Percutaneous treatment of hepatocellular carcinoma: State of the art and innovations

Radiofrequency ablation of hepatocellular carcinoma: Prognostic factors and recent advances

With the improvement of technology and diagnostic level, radiofrequency ablation (RFA) has made rapid progress in the treatment of primary hepatocellular carcinoma (HCC) in the past two decades. Especially, the overall survival after the treatment of small HCCs by RFA can be comparable to that achieved by hepatic resection. The 10-year survival rates of RFA for HCC were 27.3%-46.1%, and for solitary HCC less than 3 cm, the 10-year survival rate is about 74.0%. RFA combined with other therapies can expand the indications of RFA treatment and benefit the survival of patients with HCC. The prognostic model of RFA for HCC provides a powerful tool for individualized clinical diagnosis and treatment.

Short pulsed microwave ablation: computer modeling and ex vivo experiments

PURPOSE

To study the differences between continuous and short-pulse mode microwave ablation (MWA).

METHODS

We built a computational model for MWA including a 200 mm long and 14 G antenna from Amica-Gen and solved an electromagnetic-thermal coupled problem using COMSOL Multiphysics. We compared the coagulation zone (CZ) sizes created with pulsed and continuous modes under ex vivo and in vivo conditions. The model was used to compare long vs. short pulses, and 1000 W high-powered short pulses. Ex vivo experiments were conducted to validate the model.

RESULTS

The computational models predicted the axial diameter of the CZ with an error of 2-3% and overestimated the transverse diameter by 9-11%. For short pulses, the ex vivo computer modeling results showed a trend toward larger CZ when duty cycles decreases. In general, short pulsed mode yielded higher CZ diameters and volumes than continuous mode, but the differences were not significant (<5%), as in terms of CZ sphericity. The same trends were observed in the simulations mimicking in vivo conditions. Both CZ diameter and sphericity were similar with short and long pulses. Short 1000 W pulses produced smaller sphericity and similar CZ sizes under in vivo and ex vivo conditions.

CONCLUSIONS

The characteristics of the CZ created by continuous and pulsed MWA show no significant differences from ex vivo experiments and computer simulations. The proposed idea of enlarging coagulation zones and improving their sphericity in pulsed mode was not evident in this study.

Early recurrence after radiofrequency ablation for hepatocellular carcinoma: a multicenter retrospective study on definition, patterns and risk factors

OBJECTIVE

To define an optimal cutoff time to distinguish early and late recurrence in hepatocellular carcinoma (HCC) patients after radiofrequency ablation (RFA), and to determine the risk factors and patterns of early recurrence.

MATERIALS AND METHODS

This retrospective study included HCC patients who developed recurrence after RFA as the primary therapy at three Chinese hospitals from January 2011 to December 2016. The best cutoff time to define early and late recurrence was determined based on differences in post recurrence survival (PRS). The clinical variables were assessed by univariate and multivariate logistic regression analyses.

RESULTS

A total of 279 eligible patients were included. The optimal cutoff time interval after RFA to differentiate early and late recurrence was identified as 12 months (p = 0.029). The independent risk factors of early recurrence were multiple tumors, alpha fetoprotein (AFP) levels, gamma-glutamyl transferase (γ-GT), and serum albumin (ALB) levels. A well-discriminated nomogram was constructed to predict risk of early recurrence. The incidence of intrahepatic distant recurrence (IDR) alone and IDR + extrahepatic recurrence (ER) in early recurrence group was significantly higher than those in late recurrence group (80.73% vs. 66.47%, p = 0.009).

CONCLUSION

Twelve months was determined as the optimal cutoff time for differentiating early and late recurrence after RFA for HCC patients. The factors affecting early recurrence after RFA were multiple tumors, AFP levels, ALB level, and γ-GT level. Patients in early recurrence cohort were more likely to develop IDR alone or IDR + ER.

Microwave ablation shows similar survival outcomes compared with surgical resection for hepatocellular carcinoma between 3 and 5 cm

BACKGROUND

Microwave ablation (MWA) is a safe and effective locoregional ablation modality, but it is not clear whether the curative effect of MWA as to hepatocellular carcinoma (HCC) is comparable to that of surgical resection (SR). We aimed to compare the outcomes of MWA and SR for patients with HCC ranging from 3 to 5 cm.

METHODS

197 patients treated for HCC between 3 and 5 cm by MWA or SR were included from 2010 to 2017. Overall survival (OS), progression-free survival (PFS), complication and hospital stay of those patients were compared by using propensity score matching. The registration number of this clinical trial was ChiCTR2000033983.

RESULTS

For patients with HCC between 3 and 5 cm, the 1-, 3-, and 5- years OS rates were 90.3%, 79.7%, and 65.5% in the MWA group, and 96.7%, 88.6%, and 71%% in the SR group, respectively (p = 0.457). The 1-, 3- and 5- years PFS rates were 63.6%, 36.8% and 32.7% in the MWA group, and 74.2%, 41.9% and 35.5% in the SR group, respectively (p = 0.397). The MWA group showed fewer complications (55% versus 78.8%, p = 0.041) and shorter hospital stays (8 versus 15 days, p < 0.001) compared with the SR group.

CONCLUSION

MWA showed similar survival outcomes compared with SR for HCCs ranging from 3 to 5 cm. However, it showed favorable results in terms of hospital stay and complication rate compared to SR.

Challenges Facing Percutaneous Ablation in the Treatment of Hepatocellular Carcinoma: Extension of Ablation Criteria

As an emerging minimally invasive treatment method, percutaneous ablation is more and more widely used in the treatment of liver tumors. It has been recommended by guidelines for diagnosis and treatment of hepatocellular carcinoma (HCC) as a curative treatment alongside surgical resection and liver transplantation. In recent years, with the continuous advancement and innovation of percutaneous ablation technologies, their clinical efficacy and safety have been significantly improved, which has led to the expanded application of percutaneous ablation in the treatment of HCC—more and more patients who were previously considered unsuitable for ablation therapies are now being treated with percutaneous ablation. Obviously, percutaneous ablation can reduce the risk of treatment changes from curative strategies to palliative strategies. Based on clinical practice experience, this review enumerates the advantages and disadvantages of different ablative modalities and summarizes the existing combinations of ablation techniques, thus will help clinicians choose the most appropriate ablative modality for each patient and will provide scientific guidance for improving prognosis and making evidence-based treatment decisions. In addition, we point out the challenges and future prospects of the ablation therapies, thereby providing direction for future research.

Image-Guided Peri-Tumoral Radiofrequency Hyperthermia-Enhanced Direct Chemo-Destruction of Hepatic Tumor Margins

Purpose

To validate the feasibility of using peri-tumoral radiofrequency hyperthermia (RFH)-enhanced chemotherapy to obliterate hepatic tumor margins.

Method and Materials

This study included in vitro experiments with VX2 tumor cells and in vivo validation experiments using rabbit models of liver VX2 tumors. Both in vitro and in vivo experiments received different treatments in four groups (n=6/group): (i) RFH-enhanced chemotherapy consisting of peri-tumoral injection of doxorubicin plus RFH at 42°C; (ii) RFH alone; (iii) doxorubicin alone; and (iv) saline. Therapeutic effect on cells was evaluated using different laboratory examinations. For in vivo experiments, orthotopic hepatic VX2 tumors in 24 rabbits were treated by using a multipolar radiofrequency ablation electrode, enabling simultaneous delivery of both doxorubicin and RFH within the tumor margins. Ultrasound imaging was used to follow tumor growth overtime, correlated with subsequent histopathological analysis.

Results

In in vitro experiments, MTS assay demonstrated the lowest cell proliferation, and apoptosis analysis showed the highest apoptotic index with RFH-enhanced chemotherapy, compared with the other three groups (p<0.01). In in vivo experiments, ultrasound imaging detected the smallest relative tumor volume with RFH-enhanced chemotherapy (p<0.01). The TUNEL assay further confirmed the significantly increased apoptotic index and decreased cell proliferation in the RFH-enhanced therapy group (p<0.01).

Conclusion

This study demonstrates that peri-tumoral RFH can specifically enhance the destruction of tumor margins in combination with peri-tumoral injection of a chemotherapeutic agent. This new interventional oncology technique may address the critical clinical problem of frequent marginal tumor recurrence/persistence following thermal ablation of large (>3 cm) hepatic cancers.

A review of cutting-edge therapies for hepatocellular carcinoma (HCC): Perspectives from patents

Rationale: Hepatocellular carcinoma (HCC) is a challenging disease due to its heterogenous etiology. Several breakthroughs have occurred in treatment of HCC, associated with an enormous number of patent publications for a variety of HCC treatment modalities. As patents can provide valuable information for academic research and commercial development, this study aims to unravel the cutting-edge therapies for HCC by using patents as an indicator. The outcome from this analysis may offer meaningful insights for respective policymaking, strategic plan and research and development (R&D) prioritization. Methods: Derwent Innovation platform was employed to collect the sample data of patents related to HCC treatment technologies worldwide as of December 31, 2019. Data inclusion, screening and exclusion were according to the rules of preferred reporting items for systematic reviews and meta-analyses (PRISMA). Technologies were classified based on Barcelona Clinic Liver Cancer (BCLC) staging system and recent clinical publications. Patent citation network analysis was carried out to identify and understand HCC therapeutic technology flow. Results: A dataset of 2543 patent documents and 528 patent families was generated. 11 technological categories were classified. Numerous researches were focalized on refinements in technologies and innovations within the field of HCC therapy, and the major achievements are technology advancement on molecular target therapy, chemotherapy, locoregional therapy, combination therapy and immunotherapy with demonstrated clinical benefits. In patent citation network, Notch pathway investigation, antibody drug conjugate (ADC) technology development and drug eluting beads trans artery chemoembolization (DEB-TACE) advancement are the major technological communities involving patents with the greatest future exploratory potential. Conclusion: Numerous emerging technologies have been identified in this study, in which exploring novel therapeutic targets in molecular target therapy, more localized and visible locoregional therapy and combination of immunotherapy with target therapy or other traditional therapies are highlighted as the future trends in treating HCC.

The Short-Term Efficacy of Novel No-Touch Combined Directional Perfusion Radiofrequency Ablation in the Treatment of Small Hepatocellular Carcinoma with Cirrhosis

BACKGROUND

No-touch combined directed perfusion radiofrequency ablation (NTDP-RFA) is a new technique for the treatment of hepatocellular carcinoma (HCC). The purpose of this study was to evaluate the short-term efficacy of this new technique for the treatment of small HCC with cirrhosis.

METHODS

From January 2017 to March 2018, 56 consecutive patients treated with NTDP-RFA at our center were enrolled in this retrospective study. All NTDP-RFA procedures involved the use of internally cooled wet electrodes with a directional injection function, which can perform both intraelectrode cooling and extraelectrode saline perfusion. Survival curves were analyzed using Kaplan-Meier methods, and Cox proportional hazards regression analyses were used to assess predictors of tumor progression and overall survival. Operative characteristics and complications were also assessed.

RESULTS

No technical failure occurred, and the complete ablation rate after single NTDP-RFA treatment was 98.2%. The median tumor diameter and ablation time were 26 (18.0 - 28.0) mm and 8 (6 - 8) min, respectively. Mild complications occurred in five patients (8.9%) postoperatively, and the median hospital stay was 4 (4 - 5) days. In the 18 patients (32.1%) with poor liver function reserve (indocyanine green retention rate at 15 min > 15%, their liver function returned to normal on the third day after the postoperation. The 1- and 2-year local and distant progression rates were 1.7%, 7.1%, 3.5% and 10.7%, respectively.

CONCLUSIONS

NTDP-RFA in the treatment of small HCC with cirrhosis has a low incidence of complications and provides a high survival rate without local tumor progression.

Hepatocellular Carcinoma: An Overview of the Changing Landscape of Treatment Options

The last three years have seen remarkable progress in comprehending predisposing factors and upgrading our treatment arsenal concerning hepatocellular carcinoma (HCC). Until recently, there were no means to withstand the progression of viral hepatitis-associated liver cirrhosis to HCC. A deeper understanding of the molecular mechanism of the disease, the use of biomarkers, and the follow-up, allowed us to realize that conventional chemotherapy failing to increase survival in patients with advanced HCC tends to be exiled from clinical practice. Multi-kinase inhibitors (TKIs) such as sorafenib, lenvatinib targeting mainly the vascular endothelial growth factor receptors 1–3 VEGFRs 1–3 provided until recently the standard of care for these patients, as first- or second-line treatment. Since May 2020, the atezolizumab plus bevacizumab combination (immunotherapy plus anti-VEGF) has become the new reference standard in first-line HCC treatment. Additionally, anti-programmed cell death protein 1 (anti-PD-1) immunotherapy can be used as a second-line treatment following first-line treatment’s failure. Phase III clinical trials have recently suggested the efficacy of novel anti-angiogenic factors such as cabozantinib and ramucirumab as a second-line treatment option. With considerations about toxicity arising, clinical trials are investigating combinations of the aforementioned targeted therapies with immunotherapy as first-line treatment. This paper aims to perform a systematic review describing the evolving treatment options for HCC over the last decades, ranging from neoadjuvant treatment to systemic therapy of advanced-stage HCC. With the landscape of HCC treatment shifting towards novel agents the forming of a new therapeutic algorithm for HCC seems to be imperative.

Caudate Lobe Hepatocellular Carcinoma Treated with Sequential Transarterial Chemoembolization and Iodine 125 Seeds Implantation: A Single-Center Retrospective Study

Purpose

Resection of the hepatocellular carcinoma (HCC) in the caudate lobe (CL) is challenging even for accomplished surgeons. This retrospective study evaluated the safety and efficacy of transarterial chemoembolization (TACE) and iodine 125 seeds implantation (ISI) for unresectable or “ablation unsuitable” HCC-CL detected at the initial presentation in clinical practice.

Patients and Methods

A total of 20 HCC-CL patients undergoing sequential TACE and ISI from January 2014 to October 2018 were enrolled in this study. The overall survival (OS), progression-free survival (PFS), tumor response rate, and complication rates were analyzed and compared to non-caudate lobe (NCL) HCC patients. Multivariate analyses for potential clinical and radiological factors were performed using the Cox proportional hazard model.

Results

The technical success rate was 100%, as all the patients received 28 ISI treatments. The median OS was 35 months. The 1-, 3-, and 5-year OS rates were 100%, 63.2%, and 11.1%, respectively. The median PFS was 16 months. The objective response rate was 60.0%. The puncture tract bleeding (2/20) and pneumothorax (1/20) were the most common complications in operation, but no operation-related deaths occurred. One year after the surgery, biliary tract injury occurred in 1 patient, necessitating percutaneous biliary intervention. No statistical difference was observed between the CL and NCL groups. Multivariable analysis revealed that Barcelona Clinic Liver Cancer stage B and tumor size >3 cm were two significant factors associated with OS.

Conclusion

Sequential TACE and ISI were associated with the survival benefits in HCC-CL and should be considered as a reliable therapy for surgeons and interventional radiologists.

The efficacy of radiofrequency ablation versus cryoablation in the treatment of single hepatocellular carcinoma: A population-based study

BACKGROUND

Radiofrequency ablation (RFA) is an effective treatment for single hepatocellular carcinoma (HCC), but it is difficult to use against tumors in some locations and often leads to incomplete ablation as a result of the heat-sink effect. This study was conducted to evaluate the efficacy of cryoablation compared with that of RFA in the treatment of single HCC.

METHODS

This retrospective study was conducted based on the Surveillance, Epidemiology, and End Results (SEER) database. From 2004 to 2015, patients aged 40 to 79 diagnosed with HCC were included in the study. A propensity score matching (PSM) model was used to reduce selection biases.

RESULTS

Before PSM, the median overall survival (mOS) and median cancer-specific survival (mCSS) in the RFA group were slightly longer than those in the cryoablation group (p > 0.05). In the subgroup analysis, the mOS and mCSS of patients with tumor sizes <3, 3-5, and >5 cm who received RFA treatment were longer than those of patients given cryoablation treatment, but there was no significant difference (p > 0.05). Similar results were presented in patients at American Joint Committee on Cancer (AJCC) stages I and II. After PSM, the mOS and mCSS were slightly better in the RFA group than the cryoablation group but without significant differences. Univariate and multivariate analysis showed that cryoablation treatment was not an unfavorable factor for OS and CSS before or after PSM (p > 0.05). In the multivariable competing risk model, non-cancer-specific death was taken as a competing factor and cryoablation was also not unfavorable for the survival of patients before and after PSM (p > 0.05).

CONCLUSION

Cryoablation is non-inferior to RFA therapy for single HCC patients without lymph node invasion or distant metastasis.

Locoregional therapies in the era of molecular and immune treatments for hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the fourth leading cause of cancer-related mortality and has an increasing incidence worldwide. Locoregional therapies, defined as imaging-guided liver tumour-directed procedures, play a leading part in the management of 50-60% of HCCs. Radiofrequency is the mainstay for local ablation at early stages and transarterial chemoembolization (TACE) remains the standard treatment for intermediate-stage HCC. Other local ablative techniques (microwave ablation, cryoablation and irreversible electroporation) or locoregional therapies (for example, radioembolization and sterotactic body radiation therapy) have been explored, but have not yet modified the standard therapies established decades ago. This understanding is currently changing, and several drugs have been approved for the management of advanced HCC. Molecular therapies dominate the adjuvant trials after curative therapies and combination strategies with TACE for intermediate stages. The rationale for these combinations is sound. Local therapies induce antigen and proinflammatory cytokine release, whereas VEGF inhibitors and tyrosine kinase inhibitors boost immunity and prime tumours for checkpoint inhibition. In this Review, we analyse data from randomized and uncontrolled studies reported with ablative and locoregional techniques and examine the expected effects of combinations with systemic treatments. We also discuss trial design and benchmarks to be used as a reference for future investigations in the dawn of a promising new era for HCC treatment.

Actin-binding protein anillin promotes the progression of hepatocellular carcinoma in vitro and in mice

Hepatocellular carcinoma (HCC) is a common type of tumor with high mortality worldwide. Investigations associated with the molecular etiology of HCC and screening novel therapeutic targets are still urgently in need. Anillin (ANLN), as a type of evolutionarily conserved actin-binding protein, is involved in multiple cellular processes. ANLN widely affected the progression and metastasis of several types of cancer, and its overexpression was frequently demonstrated in previous studies. The present study demonstrated high expression of ANLN in human HCC tissues, which was also associated the prognosis of patients with HCC. The associations between ANLN expression and the clinicopathological features were determined, including the number of tumor nodes (P=0.011) and tumor size (P=0.003) of patients with HCC. It was found that ANLN promoted cell proliferation, invasion and migration of HCC cells in vitro, and affected tumor growth in vivo. Therefore, ANLN is suggested as a promising therapeutic target for the treatment of HCC.

Switching monopolar radiofrequency ablation improves long-term outcomes of medium-sized hepatocellular carcinoma

OBJECTIVES

Radiofrequency ablation (RFA) of medium-sized (3-5 cm) hepatocellular carcinoma (HCC) is suboptimal. Switching monopolar RFA (SW-RFA) enlarges the ablative volume to better cover larger tumors. This study aims to compare the long-term outcomes of medium-sized HCC treated by either SW-RFA or single-monopolar RFA (S-RFA).

METHODS

We retrospectively reviewed 139 cases (147 medium-size HCC) between 2008 and 2014. Under propensity score matching, a total of 43 paired patients with medium-size HCC and balanced clinical variables treated by either SW-RFA or S-RFA were selected for comparison.

RESULTS

SW-RFA showed a higher rate of achieving an adequate safety margin (p = 0.002). After a mean follow-up period of 40.4 months, SW-RFA produced significantly lower global RFA failure rates (p < 0.001) and better overall survival (p = 0.005) compared to S-RFA. SW-RFA was independently associated with a decreased risk of global RFA failure (hazard ratio [HR]: 0.136, 95% confidence interval [CI]: 0.030-0.607, p = 0.009) and improved overall survival (HR: 0.337, 95% CI: 0.152-0.747, p = 0.007). By last follow-up, the SW-RFA group maintained a superior tumor-free rate (p = 0.010) and fewer progressions to Barcelona Clinic Liver Cancer stage C (p = 0.011). Major complication rates were comparable in both groups (SW-RFA: 2.3% vs. S-RFA: 4.7%, p = 1.000).

CONCLUSIONS

The switching multi-monopolar ablation technique could be beneficial for patients with medium-sized HCCs given sustained control of larger tumors with better overall survival.

KEY POINTS

• Switching monopolar ablation could provide a sustained local tumor control and better overall survival than single-monopolar ablation for the medium-sized hepatocellular carcinoma. • Compared to single-monopolar ablation, switching monopolar ablation could create a larger homogeneous coagulation volume by using a shorter total ablation time to achieve a higher rate of adequate safety margin for a medium-sized HCC. • Patients with medium-sized HCC can be maintained at a higher rate of tumor-free status and at a lower risk of progression into BCLC stage C in the follow-up period after ablation by switching monopolar than by single-monopolar ablation.

Sequential transarterial chemoembolization and early radiofrequency ablation improves clinical outcomes for early-intermediate hepatocellular carcinoma in a 10-year single-center comparative study

Background

Transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) are effective treatment methods for unresectable hepatocellular carcinoma (HCC). However, there is still a lack of clinical research on whether early sequential RFA, compared with late combination therapy, can improve the long-term efficacy of initial TACE treatment.

Methods

This retrospective study investigated a cohort of patients who underwent combination therapy using TACE and RFA (TACE followed by RFA) from January 2010 to January 2020 at our medical centre. A total of 96 patients underwent TACE combined with early RFA (usually during the first hospitalization), which was called TACE + eRFA. Thirty-four patients received 1–2 palliative TACE treatments first and then underwent TACE treatment combined with late RFA (TACE + lRFA). All patients continued to receive palliative TACE treatments after intrahepatic lesion progression until reaching intolerance. The overall survival (OS) rate, time to tumour progression (TTP), tumour response rate and major complication rates were compared between the two groups.

Results

There were significant differences in the median OS (46 months vs 33 months; P = 0.013), median TTP (28 months vs 14 months; P < 0.00), objective response rate (ORR) (89.6% vs 61.8%, P = 0.000) and disease control rate (DCR) (94.8% vs 73.5% P = 0.002) between the two groups. Multivariable analysis revealed that the Barcelona Clinic Liver Cancer stage was an independent risk factor for OS. Meanwhile, multivariable analysis revealed that TACE + eRFA was associated with an enhanced TTP.

Conclusion

Early sequential RFA treatment in patients with early-intermediate HCC can improve local tumour control and clinical outcomes while reducing the frequency of TACE treatment. In clinical practice, in HCC patients initially treated with TACE, it is recommended to combine RFA as soon as possible to obtain long-term survival.

Inferior Vena Cava Syndrome as a Manifestation of Metastatic Carcinoid Tumor

Small bowel-origin carcinoid tumor is indolent but may metastasize relentlessly to various sites, including the liver. Over the past 9 years, we have treated a 69-year-old woman who has undergone 5 percutaneous liver ablations, 5 hepatic intra-arterial chemoembolizations, an ovarian cryoablation, and a trans-ventral hernia mesenteric cryoablation. These interventions are all related to her inoperable carcinoid malignancy. After the patient presented with swelling of the abdomen and both lower extremities, computed tomography (CT) angiography was performed, revealing a circumferential hepatic metastatic mass encasing the intrahepatic inferior vena cava (IVC) and extensive third spacing of fluids specific to the IVC distribution below the diaphragm. A venogram of the intrahepatic IVC revealed extrinsic compression causing 95% narrowing of the vessel. A balloon was advanced to the level of the lesion and inflated, increasing the caliber of the vessel. Subsequently, 2 covered aortic stent graft cuffs were deployed in an overlapping fashion within the lumen of the IVC, traversing the area of narrowing. Next, an open-cell aortic dissection stent was placed across both overlapping aortic stents from the renal veins to the hepatic veins. Following this, three 17-gauge cryoablation probes were inserted into the segment 1 intrahepatic lesions encasing the newly stented IVC via an anterior percutaneous approach. Two 10-min freeze cycles were performed with intraoperative CT imaging, demonstrating circumferential coverage of the lesions. Posttreatment venogram revealed patent stent grafts within the intrahepatic IVC, and restoration of vessel patency. No immediate postoperative complications were noted. The patient's abdominal and lower extremity swelling resolved completely within 1 week after procedure. Two-month follow-up CT demonstrated markedly decreased size of the metastatic lesions and no adverse effects. Six- and 9-month PET-CT scans demonstrated maintained patency of the IVC stent. This palliative procedure allowed the patient to maintain good performance status and alleviated her symptoms of IVC syndrome. The radial force generated by the multiple aortic stents will ostensibly maintain the patency of the intrahepatic IVC. Cryoablation of the encasing metastatic lesion was performed with markedly decreased size of the tumor on the 2-month follow-up.

Small Steatotic HCC: A Radiological Variant Associated With Improved Outcome After Ablation

Percutaneous thermal ablation is a validated treatment option for small hepatocellular carcinoma (HCC). Steatotic HCC can be reliably detected by magnetic resonance imaging. To determine the clinical relevance of this radiological variant, we included 235 patients (cirrhosis in 92.3%, classified Child-Pugh A in 97%) from a prospective database on percutaneous thermal ablation for <3 cm HCC. Among these patients, 52 (22.1%) had at least one steatotic HCC nodule. Nonalcoholic steatohepatitis was more frequent in patients with than without steatotic HCC (P = 0.057), whereas body mass index, diabetes mellitus, liver steatosis, and liver fat content did not differ between groups. Liver disease was less advanced in patients with than without steatotic HCC: lower total bilirubin ( - 2.1 µmol/L; P = 0.035), higher albumin (+0.8 g/L; P = 0.035), and lower Model for End-Stage Liver Disease score (-0.8; P = 0.014). Tumor phenotype was less aggressive in patients with steatotic HCC: lower alpha-fetoprotein (AFP) concentration (P = 0.019), less frequent AFP > 100 ng/mL (P = 0.045), and multifocality (P = 0.015). During the follow-up (median: 28.3 months), overall mortality (3.8% vs. 23.5%; P = 0.001) and HCC-specific mortality (0.0% vs. 14.2%; P = 0.002) rates were lower in patients with steatotic HCC. Early (<2 years) recurrence was also less frequent (32.7% vs. 49.2%; P = 0.041). The mean time to intrahepatic distant recurrence (16.4 vs. 9 months, P = 0.006) and the median time to recurrence and recurrence-free survival (32.4 vs. 18.6 months, P = 0.024 and 30.4 vs. 16.4 months, P = 0.018) were longer in patients with steatotic versus nonsteatotic HCC. The 3-year overall survival was 94.4% and 70.9% in steatotic and nonsteatotic HCC (P = 0.008). In multivariate analysis, steatotic HCC (hazard ratio = 0.12; P = 0.039) and AFP (HR=1.002; P < 0.001) independently predicted overall survival. Conclusion: Small steatotic HCC detected by magnetic resonance imaging is associated with a less aggressive tumor phenotype. In patients with such radiological variant, percutaneous thermal ablation results in improved outcome.

Evolutions in the Management of Hepatocellular Carcinoma over Last 4 Decades: An Analysis from the 100 Most Influential Articles in the Field

INTRODUCTION

Over the past 4 decades, the management of hepatocellular carcinoma (HCC) has changed dramatically. The publications that have had the most significant impact on HCC management have not been quantitatively analyzed. In this article, we analyzed the 100 most influential articles over the past 4 decades using bibliometric citation analysis to characterize the evolution in HCC treatment.

METHODS

The top-cited publications were identified and analyzed from the Clarivate Analytics Web of Science Core Collection database.

RESULTS

The 100 most cited articles were identified with an average of 738 citations (range: 349-6,799). There was an increase in the number of influential articles in the late 1990s, which was paralleled by an increase in reports focused on locoregional treatment of HCC. Most top 100 articles came from the USA (n = 35), followed by Italy (n = 28), mainland China (n = 26), and Japan (n = 24). The surgical management was the most studied topic (n = 33). The Annals of Surgery published the highest number of papers (n = 26) with 13,978 citations. While other 3 topics (surgical management, locoregional treatment, and outcome prediction) declined among publications beginning in the 2000s, there was an emergence of highly cited papers on targeted drugs and immune checkpoint inhibitors with a concomitant increase in the number of publications on systemic therapy.

CONCLUSIONS

Based on bibliometric analysis of the literature over the last 40 years, a comprehensive analysis of the most historically significant HCC management articles highlighted the key contributions made to the evolution and advancement of this specialist field. The data should provide clinicians and researchers insight into future directions relative to the advancement of HCC management.

Use of Contrast-Enhanced Ultrasound with Sonazoid for Evaluating the Radiotherapy Efficacy for Hepatocellular Carcinoma

Radiotherapy is one of the available curative therapies for hepatocellular carcinoma (HCC). We investigate the use of contrast-enhanced ultrasound using Sonazoid (SCEUS) in evaluating the efficacy of radiotherapy for HCC. We enrolled 59 patients with 59 HCCs in this retrospective study. Tumor size and tumor vascularity were evaluated using SCEUS before and 1, 3, 7, 10, and 13 months after radiotherapy. The median follow-up period was 44.5 months (range: 16–82 months). Of the HCCs, 95% (56/59) had no local recurrence, while 5% (3/59) did. At 13 months after radiotherapy, in cases with no local recurrence, SCEUS showed a reduction in tumor vascularity in all cases, while tumor size reduction (>30% reduction, compared with pre-radiotherapy) was observed in 82.1% (46/56). In all three cases of local recurrence, vascularity and tumor size reduction were not observed during the follow-up period and residual HCCs were demonstrated pathologically. Compared with cases with local recurrence, tumor size reduction and reduction in tumor vascularity (p < 0.001) were significantly greater in cases with no local recurrence at 13 months after radiotherapy. SCEUS may be useful in evaluating radiotherapy efficacy for HCC.

Current updates in machine learning in the prediction of therapeutic outcome of hepatocellular carcinoma: what should we know?

With the development of machine learning (ML) algorithms, a growing number of predictive models have been established for predicting the therapeutic outcome of patients with hepatocellular carcinoma (HCC) after various treatment modalities. By using the different combinations of clinical and radiological variables, ML algorithms can simulate human learning to detect hidden patterns within the data and play a critical role in artificial intelligence techniques. Compared to traditional statistical methods, ML methods have greater predictive effects. ML algorithms are widely applied in nearly all steps of model establishment, such as imaging feature extraction, predictive factor classification, and model development. Therefore, this review presents the literature pertaining to ML algorithms and aims to summarize the strengths and limitations of ML, as well as its potential value in prognostic prediction, after various treatment modalities for HCC.

Feasibility, safety and accuracy of a CT-guided robotic assistance for percutaneous needle placement in a swine liver model

Evaluate the feasibility, safety and accuracy of a CT-guided robotic assistance for percutaneous needle placement in the liver. Sixty-six fiducials were surgically inserted into the liver of ten swine and used as targets for needle insertions. All CT-scan acquisitions and robotically-assisted needle insertions were coordinated with breath motion using respiratory monitoring. Skin entry and target points were defined on planning CT-scan. Then, robotically-assisted insertions of 17G needles were performed either by experienced interventional radiologists or by a novice. Post-needle insertion CT-scans were acquired to assess accuracy (3D deviation, ie. distance from needle tip to predefined target) and safety. All needle insertions (43/43; median trajectory length = 83 mm (interquartile range [IQR] 72–105 mm) could be performed in one (n = 36) or two (n = 7) attempts (100% feasibility). Blinded evaluation showed an accuracy of 3.5 ± 1.3 mm. Accuracy did not differ between novice and experienced operators (3.7 ± 1.3 versus 3.4 ± 1.2 mm, P = 0.44). Neither trajectory angulation nor trajectory length significantly impacted accuracy. No complications were encountered. Needle insertion using the robotic device was shown feasible, safe and accurate in a swine liver model. Accuracy was influenced neither by the trajectory length nor by trajectory angulations nor by operator’s experience. A prospective human clinical trial is recruiting.

Predictors and patterns of recurrence after radiofrequency ablation for hepatocellular carcinoma within up-to-seven criteria: A multicenter retrospective study

PURPOSE

To determine the risk factors and patterns of recurrence after radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) meeting the up-to-seven criteria and to develop a nomogram to predict the recurrence free survival (RFS).

MATERIALS AND METHODS

This retrospective study included 481 HCC patients meeting the up-to-seven criteria and who received RFA as the primary therapy at three Chinese hospitals from January 2013 to December 2016. All clinical variables were assessed by univariate and multivariate Cox regression analyses and a nomogram was constructed to predict the probability of RFS.

RESULTS

The recurrence rate was 50.7 % (244/481). Age > 60 years, male gender, and multiple tumors were independent risk factors of recurrence. The incidence of early and late recurrence was 68.03 % (n = 166) and 31.97 % (n = 78), respectively. Seven patterns of spatial recurrence were identified: local tumor progression (LTP) alone (n = 18, 7.38 %), intrahepatic distant recurrence (IDR) alone (n = 136, 55.74 %), extrahepatic recurrence (ER) alone (n = 21, 8.61 %), IDR + ER (n = 45, 18.44 %), LTP + IDR (n = 16, 6.56 %), LTP + ER (n = 4, 1.64 %) and LTP + IDR + ER (n = 4, 1.64 %). The 1-, 2-, and 3-year RFS rates were 79.63 %, 65.23 %, and 51.03 %, respectively. A well-discriminated and calibrated nomogram was constructed.

CONCLUSIONS

The factors affecting recurrence after RFA were age, gender, and the number of tumors. IDR was the most common type of recurrence after complete ablation.

Higher Efficiency of Percutaneous Microwave (MWA) Than Radiofrequency Ablation (RFA) in Achieving Complete Response in Cirrhotic Patients with Early Hepatocellular Carcinoma

BACKGROUND

Contrasting data are available in the literature regarding the superiority of percutaneous microwave ablation (MWA) or radiofrequency ablation (RFA) in very early or early (BCLA 0 or A) hepatocellular carcinoma (HCC).

AIMS

The primary outcome was to compare the efficacy of RFA and MWA in achieving complete response in cirrhotic patients with early and very early HCC. The secondary outcomes were to evaluate the overall survival and the recurrence rate.

METHODS

A retrospective, observational, single-center study was performed. Inclusion criteria were liver cirrhosis, new diagnosis of a single node of HCC measuring a maximum of 50 mm or up to three nodules with diameter up to 35 mm, treatment with RFA or MWA. Radiological response was evaluated with multiphasic contrast-enhanced Computed Tomography or Magnetic Resonance Imaging at 5-7 weeks after thermal ablation. Complete response was defined when no vital tissue was detected after treatment.

RESULTS

Overall, 251 HCC patients were included in this study; 81 patients were treated with MWA and 170 with RFA. The complete response rate was similar in MWA and RFA groups (out of 331 nodules, 87.5% (91/104) were treated with MWA and 84.2% (186/221) were treated with RFA, p = 0.504). Interestingly, a subanalysis demonstrated that for 21-35 mm nodules, the probability to achieve a complete response using MWA was almost 5 times higher than for RFA (OR = 4.88, 95% CI 1.37-17.31, p = 0.014). Moreover, recurrence rate in 21-35 mm nodules was higher with RFA with respect to MWA (31.9% versus 13.5%, p = 0.019). Overall survival was 80.4% (45/56) when treated with MWA and 62.2% (56/90) when treated with RFA (p = 0.027). No significant difference was observed between MWA and RFA treatment in the 15-20 mm nodules group.

CONCLUSION

This study showed that MWA is more efficient than RFA in achieving complete response in HCC nodules with 21 to 35 mm diameter.

Liver resection versus transarterial chemoembolization for huge hepatocellular carcinoma: a propensity score matched analysis

To date, it is unclear which treatment modality, liver resection (LR) or transarterial chemoembolization (TACE) is the more appropriate for patients with huge (≥ 10 cm) hepatocellular carcinoma (HCC). The study aim was to compare, using propensity score matching, short- and long-term outcomes of patients with huge HCC who underwent potentially curative LR or TACE. Patients with huge HCC who had been managed at the Clinical Center by curative-intent LR or by palliative TACE between November 2001 and December 2018 were retrospectively identified. The morbidity and mortality rates and overall survival were compared between the groups before and after the propensity score matching. Independent predictors of long-term survival were determined by multivariate analysis. A total of 103 patients with huge HCC were included; 68 were assigned to the LR group and 35 to the TACE group. The overall morbidity rate was higher in the LR group than in the TACE group before matching (64.7% vs. 37.1%, p = 0.012), while there was no difference after matching (60% vs. 30%, p = 0.055). The major morbidity and 30-days mortality were similar between the groups before and after matching. The LR group was associated with longer overall survival than the TACE group before matching (p = 0.032) and after matching (p = 0.023). Total bilirubin and TACE treatment were independent prognostic factors associated with long-term survival. In patients with huge HCC, liver resection provides better long-term survival than TACE and should be considered as the initial treatment whenever possible.

Actin-binding protein Anillin promotes the progression of gastric cancer in vitro and in mice

BACKGROUND

To detect the expression levels of actin-binding protein anillin (ANLN) in human gastric cancer (GC) tissues and explore the possible involvement of ANLN in GC cell proliferation, migration, and invasion.

METHODS

The bioinformation analysis was performed in TCGA database to explore the expression of ANLN in human GC tissues and the difference of ANLN expression between multiple types of cancers. IHC assays and clinical pathological analysis were performed to confirm ANLN expression and its correlation with clinical features of GC patients. Colony formation, CCK-8, wound closure, and transwell assays were performed to detect its effects on GC cell proliferation, migration, and invasion in vitro. Tumor growth was also measured using a xenograft animal model.

RESULTS

We found the high expression of ANLN in human GC tissues based on the results from TCGA database and IHC staining. We further noticed ANLN depletion resulted in the inhibition of GC cell proliferation, migration, and invasion. Our data further confirmed that ANLN contributed to tumor growth of GC cells in vivo.

CONCLUSIONS

We confirmed the involvement of ANLN in GC progression and thought ANLN could serve as a promising therapeutic target for GC.

Performance of the Emprint and Amica Microwave Ablation Systems in ex vivo Porcine Livers: Sphericity and Reproducibility Versus Size

PURPOSE

To investigate the performance of two microwave ablation (MWA) systems regarding ablation volume, ablation shape and variability.

MATERIALS AND METHODS

In this ex vivo study, the Emprint and Amica MWA systems were used to ablate porcine livers at 4 different settings of time and power (3 and 5 minutes at 60 and 80 Watt). In total, 48 ablations were analysed for ablation size and shape using Vitrea Advanced Visualization software after acquisition of a 7T MRI scan.

RESULTS

Emprint ablations were smaller (11,1 vs. 21,1 mL p < 0.001), more spherical (sphericity index of 0.89 vs. 0.59 p < 0.001) and showed less variability than Amica ablations. In both systems, longer ablation time and higher power resulted in significantly larger ablation volumes.

CONCLUSION

Emprint ablations were more spherical, and the results showed a lower variability than those of Amica ablations. This comes at the price of smaller ablation volumes.

Impact of needle positioning on ablation success of irreversible electroporation: a unicentric retrospective analysis

Irreversible electroporation (IRE) is an ablation procedure in which cell death is induced by ultrashort electrical pulses. In this unicentric retrospective study we investigated the influence of needle positioning on ablation success. 15 IREs with residual tumor after ablation, detected in the first follow-up MRI, were included, and compared with 30 successful ablations. Evaluation of needle geometry revealed significantly higher values for needle divergence (NDiv, 7.0° vs. 3.7°, p = 0.02), tumor-center-to-ablation-center distance (TACD, 11.6 vs. 3.2 mm, p < 0.001), tumor-to-needle distance (4.7 vs. 1.9 mm, p = 0.04), and tumor diameter per needle (7.5 vs. 5.9 mm/needle, p = 0.01) in patients with residual tumor. The average number of needles used was higher in the group without residual tumor after ablation (3.1 vs. 2.4, p = 0.04). In many cases with residual tumor, needle depth was too short (2.1 vs. 6.8 mm tumor overlap beyond the most proximal needle tip, p < 0.01). The use of a stereotactic navigation system in 10 cases resulted in a lower NDiv value (2.1° vs. 5.6°, p < 0.01). Thus, correct needle placement seems to be a crucial factor for success and the assistance of a stereotactic navigation system might be helpful. As most important geometrical parameter TACD could be identified. Main reasons for high TACD were insufficient needle depth and a lesion location out of the needle plane.

Safety and efficacy of percutaneous radiofrequency ablation for hepatocellular carcinoma patients with haemophilia

Haemophilia is an X-linked inherited bleeding disorder caused by coagulation factor deficiency. Hepatocellular carcinoma (HCC) is a major complication associated with the disease. No study thus far has investigated the safety and efficacy of percutaneous radiofrequency ablation (RFA) for HCC in patients with haemophilia.

AIM

This study aimed to evaluate the safety and efficacy of RFA for HCC in haemophilia patients.

METHODS

From July 2008 to June 2019, 217 patients with HCC underwent 300 RFA sessions. Of these, 18 sessions were performed in ten haemophilia patients (H group) and 282 in 207 non-haemophilia patients (NH group). The patients' characteristics, incidence of haemorrhagic complications and rates of local tumour recurrence were compared between the groups.

RESULTS

A majority of the haemophilia patients received clotting factor concentrate replacement therapy before and after RFA treatment, with the aim of reaching a plasma clotting factor level of higher than 60%-80%. Twelve haemorrhagic complications were observed in the NH group (4.2%; 12/282). Major bleeding requiring control procedures was observed in two patients and minor bleeding with careful observation was noted in ten patients. No bleeding complications were observed in the H group (0/18). There were no significant differences in the 5-year local tumour recurrence rates after RFA treatment between the groups (35.0% in the H group and 32.1% in the NH group).

CONCLUSION

RFA could be an effective and a safe method for HCC treatment in patients with haemophilia.

Immune response triggered by the ablation of hepatocellular carcinoma with nanosecond pulsed electric field

Nanosecond pulsed electric field (nsPEF) is a novel, nonthermal, and minimally invasive modality that can ablate solid tumors by inducing apoptosis. Recent animal experiments show that nsPEF can induce the immunogenic cell death of hepatocellular carcinoma (HCC) and stimulate the host's immune response to kill residual tumor cells and decrease distant metastatic tumors. nsPEF-induced immunity is of great clinical importance because the nonthermal ablation may enhance the immune memory, which can prevent HCC recurrence and metastasis. This review summarized the most advanced research on the effect of nsPEF. The possible mechanisms of how locoregional nsPEF ablation enhances the systemic anticancer immune responses were illustrated. nsPEF stimulates the host immune system to boost stimulation and prevail suppression. Also, nsPEF increases the dendritic cell loading and inhibits the regulatory responses, thereby improving immune stimulation and limiting immunosuppression in HCC-bearing hosts. Therefore, nsPEF has excellent potential for HCC treatment.

Late recurrence of hepatocellular carcinoma after radiofrequency ablation: a multicenter study of risk factors, patterns, and survival

OBJECTIVE

This study aims to determine the risk factors, patterns, and long-term survival outcomes of late recurrence after radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) within the Milan criteria and develop a nomogram to predict the recurrence-free survival (RFS).

MATERIALS AND METHODS

This retrospective study included patients with HCC within the Milan criteria, who received RFA at three hospitals in China from January 2011 to December 2016. The clinical variables were assessed by univariate and multivariate Cox regression analyses.

RESULTS

A total of 398 patients were included. The median follow-up was 58.7 months (range: 24.1-96.0). Ninety-eight patients had late recurrence. Furthermore, 14 patients (14.29%) had local tumor progression (LTP) alone, 43 patients (43.88%) had intrahepatic distant recurrence (IDR) alone, 15 patients (15.31%) had extrahepatic recurrence (ER) alone, three patients (3.06%) had both LTP and IDR, six patients (6.12%) had both LTP and ER, and 17 patients (17.35%) had both IDR and ER. Patients without late recurrence had better long-term overall survival (OS) compared to those with late recurrence (p < 0.001). Male gender, multiple tumors, and cirrhosis were the independent risk factors of late recurrence. A well-discriminated and calibrated nomogram was constructed to predict the probability of RFS.

CONCLUSION

Male gender, multiple tumors, and cirrhosis are the independent risk factors of late recurrence after RFA for HCC within the Milan criteria. Late recurrence might mainly occur from de novo HCC under the background of cirrhosis. An individualized surveillance and prevention strategy for HCC patients after RFA should be developed.

KEY POINTS

• In the present retrospective study of 398 patients, male gender, multiple tumors, and cirrhosis were the independent risk factors of late recurrence (> 2 years) of HCC after RFA. • The most common pattern of late recurrence was intrahepatic distant recurrence alone (n = 43, 43.88%). Late recurrence might mainly occur from de novo HCC under the background of cirrhosis. • A prognostic nomogram was built to predict the individualized recurrence-free survival after RFA, which achieved good calibration and discriminatory ability with a concordance index of 0.763.

Lesion outline and thermal field distribution of ablative in vitro experiments in myocardia: comparison of radiofrequency and laser ablation

OBJECTIVES

To explore the lesion outline and thermal field distribution of radiofrequency ablation (RFA) and laser ablation (LA) in myocardial ablation in vitro.

MATERIALS AND METHODS

Twenty-four fresh porcine hearts were ablated with RFA or LA in vitro. The radiofrequency electrode or laser fiber and two parallel thermocouple probes were inserted into the myocardium under ultrasound guidance. The output power for RFA was 20 W/s and for LA was 5 W/s, and the total thermal energies were 1200 J, 2400 J, 3600 J, and 4800 J. The range of ablation lesions was measured, and temperature data were recorded simultaneously.

RESULTS

All coagulation zones were ellipsoidal with clear boundaries. The center of LA was carbonized more obviously than that of RFA. With the accumulation of thermal energy and the extended time, all the ablation lesions induced by both RFA and LA were enlarged. By comparing the increase in thermal energy between the two groups, both the short-axis diameter and the volume change showed significant differences between the 1200 J and 3600 J groups and between the 2400 J and 4800 J groups (all P < 0.05). Both the short-axis diameter and the volume of the coagulation necrosis zone formed by LA were always larger than those of RFA at the same accumulated thermal energy. The temperatures of the two thermocouple probes increased with each energy increment. At the same accumulated energy, the temperature of LA was much higher than that of RFA at the same point. The initial temperature increase at 0.5 cm of LA was rapid. The temperature reached 43 °C and the accumulated energy reached 1200 J after approximately 4 min. After that the temperature increased at a slower rate to 70  C. For the RFA at the point of 0.5 cm, the initial temperature increased rapidly to 30 °C with the same accumulated energy of 1200 J after only 1 min. In the range of 4800 J of accumulated thermal energy, only the temperature of LA at the point of 0.5 cm exceeded 60 °C when the energy reached approximately 3000 J.

CONCLUSIONS

Both RFA and LA were shown to be reliable methods for myocardial ablation. The lesion outline and thermal field distribution of RFA and LA should be considered when performing thermal ablation in the intramyocardial septum during hypertrophic obstructive cardiomyopathy.

Ablation Reboots the Response in Advanced Hepatocellular Carcinoma With Stable or Atypical Response During PD-1 Therapy: A Proof-of-Concept Study

Background: The anti-programmed cell death protein-1 (PD-1) inhibitor is one of the second-line therapies for advanced hepatocellular carcinoma (HCC) after sorafenib failure. The goal of this study is to evaluate the feasibility and safety of ablation on the tumor in patients with advanced HCC who had stable disease or atypical response during single anti-PD-1 therapy after sorafenib failure. Atypical response defined as mixed responses in different lesions of the same individual (e.g., active or stable lesions mixed with progressive lesions).

Patients and Methods: This proof-of-concept clinical trial enrolled 50 patients treated with an anti-PD-1 inhibitor of nivolumab or pembrolizumab monotherapy between July 2015 and Nov 2017. Thirty-three cases with stable disease or atypical response to anti-PD-1 inhibitor received subtotal thermal ablation. The safety and the response of ablation during anti-PD-1 therapy were evaluated. The survival was estimated by the Kaplan-Meier curve.

Results: Of all 50 patients treated with anti-PD-1 therapy, the rate of response, stable disease, atypical and typical progression were 10% (n = 5), 42% (n = 21) 32% (n = 16), and 12% (n = 6), respectively. Additional ablation improved efficacy with tolerable toxicity, and the response rate was increased from 10 to 24% (12/50). The median time to progression, progression-free survival, and overall survival was 6.1 months (95%CI, 2.6–11.2), 5 months (95%CI, 2.9–7.1), and 16.9 months (95%CI, 7.7–26.1), respectively.

Conclusions: This proof-of-concept trial suggested that additional ablation may increase the objective response rate with tolerated toxicity and achieved a relatively better median survival, in advanced HCC patients who had stable or atypical progressive diseases during anti-PD-1 therapy, which may provide a potentially promising strategy to treat advanced HCC.

Trial registration number:ClinicalTrials.gov identifier: NCT03939975.

Prognostic significance of controlling nutritional status score-based nomogram for hepatocellular carcinoma within Milan criteria after radiofrequency ablation

Background

Radiofrequency ablation (RFA) is a curative therapy for hepatocellular carcinoma (HCC) within Milan criteria. This study was conducted to evaluate the association between controlling nutritional status (CONUT) score and oncological outcomes in HCC patients within Milan criteria after RFA. Nomograms were constructed for the prediction of prognosis.

Methods

The study included 403 HCC patients within Milan criteria who underwent RFA at National Cancer Center and the First Hospital of Shanxi Medical University from January 2010 to December 2014. Oncological outcomes included disease-free survival (DFS) and overall survival (OS). The clinical variables were assessed by univariate and multivariate Cox regression analyses. C-index, time-dependent receiver operating characteristic (t-ROC) curve (t-AUC) and calibration plots were used to evaluate discrimination and calibration of the nomograms.

Results

Patients were divided into CONUT ≤4 and ≥5 groups. The common prognostic factors affecting DFS and OS were number of lesions, tumor differentiation, and CONUT score. Age and total bilirubin (TBIL) were prognostic factors for OS only. Both DFS and OS rates in CONUT ≤4 group were significantly higher than those in CONUT ≥5 group (P=0.033, P<0.001). Two well-discriminated and calibrated nomograms were constructed to predict the probability of 1-, 2-, and 3-year DFS and 1-, 2-, 3-, 5-year OS with C-indexes of 0.798 and 0.757, respectively.

Conclusions

CONUT score is an independent prognostic factor for HCC after RFA treatment and a reliable indicator for nutritional interventions. Higher CONUT scores were associated with poor oncological outcomes. Nomograms based on CONUT score could efficiently predict DFS and OS for HCC patients within Milan criteria after RFA.

Master Protocol Trial Design for Efficient and Rational Evaluation of Novel Therapeutic Oncology Devices

Historically, the gold standard for evaluation of cancer therapeutics, including medical devices, has been the randomized clinical trial. Although high-quality clinical data are essential for safe and judicious use of therapeutic oncology devices, class II devices require only preclinical data for US Food and Drug Administration approval and are often not rigorously evaluated prior to widespread uptake. Herein, we review master protocol design in medical oncology and its application to therapeutic oncology devices, using examples from radiation oncology. Unique challenges of clinical testing of radiation oncology devices (RODs) include patient and treatment heterogeneity, lack of funding for trials by industry and health-care payers, and operator dependence. To address these challenges, we propose the use of master protocols to optimize regulatory, financial, administrative, quality assurance, and statistical efficiency of trials evaluating RODs. These device-specific master protocols can be extrapolated to other devices and encompass multiple substudies with the same design, statistical considerations, logistics, and infrastructure. As a practical example, we outline our phase I and II master protocol trial of stereotactic magnetic resonance imaging–guided adaptive radiotherapy, which to the best of our knowledge is the first master protocol trial to test a ROD. Development of more efficient clinical trials is needed to promote thorough evaluation of therapeutic oncology devices, including RODs, in a resource-limited environment, allowing more practical and rapid identification of the most valuable advances in our field.

Gastrointestinal tract injuries after thermal ablative therapies for hepatocellular carcinoma: A case report and review of the literature

BACKGROUND

Radiofrequency ablation (RFA) and microwave ablation (MWA) represent the standard of care for patients with early hepatocellular carcinoma (HCC) who are unfit for surgery. The incidence of reported adverse events is low, ranging from 2.4% to 13.1% for RFA and from 2.6% to 7.5% for MWA. Gastrointestinal tract (GIT) injury is even more infrequent (0.11%), but usually requires surgery with an unfavourable prognosis. Due to its low incidence and the retrospective nature of the studies, the literature reporting this feared complication is heterogeneous and in many cases lacks information on tumour characteristics, comorbidities and treatment approaches.

CASE SUMMARY

A 77-year-old man who had undergone extended right hepatectomy for HCC was diagnosed with early disease recurrence with a small nodule compatible with HCC in the Sg4b segment of the liver with a subcapsular location. He was treated with percutaneous RFA and a few week later he was urgently admitted to the Surgery ward for abdominal pain and fever. A subcutaneous abscess was diagnosed and treated by percutaneous drainage. A fistulous tract was then documented by the passage of contrast material from the gastric antrum to the abdominal wall. The oesophagogastroduodenoscopy confirmed a circular wall defect at the lesser curvature of gastric antrum, leading directly to the purulent abdominal collection. An over-the-scope clip (OTSC) was used to successfully close the defect

CONCLUSION

This is the first reported case of RFA-related GIT injury to have been successfully treated with an OTSC, which highlights the role of this endoscopic treatment for the management of this complication.

"Primum Non Nocere" in Interventional Oncology for Liver Cancer: How to Reduce the Risk for Complications?

Interventional oncology represents a relatively new clinical discipline based upon minimally invasive therapies applicable to almost every human organ and disease. Over the last several decades, rapidly evolving research developments have introduced a newer generation of treatment devices, reagents, and image-guidance systems to expand the armamentarium of interventional oncology across a wide spectrum of disease sites, offering potential cure, control, or palliative care for many types of cancer patients. Due to the widespread use of locoregional procedures, a comprehensive review of the methodologic and technical considerations to optimize patient selection with the aim of performing a safe procedure is mandatory. This article summarizes the expert discussion and report from the Mediterranean Interventional Oncology Live Congress (MIOLive 2020) held in Rome, Italy, integrating evidence-reported literature and experience-based perceptions as a means for providing guidance on prudent ways to reduce complications. The aim of the paper is to provide an updated guiding tool not only to residents and fellows but also to colleagues approaching locoregional treatments.

Prognosis of Early-Stage Hepatocellular Carcinoma: Comparison between Trans-Arterial Chemoembolization and Radiofrequency Ablation

Radiofrequency ablation (RFA) is a curative treatment for early-stage hepatocellular carcinoma (HCC) ineligible for surgery or liver transplantation. However, trans-arterial chemoembolization (TACE) might be an alternative when RFA is contraindicated due to structural problems. Here, we aimed to compare their long-term outcomes. Treatment-naive HCC patients fulfilling the Milan criteria who underwent RFA (n = 136) or TACE (n = 268) were enrolled. Complete response (CR) and 5-year recurrence-free survival (RFS) rates were higher in the RFA group than in the TACE group (94.1% vs. 71.6% and 35.8% vs. 17.0%, respectively; both p < 0.001), whereas 5-year overall survival (OS) rates were not significantly different (65.5% vs. 72.3%, respectively; p = 0.100). Multivariate analysis showed that RFA was associated with better RFS (adjusted hazard ratio [aHR] 0.628; p = 0.001) than TACE, but not with better OS (aHR 1.325; p = 0.151). The most common 1st-line treatment after recurrence were TACE (n = 53), followed by RFA (n = 21) among the RFA group and TACE (n = 150), followed by RFA (n = 44) among the TACE group. After propensity-score matching, similar results were reproduced. Hence, TACE could be an effective alternative to RFA in terms of OS rates. However, TACE should be confined only to RFA-difficult cases, given its lower CR and RFS rates and multi-disciplinary approaches are desirable in decision-making.

Unresectable Hepatocellular Carcinoma: Transcatheter Arterial Chemoembolization Combined With Microwave Ablation vs. Combined With Cryoablation

Background: Transcatheter arterial chemoembolization (TACE) combined with ablation has been widely used for treating unresectable hepatocellular carcinoma (HCC). However, the technique with which TACE should be combined for it to be more effective remains unknown. Purpose: To retrospectively evaluate the efficacy and safety of TACE combined with microwave ablation (MWA) vs. TACE combined with cryoablation (CRA) in treating unresectable HCC. Materials and Methods: From January 2011 to December 2018, 108 patients diagnosed with unresectable HCC were divided into either the TACE-MWA group (n = 48) or TACE-CRA group (n = 60). Overall survival (OS) and time to progression (TTP) were compared between the two groups. To reduce potential bias, a propensity score matching (PSM) was performed. Complications were observed. Kaplan-Meier survival curves were constructed and compared using the log-rank test. Results : The baseline characteristics of the two groups were balanced. The median OS was 20.9 months (95% CI 14.3-27.6 months) in the TACE-MWA group and 13.0 months (95% CI 8.8-17.1 months) in the TACE-CRA group (P = 0.096). The median TTP was 8.8 months (95% CI 4.3-13.4 months) in the TACE-MWA group and 9.3 months (95% CI 7.1-11.5 months) in the TACE-CRA group (P = 0.675). After PSM, 48 patients remained in each group. The median OS in the TACE-MWA and TACE-CRA groups was 20.9 months (95% CI 14.3-27.6 months), and 13.5 months (95% CI 8.4-18.6 months, P = 0.100), respectively. The median TTP in the TACE-MWA and TACE-CRA groups was 8.8 months (95% CI 4.3-13.4 months), and 8.6 months (95% CI 3.1-14.2 months, P = 0.909), respectively. The overall incidence rate of ablation-related complications was lower in the TACE-MWA group than in the TACE-CRA group (66.7 vs. 88.3%, P = 0.006). Multivariate analysis showed that the presence of portal vein tumor thrombus (PVTT) and the maximum diameter of intrahepatic tumor were significant prognostic factors for OS and TTP. Conclusion: The efficacy of TACE-MWA and TACE-CRA in the treatment of unresectable HCC was comparable. TACE-MWA was more promising because of a lower complication rate, especially with regard to thrombocytopenia. Further prospective randomized controlled trials are required to validate our findings.

Preoperative identification of microvascular invasion in hepatocellular carcinoma by XGBoost and deep learning

PURPOSE

Microvascular invasion (MVI) is a valuable predictor of survival in hepatocellular carcinoma (HCC) patients. This study developed predictive models using eXtreme Gradient Boosting (XGBoost) and deep learning based on CT images to predict MVI preoperatively.

METHODS

In total, 405 patients were included. A total of 7302 radiomic features and 17 radiological features were extracted by a radiomics feature extraction package and radiologists, respectively. We developed a XGBoost model based on radiomics features, radiological features and clinical variables and a three-dimensional convolutional neural network (3D-CNN) to predict MVI status. Next, we compared the efficacy of the two models.

RESULTS

Of the 405 patients, 220 (54.3%) were MVI positive, and 185 (45.7%) were MVI negative. The areas under the receiver operating characteristic curves (AUROCs) of the Radiomics-Radiological-Clinical (RRC) Model and 3D-CNN Model in the training set were 0.952 (95% confidence interval (CI) 0.923-0.973) and 0.980 (95% CI 0.959-0.993), respectively (p = 0.14). The AUROCs of the RRC Model and 3D-CNN Model in the validation set were 0.887 (95% CI 0.797-0.947) and 0.906 (95% CI 0.821-0.960), respectively (p = 0.83). Based on the MVI status predicted by the RRC and 3D-CNN Models, the mean recurrence-free survival (RFS) was significantly better in the predicted MVI-negative group than that in the predicted MVI-positive group (RRC Model: 69.95 vs. 24.80 months, p < 0.001; 3D-CNN Model: 64.06 vs. 31.05 months, p = 0.027).

CONCLUSION

The RRC Model and 3D-CNN models showed considerable efficacy in identifying MVI preoperatively. These machine learning models may facilitate decision-making in HCC treatment but requires further validation.

Effect of microwave ablation treatment of hepatic malignancies on serum cytokine levels

Background

Microwave ablation (MWA) is widely used to treat unresectable primary and secondary malignancies of the liver, and a limited number of studies indicate that ablation can cause not only necrosis at the in situ site but also an immunoreaction of the whole body. This study aimed to investigate the effects of MWA on cytokines in patients who underwent MWA for a hepatic malignancy.

Methods

Patients admitted to the Oncology Department in the First Affiliated Hospital of Soochow University between June 2015 and February 2019 were selected. Peripheral blood was collected from patients with a hepatic malignancy treated with MWA. The levels of cytokines (IL-2, IFN-γ, TNF-α, IL-12 p40, IL-12 p70, IL-4, IL-6, IL-8, IL-10, and vascular endothelial growth factor (VEGF)) were detected with a Milliplex® MAP Kit. The comparison times were as follows: before ablation, 24 h after ablation, 15 days after ablation, and 30 days after ablation. Data were analyzed using a paired sample t-tests and Spearman’s correlation analysis.

Results

A total of 43 patients with hepatic malignancies were assessed. There were significant differences in IL-2, IL-12 p40, IL-12 p70, IL-1β, IL-8, and TNF-α at 24 h after MWA. Significant increases (> 2-fold vs. before ablation) were observed in IL-2, IL-1β, IL-6, IL-8, IL-10, and TNF-α after MWA. Elevated IL-2 and IL-6 levels after ablation were positively correlated with energy output during the MWA procedure.

Conclusions

WA treatment for hepatic malignancies can alter the serum levels of several cytokines such as IL-2 and IL-6.

Tearable and Fillable Composite Sponges Capable of Heat Generation and Drug Release in Response to Alternating Magnetic Field

Tearable and fillable implants are used to facilitate surgery. The use of implants that can generate heat and release a drug in response to an exogenous trigger, such as an alternating magnetic field (AMF), can facilitate on-demand combined thermal treatment and chemotherapy via remote operation. In this study, we fabricated tearable sponges composed of collagen, magnetite nanoparticles, and anticancer drugs. Crosslinking of the sponges by heating for 6 h completely suppressed undesirable drug release in saline at 37 °C but allowed drug release at 45 °C. The sponges generated heat immediately after AMF application and raised the cell culture medium temperature from 37 to 45 °C within 15 min. Heat generation was controlled by switching the AMF on and off. Furthermore, in response to heat generation, drug release from the sponges could be induced and moderated. Thus, remote-controlled heat generation and drug release were achieved by switching the AMF on and off. The sponges destroyed tumor cells when AMF was applied for 15 min but not when AMF was absent. The tearing and filling properties of the sponges may be useful for the surgical repair of bone and tissue defects. Moreover, these sponges, along with AMF application, can facilitate combined thermal therapy and chemotherapy.

Underestimation of hepatocellular carcinoma incidence resulting from a competition between modern and traditional medicine: the case of Gabon

Primary liver cancer, particularly hepatocellular carcinoma (HCC), remains a major killer in sub-Saharan Africa. In this dreadful landscape, West and Central Africas are more particularly affected. However, a small country located on the equator, Gabon, is apparently not concerned by this adverse situation. Despite worrying prevalences of many bona fide risk factors of HCC, including high rates of chronic infections with hepatitis viruses and very high alcohol consumption, Gabon presents theoretically an amazingly low incidence of HCC when compared to other countries of the region. Reports from many places in the world have emphasized the widespread underreporting of HCC cases presumably attributable to the difficulties of proper diagnosis or to a lack of local cancer registry. In Gabon, the remarkably vivid tradition of religious initiation called Bwiti includes some therapeutic rituals exerted by healers or Ngangas. Those treatments are particularly popular in case of severe diseases generally associated with a supernatural etiology. In the present paper, we hypothesize that, in Gabon, the remarkably low incidence of HCC is primarily due to the diversion of patients from the modern medical system due to their preference for Ngangas. Promotion of a form of medical syncretism respecting both systems might be an efficient policy to increase the attractiveness of modern medicine and to ultimately promote public health in Gabon.

Emerging Opportunities for Combining Locoregional Therapy with Immune Checkpoint Inhibitors in Hepatocellular Carcinoma

PURPOSE OF REVIEW

Immunotherapy shows great promises in solid tumors. Locoregional therapy can promote systemic immune response in hepatocellular carcinoma (HCC). The combination of locoregional therapy and immune checkpoint inhibitors (ICIs) activates a synergistic effect that can enhance the potency of anti-tumor immunity. This review aims to summarize the underlying mechanisms of locoregional therapy combined with ICIs and their applications in clinical settings.

RECENT FINDINGS

The characteristics of high invasiveness and refractoriness of HCC are what limit the outcomes of treatments. Sorafenib provides an additional treatment option for extrahepatic spread and vascular invasion, making long-term survival possible for patients with advanced HCC to some degree. However, its shortcomings of low response rate and high toxicity result in limited applications in clinical practice. Immunotherapy is a promising emerging therapy with great prospect in HCC, but the self-tolerance of HCC constrains the effectiveness of ICIs. Consequently, the efficacy of single immunotherapy is unsatisfactory. Locoregional therapy can not only destroy primary tumors but also stimulate the release of neoplasm antigens to increase the efficiency of immune response in HCC. Locoregional therapy combined with ICIs may have an amplification effect on immune response. Locoregional therapy plays a vital role in stimulating anti-tumor immune response. The combination of locoregional therapy and ICIs has a synergistic effect on anti-tumor immunity.

Recent progress in pulsed electric field ablation for liver cancer

The number of liver cancer patients is likely to continue to increase in the coming decades due to the aging of the population and changing risk factors. Traditional treatments cannot meet the needs of all patients. New treatment methods evolved from pulsed electric field ablation are expected to lead to breakthroughs in the treatment of liver cancer. This paper reviews the safety and efficacy of irreversible electroporation in clinical studies, the methods to detect and evaluate its ablation effect, the improvements in equipment and its antitumor effect, and animal and clinical trials on electrochemotherapy. We also summarize studies on the most novel nanosecond pulsed electric field ablation techniques in vitro and in vivo. These research results are certain to promote the progress of pulsed electric field in the treatment of liver cancer.

Percutaneous Ablation-Induced Immunomodulation in Hepatocellular Carcinoma

Hepatocellular carcinoma (HCC) is one of the most common causes of cancer-related deaths worldwide and its incidence is rising. Percutaneous locoregional therapies, such as radiofrequency ablation and microwave ablation, are widely used as curative treatment options for patients with small HCC, but their effectiveness remains restricted because of the associated high rate of recurrence, occurring in about 70% of patients at five years. These thermal ablation techniques have the particularity to induce immunomodulation by destroying tumours, although this is not sufficient to raise an effective antitumour immune response. Ablative therapies combined with immunotherapies could act synergistically to enhance antitumour immunity. This review aims to understand the different immune changes triggered by radiofrequency ablation and microwave ablation as well as the interest in using immunotherapies in combination with thermal ablation techniques as a tool for complementary immunomodulation.