Evaluation of the vascular pattern of hepatocellular carcinoma with dynamic computed tomography and its use in identifying optimal temporal windows for helical computed tomography

Combination therapy with sorafenib and radiofrequency ablation for BCLC Stage 0-B1 hepatocellular carcinoma: a multicenter retrospective cohort study

OBJECTIVES

The objective of this study was to evaluate the efficacy of combined therapy using Sorafenib and radiofrequency ablation (RFA) with curative intent for all detectable lesions in patients with Barcelona Clinic Liver Cancer (BCLC) Stage 0-B1 hepatocellular carcinoma (HCC).

METHODS

One hundred and twenty-eight patients with HCC from 12 centers were enrolled in this retrospective study; 64 patients who received Sorafenib plus RFA (Sorafenib-RFA) were compared with a control group treated with RFA alone. The two patient groups were selected with a predefined criterion and matched in terms of their clinical and tumor characteristics at baseline. The primary end point of the study was the incidence of post-RFA HCC recurrence. Secondary end points were overall survival (OS) and treatment toxicity.

RESULTS

During a median follow-up of 134.1 weeks, 49 patients died and 79 survived. The 1-, 2-, and 3-year cumulative incidences of post-RFA recurrence were 40.5%, 62.9%, and 74.5%, respectively, in the Sorafenib-RFA group, and 62.8%, 85.4%, and 92.7%, respectively, in the RFA group. The 1-, 2-, 3-, and 4-year OS rates were 85.6%, 64.0%, 58.7%, and 50.3%, respectively, in the Sorafenib-RFA group, and 80.7%, 47.2%, 30.9%, and 30.9%, respectively, in the RFA group. Thus, the Sorafenib-RFA group exhibited better survival than the RFA alone group.

CONCLUSIONS

Combined therapy with Sorafenib-RFA was associated with a lower incidence of post-RFA recurrence and better OS than RFA alone in patients with BCLC Stage 0-B1 HCC. Although these findings suggest that Sorafenib and RFA is safe and effective for the treatment of early HCC, prospective and randomized controlled trials are needed to validate them.

Magnetic resonance imaging in cirrhosis: what's new?

Cirrhosis is the main risk factor for the development of hepatocellular carcinoma (HCC). The major causative factors of cirrhosis in the United States and Europe are chronic hepatitis C infection and excessive alcohol consumption with nonalcoholic steatohepatitis emerging as another important risk factor. Magnetic resonance imaging is the most sensitive imaging technique for the diagnosis of HCC, and the sensitivity can be further improved with the use of diffusion-weighted imaging and hepatocyte-specific contrast agents. The combination of arterial phase hyperenhancement, venous or delayed phase hypointensity "washout feature," and capsular enhancement are features highly specific for HCC with reported specificities of 96% and higher. When these features are present in a mass in the cirrhotic liver, confirmatory biopsy to establish the diagnosis of HCC is not necessary. Other tumors, such as cholangiocarcinoma, sometimes occur in the cirrhotic at a much lower rate than HCC and can mimic HCC, as do other benign lesions such as perfusion abnormalities. In this article, we discuss the imaging features of cirrhosis and HCC, the role of magnetic resonance imaging in the diagnosis of HCC and other benign and malignant lesions that occur in the cirrhotic liver, and the issue of nonspecific arterially hyperenhancing nodules often seen in cirrhosis.

MR-guided radiofrequency ablation of hepatocellular carcinoma: long-term effectiveness

PURPOSE

To evaluate long-term effectiveness of magnetic resonance (MR)-guided radiofrequency (RF) ablation of hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

This prospective study was approved by the institutional review board. In 20 patients, 28 HCCs (mean diameter, 28.0 mm; range, 6-58 mm) were treated with 25 sessions of MR-guided RF ablation. Previous chemoembolization had been performed in nine HCCs with diameters greater than 3 cm. The entire RF ablation procedures were carried out on a 0.2-T open MR system. Placement of MR-compatible internally cooled electrodes was performed under MR fluoroscopic imaging with fast gradient-echo sequences. Therapeutic assessment was based on dynamic MR-imaging (1.5 T) at a mean follow-up of 24.2 months (range, 6-52 mo).

RESULTS

MR-guided RF ablation was technically successful in all 25 sessions (100%), as assessed at the end of each session. T2-weighted sequences were accurate to monitor the ablation zone and supported guidance of overlapping ablations if necessary. Technique effectiveness, defined as complete ablation confirmed at MR imaging 4 months after RF ablation, was achieved in 27 of 28 HCCs (96.4%). To achieve complete ablation, 25 of 27 tumors (92.6%) were treated in a single session and two tumors were treated twice. In one tumor initially defined as having been treated with technically effective RF ablation, local tumor progression was detected more than 4 months after ablation. Consequently, the available follow-up indicated complete ablation in 26 of 28 HCCs (92.9%). There was one major complication (4.0%) and one minor complication (4.0%).

CONCLUSIONS

On a long-term basis, MR-guided RF ablation is an effective therapy option in the treatment of HCC.

Long-term outcome of cirrhotic patients with early hepatocellular carcinoma treated with ultrasound-guided percutaneous laser ablation: a retrospective analysis

PURPOSE

Percutaneous laser ablation (PLA) has been proposed as an active treatment in patients with hepatocellular carcinoma (HCC). However, large multicenter studies using this technique have not been reported.

PATIENTS AND METHODS

We retrospectively analyzed treatment and survival parameters of 432 cirrhotic patients with nonsurgical early HCC (single nodule < or = 4 cm or three nodules < or = 3 cm each) who had received PLA in nine Italian centers.

RESULTS

Single tumors were seen in 344 (80%) of 432 patients, and two to three nodules were seen in 88 patients (20%), for a total of 548 tumors. An initial complete response after PLA was observed in 338 patients (78%). Median overall survival time was 47 months (95% CI, 41 to 53 months). The 3- and 5-year cumulative survival rates were 61% and 34%, respectively. In multivariate analysis, independent predictors of survival were serum albumin levels more than 3.5 g/dL (P = .002; risk ratio [RR] = 0.580; 95% CI, 0.409 to 0.821), the achievement of a complete tumor ablation (P = .001; RR = 0.517; 95% CI, 0.346 to 0.771), and age less than 73 years (P < .001; RR = 0.466; 95% CI, 0.320 to 0.681). Child-Turcotte-Pugh class A patients had a 5-year cumulative survival rate of 41%; this figure increased up to 60% with a median survival time of 63 months (95% CI, 48 to 78 months) in patients with tumors < or = 2.0 cm.

CONCLUSION

This analysis confirms that a complete tumor ablation results in improved survival in patients with nonsurgical HCC. Ideal candidates for PLA are younger patients with normal serum albumin levels and tumor size < or = 2 cm.

Treatment of small hepatocellular carcinoma: a comparison of techniques and long-term results

OBJECTIVE

The aim of this study was to compare the results over time of transcatheter arterial chemoembolization (TACE), percutaneous ethanol injection (PEI), laser thermal ablation (LTA) and combined therapy in the treatment of small hepatocellular carcinoma.

METHODS

Between 1998 and 2004, 131 cirrhosis patients (99 Child-Pugh class A, 32 Child-Pugh class B) with a small hepatocellular carcinoma were included in the study; 34 were treated with PEI, 46 with LTA, 18 with TACE and 33 with combined therapy.

RESULTS

No major complication occurred during any procedure. Computed tomography scan showed that complete necrosis was achieved in 81% of treated nodules (120 out of 148); as a whole, the disease relapsed in 42 (32.0%) patients (with a disease-free interval of 17.0+/-13.7 months). The cumulative survival rates were 81.9, 35.7 and 20.8% at 12, 36 and 60 months respectively. A univariate analysis of survival showed statistically significant differences in the comparison between Child-Pugh class A with respect to Child-Pugh class B (P<0.0001) and between nodules with a diameter of 20 mm or less as opposed to larger than 20 mm (P=0.001). Patients subjected to LTA showed a statistically significant longer survival than those treated with TACE and PEI.

CONCLUSIONS

LTA proves to be the most effective treatment, affording reduced invasiveness, a limited number of sessions, complete necrosis in almost all cases and better total survival in the treated patients.

Comparison of two contrast materials with different iodine concentrations in enhancing the density of the the aorta, portal vein and liver at multi-detector row CT: a randomized study

This work investigates differences in contrast enhancement of the aorta, portal vein and liver by two different concentrations of contrast materials using an automatic bolus tracking technique. Seventy patients were assigned randomly into one of two groups. Contrast materials with iodine concentrations of 300 and 370 mg/ml were administered to patients in groups A and B, respectively. The total iodine load (600 mg/kg) and injection time (30 s) were identical. Differences in the increase of the Hounsfield unit of the aorta, portal vein and liver between the two groups were examined by t-test. There were no significant differences between the two groups in any of the contrast enhancements of the aorta, portal vein and liver parenchyma at all phases, except for enhancement of the portal vein at the late arterial phase. Females showed better contrast enhancement of the aorta and portal vein than males. With the same iodine dose and injection time, the concentration of contrast materials did not seem to influence the efficacy of contrast enhancement of the aorta, portal vein and liver, except for the portal vein at the late arterial phase. Planning of protocols for contrast media injection may be made irrespective of the iodine concentrations.

[Visualization by dynamic CT: invention of 2D-CT chronogram]

Dynamic computed tomography is one of the methods used for the functional analysis of blood flow information. We devised a simple method of visualization for dynamic CT. Re-sliced images were stacked as multi-slice images for the different acquisition times to show a continuous spatial arrangement with dynamic data. Images processed into re-sliced images termed 2D-CT Chronograms were observed in many directions and were useful for comprehending the blood flow function of the target organ. Time-density curves with motion dependency and color displays similar to those of ultrasound images are easily acquired from the 2D-Chronogram. We introduce some clinical applications of the 2-D Chronogram.

Laser thermal ablation in the treatment of small hepatocellular carcinoma: results in 74 patients

PURPOSE

To evaluate the safety, local effectiveness, and long-term results of laser thermal ablation (LTA) in the treatment of small hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Ninety-two biopsies proved small HCCs (range, 0.8-4.0 cm) in 74 patients who were treated percutaneously with LTA in an outpatient clinic. A laser at a power of 5.0 W was coupled with one to four fibers that were advanced through 21-gauge needle(s) for 6-12 minutes. All lesions were evaluated with computed tomography (CT) for changes in size and vascular pattern, recurrence rates, and cumulative survival rates. Patients were examined for complications.

RESULTS

No major complications occurred in 117 LTA sessions, with an average of 1.3 sessions per tumor. At 3 months, CT scans showed a nonenhancing area (complete necrosis) in 89 (97%) of 92 lesions. During follow-up (range, 6-66 months; mean, 25.3 months), 84 tumors (91%) decreased in size. The local recurrence rates (range, 1-5 years) ranged from 1.6% to 6.0%. Recurrence rates (range, 12-60 months) in other liver segments ranged from 24% to 73%. Cancer-free survival rates (range, 1-4 years) ranged from 73% to 24%. Overall survival rates were 99%, 68%, and 15% at 1, 3, and 5 years, respectively. Twenty-one patients (28%) died.

CONCLUSION

LTA is a safe and effective treatment for small HCC.

Hepatocellular Carcinoma: Long-term Results of Combined Treatment with Laser Thermal Ablation and Transcatheter Arterial Chemoembolization

PURPOSE

To determine the potential long-term effectiveness of laser thermal ablation (LTA) followed by transcatheter arterial chemoembolization (TACE) in the percutaneous ablation of large hepatocellular carcinoma (HCC).

MATERIALS AND METHODS

Thirty large HCCs 3.5-9.6 cm in diameter (mean diameter, 5.2 cm) and 15 small HCCs 0.8-3.0 cm (mean diameter, 1.9 cm) were treated with ultrasonographically guided LTA with TACE and with LTA alone, respectively, in 30 patients: 19 with a solitary large HCC, and 11 with one to three additional synchronous small HCCS: A 1.064-microm neodymium yttrium-aluminium-garnet (Nd-YAG) laser at a power of 5.0 W was coupled with one to four quartz optic fibers that were advanced through 21-gauge needles. Segmental TACE was performed 30-90 days after LTA. All lesions were evaluated for change in size at computed tomography (CT), alpha-fetoprotein (AFP) levels, recurrence rates, and cumulative survival rates.

RESULTS

No major complications occurred in 127 LTA sessions. CT showed complete tumor necrosis in 27 (90%) of 30 large HCCS: Twenty-eight patients were followed up for 6-41 months (mean, 17.1 months). In 25 patients, all lesions appeared stable or smaller at CT. AFP levels decreased to the normal range in all patients with high pretreatment values. The 1-, 2-, and 3-year local recurrence rate was 7% in large HCCS: Complete tumor necrosis was achieved in all 15 (100%) small HCCs; none of them recurred locally. The 1-, 2-, and 3-year cumulative survival rates were 92%, 68%, and 40%, respectively.

CONCLUSION

LTA followed by TACE is an effective palliative therapy in treating large HCCS: