Outcome of transarterial chemoembolization monotherapy, and in combination with percutaneous ethanol injection, or radiofrequency ablation therapy for hepatocellular carcinoma

Aim:  Hepatocellular carcinoma (HCC) is one of the most commonly occurring malignances worldwide. Curative therapies such as resection, percutaneous ethanol injection (PEI) and radiofrequency ablation (RFA) have been applied to patients with early-stage HCC. Patients with more advanced cancers require local or systemic therapies. We present the results of our retrospective review conducted to evaluate whether transarterial chemoembolization (TACE) alone and combined TACE with percutaneous ablation for HCC exhibited superior efficacy to palliative treatment.
Methods:  The effects of TACE and of the combined therapies (TACE + PEI or TACE + RFA) on the long-term survival rates were evaluated in 268 untreated HCC patients by various statistical analyses.
Results:  The cumulative survival rates in the TACE alone group were significantly superior to those in the palliative treatment group. Further, the cumulative survival rates in the combined TACE + PEI/RFA group were significantly superior to those in the TACE alone group. When the comparison among the groups was restricted to patients with two or three tumors fulfilling the Milan criteria, significantly greater prolongation of survival was observed in the combined TACE + PEI/RFA group than in the PEI/RFA alone group.
Conclusions:  The aforementioned treatment modalities yielded greater improvements of the survival rate and survival duration as compared to palliative treatment in HCC patients. Furthermore, in terms of the effect on the survival period, combined TACE + PEI/RFA therapy was more effective than TACE monotherapy, and also more effective than PEI or RFA monotherapy in cases with multiple tumors fulfilling the Milan criteria.     

Locoregional management of hepatocellular carcinoma. Surgical and ablation therapies

The selection of an appropriate treatment strategy for patients with HCC depends on careful tumor staging and assessment of the underlying liver disease (Fig. 5). All patients with localized HCC (involvement of one single lobe, no vascular invasion or extrahepatic disease) should be evaluated for the potentially curative therapeutic options of partial hepatectomy or OLT. Candidates for partial hepatectomy must have no liver disease or Child's A cirrhosis, normal portal pressure, and normal serum bilirubin. For patients not meeting these criteria, OLT should be considered if there is a solitary lesion smaller than 5 cm in diameter or fewer than three lesions smaller than 3 cm. Local ablative therapies such as PEI, RFA, and TACE offer palliation for patients for whom surgical approaches are contraindicated. Percutaneous alcohol injection and RFA are minimally invasive and can be used on an outpatient basis, usually for tumor nodules smaller than 3 cm. When these therapies are used for small tumors, the survival rates can be similar to those achieved by partial hepatectomy. Transcatheter [figure: see text] arterial chemoembolization may be used as an interim treatment for patients waiting for OLT. Although TACE is often used for the palliation of large tumors, significant survival benefits have not yet been demonstrated for this indication.     

Transarterial chemoembolization in combination with percutaneous ablation therapy in unresectable hepatocellular carcinoma: a meta‐analysis

Background: Recent evidence suggests that transcatheter arterial chemoembolization (TACE) combined with radiofrequency ablation (RFA) or a percutaneous ethanol injection (PEI) may have a synergistic effect in treating hepatocellular carcinoma (HCC). The aim of the current meta‐analysis was to identify the survival benefits of TACE combined with percutaneous ablation (PA) therapy (RFA or PEI) for unresectable HCC compared with those of TACE or PA alone. Methods: Randomized‐controlled trials (RCTs) published as full papers or abstracts were searched to assess the survival benefit or tumour recurrence for patients with unresectable HCC on electronic databases. The primary outcome was survival. The secondary outcomes were response to therapy and tumour recurrence. Results: Ten RCTs met the criteria to perform a meta‐analysis including 595 participants. TACE combined with PA therapy, respectively improved, 1‐, 2‐, and 3‐year overall survival compared with that of monotherapy [odds ratio (OR) 2.28, 95% confidence interval (CI) 1.14–4.57; P=0.020], (OR=4.53, 95% CI 2.62–7.82, P<0.00001) and (OR=3.50, 95% CI 1.75–7.02, P=0.0004). Sensitivity analysis demonstrated a significant benefit in 1‐, 2‐ and 3‐year overall survival of TACE plus PEI compared with that of TACE alone for patients with large HCC lesions, but not in TACE plus RFA vs RFA for patients with small HCCs. The pooled result of five RCTs showed that combination therapy decreased tumour recurrence compared with that of monotherapy (OR=0.45, 95% CI 0.26–0.78, P=0.004). Conclusion: TACE combined with PA therapy especially PEI improved the overall survival status for large HCCs.     

Radiofrequency ablation or percutaneous ethanol injection for the treatment of liver tumors

The liver is a common location of both primary and secondary malignancies. For unresectable liver cancer, many local ablative therapies have been developed. These include e.g., percutaneous ethanol injection (PEI), percutaneous acetic acid injection, radiofrequency ablation (RFA), cryoablation, microwave ablation, laserinduced thermotherapy, and high-intensity focused ultrasound. RFA has recently gained interest and is the most widely applied thermoablative technique. RFA allows more effective tumor control in fewer treatment sessions compared with PEI, but with a higher rate of complications. However, there are certain circumstances where PEI therapy represents a better strategy to control liver tumors than RFA, especially in situations where RFA is difficult, for example when large vessels surround the tumor. In the context of hepatocellular carcinoma (HCC), both RFA and PEI are feasible and of benefit in non-operable patients. RFA seems superior to PEI in HCC 2 cm, and the combination of interventions may be of benefit in selected patients. Liver resection is superior to RFA for patients with HCC meeting the Milan criteria, but RFA can be employed in tumors ≤ 3 cm and where there is an increased expected operative mortality. In addition, some lines of evidence indicate that RFA and PEI can be employed as a bridge to liver transplantation. The use of RFA in colorectal liver metastases is currently limited to unresectable disease and for patients unfit for surgery. The aim of this article is to summarize the current status of RFA in the management of liver tumors and compare it to the cheap and readily available technique of PEI.     

Multimodal therapy for hepatocellular carcinoma: A complementary approach to liver transplantation

Objective. To evaluate the survival benefit of multimodal therapy for the treatment of HCC.Background. Orthotopic liver transplantation (OLT) is considered the treatment of choice for selected patients with hepatocellular carcinoma (HCC). However, donor organ shortages and patients whose HCCs exceed OLT criteria require consideration of alternate therapeutic options such as hepatic resection, radiofrequency ablation (RFA), ethanol injection (EI), transarterial chemoembolization (TACE), and chemotherapy (CTX). This study was performed to evaluate the survival benefit of multimodal therapy for treatment of HCC as complementary therapy to OLT.Methods. A retrospective review was conducted of HCC patients undergoing therapy following multidisciplinary review at our institution from 1996 - 2006 with a minimum of a 2 year patient follow-up. Data were available on 247/252 patients evaluated. Relevant factors at time of diagnosis included symptoms, hepatitis B (HBV) and C (HCV) status, antiviral therapy, Child-Pugh classification, portal vein patency, and TNM staging. Patients underwent primary treatment by hepatic resection, RFA, EI, TACE, CTX, or were observed (best medical management). Patients with persistent or recurrent disease following initial therapy were assessed for salvage therapy. Survival curves and pairwise multiple comparisons were calculated using standard statistical methods.Results. Mean overall survival was 76.8 months. Pairwise comparisons revealed significant mean survival benefits with hepatic resection (93.2 months), RFA (66.2 months), and EI (81.1 months), compared with TACE (47.4 months), CTX (24.9 months), or observation (31.4 months). Shorter survival was associated with symptoms, portal vein thrombus, or Child-Pugh class B or C. HCV infection was associated with significantly shorter survival compared with HBV infection. Antiviral therapy was associated with significantly improved survival in chronic HBV and HCV patients only with earlier stage disease.Conclusion. Multimodal therapy is effective therapy for HCC and may be used as complementary treatment to OLT.     

Role of percutaneous ethanol injection in the treatment of hepatocellular carcinoma

In the treatment of early and intermediate hepatocellular carcinoma, the range of indications for percutaneous ablation techniques is becoming wider than surgery or intra-arterial therapies. Indeed, whereas for some years only patients with up to three small tumors were treated, with the introduction of the single-session percutaneous ethanol injection (PEI), performed under general anesthesia, even patients with more advanced disease are now being treated. Although it is understood that partial resection assures the highest local control, the survival rates after surgery are roughly comparable with PEI. The explanation for this is a balance among the advantages and disadvantages of the two therapies. PEI survival curves are better than curves for resected patients who present adverse prognostic factors, and this means that surgery needs a better selection of the patients. Indications for both therapies are reported. An open question remains the choice between PEI and other new ablation procedures. In our department we currently use radiofrequency ablation in the majority of patients but consider PEI and segmental transarterial chemoembolization complementary, and use them according to the features of the disease and the response.     

Management of inoperable hepatocellular carcinoma

Abstract   Hepatocellular carcinoma (HCC) is a common and difficult-to-treat malignant tumor. Surgical interventions are feasible in only a small proportion of patients, and non-surgical therapy has been frequently administered to patients with inoperable HCC. Various modalities of loco-regional therapy have gained much interest during the past decade. Among them, transarterial chemoembolization (TACE), percutaneous injection of ethanol (PEI) or acetic acid (PAI), radiofrequency ablation (RFA) and microwave coagulation therapy (MCT) are effective treatment options. TACE can target multiple hypervascular tumors but has the potential risk of inducing hepatic or renal failure. PEI is a well-established method for small (< 3 cm) HCC, and PAI has the advantage over PEI as being more effective with fewer treatment sessions. RFA has excellent tumor ablation ability, and has been extended to treat medium- or large-sized HCC. However, the overall complication rate may be higher than previously assumed. MCT is similar to RFA in its clinical application and adverse effects. Although combination therapy often achieves a higher response rate, the side-effects may also be additive. Other therapies, such as injection of hot saline or yttrium-90 microspheres, interstitial laser photocoagulation and cryoablation are seldom used nowadays. Thalidomide may be useful in a minority of HCC patients, whereas radiotherapy, chemotherapy and tamoxifen are generally ineffective. In conclusion, although long-term survival in patients with inoperable HCC is possible in selected patients, the overall prognosis remains unsatisfactory, especially in those with aggressive tumor behavior. Newer antitumor therapy with better treatment efficacy is urgently needed. Information of the design for a more comprehensive approach using the existing therapeutic options may help refine the treatment strategy.     

Survival rates according to the Cancer of the Liver Italian Program scores of 345 hepatocellular carcinoma patients after multimodality treatments during a 10-year period in a retrospective study

Background and Aim: The Cancer of the Liver Italian Program (CLIP) score has been demonstrated to have superior prognostic ability in hepatocellular carcinoma (HCC) patients worldwide, but there has never been sufficient assessment of the efficacy of treatment modalities according to the CLIP score. This retrospective cohort study of HCC patients was conducted to assess the efficacy of treatment modalities according to the CLIP score. Methods: We compared the efficacy of hepatic resection (HR) (n = 101), radiofrequency ablation with prior transcatheter arterial chemoembolization (RFA + TACE) (n = 115), percutaneous ethanol injection with prior TACE (PEI + TACE) (n = 43), and TACE (n = 86) as a primary treatment in terms of survival among 345 patients treated at Mie University Hospital between 1995 and 2004, according to CLIP score. Results: The overall survival rates in the RFA + TACE group were significantly higher in the patients with CLIP scores of 1, 2, and 3 or more (5‐year, 70.9%; 3‐year, 73.7%; and 3‐year, 100%, respectively), but they were not significantly different from the 5‐year survival rates of the HR group with a CLIP score of 0 (83.7%). Among the patients with a CLIP score of 0, a significantly higher disease‐free survival rate (5‐year: 33.7%) was obtained in the HR subgroup (n = 35) than in the RFA + TACE subgroup (n = 35), both of which were followed since 2000, but morbidity (21.8%) was highest in the HR group. Conclusion: RFA + TACE is concluded to be a safe treatment modality with better overall survival (5‐year, > 60%) in HCC patients regardless of their CLIP score.     

原发性肝癌外科治疗的理性思考

全球肝细胞癌（hepatocellular carcinoma,HCC）的发病率一直呈上升趋势,肝切除仍然是HCC患者的首选治疗。有临床症状肝癌患者的可切除率为20％～30％。大型肝切除术不输血是肝切除术的一个进展。原位肝移植应遵照米兰标准执行,并应把肝移植数量控制在肝切除数量的10％以下。HCC的微创治疗,包括经皮射频消融、经皮微波凝固治疗、冷冻治疗、高强度聚焦超声热疔等,一直在临床应用。芮静安提出的“120”肝外科技术适用于城市和农村的医院。未来,HCC患者治疗后的无瘤生存率将会提高。     

Therapeutic radiological interventional procedures in hepatocellular carcinoma.

BACKGROUND: To improve the survival rate of patients with hepatocellular carcinoma (HCC) in whom surgery is not possible, various methods have been developed employing angiographic and percutaneous techniques. We analyzed our experience with various percutaneous therapeutic interventional techniques done for HCC in our center. METHODS: Sixty-one patients with inoperable HCC (mean age 48.9 [SD 13.8] y; 47 men) were treated between January 1997 and December 2000 by transcatheter arterial chemoembolization (TACE) alone (22), TACE with percutaneous alcohol injection (PEI) (20), transcatheter arterial embolization (TAE) with steel coils and gel foam for gastrointestinal bleed (7), percutaneous radiofrequency ablation (1), percutaneous preoperative right portal vein embolization (3) and percutaneous preoperative tumor embolization to reduce blood loss at surgery (8). RESULTS: In 42 patients treated by TACE and PEI and TACE alone, tumor necrosis was scored; over 50% necrosis was seen only after six and nine months in both treatment groups. The survival rates after six and nine months and the median survival were similar in the two groups. Of 7 cases treated with TAE with steel coils and gel foam, the gastrointestinal bleeding stopped in four; in the other three, bleeding did not stop completely although less transfusion was required. In the patient treated by radiofrequency ablation, follow-up contrast-enhanced CT did not show enhancing tumor mass. We noted left lobe enlargement after percutaneous preoperative right portal vein embolization, prior to right hepatectomy. CONCLUSION: In patients with HCC not amenable to surgical intervention, a variety of percutaneous therapeutic interventional techniques may be used.     

Indications for hepatectomy for hepatocellular carcinoma — What stage of the disease is the best indication for surgery?

To determine the clinical and tumor stage of hepatocellular carcinoma (HCC) that is the best indication for surgery, the postoperative long-term outcomes of patients who underwent hepatic resection were examined retrospectively. Of 975 patients with HCC who underwent regional therapy, 384 patients (39%) received hepatic resection (HR), 534 (55%) had transcatheter arterial chemoembolization (TACE), and the remaining 57 (6%) received percutaneous ethanol injection (PEI) into the tumor. The criteria defined by liver Cancer Study Group of Japan was used for staging and liver functional reserve (i.e., clinical staging).¹ In the 133 patients with stage I HCC, there were no significant differences among the survivals of the HR, TACE, and PEI groups. In the 314 patients with stage II HCC, the 5- and 7-year survival rates were 51% and 46% in the HR group, 23% and 10% in the TACE group, and 0% and 0% in the PEI group. The survival of the HR group was significantly better than the survivals of the TACE and PEI groups (P < 0.001). The 5- and 10-year survivals of the stage II HCC patients who had HR were 64% and 47% in the clinical stage I (i.e., good liver function) group, significantly better than the 5; and 10-year survivals (32% and 23%) in the clinical stage II (i.e., bad liver function) group (P < 0.0001). Patients with good liver function in stage II are expected to have better survival and are considered to be the most suitable for HR.     

Transarterial chemoembolization in hepatocellular carcinoma treatment: Barcelona clinic liver cancer staging system

Hepatocellular carcinoma(HCC),the fifth most common cancer that predominantly occurs in liver cirrhosis patients,requires staging systems to design treatments. The barcelona clinic liver cancer staging system(BCLC) is the most commonly used HCC management guideline. For BCLC stage B(intermediate HCC),transarterial chemoembolization(TACE) is the standard treatment. Many studies support the use of TACE in early and advanced HCC patients. For BCLC stage 0(very early HCC),TACE could be an alternative for patients unsuitable for radiofrequency ablation(RFA) or hepatic resection. In patients with BCLC stage A,TACE plus RFA provides better local tumor control than RFA alone. TACE can serve as bridge therapy for patients awaiting liver transplantation. For patients with BCLC B,TACE provides survival benefits compared with supportive care options. However,because of the substantial heterogeneity in the patient population with this stage,a better patient stratification system is needed to select the best candidates for TACE. Sorafenib represents the first line treatment in patients with BCLC C stage HCC. Sorafenib plus TACE has shown a demonstrable effect in delaying tumor progression. Additionally,TACE plus radiotherapy has yielded better survival in patients with HCC and portal venous thrombosis. Considering these observations together,TACE clearly has a critical role in the treatment of HCC as a stand-alone or combination therapy in each stage of HCC. Diverse treatment modalities should be used for patients with HCC and a better patient stratification system should be developed to select the best candidates for TACE.     

Radiofrequency ablation versus ethanol injection for early hepatocellular carcinoma: A randomized controlled trial

Objective. To compare percutaneous ethanol injection (PEI), the standard approach which has been used for many years to treat early non-surgical hepatocellular carcinoma (HCC) in cirrhotic patients, and radiofrequency ablation (RFA), which has become an interesting alternative. Material and methods. A randomized trial was carried out on 139 cirrhotic patients in Child-Pugh classes A/B with 1–3 nodes of HCC (diameter 15–30 mm), for a total of 177 lesions. Patients were randomized to receive RFA (n=70) or PEI (n=69). The primary end-point was complete response (CR) 1 year after the percutaneous ablation of all HCC nodes identified at baseline. Secondary end-points were: early (30–50 days) CR, complications, survival and costs. Results. In an intention-to-treat analysis, 1-year CR was achieved in 46/70 (65.7%) and in 25/69 (36.2%) patients treated by RFA and PEI, respectively (p=0.0005). For lesions >20 mm in diameter, there was a larger CR rate in the RFA group (68.1% versus 26.3%). An early CR was obtained in 67/70 (95.7%) patients treated by RFA compared with 42/64 (65.6%) patients treated by PEI (p=0.0001). Complications occurred in 10 and 12 patients treated by RFA and PEI, respectively. The overall survival rate was not significantly different in the RFA versus PEI arm (adjusted hazard ratio=0.88, 95% CI: 0.50–1.53). There was an incremental health-care cost of 8286 € for each additional patient successfully treated by RFA. Conclusions. The 1-year CR rate after percutaneous treatment of early HCC was significantly better with RFA than with PEI but did not provide a clear survival advantage in cirrhotic patients.     

Hepatocellular carcinoma ≤ 4 cm treated with radiofrequency ablation with or without percutaneous ethanol injection

Background. To compare the survival of Chinese cirrhotic patients with hepatocellular carcinoma (HCC) ≤ 4 cm who underwent radiofrequency ablation (RFA) alone or a combination of RFA with percutaneous ethanol injection (PEI).Material and methods. Retrospective analysis was performed for 681 cases with HCC ≤ 4 cm who were treated with RFA alone or RFA combined with PEI (RFA + PEI) between 2004 and 2011.Results. As a result, 180 patients in each group were selected after propensity score matching (PSM). Higher overall survival (OS) and recurrence-free survival (RFS) rates were achieved by RFA + PEI compared with RFA alone (P = 0.019 and 0.009, respectively). The 1-, 3-, and 5-year cumulative OS rates were 78.0, 44.4, and 30.1% for patients in RFA group and 88.2, 58.0, and 41.1% for patients in RFA + PEI group, respectively. Besides, the 1-, 3-, and 5-year cumulative RFS rates were 77.0, 43.8, and 29.2% in RFA group, and 87.9, 57.6, and 38.4% in RFA + PEI group, respectively. The local recurrence, complete ablation and five-year mortality showed no distinct differences between RFA and RFA + PEI groups in three subgroups classified with tumor size. Moreover, Cox regression multivariate analysis results showed that sex and treatment approach were significantly related to OS, whereas sex, status of HBsAg, local recurrence, and number of tumor nodule were related to RFS.Conclusion. Therefore, the combination of RFA and PEI yielded better OS and RFS rates than RFA alone for Chinese patients with HCC ≤ 4 cm.     

Radiofrequency Ablation of Liver Metastases from Colorectal Cancer: A Literature Review

Liver metastases occur in up to 60% of patients with colorectal cancer, and the control of liver metastases is considered to be of primary importance because it is a critical factor in determining prognosis. Radiofrequency ablation (RFA) therapy is one of the least invasive techniques for unresectable hepatic malignancies and can be performed safely using percutaneous, laparoscopic, or open surgical techniques. The local tumor progression rates after RFA for colorectal liver metastases range from 8.8% to 40.0%, and 5-year survival rates range from 20.0% to 48.5%. No prospective, randomized trials comparing the efficacy of RFA with that of surgical resection for colorectal liver metastases are currently available. However, some retrospective studies have reported that patients who received RFA had a survival rate similar to that observed in surgically treated groups, while other studies have reported better survival among patients who underwent surgical resection. The use of a laparoscopic or open surgical approach allows the repeated placement of RFA electrodes at multiple sites to ablate larger tumors. An accurate evaluation of treatment response is very important for the success of RFA therapy because a sufficient safety margin (at least 0.5 cm) can prevent local tumor progression. This review critically summarizes the current status of RFA for liver metastases from colorectal cancer.     

Surgical resection versus radiofrequency ablation for small hepatocellular carcinomas within the Milan criteria

Background/Purpose

It has been reported that hepatic resection may be preferable to other modalities for the treatment of small hepatocellular carcinomas (HCCs), by contributing to improved overall and disease-free survival. Ablation techniques such as radiofrequency ablation (RFA) have also been used as therapy for small HCCs; however, few studies have compared the two treatments based on long-term outcomes. The effectiveness of hepatic resection and RFA for small nodular HCCs within the Milan criteria were compared.

Methods

A retrospective cohort study was performed with 278 consecutive patients who underwent curative hepatic resection (n = 123) or initial RFA percutaneously (n = 110) or surgically (thoracoscopic-, laparoscopic-, and open-approaches; n = 45) for HCC. The selection criteria for treatment were based on uniform criteria. Mortality related to therapy and 3- and 5-year overall and disease-free survivals were analyzed.

Results

The model for endstage liver disease (MELD) scores for all patients in the series were less than 13. There were no therapy-related mortalities in either the hepatic resection or RFA groups. The incidence of death within 1 year after therapy (1.6 and 1.9%, respectively) was similar in the hepatic resection and RFA groups. The group that underwent hepatic resection showed a trend towards better survival (P = 0.06) and showed significantly better disease-free survival (P = 0.02) compared with the RFA group, although differences in liver functional reserve existed. The advantage of hepatic resection was more evident for patients with single tumors and patients with grade A liver damage. In contrast, patients with multinodular tumors survived longer when treated with RFA, regardless of the grade of liver damage. Further analysis showed that surgical RFA could potentially have survival benefits similar to those of hepatic resection for single tumors, and that surgical RFA had the highest efficacy for treating multinodular tumors.

Conclusions

In patients with small HCCs within the Milan criteria, hepatic resection should still be employed for those patients with a single tumor and well-preserved liver function. RFA should be chosen for patients with an unresectable single tumor or those with multinodular tumors, regardless of the grade of liver damage. In order to increase long-term oncological control, surgical RFA seems preferable to percutaneous RFA, if the patient’s condition allows them to tolerate surgery.     

双途径介入疗法治疗原发性肝癌疗效评价

目的　探讨双途径介入疗法 (下称双介入法 )治疗原发性肝癌的临床价值。方法　选择原发性肝癌患者 6 5例 ,对其中 34例单纯行肝动脉化疗栓塞 (TACE,对照组 ) ,31例行 TACE和分次多点经皮肝穿刺注射无水乙醇 (双介入法 ,观察组 )。全部病例定期做 CT检查和 AFP测定 ,观察肿瘤客观疗效。结果　对照组及观察组肿瘤客观有效率 (CR+PR)分别为 35 .3%、6 4 .4 % (P<0 .0 5 ) ;AFP下降幅度分别为 5 6 .1%、78.6 % (P<0 .0 5 ) ;2年存活率分别为 5 0 %、6 1.3% (P<0 .0 5 )。结论　双介入法治疗原发性肝癌疗效肯定 ,优于单纯应用 TACE。     

Interventional therapies of unresectable liver metastases

Liver metastases are the major cause of mortality in patients with gastrointestinal carcinomas and other malignant tumors, carrying a poor prognosis and presenting considerable management. Surgical resection remains the only curative therapy for liver metastases up to now. However, only a small percentage of patients are suitable for curative resection due to many factors: multi-centric tumors, extrahepatic metastases, early vascular invasion, and coexisting advanced liver cirrhosis. In non-surgical cases, regional interventional therapies have led to a major break through in the treatment of unresectable liver metastases, which include transarterial chemoembolization (TACE), radiofrequency ablation (RFA), laser-induced thermotherapy (LITT), cryosurgical ablation (CSA), microwave coagulation therapy (MCT), percutaneous ethanol injection (PEI), and others. As a result of the technical development of locoregional approaches for unresectable liver metastases during recent decades, the range of combined interventional therapies has been continuously enlarged. The current roles of these treatment options for liver metastases are discussed in this review.     

Idiopathic Thrombocytopenic purpura and Helicobacter pylori Infection

Abstract

Objective. As a minimally invasive modality, radiofrequency ablation (RFA) has been increasingly applied not only for the treatment of hepatocellular carcinoma, but also for that of colorectal liver metastasis (CLM). However, RFA for CLM has been shown to be associated with a high local recurrence rate, and no optimal treatment for RFA failure has been established yet. The aim of this study was to evaluate the feasibility and outcome of surgical resection for local recurrence after RFA. Material and methods. A retrospective study of 17 patients, who underwent surgery for local recurrence after RFA for resectable CLM, was carried out. The surgical procedures involved in the actual surgery were compared with those envisioned for the primary resection if RFA had not been selected. Results. Surgical resection for RFA recurrence was more invasive than the envisioned surgical procedure in 10 cases (58%). In addition, the proportions of cases that required technically demanding procedures among the patients receiving surgery for RFA recurrence were higher than those in envisioned operations; major hepatectomy, eight cases [47%] versus two cases [12%] (p < 0.0205); excision and/or reconstruction of the major hepatic veins, three cases [18%] versus zero case [0%] (p = 0.035); excision of diaphragm: three cases [18%] versus zero case [0%] (p = 0.035). The 1-, 3- and 5-year overall survival rates were 92%, 45% and 45%, respectively. Conclusions. Surgical resection for RFA recurrence for CLM required more invasive and technically demanding procedures. Thus, RFA for CLM should be limited to unresectable cases, and patients with resectable CLM should be thoroughly advised not to undergo RFA, but rather surgical resection.     

Treatment of hepatocellular carcinoma by percutaneous interventional methods

In the treatment of early and intermediate hepatocellular carcinoma the range of indications for percutaneous ablation techniques is becoming wider than surgery or intra-arterial therapies. Indeed, whereas for some years only patients with up to three small tumors were treated, with the introduction of the single-session technique performed under general anesthesia, even patients with more advanced disease are now being treated. Although it is understood that partial resection assures the highest local control, the survival rates after surgery are roughly comparable with percutaneous ethanol injection. The explanation is due to a balance among advantages and disadvantages of the two therapies. Percutaneous ethanol injection survival curves are better than curves of resected patients who present adverse prognostic factors, and this means that surgery needs a better selection of the patients. Indications for both of these therapies are reported. An open question remains about the choice between percutaneous ethanol injection and other new ablation procedures. In our department we currently use radiofrequency ablation in the majority of patients but consider percutaneous ethanol injection and segmental transarterial chemoembolization complementary, and use them according to the features of the disease and the response. Evaluation of their therapeutic efficacy, techniques and results are reported.