Combination of radiofrequency ablation with transarterial chemoembolization for hepatocellular carcinoma: an up-to-date meta-analysis. Tumour Biol. 2014;35:7407-7413. [PMID: 24777334 DOI: 10.1007/s13277-014-1976-z]

Combined Transarterial Chemoembolization and Radiofrequency Ablation for Hepatocellular Carcinoma Infeasible for Ultrasound-Guided Percutaneous Radiofrequency Ablation: A Comparative Study with General Ultrasound-Guided Radiofrequency Ablation Outcomes

OBJECTIVES

This study aimed to evaluate the therapeutic outcomes of transarterial chemoembolization combined with radiofrequency ablation (TACE + RFA) for hepatocellular carcinomas (HCC) measuring ≤3 cm infeasible for ultrasound (US)-guided percutaneous RFA.

METHODS

Twenty-four patients who underwent fluoroscopy-guided TACE + RFA for single HCC between January 2012 and December 2016 were screened. To evaluate the TACE + RFA outcomes compared with those of US-guided RFA, 371 patients who underwent US-guided RFA during the same period were screened. We compared local tumor progression (LTP) and intrahepatic distant recurrence (IDR) between the two groups before and after propensity score (PS) matching, and performed univariable and multivariable Cox proportional hazard regression analyses for all patients.

RESULTS

PS matching yielded 21 and 42 patients in the TACE + RFA and US-guided RFA groups, respectively. Cumulative LTP rates after PS matching were not significantly different between the two groups at 1 (0.0% vs. 7.4%, p = 0.072), 2 (10.5% vs. 7.4%, p = 0.701), and 5 years (16.9% vs. 10.5%, p = 0.531). IDR rates did not differ significantly between the two groups at 1 (20.6% vs. 10%, p = 0.307), 2 (25.9% vs. 25.9%, p = 0.999), or 5 years (49.9% vs. 53%, p = 0.838). Multivariable analysis showed that treatment type was not a significant factor for LTP or IDR.

CONCLUSION

The outcomes of TACE + RFA for HCC were similar to those of general US-guided RFA. Fluoroscopy-guided TACE + RFA may be an effective treatment when US-guided RFA is not feasible.

Advances in the interventional therapy of hepatocellular carcinoma originating from the caudate lobe

Hepatocellular carcinoma originating from the caudate lobe, also known as segment I hepatocellular carcinoma, is difficult to treat because of its special location, complex vascular supply, and the proximity of important vessels, bile ducts, and organs. This research is conducted to examine the efficacy and safety of interventional therapy for hepatocellular carcinoma in the caudate lobe.

Conclusion

Superselective chemoembolization and ablation techniques for the treatment of caudate lobe hepatocellular carcinoma still need to be improved. The combination of multiple interventional methods and the application of multiple imaging techniques can improve the effectiveness and safety of interventional therapy for hepatocellular carcinoma in the caudate lobe. Multidisciplinary treatment is also essential to improve the prognosis of patients with caudate lobe hepatocellular carcinoma.

•

The anatomical characteristics of the arteries in the caudate lobe hepatocellular carcinoma remains an important factor restricting the success rate of superselective transcatheter arterial chemoembolization.

•

The application of multiple imaging techniques may improve the effectiveness and safety of interventional therapy.

•

The combination of multiple interventional methods has more advantages than disadvantages.

•

Multidisciplinary treatment is increasingly becoming a trend in the treatment of caudate lobe hepatocellular carcinoma.

Combined treatments in hepatocellular carcinoma: Time to put them in the guidelines?

The time for battling cancer has never been more suitable than nowadays and fortunately against hepatocellular carcinoma (HCC) we do have a far-reaching arsenal. Moreover, because liver cancer comprises a plethora of stages-from very early to advanced disease and with many treatment options–from surgery to immunotherapy trials–it leaves the clinician a wide range of options. The scope of our review is to throw light on combination treatments that seem to be beyond guidelines and to highlight these using evidence-based analysis of the most frequently used combination therapies, discussing their advantages and flaws in comparison to the current standard of care. One particular combination therapy seems to be in the forefront: Transarterial chemoembolization plus ablation for medium-size non-resectable HCC (3-5 cm), which is currently at the frontier between Barcelona Clinic Liver Cancer classification A and B. Not only does it improve the outcome in contrast to each individual therapy, but it also seems to have similar results to surgery. Also, the abundance of immune checkpoint inhibitors that have appeared lately in clinical trials are bringing promising results against HCC. Although the path of combination therapies in HCC is still filled with uncertainty and caveats, in the following years the hepatology and oncology fields could witness an HCC guideline revolution.

Transcatheter Arterial Chemoembolization Combined with Simultaneous Cone-beam Computed Tomography-guided Microwave Ablation in the Treatment of Small Hepatocellular Carcinoma: Clinical Experiences From 50 Procedures

RATIONALE AND OBJECTIVES

To investigate the technical success, safety and outcomes of transcatheter arterial chemoembolization (TACE) combined with simultaneous cone-beam computed tomography (CBCT)-guided microwave ablation (MWA) in small hepatocellular carcinoma (SHCC).

MATERIALS AND METHODS

Retrospective analysis of 66 lesions in 50 patients (38 men, 12 women) who underwent TACE combined with simultaneous CBCT-guided MWA for SHCC. After 1 month of treatment, the tumor responses were assessed using the mRECIST criteria, along with interventional-related complications and changes in hepatic and renal function. Moreover, progression-free survival (PFS) and overall survival (OS) were calculated.

RESULTS

All patients achieved technical success. The mean target tumor size was 3.4 ± 0.7 (range, 2.2-4.9) cm. The mean energy, ablation duration per tumor, and the mean safety margin were 51.3  ±  8.4  kJ, 6.7  ±  0.8  minutes and 1.4 ± 0.6 cm, respectively. The 1-, 3-, and 5-year PFS rates were 90.0%, 65.4%, and 35.7%, respectively, with a mean PFS of 43.46 months; and the 1-, 3-, and 5-year OS rates were 98.0%, 89.8%, and 74.3%, respectively, with a mean OS of 54.90 months. Multivariate Cox regression analysis further illustrated that TACE combined with MWA in the treatment of a single tumor with a diameter of less than 3 cm was an independent protective factor for PFS and OS (p < 0.001). The patients had no major complications. Among the exceptions, one patient (2%) had an asymptomatic perihepatic effusion that resolved spontaneously, two patients (4%) developed massive right pleural effusion, requiring thoracic drainage, and another patient (2%) developed a hepatic subcapsular hemorrhage required interventional embolization.

CONCLUSION

CBCT-guided TACE combined with simultaneous MWA was a safe and successful treatment of SHCC with a high technical efficacy.

Making timely remedial measures after TACE based on the results of cone-beam CT liver perfusion

OBJECTIVE

To evaluate the feasibility and safety of using cone-beam CT (CBCT) to measure changes in parenchymal blood volume (PBV) of patients with hepatocellular carcinoma (HCC) after transcatheter arterial chemoembolization (TACE) and to guide microwave ablation (MWA) for residual tumors.

METHODS

A retrospective study was performed on 42 patients with HCC who completed TACE and received CBCT-guided perfusion imaging. The residual active lesions after TACE were supplemented with MWA to complete the treatment process according to the residual PBV. The outcomes were analyzed, including PBV changes, interventional-related complications, local tumor progression (LTP) and overall survival (OS).

RESULTS

Technical success was achieved in all lesions. Correlation analysis revealed that greater volume of residual PBV after MWA is negatively correlated with LTP. (p = .000); and the decrease of PBV was positively correlated with LTP (p = .000). All adverse events and complications were CTCAE Grade 1/2. After combination treatment, the 1-, 3-, and 5-year LTP-free survival were 97.6%, 69.0% and 15.1%, respectively, with a median LTP of 49.0 months (95% CI:43.129,54.871). Multivariate Cox regression revealed that the residual PBV > 13 ml/1000 was an independent factor predicting a shorter OS and LTP (Both p< .05). For LTP, multivariate Cox regression showed that a tumor in a single lesion were independently predicted to have a longer LTP in patients with HCC (p = .033).

CONCLUSION

CBCT is feasible and safe to use to measure changes in the PBV before and after TACE treatment, while it can also guide MWA for the treatment of residual tumors in one session.

Individual or combined transcatheter arterial chemoembolization and radiofrequency ablation for hepatocellular carcinoma: a time-to-event meta-analysis

Background

There is still some debate as to whether transcatheter arterial chemoembolization (TACE) plus radiofrequency ablation (RFA) is better than TACE or RFA alone. This meta-analysis aimed to compare the efficacy and safety of TACE plus RFA for hepatocellular carcinoma (HCC) with RFA or TACE alone.

Methods

We searched PubMed, MEDLINE, Embase, Cochrane Library, and CNKI (China National Knowledge Infrastructure) for all relevant randomized controlled trials and retrospective studies reporting overall survival (OS), recurrence-free survival (RFS), and complications of TACE plus RFA for HCC, compared with RFA or TACE alone.

Results

Twenty-one studies involving 3413 patients were included. TACE combined with RFA was associated with better OS (hazard ratio [HR]=0.62, 95% confidence intervals [CI] = 0.55–0.71, P < 0.001) and RFS (HR = 0.52, 95% CI = 0.39–0.69, P < 0.001) than TACE alone; compared with RFA alone, TACE plus RFA resulted in longer OS (HR = 0.63, 95% CI = 0.53–0.75, P < 0.001) and RFS (HR = 0.60, 95% CI = 0.51–0.71, P < 0.001). Subgroup analyses by tumor size also showed that combined treatment resulted in better OS and RFS compared with RFA alone in patients with HCC larger than 3 cm. Combined treatment resulted in similar rate of major complications compared with TACE or RFA alone (OR = 1.78, 95% CI = 0.99–3.20, P = 0.05; OR = 1.00, 95% CI = 0.42–2.38, P = 1.00, respectively).

Conclusions

TACE combined with RFA was more effective for HCC than TACE alone. For patients with a tumor larger than 3 cm, the combined treatment also achieved a better effect than RFA alone.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12957-021-02188-4.

Transcatheter arterial chemoembolization combined with simultaneous DynaCT-guided microwave ablation in the treatment of small hepatocellular carcinoma

PURPOSE

To evaluate the method and effectiveness of transcatheter arterial chemoembolization (TACE) combined with simultaneous DynaCT-guided Microwave ablation (MWA) for the treatment of small hepatocellular carcinoma (SHCC).

MATERIALS AND METHODS

From June 2015 to May 2017, a total of 28 consecutive patients with SHCC received single treatment of TACE and 23 subjects received a combination treatment of TACE with simultaneous DynaCT-guided MWA. Following 1 month of treatment, the tumor response was assessed using the mRECIST criteria and the outcomes were analyzed including intervention-associated complications, changes in liver function, imaging response, and progression-free survival (PFS).

RESULTS

The technical success rate was 100%. The rates of CR (65%) in the combined TACE and MWA group were higher than those of the TACE group (46%). The rate of common adverse events, such as liver abscess, spontaneous bacterial peritonitis and liver dysfunction, in the combined TACE and MWA group (56%) was comparable to the corresponding rate of the TACE group (P > 0.411). The median and mean PFS of the TACE group were significantly lower than those of the combined TACE and MWA group (19.00 months vs. 29.00 months, 21.076 months vs. 24.693 months, p = 0.019, log-rank test).

CONCLUSION

Stereotactic DynaCT-guided MWA is a safe and effective method for the treatment of SHCC, which usually provides an effective tumor puncture path, notably for lesions that cannot be detected following TACE. Overall, the data suggested that this treatment method could improve the clinical outcome of patients with SHCC.

Enhancement Effect of Microbubble-Enhanced Ultrasound in Microwave Ablation in Rabbit VX2 Liver Tumors

Objectives

One reason for the high recurrence and metastatic rates of tumors such as hepatocellular carcinoma (HCC) treated by microwave ablation (MWA) is the presence of residual foci in the tumor due to heat sink effect. Microbubble-enhanced ultrasound (MEUS) can noninvasively disrupt and block the tumor blood perfusion and has the potential to overcome the heat sink effect and enhance the therapeutic effect of MWA. The study aimed at evaluating the potential additional benefit of microbubble-enhanced ultrasound (MEUS) in hepatocellular carcinoma (HCC) treated by microwave ablation (MWA).

Methods

In this study, a new strategy of combining MWA with MEUS for treating HCC was proposed. Twenty-four rabbits with VX2 tumors in livers were randomly divided into MEUS + MWA, MEUS alone, MWA alone, and blank control groups, respectively (n = 6). In the MEUS group, the tumors were directly exposed to therapeutic ultrasound for 5 min with a concurrent intravenous injection of microbubbles (0.1 ml/kg diluted into 5 ml saline). In the MWA group, the tumors were treated by MWA for 1 min. In the MEUS + MWA group, tumors were ablated by MWA for 1 min after ultrasound cavitation enhanced by microbubbles as in the MEUS group. In the blank control group, the tumors received probe sham and intravenous saline. Contrast-enhanced ultrasound (CEUS) was performed before treatment and immediately after treatment to display the size, shape, and contour of the tumors. Throughout the treatment process, the local temperature of the treatment area was detected by a temperature needle punctured into the tumor. The blood samples of animals were obtained after treatment for evaluating the liver function. Tumor cell necrosis and apoptotic rates were observed after treatment by histological examination.

Results

CEUS showed that although perfusion defects appeared in all the treatment groups, especially in the MEUS + MWA group, there was no significant difference between the two groups on the volumes of perfusion defects, which were 1.78 ± 0.31 (cm³) in the MWA group and 1.84 ± 0.20 (cm³) in the combined group (P < 0.01). The time to reach the peak temperature of the treatment area was 21.7 ± 5.0 (s) in the MWA group and 10.3 ± 5.0 (s) in the MEUS + MWA group (P < 0.01). The time to reach the peak temperature of the treatment area was 21.7 ± 5.0 (s) in the MWA group and 10.3 ± 5.0 (s) in the MEUS + MWA group (P < 0.01). The time to reach the peak temperature of the treatment area was 21.7 ± 5.0 (s) in the MWA group and 10.3 ± 5.0 (s) in the MEUS + MWA group (

Conclusions

These results suggested MEUS treatment alone may significantly reduce tumor blood perfusion and led to a sharp rise in the local temperature of the treatment area to a higher PT using MEUS + MWA with higher rates of necrosis and apoptosis of cancer cells without severe liver function damage, which might be a safe strategy for treating HCC.

Mathematical modeling of mass and energy transport for thermoembolization

Background: Thermoembolization presents a unique treatment alternative for patients diagnosed with hepatocellular carcinoma. The approach delivers a reagent that undergoes an exothermic chemical reaction and combines the benefits of embolic as well as thermal- and chemical-ablative therapy modalities. The target tissue and vascular bed are subjected to simultaneous hyperthermia, ischemia, and chemical denaturation in a single procedure. To guide optimal delivery, we developed a mathematical model for understanding the competing diffusive and convective effects observed in thermoembolization delivery protocols.Methods: A mixture theory formulation was used to mathematically model thermoembolization as chemically reacting transport of an electrophile, dichloroacetyl chloride (DCACl), within porous living tissue. Mass and energy transport of each relevant constituent are considered. Specifically, DCACl is injected into the vessels and exothermically reacts with water in the blood or tissue to form dichloroacetic acid and hydrochloric acid. Neutralization reactions are assumed instantaneous in this approach. We validated the mathematical model predictions of temperature using MR thermometry of the thermoembolization procedure performed in ex vivo kidney.Results: Mathematical modeling predictions of tissue death were highly dependent on the vascular geometry, injection pressure, and intrinsic amount of exothermic energy released from the chemical species, and were able to recapitulate the temperature distributions observed in MR thermometry.Conclusion: These efforts present a first step toward formalizing a mathematical model for thermoembolization and are promising for providing insight for delivery protocol optimization. While our approach captured the observed experimental temperature measurements, larger-scale experimental validation is needed to prioritize additional model complexity and fidelity.

Combination therapy of transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) for small hepatocellular carcinoma: comparison with TACE or RFA monotherapy

PURPOSE

To compare the safety and efficacy of combined transarterial chemoembolization (TACE) and radiofrequency ablation (RFA) for small hepatocellular carcinoma (HCC) with those of TACE or RFA monotherapy.

METHODS

This study included 34 combined TACE and RFA (TACE-RFA), 87 TACE, and 136 ultrasound-guided RFA, which were performed to treat HCC (≤ 3 cm, 3 or fewer) between March and August 2009. The safety (Child-Pugh score indicating hepatic functional reserve, patient discomfort requiring medication, duration of hospitalization, and complications) and efficacy (1-month, 6-month, and 1-year tumor responses) profiles of each treatment were evaluated and compared.

RESULTS

TACE-RFA group showed longer hospital stay and more frequent patient discomfort requiring medication than TACE or RFA group (P < 0.001). The frequency of overall complications after TACE-RFA was higher than TACE (P = 0.006) or RFA (P = 0.009). There were no statistical differences in major complication rates between the three groups (P = 0.094). Child-Pugh score at 1-month follow-up showed no significant difference between the three groups (P = 0.162). 1-month, 6-month, and 1-year tumor responses of TACE-RFA were similar to those of RFA and better than those of TACE.

CONCLUSIONS

TACE-RFA appears to result in more frequent patient discomfort requiring medication, longer hospital stay, and more frequent complications than TACE or RFA monotherapy. Tumor response of TACE-RFA seems to be similar to that of RFA and better than TACE monotherapy. Thus, TACE-RFA for treating small HCC may be required for the selected patients, especially patients with small HCC ineligible for RFA monotherapy.

Combination transarterial chemoembolization and microwave ablation improves local tumor control for 3- to 5-cm hepatocellular carcinoma when compared with transarterial chemoembolization alone

PURPOSE

To compare transarterial chemoembolization (TACE) monotherapy to combination TACE and microwave ablation (MWA) for local control of 3- to 5-cm hepatocellular carcinoma (HCC).

METHODS

Patients with HCC between 3 and 5 cm treated with TACE monotherapy or combination TACE + MWA at a single institution between 2007 and 2016 were retrospectively reviewed. Twenty-four HCCs (median diameter 3.8 cm) in 16 patients (13 males; median age 64 years) were treated using TACE monotherapy. Combination TACE + MWA was used to treat 23 HCCs (median diameter 4.2 cm) in 22 patients (18 males; median age 61 years). Microwave ablation was performed at a target time of two weeks following TACE. Individual tumors were followed by serial contrast-enhanced CT or MR. Response to treatment was evaluated on a tumor-by-tumor basis using mRECIST criteria with the primary outcome being local tumor progression (LTP). Data were analyzed using Fisher's exact test for categorical variables and Wilcoxon rank sum test for continuous variables. Time to LTP was estimated with the Kaplan-Meier method.

RESULTS

Relative to TACE monotherapy, TACE + MWA provided a trend toward both a lower rate of LTP (34.8% vs. 62.5%, p = 0.11) and a higher complete response rate (65.2% vs. 37.5%; p = 0.12). Time to LTP (22.3 months vs. 4.2 months; p = 0.001) was significantly longer in the TACE + MWA group compared to TACE monotherapy.

CONCLUSIONS

Combination therapy with TACE and microwave ablation improves local control and increases time to LTP for 3-5 cm HCC.

Transcatheter arterial chemoembolization combined with simultaneous DynaCT-guided radiofrequency ablation in the treatment of solitary large hepatocellular carcinoma

PURPOSE

To introduce the technique and investigate the clinical efficacy of transcatheter arterial chemoembolization (TACE) in combination with simultaneous DynaCT-guided radiofrequency ablation (RFA) in the treatment of solitary large hepatocellular carcinomas (HCCs) (maximal diameter > 5 cm).

MATERIALS AND METHODS

Forty-six patients who received TACE combined with simultaneous DynaCT-guided RFA for solitary large HCCs between January 2012 and August 2016 were reviewed, and the success rate, safety, local tumor progression (LTP), and overall survival (OS) were retrospectively investigated. OS and time to progression were analyzed with the Kaplan-Meier method.

RESULTS

Technical success rate was 100%, average operative time for DynaCT-guided RFA was 45.3 ± 4.8 min, average radiation dose was 730.5 ± 78.8 mGy, and no life-threatening complications were observed. At 1-month follow-up enhanced MRI, complete remission was achieved in 82.6% of patients (38/46), and partial remission in 17.4% (8/46). The median follow-up period was 29.5 months (interquartile range 4.0-69.0 months). At 1, 2, and 3 years after surgery, the LTP rates were 4.3, 13.1, and 30.4%, respectively, and the OS rates were 89.1, 71.7, and 56.5%, respectively.

CONCLUSION

DynaCT-guided TACE + RFA is safe and feasible for the treatment of solitary large HCCS. TACE combined with simultaneous RFA provides a new treatment option for solitary large HCCs in which DynaCT has important clinical value.

Radiofrequency ablation combined with transcatheter arterial chemoembolization therapy versus surgical resection for Barcelona-Clinic Liver Cancer (BCLC) A hepatocellular carcinoma: a meta-analysis

Purpose: The objective of our study was to compare the effectiveness of the combination of transcatheter arterial chemoembolization (TACE) and radiofrequency ablation (RFA) with that of surgical resection (SR) in Barcelona-Clinic Liver Cancer (BCLC) A hepatocellular carcinoma.

Materials and Methods: PubMed, Medline, Embase, and Cochrane Library were searched for comparisons of the two therapies from January 2006 to December 2017. Overall survival rate (OS), recurrence-free survival rate (RFS), complications, and the average length of hospital stay were compared and analyzed. Review Manager v. 5.2 from the Cochrane Collaboration was used for statistical analyses.

Results: Seven case-control studies and one randomized controlled trial were identified, of which 717 were treated with a combination of TACE and RFA and 785 were treated with SR. Meta-analysis data revealed that TACE plus RFA had significantly better effectiveness on 1.0-y OS (OR = 0.50, p = .009). The major complications (ORcomplications = 1.88, p = .02) after the combined therapy were significantly lower than those after SR. There were three studies that reported the average length of hospital stay. The hospital stay for the SR group vs the combined therapy group was 19.8 ± 8.4 d vs 7.4 ± 2.2 d, respectively (p < .0001); 18.7 ± 4.9 d vs 11.5 ± 6.9 d, respectively (p < .0001); and 16.6 ± 6.7 d vs 8.5 ± 4.1 d, respectively (p < .0001). There was no significant difference in 3.0- or 5.0-y OS and 1.0-, 3.0-, or 5.0-y RFS.

Conclusion: The combination of TACE and RFA has advantages in improving 1.0-y OS, reducing complications, and shortening the length of hospital stay over that of SR in the treatment of patients with BCLC A HCC.

Cryoablation with drug-loaded bead embolization in the treatment of unresectable hepatocellular carcinoma: safety and efficacy analysis

This study aimed to explore the efficacy and safety of drug-eluting bead (DEB) embolization (DEB-TACE) when combined with cryoablation in the treatment of unresectable hepatocellular carcinoma (HCC). The study was a single-center randomized controlled trial comprised of 60 patients with HCC conducted between August 2015 and October 2017. The patients were randomly divided into two groups: DEB-TACE combined with cryoablation (DEB-TACE-Cryo group) or cryoablation alone (Cryo group). Inter-group differences in overall survival, progression-free survival, and adverse reactions were assessed. The operative success rates were 82.7% and 77.4% in the DEB-TACE-Cryo group and Cryo group, respectively, with no operative mortality. The overall survival and progression-free survival in the DEB-TACE-Cryo group were significantly higher than those in the Cryo group (16.8 months vs.13.4 months, P = 0.0493; 8.1 months vs. 6.0 months, P = 0.0089, respectively). The postoperative complications in the two groups were rated as grade 1 or grade 2, according to guidelines set by the National Cancer Institute Common Terminology Criteria for Adverse Events Version 4.0 (CTCAE V4.0). We demonstrated that DEB-TACE combined with cryoablation was effective, well tolerated, and had a low complication rate. Therefore, this combination therapy may be a better choice for the treatment of unresectable hepatocellular carcinoma.

Comparing the long-term efficacy of standard and combined minimally invasive procedures for unresectable HCC: a mixed treatment comparison

A small proportion of hepatocellular carcinoma (HCC) patients are suitable for surgical resections and various minimally invasive procedures have been introduced as alternatives to surgical resections. However, the relative efficacy of minimally invasive procedures remains to be studied in the current literature. Several popular minimally invasive procedures (monotherapy or combined therapies) were selected for comparison and their relative long-term efficacy were determined by using the statistics of hazard ratio (HR) which evaluates the survival status of HCC patients in one, two, three and four years, respectively. Evidence were obtained from the current literature and synthesized by using the approach of conventional pairwise meta-analysis and network meta-analysis (NMA). Moreover, selected minimally invasive procedures were ranked according to their surface under the cumulative ranking curve (SUCRA) which was produced by NMA in conjunction with the Markov Chain Monte Carlo (MCMC) sampling method. HCC patients treated by combined minimally invasive procedures, particularly transcatheter arterial chemoembolization (TACE) + high intensity focused ultrasound (HIFU), TACE + radiofrequency ablation (RFA), TACE + radiotherapy (RT) and TACE + Sorafenib (SOR) exhibited a significant decrease in the HR compared to those with standard TACE (HR < 1). The combined minimally invasive procedure of TACE + HIFU appears to be the most preferable therapy. PEI seems to be less favorable than other minimally invasive procedures. Combined minimally invasive procedures may be more preferable than standard minimally invasive procedures. Percutaneous ethanol injection (PEI) may not provide adequate efficacy compared to other minimally invasive procedures for unresectable HCC patients.

The Number of Positive Tumor Marker Status Is Beneficial for the Selection of Therapeutic Modalities in Patients with Hepatocellular Carcinoma

Hepatic resection (HR) and radiofrequency ablation (RFA) are popular local therapies for early-stage hepatocellular carcinoma (HCC). Alpha-fetoprotein, Lens culinaris agglutinin-reactive fraction of alpha-fetoprotein, and des-c-carboxy prothrombin are well-known and useful tumor markers for HCC. The positive number status of these tumor markers has recently been demonstrated as beneficial for predicting outcome for HCC patients treated with local therapy. Although the normal ranges reported have differed by institution, the positivity of tumor markers is consistent and can easily be assessed. Kumamoto and Wakayama's group clearly demonstrated the following: 1) Regardless of the degree of tumor stage, a triple-positive tumor marker profile can predict poor outcome in HCC patients undergoing HR; 2) For RFA alone, HCC patients with double- and triple-positive status, having less than three lesions and lesions ≤3 cm in diameter show comparably insufficient outcomes; 3) For HCC patients with lesions ≤5 cm in Child-Pugh grade A, HR is preferred over RFA; 4) Microvascular invasion rates increased even in the double-positive patients, while poorly differentiated HCC was frequently observed only in the triple-positive patients; and 5) RFA with chemoembolization, anatomical liver resection, and postoperative adjuvant chemoembolization or hepatic arterial chemotherapy might improve the outcome for patients with highly malignant HCC with multiple positive tumor markers. However, the impacts of these therapies still need to be evaluated in prospective comparative studies.

Metastatic Liver Disease: Indications for Locoregional Therapy and Supporting Data

Metastatic liver disease is a major cause of cancer-related morbidity and mortality. Surgical resection is considered the only curative treatment, yet only a minority is eligible. Patients who present with unresectable disease are treated with systemic agents and/or locoregional therapies. The latter include thermal ablation and catheter-based transarterial interventions. Thermal ablation is reserved for those with limited tumor burden. It is used to downstage the disease to enable curative surgical resection, as an adjunct to surgery, or in select patients it is potentially curative. Transarterial therapies are indicated in those with more diffuse disease. The goals of care are to palliate symptoms and prolong survival. The indications and supporting data for thermal ablation and transarterial interventions are reviewed, technical and tumor factors that need to be considered prior to intervention are outlined, and finally several cases are presented.

A Review and Update of Treatment Options and Controversies in the Management of Hepatocellular Carcinoma

OBJECTIVE

To review the current management, outline recent advances and address controversies in the management of hepatocellular carcinoma (HCC).

SUMMARY OF BACKGROUND DATA

The treatment of HCC is multidisciplinary involving hepatologists, surgeons, medical oncologists, radiation oncologists, radiologists, interventional radiologists, and other disciplines. Each of these disciplines brings its unique perspective and differing opinions that add to controversies in the management of HCC.

METHODS

A focused literature review was performed to identify recent studies on the management of HCC and thereby summarize relevant information on the various therapeutic modalities and controversies involved in the treatment of HCC.

RESULTS

The main treatment algorithms continue to rely on hepatic resection or transplantation with controversies involving patients harboring early stage disease and borderline hepatic function. The other treatment strategies include locoregional therapies, radiation, and systemic therapy used alone or in combination with other treatment modalities. Recent advances in locoregional therapies, radiation, and systemic therapies have provided better therapeutic options with curative intent potential for some locoregional therapies. Further refinements in combination therapies such as algorithms consisting of locoregional therapies and systemic or radiation therapies are likely to add additional options and improve survival.

CONCLUSIONS

The management of HCC has witnessed significant strides with advances in existing options and introduction of several new treatment modalities of various combinations. Further refinements in these treatment options combined with enrollment in clinical trials are essential to improve the management and outcomes of patients with HCC.

Transarterial Chemoembolization Combined with Either Radiofrequency or Microwave Ablation in Management of Hepatocellular Carcinoma

Introduction:

Local ablative therapy and trans arterial chemoembolization (TACE) are applied to ablate non resectable hepatocellular carcinoma (HCC). Combination of both techniques has proven to be more effective. We aimed to study combined ablation techniques and assess survival benefit comparing TACE with radiofrequency (RFA) versus TACE with microwave (MWA) techniques.

Methods:

We retrospectively studied 22 patients who were ablated using TACE-RFA and 45 with TACE-MWA. All were classified as Child A-B and lesions did not exceed 5 cm in diameter. TACE was followed within two weeks by either RFA or MWA. We recorded total and partial ablation rates and complication rates. Survival analysis was then performed.

Results:

TACE-MWA showed a higher tendency to provide complete response rates than TACE-RFA (P 0.06). This was particularly evident with lesions sized 3-5 cm (P 0.01). Rates of complications showed no significant difference between the groups. Overall median survival was 27 months. The overall actuarial probability of survival was 80.1% at 1 year, 55% at 2 years, and 36.3% at 3 years. The recurrence free survival at 1 year, 2years and 3 years for the TACE-RFA group was 70%, 42% and 14% respectively and for TACE-MWA group 81.2%, 65.1% and 65.1% without any significant difference (P 0.1). In relation to the size of focal lesions, no statistically significant difference in the survival rates was detected between the groups.

Conclusion:

TACE-MWA led to better response rates than TACE-RFA with tumors 3-5 cm, with no difference in survival rates.

Comparison of laparoscopic hepatectomy, percutaneous radiofrequency ablation and open hepatectomy in the treatment of small hepatocellular carcinoma

OBJECTIVE

Three mainstream techniques--laparoscopic hepatectomy (LH), percutaneous radiofrequency ablation (pRFA), and open hepatectomy (OH)--were compared in this study, in terms of their efficacies in the treatment of small hepatocellular carcinoma (HCC).

METHODS

A comparative study was performed within a total of 94 patients diagnosed with small HCC in our hospital from 2005 to 2010, who underwent LH (28), RFA (33), or OH (33). They had either a single tumor lesion of less than or up to three nodules with diameters of less than each. Outcomes were carefully evaluated throughout a 3-year follow-up interval and statistically interpreted.

RESULTS

The pRFA group had a significantly lower disease-free survival rate compared with the two surgical groups (P=0.001) and significantly shorter overall survival (P=0.005), while the LH group and the OH group had no difference in survival results. For patients younger than 60 years old, surgical approaches offered a better long-term overall survival prognosis (P=0.008). There were no statistically significant differences among the three groups in overall survival for elderly patients (P=0.104).

CONCLUSIONS

Among patients with small HCC, LH may provide better curative effects than pRFA without increasing complication rates. pRFA leads to faster recurrence than surgical resections. LH has similar therapeutic effects to OH and causes less trauma. For patients younger than 60 years old, LH may be the best curative treatment. Elderly patients may choose either surgery or pRFA.

Novel implications in the treatment of hepatocellular carcinoma

Worldwide hepatocellular carcinoma remains one of the leading causes of cancer-related death, associated with a poor prognosis due to late diagnosis in the majority of cases. Physicians at care are frequently confronted with patients who are ineligible for curative treatment such as liver resection, transplantation or radiofrequency ablation. Besides established palliative locoregional therapies, such as ablation or chemoembolization, new treatment options, such as microwave ablation, drug-eluting bead transarterial chemoembolization or selective internal radiation therapy, are emerging; however, data from randomized controlled trials are still lacking. In order to achieve optimal tumor control, patients should receive tailored treatment concepts, considering their tumor burden, liver function and performance status, instead of strictly assigning patients to treatment modalities following algorithms that may be partly very restrictive. Palliative locoregional pretreatment might facilitate downstaging to ensure later curative resection or transplantation. In addition, the combined utilization of different locoregional treatment options or systemic co-treatment has been the subject of several trials. In cases where local tumor control cannot be achieved, or in the scenario of extrahepatic spread, sorafenib remains the only approved systemic therapy option. Alternative targeted therapies, such as immune checkpoint inhibitors have shown encouraging preliminary results, while data from phase III studies are pending.

Pre-treatment double- or triple-positive tumor markers are predictive of a poor outcome for patients undergoing radiofrequency ablation for hepatocellular carcinoma

PURPOSES

We evaluated the therapeutic effect of radiofrequency ablation (RFA) on hepatocellular carcinoma (HCC) according to the number of positive tumor markers.

METHODS

The subjects of this study were 160 patients who underwent percutaneous and surgical RFA for HCC. Patients were divided into negative (n = 51), single- (n = 69), double- (n = 31), and triple-positive (n = 9) tumor marker groups according to the pre-treatment expression of these markers. We looked for any relationships among clinical parameters, outcomes, and tumor markers.

RESULTS

The 3-year recurrence-free and overall survival rates of the negative, single-, double-, and triple-positive groups were 30, 19, 16, and 11 % (P = 0.02), and 94, 88, 67, and 37 % (P < 0.001), respectively. The 2-year local recurrence rates were 6.5, 0, 41.2, and 61.9 %, respectively (P < 0.001). Multivariate analysis revealed that a double- or triple-positive pre-treatment tumor marker profile was independently associated with local recurrence [hazard ratio (HR) 5.48, 95 % confidence interval (CI) 2.44-12.33, P < 0.001] and overall survival (HR 4.21, 95 % CI 1.89-9.37, P < 0.001).

CONCLUSION

RFA may not be suitable for patients with HCC who have pre-treatment expression of ≥two of these tumor markers.

Imaging Intratumoral Nanoparticle Uptake After Combining Nanoembolization with Various Ablative Therapies in Hepatic VX2 Rabbit Tumors

Combining image-guided therapy techniques for the treatment of liver cancers is a strategy that is being used to improve local tumor control rates. Here, we evaluate the intratumoral uptake of nanoparticles used in combination with radiofrequency ablation (RFA), irreversible electroporation (IRE), or laser induced thermal therapy (LITT). Eight rabbits with VX2 tumor in the liver underwent one of four treatments: (i) nanoembolization (NE) with radiolabeled, hollow gold nanoparticles loaded with doxorubicin (⁶⁴Cu-PEG-HAuNS-DOX); (ii) NE + RFA; (iii) NE + IRE; (iv) NE +LITT. Positron emission tomography/computed tomography (PET/CT) imaging was obtained 1-hr or 18-hrs after intervention. Tissue samples were collected for autoradiography and transmission electron microscopy (TEM) analysis. PET/CT imaging at 1-hr showed focal deposition of oil and nanoparticles in the tumor only after NE+ RFA but at 18-hrs, all animals had focal accumulation of oil and nanoparticles in the tumor region. Autoradiograph analysis demonstrated nanoparticle deposition in the tumor and in the ablated tissues adjacent to the tumor when NE was combined with ablation. TEM results showed the intracellular uptake of nanoparticles in tumor only after NE + IRE. Nanoparticles demonstrated a structural change, suggesting direct interaction, potentially leading to drug release, only after NE + LITT. The findings demonstrate that a combined NE and ablation treatment technique for liver tumors is feasible, resulting in deposition of nanoparticles in and around the tumor. Depending on the ablative energy applied, different effects are seen on nanoparticle localization and structure. These effects should be considered when designing nanoparticles for use in combination with ablation technologies.

Management of hepatocellular carcinoma: an overview of major findings from meta-analyses

This paper aims to systematically review the major findings from meta-analyses comparing different treatment options for hepatocellular carcinoma (HCC). A total of 153 relevant papers were searched via the PubMed, EMBASE, and Cochrane library databases. They were classified according to the mainstay treatment modalities (i.e., liver transplantation, surgical resection, radiofrequency ablation, transarterial embolization or chemoembolization, sorafenib, and others). The primary outcome data, such as overall survival, diseases-free survival or recurrence-free survival, progression-free survival, and safety, were summarized. The recommendations and uncertainties regarding the treatment of HCC were also proposed.

Treatment of Small Hepatocellular Carcinoma (≤2 cm) in the Caudate Lobe with Sequential Transcatheter Arterial Chemoembolization and Radiofrequency Ablation

PURPOSE

To evaluate technical feasibility and treatment results of sequential transcatheter arterial chemoembolization (TACE) and cone-beam computed tomography-guided percutaneous radiofrequency ablation (CBCT-RFA) for small hepatocellular carcinoma (HCC) in the caudate lobe.

MATERIALS AND METHODS

Institutional review board approved this retrospective study. Radiologic database was searched for the patients referred to perform TACE and CBCT-RFA for small caudate HCCs (≤2 cm) between February 2009 and February 2014. A total of 14 patients (12 men and 2 women, mean age; 61.3 years) were included. Percutaneous ultrasonography-guided RFA (pUS-RFA) and surgery were infeasible due to poor conspicuity, inconspicuity or no safe electrode pathway, and poor hepatic reserve. Procedural success (completion of both TACE and CBCT-RFA), technique efficacy (absence of tumor enhancement at 1 month after treatment), and complication were evaluated. Treatment results including local tumor progression (LTP), intrahepatic distant recurrence (IDR), overall survival (OS), and progression-free survival (PFS) were analyzed.

RESULTS

Procedural success and technique efficacy rates were 78.6 % (11/14) and 90.9 % (10/11), respectively. Average follow-up period was 45.3 months (range, 13.4-64.6 months). The 1-, 3-, and 5-year LTP probabilities were 0, 12.5, and 12.5 %, respectively. IDR occurred in seven patients (63.6 %, 7/11). The 1-, 3-, and 5-year PFS probabilities were 81.8, 51.9, and 26 %, respectively. The 1-, 3-, and 5-year OS probabilities were 100, 80.8, and 80.8 %, respectively.

CONCLUSION

Combination of TACE and CBCT-RFA seems feasible for small HCC in the caudate lobe not amenable to pUS-RFA and effective in local tumor control.

Combined locoregional treatment of patients with hepatocellular carcinoma: State of the art

In recent years, a combination of intervention therapies has been widely applied in the treatment of hepatocellular carcinoma (HCC). One such combined strategy is based on the combination of the percutaneous approach, such as radiofrequency ablation (RFA), and the intra-arterial locoregional approach, such as trans-arterial chemoembolization (TACE). Several types of evidence have supported the feasibility and benefit of combined therapy, despite some studies reporting conflicting results and outcomes. The aim of this review was to explain the technical aspects of different combined treatments and to comprehensively analyze and compare the clinical efficacy and safety of this combined treatment option and monotherapy, either as TACE or RFA alone, in order to provide clinicians with an unbiased opinion and valuable information. Based on a literature review and our experience, combined treatment seems to be a safe and effective option in the treatment of patients with early/intermediate HCC when surgical resection is not feasible; furthermore, this approach provides better results than RFA and TACE alone for the treatment of large HCC, defined as those exceeding 3 cm in size. It can also expand the indication for RFA to previously contraindicated “complex cases”, with increased risk of thermal ablation related complications due to tumor location, or to “complex patients” with high bleeding risk.

Efficacy and Safety of Radiofrequency Ablation Combined with Transcatheter Arterial Chemoembolization for Hepatocellular Carcinomas Compared with Radiofrequency Ablation Alone: A Time-to-Event Meta-Analysis

OBJECTIVE

To compare the efficacy and safety of combined radiofrequency ablation (RFA) and transcatheter arterial chemoembolization (TACE) with RFA alone for hepatocellular carcinomas (HCC).

MATERIALS AND METHODS

Randomized controlled trial (RCT) studies that compared the clinical or oncologic outcomes of combination therapy of TACE and RFA versus RFA for the treatment of HCC were identified through literature searches of electronic databases (Pubmed, Embase, Cochrane Library, China Biology Medicine disc, China National Knowledge Infrastructure, and Google Scholar). Hazard ratios (HRs) or odds ratios (ORs) with their corresponding 95% confidence interval (CI) were combined as the effective value to assess the summary effects. The strength of evidence was rated by the Grading of Recommendations Assessment, Development, and Evaluation system.

RESULTS

Six RCTs with 534 patients were eligible for inclusion in this meta-analysis. The meta-analysis showed that the combination of TACE and RFA is associated with a significantly longer overall survival (HR = 0.62, 95% CI: 0.49-0.78, p < 0.001) and recurrence-free survival (HR = 0.55, 95% CI: 0.40-0.76, p < 0.001) in contrast with RFA monotherapy. The seemingly higher incidence of major complications in the combination group compared with RFA group did not reach statistical significance (OR = 1.17, 95% CI: 0.39-3.55, p = 0.78).

CONCLUSION

In patients with HCC, the combination of TACE and RFA is associated with significantly higher overall survival and recurrence-free survival, as compared with RFA monotherapy, without significant difference in major complications.

Effect of iodized oil embolization on ablation rates in primary hepatic carcinoma

AIM: To investigate whether preoperative embolization with lipiodol can increase the rate of ablation for primary hepatic carcinoma.

METHODS: A retrospective analysis was performed of 85 patients with primary liver cancer, including 45 patients treated by hepatic arterial embolization (TAE) plus radiofrequency ablation (RFA) (group A) and 40 patients treated by RFA only (group B). We compared tumor ablation rates between the two groups and analyzed whether preoperative embolization with lipiodol can effectively improve the ablation rate.

RESULTS: Tumor ablation rate in group A was 84.4%, significantly higher than that of group B (57.5%). Tumor residual rate was significantly lower in group A than in group B (8.9% vs 35.0%, P < 0.05). For single tumors with a diameter ≤ 3 cm, ablation rate in group A was 93.3% (14/15), which was not significantly different from that of group B [92.3% (12/13), P > 0.05]. But for multiple tumors and/or tumors with a diameter between 3-5 cm, ablation rate was significantly higher in group A than in group B [80% (24/30) vs 40.7% (11/27), P < 0.05].

CONCLUSION: Preoperative embolization with lipiodol can improve the ablation rates for multiple tumors and/or tumors with a diameter between 3-5 cm.

Current management of hepatocellular carcinoma: an Eastern perspective

Hepatocellular carcinoma (HCC) is one of the leading causes of cancer death, especially in Eastern areas. With advancements in diagnosis and treatment modalities for HCC, the survival and prognosis of HCC patients are improving. However, treatment patterns are not uniform between areas despite efforts to promote a common protocol. Although many hepatologists in Asian countries may adopt the principles of the Barcelona Clinic Liver Cancer staging system, they are also independently making an effort to expand the indications of each treatment and to combine therapies for better outcomes. Several expanded criteria for liver transplantation in HCC have been developed in Asian countries. Living donor liver transplantation is much more commonly performed in these countries than deceased donor liver transplantation, and it may be preceded by other treatments such as the down-staging of tumors. Local ablation therapies are often combined with transarterial chemoembolization (TACE) and the outcome is comparable to that of surgical resection. The indications of TACE are expanding, and there are new types of transarterial therapies. Although data on drug-eluting beads, TACE, and radioembolization in Asian countries are still relatively sparse compared with Western countries, these methods are gradually gaining popularity because of better tolerability and the possibility of improved response rates. Hepatic arterial infusion chemotherapy and radiotherapy are not included in Western guidelines, but are currently being used actively in several Asian countries. For more advanced HCCs, appropriate combinations of TACE, radiotherapy, and sorafenib can be considered, and emerging data indicate improved outcomes of combination therapies compared with single therapies. To include these paradigm shifts into newer treatment guidelines, more studies may be needed, but they are certainly in progress.

Transcatheter embolization therapy in liver cancer: an update of clinical evidences

Transarterial chemoembolization (TACE) is a form of intra-arterial catheter-based chemotherapy that selectively delivers high doses of cytotoxic drug to the tumor bed combining with the effect of ischemic necrosis induced by arterial embolization. Chemoembolization and radioembolization are at the core of the treatment of liver hepatocellular carcinoma (HCC) patients who cannot receive potentially curative therapies such as transplantation, resection or percutaneous ablation. TACE for liver cancer has been proven to be useful in local tumor control, to prevent tumor progression, prolong patients' life and control patient symptoms. Recent evidence showed in patients with single-nodule HCC of 3 cm or smaller without vascular invasion, the 5-year overall survival (OS) with TACE was similar to that with hepatic resection and radiofrequency ablation. Although being used for decades, Lipiodol(®) (Lipiodol(®) Ultra Fluid(®), Guerbet, France) remains important as a tumor-seeking and radio-opaque drug delivery vector in interventional oncology. There have been efforts to improve the delivery of chemotherapeutic agents to tumors. Drug-eluting bead (DEB) is a relatively novel drug delivery embolization system which allows for fixed dosing and the ability to release the anticancer agents in a sustained manner. Three DEBs are available, i.e., Tandem(®) (CeloNova Biosciences Inc., USA), DC-Beads(®) (BTG, UK) and HepaSphere(®) (BioSphere Medical, Inc., USA). Transarterial radioembolization (TARE) technique has been developed, and proven to be efficient and safe in advanced liver cancers and those with vascular complications. Two types of radioembolization microspheres are available i.e., SIR-Spheres(®) (Sirtex Medical Limited, Australia) and TheraSphere(®) (BTG, UK). This review describes the basic procedure of TACE, properties and efficacy of some chemoembolization systems and radioembolization agents which are commercially available and/or currently under clinical evaluation. The key clinical trials of transcatheter arterial therapy for liver cancer are summarized.

Adjuvant therapy for hepatocellular carcinoma after curative treatment

Hepatocellular carcinoma (HCC) is a common malignancy in the world. Although resection and various locoregional therapies can achieve eradication or complete ablation of small HCC, HCC recurrence after these therapies is still common. Although candidates for medical ablation usually exhibit compensated hepatic functional status, the frequent recurrence of HCC after successful ablation contributes to short survival. Therefore, attempts to prevent HCC recurrence are essential to prolong survival. Efforts in preventing HCC recurrence after curative therapies include prevention of early recurrence by improving liver immunity and eliminating microscopic tumor foci or micrometastases, and prevention of late recurrence by reducing the hepatitis activity and using antiviral therapies based on viral suppression/eradication. In HCC with vascular invasion, adjuvant transcatheter arterial chemoembolization should be considered to provide better control. Whether the adjuvant use of sorafenib may suppress microscopic tumor foci or micrometastases may be unveiled in the near future. This review article will update the algorithms, novel medication or study drugs in the prevention of HCC after curative therapies.