Percutaneous local ablative therapy for hepatocellular carcinoma: a review and look into the future

Radiofrequency ablation for pulmonary metastases from gastrointestinal cancers

The lung is one of the most common targets of metastases from gastrointestinal (GI) cancers. Surgical treatment (i.e., metastasectomy) is an accepted therapeutic option for pulmonary metastases from GI cancers. However, surgery may be contraindicated in advanced stages of cancer, compromised lung function, and/or comorbidities. This issue has prompted the search for innovative and less invasive ways of treating pulmonary metastases. Image-guided radiofrequency ablation (RFA) has attracted great interest as a minimally invasive approach against intrathoracic malignancies. In this technique, radiofrequency energy is applied via a needle electrode inserted into the target tissue. As the cells are agitated by the applied energy, they release heat, causing denaturation and cell death. Recently, this technique has been used on patients with pulmonary metastatic disease arising from GI cancers such as colorectal cancer, esophageal cancer, and hepatocellular carcinoma, as well as on patients with primary lung cancer. The present review updates the clinical outcomes and advances in RFA therapy of lung metastases from GI cancers.

Radiofrequency ablation following first-line transarterial chemoembolization for patients with unresectable hepatocellular carcinoma beyond the Milan criteria

BACKGROUND

Recent studies suggest that a combination of radiofrequency ablation (RFA) and transarterial chemoembolization (TACE) may have theoretical advantages over TACE alone for treatment of hepatocellular carcinoma (HCC). The purpose of this study was to evaluate the effectiveness and safety of radiofrequency ablation following first-line TACE treatment in the management of HCC beyond the Milan Criteria.

METHODS

Forty-five patients who consecutively underwent RFA following first-line TACE treatment for HCC beyond the Milan criteria were enrolled in this study. RFA was performed within 1-2 months after TACE treatment in patients who had incomplete necrotic tumor nodules. Primary effectiveness, complications, survival rates, and prognostic factors were evaluated retrospectively.

RESULTS

Complete ablation was achieved in 76.2% of the lesions according to 1-month follow-up computed tomography/magnetic resonance imaging evaluation. The mean follow-up period was 30.9 months (range 3-94 months). There were no major complications after RFA therapy. The median overall survival was 29 months (range 20-38 months), with 1-, 2-, and 3-year survival of 89%, 61%, and 43%, respectively. Multivariate analysis revealed that tumor diameter (P = 0.045, hazard ratio [HR] = 0.228, 95% confidence interval [CI]: 0.054-0.968) and pretreatment serum alpha-fetoprotein level (P = 0.024, HR = 2.239, 95% CI: 1.114-4.500) were independent predictors for long-term survival.

CONCLUSIONS

HCC beyond the Milan criteria can be completely and safely ablated by radiofrequency ablation following first-line TACE treatment with a low rate of complications and favorable survival outcome. Further assessment of the survival benefits of combination treatment for HCCs beyond the Milan Criteria is warranted.

Comparison of long-term effectiveness and complications of radiofrequency ablation with hepatectomy for small hepatocellular carcinoma

BACKGROUND AND AIM

To determine and compare the adverse events and long-term effectiveness for patients with small hepatocellular carcinoma (HCC) (≤ 3 cm) treated by percutaneous radiofrequency ablation (RFA) or hepatectomy.

METHODS

Small HCC from 120 patients were randomized into either percutaneous RFA therapy or hepatectomy group, and the effectiveness and complications of two treatment modalities were analyzed. The complications of post-RFA or hepatectomy, the complete treatment rate, treatment-related mortality, and disease-free and overall survival rate were followed up and conducted.

RESULTS

In patients with small HCC, complete remission rates were achieved in 95% and 96.7% in the percutaneus RFA and hepatectomy groups, respectively (P > 0.05). Hepatic function at day-7 status post-treatment, including albumin and bilirubin levels, were significantly worse in the hepatectomy group (P < 0.01). Compared with the RFA group, the incidence of postoperative complications (27.5% vs 5.0%) and hospital stay (11.8 ± 3.1 vs 4.3 ± 1.5) were significantly higher in the hepatectomy group (P < 0.01). After a mean follow-up of 40 months, 22 patients (36.6%) in the RFA group and 21 patients (35.0%) in the hepatectomy group developed a recurrence (P > 0.05). There was no significant difference of the disease-free and overall survival rates at 1, 2, and 3 years between the RFA group and the surgical hepatectomy group (P = 0.443 and P = 0.207, respectively).

CONCLUSIONS

In patients with small HCC, percutaneous RFA showed similar local control and long-term survival compared with hepatectomy. Importantly, percutaneous RFA are accompanied with a lower complication rate and shorter hospital stay day.

Development of a Simple Miniature Thermochemical Ablation Device Suitable for Tumor Ablation Research in Rodent Models

Thermochemical ablation is a recently developed minimally invasive method with potential for solid tumor treatment such as in liver cancer. A recently described prototype device, however, is too large for use in the more common rodent models of cancer. In this report we describe a simple, low-cost variant of the device that is easy to assemble, small enough to be readily applicable to small animal models, and then demonstrate its use in an ex vivo model for ablation. It should therefore enable study of the method without requiring specialized equipment or access to a machine shop for device manufacture.

Microwave coagulation for liver metastases

BACKGROUND

Primary liver cancer and liver metastases from colorectal carcinoma are the two most common malignant tumours to affect the liver. The liver is second only to the lymph nodes as the most common site for metastatic disease. More than half of patients with metastatic liver disease will die from metastatic complications. Microwave coagulation involves placing an electrode into a lesion under ultrasound or computed tomography guidance. The microwave coagulator generates and transmits microwave energy to the electrode. Coagulative necrosis causes cellular death and destroys tissue in the treatment area, resulting in reduction of tumour size.

OBJECTIVES

To study the beneficial and harmful effects of microwave coagulation compared with no intervention, other ablation methods, or systemic treatments in patients with liver metastases.

SEARCH METHODS

We searched the Cochrane Hepato-Biliary Group Controlled Trials Register, The Cochrane Central Register of Controlled Trials (CENTRAL) in The Cochrane Library, MEDLINE, EMBASE, Science Citation Index Expanded, LILACS, and CINAHL up to December 2012.

SELECTION CRITERIA

We included all randomised clinical trials assessing beneficial and harmful effects of microwave coagulation and its comparators, irrespective of the location of the primary tumour.

DATA COLLECTION AND ANALYSIS

We extracted relevant information on participant characteristics, interventions, and study outcomes and data on outcome measures for our review, as well as information on design and methodology of the studies. Bias risk assessment of trials, determination of whether they fulfilled the inclusion criteria, and data extraction from retrieved for final evaluation trials were done by one review author and were checked by a second review author.

MAIN RESULTS

One randomised clinical trial fulfilled the inclusion criteria of the review. Forty participants with multiple liver metastases of colorectal cancer and no evidence of extrahepatic disease were randomly assigned. Thirty of these participants (14 females and 16 males) were included in the analysis: 14 participants received microwave coagulation and 16 underwent conventional surgery (hepatectomy or liver resection). The diagnosis of colorectal cancer (Stage IB to IIIC; tumour (T)2 node (N)0 to T3N2) and liver metastases was confirmed by histological assessment. Mean participant age was 61 years. The tumours were resectable. The risk of bias in the trial was judged to be high.Participants were followed for three years. Mortality at the last follow-up was 64% (9/14) in the microwave group and 75% (12/16) in the conventional surgery group (risk ratio (RR) 0.86; 95% confidence interval (CI) 0.53 to 1.39), that is, no significant difference was observed. In the microwave coagulation group, 71%, 57%, and 14% survived 1, 2, and 3 years, and in the conventional surgery group, the percentages were 69%, 56%, and 23%. The hazard ratio calculated using the Parmar method was 0.91 (0.39 to 2.15).Mean survival time was 27 months in the microwave group and 25 months in the conventional surgery group, and the mean disease-free interval was 11.3 months in the microwave group and 13.3 months in the hepatectomy group. Differences for both outcomes were not statistically significant. Reported frequency of adverse events was similar between the microwave coagulation and conventional surgery groups, except for the required blood transfusion, which was more common in the conventional surgery group. No intervention-related mortality was observed. After treatment, the carcinoembryonic antigen level decreased significantly in both groups.

AUTHORS' CONCLUSIONS

On the basis of one randomised clinical trial, which did not describe allocation concealment or blinding, and which excluded from analysis 25% of participants after random assignment, evidence is insufficient to show whether microwave coagulation brings any significant benefit in terms of survival or recurrence compared with conventional surgery for participants with liver metastases from colorectal cancer. The number of adverse events, except for the requirement for blood transfusion, which was more common in the liver resection group, was similar in both groups. At present, microwave therapy cannot be recommended outside randomised clinical trials.

Pure laparoscopic hepatectomy for hepatocellular carcinoma with chronic liver disease

Pure laparoscopic hepatectomy is a less invasive procedure than conventional open hepatectomy for the resection of hepatic lesions. Increases in experiences with the technique, in combination with advances in technology, have promoted the popularity of pure laparoscopic hepatectomy. However, indications for usage and potential contraindications of the procedure remain unresolved. The characteristics and specific advantages of the procedure, especially for hepatocellular carcinoma (HCC) patients with chronic liver diseases, are reviewed and discussed in this paper. For cirrhotic patients with liver tumors, pure laparoscopic hepatectomy minimizes destruction of the collateral blood and lymphatic flow from laparotomy and mobilization, and mesenchymal injury from compression. Therefore, pure laparoscopic hepatectomy has the specific advantage of minimal postoperative ascites production that leads to lowering the risk of disturbance in water or electrolyte balance and hypoproteinemia. It minimizes complications that routinely trigger postoperative serious liver failure. Under adequate patient positioning and port arrangement, the partial resection of the liver in the area of subphrenic space, peri-inferior vena cava area or next to the attachment of retro-peritoneum is facilitated in pure laparoscopic surgery by providing good vision and manipulation in the small operative field. Furthermore, the features of reduced post-operative adhesion, good vision, and manipulation within the small area between the adhesions make this procedure safer in the context of repeat hepatectomy procedures. These improved features are especially advantageous for patients with liver cirrhosis and multicentric and/or metachronous HCCs.

Contrast-enhanced ultrasound in the characterization of hepatocellular carcinomas treated by ablation: comparison with contrast-enhanced magnetic resonance imaging

The purpose of this study was to evaluate the clinical utility of low-mechanical-index contrast-enhanced ultrasound (CEUS) in assessing the response to percutaneous microwave ablation in patients with hepatocellular carcinoma by comparing the results with those of contrast-enhanced magnetic resonance imaging (CEMRI). Between August 2005 and July 2011, 182 patients with 231 lesions treated by microwave ablation were included in the study. One month after microwave ablation, CEUS and CEMRI were performed to evaluate therapeutic responses. The difference in diagnostic accuracy between the two methods was analyzed to evaluate the value of contrast-enhanced ultrasound after microwave ablation. The final diagnosis was based on computed tomography and MRI typical findings of therapeutic response of hepatocellular carcinoma, proven serum tumor marker levels and additional follow-up. The sensitivity of CEUS and CEMRI in evaluating the therapeutic effect of hepatocellular carcinoma was 86.5% and 84.6%; the specificity, 98.3% and 98.9%; and the accuracy, 95.7% and 95.7%.There was no significant statistical disparity between CEUS and CEMRI (p > 0.05).The sensitivity, specificity and accuracy were 98.1, 97.2 and 97.8% when CEUS was used in combination with CEMRI to evaluate the therapeutic response of hepatocellular carcinoma to microwave ablation. CEUS examination was proven to be a tolerable and easy modality for assessment of the therapeutic effect of microwave ablation and can provide results comparable to those obtained with CEMRI. Combining the results of these two examinations may reduce false-positive and false-negative diagnoses.

Percutaneous radiofrequency ablation versus partial hepatectomy for small centrally located hepatocellular carcinoma

BACKGROUND

It is not known whether percutaneous radiofrequency ablation (PRFA) could get the same treatment efficacy and fewer complications as partial hepatectomy (PH) in patients with small centrally located hepatocellular carcinoma (HCC). The present study was designed to evaluate the efficacy of PH and PRFA in the treatment of small centrally located HCC.

METHODS

From January 2002 until December 2007, 196 patients with small centrally located HCC (≤5 cm) were included. Of these 196 patients, 94 received PRFA and 102 patients were treated with PH. Treatment outcomes, including major complications and survival data, were studied.

RESULTS

No treatment-related death occurred in either group. There were no significant differences in survival rates between the two groups. The 1-, 3-, and 5-year disease-free survival rates for the PRFA and PH groups were 57.9%, 36.4%, 34.0%, and 59.8%, 42.4%, 40.8%, respectively (P = 0.50). The 1-, 3-, and 5-year overall survival rates for the two groups were 94.3%, 74.7%, and 49.8%, and 89.2%, 74.1%, and 63.1%, respectively (P = 0.96). PRFA had a lower rate of major complications than PH (8.5 vs. 19.6%), and the hospital stay was also shorter in the PRFA group than in the PH subgroup (4 vs. 13 days).

CONCLUSIONS

Based on the data obtained, we concluded that PRFA might be equal to PH for the treatment of small centrally located HCC. However, PRFA has the benefits of shorter hospital stay as well as a lower rate of complications.

Lung flooding enables efficient lung sonography and tumour imaging in human ex vivo and porcine in vivo lung cancer model

BACKGROUND

Sonography has become the imaging technique of choice for guiding intraoperative interventions in abdominal surgery. Due to artefacts from residual air content, however, videothoracoscopic and open intraoperative ultrasound-guided thermoablation of lung malignancies are impossible. Lung flooding is a new method that allows complete ultrasound imaging of lungs and their tumours.

METHODS

Fourteen resected tumourous human lung lobes were examined transpleurally with B-mode ultrasound before (in atelectasis) and after lung flooding with isotonic saline solution. In two swine, the left lung was filled with 15 ml/kg isotonic saline solution through the left side of a double-lumen tube. Lung tumours were simulated by transthoracic ultrasound-guided injection of 5 ml of purified bovine serum albumin in glutaraldehyde, centrally into the left lower lung lobe. The rate of tumour detection, the severity of disability caused by residual gas, and sonomorphology of the lungs and tumours were assessed.

RESULTS

The ex vivo tumour detection rate was 100% in flooded human lung lobes and 43% (6/14) in atelectatic lungs. In all cases of atelectasis, sonographic tumour imaging was impaired by residual gas. Tumours and atelectatic tissue were isoechoic. In 28% of flooded lungs, a little residual gas was observed that did not impair sonographic tumour imaging. In contrast to tumours, flooded lung tissue was hyperechoic, homogeneous, and of fine-grained structure. Because of the bronchial wall three-laminar structure, sonographic differentiation of vessels and bronchi was possible. In all cases, malignant tumours in the flooded lung appeared well-demarcated from the lung parenchyma. Adenocarcinoma, squamous, and large cell carcinomas were hypoechoic. Bronchioloalveolar cell carcinoma was slightly hyperechoic. Transpleural sonography identifies endobronchial tumour growth and bronchial wall destruction. With transthoracic sonography, the flooded animal lung can be completely examined in vivo. There is no residual gas, which interferes with ultrasound. Pulmonary vessels and bronchi are clearly differentiated. Simulated lung lesions can easily be detected inside the lung lobe.

CONCLUSIONS

Lung flooding enables complete lung sonography and tumour detection. We have developed a novel method that efficiently uses ultrasound for guiding intraoperative interventions in open and endoscopic lung surgery.

Hepatocellular carcinoma: Clinical study of long-term survival and choice of treatment modalities

AIM: To analyze the prognostic factors of 5-year survival and 10-year survival in hepatocellular carcinoma (HCC) patients, and to explore the reasons for long-term survival and provide choice of treatment modalities for HCC patients.

METHODS: From January 1990 to October 2012, 8450 HCC patients were included in a prospective database compiled by the Information Center after hospital admission. Long-term surviving patients were included in a 10-year survival group (520 patients) and a 5-year survival group (1516 patients) for analysis.The long-term survival of HCC patients was defined as the survival of 5 years or longer. Clinical and biologic variables were assessed using univariate and multivariate analyses. The survival of patients was evaluated by follow-up data.

RESULTS: The long-term survival of HCC patients was associated with the number of lesions, liver cirrhosis and Child-Pugh classification. It was not found to be associated with tumor diameter, histological stage, and pretreatment level of serum α-fetoprotein. The differences in clinical factors between the 5-year survival and the 10-year survival were found to be the number of lesions, liver cirrhosis, Child-Pugh classification, and time elapsed until first recurrence or metastasis. The survival period of different treatment modalities in the patients who survived for 5 years and 10 years showed significant differences: (in order of significance) surgery alone > surgery-transcatheter arterial chemoembolization (TACE) > TACE-radiofrequency ablation (RFA) > TACE alone > surgery-TACE-RFA. The 10-year survival of HCC patients was not associated with the choice of treatment modality.

CONCLUSION: This retrospective study elucidated survival outcomes, prognostic factors affecting survival and treatment modalities in HCC patients.

Cationic lipid nanoparticles for therapeutic delivery of siRNA and miRNA to murine liver tumor

miR-122, a liver-specific tumor suppressor microRNA, is frequently down-regulated in hepatocellular carcinoma (HCC). LNP-DP1, a cationic lipid nanoparticle formulation, was developed as a vehicle to restore deregulated gene expression in HCC cells by miR-122 delivery. LNP-DP1 consists of 2-dioleyloxy-N,N-dimethyl-3-aminopropane (DODMA), egg phosphatidylcholine, cholesterol and cholesterol-polyethylene glycol. In vitro, LNP-DP1-mediated transfection of a miR-122 mimic to HCC cells down-regulated miR-122 target genes by >95%. In vivo, siRNAs/miRNAs encapsulated in LNP-DP1 were preferentially taken up by hepatocytes and tumor cells in a mouse HCC model. The miR-122 mimic in LNP-DP1 was functional in HCC cells without causing systemic toxicity. To demonstrate its therapeutic potential, LNP-DP1 encapsulating miR-122 mimic was intratumorally injected and resulted in ~50% growth suppression of HCC xenografts within 30 days, which correlated well with suppression of target genes and impairment of angiogenesis. These data demonstrate the potential of LNP-DP1-mediated microRNA delivery as a novel strategy for HCC therapy.

FROM THE CLINICAL EDITOR

In this study, LNP-DP1 -a cationic lipid nanoparticle formulation -is reported as a vehicle to restore deregulated gene expression in hepatic carcinoma cells by siRNA and miRNA delivery using a mouse model. Further expansions to this study may enable transition to clinical trials of this system.

Hepatitis B virus reactivation after radiofrequency ablation or hepatic resection for HBV-related small hepatocellular carcinoma: a retrospective study

BACKGROUND AND PURPOSE

Reactivation of hepatitis B virus (HBV) happens after systemic chemotherapy, transarterial chemoembolization (TACE) or hepatic resection for HBV-related hepatocellular carcinoma (HCC) patients. The incidence and risk factors of HBV reactivation after radiofrequency ablation (RFA) are unclear.

PATIENTS AND METHODS

From August 2006 to August 2011, 218 consecutive patients with HBV-related small HCC treated with RFA (n = 125) or hepatic resection (n = 93) were retrospectively studied. The incidence of HBV reactivation and risk factors were analyzed.

RESULTS

HBV reactivation developed in 20 (9.2%) patients after treatment. The incidence of HBV reactivation was significantly lower in the RFA group (5.6%, 7/125) than the hepatic resection group (14.0%, 13/93, P = 0.034). On univariate and multivariate analyses, no antiviral therapy (OR 11.7; 95% CI 1.52-90.8, P = 0.018) and treatment with RFA/hepatic resection (OR3.36; 95% CI 1.26-8.97, P = 0.016) were significant risk factors of HBV reactivation. On subgroup analysis, the incidence of HBV reactivation was lower in patients who received antiviral therapy than those who did not receive antiviral therapy in both the hepatic resection group (2.9% vs. 20.7%, P = 0.027) and the RFA group (0% vs. 7.6%, P = 0.188), although the difference was not significant in the latter group.

CONCLUSION

The incidence of HBV reactivation after RFA was relatively low when compared with hepatic resection. Prophylactic antiviral therapy is recommended, especially for patients who are going to receive hepatic resection for HBV-related HCC to decrease the incidence of post-treatment HBV reactivation.

Diaphragmatic necrosis after radiofrequency ablation of hepatocellular carcinoma: a successful surgical repair

We report a case of complete hemidiaphragmatic necrosis with liver abscess complicating radiofrequency ablation of a large subdiaphragmatic hepatocellular carcinoma in a patient with unrecognized history of endoscopic oddi sphincterotomy. At 2-year follow-up after surgical repair using a pedicled latissimus dorsi flap, clinical examination and imaging did not show complication or cancer recurrence. The risk of complete hemidiaphragmatic necrosis resulting from both thermal and septic injuries should be considered when radiofrequency ablation is performed for liver dome tumors, particularly in patients with impaired oddi sphincter. In this septic situation, a latissimus dorsi flap appears as the unique opportunity to repair the injured hemidiaphragm.

Postoperative neutrophil-to-lymphocyte ratio change predicts survival of patients with small hepatocellular carcinoma undergoing radiofrequency ablation

BACKGROUND

An elevated preoperative neutrophil-to-lymphocyte ratio (NLR) has been reported to be a prognostic factor for hepatocellular carcinoma (HCC) patients after treatment. However, the clinical implication of postoperative NLR change remains unclear.

MATERIALS AND METHODS

From May 2005 to Aug 2008, a cohort of consecutive 178 small HCC patients treated with radiofrequency ablation (RFA) was retrospectively reviewed. The NLR was recorded within 3 days before and 1 month after RFA. Baseline characteristics, overall survival (OS) and recurrence free survival (RFS) were compared according to preoperative NLR and/or postoperative NLR change. Prognostic factors were assessed by multivariate analysis.

RESULTS

Compared with preoperative NLR level, postoperative NLR decreased in 87 patients and increased in 91 patients after RFA. No significant differences were identified between two groups in commonly used clinic-pathologic features. The 1, 3, 5 years OS was 98.8%, 78.6%, 67.1% for NLR decreased group, and 92.2%, 55.5%, 35.4% for NLR increased group respectively (P<0.001); the corresponding RFS was 94.2%, 65.2%, 33.8% and 81.7%, 46.1%, 12.4% respectively (P<0.001). In subgroup analysis, the survival of patients with lower or higher preoperative NLR can be distinguished more accurate by postoperative NLR change. Multivariate analysis showed that postoperative NLR change, but not preoperative NLR, was an independent prognostic factor for both OS (P<0.001, HR = 2.39, 95%CI 1.53-3.72) and RFS (P = 0.003, HR = 1.69, 95%CI 1.87-8.24).

CONCLUSION

The postoperative NLR change was an independent prognostic factor for small HCC patient undergoing RFA, and patients with decreased NLR indicated better survival than those with increased NLR.

Postoperative neutrophil-to-lymphocyte ratio change predicts survival of patients with small hepatocellular carcinoma undergoing radiofrequency ablation

BACKGROUND

An elevated preoperative neutrophil-to-lymphocyte ratio (NLR) has been reported to be a prognostic factor for hepatocellular carcinoma (HCC) patients after treatment. However, the clinical implication of postoperative NLR change remains unclear.

MATERIALS AND METHODS

From May 2005 to Aug 2008, a cohort of consecutive 178 small HCC patients treated with radiofrequency ablation (RFA) was retrospectively reviewed. The NLR was recorded within 3 days before and 1 month after RFA. Baseline characteristics, overall survival (OS) and recurrence free survival (RFS) were compared according to preoperative NLR and/or postoperative NLR change. Prognostic factors were assessed by multivariate analysis.

RESULTS

Compared with preoperative NLR level, postoperative NLR decreased in 87 patients and increased in 91 patients after RFA. No significant differences were identified between two groups in commonly used clinic-pathologic features. The 1, 3, 5 years OS was 98.8%, 78.6%, 67.1% for NLR decreased group, and 92.2%, 55.5%, 35.4% for NLR increased group respectively (P<0.001); the corresponding RFS was 94.2%, 65.2%, 33.8% and 81.7%, 46.1%, 12.4% respectively (P<0.001). In subgroup analysis, the survival of patients with lower or higher preoperative NLR can be distinguished more accurate by postoperative NLR change. Multivariate analysis showed that postoperative NLR change, but not preoperative NLR, was an independent prognostic factor for both OS (P<0.001, HR = 2.39, 95%CI 1.53-3.72) and RFS (P = 0.003, HR = 1.69, 95%CI 1.87-8.24).

CONCLUSION

The postoperative NLR change was an independent prognostic factor for small HCC patient undergoing RFA, and patients with decreased NLR indicated better survival than those with increased NLR.

Ultrasound-guided characterization of interstitial ablated tissue using RF time series: feasibility study

This paper presents the results of a feasibility study to demonstrate the application of ultrasound RF time series imaging to accurately differentiate ablated and nonablated tissue. For 12 ex vivo and two in situ tissue samples, RF ultrasound signals are acquired prior to, and following, high-intensity ultrasound ablation. Spatial and temporal features of these signals are used to characterize ablated and nonablated tissue in a supervised-learning framework. In cross-validation evaluation, a subset of four features extracted from RF time series produce a classification accuracy of 84.5%, an area under ROC curve of 0.91 for ex vivo data, and an accuracy of 85% for in situ data. Ultrasound RF time series is a promising approach for characterizing ablated tissue.

Advances in treatment of liver metastases of colorectal cancer

Liver metastasis of colorectal cancer has a high incidence and mortality and is the main factor affecting prognosis, which necessitates the development of more reasonable therapeutic strategy for this condition. Nowadays, surgical resection is the only probable curative method; however, surgical intervention is indicated in only a few patients. The development of medical technology and accumulation of clinical experience have led to the wide use of multimodal treatment for liver metastases of colorectal cancer. Multimodal treatment includes surgical resection, neoadjuvant chemotherapy, transcatheter hepatic arterial chemoembolization, radiation therapy, radiofrequency ablation, cryotherapy, percutaneous ethanol injection, and Chinese medicine treatment. The combined application of the above treatments can improve the survival rate and the quality of life of patients. This article summarizes the advances in comprehensive treatment for colorectal liver metastases.

Meta-analysis of laparoscopic vs open liver resection for hepatocellular carcinoma

AIM: To conduct a meta-analysis to determine the safety and efficacy of laparoscopic liver resection (LLR) and open liver resection (OLR) for hepatocellular carcinoma (HCC).

METHODS: PubMed (Medline), EMBASE and Science Citation Index Expanded and Cochrane Central Register of Controlled Trials in the Cochrane Library were searched systematically to identify relevant comparative studies reporting outcomes for both LLR and OLR for HCC between January 1992 and February 2012. Two authors independently assessed the trials for inclusion and extracted the data. Meta-analysis was performed using Review Manager Version 5.0 software (The Cochrane Collaboration, Oxford, United Kingdom). Pooled odds ratios (OR) or weighted mean differences (WMD) with 95%CI were calculated using either fixed effects (Mantel-Haenszel method) or random effects models (DerSimonian and Laird method). Evaluated endpoints were operative outcomes (operation time, intraoperative blood loss, blood transfusion requirement), postoperative outcomes (liver failure, cirrhotic decompensation/ascites, bile leakage, postoperative bleeding, pulmonary complications, intraabdominal abscess, mortality, hospital stay and oncologic outcomes (positive resection margins and tumor recurrence).

RESULTS: Fifteen eligible non-randomized studies were identified, out of which, 9 high-quality studies involving 550 patients were included, with 234 patients in the LLR group and 316 patients in the OLR group. LLR was associated with significantly lower intraoperative blood loss, based on six studies with 333 patients [WMD: -129.48 mL; 95%CI: -224.76-(-34.21) mL; P = 0.008]. Seven studies involving 416 patients were included to assess blood transfusion requirement between the two groups. The LLR group had lower blood transfusion requirement (OR: 0.49; 95%CI: 0.26-0.91; P = 0.02). While analyzing hospital stay, six studies with 333 patients were included. Patients in the LLR group were found to have shorter hospital stay [WMD: -3.19 d; 95%CI: -4.09-(-2.28) d; P < 0.00001] than their OLR counterpart. Seven studies including 416 patients were pooled together to estimate the odds of developing postoperative ascites in the patient groups. The LLR group appeared to have a lower incidence of postoperative ascites (OR: 0.32; 95%CI: 0.16-0.61; P = 0.0006) as compared with OLR patients. Similarly, fewer patients had liver failure in the LLR group than in the OLR group (OR: 0.15; 95%CI: 0.02-0.95; P = 0.04). However, no significant differences were found between the two approaches with regards to operation time [WMD: 4.69 min; 95%CI: -22.62-32 min; P = 0.74], bile leakage (OR: 0.55; 95%CI: 0.10-3.12; P = 0.50), postoperative bleeding (OR: 0.54; 95%CI: 0.20-1.45; P = 0.22), pulmonary complications (OR: 0.43; 95%CI: 0.18-1.04; P = 0.06), intra-abdominal abscesses (OR: 0.21; 95%CI: 0.01-4.53; P = 0.32), mortality (OR: 0.46; 95%CI: 0.14-1.51; P = 0.20), presence of positive resection margins (OR: 0.59; 95%CI: 0.21-1.62; P = 0.31) and tumor recurrence (OR: 0.95; 95%CI: 0.62-1.46; P = 0.81).

CONCLUSION: LLR appears to be a safe and feasible option for resection of HCC in selected patients based on current evidence. However, further appropriately designed randomized controlled trials should be undertaken to ascertain these findings.

Hospital volume of percutaneous radiofrequency ablation is closely associated with treatment outcomes for patients with hepatocellular carcinoma

BACKGROUND

Hospital volume for several major operations is associated with treatment outcomes. In this study, the authors explored the influence of hospital radiofrequency ablation (RFA) volume on the prognosis of patients who received RFA for hepatocellular carcinoma (HCC).

METHODS

The authors searched for all patients who were diagnosed with stage I or stage II HCC from 2004 to 2006 and who received RFA as first-line therapy in a population-based cohort. Overall survival (OS) and liver cancer-specific survival (CSS) were compared according to hospital volume. A Cox proportional hazards model was used for multivariate analysis.

RESULTS

In total, 661 patients received first-line RFA for stage I and II HCC in 28 hospitals. Among these, there were 480 patients (72.6%) in the high-volume group (those who received RFA at hospitals that treated >10 first-line patients per year), and there were 181 patients (27.4%) in the low-volume group (those who received RFA at hospitals that treated ≤ 10 first-line patients per year). The sex, age, stage, tumor size, and year of diagnosis for patients in the 2 groups did not differ significantly. Patients in the high-volume group demonstrated significantly longer OS and CSS than those in the low-volume group (5-year OS rate, 58.7% vs 47.2%; P = .001; 5-year CSS rate, 67.1% vs 57.1%; P = .009). After adjusting for covariates, high-volume hospitals remained an independent predictor of longer OS (hazard ratio, 0.57; P < .001) and CSS (hazard ratio, 0.57; P = .003).

CONCLUSIONS

Patients who received first-line RFA for HCC in high-volume hospitals demonstrated better survival outcomes.

Imaging and Imaging-Guided Interventions in the Diagnosis and Management of Hepatocellular Carcinoma (HCC)-Review of Evidence

The imaging of hepatocellular carcinoma (HCC) is challenging and plays a crucial role in the diagnosis and staging of the disease. A variety of imaging modalities, such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and nuclear medicine are currently used in evaluating patients with HCC. Although the best option for the treatment of these cases is hepatic resection or transplantation, only 20% of HCCs are surgically treatable. In those patients who are not eligible for surgical treatment, interventional therapies such as transcatheter arterial chemoembolization (TACE), percutaneous ethanol injection (PEI), radio-frequency ablation (RFA), percutaneous microwave coagulation therapy (PMC), laser ablation or cryoablation, and acetic acid injection are indicated. In this paper, we aimed to review the evidence regarding imaging modalities and therapeutic interventions of HCC.

Treatment of hepatocellular carcinoma: a systematic review

Hepatocellular carcinoma (HCC) is one of the most common malignancies, with an increasing incidence. With advances in surgical techniques and instrumentation and the development of molecular-target drugs, a number of potentially curative treatments have become available. Management of HCC patients depends on the stage of their tumor. Liver resection remains the first choice for very early-stage HCC, but it is being challenged by local ablative therapy. For early-stage HCC that meet the Milan criteria, liver transplantation still offers a better outcome; however, local ablative therapy can be a substitute when transplantation is not feasible. Local ablation is also used as a bridging therapy toward liver transplantation. HCC recurrence is the main obstacle to successful treatment, and there is currently no effective means of preventing or treating HCC recurrence. Transarterial therapy is considered suitable for intermediate-stage HCC, while sorafenib is recommended for advanced-stage HCC. This stage-based approach to therapy not only provides acceptable outcomes but also improves the quality of life of HCC patients. Because of the complexity of HCC, therapeutic approaches must be adapted according to the characteristics of each individual patient. This review discusses the current standards and trends in the treatment of HCC.

Safety and efficacy of laparoscopic radiofrequency ablation for hepatic malignancies

Purpose

Radiofrequency ablation (RFA) is an accepted treatment option for primary and metastatic liver tumors. As percutaneous RFA has some limitations, laparoscopic RFA (LRFA) has been used as a therapeutic alternative for the treatment of hepatic malignancies.

Methods

Between March 2006 and September 2009, thirty patients with hepatic malignancies that were contraindicated for resection or percutaneous RFA underwent LRFA. Indications for this procedure were hepatocellular carcinoma (HCC, 21 patients), metastatic liver tumor (8 patients) and intrahepatic cholangiocarcinoma (1 patient).

Results

Among the 30 patients who underwent LRFA, 5 patients underwent concomitant laparoscopic liver resection. Intraoperative laparoscopic ultrasound detected new malignant lesions in 4 patients (13.3%). A total of 46 lesions were ablated by LRFA. There was no postoperative mortality. The three-year overall survival rate was 83.7% for the HCC group and 64.3% for the metastatic group.

Conclusion

LRFA for hepatic malignancies proved to be a safe and effective treatment. Also, this procedure is indicated for lesions that are not amenable to percutaneous RFA or liver resection.

Image-based 3D modeling and validation of radiofrequency interstitial tumor ablation using a tissue-mimicking breast phantom

PURPOSE

Minimally invasive treatment of solid cancers, especially in the breast and liver, remains clinically challenging, despite a variety of treatment modalities, including radiofrequency ablation (RFA), microwave ablation or high-intensity focused ultrasound. Each treatment modality has advantages and disadvantages, but all are limited by placement of a probe or US beam in the target tissue for tumor ablation and monitoring. The placement is difficult when the tumor is surrounded by large blood vessels or organs. Patient-specific image-based 3D modeling for thermal ablation simulation was developed to optimize treatment protocols that improve treatment efficacy.

METHODS

A tissue-mimicking breast gel phantom was used to develop an image-based 3D computer-aided design (CAD) model for the evaluation of a planned RF ablation. First, the tissue-mimicking gel was cast in a breast mold to create a 3D breast phantom, which contained a simulated solid tumor. Second, the phantom was imaged in a medical MRI scanner using a standard breast imaging MR sequence. Third, the MR images were converted into a 3D CAD model using commercial software (ScanIP, Simpleware), which was input into another commercial package (COMSOL Multiphysics) for RFA simulation and treatment planning using a finite element method (FEM). For validation of the model, the breast phantom was experimentally ablated using a commercial (RITA) RFA electrode and a bipolar needle with an electrosurgical generator (DRE ASG-300). The RFA results obtained by pre-treatment simulation were compared with actual experimental ablation.

RESULTS

A 3D CAD model, created from MR images of the complex breast phantom, was successfully integrated with an RFA electrode to perform FEM ablation simulation. The ablation volumes achieved both in the FEM simulation and the experimental test were equivalent, indicating that patient-specific models can be implemented for pre-treatment planning of solid tumor ablation.

CONCLUSION

A tissue-mimicking breast gel phantom and its MR images were used to perform FEM 3D modeling and validation by experimental thermal ablation of the tumor. Similar patient-specific models can be created from preoperative images and used to perform finite element analysis to plan radiofrequency ablation. Clinically, the method can be implemented for pre-treatment planning to predict the effect of an individual's tissue environment on the ablation process, and this may improve the therapeutic efficacy.

Diabetes mellitus is associated with increased mortality in patients receiving curative therapy for hepatocellular carcinoma

BACKGROUND

Diabetes mellitus (DM) is closely associated with hepatocarcinogenesis. This study explores the prognostic impact of DM in patients who received curative therapy for localized hepatocellular carcinoma (HCC).

METHODS

Patients who had been diagnosed with stage I or II HCC in 2003 and 2004 and received surgical resection or local ablation therapy were identified from the population-based Taiwan National Cancer Registry. Data pertaining to DM and other comorbidities were retrieved from the Taiwan National Health Insurance database. Liver cancer-specific survival (LCS), liver disease-related survival (LDS) and overall survival (OS) rates were compared between patients with and without DM. The presence of other comorbidities and tumor status were adjusted using multivariate analysis.

RESULTS

A total of 931 patients who fulfilled the study criteria were analyzed; 185 (20%) of them had DM (type 1 or type 2). The LCS, LDS, and OS rates were significantly worse for patients with DM than patients without DM (all p < .001). After adjusting for age, sex, tumor stage, treatment, and the presence of other comorbidities, DM remained an independent predictor of poorer LCS (hazard ratio [HR] = 1.57; p < .001), LDS (HR = 1.70; p < .001), and OS (HR = 1.69; p < .001). The associations between DM and mortality were consistent among subgroups, irrespective of tumor size, stage, treatment modality, and liver cirrhosis.

CONCLUSIONS

DM is an independent factor for poorer prognosis in patients who received curative therapy for localized HCC.

Efficacy of microwave versus radiofrequency ablation for treatment of small hepatocellular carcinoma: experimental and clinical studies

OBJECTIVE

To prospectively compare microwave (MW) ablation using a modified internal cooled-shaft antenna with radiofrequency (RF) ablation in in vivo porcine liver and in patients with small hepatocellular carcinoma (sHCC).

METHODS

In an animal study, MW and RF ablations using a cooled-shaft antenna or internally cooled electrode were performed in in vivo porcine liver. Coagulation diameters of both ablations were compared. For clinical study, 42 patients with sHCC were treated with MW or RF ablation. Complete ablation (CA) and local tumour progression (LTP) were compared.

RESULTS

MW ablation produced significantly larger ablation zones than RF ablation in both porcine liver and sHCC with an ablated volume of 33.3 ± 15.6 cm(3) vs. 18.9 ± 9.1 cm(3) and 109.3 ± 58.3 cm(3) vs. 48.7 ± 30.5 cm(3), respectively. The CA rate was 95.5 % (21/22) for MW ablation and 95.0 % (19/20) for RF ablation. In a 5.1-month follow-up, the LTP rate was 18.2 % (4/22) in the MW ablation group and 15.0 % (3/20) in the RF ablation group.

CONCLUSION

MW ablation using a modified cooled-shaft antenna produces a larger ablation zone than RF ablation, with an efficacy similar to RF ablation in local tumour control. MW ablation is a safe and promising treatment of sHCC.

High-powered gas-cooled microwave ablation: shaft cooling creates an effective stick function without altering the ablation zone

OBJECTIVE

The purpose of our study was to validate the ability of a new gas-cooled microwave device to secure antennas into tissue before ablation via shaft cooling and to verify that such cooling does not compromise the intended ablation.

MATERIALS AND METHODS

The force required to extract several types of applicators from ex vivo bovine liver before and after ablation was measured. Six groups were compared: cooled needle and multitined radiofrequency electrodes, secured and unsecured cryoprobes, and gas-cooled microwave antennas (n = 6 each). Ablations were next created in in vivo porcine livers for 2 and 10 minutes (n = 6 each) using the gas-cooled microwave system at 140 W. Extraction force was again measured before and after ablation and compared between groups using analysis of variance with post hoc Student t tests. Histologic analysis of the ablation zone was performed to evaluate cellular necrosis along the antenna shaft.

RESULTS

Ex vivo, the secured cryoprobe and microwave antenna required significantly more force to remove than unsecured radiofrequency, cryoprobe, and microwave applicators (p < 0.05, all comparisons). The multitined radiofrequency electrode and cooled radiofrequency electrode required significantly more force to remove after ablation than before ablation (p = 0.006 and 0.02, respectively). In vivo, the secured antenna required significantly more force to remove before ablation than after ablation at both 2 (p < 0.0001) and 10 minutes (p < 0.0001). There was no histologic evidence of cell preservation along the antenna shaft.

CONCLUSION

The gas cooling used in this microwave device can effectively secure antennas into tissue without altering ablation shape or reducing the intended thermal damage.

Radiofrequency ablation versus hepatic resection for the treatment of hepatocellular carcinomas 2 cm or smaller: a retrospective comparative study

PURPOSE

To compare retrospectively the effects of percutaneous radiofrequency (RF) ablation with those of hepatic resection in the treatment of hepatocellular carcinoma (HCC) measuring 2 cm or smaller.

MATERIALS AND METHODS

This study was approved by the institutional ethics committee, and all patients provided written informed consent before treatment. From December 2003 to December 2008, 145 patients with a resectable HCC measuring 2 cm or smaller were studied. Sixty-six patients had a central HCC (located at least 3 cm from the liver capsule). As an initial treatment, 71 patients were treated with percutaneous RF ablation and 74 with surgical resection. Of the patients with central HCC, 37 underwent percutaneous RF ablation and 29 underwent surgical resection. Survival curves were constructed with the Kaplan-Meier method and compared by using the log-rank test. The relative prognostic significance of the variables for predicting overall survival rates was assessed with multivariate Cox proportional hazards regression analysis. Complications were observed clinically when patients were admitted and assessed by telephone interview after patients were discharged.

RESULTS

One death was considered to be related to treatment after surgical resection. Major complications occurred significantly more often in the surgical resection group (38 of 74 patients) than in the RF ablation group (14 of 71 patients) (P = .009). The 1-, 3-, and 5-year overall survival rates were 98.5%, 87.7%, and 71.9%, respectively, with RF ablation and 90.5%, 70.9%, and 62.1% with surgical resection (P = .048). The corresponding recurrence-free survival rates were 76.4%, 65.2%, and 59.8% with RF ablation and 75.6%, 56.1%, and 51.3% with surgical resection (P = .548). At subgroup analysis of patients with central HCC, 1-, 3-, and 5-year overall survival rates were 96.6%, 93.0%, and 79.9% with RF ablation and 92.0%, 71.6%, and 61.5% with surgical resection (P = .020). The corresponding recurrence-free survival rates were 86.5%, 74.0%, and 67.0% with RF ablation and 68.0%, 40.0%, and 40.0% with surgical resection (P = .033). For patients with peripheral HCC, 1-, 3-, and 5-year overall survival rates were 97.3%, 83.3%, and 65.1% with RF ablation and 87.8%, 68.4%, and 62.9% with surgical resection (P = .464). The corresponding recurrence-free survival rates were 68.7%, 59.2%, and 54.9% with RF ablation and 82.9%, 66.6%, and 52.9% with surgical resection (P = .351).

CONCLUSION

The efficacy and safety of percutaneous RF ablation were better than those of surgical resection in patients with HCC measuring 2 cm or smaller, especially those with central HCC.

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, laser-induced 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.

Hepatic arterial infusion chemotherapy for advanced hepatocellular carcinoma in Japan

Transcatheter methods such as transcatheter arterial chemoembolization (TACE) and hepatic arterial infusion chemotherapy (HAIC) have an important role in the treatment for advanced hepatocellular carcinoma (HCC). Recently, sorafenib, an inhibitor of tyrosine kinases, has been found to obtain survival benefits in patients with HCC, leading to major advances in the treatment of advanced HCC. However, it is associated with a low tumor response rate, minimal survival advantage, and high rates of adverse events. On the other hand, high rates of objective treatment response with HAIC for advanced HCC have been reported, although convincing evidence of it contributing to overall survival in HAIC has been lacking. In Japan, HAIC still tends to be the preferred method for the treatment of advanced HCC, even in patients with poor liver function. However, the choice of chemotherapeutic agents in TACE/HAIC for HCC varies between institutions. In this review, based on studies reported to date in the literature, we refer to current knowledge regarding the chemotherapeutic agents used for TACE/HAIC for HCC in Japan and consider the future perspectives for HAIC for this cancer.

Clinical outcomes of radiofrequency ablation and surgical resection for small hepatocellular carcinoma: a meta-analysis

BACKGROUND AND AIM

To evaluate the evidence comparing radiofrequency ablation (RFA) and surgical resection (RES) on the treatment of hepatocellular carcinoma (HCC) using meta-analytical techniques.

METHODS

Literature search was undertaken until March 2011 to identify comparative studies evaluating survival rates, recurrence rates, and complications. Pooled odds ratios (OR) and 95% confidence intervals (95% CI) were calculated with either the fixed or random effect model.

RESULTS

These studies included a total of 877 patients: 441 treated with RFA and 436 treated with RES. The overall survival was significantly higher in patients treated with RES than RFA at 1, 3 and 5 years (respectively: OR: 0.50, 95% CI: 0.29-0.86; OR: 0.51, 95% CI: 0.28-0.94; OR: 0.62, 95% CI: 0.45-0.84). In the RES group the 1, 3, and 5 years recurrence-free survival rates were significantly higher than the RFA group (respectively: OR: 0.65, 95% CI: 0.44-0.97; OR: 0.65, 95% CI: 0.47-0.89; OR: 0.52, 95% CI: 0.35-0.77). RFA had a higher rate of local recurrence (OR: 4.08, 95% CI: 2.03-8.20). For tumors ≤ 3 cm RES was better than RFA in the 3-year overall survival rates (OR: 0.38, 95% CI: 0.16-0.89).

CONCLUSIONS

Surgical resection was superior to RFA in the treatment of HCC. However, the findings have to be carefully interpreted due to the lower level of evidence.

Comparison of percutaneous radiofrequency thermal ablation and surgical resection for small hepatocellular carcinoma

Background

The purpose of this investigation was to compare the outcome of percutaneous radiofrequency thermal ablation therapy (PRFA) with surgical resection (SR) in the treatment of single and small hepatocellular carcinoma (HCC).

Methods

We conducted a retrospective cohort study on 231 treatment naive patients with a single HCC ≤ 3 cm who had received either curative PRFA (162 patients) or curative SR (69 patients). All patients were regularly followed up after treatment at our department with blood and radiologic tests.

Results

The 1-, 3- and 5-year overall survival rates after PRFA and SR were 95.4%, 79.6% and 63.1%, respectively in the PRFA group and 100%, 81.4% and 74.6%, respectively in the SR group. The corresponding recurrence free survival rates at 1, 3 and 5 years after PRFA and SR were 82.0%, 38.3% and 18.0%, respectively in the PRFA group and 86.0%, 47.2% and 26.0%, respectively in the SR group. In terms of overall survival and recurrence free survival, there were no significant differences between these two groups. In comparison of PRFA group patients with liver cirrhosis (LC) (n = 127) and SR group patients with LC (n = 50) and in comparison of PRFA group patients without LC (n = 35) and SR group patients without LC (n = 19), there were also no significant differences between two groups in terms of overall survival and recurrence free survival. In the multivariate analysis of the risk factors contributing to overall survival, serum albumin level was the sole significant factor. In the multivariate analysis of the risk factors contributing to recurrence free survival, presence of LC was the sole significant factor. The rate of serious adverse events in the SR group was significantly higher than that in the PRFA group (P = 0.023). Hospitalization length in the SR group was significantly longer than in the PRFA group (P = 0.013).

Conclusions

PRFA is as effective as SR in the treatment of single and small HCC, and is less invasive than SR. Therefore, PRFA could be a first choice for the treatment of single and small HCC.

Stereotactic body radiation therapy in hepatocellular carcinoma and cirrhosis: evaluation of radiological and pathological response

BACKGROUND

Loco-regional therapies for cirrhotic patients with hepatocellular carcinoma (HCC) who are awaiting liver transplantation (OLT) attempt to prevent tumor progression. However, there is limited data regarding the efficacy of stereotactic body radiation therapy (SBRT) as loco-regional treatment.

METHODS

From 2006 to 2009, 27 HCC patients (AJCC I, II) listed for OLT underwent SBRT. Thirty-nine lesions were treated and 27 assessed radiologically. Seventeen patients had OLT, liver explants were analyzed and 22 lesions underwent pathological evaluation.

RESULTS

In a cumulative analysis of all imaging, 30% had complete response, 7% had partial response, 56% were stable, and 7% had progression of disease. Of the 22 pathologically evaluated lesions, 37% were responders: 14% with complete response, 23% with partial response, and 63% with no response. Side effects from SBRT were recorded in three patients, which included nausea in two and liver decompensation in one.

CONCLUSION

SBRT achieves total or partial radiological response in 37% of patients and total or partial pathological response in 37% of patients with early HCC in the setting of cirrhosis. SBRT may be a safe and effective alternative for local tumor control in patients with HCC and cirrhosis awaiting OLT.

Meta-analysis of trials comparing minimally-invasive and open liver resections for hepatocellular carcinoma

BACKGROUND

Recent literature suggests that minimally-invasive hepatectomy (MIH) for hepatocellular carcinoma (HCC) is associated with better perioperative results and similar oncologic outcomes compared to open hepatectomy (OH). However, previous reports have been limited by small sample size and single-institution design.

METHODS

To overcome these limitations, we performed a meta-analysis of studies comparing MIH and OH in patients with HCC using a random-effects model.

RESULTS

Nine eligible studies were identified that included 227 patients undergoing MIH and 363 undergoing OH. Patients were similar respect to age, gender, rates of cirrhosis, hepatitis C infection, tumour size, and American Society of Anesthesiology classification. The MIH group had lower rates of hepatitis B infection. There were no differences in type of resection (anatomic or non-anatomic), use of Pringle's maneuver, and operative time. Patients undergoing MIH had less blood loss [difference -217 mL; 95% confidence interval (CI), -314 to -121], lower rates of transfusion [odds ratio (OR), 0.38; 95% CI, 0.24 to 0.59], shorter postoperative stay (difference -5 days; 95% CI, -7.84 to -2.25), lower rates of positive margins (OR, 0.30; 95% CI, 0.12 to 0.69) and perioperative complications (OR, 0.45; 95% CI, 0.31 to 0.66). Survival outcomes were similar in the two groups.

CONCLUSIONS

Although patient selection might have influenced some of the observed outcomes, MIH was associated with decreased blood loss, transfusions, rates of positive resection margins, overall and specific morbidity, and hospital stay. Survival outcomes did not differ between MIH and OH, although further studies are needed to evaluate the impact of MIH on long-term results.

Selective ex-vivo photothermal ablation of human pancreatic cancer with albumin functionalized multiwalled carbon nanotubes

The process of laser-mediated ablation of cancer cells marked with biofunctionalized carbon nanotubes is frequently called "nanophotothermolysis". We herein present a method of selective nanophotothermolisys of pancreatic cancer (PC) using multiwalled carbon nanotubes (MWCNTs) functionalized with human serum albumin (HSA). With the purpose of testing the therapeutic value of these nanobioconjugates, we have developed an ex-vivo experimental platform. Surgically resected specimens from patients with PC were preserved in a cold medium and kept alive via intra-arterial perfusion. Additionally, the HSA-MWCNTs have been intra-arterially administered in the greater pancreatic artery under ultrasound guidance. Confocal and transmission electron microscopy combined with immunohistochemical staining have confirmed the selective accumulation of HSA-MWCNTs inside the human PC tissue. The external laser irradiation of the specimen has significantly produced extensive necrosis of the malign tissue after the intra-arterial administration of HSA-MWCNTs, without any harmful effects on the surrounding healthy parenchyma. We have obtained a selective photothermal ablation of the malign tissue based on the selective internalization of MWCNTs with HSA cargo inside the pancreatic adenocarcinoma after the ex-vivo intra-arterial perfusion.

Percutaneous radiofrequency ablation versus partial hepatectomy for multicentric small hepatocellular carcinomas: a nonrandomized comparative study

BACKGROUND

The aim of this study was to compare the results of percutaneous radiofrequency ablation (RFA) with those of partial hepatectomy (PH) in the treatment of multicentric small hepatocellular carcinomas (HCCs). With advances in RFA, it is not known whether the minimally invasive approach with percutaneous RFA could attain comparable survival outcomes but with a lower morbidity in patients with multicentric HCCs.

METHODS

From January 2002 and December 2007, 159 patients who had two or three HCCs, with the largest tumor no more than 5 cm in diameter, had no major vascular invasion or extrahepatic metastases, and were treated with either PH (n = 73) or RFA (n = 86) were included in the study.

RESULTS

There was no procedure-related mortality in both groups of patients. Major complications happened significantly more often after PH than after RFA (19.2 vs. 8.1%). The hospital stay was significantly longer after PH than after RFA (median = 9 vs. 3 days). The 1-, 3-, and 5-year overall survival rates for the PH and RFA groups were 91.8, 68.7, 44.5% and 94.2, 64.4, 21.2%, respectively. The corresponding disease-free survival rates for the two groups were 62.1, 33.6, 3.6% and 29.4, 2.7, 0%, respectively. The PH group had significantly longer overall survival and disease-free survival than the RFA group.

CONCLUSIONS

PH resulted in better survival outcomes than RFA for patients with multicentric small HCCs. However, RFA had the benefits of lower procedure-related morbidity and shorter hospital stay.

Radiofrequency ablation versus surgical resection for hepatocellular carcinoma in Childs A cirrhotics-a retrospective study of 1,061 cases

INTRODUCTION

The long-term outcomes of radiofrequency ablation (RFA) vs. surgical resection in cirrhotic patients with hepatocellular carcinoma (HCC) remain controversial. One thousand sixty-one cirrhotic HCC patients were included into a retrospective study. Four hundred thirteen received RFA and 648 received surgical resection.

RESULTS

Overall (OS), recurrence-free (RFS), and tumor-free survival (TFS) were compared between the two groups and in subgroup analyses. The 5-year OS and corresponding RFS as well as DFS were significantly higher in the surgical resection group compared with the RFA group (p < 0.001, p < 0.001, p < 0.001). In subgroup analyses of solitary HCC ≤3 cm, there was no significant difference in RFS between the two groups (p = 0.719). Nonetheless, surgical resection was superior to RFA for OS and TFS in this subgroup as well as for OS, RFS, and TFS in subgroup analyses for solitary lesions 3 cm < HCC < 5 cm and multifocal HCC. Serum AFP was the only significant predicting factor for all survival analyses.

CONCLUSIONS

When treating Childs A cirrhotic patients with solitary HCC larger than 3 cm but less than 5 cm, or with two or three lesions each less than 5 cm, surgical resection provides a better survival than RFA. When treating Childs A cirrhotics with solitary HCC ≤ 3 cm, RFA has a comparable RFS to surgical resection, but RFA is less invasive.

Conformal radiofrequency ablation of hepatocellular carcinoma with a multi-pin bipolar system

BACKGROUND

To retrospectively evaluate the effectiveness and safety of radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) with a multi-pin bipolar system.

METHODS

Between August 2005 and December 2006, 18 patients with 30 HCCs (3.40 ± 1.24 cm, range 1.30-6.0 cm; median number of treated lesions is two per patient, range, 1-3) underwent percutaneous RFA with a multi-pin bipolar system under ultrasound guidance. The primary end-point were treatment efficacy, major and minor complications, and the secondary end-point were overall survival and tumor-free survival.

RESULTS

Complete ablation with conformed shape to the index tumor was achieved in 16 of 18 patients, and 28 of the 30 tumors were completely ablated. On follow-up, local and distant intrahepatic tumor progression rates were 12.5% (2 of 16 patients) and 62.5% (10 of 16 patients). There was no patient who developed extrahepatic metastasis. There were no major complications. The 1-, 2-year overall survival rates for all patients were 83.3%, 55.6%, respectively, and the corresponding tumor-free survivals were 50.0%, 22.2%, respectively.

CONCLUSION

RFA with a multi-pin bipolar system was effective and safe for HCC. A large ablation volume could be achieved which conformed to the shape of the index tumor.

Surgical vs percutaneous radiofrequency ablation for hepatocellular carcinoma in dangerous locations

AIM: To compare the long-term outcome of percutaneous vs surgical radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) in dangerous locations.

METHODS: One hundred and sixty-two patients with HCC in dangerous locations treated with percutaneous or surgical RFA were enrolled in this study. The patients were divided into percutaneous RFA group and surgical RFA group. After the patients were regularly followed up for a long time, their curative rate, hospital stay time, postoperative complications and 5-year local tumor progression were compared and analyzed.

RESULTS: No significant difference was observed in curative rate between the two groups (91.3% vs 96.8%, P = 0.841). The hospital stay time was longer and more analgesics were required while the incidence of bile duct injury and RFA-related hemorrhage was lower in surgical RFA group than in percutaneous RFA group (P < 0.05). The local progression rate of HCC in dangerous locations was significantly lower in surgical RFA group than in percutaneous RFA group (P = 0.05). The relative risk of local tumor progression was 14.315 in percutaneous RFA group.

CONCLUSION: The incidence of severe postoperative complications and local tumor progression is lower after surgical RFA than after percutaneous RFA.

A randomized trial comparing radiofrequency ablation and surgical resection for HCC conforming to the Milan criteria

OBJECTIVE

To compare the long-term outcomes of surgical resection and radiofrequency ablation for the treatment of small hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

Radiofrequency ablation (RFA) is a promising, emerging therapy for small HCC. Whether it is as effective as surgical resection (RES) for long-term outcomes is still indefinite.

METHODS

Two hundred thirty HCC patients who met the Milan criteria and were suitable to be treated by either RES or RFA entered into a randomized controlled trial. The patients were regularly followed up after treatment for 5 years (except for those who died). The primary end point was overall survival; the secondary end points were recurrence-free survival, overall recurrence, and early-stage recurrence.

RESULTS

The 1-, 2-, 3-, 4- and 5-year overall survival rates for the RFA group and the RES group were 86.96%, 76.52%, 69.57%, 66.09%, 54.78% and 98.26%, 96.52%, 92.17%, 82.60%, 75.65%, respectively. The corresponding recurrence-free survival rates for the 2 groups were 81.74%, 59.13%, 46.08%, 33.91%, 28.69% and 85.22%, 73.92%, 60.87%, 54.78%, 51.30%, respectively. Overall survival and recurrence-free survival were significantly lower in the RFA group than in the RES group (P = 0.001 and P = 0.017). The 1-, 2-, 3-, 4-, and 5-year overall recurrence rates were 16.52%, 38.26%, 49.57%, 59.13%, and 63.48% for the RFA group and 12.17%, 22.60%, 33.91%, 39.13%, and 41.74% for the RES group. The overall recurrence was higher in the RFA group than in the RES group (P = 0.024).

CONCLUSIONS

Surgical resection may provide better survival and lower recurrence rates than RFA for patients with HCC to the Milan criteria.

Ultrasound-guided percutaneous cryotherapy of hepatocellular carcinoma

BACKGROUND

Reports on percutaneous cryoablation to treat patients with HCC are sparse in the medical literature. This study aimed to determine the safety and efficacy of percutaneous cryotherapy for unresectable or recurrent hepatocellular carcinoma (HCC).

METHODS

The results of 40 patients with unresectable HCC and 26 patients with recurrent HCC treated with ultrasound-guided percutaneous cryotherapy from January 2006 to June 2009 were retrospectively analyzed.

RESULTS

We used percutaneous cryotherapy to treat 76 tumors in 40 patients with unresectable and 76 tumors in 26 patients with recurrent HCC. The size of the tumors was 2.8 ± 1.7 cm (mean ± S.D.). The mean number of treatment sessions for unresectable and recurrent HCC were 1.7 and 1.4, respectively. All cryotherapy procedures were technically successful. No procedure-related death was observed. The overall complication rate was 12.1%. Patients with unresectable HCC had 1-, and 3-year overall survival rates of 81.4%, and 60.3%, while the disease-free survival rates at 1 year and 3 years were 67.6% and 20.8%, respectively. Patients with recurrent HCC had 1-, and 3-year overall survival rates of 70.2%, and 28.8%, while the disease-free survival rates at 1 year and 3 years were 53.8% and 7.7%, respectively.

CONCLUSION

Ultrasound-guided percutaneous cryotherapy was safe and efficacious in the treatment of unresectable and recurrent HCC. Further randomized trials are needed to compare the safety and efficacy of cryotherapy with other forms of percutaneous treatment so that an unbiased therapeutic strategy can be devised.

Meta-analysis of the therapeutic effect of hepatectomy versus radiofrequency ablation for the treatment of hepatocellular carcinoma

Surgical resection has been considered to be the best treatment for hepatocellular carcinoma (HCC). However, in recent years, there has been growing interest in the therapy of radiofrequency ablation (RFA). This meta-analysis is to evaluate the therapeutic effect of those 2 therapeutic methods. Outcomes evaluated were death rate, complications, survival rates, recurrence-free survival rates, and recurrence. Primary authors were contacted to retrieve further information if necessary. There is no significant difference in death rates of the treatment of HCC in the groups of hepatectomy and RFA, although the recurrence of HCC may be lower in the hepatectomy group. In the group of RFA, the recurrence rate in the previous site was higher but was lower in the new area, whereas it seems equal in the extrahepatic area. RFA may have comparable results with surgical resection in patients in the therapeutic effect of ablation for the treatment of HCC, if recurrence of HCC after RFA could be timely detected and effectively treated.

Radiofrequency ablation as first-line treatment for small solitary hepatocellular carcinoma: long-term results

AIMS

To evaluate long-term results of patients with small solitary hepatocellular carcinoma (HCC) and well-preserved liver function who received radiofrequency ablation (RFA) as first-line treatment.

MATERIALS AND METHODS

Between November 1999 and June 2007, 247 patients with solitary HCC ≤5 cm and liver status scored as Child-Pugh class A were enrolled. RFA was performed in 224 patients as first-line treatment; 23 patients excluded from RFA because of unfavorable tumor location or their unwillingness, and all of these patients converted to surgical resection.

RESULTS

In the 224 patients treated with RFA, the overall 5-, 7-, 10-year survival rates were 59.8%, 55.2%, 33.9%, respectively, and the median of overall survival was 76.1 months. Complete ablation was achieved in 216 patients (96.4%). Major complications occurred in two patients (0.9%), with no treatment-related death or needle track seeding. Indocyanine green retention rate in 15 min (ICGR15) (P = 0.014) and prothrombin activity (P = 0.004) were associated with overall survival. A subgroup of patients with ICGR15 ≤ 10% and prothrombin activity >75% had 5-, 7-, 10-year survival rates of 67.1%, 64.2%, 57.1%, respectively, with a median survival of 87.7 months. The 10-year recurrence-free, tumor-free survival rates were 17.5%, 28.2%, respectively. Serum albumin was the only factor that significantly impacted recurrence-free and tumor-free survival (P = 0.008, 0.002, respectively).

CONCLUSION

RFA is considered to be the treatment of first choice for patients with solitary HCC ≤5 cm and well-preserved liver function. Surgery can be used as second-line therapy for few patients if RFA is unfeasible.

Therapeutic effects and prognostic factors in high-intensity focused ultrasound combined with chemoembolisation for larger hepatocellular carcinoma

The purpose of this study is to evaluate high-intensity focused ultrasound (HIFU) ablation combined with transcatheter arterial chemoembolisation (TACE) in the treatment of larger hepatocellular carcinoma (HCC). Eighty-nine (89) patients with unrespectable larger HCC were randomised into a TACE group (n=45) and a TACE plus HIFU group (n=44). Therapeutic effects were assessed at follow-up with physical examination, level of serum alpha-fetoprotein and computed tomography or magnetic resonance imaging. All patients were followed up to observe long-term therapeutic effects and evaluated prognostic factors for survival. No severe complication was observed. Follow-up images showed that total effective rate in tumour response accounted for 72.8% in the TACE-HIFU group, which were significantly higher than that of TACE group (44.5%, P<0.05). The 1-, 2-, 3- and 5-year overall survival rates for the TACE-HIFU group were 72.7%, 50.0%, 31.8% and 11.4%, respectively; correspondingly, for the TACE group were 47.2%, 16.7%, 2.8% and 0%, respectively (P<0.01). The 1-, 2-, 3- and 5-year disease-free survival rates for the TACE-HIFU group were 34.1%, 18.2%, 9.1% and 0%, respectively; correspondingly, for the TACE group were 13.9%, 5.6%, 0% and 0%, respectively (P<0.01). TNM stage, portal vein tumour thrombosis and Child-Pugh classification each had a significant effect on the survival. HIFU ablation combined with TACE is safe, effective and a promising approach for the treatment of larger HCC.

Role of radiofrequency ablation in the treatment of small hepatocellular carcinoma

Radiofrequency ablation (RFA), one of the most advanced loco-regional ablative therapeutic methods, is widely utilized in the treatment of hepatocellular carcinoma (HCC). Because of its minimal invasiveness and high efficacy, RFA has been regarded as a curative therapy as alternative to surgical resection and liver transplantation. It brings new hope and a new treatment pattern for small HCC. In this article, we summarize the important role of RFA in the treatment of small HCC according to our clinical experience over six years. The prognosis of small HCC after RFA is comparable to that of surgical resection but with higher safety, less complications, wider applicability, and good long-term survival. RFA will play a more and more important role in the clinical treatment of small HCC.

Sorafenib improves the survival of patients with advanced hepatocellular carcinoma: a meta-analysis of randomized trials

There is no effective systemic therapy for patients with advanced hepatocellular carcinoma (HCC) except liver transplantation. Sorafenib, a multikinase inhibitor, has been shown to significantly increase overall survival (OS) in a randomized, placebo-controlled, phase III trial of patients with HCC (SHARP). The aim of this study was to evaluate the effectiveness of sorafenib for advanced HCC by carrying out a meta-analysis of randomized controlled trials that compared sorafenib-based therapy with other agent-based therapy. Randomized controlled trials comparing sorafenib or combined chemotherapy with placebo or combined chemotherapy in advanced HCC between 2000 and 2008 were identified and the data were extracted from reports. Outcomes analyzed were objective response rate, time to progression (TTP), OS, and toxicity. The summary hazard ratios (HRs), odds ratios, and their 95% confidence intervals (CIs) for mortality, objective response rate, and toxicity were estimated. All statistical tests were two-sided. Three trials including 924 patients were identified. Sorafenib-based chemotherapy was also associated with a 79% prolongation of TPP (HR = 0.58, 95% CI = 0.49-0.69, P<0.001), and a 37.3% increase in OS (HR = 0.66, 95% CI = 0.55-0.78, P<0.001). Despite significant increases in the frequencies of hand-foot syndrome and diarrhea in patients receiving sorafenib-containing chemotherapy, no significant difference in other toxic events was observed. This meta-analysis suggests that sorafenib-based chemotherapy is superior to placebo-based chemotherapy in terms of TPP and OS without increase in severe toxic effects.

Total laparoscopic liver resection for hepatocellular carcinoma located in all segments of the liver

BACKGROUND

Laparoscopic liver resection (LLR) is still not a well-established treatment modality for hepatocellular carcinoma (HCC). Moreover, most reported cases have been limited to tumors in the anterolateral (AL) segments (segments 2, 3, 4b, 5, and 6). We evaluated clinical and oncologic outcomes after LLR for HCC located in all segments, including lesions located in the posterosuperior (PS) segments (segments 1, 4a, 7, and 8).

METHODS

This retrospective study included 69 patients who had undergone LLR for HCC between September 2003 and November 2008. The patients were divided into two groups (group AL and group PS) according to tumor location. The clinical data of the two groups were retrospectively analyzed.

RESULT

There was no postoperative mortality. Fifteen patients (21.7%) experienced 19 postoperative complications. During a median follow-up period of 21.3 months, recurrence was detected in 21 (30.4%) patients. The 3-year overall survival rate and disease-free survival rate were 90.4 and 60.4%, respectively. There was no difference in clinicopathologic characteristics between the two groups except for a male predominance in group PS (p = 0.021) and that there were more patients with thrombocytopenia in group AL (p = 0.001). Although group PS patients had longer operative time (p = 0.001) and longer postoperative hospital stay (p = 0.039), along with a tendency toward a higher rate of open conversion (p = 0.054) and greater blood loss (p = 0.068), there was no significant difference in rates of postoperative complications (p = 0.375), recurrence (p = 0.740), 3-year overall survival (p = 0.237) or disease-free survival (p = 0.411) between the two groups.

CONCLUSIONS

Our experience shows that LLR can be safely performed in selected patients with HCC located in all segments of the liver, including the posterosuperior segments, with acceptable postoperative morbidity and oncologic results.

Approach to radiation therapy in hepatocellular carcinoma

Hepatocellular carcinoma (HCC), the 5th most common cancer and the third most common cause of cancer-related death in the world with an estimated incidence of approximately 1 million new cases annually, has becoming a major global health problem in the world. A variety of treatment modalities, including resection, liver transplantation, transarterial chemoembolization (TACE), local ablative therapy and radiation therapy (RT) have been reported. Although partial hepatectomy and liver transplantation may offer the best chance of cure, only 15% of the patients have the chance to be treated by surgery when diagnosed. The effectiveness of systemic chemotherapy for HCC has been minimal, and local ablative therapy may offer comparable survival in patients with small HCC and preserve liver function. Recently, with developments in radiotherapy techniques, radiotherapy has been shown to play potential roles in a wide spectrum of HCC and to become more important so that it is necessary to evaluate the effect of radiotherapy in treatment of HCC. This paper is aiming mainly at the current radiation therapy strategies and their current advances, the optimal radiation therapy strategies will complement the current treatments and improve the treatment efficiency.

Adjuvant approaches to enhance cryosurgery

Molecular adjuvants can be used to enhance the natural destructive mechanisms of freezing within tissue. This review discusses their use in the growing field of combinatorial or adjuvant enhanced cryosurgery for a variety of disease conditions. Two important motivations for adjuvant use are: (1) increased control of the local disease in the area of freezing (i.e., reduced local recurrence of disease) and (2) reduced complications due to over-freezing into adjacent tissues (i.e., reduced normal functional tissue destruction near the treatment site). This review starts with a brief overview of cryosurgical technology including probes and cryogens and major mechanisms of cellular, vascular injury and possible immunological effects due to freeze-thaw treatment in vivo. The review then focuses on adjuvants to each of these mechanisms that make the tissue more sensitive to freeze-thaw injury. Four broad classes of adjuvants are discussed including: thermophysical agents (eutectic forming salts and amino acids), chemotherapuetics, vascular agents and immunomodulators. The key issues of selection, timing, dose and delivery of these adjuvants are then elaborated. Finally, work with a particularly promising vascular adjuvant, TNF-alpha, that shows the ability to destroy all cancer within a cryosurgical iceball is highlighted.