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.     

A Retrospective Comparison of Microwave Ablation vs. Radiofrequency Ablation for Colorectal Cancer Hepatic Metastases

Background

Microwave (MWA) and radiofrequency ablation (RFA) are the most commonly used techniques for ablating colorectal-liver metastases (CRLM). The technical and oncologic differences between these modalities are unclear.

Methods

We conducted a matched-cohort analysis of patients undergoing open MWA or RFA for CRLM at a tertiary-care center between 2008 and 2011; the primary endpoint was ablation-site recurrence. Tumors were matched by size, clinical-risk score, and arterial-intrahepatic or systemic chemotherapy use. Outcomes were compared using conditional logistic regression and stratified log-rank test.

Results

We matched 254 tumors (127 per group) from 134 patients. MWA and RFA groups were comparable by age, gender, median number of tumors treated, proximity to major vessels, and postoperative complication rates. Patients in the MWA group had lower ablation-site recurrence rates (6% vs. 20%; P < 0.01). Median follow-up, however, was significantly shorter in the MWA group (18 months [95% confidence interval 17–20] vs. 31 months [95% confidence interval 28–35]; P < 0.001). Kaplan–Meier estimates of ablation-site recurrence at 2 years were significantly lower for the lesions treated with MWA (7% vs. 18%, P: 0.01).

Conclusions

Ablation-site recurrences of CRLM were lower with MWA compared with RFA in this matched cohort analysis. Longer follow-up time in the MWA may increase the recurrence rate; however, actuarial local failure estimations demonstrated better local control with MWA.     

Local treatment of pulmonary metastases: from open resection to minimally invasive approach? Less morbidity, comparable local control

Background

The level of evidence for efficacy of local treatment of pulmonary metastases is low; therefore, complication rates should be minimized. Minimally invasive techniques may have the potential to reduce morbidity but potentially lead to more local and/or ipsilateral recurrences. The objective of this study was to evaluate the introduction of a new treatment strategy incorporating the increased use of video-assisted thoracic surgery (VATS) and radiofrequency ablation (RFA), weighing complications against recurrence rates.

Methods

We retrospectively reviewed results of all local treatment of pulmonary metastases in the Netherlands Cancer Institute from 2002 to 2007. Each of 158 identified interventions was analyzed separately to retrieve procedure-related data. Overall survival data were analyzed per patient. To evaluate the introduction of a strategy incorporating minimally invasive techniques, the study period was split in two (before and after the introduction of this strategy in July 2004).

Results

In Strategy I, 47 interventions (2 VATS, no RFA) were performed in 37 patients; in Strategy II 111 interventions (51 VATS and RFA) in 86 patients. Metastases of a variety of primary tumors were treated. Median hospital stay was shorter (5 vs. 7 days) and procedure-related morbidity was less with Strategy II (p < 0.01). Time-to-recurrence rates were comparable (p = 0.18), as were local and ipsilateral recurrence rates within 3 years (p = 0.72). Estimated overall 3-year survival was 59% for patients treated with Strategy I and 54% with Strategy II.

Conclusions

Increased use of minimally invasive techniques for local treatment of pulmonary metastatic disease is associated with low morbidity, without apparent reduction in (local) disease control.     

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).     

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.     

Minimally invasive approaches to extrapancreatic cholangiocarcinoma

Background

Due to the perceived difficulty in dissecting gallbladder cancers and extrapancreatic cholangiocarcinomas off of the portal structures and in performing complex biliary reconstructions, very few centers have used minimally invasive techniques to remove these tumors. Furthermore, due to the relative rarity of these tumors when compared to hepatocellular carcinoma, only a few reports have focused on short- and long-term results.

Methods

We performed a review by combining the experience of three international centers with expertise in complex minimally invasive hepatobiliary surgery. Patients were entered into a database prospectively. All patients with gallbladder cancer and cholangiocarcinoma were analyzed; patients with distal cholangiocarcinomas who underwent laparoscopic pancreatoduodenectomies were excluded. Patients were divided according to if they had gallbladder cancer, hilar cholangiocarcinoma, or intrahepatic cholangiocarcinoma.

Results

A total of 15 patients underwent laparoscopic resection for gallbladder cancer and 10 for preoperatively suspected gallbladder cancer, and 5 underwent laparoscopic completion procedures. An average of four lymph nodes (range = 1–11) were retrieved and all patients had an R0 resection. One patient (7 %) required conversion to an open procedure. No patients developed a biliary fistula, required percutaneous drainage, or had endoscopic stent placement. One patient had a recurrence at 3 months despite a negative final pathological margin, and a second patient had a distant recurrence at 20 months with a mean follow-up of 23 months. Nine patients underwent laparoscopic hepatectomy for intrahepatic cholangiocarcinoma. All anastomoses were completed laparoscopically. Biliary fistula was seen in two patients, one of which died after a transhepatic percutaneous biliary drain resulted in uncontrollable intra-abdominal hemorrhage despite reoperation. A third patient developed a pulmonary embolism. Thus, the morbidity and mortality rates were 33 and 11 %, respectively. One patient was converted to open and six patients (66 %) are alive with a median follow-up of 22 months. Five patients underwent minimally invasive resection for hilar cholangiocarcinoma; of these, two also required laparoscopic major hepatectomy. The mean estimated blood loss (EBL) was 240 mL (range = 0–400 mL) and the median length of stay (LOS) was 15 days (range = 11–21 days). All patients are alive with a median follow-up of 11 months (range = 3–18 months). None of the 29 patients developed port site recurrences.

Conclusion

Minimally invasive approaches to gallbladder cancer and intrahepatic and extrahepatic cholangiocarcinoma seem feasible and safe in the short term. Larger series with longer follow-up are needed to see if there are any long-term disadvantages or advantages to laparoscopic resection of extrapancreatic cholangiocarcinoma.     

Safety and long-term results of endoscopic transanal resection in treating rectal adenomas: 15 years’ experience

Background

Endoscopic transanal resection (ETAR) is a scarcely used technique to treat large or sessile rectal adenomas not amenable to polypectomy. The purpose of this study was to evaluate safety and long-term results of ETAR in treating rectal adenomas in three hospitals over 15 years.

Methods

Patients who underwent ETAR during 1996–2010 were retrospectively analyzed with respect to patient, adenoma, and operative characteristics, earlier operations, complications, follow-up time, recurrence rates, recurrence treatment, and cancer incidence.

Results

Ninety-two patients underwent a total 111 ETARs to treat rectal adenoma. The mean age of patients was 71 years, and the median ASA class 3. Twenty-eight patients previously had received other treatments for rectal adenoma. Incidental carcinoma was found in eight patients. Sixty-seven adenomas were treated with only one ETAR and 17 with two or three ETARs. Sixty-seven patients did not have a recurrence, whereas 14 patients had an adenoma recurrence and 3 patients developed invasive carcinoma during a mean follow-up of 30 months. Complications occurred in 14 patients; all were minor, except for one explorative laparotomy without findings. No mortalities or conversions to open surgery occurred.

Conclusions

ETAR is a minimally invasive and safe technique with inexpensive instrumentation to treat rectal adenomas that are not amenable to polypectomy. Adenoma recurrence rate was 15 % and cancer incidence 3 % in follow-up.     

Re-resection for Isolated Local Recurrence of Pancreatic Cancer is Feasible, Safe, and Associated with Encouraging Survival

Background

Local recurrence of pancreatic cancer occurs in 80 % of patients within 2 years after potentially curative resections. Around 30 % of patients have isolated local recurrence (ILR) without evidence of metastases. In spite of localized disease these patients usually only receive palliative chemotherapy and have a short survival.

Purpose

To evaluate the outcome of surgery as part of a multimodal treatment for ILR of pancreatic cancer.

Methods

All consecutive operations performed for suspected ILR in our institution between October 2001 and October 2009 were identified from a prospective database. Perioperative outcome, survival, and prognostic parameters were assessed.

Results

Of 97 patients with histologically proven recurrence, 57 (59 %) had ILR. In 40 (41 %) patients surgical exploration revealed metastases distant to the local recurrence. Resection was performed in 41 (72 %) patients with ILR, while 16 (28 %) ILR were locally unresectable. Morbidity and mortality were 25 and 1.8 % after resections and 10 and 0 % after explorations, respectively. Median postoperative survival was 16.4 months in ILR versus 9.4 months in metastatic disease (p < 0.0001). In ILR median survival was significantly longer after resection (26.0 months) compared with exploration without resection (10.8 months, p = 0.0104). R0 resection was achieved in 18 patients and resulted in 30.5 months median survival. Presence of metastases, incomplete resection, and high preoperative CA 19-9 serum values were associated with lesser survival.

Conclusions

Resection for isolated local recurrence of pancreatic cancer is feasible, safe, and associated with favorable survival outcome. This concept warrants further evaluation in other institutions and in randomized controlled trials.     

Transoral Endoscopic Resection of Low-Grade,Cricoid Chondrosarcoma

Background

Low-grade chondrosarcomas account for 1 % of all laryngeal tumors and typically arise in the cricoid cartilage. They are usually indolent, slow-growing cancers that are locally invasive and rarely metastasize. Surgical excision is considered the treatment of choice. Radiotherapy and chemotherapy generally are ineffective. Surgical management must balance tumor clearance with preservation of laryngeal functions (swallowing, voice, and respiration).

Methods

Prospective outcome analysis of seven patients operated with endoscopic resection for low grade cricoid chondrosarcomas.

Results

Mean age at presentation was 61 years (range 49–75), male:female ratio was 4:3. All patients are currently alive and free of disease with an average follow-up of 80 months (range 63–138). Overall 5-year survival is 100 %, 5-year disease-free survival rate 85.7 %, and overall recurrence rates 14.3 %. One of the seven patients developed a limited recurrence at 21 months and underwent a second endoscopic resection. During initial management two patients needed temporary tracheotomy. Successful decannulation and normal breathing were obtained within 3 months with no long-term sequelae. The airway calibre of the remaining patients was minimally affected. All patients have normal postoperative swallowing function and adequate voice that is unassisted by amplification.

Conclusions

These findings support the use of endoscopic resection for managing selected newly diagnosed cases of cricoid chondrosarcoma as well as the role of repeated endoscopic resection for managing cases of recurrent cricoid chondrosarcoma.     

Durability of Focused Minimally Invasive Parathyroidectomy in Young Patients with Sporadic Primary Hyperparathyroidism

Background

Historically, multigland hyperplasia was believed to be the predominant cause of primary hyperparathyroidism (PHPT) in young patients, and hence a relative contraindication for minimally invasive parathyroidectomy. Recent studies, however, demonstrate that the most common aetiology across all age groups is a solitary functioning adenoma. The aim of this study was to compare long-term outcomes in young patients (≤45 years), especially those under 30 years of age, with their older counterparts (>45 years) following focused minimally invasive parathyroidectomy (FMIP).

Materials and Methods

Patients ≤45 years who underwent FMIP between January 1999 and December 2007 were identified from an endocrine surgery database and compared with a matched control group of patients >45 years old also undergoing FMIP within that time period. The patients’ most recent calcium levels (≥6 months postoperatively) were examined to establish recurrence rates. Recurrence was defined as an elevation of serum calcium more than 6 months after surgery following initial postsurgical normocalcemia.

Results

A total of 117 patients ≤45 years and 160 patients >45 years who underwent FMIP were examined. Follow-up calcium levels were available for 72% of patients. The median length of follow-up was 46 months. No recurrences were identified in both the younger and older cohort of patients; therefore, no statistically significant difference in rates of recurrence could be determined between age groups.

Conclusion

Recurrence of PHPT following FMIP is rare with no evidence of a higher incidence in younger patients. FMIP can be safely offered to young patients as a long-term durable treatment option.     

Minimally invasive treatment for pubic ramus fractures combined with a sacroiliac joint complex injury

Purpose

Fractures of the pubic rami due to low energy trauma are common in the elderly, with an incidence of 26 per 100,000 people per year in those aged more than 60 years. The purpose of this study was to evaluate the clinical application of this minimally invasive technique in patients with pubic ramus fractures combined with a sacroiliac joint complex injury, including its feasibility, merits, and limitations.

Methods

Fifteen patients with pubic ramus fractures combined with sacroiliac joint injury were treated with the minimally invasive technique from June 2008 until April 2012. The quality of fracture reduction was evaluated according to the Matta standard.

Results

Fourteen cases were excellent (93.3 %), and one case was good (6.7 %). The fracture lines were healed 12 weeks after the surgery. The 15 patients had follow-up visits between four to 50 months (mean, 22.47 months). All patients returned to their pre-injury jobs and lifestyles. One patient suffered a deep vein thrombosis during the peri-operative period. A filter was placed in the patient before the surgery and was removed six weeks later. There was no thrombus found at the follow-up visits of this patient.

Conclusion

The minimally invasive technique in patients with pubic ramus fractures combined with a sacroiliac joint complex injury provided satisfactory efficacy.     

Metastatic Behavior of Upper Tract Urothelial Carcinoma After Radical Nephroureterectomy: Association with Primary Tumor Location

Purpose

To investigate the site-specific pattern of disease recurrence and/or metastasis and the associated patient outcomes after radical nephroureterectomy (RNU) in upper tract urothelial carcinoma (UTUC).

Methods

A total of 733 patients with UTUC from a retrospective multi-institutional cohort were included, with a median follow-up of 34 months. Associated patient outcomes were analyzed by multivariate analysis. To evaluate the influence of primary tumor location, we divided it into four areas: renal pelvis, and upper, middle, and lower ureter.

Results

A total of 218 patients experienced disease recurrence, with the majority of relapses occurring within the first 3 years. Cumulative incidence rates of first disease recurrence at 1 and 3 years were 18.9 and 29.8 %, respectively. Of these patients, 38.5 % developed distant recurrence; 17.4 % experienced both local and distant recurrences; and 44.0 % developed isolated local recurrence. The predominant sites of distant metastasis were lung, liver, and bone. Multivariate analysis revealed that the prevalence of local recurrence and lung metastasis was significantly associated, with primary tumor location being independent of other clinicopathological variables. Lower/middle ureter tumors had a higher rate of local recurrence in the pelvic cavity, and renal pelvic tumors had a higher prevalence of distant relapse in the lungs. Similar results were obtained when rerunning the data set by excluding patients who received adjuvant chemotherapy (n = 131).

Conclusions

This multi-institutional study provided a detailed picture of metastatic behavior after RNU, and primary tumor locations were associated with unique patterns of metastatic spread in UTUC patients.     

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.     

Ultrasound-guided double-tract percutaneous cholecystostomy combined with a choledochoscope for performing cholecystolithotomies in high-risk surgical patients

Background

Cholecystolithiasis is the most common disease treated by general surgery, with an incidence of about 0.15–0.22 %. The most common therapies are open cholecystectomy (OC) or laparoscopic cholecystectomy (LC). However, with a greater understanding of the function of the cholecyst, more and more patients and surgeons are aware that preserving the functional cholecyst is important for young patients, as well as patients who would not tolerate anesthesia associated with either OC or LC. Based on these considerations, we have introduced a notable, minimally invasive treatment for cholecystolithotomy.

Methods

We performed a retrospective review of patients with cholecystolithiasis who were unable to tolerate surgery or who insisted on preserving the functional cholecyst. Our particular approach can be simply described as ultrasound-guided percutaneous cholecystostomy combined with a choledochoscope for performing a cholecystolithotomy under local anesthesia.

Results

Ten patients with cholecystolithiasis were treated via this approach. All except one patient had their gallbladder stones totally removed under local anesthesia, without the aggressive procedures associated with OC or LC. The maximum number of gallbladder stones removed was 16, and the maximum diameter was 13 mm without lithotripsy. After the minimally invasive surgery, the cholecyst contractile functions of all patients were normal, confirmed via ultrasound after a high-fat diet. Complications such as bile duct injury, biliary fistula, and bleeding occurred significantly less often than with OC and LC. The recurrence rates for each of 2 post-operative years were about 11.11 % (1/9, excluding a failure case) with uncertainty surrounding recurrence or residue, and 22.22 % (2/9, including one non-recurrence patient with follow-up time of 22 months), respectively.

Conclusions

Ultrasound-guided percutaneous cholecystostomy combined with choledochoscope is a safe, efficient, and minimally invasive cholecystolithotomy method. We recommend this technique for the management of small stones (less than 15 mm) in high-risk surgical patients.     

超声引导经皮复合热消融技术治疗中、大肝细胞癌

目的　评估超声引导复合热消融技术治疗中、大肝细胞癌 (HCC)的应用价值。方法在超声引导下经皮采用多针插入、多点能量输出的射频消融 (RFA)或微波消融 (MWA)技术 ,治疗 6 8例HCC患者共 73个肿瘤结节 ,平均直径 (4 5± 1 7)cm (3 1～ 13 0cm) ,经 1 9～ 6 7 6个月 [平均(16 0± 14 8)个月 ]随访 ,检测局部及远期治疗效果。结果　治疗后合并肝包膜下血肿及皮肤烧伤的患者各 1例。肿瘤完全消融率 78 1% (5 7/73) ,2 4 6 % (14 /5 7)的病灶出现局部肿瘤进展 ,远处复发率 5 6 7% (38/6 7) ,1、3、5年生存率分别为 6 2 3%、2 9 6 %、2 1 6 % ,中位生存时间为 18 6个月 (95 %可信区间为 10 9～ 2 6 3个月 )。RFA与MWA在完全消融率、局部肿瘤进展率与远处复发率、生存率方面差异均无显著意义。结论　经皮复合热消融技术治疗不能手术切除的中、大肝细胞癌创伤小 ,可获得良好的局部控制和远期疗效 ,RFA与MWA疗效无明显差异     

Early Viral Suppression Predicts Good Postoperative Survivals in Patients with Hepatocellular Carcinoma with a High Baseline HBV-DNA Load

Purpose

To correlate early HBV-DNA suppression by antiviral treatment with posthepatectomy long-term survivals in patients with HBV-related hepatocellular carcinoma (HCC).

Methods

A retrospective study was conducted on patients with a baseline HBV-DNA load of >2,000 IU/ml. The cumulative rates of HBV-DNA undetectability at weeks 24 and 48, as well as long-term tumor recurrence and overall survivals were determined.

Results

Of 1,040 patients with a high baseline HBV-DNA load, 865 patients received antiviral treatment. At a median follow-up of 42 months, 616 patients (59.2 %) had developed HCC recurrence and 482 patients (46.3 %) had died. The median time to recurrence was 25 months. In patients who received antiviral treatment, the cumulative rates of HBV-DNA undetectability (<200 IU/ml) were 54.3 and 88.1 % at weeks 24 and 48, respectively. There was no significant difference between the two groups of patients who received antiviral treatment or not for disease-free survival. On multivariate analyses, tumor size >5 cm, blood transfusion, surgical margin <1 cm, presence of satellite nodules, presence of portal vein tumor thrombus and high Ishak inflammation score were significant risk factors of HCC recurrence. Also, tumor size >5 cm, surgical margin <1 cm, presence of satellite nodules, presence of portal vein tumor thrombus and high Ishak fibrosis score were significant factors associated with poor postoperative overall survival. On the other hand, an undetectable HBV-DNA level before week 24 was a significant protective factor of disease-free survival and overall survival.

Conclusions

Early HBV-DNA suppression with antiviral treatment improved prognosis of patients with HBV-related HCC.     

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.     

Independent predictors for local recurrence following surgery for spinal metastasis

Background

Local recurrence of spinal metastasis after surgical resection is relatively common. We sought to determine risk factors and independent predictors for local recurrence after primary surgical resection of spinal metastasis.

Methods

Demographic and clinical variables were collected for patients who underwent surgery for spinal metastasis June 2005 to June 2011. Primary outcome of interest was local recurrence. Significant associations between covariates of interest and recurrence were identified using the chi-square test. Multivariable logistic regression models for recurrence risk were fit and adjusted for potential confounders.

Results

A total of 99 patients were analyzed. Mean time to metastatic recurrence was 9.8 months. Thirty-two patients (32.3 %) had local recurrence of metastatic disease following initial surgery. Patients who underwent radiotherapy had significantly higher recurrence rates than patients who did not (39.2 % vs. 12.0 %, respectively; P?=?0.012). Patients with metastatic disease affecting more levels had significantly lower recurrence rates. On multivariate analysis, older age was an independent predictor of decreased likelihood of local recurrence. Melanoma was the only cancer type independently associated with higher risk for recurrence. Patients with recurrence had significantly higher 1- and 2-year survival rates than patients without recurrence. Median length of survival was longer in the recurrent group as well.

Conclusions

Other than melanoma, covariates significantly associated with recurrence were factors likely associated with increased survival, including less-extensive spinal disease and radiotherapy. Thus, longer survival time following surgery likely results in a greater chance for local recurrence. As advancements in treatment provide prolonged survival, local recurrence rates will likely increase.     

Treatment of Extensive Metastatic Colorectal Cancer to the Liver with Systemic and Hepatic Arterial Infusion Chemotherapy and Two-Stage Hepatic Resection: The Role of Salvage Therapy for Recurrent Disease

Background

Two-stage hepatectomy (TSH) has been adopted as a treatment modality for resection of advanced colorectal liver metastases (CRLM). This study analyzed the recurrence pattern, salvage rate, and survival after TSH combined with systemic and regional chemotherapy.

Methods

A retrospective review of a prospective database identified patients who underwent a TSH for CRLM was performed and outcome data analyzed.

Results

From September 2000 to May 2009, a total of 40 patients were eligible for TSH, and 88 % completed both resections. Of the 35 resected patients, the median number of tumors was 8, with 38 % having a tumor >5 cm and 35 % having a carcinoembryonic antigen value >200 ng/ml. All patients received systemic chemotherapy, and 86 % received regional therapy with hepatic artery infusion. Median follow-up for survivors was 40 months; median disease-specific survival was 52 months, and 5-year disease-specific survival was 49 %. The combined rate of major complication for all procedures was 45 % with no operative deaths. Median recurrence-free survival was 11 months with a 3-year probability of recurrence of 81 %. Disease recurrence occurred in 27 patients (77 %), with the liver (42 %) and lung (37 %) being the most common sites. Sixteen of these patients (60 %) underwent salvage therapy via either surgery and/or ablation, 7 (44 %) of whom were free of disease at a median follow-up of 54 months.

Conclusions

TSH combined with systemic and hepatic artery infusion chemotherapy is an effective treatment strategy for selected patients with advanced CRLM. These patients are at considerable risk of local and distant recurrence; however, the majority can be salvaged, and long-term survival can be achieved.     

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.