Role of the width of the surgical margin in a hepatectomy for small hepatocellular carcinomas eligible for percutaneous local ablative therapy

pH-Activatable Molecular Probe for COX-2 Imaging in Human Oral Squamous Carcinoma Cells and Patient-Derived Tissues

For developing a successful cancer therapeutic modality, the early precise detection of cancer cells in patient biopsies in oral squamous cell carcinoma (OSCC) is crucial. This could help researchers create new diagnostic and therapeutic tools and assist clinicians in recommending more effective treatment plans and improving patient survival. We have developed an SMPD, cyclooxygenase-2 (COX-2) targeting pH-activable fluorophore named CNP, combining a potent COX-2 inhibitor, celecoxib, linked to a naphthalimide fluorophore with an acidic microenvironment-responsive piperazine moiety for specific optical imaging of OSCC in cells and patient tissues. Compared to reference probe RNP lacking celecoxib, CNP selectively enters the COX-2 overexpressing oral cancer cells. Its acidity-responsive imaging response enhances selectivity over cancers with lower COX-2 expression levels and normal cells. Further, CNP is demonstrated in imaging OSCC cells in patient-derived biopsies. Thus, multifunctional CNP shows potential in exploring more reagents for fluorescence-based detection of OSCC cells in patient tissues with translational applications.

Low CD8+ Density Variation and R1 Surgical Margin as Independent Predictors of Early Post-Resection Recurrence in HCC Patients Meeting Milan Criteria

Our study included 41 patients fulfilling the Milan criteria preoperatively and aimed to identify individuals at high risk of post-resection HCC relapse, which occurred in 18 out of 41 patients (43.9%), retrospectively. We analyzed whole slide images of CD8 immunohistochemistry with automated segmentation of tissue classes and detection of CD8+ lymphocytes. The image analysis outputs were subsampled using a hexagonal grid-based method to assess spatial distribution of CD8+ lymphocytes with regards to the epithelial edges. The CD8+ lymphocyte density indicators, along with clinical, radiological, post-surgical and pathological variables, were tested to predict HCC relapse. Low standard deviation of CD8+ density along the tumor edge and R1 resection emerged as independent predictors of shorter recurrence-free survival (RFS). In particular, patients presenting with both adverse predictors exhibited 100% risk of relapse within 200 days. Our results highlight the potential utility of integrating CD8+ density variability and surgical margin to identify a high relapse-risk group among Milan criteria-fulfilling HCC patients. Validation in cohorts with core biopsy could provide CD8+ distribution data preoperatively and guide preoperative decisions, potentially prioritizing liver transplantation for patients at risk of incomplete resection (R1) and thereby improving overall treatment outcomes significantly.

Correlation of pathological examination with indocyanine green (ICG) intensity gradients: a prospective study in patients with liver tumor

BACKGROUND

Intraoperative indocyanine green (ICG) fluorescence imaging has been shown to be a new and innovative way to illustrate the optimal resection margin in hepatectomy for hepatocellular carcinoma. This study investigated its accuracy in resection margin determination by looking into the correlation of ICG intensity gradients with pathological examination results of resected specimens.

METHODS

This was a prospective, single-center, non-randomized controlled study. Patients who had liver tumors indicating liver resection were recruited. The hypothesis was that the use of intraoperative near-infrared/ICG fluorescence imaging would be a promising guiding tool for removing hepatocellular carcinoma with a better resection margin. Patients were given ICG (0.25 mg/kg) 1 day before operation. Resected specimens were inspected under a fluorescent imaging system. Biopsies were taken from tumors and normal tissue. Color signals obtained from ICG fluorescence imaging were compared with biopsies for analysis.

RESULTS

Twenty-two patients were recruited for study. The median size of their tumors was 2.25 cm. One patient had resection margin involvement. Under ICG fluorescence, the tumors typically lighted up as yellow color, wrapped by a zone of green color. Tumors of 17 patients (77.3%) displayed yellow color and were confirmed malignancy, while tumors of 12 patients (54.5%) displayed green color and were confirmed malignancy. Receiver operating characteristic curve was used to measure the sensitivity and specificity of the green color to look for a clear resection margin. The area under the curve was 85.3% (p = 0.019, 95% confidence interval 0.696-1.000), with a sensitivity of 0.706 and specificity of 1.000.

CONCLUSION

The use of ICG fluorescence can be helpful in determining resection margins. Resection of tumor should include complete resection of the green zone shown in the fluorescence image.

Patterns, Risk Factors, and Outcomes of Recurrence After Hepatectomy for Hepatocellular Carcinoma with and without Microvascular Invasion

Purpose

The patterns and risk factors of postsurgical recurrence of patient with hepatocellular carcinoma (HCC) with microvascular invasion (MVI) are not clarified. This study aimed to decipher and compare the postoperative recurrent patterns and the risk factors contributing to recurrence between MVI positive (MVI(+)) and MVI negative (MVI(-)) HCC after hepatectomy.

Patients and methods

Patients with HCC who underwent hepatectomy in three Chinese academic hospitals between January 1, 2009, and December 31, 2018, were enrolled. Recurrent patterns included early (≤2 years) or late (>2 years) recurrence, recurrent sites and number, and risk factors of recurrence were compared between the MVI(+)and MVI(-) groups by propensity score-matching (PSM).

Results

Of 1756 patients included, 581 (33.1%) were MVI(+), and 875 (49.8%) patients developed early recurrence. Compared with the MVI(-) group, the MVI(+) group had a higher 2-year recurrence rate in the PSM cohort (hazard ratio [HR], 1.82; 95% confidence interval [CI], 1.59-2.10; P < 0.001), and more patients with multiple tumor recurrence. Patients with early recurrence in the MVI(+) group had a worse overall survival (OS) than those in the MVI(-) group (HR, 1.24; 95% CI, 1.02-1.50; P = 0.034). Resection margin (RM) ≤1.0 cm is a surgical predictor of early recurrence for the MVI(+) group (HR, 0.68; 95% CI, 0.54-0.87; P = 0.002), but not for the MVI(-) group.

Conclusion

Compared to MVI(-) HCC, MVI(+) HCC tends to be early, multiple recurrence and lung and lymph node metastasis after resection. RM ≤1.0 cm is a surgical risk factor of early recurrence for patient with MVI.

Radiation and Immune Checkpoint Inhibitors: Combination Therapy for Treatment of Hepatocellular Carcinoma

The liver tumor immune microenvironment has been thought to possess a critical role in the development and progression of hepatocellular carcinoma (HCC). Despite the approval of immune checkpoint inhibitors (ICIs), such as programmed cell death receptor 1 (PD-1)/programmed cell death ligand 1 (PD-L1) and cytotoxic T lymphocyte associated protein 4 (CTLA-4) inhibitors, for several types of cancers, including HCC, liver metastases have shown evidence of resistance or poor response to immunotherapies. Radiation therapy (RT) has displayed evidence of immunosuppressive effects through the upregulation of immune checkpoint molecules post-treatment. However, it was revealed that the limitations of ICIs can be overcome through the use of RT, as it can reshape the liver immune microenvironment. Moreover, ICIs are able to overcome the RT-induced inhibitory signals, effectively restoring anti-tumor activity. Owing to the synergetic effect believed to arise from the combination of ICIs with RT, several clinical trials are currently ongoing to assess the efficacy and safety of this treatment for patients with HCC.

Survival benefit of radiotherapy following narrow-margin hepatectomy in patients with hepatocellular carcinoma: A propensity score-matched analysis based on phase II study

BACKGROUND AND PURPOSE

We evaluated the postoperative radiotherapy (PORT) effects on hepatocellular carcinoma (HCC) prognosis and recurrence in patients who underwent narrow-margin (<1.0 cm) hepatectomy (NH).

MATERIALS AND METHODS

This two-arm cohort study based on the phase II study compared NH with or without PORT in patients with HCC. All patients underwent NH; 76 patients who received PORT following NH in the phase II study were assigned to the NH + RT group, and 171 who underwent NH alone were assigned to the NH group. Propensity score matching (PSM) was used to balance clinicopathological characteristic differences between groups.

RESULTS

Before PSM, the 5-year overall survival (OS) rates between groups differed significantly (72.2 % vs 60.7 %, P = 0.017). Moreover, the 5-year disease-free survival (DFS) rate was significantly higher in the NH + RT group (51.4 % vs 35.7 %, P = 0.002). After PSM, the between-group difference in OS rates remained high (P = 0.045); the 5-year OS rates were 74.7 % and 63.6 % in the NH + RT and NH groups, respectively. Similarly, the DFS rate remained significantly higher in the NH + RT group (P = 0.001); the 5-year DFS rates were 56.3 % and 31.6 %, respectively. Furthermore, both before and after PSM, patients in the NH + RT group showed significantly lower early, intrahepatic, and extrahepatic recurrence rates than those in the NH group.

CONCLUSIONS

PORT may have significant OS and DFS benefits in patients with HCC undergoing NH.

Effect of the normal liver mean dose on intrahepatic recurrence in patients with hepatocellular carcinoma after receiving liver stereotactic body radiation therapy

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The normal liver mean dosage is rarely studied in its association with metastasis related survival.

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Higher normal liver mean dosage was related to a better intra-hepatic progression free survival.

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No associations were found between normal liver mean dose with Local control rate, Overall Survival, Distant Metastasis Free Survival, Progression Free Survival.

Background and purpose

This study aims to evaluate whether dosimetric parameters affect the intrahepatic out-field recurrence or distant metastasis-free survival following the stereotactic body radiation therapy (SBRT) in patients with hepatocellular carcinoma (HCC).

Materials and methods

A total of 76 patients with HCC who were treated with SBRT from January 2015 to May 2020 were included in this retrospective study. The main clinical endpoints considered were intrahepatic out-field free survival (OutFFS) and distant metastasis-free survival (DMFS). The target parameters and the liver were documented including tumor diameters, gross tumor volume (GTV), Liver minus GTV volume (LGV), and Liver minus GTV mean dose (LGD). Multivariable Cox regression with forward stepwise selection was performed to identify independent risk factors for OutFFS and DMFS. Maximally selected rank statistics were used to determine the most informative cut-off value for age and LGD.

Results

The median follow-up was 28.2 months (range, 7.7–74.5 months). LGD higher than 12.54 Gy [HR, 0.861(0.747–0.993); p = 0.040] and age greater than 67-year-old [HR, 0.966(0.937–0.997); p = 0.030] are two independent predictors of OutFFS, previous TACE treatment [HR, 0.117(0.015–0.891); p = 0.038] was an independent predictor of DMFS.

Conclusions

The results of this study suggested that the higher the dose received by the normal liver (greater than 12.54 Gy) the better the intrahepatic out-field recurrence-free survival (RFS) rate. Further study is warranted to confirm and to better understand this phenomenon.

Long-Term Outcomes of Mesohepatectomy for Centrally Located Liver Tumors: Two-Decade Single-Center Experience

BACKGROUND

Mesohepatectomy is a viable treatment option for patients diagnosed with centrally located liver tumors (CLLTs). There are several reports from Eastern centers, but few data are available on this topic from Western centers.

STUDY DESIGN

Data of 128 consecutive patients who underwent mesohepatectomy between September 2000 and September 2020 in our center were analyzed from a prospectively collected database. Patient demographic data, liver tumor characteristics, and intraoperative data were collected. In addition, posthepatectomy bile leakage (PHBL), posthepatectomy hemorrhage (PHH), posthepatectomy liver failure (PHLF), and 90-day mortality after mesohepatectomy were assessed. Long-term outcomes were also reported, and factors that may influence disease-free survival were evaluated.

RESULTS

Of 128 patients, 113 patients (88.3%) had malignant hepatic tumors (primary and metastatic tumors in 41 [32%] and 72 [56.3%] patients, respectively), and 15 patients suffered from benign lesions (11.7%). Among the relevant surgical complications (grade B or C), PHBL was the most common complication after mesohepatectomy and occurred in 11.7% of patients, followed by PHLF in 3.1% of patients and PHH in 2.3% of patients. Only four patients (3.1%) died within 90 days after mesohepatectomy. The 5-year overall survival and overall recurrence (for malignant lesion) rates were 76.5% and 45.1%, respectively.

CONCLUSION

Mesohepatectomy is a safe and feasible surgical treatment with low morbidity and mortality for patients with CLLT. Long-term outcomes can be improved by increased surgical expertise.

Prognostic Impact of Surgical Margin in Hepatectomy on Patients With Hepatocellular Carcinoma: A Meta-Analysis of Observational Studies

Objective

This study aims to comprehensively evaluate the prognostic impact of the surgical margin in hepatectomy on patients diagnosed with hepatocellular carcinoma (HCC).

Methods

A comprehensive and systematic search for eligible articles published in English before July 2021 was conducted across PubMed, Cochrane Library, Web of Science, and Embase electronic databases. The overall survival (OS) and disease-free survival (DFS) were the primary endpoints.

Results

In total, 37 observational studies with 12,295 cases were included in this meta-analysis. The results revealed that a wide surgical margin (≥1 cm) was associated with better OS (hazard ration (HR), 0.70; 95% confidence interval (CI), 0.63–0.77) and DFS (HR, 0.66; 95% CI, 0.61–0.71) compared to a narrow surgical margin (<1 cm). Subgroup analyses were conducted based on median follow-up time, gender, country, hepatitis B surface antigen (HBsAg) status, tumor number, and liver cirrhosis. The prognostic benefit of a wide surgical margin was consistent in most subgroups, however, analysis of studies from Western countries showed that margin width was not associated with prognosis.

Conclusion

In summary, a surgical margin wider than 1 cm prolongs the long-term prognosis of HCC patients compared to a surgical margin narrower than 1 cm.

Modified median hepatic fissure approach for resection of liver tumours located in the angle between the root of the middle and right hepatic veins

Background

Liver tumours between the root angle of the middle and right hepatic veins are a special type of liver segment VIII tumour. In this study, we designed a modified median hepatic fissure approach to remove these tumours. The safety and effectiveness of the approach were evaluated.

Materials and methods

From April 2015 to November 2019, 11 patients with liver tumours between the angle of the middle and right hepatic veins underwent this modified median hepatic fissure approach. We retrospectively analysed data from the perioperative periods of these 11 patients, including general condition, operation time, intraoperative bleeding, and postoperative complications. Disease-free survival and overall survival were assessed.

Results

Of the 11 patients, 9 patients had primary hepatocellular carcinoma and 2 had colorectal liver metastases. The average intraoperative blood loss was 285 mL (150–450 mL). Two patients developed postoperative bile leakage, but there were no significant serious complications, such as intraabdominal bleeding and liver failure, in any of the patients. The liver function returned to the normal range on the 5th day after surgery. Of the 11 patients, 5 have survived for more than 3 years (45.5%), and 4 have been disease-free for more than 3 years (36.3%).

Conclusions

For liver tumours between the root angle of the middle and right hepatic veins, the modified median hepatic fissure approach is a safe and feasible method.

Phase 2 Study of Adjuvant Radiotherapy Following Narrow-Margin Hepatectomy in Patients With HCC

BACKGROUND AND AIMS

Surgical resection is the primary treatment for HCC; however, it is associated with a high rate of recurrence and death. We conducted this phase 2 study to investigate the efficacy and safety of postoperative intensity-modulated radiotherapy (IMRT) for HCC after narrow-margin hepatectomy.

APPROACH AND RESULTS

We designed a single-arm, prospective phase 2 trial to evaluate overall survival (OS), disease-free survival (DFS), recurrence patterns, and toxicity in patients receiving adjuvant radiotherapy. The eligibility criteria included the following: pathological diagnosis of HCC after hepatectomy, with narrow pathological margins (< 1 cm); age > 18 years; and Eastern Cooperative Oncology Group performance status score of 0 or 1. Patients received IMRT within 4-6 weeks after surgical resection. This trial was registered at ClinicalTrials.gov (NCT01456156). Between 2008 and 2016, a total of 76 eligible patients who underwent narrow-margin resection were enrolled. The median follow-up duration was 70 months; the 3-year OS and DFS rates were 88.2% and 68.1%, respectively; and the 5-year OS and DFS rates were 72.2% and 51.6%, respectively. Intrahepatic recurrence was the primary recurrence pattern. No marginal recurrence was found. Intrahepatic, extrahepatic, and combined recurrences at the first relapse were found in 33, 5, and 1 patient, respectively. The most common radiation-related grade-3 toxicities were leukopenia (7.9%), elevated alanine aminotransferase (3.9%) and aspartate aminotransferase (2.6%) levels, and thrombocytopenia (1.3%). Classical or nonclassical radiation-induced liver disease was not noted.

CONCLUSIONS

Adjuvant radiotherapy is an effective, well-tolerated, and promising adjuvant regimen in patients with HCC who have undergone narrow-margin hepatectomy. Our trial provides evidence and a rationale for planning a future phase 3 trial.

Laparoscopic in Situ Anatomical Mesohepatectomy for Solitary Massive HCC Using Combined Intrafascial and Extrafascial Approaches With Indocyanine Green Navigation (with Video)

BACKGROUND

Laparoscopic anatomic mesohepatectomy for patients with hepatocellular carcinoma (HCC) remains technically challenging, especially for those with a massive tumor larger than 10 cm.

METHODS

In this study, a 65-year-old man with a 13 × 10-cm² solitary liver tumor located at segments 4, 5, and 8 underwent laparoscopic mesohepatectomy. To reduce the possibility of releasing cancer cells from the primary tumor, the in situ resection strategy for tumor removal was implemented. The intrafascial approach was used to dissect the right Glissonean pedicle, to transect the right anterior hepatic artery, and to ligate the right anterior portal vein. The extrafascial and transfissural approach was performed along the umbilical fissure to transect the Glissonean pedicle of segment 4. Indocyanine green (ICG) then was applied using "reverse staining" to visualize the resection extent and the right posterior hepatic duct (RPHD). During parenchymal resection, the right anterior Glissonean pedicle was adequately exposed and transected via the extrafascial approach above the plane of the RPHD. Finally, the right coronary ligament was dissected, and the tumor was removed.

RESULTS

The operation was completed in 360 min, with a blood loss of 200 mL. The histopathologic diagnosis indicated a moderately differentiated HCC. The patient was discharged on postoperative day 8 without any complications.

CONCLUSION

Laparoscopic in situ anatomic mesohepatectomy using combined intra- and extrafascial approaches with ICG navigation may be feasible for patients with a centrally located solitary massive HCC.

Adjuvant transarterial chemotherapy for margin-positive resection of hepatocellular carcinoma-a propensity score matched analysis

BACKGROUND AND AIMS

Hepatectomy is a well-established curative treatment for hepatocellular carcinoma. However, the role of adjuvant therapy is controversial. This study examines the efficacy of adjuvant transarterial chemotherapy for hepatocellular carcinoma.

METHODS

The data of hepatocellular carcinoma patients undergoing curative hepatectomy was reviewed. Those with adjuvant transarterial chemotherapy were matched with those without using propensity score analysis, by tumour size and number, indocyanine green retention rate, disease staging and Child-Pugh grading. The groups were compared.

RESULTS

Eighty-seven patients with hepatocellular carcinoma who underwent hepatectomy received adjuvant transarterial chemotherapy (TAC group), and were matched with 870 patients who did not (no-TAC group). The groups were largely comparable in patient and disease characteristics, but the TAC group experienced more blood loss, higher transfusion rates, narrower margins and more positive margins. The two groups were found to be comparable in disease-free and overall survival rates. In margin-positive patients, those given TAC survived longer than those without, and margin-positive patients in the TAC group had overall survival rates similar to margin-negative patients in the no-TAC group.

CONCLUSIONS

Margin involvement is an adverse factor for survival in HCC. Adjuvant transarterial chemotherapy may offer survival benefits to hepatocellular carcinoma patients with positive surgical margins.

Radiofrequency Ablation Covering the Entire Tumor Blood Drainage Area Improves Survival in Hepatocellular Carcinoma

Hepatocellular carcinoma has been considered to disseminate through the tumor blood drainage area. To improve curation rates, treatment should cover this area as it may contain satellite lesions. This retrospective study aimed to investigate whether radiofrequency ablation (RFA) completely covering the blood drainage area can improve the overall and disease-free survival. We enrolled 526 patients who underwent computed tomography during hepatic arteriography following RFA from April 2001 to May 2019. Patients were categorized into a covered group in which the blood drainage area was completely covered by RFA and a noncovered group in which coverage was incomplete. The primary endpoint was the overall survival rate; secondary outcomes included disease-free survival rate, distant intrahepatic and local recurrence rate, and changes in the Child-Pugh score. There were no significant differences in baseline characteristics between the two groups. Cumulative overall survival rates were significantly higher in the covered group than in the noncovered group (hazard ratio, 0.63; 95% confidence interval, 0.48-0.84; P = 0.002). On multivariate Cox proportional hazard model analysis, age <65 years, Child-Pugh class A, and coverage of the entire drainage area were independent protective factors. Child-Pugh worsened in 11 (4.2%) patients in the covered group compared to 18 (6.7%) patients in the noncovered group. Conclusion: RFA covering the complete drainage area improved overall survival without decreasing liver function.

Hepatectomy for Solitary Hepatocellular Carcinoma: Resection Margin Width Does Not Predict Survival

BACKGROUND

The survival benefit of negative margins for hepatocellular carcinoma (HCC) has been demonstrated. However, there is no consensus regarding the optimal resection margin width. We assessed the impact of hepatic resection margin width for solitary HCC on overall (OS), recurrence-free (RFS), and liver-specific recurrence-free survival (LSRFS).

METHODS

Clinicopathologic data were retrospectively collected for solitary HCC patients who underwent a negative margin hepatectomy (1992-2015). Margin width was categorized in tertiles as "narrow" (≤ 0.3 cm), "intermediate" (0.31-1.0 cm), or "wide" (> 1.0 cm). Survival was compared among groups.

RESULTS

Of the 178 included patients, most were male (76%); median age, MELD score, and tumor size were 63 years, 8, and 5.2 cm, respectively; 93% were Child-Pugh class A. Median margin width was 0.5 cm. Median follow-up and OS were 47.8 months and 76.7 months, respectively. There was no significant survival difference among narrow, intermediate, and wide margin groups with a median OS of 53 months (IQR 21-not reached [NR]), 74 months (IQR 14-138), and 97 months (IQR 37-142) (p = 0.87), respectively. Median RFS was 33.0 months; again, there was no difference among narrow, intermediate, and wide margin groups with a median of 31 months (IQR 18-NR), 45 months (IQR 14-NR), and 27 months (IQR 11-NR), respectively (p = 0.66). Median LSRFS was 63.0 months (IQR 14-NR) with no difference among groups (p = 0.87). In multivariate analyses, margin width was not associated with OS (p = 0.77), RFS (p = 0.74), or LSRFS (p = 0.92). Findings were similar in all subgroups analyzed (≤ 5 cm, > 5 cm, microvascular invasion, T1, T2/T3, anatomical or non-anatomical resection, major or minor hepatectomy).

CONCLUSIONS

Narrow margins appear to be oncologically safe and the feasibility of achieving wide margins should not determine resectability.

Impact on Oncological Outcomes and Intent-to-Treat Survival of Resection Margin for Transplantable Hepatocellular Carcinoma in All-Comers and in Patients with Cirrhosis: A Multicenter Study

BACKGROUND

The outcomes of liver resection (LR) with a narrow margin in patients with transplantable hepatocellular carcinoma (HCC) have not been studied. The aim was to assess whether narrow margin following up-front LR impacts the incidence, timing, pattern, and transplantability of tumor recurrence in patients with initially transplantable HCC.

METHODS

All initially transplantable HCC patients undergoing hepatectomy with either narrow (<10 mm) or wide (≥10 mm) margins from 2007 to 2016 at four Western university centers were compared in terms of recurrence, transplantability of recurrence, recurrence-free survival (RFS), and intention-to-treat overall survival (ITT-OS). Independent predictors of non-transplantability of recurrence were assessed.

RESULTS

This study included 187 patients (narrow group, n = 107 vs. wide group, n = 80). Recurrence was significantly more frequent in the narrow margin group (44% vs. 26%; p = 0.01) with a shorter RFS (p = 0.03). The transplantability of recurrence and ITT-OS were, however, not different between the two groups. The presence of satellite nodules on the resected specimens emerged as the sole independent predictor of non-transplantability of tumor recurrence. The stratification of the analysis according to the presence of cirrhosis achieved essentially the same results as in the whole study population.

CONCLUSIONS

Narrow margin was associated with a higher tumor recurrence rate and a shorter RFS for patients with initially transplantable HCC. However, transplantability of recurrence and long-term ITT-OS were not impaired.

Preoperative three-dimensional versus two-dimensional evaluation in assessment of patients undergoing major liver resection for hepatocellular carcinoma: a propensity score matching study

Background

Compared with 2D evaluation, 3D evaluation possesses the virtues of displaying spatial anatomy of intrahepatic blood vessels and its relations to tumors, and enabling calculation of liver volumes, thus facilitating preoperative surgery planning.

Methods

The objective of this study is to study whether preoperative 3D (three-dimensional) evaluation produced better long-term overall survival (OS) outcomes compared to the traditional 2D (two-dimensional) evaluation in patients who underwent major hepatectomy for hepatocellular carcinoma (HCC). This retrospective study matched patients who underwent preoperative 2D evaluation with those who underwent preoperative 3D evaluation in a 1:1 ratio using propensity score matching. The primary endpoints were long-term survival outcomes in the two groups after major hepatectomy for HCC.

Results

Of the 248 patients in each of the 2 matched groups, the baseline characteristics were comparable. The median follow-up for all patients was 36 months (range, 0-40 months). The 3-year OS of patients in the PSM cohort was 38.5%. Compared with the 2D Group, patients in the 3D Group had a better OS rate (HR 0.722, 95% CI: 0.556-0.938, P=0.015) and disease-free survival (DFS) rate (HR 0.741, 95% CI: 0.590-0.929, P=0.009). The 3-year OS and DFS rate for the 3D Group versus the 2D group were 58.9% and 44.0% versus 47.4% and 33.1%, respectively.

Conclusions

3D preoperative evaluation resulted in significantly better intermediate-term (3-year) overall survival rate than the traditional 2D evaluation.

"Logic-Based Medicine" Is More Feasible than "Evidence-Based Medicine" in the Local Treatment for Hepatocellular Carcinoma

The optimal type of surgery (e.g., anatomic or non-anatomic resection) or radiofrequency ablation (RFA) for hepatocellular carcinoma (HCC) is still under debate despite numerous comparative studies based on overall survival. This debate continues not only because these endpoints are influenced by non-surgical factors, such as liver function, but because the definition of non-anatomic resection for HCC has remained unclear. The optimal surgery could be logically determined based on the mechanism of local intrahepatic metastasis, that is, the drainage of tumour blood flow (TBF), because HCC spreads locally through tumour blood flowing to the peri-tumourous liver parenchyma. Since TBF is clearly demonstrated by CT scan under hepatic arteriography, the surgical margin can be determined individually based on the drainage of TBF without deteriorating local curability. Controversy regarding RFA and surgery does not result from the curability of treatment itself but from the lack of scientific evidence on safety margins. Based on proper concepts and self-evident truths, an algorithm of loco-regional treatment for HCC is proposed.

Impact of narrow margin and R1 resection for hepatocellular carcinoma on the salvage liver transplantation strategy. An intention-to-treat analysis

BACKGROUND

No studies have investigated whether narrow margin is a risk factor for hepatocellular carcinoma recurrence outside transplantability criteria. The objective was to assess on an intent-to-treat (ITT) basis whether hepatectomy with narrow margin affects the outcomes in patients enrolled in the salvage liver transplantation (LT) strategy.

METHODS

From 2007 to 2016, patients enrolled in the salvage LT strategy were divided into 2 groups: narrow (<10 mm) vs. wide (≥10 mm) margin groups. R1 resection was defined as positive histologic margin involvement. Recurrence rate, transplantability rate of recurrence and ITT overall survival (ITT-OS) were evaluated.

RESULTS

A total of 81 patients were studied: 43 patients with narrow margin and 38 with wide margin. The recurrence rates, pattern and delay of recurrence, transplantability following recurrence, and ITT-OS were similar between the two groups. These results were maintained when comparing patients with R1 resection to those with R0 resection.

CONCLUSION

On an ITT basis, hepatectomy with narrow margin or R1 resection did not impair the transplantability of recurrence and survival of patients enrolled in the salvage LT strategy. Narrow margin and even R1 resection following hepatectomy in the setting of salvage LT strategy should not be the basis for altering the strategy.

Evaluation of tissue deformation during radiofrequency and microwave ablation procedures: Influence of output energy delivery

PURPOSE

The purpose of this study was to quantitatively analyze tissue deformation during radiofrequency (RF) and microwave ablation for varying output energy levels.

METHODS

A total of 46 fiducial markers which were classified into outer, middle, and inner lines were positioned into a single plane around an RF or microwave ablation applicator in each ex vivo bovine liver sample (8 cm × 6 cm × 4 cm, n = 18). Radiofrequency (500 kHz; ~35 W average) or microwave (2.4 GHz; 50-100 W output, ~35-70 W delivered) ablation was performed for 10 min (n = 4-6 each setting). CT images were acquired over the entire liver volume every 15 s. Principle strain magnitude and direction were determined from fiducial marker displacement. Normal and shear strain were then calculated such that negative strain denoted contraction and positive strain denoted expansion. Temporal variations, the final magnitudes, and angles of the strain were compared across energy delivery settings, using one-way ANOVA with post hoc Tukey's tests.

RESULTS

On average, tissue strain rates peak at around 1 min and decayed exponentially over time. No evidence of tissue expansion was observed. The tissue strains from RF and 50 W, 75 W, and 100 W microwave ablation at 10 min were -8.5%, -38.9%, -54.4%, and -65.7%, respectively, from the inner region and -3.6%, -23.7%, -41.8%, and -44.3%, respectively, from the outer region. Negative strain magnitude was positively correlated to energy delivery in the inner region (Spearman's ρ  = -0.99). Microwaves at higher powers (75-100 W) induced significantly more strain than at lower power (50 W) or after RF ablation (P < 0.01). Principal strain angles ranged from 0.8° to -8.1°, indicating that tissue deformed more in the direction transverse to the applicator than along the direction of the applicator.

CONCLUSIONS

The influence of output energy on tissue deformation during RF and microwave ablation was analyzed. Microwave ablation created significantly greater contraction than RF ablation with similar energy delivery. During microwave ablation, more contraction was noted at higher power levels and in proximity to the antenna. Contraction primarily transverse to the antenna produces ablation zones that are more elongated than the original tissue volume.

Veterinary Clinics: Tumor Ablation

Over the past decade, interventional oncology techniques have become integrated into the treatment plans of companion animals with cancer on a regular basis. Although procedures such as stenting are performed commonly, other less frequently utilized techniques for locoregional therapy, such as embolization and ablation, are emerging and demonstrating promise. Tumor ablation techniques are categorized into two subgroups: chemical ablation and energy-based ablation. Increased utilization of ablation will allow for the determination of specific indications and evaluation of outcomes for these techniques.

Optimal postoperative adjuvant treatment strategy for HBV-related hepatocellular carcinoma with microvascular invasion: a propensity score analysis

Background

Microvascular invasion (MVI) is the most important risk factor associated with early postoperative recurrence in patients with hepatocellular carcinoma (HCC). However, the efficacy of postoperative adjuvant treatment for preventing recurrence in HCC patients with MVI has not been assessed. This study investigated the efficacy of postoperative adjuvant radiotherapy (RT) and transcatheter arterial chemoembolization (TACE) in HCC patients with MVI.

Materials and methods

From July 2008 to December 2016, 117 hepatitis B virus (HBV)-related HCC patients with MVI were retrospectively divided into two groups based on postoperative adjuvant treatments. Propensity score matching (PSM) was performed to adjust for significant differences in baseline characteristics. Relapse-free survival (RFS) and overall survival (OS) of the two groups were analyzed before and after PSM.

Results

Of all patients, the RT group had significantly smaller tumor size and milder MVI classification. PSM analysis created 46 pairs of patients. After matching, the two groups of patients were similar in baseline characteristics. Multivariate analysis indicated that tumor size, MVI classification, and postoperative treatment strategies were independently associated with RFS; tumor size and MVI classification were independently associated with OS. Similar multivariate analysis results were demonstrated after matching propensity score. Survival analysis revealed that the estimated median RFS and OS of patients with RT and TACE were 25.74±8.12 vs 9.18±1.67 months (P=0.003) and 60.69±7.36 vs 36.53±5.34 months (P=0.262), respectively. The RT group had significantly longer RFS than the TACE group.

Conclusion

Postoperative adjuvant RT offers better RFS for HCC patients with MVI than TACE.

Correlation between Resection Margin and Disease Recurrence with a Restricted Cubic Spline Model in Patients with Resected Hepatocellular Carcinoma

BACKGROUND

The relationship between resection margin (RM) and recurrence of resected hepatocellular carcinoma (HCC) is unclear.

METHODS

We reviewed clinical data for 419 patients with HCC. The oncologic outcomes were compared between 2 groups of patients classified according to the inflexion point of the restricted cubic spline plot.

RESULTS

The patients were divided according to an RM of <1 cm (n = 233; narrow RM group) or ≥1 cm (n = 186; wide RM group). The 5-year recurrence-free survival (RFS) rate was lower (34.8 vs. 43.8%, p = 0.042) and recurrence near the resection site was more frequent (4.7 vs. 0%, p = 0.010) in the narrow RM group. Patients with multiple lesions, or prior transarterial chemoembolization (TACE) or radiofrequency ablation (RFA) were excluded from subgroup analyses. In patients with a 2-5 cm HCC, the 5-year RFS was greater in the wide RM group (54.4 vs. 32.5%, p = 0.036). Narrow RM (hazard ratio 1.750, 95% CI 1.029-2.976, p = 0.039) was independently associated with disease recurrence.

CONCLUSION

In patients with a single 2-5 cm HCC without prior TACE/RFA, an RM of ≥1 cm was associated with lower risk of recurrence after liver resection.

Prognostic impact of surgical margin in patients with hepatocellular carcinoma: A meta-analysis

BACKGROUND

Surgical margin is an important prognostic factor in hepatectomy for patients with hepatocellular carcinoma (HCC). But the extent of surgical margins is still controversial. Our study was designed to systematically evaluate the prognosis of different width of resection margin.

METHODS

We conducted comprehensive searches of electronic databases including PubMed, MEDLINE, EMBASE, Cochrane, and the ISI Web of Science for relevant studies. A meta-analysis was performed by RevMan 5.3 software.

RESULTS

A total of 7 studies comprising 1932 patients were included. The patients with wider surgical margin were significantly higher than those with narrow surgical margin on 3-year overall survival (odds ratio [OR]: 1.58, 95% confidence interval (95% CI): 1.21-2.06, P = .0008), 5-year overall survival (OR: 1.76, 95% CI: 1.20-2.59, P = .004), 1-year disease-free survival (DFS)/recurrence-free survival (RFS) (OR: 1.43, 95% CI: 1.12-1.82, P = .005), 3-year DFS/RFS (OR: 1.66, 95% CI: 1.35-2.03, P < .00001), and 5-year DFS/RFS (OR: 1.69, 95% CI: 1.37-2.08, P < .00001). There was no significant difference in the 1-year overall survival rate for the 2 groups (OR: 1.24, 95% CI: 0.89-1.72, P = .20).

CONCLUSION

In comparison with the narrow surgical margin group (<1 cm), the wide surgical margin (≥1 cm) can significantly improve the prognosis in patients with HCC.

Postoperative adjuvant radiotherapy is associated with improved survival in hepatocellular carcinoma with microvascular invasion

Purpose

Limited studies have compared the efficacy of postoperative adjuvant therapies in HCC patients with microvascular invasion (MVI). In this study we assess the efficacy of postoperative adjuvant conservative therapy (CT), trans-catheter arterial chemoembolization (TACE) and radiotherapy (RT) in HCC patients with MVI.

Results

Kaplan-Meier survival analysis revealed that patients in the RT group have significantly improved RFS (RT vs TACE: p = 0.011; RT vs CT: p < 0.001) and OS (RT vs. TACE: p = 0.034; RT vs CT: P < 0.001) compared to TACE and CT groups. Further, subgroup analysis based on the degree of MVI and surgical margin width showed that patients with narrow surgical margin have significantly longer RFS and OS after adjuvant RT than the TACE and CT, independent of degree of MVI. Multivariate analysis indicated that MVI classification is the independent prognostic factor associated with RFS and OS.

Materials and Methods

Between July 2008 and December 2015, 136 HCC patients with MVI were divided into three groups according to their adjuvant therapies. Survival outcomes namely relapse-free survival (RFS) and overall survival (OS) of the three groups were analyzed.

Conclusions

Adjuvant radiotherapy following hepatectomy could result in better survival outcomes for HCC patients with MVI than TACE or CT.

Wide versus narrow margins after partial hepatectomy for hepatocellular carcinoma: Balancing recurrence risk and liver function

BACKGROUND

The goal of this study was to compare the outcome after partial hepatectomy for hepatocellular carcinoma (HCC) in which a margin less than or equal to 5 mm or greater than 5 mm was achieved.

METHODS

A review of our 3300-patient prospective HPB database was performed from 12/2002 to 4/2015. Patients were stratified into two groups: resection margins ≤5 ("narrow") and >5 mm ("wide") as measured on final pathologic assessment.

RESULTS

One-hundred thirty patients were included in the analysis (margin ≤5 mm, n = 41 and margin >5 mm, n = 89). At the time of analysis 54 patients had developed 56 recurrences, 15 (37%) in the narrow margin group and 41 (46%) in the wide margin group, p = 0.45. The pattern of recurrence was similar in the two groups: intrahepatic 11 (79%) versus 30 (75%), p = 1, and extra-hepatic 6 (43%) versus 17 (43%), p = 1. Median disease-free survival was similar in both groups, 18.1 versus 19.5 months (p = 0.85).

CONCLUSIONS

A narrow resection margin (5 mm or less) does not detract from oncologic outcomes after partial hepatectomy for HCC. Tailoring resection margins may lead to greater preservation of hepatic parenchyma. Factors other than margin status represent the driving forces for local and systemic recurrence.

Traditional surgical planning of liver surgery is modified by 3D interactive quantitative surgical planning approach: a single-center experience with 305 patients

BACKGROUND

Decision making and surgical planning are to achieve the precise balance of maximal removal of target lesion, maximal sparing of functional liver remnant volume, and minimal surgical invasiveness and therefore, crucial in liver surgery. The aim of this prospective study was to validate the accuracy and predictability of 3D interactive quantitative surgical planning approach (IQSP), and to evaluate the impact of IQSP on traditional surgical plans based on 2D images.

METHODS

A total of 305 consecutive patients undergoing hepatectomy were included in this study. Surgical plans were created by traditional 2D approach using picture archiving and communication system (PACS) and 3D approach using IQSP respectively by two groups of physicians who did not know the surgical plans of the other group. The two surgical plans were submitted to the chief surgeon for selection before operation. The specimens were weighed. The two surgical plans were compared and analyzed retrospectively based on the operation results.

RESULTS

The two surgical plans were successfully developed in all 305 patients and all the 3D IQSP surgical plans were selected as the final decision. Total 278 patients successfully underwent surgery, including 147 uncomplex hepatectomy and 131 complex hepatectomy. Twenty-seven patients were withdrawn from hepatectomy. In the uncomplex group, the two surgical plans were the same in all 147 patients and no statistically significant difference was found among 2D calculated resection volume (2D-RV), 3D IQSP calculated resection volume (IQSP-RV) and the specimen volume. In the complex group, the two surgical plans were different in 49 patients (49/131, 37.4%). According to the significance of differences, the 49 different patients were classified into three grades. No statistically significant difference was found between IQSP-RV and specimen volume. The coincidence rate of territory analysis of IQSP with operation was 92.1% (93/101) for 101 patients of anatomic hepatectomy.

CONCLUSIONS

The accuracy and predictability of 3D IQSP were validated. Compared with traditional surgical planning, 3D IQSP can provide more quantitative information of anatomic structure. With the assistance of 3D IQSP, traditional surgical plans were modified to be more radical and safe.

Management of centrally located hepatocellular carcinoma: Update 2016

Centrally located hepatocellular carcinoma (HCC) is sited in the central part of the liver and adjacent to main hepatic vascular structures. This special location is associated with an increase in the difficulty of surgery, aggregation of the recurrence disease, and greater challenge in disease management. This review summarizes the evolution of our understanding for centrally located HCC and discusses the development of treatment strategies, surgical approaches and recurrence prevention methods. To improve patient survival, a multi-disciplinary modality is greatly needed throughout the whole treatment period.

The importance of surgical margins in primary malignancies of the liver

Resection is an important treatment modality for hepatocellular carcinoma (HCC) and intrahepatic cholangiocarcinoma (ICC). Anatomic resection is generally preferred for HCC. When anatomic resection is not feasible, prospective data have demonstrated an improved outcome among HCC patients who have a resection with wide versus narrow surgical margins. Similarly, among patients with ICC, R1 resection has been associated with worse outcomes. In addition, margin width may also impact risk of recurrence and survival. As such, provided adequate functional liver remnant remains, anatomic resection with wide margins is recommended for HCC and ICC.

Mesohepatectomy for centrally located large hepatocellular carcinoma: Indications, techniques, and outcomes

BACKGROUND

Whether mesohepatectomy should be performed for large hepatocellular carcinoma (HCC) located in the central part of the liver is controversial, and the safety and long-term survival after this operation remain to be investigated.

METHODS

Between January 2002 and December 2012, 696 patients with HCC located in the central part of the liver who received liver resection in our hospital were included in this study. These patients were divided into three groups: 158 patients with large HCC (tumor size >5.0 cm) and 192 patients with small HCC (tumor size ≤ 5.0 cm) who received mesohepatectomy were classified as the mesohepatectomy for large HCC (MHG-L) group and the mesohepatectomy for small HCC (MHG-S) groups, respectively, and 346 patients with large HCC who received hemihepatectomy or less were classified as the non-mesohepatectomy for large HCC (NMHG-L) group. The operative indications, techniques, and outcomes of the three groups were analyzed retrospectively.

RESULTS

There were no substantial differences among the three groups in in-hospital mortality or postoperative complication rates. The overall survival and disease-free survival were not different between the MHG-L group and the NMHG-L group or between the MHG-L group and the MHG-S group. Univariable and multivariable analyses of the MHG-L mesohepatectomy group indicated that cirrhosis, tumor number, and vascular invasion were independent risk factors of poor long-term survival of mesohepatectomy. In the MHG-L and NMHG-L groups, solitary large hepatocellular carcinoma had better long-term survival than nodular large hepatocellular carcinoma.

CONCLUSION

Mesohepatectomy is safe and efficacious for BCLC B/C patients who have centrally located large HCC, especially for solitary tumors, with good survival outcomes.

Tumor ablation: common modalities and general practices

Tumor ablation is a minimally invasive technique that is commonly used in the treatment of tumors of the liver, kidney, bone, and lung. During tumor ablation, thermal energy is used to heat or cool tissue to cytotoxic levels (less than -40°C or more than 60°C). An additional technique is being developed that targets the permeability of the cell membrane and is ostensibly nonthermal. Within the classification of tumor ablation, there are several modalities used worldwide: radiofrequency, microwave, laser, high-intensity focused ultrasound, cryoablation, and irreversible electroporation. Each technique, although similar in purpose, has specific and optimal indications. This review serves to discuss general principles and technique, reviews each modality, and discusses modality selection.

Adjuvant radiotherapy in centrally located hepatocellular carcinomas after hepatectomy with narrow margin (<1 cm): a prospective randomized study

BACKGROUND

Although radiotherapy (RT) provides potential benefits for patients with hepatocellular carcinomas (HCCs) that are unsuitable for operation, the specific role of adjuvant RT in HCC after hepatectomy remains ill defined. The current study's aim was to evaluate the safety and efficacy of adjuvant RT for centrally located HCCs after narrow-margin (<1 cm) hepatectomy.

STUDY DESIGN

The study included 119 patients with centrally located HCCs who underwent narrow-margin hepatectomy between July 2007 and March 2012. Patients were prospectively randomized to receive adjuvant RT (n = 58) or were assigned to a control group (n = 61). Surgical outcomes, safety, and survival rates were evaluated.

RESULTS

Hepatectomy was successfully performed in all patients. No cases of radiation-induced liver disease were observed. One-, 3-, and 5-year recurrence-free survival rates were 78.1%, 56.5%, and 36.9% in the adjuvant RT group and 72.4%, 40.1%, and 16.0% in the control group, respectively (p = 0.06, log-rank test). Corresponding overall survival rates were 96.2%, 72.6%, 48.4%, and 89.6%, 74.5%, 37.2%, respectively (p = 0.48, log-rank test). One-, 3-, and 5-year recurrence-free survival rates in patients with small-diameter tumors (≤5 cm) were 88.8%, 67.4%, 42.9% in the adjuvant RT group and 82.3%, 42.9%, 21.5% in the control group (p = 0.03, log-rank test). Corresponding overall survival rates were 97.5%, 75.3%, 75.3%, and 94.7%, 84.1%, 65.4%, respectively (p = 0.92, log-rank test).

CONCLUSIONS

Adjuvant RT for centrally located HCCs after narrow-margin hepatectomy was technically feasible and relatively safe. No significant between-group difference was observed in recurrence-free and overall survival. The post-hoc subgroup comparison showed that adjuvant RT improved recurrence-free survival considerably, but not overall survival, in patients with small HCCs (≤5 cm). More in-depth studies are needed to validate this finding.

Hepatic resection for hepatocellular carcinoma based on tumor hemodynamics

Survival or disease-free survival is not considered an appropriate surrogate outcome for the locoregional curability (i.e. surgical margin) of hepatectomy for hepatocellular carcinoma because these are greatly influenced by non-metastatic factors like multicentric carcinogenesis (MC) or liver function. Hepatocellular carcinoma metastasizes by hematogenous seeding; therefore, the tumor blood flow (TBF) drainage area is a high-risk area for intrahepatic metastasis, and can be identified by computed tomography under hepatic arteriography and completely resected as part of the surgical margin. The TBF pattern is classified into marginal, portal vein or hypovascular types. Partial hepatectomies were mostly performed in patients with marginal or hypovascular type, whereas anatomical surgery was frequently performed in those with portal vein type. Pathologically, nodules inside the TBF drainage area were moderately or poorly differentiated carcinomas, suggesting intrahepatic metastasis. In contrast, those outside the drainage area were frequently solitary and contained well-differentiated carcinoma, which is consistent with MC. The pattern of tumor recurrences after TBF-based hepatectomy is divided into two distinct groups - "a few nodules" and "many nodules in multiple segments or extrahepatic" - indicating that intrahepatic recurrences develop from MC and from circulating tumor cells in peripheral blood, respectively. Anatomical resection has not shown a survival benefit over that of TBF-based partial hepatectomy. TBF-based hepatectomy enables us to preserve liver function without compromising locoregional curability.

Surgical resection for small hepatocellular carcinoma in cirrhosis: the Eastern experience

Detection of small Hepatocarcinoma (HCC) by screening of high-risk populations is important to increase the percentage of patients suitable for curative treatment, which would lead to prolongation of the mean survival of patients with HCC. It should be remembered that small HCC is not always necessarily equivalent to early HCC as defined histologically. With recent advances in diagnostic imaging modalities, including contrast-enhanced ultrasonography and magnetic resonance imaging with liver-specific contrast enhancement, accurate differential diagnosis of early HCCs from dysplastic nodules has become possible. Because a certain proportion of small HCCs is known to show microscopic vascular invasion, surgical resection would be the treatment of first choice. To minimize potential microscopic invasion, anatomic resection and/or resection with a wide margin should be performed, while preserving liver function to the maximum extent possible. Surgical resection, however, cannot prevent multicentric occurrence of HCC, which remains a major issue precluding curative treatment of HCC.

Prognostic impact of marginal resection for patients with solitary hepatocellular carcinoma: evidence from 570 hepatectomies

BACKGROUND

During resection of a hepatocellular carcinoma, surgeons encounter occasionally a situation where marginal resection is inevitable because of a close association between the hepatocellular carcinoma and major vasculature and/or underlying impaired liver function. We investigated the impact of marginal resection on recurrence-free survival after a resection of a solitary hepatocellular carcinoma.

METHODS

The data of 570 patients who underwent macroscopically curative hepatectomy for a solitary hepatocellular carcinoma in our institution between 1990 and 2007 were analyzed. Marginal resection and non-marginal resection were defined as a cancer-negative surgical margin of ≤ 1 mm and a surgical margin of >1 mm, respectively. The macroscopic appearance of the hepatocellular carcinoma was classified as the simple nodular type or non-simple nodular type based on the classification of the Liver Cancer Study Group of Japan, and patients were categorized into 4 groups: group A, simple nodular type with cirrhosis; group B, simple nodular type without cirrhosis; group C, non-simple nodular type with cirrhosis; and group D, non-simple nodular type without cirrhosis.

RESULTS

The surgical margins were diagnosed as cancer-positive in 31 patients, as marginal resection in 165 patients, and as non-marginal resection in 374 patients. The marginal resection group showed a better recurrence-free survival than the positive surgical margin group (P = .001), and also a worse recurrence-free survival than the non-marginal resection group (P = .003). In groups A, B, and C, the recurrence-free survival rates were similar between marginal resection and non-marginal resection patients (P = .458), while in group D, marginal resection was a significant poor prognostic factor of recurrence-free survival in both univariate and multivariate analyses.

CONCLUSION

Marginal resection is acceptable in group A, B, and C patients, because it did not negatively affect postoperative recurrence-free survival.

Synergy in cancer treatment between liposomal chemotherapeutics and thermal ablation

Minimally invasive image-guided tumor ablation using short duration heating via needle-like applicators using energies such as radiofrequency or microwave has seen increasing clinical use to treat focal liver, renal, breast, bone, and lung tumors. Potential benefits of this thermal therapy include reduced morbidity and mortality compared to standard surgical resection and ability to treat non-surgical patients. However, improvements to this technique are required as achieving complete ablation in many cases can be challenging particularly at margins of tumors>3 cm in diameter and adjacent to blood vessels. Thus, one very promising strategy has been to combine thermal tumor ablation with adjuvant nanoparticle-based chemotherapy agents to improve efficiency. Here, we will primarily review principles of thermal ablation to provide a framework for understanding the mechanisms of combination therapy, and review the studies on combination therapy, including presenting preliminary data on the role of such variables as nanoparticle size and thermal dose on improving combination therapy outcome. We will discuss how thermal ablation can also be used to improve overall intratumoral drug accumulation and nanoparticle content release. Finally, in this article we will further describe the appealing off-shoot approach of utilizing thermal ablation techniques not as the primary treatment, but rather, as a means to improve efficiency of intratumoral nanoparticle drug delivery.

Principles of and advances in percutaneous ablation

Image-guided tumor ablation with both thermal and nonthermal sources has received substantial attention for the treatment of many focal malignancies. Increasing interest has been accompanied by continual advances in energy delivery, application technique, and therapeutic combinations with the intent to improve the efficacy and/or specificity of ablative therapies. This review outlines clinical percutaneous tumor ablation technology, detailing the science, devices, techniques, technical obstacles, current trends, and future goals in percutaneous tumor ablation. Methods such as chemical ablation, cryoablation, high-temperature ablation (radiofrequency, microwave, laser, and ultrasound), and irreversible electroporation will be discussed. Advances in technique will also be covered, including combination therapies, tissue property modulation, and the role of computer modeling for treatment optimization.

Outcomes of non-anatomic liver resection for hepatocellular carcinoma in the patients with liver cirrhosis and analysis of prognostic factors

PURPOSE

In the east countries, patients with hepatocellular carcinoma (HCC) are usually associated with varied degrees of liver cirrhosis, and anatomic resection is therefore limited to use, especially in those with severe liver cirrhosis. This study aims to evaluate the clinical value of non-anatomic resection in HCC patients with cirrhosis.

METHODS

Seventy-seven consecutive HCC patients with cirrhosis underwent non-anatomic liver resection in Tongji Hospital from January 2003 to December 2006. The clinical data, severity of liver cirrhosis, and survival rates of these patients were retrospectively evaluated, and the prognostic factors were analyzed.

RESULTS

One-, 2-, and 3-year overall and disease-free survival rates of this cohort of patients were 78%, 68%, 56%, and 66%, 58%, 55%, respectively. The hospital mortality and morbidity were 0% and 24.7%, respectively. The 1-, 2-, and 3-year overall survival rates were 85.7%, 77.1%, and 74.3% in the patients with mild cirrhosis, 81.5%, 63%, and 48.1% in the patients with moderate cirrhosis, and 60.0%, 53.3%, and 26.7% in the patients with severe cirrhosis, respectively. There was a significant difference among the patients with different grades of cirrhosis (P = 0.001). Multivariate and univariate analyses revealed that severity of cirrhosis, tumor diameter larger than 5 cm, and vascular invasion were independent prognostic factors.

CONCLUSIONS

Non-anatomic liver resection for HCC could yield comparable outcomes with anatomic resection in the patients with mild cirrhosis or tumors diameter smaller than 5 cm. Severity of cirrhosis is an independent factor worsening long-time survival. Non-anatomic resection is a safe and effective surgical modality in the treatment of HCC patients with cirrhosis.