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Albadawi H, Zhang Z, Altun I, Hu J, Jamal L, Ibsen KN, Tanner EEL, Mitragotri S, Oklu R. Percutaneous liquid ablation agent for tumor treatment and drug delivery. Sci Transl Med 2021; 13:13/580/eabe3889. [PMID: 33568519 DOI: 10.1126/scitranslmed.abe3889] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2020] [Accepted: 01/15/2021] [Indexed: 12/18/2022]
Abstract
Percutaneous locoregional therapies (LRTs), such as thermal ablation, are performed to limit the progression of hepatocellular carcinoma (HCC) and offer a bridge for patients waiting for liver transplantation. However, physiological challenges related to tumor location, size, and existence of multiple lesions as well as safety concerns related to potential thermal injury to adjacent tissues may preclude the use of thermal ablation or lead to its failure. Here, we showed a successful injection of an ionic liquid into tissue under image guidance, ablation of tumors in response to the injected ionic liquid, and persistence (28 days) of coinjected chemotherapy with the ionic liquid in the ablation zone. In a rat HCC model, the rabbit VX2 liver tumor model, and 12 human resected tumors, injection of the ionic liquid led to consistent tumor ablation. Combining the ionic liquid with the chemotherapy agent, doxorubicin, resulted in synergistic cytotoxicity when tested with cultured HCC cells and uniform drug distribution throughout the ablation zone when percutaneously injected into liver tumors in the rabbit liver tumor model. Because this ionic liquid preparation is simple to use, is efficacious, and has a low cost, we propose that this new LRT may bridge more patients to liver transplantation.
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Affiliation(s)
- Hassan Albadawi
- Minimally Invasive Therapeutics Laboratory, Department of Vascular and Interventional Radiology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Zefu Zhang
- Minimally Invasive Therapeutics Laboratory, Department of Vascular and Interventional Radiology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Izzet Altun
- Minimally Invasive Therapeutics Laboratory, Department of Vascular and Interventional Radiology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Jingjie Hu
- Minimally Invasive Therapeutics Laboratory, Department of Vascular and Interventional Radiology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Leila Jamal
- Minimally Invasive Therapeutics Laboratory, Department of Vascular and Interventional Radiology, Mayo Clinic, Phoenix, AZ 85054, USA
| | - Kelly N Ibsen
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
| | - Eden E L Tanner
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA
| | - Samir Mitragotri
- John A. Paulson School of Engineering and Applied Sciences, Harvard University, Cambridge, MA 02138, USA.
| | - Rahmi Oklu
- Minimally Invasive Therapeutics Laboratory, Department of Vascular and Interventional Radiology, Mayo Clinic, Phoenix, AZ 85054, USA.
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2
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Nief C, Morhard R, Chelales E, Adrianzen Alvarez D, Bourla BS I, Lam CT, Sag AA, Crouch BT, Mueller JL, Katz D, Dewhirst MW, Everitt JI, Ramanujam N. Polymer-assisted intratumoral delivery of ethanol: Preclinical investigation of safety and efficacy in a murine breast cancer model. PLoS One 2021; 16:e0234535. [PMID: 33507942 PMCID: PMC7843014 DOI: 10.1371/journal.pone.0234535] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2020] [Accepted: 12/10/2020] [Indexed: 12/24/2022] Open
Abstract
Focal tumor ablation with ethanol could provide benefits in low-resource settings because of its low overall cost, minimal imaging technology requirements, and acceptable clinical outcomes. Unfortunately, ethanol ablation is not commonly utilized because of a lack of predictability of the ablation zone, caused by inefficient retention of ethanol at the injection site. To create a predictable zone of ablation, we have developed a polymer-assisted ablation method using ethyl cellulose (EC) mixed with ethanol. EC is ethanol-soluble and water-insoluble, allowing for EC-ethanol to be injected as a liquid and precipitate into a solid, occluding the leakage of ethanol upon contact with tissue. The aims of this study were to compare the 1) safety, 2) release kinetics, 3) spatial distribution, 4) necrotic volume, and 5) overall survival of EC-ethanol to conventional ethanol ablation in a murine breast tumor model. Non-target tissue damage was monitored through localized adverse events recording, ethanol release kinetics with Raman spectroscopy, injectate distribution with in vivo imaging, target-tissue necrosis with NADH-diaphorase staining, and overall survival by proxy of tumor growth. EC-ethanol exhibited decreased localized adverse events, a slowing of the release rate of ethanol, more compact injection zones, 5-fold increase in target-tissue necrosis, and longer overall survival rates compared to the same volume of pure ethanol. A single 150 μL dose of 6% EC-ethanol achieved a similar survival probability rates to six daily 50 μL doses of pure ethanol used to simulate a slow-release of ethanol over 6 days. Taken together, these results demonstrate that EC-ethanol is safer and more effective than ethanol alone for ablating tumors.
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Affiliation(s)
- Corrine Nief
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States of America
| | - Robert Morhard
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States of America
| | - Erika Chelales
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States of America
| | - Daniel Adrianzen Alvarez
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States of America
| | - Ioanna Bourla BS
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States of America
| | - Christopher T. Lam
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States of America
| | - Alan A. Sag
- Department of Interventional Radiology, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Brian T. Crouch
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States of America
- The Preston Robert Tisch Brain Tumor Center, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Jenna L. Mueller
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States of America
| | - David Katz
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States of America
- Department of Obstetrics and Gynecology, Duke University, Durham, North Carolina, United States of America
| | - Mark W. Dewhirst
- Department of Radiation Oncology, Duke University School of Medicine, Durham, North Carolina, United States of America
| | - Jeffrey I. Everitt
- Department of Pathology, Duke University, Durham, North Carolina, United States of America
| | - Nirmala Ramanujam
- Department of Biomedical Engineering, Duke University, Durham, North Carolina, United States of America
- Department of Pharmacology and Cancer Biology, Duke University, Durham, North Carolina, United States of America
- Duke Global Health Institute, Duke University, Durham, North Carolina, United States of America
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3
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Hansen PD, Cassera MA, Wolf RF. Ablative technologies for hepatocellular, cholangiocarcinoma, and metastatic colorectal cancer of the liver. Surg Oncol Clin N Am 2014; 24:97-119. [PMID: 25444471 DOI: 10.1016/j.soc.2014.09.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
A wide array of ablation technologies, in addition to the progressive sophistication of imaging technologies and percutaneous, laparoscopic, and open surgical techniques, have allowed us to expand treatment options for patients with liver tumors. In this article, technical considerations of chemical and thermal ablations and their application in hepatic oncology are reviewed.
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Affiliation(s)
- Paul D Hansen
- Hepatobiliary and Pancreatic Surgery Program, Providence Cancer Center, Providence Portland Medical Center, 4805 NE Glisan St, Suite 6N60, Portland, OR 97213, USA.
| | - Maria A Cassera
- Hepatobiliary and Pancreatic Surgery Program, Providence Cancer Center, Providence Portland Medical Center, 4805 NE Glisan St, Suite 6N60, Portland, OR 97213, USA
| | - Ronald F Wolf
- Hepatobiliary and Pancreatic Surgery Program, Providence Cancer Center, Providence Portland Medical Center, 4805 NE Glisan St, Suite 6N60, Portland, OR 97213, USA
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Yu H, Burke CT. Comparison of percutaneous ablation technologies in the treatment of malignant liver tumors. Semin Intervent Radiol 2014; 31:129-37. [PMID: 25071303 PMCID: PMC4078184 DOI: 10.1055/s-0034-1373788] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Tumor ablation is a minimally invasive technique used to deliver chemical, thermal, electrical, or ultrasonic damage to a specific focal tumor in an attempt to achieve substantial tumor destruction or complete eradication. As the technology continues to advance, several image-guided tumor ablations have emerged to effectively manage primary and secondary malignancies in the liver. Percutaneous chemical ablation is one of the oldest and most established techniques for treating small hepatocellular carcinomas. However, this technique has been largely replaced by newer modalities including radiofrequency ablation, microwave ablation, laser-induced interstitial thermotherapy, cryoablation, high-intensity-focused ultrasound ablation, and irreversible electroporation. Because there exist significant differences in underlying technological bases, understanding each mechanism of action is essential for achieving desirable outcomes. In this article, the authors review the current state of each ablation method including technological and clinical considerations.
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Affiliation(s)
- Hyeon Yu
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
| | - Charles T. Burke
- Division of Vascular and Interventional Radiology, Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina
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Watanabe S, Morishita A, Deguchi A, Nakai S, Sakamoto T, Fujita K, Maeda E, Nomura T, Tani J, Miyoshi H, Yoneyama H, Fujiwara S, Kobara H, Mori H, Himoto T, Masaki T. Ethanol injection therapy for small hepatocellular carcinomas located beneath a large vessel using a curved percutaneous ethanol injection therapy needle. Oncol Lett 2014; 7:1831-1834. [PMID: 24932242 PMCID: PMC4049773 DOI: 10.3892/ol.2014.2053] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/28/2013] [Accepted: 03/14/2014] [Indexed: 11/16/2022] Open
Abstract
Percutaneous ethanol injection therapy (PEIT) has been administered as a safe therapeutic modality for patients with small hepatocellular carcinoma (HCC). Due to the nature of the straight approaching line of a PEIT or radiofrequency ablation needle, penetrating the vessels that are interposed between the dermal insertion point and the nodule is unavoidable. A device with an overcoat needle and coaxial curved PEIT needle was created that facilitated a detour around interposing large vessels in order to avoid unnecessary harmful effects that result from the PEIT procedure. Two cases of HCC located adjacent to a neighboring large vessel were treated with a curved PEIT needle. The curved PEIT needle, which is connected to an outer needle, enabled deviation around the interposing vessels and successful connection with the HCC. Careful use of the curved line of the PEIT needle enabled the safe and successful performance of the PEIT without any requirement for specific training. This hand-assisted technique may be an applicable treatment for small HCC located beneath large vessels as a direct therapeutic method using ultrasound guidance.
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Affiliation(s)
- Seishiro Watanabe
- Department of Internal Medicine, Kagawa Prefectural Central Hospital, Takamatsu, Kagawa 760-8557, Japan
| | - Asahiro Morishita
- Department of Gastroenterology and Neurology, Kagawa University School of Medicine, Miki-cho, Kida-gun, Kagawa 761-0793, Japan
| | - Akihiro Deguchi
- Department of Gastroenterology and Neurology, Kagawa University School of Medicine, Miki-cho, Kida-gun, Kagawa 761-0793, Japan
| | - Seiji Nakai
- Department of Gastroenterology and Neurology, Kagawa University School of Medicine, Miki-cho, Kida-gun, Kagawa 761-0793, Japan
| | - Teppei Sakamoto
- Department of Gastroenterology and Neurology, Kagawa University School of Medicine, Miki-cho, Kida-gun, Kagawa 761-0793, Japan
| | - Koji Fujita
- Department of Gastroenterology and Neurology, Kagawa University School of Medicine, Miki-cho, Kida-gun, Kagawa 761-0793, Japan
| | - Emiko Maeda
- Department of Gastroenterology and Neurology, Kagawa University School of Medicine, Miki-cho, Kida-gun, Kagawa 761-0793, Japan
| | - Takako Nomura
- Department of Gastroenterology and Neurology, Kagawa University School of Medicine, Miki-cho, Kida-gun, Kagawa 761-0793, Japan
| | - Joji Tani
- Department of Gastroenterology and Neurology, Kagawa University School of Medicine, Miki-cho, Kida-gun, Kagawa 761-0793, Japan
| | - Hisaaki Miyoshi
- Department of Gastroenterology and Neurology, Kagawa University School of Medicine, Miki-cho, Kida-gun, Kagawa 761-0793, Japan
| | - Hirohito Yoneyama
- Department of Gastroenterology and Neurology, Kagawa University School of Medicine, Miki-cho, Kida-gun, Kagawa 761-0793, Japan
| | - Shintaro Fujiwara
- Department of Gastroenterology and Neurology, Kagawa University School of Medicine, Miki-cho, Kida-gun, Kagawa 761-0793, Japan
| | - Hideki Kobara
- Department of Gastroenterology and Neurology, Kagawa University School of Medicine, Miki-cho, Kida-gun, Kagawa 761-0793, Japan
| | - Hirohito Mori
- Department of Gastroenterology and Neurology, Kagawa University School of Medicine, Miki-cho, Kida-gun, Kagawa 761-0793, Japan
| | - Takashi Himoto
- Department of Integrated Medicine, Kagawa University School of Medicine, Miki-cho, Kida-gun, Kagawa 761-0793, Japan
| | - Tsutomu Masaki
- Department of Gastroenterology and Neurology, Kagawa University School of Medicine, Miki-cho, Kida-gun, Kagawa 761-0793, Japan
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Gu L, Liu H, Fan L, Lv Y, Cui Z, Luo Y, Liu Y, Li G, Li C, Ma J. Treatment outcomes of transcatheter arterial chemoembolization combined with local ablative therapy versus monotherapy in hepatocellular carcinoma: a meta-analysis. J Cancer Res Clin Oncol 2014; 140:199-210. [PMID: 24077865 DOI: 10.1007/s00432-013-1528-8] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/26/2013] [Accepted: 09/13/2013] [Indexed: 12/16/2022]
Abstract
PURPOSE To evaluate the effectiveness comparing the combination of TACE with local ablative therapy and monotherapy on the treatment of HCC using meta-analytical techniques. METHODS Randomized controlled trials and clinical studies comparing TACE plus local ablative therapy with monotherapy for HCC were included in this meta-analysis. Response rate, 1-, 2-, 3-, and 5-year survival rate, and overall survival (OS) were analyzed and compared. RESULTS Eighteen studies included a total of 2,120 patients with HCC 1,071 and 1,049 patients for treatment with combination therapy and monotherapy, respectively. The combination therapy group had a significantly better survival in terms of 1-, 2-, 3-, and 5-year survival rate (RR 1.10, 95 % CI 1.03–1.18, P = 0.005; RR 1.20, 95 % CI 1.10–1.30, P < 0.0001; RR 1.43, 95 % CI 1.18–1.73, P < 0.0001; RR 1.40, 95 % CI 1.22–1.61, P < 0.0001, respectively), OS (HR 0.66, 95 % CI 0.51–0.85, P = 0.001), and response rate (RR 1.54, 95 % CI 1.09–2.18, P = 0.013) than that monotherapy group in patients with HCC. CONCLUSIONS The meta-analysis indicates that the combination of TACE with local ablative therapy was superior to monotherapy in the treatment for patients with HCC.
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Ghanaati H, Alavian SM, Jafarian A, Ebrahimi Daryani N, Nassiri-Toosi M, Jalali AH, Shakiba M. Imaging and Imaging-Guided Interventions in the Diagnosis and Management of Hepatocellular Carcinoma (HCC)-Review of Evidence. IRANIAN JOURNAL OF RADIOLOGY 2012; 9:167-77. [PMID: 23407596 PMCID: PMC3569547 DOI: 10.5812/iranjradiol.8242] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/19/2012] [Revised: 10/24/2012] [Accepted: 10/27/2012] [Indexed: 12/12/2022]
Abstract
The imaging of hepatocellular carcinoma (HCC) is challenging and plays a crucial role in the diagnosis and staging of the disease. A variety of imaging modalities, such as ultrasound, computed tomography (CT), magnetic resonance imaging (MRI) and nuclear medicine are currently used in evaluating patients with HCC. Although the best option for the treatment of these cases is hepatic resection or transplantation, only 20% of HCCs are surgically treatable. In those patients who are not eligible for surgical treatment, interventional therapies such as transcatheter arterial chemoembolization (TACE), percutaneous ethanol injection (PEI), radio-frequency ablation (RFA), percutaneous microwave coagulation therapy (PMC), laser ablation or cryoablation, and acetic acid injection are indicated. In this paper, we aimed to review the evidence regarding imaging modalities and therapeutic interventions of HCC.
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Affiliation(s)
- Hossein Ghanaati
- Department of Radiology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran
- Corresponding author: Hossein Ghanaati, Medical Imaging Center, Imam Khomeini Hospital, Keshavarz Blvd., Tehran, Iran. Tel.: +98-2166581516, Fax: +98-2166581578, E-mail:
| | - Seyed Moayed Alavian
- Baqiyatallah Research Center for Gastroenterology and Liver Diseases, Baqiyatallah University of Medical Sciences, Tehran, Iran
| | - Ali Jafarian
- Hepatobilliary and Liver Transplantation Division, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Nasser Ebrahimi Daryani
- Department of Gastroenterology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Mohsen Nassiri-Toosi
- Department of Gastroenterology, Faculty of Medicine, Tehran University of Medical Sciences, Tehran, Iran
| | - Amir Hossein Jalali
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran
| | - Madjid Shakiba
- Advanced Diagnostic and Interventional Radiology Research Center (ADIR), Tehran University of Medical Sciences, Tehran, Iran
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Abstract
Locoregional therapies for hepatocellular carcinoma have progressed greatly in the last 30 years, beginning with the introduction of chemoembolization. Embolization techniques have evolved with the use of drug-eluting beads and radioembolization with yttrium-90. In the last 10 years, several new ablation techniques were developed including radiofrequency ablation, microwave ablation, cryoablation, laser ablation, and irreversible electroporation. Isolated or in combination, these techniques have already shown that they can improve patient survival and/or provide acceptable palliation.
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Affiliation(s)
- Marcelo Guimaraes
- Division of Vascular & Interventional Radiology, Medical University of South Carolina, 25 Courtenay Drive, MSC 226, Charleston, SC 29425, USA.
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9
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McWilliams JP, Yamamoto S, Raman SS, Loh CT, Lee EW, Liu DM, Kee ST. Percutaneous ablation of hepatocellular carcinoma: current status. J Vasc Interv Radiol 2010; 21:S204-13. [PMID: 20656230 DOI: 10.1016/j.jvir.2009.11.025] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2009] [Revised: 10/28/2009] [Accepted: 11/07/2009] [Indexed: 02/08/2023] Open
Abstract
Hepatocellular carcinoma (HCC) is an increasingly common disease with dismal long-term survival. Percutaneous ablation has gained popularity as a minimally invasive, potentially curative therapy for HCC in nonoperative candidates. The seminal technique of percutaneous ethanol injection has been largely supplanted by newer modalities, including radiofrequency ablation, microwave ablation, cryoablation, and high-intensity focused ultrasound ablation. A review of these modalities, including technical success, survival rates, and complications, will be presented, as well as considerations for treatment planning and follow-up.
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Affiliation(s)
- Justin P McWilliams
- Department of Interventional Radiology, University of California Los Angeles Medical Center, 757 Westwood Plaza, Suite 2125C, Los Angeles, CA 90095, USA.
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Maeda T, Hong J, Konishi K, Nakatsuji T, Yasunaga T, Yamashita YI, Taketomi A, Kotoh K, Enjoji M, Nakashima H, Tanoue K, Maehara Y, Hashizume M. Tumor ablation therapy of liver cancers with an open magnetic resonance imaging-based navigation system. Surg Endosc 2008; 23:1048-53. [PMID: 18813998 DOI: 10.1007/s00464-008-0123-6] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2008] [Revised: 06/29/2008] [Accepted: 07/24/2008] [Indexed: 12/13/2022]
Abstract
BACKGROUND As minimally invasive treatments for liver cancers, percutaneous ablation therapies represent a valid alternative to liver resections, especially in patients with poor liver function. Recently, image-guided surgical and interventional procedures using open magnetic resonance imaging (MRI) have been introduced. METHODS We performed percutaneous ablation therapy for 51 nodules of liver cancer in 34 patients using a navigation system based on open MRI. During the ablation therapy, the ultrasonography (US) probe, needle, and tumor were displayed on the MR image. Immediately after the procedure, the therapeutic effect was evaluated by open MRI. RESULTS In all cases, percutaneous puncture into the tumors was successful, even in the case of tumor undetectable by US. Mean fiducial registration error was approximately 3 mm. MR images captured after the procedure clearly demonstrated the ablated area. No mortality or major complications occurred, except for mild hemorrhage, pyrexia, and ascites. CONCLUSIONS We developed a novel navigation system integrating US and MR images using open MRI for percutaneous ablation therapy of liver cancers. The presented system allows a safe and accurate approach to liver cancers, especially certain tumors that cannot be adequately visualized by US, and an evaluation of therapeutic results immediately after the procedures.
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Affiliation(s)
- Takashi Maeda
- Department of Future Medicine and Innovative Medical Information, Faculty of Medical Sciences, Kyushu University, Fukuoka, Japan.
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Fuke H, Sugimoto K, Shiraki K, Tanaka J, Beppu T, Yoneda K, Yamamoto N, Ito K, Takaki H, Nakatsuka A, Yamakado K, Takeda K, Takei Y. Predictive factors for distant recurrence of HCV-related hepatocellular carcinoma after radiofrequency ablation combined with chemoembolization. Aliment Pharmacol Ther 2008; 27:1253-60. [PMID: 18221404 DOI: 10.1111/j.1365-2036.2008.03627.x] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Radiofrequency ablation (RFA) therapy for hepatocellular carcinoma has enabled good local control to be possible. However, after successful local control, distant recurrences frequently occur in the remnant liver. AIM To identify the predictive factors for distant recurrence after RFA. METHODS A total of 117 patients with initial non-advanced hepatocellular carcinoma with HCV who underwent RFA in our hospital were selected for this study. After transcatheter chemoembolization, RFA was performed under real-time computed tomography-fluoroscopic guidance. We studied survival rates, local (adjacent to treated tumour) and distant (intrahepatic site distant from the treated tumours) recurrence rates, as well as predictive factors for distant recurrence. RESULTS After RFA, survival rates were 98.2% and 64.7% at 1 and 5 years, respectively. Child B patients had a significantly worse survival than Child A. Recurrence rates were 2.4% at 5 years for local, and 17.1% and 76.9% at 1 and 5 years, respectively, for distant. The Kaplan-Meier method revealed significantly high recurrence rates in cases with low albumin levels (Alb < 3.5 g/dL), high aspartate aminotransferase levels (AST > 60 IU/L), high alanine aminotransferase levels (ALT > 60 IU/L), low platelet counts (Plt < 10 x 10(4)/microL), and high alpha-fetoprotein levels (AFP > 50 ng/mL). On multivariate analysis, low Alb levels and high AST levels were independent predictive factors for distant recurrence. CONCLUSIONS Although RFA enables good local control for initial hepatocellular carcinoma, distant recurrence is observed at high rates in HCV patients. Low albumin and high AST levels are predictive factors for distant recurrence.
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Affiliation(s)
- H Fuke
- Department of Gastroenterology, Mie University School of Medicine, Tsu, Mie, Japan
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12
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Okuwaki Y, Nakazawa T, Shibuya A, Ono K, Hidaka H, Watanabe M, Kokubu S, Saigenji K. Intrahepatic distant recurrence after radiofrequency ablation for a single small hepatocellular carcinoma: risk factors and patterns. J Gastroenterol 2008; 43:71-8. [PMID: 18297439 DOI: 10.1007/s00535-007-2123-z] [Citation(s) in RCA: 67] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/04/2007] [Accepted: 10/01/2007] [Indexed: 02/04/2023]
Abstract
BACKGROUND The pathogenesis of frequent intrahepatic recurrence of hepatocellular carcinoma (HCC) after surgical resection or local ablation therapy remains uncertain. Risks and patterns of intrahepatic distant recurrence (IDR) of a single, primary HCC lesion after radiofrequency (RF) ablation were examined. METHODS Ninety patients with a single primary HCC lesion of less than 3 cm who had complete RF ablation were enrolled in the study. Risk factors for IDR and the patterns of IDR after RF ablation were analyzed. RESULTS The median follow-up was 37.4 months. IDR was observed in 44 (48.9%) patients. The cumulative rate of IDR was 10.4%, 52.5%, and 77.0% at 1, 3, and 5 years, respectively. Univariate analysis revealed that a pretreatment serum alpha-fetoprotein (AFP) level of > or =50 ng/ml (P = 0.0324), a des-gamma-carboxy prothrombin (DCP) level of > or =40 mAu/ml (P = 0.006), an ablative margin of <5 mm of the ablation zone (P = 0.0306), and a prothrombin time of <70% (P = 0.0188) were related to IDR. A multivariate stepwise Cox proportional hazards regression model revealed that pretreatment serum AFP and DCP level and the ablative margin were independent risk factors for IDR pretreatment. Serum DCP level > or = 40 mAu/ml (P = 0.025), local tumor progression (P = 0.011), and ablative margin < 5 mm (P = 0.024) were related to multiple IDR. CONCLUSIONS HCC patients with high serum AFP or DCP before RF ablation should be carefully followed up to monitor any IDR. A sufficient ablative margin in RF ablation for HCC is required to prevent IDR.
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Affiliation(s)
- Yusuke Okuwaki
- Department of Gastroenterology, Kitasato University East Hospital, 2-1-1 Asamizodai, Sagamihara, 228-8520, Japan
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Nouso K, Matsumoto E, Kobayashi Y, Nakamura SI, Tanaka H, Osawa T, Ikeda H, Araki Y, Sakaguchi K, Shiratori Y. Risk factors for local and distant recurrence of hepatocellular carcinomas after local ablation therapies. J Gastroenterol Hepatol 2008; 23:453-8. [PMID: 17725599 DOI: 10.1111/j.1440-1746.2007.05120.x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
BACKGROUND AND AIM Hepatocellular carcinoma (HCC) recurs frequently after local ablation therapies. Recurrence following the therapies may be of two types: local recurrence and distant recurrence. The aim of the current study is to separately elucidate the predisposing factors for each recurrence. METHODS Among the 2141 consecutive patients with HCC who were admitted to our institute and affiliated hospital between May 1997 and April 2004, 621 patients who had undergone local ablation therapies as the initial treatment were enrolled. Correlations between the clinical backgrounds of the patients and the type of recurrence were analyzed by the Cox proportional hazard model. RESULTS A multivariate analysis revealed that tumor size (>30 mm; risk ratio 2.80; 95% confidence interval, 1.77-4.45; P < 0.0001), tumor number (> or =2; 1.74, 1.23-2.47, P = 0.002), and the serum alpha-fetoprotein level (>100 ng/mL; (1.62, 1.09-2.41, P = 0.014), which were classified as "tumor factors", were significant predisposing factors for the local recurrence of HCC. In contrast, a low platelet count (<100,000/microL; 1.34, 1.04-1.74, P = 0.03) and the presence of ascites (1.73, 1.16-2.57, P = 0.008), which were classified as "background factors", as well as tumor size (1.83, 1.11-3.01, P = 0.02) and tumor number (2.23, 1.72-3.00, P < 0.0001) were predisposing factors for distant recurrence. CONCLUSION The predisposing factors for local and distant recurrence of HCC differ and different precautions must be observed to prevent recurrence, depending on the HCC status and background liver functions.
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Affiliation(s)
- Kazuhiro Nouso
- Department of Internal Medicine, Hiroshima City Hospital, Hiroshima, Japan.
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Abstract
This article reviews the current developments and significant trends in the treatment of hepatocarcinoma (HCC). Prevention programs should be based on large vaccination campaigns and the use of immunologic or biologic molecules to delay the onset of HCC in already cirrhotic patients. Surgery remains the therapy of choice in patients with a small and limited number of tumor nodules. To date, no preoperative treatment has been proven useful. Adjuvant treatments involving systemic chemotherapy, intra-arterial infusion, or chemoembolization failed to improve survival, whereas immune therapy, retinoids, radiolabeled isotopes, and antiangiogenic agents seem promising. Such local treatments as percutaneous ethanol injection, cryotherapy, and radiofrequency are proposed for patients with limited hepatic function and should be combined with other treatment modalities to optimize their efficacy and limit their toxicity. Regional therapy should take a selective, subsegmental approach at intervals depending on tumor response and possibly combined with other treatment modalities. Systemic therapy with cytotoxic agents remains disappointing. Hormonal therapy with tamoxifen or antiandrogens has shown no efficacy and might even be detrimental. Further progress may be expected from targeted therapy.
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Affiliation(s)
- Beatrice Gerard
- Institut Jules Bordet, 1 Rue Heger-Bordet, Brussels, 1000, Belgium
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15
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Cho YB, Lee KU, Suh KS, Kim YJ, Yoon JH, Lee HS, Hahn S, Park BJ. Hepatic resection compared to percutaneous ethanol injection for small hepatocellular carcinoma using propensity score matching. J Gastroenterol Hepatol 2007; 22:1643-9. [PMID: 17845692 DOI: 10.1111/j.1440-1746.2007.04902.x] [Citation(s) in RCA: 18] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Several surgical and non-surgical therapeutic modalities have been used for the treatment of hepatocellular carcinoma (HCC). There have been several studies comparing hepatic resection (HR) and percutaneous ethanol injection (PEI) for the treatment of HCC. However, there is still disagreement about the best treatment modality. METHODS From 130 patients undergoing HR, 116 patients were individually matched to 116 controls from 249 patients undergoing PEI using propensity score matching to overcome possible biases in non-randomized study. Survival analyses were undertaken to compare these propensity score-matched groups. RESULTS After matching by propensity score, the major clinical outcomes in the HR (n = 116) and the PEI (n = 116) groups were found to be similar. The 1-, 3- and 5-year overall survival rates were higher in the HR group (94.8%, 76.5% and 65.6%) compared to the PEI group (95.7%, 73.5% and 49.3%) (P = 0.059). The cumulative 1-, 3- and 5-year disease-free survival rates showed the same trend (HR: 76.1%, 50.6% and 40.6%; PEI: 62.6%, 25.5% and 19.1%) (P < 0.001). However, when stratified by Child-Pugh classification, it was no longer the case in the Child B patients. Single intrahepatic recurrence was the most common pattern of tumor recurrence after both treatments. CONCLUSIONS Patients undergoing HR had a better survival profile than those undergoing PEI. However, when considering which technique to use for optimal HCC management, the individual patient's hepatic function must be considered.
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Affiliation(s)
- Yong Beom Cho
- Department of Surgery, Seoul National University College of Medicine, Seoul, Korea
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16
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Parikh S, Hyman D. Hepatocellular cancer: a guide for the internist. Am J Med 2007; 120:194-202. [PMID: 17349437 DOI: 10.1016/j.amjmed.2006.11.020] [Citation(s) in RCA: 125] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/21/2006] [Revised: 11/14/2006] [Accepted: 11/20/2006] [Indexed: 12/18/2022]
Abstract
Hepatocellular cancer is the third leading cause of cancer-related deaths worldwide. Its incidence has increased dramatically in the United States because of the spread of hepatitis C virus infection and is expected to increase for the next 2 decades. Hepatitis B virus, hepatitis C virus, and chronic heavy alcohol use leading to cirrhosis of the liver remain the most important causes. The diagnosis of hepatocellular cancer rests on a combination of radiologic, serologic, and histopathologic criteria. Liver transplantation is the only definitive treatment. Resection of the tumor and other percutaneous therapies are more commonly used in practice, because most hepatocellular cancers are detected at an advanced stage. Patients who are at high risk for the development of hepatocellular cancer should be screened with an ultrasound of the liver every 6 months. The prognosis is dependent on both the underlying liver function and the stage at which the tumor is diagnosed. The aim of this review is to familiarize internists in screening, diagnosis, and referral of patients with hepatocellular cancer in an appropriate and timely fashion.
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Affiliation(s)
- Sameer Parikh
- Department of Medicine, Baylor College of Medicine, Houston, Tex, USA.
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Hong K, Georgiades CS, Geschwind JFH. Technology insight: Image-guided therapies for hepatocellular carcinoma--intra-arterial and ablative techniques. ACTA ACUST UNITED AC 2006; 3:315-24. [PMID: 16757969 DOI: 10.1038/ncponc0512] [Citation(s) in RCA: 45] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2005] [Accepted: 04/03/2006] [Indexed: 02/06/2023]
Abstract
Locoregional techniques have become the mainstay of therapy for patients with unresectable hepatocellular carcinoma (HCC). Such image-guided interventions include catheter-based approaches (transarterial chemoembolization and yttrium-90 radiotherapy) and locoregional ablative techniques, either chemical (percutaneous ethanol injection), or thermal (radiofrequency ablation, laser ablation, microwave ablation and cryoablation). These therapies are mainly utilized for palliation, but have also been used with curative intent. In selected cases, percutaneous interventional treatments have shown good results (5-year survival 40-50%), but, even when chosen as first-line treatment, have not been able to achieve the response rates and outcomes achieved by surgical options (resection or transplantation). New promising image-guided therapies are continuously emerging, as we attempt to improve tumor targeting, minimize hepatic toxicity and ultimately improve quality of life and survival of patients with HCC. With new technologies in imaging and drug delivery becoming available, it is likely that, in the future, patients with HCC will be best treated by a multidisciplinary team approach, utilizing a combination of techniques to improve patient survival. This review outlines the current status of the most commonly used image-guided locoregional interventions in the treatment of patients with HCC, and describes recent research and advances related to image-guided interventions for liver cancer.
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Affiliation(s)
- Kelvin Hong
- Division of Interventional Radiology, Johns Hopkins School of Medicine, Baltimore, MD 21287, USA.
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19
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Braga L, Guller U, Semelka RC. Pre-, peri-, and posttreatment imaging of liver lesions. Radiol Clin North Am 2005; 43:915-27, viii. [PMID: 16098347 DOI: 10.1016/j.rcl.2005.05.005] [Citation(s) in RCA: 24] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
This article provides an overview of current treatment approaches in patients with primary or secondary liver diseases. Emphasis is placed on MR imaging prior, during, and after various treatments, including liver resection, systemic chemotherapy, transcatheter arterial chemoembolization, ablative therapies, and liver transplantation. Findings described for MR imaging are directly applicable to findings for CT and potentially contrast-enhanced ultrasound. The authors' description, however, will deal mainly with MR imaging as this is the their preferred approach due to diagnostic accuracy and patient safety, and the findings are most demonstrative on MR imaging.
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Affiliation(s)
- Larissa Braga
- Department of Radiology, School of Medicine, University of North Carolina at Chapel Hill, 101 Manning Drive, CB 7510, Chapel Hill, NC 27599-7510, USA
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20
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Abstract
In patients with cirrhosis and hepatocellular carcinoma (HCC), orthotopic liver transplantation (OLT) offers hope for cure of both the complicating HCC and the underlying chronic liver disease. Excellent 5 year survival has been reported when the restrictive Milan criteria are used to select transplant candidates. Alternative recommendations have recently been proposed by groups at University of California San Francisco, University of Pittsburgh and Mount Sinai. We review current and evolving concepts regarding selection criteria for OLT in patients with HCC, along with strategies to reduce waiting times, such as the impact of the implementation of the model for end-stage liver disease (MELD) scoring system on organ distribution and the role of living donor OLT for this indication. The possible efficacy of adjuvant anti-tumour therapies in limiting HCC growth while waiting for OLT, along with factors influencing the risk of HCC recurrence post-OLT, the major cause of death in this setting, are also discussed.
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Affiliation(s)
- Jelica Kurtovic
- Gastrointestinal and Liver Unit, The Prince of Wales Hospital and University of New South Wales, Sydney, NSW, Australia
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21
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Sasaki A, Kai S, Iwashita Y, Hirano S, Ohta M, Kitano S. Microsatellite distribution and indication for locoregional therapy in small hepatocellular carcinoma. Cancer 2005; 103:299-306. [PMID: 15578688 DOI: 10.1002/cncr.20798] [Citation(s) in RCA: 138] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
BACKGROUND Intrahepatic disease recurrence is observed frequently after locoregional therapies for patients with hepatocellular carcinoma (HCC). However, the indication for locoregional therapy is still unclear. To clarify the indication for locoregional therapy for small HCC tumors, the authors measured the distance of microsatellites from the main tumor and analyzed the relation between this distance and clinicopathologic factors. METHODS The authors retrospectively analyzed 100 patients with small HCC tumors (</= 5 cm in dimension) treated by curative hepatectomy. A microsatellite was defined as invasion into the portal vein or intrahepatic metastasis, and the distance from the main tumor to the most distant microsatellite was determined under light microscopy. The current study investigated the relation between microsatellite distance (0 mm if none present, </= 5 mm, and > 5 mm) and clinicopathologic factors, as well as overall and disease-free survival rates after hepatectomy. RESULTS Of the 100 patients, 46 had microsatellites with a mean distance of 9.9 mm (median, 5.0 mm). Of the clinicopathologic factors investigated, tumor grade and preoperative alpha-fetoprotein level significantly correlated with the presence of a microsatellite. Tumor size and distance to the microsatellite were significantly correlated. All but 1 tumor associated with a microsatellite distance > 5 mm was a high-grade tumor > 25 mm in greatest dimension. The overall survival rate of patients with a microsatellite distance of > 5 mm was lower than that of patients with a microsatellite distance < 5 mm. CONCLUSIONS Locoregional therapy, including limited resection and ablation therapies, was appropriate for patients with low-grade HCC tumors or with tumors < 25 mm in diameter.
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Affiliation(s)
- Atsushi Sasaki
- Department of Surgery I, Oita University Faculty of Medicine, Oita, Japan.
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22
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Sala M, Llovet JM, Vilana R, Bianchi L, Solé M, Ayuso C, Brú C, Bruix J. Initial response to percutaneous ablation predicts survival in patients with hepatocellular carcinoma. Hepatology 2004; 40:1352-60. [PMID: 15565564 DOI: 10.1002/hep.20465] [Citation(s) in RCA: 329] [Impact Index Per Article: 16.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/07/2022]
Abstract
Outcome predictors in patients with hepatocellular carcinoma (HCC) who are treated with percutaneous ablation are ill defined, and it is unknown if successful therapy is associated with improved survival. In our study, 282 cirrhotic patients with early nonsurgical HCC were treated with percutaneous ablation during a 15-year period. Single tumors were seen in 244 patients, and 2 to 3 nodules were seen in 38 patients. Initial complete response was achieved in 192 patients and was independently related to the size of the main tumor (P = .015) and tumor stage (P = .0001) (< or =2 cm, 96%; 2.1-3 cm, 78%; >3 cm, 56%; 2-3 nodules, 46%). At the end of follow-up, 80 patients presented sustained complete response. The 1-, 3-, and 5-year survival rates were 87%, 51%, and 27%, respectively. The independent predictors of survival were Child-Turcotte-Pugh class (P = .0001) and initial complete response (P = .006). Child-Turcotte-Pugh class A patients with initial complete response achieved 42% survival at 5 years; this figure increased to 63% in patients with tumors 2 cm or smaller. In conclusion, our results demonstrate that initial complete response to percutaneous ablation is associated with an improved survival in both Child-Turcotte-Pugh class A and B patients with nonsurgical HCC. Accordingly, initial complete tumor necrosis should be considered a relevant therapeutic target irrespective of tumor size and liver function.
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Affiliation(s)
- Margarita Sala
- Liver Unit, Institut d'Investigacions Biomèdiques August Pi i Sunyer (IDIBAPS), Hospital Clínic, University of Barcelona, Catalonia, Spain
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23
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Abstract
Because hepatocellular carcinoma (HCC) arises in cirrhotic livers and is often multifocal, transplantation seems to be a rational approach. Early results were poor, but current restrictive selection criteria can yield excellent results. Patients with 1 HCC nodule </=5 cm in diameter, or 2-3 nodules </=3cm, receive United Network Organ Sharing priority; nevertheless, dropout from the waiting list is common. Predictors of dropout include multiple tumors and tumors with a diameter >3 cm. Nonsurgical methods are commonly used to prevent tumor progression and thus prevent dropout. Expanding selection criteria results in more patients with HCC being cured at the expense of a higher incidence of recurrence. Molecular/biologic information is beginning to be incorporated into current staging systems in order to better predict HCC recurrence. In considering liver transplantation, the impact of the underlying liver disease is an important consideration; recurrent hepatitis C after transplant lowers patient survival independent of tumor recurrence.
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Affiliation(s)
- Myron Schwartz
- Department of Adult Liver Transplantation and Hepatobiliary Surgery, The Mount Sinai School of Medicine, 1 Gustave Levy Pl, Box 1104, New York, New York 10029, USA.
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24
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25
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Abstract
The preferred therapy for hepatocellular carcinoma (HCC) apparently confined to the liver is surgical removal of the tumor. If the location of the tumor and the functional status of the liver are such that resection with an adequate margin can be achieved with low likelihood of subsequent hepatic failure, liver resection is the preferred approach. When HCC apparently localized to the liver is diagnosed in a patient who, by virtue of tumor characteristics or diminished hepatic reserve, is not a candidate for liver resection, liver transplantation becomes a consideration. This work outlines the approach at The Mount Sinai Hospital to the diagnosis, evaluation, preoperative management, transplantation, and posttransplant follow-up in patients with unresectable HCC. The allocation of livers to patients with HCC is reviewed, and predictors of tumor recurrence and results of liver transplantation for HCC are discussed. Finally, the impact of viral hepatitis and of immunosuppression on transplant outcome are discussed.
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Affiliation(s)
- Myron Schwartz
- Adult Liver Transplantation and Hepatobiliary Surgery, The Mount Sinai School of Medicine, New York, New York, USA.
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26
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Ku Y, Iwasaki T, Tominaga M, Fukumoto T, Takahashi T, Kido M, Ogata S, Takahashi M, Kuroda Y, Matsumoto S, Obara H. Reductive surgery plus percutaneous isolated hepatic perfusion for multiple advanced hepatocellular carcinoma. Ann Surg 2004; 239:53-60. [PMID: 14685100 PMCID: PMC1356192 DOI: 10.1097/01.sla.0000103133.03688.3d] [Citation(s) in RCA: 46] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE To evaluate the efficacy of a novel 2-stage treatment with reductive surgery plus percutaneous isolated hepatic perfusion (PIHP) for multiple hepatocellular carcinoma (HCC), which was previously unresectable. SUMMARY BACKGROUND DATA Surgical resection is the treatment of choice for HCC, but the majority of patients with advanced HCC are not suitable candidates. PIHP is a minimally invasive surgery that allows high-dose regional chemotherapy of the liver, and our phase II studies have shown its profound efficacy for the local control of advanced HCC. METHODS Twenty-five patients with multiple advanced HCC were enrolled in this prospective study. In the first stage, all patients underwent reductive hepatectomy: major hepatectomy in 13 patients and segmentectomy or less in 12. In 2 patients with subsegmentectomy, the retropancreatic and periportal metastatic lymph nodes were synchronously resected. Regardless of the type of hepatectomy, all patients routinely underwent cholecystectomy, and ligations of the right gastric artery and arterial collaterals of the remnant liver to increase the safety and efficacy of PIHP. In the second stage, PIHP with doxorubicin 60-120 mg/m2/treatment was planned for a period of 1 to 3 months after surgery. RESULTS Of 25 enrolled patients, 22 successfully underwent PIHP an average of 1.8 times for the local control of residual liver tumors. In the remaining 3 patients, PIHP was abandoned because 2 had rapid disease progression and 1 had liver failure after surgery. In 22 patients with the 2-stage treatment, 19 (86%) had objective local tumor control (10 complete remissions and 9 partial responses with a median response duration of 16 months). The actuarial survival rate of all 25 patients was 42% at 5 years. CONCLUSIONS Reductive surgery plus PIHP produced a strong antitumoral effect on multiple advanced HCC, when liver function allows this concentrated treatment approach, and offers long-term survival in a subset of patients who were previously deemed to have unresectable disease.
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Affiliation(s)
- Yonson Ku
- Department of Gastroenterological Surgery, Graduate School of Medical Sciences, Kobe University, Kobe, Japan.
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27
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Donckier V, Van Laethem JL, Van Gansbeke D, Ickx B, Lingier P, Closset J, El Nakadi I, Feron P, Boon N, Bourgeois N, Adler M, Gelin M. New considerations for an overall approach to treat hepatocellular carcinoma in cirrhotic patients. J Surg Oncol 2003; 84:36-44; discussion 44. [PMID: 12949989 DOI: 10.1002/jso.10281] [Citation(s) in RCA: 13] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Increasing numbers of cases and organ shortage justify reconsidering the global therapeutic approach for hepatocelluar carcinoma in cirrhotic patients. METHODS Recent literature was reviewed, focused on new therapeutic technologies such as radiofrequency. RESULTS For small tumors, liver transplantation offers theoretically the best chance for cure. However, organ shortage may eliminate this advantage, because of tumor progression while waiting for a graft. For small tumors, arising on compensated cirrhosis, resection or radiofrequency ablation may provide efficient local tumor control without precluding subsequent transplantation in case of tumor recurrence and/or cirrhosis decompensation. CONCLUSIONS For small tumors and compensated cirrhosis, resection or radiofrequency could represent acceptable first line treatments. In addition to permit safe and immediate tumor control, this strategy would allow a preferential redistribution of grafts to patients with decompensated cirrhosis in whom transplantation is the only possibility.
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Affiliation(s)
- Vincent Donckier
- Medicosurgical Department of Hepatogastroenterology, Hôpital Erasme, Université Libre de Bruxelles, Brussels, Belgium.
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Coad JE, Kosari K, Humar A, Sielaff TD. Radiofrequency ablation causes 'thermal fixation' of hepatocellular carcinoma: a post-liver transplant histopathologic study. Clin Transplant 2003; 17:377-84. [PMID: 12868996 DOI: 10.1034/j.1399-0012.2003.00062.x] [Citation(s) in RCA: 51] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
Abstract
Radiofrequency ablation (RFA) is increasingly used to treat hepatocellular carcinoma (HCC) in patients awaiting a liver transplant. Despite its increasing use, detailed histologic information is scarce regarding the nature of RFA-treated lesions. We identified four chronic hepatitis C patients who had RFA of their HCC before their liver transplant. For these four patients, we conducted a detailed histopathologic analysis of the treated lesions in their explanted livers. The five lesions included immediate (4 d) and long-term (14 months) post-RFA specimens. Of the five lesions, four were completely ablated. The one incompletely ablated lesion was also treated with chemoembolization. In the acute post-RFA period, a zone of interstitial hemorrhage occurred at the outer boundary of the lesion. Differing from classic tissue necrosis, the treated lesions all showed 'thermal fixation', with preserved tissue architecture and microscopic cellular detail. The cellular staining characteristics faded with time, but the treated tissue became brittle, resisted tissue breakdown, and generated a minimal wound healing response. At the periphery of the lesion, the fibrous septae of the cirrhotic liver and vascular structures appeared to demarcate or limit progression of the ablation front. A narrow hypocellular fibrous boundary with a focal 'foreign body' giant cell-type reaction developed around the edge of the ablation zone. Thus, RFA can produce immediate and complete thermal fixation of select lesions with an appropriate liver margin and can provide a satisfactory treatment option for select HCC patients before a liver transplant.
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Affiliation(s)
- James E Coad
- Department of Pathology, West Virginia University School of Medicine, Morgantown, WV 26508, USA.
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29
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Verhoef C, Kuiper JW, Heisterkamp J, de Man RA, Pattynama PMT, IJzermans JNM. Interstitial laser coagulation with temporary hepatic artery occlusion for patients with cirrhosis and irresectable hepatoma. Br J Surg 2003; 90:950-5. [PMID: 12905547 DOI: 10.1002/bjs.4135] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022]
Abstract
BACKGROUND The aim was to determine the degree of local control of hepatocellular carcinoma (HCC) in patients with cirrhotic liver disease when treated with ultrasonographically guided interstitial laser coagulation (ILC) with temporary hepatic artery occlusion. METHODS Sixteen patients with 24 HCC tumours were treated. Follow-up was by computed tomography or magnetic resonance imaging every 3 months. RESULTS Nineteen of 24 tumours showed complete necrosis immediately after treatment, and there was no tumour recurrence during follow-up (mean 14 months, median 12 months). No effect on liver function was observed after 1 week and there was no death. In 13 of the 16 patients, new HCC foci developed at other sites. CONCLUSION Percutaneous ILC combined with temporary hepatic artery occlusion during a single session is an effective local treatment for HCC nodules smaller than 5 cm. However, new HCC lesions develop in the majority of patients, which underscores the need for adjuvant therapy or repeated treatment in these patients.
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Affiliation(s)
- C Verhoef
- Department of Surgery, Erasmus Medical Centre, Rotterdam, The Netherlands
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30
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Stippel DL, Kasper HU, Schleimer K, Benz C, Hölscher AH, Beckurts KTE. Underestimation of nodules while staging hepatocellular carcinoma prior to neoadjuvant treatment on waiting list for transplantation. Transplant Proc 2003; 35:1423-4. [PMID: 12826177 DOI: 10.1016/s0041-1345(03)00456-1] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Neoadjuvant therapy of hepatocellular carcinoma (HCC) has increasing importance for patients awaiting liver transplantation, as waiting time increases. The therapeutic options (ethanol injection, radiofrequency ablation, chemoembolization) are only effective locally. Therefore, occult carcinomas can overcome the efficacy of these therapies. To evaluate the impact of occult nodules, we analyzed the staging results and histology from 21 HCC patients. The average pretransplant waiting time was 5.2 +/- 3.2 months. The staging before transplantation was reliable concerning the maximum diameter of the HCC. The number of HCC nodules increased from 30 at the time of clinical staging to 59 in histology, hence from 1.4 +/- 1.5 to 2.8 +/- 1.9 per patient. Patients with pT1/2 HCCs experienced an even larger increase (from 1.3 to 3.2 nodules) than patients suffering of pT3/4 HCCs (2.6 to 3.4 nodules). All occult HCCs were less than 2 cm in diameter and showed no prognostically negative histological features such as vascular invasion. The 3-year survival of the patients with small HCCs was 86% compared to 34% for those with advanced cancer. The survival of patients with small HCCs was similar to the survival of patients receiving a transplant for a nonmalignant indication. Only after neoadjuvant therapy with radiofrequency ablation or ethanol injection but not with chemoembolization, was significant necrosis of HCC observed. Considering the current average waiting time, repetitive staging and treatment of new nodules seems justified to achieve a low dropout rate during the waiting time.
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Affiliation(s)
- D L Stippel
- Department of Visceral and Vascular Surgery, University of Cologne, Köln, Germany.
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31
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Ng KKC, Lam CM, Poon RTP, Ai V, Tso WK, Fan ST. Thermal ablative therapy for malignant liver tumors: a critical appraisal. J Gastroenterol Hepatol 2003; 18:616-29. [PMID: 12753142 DOI: 10.1046/j.1440-1746.2003.02991.x] [Citation(s) in RCA: 49] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
The management of primary and secondary malignant liver tumors poses a great challenge to clinicians. Although surgical resection is the gold-standard treatment, most patients have unresectable malignant liver tumors. Over the past decade, various modalities of loco-regional therapy have gained much interest. Among them, thermal ablative therapy, including cryotherapy, microwave coagulation, interstitial laser therapy, and radiofrequency ablation (RFA), have been proven to be safe and effective. Despite the effective tumor eradication achieved within cryotherapy, the underlying freeze/thaw mechanism has resulted in serious complications that include bleeding from liver cracking and the 'cryoshock' phenomenon. Thermal ablation using microwave and laser therapy for malignant liver tumors is curative and is associated with minimal complications. However, this treatment modality is effective only for tumors <3 cm diameter. Radiofrequency ablation seems to be the most promising form of thermal ablative therapy in terms of a lower complication rate and a larger volume of ablation. However, its use is restricted by the difficulty encountered when using imaging studies to monitor the areas of ablation during and after the procedure. Moreover, the techniques of RFA need to be refined in order to achieve the same oncological radicality of malignant liver tumors as achieved by surgical resection. As each of the loco-regional therapies has its own advantages and limitations, a multidisciplinary approach using a combination of therapies will be the future trend for the management of malignant liver tumors.
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Affiliation(s)
- Kelvin Kwok-Chai Ng
- Departments of Surgery, Centre for the Study of Liver Disease, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China.
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Komorizono Y, Oketani M, Sako K, Yamasaki N, Shibatou T, Maeda M, Kohara K, Shigenobu S, Ishibashi K, Arima T. Risk factors for local recurrence of small hepatocellular carcinoma tumors after a single session, single application of percutaneous radiofrequency ablation. Cancer 2003; 97:1253-62. [PMID: 12599233 DOI: 10.1002/cncr.11168] [Citation(s) in RCA: 244] [Impact Index Per Article: 11.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND The objectives of this study were to clarify risk factors for local tumor recurrence and to determine which patients with hepatocellular carcinoma (HCC) are most suitable for a single session, single application of percutaneous radiofrequency (RF) ablation. METHODS Fifty-six consecutive patients with 65 HCC tumors measuring <or= 3 cm in greatest dimension who received a single session, single application of percutaneous RF ablation and who achieved optimal tumor ablation, as assessed by an immediate computed tomography scan, were enrolled in this study. Six possible factors for local recurrence were analyzed using a Cox proportional hazards regression model: tumor size, tumor location, proximity of the tumor to intrahepatic large vessels, types of electrodes used, prior treatment, and observation of impedance rises. Local recurrence free intervals were estimated using the Kaplan-Meier method, and differences between groups were compared using the log-rank test. RESULTS The Kaplan-Meier estimates of overall cumulative local recurrence free intervals after a single RF ablation treatment were 76% (95% confidence interval [95%CI], 70.9-81.7%) at 12 months and 74% (95%CI, 68.2-79.6%) at 15 months. The log-rank test revealed a statistically significant difference between the local recurrence free intervals according to tumor size (P = 0.001) and tumor location (P < 0.001). Further investigation with a Cox regression analysis indicated that a greatest tumor dimension > 2 cm (risk ratio [RR], 4.9; 95%CI, 1.3-16.4; P = 0.019) and subcapsular location (RR, 5.2; 95%CI, 1.7-16.6; P = 0.005) were associated independently with local recurrence. The other four factors were not associated with local recurrence in this study. CONCLUSIONS A single session, single application of RF ablation produced favorable local control. Patients who have nonsubcapsular HCC tumors measuring <or= 2 cm in greatest dimension may be the most suitable candidates for a single-session, single application of RF ablation.
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Affiliation(s)
- Yasuji Komorizono
- Second Department of Internal Medicine, Faculty of Medicine, Kagoshima University, Kagoshima, Japan.
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Abstract
BACKGROUND Most patients with liver tumours are not suitable for surgery but interstitial ablative techniques may control disease progression and improve survival rates. METHODS A review was undertaken using Medline of all reported studies of cryoablation, radiofrequency ablation, microwave ablation, interstitial laser photocoagulation, high-intensity focused ultrasound and ethanol ablation of primary liver tumours and hepatic metastases. RESULTS Although there are no randomized clinical trials, cryoablation, thermal ablation and ethanol ablation have all been shown to be associated with improved palliation in patients with primary and secondary liver cancer. The techniques can be undertaken safely with minimal morbidity and mortality. CONCLUSION Although surgical resection remains the first line of treatment for selected patients with primary and secondary liver malignancies, interstitial ablative techniques are promising therapies for patients not suitable for hepatic resection or as an adjunct to liver surgery.
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Affiliation(s)
- C Erce
- Department of Clinical and Surgical Sciences (Surgery), University of Edinburgh, Edinburgh, UK
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Ng KKC, Lam CM, Poon RTP, Fan ST. Portal vein thrombosis after radiofrequency ablation for recurrent hepatocellular carcinoma. Asian J Surg 2003; 26:50-3; discussion 54. [PMID: 12527497 DOI: 10.1016/s1015-9584(09)60218-9] [Citation(s) in RCA: 18] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Recurrent hepatocellular carcinoma (HCC) deserves multidisciplinary treatment in addition to surgical resection. Radiofrequency ablation (RFA) is an evolving, localized, thermal ablative treatment for unresectable hepatocellular carcinoma (HCC). Though the preliminary results of RFA in clinical studies are encouraging, its serious complications should not be underestimated. Portal vein thrombosis as a result of direct blood vessel injury by RFA is rarely reported and is potentially fatal in patients with limited liver reserve due to underlying liver cirrhosis. We present a case of portal vein thrombosis as a complication of RFA treatment for recurrent HCC and illustrate its underlying possible mechanism.
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Affiliation(s)
- Kelvin Kwok-Chai Ng
- Centre for the Study of Liver Disease, Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong
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35
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Abstract
Minimally invasive therapies are gaining increasing attention as an alternative to standard surgical therapies in the treatment of primary hepatocellular carcinoma. These include therapies administered transcatheterally (arterial embolization, intraarterial chemoinfusion, and combination chemoembolization) and percutaneously (chemical ablation with ethanol or acetic acid, and thermal ablation with radiofrequency, microwave, or laser energies). Benefits over surgical resection include the anticipated reduction in morbidity and mortality, low cost, suitability for real time image guidance, the ability to perform ablative procedures on outpatients, and the potential application in a wider spectrum of patients, including nonsurgical candidates. This review examines reported clinical success, potential complications, current limitations, and future directions of development of chemoembolization, ethanol and acetic acid instillation, and radiofrequency, microwave, and laser thermal ablation.
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Affiliation(s)
- S Nahum Goldberg
- Minimally Invasive Tumor Therapy Laboratory, Department of Radiology, Beth Israel Deaconess medical Center, Harvard Medical School, Boston Massachusetts 02215, USA.
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Ziparo V, Balducci G, Lucandri G, Mercantini P, Di Giacomo G, Fernandes E. Indications and results of resection for hepatocellular carcinoma. EUROPEAN JOURNAL OF SURGICAL ONCOLOGY 2002; 28:723-8. [PMID: 12431469 DOI: 10.1053/ejso.2002.1299] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
AIM In this retrospective series we evaluate our experience in surgical treatment of HCC and examine early and long-term results of 46 hepatic resections. METHODS Eighty-eight patients with HCC have been observed at our Department. Fifty patients (57%) have been operated, but only 46 (92%) could be resected; 43 patients (93.5%) carried liver cirrhosis. We performed 28 non-anatomical resections (60.8%) and 18 anatomical resections (39.2%). Tumour clearance at resection margin of at least 1cm was considered for a curative resections. RESULTS Overall mortality and morbidity were 8.7 and 30.4% respectively. These rates significantly decreased in the last years: from 1995 to 2000 no hospital mortality has been recorded. Hospital mortality among non-anatomical and anatomical resection subgroups was 3.5 and 16.6% respectively (P<0.02). After a median f.u. of 41 months, 19 patients (45.2%) had recurrences: it was intrahepatic in 16 (84.4%). We observed a 3-, 5- and 10-years actuarial survival rate 62, 51.1 and 22.5% respectively. Long term survival significantly differed between non-anatomical and anatomical resections, with 5-year and 10-year values of 61.1 and 34.3% vs 37.7 and 18.8% respectively (P=0.0224). CONCLUSIONS Early results after hepatic resection for HCC can be improved by using a limited surgical approach. Long-term results are still unsatisfactory, because of the high recurrence rate that is not influenced by different surgical approaches.
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Affiliation(s)
- V Ziparo
- Department of Surgery 'Pietro Valdoni' University 'La Sapienza' Rome, Italy.
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Yamamoto M, Takasaki K, Otsubo T, Saito A, Nakano M. Extent of resection for hepatocellular carcinoma 2 cm or less in greatest diameter. Am J Surg 2002; 184:437-40. [PMID: 12433609 DOI: 10.1016/s0002-9610(02)01005-x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND The effectiveness of liver segmentectomy or larger resection in patients with hepatocellular carcinoma (HCC) 2 cm or less in greatest diameter has not been clarified. METHODS From 1985 to 1994, 125 patients with solitary HCC 2 cm or less in greatest diameter underwent curative hepatectomy (liver segmentectomy or larger resection, 94; subsegmentectomy, 31). The relationship between clinicopathological findings and surgical outcomes were examined. RESULTS The 5- and 10-year survival rates were 68% and 47%, respectively. Univariate and multivariate analysis showed the Child-Pugh class to be a significant prognostic factor. However, liver segmentectomy or larger resection did not have any significant effect on long-term survival. CONCLUSIONS Our data suggest that no further improvement of the survival rate can be achieved by liver segmentectomy or larger resection, compared with subsegmentectomy in patients with solitary HCC 2 cm or less in greatest diameter.
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Affiliation(s)
- Masakazu Yamamoto
- Department of Surgery, Institute of Gastroenterology, Tokyo Women's Medical University, 8-1, Kawada-cho, Shinjuku-ku, 162-8666, Tokyo, Japan.
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Kuriyama H, Okada S, Okusaka T, Ueno H, Ikeda M. Prognostic factors in patients with small hepatocellular carcinoma treated by percutaneous ethanol injection. J Gastroenterol Hepatol 2002; 17:1205-10. [PMID: 12453281 DOI: 10.1046/j.1440-1746.2002.02807.x] [Citation(s) in RCA: 15] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
BACKGROUND Percutaneous ethanol injection (PEI) has been widely performed and is now accepted as a viable alternative to hepatic resection in patients with small hepatocellular carcinomas (HCC). However, only a few extensive investigations have been conducted regarding the prognostic factors for HCC patients treated with PEI. METHODS We investigated the prognostic factors in 100 patients with small HCC who had undergone PEI. Univariate analysis and multivariate analysis with Cox's proportional hazards model were used to determine the factors potentially related to survival. For clinical application, a prognostic index was calculated based on the regression coefficients of the independent variables identified from the multivariate analysis. RESULTS Median survival time and 1, 3 and 5 year survival rates were 71 months and 100, 84 and 62%, respectively. Among the 15 potential prognostic variables investigated, only three variables, namely a serum albumin level < or = 3.5 g/dL, the presence of tumor stain and a serum glutamic oxaloacetic transaminase level > 66 IU/L, were identified as factors independently associated with a shorter survival. A prognostic index based on the regression coefficients of these three factors was proposed to classify patients into three groups, those with a good (5 year survival rate 91%), intermediate (64%) and poor prognosis (22%). CONCLUSIONS The results of the present study may be useful in predicting the survival of HCC patients treated with PEI and in the design and analysis of future clinical trials of PEI for HCC.
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Affiliation(s)
- Hitoshi Kuriyama
- Hepatobiliary and Pancreatic Oncology Division, National Cancer Center Hospital, Tokyo, Japan
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Kamada K, Kitamoto M, Aikata H, Kawakami Y, Kono H, Imamura M, Nakanishi T, Chayama K. Combination of transcatheter arterial chemoembolization using cisplatin-lipiodol suspension and percutaneous ethanol injection for treatment of advanced small hepatocellular carcinoma. Am J Surg 2002; 184:284-90. [PMID: 12354601 DOI: 10.1016/s0002-9610(02)00933-9] [Citation(s) in RCA: 60] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
Abstract
BACKGROUND We evaluated the long-term efficacy of the combination of transcatheter arterial chemoembolization (TACE) using cisplatin-lipiodol suspension and percutaneous ethanol injection (PEI) for treatment of advanced small hepatocellular carcinoma (HCC). PATIENTS AND METHODS Sixty-nine patients with HCC less than 3 cm in diameter and at most three lesions were enrolled in this study. HCC nodules were confirmed to be hypervascular by angiography. Thirty-two patients were treated with a combination of TACE and PEI (TACE/PEI group) and 37 patients with TACE alone (TACE group). RESULTS The 5-year survival rates were 50% for the TACE/PEI group and 22% for the TACE group. The TACE/PEI group had a slightly but not significantly better survival than the TACE group. The 5-year survival rates of patients with solitary HCC were 61% for the TACE/PEI group and 24% for the TACE group. Although the two therapeutic groups both had high rates of recurrence, the rates in the TACE/PEI group were significantly lower than those in the TACE group (P <0.05). Severe complications such as intraperitoneal bleeding and segmental hepatic infarction were observed at low incidence, and recovered with supportive treatment. CONCLUSIONS The combination of TACE and PEI appears to prolong survival, compared with TACE alone. This combination therapy can thus be a valuable form of treatment for unresectable advanced small HCC.
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Affiliation(s)
- Koji Kamada
- First Department of Internal Medicine, Hiroshima University School of Medicine, 1-2-3 Kasumi, Minami-ku, 734-8551, Hiroshima City, Hiroshima, Japan.
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40
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Chang CK, Hendy MP, Smith JM, Recht MH, Welling RE. Radiofrequency ablation of the porcine liver with complete hepatic vascular occlusion. Ann Surg Oncol 2002; 9:594-8. [PMID: 12095977 DOI: 10.1007/bf02573897] [Citation(s) in RCA: 41] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND We studied the effects of radiofrequency ablation, relative to hepatic blood flow, on the volume and shape of the resulting tissue necrosis. The extent of necrosis is directly proportional to the size of the electrode and inversely related to blood flow, which dissipates the heat generated. METHODS Two areas of necrosis were created in each of eight porcine livers, which were assigned to four groups according to blood flow occlusion: no occlusion, occlusion of the hepatic artery and portal vein, occlusion of the hepatic veins, and complete hepatic vascular occlusion. After 25 minutes of liver reperfusion, the animals were euthanized, and the livers were examined. RESULTS Complete vascular occlusion resulted in the greatest area of necrosis (28.6 +/- 3.4 cm(3)), followed by occlusion of the hepatic artery and portal vein (19.2 +/- 5.9 cm(3)), occlusion of hepatic veins (14.4 +/- 2.6 cm(3)), and no occlusion (4.9 +/- 1.5 cm(3)). The volume of the necrotic areas created during complete vascular occlusion were significantly greater than those created with no occlusion, as well as those created with only the hepatic artery and portal vein occluded (P <.05). CONCLUSIONS Complete vascular occlusion, combined with radiofrequency ablation, increases the volume of necrosis and creates a more spherical ablative area.
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Affiliation(s)
- C K Chang
- Department of Surgery, Good Samaritan Hospital, Cincinnati, Ohio 45220, USA
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41
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Wayne JD, Lauwers GY, Ikai I, Doherty DA, Belghiti J, Yamaoka Y, Regimbeau JM, Nagorney DM, Do KA, Ellis LM, Curley SA, Pollock RE, Vauthey JN. Preoperative predictors of survival after resection of small hepatocellular carcinomas. Ann Surg 2002; 235:722-30; discussion 730-1. [PMID: 11981219 PMCID: PMC1422499 DOI: 10.1097/00000658-200205000-00015] [Citation(s) in RCA: 140] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Abstract
OBJECTIVE To determine preoperative predictors of survival that can guide the choice of treatment for patients with small hepatocellular cancers (HCCs). SUMMARY BACKGROUND DATA The treatment of patients with small (</=5 cm in diameter) HCCs is controversial. METHODS A cohort of 249 patients (69 women, 180 men; median age 62 years) who underwent resection with curative intent for small HCC was identified from a multiinstitutional database. For each patient, the clinical data and pathology slides were reviewed. Six clinical factors (age, gender, preoperative alpha-fetoprotein level, hepatitis serology, number of tumors [single vs. multiple], and Child-Pugh score) and three pathologic factors (hepatitis activity score, fibrosis score, and Edmondson-Steiner tumor grade) that can be determined before surgery were correlated with survival. Log-rank tests and Cox proportional hazards modeling were used to determine factors influencing survival. RESULTS The median overall survival for the entire cohort was 4.2 years. The estimated overall 5- and 8-year survival rates were 41.1% and 19.8%, respectively. Multivariate Cox analysis indicated that fibrosis score, Edmondson-Steiner grade, and Child-Pugh score were simultaneously significant predictors of survival after resection. A prognostic scoring system based on these covariates was derived and applied to the entire cohort. Patients lacking all three risk factors were assigned a score of 1, patients with one risk factor were assigned a score of 2, and patients with two or three risk factors were assigned a score of 3. Pairwise log-rank tests indicated significant differences in survival between scores 1 and 2, scores 2 and 3, and scores 1 and 3. This scoring system retained its prognostic significance when a subset of 98 patients with positive hepatitis C serology was analyzed separately. CONCLUSIONS Patients with small HCCs who will derive the least benefit from resection can be identified before surgery using a score based on tumor grade and the severity of underlying liver disease. In these patients, transplantation and/or ablation should be considered as possible alternative therapies.
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Affiliation(s)
- Jeffrey D Wayne
- International Cooperative Study Group on Hepatocellular Carcinoma: Department of Surgical Oncology, the University of Texas M. D. Anderson Cancer Center, Houston, Texas 77030, USA
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Nghiem HV, Francis IR, Fontana R, Hussain H, Platt JF, Higgins E, Bree RL. Computed tomography appearances of hypervascular hepatic tumors after percutaneous radiofrequency ablation therapy. Curr Probl Diagn Radiol 2002; 31:105-11. [PMID: 12140514 DOI: 10.1067/cdr.2002.125400] [Citation(s) in RCA: 19] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022]
Abstract
A retrospective review of the computed tomography (CT) findings of patients with hypervascular liver tumors (26 hepatocellular carcinomas and 2 metastases [1 periampullary carcinoma and 1 neuroendocrine tumor]) who underwent percutaneous ultrasound-guided radiofrequency ablation (RFA) was performed. CT images consisted of nonenhanced and dual-phase contrast-enhanced helical CT images performed on a multidetector CT scan. Findings indicative of adequate tumor ablation on multidetector CT scanwere complete nonenhancement of the treated tumor with or without faint, thin, peripheral rim enhancement. Ablated lesions that showed complete nonenhancement on initial and subsequent follow-up CT examinations either remained stable or became progressively smaller. Thick rim or nodular peripheral enhancement was indicative of tumor residual or recurrence.
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MESH Headings
- Aged
- Aged, 80 and over
- Carcinoma, Hepatocellular/diagnostic imaging
- Carcinoma, Hepatocellular/pathology
- Carcinoma, Hepatocellular/secondary
- Carcinoma, Hepatocellular/surgery
- Carcinoma, Neuroendocrine/diagnostic imaging
- Carcinoma, Neuroendocrine/pathology
- Carcinoma, Neuroendocrine/secondary
- Carcinoma, Neuroendocrine/surgery
- Catheter Ablation
- Female
- Humans
- Liver/diagnostic imaging
- Liver/pathology
- Liver/surgery
- Liver Neoplasms/diagnostic imaging
- Liver Neoplasms/pathology
- Liver Neoplasms/secondary
- Liver Neoplasms/surgery
- Male
- Middle Aged
- Tomography, X-Ray Computed/methods
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Affiliation(s)
- Hanh Vu Nghiem
- Department of Radiology, The University of Michigan Health System, Ann Arbor, MI 48109, USA
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Poon RTP, Fan ST, Tsang FHF, Wong J. Locoregional therapies for hepatocellular carcinoma: a critical review from the surgeon's perspective. Ann Surg 2002; 235:466-86. [PMID: 11923602 PMCID: PMC1422461 DOI: 10.1097/00000658-200204000-00004] [Citation(s) in RCA: 303] [Impact Index Per Article: 13.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECTIVE This article reviews the current results of various locoregional therapies for hepatocellular carcinoma (HCC), with special reference to the implications for surgeons. SUMMARY BACKGROUND DATA Resection or transplantation is the treatment of choice for HCC, but most patients are not suitable candidates. The past decade has witnessed the development of a variety of locoregional therapies for HCC. Surgeons are faced with the challenge of adopting these therapies in the management of patients with resectable or unresectable HCC. METHODS A review of relevant English-language articles was undertaken based on a Medline search from January 1990 to August 2001. RESULTS Retrospective studies suggested that transarterial chemoembolization is an effective treatment for inoperable HCC, but its perceived benefit for survival has not been substantiated in randomized trials, presumably because its antitumor effect is offset by its adverse effect on liver function. Nonetheless, it remains a widely used palliative treatment for HCC not amenable to resection or ablative therapies, and it also plays an important role as a treatment of postresection recurrence and as a pretransplant therapy for transplantable HCC. Better patient selection, selective segmental chemoembolization, and treatment repetition tailored to tumor response and patient tolerance may improve its benefit-risk ratio. Transarterial radiotherapy is a less available alternative that produces results similar to those of chemoembolization. Percutaneous ethanol injection has gained wide acceptance as a safe and effective treatment for HCCs 3 cm or smaller. Uncertainty in tumor necrosis limits its potential as a curative treatment, but its repeatability allows treatment of recurrence after ablation or resection of HCC that is crucial to prolongation of survival. Cryotherapy affords a better chance of cure because of predictable necrosis even for HCCs larger than 3 cm, but its use is limited by a high complication rate. There has been recent enthusiasm for heat ablation by microwave, radiofrequency, or laser, which provides predictable necrosis with a low complication rate. Preliminary data indicated that radiofrequency ablation is superior to ethanol injection in the radicality of tumor ablation. The advent of more versatile radiofrequency probes has allowed ablation of HCCs larger than 5 cm. Recent studies have suggested that combined transarterial embolization and heat ablation is a promising strategy for large HCCs. Thus far, no randomized trials comparing various thermoablative therapies have been reported. It is also uncertain whether a percutaneous route, laparoscopy, or open surgery affords the best approach for these therapies. Thermoablative therapies have been combined with resection or used to treat postresection recurrence, and they have also been used as a pretransplant therapy. However, the value of such strategies requires further evaluation. CONCLUSIONS Advances in locoregional therapies have led to a major breakthrough in the management of unresectable HCC, but the exact role of the various modalities needs to be defined by randomized studies. Novel thermoablative techniques provide the surgeon with an exciting opportunity to participate actively in the management of unresectable HCC. Locoregional therapies are also useful adjuncts in the management of patients with resectable or transplantable disease. Hence, surgeons must be equipped with the latest knowledge and techniques of ablative therapy to provide the most appropriate treatment for the wide spectrum of patients with HCC.
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Affiliation(s)
- Ronnie Tung-Ping Poon
- Centre for the Study of Liver Disease & Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China.
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Braga L, Semelka RC, Pedro MS, de Barros N. Post-treatment malignant liver lesions. MR imaging. Magn Reson Imaging Clin N Am 2002; 10:53-73. [PMID: 11998575 DOI: 10.1016/s1064-9689(03)00049-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
MR imaging is very accurate in the diagnosis and staging of tumors and in surgical planning. MR imaging is also an excellent method for evaluation of the liver after surgical resection, systemic or local tumor therapies, and liver transplantation. It permits early recognition of complications and the presence of recurrent tumor, providing an opportunity to repeat treatment or use alternative treatment. Surgical resection remains the standard therapy for treating liver metastases. The relatively small number of patients who are candidates for curative resection have provided impetus for the implementation and improvement of other techniques. The variety of techniques and the sensitivity for contrast enhancement have made MR imaging an ideal method to follow the response of tumors to various treatment approaches. The appearance of tumor recurrence and the response to treatment are relatively consistently shown on MR images; however, the time course of change in lesion appearance has not been fully elucidated, particularly in the setting of chemotherapy. Evaluating the response to chemotherapy is rendered complex because of the longer duration of the therapy, the types of response that various chemotherapeutic agents engender, the method of action of this therapy and the time of imaging in relation to therapy. The various local therapies share some general principles of action, and many have similar MR imaging findings. Some local therapies are effective only with certain malignancies (e.g., alcohol therapy and HCC), whereas other therapies are more limited because of the size of the tumor kill zone (e.g., interstitial laser therapy). We are in the early stages of using MR imaging to guide local therapies and to monitor response during treatment in real time. This appears to be an important future direction for MR imaging. The role of MR imaging in liver transplantation involves pre- and postoperative investigation of both donors (in the case of living-related transplantation) and recipients. These issues are described further in the section on MR imaging of liver transplantation.
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Affiliation(s)
- Larissa Braga
- Department of Radiology, University of North Carolina School of Medicine, Chapel Hill, North Carolina, USA
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45
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Tang ZY. Hepatocellular carcinoma--cause, treatment and metastasis. World J Gastroenterol 2001; 7:445-54. [PMID: 11819809 PMCID: PMC4688653 DOI: 10.3748/wjg.v7.i4.445] [Citation(s) in RCA: 297] [Impact Index Per Article: 12.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/13/2001] [Revised: 07/20/2001] [Accepted: 07/27/2001] [Indexed: 02/06/2023] Open
Abstract
In the recent decades, the incidence of hepatocellular carcinoma (HCC) has been found to be increasing in males in some countries. In China, HCC ranked second of cancer mortality since 1990s. Hepatitis B and C viruses (HBV and HCV) and dietary aflatoxin intake remain the major causative factors of HCC. Surgery plays a major role in the treatment of HCC, particularly for small HCC. Down-staging unresectable huge HCC to smaller HCC and followed by resection will probably be a new approach for further study. Liver transplantation is indicated for small HCC, however, some issues remain to be solved. Different modes of regional cancer therapy for HCC have been tried. Systemic chemotherapy has been disappointing in the past but the future can be promising. Biotherapy, such as cytokines, differentiation inducers, anti-angiogenic agents, gene therapy and tumor vaccine will probably play a role, particularly in the prevention of tumor recurrence. HCC invasiveness is currently the major target of study. Tremendous works have been done at the molecular level, which will provide clues for biomarker of HCC progression as well as targets for intervention.
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Affiliation(s)
- Z Y Tang
- Liver Cancer Institute of Fudan University, 136 Yixueyuan Road, Zhongshan Hospital, Shanghai 200032, China.
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46
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Abstract
The number of papers published regarding hepatocellular carcinoma between 1999 and 2001 increased from previous years. This year a study confirmed the increase in incidence in the United States. Also, several studies established for the first time that tobacco smoking was a risk factor for the development of this tumor. Several studies established that the process of angiogenesis is critical for the development of hepatocellular carcinoma, and one paper indicated that inhibiting this process might lead to possible treatment of this tumor. Resection was compared with liver transplantation for the first time in two studies. It was shown that transplantation offered the overall best long-term option, but in a certain group of patients without portal hypertension and well-preserved liver function resection is the best option.
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Affiliation(s)
- M M Chokshi
- Department of Internal Medicine, University of Michigan Medical Center, Ann Arbor, Michigan 48109, USA
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47
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Abstract
The majority of patients with primary or metastatic hepatic tumors are not candidates for resection because of tumor size, location near major intrahepatic blood vessels precluding a margin-negative resection, multifocality, or inadequate hepatic function related to coexistent cirrhosis. Radiofrequency ablation (RFA) is an evolving technology being used to treat patients with unresectable primary and metastatic hepatic cancers. RFA produces coagulative necrosis of tumor through local tissue heating. Liver tumors are treated percutaneously, laparoscopically, or during laparotomy using ultrasonography to identify tumors and guide placement of the RFA needle electrode. For tumors smaller than 2.0 cm in diameter, one or two deployments of the monopolar multiple array needle electrode are sufficient to produce complete coagulative necrosis of the tumor. However, with increasing size of the tumor, there is a concomitant increase in the number of deployments of the needle electrode and the overall time necessary to produce complete coagulative necrosis of the tumor. In general, RFA is a safe, well-tolerated, effective treatment for unresectable hepatic malignancies less than 6.0 cm in diameter. Effective treatment of larger tumors awaits the development of more powerful, larger array monopolar and bipolar RFA technologies.
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Affiliation(s)
- S A Curley
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030-4095, USA.
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Izumi N, Asahina Y, Noguchi O, Uchihara M, Kanazawa N, Itakura J, Himeno Y, Miyake S, Sakai T, Enomoto N. Risk factors for distant recurrence of hepatocellular carcinoma in the liver after complete coagulation by microwave or radiofrequency ablation. Cancer 2001. [DOI: 10.1002/1097-0142(20010301)91:5<949::aid-cncr1084>3.0.co;2-h] [Citation(s) in RCA: 78] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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Rajeshkumar NV, Kuttan R. Phyllanthus amarus extract administration increases the life span of rats with hepatocellular carcinoma. JOURNAL OF ETHNOPHARMACOLOGY 2000; 73:215-219. [PMID: 11025159 DOI: 10.1016/s0378-8741(00)00311-1] [Citation(s) in RCA: 45] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/23/2023]
Abstract
The effect of Phyllanthus amarus extract administration after induction of hepatocellular carcinoma (HCC) by N-nitrosodiethylamine (NDEA) was studied in Wistar rats. Administration of an aqueous extract of P. amarus was found to significantly increase the survival of hepatocellular carcinoma harboring animals. All the untreated rats died of tumour burden by 33.7+/-1.6 weeks. Administration of P. amarus extract (150 mg/kg b.w.) after tumour development increased the survival of animals to an average of 52. 2+/-2.3 weeks. Serum gamma-glutamyl transpeptidase activity which was elevated to 182+/-23 U/l by NDEA administration was lowered to 112+/-19 U/l by the administration of P. amarus extract. Similarly elevated glutathione S-transferase activity (1534+/-116 nmol/min per mg protein) and glutathione (20.5+/-2.4 nmol/mg protein) levels in the NDEA administered group were found to be lowered to 1112+/-89 nmol/min per mg protein and 14.2+/-2.2 nmol/mg protein respectively. P. amarus administration was found to be ineffective in controlling the liver weight, elevation of tissue gamma-glutamyl transpeptidase, serum alkaline phosphatase and serum glutamate pyruvate transaminase of HCC harboring animals.
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Affiliation(s)
- N V Rajeshkumar
- Amala Cancer Research Centre, Thrissur, 680 553, Kerala, India
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Curley SA, Izzo F, Ellis LM, Nicolas Vauthey J, Vallone P. Radiofrequency ablation of hepatocellular cancer in 110 patients with cirrhosis. Ann Surg 2000; 232:381-91. [PMID: 10973388 PMCID: PMC1421151 DOI: 10.1097/00000658-200009000-00010] [Citation(s) in RCA: 522] [Impact Index Per Article: 21.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE To determine the treatment efficacy, safety, local tumor control, and complications related to radiofrequency ablation (RFA) in patients with cirrhosis and unresectable hepatocellular carcinoma (HCC). SUMMARY BACKGROUND DATA Most patients with HCC are not candidates for resection because of tumor size, location, or hepatic dysfunction related to cirrhosis. RFA is a technique that permits in situ destruction of tumors by means of local tissue heating. METHODS One hundred ten patients with cirrhosis and HCC (Child class A, 50; B, 31; C, 29) were treated during a prospective study using RFA. Patients were treated with RFA using an open laparotomy, laparoscopic, or percutaneous approach with ultrasound guidance to place the RF needle electrode into the hepatic tumors. All patients were followed up at regular intervals to detect treatment-related complications or recurrence of disease. RESULTS All 110 patients were followed up for at least 12 months after RFA (median follow-up 19 months). Percutaneous or intraoperative RFA was performed in 76 (69%) and 34 patients (31%), respectively. A total of 149 discrete HCC tumor nodules were treated with RFA. The median diameter of tumors treated percutaneously (2.8 cm) was smaller than that of lesions treated during laparotomy (4.6 cm). Local tumor recurrence at the RFA site developed in four patients (3.6%); recurrent HCC subsequently developed in other areas of the liver in all four. New liver tumors or extrahepatic metastases developed in 50 patients (45. 5%), but 56 patients (50.9%) had no evidence of recurrence. There were no treatment-related deaths, but complications developed in 14 patients (12.7%) after RFA. CONCLUSIONS In patients with cirrhosis and HCC, RFA produces effective local control of disease in a significant proportion of patients and can be performed safely with minimal complications.
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Affiliation(s)
- S A Curley
- Department of Surgical Oncology, The University of Texas M.D. Anderson Cancer Center, Houston, Texas 77030, USA.
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