Randomized clinical trial of hepatic resection versus radiofrequency ablation for early-stage hepatocellular carcinoma

Stereotactic body radiotherapy is an alternative to radiofrequency ablation for single HCC ≤5.0 cm

Background & Aims

Radiation therapy has been refined with increasing evidence of the benefits of stereotactic body radiation therapy (SBRT) in treating hepatocellular carcinoma (HCC). In this study, we aimed to evaluate whether SBRT could serve as an alternative to radiofrequency ablation (RFA) for small HCC with a single lesion ≤5.0 cm.

Methods

Patients with a single HCC lesion ≤5.0 cm who received RFA or SBRT were included. Cumulative local/distant recurrence rate, progression-free survival, overall survival, adverse events and subsequent treatments after recurrence were analyzed.

Results

A total of 288 patients receiving RFA (n = 166) or SBRT (n = 122) were enrolled. The baseline characteristics between the two groups were comparable. The cumulative local recurrence rate in the SBRT group was significantly lower than that in the RFA group (hazard ratio [HR] 0.30, 95% CI 0.16-0.57, p <0.001), especially for patients with tumours >2.0 cm (HR 0.20, 95% CI 0.08-0.50, p <0.001) or adjacent to major vessels (HR 0.29, 95% CI 0.13-0.66, p <0.001). Cumulative distant recurrence rate, progression-free survival and overall survival were not significantly different between the two groups (all p >0.050). Adverse events were mild and easily reversible. However, more patients in the SBRT group suffered from Child-Pugh score and total bilirubin increases. More treatment options after recurrence or progression might be available for patients in the RFA group compared to those in the SBRT group (p <0.001).

Conclusions

Both RFA and SBRT were effective and safe for HCC with a single lesion ≤5.0 cm. SBRT could be an alternative treatment to RFA, especially for tumours >2.0 cm or adjacent to major vessels.

Impact and implications

Stereotactic body radiation therapy (SBRT) may be used as an alternative treatment to thermal ablation for patients with BCLC stage A hepatocellular carcinoma (HCC) who are not candidates for surgical resection, including those with tumours >3 cm and those with 1 to 3 tumours. This study focused on HCC patients with a specific tumour burden, namely a single lesion ≤5.0 cm, demonstrating that SBRT could be an effective and safe alternative to radiofrequency ablation (RFA), especially for those with tumours >2.0 cm or adjacent to major vessels. The findings of this study provided robust empirical evidence supporting the utilization of SBRT in treating small HCC, while also establishing a solid foundation for future prospective clinical investigations.

Oncological outcomes of tumor ablation compared to surgical resection in early-stage hepatocellular carcinomas: a systematic review with meta-analysis

BACKGROUND

The optimal choice of treatment for early-stage hepatocellular carcinomas (HCC) remains controversial, with recent conflicted guidelines. This systematic review evaluated whether ablation is oncologically non-inferior to surgical resection.

METHODS

We performed a systematic search of the EMBASE, MEDLINE, CENTRAL and Web of Science databases to identify randomized controlled trials comparing tumor ablation and surgical resection for early-stage HCCs. A non-inferiority margin of 5% (RR 0.93) for overall survival (OS) was considered, following a consensus of clinical experts.

RESULTS

We identified 5829 citations from which 11 trials (n = 1736) were included. The non-inferiority of tumor ablation was not observed for OS (RR 0.92; 95%CI 0.85-1.00,I2 = 33%). Recurrence-free survival was reduced with ablation (RR 0.80; 95%CI 0.69-0.93,I2 = 49%). There was no difference in terms of extra-hepatic recurrence and minor complications. Tumor ablation was associated with decreased overall morbidity (RR 0.43; 95%CI 0.30-0.62,I2 = 31%) and major complications (RR 0.22; 95%CI 0.07-0.71,I2 = 66%). Intra-hepatic recurrence was higher with ablation (RR 1.28; 95%CI 1.10-1.48,I2 = 12%). Certainty of evidence was low to moderate.

CONCLUSION

We did not observe the oncological non-inferiority of tumor ablation when compared to surgical resection. Nevertheless, most analyses were of low quality of evidence, including the overall survival. We cannot exclude that the true effect of tumor ablation is different than the currently observed one.

Percutaneous ablation in perivascular-HCC: impact of liver parenchyma and characteristics of vascular structures on the outcomes

AIM

Percutaneous radiofrequency ablation (RFA) is a standard treatment for small-HCC (<3 cm). However, some features such as proximity to intrahepatic vascular structures (perivascular location) seem to be related to short- and long-term outcomes. The aims of the study were to investigate the features related to ablation success and local tumor progression (LTP) in patients submitted to percutaneous ablation for perivascular-HCC.

MATERIALS AND METHODS

From January 2010 to May 2021, 132 perivascular-HCC nodules ablated with US-guided single probe percutaneous RFA were retrospectively analyzed. Univariate analysis and multivariable Cox regression model were used to identify factors that were independently related to ablation success and LTP-free survival.

RESULTS

The overall ablation success rate was 71.9% (n=95). Morbidity and mortality rates were 4.0% and 0.0%. The features related to ablation success: nodule size (≤20 mm vs. >20 mm) (OR 2.442, p=0.031), major vascular structures diameter (3-5 mm vs ≥ 5 mm) (OR 2.167, p=0.037) and liver parenchyma (cirrhosis vs no-cirrhosis) (OR 2.373, p=0.033). The following features resulted independently related to better LTP-free survival: nodule size ≤20 mm (HR 2.802, p=0.003), proximity to glissonean pedicles (HR 1.677, p=0.028), and major vascular structure diameter <5 mm (HR 1.987, p=0.041).

CONCLUSIONS

Perivascular location confirmed to be a difficult and unfavorable indication for percutaneous ablation for HCC nodules. However, perivascular nodules not suitable for surgery with low-risk features (size <20 mm, proximity to glissonian pedicles and vascular diameter <5 mm) may be treated with RFA with satisfactory outcomes.

Therapeutic analysis of 632 cases treated by transcatheter arterial chemoembolization combined with ablation in hepatocellular carcinoma: A retrospective study

OBJECTIVES

This study aims to analyze the efficacy of transcatheter arterial chemoembolization (TACE) combined with radiofrequency ablation (RFA), microwave ablation (MWA), and cryoablation (CA) in hepatocellular carcinoma (HCC).

METHODS

A retrospective analysis was conducted on 632 patients with HCC at Barcelona Clinic Liver Cancer Staging (BCLC) System stages 0, A, and B from Beijing You'an Hospital affiliated with Capital Medical University. The primary outcomes analyzed were overall survival (OS) and progression-free survival (PFS), while the secondary outcomes included one-, three-, and five-year OS rates among different groups.

RESULTS

The median follow-up period for 632 cases identified with HCC was 52.1 months (range: 3-162 months), while 127 patients died during follow-up. The one-, three-, and five-year OS rates were 97.1 %, 89.5 %, and 80.4 %, respectively. Moreover, the one-, three-, and five-year PFS rates were 58.1 %, 29.3 %, and 19.8 %, respectively. Multivariate analysis revealed that the BCLC stages and complete ablation were independent predictors of OS and PFS (all p < 0.05). Subgroup analysis showed no difference in OS rate among TACE-RFA, TACE-MWA, and TACE-CA groups, but TACE-CA showed better efficacy in improving the PFS rate (all p < 0.05).

CONCLUSIONS

The combination of TACE and ablation is effective in early-stage HCC and BCLC stage B. Complete ablation and BCLC stages are significant prognostic factors for PFS and OS. Further research, including randomized controlled trials, is needed to validate these findings.

Short-Term Out-of-Pocket and Total Costs of Care After Ablation, Resection, or Transplant for Early-Stage Hepatocellular Carcinoma: A National SEER-Medicare Cost Comparison

BACKGROUND. Differences in survival and morbidity among treatment options (ablation, surgical resection, and transplant) for early-stage hepatocellular carcinoma (HCC) have been well studied. Additional understanding of the costs of such care would help to identify drivers of high costs and potential barriers to care delivery. OBJECTIVE. The purpose of this article was to quantify total and patient out-of-pocket costs for ablation, surgical resection, and transplant in the management of early-stage HCC and to identify factors predictive of these costs. METHODS. This retrospective U.S. population-based study used the SEER-Medicare linked dataset to identify a sample of 1067 Medicare beneficiaries (mean age, 73 years; 674 men, 393 women) diagnosed with early-stage HCC (size ≤ 5 cm) treated with ablation (n = 623), resection (n = 201), or transplant (n = 243) between January 2009 and December 2016. Total costs and patient out-of-pocket costs for the index procedure as well as for any care within 30 and 90 days after the procedure were identified and stratified by treatment modality. Additional comparisons were performed among propensity score-matched subgroups of patients treated by ablation or resection (each n = 172). Multivariable linear regression models were used to identify factors predictive of total costs and out-of-pocket costs for index procedures as well as for 30- and 90-day post-procedure periods. RESULTS. For ablation, resection, and transplant, median index-procedure total cost was US$6689, US$25,614, and US$66,034; index-procedure out-of-pocket cost was US$1235, US$1650, and US$1317; 30-day total cost was US$9456, US$29,754, and US$69,856; 30-day out-of-pocket cost was US$1646, US$2208, and US$3198; 90-day total cost was US$14,572, US$34,984, and US$88,103; and 90-day out-of-pocket cost was US$2138, US$2462, and US$3876, respectively (all p < .001). In propensity score-matched subgroups, ablation and resection had median index-procedure, 30-day, and 90-day total costs of US$6690 and US$25,716, US$9995 and US$30,365, and US$15,851 and US$34,455, respectively. In multivariable analysis adjusting for socioeconomic factors, comorbidities, and liver-disease prognostic indicators, surgical treatment (resection or transplant) was predictive of significantly greater costs compared with ablation at all time points. CONCLUSION. Total and out-of-pocket costs for index procedures as well as for 30-day and 90-day postprocedure periods were lowest for ablation, followed by resection and then transplant. CLINICAL IMPACT. This comprehensive cost analysis could help inform future cost-effectiveness analyses.

Risk Factors for Hospitalization Duration Longer Than 24 Hours Following Percutaneous Radiofrequency Ablation of Liver Tumours

PURPOSE

Prior studies have described complications of radiofrequency ablation (RFA) of liver tumours. The aim of this study was to identify risk factors for hospitalization duration longer than 24 hours following RFA of liver tumours.

METHODS

This retrospective, single-centre study included patients with liver tumours undergoing RFA between October 2017 and July 2020. Medical records were reviewed to collect patient, tumours, and procedure characteristics for each RFA session. The association between potential risk factors and duration of hospitalization (less than or more than 24 hours) was analyzed using univariate and multivariate logistic regressions.

RESULTS

Our study included 291 patients (mean age: 65.2 ± 11.2 [standard deviation]; 201 men) undergoing 324 RFA sessions. Sixty-eight sessions (21.0%) resulted in hospitalization of more than 24 hours. Multivariate analysis identified each additional needle insertion per session (OR 1.4; 95% CI [1.1-1.9]; P = .02), RFA performed in segment V (OR 2.8; 95% CI [1.4-5.7]; P = .004), and use of artificial pneumothorax (OR 14.5; 95% CI [1.4-146.0]; P = .02) as potential risk factors. A history of hepatic encephalopathy (OR 2.6; 95% CI [1.1-6.0]; P = .03) was only significant in univariate analysis. Post-hoc, subgroup analysis of patients with hepatocellular carcinoma (69.8%) did not identify other risk factors.

CONCLUSION

Risk factors for a hospitalization duration longer than 24 hours include a higher number of needle insertions per session, radiofrequency ablation in segment V, and use of an artificial pneumothorax.

Meta analysis of radiofrequency ablation versus surgical resection in small and large nodule of hepatocellular carcinoma

INTRODUCTION

Although studies have indicated comparable outcomes between RFA and surgical resection in early HCC, there is still unclear evidence of benefit in larger tumor sizes. This study aimed to assess the efficacy and safety of RFA versus surgical resection in HCC patients, considering nodule size with a cutoff at 3 cm.

METHODS

A comprehensive search of multiple databases was conducted. The systematic review and meta-analysis followed the PRISMA guidelines.

RESULT

Surgical resection showed superior OS (HR = 1.18, 95% CI: 1.11-1.27, p = 0.008) and RFS (HR = 1.17, 95% CI: 1.11-1.25, p < 0.00001), compared to RFA. For nodules less than 3 cm or larger than 5 cm, the OS and RFS in the surgical resection group were significantly higher than those in the RFA group, while no significant differences were observed for nodules sized 3-5 cm. However, significantly more adverse events occurred following surgical resection (OR = 0.43, 95% CI: 0.33-0.56, P < 0.00001).

CONCLUSION

Surgical resection has better OS and RFS compared to RFA for liver tumors less than 3 cm or larger than 5 cm. For liver tumors sized 3-5 cm, RFA and surgical resection yield similar findings. RFA may become a preferable option in these 3-5 cm tumors due to its comparable efficacy and fewer adverse events for patients unsuitable for surgery.

Complications of Percutaneous Radiofrequency Ablation for Hepatocellular Carcinoma

Radiofrequency ablation (RFA) is a potentially curative treatment option for early Hepatocellular carcinoma. The RFA is considered safe with a relatively low incidence of complications ranging from 2%-7.9%. Though most of the complications are self-limiting, sometimes they can be life-threatening. The occurrence of the particular complication depends on various factors like tumour location and morphology, underlying disease and ablation technique. A detailed understanding of potential complications along with the associated risk factors will help to employ strategies to prevent them, identify them early and manage them when they occur. This article demonstrates various radiofrequency ablation-related complications and discusses the risk factors and technical strategies to minimise them and achieve complete ablation of the tumour.

Adjuvant holmium-166 radioembolization after radiofrequency ablation in early-stage hepatocellular carcinoma patients: a dose-finding study (HORA EST HCC trial)

PURPOSE

The aim of this study was to investigate the biodistribution of (super-)selective trans-arterial radioembolization (TARE) with holmium-166 microspheres (166Ho-MS), when administered as adjuvant therapy after RFA of HCC 2-5 cm. The objective was to establish a treatment volume absorbed dose that results in an absorbed dose of ≥ 120 Gy on the hyperemic zone around the ablation necrosis (i.e., target volume).

METHODS

In this multicenter, prospective dose-escalation study in BCLC early stage HCC patients with lesions 2-5 cm, RFA was followed by (super-)selective infusion of 166Ho-MS on day 5-10 after RFA. Dose distribution within the treatment volume was based on SPECT-CT. Cohorts of up to 10 patients were treated with an incremental dose (60 Gy, 90 Gy, 120 Gy) of 166Ho-MS to the treatment volume. The primary endpoint was to obtain a target volume dose of ≥ 120 Gy in 9/10 patients within a cohort.

RESULTS

Twelve patients were treated (male 10; median age, 66.5 years (IQR, [64.3-71.7])) with a median tumor diameter of 2.7 cm (IQR, [2.1-4.0]). At a treatment volume absorbed dose of 90 Gy, the primary endpoint was met with a median absorbed target volume dose of 138 Gy (IQR, [127-145]). No local recurrences were found within 1-year follow-up.

CONCLUSION

Adjuvant (super-)selective infusion of 166Ho-MS after RFA for the treatment of HCC can be administered safely at a dose of 90 Gy to the treatment volume while reaching a dose of ≥ 120 Gy to the target volume and may be a favorable adjuvant therapy for HCC lesions 2-5 cm.

TRIAL REGISTRATION

Clinicaltrials.gov NCT03437382 . (registered: 19-02-2018).

Proton Beam Therapy for Treating Patients with Hepatocellular Carcinoma with Major Portal Vein Tumor Invasion: A Single Center Retrospective Study

Hepatocellular carcinoma (HCC) with portal vein tumor thrombosis (PVTT) has a poor prognosis and is generally not indicated for surgery. Proton beam therapy (PBT) may offer an alternative treatment. In this study, long-term outcomes were examined in 116 patients (median age 66 years, 100 males) with HCC with advanced PVTT (Vp3 or Vp4) who received PBT from April 2008 to March 2018. Of these patients, 63 received PBT as definitive treatment and 53 as palliative treatment. The representative dose was 72.6 Gy (RBE) in 22 fractions. Eight patients died in follow-up, including 72 due to tumor progression. The 5-year overall survival (OS) rate was 18.0% (95% CI 9.8-26.2%) and the 5-year local control (LC) rate was 86.1% (74.9-97.3%). In multivariate analyses, performance status and treatment strategy were significantly associated with OS. The median follow-up period for survivors with definitive treatment was 33.5 (2-129) months, and the 5-year OS rate was 25.1% (12.9-37.3%) in these cases. The median survival time after definitive irradiation was >20 months. The 5-year OS rate was 9.1% (0-19.7%) for palliative irradiation. These results compare favorably with those of other therapies and suggest that PBT is a useful option for cases of HCC with advanced PVTT that cannot undergo surgery, with an expected survival benefit and good local control. Determining the optimal indication for this treatment is a future challenge.

Different Patterns of Care and Survival Outcomes in Transplant-Centre Managed Patients with Early-Stage HCC: Real-World Data from an Australian Multi-Centre Cohort Study

The management of early-stage hepatocellular carcinoma (HCC) is complex, with multiple treatment strategies available. There is a paucity of literature regarding variations in the patterns of care and outcomes between transplant and non-transplant centres. We conducted this real-world multi-centre cohort study in two liver cancer referral centres with an integrated liver transplant program and an additional eight non-transplant HCC referral centres across Australia to identify variation in patterns of care and key survival outcomes. Patients with stage Barcelona Clinic Liver Cancer (BCLC) 0/A HCC, first diagnosed between 1 January 2016 and 31 December 2020, who were managed at a participating site, were included in the study. Patients were excluded if they had a history of prior HCC or if they received upfront liver transplantation. A total of 887 patients were included in the study, with 433 patients managed at a liver cancer centre with a transplant program (LTC) and 454 patients managed at a non-transplant centre (NTC). Management at an LTC did not significantly predict allocation to resection (adjusted OR 0.75, 95% CI 0.50 to 1.11, p = 0.148). However, in those not receiving resection, LTC and NTC patients were systematically managed differently, with LTC patients five times less likely to receive upfront ablation than NTC patients (adjusted OR 0.19, 95% CI 0.13 to 0.28, p < 0.001), even after adjusting for tumour burden, as well as for age, gender, liver disease aetiology, liver disease severity, and medical comorbidities. LTCs exhibited significantly higher proportions of patients undergoing TACE for every tumour burden category, including those with a single tumour measuring 2 cm or less (p < 0.001). Using multivariable Cox proportional hazards analysis, management at a transplant centre was associated with reduced all-cause mortality (adjusted HR 0.71, 95% CI 0.51 to 0.98, p = 0.036), and competing-risk regression analysis, considering liver transplant as a competing event, demonstrated a similar reduction in risk (adjusted HR 0.70, 95% CI 0.50 to 0.99, p = 0.041), suggesting that the reduced risk of death is not fully explained by higher rates of transplantation. Our study highlights systematic differences in HCC care between large volume liver transplant centres and other sites, which has not previously been well-described. Further work is needed to better define the reasons for differences in treatment allocation and to aim to minimise unwarranted treatment variation to maximise patient outcomes across Australia.

Magnetic resonance imaging-based rim enhancement could effectually predict poor prognosis in hepatocellular carcinoma: a meta-analysis

Recent studies have initially shown that MRI-based rim enhancement associates with poor prognosis in hepatocellular carcinoma (HCC) patients, but their sample sizes are small, leading to a necessary of comprehensive analyses to make a relatively solid statement. Thus, this meta-analysis aimed to summarize the correlation between MRI-based rim enhancement and prognosis in HCC patients. Until March 2023, a literature search was conducted on Web of Science, PubMed, EMBASE, Cochrane, CNKI, Wangfang, and CQVIP databases in order to identify studies that report the correlation between MRI-based rim enhancement and the prognosis of HCC patients. MRI-based rim enhancement and prognostic data were extracted and analyzed. In our study, eight studies containing 1816 HCC patients were analyzed. Generally, the presence of MRI-based rim enhancement was related to shortened disease-free survival (DFS) [hazard ratio (HR): 2.77, 95% confidence interval (CI): 2.11-3.62, P < 0.001], and worse overall survival (OS) (HR: 5.43, 95% CI: 2.14-13.79, P < 0.001). While no other prognostic data could be retrieved. Funnel plots, Begg's test, and Egger's test all indicated that no publication bias existed; and the risk score by Newcastle-Ottawa Scale criteria ranged from 7-9 points, suggesting a generally low risk of bias. Meanwhile, the sensitivity analysis showed that the significant findings did not change by omitting each study. Then, subgroup analyses revealed that no matter stratified by tumor size, treatment option, or sample size, rim enhancement was linked with unsatisfied DFS (all P < 0.05). Conclusively, MRI-based rim enhancement could effectually estimate poor survival in HCC patients, indicating its good prognostic value.

Development and validation of nomograms for predicting prognosis in patients with solitary HCC: A TRIPOD-Compliant study

Objective

To develop and validate nomograms for predicting the OS and CSS of patients with Solitary Hepatocellular Carcinoma (HCC).

Methods

Using the TRIPOD guidelines, this study identified 5206 patients in the Surveillance, Epidemiology, and End Results (SEER) 17 registry database. All patients were randomly divided in a ratio of 7:3 into a training cohort (n = 3646) and a validation cohort (n = 1560), and the Chinese independent cohort (n = 307) constituted the external validation group. The prognosis-related risk factors were selected using univariate Cox regression analysis, and the independent prognostic factors of OS and CSS were identified using the Lasso-Cox regression model. The nomograms for predicting the OS and CSS of the patients were constructed based on the identified prognostic factors. Their prediction ability was evaluated using the concordance index (C-index), receiver operating characteristic (ROC) curve, and calibration curve in both the training and validation cohorts.

Results

We identified factors that predict OS and CSS and constructed two nomograms based on the data. The ROC analysis, C-index analysis, and calibration analysis indicated that the two nomograms performed well over the 1, 3, and 5-year OS and CSS periods in both the training and validation cohorts. Additionally, these results were confirmed in the external validation group. Decision curve analysis (DCA) demonstrated that the two nomograms were clinically valuable and superior to the TNM stage system.

Conclusion

We established and validated nomograms to predict 1,3, and 5-year OS and CSS in solitary HCC patients, and our results may also be helpful for clinical decision-making.

Osteosarcopenia impacts treatment outcomes for Barcelona Cancer Liver Classification stage A hepatocellular carcinoma

AIM

To study the effect of preoperative osteosarcopenia (OSP) on the prognosis of treatment (surgery or radiofrequency ablation (RFA)) in patients with Barcelona Cancer Liver Classification stage A hepatocellular carcinoma (BCLC A HCC).

METHODS

This study enrolled 102 patients with BCLC A HCC who underwent surgical resection (n = 45) and RFA (n = 57); the patients were divided into two groups: OSP (n = 33) and non-OSP (n = 69). Overall survival (OS) and disease-free survival (DFS) curves for both the groups and treatment methods (surgery and RFA) were generated using the Kaplan-Meier method and compared using the log-rank test. Univariate analyses for OS and DFS were performed using log-rank test. Multivariate analyses were performed for factors that were significant at univariate analysis by Cox proportional hazard model.

RESULTS

Multivariate analysis showed that OSP (HR 2.44; 95 % CI 1.30-4.55; p < 0.01) and treatment (HR 0.57; 95 % CI 0.31-0.99; p = 0.05) were significant independent predictors of DFS; and treatment (HR, 0.30; 95 % CI 0.10-0.85; p = 0.03) was a significant independent predictor of OS in the non-OSP group, in which the OS rate was significantly lower in patients treated with RFA than in those treated by resection (p = 0.01).

CONCLUSIONS

OSP is a prognostic factor for BCLC A HCC treatment. Surgical approach was associated with a significantly better prognosis in patients without OSP compared to those who underwent RFA.

Treatment options for solitary hepatocellular carcinoma ≤5 cm: surgery vs. ablation: a multicenter retrospective study

BACKGROUND/AIM

The aim of this study was to compare the therapeutic efficacy of ablation and surgery in solitary hepatocellular carcinoma (HCC) measuring ≤5 cm with a large HCC cohort database.

METHODS

The study included consecutive 2,067 patients with solitary HCC who were treated with either ablation (n=1,248) or surgery (n=819). Th e patients were divided into three groups based on the tumor size and compared the outcomes of the two therapies using propensity score matching.

RESULTS

No significant difference in recurrence-free survival (RFS) or overall survival (OS) was found between surgery and ablation groups for tumors measuring ≤2 cm or >2 cm but ≤3 cm. For tumors measuring >3 cm but ≤5 cm, RFS was significantly better with surgery than with ablation (3.6 and 2.0 years, respectively, P=0.0297). However, no significant difference in OS was found between surgery and ablation in this group (6.7 and 6.0 years, respectively, P=0.668).

CONCLUSION

The study suggests that surgery and ablation can be equally used as a treatment for solitary HCC no more than 3 cm in diameter. For HCCs measuring 3-5 cm, the OS was not different between therapies; thus, ablation and less invasive therapy can be considered a treatment option; however, special caution should be taken to prevent recurrence.

Evaluation of the effectiveness of surgical resection and ablation for the treatment of early-stage hepatocellular carcinoma: A retrospective cohort study

BACKGROUND

The optimal treatment strategy for early-stage hepatocellular carcinoma (HCC) remains controversial, specifically in regard to surgical resection (SR) and ablation. The aim of this study was to investigate the impact of SR and ablation on recurrence and prognosis in early-stage HCC patients, to optimize treatment strategies and improve long-term survival.

METHODS

A retrospective analysis was conducted on 801 patients diagnosed with Barcelona Clinic Liver Cancer (BCLC) stage 0/A HCC and treated with SR or ablation between January 2015 and December 2019. The effectiveness and complications of both treatments were analyzed, and patients were followed up to measure recurrence and survival. Propensity score matching (PSM) was employed to increase comparability between the two groups. The Kaplan-Meier method was used to analyze recurrence and survival, and a Cox risk proportional hazard model was used to identify risk factors that affect recurrence and surviva.

RESULTS

Before PSM, the overall survival (OS) rates were similar in both groups, with recurrence-free survival (RFS) rates better in the SR group than in the ablation group. After PSM, there was no significant difference in OS between the two groups. However, the RFS rates were significantly better in the SR group than in the ablation group. The ablation group exhibited superior outcomes compared to the SR group, with shorter treatment times, reduced bleeding, shorter hospital stays, and lower hospital costs. Concerning the location of the HCC within the liver, comparable efficacy was observed between SR and ablation for disease located in the noncentral region or left lobe. However, for HCCs located in the central region or right lobe of the liver, SR was more effective than ablation.

CONCLUSIONS

This study revealed no significant difference in OS between SR and ablation for early-stage HCC, with SR providing better RFS and ablation demonstrating better safety profiles and lower hospital costs. These findings offer valuable insights for clinicians in determining optimal treatment strategies for early-stage HCC patients, particularly in terms of balancing efficacy, safety, and cost considerations.

Proton Beam Therapy for Hepatocellular Carcinoma: Multicenter Prospective Registry Study in Japan

PURPOSE

A prospective multicenter registry study was started May 2016 in Japan to evaluate the efficacy and safety of proton beam therapy (PBT) for hepatocellular carcinoma (HCC).

METHODS AND MATERIALS

Patients who received PBT for HCC from May 2016 to June 2018 were registered in the database of the Particle Beam Therapy Committee and Subcommittee of the Japanese Society for Radiation Oncology. Overall survival (OS), progression-free survival (PFS), and local recurrence were evaluated.

RESULTS

Of the 755 registered patients, 576 with initial PBT and no duplicate cancer were evaluated. At final follow-up, 322 patients were alive and 254 had died. The median follow-up period for survivors was 39 months (0-58 months). The median OS time of the 576 patients was 48.8 months (95% CI, 42.0-55.6 months) and the 1-, 2-, 3-, and 4-year OS rates were 83.8% (95% CI, 80.5%-86.6%), 68.5% (64.5%-72.2%), 58.2% (53.9%-62.2%), and 50.1% (44.9%-55.0%), respectively. Recurrence was observed in 332 patients, including local recurrence in 45 patients. The median PFS time was 14.7 months (95% CI, 12.4-17.0 months) and the 1-, 2-, 3-, and 4-year PFS rates were 55.2% (95% CI, 51.0%-59.2%), 37.5% (33.5%-41.5%), 30.2% (26.3%-34.2%), and 22.8% (18.5%-27.4%), respectively. The 1-, 2-, 3-, and 4-year OS rates were significantly higher for tumor size <5 versus 5 to 10 cm (P < .001) and <5 versus ≥10 cm (P < .001); Child-Pugh score A/B versus C (P < .001); and distance of the tumor from the gastrointestinal tract <1 versus 1 to 2 cm (P < .008) and <1 versus >2 cm (P < .001). At final follow-up, 27 patients (4.7%) had late adverse events of grade 3 or higher, with liver failure (n = 7), and dermatitis (n = 7) being most common.

CONCLUSIONS

This multicenter prospective data registry indicated that PBT for HCC gives good therapeutic effects (3-year local control rate of 90%) with a low risk of severe late adverse events.

Development and evaluation of nomograms and risk stratification systems to predict the overall survival and cancer-specific survival of patients with hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is the most common type of primary liver cancer, and patients with HCC have a poor prognosis and low survival rates. Establishing a prognostic nomogram is important for predicting the survival of patients with HCC, as it helps to improve the patient's prognosis. This study aimed to develop and evaluate nomograms and risk stratification to predict overall survival (OS) and cancer-specific survival (CSS) in HCC patients. Data from 10,302 patients with initially diagnosed HCC were extracted from the Surveillance, Epidemiology, and End Results (SEER) database between 2010 and 2017. Patients were randomly divided into the training and validation set. Kaplan-Meier survival, LASSO regression, and Cox regression analysis were conducted to select the predictors of OS. Competing risk analysis, LASSO regression, and Cox regression analysis were conducted to select the predictors of CSS. The validation of the nomograms was performed using the concordance index (C-index), the Akaike information criterion (AIC), the Bayesian information criterion (BIC), Net Reclassification Index (NRI), Discrimination Improvement (IDI), the receiver operating characteristic (ROC) curve, calibration curves, and decision curve analyses (DCAs). The results indicated that factors including age, grade, T stage, N stage, M stage, surgery, surgery to lymph node (LN), Alpha-Fetal Protein (AFP), and tumor size were independent predictors of OS, whereas grade, T stage, surgery, AFP, tumor size, and distant lymph node metastasis were independent predictors of CSS. Based on these factors, predictive models were built and virtualized by nomograms. The C-index for predicting 1-, 3-, and 5-year OS were 0.788, 0.792, and 0.790. The C-index for predicting 1-, 3-, and 5-year CSS were 0.803, 0.808, and 0.806. AIC, BIC, NRI, and IDI suggested that nomograms had an excellent predictive performance with no significant overfitting. The calibration curves showed good consistency of OS and CSS between the actual observation and nomograms prediction, and the DCA showed great clinical usefulness of the nomograms. The risk stratification of OS and CSS was built that could perfectly classify HCC patients into three risk groups. Our study developed nomograms and a corresponding risk stratification system predicting the OS and CSS of HCC patients. These tools can assist in patient counseling and guiding treatment decision making.

Comparison of liver resection and radiofrequency ablation in long-term survival among patients with early-stage hepatocellular carcinoma: a meta-analysis of randomized trials and high-quality propensity score-matched studies

BACKGROUND

Whether radiofrequency ablation (RFA) and liver resection (LR) are comparable treatments for early-stage hepatocellular carcinoma (HCC) is controversial. We conducted this study to provide ample clinical evidence for the argument.

METHODS

The PubMed, Embase, Web of Science, and Cochrane Library databases were systematically searched to identify randomized controlled trials (RCTs) and propensity score-matched (PSM) studies that compared long-term outcomes of both RFA and LR for patients with early-stage HCC. The hazard ratios (HRs) with 95% confidence intervals (95% CI) of overall survival (OS) and disease-free survival (DFS) were calculated.

RESULTS

Thirty-six studies consisting of six RCTs and 30 PSM studies were included in this study, and a total of 7384 patients were involved, with 3694 patients being treated with LR and 3690 patients with RFA. Meta-analysis showed that LR provided better OS and DFS than RFA (HR: 1.22, 95% CI: 1.13-1.31; HR: 1.56, 95% CI: 1.39-1.74, respectively). A sensitivity analysis indicated that the results were stable. For the subgroup of patients with BCLC 0 stage, RFA and LR resulted in similar OS and DFS. For the subgroup of patients with single tumor sizes less than 3 cm, RFA reached similar OS (HR: 1.19, 95% CI: 0.90-1.58) but worse DFS compared with LR (HR: 1.45, 95% CI: 1.11-1.90). For the subgroup of ablation margin larger than 0.5 cm, LR still resulted in better OS than RFA (HR: 1.29, 95% CI: 1.09-1.53); while the ablation margin was larger than 1 cm, both RFA and LR resulted in similar OS. The modality of RFA was also a factor that affected results. Subgroup analysis showed that patients receiving ultrasound-guided RFA had worse OS and DFS than LR (HR: 1.24, 95% CI: 1.14-1.36; HR: 1.44, 95% CI: 1.25-1.66, respectively).

CONCLUSIONS

Meta-analysis showed that LR provided better OS and DFS for patients with early-stage HCC. However, RFA and LR had similar effects on long-term survival in patients with BCLC 0 stage HCC. RFA and LR probably had similar effects on OS in patients with solitary HCC less than 3 cm or when the ablation margin was larger than 1 cm which need more studies to confirm. The effects of different modalities of RFA on long-term survival are needed for further assessment.

Cryoablation in the liver: how accurately does the iceball predict the ablation zone?

PURPOSE

To evaluate the accuracy with which the iceball predicts the realized ablation zone in patients undergoing cryoablation of the liver.

MATERIALS AND METHODS

Continuous patients who underwent cryoablation of primary or secondary malignancies of the liver were retrospectively reviewed. Iceball and ablation zone dimensions on 1 month follow up imaging were collected in three orientations, the long axis (LA), perpendicular transverse (PTR), and perpendicular craniocaudal (PCC). Factors which may predict differences in the measurements were evaluated with regression analysis. Oncologic outcomes were also collected.

RESULTS

The mean size of the iceball was 5.5 ± 1.1 cm, 3.9 ± 1.1 cm, and 4.4 ± 1.4 cm in the LA, PTR, and PCC orientations, respectively. The mean size of the one-month ablation cavity was 4.3 ± 1.3 cm, 3 ± 1.1 cm, and 3 ± 1.3 cm in the LA, PTR, and PCC orientations, respectively. The iceball was significantly larger than the ablation zone in all orientations (p < 0.001). When comparing HCC and non-HCC patients the Kaplan-Meier analysis of TTLP, the Kaplan Meier curves deviated significantly (p = 0.015, HR 2.26 (95%CI 1.17-4.37)). When a similar analysis was performed looking at TTP again the curves diverged significantly (p = 0.002, HR 2.4 (95%CI 1.37-4.19)).

CONCLUSION

The iceball seems to overestimate the realized ablation zone by about 1 cm in all orientations during hepatic cryoablation.

Comparison of clinical outcome between laparoscopic and open hepatectomy of high difficulty score for hepatocellular carcinoma: a propensity score analysis

BACKGROUND

Laparoscopic liver resection (LLR) of high difficulty score is technically challenging. There is a lack of clinical evidence to support its applicability in terms of the long-term survival benefits. This study aims to compare clinical outcomes between LLR and the open liver resection of high difficulty score for hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

From 2010 to 2020, using Iwate criteria, 424 patients underwent liver resection of high difficulty score by the laparoscopic (n = 65) or open (n = 359) approach. Propensity score (PS) matching was performed between the two groups. Short-term and long-term outcomes were compared between PS-matched groups. Univariate and multivariate analyses were performed to identify prognostic factors affecting survival.

RESULTS

The laparoscopic group had significantly fewer severe complications (3% vs. 10.8%), and shorter median hospital stays (6 days vs. 8 days) than the open group. Meanwhile, the long-term oncological outcomes were comparable between the two groups, in terms of the tumor recurrence rate (40% vs. 46.1%), the 5-year overall survival rate (75.4% vs. 76.2%), and the 5-year recurrence-free survival rate (50.3% vs. 53.5%). The high preoperative serum alpha-fetoprotein level, multiple tumors, and severe postoperative complications were the independent poor prognostic factors associated with worse overall survival. The surgical approach (Laparoscopic vs. Open) did not influence the survival.

CONCLUSION

LLR of high difficulty score for selected patients with HCC has better short-term outcomes than the open approach. More importantly, it can achieve similar long-term survival outcomes as the open approach.

Identification and validation of an H2AZ1-based index model: a novel prognostic tool for hepatocellular carcinoma

The H2A.Z variant histone 1 (H2AZ1) is aberrantly expressed in various tumors, correlating with an unfavorable prognosis. However, its role in hepatocellular carcinoma (HCC) remains unclear. We aimed to elucidate the pathways affected by H2AZ1 and identify promising therapeutic targets for HCC. Following bioinformatic analysis of gene expression and clinical data from The Cancer Genome Atlas and Gene Expression Omnibus database, we found 6,344 dysregulated genes related to H2AZ1 overexpression in HCC tissues (P < 0.05). We performed weighted gene co-expression network analysis to identify the gene module most related to H2AZ1. The H2AZ1-based index was further developed using Cox regression analysis, which revealed that the poor prognosis in the high H2AZ1-based index group could be attributed to elevated tumor stemness (P < 0.05). Moreover, the clinical model showed good prognostic potential (AUC > 0.7). We found that H2AZ1 knockdown led to reduced superoxide dismutase (SOD) activity, elevated malondialdehyde (MDA) levels, and increased apoptosis rate in tumor cells (P < 0.001). Thus, we developed an H2AZ1-based index model with the potential to predict the prognosis of patients with HCC. Our findings provide initial evidence that H2AZ1 overexpression plays a pivotal role in HCC initiation and progression.

Laparoscopic liver resection versus radiofrequency ablation for caudate lobe solitary hepatocellular carcinoma: A propensity score matching study

OBJECTIVE

This study aimed to compare the clinical efficacy of laparoscopic liver resection (LLR) and radiofrequency ablation (RFA) in treating solitary hepatocellular carcinoma (HCC) of the hepatic caudate lobe.

METHODS

Patients with hepatic caudate lobe HCC who underwent LLR or RFA at three hospitals in China between February 2015 and February 2021 were included. In total, 112 patients met the inclusion criteria, of whom 52 underwent RFA and 60 underwent LLR. The outcomes of the two groups were compared and analyzed using propensity score matching (PSM) method.

RESULTS

There were no significant differences between the two groups in terms of sex, HBV/HCV positivity, AFP positivity (>100 ng/mL), tumor position, Child-Pugh score, or preoperative liver function tests (ALT, AST, TBIL, ALB, and PT) (p > 0.05). Compared to the LLR group, the RFA group had a shorter operation time, less intraoperative bleeding, and shorter postoperative hospital stay (p < 0.05). There was no statistically significant difference in overall postoperative complications between the two groups (p > 0.05). Despite the larger tumor size, the LLR group had better postoperative recurrence-free survival (RFS) (p = 0.00027) and overall survival (OS) (p = 0.0023) than the RFA group. After one-to-one PSM, 31 LLR patients and 31 RFA patients were selected for further analyses. The advantages of LLR over RFA were observed in terms of RFS (p < 0.0001) and OS (p = 0.00029).

CONCLUSION

LLR should probably be recommended as the preferred method for solitary caudate lobe HCC.

Multidisciplinary Treatment of Hepatocellular Carcinoma in 2023: Italian practice Treatment Guidelines of the Italian Association for the Study of the Liver (AISF), Italian Association of Medical Oncology (AIOM), Italian Association of Hepato-Bilio-Pancreatic Surgery (AICEP), Italian Association of Hospital Gastroenterologists (AIGO), Italian Association of Radiology and Clinical Oncology (AIRO), Italian Society of Pathological Anatomy and Diagnostic Cytology (SIAPeC-IAP), Italian Society of Surgery (SIC), Italian Society of Gastroenterology (SIGE), Italian Society of Medical and Interventional Radiology (SIRM), Italian Organ Transplant Society (SITO), and Association of Patients with Hepatitis and Liver Disease (EpaC) - Part I - Surgical treatments

Worldwide, hepatocellular carcinoma (HCC) is the third most common cause of cancer-related death. The remarkable improvements in treating HCC achieved in the last years have increased the complexity of HCC management. Following the need to have updated guidelines on the multidisciplinary treatment management of HCC, the Italian Scientific Societies involved in the management of this cancer have promoted the drafting of a new dedicated document. This document was drawn up according to the GRADE methodology needed to produce guidelines based on evidence. Here is presented the first part of guidelines, focused on the multidisciplinary tumor board of experts and surgical treatments of HCC.

Radiation Segmentectomy for Hepatocellular Carcinoma

The application of trans-arterial radioembolization (TARE) with Yttrium-90, historically a palliative treatment option for patients with advanced hepatocellular carcinoma (HCC), is evolving. Radiation segmentectomy (RADSEG), the segmental delivery of an ablative radiation dose, is a treatment option for patients with earlier-stage HCC. This review presents an in-depth exploration of RADSEG, emphasizing its technical considerations, dosimetry advancements, and patient selection. The integration of RADSEG into the Barcelona Clinic Liver Cancer (BCLC) paradigm will be highlighted. RADSEG outcomes concerning safety and efficacy will be explored and compared with traditional locoregional cancer treatments like trans-arterial chemoembolization (TACE), percutaneous thermal ablation, and surgical resection, with an eye on future directions and considerations.

LI-RADS category is associated with treatment outcomes of small single HCC: surgical resection vs. radiofrequency ablation

OBJECTIVES

To assess whether the Liver Imaging Reporting and Data System (LI-RADS) category is associated with the treatment outcomes of small single hepatocellular carcinoma (HCC) after surgical resection (SR) and radiofrequency ablation (RFA).

METHODS

This retrospective study included 357 patients who underwent SR (n = 209) or RFA (n = 148) for a single HCC of ≤ 3 cm between 2014 and 2016. LI-RADS categories were assigned. Overall survival (OS), recurrence-free survival (RFS), and local tumor progression (LTP) rates after treatment were compared according to the LI-RADS category (LR-4/5 vs. LR-M) before and after propensity score matching (PSM). Prognostic factors for treatment outcomes were assessed.

RESULTS

In total, 357 patients (mean age, 59 years; men, 272) with 357 HCCs (294 LR-4/5 and 63 LR-M) were included. After PSM (n = 78 in each treatment group), there were 10 and 11 LR-M HCCs in the SR and RFA group, respectively. There were no significant differences in OS or RFS. However, SR provided a lower 5-year LTP rate than RFA (1.4% vs. 14.9%, p = 0.001). SR provided a lower 5-year LTP rate than RFA for LR-M HCCs (0% vs. 34.4%, p = 0.062) and LR-4/5 HCCs (1.5% vs. 12.0%, p = 0.008). The LI-RADS category was the sole risk factor associated with poor OS (hazard ratio [HR] 3.79, p = 0.004), RFS (HR 2.12; p = 0.001), and LTP (HR 2.89; p = 0.032).

CONCLUSION

LI-RADS classification is associated with the treatment outcome of HCC, supporting favorable outcomes of SR over RFA for LTP, especially for HCCs categorized as LR-M.

CLINICAL RELEVANCE STATEMENT

Liver Imaging Reporting and Data System category has a potential prognostic role, supporting favorable outcomes of surgical resection over radiofrequency ablation for local tumor progression, especially for hepatocellular carcinoma categorized as LR-M.

KEY POINTS

• SR provided a lower 5-year LTP rate than RFA for HCCs categorized as LR-M (0% vs. 34.4%, p = 0.062) and HCCs categorized as LR-4/5 (1.5% vs. 12.0%, p = 0.008). • There is a steeply increased risk of LTP within 1 year after RFA for LR-M HCCs, compared to SR. • The LI-RADS category was the sole risk factor associated with poor OS (HR 3.79, p = 0.004), RFS (HR 2.12; p = 0.001), and LTP (HR 2.89; p = 0.032) in patients with HCC of ≤ 3 cm treated with SR or RFA.

Research in interventional oncology: How sound is the evidence base?

INTRODUCTION

Interventional oncology (IO) is an essential component of cancer care, which has gained substantial recognition in recent years. The aim of this review is to evaluate the level of evidence supporting IO and its inclusion in cancer treatment guidelines.

METHODS

A literature search of the PubMed database was performed to identify publication numbers and types for IO treatments published between 2012 and 2022. Selected cancer treatment guidelines and recommendations were reviewed for their inclusion of IO treatments.

RESULTS

With 68%, the majority of studies on IO treatments are case reports while randomised controlled trials (RCTs) amount only to 7% of studies. Despite this, IO studies have generated sufficient data to support the inclusion of IO treatments in cancer treatment guidelines and recommendations. This was frequently based on large prospective patient cohorts that corresponded to 24% (20% non-randomised studies and 4% observational studies) of all analysed studies rather than RCTs.

CONCLUSION

The level of evidence underpinning IO, as well as inclusion of IO in treatment guidelines and recommendations have increased substantially in recent years, indicating the growing importance and acceptance of IO in cancer care. The difficulty in conducting RCTs in IO is mitigated by the observation that they are not necessary to achieve guideline-inclusion. Nevertheless, it is crucial to conduct well-designed research projects to further consolidate the position of IO in the field of oncology. This will ensure that IO continues to evolve and meet the needs of cancer patients worldwide.

Tumor size and survival in intrahepatic cholangiocarcinoma treated with surgical resection or ablation

OBJECTIVES

We performed a retrospective analysis within a national cancer registry on outcomes following resection or ablation for intrahepatic cholangiocarcinoma (iCCA).

METHODS

The National Cancer Database was queried for patients with clinical stage I-III iCCA diagnosed during 2010-2018, who underwent resection or ablation. Overall survival (OS) was compared with Kaplan-Meier and multivariable Cox proportional hazards methods.

RESULTS

Of 2140 patients, 1877 (87.7%) underwent resection and 263 (12.3%) underwent ablation, with median tumor sizes of 5.5 and 3 cm, respectively. Overall, resection was associated with greater median OS (41.2 months (95% confidence interval [95% CI]: 37.6-46.2) vs. 28 months (95% CI: 15.9-28.6) on univariable analysis (p < 0.0001). There was no significant difference on multivariable analysis (p = 0.42); however, there was a significant interaction between tumor size and management. On subgroup analysis of patients with tumors <3 cm, there was no difference in OS between resection versus ablation. However, ablation was associated with increased mortality for tumors ≥3 cm.

CONCLUSION

Although resection is associated with improved OS for tumors ≥3 cm, we observed no difference in survival between management strategies for tumors < 3 cm. Ablation may be an alternative therapeutic strategy for small iCCA, particularly in patients at risk for high surgical morbidity.

Thermal ablation of hepatocellular carcinoma

Percutaneous treatment of hepatocellular carcinoma (HCC) by means of thermal ablation (TA) has been introduced in clinical guidelines as a potentially curative treatment for the early stages of the disease since the early 2000s. Due to its safety profile and cost-effectiveness, TA can be offered as a first-line treatment for patients with HCC smaller than 3 cm. Thermal ablative techniques are in fact widely available at many centres worldwide and include radiofrequency (RF) and microwave (MW) ablation, with the latter increasingly applied in clinical practice in the last decade. Pre-clinical studies highlighted, as potential advantages of MW-based ablation, the ability to achieve higher temperatures (>100°C) and larger ablation zones in shorter times, with less susceptibility to blood flow-induced heat sink effects. Despite these advantages, there is no evidence of superior overall survival in patients treated with MW as compared to those treated with RF ablation. Local control has been proven to be superior to MW ablation with a similar complication rate. It is expected that further improvement of TA results in the treatment of HCC will result from the refinement of guidance and monitoring tools and the careful assessment of ablation margins. Thermal ablative treatments may also be performed on nodules larger than 3 cm by applying multiple devices or combining percutaneous and intra-arterial approaches. The role of novel immunotherapy regimens in combination with ablation is also currently under evaluation in clinical trials, with several potential benefits. In this review, indications, technical principles, results, and future prospects of TA for the treatment of HCC will be examined.

Ablative and non-surgical therapies for early and very early hepatocellular carcinoma: a systematic review and network meta-analysis

Background

A wide range of ablative and non-surgical therapies are available for treating small hepatocellular carcinoma in patients with very early or early-stage disease and preserved liver function.

Objective

To review and compare the effectiveness of all current ablative and non-surgical therapies for patients with small hepatocellular carcinoma (≤ 3 cm).

Design

Systematic review and network meta-analysis.

Data sources

Nine databases (March 2021), two trial registries (April 2021) and reference lists of relevant systematic reviews.

Review methods

Eligible studies were randomised controlled trials of ablative and non-surgical therapies, versus any comparator, for small hepatocellular carcinoma. Randomised controlled trials were quality assessed using the Cochrane Risk of Bias 2 tool and mapped. The comparative effectiveness of therapies was assessed using network meta-analysis. A threshold analysis was used to identify which comparisons were sensitive to potential changes in the evidence. Where comparisons based on randomised controlled trial evidence were not robust or no randomised controlled trials were identified, a targeted systematic review of non-randomised, prospective comparative studies provided additional data for repeat network meta-analysis and threshold analysis. The feasibility of undertaking economic modelling was explored. A workshop with patients and clinicians was held to discuss the findings and identify key priorities for future research.

Results

Thirty-seven randomised controlled trials (with over 3700 relevant patients) were included in the review. The majority were conducted in China or Japan and most had a high risk of bias or some risk of bias concerns. The results of the network meta-analysis were uncertain for most comparisons. There was evidence that percutaneous ethanol injection is inferior to radiofrequency ablation for overall survival (hazard ratio 1.45, 95% credible interval 1.16 to 1.82), progression-free survival (hazard ratio 1.36, 95% credible interval 1.11 to 1.67), overall recurrence (relative risk 1.19, 95% credible interval 1.02 to 1.39) and local recurrence (relative risk 1.80, 95% credible interval 1.19 to 2.71). Percutaneous acid injection was also inferior to radiofrequency ablation for progression-free survival (hazard ratio 1.63, 95% credible interval 1.05 to 2.51). Threshold analysis showed that further evidence could plausibly change the result for some comparisons. Fourteen eligible non-randomised studies were identified (n ≥ 2316); twelve had a high risk of bias so were not included in updated network meta-analyses. Additional non-randomised data, made available by a clinical advisor, were also included (n = 303). There remained a high level of uncertainty in treatment rankings after the network meta-analyses were updated. However, the updated analyses suggested that microwave ablation and resection are superior to percutaneous ethanol injection and percutaneous acid injection for some outcomes. Further research on stereotactic ablative radiotherapy was recommended at the workshop, although it is only appropriate for certain patient subgroups, limiting opportunities for adequately powered trials.

Limitations

Many studies were small and of poor quality. No comparative studies were found for some therapies.

Conclusions

The existing evidence base has limitations; the uptake of specific ablative therapies in the United Kingdom appears to be based more on technological advancements and ease of use than strong evidence of clinical effectiveness. However, there is evidence that percutaneous ethanol injection and percutaneous acid injection are inferior to radiofrequency ablation, microwave ablation and resection.

Study registration

PROSPERO CRD42020221357.

Funding

This award was funded by the National Institute for Health and Care Research (NIHR) Health Technology Assessment (HTA) programme (NIHR award ref: NIHR131224) and is published in full in Health Technology Assessment; Vol. 27, No. 29. See the NIHR Funding and Awards website for further award information.

Laparoscopic hepatectomy for hepatocellular carcinoma in patients with hemophilia A and B: a report of two cases

Hepatocellular carcinoma (HCC) is a life-threatening complication of hemophilia. Reports of patients with hemophilia undergoing hepatectomy for HCC are scarce. We report the cases of patients with hemophilia A and B who underwent laparoscopic hepatectomy for HCC. Perioperative hemophilia management was supervised by the hematology team. The patients received coagulation factor bolus injections immediately preoperatively, then continuous intravenous infusions intra- and postoperatively. A laparoscopic segment II partial hepatectomy was performed in case 1. Due to severe adhesions, intermittent pedicle clamping could not be used during parenchymal transection. The surgical duration was 235 min, and the estimated blood loss was 13 mL. The patient was discharged 11 days postoperatively without any complications. In case 2, laparoscopic partial hepatectomy for segments V/VI was performed. An intermittent pedicle clamp (Pringle method) was used during parenchymal transection. The surgical duration and estimated blood loss were 219 min and 18 mL, respectively. The patient was discharged 8 days postoperatively without complications. In both cases, intraoperative bleeding was minimal, and the patients were discharged without postoperative hemorrhage with appropriate perioperative coagulation factor management. Laparoscopic hepatectomy can be safely performed and appears to be a feasible treatment option for HCC in patients with hemophilia.

Dual-targeting nanotheranostics for MRI-guided enhanced chemodynamic therapy of hepatoma via regulating the tumor microenvironment

Chemodynamic therapy (CDT), as a reactive oxygen species (ROS)-based therapeutic modality, has attracted much attention in recent years. However, the insufficient therapeutic effect of CDT is due to the antioxidant system in the tumor microenvironment, such as high levels of glutathione (GSH). In this study, we developed a biological/physical dual-targeting nanotheranostic agent (relaxation rate, r1: 6.3 mM-1 s-1 and r2: 13.11 mM-1 s-1) for enhanced CDT of SMCC-7721 tumors. This nanotheranostic agent is composed of a homologous tumor cell membrane (TCM), magnetic ferric oxide, and manganese oxide and is denoted as FM@TCM nanoparticles (NPs). A favorable effect of in vitro CDT on SMCC-7721 cells (IC50: 20 μg mL-1) is demonstrated, attributed to the Fenton reaction and oxidative stress resulting from the reduction of the GSH level. In vivo T1/T2 magnetic resonance imaging (MRI) confirms that the tumor accumulation of FM@TCM NPs is promoted by concurrent bioactive targeting of the homologous TCM and physico-magnetic targeting of tumor tissues with an external magnetic field. Impressive chemodynamic therapeutic effects on SMCC-7721 tumors are demonstrated through the catalysis of endogenous hydrogen peroxide and depletion of GSH to generate high levels of ROS. Dual-targeting FM@TCM NPs inhibit SMCC-7721 tumor growth (∼90.9%) in vivo without any biotoxicity. This nanotheranostic agent has great potential for use in MRI-guided CDT.

An evaluation of 20-year survival of radiofrequency ablation for hepatocellular carcinoma as first-line treatment

OBJECTIVES

To evaluate the changes in clinical characteristics, overall survival (OS), and progression-free survival (PFS) by investigating a 20-year cohort of patients with HCC who underwent RFA treatment.

METHODS

From 2000 to 2020, 505 consecutive patients with HCC underwent ultrasound-guided percutaneous RFA as first-line therapy at a tertiary cancer hospital. We divided the cohort according to the time when hepatitis-B antiviral therapy was covered by national medical insurance coverage (early 2011), including the first decade (2000-2010) and second decade (2011-2020). The prognostic factors for OS were analyzed by the Cox proportional hazard model. OS and PFS in different groups were compared using the Kaplan-Meier method. To reduce selection bias, matched groups of patients were selected using the propensity score matching (PSM) method.

RESULTS

In total, 726 RFA sessions were performed to treat 867 HCC lesions. Patients treated in the second decade were younger (p =.047), had smaller tumors (p <.001), had lower Child-Pugh scores (p <.001), and had a higher proportion of antiviral treatment (p <.001). A total of 96.0% of patients achieved technical efficacy from the initial RFA. After PSM analysis, improved PFS was found for the second decade (median, 68 vs. 49 months, p =.003), but no significant difference in OS was observed between the two groups (median, 71 vs. 65 months, p =.20).

CONCLUSIONS

This study demonstrated that improved PFS was achieved in patients with HCC receiving RFA as first-line treatment in the second decade. However, long-term OS was not significantly increased compared to the first decade suggesting that while RFA treatment has improved, it still might not substantially affect OS results.

Beyond Survival: Adverse Events and Care Delivery Outcomes after Early Liver Cancer Treatment in a Nationally Representative Cohort

PURPOSE

To compare secondary outcomes after ablation (AB), surgical resection (SR), and liver transplant (LT) for small hepatocellular carcinomas (HCCs), including resource utilization and adverse event (AE) rates.

MATERIALS AND METHODS

Using Surveillance, Epidemiology, and End Results Program (SEER)-Medicare, HCCs <5 cm that were treated with AB, SR, or LT in 2009-2016 (n = 1,067) were identified using Healthcare Common Procedure Coding System codes through Medicare claims. Index procedure length of stay, need for intensive care unit (ICU) level care, readmission rates, and AE rates at 30 and 90 days were compared using chi-square tests or Fisher exact tests. Examined AEs included hemorrhage, abscess formation, biliary injury, pneumonia, sepsis, liver disease-related AEs, liver failure, and anesthesia-related AEs, identified by International Classification of Diseases, Ninth/10th Revision, codes.

RESULTS

The median length of stay for initial treatment was 1 day, 6 days, and 7 days for AB, SR, and LT, respectively (P < .001). During initial hospital stay, 5.0%, 40.8%, and 63.4% of AB, SR, and LT cohorts, respectively, received ICU-level care (P < .001). By 30 and 90 days, there were significant differences among the AB, SR, and LT cohorts in the rate of postprocedural hemorrhage, abscess formation, biliary injury, pneumonia, sepsis, liver disease-related AEs, and anesthesia-related AEs (P < .05). By 90 days, the readmission rates after AB, SR, and LT were 18.6%, 28.2%, and 40.6% (P < .001), respectively.

CONCLUSIONS

AB results in significantly less healthcare utilization during the initial 90 days after procedure compared with that after SR and LT due to shorter length of stay, lower intensity care, fewer readmissions, and fewer AEs.

The effectiveness of ablative and non-surgical therapies for early hepatocellular carcinoma: Systematic review and network meta-analysis of randomised controlled trials

BACKGROUND & AIMS

Non-surgical therapies are frequently used for patients with early or very early hepatocellular carcinoma (HCC). The aim of this systematic review and network meta-analysis (NMA) was to evaluate and compare the effectiveness of ablative and non-surgical therapies for patients with small HCC.

METHODS

Nine databases were searched (March 2021) along with clinical trial registries. Randomised controlled trials (RCTs) of any ablative or non-surgical therapy versus any comparator in patients with HCC ≤3 cm were eligible. Risk of bias (RoB) was assessed using the Cochrane RoB 2 tool. The effectiveness of therapies was compared using NMA. Threshold analysis was undertaken to identify which NMA results had less robust evidence.

RESULTS

Thirty-seven eligible RCTs were included (including over 3700 patients). Most were from China (n = 17) or Japan (n = 7). Sample sizes ranged from 30 to 308 patients. The majority had a high RoB or some RoB concerns. No RCTs were identified for some therapies and no RCTs reported quality of life outcomes. The results of the NMA and treatment effectiveness rankings were very uncertain. However, the evidence demonstrated that percutaneous ethanol injection was worse than radiofrequency ablation for overall survival (hazard ratio [HR]: 1.45, 95% credible interval [CrI]: 1.16-1.82), progression-free survival (HR: 1.36, 95% CrI: 1.11-1.67), overall recurrence (relative risk [RR]: 1.19, 95% CrI: 1.02-1.39) and local recurrence (RR: 1.80, 95% CrI: 1.19-2.71). The threshold analysis suggested that robust evidence was lacking for some comparisons.

CONCLUSIONS

It is unclear which treatment is most effective for patients with small HCC because of limitations in the evidence base. It is also not known how these treatments would impact on quality of life. Further high quality RCTs are needed to provide robust evidence but may be difficult to undertake.

Therapeutic Outcome of Stereotactic Body Radiotherapy for Small Hepatocellular Carcinoma Lesions - A Systematic Review and Network Meta-analysis

Surgical resection, stereotactic body radiotherapy (SBRT) and radiofrequency ablation (RFA) have seldom been compared for small hepatocellular carcinoma (HCC). We explored the treatment outcomes of SBRT for small HCC by conducting a network meta-analysis (NMA). We compared the efficacy and safety of surgical resection, RFA and SBRT for liver-confined small HCC (three or fewer lesions with a diameter ≤5 cm). The study endpoint included the odds ratios of the 1-, 3- and 5-year progression/recurrence/disease-free survival (disease progression-free survival; DPFS) and overall survival rates, as well as severe complications. Forty-five studies included 21 468 patients. In the NMA with comparable data, SBRT had comparable 1-, 3- and 5-year DPFS but significantly worse pooled long-term overall survival (3- and 5-year overall survival) than surgical resection (odds ratio 1.39, 95% confidential interval 1.3-1.89; odds ratio 1.33, 95% confidence interval 1.06-1.69, respectively). SBRT was associated with significantly better pooled 1-year DPFS compared with RFA (odds ratio 0.39, 95% confidence interval 0.15-0.97), with the remaining outcomes being comparable. SBRT had significantly less incidence of severe complications compared with surgical resection (odds ratio 0.62, 95% confidence interval 0.42-0.88) and RFA (odds ratio 0.2, 95% confidence interval 0.03-0.94). In conclusion, for small HCCs (≤5 cm) with one to three nodules, SBRT may be favourable to reduce the risks of severe complications. In terms of DPFS, SBRT may be recommended as an alternative first-line therapy for RFA and surgical resection. The results regarding overall survival should be interpreted with caution, considering the potentially uneliminated bias. There is a clear need for well-designed randomised trials to conclusively identify real differences in efficacy between these treatments, especially SBRT and surgical resection.

Clinical outcomes and cost of open, laparoscopic, and percutaneous ablation for hepatocellular carcinoma

BACKGROUND

Open (OA), laparoscopic (LA), and percutaneous (PA) ablation are all ablation approaches for hepatocellular carcinoma (HCC) utilized in the United States today. However, it remains unclear today which approach is (A) most effective, (B) cost-efficient, and (C) nationally practiced.

METHODS

In-hospital mortality and cost were collected from the National Inpatient Sample (NIS) database for patients undergoing liver ablation from 2011 to 2018. Secondary outcomes included length of stay, disposition, and perioperative composite complications. We used inverse probability of treatment weighting (IPTW) to adjust for differences in patient and hospital baseline characteristics.

RESULTS

One thousand and one hundred and twenty-five LA, 1221 OA, and 1068 PA liver ablations were analyzed. After IPTW, in-hospital mortality risk was significantly lower in PA versus OA cohorts (0.57% vs. 2.90%, p < 0.001) and reduced among PA patients, yet not significantly different from the LA cohort (0.57% vs. 1.64%, p = 0.056). The median length of hospital stay was significantly lower in the PA and LA group compared to OA (2 days vs. 6 days, p < 0.001). The median hospitalization costs were significantly lower for PA ($44,884 vs. $90,187, p < 0.001) and LA ($61,445 vs. $90,187, p < 0.001) compared to OA. Moreover, we found significant regional differences regarding the use of each ablation approach, with the Midwest having the lowest rates of PA and LA.

CONCLUSIONS

Among patients hospitalized after ablation for HCC, PA leads to the lowest hospital cost. Both PA and LA result in lower peri-operative morbidity and mortality relative to OA. Despite these reported advantages, there are significant regional differences with respect to ablation availability suggesting the need to promote the standardization of best practices.

Exploiting targeted nanomedicine for surveillance, diagnosis, and treatment of hepatocellular carcinoma

Hepatocellular carcinoma (HCC) is one of the cancers that has the highest morbidity and mortality rates. In clinical practice, there are still many limitations in surveilling, diagnosing, and treating HCC, such as the poor detection of early HCC, the frequent post-surgery recurrence, the low local tumor control rate, the therapy resistance and side effects. Therefore, improved, or innovative modalities are urgently required for early diagnosis as well as refined and effective management. In recent years, nanotechnology research in the field of HCC has received great attention, with various aspects of diagnosis and treatment including biomarkers, ultrasound, diagnostic imaging, intraoperative imaging, ablation, transarterial chemoembolization, radiotherapy, and systemic therapy. Different from previous reviews that discussed from the perspective of nanoparticles' structure, design and function, this review systematically summarizes the methods and limitations of diagnosing and treating HCC in clinical guidelines and practices, as well as nanomedicine applications. Nanomedicine can overcome the limitations to improve diagnosis accuracy and therapeutic effect via enhancement of targeting, biocompatibility, bioavailability, controlled releasing, and combination of different clinical treatment modalities. Through an in-depth understanding of the logic of nanotechnology to conquer clinical limitations, the main research directions of nanotechnology in HCC are sorted out in this review. It is anticipated that nanomedicine will play a significant role in the future clinical practices of HCC.

Tips for Preparing and Practicing Thermal Ablation Therapy of Hepatocellular Carcinoma

Thermal ablation therapy, including radiofrequency ablation (RFA) and microwave ablation (MWA), is considered the optimal locoregional treatment for unresectable early-stage hepatocellular carcinomas (HCCs). Percutaneous image-guided ablation is a minimally invasive treatment that is being increasingly performed because it achieves good clinical outcomes with a lower risk of complications. However, the physics and principles of RFA and MWA markedly differ. Although percutaneous thermal ablation under image guidance may be challenging in HCC cases with limited access or a risk of thermal injury, a number of ablative techniques, each of which may be advantageous and disadvantageous for individual cases, are available. Furthermore, even when a HCC is eligible for ablation based on tumor selection and technical factors, additional patient factors may have an impact on whether it is the appropriate treatment choice. Therefore, a basic understanding of the advantages and limitations of each ablation device and imaging guidance technique, respectively, is important. We herein provide an overview of the basic principles of tissue heating in thermal ablation, clinical and laboratory parameters for ablation therapy, preprocedural management, imaging assessments of responses, and early adverse events. We also discuss associated challenges and how they may be overcome using optimized imaging techniques.

Predictive Factors of Treatment Outcomes After Percutaneous Radiofrequency Ablation of Hepatocellular Carcinoma in the Hepatocaval Confluence: A Propensity Score Matching Analysis

RATIONALE AND OBJECTIVES

To compare the efficacy and complications of ultrasound-guided percutaneous radiofrequency ablation of hepatocellular carcinoma (HCC) in the hepatocaval confluence with those of HCC in the non-hepatocaval confluence and to explore the risk factors that lead to radiofrequency ablation failure and patient local tumor progression (LTP).

MATERIALS AND METHODS

From January 2017 to January 2022, 86 patients with HCC in the hepatocaval confluence who had radiofrequency ablation were included. A 1:1 propensity-matched group of patients with HCC in the non-hepatocaval confluence with comparable clinical baseline traits, such as tumor diameter and tumor number, served as the control group. The two groups' complications, primary efficacy rate (PER), technical success rate (TSR), and prognosis were estimated.

RESULTS

After PSM, no significant difference of TSR (91.7% vs 95.8%, p = 0.491) and PER (95.8% vs 97.2%, p = 1.000) and 1-, 3-, and 5-year LTP rate (12.5% vs 9.9%, 28.2% vs 27.7%, 40.8% vs 43.8%, p = 0.959) and 1-, 3-, and 5-year DFS rate (87.5% vs 87.5%, 62.3% vs 54.2%, 18.1% vs 22.6%, p = 0.437) and 1-, 3-, and 5-year OS rate (94.3% vs 95.7%, 72.7% vs 69.6%, 20.9% vs 33.6%, p = 0.904) was detected between the two groups. The tumor-to-IVC distance was an independent risk factor for radiofrequency ablation failure in HCC patients in the hepatocaval confluence (OR = 0.611, p = 0.022). Besides, tumor diameter was an independent risk factor for predicting LTP in patients with HCC in the hepatocaval confluence (HR = 2.209, p = 0.046).

CONCLUSION

HCC in the hepatocaval confluence can be effectively treated with radiofrequency ablation. To maximize treatment efficacy, the tumor-to-IVC distance and tumor diameter should be assessed before the operation begins.

Management of early-stage hepatocellular carcinoma: challenges and strategies for optimal outcomes

Although hepatocellular carcinoma (HCC) is associated with a poor prognosis, management of early-stage HCC is often successful with highly efficacious treatment modalities such as liver transplantation, surgical resection, and radiofrequency ablation. However, unfavorable clinical outcomes have been observed under certain circumstances, even after efficient treatment. Factors that predict unsuitable results after treatment include tumor markers, inflammatory markers, imaging findings reflecting tumor biology, specific outcome indicators for each treatment modality, liver functional reserve, and the technical feasibility of the treatment modalities. Various strategies may overcome these challenges, including the application of reinforced treatment indication criteria with predictive markers reflecting tumor biology, compensation for technical issues with up-to-date technologies, modification of treatment modalities, downstaging with locoregional therapies (such as transarterial chemotherapy or radiotherapy), and recently introduced combination immunotherapies. In this review, we discuss the challenges to achieving optimal outcomes in the management of early-stage HCC and suggest strategies to overcome these obstacles.

Evolution of Response-Based Radiotherapy for Hepatocellular Cancer

ABSTRACT

Stereotactic body radiation therapy has emerged as a safe and effective treatment modality for properly selected hepatocellular cancer (HCC) patients with normal liver function. However, many HCC patients have reduced baseline liver function due to underlying cirrhosis or prior liver-directed therapies. Therefore, because of the increased risk of hepatotoxicity, the use of stereotactic body radiation therapy for patients with reduced liver function has been approached with caution. Individualized, response-based radiotherapy incorporates models, imaging tools, and biomarkers that determine the dose-response relationship of the liver before, during, and after treatment and has been useful in reducing the likelihood of liver damage without sacrificing tumor control. This review discusses the evolution of response-based radiotherapy for HCC and highlights areas for further investigation.

Radiotherapy plus anti-PD1 versus radiotherapy for hepatic toxicity in patients with hepatocellular carcinoma

PURPOSE

In this study, we aimed to compare the radiation-induced hepatic toxicity (RIHT) outcomes of radiotherapy (RT) plus antibodies against programmed cell death protein 1 (anti-PD1) versus RT alone in patients with hepatocellular carcinoma (HCC), evaluate prognostic factors of non-classic radiation-induced liver disease (ncRILD), and establish a nomogram for predicting the probability of ncRILD.

PATIENTS AND METHODS

Patients with unresectable HCC treated with RT and anti-PD1 (RT + PD1, n = 30) or RT alone (n = 66) were enrolled retrospectively. Patients (n = 30) in each group were placed in a matched cohort using propensity score matching (PSM). Treatment-related hepatotoxicity was evaluated and analyzed before and after PSM. The prognostic factors affecting ncRILD were identified by univariable logistic analysis and Spearman's rank test in the matched cohort to generate a nomogram.

RESULTS

There were no differences in RIHT except for increased aspartate aminotransferase (AST) ≥ grade 1 and increased total bilirubin ≥ grade 1 between the two groups before PSM. After PSM, AST ≥ grade 1 occurred more frequently in the RT + PD1 group (p = 0.020), and there were no significant differences in other hepatotoxicity metrics between the two groups. In the matched cohort, V25, tumor number, age, and prothrombin time (PT) were the optimal prognostic factors for ncRILD modeling. A nomogram revealed a good predictive performance (area under the curve = 0.82).

CONCLUSIONS

The incidence of RIHT in patients with HCC treated with RT + PD1 was acceptable and similar to that of RT treatment. The nomogram based on V25, tumor number, age, and PT robustly predicted the probability of ncRILD.