Radiofrequency ablation of hepatocellular carcinoma as first-line treatment: long-term results and prognostic factors in 162 patients with cirrhosis

Safety and Local Efficacy of Laser Ablation for the Extrahepatic Metastasis of Hepatocellular Carcinoma: An Available Treatment Strategy

Thermal ablation plays an important role in the treatment of extrahepatic metastasis of hepatocellular carcinoma (HCC). Yet laser ablation (LA), as a safe thermal ablative modality, is less investigated in this field. In this study, the safety and local effectiveness of LA in the treatment for the extrahepatic metastasis of HCC were evaluated. From May 2012 to May 2019, 17 patients (13 males and 4 females; mean age, 54.1 ± 14.6 years; age range, 34–80 years), who underwent LA for treatment of extrahepatic metastasis of HCC at the First Affiliated Hospital of Sun Yat-sen University, were retrospectively enrolled in this study. Local effectiveness, complications, local tumor progression (LTP), and overall survival (OS) were evaluated. Finally, a total of 28 LA treated extrahepatic metastatic lesions of HCC were reviewed. Neither LA-related mortality nor major complication occurred. Complete ablation (CA) was achieved in 20 out of 28 lesions (71.4%). During the follow-up (mean, 19.5 ± 12.8 months; range, 5–42.7 months), LTP developed in 4 out of 20 lesions with CA (20%). Four patients died of tumor progression or multiple organ dysfunction syndrome. The accumulative one- and three-year OS rates were 79.0% and 65.8%, respectively. In conclusion, LA is a safe and effective therapeutic option in the treatment of extrahepatic metastasis of HCC. Further studies are necessary to evaluate the benefit of LA.

Radiofrequency ablation using internally cooled wet electrodes in bipolar mode for the treatment of recurrent hepatocellular carcinoma after locoregional treatment: A randomized prospective comparative study

Objective

This study aimed to compare the efficacy between bipolar radiofrequency ablation (RFA), using twin internally cooled wet (TICW) electrodes, and switching monopolar RFA, using separable clustered (SC) electrodes, in the treatment of recurrent hepatocellular carcinoma (HCC) after locoregional treatment.

Materials and methods

In this single-center, two-arm, parallel-group, randomized controlled study, we performed a 1:1 random allocation on eligible patients with recurrent HCC after locoregional treatment, to receive TICW-RFA or SC-RFA. The primary endpoint was the minimum diameter of the ablation zone per unit ablation time. Secondary endpoints included other technical parameters, complication rate, technical success and technique efficacy, and clinical outcomes.

Results

Enrolled patients were randomly assigned to the TICW-RFA group (n = 40) or SC-RFA group (n = 37). The two groups did not show significant differences in the primary endpoint, the minimum diameter of the ablation zone per unit ablation time was 2.71 ± 0.98 mm/min and 2.61 ± 0.96 mm/min in the TICW-RFA and SC-RFA groups, respectively (p = 0.577). Total RF energy delivery (11.75 ± 9.04 kcal vs. 22.61 ± 12.98 kcal, p < 0.001) and energy delivery per unit time (0.81 ± 0.49 kcal/min vs. 1.45 ± 0.42 kcal/min, p < 0.001) of the TICW-RFA group were less than those of the SC-RFA group. No procedure-related death or major complications occurred. Technical success was achieved in all patients in both groups, and technique efficacy rates were 100% (46/46) in the TICW-RFA group and 95.0% (38/40) in the SC-RFA group (p = 0.213). The 1-year and 2-year cumulative LTP rates were 11.8% and 24.2%, respectively, in the TICW-RFA group, and 8.6% and 18.1%, respectively, in the SC-RFA group (p = 0.661).

Conclusion

In this single-center randomized controlled study from a Korean tertiary referral hospital, TICW-RFA demonstrated similar therapeutic efficacy and safety profile for recurrent HCC after locoregional treatment compared with SC-RFA.

Trial registration

ClinicalTrials.gov (NCT03806218)

Tumor Stiffness Measurements on MR Elastography for Single Nodular Hepatocellular Carcinomas Can Predict Tumor Recurrence After Hepatic Resection

BACKGROUND

Tumor stiffness (TS), measured by magnetic resonance elastography (MRE), could be associated with tumor mechanical properties and tumor grade.

PURPOSE

To determine whether TS obtained using MRE is associated with survival in patients with single nodular hepatocellular carcinoma (HCC) after hepatic resection (HR).

STUDY TYPE

Retrospective.

POPULATION

In all, 95 patients with pathologically confirmed HCCs.

FIELD STRENGTH/SEQUENCE

1.5T/3D spin-echo echo-planar imaging MRE.

ASSESSMENT

TS values of the whole tumor (TS-WT) and of a solid portion of the tumor (TS-SP) after excluding the necrotic area were measured on stiffness maps. Known imaging prognostic factors of HCC were also analyzed. After surgery, pathologic findings were evaluated from resected pathology specimens.

STATISTICAL TESTS

Fisher's exact test and the Mann-Whitney U-test were performed to determine the significance of differences according to the tumor grade. Overall survival (OS) / recurrence-free survival (RFS) analyses were performed using Kaplan-Meier analyses and Cox multivariable models.

RESULTS

The average TS-WT was 2.14 ± 0.74 kPa, and the average TS-SP was 2.51 ± 1.07 kPa. The cumulative incidence of RFS was 73.1%, 63.1%, and 57.3% at 1, 3, and 5 years, respectively. The TS-WT, TS-SP, and tumor size (≥5 cm) were significant prognostic factors for RFS (P < 0.001; P < 0.001; P = 0.017, respectively). The estimated overall 1-, 3-, and 5-year survival rates were 95.7%, 86.9%, and 80.8%, respectively. The alpha-fetoprotein changes, platelets, tumor size (≥5 cm), and vascular invasion in pathology were significant predictive factors for overall survival (all P < 0.05). Tumor necrosis, TS-WT, TS-SP, and vascular invasion in pathology were significantly correlated with poorly differentiated HCC (all P < 0.05).

DATA CONCLUSION

The TS-WT, TW-SP, and tumor size (≥5 cm) were significant predictive factors of RFS after HR in patients with HCC. Level of Evidence Technical Efficacy Stage 5 J. MAGN. RESON. IMAGING 2021;53:587-596.

The Perfusion Features of Recurrent Hepatocellular Carcinoma After Radiofrequency Ablation Using Contrast-Enhanced Ultrasound and Pathological Stemness Evaluation: Compared to Initial Tumors

Objective: To investigate the perfusion features of local recurrence in hepatocellular carcinoma (HCC) after radiofrequency ablation (RFA) with contrast-enhanced ultrasound (CEUS) and pathological correlation, as well as to compare with those of initial HCC. Methods: From 2010 to 2018, 42 patients with recurrent HCC after RFA were enrolled in this study. The initial HCC patients included 32 males and 10 females with an average age of 58.2 ± 8.1 years. The CEUS images for initial HCC lesions and local recurrence after RFA were compared. The perfusion features were analyzed, including enhancement time, process, boundary, morphology, washout time, washout degree, feeding vessels, and internal necrosis. H&E staining and CD133/EpCAM staining were performed with biopsy samples for the stemness study. Results: According to CEUS, 59.5% of initial HCC lesions had centripetal enhancement, and 61.9% of recurrent HCC lesions had homogeneous enhancement in the arterial phase (p < 0.001). A total of 73.8% of initial HCC lesions had well-defined margins at the peak, and 81.0% of recurrent HCC lesions had poorly defined margins (p < 0.001). A total of 78.6% of initial HCC lesions had regular morphology at the peak, and 83.3% of recurrent HCC lesions were irregular (p < 0.001). Feeding vessels were more frequently found in initial HCC lesion (71.4%) than in recurrent HCCs (38.1%, p = 0.002). In the late phase, 60% of initial HCCs had marked washout while 83.3% of recurrent HCC lesion had marked washout (p = 0.019). A total of 31.3% of the initial HCC lesions had internal necrosis areas while only 7.1% of recurrent HCC lesions had internal necrosis areas (p = 0.035). In tumors 3-5 cm in size, the washout time of recurrent HCCs was shorter than that of initial HCCs (50.3 ± 13.5 s vs. 75.6 ± 45.8 s, p = 0.013). Pathological staining showed that the tumor stem cell markers (CD133 and EpCAM) were both highly expressed in recurrent samples compared with initial tumor samples (CD133+: 19 vs. 5%, p = 0.002; EpCAM+:15 vs. 6%, p = 0.005). Conclusions: Recurrent HCC after RFA had more homogeneous enhancement with a poorly defined border, marked washout, and fewer less feeding vessels and inner necrosis areas compared to initial HCC. The stemness study also found upregulated stemness in recurrent HCC. These specific features might be related to the aggressive biological behavior of recurrent HCC.

TACE-Sorafenib With Thermal Ablation Has Survival Benefits in Patients With Huge Unresectable Hepatocellular Carcinoma

Purpose

To investigate the effectiveness and safety of transarterial chemoembolization (TACE) combined with sorafenib and thermal ablation in patients with huge hepatocellular carcinoma (HCC).

Materials and Methods

This retrospective study examined 50 patients with huge unresectable HCC treated from January 2009 to December 2015. Among them, 28 cases received TACE-sorafenib treatment (TACE-sorafenib group), and 22 cases received TACE-sorafenib plus thermal ablation treatment (TACE-sorafenib-thermal ablation group). The Overall survival (OS), progression-free survival (PFS), and adverse events (AEs) were compared.

Results

The median follow-up was 13.5 months (ranges 4.2 to 96.7 months). The median OS was significantly longer in the TACE-sorafenib-thermal ablation group than that in the TACE-sorafenib group (20.8 vs. 10.4 months, P=0.003). The median PFS of the ablation and no ablation groups were 4.3 vs. 7.1 months (P=0.546). The treatment modality was an independent predictor of OS (P=0.004). There were no notable drug-related high grade adverse events or permanent adverse sequelae.

Conclusion

TACE-sorafenib-thermal ablation provided extended OS to patients with huge unresectable HCC and could be a better choice than TACE-sorafenib.

Radiofrequency Ablation Using a Separable Clustered Electrode for the Treatment of Hepatocellular Carcinomas: A Randomized Controlled Trial of a Dual-Switching Monopolar Mode Versus a Single-Switching Monopolar Mode

OBJECTIVE

This study aimed to prospectively compare the efficacy, safety, and mid-term outcomes of dual-switching monopolar (DSM) radiofrequency ablation (RFA) to those of conventional single-switching monopolar (SSM) RFA in the treatment of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This single-center, two-arm, parallel-group, randomized controlled study was approved by the Institutional Review Board. Written informed consent was obtained from all patients upon enrollment. A total of 80 patients with 94 HCC nodules were randomized into either the DSM-RFA group or SSM-RFA group in a 1:1 ratio, using a blocked randomization method (block size 2). The primary endpoint was the minimum diameter of the ablation zone per unit time. The secondary endpoints included other technical parameters, complication rate, technique efficacy, and 2-year clinical outcomes.

RESULTS

Significantly higher ablation energy per unit time was delivered to the DSM-RFA group than to the SSM-RFA group (1.7 ± 0.2 kcal/min vs. 1.2 ± 0.3 kcal/min; p < 0.001). However, no significant differences were observed between the two groups for the analyzed variables, including primary endpoint, regarding size of the ablation zone and ablation time. Major complication rates were 4.9% in the DSM-RFA group and 2.6% in the SSM-RFA group (p = 1.000). The 2-year local tumor progression (LTP) rates of the HCC nodules treated using DSM-RFA and SSM-RFA were 8.5% and 4.7%, respectively (p = 0.316). The 2-year LTP-free survival rates of patients in the DSM-RFA and SSM-RFA groups were 90.0% and 94.4%, respectively (p = 0.331), and the 2-year recurrence-free survival rates were 54.9% and 75.7%, respectively (p = 0.265).

CONCLUSION

Although DSM-RFA using a separable clustered electrode delivers higher ablation energy than SSM-RFA, its effectiveness failed to show superiority over SSM-RFA in the treatment of HCC.

Factors Associated with Tumor Progression After Percutaneous Ablation of Hepatocellular Carcinoma: Comparison Between Monopolar Radiofrequency and Microwaves. Results of a Propensity Score Matching Analysis

PURPOSE

To identify risk factors for local and distant intrahepatic tumor progression after percutaneous ablation of HCC and to compare MWA with monopolar RFA.

MATERIALS AND METHODS

Consecutive patients with early or very early HCC who underwent percutaneous monopolar RFA or MWA were included. Factors associated with local and distant tumor progression were identified. Propensity score matching (PSM) was used to limit bias. Statistical analyses were performed with the Kaplan-Meier method using the log-rank test and Cox regression models.

RESULTS

One hundred ninety HCC (mean diameter 23 ± 8.6 mm) were treated by RFA (n = 90, 47%) or MWA (n = 100, 53%) in 152 patients (mean age 63 ± 11, 79% men) between 2009 and 2016. The technical success rate was 97.4% (n = 185 HCC). After a median follow-up of 24.6 months (IQR: 9.7-37.2), 43 (23%), HCC showed local tumor progression [after a median of 13.4 months (IQR: 5.8-24.3)] and 91 (63%) patients had distant intrahepatic tumor progression (after a median of 10.4 months (IQR: 5.7-22). The cox model after PSM identified treatment by RFA (HR, 2.89; P = 0.005), HCC size ≥ 30 mm (HR, 3.12; P = 0.007) and vascular contact (HR, 3.43; P = 0.005) as risk factors for local progression. Factors associated with distant intrahepatic progression were HCC ≥ 30 mm (HR, 1.94; P = 0.013), serum AFP > 100 ng/mL (HR, 2.56; p = 0.002), and hepatitis B carrier (HR, 0.51; p = 0.047).

CONCLUSION

The rate of local HCC progression was lower after MWA than monopolar RFA, regardless of tumor size and vascular contact. The ablation technique did not influence the risk of distant intrahepatic tumor progression.

Management of primary hepatic malignancies during the COVID-19 pandemic: recommendations for risk mitigation from a multidisciplinary perspective

Around the world, recommendations for cancer treatment are being adapted in real time in response to the pandemic of COVID-19. We, as a multidisciplinary team, reviewed the standard management options, according to the Barcelona Clinic Liver Cancer classification system, for hepatocellular carcinoma. We propose treatment recommendations related to COVID-19 for the different stages of hepatocellular carcinoma (ie, 0, A, B, and C), specifically in relation to surgery, locoregional therapies, and systemic therapy. We suggest potential strategies to modify risk during the pandemic and aid multidisciplinary treatment decision making. We also review the multidisciplinary management of intrahepatic cholangiocarcinoma as a potentially curable and incurable diagnosis in the setting of COVID-19.

CTLA-4 Blockade Suppresses Progression of Residual Tumors and Improves Survival After Insufficient Radiofrequency Ablation in a Subcutaneous Murine Hepatoma Model

PURPOSE

To evaluate whether anti-CTLA-4 therapy could suppress residual tumor progression and improve survival after insufficient radiofrequency ablation (RFA) in a subcutaneous murine hepatocellular carcinoma (HCC) model.

MATERIALS AND METHODS

Forty mice with tumors established on their right flanks were randomly divided into four groups: control group (no treatment), RFA group (insufficient RFA alone), anti-CTLA-4 group (anti-CTLA-4 monotherapy), and RFA + anti-CTLA-4 group (insufficient RFA + anti-CTLA-4). In each group, eight mice were assessed for residual tumors and survival; another two mice were killed on day 14 for histopathologic studies. On day 42, a re-challenge test was performed in the survived mice of RFA + anti-CTLA-4 group to determine whether systemic anti-tumor immunity was established.

RESULTS

The specific growth rate of residual tumors was significantly less in RFA + anti-CTLA-4 group than that of the other three groups (all p < 0.05). The disease control rate was 50% in RFA + anti-CTLA-4 group, while no animals in the other three groups showed disease control. Animals in RFA + anti-CTLA-4 group had longer survival times than those in the other three groups (all p < 0.05). Expression of CD4+ lymphocytes in residual tumors and IFN-γ production in response to H22 tumor cells were significantly higher in RFA + anti-CTLA-4 group than those in the other three groups (all p < 0.05). Three of the five survived mice in RFA + anti-CTLA-4 group underwent tumor re-challenge exhibited tumor rejection.

CONCLUSIONS

The present study demonstrated that CTLA-4 blockade injection could suppress the growth of residual tumors and improve survival after insufficient RFA in a subcutaneous murine HCC model.

Evaluation of a serum tumour marker-based recurrence prediction model after radiofrequency ablation for hepatocellular carcinoma

BACKGROUND & AIMS

A recent study showed that serum tumour marker-based MoRAL score (11×√protein induced by vitamin K absence-II [PIVKA] +2×√alpha-foetoprotein [AFP]) can reflect both tumour burden and aggressiveness of hepatocellular carcinoma (HCC). This study aimed to evaluate whether baseline MoRAL score could predict tumour recurrence after radiofrequency ablation (RFA) for very-early/early-stage HCC.

METHODS

A total of 576 HCC patients who underwent RFA as initial treatment were enrolled from two tertiary referral hospitals (256 in development cohort and 320 in validation cohort). The primary endpoint was recurrence-free survival (RFS) and the secondary endpoints included cumulative risks of intrahepatic distant recurrence (IDR) and extrahepatic metastasis (EM).

RESULTS

In the development cohort, MoRAL score was an independent prognostic factor of RFS (P = .02). The optimal cutoff MoRAL score for predicting RFS was 68. Patients with high MoRAL score (>68) showed significantly shorter RFS than did those with low MoRAL score (hazard ratio [HR] = 2.04, P < .001). The 5-year RFS rates were 32.3% and 53.2% in high- and low-MoRAL groups respectively. Risks of both IDR (HR = 1.76, P = .003) and EM (HR = 8.25, P = .006) were also significantly higher in high MoRAL group. These results were reproduced in the validation cohort: RFS (HR = 1.81, P < .001; 5-year RFS rates = 27.7% vs 53.6%) was significantly shorter and risks of IDR (HR = 1.59, P = .003) and EM (HR = 6.19, P = .004) were significantly higher in high MoRAL group.

CONCLUSION

A high MoRAL score of >68 was significant a predictive factor of tumour recurrence after RFA for very-early/early-stage HCC. Moreover, it might be warranted to evaluate EM in patients with high baseline MoRAL scores.

Fusion imaging techniques and contrast-enhanced ultrasound for thermal ablation of hepatocellular carcinoma - A prospective randomized controlled trial

Objectives: This randomized controlled trial (RCT) aims to compare the clinical application values of contrast-enhanced ultrasound (CEUS), computed tomography/magnetic resonance-CEUS (CT/MR-CEUS), and three-dimensional ultrasound-CEUS (3DUS-CEUS) Fusion imaging (FI) techniques in the assistance of thermal ablation for hepatocellular carcinoma (HCC).Methods: A RCT was conducted on 374 patients with 456 HCCs between January 2016 and September 2017. CEUS, CT/MR-CEUS, and 3DUS-CEUS FI techniques were randomly used to assist HCC ablation. All lesions were ablated according to a previously determined plan, and FI groups required a 5-mm ablative margin. The primary endpoints were technical efficacy of thermal ablation and local tumor progression (LTP).Results: According to randomization, 153 (18.8 ± 8.0 cm), 153 (18.3 ± 6.6 cm) and 150 (19.1 ± 6.9 cm) HCCs were assigned to CT/MR-CEUS, 3DUS-CEUS and CEUS groups respectively. Technical efficacy rates (99.3% vs. 100% vs. 100%) were achieved in the three groups, showing no statistical differences (p = 1.000). The median follow-up time was 24 (1-37) months. LTP rates at 1 and 2 years were 3.4%, 12.2% for CT/MR-CEUS FI, 4.8%, 9.0% for 3DUS-CEUS FI, and 8.6%, 19.9% for CEUS, respectively (p = .105). The results of subgroup analysis for LTP were statistically significant when patients with albumin-bilirubin (ALBI) grade 2 and 3 (p = .000), and tumor located at risky positions (p = .042). In addition, the p value in group of multiple tumors was close to .05 (p = .052).Conclusions: All the three techniques are feasible for intraoperative HCC thermal ablation. Compared with CEUS, FI techniques are more suitable in patients with ALBI grade 2 and 3, multiple tumors, and in tumors at risky locations.

Single-centre retrospective review of risk factors for local tumour progression and complications in radiofrequency ablation of 555 hepatic lesions

INTRODUCTION

This study aimed to assess safety, local tumour progression (LTP) and risk factors for LTP after radiofrequency ablation (RFA) of liver tumours in a single centre.

METHODS

All consecutive patients treated with RFA for liver tumours between January 2009 and October 2012 were included. Previously treated lesions that progressed were excluded. Using electronic medical records, the following data was captured: patient demographics, pre-procedural laboratory results, Child-Pugh status, tumour characteristics, development of tumoral seeding, RFA complications and LTP. Possible risk factors for LTP were identified using Cox regression.

RESULTS

In total, 555 liver tumours were treated in 337 patients. 483 (87.0%) hepatocellular carcinomas, 52 (9.4%) colorectal metastases and 20 (3.6%) other tumour types were treated. Mean tumour size was 2.1 ± 1.1 (range 0.4-6.8) cm. Mean follow-up duration was 387 days. 416 (75.0%) lesions had no LTP at the last imaging. 70 (12.6%) patients had minor complications requiring observation, while 7 (1.3%) patients had significant complications requiring prolonged hospitalisation or further interventions. Only one case of tumour seeding was detected. Using multivariate Cox regression, the following factors were statistically significant in predicting LTP: hilar location (relative ratio [RR] 3.988), colorectal metastases (RR 2.075), size (RR 1.290) and younger age (RR 0.982).

CONCLUSION

RFA of liver tumours is safe and effective, with a low significant complication rate of 1.3%. Hilar lesions are most prone to LTP, followed by lesions that were larger in size and colorectal metastases. 75.0% of patients showed no LTP at the last follow-up.

Laparoscopic thermoablation for hepatocellular carcinoma in patients with liver cirrhosis: an effective procedure for tricky tumors

The optimal treatment for hepatocellular carcinoma (HCC) is surgical resection. However, only a small percentage of patients are amenable to this option. Percutaneous radiofrequency interstitial thermal ablation (TA) proved to be effective in the treatment of unresectable HCC. Recent advances in laparoscopic ultrasound have improved the accuracy in detecting small intrahepatic HCC nodules missed by pre-operative imaging techniques. Our objective was to evaluate an operative combination of laparoscopic ultrasound with laparoscopic thermoablation (LTA) in the treatment of HCC not amenable to liver resection. The aim of our review was to evaluate the advantages and limits of the laparoscopic approach according the criteria of the evidence-based medicine. LTA of HCC proved to be a safe and effective technique both in the short- and long-term follow-up period. This technique may be indicated in selected cases when the percutaneous approach to the lesion is very difficult or contraindicated.

Long-term outcome of intraoperative radiofrequency ablation for hepatocellular carcinoma and its efficacy as a primary treatment

Backgrounds/Aims

We conducted this study to identify long-term outcomes following intraoperative radiofrequency ablation (IO-RFA) for hepatocellular carcinoma (HCC) and to reveal independent prognostic factors for survival.

Methods

From December 1998 to February 2019, 183 patients underwent IO-RFA for HCC. These patients were divided into two groups according to whether RFA was done as a first-line (1-RFA group, n=106) or secondary-line (2-RFA group, n=77) treatment. Furthermore, we compared the survival outcomes between the 1-RFA and 2-RFA groups.

Results

There were no significant differences in type of surgical approaches between the two groups (p=0.079). The number of tumors and largest tumor size were not significantly different between the two groups. Overall recurrence rate was 53%, and the 2-RFA group showed a higher recurrence rate (46.2% in 1-RFA group versus 62.3% in 2-RFA group; p=0.031). The 5-year overall survival (OS) and disease-free survival (DFS) rates of all the patients were 75.2% and 27.9%, respectively. The OS and DFS rates were significantly higher in the 1-RFA group. The 5-year OS rates were 83.6% and 64.9% in the 1-RFA and 2-RFA groups, respectively (p=0.010), whereas the 5-year DFS rates were 32.2% and 21.6%, respectively (p=0.012). On multivariate analysis, HBV-LC, 2-RFA, recurrence, and postoperative complications were independent predictive factors for survival.

Conclusions

Therapeutic outcomes of IO-RFA were comparable to those of surgical resection. Additionally, 1-RFA might be an alternative treatment for naïve HCC in patients with uncompensated liver function and severe comorbidities.

BRAZILIAN SOCIETY OF HEPATOLOGY UPDATED RECOMMENDATIONS FOR DIAGNOSIS AND TREATMENT OF HEPATOCELLULAR CARCINOMA

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer-related mortality worldwide. The Brazilian Society of Hepatology (SBH) published in 2015 its first recommendations about the management of HCC. Since then, new data have emerged in the literature, prompting the governing board of SBH to sponsor a single-topic meeting in August 2018 in São Paulo. All the invited experts were asked to make a systematic review of the literature reviewing the management of HCC in subjects with cirrhosis. After the meeting, all panelists gathered together for the discussion of the topics and the elaboration of updated recommendations. The text was subsequently submitted for suggestions and approval of all members of the Brazilian Society of Hepatology through its homepage. The present manuscript is the final version of the reviewed manuscript containing the recommendations of SBH.

Ultrasound-Guided Radiofrequency Ablation Versus Surgery for Low-Risk Papillary Thyroid Microcarcinoma: Results of Over 5 Years' Follow-Up

Background: Papillary thyroid microcarcinoma (PTMC) typically carries an excellent prognosis regardless of the treatment option pursued. Radiofrequency ablation (RFA) for thyroid disease has been utilized for benign lesions and in patients who are poor surgical candidates for thyroid cancers with compression symptoms, but the efficacy and limitations of RFA as first-line therapy for PTMC has not been described in adequate detail. The purpose of our study was to investigate RFA versus thyroidectomy in terms of efficacy, oncologic outcomes, quality of life, complications, and costs over a 5-year period of follow-up. Methods: From January 2013 to November 2013, 174 consecutive patients with an isolated, solitary intrathyroidal PTMC were identified in a Chinese teaching hospital. Those with more aggressive or advanced PTMCs were not included. Ninety-four patients elected RFA and 80 patients elected surgery for treatment of these PTMC. Nodules were confirmed to be PTMC without an aggressive histological type by core needle biopsy in the RFA group and by final surgical pathology in the surgery group. The extent of surgery was decided based on patient preferences in consultation with the surgeons. Of all the patients, 58 (72.5%) underwent lobectomy, 22 (27.5%) underwent total thyroidectomy, and 53 (66.3%) underwent lymph node dissection. Pre- and post-treatment variables were compared between the two groups, including demographics, tumor characteristics, treatment, local tumor progression, lymph node metastasis, distant metastasis, local recurrence, complications, and quality-of-life findings. Results: Patient-specific variables were similar between groups, as were oncologic outcomes after 5 years of follow-up. When compared with RFA, surgery took longer, had a longer hospitalization time, and was costlier (all p < 0.001). The surgery group had three complications, with 2 (2.5%) permanent recurrent laryngeal nerve injuries and 1 (1.3%) case of permanent hypoparathyroidism, while none was reported in the RFA group (p = 0.095). The surgery group had a lower post-treatment thyroid-related quality of life. Conclusions: For carefully selected low-risk intrathyroidal PTMC, RFA was not oncologically inferior to open surgery, and it was associated with a higher quality of life and lower overall costs.

Supramolecular Photothermal Nanomedicine Mediated Distant Tumor Inhibition via PD-1 and TIM-3 Blockage

Supramolecular nanoparticles for photothermal therapy (PTT) have shown promising therapeutic efficacy in the primary tumor and great potential for turning the whole-body immune microenvironment from "cold" to "hot," which allows for the simultaneous treatment of the primary tumor and the metastatic site. In this work, we develop a liposome-based PTT nanoparticle through the self-assembly of FDA-approved intravenous injectable lipids and a photothermal agent, indocyanine green (ICG). The obtained ICG-liposome shows long-term storage stability, high ICG encapsulation efficiency (>95%), and enhanced near-infrared (NIR) light-triggered photothermal reaction both in vitro and in vivo. The ICG-liposome efficiently eradicated the primary tumor upon laser irradiation in two colon cancer animal models (CT26 and MC38) and promoted the infiltration of CD8 T cells to distant tumors. However, PTT from ICG-liposome shows only a minimal effect on the inhibition of distant tumor growth in long-term monitoring, predicting other immunosuppressive mechanisms that exist in the distant tumor. By immune-profiling of the tumor microenvironment, we find that the distant tumor growth after PTT highly correlates to compensatory upregulation of immune checkpoint biomarkers, including program death-1 (PD-1), T-cell immunoglobulin, and mucin domain-containing protein 3 (TIM-3), in tumor-infiltrating CD8 T cells. Based on this mechanism, we combine dual PD-1 and TIM-3 blockade with PTT in an MC38 tumor model. This combo successfully clears the primary tumor, generates a systemic immune response, and inhibits the growth of the distant tumor. The ICG-liposome-combined PD-1/TIM-3 blockade strategy sheds light on the future clinical use of supramolecular PTT for cancer immunotherapy.

Multimodal Percutaneous Thermal Ablation of Small Hepatocellular Carcinoma: Predictive Factors of Recurrence and Survival in Western Patients

Background: To identify the predictive factors of recurrence and survival in an unselected population of Western patients who underwent multimodal percutaneous thermal ablation (PTA) for small Hepatocellular Carcinomas (HCCs). Methods: January 2015–June 2019: data on multimodal PTA for <3 cm HCC were extracted from a prospective database. Local tumor progression (LTP), intrahepatic distant recurrence (IDR), time-to-LTP, time-to-IDR, recurrence-free (RFS) and overall (OS) survival were evaluated. Results: 238 patients underwent 317 PTA sessions to treat 412 HCCs. During follow-up (median: 27.1 months), 47.1% patients had IDR and 18.5% died. LTP occurred after 13.3% of PTA. Tumor size (OR = 1.108, p < 0.001; hazard ratio (HR) = 1.075, p = 0.002) and ultrasound guidance (OR = 0.294, p = 0.017; HR = 0.429, p = 0.009) independently predicted LTP and time-to-LTP, respectively. Alpha fetoprotein (AFP) > 100 ng/mL (OR = 3.027, p = 0.037) and tumor size (OR = 1.06, p = 0.001) independently predicted IDR. Multinodular HCC (HR = 2.67, p < 0.001), treatment-naïve patient (HR = 0.507, p = 0.002) and AFP > 100 ng/mL (HR = 2.767, p = 0.014) independently predicted time-to-IDR. RFS was independently predicted by multinodular HCC (HR = 2.144, p = 0.001), treatment naivety (HR = 0.546, p = 0.004) and AFP > 100 ng/mL (HR = 2.437, p = 0.013). The American Society of Anesthesiologists (ASA) score > 2 (HR = 4.273, p = 0.011), AFP (HR = 1.002, p < 0.001), multinodular HCC (HR = 3.939, p = 0.003) and steatotic HCC (HR = 1.81 × 10^-16, p < 0.001) independently predicted OS. Conclusions: IDR was associated with tumor aggressiveness, suggesting a metastatic mechanism. Besides AFP association with LTP, IDR, RFS and OS, treatment-naïve patients had longer RFS, and multi-nodularity was associated with shorter RFS and OS. Steatotic HCC, identified on pre-treatment MRI, independently predicted longer OS, and needs to be further explored.

Radiofrequency Ablation of Hepatocellular Carcinoma (≤ 5 cm) with Saline-Perfused Electrodes: Factors Affecting Local Tumor Progression

Purpose

We aimed to assess local tumor progression (LTP) rate and associated prognostic factors in 92 patients who underwent radiofrequency ablation (RFA) using saline-perfused electrodes to treat hepatocellular carcinoma (HCC) (≤ 5 cm).

Materials and Methods

Total 92 patients with 148 HCCs were treated with RFA using salineperfused electrodes, from 2009 to 2015. We retrospectively evaluated technical success, technique efficacy, and LTP rates. Potential prognostic factors for LTP were perivascular tumor, subphrenic tumor, artificial ascites, tumor size (≥ 2 cm), and previous treatment of transarterial chemoembolization. Analysis was performed by lesion, rather than by person.

Results

During follow-up period from 1 to 97.4 months, total cumulative LTP rates were 7.9%, 11.4%, and 14.6% at 1, 3, and 5 years, respectively. These values were significantly higher in the perivascular (35.1%; p = 0.009) and subphrenic group (38.9%; p = 0.002) at 5-year. We did not observe any significant difference in LTP according to other prognostic factors (p > 0.05).

Conclusion

RFA with saline-perfused electrode is a safe and effective treatment modality for HCC (≤ 5 cm), with lower LTP rates. Nevertheless, perivascular and subphrenic HCCs demonstrated higher LTP rate than other sites. It is imperative to note that perivascular and subphrenic location of HCC are associated with a high risk of local recurrence, despite the use of salineperfused electrodes.

Early Hepatocellular Carcinoma Treated by Radiofrequency Ablation-Mid- and Long-Term Outcomes

BACKGROUND

Radiofrequency ablation (RFA) is a standard treatment for small inoperable hepatocellular carcinoma (HCC). Studies on mid- and long-term outcome of RFA as first-line therapy for HCC from India are limited.

METHODS

We evaluated consecutive HCC patients who underwent RFA as primary treatment modality at our institute between July 2009 and April 2016. The median follow-up period was 26 months, range 1-84 months. We evaluated post-RFA tumor response, disease-free survival (DFS), overall survival (OS), and local tumor progression (LTP). Prognostic factors were also analyzed.

RESULTS

In 147 patients (male:female = 121:26; mean age, 59.2 years), 209 RFA sessions were done for 228 lesions (mean size of 21.5 ± 8.3 mm, range 10-50 mm). Primary success rate was 94.2%. The estimated cumulative proportion survival at 1, 3, and 5 years was 90.2%, 63.8%, and 60.2%, respectively. The cumulative incidence of LTP estimated at 1, 3, and 5 years was 13.1%, 19.7%, and 20.1%, respectively. The mean estimate of LTP-free survival was 53.6 months (95% confidence interval: 0.49-0.58) which is 58.2 months in <3 cm lesions and 20.4 months in >3 cm lesions (P < 0.01). There was no significant difference in LTP rates between lesions in perivascular versus nonperivascular location (P = 0.71) and surface versus parenchymal lesions (P = 0.66). The mean DFS was 30.3 months (95% CI: 25.6-35.0). For OS, age and Child-Turcotte-Pugh class B were significant factors while for LTP, tumor size >3 cm was significant. Higher baseline alpha-fetoprotein level and LTP were poor predictors for DFS. Complication rate per RFA session was 7/209 (3.3%).

CONCLUSIONS

RFA is a safe and effective curative modality for first-line treatment of HCC < 3 cm.

Stereotactic body radiation therapy for early-stage hepatocellular carcinoma - a systematic review on outcome

Background: Hepatocellular carcinoma (HCC) incidence is rising worldwide, especially due to increased detection of early-stage or small-sized tumors. Nevertheless, most of the patients are still not qualified for surgical resection at diagnosis due to the localization of the tumor, underlying liver disease or comorbidities. Stereotactic body radiation therapy (SBRT) is a radiotherapy modality which can deliver a high dose of radiation to the target tissue with a high degree of precision. It shows promise in terms of efficacy and morbidity.Material and methods: The aim of this systematic review is to summarize current knowledge on patient-specific outcomes of SBRT for small HCC including overall survival, local control, the effect of dose escalation and the toxicity of the treatment. The systematic review was performed according to Preferred Reporting Items for Systematic Reviews and Meta-Analyses (PRISMA). After a comprehensive database search, 16 studies (973 patients with 1034 lesions) were included in qualitative and quantitative analyses; 14 of them were retrospective.Results: Average tumor diameter was 23 mm and 95% of patients were in good general condition. Median BED10 (biologically equivalent dose calculated for α/β ratio of 10 Gy) was 100 Gy (range 59.5-180 Gy). Mean weighted local control across studies was 94%, 92% and 93% at 1, 2, and 3 years, respectively. Mean weighted overall survival across studies was 90.9%, 67.5% and 73.4% at 1, 2, and 3 years, respectively. There were 171 grade 1-2 toxicities (17.5%) and 53 ≥ grade 3 toxicities (5.3%). There was no treatment-associated mortality.Conclusion: SBRT offers high local control with overall survival that is comparable with radiofrequency ablation and surgery. Quality of findings, especially on toxicities, is decreased by incomplete reporting and retrospective designs of published studies. Therefore, there is a need for better reporting and prospective studies to univocally recommend SBRT as a definitive treatment option in the guidelines for small HCCs.

Biology and significance of alpha-fetoprotein in hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the most common causes of cancer-related deaths globally due, in part, to the majority of patients being diagnosed with intermediate or advanced stage disease. Our increased understanding of the heterogeneous molecular pathogenesis of HCC has led to significant developments in novel targeted therapies. Despite these advances, there remains a high unmet need for new treatment options. HCC is a complex disease with multiple pathogenic mechanisms caused by a variety of risk factors, making it difficult to characterize with a single biomarker. In fact, numerous biomarkers have been studied in HCC, but alpha-fetoprotein (AFP) remains the most widely used and accepted serum marker since its discovery over 60 years ago. This review summarizes the most relevant studies associated with the regulation of AFP at the gene and protein levels; the pathophysiology of AFP as a pro-proliferative protein; and the correlation of AFP with molecular HCC subclasses, the vascular endothelial growth factor pathway and angiogenesis. Also described are the historical and current uses of AFP for screening and surveillance, diagnosis, its utility as a prognostic and predictive biomarker and its role as a tumour antigen in HCC. Taken together, these data demonstrate the relevance of AFP for patients with HCC and identify several remaining questions that will benefit from future research.

Radiofrequency Ablation Following Downstaging of Hepatocellular Carcinoma by Using Transarterial Chemoembolization: Long-term Outcomes

Background Transarterial chemoembolization (TACE) is an effective downstaging procedure for hepatocellular carcinoma (HCC). However, knowledge of the effectiveness of radiofrequency ablation (RFA) after downstaging of HCC is currently lacking. Purpose To evaluate the clinical outcomes of RFA after downstaging of HCC by using TACE. Materials and Methods This retrospective study investigated a cohort of patients who underwent RFA with curative intent after downstaging with TACE to meet Milan criteria (one lesion up to 5 cm or no more than three lesions ≤3 cm without vascular invasion or extrahepatic metastasis) from January 2012 to July 2017. A control group of patients initially meeting the Milan criteria also underwent RFA as first-line treatment in the same period. Overall survival (OS), disease-free survival (DFS), and major complication rates were compared by using the log-rank test. To reduce potential bias, a propensity score analysis was also performed. Results There were 72 patients (median age, 56.5 years; range, 30-78 years; 67 men) in the downstaging group and 357 patients meeting the Milan criteria (median age, 58.0 years; range, 25-87 years; 313 men) included in this study. After propensity score matching, the 1-, 3-, and 5-year OS rates were 99%, 80%, and 66%, respectively, for the patients in the downstaging group and 94%, 84%, and 69%, respectively, for the patients in the Milan criteria group. The 1-, 3-, and 5-year DFS rate were 73%, 34%, and 24% for the downstaging group and 74%, 43%, and 37% for the Milan criteria group. There were no differences in the OS, DFS, or major complication rates between the two groups (P = .74, P = .39, P = .73, respectively). Conclusion The long-term patient survival and major complication rates of radiofrequency ablation following transarterial chemoembolization downstaging for hepatocellular carcinoma were similar to that of patients initially meeting the Milan criteria. © RSNA, 2019 See also the editorial by vanSonnenberg and Mueller in this issue.

Surgical Resection plus Radiofrequency Ablation versus Radical Surgery for Hepatocellular Carcinoma: A Propensity Score Matching Analysis

Objective: To evaluate the efficacy and safety of surgical resection plus radiofrequency ablation (SR-RFA) for multifocal hepatocellular carcinoma (HCC) with 2 or 3 nodules compared with surgical resection (SR).

Method: We retrospectively evaluated 824 consecutive HCC patients (SR, n = 754; SR-RFA, n = 70) from January 2009 to December 2015 and performed propensity score matching (PSM) to adjust for patient imbalances at a ratio of 1:4.

Results: At baseline, patients in the SR-RFA group had a smaller tumour size and worse liver function (including more ascites, a higher total bilirubin level, and a longer prothrombin time) than patients in the SR group. However, the two groups had similar overall survival (OS) and recurrence-free survival (RFS) rates (P = 0.209 and P = 0.332). The local recurrence rate of the SR-RFA group was significantly higher than that of the SR group (25.71% and 14.32%, P = 0.011). More patients in the SR-RFA group had postoperative complications (P = 0.003). In the propensity model, there was no intergroup difference in OS or RFS (P = 0.229 and P = 0.311, respectively).

Conclusion: SR-RFA provides a similar long-term survival to that on SR in HCC patients with 2 or 3 nodules, and its application should be carefully considered.

3-D Contrast-Enhanced Ultrasound Fusion Imaging: A New Technique to Evaluate the Ablative Margin of Radiofrequency Ablation for Hepatocellular Carcinoma

To investigate the feasibility of assessing the ablative margin (AM) of radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) with 3-D contrast-enhanced ultrasound fusion imaging (3-DCEUS-FI), pre- and post-RFA 3-DCEUS images of 84 patients with HCC were fused for two radiologists to independently assess the AMs. The success rate, duration and influencing factors for registration; inter-observer agreement for AM classification; and local tumor progression (LTP) rate were evaluated. The success rate of the automatic registration (AR), which was completed within 4-12 s, was 57.1% (48/84). The duration and success rate of the interactive registration (IR) were 4.2 ± 1.8 min and 91.7% (77/84) for radiologist A and 4.8 ± 2.1 min and 91.7% (77/84) for radiologist B, respectively. The multivariate analysis demonstrated that the pre-RFA image quality, number of vessels (≥3 mm) and presence of acoustic shadow were independent factors for AR (p < 0.05), while the number of vessels was an independent factor for IR (p = 0.001). The agreement between observers was excellent (kappa = 0.914). LTP rate was significantly higher for AMs <5 mm than for AMs ≥5 mm (p = 0.024). Quantitatively evaluating the AM immediately after RFA for HCC with 3-DCEUS-FI was feasible.

Predictive factors of treatment outcomes after percutaneous ablation of hepatocellular carcinoma in the caudate lobe: a retrospective study

Background

Hepatocellular carcinomas (HCC) arising in the caudate lobe is rare and the treatment is difficult. The aim of this study is to summarize the experience of ultrasound-guided percutaneous ablation therapy for HCC located in the caudate lobe and to investigate the predictive factors of the treatment outcomes.

Methods

From August 2006 to June 2017, 73 patients (63 males and 10 females; mean age, 54.9 ± 11.6 years; age range, 25–79 years) with 73 caudate lobe HCCs (mean size, 2.6 ± 1.1 cm; size range, 1.0–5.0 cm) were treated with percutaneous ablation, including 33 patients with radiofrequency ablation (RFA), 23 patients with ethanol ablation (EA), and 17 patients with combination of RFA and EA. The treatment outcome and survival after ablation for caudate lobe HCC were assessed and the predictive factors were calculated by univariate and multivariate analyses.

Results

A total of 72 patients achieved complete ablation after the first or second session of ablation. The treatment effectiveness was 98.6% (72/73). During the follow-up, 16 tumors developed local tumor progression (LTP) and a total of 61 patients (61/73, 83.6%) were detected distant recurrence (DR). According to univariate and multivariate analyses, tumor size > 2 cm (hazard ratio[HR] = 3.667; 95% confidence interval[CI], 1.043–12.889; P = 0.043) was a significant prognostic factor of LTP after ablation for HCC in the caudate lobe, while tumor number (HR = 2.245; 95%CI, 1.168–4.317; P = 0.015) was a significant prognostic factor of DR. The mean overall survival time after ablation was 28.7 ± 2.8 months, without independent predictive factors detected. Four patients (4/73, 5.5%) were detected treatment-related major complications, without independent predictive factor detected.

Conclusion

Ultrasound-guided percutaneous ablation is a feasible treatment for a selected case with HCC in the caudate lobe. Tumor size > 2 cm increases the risk of LTP and intrahepatic tumor number is associated with DR after ablation.

Intraprocedural computed tomography/magnetic resonance-contrast-enhanced ultrasound fusion imaging improved thermal ablation effect of hepatocellular carcinoma: Comparison with conventional ultrasound

AIM

To retrospectively compare the treatment effect of intraprocedural computed tomography/magnetic resonance-contrast-enhanced ultrasound (CT/MR-CEUS) fusion imaging (FI) with that of conventional ultrasound (US) in the guidance and assessment of thermal ablation of hepatocellular carcinoma (HCC).

METHODS

The FI group (112 patients with 129 HCC) was treated between April 2010 and December 2012, whereas the US group (83 patients with 90 HCC) was treated between January 2008 and March 2010. Either CT/MR-CEUS FI or US was used to guide puncture, provide immediate assessment, and guide supplementary ablation. Technical efficacy, cumulative local tumor progression rate (LTP), recurrence-free survival (RFS), and overall survival (OS) were evaluated and compared during follow-up. Technical success rate of CT/MR-CEUS FI was also recorded.

RESULTS

Technical efficacy was significantly higher in the FI group than in the US group (100% vs. 86.7%, P < 0.001). The 1-, 2-, 3-, 4-, 5-, and 6-year cumulative LTP rates in the FI group were significantly lower than in the US group (3.8%, 4.9%, 6.0%, 6.0%, 7.2%, and 7.2% vs. 16.9%, 20.1%, 25%, 25%, 25%, and 25%, respectively; P < 0.001); RFS and OS were significantly higher in the FI group than in the US group (P = 0.027 and P = 0.049, respectively). The technical success rate of FI was 85.3%.

CONCLUSIONS

Intraprocedural CT/MR-CEUS FI improved the treatment effect of thermal ablation of HCC by immediately assessing treatment response and guiding supplementary ablation relative to those resulting from the use of conventional US.

Demographic and facility volume related outcomes in radiofrequency ablation for early-stage hepatocellular carcinoma

BACKGROUND

To evaluate outcomes related to disparities in facility volume and patient demographics in patients with early-stage hepatocellular carcinoma (HCC) treated with radiofrequency ablation (RFA).

METHODS

This is a retrospective study of patients with stage I/II HCC treated with RFA in the National Cancer Database. Independent contributors to overall survival were determined with Cox regression analysis. The Kaplan-Meier method and log-rank analyses were used to estimate overall survival and compare survival curves. A propensity score matched cohort analysis was performed. P-values < 0.05 were considered statistically significant.

RESULTS

In total, 2911 patients were included. Stage II disease (p-value = 0.006), increasing alpha fetoprotein (p-value = 0.007), and increasing bilirubin (p-value < 0.001) were associated with worse survival. Improved survival was seen in patients treated at high-volume centers (p-value = 0.004), which persisted following propensity score adjustment (p-value = 0.003). Asian race was associated with significantly improved survival (p-value < 0.001), while governmental insurance was associated with a significant decrease in survival (p-value < 0.001).

CONCLUSION

Treatment at a high-volume center and Asian race were significantly associated with improved survival following RFA for early-stage HCC. Governmental insurance, increasing alpha fetoprotein, increasing bilirubin, and higher disease stage were significantly associated with worse survival.

Outcomes of Patients with Hepatocellular Carcinoma Treated with Conventional Transarterial Chemoembolization Using Guidance Software

PURPOSE

To evaluate the outcomes of conventional transarterial chemoembolization using guidance software for hepatocellular carcinoma (HCC) patients.

MATERIALS AND METHODS

One hundred two patients with treatment-naïve HCC with ≤ 7-cm and ≤ 5 lesions treated with conventional transarterial chemoembolization using guidance software were selected. Technical success was classified into 3 grades by computed tomography performed 1 week after transarterial chemoembolization: (i) A, complete embolization with a safety margin; (ii) B, entire tumor embolization without a safety margin; and (iii) C, incomplete embolization. Intrahepatic tumor recurrence was classified into 2 categories: local tumor progression (LTP) and intrahepatic distant recurrence (IDR). Overall survival (OS) and tumor recurrence rates were calculated by the Kaplan-Meier method. Additionally, the incidences of LTP between grade A and B tumors, IDR with/without LTP, and OS with/without LTP were compared by the log-rank test.

RESULTS

One hundred fifty-six (82.1%) tumors were determined to be grade A, 26 (13.7%) were determined to be grade B, and 8 (4.2%) were determined to be grade C. The 1-, 3-, and 5-year LTP and IDR rates were 31.7%, 49.4%, and 59.4% and 33.9%, 58.2%, and 73.3%, respectively. LTP developed more frequently in grade B tumors than grade A tumors (P = .0016). IDR developed more frequently in patients with LTP than without LTP (P = .0004). The 1-, 3-, and 5-year OS rates were 96.1%, 71.1%, and 60%, respectively; the 1-, 3-, and 5-year OS rates in patients with/without LTP were 95.7%, 69.8%, and 59.3% and 96.2%, 71.6%, and 59.4%, respectively (P = .9984).

CONCLUSIONS

Transarterial chemoembolization guidance software promotes the technical success of transarterial chemoembolization and excellent OS in HCC patients.

Magnetic Resonance Imaging Is Cost-Effective for Hepatocellular Carcinoma Surveillance in High-Risk Patients With Cirrhosis

Ultrasonography (US) is generally recommended for the surveillance of hepatocellular carcinoma (HCC) in patients at risk. However, in patients with cirrhosis who have sufficiently high HCC incidence, surveillance using magnetic resonance imaging (MRI) with liver-specific contrast showed markedly higher sensitivity in detecting early-stage HCC than US. This study aimed to compare the cost-effectiveness of semiannual surveillance using MRI versus US in patients with compensated cirrhosis and to identify the population that would gain optimal cost-effectiveness through MRI surveillance. We designed a Markov model to compare the expected costs and quality-adjusted life-years (QALYs), between MRI and US, with a 20-year time horizon, from the health care system perspective. The starting age of the cohort was 50 years, and 71% had hepatitis B virus-associated cirrhosis. The cycle length was 6 months. Transition probabilities and costs were obtained mainly from a prospective cohort study (the PRIUS study, NCT01446666). Cost and effectiveness were discounted at 5%. An incremental cost-effectiveness ratio (ICER) was calculated and tested using sensitivity analyses. The cost-effectiveness analysis indicated that the use of MRI incurred $5,562 incremental costs, 0.384 incremental life-years (LYs), and 0.221 incremental QALYs compared to US. The annual HCC incidence was the most influential factor on the ICER. The ICERs were $14,474/LY and $25,202/QALY at an annual HCC incidence of 3%. When the HCC incidence rate was >1.81%, the ICER was below $50,000/QALY. With increased HCC incidence, MRI surveillance was acceptable as a cost-effective option, even with an increased MRI/US cost ratio. Conclusion: Semiannual surveillance using MRI with liver-specific contrast may be more cost-effective than US in patients with virus-associated compensated cirrhosis at sufficiently high HCC risk despite the higher test cost of MRI.

Hepatic resection vs percutaneous radiofrequency ablation of hepatocellular carcinoma abutting right diaphragm

BACKGROUND

It is usually difficult to adequately conduct percutaneous ultrasound-guided radiofrequency (RF) ablation for hepatocellular carcinomas (HCCs) abutting the diaphragm. Our hypothesis was that the subphrenic location of HCC could have an effect on the long-term therapeutic outcomes after hepatic resection and RF ablation.

AIM

To compare the long-term therapeutic outcomes of hepatic resection and percutaneous RF ablation for HCCs abutting the diaphragm.

METHODS

A total of 143 Child-Pugh class A patients who had undergone hepatic resection (n = 80) or percutaneous ultrasound-guided RF ablation (n = 63) for an HCC (≤ 3 cm) abutting the right diaphragm were included. Cumulative local tumor progression (LTP), cumulative intrahepatic distant recurrence (IDR), disease-free survival (DFS), and overall survival (OS) rates were estimated. Prognostic factors for DFS and OS were analyzed. Complications were evaluated.

RESULTS

The cumulative IDR rate, DFS rate, and OS rate for the hepatic resection group and RF ablation group at 5 years were “35.9% vs 65.8%”, “64.1% vs 18.3%”, and “88.4% vs 68.7%”, respectively. Hepatic resection was an independent prognostic factor for DFS (P ≤ 0.001; hazard ratio, 0.352; 95%CI: 0.205, 0.605; with RF ablation as the reference category); however, treatment modality was not an independent prognostic factor for OS. The LTP rate was 46.6% at 5 years for the RF ablation group. The major complication rate was not significantly different between the groups (P = 0.630). The rate of occurrence of peritoneal seeding was higher in the RF ablation group (1.3% vs 9.5%, P = 0.044).

CONCLUSION

Although OS was not significantly different between patients who had gone hepatic resection or percutaneous RF ablation for HCCs abutting the diaphragm, DFS was better in the hepatic resection group.

Efficacy and safety of transarterial chemoembolisation with cone-beam CT in patients with hepatocellular carcinoma within the Milan criteria: a retrospective cohort study

AIM

To compare the therapeutic efficacy and safety of transarterial chemoembolisation (TACE) for hepatocellular carcinoma (HCC) within the Milan criteria with or without the use of cone-beam computed tomography (CBCT).

MATERIALS AND METHODS

Patients with HCC within the Milan criteria who underwent conventional angiography-guided TACE (Angio-TACE group: 58 patients from January 2010 to December 2011) were compared with those who underwent CBCT-guided TACE (CBCT-TACE group: 55 patients from January 2013 to December 2014). Local progression-free survival (LPFS), progression-free survival (PFS), and overall survival (OS) were compared. Adverse events after TACE were also investigated.

RESULTS

Baseline characteristics were balanced between the two groups. LPFS was significantly longer in the CBCT-TACE group than in the Angio-TACE group (median: not reached for 36 versus 19.2 months, respectively; Log-rank p=0.029). In multivariable Cox regression analysis, CBCT guidance had a significantly lower risk of local progression or death (adjusted hazard ratio: 0.585; 95% confidence interval, 0.344-0.995; p=0.048); however, there was no significant difference in PFS (3-year PFS: 15.9% versus 26.8%, respectively; p=0.122) or OS (3-year OS: 85% versus 88.2%, respectively; p=0.761) between the Angio-TACE and CBCT-TACE groups. Post-embolisation syndrome occurred significantly less frequently in the CBCT-TACE group (p=0.002).

CONCLUSION

CBCT-guided TACE could improve local tumour control for HCC within Milan criteria and showed fewer cases of post-embolisation syndrome.

Combined Therapy with Transarterial Chemoembolization and Radiofrequency Ablation for Hepatocellular Carcinoma: Does the Degree of Ethiodized Oil Accumulation within the Tumor Affect the Therapeutic Efficacy?

PURPOSE

To evaluate the effects of the degree of ethiodized oil accumulation achieved by transarterial chemoembolization followed by radiofrequency (RF) ablation on the treatment efficacy for a single intermediate-sized hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

A total of 153 consecutive patients who underwent chemoembolization and RF ablation for a single intermediate-sized HCC (2-5 cm) were included. On the basis of the degree of ethiodized oil accumulation in HCC on cone-beam CT images, patients who underwent chemoembolization and RF ablation were classified into 2 groups: compact accumulation (≥ 75%) and noncompact accumulation (< 75%). The rates of cumulative local tumor progression (LTP), disease-free survival (DFS), and overall survival (OS) were compared between groups.

RESULTS

Of the 153 patients, 89 were classified into the compact ethiodized oil accumulation group and 64 in the noncompact ethiodized oil accumulation group. There were no significant differences in patient demographic or HCC characteristics between groups except for the incidence of liver cirrhosis (P = .038) and the tumor margin morphology (P = .008). The cumulative LTP rate was significantly lower in the compact accumulation group than in the noncompact accumulation group (P = .013). There were no significant differences in the incidences of complications, DFS rates (P = .055), or OS rates (P = .184).

CONCLUSIONS

The degree of ethiodized oil accumulation does not play a role in decreasing the OS or DFS rate after chemoembolization and RF ablation for intermediate-sized HCC; however, it may contribute to reducing the rate of LTP.

Shrinkage of hepatocellular carcinoma after radiofrequency ablation following transcatheter arterial chemoembolization: Analysis of contributing factors

Objective

This study was conducted to investigate tumor shrinkage and influencing factors in patients with hepatocellular carcinoma (HCC) from radiofrequency (RF) ablation following transcatheter arterial chemoembolization (TACE).

Methods

A total of 222 patients underwent combined sequential treatment of TACE and RF ablation for HCC at our institution between 2008 and 2014. Of those, 86 patients (men, 68; women, 18) who achieved compact iodized oil tagging and complete ablation were included for this retrospective study. We measured three-dimensional tumor diameters and calculated tumor volumes on pre-treatment CT/MRI and follow-up CT scans performed post-TACE, post-ablation, and 1 month post-treatment, respectively. To compare periodically generated tumor diameters and volumes, repeated measures analysis of variance (ANOVA) was applied. Multiple linear regression analysis was performed to identify factors impacting tumor shrinkage after RF ablation.

Results

Diameters and volumes of HCCs declined significantly in the immediate aftermath of RF ablation (i.e., between post-TACE and post-ablation CT scans) (p < 0.001, for both). Mean reduction rates in tumor diameter and volume immediately after RF ablation were 18.2 ± 9.1% and 44.4 ± 14.6%, respectively. Of note, tumors of left hepatic lobe and in subphrenic or perivascular locations showed lower rates of post-ablative volume reduction than those in counterpart locations (p = 0.002, 0.046, 0.024, respectively). Tumor size and liver function did not influence tumor shrinkage after RF ablation.

Conclusion

In patients with HCC, significant tumor shrinkage occurs immediately after RF ablation. The degree of shrinkage in response to ablative treatment seems to vary by tumor location.

Whole tumor ablation of locally recurred hepatocellular carcinoma including retained iodized oil after transarterial chemoembolization improves progression-free survival

OBJECTIVES

To evaluate and compare clinical outcomes of two different radiofrequency ablation (RFA) methods for locally recurred hepatocellular carcinoma (LrHCC) after locoregional treatment.

METHODS

Our institutional review board approved this study with a waiver of informed consent. A total of 313 patients previously treated with transarterial chemoembolization (TACE) (n = 167) and RFA (n = 146) with a single LrHCC ≤ 3 cm was included from five tertiary referral hospitals. RFA was done for LrHCCs using either viable tumor alone ablation (VTA) method (VTA: n = 61 in the TACE group and n = 127 in the RFA group) or whole tumor ablation (WTA) method which includes both viable tumor and retained iodized oil or previously ablated zone (WTA: n = 106 in the TACE group and n = 19 in the RFA group). Local tumor progression (LTP)-free survival as well as progression-free survival (PFS) were estimated using the Kaplan-Meier method, and prognostic factors were evaluated using the Cox proportional hazards regression model.

RESULTS

In 167 patients with LrHCC who underwent TACE, the 5-year LTP-free survival after RFA was significantly higher with the VTA method than with the WTA method (26.9% vs. 87.8%; p < 0.001; hazard ratio (HR) = 8.53 [4.16-17.5]). The estimated 5-year PFS after RFA for LrHCC after TACE using the VTA method was 5.7%, which was significantly lower than that with the WTA method (26.4%) (p = 0.014; HR = 1.62 [1.10-2.38]). However, in 146 patients with LrHCC after initial RFA, there were no significant differences in cumulative incidence of LTP (p = 0.514) or PFS (p = 0.905) after RFA between the two ablation methods.

CONCLUSIONS

For RFA of LrHCC after TACE, the WTA method including both viable tumor and retained iodized oil could significantly lower LTP and improve PFS than VTA.

KEY POINTS

• Whole tumor ablation (WTA) could provide significantly better local tumor control for locally recurred HCC (LrHCC) after TACE than viable tumor alone ablation (VTA). • WTA for LrHCC after TACE could also provide significantly better progression-free survival than VTA. • Regarding LrHCC after RFA, VTA would provide a comparable clinical outcome to WTA.

Surgical resection plus radiofrequency ablation for the treatment of multifocal hepatocellular carcinoma

Background

To compare the efficacy and safety of surgical resection plus radiofrequency ablation (SR-RFA) with transarterial chemoembolization (TACE) in patients with multifocal hepatocellular carcinoma (HCC) beyond the Milan criteria.

Methods

From 2009 to 2015, a total of 469 consecutive patients with multifocal HCC beyond the Milan criteria (≤5 nodules) treated with SR-RFA (n=59) or TACE (n=410) were analyzed. Their overall survival (OS) rate was compared through propensity score matching (PSM) analysis at a ratio of 1:2, and 141 patients were identified (SR-RFA, n=47; TACE, n=94). Subgroup analysis was conducted according to factors associated with treatment options.

Results

Before PSM, the 1-, 2- and 3-year OS rates were 81.5%, 68.3% and 64.3% in the SR-RFA group and 58.7%, 35.5% and 24.4% in the TACE group, respectively (all P<0.001). After PSM, the 1-, 2- and 3-year OS rates in the SR-RFA group were 81.8%, 68.7% and 63.4%, whereas those in the TACE group were 59.3%, 36.1% and 19.4%, respectively (all P<0.001). Subgroup analysis also revealed a survival advantage of SR-RFA over TACE in each subgroup. The 30-day mortality rate was 1.22% in the TACE group and nil in the SR-RFA group (P=0.861).

Conclusions

SR-RFA provides better a long-term survival rate than TACE for patients with multifocal HCC beyond the Milan criteria. SR-RFA may serve as an alternative treatment for patients with multifocal HCC in a selected patient population.

Efficacy and Safety of Deep Sedation in Percutaneous Radiofrequency Ablation for Hepatocellular Carcinoma

INTRODUCTION

Radiofrequency ablation (RFA) has been accepted as safe and effective for treating early-stage hepatocellular carcinoma (HCC). However, it often causes severe pain. Therefore, in this study, we performed RFA under deep sedation and investigated its efficacy and safety.

METHODS

We conducted a retrospective study including 511 HCC patients who received approximately 886 RFA treatments between December 2014 and November 2016 at our institution. Respiratory depression was defined as oxygen saturation of below 90%; and severe body movement was defined as movement caused by pain, which was managed by lowering the power of the generator. Factors associated with respiratory depression and severe body movement were examined via univariate and multivariate regression analyses.

RESULTS

Respiratory depression occurred in 15.3% of the patients and severe body movement in 26.5% of the patients. In the multivariate analysis, BMI (≥ 25 kg/m², odds ratio [OR] = 1.75, P = 0.035) and longer ablation (≥ 10 min, OR = 2.59, P = 0.002) were significant respiratory depression-related factors. Male sex (OR = 2.02, P = 0.005), Child-Pugh class A (odds ratio = 1.96, P = 0.018), and longer ablation (≥ 10 min, OR = 3.03, P < 0.001) were significant factors related to severe body movement.

CONCLUSION

Deep sedation for RFA can be performed safely and effectively. Higher BMI and longer ablation were risk factors for respiratory depression and male sex, Child-Pugh class A, and longer ablation were independent predictors of severe body movement during RFA under deep sedation.

Virologic control and severity of liver disease determine survival after radiofrequency ablation of hepatocellular carcinoma on cirrhosis

BACKGROUND

We aimed to identify the main determinants of long-term overall survival (OS), including virologic control, and recurrence after radiofrequency ablation (RFA) of hepatocellular carcinoma (HCC) on cirrhosis.

METHODS

Cirrhotic patients treated by RFA for HCC within Milan criteria were included. Associations between patient features and events were estimated by the Kaplan-Meier method with the log rank test and using uni/multivariate Cox models.

RESULTS

389 cirrhotic patients (Child-Pugh A 86.6%, 473 tumors) were included. OS was 79.8%, 42.4% and 16%, and overall tumor recurrence 45%, 78% and 88% at 2, 5 and 10 years, respectively. In multivariate analysis, age, Child-Pugh, GGT, HCC near major vessels, esophageal varices, alkaline phosphatase and HBV predicted OS. Gender, ALT, AFP and alcohol intake were associated with tumor recurrence. Multinodular HCC (19.5%) was associated with risk of tumor recurrence outside Milan criteria. HBV patients had longer OS than other patients (P = 0.0059); negative HBV PCR at RFA was associated with decreased tumor recurrence (P = 0.0157). Using time-dependent analysis in HCV patients, a sustained virologic response was associated with increased OS (124.5 months) compared to other patients (49.2 months, P < 0.001).

CONCLUSION

Virologic response and severity of underlying liver disease were the main determinants of long-term OS after RFA for HCC developing on cirrhosis.

Impact of follow-up interval on patients with hepatocellular carcinoma after curative ablation

Background

The optimal follow-up strategy after curative thermal ablation of hepatocellular carcinoma (HCC) remains unclear.

Methods

We retrospectively analyzed a prospective series of 616 patients who underwent curative thermal ablation for HCC within the Milan criteria. Multivariate Cox model was used to identify independent predictive factors for recurrence; accordingly, patients were stratified into 2 groups with different relapse risks: a low-risk group (solitary tumor ≤3 cm) and a high-risk group (multiple tumors ≤3 cm or solitary tumor between 3 and 5 cm). Then, patients were classified into short- (< 4 months) or long-interval (4–6 months) surveillance groups according to follow-up intensity within the first 2 years after ablation. The overall survival (OS) of patients were compared between short- and long-interval groups in low- or high-risk groups, as well as the stage of recurrent tumors and the proportion of patients who received curative-intent retreatments.

Results

In the low-risk group, 54 (83.0%) and 18 (72.0%) of patients exhibited early relapse at the Barcelona Clinic Liver Cancer (BCLC) 0/A stage in the short- and long-interval groups, respectively (P = 0.172); accordingly, 44 (77.2%) and 18 (81.8%) of patients received curative-intent retreatment (P = 0.086) after recurrence. Hence, 5-year OS was similar between short- and long-interval groups (80.4% vs. 77.5%, P = 0.400) in low-risk patients. However, in the high-risk group, patients with a short interval exhibited early relapse more frequently at the BCLC 0/A stage (83% vs. 72%, P = 0.028), with a trend showing that the corresponding proportion of patients who received curative-intent retreatment greater than that in the long-interval group (64.2% vs. 37.5%, P = 0.087). Moreover, the short-interval group showed better 5-year OS than the long-interval group in high-risk patients (69.9% vs. 42.7%, P = 0.020).

Conclusions

Compared to a short surveillance interval, a long surveillance interval does not reduce OS in low-risk patients; however, a long surveillance interval compromises OS in high-risk patients.

Periostin involved in the activated hepatic stellate cells-induced progression of residual hepatocellular carcinoma after sublethal heat treatment: its role and potential for therapeutic inhibition

BACKGROUND

Incomplete thermal ablation may induce invasiveness of hepatocellular carcinoma (HCC). Here, we investigated whether activated hepatic stellate cells (HSCs) would accelerate the progression of residual HCC after sublethal heat treatment, and thus sought to identify the potential targets.

METHODS

Hepatocellular carcinoma cells were exposed to sublethal heat treatment and then cultured with the conditioned medium from activated HSCs (HSC-CM). The cell proliferation, migration, invasion and parameters of epithelial-mesenchymal transition (EMT) were analyzed. In vivo tumor progression of heat-treated residual HCC cells inoculated with activated HSCs was studied in nude mice.

RESULTS

HSC-CM significantly enhanced the proliferation, motility, invasion, prominent EMT activation and decreased apoptosis of heat-exposed residual HCC cells. These increased malignant phenotypes were markedly attenuated by neutralizing periostin (POSTN) in HSC-CM. Furthermore, exogenous POSTN administration exerted the similar effects of HSC-CM on heat-treated residual HCC cells. POSTN induced the prominent activation of p52Shc and ERK1/2 via integrin β1 in heat-exposed residual HCC cells. Vitamin D analog calcipotriol blocked POSTN secretion from activated HSCs. Calcipotriol plus cisplatin significantly suppressed the activated HSCs-enhanced tumor progression of heat-treated residual HCC cells via the inhibited POSTN expression and the increased apoptosis.

CONCLUSIONS

Activated HSCs promote the tumor progression of heat-treated residual HCC through the release of POSTN, which could be inhibited by calcipotriol. Calcipotriol plus cisplatin could be used to thwart the accelerated progression of residual HCC after suboptimal heat treatment.

Long-term follow-up of unresectable medium-large hepatocellular carcinoma nodules treated with radiofrequency ablation using a multiple-electrode switching system

OBJECTIVE

The purpose of this study was to prospectively evaluate the safety and effectiveness of radiofrequency ablation (RFA) by using a multiple-electrode switching system to treat unresectable medium-large (3.1-6.0 cm) HCC nodules.

METHODS

RFA using a multiple-electrode switching system was performed for HCC nodules with size > 3.0 < 6.0 cm in nonsurgical candidates. Two electrodes were consecutively placed for 3.1-4.0 cm tumours, and three electrodes for 4.1-5.9 cm tumours, with a 2.0-2.5 cm spacing. The power was switched from one electrode to the next automatically when the impedance reached 30 Ω above the baseline level. 25 patients (M/F = 9/16; median age 76 years, range 61-84) with liver cirrhosis (20 HCV-positive) in Child's Class A (22 cases) and B (3 cases) and 26 HCC nodules (median diameter 4.0 cm; range 3.2-5.5 cm) underwent treatment in 25 sessions from 2013 and 2018. Therapeutic effectiveness was assessed through CT or MRI exam at 30-40 days post-ablation.

RESULTS

No procedure-related death or major complications occurred. Complete ablation was obtained in all nodules (100%). At a median follow up of 30 months, local tumor progression occurred in five out of 26 nodules (19.2%). Overall survival at 4 years was 49%.

CONCLUSION

RFA with a multiple-electrode switching system may be a safe, quick and effective therapeutic option for treatment of 3.1-6.0 cm unresectable HCC tumours.

ADVANCES IN KNOWLEDGE

RFA with multiple electrodes provides favourable clinical results in patients with medium-large HCC nodules who are not suitable for surgery.

Radiofrequency ablation of hepatocellular carcinoma: a meta-analysis of overall survival and recurrence-free survival

Background and aims

So far, no randomized trial or meta-analysis has been conducted on overall survival (OS) and recurrence-free survival (RFS) factors in patients treated with radiofrequency ablation (RFA) alone. The purpose of this meta-analysis was to evaluate prognostic factors of OS and RFS in patients treated with RFA.

Methods

A primary analysis was planned to evaluate the clinical prognostic factor of OS. RFS was the secondary aim. Thirty-four studies published from 2003 to 2017 were analyzed. They included 11,216 hepatocellular carcinoma patients.

Results

The results showed that Child-Pugh B vs Child-Pugh A (HR =2.32; 95% CI: 2.201-2.69; P<0.0001) and albumin-bilirubin score 1 vs 0 (HR =2.69; 95% CI: 2.10-3.44; P<0.0001) were predictive of poor OS. Tumor size as a continuous variable was not predictive of OS, although it was predictive of OS when we considered the size as a cutoff value (.2 cm vs <2 cm: HR =1.41; 95% CI: 1.23-1.61; P<0.0001; >3 cm vs <3 cm: HR =1.43; 95% CI: 1.17-1.74; P<0.0001) and in presence of >1 nodule (HR =1.59; 95% CI: 1.46-1.74; P<0.0001). Alpha-fetoprotein >20 ng/mL (HR =1.46; 95% CI: 1.25-1.70; P<0.0001) was the only predictive factor of poor prognosis.

Conclusion

Our meta-analysis highlighted that the maximum benefit of RFA in terms of OS and RFS is reached in the presence of Child-Pugh A, albumin-bilirubin score 1, single-nodule tumor sized <2 cm, and alpha-fetoprotein <20 ng/mL.

Interferon-α Combined With Herbal Compound "Songyou Yin" Effectively Inhibits the Increased Invasiveness and Metastasis by Insufficient Radiofrequency Ablation of Hepatocellular Carcinoma in an Animal Model

Objective: We had previously proved that insufficient radiofrequency ablation (RFA) could enhance invasiveness and metastasis of hepatocellular carcinoma (HCC) through epithelial-mesenchymal transition (EMT), which is mediated by activating β-catenin signaling. Thus, the aim of the present study was to demonstrate whether the combined treatment of interferon-α (IFN-α) and “Songyou Yin” (SYY) minimizes the pro-metastatic effects of insufficient RFA, as well as to explore its underlying mechanism. Methods: Insufficient RFA was performed in an orthotopic nude mice model of HCCLM3 with high metastatic potential. The effects of IFN-α, SYY, and combined IFN-α and SYY were observed in the animal model. Tumor sizes, lung metastasis, and survival time were assessed. Immunochemistry staining, real-time polymerase chain reaction, and Western blot were used to examine gene expression related to metastasis and angiogenesis in residual cancer after insufficient RFA. Results: For up to 8 weeks of treatment, the combined therapy significantly decreased the residual cancer sizes, minimized the lung metastasis rate, and prolonged the survival time of nude mice, which might be due to suppression of the EMT via β-catenin signal blockade, in addition to attenuating angiogenesis in residual cancer after insufficient RFA. Conclusion: IFN-α combined with SYY significantly weakened the enhanced metastatic potential of residual cancer after insufficient RFA by attenuating EMT, which is mediated through inhibiting activation of β-catenin. In addition, decreasing angiogenesis of residual cancer might also play a certain role.

Study to evaluate the immunomodulatory effects of radiofrequency ablation compared to surgical resection for liver cancer

Introduction: Hepatic cancer is a highly lethal tumour with increasing worldwide incidence. These tumours are characterized by the proliferation of malignant cells, generalised immunosuppression and chronic inflammation marked with an increase in inflammatory markers as a neutrophil-to-lymphocyte ratio (NLR), the platelet-to-lymphocyte ratio (PLR) and overexpression of CD4+CD39+ on T lymphocytes. The studies have outlined immunomodulatory changes in liver cancer patients as the plausible explanation for the better survival. The aim of this pilot study was understand the possible immunomodulatory effect of radiofrequency (RF) energy and liver resection (non-radiofrequency based devices; non-RF device) in relation to NLR, PLR and expression of CD4+CD39+ T lymphocytes and compare the magnitude of these changes. Material and Methods: In the present study, 17 patients with hepatic cancer were prospectively divided into treatment groups radiofrequency ablation (RFA group) and Liver resection using non-RF devices (LR group). A blood sample was collected from each patient, one month before and after the procedure and compared with the blood samples of age-matched healthy volunteers for group wise comparison. The Mann-Whitney U test, Mc Nemar test and Wilcoxon rank test were used for statistical comparisons as appropriate. Results: A decrease in NLR was reported after RFA from 4.7±3.3 to 3.8±1.8 (P=0.283), in contrary to an increase from 3.5±2.8 to 4.5±3.2 (P=0.183) in LR group. Likewise, a decrease was discerned in PLR following RFA from 140.5±79.5 to 137±69.2 respectively (P=0.386) and increase in the LR group from 116±42.2 to 120.8±29 respectively (P=0.391). A significant decrease in CD4+CD39+ lymphocytes from 55.8±13.8 to 24.6±21.1 (P=0.03) was observed in RFA group whilst a significant increase was reported in LR group from 47.6±8.8 to 55.7±33.2 (P=0.38). Conclusion: Studies have shown that decrease in the NLR, PLR and expression of CD4+CD39+ on T lymphocytes as the marker of better survival in hepatic cancer patients and our findings have confirmed that these changes can be induced following application of RF energy. Moreover, this could be the explanation of better survival observed in different studies using RFA or other RF-based devices in comparison to non-RF based liver resection techniques. However, further larger studies are needed to confirm these findings.