Does the choice of treatment influence survival of patients with small hepatocellular carcinoma in compensated cirrhosis?

OBJECTIVE: Untreated patients with small, single hepatocellular carcinoma (HCC) in compensated cirrhosis are characterized by a relatively good prognosis. METHODS: We report the findings generated in a retrospective study on a cohort of 186 consecutive patients with small (< 5 cm) HCC in Child A or B cirrhosis, who were transplanted (four), underwent surgery (15), or were treated with percutaneous ethanol injection (117), lipiodol chemoembolization (44) or best supportive care (six), depending on their clinical features. RESULTS: Overall survival was 26% at 5 years (31% Child A, 20% Child B), with a mean and median survival of 44 and 38 months, respectively. The longest survival was obtained with transplantation and surgery, and the worst with best supportive care. When untreated patients were not considered, no significant differences were observed between the different types of treatment, however, even when patients in the Child A group were considered alone. Almost all the patients who underwent surgery relapsed. No significant difference was observed in relation to the stage of the disease, while alpha-fetoprotein levels were singled out as the only relevant prognostic factor in a multivariate Cox's regression model. Costs per year of life saved were extremely high for transplantation and lowest for ethanol injection, with surgery being less expensive than chemoembolization. CONCLUSIONS: This study confirms that patients with single, small HCC nodules in well compensated cirrhosis should be treated. The choice of type of treatment should be based on the availability of local resources and expertise, and on the patients' preference, after they have been properly informed on the survival, morbidity and mortality related to each treatment option. The relative cost of the procedures should also be considered.     

Surgical treatment strategy for hepatocellular carcinoma in patients with impaired liver function: hepatic resection or radiofrequency ablation?

Background

To compare the survival impacts of radiofrequency ablation (RFA) as an initial treatment for hepatocellular carcinoma (HCC) in patients with impaired liver functional reserve compared to those of hepatic resection (HR).

Is percutaneous ethanol injection therapy still effective for hepatocellular carcinoma in the era of radiofrequency ablation?

Percutaneous ethanol injection (PEI) therapy has been replaced by more-effective thermal ablation techniques that have lower local recurrence rates. However, PEI therapy remains useful in certain settings. Since PEI can be performed in any portion of the liver, PEI therapy can be valuable when tumors are located in close proximity to intestinal loops or other positions that are risky for thermal local ablative techniques. PEI therapy is also valuable in other situations where radiofrequency ablation (RFA) is difficult, including technically difficult masses that are not detected with ultrasound (US), are located in the hepatic dome, in the subcapsular area, and exophytically, or are surrounded by large vessels. PEI therapy contributes to combination therapy with transcatheter arterial chemoembolization or RFA in advanced-stage hepatocellular carcinoma (HCC), and also to the treatment of large HCC or extrahepatic metastasis from HCC. These roles of PEI therapy should be stressed for the treatment of HCCs in appropriate clinical situations. This comprehensive review of articles related to PEI therapy illustrates the recent role and indications of this therapy, which is currently valuable for HCC in the era of RFA.     

Comparison of transcatheter arterial chemoembolization,laparoscopic radiofrequency ablation,and conservative treatment for decompensated cirrhotic patients with hepatocellular carcinoma

AIM:To compare the therapeutic effect of transcatheterarterial chemoembolization (TACE),laparoscopic radiofrequencyablation (LRFA),and conservative treatment for the therapyof decompensated liver cirrhosis patients with hepatocellularcarcinomas (HCC).METHODS:Between October 2000 and July 2003,onehundred patients with histologically proven primary HCC andclinical decompensated liver cirrhosis (Child classification Bor C) were included in this study.Forty patients receivedLRFA (LRFA group),twenty received TACE (TACE group),and forty received conservative treatment (control group).We compared the survival,recurrence,and complication ratesin these three groups,making adjustment using the tumormetastastic node staging system.RESULTS:The major complication rate in the TACE group(9/20) was significantly higher than that in the LRFA group(7/40).For patients with TMN stage Ⅱ HCC,the survivalrate of the LRFA group was better than that of the TACEand control groups (P=0.003) but the recurrence ratesbefween the LRFA and TACE groups did not differ.CONCLUSION:The LRFA group of patients had betterclinical outcomes in terms of survival and complication ratesin comparison with the TACE group or conservative treatmentin patients with decompensated liver cirrhosis,especially inTMN patients with stage Ⅱ HCC.LRFA is thus an appropriatealternative treatment for poor liver function among patientswith HCC.     

Is the treatment outcome of hepatocellular carcinoma inferior in elderly patients?

In view of the increasing life expectancy in different parts of the world, a larger proportion of elderly patients with hepatocellular carcinoma(HCC) requiring oncological treatment is expected. The clinicopathological characteristics of HCC in elderly patients and in younger patients are different. Elderly patients, in general, also have more comorbidities. Evaluation of the efficacy of different HCC treatment options in elderly patients is necessary to optimize treatment outcomes for them. Treatment modalities for HCC include hepatectomy, liver transplantation, radiofrequency ablation, transarterial chemoembolization, and molecular-targeted therapy with sorafenib. In this review, current evidence on the risks and outcomes of the different HCC treatments for elderly patients are discussed. According to data in the literature, elderly patients and younger patients benefited similarly from HCC treatments. More clinical data are needed for the determination of selecting criteria on elderly HCC patients to maximize their chance of getting the most appropriate and effective treatments. As such,further studies evaluating the outcomes of different HCC treatment modalities in elderly patients are warranted.     

Sustained complete response and complications rates after radiofrequency ablation of very early hepatocellular carcinoma in cirrhosis: Is resection still the treatment of choice?

If liver transplantation is not feasible, partial resection is considered the treatment of choice for hepatocellular carcinoma (HCC) in patients with cirrhosis. However, in some centers the first-line treatment for small, single, operable HCC is now radiofrequency ablation (RFA). In the current study, 218 patients with single HCC 相似文献   

Results of percutaneous radiofrequency ablation of hepatocellular carcinoma in patients with cirrhosis aged 75 years and over

Purpose

The objective of this study was to assess the results and tolerance of radiofrequency ablation in patients with cirrhosis and hepatocellular carcinoma (HCC) older than 75 years.

Patients and methods

Over a period of 9 years from January 2001, 235 patients with cirrhosis and 3 or less HCC ≤ 5 cm of diameter were treated by radiofrequency ablation. Among them, 52 patients older than 75 years were selected for this study.

Results

The mean age was 79.4 ± 3. 5 years. There were 36 males, cirrhosis was classified Child-Pugh class A (n = 52) related to alcohol (n = 13), HCV infection (n = 33), or other causes (n = 6). The mean tumour diameter was 32.5 ± 10,6 mm, and 14 patients had a multifocal HCC. A complete ablation was obtained in 50/52 patients (96%). No severe complication occurred. The estimated overall survival rates were 62%, 52% and 36% at 3 years, 4 years and 5 years, respectively; it was similar to those observed in patients younger than 75 years.

Conclusion

In patients with cirrhosis older than 75 years, radiofrequency ablation of 3 or less HCC ≤ 5 cm is well tolerated and survivals rates are similar to those of younger patients.     

Is transarterial chemoembolization beneficial for patients with diffuse infiltrative hepatocellular carcinoma?

Purpose

Diffuse infiltrative hepatocellular carcinoma (D-HCC) is an incurable disease with short survival time. Transarterial chemoembolization (TACE) was often used to alleviate patient’s symptoms and reduce tumor burden. However, it remains unknown if the TACE benefits the survival of D-HCC patients.

Methods

A hospital-based retrospective study was conducted at a large referral hospital in Taiwan for a 9-year period (2000–2008).

Results

Of the 150 D-HCC patients, 106 patients were related to hepatitis B virus (HBV), 17 to hepatitis C virus (HCV), 3 to both HBV and HCV, and 24 not to HBV or HCV. Multivariate Cox regression analysis showed treatment strategy, serum alpha-fetoprotein level, model for end-stage liver disease (MELD) score, serum gamma glutamyl transferase, and serum lactic acid dehydrogenase were associated with survival time. Compared to supportive treatment, the adjusted hazard ratios of transarterial chemoembolization (TACE) and chemotherapy including oral or systemic chemotherapy were 0.383 (p < 0.001) and 0.711 (p = 0.289), respectively.

Conclusion

TACE is a preferred therapy for D-HCC patients.     

A successful treatment for hepatocellular carcinoma with Osler–Rendu–Weber disease using radiofrequency ablation under laparoscopy

Hepatocellular carcinoma (HCC) can be difficult to diagnose and treat in patients with Osler–Rendu–Weber disease due to vascular malformation and regenerative nodular hyperplasia. In addition, percutaneous liver puncture should be avoided for the diagnosis and treatment as the procedure carries a high risk of bleeding. We herein report the successful treatment of HCC in a patient with Osler–Rendu–Weber disease using radiofrequency ablation (RFA) under laparoscopy. A 71-year-old man with Osler–Rendu–Weber disease was admitted to our hospital for the treatment of HCC. He also had chronic hepatitis C virus infection. The arterioportal shunts in the liver were detected by computed tomography (CT) and angiography. A tumor 20 mm in size was detected as a defected-lesion in the hepatic segment IV during the portal phase by CT. RFA under laparoscopy was performed for the curative treatment for HCC, with sufficient ablation obtained. Although the blood gushed out from the needle tract at the end of the procedure, complete hemostasis was achieved promptly using coagulation forceps. The post-operative course was favorable. Thus, laparoscopic RFA is a useful treatment modality for HCC in patients with Osler–Rendu–Weber disease, as a hemostasis device can be used with direct visualization.     

Is endoscopic therapy the treatment of choice in all patients with chronic pancreatitis?

Chronic pancreatitis(CP) is a progressive inflammatory disease of the pancreas characterized by destruction of the pancreatic parenchyma with subsequent fibrosis that leads to pancreatic exocrine and endocrine insufficiency.Abdominal pain and local complications(bile duct or duodenal stenosis and pancreatic tumor) secondary to CP are indications for therapy.At the beginning,medical therapy is used.More invasive treatment is recommended for patients with pancreatic duct stones(PDS) and pancreatic obstruction in whom standard medical therapy is not sufficient.Recently,Clarke et al assessed the long-term effectiveness of endoscopic therapy(ET) in CP patients.The authors compared ET with medical treatment.They reported that ET was clinically successful in 50% of patients with symptomatic CP.In this commentary,current CP treatment,including indications for ET and surgery in CP patients,is discussed.Recommendations for endoscopic treatment of CP according to the European Society of Gastrointestinal Endoscopy Clinical Guidelines are reviewed.Different surgical methods used in the treatment of CP patients are also discussed.ET is the most useful in patients with large PDS,pancreatic duct obstruction and dilation.It should be the first-line option because it is less invasive than surgery.Surgery should be the first-line option in patients in whom ET has failed or in those with a pancreatic mass with suspicion of malignancy.ET is a very effective and less invasive procedure,but it cannot be recommended as the treatment of choice in all CP patients.