Radiofrequency ablation of hepatocellular carcinoma extended into the portal vein: Preliminary results

The Treatment of Hepatocellular Carcinoma with Major Vascular Invasion

Vascular invasion of hepatocellular carcinoma involves tumor plugs in the main trunk of the portal vein, bile ducts, and veins, and it indicates poor prognosis. It is often associated with portal hypertension, which requires evaluation and management. Treatment includes hepatic resection, systemic pharmacotherapy, hepatic arterial infusion chemotherapy, and radiation therapy. Recurrence rates post-hepatic resection are high, and systemic drug therapy often has limited therapeutic potential in patients with a poor hepatic reserve. Single therapies are generally inadequate, necessitating combining multiple therapies with adjuvant and systemic pharmacotherapy before and after hepatectomy. This narrative review will provide an overview of the treatment of hepatocellular carcinoma with vascular invasion.

Percutaneous treatment of hepatocellular carcinoma: State of the art and innovations

Percutaneous treatment of hepatocellular carcinoma (HCC) encompasses a vast range of techniques, including monopolar radiofrequency ablation (RFA), multibipolar RFA, microwave ablation, cryoablation and irreversible electroporation. RFA is considered one of the main curative treatments for HCC of less than 5 cm developing on cirrhotic liver, together with surgical resection and liver transplantation. However, controversies exist concerning the respective roles of ablation and liver resection for HCC of less than 3 to 5 cm on cirrhotic liver. In line with the therapeutic algorithm of early HCC, percutaneous ablation could also be used as a bridge to liver transplantation or in a sequence of upfront percutaneous treatment, followed by transplantation if the patient relapses. Moreover, several innovations in ablation methods may help to efficiently treat early HCC, initially considered as "non-ablatable", and might, in some cases, extend ablation criteria beyond early HCC, enabling treatment of more patients with a curative approach.

Percutaneous Endovascular Radiofrequency Ablation for Malignant Portal Obstruction: An Initial Clinical Experience

PURPOSE

The Habib™ VesOpen Catheter is a new endovascular radiofrequency ablation (RFA) device used to treat malignant portal obstruction. The purpose of this study was to evaluate the clinical feasibility and safety of RFA with this device.

METHODS

We collected the clinical records and follow-up data of patients with malignant portal obstruction treated with percutaneous endovascular portal RFA using the Habib™ VesOpen Catheter. Procedure-related complications, improvement of symptoms, portal patency, survival, and postoperative biochemical tests were investigated.

RESULTS

The 31 patients enrolled in the study underwent 41 successful endovascular portal RFA procedures. Patients were divided into a portal-stenting (PS) group (n = 13), which underwent subsequent portal stenting with self-expandable metallic stents, and a non-stenting (NS) group (n = 18), which did not undergo stenting. No procedure-related abdominal hemorrhage or portal rupture occurred. Postablation complications included abdominal pain (n = 26), fever (n = 13), and pleural effusion (n = 15). Improvements in clinical manifestations were observed in 27 of the 31 patients. Of the 17 patients experiencing portal restenosis, 10 underwent successful repeat RFA. The rate of successful repeat RFA was significantly higher in the NS group than in the PS group. Median portal patency was shorter in the PS group than in the NS group. No mortality occurred during the 4 weeks after percutaneous endovascular portal RFA.

CONCLUSIONS

Percutaneous endovascular portal RFA is a feasible and safe therapeutic option for malignant portal obstruction. Prospective investigations should be performed to evaluate clinical efficacy, in particular, the need to evaluate the necessity for subsequent portal stenting.

Mass reduction by radiofrequency ablation before hepatic arterial infusion chemotherapy improved prognosis for patients with huge hepatocellular carcinoma and portal vein thrombus

OBJECTIVE

The prognosis for patients with advanced large hepatocellular carcinoma (HCC) with portal vein (PV) tumor thrombosis remains poor, and treatment is usually limited to hepatic arterial infusion (HAI) chemotherapy. In this study, we first performed mass reduction using radiofrequency ablation (RFA), followed by HAI chemotherapy. Prognosis after this treatment was evaluated.

SUBJECTS AND METHODS

HCC with PV tumor thrombosis was diagnosed in 20 patients between April 2004 and December 2008, and treatment was performed using mass-reduction therapy by RFA before HAI chemotherapy. For comparison, 33 patients treated with HAI chemotherapy without RFA were retrospectively selected as historical control subjects under the same conditions. Prognosis in each group was evaluated.

RESULTS

Mass-reduction therapy by RFA combined with HAI chemotherapy achieved complete response in six patients (30%), partial response in 11 patients (55%), stable disease in two patients (10%), and progressive disease in one patient (5%). Among the control subjects, complete response was seen in 0 patients (0%), partial response in 12 patients (33.3%), stable disease in 16 patients (44.4%), and progressive disease in eight patients (22.2%). The cumulative survival rates for those who received the combined therapy at 6, 12, and 24 months were 100%, 89.7%, and 78.8%, respectively. The median survival was 953 days (95% CI, 760-1,102 days). In the control subjects, the cumulative survival rates at 6, 12, and 24 months were 84.9%, 56.1%, and 16.9%, respectively (p < 0.0001). No serious adverse events were encountered in either group.

CONCLUSION

For patients with huge HCC and PV tumor thrombosis, mass-reduction treatment by RFA before HAI chemotherapy is safe and can improve prognosis.