Radio frequency ablation for hepatocellular carcinoma in cirrhotic patients: prognostic factors for survival

Laser ablation of liver tumors: An ancillary technique, or an alternative to radiofrequency and microwave?

Radiofrequency ablation (RFA) is currently the most popular and used ablation modality for the treatment of non surgical patients with primary and secondary liver tumors, but in the last years microwave ablation (MWA) is being technically improved and widely rediscovered for clinical use. Laser thermal ablation (LTA) is by far less investigated and used than RFA and MWA, but the available data on its effectiveness and safety are quite good and comparable to those of RFA and MWA. All the three hyperthermia-based ablative techniques, when performed by skilled operators, can successfully treat all liver tumors eligible for thermal ablation, and to date in most centers of interventional oncology or interventional radiology the choice of the technique usually depends on the physician’s preference and experience, or technical availability. However, RFA, MWA, and LTA have peculiar advantages and limitations that can make each of them more suitable than the other ones to treat patients and tumors with different characteristics. When all the three thermal ablation techniques are available, the choice among RFA, MWA, and LTA should be guided by their advantages and disadvantages, number, size, and location of the liver nodules, and cost-saving considerations, in order to give patients the best treatment option.

Signal intensity of small hepatocellular carcinoma on apparent diffusion coefficient mapping and outcome after radiofrequency ablation

AIM

It has been reported that the apparent diffusion coefficient (ADC) value of hepatocellular carcinomas (HCC) on diffusion-weighted magnetic resonance imaging (MRI) is associated with their histological grade. The present study aimed to evaluate whether the signal intensity of small hypervascular HCC on the ADC map is related to the treatment outcome of radiofrequency ablation (RFA).

METHODS

Between February 2008 and August 2012, 136 consecutive patients with initial small hypervascular HCC (≤3 tumors and ≤3 cm in diameter) were examined by diffusion-weighted MRI before RFA. The signal intensities of HCC on the ADC map were visually compared with the surrounding liver and categorized as hypointense and non-hypointense. Critical recurrence was defined as more than three intrahepatic recurrences, recurrence with vascular invasion, seeding, dissemination and/or extrahepatic metastasis.

RESULTS

The median follow up was 619 days. The cumulative 2-year recurrence rates of the hypointense and non-hypointense on the ADC map groups were 79% and 50% (P < 0.001), respectively, with cumulative 2-year local recurrence rates of 18% and 7% (P = 0.014) and cumulative 2-year critical recurrence rates of 38% and 13% (P = 0.005), respectively. The cumulative 3-year survival rates were 60% and 82% (P = 0.007), respectively. On multivariate analysis, hypointensity on the ADC map was the strongest independent factor related to recurrence and survival after RFA.

CONCLUSION

The signal intensity of HCC on the ADC map was strongly associated with outcome after RFA. These results suggest that treatment strategy should be determined carefully even for small HCC when they appear hypointense on the ADC map.

Comparison of percutaneous ablation technologies in the treatment of malignant liver tumors

Tumor ablation is a minimally invasive technique used to deliver chemical, thermal, electrical, or ultrasonic damage to a specific focal tumor in an attempt to achieve substantial tumor destruction or complete eradication. As the technology continues to advance, several image-guided tumor ablations have emerged to effectively manage primary and secondary malignancies in the liver. Percutaneous chemical ablation is one of the oldest and most established techniques for treating small hepatocellular carcinomas. However, this technique has been largely replaced by newer modalities including radiofrequency ablation, microwave ablation, laser-induced interstitial thermotherapy, cryoablation, high-intensity-focused ultrasound ablation, and irreversible electroporation. Because there exist significant differences in underlying technological bases, understanding each mechanism of action is essential for achieving desirable outcomes. In this article, the authors review the current state of each ablation method including technological and clinical considerations.

γ-Glutamyltranspeptidase is a prognostic marker of survival and recurrence in radiofrequency-ablation treatment of hepatocellular carcinoma

PURPOSE

Serum γ-glutamyltranspeptidase (GGT) level, which is often elevated in hepatocellular carcinoma (HCC), has now been found to be an oxidative stress marker which correlates with inflammation in the extracellular hepatic microenvironment. The aim of this study was to investigate the prognostic significance of GGT serum levels in patients undergoing radiofrequency ablation (RFA) therapy for the treatment of HCC.

METHODS

This retrospective study included 254 patients with small liver cancer (tumor of ≤5 cm in diameter and nodule of ≤3 cm) who had been treated with RFA. Baseline serum GGT was examined before therapy, and overall survival (OS) and recurrence-free survival were evaluated by the Kaplan-Meier method. Univariate and multivariate analyses were used to analyze the significance of GGT and other serum markers as prognostic factors.

RESULTS

After a median follow-up of 27 months, 51 patients had died and 123 had hepatic recurrence. After treatment with RFA, HCC patients with elevated GGT had a shorter OS versus those with normal GGT level (p = 0.001); they also had higher recurrence (p = 0.001). On multivariate analysis, albumin (p = 0.003), GGT (p = 0.035), and tumor size (p = 0.027) were independent risk factors for survival, and GGT (p = 0.010) and tumor size (p = 0.026) were significant risk factors for recurrence.

CONCLUSIONS

Serum GGT is a convenient prognostic biomarker related to OS and recurrence in HCC patients undergoing RFA treatment.

Post-operative pericardial effusion following treatment of small hepatocellular carcinoma with radiofrequency ablation: A case report

Radiofrequency ablation (RFA) is a minimally invasive technique used to treat liver tumors. The current study presents the case of a patient with hepatocellular carcinoma who suffered from post-operative pericardial effusion following RFA treatment. We hypothesize that RFA thermal conduction may damage the diaphragm and pericardium, leading to local edema in the pericardium. RFA is a minimally invasive technique, however, adequate preparatory work must be performed prior to surgery, including a comprehensive assessment of the patient. During surgery, the location and extent of the region to receive RFA must be determined precisely in order to reduce the range of damage and to avoid post-operative complications. This study describes a case of pericardial effusion caused by RFA of liver cancer. We analyzed the causes and preventive measures for pericardial effusion in order to contribute to the prevention pericardial effusion that is complicated by RFA of liver cancer.

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

PURPOSE

To evaluate the long-term outcomes of radiofrequency ablation (RFA) as a first-line therapy for early-stage hepatocellular carcinoma (HCC) and determine the prognostic factors for survival.

MATERIALS AND METHODS

The institutional review board approved this retrospective study. From January 2006 to December 2007, 162 consecutive patients with cirrhosis (Child-Pugh class A and B, 137 and 25 patients, respectively) who underwent RFA as a first-line treatment for up to three HCCs with a maximum diameter of 5 cm (182 HCCs; mean diameter ± standard deviation, 2.59 cm ± 0.79; 17 multinodular forms) were included. After a mean follow-up of 50.3 months ± 19.9, results were analyzed for tumor recurrence, as well as overall and recurrence-free survival time. The Kaplan-Meier method and Cox proportional hazards regression model were used to evaluate the prognostic factors.

RESULTS

The cumulative incidence of local tumor progression (LTP) was 14.5% at 5 years, with tumor size as the only significant predictive factor (relative risk = 2.13, P = .007). Overall 5-year survival and recurrence-free survival rates were 67.9% and 25.9%, respectively. Significant predictive factors for poor overall survival were Child-Pugh class B (relative risk = 2.43, P = .011), serum α-fetoprotein level (relative risk per 100 units = 1.01; P < .001), and presence of portosystemic collaterals (relative risk = 2.15, P = .025). The development of LTP significantly shortened median recurrence-free survival (28.0 months without LTP vs 12.0 months with LTP) and necessitated a higher number of interventional procedures (2.2 sessions without LTP vs 5.1 sessions with LTP).

CONCLUSION

RFA is a safe and effective first-line treatment for early-stage HCC, with a 5-year survival rate of 67.9%. High serum α-fetoprotein level, advanced Child-Pugh class, and presence of portosystemic collateral vessels had a significant negative effect on overall survival.

Role of radiofrequency ablation in unresectable hepatocellular carcinoma: An Indian experience

AIMS

To evaluate the role of radiofrequency ablation (RFA) as an ablative technique in patients with unresectable hepatocellular carcinoma (HCC).

SETTINGS AND DESIGN

A tertiary care center, prospective study.

MATERIALS AND METHODS

The subjects comprised 31 patients (30 males, one female; age range 32-75 years) with HCC (41 lesions) who were treated with image-guided RFA. The follow-up period ranged from 3 months to 6 years, and included a multiphasic computed tomography (CT) at 1, 3 and 6 months post-RFA, and every 6 months thereafter. Patient outcome was evaluated and the tumor recurrence, survival and complications were assessed.

STATISTICAL ANALYSIS USED

Discrete categorical data were presented as n (%) and continuous data as mean ± SD. Pearson correlation coefficient was used to determine the relationship between the different variables. Kaplan-Meier survival curve and Log-rank test were used to test the significance of difference between the survival time of the different groups.

RESULTS

The ablation success rate was 80.5% (33/41 HCC lesions). 12.2% (5/41) of the lesions were managed with repeat RFA due to tumor residue. 4.9% (2/41) of the lesions were managed with repeated RFA and transarterial chemoembolization. Eight patients had tumor recurrence (five patients (16.1%) had local recurrence and three patients (9.6%) had distant recurrence). Eleven patients died within 3.5-20 months post-RFA. The survival rate at 1 year in patients who completed at least 1 year of follow-up was 63.3%. There was one major complication (1/31, 3.2%) in a patient with a subcapsular lesion and ascites. This patient developed hemoperitoneum in the immediate postprocedure period and was managed with endovascular treatment. She, however, had hepatic decompensation and died 48 h post-RFA.

CONCLUSION

RFA is an effective and safe treatment for small unresectable HCC.

Ultrasonogram of hepatocellular carcinoma is associated with outcome after radiofrequency ablation

AIM

To investigate the association between B-mode ultrasound classification of small hepatocellular carcinoma (HCC) and outcome after radiofrequency ablation (RFA).

METHODS

Ninety-seven cases of HCC treated using RFA between April 2001 and March 2006 were reviewed. Ultrasound images were classified as follows: type 1, with halo (n = 29); and type 2, without halo (n = 68). Type 2 was further categorized into three subgroups: type 2a, homogenous hyperechoic (n = 9); type 2b, hypoechoic with smooth margins (n = 43); and type 2c (n = 16), hypoechoic with irregular or unclear margins. Patients with type 2a HCC were excluded from analysis due to the small number of cases.

RESULTS

Two year recurrence rates for type 2b, type 1 and type 2c were 26%, 42% and 69%, respectively, with significant differences between type 2b and type 2c (P < 0.01), and between type 1 and type 2c (P < 0.05). Five year survival rates were 89%, 43% and 65%, respectively. Survival was significantly longer for type 2b than for other types (type 1 vs type 2b, P < 0.01; type 2b vs type 2c, P < 0.05). On univariate analysis, factors contributing to recurrence were number of tumors, tumor stage, serum level of lens culinaris agglutinin-reactive alpha-fetoprotein and ultrasound classification (P < 0.05). Factors contributing to survival were tumor stage and ultrasound classification (P < 0.05). Multivariate analysis identified ultrasound classification as the only factor independently associated with both recurrence and survival (P < 0.05).

CONCLUSION

B-mode ultrasound classification of small HCC is a predictive factor for outcome after RFA.

Ultrasonogram of hepatocellular carcinoma is associated with outcome after radiofrequency ablation

AIM: To investigate the association between B-mode ultrasound classification of small hepatocellular carcinoma (HCC) and outcome after radiofrequency ablation (RFA).

METHODS: Ninety-seven cases of HCC treated using RFA between April 2001 and March 2006 were reviewed. Ultrasound images were classified as follows: type 1, with halo (n = 29); and type 2, without halo (n = 68). Type 2 was further categorized into three subgroups: type 2a, homogenous hyperechoic (n = 9); type 2b, hypoechoic with smooth margins (n = 43); and type 2c (n = 16), hypoechoic with irregular or unclear margins. Patients with type 2a HCC were excluded from analysis due to the small number of cases.

RESULTS: Two year recurrence rates for type 2b, type 1 and type 2c were 26%, 42% and 69%, respectively, with significant differences between type 2b and type 2c (P < 0.01), and between type 1 and type 2c (P < 0.05). Five year survival rates were 89%, 43% and 65%, respectively. Survival was significantly longer for type 2b than for other types (type 1 vs type 2b, P < 0.01; type 2b vs type 2c, P < 0.05). On univariate analysis, factors contributing to recurrence were number of tumors, tumor stage, serum level of lens culinaris agglutinin-reactive alpha-fetoprotein and ultrasound classification (P < 0.05). Factors contributing to survival were tumor stage and ultrasound classification (P < 0.05). Multivariate analysis identified ultrasound classification as the only factor independently associated with both recurrence and survival (P < 0.05).

CONCLUSION: B-mode ultrasound classification of small HCC is a predictive factor for outcome after RFA.

Comparison of percutaneous radiofrequency thermal ablation and surgical resection for small hepatocellular carcinoma

Background

The purpose of this investigation was to compare the outcome of percutaneous radiofrequency thermal ablation therapy (PRFA) with surgical resection (SR) in the treatment of single and small hepatocellular carcinoma (HCC).

Methods

We conducted a retrospective cohort study on 231 treatment naive patients with a single HCC ≤ 3 cm who had received either curative PRFA (162 patients) or curative SR (69 patients). All patients were regularly followed up after treatment at our department with blood and radiologic tests.

Results

The 1-, 3- and 5-year overall survival rates after PRFA and SR were 95.4%, 79.6% and 63.1%, respectively in the PRFA group and 100%, 81.4% and 74.6%, respectively in the SR group. The corresponding recurrence free survival rates at 1, 3 and 5 years after PRFA and SR were 82.0%, 38.3% and 18.0%, respectively in the PRFA group and 86.0%, 47.2% and 26.0%, respectively in the SR group. In terms of overall survival and recurrence free survival, there were no significant differences between these two groups. In comparison of PRFA group patients with liver cirrhosis (LC) (n = 127) and SR group patients with LC (n = 50) and in comparison of PRFA group patients without LC (n = 35) and SR group patients without LC (n = 19), there were also no significant differences between two groups in terms of overall survival and recurrence free survival. In the multivariate analysis of the risk factors contributing to overall survival, serum albumin level was the sole significant factor. In the multivariate analysis of the risk factors contributing to recurrence free survival, presence of LC was the sole significant factor. The rate of serious adverse events in the SR group was significantly higher than that in the PRFA group (P = 0.023). Hospitalization length in the SR group was significantly longer than in the PRFA group (P = 0.013).

Conclusions

PRFA is as effective as SR in the treatment of single and small HCC, and is less invasive than SR. Therefore, PRFA could be a first choice for the treatment of single and small HCC.

Radiofrequency ablation for recurrent hepatocellular carcinoma in postresectional patients: prognostic factors analysis

BACKGROUND

Percutaneous ablation therapies can be used for recurrent hepatocellular carcinoma (HCC) in postresectional patients not eligible for repeat surgery.

AIMS

To determine prognostic factors affecting the disease-free survival of postresectional patients after percutaneous ultrasound-guided radiofrequency ablation (RFA) for recurrent HCC.

METHODS

From August 2003 to December 2009, patients who had received previous hepatectomy because of HCC and suffered from tumor recurrence were included. Among them, 82 patients who received initial percutaneous ultrasound-guided RFA were included. Various host, treatment, and therapeutic-related factors were analyzed.

RESULTS

Eighty-two patients (64 men, mean age 64.27 years) were included. Sex (P=0.495), age (P=0.840), hepatitis marker (P=0.083), and Child-Pugh score (P=0.809) were not related to prognosis. Preresectional tumor number (P=0.502), recurrent tumor location (P=0.795), recurrent tumor number (P=0.533), pathology proved cirrhosis (P=0.889), and OKUDA stage of the primitive disease (P=0.865) were not related to prognosis, either. Survival rates were significantly related to the preresectional tumor size (P=0.008), microscopic portal vein invasion (P=0.001), recurrent tumor size (P<0.001), and preablation α-fetoprotein serum level (P=0.006). Ablation needle (P=0.373), ablation time (P=0.387), and postablation temperature (P=0.444) were not related to prognosis. Multivariate analysis revealed that microscopic portal vein invasion was the only factor that had a significant effect on patient survival.

CONCLUSION

In patients with postresectional HCC treated with percutaneous ultrasound-guided RFA for recurrent disease, those without microscopic portal vein invasion had a significantly higher probability of disease-free survival.

High serum hyaluronic acid and HBV viral load are main prognostic factors of local recurrence after complete radiofrequency ablation of hepatitis B-related small hepatocellular carcinoma

PURPOSE

The risk factors of local recurrence after complete radiofrequency ablation (RFA) of hepatitis B-related small hepatocellular carcinoma (HCC), ≤3 cm, remains to be clarified. In this study, we evaluated the potential prognostic factors that affect recurrence.

METHODS

A total of 152 consecutive patients with small HCC who had undergone complete RFA were retrospectively studied. The risk factors of local recurrence and their impact on survivals of patients were analyzed.

RESULTS

After a median follow-up of 35 months, intrahepatic recurrence occurred in 67 patients (44.1%). On univariate analysis, HBV DNA, hyaluronic acid, AFP, MELD score, and precollagen III were independent risk factors for recurrence. On multivariate analysis, HBV DNA and hyaluronic acid were independent risk factors for recurrence. The cumulative 1-, 3-, and 5-year disease-free survival rates were 86.8%, 41.2%, and 22.8% in the high viral load group and 96.4%, 65.8%, and 36.7% in the low viral load group, respectively. The difference between the two groups was significant (P=0.003). The cumulative 1-, 3-, and 5-year disease-free survival rates were 87.2%, 42%, and 27.2% in the abnormal hyaluronic acid group and 94.9%, 63.5%, and 33.9% in the normal group, respectively. The difference between the two groups also was significant (P=0.011). Multivariate analysis identified MELD score as the only independent risk factor for overall survival of all patients.

CONCLUSIONS

High serum hyaluronic acid and HBV viral load are main prognostic factors of local recurrence after complete radiofrequency ablation of hepatitis B-related small HCC.

Percutaneous ablation of hepatocellular carcinoma: current status

Hepatocellular carcinoma (HCC) is an increasingly common disease with dismal long-term survival. Percutaneous ablation has gained popularity as a minimally invasive, potentially curative therapy for HCC in nonoperative candidates. The seminal technique of percutaneous ethanol injection has been largely supplanted by newer modalities, including radiofrequency ablation, microwave ablation, cryoablation, and high-intensity focused ultrasound ablation. A review of these modalities, including technical success, survival rates, and complications, will be presented, as well as considerations for treatment planning and follow-up.

Radiofrequency ablation for hepatocellular carcinoma: a survival analysis of 117 patients

BACKGROUND

Hepatocellular carcinoma (HCC) is one of the most common malignancies in the world especially in Asia. Radiofrequency ablation is now commonly use as either first line or in combination with other treatment modality for patients with HCC. It is the objective of this article to report our experience in a tertiary referral hospital.

METHODS

Patients who diagnosed with HCC and underwent RFA in Queen Elizabeth Hospital during the period from May 2002 to February 2009 were included and analyzed.

RESULTS

During this period, 138 sessions of RFA were performed in 117 consecutive patients with HCC. The calculated rate of primary (single attempt) successful ablation during this entire period was 89.2%. The in-hospital/30-day mortality rate was zero, and morbidity was 24.1%. Hospital stays were significantly longer in the open group (4.4 days versus 8.9 days, P = 0.000). Median follow-up in this study was 21 months. 11 (9.4%), 10 (8.5%) and 49 (41.0%) patients developed local tumor progression (LTP), systemic recurrence and Intrahepatic distant recurrence (IDR), respectively. The mean and median times to recurrence were 15.4 and 11 months, respectively. Most patients (91%) with LTP developed in the first 24 months. Disease-free survival was 65% at 1 year, 40% at 3 years and 25% at 5 years. Overall survival at 1, 3 and 5 years was 85, 66 and 40%, respectively. Alpha fetoprotein, aFP > 1,000 ng/ml and multiple tumor ablation predicted increased risk of recurrence.

CONCLUSION

Radiofrequecy ablation is useful tool in treating patients with HCC with high successful rate. However, intrahepatic recurrence is common and a well designed post ablation follow up protocol based on a sound knowledge of recurrence pattern is vital.

Radiofrequency ablation of hepatocellular carcinoma: long-term results and prognostic factors in 235 Western patients with cirrhosis

For the treatment of small hepatocellular carcinoma (HCC), radiofrequency ablation (RFA) is in some centers considered a first-line therapeutic option. However, such a strategy is still under debate with regard to tumor and patient characteristics. In this single-center study we assessed the 5-year survival and prognosis factors in 235 consecutive patients with cirrhosis (Child-Pugh A/B: 205/30) who received RFA as first-line treatment for up to three HCC <or=5 cm (307 tumors; mean diameter: 29 +/- 10 mm; 53 multinodular forms). Among these patients, 67 satisfied the criteria for resection according to the Barcelona Clinic Liver Cancer. Complete ablation was obtained in 222 patients (94%). Overall, 337 RFA sessions were performed including iterative RFA for recurrence. Major complications occurred in three patients (0.9%), including one treatment-related death. After 27 +/- 20 months of mean follow-up, local or distant, or both, tumor recurrence occurred in 16, 88, and 11 patients, respectively. Twenty-nine patients underwent transplantation and were removed from the study at this point. Overall 5-year, recurrence-free, and tumor-free (including results of iterative RFA) survival rates were, respectively, 40%, 17%, and 32%. The overall 5-year survival rate was 76% for operable patients. Factors associated with overall survival were prothrombin activity (hazard ratio [HR] = 0.97, 0.96-0.98; P < 0.0001) and serum levels of alpha-fetoprotein (AFP) (HR = 1.02, 1.02-1.02; P < 0.0001), and factors associated with tumor recurrence were multinodular forms (HR = 2.34; 1.52-3.6; P = 0.0001) and serum AFP levels (HR = 1.015, 1.014-1.016; P = 0.015). Tumor size was associated with local recurrence but not with overall and tumor-free survival.

CONCLUSION

RFA is a safe and effective first-line treatment of HCC up to 5 cm in diameter, especially for patients with a single tumor, a low serum AFP level, and well-preserved liver function.

Contrast-enhanced ultrasonography (CEUS) immediately after percutaneous ablation of hepatocellular carcinoma

PURPOSE

This study evaluated the effectiveness of contrast-enhanced ultrasound (CEUS), performed immediately after percutaneous ethanol injection (PEI) or radiofrequency thermal ablation (RFTA), by comparing results with the computed tomography (CT) follow-up.

MATERIALS AND METHODS

Sixty-nine consecutive patients with a diagnosis of hepatocellular carcinoma (HCC) were included in this prospective study. All patients underwent PEI or RFTA. After treatment, three CEUS enhancement patterns were observed: isovascular, hypovascular and avascular, which were compared with the CT findings. Sensitivity of the avascular pattern at CEUS and effectiveness of the ablative procedures were evaluated and compared with the chi-square test.

RESULTS

Ninety hypervascular HCCs, with a mean diameter of 2.6 cm (0.5-4.9 cm), underwent PEI (n=54) and RFTA (n=36). In the first group, CT identified complete necrosis in 28/54 (52%) lesions, 21 (75%) of which had avascular, one (4%) isovascular and six (21%) hypovascular patterns at CEUS. In the second group, CT showed complete necrosis in 31/36 (86%) lesions, all (100%) of which had a corresponding avascular pattern at CEUS. Sensitivity, specificity, positive predictive value, negative predictive value and accuracy of the avascular pattern at CEUS compared with CT findings were 75%, 69%, 72%, 72% and 72% for PEI and 100%, 20%, 89%, 100% and 89%, for RFTA, respectively. A statistically significant difference (p<0.05) between the sensitivity of CEUS after PEI and after RFTA and between the necrosis obtained by RFTA and PEI were observed.

CONCLUSIONS

CEUS performed immediately after percutaneous ablation of hepatocellular carcinoma to evaluate treatment efficacy is compulsory in the case of RFTA but not for PEI.

Comparison of therapeutic effects between radiofrequency ablation and percutaneous microwave coagulation therapy for small hepatocellular carcinomas

BACKGROUND

Although thermal ablation therapies have gained fairly wide acceptance as an effective treatment for small hepatocellular carcinoma (HCC), there have been only a few clinical studies comparing the response to radiofrequency ablation (RFA) and percutaneous microwave coagulation therapy (PMCT). We evaluated the therapeutic efficacy and safety of these two procedures for the treatment of small HCC measuring < or = 2 cm in diameter.

METHODS

Thirty-four patients who had 37 nodules were treated by RFA and were compared with 49 patients (56 nodules) who underwent PMCT. Treatment was repeated until complete tumor necrosis was confirmed by contrast computed tomography (CT) scanning. The therapeutic efficacy and complications were retrospectively compared between the two procedures.

RESULTS

(i) There were significantly fewer treatment sessions (P < 0.001) in the RFA group than in the PMCT group, but the necrotic area was significantly larger (P < 0.001) in the former group. (ii) The local recurrence rate was significantly lower (P = 0.031) after RFA than after PMCT, although the ectopic recurrence rate showed no significant difference. (iii) The cumulative survival rate was significantly higher (P = 0.018) after RFA than after PMCT. (iv) The incidence of pain and fever after treatment was significantly higher in the PMCT group. Bile duct injury, pleural effusion, and ascites were also significantly more common in the PMCT group.

CONCLUSIONS

RFA is more useful than PMCT for the treatment of small HCC because it is minimally invasive and achieves a low local recurrence rate, high survival rate, and extensive necrosis after only a few treatment sessions.

The current role of radiofrequency ablation in the management of hepatocellular carcinoma: a systematic review

OBJECTIVE

To review the current status of radiofrequency ablation (RFA) in the management of hepatocellular carcinoma (HCC).

SUMMARY BACKGROUND DATA

The development of local ablative therapy has been 1 of the major advances in the treatment of HCC. Its role in the management of HCC is still rapidly evolving.

METHODS

Studies were identified by searching Medline, and PubMed databases for articles from January 1997 to April 2008 using the keywords "radiofrequency ablation," "hepatocellular carcinoma" and "ablation of HCC." Additional papers were identified by a manual search of the references from the key articles. Randomized controlled trials, nonrandomized comparative studies, cohort studies, were reviewed. Cohort studies with follow-up of less than 12 months and case reports were excluded.

RESULTS

Five aspects of RFA were analyzed: (1) RFA in comparison with other local ablative therapies; (2) RFA for unresectable HCC; (3) RFA as bridging therapy before liver transplantation; (4) RFA as primary treatment for resectable HCC; and (5) RFA for recurrent HCC after partial hepatectomy. Ten RCTs, 8 nonrandomized controlled trials and 26 cohort studies were included in this analysis.

CONCLUSIONS

The evidence in the medical literature showed RFA was more effective than other local ablative therapies, and supported its use in the treatment of unresectable small HCC, recurrent small HCC, and as bridging therapy before liver transplantation, and as a primary treatment in competition with partial hepatectomy for resectable small HCC.

Radiofrequency ablation and chemoembolization for hepatocellular carcinoma

PURPOSE

To provide an up-to-date review of the technique, efficacy, safety and clinical applications for radiofrequency ablation (RFA) and transarterial chemoembolization (TACE) for hepatocellular carcinoma (HCC).

METHODS

A thorough review of the literature was performed as related to RFA and TACE for the treatment of HCC. We mixed these findings with our own extensive research and clinical experience on this subject by drawing from a pool of more than 1000 patients treated with both modalities.

RESULTS

TACE has been shown with the work of Llovet, Camma, and Lo to provide a significant survival benefit for patients with unresectable HCC. The former showed a 1-, 2-, and 3-year survival at 57%, 31%, and 26% in the treatment group vs. 32%, 11%, and 3% in the supportive treatment alone group, respectively. Repeatedly, RFA has been shown to be very effective in the treatment of small (<or=3 cm) HCC lesions with a complete response rate of about 90%. Studies have shown that RFA may be equivalent to surgical resection in this subgroup of patients. For both modalities, patient selection and proper technique are important in minimizing the possible complications associated with them, which rarely includes liver failure, abscess formation, and hemorrhage.

DISCUSSION

RFA and TACE have both been shown to provide a survival benefit for patients with unresectable HCC. More recent studies have paired these modalities with surgical resection with favorable results. Refined technique, improvements in technology, and research on better-targeted chemotherapy will likely result in further improved survival benefit. Additionally, the scope of this treatment is broadening to include resectable patients, patients awaiting liver transplantation, and, in combination with other systemic (bevacizumab, sorafenib, etc) or locoregional (RFA-TACE combination, RFA-resection etc) treatments.

Current situation and progress of local ablation therapy for hepatocellular carcinoma

Local ablation therapy with satisfactory therapeutic effects has been an important combined therapy for hepatocellular carcinoma (HCC). There are mainly two ablation methods available including thermal ablation and chemical ablation. Thermal ablation techniques include microwave ablation, radiofrequency ablation, laser ablation, high intensity focus ultrasound (HIFU) and cryoablation, etc. Chemical ablation methods include mainly ethanol ablation and acetic acid ablation. In this article, our objective was to evaluate the current situation and progress of local ablation therapy in terms of its principles, indications, therapeutic effects, complications, contraindications and pros and cons of various ablation therapies for HCC.

Comparison of seven staging systems in cirrhotic patients with hepatocellular carcinoma in a cohort of patients who underwent radiofrequency ablation with complete response

BACKGROUND AND AIMS

Many staging systems for hepatocellular carcinoma (HCC) have been proposed but the best tool for staging of HCC remains controversial. The aim of the present study was to identify the best staging system evaluating the predictive ability for outcome for each of the seven different staging systems applied in a homogeneous group of patients who underwent percutaneous radiofrequency ablation (RFA).

METHODS

We analyzed retrospectively 112 patients with HCC and cirrhosis treated with percutaneous RFA from January, 1998 to April, 2005. Response to treatment after 30 days and for long-term follow-up was evaluated with computed tomography (CT) or magnetic resonance imaging (MRI) and serum alpha-fetoprotein level (AFP). All of the 112 patients were grouped according to each one of the seven different staging systems: Okuda, TNM, BCLC, CLIP, GRETCH, CUPI, JIS.

RESULTS

The mean follow-up time of the 112 patients submitted to RFA was 24 months (range 3-92 months) with survival rates at 1, 3, and 5 yr of 82%, 40%, and 18%, respectively. Univariate and multivariate analyses showed that factors related to survival were Child-Pugh score (P</= 0.01), serum AFP (P</= 0.01), and the response to treatment (P</= 0.01) with hazard ratios of 2.09 (95% CI 1.21-3.61), 2.79 (95% CI 1.59-4.90), and 2.76 (95% CI 1.25-6.09), respectively. The comparison of the results of the different staging systems in all of the 112 patients and in a subgroup of 96 patients with complete response to treatment showed that BCLC had the best discrimination ability, monotonicity of gradient (linear trend chi(2) 6.07, P= 0.01), and homogeneity ability (LR chi(2) test 10.00, P= 0.008).

CONCLUSIONS

The BCLC staging system shows a superior discriminatory power in our cohort of HCC patients who underwent RFA; moreover, it can give important prognostic information after complete response to treatment. Our study confirms the validity of the BCLC staging system in patients with HCC in cirrhosis.

Radiofrequency ablation versus surgical resection for the treatment of hepatocellular carcinoma in cirrhosis

BACKGROUND AND AIMS

Percutaneous radiofrequency ablation (RFA) demonstrated good results for the treatment of hepatocellular carcinoma (HCC) in cirrhotic patients; it is still not clear whether the overall survival and disease-free survival after RFA are comparable with surgical resection. The aims of this study are to compare the overall survival and disease-free survival in two groups of cirrhotic patients with HCC submitted to surgery or RFA.

METHODS

Two hundred cirrhotic patients with HCCs smaller than 6 cm were included in this retrospective study: 109 underwent RFA and 91 underwent surgical resection at a single Division of Surgery of University of Verona.

RESULTS

Median follow-up time was 27 months. Overall survival was significantly longer in the resection group in comparison with the RFA group with a median survival of 57 and 28 months, respectively (P=0.01). In Child-Pugh class B patients and in patients with multiple HCC, survival was not significantly different between the two groups. In patients with HCC smaller than 3 cm, the overall survival and disease-free survival for RFA and resection were not significantly different in univariate and multivariate analysis. Whereas in patients with HCC greater than 3 cm, surgery showed improvement in outcome in both univariate and multivariate analysis.

CONCLUSIONS

Surgical resection significantly improves the overall survival and disease-free survival in comparison with RFA. In a selected group of patients (Child-Pugh class B, multiple HCC, or in HCC<or=3 cm), the results between the two treatments did not show significant differences.

Validation of the Obesity Surgery Mortality Risk Score in a Multicenter Study Proves It Stratifies Mortality Risk in Patients Undergoing Gastric Bypass for Morbid Obesity

BACKGROUND

A scoring system for clinical assessment of mortality risk has been previously proposed for bariatric surgery (Demaria EJ, Portenier D, Wolfe L, Surg Obes Relat Dis. 2007;3:34-40.). The Obesity Surgery Mortality Risk Score (OS-MRS) was developed from a single institution experience of 2075 patients. The current study provides multicenter validation of the value of the OS-MRS. The OS-MRS assigns 1 point to each of 5 preoperative variables, including body mass index>or=50 kg/m2, male gender, hypertension, known risk factors for pulmonary embolism (previous thromboembolism, preoperative vena cava filter, hypoventilation, pulmonary hypertension), and age>or=45 years. Patients with total score of 0 to 1 are classified as 'A' (lowest) risk group, score 2 to 3 as 'B' (intermediate) risk group, and score 4 to 5 as 'C' (high) risk group.

METHODS

Prospectively-collected data from 4431 consecutive patients undergoing a primary gastric bypass at 4 bariatric programs recruited to validate the proposed system were analyzed to assess OS-MRS as a means of stratifying surgical mortality risk.

RESULTS

There were 33 total deaths for an overall mortality for the validation cohort of 0.7% consistent with published standards. Mortality for 2164 class A patients was 0.2%, for 2142 class B patients was 1.1%, and for 125 class C patients was 2.4%. Mortality was significantly different between each of the class A, B, and C groupings (P<0.05, chi2). Mortality was 5-fold greater in the class B group than in class A. Only 6 patients with all 5 risk factors were identified. Class C patients (n=125, 3% of total cohort) were characterized by a 12-fold greater mortality than the lowest risk group (A) and a disproportionate 9% of all mortalities.

CONCLUSION

The OS-MRS was found to stratify mortality risk in 4431 patients from 4 validation centers that were nonparticipants in the original defining cohort study. The score represents the first validated scoring system for risk stratification in bariatric surgery and is anticipated to aid informed consent discussions, guide surgical decision-making, and allow standardization of outcome comparisons between treatment centers.