The heat of radiofrequency energy results in local cell coagulation and causes cellular ablation necrosis of tumor tissue. METHODOLOGY: Eighteen cases of hepatocellular carcinoma were treated with radiofrequency ablation in our institute. We used a RFA 2000 generator (Boston Scientific Co, USA) with LeVeen needle with the maximum diameter of 3.5 cm when the array electrodes were fanned out. The indications for this method included; i) normal prothrombin profile, ii) no ascites, iii) tumor can be detected and approached by ultrasound, iv) tumor cannot be resected or patient is not willing to take the operation. RESULTS: No specific complication was noted during or after the procedure. Only two cases needed more analgesics after the procedure. One case was found with burning of the stomach serosa proved by laparoscopic examination, in which radiofrequency ablation was performed to the tumor located in the left lobe of the segment 3. Impedance could not raise up completely in two cases with larger size tumor more than 5 cm. The decreased levels of alpha-fetoprotein were significant (P = 0.005) after radiofrequency ablation treatment. Residual tumor was found in four cases (20%) in the follow-up abdominal computed tomography scan. CONCLUSIONS: Radiofrequency ablation resulted in a higher rate of complete necrosis of tumor tissue and the complication rate was low as well. Therefore, we believed that radiofrequency ablation is an ideal treatment modality for most liver tumors, which cannot tolerate the conventional surgical procedures.     

Combination of interventional therapies in hepatocellular carcinoma

Many interventional techniques aimed at achieving nonsurgical ablation of hepatocellular carcinoma have been developed and clinically tested over the last decade. Percutaneous image-guided therapies such as ethanol injection and radiofrequency thermal ablation provide an effective means for treating hepatocellular carcinoma lesions smaller than 3 cm, but do not ensure successful ablation of larger tumors. In view of the limitations of available interventional therapies, there is currently a focus on a multimodality strategy for the treatment of large hepatocellular carcinomas. Combination of transcatheter arterial chemoembolization and ethanol injection overcomes the weakness of each of the two procedures, enhancing local therapeutic effect and long-term survival. More recently, a new technique for single-session ablation of large hepatocellular carcinoma lesions has been devised by combining transcatheter hepatic arterial balloon occlusion/embolization and radiofrequency treatment. This combined approach substantially increases the thermal necrosis volume that can be created with respect to the conventional radiofrequency technique, as a result of the reduction of heat loss caused by convection. In a pilot multicentric clinical trial performed in 62 patients, successful ablation of hepatocellular carcinoma lesions ranging 3.5-8.5 cm in diameter was achieved in 82% of cases in the absence of major complications. This new technique seems to have the potential to replace other interventional methods for the treatment of large hepatocellular carcinoma.     

Treatment efficacy of radiofrequency ablation of 338 patients with hepatic malignant tumor and the relevant complications

AIM: To investigate the treatment efficacy of radiofrequency ablation (RFA) of hepatic malignant tumor and the relevant complications.METHODS: A total of 338 patients with 763 hepatic tumors underwent ultrasound-guided RFA (565 procedures).There were 204 cases of hepatic cellular carcinoma (HCC)with 430 tumors, the mean largest diameter was 4.0 cm.Of them, 48 patients (23.5％) were in stages Ⅰ-Ⅱ (UICC Systems) and 156 (76.5％) in stages Ⅲ-Ⅳ There were 134 cases of metastatic liver carcinoma (MLC), with 333metastases in the liver, the mean diameter was 4.1 cm,the liver metastases of 96 patients (71.6％) came from gastrointestinal tract. Ninety-three percent of the 338patients were treated using the relatively standard protocol. Crucial attention must be paid to monitor the abnormal changes in ultrasound images as well as the vital signs of the patients to find the possible hemorrhage and peripheral structures injury in time. The tumors were considered as ablated completely, if no viability was found on enhanced CT within 24 h or at 1 mo after RFA. These patients were followed up for 3-57 mo.RESULTS: The ablation success rate was 93.3％ (401/430tumors) for HCC and was 96.7％ (322/333 tumors) for MLC. The local recurrence rate for HCC and MLC was 7.9％ (34/430 tumors) and 10.5％ (35/333 tumors),respectively. A total of 137 patients (40.5％) underwent 2-11times of repeated ablations because of tumor recurrence or metastasis. The 1st, 2nd, and 3rd year survival rate was84.6％, 66.6％, and 63.1％, respectively;the survival rate from 48 patients of Ⅰ-Ⅱ stage HCC was 93.7％, 80.4％,and 80.4％, respectively. The major complication rate in this study was 2.5％ (14 of 565 procedures), which consisted of 5 hemorrhages, 1 colon perforation, 5 injuries of adjacent structures, 2 bile leakages, and 1 skin burn.CONCLUSION: RFA, as a minimally invasive local treatment,has become an effective and relatively safe alternative for the patients of hepatic malignant tumor, even of advanced liver tumor, tumor recurrence, and liver metastases. Knowledge about possible complications and their control may increase the treatment efficacy and help to promote the use of RFA technique.     

Ultrasound guided percutaneous ethanol injection of hepatocellular carcinoma

Percutaneous ethanol injection (PEI), as the first minimally invasive ablation method, has now been in use for more than 20 years. Its main indication is the treatment of small hepatocellular carcinomas superimposed on liver cirrhosis. PEI is highly effective for small tumors (<3 cm) with a complete response in 80% of patients. The efficacy for larger tumors (3-5 cm) is lower, with a complete response in 50%. To increase the effect in larger tumors some special techniques have been developed: single session therapy in general anesthesia, "multiple needles insertion", injection in the feeding artery. PEI is a well tolerated therapy, with a very low complication rate. Recurrences, either local or distant, may occur after PEI and can be treated with new sessions. Although it is still considered the standard percutaneous technique in the treatment of hepatocellular carcinoma, its place is challenged by the new thermal ablative percutaneous techniques, especially radiofrequency ablation.     

Treatment efficacy of radiofrequency ablation of 338 patients with hepatic malignant tumor and the relevant complications

AIM: To investigate the treatment efficacy of radiofrequency ablation (RFA) of hepatic malignant tumor and the relevant complications. METHODS: A total of 338 patients with 763 hepatic tumors underwent ultrasound-guided RFA (565 procedures). There were 204 cases of hepatic cellular carcinoma (HCC) with 430 tumors, the mean largest diameter was 4.0 cm. Of them, 48 patients (23.5%) were in stages Ⅰ-Ⅱ (UICC Systems) and 156 (76.5%) in stages Ⅲ-Ⅳ There were 134 cases of metastatic liver carcinoma (MLC), with 333 metastases in the liver, the mean diameter was 4.1 cm, the liver metastases of 96 patients (71.6%) came from gastrointestinal tract. Ninety-three percent of the 338 patients were treated using the relatively standard protocol. Crucial attention must be paid to monitor the abnormal changes in ultrasound images as well as the vital signs of the patients to find the possible hemorrhage and peripheral structures injury in time. The tumors were considered as ablated completely, if no viability was found on enhanced CT within 24 h or at 1 mo after RFA. These patients were followed up for 3-57 mo. RESULTS: The ablation success rate was 93.3% (401/430 tumors) for HCC and was 96.7% (322/333 tumors) for MLC. The local recurrence rate for HCC and MLC was 7.9% (34/430 tumors) and 10.5% (35/333 tumors), respectively. A total of 137 patients (40.5%) underwent 2-11 times of repeated ablations because of tumor recurrence or metastasis. The 1st, 2nd, and 3rd year survival rate was 84.6%, 66.6%, and 63.1%, respectively; the survival rate from 48 patients of Ⅰ-Ⅱ stage HCC was 93.7%, 80.4%, and 80.4%, respectively. The major complication rate in this study was 2.5% (14 of 565 procedures), which consisted of 5 hemorrhages, 1 colon perforation, 5 injuries of adjacent structures, 2 bile leakages, and 1 skin burn. CONCLUSION: RFA, as a minimally invasive local treatment, has become an effective and relatively safe alternative for the patients of hepatic malignant tumor, even of advanced liver tumor, tumor recurrence, and liver metastases. Knowledge about possible complications and their control may increase the treatment efficacy and help to promote the use of RFA technique.     

Challenges in everyday surgical practice: synchronous bilobar hepatic colorectal metastases--newer multimodality approach

BACKGROUND/AIMS: This study was designed to assess the efficacy of two-stage liver surgery and hepatic directed chemo-biological therapy in treatment of synchronous bilobar hepatic metastases of colorectal origin. METHODOLOGY: A total of thirty-two patients were included in this study that were diagnosed to have colorectal carcinoma with synchronous bilobar hepatic metastases. During stage one surgery along with excision of primary colorectal carcinoma; ligation and transection of main portal branch on side of bulky metastases disease (right branch in 28 and left in 4 patients) was performed. The metastatic nodules in the opposite lobe were ablated by microwave therapy and a hepatic arterial jet port catheter was introduced via the gastroduodenal artery for liver directed chemo-biological therapy. The catheter was connected to a subcutaneously placed port. Three cycles of chemotherapeutic drugs and Avastin (Bevacizumab) were given via hepatic arterial infusion (HAI) at intervals of twenty-five days. During the second stage surgery hepatic resection was carried out followed by continuation of hepatic arterial infusion of chemobiological drugs as adjuvant therapy. RESULTS: In the follow-up period of 31 months, 1-year survival of 100% and 2-year survival of 80% with a mean 28 months survival was noted. CONCLUSIONS: Combined approach of ligating the portal branch, microwave ablation, hepatic regional chemo-biological therapy and staged liver surgery (a multimodality approach) in the treatment of advanced liver metastatic disease synchronous with colorectal cancer is an effective method of treatment which improves the overall survival and quality of life of the patient with hepatic bilobar metastases synchronous with colorectal carcinoma. Avastin, a monoclonal antibody against vascular endothelial growth factor; used for inhibition of tumor growth has shown its efficacy in early results and holds good promise for the future.     

A randomized controlled trial of radiofrequency ablation with ethanol injection for small hepatocellular carcinoma

BACKGROUND & AIMS: Percutaneous radiofrequency ablation is a recently introduced treatment for hepatocellular carcinoma, whereas ethanol injection is now a standard therapy. We compared their long-term outcomes. METHODS: Two hundred thirty-two patients with hepatocellular carcinoma who had 3 or fewer lesions, each 3 cm or less in diameter, and liver function of Child-Pugh class A or B were entered onto a randomized controlled trial. The primary end point was survival, and the secondary end points were overall recurrence and local tumor progression. RESULTS: One hundred eighteen patients were assigned to radiofrequency ablation and 114 to ethanol injection. The number of treatment sessions was smaller (2.1 times vs 6.4 times, respectively, P < .0001) and the length of hospitalization was shorter (10.8 days vs 26.1 days, respectively, P < .0001) in radiofrequency ablation than in ethanol injection. Four-year survival rate was 74% (95% CI: 65%-84%) in radiofrequency ablation and 57% (95% CI: 45%-71%) in ethanol injection. Radiofrequency ablation had a 46% smaller risk of death (adjusted relative risk, 0.54 [95% CI: 0.33-0.89], P = .02), a 43% smaller risk of overall recurrence (adjusted relative risk 0.57 [95% CI: 0.41-0.80], P = .0009), and an 88% smaller risk of local tumor progression (relative risk, 0.12 [95% CI: 0.03-0.55], P = .006) than ethanol injection. The incidence of adverse events was not different between the 2 therapies. CONCLUSIONS: Judging from higher survival but similar adverse events, radiofrequency ablation is superior to ethanol injection for small hepatocellular carcinoma.     

Short- and-long term results of intraoperative radiofrequency ablation of liver metastases

BACKGROUND: Surgical resection is the only therapeutic option with curative effect on malignant liver tumours, but in over 70% of cases, this is not a feasible option. A prospective study was performed to assess the short- and long-term effects of intraoperative radiofrequency ablation on unresectable liver metastases. PATIENTS: Between 1997 and 2001, 57 patients (mean age 61.9 years; range 31-83 years) with 297 unresectable liver metastases (colorectal adenocarcinoma, n=38; carcinoid tumour, n=4; malignant melanoma, n=3; other metastases, n=12) underwent intraoperative radiofrequency ablation. RESULTS: No mortality was observed in patients managed solely with radiofrequency ablation. Eight postoperative complications occurred in eight patients (14%). Three occurred when radiofrequency ablation was combined with resection. Of the 33 patients completely ablated, 30 patients are still alive and 21 are disease-free after a median follow-up of 18.1 months (range 2-43). Ten patients underwent more than one intraoperative radiofrequency ablation episode. Overall survival was 72.5% at 1 year and 52.5% at 3 years. Complete ablation and the number of lesions were significant independent prognostic factors for survival, with p<0.001 and p<0.0001, respectively. CONCLUSION: Radiofrequency ablation is a safe and effective option for patients with inoperable liver metastases without extra hepatic disease. Prospective controlled trials comparing the results of different treatments are required to assess which patients will benefit best from this emerging new treatment.     

Is resection for large hepatocellular carcinoma in cirrhotic patients beneficial? Study of 38 cases.

BACKGROUND/AIMS: Hepatocellular carcinoma in cirrhotic patients generally carries a poor prognosis either due to recurrence or to postoperative morbidity or both. Several factors affect the prognosis of hepatocellular carcinoma resection as presence of cirrhosis of the liver, tumor diameter and tumor capsulation. METHODOLOGY: Thirty-eight patients with large hepatocellular carcinoma greater than 5 cm with a background of cirrhotic liver were divided into two groups according to tumor diameter. Group A (n = 20) with tumors less than 10 cm in diameter, and group B (n = 18) with tumors larger than 10 cm. All patients underwent preoperative investigations including clinical laboratory tests, sonography, computed tomography, selective angiography and upper gastrointestinal endoscopy. All patients were subjected to different types of hepatic resection. RESULTS: A significant difference in tumor size, capsulation, and operation time were recorded between the two groups, of patients. No significant difference was detected between both groups regarding sex, age, viral markers, pathologic features, and Child classification. Hospital mortality occurred in 5% versus 11.1% of both groups, respectively. Postoperative jaundice and ascitis occurred in 30%, 35% versus 44.4%, 72.0%, respectively (P < 0.005, P < 0.04). Late mortality occurred in 65% of patients in group A and in 77% of group B. Recurrence was detected in 42% of group A and 62% in group B. Recurrence after resection in capsulated tumors was significantly lower than in noncapsulated tumors in group A (P < 0.01), but not significant in group B. Also, survival rate in patients with capsulated tumors was significantly better in both groups (P < 0.01) than that with noncapsulated tumors. CONCLUSIONS: Resection of hepatocellular carcinoma with diameter larger than 10 cm recorded bad prognosis regarding recurrence and mortality rates than tumors less than 10 cm. However, capsulated tumors gave better postoperative prognosis than noncapsulated ones.