Conventional Chemoembolization Plus Radiofrequency Ablation versus Surgical Resection for Single, Medium-Sized Hepatocellular Carcinoma: Propensity-Score Matching Analysis

Microwave ablation followed by cTACE in 5-cm HCC lesions: does a single-session approach affect liver function?

PURPOSE

Microwave ablation (MWA) and conventional transarterial chemoembolization (cTACE) are locoregional treatments commonly performed in very early, early and intermediate stages of hepatocellular carcinoma (HCC). Despite combined locoregional approaches have shown encouraging results in obtaining complete tumor necrosis, their application in a single session is poorly described. Our aim was to evaluate the safety and efficacy of single-session MWA and cTACE treatment in 5-cm HCCs and its influence on liver function.

MATERIALS AND METHODS

All 5-cm HCCs treated by MWA and cTACE performed in a single-session in our Interventional Radiology unit between January 2020 and December 2022 were retrospectively recorded and analyzed. Patients with poor or missing pre- and post-treatment imaging were excluded. Technical success, clinical success, and complications rate were examined as primary endpoints. Pre- and post-treatment liver function laboratory parameters were also evaluated.

RESULTS

A total of 15 lesions (mean lesion diameter, 5.0 ± 1.4 cm) in 15 patients (11 men; mean age, 67.1 ± 8.9 years) were retrospectively evaluated. Technical and clinical success were 100% and 73%, respectively. Four (27%) cases of partial response and no cases of progressive or stable disease were recorded. AST and ALT values have found to be significantly higher in post-treatment laboratory tests. No other significant differences between pre- and post-treatment laboratory values were registered. AST and ALT pre- and post-treatment higher differences (ΔAST and ΔALT) were significantly associated with a lower clinical success rate.

CONCLUSION

MWA and cTACE single-session approach is safe and effective for 5-cm HCCs, without significant liver function impairment. A post-treatment increase in AST and ALT values may be a predictor for clinical failure.

TACE-assisted multi-image guided radiofrequency ablation for the treatment of single hepatocellular carcinoma ≤ 5 cm: a retrospective study

Background/Objective

Treatment of hepatocellular carcinoma (HCC) with ablation alone often results in high rates of recurrence and metastasis, reaching up to 25.9% within two years. Therefore, this study aimed to examine the efficacy and safety of transarterial chemoembolization (TACE)-assisted multi-image guided radiofrequency ablation (RFA) for the treatment of stage Ia HCC according to the China liver cancer staging (CNLC).

Methods

This study enrolled and analyzed a total of 118 patients diagnosed with HCC, each with a single nodular lesion no larger than 5 cm, who received TACE-RFA as first-line therapy between February 1, 2014, and December 31, 2021. The median/mean follow-up period was 29.0 months [95% confidence interval (CI): 21.8-36.2 months] and 31.8 months (95% CI: 27.5-36.0 months), respectively. We assessed the treatment's effectiveness, potential complications, and survival rate.

Results

The technical success rate was 100% (118/118) after the initial treatment. Out of the total, 3 out of 118 patients (2.5%) developed local tumor progression (LTP) during the follow-up period. The median time for LTP was 29.0 months (95%CI: 21.9-36.1 months; mean: 31.5 months; range 1-92 months). At 1, 3, 5, and 7 years after treatment, the cumulative LTP rates were 0%, 4.6%, 4.6%, and 4.6%, respectively. The overall survival rates at 1, 3, 5, and 7 years were 100%, 95.2%, 95.2%, and 95.2%, respectively. In total, 28 patients experienced minor Grade B complications, and no major complications or treatment-related mortality occurred.

Conclusion

The treatment of CNLC stage Ia HCC using TACE-assisted multi-image-guided RFA was found to be both safe and feasible.

Chemoembolization Plus Ablation: Current Status

Hepatocellular carcinoma (HCC) is a leading cause of cancer-related death worldwide. The treatment landscape for HCC has evolved significantly over the past decade, with several modalities available to treat various stages of disease. The Barcelona Clinic Liver Cancer (BCLC) system provides a foundation for treatment guidance. However, given the complex nature of HCC, a more nuanced approach is often required, especially for lesions sized between 3 and 5 cm. This review aims to analyze the available treatments for early-stage HCC lesions between 3 and 5 cm, with a focus on the therapeutic potential and efficacy of transarterial chemoembolization (TACE)-ablation. Additional therapies including TACE, ablation, transarterial radioembolization, and surgical resection are also reviewed and compared with TACE-ablation. TACE-ablation is a viable therapeutic option for early-stage HCC lesions between 3 and 5 cm. Surgical resection remains the gold standard. Although recent studies suggest radiation segmentectomy may be a curative approach for this patient population, further studies are needed to compare the relative efficacies between TACE-ablation and radiation segmentectomy.

Liver resection, radiofrequency ablation, and radiofrequency ablation combined with transcatheter arterial chemoembolization for very-early- and early-stage hepatocellular carcinoma: A systematic review and Bayesian network meta-analysis for comparison of efficacy

OBJECTIVE

To compare the efficacy of liver resection (LR), radiofrequency ablation (RFA), and radiofrequency ablation combined with transcatheter arterial chemoembolization (RFA+TACE) in the treatment of very-early- and early-stage hepatocellular carcinoma (HCC).

METHODS

We systemically searched the PubMed, Embase, and Cochrane Library databases. Randomized controlled trials (RCTs) and observational analyses with propensity score-matched cohort analyses (PSMs) comparing any two of the three treatments were included in this study. The primary result was overall survival (OS) and the secondary result was recurrence-free survival (RFS), which were analyzed by calculating the hazard ratio (HR) and 95% confidence intervals (CI).

RESULTS

A total of 25 studies (4249 patients), including 10 RCTs and 15 PSM observational studies, met the inclusion criteria. Although there was no significant difference between LR and RFA in terms of one-year OS, though LR showed superior performance for three- and five-year OS (at three years, HR: 0.74, 95% CI: 0.56-0.96; at five years, HR: 0.73, 95% CI: 0.55-0.94). In addition, significantly higher rates of RFS at one-, three- and five-year follow-up were found for LR than for RFA alone (at one year, HR: 0.68, 95% CI: 0.51-0.92; at three years, HR: 0.67, 95% CI: 0.55-0.81; at five years, HR: 0.61, 95% CI: 0.48-0.78). The combination of RFA+TACE was superior to RFA alone based on one-year RFS (HR: 0.57, 95% CI: 0.34-0.96), while there were no significant differences in OS at one, three, and five years, and in RFS at three and five years.

CONCLUSIONS

For very-early- and early-stage HCC, this systematic review and network meta-analysis showed that the efficacy of LR is superior to that of RFA alone, regardless of whether the evaluation is based on either OS or RFS. The advantages of RFA+TACE compared to RFA alone are limited, and further studies are needed to determine whether combination therapy is necessary, i.e., results in significantly improved outcomes.

SYSTEMATIC REVIEW REGISTRATION

The study was registered with http://www.crd.york.ac.uk/PROSPERO, identifier: CRD42022299269.

Intelligent Algorithm-Based Ultrasound Images in Evaluation of Therapeutic Effects of Radiofrequency Ablation for Liver Tumor and Analysis on Risk Factors of Postoperative Infection

This research aimed to explore the therapeutic effects of radiofrequency ablation (RFA) for liver tumors and to investigate the postoperative infection factors. Specifically, 80 patients with liver tumors undergoing ultrasound-guided FRA were selected as research subjects. They were diagnosed in the hospital. An intelligent fitting (IF) algorithm was compared with a genetic algorithm (GA) and applied to the RFA of the 80 patients. It was found that the running time of the IF algorithm was about 0.2 times than that of the GA, demonstrating better global searching capabilities. The mean diameter of single liver tumors was (3.45 ± 1.24) cm, and the complete ablation rate of tumors with diameters less than 3 cm was 87.88%, that of tumors with diameters of 3-5 cm was 72.92%, and that of tumors with a diameter of more than 5 cm was 63.33%. Posttreatment, the AST level decreased significantly and the ALB level increased significantly, and the difference was notable (P < 0.05P<); the TBIL level (36.8 ± 9.7 umol/L) was lower than prior treatment (17.9 ± 8.5 umol/L) and the ALT level (45.2 ± 6.8 g/L) was lower than prior treatment (19.6 ± 5.7 g/L), showing a notable difference (P < 0.05P<). The diameter, whether there was great vessel invasion, and TNM staging were associated with infection after RFA, and the difference was notable. The ultrasound images can effectively evaluate the therapeutic effects of RFA and the degree of inactivation of liver tumors. In addition, the tumor stage was an independent risk factor for postoperative infection.

Transarterial Chemoembolization Combined With Radiofrequency Ablation Versus Hepatectomy for Hepatocellular Carcinoma: A Meta-Analysis

Background

Although many studies reported the effectiveness of transarterial chemoembolization (TACE) combined with radiofrequency ablation (RFA) or surgical resection (SR) in the treatment of hepatocellular carcinoma (HCC), the efficacy of these two strategies remains controversial. Therefore, this meta-analysis aimed to evaluate and compare the efficacy of sequential use of TACE plus RFA (TACE + RFA) and SR alone in treating HCC.

Methods

Relevant studies with unmatched and propensity score-matched patients were identified by comprehensive search of MEDLINE, PubMed, EMBASE, Web of Science, and Cochrane electronic databases. Meta-analysis was conducted using Review Manager (RevMan) software version 5.4.1. Finally, 12 eligible studies were included in this study, including 11 case–control studies and 1 randomized controlled trial. The primary outcome of interest for this study was to compare the 1-, 3-, and 5-year overall survival (OS) and disease-free survival (DFS), major complications, 5-year OS in different tumor diameters between the two treatment strategies, and hospital stay time.

Results

HCC patients who received TACE + RFA had a lower incidence of complication rates and shorter hospital stay time than those who received SR alone. Among these studies using propensity score-matched cohorts, SR had better 3- and 5-year OS than TACE + RFA, whereas there were no significant differences between TACE + RFA and SR regarding the 1-, 3-, and 5-year DFS. When the tumor diameter is longer than 3 cm, the 5-year OS rate is better when SR is selected.

Conclusion

There was no significant difference in the short-term survival outcomes between TACE + RFA and SR in HCC patients. Moreover, SR is superior to TACE + RFA in terms of long-term beneficial effects but may result in a higher risk of major complications and a longer hospital stay time.

Risk factors for the recurrence of early hepatocellular carcinoma treated by percutaneous radiofrequency ablation with a multiple-electrode switching system: a multicenter prospective study

PURPOSE

To investigate the long-term efficacy of radiofrequency ablation (RFA) with a multiple-electrode switching system (MESS) in the treatment of early hepatocellular carcinoma (HCC) and evaluate the patterns and risk factors of intrahepatic recurrence of HCC after RFA.

METHODS

In total, 139 patients with early HCC who underwent RFA with MESS as primary treatment at multiple centers were prospectively enrolled according to the inclusion criteria. We evaluated the local tumor progression (LTP), intrahepatic distant recurrence (IDR), the incidence of cumulative disease-free survival (DFS), LTP-free survival, IDR-free survival, and overall survival. We also analyzed the associated risk factors.

RESULTS

A total of 139 patients were included in the study and the median follow-up time was 64 months, ranging from 11 to 72 months. The complete ablation rate was 98.56%. Sixty-nine (49.64%) were found to have intrahepatic recurrence (LTP, n = 15; IDR, n = 55) during follow-up. The 1-year, 3-year and 5-year cumulative DFS, LTP-free survival, and IDR-free survival rates were 74.82, 94.46 and 78.75%; 54.68, 88.03 and 61.79%; and 51.80, 85.67 and 60.17%, respectively. In the multivariable analysis, tumor size > 4 cm was the only important risk factor for LTP. The alkaline phosphatase (ALP) level and the number of tumors were independent risk factors for IDR; α-fetoprotein (AFP) level > 400 µg/L and recurrence interval were risk factors for the overall survival period.

CONCLUSIONS

The MESS-RFA is an effective method for local control of tumors in early HCC. Early HCC with multiple high-ALP tumors has a higher rate of recurrence, which mainly occurs in an IDR pattern. Early HCC with high AFP levels and a shorter initial recurrence interval resulted in a poorer prognosis. Thus, treatments such as liver transplantation or surgical resection may be a good strategy in those cases.

CLINICALTRIALS.GOV ID

NCT02046356.

Liver Resection Versus Local Ablation Therapies for Hepatocellular Carcinoma Within the Milan Criteria: A Systematic Review and Meta-analysis

OBJECTIVE

To compare the oncologic outcomes of liver resection (LR) and local ablation therapies for HCC.

SUMMARY OF BACKGROUND DATA

Although several studies have compared LR and local ablation therapies, the optimal treatment of choice for HCC within the Milan criteria remains controversial.

METHODS

We systemically searched the MEDLINE, Embase, and Cochrane Library databases for randomized control trials (RCTs) and matched nonrandomized trials (NRTs) that compared LR and local ablation therapies for HCC within the Milan criteria. The primary outcome was overall survival (OS). Secondary outcomes were recurrence free survival (RFS) and recurrence pattern.

RESULTS

A total of 7 RCTs and 18 matched NRTs, involving 2865 patients in the LR group and 2764 patients in the local ablation therapy group [RFA, MWA, RFA plus trans-arterial chemoembolization (TACE)], were included. Although there was no significant difference in OS between LR and RFA, LR showed a significantly better 5-year RFS than RFA in the analysis of RCTs (hazards ratio: 0.75; 95% confidence interval: 0.62-0.92; P = 0.006). The RFA group showed a significantly higher local recurrence than the LR group in both analyses of RCTs and NRTs. Additionally, the LR group showed better OS and RFS than the MWA or RFA plus TACE groups.

CONCLUSION

Our meta-analysis showed that LR was superior to RFA in terms of RFS and incidence of local recurrence. Moreover, LR showed better oncologic outcomes than MWA or RFA plus TACE.

Computed tomography-guided percutaneous microwave ablation with artificial ascites for problematic hepatocellular tumors

Background: The aim of this study was to assess the feasibility, safety and efficacy of computed tomography (CT)-guided percutaneous microwave ablation with artificial ascites for problematic hepatocellular tumors.Methods: Forty-eight patients with 61 problematic hepatocellular carcinomas who underwent CT-guided percutaneous microwave ablation with artificial ascites were reviewed retrospectively. Lesions less than 5 mm away from the gastrointestinal system, diaphragm, pericardium or kidney were defined as problematic tumors with the potential risk of thermal damage. Microwave ablation was performed after artificial ascites was established between tumors and the adjacent high-risk organs. The technical effectiveness of microwave ablation, local tumor progression and complications was assessed.Results: Microwave ablation with artificial ascites was successfully performed in all 61 tumors. The technical effectiveness rate was 100% with contrast-enhanced CT performed immediately after the ablation procedure. Local tumor progression occurred in three (6%) of the 48 patients during the follow-up period (mean, 15 months; range, 6-24 months). No major complications related to the procedure occurred.Conclusion: CT-guided percutaneous microwave ablation with artificial ascites is a feasible, safe and effective choice for treating problematic hepatocellular tumors, avoiding potential thermal damage to the adjacent high-risk organs.

Trans-arterial chemoembolization + radiofrequency ablation versus surgical resection in hepatocellular carcinoma - A meta-analysis

BACKGROUND

Hepatocellular Carcinoma (HCC) remains the third most common cause of cancer death worldwide, with countries in Asia being affected the most. The mainstay of curative therapy for early HCC is radiofrequency ablation (RFA) or surgery; either surgical resection (SR) or liver transplantation. Latest evidence however suggests that combination of TACE+ RFA may provide outcomes comparable to SR.

AIM

To compare oncologic outcomes and safety profile of TACE + RFA to SR alone in HCC.

MATERIALS AND METHODS

A systematic review was conducted through Pubmed, EMBASE and Cochrane Library for literature published before April 2019. Outcomes measured were disease-free survival(DFS), overall survival(OS) and major complications. DFS was further divided into local tumour progression(LTP), intrahepatic distant recurrence(IDR) and distant metastasis(DM).

RESULTS

Eight retrospective studies and one randomized controlled trial, involving 1892 patients met eligibility criteria and were included. Unadjusted pooled analysis demonstrated no significant difference in 1-year, 3-year and 5-year OS and 1-year DFS between TACE+RFA and SR. SR had superior 3-year DFS (OR 0.78, 95% CI 0.62-0.98, p = 0.03) and 5-year DFS (OR 0.74, 95% CI 0.58-0.95, p = 0.02) compared to TACE+RFA. When analysing only the propensity matched data, the difference in 3-year DFS and 5-year DFS was not significant. TACE+RFA had a higher LTP rate (OR 2.48, 95% CI 1.05-5.86, p = 0.04) compared to SR but IDR and DM rates were not significant.

DISCUSSION AND CONCLUSION

TACE+RFA offer comparable oncologic outcomes in patients with HCC as compared with SR and with added benefit of lower morbidity.

Locoregional Therapies in the Treatment of 3- to 5-cm Hepatocellular Carcinoma: Critical Review of the Literature

OBJECTIVE. Treatment options for hepatocellular carcinoma (HCC) continue to expand. However, given the complexity of the patients including factors such as codominant cirrhosis or portal hypertension and transplant status, it can be difficult to know which treatment is most advantageous. The choice of HCC treatment is perhaps most complex in the setting of HCCs that are 3-5 cm. This article reviews the evidence for locoregional therapies in treating 3- to 5-cm HCCs. CONCLUSION. Combination therapy with transarterial chemoembolization (TACE) and ablation has the most robust and highest level of evidence to support its efficacy and therefore should be considered first-line therapy for nonresectable HCCs that measure 3-5 cm. The studies support that TACE followed by ablation is superior to either TACE alone or ablation alone. Data for transarterial radioembolization (TARE) to treat HCCs in this specific size range are very limited. Additional data are needed about the comparative effectiveness of TACE-ablation combination and TARE and how the TACE-ablation combination compares with surgical resection.

Long-term outcome of intraoperative radiofrequency ablation for hepatocellular carcinoma and its efficacy as a primary treatment

BACKGROUNDS/AIMS

We conducted this study to identify long-term outcomes following intraoperative radiofrequency ablation (IO-RFA) for hepatocellular carcinoma (HCC) and to reveal independent prognostic factors for survival.

METHODS

From December 1998 to February 2019, 183 patients underwent IO-RFA for HCC. These patients were divided into two groups according to whether RFA was done as a first-line (1-RFA group, n=106) or secondary-line (2-RFA group, n=77) treatment. Furthermore, we compared the survival outcomes between the 1-RFA and 2-RFA groups.

RESULTS

There were no significant differences in type of surgical approaches between the two groups (p=0.079). The number of tumors and largest tumor size were not significantly different between the two groups. Overall recurrence rate was 53%, and the 2-RFA group showed a higher recurrence rate (46.2% in 1-RFA group versus 62.3% in 2-RFA group; p=0.031). The 5-year overall survival (OS) and disease-free survival (DFS) rates of all the patients were 75.2% and 27.9%, respectively. The OS and DFS rates were significantly higher in the 1-RFA group. The 5-year OS rates were 83.6% and 64.9% in the 1-RFA and 2-RFA groups, respectively (p=0.010), whereas the 5-year DFS rates were 32.2% and 21.6%, respectively (p=0.012). On multivariate analysis, HBV-LC, 2-RFA, recurrence, and postoperative complications were independent predictive factors for survival.

CONCLUSIONS

Therapeutic outcomes of IO-RFA were comparable to those of surgical resection. Additionally, 1-RFA might be an alternative treatment for naïve HCC in patients with uncompensated liver function and severe comorbidities.

Ablation plus Transarterial Embolic Therapy for Hepatocellular Carcinoma Larger than 3 cm: Science, Evidence, and Future Directions

Thermal ablation is widely regarded as definitive therapy for early-stage hepatocellular carcinoma, but its efficacy decreases in tumors greater than 3 cm. Extensive clinical studies have supported improved outcomes provided through combining transarterial embolic therapy with ablation in the treatment of larger tumors. This article will provide a survey of the science and data for combination therapy in both thermal and nonthermal ablation modalities, as well as describe emerging applications.

Chemoembolization Combined with Radiofrequency Ablation for Medium-Sized Hepatocellular Carcinoma: A Propensity-Score Analysis

PURPOSE

To compare survival outcomes of patients with single medium-sized hepatocellular carcinomas (HCCs) who underwent treatment with transarterial chemoembolization, radiofrequency (RF) ablation, or a combination of the 2 therapies.

MATERIALS AND METHODS

Between 2000 and 2016, 538 patients underwent combined chemoembolization and RF ablation (n = 109), chemoembolization alone (n = 314), or RF ablation alone (n = 115) as first-line treatment for a single medium-sized (3.1-5.0 cm) HCC. Baseline demographic data (age, sex, etiology, Eastern Cooperative Oncology Group performance status, presence of liver cirrhosis, and serum bilirubin, albumin, and α-fetoprotein levels) were similar among groups except for Child-Pugh class, albumin level, and tumor size. Propensity-score analysis with inverse probability weighting (IPW) was used to reduce any bias in treatment selection and other potential confounding factors.

RESULTS

Median follow-up time was 46.2 months. Before IPW, overall survival (OS) durations were significantly different among the 3 groups (median, 85 months for combined therapy, 56.5 months for chemoembolization alone, and 52.1 months for RF ablation alone; P = .01). The 10-year OS rates were 40.1%, 25.5%, and 19.5% for the combined, chemoembolization-only, and RF ablation-only groups, respectively. After IPW, OS remained superior in the combined chemoembolization/RF ablation group compared with the monotherapy groups (10-y OS, 41.8% with combined therapy, 28.4% with chemoembolization alone, and 11.9% with RF ablation alone; P = .022).

CONCLUSIONS

Chemoembolization plus RF ablation may provide better survival outcomes than chemoembolization or RF ablation monotherapy, and can be considered a viable alternative treatment for unresectable single medium-sized HCCs.