Single-step multimodal locoregional treatment for unresectable hepatocellular carcinoma: balloon-occluded percutaneous radiofrequency thermal ablation (BO-RFA) plus transcatheter arterial chemoembolization (TACE)

Purpose

This study was undertaken to evaluate the feasibility, safety and efficacy of a new combined single-step therapy in patients with unresectable multinodular unilobar hepatocellular carcinoma (HCC), with at least one lesion >3 cm, with balloon-occluded radiofrequency ablation (BO-RFA) plus transcatheter arterial chemoembolization (TACE) of the main lesion and TACE of the other lesions. The second purpose of our study was to compare the initial effects in terms of tumour necrosis of this new combined therapy with those obtained in a matched population treated with TACE alone in a singlestep treatment in our centre in the previous year.

Methods and materials

This pilot study was approved by the institutional review board, and informed consent was obtained from all patients. Ten consecutive patients with multinodular (two to six nodules) unilobar unresectable HCC and with a main target lesion >3 cm (range, 3.5–6 cm) not suitable for curative therapy were enrolled in our single-centre multidisciplinary pilot study. The schedule consisted of percutaneous RFA (single 3-cm monopolar needle insertion) of the target lesion during occlusion of the hepatic artery supplying the tumour, followed by selective TACE, plus lobar TACE for other lesions (450-mg carboplatin and lipiodol plus temporary embolisation with SPONGOSTAN). Adverse events and intra- and periprocedural complications were clinically assessed. Early local efficacy was evaluated on 1-month follow-up multiphasic computed tomography (CT) on the basis of the Modified Response Evaluation Criteria in Solid Tumors (m-RECIST). A separate evaluation of target lesions in terms of enhancement, necrotic diameter and presence and distribution of lipiodol uptake was also performed.

Results

No major complications occurred. Overall technical success, defined as complete devascularisation of all nodules during the arterial phase, was achieved in seven of 10 patients, with three cases of partial response (persistence of small hypervascular nodules). When considering only target lesions, technical success was obtained in all patients, with a nonenhancing area corresponding in shape to the previously identified HCC (necrotic diameter, 3.5–5 cm) and with circumferential peripheral lipiodol uptake (safety margin) of at least 0.5 cm (0.5–1.3cm).

Conclusions

TACE and BO-RFA, plus TACE in a singlestep approach seems to be a safe and effective combined therapy for treating advanced, unresectable HCC lesions, allowing a high rate of complete local response to be achieved in large lesions also.     

The combined effect of radiofrequency and ethanol ablation in the management of large hepatocellular carcinoma

Only a small percentage of patients with large hepatocellular carcinoma (HCC) may benefit out of surgical resection. Thus, most of these patients are in need of a form of local control, such as ethanol ablation, transarterial chemoembolization (TACE), radiofrequency thermal ablation (RF), or laser induced thermotherapy (LITT). The purpose of this study was to assess the short-term effect of sequential RF and ethanol ablation in the management of large HCC (>5 cm). Our series included 40 patients with large HCC tumors (>5 cm in diameter). We adopted a protocol of overlapping RF applications, followed by repeated ethanol ablation sessions. Our results showed that the volume of tumor coagulative necrosis initially induced by RF has significantly risen after adjuvant ethanol ablation sessions (P < 0.001). Patients who achieved complete tumor necrosis after RF ablation were 52.5% of the series. This percent has jumped to 80% of the series at the end of the protocol. This indicates that such combined protocol is more effective than RF alone. Besides, it is valuable in reducing the number of RF sessions.     

Biplane fluoroscopy-guided radiofrequency ablation combined with chemoembolisation for hepatocellular carcinoma: initial experience

Objective

The purpose of this study was to assess the technical feasibility and local efficacy of biplane fluoroscopy-guided percutaneous radiofrequency (RF) ablation combined with transcatheter arterial chemoembolisation (TACE) for hepatocellular carcinoma (HCC).

Method

Our retrospective study was approved by the institutional review board and informed consent was waived. 18 patients with 19 HCCs (mean 2.5 cm diameter; range 2–4.2 cm) were treated with percutaneous RF ablation combined with TACE. After segmental TACE, 18 (95%) of 19 HCCs were visible on fluoroscopy. Shortly (median 2 days; range 1–4 days) after TACE, percutaneous RF ablation was performed under real-time biplane fluoroscopic guidance. We evaluated major complications, rate of technical success at immediate post-RF ablation CT images and local tumour progression at follow-up CT images.

Results

Major complication was not observed in any patients. Technical success was achieved for all 18 visible HCCs. During the follow-up period (median 20 months; range 5–30 months), no local tumour progression was found.

Conclusion

Biplane fluoroscopy-guided RF ablation combined with TACE is technically feasible and effective for treatment of HCC.Percutaneous radiofrequency (RF) ablation has been widely implemented in the management of hepatocellular carcinoma (HCC) with promising results. Although its local efficacy for small tumours (i.e. <2 cm) is similar to surgical outcomes [1], results for medium-sized and large tumours are less robust. Thus, multimodal treatments such as combined percutaneous RF ablation with transarterial chemoembolisation (TACE) have been explored for medium or large HCCs in order to enhance the therapeutic effect. In a recent study, RF ablation combined with TACE was similar to surgical resection in patients with early-stage disease [2].Percutaneous RF ablation shortly following TACE has been usually performed under guidance of either ultrasonography or CT/CT fluoroscopy. Since intratumoural retention of radio-opaque iodised oil induced by TACE conveniently provides radiographic contrast to the index lesion, biplane fluoroscopy (anterior posterior and lateral projections) can be used as an alternative guiding modality for RF ablation combined with TACE. Easier targeting of dome lesions, often difficult to visualise on ultrasound, through an oblique approach without pleural transgression is one potential advantage of biplane fluoroscopy guidance. Also unlike on ultrasound, microbubble formation during ablation would not obscure the index lesion on biplane fluoroscopy, allowing easier and more spatially accurate application of overlapping ablations that are often needed for larger tumours. However, to our knowledge, there have been no studies investigating the role of biplane fluoroscopy as a guidance modality in this clinical setting. The purpose of our study was to retrospectively assess the technical feasibility and local efficacy of biplane fluoroscopy-guided percutaneous RF ablation combined with TACE for HCC ≥2 cm.     

Radiofrequency ablation combined with chemoembolization for the treatment of hepatocellular carcinomas 5 cm or smaller: risk factors for local tumor progression

PURPOSE: To investigate the risk factors for local tumor progression after radiofrequency (RF) ablation combined with chemoembolization for the treatment of hepatocellular carcinoma (HCC). MATERIALS AND METHODS: A total of 255 HCC lesions 5 cm or less in maximum diameter were treated by RF ablation in 173 patients within 2 weeks after chemoembolization was performed. Therapeutic response was evaluated by contrast medium-enhanced computed tomography studies. The disappearance of tumor enhancement was considered to indicate complete necrosis. Local tumor progression was defined by the appearance of enhanced tumor adjacent to the zone of ablation. The risk factors for local tumor progression after RF ablation were retrospectively assessed by univariate and multivariate analyses. RESULTS: All tumors showed complete necrosis after RF ablation. Local tumor progression was found in 18 of the 255 lesions (7%) during a mean follow-up period of 23 months (range, 1-63 months). The cumulative local tumor progression rate was 12% at 5 years. Larger tumor (3.1-5 cm), infiltrating tumor, and previous treatments were found to increase the risk of local tumor progression in univariate and multivariate analyses. CONCLUSIONS: The combination of chemoembolization with RF ablation is an effective treatment to control HCC lesions. The factors identified in the present study may help to predict the therapeutic response.     

Combined Ethanol Injection Therapy and Radiofrequency Ablation Therapy in Percutaneous Treatment of Hepatocellular Carcinoma Larger than 4 cm

Background Optimal treatment of large-sized hepatocellular carcinoma (HCC) is still debated, because percutaneous ablation therapies alone do not always achieve complete necrosis. Objective To report our experience in the treatment of patients with HCC larger than 4 cm in diameter by combined percutaneous ethanol injection and radiofrequency thermal ablation. Methods In a 5-year period there were 40 consecutive patients meeting the inclusion criteria (24 men and 16 women; age range 41–72 years, mean 58 years). These subjects had a single HCC larger than 4 cm. Twelve subjects also had one or two additional nodules smaller than 4 cm (mean 1.2 nodules per patient). Patients were submitted to one to three sessions consisting of ethanol injection at two opposite tumor poles (mean 12 ml) and then of radiofrequency application through one or two electrodes placed at the tumor center (mean treatment duration 30 min). Results Complete necrosis was obtained in all cases with one to three sessions (mean 1.3 sessions per patient). All patients experienced pain and fever but one only subject had a major complication requiring treatment (abscess development and fistulization). Overall follow-up was 7–69 months. Two patients showed local recurrence and 9 developed new etherotopic HCC nodules. Seven subjects died during follow-up while 33 were free from recurrence 8–69 months after treatment. Conclusion A combination of ethanol injection and radiofrequency ablation is effective in the treatment of large HCC.     

肝动脉化疗栓塞联合CT引导下射频消融术治疗肝癌的疗效分析

目的 评价肝动脉化疗栓塞(TACE)联合CT引导下射频消融术(RFA)治疗肝癌的疗效.方法 HCC患者200例先行TACE术,然后在CT引导下行RFA术.200例患者共行TACE术495例次.肿瘤病灶共计378个,直径为O.5-16 cm,共行RFA术362人次,663个位点.结果 术前、术后12个月AFP分别为(2 156.79±574.61)ng/ml、(269.53±146.65)ng/ml,两者差异有统计学意义(t=16.11,P<0.01).术前、术后3、6和12个月的肿瘤体积分别是(72.64±24.74)cm3、(46.78±18.95)cm3、(28.27±11.70)cm3和(10.82±8.31)cm3,差异有统计学意义(F=10.77,P<0.01).肿瘤完全坏死率为87.8%.结论 肝TACE联合CT引导下RFA治疗肝癌是一种有效的微创治疗方法.     

Radiofrequency ablation of hepatocellular carcinoma: treatment success as defined by histologic examination of the explanted liver

PURPOSE: To retrospectively evaluate the effectiveness of radiofrequency (RF) ablation of hepatocellular carcinoma (HCC) by using histologic examination of the explanted liver. MATERIALS AND METHODS: The study was approved by the medical center Institutional Review Board, with waiver of informed consent. Forty-seven HCC nodules in 24 patients (18 men, six women; age range, 33-71 years; mean age, 56 years) were treated with single or double RF ablation sessions prior to liver transplantation. Histologic data from hematoxylin-eosin staining of explanted liver specimens were retrospectively reviewed to determine treatment success, which was defined as the absence of residual or recurrent viable carcinoma cells at treatment site. Tumor size and the presence of large (> or =3 mm) abutting vessels that were observed during imaging were tested as potential predictors of treatment success or failure (Fisher exact test). In patients who underwent postablation computed tomographic (CT) or magnetic resonance (MR) imaging within 3 months prior to transplantation (21 patients with 44 tumors), imaging results were analyzed for sensitivity and specificity of residual or recurrent tumor by using histologic data as the reference standard. RESULTS: Thirty-five (74%) of 47 ablated tumors, including 29 (83%) of 35 tumors less than 3 cm, were found to be successfully treated on the basis of histologic findings after a mean interval of 7.5 months between RF ablation and transplantation. Nodules that were successfully treated had mean maximal diameter of 2.0 cm, and nodules that were unsuccessfully treated had mean maximal diameter of 3.1 cm (P=.014). Seven (47%) of 15 perivascular lesions were successfully treated whereas 28 (88%) of 32 nonperivascular lesions were successfully treated (P <.01). Imaging correlation showed 100% (33 of 33) specificity and 36% (four of 11) sensitivity of postablation CT and MR imaging for the depiction of residual or recurrent tumor. CONCLUSION: Histologic evidence directly validates RF ablation as an effective treatment of small (<3 cm) HCC.     

Computed Tomography Follow-up for the Detection of Hepatocellular Carcinoma Recurrence after Initial Radiofrequency Ablation: A Single-center Experience

PurposeRecurrence of hepatocellular carcinoma (HCC) is very common even after curative resection or ablation. This retrospective study compared the radiologic features of recurrent HCC seen by computed tomography (CT) to evaluate our empirical protocol of CT surveillance using 4-month intervals.Materials and MethodsA total of 113 patients who were diagnosed with a first HCC recurrence after radiofrequency (RF) ablation between January 2005 and December 2006 were enrolled at a single center. Definite HCC was defined as hyperattenuation in the arterial phase with washout in the portal venous phase, and a diagnosis of naive and recurrent HCC was based on dynamic CT findings. Recurrent nodules were classified according to the enhancement patterns of previous CT images. The treatment modality for recurrent HCC and survival were evaluated.ResultsOne hundred seventy-seven nodules were diagnosed as recurrent HCC: 31 (17.5%) had already been diagnosed on previous CT images as typical HCC, 72 (40.6%) had arterial hypervascularity without washout in the portal venous phase, 21 (11.9%) showed portal venous phase washout without arterial hypervascularity, and no lesions were noted in the remaining 49 (27.7%). Tumor size at recurrence was smaller than 2 cm in diameter in 98 (86.7%) cases. One hundred four patients were treated for recurrent HCC with RF ablation. The 5-year survival rate after recurrence was 49.8%. There was no significant difference in survival among groups divided by the enhancement pattern on the previous CT examination.ConclusionsDynamic CT in 4-month intervals is an acceptable recurrence-monitoring strategy because it detects most recurrent nodules at a stage at which RF ablation is still feasible.     

Hepatocellular carcinoma: long-term results of combined treatment with laser thermal ablation and transcatheter arterial chemoembolization

PURPOSE: To determine the potential long-term effectiveness of laser thermal ablation (LTA) followed by transcatheter arterial chemoembolization (TACE) in the percutaneous ablation of large hepatocellular carcinoma (HCC). MATERIALS AND METHODS: Thirty large HCCs 3.5-9.6 cm in diameter (mean diameter, 5.2 cm) and 15 small HCCs 0.8-3.0 cm (mean diameter, 1.9 cm) were treated with ultrasonographically guided LTA with TACE and with LTA alone, respectively, in 30 patients: 19 with a solitary large HCC, and 11 with one to three additional synchronous small HCCS: A 1.064-microm neodymium yttrium-aluminium-garnet (Nd-YAG) laser at a power of 5.0 W was coupled with one to four quartz optic fibers that were advanced through 21-gauge needles. Segmental TACE was performed 30-90 days after LTA. All lesions were evaluated for change in size at computed tomography (CT), alpha-fetoprotein (AFP) levels, recurrence rates, and cumulative survival rates. RESULTS: No major complications occurred in 127 LTA sessions. CT showed complete tumor necrosis in 27 (90%) of 30 large HCCS: Twenty-eight patients were followed up for 6-41 months (mean, 17.1 months). In 25 patients, all lesions appeared stable or smaller at CT. AFP levels decreased to the normal range in all patients with high pretreatment values. The 1-, 2-, and 3-year local recurrence rate was 7% in large HCCS: Complete tumor necrosis was achieved in all 15 (100%) small HCCs; none of them recurred locally. The 1-, 2-, and 3-year cumulative survival rates were 92%, 68%, and 40%, respectively. CONCLUSION: LTA followed by TACE is an effective palliative therapy in treating large HCCS:     

Percutaneous radio-frequency thermal ablation of nonresectable hepatocellular carcinoma after occlusion of tumor blood supply

PURPOSE: To evaluate the usefulness of percutaneous radio-frequency (RF) thermal ablation of nonresectable hepatocellular carcinoma (HCC) after occlusion of the tumor arterial supply. MATERIALS AND METHODS: Sixty-two patients with cirrhosis and biopsy-proved HCC underwent RF ablation after interruption of the tumor arterial supply by means of occlusion of either the hepatic artery with a balloon catheter (40 patients) or the feeding arteries with gelatin sponge particles (22 patients). RESULTS: After a single RF procedure in 56 patients and after two procedures in six patients, spiral computed tomography (CT) demonstrated a nonenhancing area corresponding in shape to the previously identified HCC, which was suggestive of complete necrosis. No major complications occurred. Two patients subsequently underwent surgical resection; the remaining 60 patients were followed up with spiral CT. During a mean follow-up of 12.1 months, 11 HCC nodules showed areas of local progression; 49 were identified as nonenhancing areas with a 40%-75% reduction in maximum diameter. The 1-year estimate of failure risk was 19% for local recurrence and 45% for overall intrahepatic recurrence. The estimated 1-year survival was 87%. Histopathologic analysis of one autopsy and two surgical specimens revealed more than 90% necrosis in one specimen and 100% necrosis in two. CONCLUSION: HCC nodules 3.5-8.5 cm in diameter can be ablated in one or two RF sessions after occlusion of the tumor arterial supply.     

Radiofrequency ablation in the treatment of small hepatocellular carcinomas: comparison of the radiofrequency effect with and without chemoembolization

OBJECTIVE: The purpose of this study was to determine whether a combination of transcatheter arterial chemoembolization using doxorubicin and radiofrequency ablation can increase tumor destruction compared with radiofrequency alone in the treatment for hepatocellular carcinoma. SUBJECTS AND METHODS. Twenty-one patients with 26 nodules smaller than 3 cm in diameter were treated with radiofrequency ablation. Of these, 10 nodules were treated with a combination of radiofrequency ablation and chemoembolization using doxorubicin. All nodules were evaluated for size of induced coagulation, local recurrence, and complication. RESULTS: The therapeutic areas averaged 27.6 x 22.3 mm using an electrode with a 2-cm tip and 37.2 x 29.1 mm using an electrode with a 3-cm tip. With respect to the results for 14 nodules treated using an electrode with a 3-cm tip with or without chemoembolization, the greatest dimension of the area coagulated by combined therapy was significantly larger (longest axis dimension, 39.9 +/- 4.4 mm; shortest axis dimension, 32.3 +/- 5.2 mm; n = 7 nodules) than areas without chemoembolization (longest axis dimension, 34.6 +/- 2.6 mm; shortest axis dimension, 26.0 +/- 3.3 mm; n = 7 nodules) (longest and shortest axis dimensions, p < 0.05). No recurrence occurred in the nodules smaller than 2 cm in diameter. Among the nodules larger than 2 cm in diameter, one local recurrence was observed in seven nodules treated by combined therapy, while two local recurrences were observed in seven nodules treated by radiofrequency alone. Minor complications developed in three patients, two with persistent high fever and one with biliary stenosis. CONCLUSION: The combination of radiofrequency ablation and transcatheter arterial chemoembolization using doxorubicin markedly increased the extent of induced coagulation compared with radiofrequency alone, despite a small number of patients and the preliminary nature of this study.     

Percutaneous Radiofrequency Ablation and Transcatheter Arterial Chemoembolization for Hypervascular Hepatocellular Carcinoma: Rate and Risk Factors for Local Recurrence

PURPOSE: To analyze local recurrence-free rates and risk factors for recurrence following percutaneous radiofrequency ablation (RFA) or transcatheter arterial chemoembolization (TACE) for hypervascular hepatocellular carcinoma (HCC). METHODS: One hundred and nine nodules treated by RFA and 173 nodules treated by TACE were included. Hypovascular nodules were excluded from this study. Overall local recurrence-free rates of each treatment group were calculated using the Kaplan-Meier method. The independent risk factors of local recurrence and the hazard ratios were analyzed using Cox's proportional-hazards regression model. Based on the results of multivariate analyses, we classified HCC nodules into four subgroups: central nodules < or =2 cm or >2 cm and peripheral nodules < or =2 cm or >2 cm. The local recurrence-free rates of these subgroups for each treatment were also calculated. RESULTS: The overall local recurrence-free rate was significantly higher in the RFA group than in the TACE group (p = 0.013). The 24-month local recurrence-free rates in the RFA and TACE groups were 60.0% and 48.9%, respectively. In the RFA group, the only significant risk factor for recurrence was tumor size >2 cm in greatest dimension. In the TACE group, a central location was the only significant risk factor for recurrence. In central nodules that were < or =2 cm, the local recurrence-free rate was significantly higher in the RFA group than in the TACE group (p < 0.001). In the remaining three groups, there was no significant difference in local recurrence-free rate between the two treatment methods. CONCLUSION: A tumor diameter of >2 cm was the only independent risk factor for local recurrence in RFA treatment, and a central location was the only independent risk factor in TACE treatment. Central lesions measuring < or =2 cm should be treated by RFA.     

Correlation of Multislice CT and Histomorphology in HCC Following TACE: Predictors of Outcome

The purpose of this study was to correlate histopathological with CT findings in patients suffering from hepatocellular carcinoma (HCC) eligible for orthotopic liver transplantation (OLT), with a special focus on the antitumoral effect of transarterial chemoembolization (TACE) therapy. A total of 42 consecutive patients suffering from HCC had been treated prior to OLT by means of TACE. TACE was carried out with a mixture of Lipiodol (10-20 ml) and mitomycin C (max. dosage, 10 mg). TACE was performed at 6- to 8-week intervals. Follow-up investigation included contrast-enhanced multislice CT controls and laboratory control. Liver explants were evaluated macroscopically and microscopically to determine the number and size of the tumor lesions as well as the degree of tumor necrosis. Necrosis was investigated in H&E-stained sections. The degree of necrosis was classified as follows: 0-25%, 26-50%, 51-75%, 75-99%, and complete necrosis. Two hundred thirty-one TACE procedures (5.5 +/- 2.9; range, 1-14) were performed. Mean tumor size in CT before and after TACE was 4.1 +/- 2.4 (range, 1.0-12.0 cm) and 2.7 +/- 1.2 (range, 1.0-6.0 cm; p < 0.001). Mean tumor number before and after TACE in CT was 2.5 +/- 1.5 (n = 105; range, 1-8) and 2.4 +/- 2.0 (n = 103; range, 1-6; p = 0.99). In the surgical specimen tumor size and tumor number were 2.8 +/- 1.6 (range, 1.0-7.0 cm; p = 0.78) and 1.9 +/- 1.2 (range, 1-7; p = 0.003). Mean tumor necrosis was 67.8% +/- 28.1%. Tumor necrosis was subtotal or complete in 17 of 42 (40.5%) patients. Tumor necrosis correlated significantly with the degree of arterial devascularization in CT (p = 0.001), the amount of Lipiodol washout (p = 0.002), and the number of tumor lesions (i.e., unifocal vs. multifocal). Furthermore, elevated serum levels of bilirubin (p = 0.005) and decreased albumin (p = 0.004) affected the local antitumoral effect. A poor necrosis rate (< 25%) significantly correlated with the number of TACE procedures accomplished (p = 0.023). In conclusion, TACE provided an acceptable local antitumoral effect in patients scheduled for liver transplantation. Tumor necrosis depended significantly on the degree of arterial devascularization and the accumulation of Lipiodol within the HCC lesions. Unifocal tumors and preserved liver function were positive predictors for a more favorable local antitumoral effect. Poor necrosis rates were found in patients with significant Lipiodol washout and who received a limited number of TACE procedures.     

Percutaneous pulmonary radiofrequency ablation: difficulty achieving complete ablations in big lung lesions

The size of both primary and metastatic lung tumours often exceeds 3 cm in diameter at the time of diagnosis. The radiofrequency (RF) electrodes of the three leading companies currently in use are designed for a maximum ablation diameter of 5 cm. Therefore, the tumour to be ablated should not exceed 3 cm in maximum diameter, as a 1 cm safety ablation margin surrounding the tumour should ideally be achieved. A possible solution in treating larger tumours is to create overlapping ablations, a method successfully used in the radiofrequency ablation (RFA) of liver tumours. We report on the percutaneous overlapping ablation of three large lung metastases, 4 cm, 4.5 cm and 5 cm in their longest diameter. The largest of them showed incomplete ablation with residual viable tumour tissue. The overlapping percutaneous RFA of large lung tumours is feasible although the bigger the lesion, the higher the risk of incomplete ablation appears compared with smaller tumours treated by a single ablation.     

Percutaneous radiofrequency ablation of small hepatocellular carcinoma: long-term results

The aim of this study was to evaluate the effectiveness and the safety of percutaneous radiofrequency (RF) thermal ablation of hepatocellular carcinoma (HCC) in 88 patients with a long follow-up, and to compare conventional electrodes and expandable electrodes. Eighty-eight patients with 101 hepatocellular carcinoma nodules (≤ 3.5 cm in diameter) underwent RF thermal ablation by means of either conventional electrodes or an expandable electrode. Therapeutic efficacy was evaluated with dynamic contrast CT, serum α-feto protein level, US examination at the end of the treatment, and during follow-up. Complete necrosis was obtained in all tumor nodules in a mean number of 3.3 sessions (tumor treated by conventional electrodes) or 1.5 sessions (tumor treated by expandable electrode). The mean follow-up was 34 months; overall survival rate was 33 % at 5 years. Disease-free survival at 5 years was 3 %; local recurrence rate was 29 % in patients treated with conventional electrodes; 14 % in patients treated with the expandable electrode. Two major complications and 14 minor complications were observed. Radiofrequency thermal ablation in small HCC is very effective with a low percentage of major complications. The use of an expandable electrode substantially reduced the number of treatment sessions but did not modify the overall survival rate and the disease-free survival rate. Received: 7 January 2000 Revised: 19 July 2000 Accepted: 11 August 2000     

Radiofrequency Ablation versus Transarterial Chemoembolization in Patients with Hepatocellular Carcinoma Awaiting Liver Transplant: An Analysis of the Scientific Registry of Transplant Recipients

PurposeTo evaluate differences in waitlist mortality and dropout in liver transplant candidates with hepatocellular carcinoma (HCC) who undergo radiofrequency (RF) ablation versus transarterial chemoembolization (TACE).Material and MethodsFrom 2004 to 2013, 11,824 patients with HCC in the Scientific Registry of Transplant Recipients who underwent RF ablation or TACE were included and followed until December 31, 2019, or 5 years, whichever came first, and were stratified by the Milan criteria. Competing risk and Cox regression analyses to compare waitlist mortality and dropout were performed using adjusted hazard ratios (asHRs, with RF ablation group as reference). Regression models were adjusted for age, race, sex, calculated Model for End-Stage Liver Disease score, tumor size, and number.ResultsThere was no difference in waitlist mortality and dropout for patients outside the Milan criteria (n = 1,226) who underwent TACE (19.2%) or RF ablation (19.0%) (asHR, 0.91; 95% CI, 0.79–1.03). There was also no difference for patients inside the Milan criteria (n = 10,598) in waitlist mortality/dropout (TACE 13.4% vs RF ablation 12.9%) (asHR, 1.29; 95% CI, 0.79–2.09). A subgroup analysis within the Milan criteria demonstrated no difference between TACE and RF ablation treatments in patients with a single tumor of ≤3 cm (asHR, 0.92; 95% CI, 0.77–1.10), with a single tumor of >3 cm (asHR, 1.03; 95% CI, 0.79–1.34), or with >1 tumor (asHR, 0.89; 95% CI, 0.72–1.09).ConclusionsUsing the national registry data, no difference was found in waitlist mortality and dropout for transplant candidates with HCC who received TACE versus RF ablation.     

Transarterial chemoembolization using drug eluting beads and subsequent percutaneous MR-guided radiofrequency ablation in the therapy of intermediate sized hepatocellular carcinoma

Objective

To evaluate safety, efficacy, survival and recurrence-free survival of transarterial chemoembolization (TACE) with drug eluting (DC) beads combined with MR-guided radiofrequency (RF) ablation for the treatment of hepatocellular carcinomas (HCC) larger than 3 cm.

Materials and methods

This retrospective study was approved by the institutional review board. 20 patients (69.6 years ±SD 8.8) with HCC underwent DC Bead TACE and subsequent MR-guided RF ablation. Treatment interval varied between 5 and 15 days. Mean HCC diameter was 39 mm ±SD 7 mm (range 31–50 mm). Rates of recurrence-free survival and overall survival were estimated using the Kaplan–Meier method.

Results

Technical success rate, primary and secondary technical effectiveness rate were 100%, 90% and 95%, respectively. Local tumour progression developed in one patient. Cumulative survival rates at 1, 3 and 5 years were 90% (Confidence Interval [CI]: 67%–97%), 50% (CI: 29%–70%), 27% (CI: 11%–51%) respectively. Median survival time was 37.4 months. During follow up (mean: 39.1 months ±SD 22.4; range 5–84 months), tumour progression in untreated liver developed in 14 cases. Cumulative recurrence-free survival rates at 1, 3 and 5 years were 48% (CI: 27–69%), 16% (5–39%), 16% (5–39%) respectively. Median recurrence-free survival time was 10.7 months. One major complication occurred due to misdiagnosed local recurrence.

Conclusion

In conclusion, we demonstrated that MR-guided RF ablation with subsequent DC Bead TACE is safe and effective in local tumour control in patients with intermediate sized HCC.     

Hepatocellular carcinoma: radio-frequency ablation of medium and large lesions

PURPOSE: To study local therapeutic efficacy, side effects, and complications of radio-frequency (RF) ablation in the treatment of medium and large hepatocellular carcinoma (HCC) lesions in patients with cirrhosis or chronic hepatitis. MATERIALS AND METHODS: One-hundred fourteen patients who were under conscious sedation or general anesthesia had 126 HCCs greater than 3.0 cm in diameter treated with RF by using an internally cooled electrode. Eighty tumors were medium (3.1-5.0 cm), and 46 were large (5.1-9.5 cm). The mean diameter for all tumors was 5.4 cm. At imaging, 75 tumors were considered noninfiltrating, and 51 were considered infiltrating. RESULTS: Complete necrosis was attained in 60 lesions (47.6%), nearly complete (90%-99%) necrosis in 40 lesions (31.7%), and partial (50%-89%) necrosis in the remaining 26 lesions (20.6%). Medium and/or noninfiltrating tumors were treated successfully significantly more often than large and/or infiltrating tumors. Two major complications (death, hemorrhage requiring laparotomy) and five minor complications (self-limited hemorrhage, persistent pain) were observed. The single death was due to a break in sterile technique rather than to the RF procedure itself. CONCLUSION: RF ablation appears to be an effective, safe, and relatively simple procedure for the treatment of medium and large HCCs.     

Ethanol injection for the treatment of hepatic tumours

Percutaneous ethanol injection (PEI) is a relatively new therapeutic technique for the treatment of liver tumours. PEI is now considered a reliable alternative to surgical resection for cirrhotic patients with a single, small hepatocellular carcinoma (HCC). Intratumoral injection of absolute ethanol, in fact, achieves complete ablation of HCC nodules 3 cm or less in diameter with a high probability. Moreover, PEI is not associated with significant morbidity or mortality and does not damage non-cancerous liver parenchyma. Long-term survival rates of PEI-treated patients were similar to those obtained in matched patients submitted to partial hepatectomy. In large HCC lesions, the anticancer effect of PEI can be significantly enhanced by pretreatment of the tumour with transcatheter arterial chemoembolisation. PEI may also be effectively used to destroy adenomatous hyperplastic nodules in liver cirrhosis, which represent precancerous lesions. The results of PEI in the treatment of liver metastases, in contrast, have been far less encouraging than in the case of HCC, so that PEI is not recommended when other interventional procedures such as radiofrequency electrocautery or interstitial laser photocoagulation are available. Imaging procedure plays a key role in PEI, as they provide a reliable assessment of the therapeutic effect of the procedure. Correspondence to: C. Bartolozzi     

Image-guided multipolar radiofrequency ablation of liver tumours: initial clinical results

The local effectiveness and clinical usefulness of multipolar radiofrequency (RF) ablation of liver tumours was evaluated. Sixty-eight image-guided RF sessions were performed using a multipolar device with bipolar electrodes in 53 patients. There were 45 hepatocellular carcinomas (HCC) and 42 metastases with a diameter ≤3 cm (n = 55), 3.1–5 cm (n = 29) and >5 cm (n = 3); 26 nodules were within 5 mm from large vessels. Local effectiveness and complications were evaluated after RF procedures. Mean follow-up was 17 ± 10 months. Recurrence and survival rates were analysed by the Kaplan-Meier method. The primary and secondary technical effectiveness rate was 82% and 95%, respectively. The major and minor complication rate was 2.9%, respectively. The local tumour progression at 1- and 2-years was 5% and 9% for HCC nodules and 17% and 31% for metastases, respectively; four of 26 nodules (15%) close to vessels showed local progression. The survival at 1 year and 2 years was 97% and 90% for HCC and 84% and 68% for metastases, respectively. Multipolar RF technique creates ablation zones of adequate size and tailored shape and is effective to treat most liver tumours, including those close to major hepatic vessels.